Autism and Addiction

Autism, also known as autism spectrum disorders (ASD), is a disorder that affects how individuals perceive, understand, and interact with the world.

Usually diagnosed in early childhood, autism afflicts many thousands of American children—an estimated one in 54 8-year-olds, according to one Centers for Disease Control and Prevention analysis—but it’s not one-size-fits-all. Its severity differs from person to person.

One contributing factor can be a co-occurring disorder, such as anxiety or substance use disorder.

At one time it was widely believed that people with ASD could not develop a co-occurring substance use disorder (SUD), such as alcoholism or drug addiction.

Now, researchers find that—at least when the ASD is of a mild form—addiction may be even more likely than for people with no autism symptoms.

What Is Autism?

Autism is a neurodevelopmental disorder characterized by impaired social skills, and sometimes by language and intellectual skills as well. At its worst, autism prevents a person from living a normal, independent life.

According to the American Psychiatric Association’s authoritative Diagnostic and Statistical Manual of Mental Disorders (DSM-5), to meet its Autism Diagnostic Criteria, there must be persistent deficits in communicating with, interacting with, and forming emotional connections with other people. Lifelong care may be necessary.

In the 1988 film Rain Man, Dustin Hoffman portrayed a man with autism who, although he was also a savant—as are 1 in 10 people with ASD—could not take care of himself.

One in 45 American adults—2.2% or 5.4 million—has autism. Sometimes autism isn’t diagnosed until adulthood.

Signs of Autism

The signs that someone has autism may differ based on severity and age. Some signs of autism may include a person who

• Doesn’t respond to their name.
• Has difficulty making eye contact.
• Doesn’t respond or seem aware that others are speaking.
• Isn’t willing to take turns or share.
• Doesn’t display facial expressions.
• Repeats words or phrases.
• Doesn’t seem able to play with others.
• Is unable to adapt to change.
• Is extremely sensitive to light and sounds.
• Takes longer to learn to talk and make hand gestures.
• Forgets skills they already learned.
• Is very literal-minded; doesn’t understand figures of speech, sarcasm, or irony.
• Doesn’t understand body language.
• Doesn’t make friends easily.
• Experiences emotional spells.
• Often speaks in a monotone.
• Displays an intense interest in a small range of subjects.
• Experiences seizures.
• Engages in self-stimulating behaviors (“stimming”).

Stimming

Some ASD symptoms are obvious, such as flapping your hands like a bird. These are “stimming” or self-stimulation behaviors, and people with ASD aren’t the only ones who do them.

The reason for stimming is to calm oneself, reduce feelings of anxiety, and vent frustration. Biting your fingernails, drumming your fingers on the table, tapping your foot, and whistling are common stimming behaviors that anybody might engage in. These behaviors may occur more often and continue longer in people with ASD.

With ASD, people either continue these behaviors without regard to how they disturb the people around them or engage in more extreme behaviors such as rocking back and forth, staring at fans or lights, compulsively rearranging objects, or banging their heads against the wall and other self-damaging behaviors.

Types of Autism

While the most severe cases of autism seem to be on the decline, the total number of reported cases is on the rise. That’s because the definition of autism has expanded.

Once autism was considered a monolith and represented the worst-case-scenario: nonverbal, unable to read or write, engaging in repetitive motions, and even violent.

The term autism was coined in 1908, but the condition was first widely studied in the 1940s. A milder version of autism, without the language or intellectual deficits, was studied by Hans Asperger and eventually dubbed Asperger syndrome (or Asperger’s).

As autism study ramped up in the 1970s and ’80s, researchers realized autism was a spectrum, some people had milder symptoms and some much more severe. The disorder became subdivided into a few main types:

• Autistic disorder. This was the “classic” type of autism, the most severe type that needed the most support. People diagnosed with autistic disorder frequently had learning disabilities and poor communication skills. They seemed to live in a world of their own.
• PDD-NOS. Short for “pervasive developmental disorder. not otherwise specified,” this was autism with fewer or milder symptoms, but more severe than Asperger syndrome.
• Childhood disintegrative disorder.  This diagnosis was applied to children who started out developing normally but began to display autism-like symptoms. It was also on the severe side of the spectrum and required much support.

