The Expectancies and Motivations for Heavy Episodic Drinking of Alcohol in Autistic Adults

Abstract

Background:

For autistic adults, the perceived benefits of drinking alcohol to facilitate social interaction may be particularly appealing. Alcohol may be considered “self-medication” for clinical features of autism or may be used to help cope with elevated levels of co-occurring anxiety.

Methods:

We developed an online survey and 507 autistic adults responded to questions concerning their expectancies and motivations for heavy episodic drinking. The survey also included questions about ways of seeking support, if needed, and barriers to seeking support.

Results:

Over half of those who had drunk alcohol reported heavy episodic drinking in the past year (6 or more units of alcohol at one time). Heavy episodic drinkers endorsed traditional expectancies (e.g., “Alcohol generally has powerful positive effects on people”) and autism-specific expectancies (e.g., “Alcohol makes verbal communication easier”) to a greater degree than nonheavy episodic drinkers. Autism-specific expectancies, not traditional expectancies, related to frequency of drinking. The strongest motivations for heavy episodic drinking were for social reasons and to enhance positive feelings, rather than for conformity or coping. If support was required for problematic drinking, the internet was the most commonly chosen resource, although 45% of the participants indicated that they would not seek support. Perceived barriers to support included concern that it would take place in an unfamiliar chaotic environment and concern about being misunderstood and judged by a therapist.

Conclusions:

This study is the first to identify the expectancies and motivations for heavy episodic drinking in autistic adults as well as identifying barriers to seeking support. There may be some autism-specific expectancies related to the nature of autism that impact upon heavy episodic drinking, as well as impacting upon seeking support. The autistic and broader autism communities can benefit from an awareness of these findings, and service providers can adapt support appropriately.

Lay summary

Why was this study done?

Little is known about how alcohol is used within the autistic community. One population-based study found that autistic adults were four times more likely to experience problematic drinking compared with nonautistic adults.

What was the purpose of this study?

This study identified the expectations and motivations for heavy episodic—or “binge”—drinking alcohol among autistic adults. Binge drinking is a risk factor for problematic drinking. The study also identified how autistic adults accessed support should it be needed, and what the potential barriers were to accessing support.

What did the researchers do?

We conducted an online survey with 507 autistic adults with formal or informal diagnoses of autism. The survey asked about the frequency of drinking alcohol and binge drinking. Participants then answered a questionnaire about why they drank alcohol. The questions asked about general reasons for drinking (such as: “Alcohol generally has powerful positive effects on people [e.g., makes you feel good or happy; future seems brighter]”) as well as autism-related reasons (such as: “Alcohol makes verbal communication easier [e.g., starting conversations, responding to what other people say, or maintaining a normal back-and-forth conversation]”). Finally, participants answered questions about seeking help and potential barriers to help-seeking.

What were the results of the study?

Binge drinkers reported a greater number of traditional and autism-relevant expectations for drinking alcohol than nonbinge drinkers. The strongest motivations for drinking alcohol were for social reasons and to enhance positive feelings, rather than coping or to conform. The internet was the most common source of support for problematic drinking (49% of participants); however, 45% of participants indicated that they would not seek any support. Perceived barriers to support were an unfamiliar chaotic environment and being misunderstood and judged by a therapist. Around one fifth of participants self-diagnosed themselves with autism, rather than having a formal diagnosis from a clinician. These two groups were very similar to each other.

What do these findings add to what was already known?

This is the first study to identify the expectations and motivations for binge drinking alcohol in the autistic community.

What are potential weaknesses in the study?

This was an online survey, and the diagnostic status of participants cannot be verified. Participants chose to take part in the study, and this may represent a bias as some people may not want to take part in online surveys or may not have access to the internet, or may not be part of networks that send out invitations to take part in research. In addition, the sample was largely female and well educated, which is not reflective of the autistic population as a whole.

How will these findings help autistic adults now or in the future?

Better understanding the expectations and motivations for binge drinking alcohol can help inform support that is targeted at the autistic community. Alcohol support services can be better informed about how to adapt their provision for the autistic community specifically.

