Understanding Current Trends in Autism Spectrum Disorders and Co-occurring Conditions Among Those Engaging in Substance Misuse

This text-based course format is a transcript of a live webinar that was created by Continued and edited with AI assistance.

Learning Outcomes

After this course, participants will be able to:

1. Describe the characteristics and variance in the manifestation of autism.
2. Identify common co-occurring mental health conditions among individuals with autism.
3. Explain substance use and abuse realities relevant to individuals with autism.

Introduction

As the prevalence and diagnosis of autism spectrum disorder continues to increase, it is relevant to have an understanding of the multi-faceted nature of this condition. Individuals with autism have a high propensity to develop other co-occurring conditions that impact their lives and their overall quality of life. High rates of mental health conditions and substance use disorders have been found among individuals with autism. This course will provide a foundation of autism, discuss common co-occurring conditions, and explore substance use and abuse realities.

Substance Use Disorder

To set the stage for our discussion, it is important to understand Substance Use Disorder (SUD) from a diagnostic perspective. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) provides comprehensive criteria for SUD. It recognizes 10 separate classes of drugs and outlines 11 diagnostic criteria. The DSM-5-TR integrates the historical categories of substance abuse and dependence into a single disorder, Substance Use Disorder, with varying severity levels: mild, moderate, and severe.

The four main categories of criteria for SUD include:

1. Physical dependence
2. Risky use
3. Social problems
4. Impaired control

Examples of the 11 diagnostic criteria include: taking the substance in larger amounts or for longer than intended; not managing to do what one should at work, home, or school because of substance use; and needing more of the substance to achieve the desired effect, indicating tolerance. It is crucial to differentiate whether observed behaviors are primarily due to SUD, autism, or a combination of both, as this has significant implications for accurate diagnosis and tailored intervention.

Overview of Autism

Characteristics, Variance in the Manifestation, and Prevalence

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by specific diagnostic criteria outlined in the DSM-5-TR. It is essential to note that these challenges are not better explained by an intellectual disability or global developmental delay.

Autism Spectrum Disorder Characteristics

The diagnostic criteria for ASD, according to the DSM-5-TR, include:

1. Social communication and social interaction deficits. These encompass challenges in expressive, receptive, and social language, making everyday communication and social nuances particularly confusing.
2. Restricted, repetitive behaviors, interests, or activities. This can manifest in various ways, from repetitive movements to intense, narrow interests, and adherence to routines.
3. Symptoms must be present in the early developmental period. Even if a diagnosis is received later in life, the symptoms must have been evident during early development, though they may have been masked or camouflaged.
4. Impairment in social, occupational, or other domains impacting current functioning. The symptoms must cause significant impairment across multiple contexts, such as school, work, relationships, and other functional areas of life.

The concept of "social camouflaging" or "masking" is particularly relevant. Individuals with autism may learn to blend in or hide their autistic traits in social situations, which can be incredibly exhausting and may lead to delayed or missed diagnoses. This ability to mask can make it difficult for others to recognize the underlying challenges, leading to a lack of appropriate support.

Points of Consideration

Understanding the variance in the manifestation of autism is paramount. As the saying goes, "If you've met one person with autism, you've met one person with autism." This highlights the unique ways ASD can present in individuals, making a one-size-fits-all approach to support and intervention ineffective.

Prevalence

The prevalence of autism has seen a significant increase over the past few decades. According to the Centers for Disease Control and Prevention (CDC), as of April 15, 2025, approximately 1 in 31 children in the United States are diagnosed with ASD. This marks a notable rise from previous estimates, such as 1 in 36 children in 2022 and 1 in 44 prior to that. While data on adults with autism is still developing, emerging literature suggests that the prevalence among adults may be even higher.

Broadening of Diagnostic Criteria, Greater Awareness, Screening in Part, Greater Identification

Several factors contribute to this increasing prevalence. The broadening of diagnostic criteria in the DSM, coupled with greater public awareness and increased screening efforts, has led to greater identification of individuals with ASD. Many individuals who historically went undiagnosed or were misdiagnosed with other conditions, such as depression or anxiety, are now receiving accurate autism diagnoses. Early and accurate diagnosis is crucial for accessing specialized treatment and support. Increased survival rates for preterm babies and various environmental factors also play a role in the rising numbers.

