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C59. Introducing the Ritvo Autism Asperger Diagnostic Screening Tool – Revised in a Residential Substance Use Disorder Treatment Facility

C59. Introducing the Ritvo Autism
Asperger Diagnostic Screening Tool:
Revised in a residential substance use
disorder treatment facility

Learner category:

  •  Expert Level

Learning objectives:

  • The purpose of this quantitative quasi-experimental
    project was to compare the prevalence or rate of patients
    identified with comorbid ASD/SUD after implementation
    of a validated ASD screening tool to the prevalence or rate
    of patients identified with no screening tool among adult
    patients admitted to a dual-diagnosis residential SUD
    treatment program in the western region of the United
    States within a four week period. The independent variable
    was the use of the RAADS-R and the dependent variable
    was the number or rate of patients screened positive by
    scoring 65 or higher on the RAADS-R, which is consistent
    with a diagnosis of ASD, or a prior diagnosis of ASD (Ritvo
    et al., 2016).
  • A second part of this quality improvement project was to
    show changes in staff confidence levels in diagnosis and
    individualized ASD interventions after provider education.
    An online video education was provided on the DSM-5
    ASD diagnostic criteria and adaptive ASD interventions,
    and was intended to improve the effectiveness of
    increasing referrals for further ASD diagnostic work-up
    and providing interventions consistent with ASD/SUD
    comorbidity in order to possibly enhance treatment
    Staff confidence levels were analyzed in a pre and post- type of survey measure using the TCS-ID


Undiagnosed autism spectrum disorder (ASD) in residential
substance use disorder (SUD) programs can lead to premature
departure and increased morbidity and mortality and could
be prevented using quality improvement measures. Available
literature lacks sufficient evidence on the impact of screening tool
implementation combined with staff education in increase of ASD
diagnoses. The purpose of this quantitative, quasi-experimental
quality improvement project was to investigate whether
implementing the Ritvo Autism Asperger Diagnostic Scale – Revised
(RAADS-R) tool with staff education increased the rate and number
of ASD diagnoses pre- and post-implementation compared with
prior practice where no validated tool or education were used. Staff
pre- and post-ASD knowledge, experience, and comfort levels were
analyzed using the Therapist Confidence Scale – Intellectual Disability
(TCS-ID). The theory of diffusion of innovation framed this project by
introduction of the RAADS-R and results (innovation) to generate
a new practice of utilizing the tool (diffusion). Participants included
all patients 18 years or older admitted to an adult residential dualdiiagnosis SUD treatment facility in western California. Total data
analysis time period was 12 months pre-implementation and four
weeks post-implementation. A total of five ASD diagnoses occurred—
zero pre-implementation and five post-implementation. The total
percentage of ASD diagnoses increased significantly from 0% to 16.1%
post-implementation (p <.00001). A paired-samples t test comparing
pre- and post-education staff confidence levels in treating ASD
revealed significant changes across time (p = .012). Patients identified
were referred for further diagnostics and individualized treatment
plans. Additional investigation with a longer intervention period is


Deborah Bowman
DNP, PhD, CARN-AP, NP MindTherapy Clinic

MindTherapy Clinic, California, USA
Dr. Bowman is a board certified addiction nurse practitioner
specializing in co-occurring disorders at the MindTherapy Clinic,
a psychiatric outpatient clinic as well as the Alta Mira and Living
at Reflections residential substance use disorder facilities in
Marin County, California. She is EMDR certified and provides
substance detoxification as well as multiple forms of MAT to include
buprenorphine (sublingual, subcutaneous and implanted) and
ketamine-assisted psychotherapy. Dr. Bowman has worked in
substance use disorder for thirty years and graduated from the
University of Michigan, Michigan State University and Grand Canyon
University and is a veteran of the United States Marine Corps.

Comments (11)


    Great Presentation ! Love that you address patients with Aspergers which I believe has been under identifed in treatment. Thank you for this presentation.

    1. Deborah Bowman

      Thank you for watching the presentation. It was my experience in multiple treatment programs of a lack of identification that led me to carry out this study. Just the beginning, though, next step is identifying evidence-based interventions!