Introduction

Autism spectrum disorder (hereafter autism except where referring to the formal diagnosis) is a neurodevelopmental condition defined by persistent difficulties across multiple contexts within two distinct domains: (1) social communication and interaction and (2) restricted and repetitive patterns of behaviors, activities, or interests.^1,2 Studies in Asia, Europe, and North America have identified an average prevalence of autism of between 1% and 2%.³ A large Swedish population-based study suggests that autistic individuals have four times the risk of alcohol use-related problems compared with population controls.⁴ The study also reported an elevated risk for illegal substance use in their cohort; however, alcohol misuse specifically may be elevated among autistic adults. As alcohol consumption is legal, a literal interpretation of rules may make autistic people less likely to experiment with illegal substances.⁵ Although there is variability in the rate identified, research has consistently highlighted elevated alcohol-related mental health problems in autistic adults (between 2% and 18%).^6–10 A recent review has highlighted a critical lack of data on alcohol (and marijuana) use by autistic adolescents,¹¹ and we do not know how alcohol consumption affects morbidity and mortality rates for autistic adults.¹²

Autistic individuals report that social facilitation and self-medication to help manage co-occurring anxiety are perceived benefits of drinking alcohol.^13–15 For example, an anecdotal account from an autistic adult suggests that alcohol can be used to cope with anxiety, to maintain friendships, and to give access to a whole host of relationships and even to sustain careers.¹⁵ Autistic adults may superficially display a “normal” facade when they drink alcohol, which may explain difficulties diagnosing and supporting problematic drinking in this group.¹³ As autism is characterized by difficulties with social communication and interaction, it may be that perceived benefits of drinking alcohol for social facilitation are particularly appealing. One criticism of this self-medication hypothesis is that it assumes that alcohol use within the autistic community is primarily motivated by the features of autism itself. Little attention is given to the role of cognitions or individual differences.

An alternative approach is expectancy theory, which proposes that the fulfillment of an individual's expectancies motivates drinking alcohol.¹³ Previous research in nonautistic adults has shown sex differences in alcohol expectancies and their relationship with drinking frequency. Males tend to report stronger expectancies of increased social and physical pleasure, global positive changes,¹⁶ and aggression,¹⁷ and females report expectancies that alcohol will reduce tension¹⁶ and lead to increased cognitive and motor performance.¹⁸ To the best of our knowledge, no previous studies have explored sex differences in alcohol expectancies in autistic drinkers. In terms of accessing services, autistic young people and people with intellectual disability are less likely to be enrolled in alcohol and drug or juvenile justice services, compared with mental health, child welfare, or serious emotional disturbance-related services.¹⁹ When autistic people do seek treatment, outcomes are less favorable than for other groups.*

In the United States, heavy episodic drinking or “binge drinking”²⁰ is defined as consuming four or more alcoholic drinks on one occasion (6–8 “units” of alcohol in the United Kingdom) and has a prevalence rate of 17.1%–18.4% in adults from the general population in both the United States and United Kingdom^21–23 and 15.2% of autistic adults in the United Kingdom.⁶ Heavy episodic drinking is a risk factor for problematic drinking,²⁴ and to date, there is little understanding of the expectancies and motivations for heavy episodic drinking in the autistic community.

The present study is the first survey of these factors in the autistic community. We also explore perceptions of accessing support should drinking alcohol become problematic. Finally, the autistic community may contain adults who have not received a formal diagnosis. A recent study reported that around one fifth of their adult sample identified as autistic, although they did not have a formal diagnosis from a professional.²⁵ An “informally diagnosed” category has been used for online surveys of the autistic community to capture those who do not have a formal diagnosis.^26,27

Methods

Participants

We sent invitations to participate in an online survey about alcohol through UK-based autism networks, including the Cambridge Autism Research Database, Autistica, The Centre for Applied Autism Research, and Network Autism. The inclusion criteria were as follows: being 16 years of age or older, being fluent in written English, and a diagnosis of autism (formal or informal—see Procedure). A total of 716 respondents accessed the survey, and of these, 563 (79%) took the survey. Of the 563 survey respondents, 56 indicated that they did not have either a formal or an informal diagnosis of autism and were excluded. Therefore, we analyzed the data from 507 participants (71% of those who accessed the survey). Eighty-five percent of the sample reported being in the United Kingdom, 7% in North America, 6% in Europe, and 1% from the rest of the world.

