Alcohol, drugs and eating disorders

Studies do not agree on whether autistic people have more alcohol and drug problems than other people. In Swedish national registers covering 26,986 autistic people and 1,349,300 matched controls, 4.0% of the autistic group had a substance-related problem (a diagnosis, a related crime or death, or alcohol-related disease), against 1.3% of controls.¹ Autism without ADHD or intellectual disability roughly doubled the odds after adjustment, autism with intellectual disability alone did not raise the odds of substance-related problems overall, though it modestly raised the odds of a substance use disorder diagnosis, and people diagnosed under the older diagnostic criteria had lower risk than controls.¹ Taiwanese insurance records, mostly of boys and young people, also found a raised risk, about 2.3 times.²

Other large datasets point the other way. In US Medicaid records for 2012, 1.75% of autistic enrollees without intellectual disability had a substance use disorder, against 4.44% of enrollees with neither autism nor intellectual disability.³ A later analysis of Medicaid claims for 2012 to 2016 by the same group, covering 388,426 autistic people (about 70% aged 11 to 17, 78% male), found a recorded substance use disorder in about 7% of them against 16% of other enrollees. Risk was the same or lower between ages 11 and 29; between 30 and 64, small raised rates of some specific disorders, such as alcohol and cannabis, reversed once other mental health conditions were taken into account.⁴ In a UK birth cohort, 38% of autistic 17-year-olds reported problematic substance use against 56% of their peers; the gap was in alcohol, not tobacco or cannabis. Comparing their result with adult studies, the authors suggested the relationship may reverse in adulthood.⁵ In a UK online survey, autistic adults were less likely to drink regularly or to binge than non-autistic adults, and autistic men were less likely to have ever smoked or used drugs; among women there was no significant difference.⁶ In UK primary-care records, autistic adults without intellectual disability had harmful alcohol use at about the same rate as other patients (an incidence rate ratio of 1.01, with a range from 0.85 to 1.18), while substance use overall was slightly higher (1.24, 1.02 to 1.51).⁴²

Pooled figures are modest. A meta-analysis put substance use disorder at 8.3% of autistic adults, among the least common co-occurring diagnoses, with very large differences between studies.⁷ A 2025 review found alcohol use disorder in 1.6% of autistic people in large registers, against 16.1% in clinical samples.⁸

Gambling is a behavioral addiction rather than a substance one, and the autism evidence there is thinner still. A 2026 systematic review of gambling harm screened four databases and included 14 studies, but only 2 reported any data on autism, so it gave a narrative summary rather than a pooled figure; no study found as of October 2026 has estimated how common autism is among people harmed by gambling.⁴³

ADHD may carry much of the risk. In the Swedish registers, autism with ADHD went with about eight times the odds of a substance-related problem, against about two and a half times for autism alone, though the gap was much smaller when only ADHD diagnoses made before the substance problem were counted.¹ Among Dutch adults seeking treatment, 30% of 70 autistic adults had ever had a substance use disorder, against 58% of 53 adults with ADHD.⁹ In a US clinic group where most autistic participants also had ADHD, substance use disorders were less likely than in both an ADHD group and a comparison group, so having both conditions does not always mean high risk.¹⁰

Other conditions and circumstances matter too. A review of 26 studies named substance use in the family, co-occurring mental health problems and limited social support as risk factors, and a low appetite for sensation-seeking as protective.¹¹ In the US Medicaid data, half of autistic enrollees without intellectual disability had another mental health condition, against about a quarter of others.⁴ In Sweden, full siblings and parents of autistic people also had modestly raised odds, and half-siblings slightly raised odds.¹