Diagnosis Ratio

Historically, findings exhibit a 3:1 male-to-female ratio, with many studies indicating a 4:1 ratio. However, it is important to consider that females with autism may be more adept at social camouflaging, leading to underdiagnosis in this population.

Autism and Co-Occurring Conditions

The presence of co-occurring conditions, or comorbidities, is a significant aspect of the autistic experience. Individuals with ASD often experience a higher likelihood of developing other mental and physical health challenges compared to the general population.

Common Co-Morbidities

Common co-occurring mental health conditions among individuals with autism include:

• Attention-deficit/Hyperactivity disorder (ADHD)
• Executive functioning challenges
• Anxiety disorders
• Depression
• Eating disorders, such as Anorexia and Avoidant/Restrictive Food Intake Disorder (ARFID). ARFID is a newer eating disorder characterized by highly selective eating or a general lack of interest in food, which can lead to poor growth and nutrition.

It is crucial to note that misdiagnosis with other conditions can be common, highlighting the need for thorough assessment and a nuanced understanding of how ASD presents alongside other challenges.

Possible Reasons for Co-morbidities

Several factors contribute to the high rates of comorbidities in individuals with ASD:

• Social isolation: A significant challenge, with recent reports indicating high rates of loneliness in the general population, which is often amplified for individuals with autism.
• Need to control one's own environment: This can manifest in behaviors resembling obsessive-compulsive disorder or various anxieties.
• Craving social inclusion, but challenges with obtaining it: Many individuals with autism desire social connection but struggle with the nuances of forming and maintaining friendships.
• Sensory challenges: Difficulties processing sensory input (e.g., tactile experiences, smells) can lead to distress and contribute to maladaptive coping mechanisms.
• Challenges across all settings: If daily life feels consistently difficult across work, school, and relationships, the likelihood of developing co-occurring conditions increases.
• Disrupted plans and routines: Unexpected changes can lead to significant distress and emotional dysregulation.

Other Considerations

Beyond mental health conditions, individuals with autism may face additional challenges throughout their lives, from childhood to adulthood, across various settings such as school, work, and relationships. These include:

• Bullying: Individuals with ASD are often targets of bullying due to their social differences.
• Safety issues: They are at an increased risk for abuse, exploitation, and neglect, partly due to challenges with social language, naivety, and trusting nature.

Autism and Substances

Substance Use and Abuse Realities

The intersection of autism and substance use is a critical area of study, revealing unique vulnerabilities and patterns of misuse within the autistic population.

Prevalence of Substance Misuse in Autism

The prevalence of Substance Use Disorder (SUD) in people with Autism Spectrum Disorder (ASD) appears to be higher than once considered. While previous data may have underestimated this, current research suggests a greater extent of use and misuse. Studies indicate a ranging prevalence of substance abuse in samples with ASD, from 1.3% to 36% (Ressel et al., 2020). Some research even suggests a double risk for individuals with ASD to develop an SUD compared to those without autism (Kunreuther, 2021). The variability in prevalence rates can be attributed to differences in sample characteristics and diagnostic measures across studies. It is important to note that assessment measures specifically designed to screen for substance abuse in individuals with ASD are often lacking, leading to limitations in establishing a general prevalence.

Common Substances Used

When data is collected regarding specific types of substances used, the following are commonly reported:

• Tobacco
• Alcohol
• Cannabis

A systematic review by Ressel et al. (2020) highlighted that while these substances are commonly used, studies often report varying rates of associated substance abuse. For instance, rates of alcohol use disorder (AUD) range from 1.3% to 16%, and cannabis use disorder rates are reported between 6.5% and 8% among ASD samples.

Considerations

Individuals with ASD might be less likely to self-report substance misuse, making accurate data collection challenging. Drug use is often reported as a means of self-medication. Studies indicate that individuals with ASD are nine times more likely to use recreational substances to manage behavior and are also more likely to use them to manage mental health symptoms (Weir et al., 2021). This suggests that substance use can be a maladaptive coping mechanism for the unique challenges faced by autistic individuals, such as social difficulties, sensory overload, and emotional dysregulation. The visual of a backpack, for instance, can symbolize the hidden struggles and the search for relief that individuals might undertake, sometimes leading to the exploration of substances. The image of a solitary figure contemplating a landscape can evoke feelings of disconnection, while a group of individuals embracing at sunset can represent the crucial need for community and belonging, especially in the context of recovery.