Procedure

We first asked respondents for their diagnostic status by asking: “Do you have a formal clinical diagnosis of autism (i.e., from a qualified health professional)? A formal diagnosis may include terms such as Asperger's Syndrome or Autism Spectrum Disorder (ASD).” If participants indicated that they did not have a formal diagnosis, we asked: “Do you have any issues related to autism but do NOT have a formal clinical diagnosis from a qualified health professional? Informal diagnoses may come from a family member or colleague or a self-diagnosis.” We labeled these two groups the formally diagnosed and the informally diagnosed groups, respectively. It was not possible to confirm diagnostic status, so participants were asked to identify how frequently they experienced the two diagnostic criteria for autism: “1) How often do you have difficulties with social communication and social interaction with other people? (For example, difficulties with normal back-and-forth social conversation, or making normal eye contact or making friends); 2) How often do you have difficulties with restricted and repetitive patterns of behaviours, activities or interests? (For example, difficulties with repetitive movements, or insisting on sameness or routine, or fixated and intense interests, or very high (or very low) sensitivity to the environment - such as light, sound or texture).” Both questions had a 5-point Likert-type response scale: (0) Almost never/in almost no situations; (1) Rarely/in rare situations; (2) Sometimes/in some situations; (3) Mostly/in most situations; and (4) Almost always/in almost all situations. Scores could range from 0 to 4 for each item. Both these items distinguish autistic from nonautistic groups and correlate with established measures of autistic-like traits.²⁸ This measure served as a check that the informally diagnosed group perceived a comparable level of difficulty to the formally diagnosed group.

We asked respondents to report demographic information, including their gender, age, level of education, and current employment. We then asked about frequency of alcohol drinking as well as asking whether participants had engaged in heavy episodic drinking. Participants were told: “By alcohol, we mean drinks such as beer, lager, stout, cider, wine, fortified wines (such as sherry, port, vermouth), spirits, liqueurs or cocktails (such as gin, whisky, rum, brandy, vodka, tequila, Baileys, Archers) or alcopops (alcoholic soft drinks such as WKD, Bacardi Breezer, Smirnoff Ice, Archers Aqua, Reef, schnapps).” We then asked participants, “Have you ever had an alcoholic drink (not counting sips you might have had as a child from an older person's drink)?” If yes, participants were asked, “How often have you had an alcoholic drink of any kind during the last 12 months (not counting a sip you might have had from another person's drink)?” Then, to assess heavy episodic drinking, we asked, “Do you ever drink 6 or more units of alcohol at a time? 6 units is equivalent to drinking between 2 and 3 pints of beer/lager/cider (4% strength) or between 2 and 3 standard (175ml) glasses of wine (13% strength) or 6 single small (25ml) shots of spirit (40% strength).”²⁹

Participants then completed a 14-item Autism Factor Alcohol Expectancies Questionnaire (AF-AEQ), developed for this study. The first 7 items related to the seven factors established from the general population¹⁷: (1) global positive changes, (2) changes in social behavior, (3) improved cognitive and motor abilities, (4) sexual enhancement, (5) cognitive, and motor impairment, (6) increased arousal, and (7) relaxation and tension reduction. For example, “Alcohol generally has powerful positive effects on people (e.g., makes a person feel good or happy; future seems brighter).” We labeled these 7 items as traditional expectancy factors for alcohol use. In addition to these seven traditional motivations, we developed an autism-specific variant, which related to each of the seven diagnostic criteria¹: (1) verbal communication, (2) nonverbal communication, (3) developing, maintaining, and understand relationships, (4) stereotyped or repetitive motor movements, (5) insistence on sameness, (6) highly restricted, fixated interests, and (7) hyper- or hyporeactivity to sensory stimuli. For example, “Alcohol makes verbal communication easier (e.g., starting conversations, responding to what other people say, or maintaining a normal back-and-forth conversation).” Response options ranged from 1 (almost never/never), 2 (some of the time), 3 (about half of the time), 4 (most of the time), through to 5 (almost always/always). We labeled these autism-specific expectancies factors. Participants then completed the Drinking Motives Questionnaire-Revised Short Form,³⁰ which has 12 items, including 3 items for each of four motivation factors, namely: (1) Enhancement (e.g., because you like the feeling), (2) Social (e.g., because it makes social gatherings more fun), (3) Conformity (e.g., to fit in with a group you like), and (4) Coping (e.g., because it helps you when you feel depressed or nervous). The 4 scales have internal consistency between 0.70 and 0.83. Participants responded to this questionnaire on the same scale as the AF-AEQ. We calculated and compared the means of the total expectancies and motivations scales. Finally, we asked participants if they were to experience alcohol-related difficulties, where would they seek support and what did they perceive any potential barriers to be?