When autistic people do use substances, some studies find coping reasons more common, and others do not. In the open-ended part of a UK survey (919 people, mostly women, White and without intellectual disability), only 91 autistic and 47 non-autistic people gave a reason for using drugs. Among them, autistic people were about nine times as likely to say they used drugs to manage their behavior, such as autistic traits or sensory overload, though the estimate is very uncertain (26 people against 2), They were also about three times as likely to say they used drugs to manage mental health symptoms, and less likely to give social reasons. Across all the open-ended answers, autistic people were about four times as likely to describe vulnerability (7% against 2%), such as being forced or tricked into using or starting in childhood.⁶ The authors linked "managing behavior" to camouflaging, a word the participants themselves did not use.⁶

Other studies stress social reasons. In a survey of 507 autistic adults, more than half of those who drank had drunk heavily on at least one occasion in the past year; expectations such as "Alcohol makes verbal communication easier" were associated with how often they drank, and among heavy drinkers social reasons and enhancing positive feelings were stronger motives than conformity or coping.¹² Interviews with eight adults with Asperger syndrome found self-medication and easing social contact among the themes.¹³ Forty US autistic young people aged 16 to 20 named reasons to drink including others' acceptance, coping with problems, irritability or boredom, sensory problems and fitting in; the authors suggested drinking may offer brief relief from social anxiety and loneliness.¹⁴ In a survey of 94 autistic and 92 non-autistic young people by the same group, autistic youth were no more likely to drink to cope and less likely to drink for social, conformity or enhancement reasons. Among the autistic youth, a history of being bullied or excluded went with drinking more often, and those who masked more reported drinking less often.¹⁵ Twelve Dutch patients with autism and a substance use disorder described substances as helping at first, then making daily life worse.¹⁶

Therapists report gaps. In a convenience survey of 122 drug and alcohol therapists, most had autistic clients but no autism training, and most said outcomes were worse for their autistic clients.¹⁷ In the survey of 507 autistic adults, 45% said they would not seek support if their drinking became a problem, and respondents named unfamiliar, chaotic settings and the fear of being misunderstood or judged as barriers.¹² In US Medicaid data, autistic enrollees with a substance use disorder used fewer substance use services than matched enrollees and had higher risks of overdose and hospitalization.¹⁸

Treatment research is thin. A 2016 review found no treatment studies, and a 2020 review found one exploratory adapted intervention and no assessment tools designed for autistic people.^19,11 In a Norwegian outpatient clinic, therapists given regular autism training and supervision offered adapted CBT; seven people started, four men completed, two stopped using, one cut down and one still drank heavily.²⁰ In their introduction, the same authors suggested that standard treatments such as group therapy "may be particularly unsuitable" for autistic people, a view rather than a finding of the study.²⁰ A Dutch group program adapted for autistic adults, with no comparison group, was followed by lower alcohol use, craving, depression and anxiety among the 30 of 57 who completed it, which suggests a group format can work when it is adapted.²¹

Autistic people are more often diagnosed with eating disorders than other people, though most never are. In Danish national registers covering everyone born from 1981 to 2008, 2.57% of autistic people had an eating-disorder diagnosis from specialist hospital care, against 0.91% of people without autism.²² Autism was linked more strongly with anorexia and unspecified eating disorders than with bulimia.²² A mediation analysis estimated that mood and anxiety disorders could account for roughly 44% to 100% of the links between ADHD or autism and eating disorders.²² In Finnish registers, autism was more common among people with anorexia and among those with other or unspecified eating disorders; the gap was largest in males with other or unspecified eating disorders, though that estimate is very uncertain (odds ratio about 32, with a range from about 10 to 107).²³

Across studies of autistic adults, eating disorders were found in 2% to 11%, and reviews covering all ages put feeding and eating disorders at 1.4% to 7.9%; the umbrella review includes the review of adult studies, so the two overlap.^24,25 In a one-time survey of 180 autistic adults in the UK, camouflaging predicted eating-disorder symptoms in a statistical model; sensory processing was related to symptoms but did not predict them once other factors were counted, and autistic identity showed no link.²⁶

