Autism and the lure of substances

One of the commonly understood facets of Autism Spectrum Disorder (ASD) is that it is a permanent condition, one that stays with an individual for life. While there are effective ways to treat symptoms, teach skills, and mediate disruptive behavior, people with ASD will need to work at it for their entire lives. While many people know this, the visibility of autism in adults is much lower than it is in children, and therefore specific needs of adults with the condition are less understood.

As individuals with ASD grow and approach adulthood, many are introduced to the same adult influences as typically developing teens. Unlike other youths, however, these particular young people are faced with conditions that may make it more difficult for them to navigate these situations in healthy ways. As addiction professionals know, young people use substances for many reasons: as a social lubricant, because their peers are using, or to self-medicate. And while individuals on the autism spectrum are no different in these respects, they may be even more vulnerable to these influences, as their difficulty socializing may push them toward the social benefits of substance use. Once they start using, they may find that the effects appear to alleviate some of their symptoms. Further, they may not have been talked to about drugs and alcohol and may not know how to behave responsibly.

Risk scenarios

One of the most distinctive symptoms of ASD is difficulty socializing. This may push individuals who are on the spectrum toward using alcohol or drugs as a way of relating to their peers. Like typically developing teenagers, teens with ASD are willing to try new things in order to associate with peers, even going as far as using drugs and alcohol. If they encounter some positive results with this strategy, such as a meaningful interaction with a peer at a party, they will be more likely to continue to use these methods.

Another common reason people use is as a form of self-medication. Typically developing individuals may use substances when they are feeling down, to make themselves feel better. In this regard, individuals with ASD are no different. Their social struggles may leave them feeling lonely or isolated, and substances may cover up these feelings, albeit only temporarily.

Another form of self-medication that individuals on the autism spectrum may use involves taking a drug meant to treat symptoms they actually have. For instance, attention-deficit/hyperactivity disorder (ADHD) commonly co-occurs in individuals on the spectrum. A teen diagnosed with ASD alone may find that prescription stimulants, such as those prescribed to a peer who is diagnosed with ADHD, make him/her feel more attentive, or more “normal.” While the drug is doing what it is typically intended to do, it is generally regulated by doctors who monitor and adjust the dosage. A teen taking whatever he or she can acquire is ill-equipped to regulate the dose, may build a tolerance, and may become addicted.

This scenario also carries further risks for ASD teens, as their social deficits may prevent them from sensing subtle social cues indicating a risky situation. This in turn may expose them to potential trouble, ranging from being taken advantage of to legal problems.

A unique factor influencing individuals with autism and their behavior around substances is a lack of education on the subject. One potential reason individuals with ASD may not be taught how to effectively use or abstain from using substances is because we like to think of them—as with many other individuals with disabilities—as different from ourselves. We perceive them as more simple beings who do not face the same temptations many adults encounter. Another reason may be that the thought of approaching these subjects remains uncomfortable, made even more so by the thought of having to explain the social nuances in great detail.

To illustrate, imagine having “the talk” with a teen who is entering puberty and thinking about sex. Now imagine having this conversation with someone who does not understand many of the social intricacies of sex—someone who may ask even more blunt questions. You’re probably much less inclined to have the second conversation than the first. The same goes for substances. While no one wants to think their child is going to come in contact with substances, ignoring the presence of drugs and alcohol does not make them go away. Because the caretakers of young people on the spectrum are so focused on helping them learn more basic life skills, the task of teaching them how to navigate pressures and temptations successfully is often forgotten. Without proper knowledge on these sensitive subjects, people on the spectrum sometimes struggle to regulate their use and fall into addiction.

Treatment barriers

Whatever reasons individuals with ASD have for misusing drugs or alcohol, they face greater obstacles to treatment than typically developing addicts. People on the spectrum tend to have a strong desire for routine and an aversion to change. Once a substance becomes a part of the routine, someone on the spectrum may struggle to remove the habit, regardless of the substance’s effects.

Another unique struggle a person with ASD may face during treatment is the threat to one's independence. ASD often interferes with an individual’s ability to live independently, hold employment, etc., all of which give adults a sense of identity. Thus, as an individual on the spectrum uses, he/she may see it as a means of exerting independence or establishing an identity. These factors may make an individual on the spectrum more resistant to substance use treatment.

The outlook isn’t impossibly bleak, however, as some modes of treatment have proven successful in addressing a number of maladaptive behaviors in individuals with autism. Using principles of operant conditioning and the classic understanding of behavior, Applied Behavior Analysis (ABA) is a technique that involves looking at an individual’s behavior patterns, observing reinforcing consequences, and using a variety of methods to help an individual adjust his/her behavior in a healthier direction. ABA has been empirically supported for use in both ASD and addiction populations.

In the autism treatment community, ABA is widely known as the most effective form of treatment. Its principles can be applied to nearly any behavioral symptom. To illustrate its use, consider the following case: A 14-year-old girl is struggling to do her chores. Her behavior analyst would observe her in multiple settings (if possible) until the underlying factors of the behaviors can be determined. She must have a reason for behaving the way she does. For this client, doing chores, as it is for most teens, is unpleasant. Her behavior analyst would attempt to determine what the girl finds rewarding, something she may enjoy. The behavior analyst then would establish a reward system, with the cooperation of the girl’s parents, to make the outcome of completing her chores more pleasant than the act itself is unpleasant.

The same principles can be applied to substance abuse. For example, a small study in the early 1990s established a voucher system to encourage individuals to maintain abstinence from cocaine.1 The program required participants to submit three urinalysis samples per week. For each negative sample, the individual would receive a voucher with a monetary value exchangeable for goods or services. With consecutive clean samples, the value of the vouchers would increase. However, a positive sample, or failure to produce one, would cause the value to reset. As both ASD and substance abuse have strong behavioral components, ABA lends itself to the treatment of both conditions. It revolves around getting to know the individual, understanding his/her wants and needs, and establishing a system to help them meet those in a more constructive, socially acceptable and healthy manner.

Although ABA has a large body of research supporting its efficacy, it is fairly limited in its scope. To address efficaciously all of the potential factors that drive young people to use, a multidisciplinary approach is best. Combining talk therapy with behavior therapy will allow clients to work on both the behavioral aspects of their problems and the emotional distress that may accompany the pervasive changes they are making in their lives. As with any treatment, an openness and desire to understand the client remains crucial to helping the client meet goals.

Kyle Simon is Vice President and co-founder of the Autism Family Center near Chicago, a multidisciplinary treatment center focused on helping individuals and families living with autism. He is working on a clinical doctorate of psychology at the Chicago School of Professional Psychology.

References

1. Higgins ST, Delaney DD, Budney AJ, et al. A behavioral approach to achieving initial cocaine abstinence. Am J Psychiatry 1991;148:1218-24.