Analysis

We analyzed using IBM SPSS version 25. As a number of adults are likely to be informally diagnosed, we compared self-reported autism characteristics between this group and the formally diagnosed group to identify potential similarities or differences. The main focus of the analysis was to compare heavy episodic drinkers with nonheavy episodic drinkers. We compared gender and frequency of drinking between the groups using nonparametric tests. We then compared motivations and the expectancies between these two groups using parametric tests. As sex differences have been identified between males and females in the nonautistic literature, we conducted a 2 (male/female) × 2 (formally diagnosed/informally diagnosed) Multiple Analysis of Covariance (MANCOVA) on expectancies and motivations with age as a covariate. Consistent with previous research,²⁷ we did not include the nonbinary group in this analysis as there are no data from the nonautistic literature to inform a hypothesis and the numbers are relatively small. We therefore analyzed gender as a binary variable (male/female). We then correlated frequency of drinking alcohol with expectations and motivations using nonparametric analysis for heavy and nonheavy episodic drinkers. Finally, we collated the frequencies of the sources of support reported by participants, as well as perceived barriers to accessing this support. The Psychology Research Ethics Committee at the University of Bath provided ethical approval. Participants did not receive any reimbursement.

Results

The 507 respondents comprised 393 (77.5%) participants who reported having a formal diagnosis and 114 (22.5%) participants who reported having an informal diagnosis. There were 331 (65.3%) participants identifying as female, 117 (23.1%) identifying as male, and 59 (11.6%) identifying as nonbinary respondents, with a mean age of 38.24 years (standard deviation [SD] = 12.42, range = 16–76). In terms of highest level of education, 88% reported having taken General Certificates of Secondary Education (GCSEs) (typically at 16 years of age in the United Kingdom), 81% reported studying for or having A-levels (typically at 18 years of age in the United Kingdom), and 76% reported studying for or having a university degree. Thirty-two percent reported having full-time paid employment and 23% reported having part-time paid employment. For those with a formal diagnosis of autism, the mean age at diagnosis was 32.89 years (SD = 14.25, range = 0–67). Self-reported autism characteristics had a mean of 2.9 (out of 4, see the Methods section) for both the formally diagnosed and informally diagnosed groups (SD = 0.8/0.9, range = 0–4). This similarity in means indicated that these groups comparably perceived their level of difficulties associated with autism to be occurring “mostly/in most situations.”²⁸

Of the 507 respondents, 472 (93%) had drunk alcohol in the past year. Of these 472 respondents, 217 were nonheavy episodic drinkers and 255 were heavy episodic drinkers, and the analysis compared these two groups. Nonheavy episodic drinkers did not differ significantly from the heavy episodic drinkers on any of the demographic variables, including gender, age, age at diagnosis, education level, or employment status (all p > 0.05). The only exception was that heavy episodic drinkers were more likely to have an informal (self) diagnosis than a formal (clinical diagnosis) [t(469) = 2.05, p < 0.05]. Table 1 confirms that heavy episodic drinkers drink more frequently, usually “once or twice a week” or more, whereas nonheavy episodic drinkers usually drink “once or twice a year” or less.

Table 1.

Frequency of Drinking Alcohol Reported by Participants Who Did and Did Not Self-Report Heavy Episodic Drinking

Frequency of drinking	Non-HED, n (%)	HED, n (%)
Almost every day	1 (0.5)	37 (14.5)
Five or 6 days a week	3 (1.4)	23 (9.0)
Three or 4 days a week	8 (3.7)	53 (20.8)
Once or twice a week	27 (12.4)	50 (19.6)
Once or twice a month	30 (13.8)	33 (12.9)
Once every couple of months	33 (15.2)	29 (11.4)
Once or twice a year	41 (18.9)	15 (5.9)
Not at all in the last 12 months	74 (34.1)	15 (5.9)

HED, heavy episodic drinking.