Risk and Protective Factors

Understanding the specific risk and protective factors for individuals with ASD is crucial, as they may differ from those in the general population.

Risk and Protective Factors for General Population May Differ for Those with ASD

Factors that may be more common among those with ASD and contribute to increased risk include:

• Fewer social resources: This can encompass a lack of belonging, diminished social networks, and lower social capital.
• Less/lack of appropriate support and services: Inadequate access to tailored interventions can exacerbate vulnerabilities.
• Greater likelihood to experience physical and mental health conditions: The high comorbidity rates increase the overall burden on individuals.
• Difficulties with emotional regulation: Challenges in managing emotions can lead to maladaptive coping strategies, including substance use.
• Challenges with behavior management: Difficulties in self-regulation can contribute to impulsive behaviors related to substance use.

The image of a building with the question "HOW ARE YOU, REALLY?" painted on its side powerfully conveys the often-unseen struggles and the importance of truly understanding the internal experiences of individuals, particularly those with ASD who may mask their difficulties.

Risk Factors for SUD in ASD Population

Several factors specifically increase the risk of SUD in the ASD population:

• Comorbid externalizing disorders.
• Perceived social deficits.
• Psychological distress.

While some studies have found these factors to be statistically non-significant in isolation, the cumulative effect and the interplay of these elements are important. High autistic traits have been found in some studies to increase the risk for "high drug use" in adolescent populations with autism. However, conclusions regarding the direct association between substance abuse and autistic traits require cautious interpretation due to variations in study methodologies and sample sizes.

Environmental Risk Factors for Substance Use or Abuse

Ressel et al. (2020) identified six key environmental risk factors that increase the likelihood of developing substance abuse among individuals with ASD and ADHD:

1. Late ASD diagnosis: A delayed diagnosis can mean a prolonged period without appropriate support and understanding, increasing vulnerability.
2. Few social resources: Limited social connections and support networks can lead to isolation and a greater propensity for maladaptive coping.
3. Lack of structure: Unstructured environments can be particularly challenging for individuals with ASD who often thrive on routine and predictability.
4. Family history of SUD: This is a common risk factor across populations, but its impact can be amplified for individuals with ASD.
5. Early smoking onset: Initiating smoking at a young age is a known predictor of future substance use.
6. Family history of adversity: Adverse childhood experiences and other traumatic events within the family environment can significantly increase the risk for SUD.

Other Considerations for Possible Elevated Risk of SUD in ASD

Beyond environmental factors, several individual characteristics contribute to an elevated risk of SUD in individuals with ASD:

• Sensory challenges: Individuals with autism may engage in substance use to mitigate the impact of adverse sensory experiences, such as difficulties processing tactile input, under-responsiveness to sensory input, or challenges with processing smells. The image of headphones on a yellow background can symbolize the need for sensory regulation and the potential use of substances to achieve it.
• ADHD: The comorbidity of ADHD with ASD is common, and the associated challenges with executive functioning can increase vulnerability to SUD.
• Mood and/or anxiety disorders: These co-occurring mental health conditions are frequently self-medicated with substances.
• Individual cognitive characteristics:

• Perceived social deficits: Some individuals with autism report that substance use increases their confidence in social environments and eases communication, leading them to use substances to reduce social anxiety.
• High social motivation: Paradoxically, individuals with ASD who have a high desire for social interaction and high social interest (high reward dependence) may be more prone to SUDs if they struggle to achieve meaningful social connections naturally.
• Psychological distress: High levels of psychological distress are a significant precipitating factor for substance use and abuse in individuals with autism. The blurred image of the word "FOCUS" can represent the cognitive challenges and psychological distress that individuals with ASD may experience, leading them to seek relief through substances.
• Weak executive functioning: Deficits in executive functioning (e.g., planning, reasoning, problem-solving, self-management) can contribute to difficulties with self-management and increase the likelihood of using substances as a maladaptive coping mechanism. The prefrontal cortex, responsible for executive functions, is the last part of the brain to develop, and developmental delays in this area can be particularly challenging for individuals with ASD, especially when compounded by other comorbidities.