  2. Cheryl Rush

    Wonderful presentation. Very thought-provoking, and I enjoyed your speaking style. I will look for this screening tool-hopefully it is easily available. .

  3. Rachel Shuster, BSN, RN, CARN, CAAP

    Absolutely fascinating. I don’t think many recognize the importance of recognizing when ASD and SUDs are co-occurring. Thank you for your presentation!

    1. Deborah Bowman

      Thank you for watching! I agree, co-occurring ASD/SUD presents significant challenges. When you recognize the ASD component it’s like a light turns on and it can become one of the most rewarding experiences for the whole team to intervene from a culturally appropriate viewpoint. I’m attaching a link to the RAADS-R put out by its authors below.

  4. Dr Shirley Sunn

    Very informative presentation, thank you. I like how you described the more subtle aspect of Aspergers. I suddenly realized one of my challenging patients probably has Apergers and this has opened up some options for me in her treatment.
    Dr Shirley Sunn

    1. Deborah Bowman

      Thank you for watching the presentation Dr. Sunn! Adults have often learned to “fit in” and picking up on clues can be challenging. . In ASD, the literal reporting (often over-reporting) of symptoms and inability to accurately describe emotions due to communication difficulties throughout treatment can be easily misdiagnosed as related to substance use or alternative disorders. Females in particular can look quite borderline when outwardly they’ve learned to mimic personas to fit in. I have found adults often already have an idea they are on the spectrum as Aspergers has been more readily recognized and less stigmatized through television. Unfortunately, a patient rarely knows much more and certainly have no idea what to do with this information. When a diagnosis is made it can be such a life-altering relief for them. Good luck and feel free to contact me if you’d like any more specific information.

  5. Dr Shirley Sunn

    Very informative presentation, thank you. I like how you described the more subtle aspect of Aspergers. I suddenly realized one of my challenging patients probably has Aspergers and this has opened up some options for me in her treatment.
    Dr Shirley Sunn

  6. Kaitlin Chabot

    Hi there, I really enjoyed this! I work on a team who’s population is ages 13-21 with SUDs and trauma Hx. Consequently some of our clients have ASD, and some others are identified as having been substance exposed in utero. I was wondering what you think the likelihood is that the people who tend to score higher on the RAADS-R are actually substance exposed in utero vs having ASD? I know that substance exposure in utero can look identical to ASD in some cases but the treatment modalities are not the same. Was there anything in your study to account for this?

    1. Deborah Bowman

      Thank you Kaitlin for this thought-provoking observation and excellent question!
      Studies have found that autism spectrum disorder (ASD) aggregates in families, and twin studies estimate the proportion of the phenotype variance due to genetic factors (heritability) to be about 90%. At this time we don’t know what “causes” autism spectrum disorder and it may be multifactorial, but studies show those exposed to illicit substances in utero tend to score higher in ADHD and ASD screening symptoms and may reflect a neurodevelopmental vulnerability in exposed children. ASD is characterized by symptoms of social impairment as does in-utero exposure and other mental health disorders such as reactive attachment disorder. Prenatally exposed patients may score higher in many mental health screens, but may not necessarily fulfill the diagnostic criteria of a specific psychiatric disorder. The DSM-V ASD criteria is now quantifiable, but clearly, those on the spectrum often have co-occurring disorders.
      To answer your question, I am not the author of the RAADS-R and will follow up with a more definitive answer as to how this was ruled out during the development of the tool. In this study, I relied on the quantitative result of greater than 65 as a predictor of ASD and the patients were then referred for much more in-depth neuropsychological testing. We do assess for familial substance use and mental health disorders, but confirmation of actual exposure is not part of the psychiatric assessment.
      You have brought up such an important piece in the interventions are different. I was taken aback at the lack of specific ASD/SUD evidence-based interventions. Another gap to fill…..


    Great Presentation! I enjoyed your presentation. ASD needs more attention from residential programs as it has been unrecognized. ASD recognition will help tailor people’s needs in long term sobriety.

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