A chi-square analysis identified that those identifying as male and female were comparably distributed between the heavy episodic drinking and the nonheavy episodic drinking groups (χ² = 0.01, df = 1, p = 0.95). This absence of a gender difference was also the case for the formally diagnosed group only (χ² = 0.24, df = 1, p = 0.62) and for the informally diagnosed group only (χ² = 0.27, df = 1, p = 0.61). In addition, there was not a gender difference in the reported frequency of drinking alcohol, overall (U = 0.07, p = 0.95) for the formally diagnosed group only (U = 0.49, p = 0.62) or for the informally diagnosed group only (U = 0.51, p = 0.61).

Table 2 highlights the mean differences between the nonheavy episodic drinkers and heavy episodic drinkers for their expectancies (traditional and autism-related) and motivations (enhancement, social, conformity, coping). The heavy episodic drinkers endorsed both sets of expectancies and all four motivations significantly more than the nonheavy episodic drinkers. This greater endorsement by heavy episodic drinkers was also the case when each expectancy item was explored individually (all p < 0.05). For both nonheavy episodic drinkers and heavy episodic drinkers, a repeated-measures t-test highlighted that traditional expectancies were endorsed to a significantly greater degree than autism-related expectancies [t(212) = 16.48, p < 0.001; t(251) = 7.97, p < 0.001; respectively]. For the nonheavy episodic drinkers, all the motivations were endorsed comparably, except that conformity was endorsed significantly more than coping [t(212) = 2.12, p < 0.05; all other comparisons, p > 0.05]. For the heavy episodic drinkers, social and enhancement motivations were endorsed comparably, and both were endorsed significantly more than conformity and coping (all p < 0.001).

Table 2.

Mean (Standard Deviation) of Drinking Expectancies and Motivations for Nonheavy Episodic Drinkers and Heavy Episodic Drinkers

	Non-HED, mean (SD)	HED, mean (SD)
Traditional expectancies	3.69 (0.70)	4.15 (0.82)	t = 6.57, p < 0.001
Autism-related expectancies	2.79 (1.01)	3.65 (1.17)	t = 8.55, p < 0.001
Enhancement motivations	1.83 (0.95)	3.12 (1.19)	t = 13.13, p < 0.001
Social motivations	1.86 (1.02)	3.16 (1.23)	t = 12.48, p < 0.001
Conformity motivations	1.91 (1.08)	2.34 (1.20)	t = 4.12, p < 0.001
Coping motivations	1.74 (0.98)	2.84 (1.27)	t = 10.51, p < 0.001

SD, standard deviation.

We ran a MANCOVA analysis to identify any differences in the expectancies and motivation variables between the formally diagnosed and informally diagnosed groups, as well as gender differences between those identifying as male and female, and any interactions between these two factors (with age as a covariate). The only significant difference was that social motivation was higher for the informally diagnosed group compared with the formally diagnosed group [means = 2.81 and 2.53, respectively; F(1,391) = 4.58, p = 0.033]. There were no significant gender differences and no significant interactions between diagnostic status and gender (all p > 0.05; the identical pattern occurred when the analysis was repeated without age as a covariate).

For the nonheavy episodic drinkers and the heavy episodic drinkers separately, the frequency of drinking was correlated with the expectancies and motivations for drinking alcohol. Spearman's nonparametric correlations were conducted as the frequency scale is not an interval scale. Both groups showed the same pattern of results. The frequency of drinking significantly correlated with autism-related expectancies, not traditional expectancies, as well as enhancement, social, and coping motivations but not conformity motivations (Table 3). That is to say, those who drank more often felt more strongly that alcohol would reduce their autistic characteristics. They also felt that there would be more benefits socially.

Table 3.

Correlations of Drinking Frequency with Expectancies and Motivations for Nonheavy Episodic Drinkers and Heavy Episodic Drinkers

	Non-HED	HED
Traditional expectancies	0.12	0.05
Autism-related expectancies	0.21^**	0.15^*
Enhancement motivations	0.41^**	0.23^*
Social motivations	0.30^**	0.15^*
Conformity motivations	0.05	0.01
Coping motivations	0.31^**	0.32^*

p < 0.05, ^**p < 0.01.