Other Vulnerability Factors

Additional factors that increase the risk of substance use among people with autism include:

• Childhood use of drugs: Early initiation of drug use is a strong predictor of future SUD.
• Being coerced or tricked into drug use: Individuals with developmental disabilities may be more susceptible to coercion due to traits such as naivety, trusting nature, and difficulties in discerning intentions. Augmenting skills to reduce this vulnerability is crucial.
• Trauma: Adverse childhood experiences and other traumatic events can significantly increase the risk for SUD. The impact of trauma on individuals with autism can be unique and requires specialized understanding and intervention.

Demographics to Consider

Research on the intersection of disability, opioid misuse, and suicidality provides important demographic considerations. A study by Marsack-Topolewski and Chan (2024) on a sample of people with disabilities (not exclusively autism) revealed:

"Results indicated NMPOU [non-medical prescription opioid misuse] was associated with higher odds for serious thoughts of suicide. Having a disability was associated with higher odds for having a plan for suicide and having a suicide attempt. Adolescents with disabilities who engaged in NMPOU had over three times the likelihood for serious thoughts of suicide. Social work services can be tailored for adolescents with disabilities within the context of the family unit to address the impact of the opioid epidemic using a disability-oriented framework." (Marsack-Topolewski & Chan, p. 1, 2024).

Further analysis using the National Survey for Drug Use and Health (NSDUH) by Chan and Marsack-Topolewski (2023) examined the effect of opioid misuse and disability on serious thoughts of suicide, having a suicide plan, and making a suicide attempt. The findings indicated that NMPOU was associated with 37% higher odds for having a suicide plan and 73% higher odds for having a suicide plan over the last year. Opioid misuse is suggested to be a significant risk factor for suicide, and individuals with disabilities are found to be at greater risk. These studies underscore the critical need for targeted interventions and support for adolescents with disabilities, including those with ASD, who are at heightened risk for both substance misuse and suicidality.

Protective Factors

While the risks are significant, it is equally important to identify and leverage protective factors that can decrease the risk of substance use and abuse among individuals with ASD.

• Individual personality: Traits such as low sensation-seeking tendencies can serve as a protective factor.
• Environmental factors: Limited access to drugs significantly reduces the opportunity for substance use.
• Specialized interventions: Tailored support and treatment approaches can build resilience and reduce vulnerabilities.

However, it is also noted that among a clinical sample of adolescents with ASD, there was a higher prevalence of smoking and over four times the risk of illicit drug use, highlighting the complexities in this population.

Clinical Implications: Assessment, Diagnosis, Treatment

Targeted Screening and Diagnosis

A critical clinical implication is the need for targeted screening and diagnosis for both SUD and mental health conditions, particularly in adolescents with ASD. Current screening methods and tools may not be adequately geared to capture these phenomena in the autistic population, leading to undiagnosed cases. Screening should be provided and meticulously aligned with the unique needs and presentation of individuals with ASD. Many individuals with co-occurring ASD and SUD remain undiagnosed, underscoring the urgency for improved assessment practices.

Treatment (SUD and Mental Health Conditions)

• Targeted prevention: Proactive measures are essential to prevent the onset of SUD in individuals with ASD.
• Tailored approach for treatment: A "one-size-fits-all" approach is ineffective. Cognitive Behavioral Therapy (CBT), when tailored to the needs of individuals with ASD, has shown promising results.
• Group CBT: Studies have indicated that group CBT, specifically designed for patients with ASD and co-occurring SUD, yielded positive outcomes (Walhout et al., 2022). This intervention led to lower levels of alcohol use, less passive coping styles, reduced depression, decreased anxiety, and less stress. Notably, a three-month follow-up after the group intervention showed even stronger effects, suggesting the benefit of sustained support. This highlights the potential for specialized and tailored interventions to be highly efficacious for this specific population.

Considerations for Substance-Use Services

Substance use services must be designed to account for the unique needs of individuals with ASD and their co-occurring substance use challenges. Many individuals with ASD who seek substance use services also experience high rates of anxiety (87%), depression (75%), and ADHD, with chronic pain also being commonly reported (Munday et al., 2025). The reasons for substance use vary, often including self-medication for anxiety, depression, sensory challenges, or to enhance social confidence and communication.

