David is a 17-year-old high-functioning autistic teen whose grades have dropped. He seems more irritable and has been smoking marijuana with “friends.” David reports that marijuana calms his social anxiety, but he seems unaware of how cannabis may contribute to his academic struggles and emotional instability. 

Whether to feel better or to fit in with peers, autistic youth face unique challenges with substance use. In this article, we’ll explore the intersection of autism and substance use, how to assess and treat these patients, and how to involve families in a meaningful way.

The scope of the problem
Autism occurs in 1 in 36 children. Emerging data reveal that autistic youth, especially those engaged in typical school and activities, are at greater risk for substance use disorder (SUD). Although the overall rates of SUD in those with autism are lower than for kids without autism, this trend is reversed in adulthood (Weir E et al, Lancet Psychiatry 2021;8(8):673–685; Lushin V et al, Autism 2025;29(7):1674–1687). In Lushin et al, autistic males reported less overall use than nonautistic peers. However, teens participating in this and another study stated that they use substances to reduce autism-related behaviors and self-medicate mental health symptoms such as depression, anxiety, and ADHD (Huang J et al, JAMA Pediatr 2021;175(2):e205371). 

What drives this risk? Autistic teens often experience isolation, loneliness, anxiety, and depression. Many are aware of their social difficulties and desire connections with peers. Substances, especially marijuana or alcohol, offer a quick way to feel more relaxed. 

Research suggests that the overall lower rate of substance use in autistic youth may be because these kids tend to adhere to societal rules in a more rigid manner, while increased rates of SUD in autistic youth specifically to self-medicate may be related to certain factors that increase vulnerability (Arnevik EA and Helverschou SB, Subst Abuse 2016;10:69–75). These factors include higher IQ, social isolation, school struggles, and emotional regulation problems. While autistic teens are more likely to adhere to a fixed rule that substances will cause permanent harm, many are like typical teens who do not think about or accept the long-term risks of substance use. Also, like neurotypical kids, autistic youth who engage in criminal activity have a higher rate of co-occurring substance use compared to the vast majority of autistic youth who are not involved in crime. 

Assessing substance use in autistic youth
When assessing an autistic teen for substance use, traditional approaches need adjustment. Use clear, specific language when discussing substance use. For example, abstract questions like “How often do you drink?” might not elicit accurate responses compared to concrete questions such as “In the past week, how many times did you drink alcohol?” 

We are not aware of research evaluating substance use rating scales in autistic populations; however, instruments such as the Screening to Brief Intervention (S2BI; www.tinyurl.com/3u7wrje8) and the CRAFFT (www.tinyurl.com/msrxsd3k) use concrete questions that may be helpful with autistic youth. 

Assessment should also look at the teen’s:

• Developmental capacity for reflection: How do I feel about my substance use?
• Seeing the perspectives of others: What do my peers think about my substance use?
• Multicausal thinking: Am I doing badly in school due to bad teaching, or does my substance use also affect my grades? 
• Nuanced vs black and white thinking. Do I need this substance to function, or are there times when I do okay without it?

Understanding how the teen thinks will provide a better idea of how to communicate with them effectively and support the continued development of their problem-solving ability. 

Collateral data from family, school staff, and other caregivers will provide a better picture of the teen’s behavior. Family members might notice mood changes, shifts in academic performance, or new social circles that suggest substance use.

Drug testing can be useful; however, it’s important to approach the process with transparency and collaboration, explaining clearly to both the teen and the family that drug tests are used like any other medical test to track the presence of level of substances.

Tailoring treatment for autistic teens
Traditional substance use treatments, like group therapy or 12-step programs, rely on neurotypical social communication skills, which can pose a challenge for autistic individuals. Before recommending a group setting, consider the teen’s social functioning. David, for example, might struggle in a group setting due to his difficulties with social cues and communication, making it harder for him to engage in typical treatment modalities. Research on group therapy for autistic adults with SUDs suggests that such approaches might be used with teens (Walhout SJN et al, Subst Abuse 2022;16:11782218221085599). Multimodal substance use treatment involving the teen, parents, and joint sessions has been adapted for use with autistic teens with good preliminary results, as have a variety of cognitive behavioral and social skills approaches (McKowen J et al, Case Rep Psychiatry 2023;2023:8998160). 

Still, individual therapy might be a good starting point. Motivational interviewing (MI) can be effective, particularly if you can adjust your approach to fit the patient’s cognitive style. Visual aids, structured routines, and predictable session formats can help maintain engagement and ensure progress (Larson E et al, PEC Innov 2023;2:100149). Instead of focusing on abstract future goals, you might phrase questions in a more concrete, immediate way: “What do you think would happen if you stopped using marijuana for one week? How would you feel?”

Medications also have a role in managing co-occurring conditions like anxiety or depression, which often drive substance use in autistic teens. In some cases, medications to reduce cravings (eg, naltrexone or acamprosate for alcohol) might be appropriate, though these decisions should be made carefully with consideration for the teen’s overall mental and physical health.

Engaging the family
David’s parents worry about his use of marijuana, but they are also conflicted. They want to support his desire for social connections, but they fear that these connections may lead to more substance use.

Engage the family when treating substance use in autistic youth. Help parents recognize that while social connection is central to overall health and function, it is of little value unless their teen can function free from substance use. You might work with the family on finding structured social groups or clubs where the teen can meet peers in a facilitated, less risky environment, and on helping the teen think about who is and is not a real friend.

After a thorough assessment and some MI, you recommend individual therapy and family work with a focus on managing social anxiety and expanding David’s ability to recognize the advantages of clean living. You also explore the possibility of using medication to help reduce David’s cravings for marijuana while treating his anxiety.

Carlat Verdict: For clinicians working with autistic teens, managing substance use requires a flexible, individualized approach. Be sure to address the struggles with social connection, anxiety, and depression that drive teens’ substance use. By tailoring assessments and treatments to their specific needs—and actively involving the family—you can help your autistic patients find healthier ways to cope and connect.