Finally, Table 4 highlights where members of the autistic community would seek help if they perceived problematic issues with their drinking. Participants could respond to as many responses as they wanted to, the most common of which were searching online and not seeking help. Table 4 also highlights the potential barriers to seeking support, again participants could respond to as many items as they wanted to. The most common barriers related to going to an unfamiliar chaotic environment and being misunderstood or judged for drinking.

Table 4.

Sources of Support and Barriers to Accessing Support

Support	n (%)
Search online for information	250 (49.3)
I would not seek help or I'd try on my own	229 (45.2)
A family member or a friend	176 (34.7)
My doctor	176 (37.4)
A local alcohol service	65 (12.8)
A self-help group like Alcoholics Anonymous	59 (11.6)
Other	30 (5.9)
Other included my therapist, my psychologist, religious leader
Barriers
Going somewhere unfamiliar	301 (59.4)
Worrying they won't understand me	289 (57.0)
Being in a crowded or chaotic place	286 (56.4)
Fear of being judged for drinking	233 (46.0)
Other	88 (17.4)
Other included having to interact with other people, work in groups, anxiety/mental health

Discussion

This study is the first survey of the expectancies and motivations of autistic adults to investigate heavy episodic drinking, as well as the frequency of drinking alcohol and barriers to seeking support for problematic drinking. Fifty-four percent of the drinkers in the present study reported heavy episodic drinking. In addition to endorsing traditional expectancies for drinking alcohol (e.g., “Alcohol generally has powerful positive effects on people”), heavy episodic drinkers also endorsed autism-specific expectancies for drinking alcohol (e.g., “Alcohol makes verbal communication easier”) to a greater degree than nonheavy episodic drinkers. Heavy episodic drinkers also endorsed traditional motivations for drinking alcohol (enhancement, social, conformity, coping) to a greater degree than nonheavy episodic drinkers. For all autistic drinkers, autism-specific expectancies, not traditional expectancies, correlated with frequency of drinking alcohol. Also, enhancement, social, and coping motivations, but not conformity, correlated with frequency of drinking alcohol for all autistic drinkers.

Fifty-four percent of the sample reported heavy episodic drinking, which is higher than the reported norms for the general population of 17.1%–18.4%.^21–23 In addition, less than one fifth of autistic samples have been identified in previous research as having problematic drinking.^4,6–10 Importantly, the present study focused on heavy episodic drinking in the past year rather than problematic drinking specifically, and defining what constitutes problematic drinking has been found to be an issue for autistic adults.¹³ The convenience nature of the sample recruited for an online survey on alcohol therefore needs to be borne in mind when considering the results. While demographic variables such as educational level did not impact upon the findings in the present study, the sample was relatively highly educated with over three quarters having a university degree. Generally, university students are reported to have higher levels of heavy episodic drinking.³¹

Expectancy theory proposes that the fulfillment of an individual's expectancies motivates drinking alcohol.¹³ Consistent with this theory, both traditional and autism-specific expectancies were endorsed to a greater degree by heavy episodic drinkers than nonheavy episodic drinkers. This finding would suggest that in addition to sharing traditional expectancies of alcohol with the general population,¹⁷ there may be additional autism-specific expectancies that need to be taken into account when considering alcohol consumption within the autistic community. Thus, should members of the autistic community or service providers need to address drinking behavior in autistic adults, any support should be underpinned by understanding the fulfillment of both the individual's traditional and autism-specific (related to diagnostic criteria specifically) expectancies of alcohol.