Therefore, there is a clear need for personalized, inclusive, and neuro-affirming care. This involves:

• Trauma-informed approaches: Recognizing and addressing the impact of past traumas, which are prevalent in the ASD population.
• Neuro-affirming environments: Providing quiet spaces free of sensory stressors, which can be highly beneficial for individuals with sensory sensitivities.
• Individualized and tailored communication: Adapting communication styles to suit the specific needs of the individual, recognizing that social masking can be exhausting and may hide underlying difficulties.
• Understanding social masking: Professionals must be aware that individuals with ASD may acutely blend in or mask their characteristics in social situations, leading to exhaustion and withdrawal afterward. This masking can contribute to delayed diagnoses and a lack of understanding of their true needs.
• Managing co-occurring conditions: Treatment plans must integrate support for all co-occurring mental and physical health conditions, as they are often intertwined with substance use.

Studies by Marsack-Topolewski and Weiss (2020) and Munday et al. (2025) have highlighted significant access issues and barriers to substance use services for adults with autism, including challenges related to accommodation, acceptability, availability, and affordability. These findings underscore the importance of professional development for practitioners in substance use supportive spaces to ensure that services are trauma-informed, neuro-affirming, tailored, and specific to individuals with ASD who are dealing with SUDs.

Complexities in Supporting Care Recipients, their Families, and Providers

Supporting individuals with ASD who are experiencing substance misuse challenges involves navigating significant complexities, balancing multiple viewpoints and perspectives. This includes:

• Balancing viewpoints and perspectives: Ensuring that all voices are heard, including those of the person with SUD, their family, and care providers.
• Safety is key: Prioritizing the safety and well-being of the individual throughout the treatment and recovery process.
• Dreams for now and the future: Helping individuals and their families envision realistic and achievable goals for their present and future.
• Limited supports: Acknowledging that formal and informal supports can be limited due to factors such as waitlists and costs. Leveraging relevant formal supports and emphasizing the importance of robust informal support networks and community engagement (to reduce social isolation and loneliness) is crucial.
• Changing and evolving needs: Recognizing that the needs of the person with SUD, as well as paid and unpaid care providers, will change over time, requiring flexible and adaptive support strategies.

Multi-pronged Approach

Moving forward, a multi-pronged approach is necessary to address the complex interplay of autism, co-occurring challenges, and substance misuse. Key areas of focus include:

• Awareness: Increasing understanding among the general public, healthcare professionals, educators, and families about the unique vulnerabilities and needs of individuals with ASD regarding substance use.
• Prevention: Developing and implementing targeted prevention strategies that consider the specific risk factors and protective factors for the autistic population.
• Treatment: Enhancing access to and the quality of specialized, neuro-affirming treatment options for SUDs in individuals with ASD. This includes leveraging interventions like group CBT and ensuring services are trauma-informed and individualized.
• Support for the person with SUD: Providing comprehensive support that addresses not only substance use but also underlying mental health conditions, sensory challenges, and social difficulties.
• Support for family and caregivers: Recognizing the vital role of families and caregivers and providing them with resources, education, and emotional support.
• Professional development: Ensuring that professionals across various disciplines receive ongoing training and education to understand the intricate relationships among autism, co-occurring challenges, and substance misuse.
• Understanding the relationship: Continuing research to deepen our understanding of these complex interconnections to inform evidence-based practices.

The image depicting Naloxone (Narcan) nasal spray and Zimhi (naloxone HCl injection) serves as a stark reminder of the opioid crisis and the importance of overdose prevention and response, highlighting a critical aspect of substance misuse realities.

Treatment and Services

Effective treatment and services for individuals with ASD and SUD require a comprehensive and integrated approach. Key components include:

• Hotline support: Providing immediate access to crisis lines and helplines for guidance and support.
• Recovery support: Offering ongoing support systems to aid in long-term recovery, including peer support groups and community-based programs.
• Treatment options: Ensuring a range of evidence-based treatment modalities are available, tailored to the individual's needs and preferences.
• Education, advocacy, community, family support: Empowering individuals and their families through education, advocating for their rights and needs, fostering a sense of community, and strengthening family support systems.