A couple of related disorders included:

• Asperger syndrome. At that time, Asperger syndrome was thought to be a separate disorder, not a type of autism. People with Asperger’s differed in having fewer and milder symptoms, average or above-average intelligence, and “distinctive strengths” such as sometimes having greater focus and observational skills.

• Rett syndrome. Because it causes some autism-like symptoms—as well as other symptoms, such as microcephaly and curvature of the spine—Rett syndrome was sometimes thought to be a type of autism too. Rett’s is due to a mutated gene, however, so it was removed from the category. It almost exclusively affects girls.

High-functioning autism is not a scientific designation but is commonly used to describe someone who has some signs of low-level autism but functions normally, often better than normal.

Some people with autism and doctors still use these terms, but in 2013, the American Psychiatric Association’s authoritative Diagnostic and Statistical Manual of Mental Disorders (DSM-5), eliminated them.

Autism was changed to autism spectrum disorder (ASD), and the types were replaced with three levels of severity, with Level 1 the mildest. Asperger syndrome was folded in as part of the spectrum.

Now, although there hasn’t been a new DSM, even these levels have been mostly abandoned, with autism as a wider spectrum, with individuals falling at various points along that spectrum. That point is determined by the number and severity of symptoms or signs.

Risk Factors for Autism

Despite a flawed 1998 paper in The Lancet and the claims of anti-vaxxers, there is no evidence that children’s vaccinations in any way cause or increase the likelihood of developing autism, and plenty of evidence to the contrary.

The most likely cause seems to be genetics, but that is probably not the only risk factor. Although it does run in families, it doesn’t mean that the child of a person with ASD will necessarily have it:

• If one identical twin has ASD, the other may not (as few as 36% or as many as 95%).
• If one fraternal (nonidentical) twin has ASD, there’s a 31% chance that the other will also.
• Even if a firstborn child has ASD, the second child has less than a 1-in-5 (2%–18%) chance of also having ASD.
• The age of the parents may also be a factor. In general, older parents are at a higher risk of having a child with ASD.
• Significantly preterm or premature children (26 weeks or less) are also at higher risk.
• Statistically, male children are four times more likely to have ASD than females.
• Some pre-existing conditions also increase the risk, including Rett syndrome, fragile X syndrome, and tuberous sclerosis (“a rare genetic condition that causes benign tumors,” mainly found among people with low-functioning ADS), can have a greater chance of having ASD.

Environmental factors, such as the mother or the child being exposed to dangerous chemicals, may also contribute, but there hasn’t been enough study to say how much.

Misconceptions About Autism

Despite well-done and fairly accurate (if not always typical) portrayals of autism in the media, many people still have misconceptions about ASD. Among the most glaring are:

• People with ASD are intellectually disabled. Don’t make that assumption. Although some of the genes connected to autism and intellectual disability are the same, a 2014 study found that fewer than one-third—30%—of people with ASD also had an intellectual disability. Earlier figures of more than two-thirds were based on people with ASD not being able to explain some “confounding issue” that prevented them from doing well in class. Sometimes it was as simple as needing glasses.
• People with ASD are violent.  No. When it was learned that the killer in the 2012 Sandy Hook Elementary School shooting was diagnosed with Asperger syndrome, many observers thought that explained his actions. Experts from the Office of the Child Advocate, however, concluded that his “murderous acts” weren’t caused by his ASD, anxiety, depression, or any other psychiatric issues.

While attention-deficit/hyperactivity disorder (ADHD)—which often co-occurs with ASD—is a contributing factor to violence, a University of Bristol study found that when the individual also had ASD, the likelihood of violence decreased.

• People with ASD lack empathy. That’s not so. People with autism feel affection, anxiety, fear, and the whole range of emotions. It’s just that they have difficulty communicating their emotions to others or interpreting the feelings of others.

It’s not a problem with feeling; it’s a problem with learning. A lot of communication is nonverbal. It’s learning to pick up on social cues, body language, knowing what the right response is for a given situation. Don’t assume they are rude. People with autism may not be able to read those cues.

What Is Addiction?

Substance use disorder is another self-stimulating behavior not solely used by people with ASD. The “substance” can vary from alcohol, prescription medications such as opioids or stimulants, and illegal drugs such as cocaine, heroin, and fentanyl.