Rates may be higher in some groups, but the evidence is thin. A 2025 lived-experience-led scoping review found five studies of disordered eating in autistic transgender and gender-diverse people, all from 2021 to 2025. It judged their rates high and suggested atypical presentations may be common, but the finding rested on one self-report study of eating-disorder diagnoses, with much higher rates than in allistic transgender and gender-diverse peers (about 52% against about 14%), and one clinical-records study whose difference was not significant (about 10% against about 8%), and the authors said only tentative conclusions about prevalence were possible.⁴⁴ A 2026 preprint by a group led by the same first author (not peer reviewed) interviewed 21 autistic transgender and nonbinary adults; they described disordered eating as a survival technique, in response to hostility and a struggle to belong, but the study measured no rates.⁴⁵

For selective eating, ARFID and autistic traits in anorexia, see Eating and sleep.

Most of the evidence on how services respond comes from women and girls. In UK interviews, none of 15 autistic women had an autism diagnosis when first seen by eating-disorder services.²⁷ One was told off in hospital for walking on tiptoe and fidgeting because staff thought she was burning calories.²⁷ In the same project, almost all the women described sensitivities to particular foods, clinicians said restriction was often driven by the sensory properties of food, and some women seemed to use starvation to numb sensory overload; for some, the assumption that body image drove their illness left them feeling misunderstood.²⁸ Most of the women had negative experiences of CBT, though a couple found it helpful, and many found the social demands of group therapy a barrier.²⁷ In Australia, nine autistic people and nine parents, describing treatment in childhood and adolescence, spoke of being "misunderstood", with autistic traits misattributed and one-size-fits-all care.²⁹ A 2025 systematic review and qualitative synthesis of nine studies reached a similar conclusion: autism-related mechanisms were, in its words, "not consistently acknowledged and addressed in current care provision".⁴⁶ A 2026 interview study by UK-based researchers, of 12 autistic adults (11 women, 1 man, aged 18 to 50) across five countries who identified as in recovery or recovered from anorexia, found that autism was often not considered during treatment: several said their sensory sensitivities and preference for structure were read as eating-disorder features and they were labeled resistant to treatment, and clinicians were described as not well informed about autism, though the structure of inpatient care helped some.⁴⁷

Screening is hard. In 160 women with restrictive eating disorders, a 10-item autism screen picked up only 69% of the autistic women.³⁰ In one London adult service, between 17% and 40% of patients, depending on their eating disorder, scored above an autism-trait cut-off, while 6.1% of intake patients reported known or suspected autism.^31,32 In that service's three years of intake data (1,252 patients), those classified as autistic, ADHD or both reported more distress and poorer work and social functioning than other patients, most when both were present, though the group differences were small.³² High trait scores do not always mean autism: in Swedish twins, autistic traits were not raised at age 9 in those later diagnosed with anorexia, and parent-reported traits at 18, mainly restricted and repetitive behaviors, were raised only during acute illness.³³ In Danish registers, a first autism diagnosis was several times as likely in the first years after an anorexia diagnosis as in matched controls, but so were first diagnoses of mood, personality and obsessive-compulsive disorders, so this may reflect late recognition, effects of the illness, or both.³⁴

PEACE, a pathway for autistic patients developed in a London eating-disorder service, changed the ward environment with a "sensory box" of items such as weighted blankets, a neutral color scheme and communication passports.³⁵ In preliminary before-and-after figures, autistic patients' admissions were shorter after it was introduced, while non-autistic patients' were not, with an estimated saving of about £22,837 per patient; there was no randomized comparison.³⁶ Clinicians working in it found it hard to tell autism from the eating disorder and asked for better screening and aftercare.³⁷ A 2025 multi-site study turned PEACE into a self-assessment checklist across eight areas, without outcome data.³⁸ No controlled trial of PEACE was found as of October 2026.