Treatment Directions

The direction of treatment should prioritize personalized, inclusive, and neuro-affirming care, recognizing the unique presentation of ASD and its comorbidities.

Supporting Clients in Building and Maintaining Relationships

Community and social connection are often missing pieces for individuals with ASD, yet they are vital for well-being and recovery. Supporting clients in building and maintaining relationships involves:

• Connecting with local support groups (e.g., through SAMHSA's Find Support services).
• Seeking out local activities, events, and faith communities that align with their interests.
• Connecting with online informational groups for peer support and shared experiences.
• Making time for existing friendships and relationships.
• Reinforcing the message: "Remember – you are not alone!"

The image of multiple hands reaching out to touch a tree trunk powerfully symbolizes the importance of connection, support, and the collective strength found in community.

Remind and Help Clients and Consumers Know that They are Not Alone

Emphasizing that individuals are not alone in their struggles is a powerful message that can foster hope and encourage help-seeking behaviors. Resources such as SAMHSA's support group locator and information on group therapy for substance abuse can be invaluable tools for clients and their families.

Resources

A wealth of organizational resources is available to support individuals, families, and professionals in addressing autism, mental health, and substance misuse.

Organizational Resources – Opioid Prevention and Misuse

• Centers for Disease Control (CDC) Opioid Overdose: Offers an overdose prevention and response toolkit.
• CDC – Overdose Prevention Resources: Provides a variety of communication resources for overdose prevention.
• CDC – Health Care Provider Toolkits: Includes toolkits specifically for healthcare providers, such as the Naloxone Toolkit.
• Rural Community Toolbox: A valuable resource for rural communities, particularly concerning opioid prevention and misuse.
• SAMHSA Opioid Prevention Toolkit: Another comprehensive toolkit for overdose prevention and response.
• State of Michigan Opioid Resources: Provides diverse resources, including access to the "Michigan Safer Opioid Prescribing Toolkit."
• Wyoming Prevention Depot: Offers resources on opioid risk and protective factors.
• National Helplines: Many states offer helplines, in addition to the national helpline: 1-800-662-4357.

Organizational Resources – Support

• Mental Health America: A leading community-based nonprofit dedicated to addressing the needs of those living with mental illness.
• NAADAC: The Association for Addiction Professionals: Provides education, clinical training, and advocacy for addiction professionals.
• National Institute on Alcohol Abuse and Alcoholism (NIAAA): Offers publications and resources on treatment for alcohol problems.
• National Institute on Drug Abuse (NIDA): Provides scientific information on drug abuse and addiction.
• National Institute on Mental Health (NIMH): The lead federal agency for research on mental disorders.

Resources

• SAMHSA Buprenorphine Practitioner Locator: Helps locate practitioners who can provide buprenorphine for opioid use disorder.
• SAMHSA Find Help: A comprehensive tool to find treatment services.
• SAMHSA Opioid Treatment Program Directory: Provides a directory of opioid treatment programs.

Organizational Resources

Note - Links are subject to change.

• Substance Abuse and Mental Health Services Administration (SAMHSA):
• Website: https://www.samhsa.gov/
• SAMHSA’s National Hotline: 1-800-662-HELP (4357)
• Substance Abuse and Mental Health Services Administration (SAMHSA) – Find Treatment:
• Website: https://findtreatment.gov/

Supports

• 988 Lifeline:
  • 988 Suicide & Crisis Lifeline Website: https://988lifeline.org/
• National Helpline:
  • Treatment referral and information, 24/7
  • Website: https://findtreatment.gov/
  • 1-800-662-HELP

Online resources are available for practitioners working with specific populations, such as the Deaf and hard of hearing, to ensure that information and support are accessible and aligned with their unique needs.

Limitations and Risks

Substance use and abuse are complex and the coinciding needs for individuals with autism can be wide ranging. This webinar will not cover every aspect of these topics. Therefore, continued and additional training and education on this topic are recommended. Treatment and approaches to support individuals with autism experiencing substance misuse challenges do not coincide with a one-size-fits-all approach. Practitioners should engage in cultural humility at all times and acknowledge cultural variations regarding substance use and abuse, as well as treatment. Adequate support often require a multi-disciplinary team to ensure comprehensive treatment.

References

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