Addiction is “the most severe form of substance use disorder” (SUD), according to Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health (2016), as well as “a chronic brain disease.”

Initially used for pleasure or legitimate medical reasons, substance use can short circuit, hijack, and rewire the brain’s reward system until the substance must be taken to avoid painful withdrawal.

While some see addiction as a moral failing, the surgeon general’s report states that it has no more to do with morality than other chronic illnesses such as high blood pressure, heart disease, diabetes, or cancer.

Links Between Autism and Addiction

At first glance, addiction and autism wouldn’t seem to be connected. Addiction normally develops in the teens or early 20s. ASD usually is diagnosed at a much younger age, as early as 18 months.

Sometimes, however, the symptoms of autism are overlooked until the teens or adulthood. One person with ASD wasn’t diagnosed until his mid-30s, at which time he was struggling with addiction. That missing information helped to explain his addiction.

Until recently, most researchers believed that people with autism rarely became addicted because:

• They are regimented rule-followers. They don’t want to use drugs.
• They are isolated from their peers. They don’t face pressure to use drugs to fit in.
• People with severe autism can’t live independently. They don’t have opportunities to go out, find, and use drugs.

That belief—based on “limited and ambiguous empirical data”—now seems to be very wrong except in the most severe cases.

According to a Swedish study, when people with ASD have average or better intelligence—that’s 70% of them—they may be twice as likely to have a SUD as their peers. The likelihood is even higher for people with ADHD.

Like autism, addiction also has a genetic component. The best evidence now suggests that there is a biological predisposition towards addiction. That’s why some people can have one drink and stop while others feel compelled to continue until they pass out.

Another similarity is that, like addiction, there is no cure for autism spectrum disorder. The goal of autism treatment, therefore, is living with the symptoms of ASD. Treatment must be ongoing, probably for life (barring new medical or psychological breakthroughs). Early intervention—by age 3 or earlier—has the best results.

Dual Diagnosis: When Autism and Addiction Co-Occur

When an individual has both a substance use disorder problem and another physical or mental health issue, it is called a dual diagnosis or a co-occurring disorder. Between 40% and 60% of SUD cases have a dual diagnosis, which complicates treatment and may lead to relapse.

The rates for autism are similar. About 45% of people with ASD also have another mental health issue.

One of the main reasons that such disorders co-occur is self-medication. For example, when people have an undiagnosed mental health issue, they may discover that drinking alcohol, smoking marijuana, or taking opioids or stimulants might make them feel better, at least temporarily.

Alcohol and other substances can also reduce social anxiety, making it easier for people to open up and relax.

Treatments for Autism

Some of these treatments are similar to treatments for substance use disorder, though not identical. What helps treat SUD may not be viable for someone with ASD.

Drugs

One of the main treatments for autism is medications. Even though there is no cure, many of the symptoms of ASD can be controlled, such as anxiety, stress, depression, and even some obsessive-compulsive and repetitive behaviors.

Perhaps due to the perceived difficulty of their becoming addicted, as many as one-third of people with ASD in the United Kingdom are prescribed psychotropic drugs—drugs that affect “behavior, mood, thoughts, or perception”—and it may be as high as two-thirds in the United States, based on a 2014 study. Ten percent may be prescribed more than one medication.

Researchers estimate, however, that 14% of people with ASD are prescribed psychotropics when there are no co-occurring disorders.

Support Groups

One hallmark of the addiction rehab movement has been the peer support group, most famously Alcoholics Anonymous.

While not a complete or scientific treatment, such peer support groups allow people with addictions to interact with others who also have addictions. They offer moral support, a nonjudgmental ear, and advice by example.

Everyone who attends the peer support group meetings is encouraged to share their life story, to recount how they faced temptation but remained sober another day. They learn from older members who have remained sober longer, who may even sponsor them as a mentor or friend. It’s a safety valve and classroom.

People with ASD may not function well in such settings. Autism support groups are mainly for parents and other family members of people with autism.

Other Treatments for Autism

Although there is no single recommended treatment, the main treatments are behavioral, psychological, and educational therapies, including:

• Cognitive behavioral therapy
• Nutritional therapy
• Occupational therapy
• Physical therapy
• Speech language therapy
• Educational and school-based therapies
• Social skills training