Outcome studies disagree. In 81 people with anorexia treated with an intensive standard therapy, CBT-E, autistic traits measured by questionnaire did not predict dropout, eating-disorder symptoms or weight at the end of treatment or at follow-up. The study had no control group and did not assess diagnosed autism; its authors suggested CBT-E can work without systematic adaptations for autistic traits, a challenge to the case for pathways like PEACE.³⁹ In a Swedish cohort of 51 people with anorexia that began in adolescence, followed for about 30 years, core anorexia symptoms had settled only among those never diagnosed autistic; 16 had been diagnosed at some point. Autism was assessed four times during the illness, and the more often it had been diagnosed, the worse people's mental state, social contacts and work at 30 years.⁴⁰ UK clinicians named a belief that accommodating eating-disorder behaviors is risky, and separate autism and eating-disorder training, as barriers to autism-affirming care.⁴¹

Several autistic writers describe self-medication as part of masking. Devon Price writes that "Drinking is really the only release valve neurotypical people can respect", and that substance use "can mask Autism super effectively".^c1 Price tells the story of Thomas, who found after years of drinking and misdiagnosis that he had been "using alcohol to numb" lifelong social anxiety and sensory issues, and quotes the writer Jesse Meadows: "I became a more autistic person when I got sober."^c1 Megan Griffith, writing about AuDHD, guesses that the reasons include overwhelm, alcohol as a social lubricant, and "our ongoing identity crisis caused by masking."^c3

Other writers tie drinking to social demands. Pete Wharmby relied on alcohol to get through social life at university and slowly left it behind in his twenties; now that he no longer drinks, he avoids socializing altogether. He argues that the whole burden of fitting in falls on autistic people, asks "who can blame us for finding solace in the bottom of a bottle?", and would change how going out is organized so that autistic people can enjoy it too.^c7 Maggie, writing in her sixties in Alex Ratcliffe's collection of autistic adults' accounts, says of alcohol: "It made it easier for me to mix with people." Maggie drank through jobs and money and has not had a drink in eight years.^c8 Gwen Greenwood, who volunteers with an autism support charity, believes autistic people are "particularly vulnerable to addiction" because of a need for repetition and routine, which drink can quickly become part of.^c9

Sol Smith compares masks and addictions to "two rooms in a house": one kept tidy for guests, the other where the mess goes.^c2 For him the hidden room held nearly thirty years of secret binge eating; when he stopped, "stimming returned" and everything under his mask came out.^c2 Bianca Toeps describes eight months in an eating-disorder clinic that never noticed her autism, and fellow patients with anorexia who said that eating more made them feel more, which she reads as sensory overload.^c6

Some writers describe restrictive eating that has little to do with body image. Carly Jones, writing for professionals, tells of Sasha, 19, who restricted food to feel in control in an unpredictable world, and warns that "Traditional methods for treating eating disorders may make Autistic girls with an eating disorder worse rather than better."^c10 Jones suggests offering more choice and control in other parts of life, and describes keeping her own eating disorder, which began in her twenties, from returning with no scales, no weight goals and her special interests.^c10 Daniel Burford separates anorexia from ARFID (avoidant/restrictive food intake disorder), one of whose criteria is the absence of any disturbance in how a person experiences body weight or shape: "ARFID is about the food." Burford writes that autistic women describe eating-disorder clinicians who did not believe them when they said their eating was not about their body.^c11 A clinicians' guide by Donna Henderson, Sarah Wayland and Jamell White relays the account of Kim Clairy, an autistic occupational therapist who nearly died from an eating disorder: her vomiting, which met a sensory need for rhythmic movement, was read as purging, and her need to move was read as exercise to burn calories.^c12

Writers also describe drink as something to manage deliberately. Sarah Nannery holds one drink at work events as a signal that she is taking part, and never has a second there.^c5 Megan Anna Neff asks readers who once relied on alcohol or other substances to cope to forgive themselves: "you were doing the best you could with the resources and knowledge you had at the time."^c4