Youth patient A (YP-A) was a 17.5-year-old, Caucasian male with previous diagnosis of ASD from neuropsychological testing at age 8. At intake, he reported history of heavy binge use of alcohol (approximately 2 binge episodes per week, 6-8 standard units of alcohol per binge) and marijuana (5/7 days of cannabis use, unknown potency, but 1-2 joints per time). He had also been misusing cough medications daily (approximately 900 mg of Delsym; dextromethorphan per occasion) for the majority of days in the three months prior to the initial evaluation and reported stealing this product from a local pharmacy. YP-A and his parents also reported challenges in patient's emotional regulation typified by explosive outbursts with intermittent nonsuicidal self-injurious behavior (NSSIB) in the home. He was diagnosed with DSM-V autism level 1, alcohol use disorder - mild and cannabis use disorder - mild. He did not meet DSM-V criteria for other substance use despite evidencing problematic use patterns, a rule out of mood disorder was also given due to explosive behavior and intermittent NSSIB. Age of onset of first alcohol use was 16 years, cannabis 16 years, and dextromethorphan was 17 years. All DSM-V substance use diagnoses were given at the intake with assessed time period being the past 12 months. Family history was significant for alcohol problems on paternal side (although it was not known who specifically). Treatment goals focused on safety planning, communication skills, functional analysis of use, contingency management, and emotion regulation skill development.
YP-A was able to complete 9/12 youth modules (75% of modules implemented) over 11 sessions, over approximately a 5-month period; specifically, those focusing on psychoeducation about ASD and SUD, emotional identification and regulation skills training, sobriety sampling, and social and communication skills. The order of modules was altered at times to accommodate the patient's needs of the session, and modifications were made to abbreviate some modules or extend them over multiple sessions as the patient was only able to tolerate meetings that were less than 20 minutes in duration. The patient was able to track use of substances, set goals for reducing use of cannabis, avoid binge drinking, and set a 30-day sobriety sample from more risky cough syrup use. He also used emotion regulation skills and communication strategies to reduce anger outburst with his parents at home. The patient was also willing to engage with the psychiatrist for a trial of mood stabilizing medication by seeing the clinic psychiatrist.
Parent engagement was limited as his parents were well educated on ASD given the early diagnosis in childhood. Parents completed 5/7 modules (70% of modules implemented) with sessions focused on how to use contingency management and communication skills in order to enhance positive reward for improved or nonsubstance use behavior, reduced behavioral dysregulation (e.g., anger management-taking space, using communication skills more effectively, reaching out to therapist when in distress) as well as improving overall relationships within the home. A joint session via telehealth was unsuccessful due to YP-A feeling overwhelmed with the video-based format (implemented during the COVID-19 pandemic; thus, a combination of video visits were done) Despite limited parental engagement, this patient engaged consistently with therapy, started medication to target his mood, and was still smoking cannabis but fewer times per week (3-4 days per week). Importantly, he had not used cough medicine or engaged in binge alcohol use since starting treatment. Though not sober, engaging in less risky substance use was an important treatment outcome in this case. Regarding CGI outcomes incorporating both patient and parent therapist impressions, outcomes for substance use, YP-A initial CGI-S score was 5-6 (markedly/severely ill), and at the end 3 (mildly ill), with CGI-I indicating 2 (much improved). Regarding ASD symptoms, initial CGI-S score was 4 (moderately ill), and at the end 3 (mildly ill), with CGI-I indicating 2-3 (much improved/minimally improved).