The role of expectancies has been argued to be important for expanding our understanding of alcohol as “self-medication.” Although there is some overlap, self-medicating with alcohol to address co-occurring levels of anxiety is separate from using alcohol to aide social facilitation.^13–15 In the present study, all four motivation factors for drinking alcohol were endorsed significantly more by the heavy episodic drinkers than the nonheavy episodic drinkers, again suggesting similarities with drinking motives in the general population.³⁰ Overall, heavy episodic drinkers endorsed the enhancement and social motivations more than the conformity or coping motivations. This finding may be pertinent as some research has indicated that the behavior of autistic people is rarely reinforced by socially oriented rewards, making drinking for socially facilitative reasons theoretically unlikely.¹³ The present study is not consistent with this theoretical contention, rather suggesting that social facilitation may be the strongest motivation for autistic adults to drink heavily. While the formally diagnosed and informally diagnosed groups were highly similar, the informally diagnosed group did report greater social motivation to drink alcohol than the formally diagnosed group. Future research seeking to explore social motivation for drinking alcohol in autistic adults will need to clarify diagnostic status before firm conclusions can be drawn.

The largest source of support for problematic drinking was the internet, which highlights the need for autism-specific online support. It is of potential concern that just under half of the sample reported that they would not seek support if they felt their drinking had become problematic. The perceived barriers to seeking support were a challenging physical environment and being misunderstood by therapists. Reasonable adjustments can be combined with autism-specific training to address these concerns, although services need the time and resources to deliver a personalized approach to supporting autistic adults.*^,32,33 Understanding the autism-specific expectancies of, and motivations for, heavy episodic drinking can form an important part of autism-specific training.

In the present survey, around one fifth of participants had an informal (e.g., self) diagnosis of autism without a formal diagnosis from a clinician, which is consistent with the literature.^25,27 The formally diagnosed and informally diagnosed adults were very similar to each other, except that the informally diagnosed were significantly more likely to heavily episodically drink than the formally diagnosed group. Although well evidenced for nonautistic drinkers,²⁴ the relationship between heavy episodic drinking and problematic drinking for autistic drinkers needs to be clarified in future research. The present study suggests that the informally diagnosed group may be at particular risk of problematic drinking and in need of support. In addition, the lack of a formal diagnosis in adults seeking support needs to be considered by service providers. This implication is pertinent as problematic drinkers have poorer mental health compared with nonproblematic drinkers, and screening for alcohol use is recommended as part of routine health care assessments for autistic adults.⁶

In contrast to previous research in the general population,^16–18 we did not observe gender differences in alcohol expectancies in the present sample between those identifying as male and female. Therefore, the findings of the present study may suggest that sex differences in expectancies about alcohol observed in the general population may not transfer to autistic drinkers. However, further research is required to replicate this finding; no previous work has examined the influence of demographic variables such as gender on alcohol expectancies in autistic adults. Currently, there is little research focused on those who identify as nonbinary, and future research could explore how this relates to autism and alcohol consumption.

As noted above, a major limitation of the survey is the convenience nature of the online sample. In addition, although participants could identify whether or not they had a formal diagnosis of autism, diagnostic status was not verifiable. The sample was predominantly female, well educated and late diagnosed (and based in the United Kingdom). This profile of participants is frequently the case for online surveys and does not reflect the autistic population as a whole.²⁸ In addition, there may be additional factors to consider in future research, such as previous trauma or abuse,³⁴ which may influence alcohol use. Short forms of assessments were made in the present study, and future research using longer assessments of autistic-like traits, expectancies, and motivations will be welcomed. Importantly, the expectancies questionnaire was adapted specifically for this study, and validity and reliability needs to be established through future research. Great care therefore needs to be taken when considering these findings, reflecting on the nature of the sample and the assessments. Finally, the present study collected data from participants who were predominately located in the United Kingdom (85%). However, 7% of the sample reported being located in North America. Evidence has indicated that the self-reported proportion of adults who have drunk alcohol in the past 12 months is substantially higher in the United Kingdom (83.9%) compared with the United States (68.9%), Canada (77.1%), and Mexico (56.9%).³⁵ Therefore, future research may seek to explore cross-country differences in alcohol expectancies and motivations, given reported differences in drinking behaviors.

Overall, the current study has identified the expectancies and motivations for heavy episodic drinking as well as the barriers to seeking support for the autistic community. There were many similarities in the expectancies and motivations for drinking alcohol with the general population, indicating that traditional support may be beneficial to the autistic community, should it be needed. In addition to this, however, there may be some autism-specific expectancies about drinking alcohol, which also impact upon seeking support. The autistic and broader autism communities can benefit from an awareness of these findings, and service providers can adapt support appropriately.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This research was funded by the charity Alcohol Change UK.

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