Substance Use and FASD
As mentioned in other sections of this resource guide, a large proportion of people with FASD (90%) experience mental health challenges across their lifetime2. In addition, prenatal alcohol exposure has been associated with substance use challenges later in life3. However, it is important to know that not everyone with FASD will struggle with substance use. The reasons why someone with FASD may have challenges with substance use are complex and involve intersecting biological (e.g., disrupted stress-response system) and environmental (e.g., adverse life experiences such as trauma) factors3. For example, women with FASD have made the connection between their use of alcohol and drugs to experiences of violence, abuse, trauma, and disconnection from community4. However, everyone’s experiences will be different, and substance use treatment needs to consider the needs and abilities of each client.
Substance Use Treatment
When supporting people with FASD with challenges around substance use it is important to consider the unique strengths, challenges, and needs of each client. There are some FASD-informed considerations to make when providing treatment that may make support more accessible.
The following table outlines some considerations around challenges people with FASD may experience and some potential treatment strategies. Adapted from The Impact of PAE on Addiction Treatment.
|Potential Area of Challenge||Potential Responses|
|Executive Functioning (e.g., challenges to storing information, planning future activities, regulating behaviour, and thinking flexibly)||· Establish, teach, and model structure and consistency
· Be consistent with appointments
· Schedule multiple brief sessions versus one long session
· Help with appointment reminders
· Role-play situations
· Use positive, immediate, and clear reinforcement
· Limit changes to treatment plan
· If changes are needed, plan changes carefully and model in advance problem-solving strategies
|Thinking Abstractly (e.g., challenges with time, space, money, cause and effect, humour, etc.)||· Use literal and concrete terms
· Limit metaphors
· Teach and discuss generalizability
· Make clear if something is a joke or sarcasm
|Verbal Language Processing (e.g., challenges with accurately processing and understanding verbal information)||· Learn clients’ unique language patterns
· Use multiple sensory modes
· Use simple step-by-step instructions (i.e., written and illustrated)
· Role-play to give client’s the opportunity to show skills
· Revisit important points from each session
|Social Difficulties (e.g., challenges reading and responding to social cues and body language)||· Role play social situations
· Discuss potential misinterpretations
· Discuss clients body language (I.e., do not interpret lack of eye contact as lack of interest)
|Memory (e.g., challenges remembering information and following verbal instructions)||· Communicate concretely and repetitively
· Provide support for task completion
· Review expectations
|Coping (e.g., challenges with stress)||· Implement and improve coping strategies
· Help client learn how to identify feelings when getting upset
· Model and have patience
· Practice relaxation and mindfulness techniques
· Help identify activities that may reduce anxiety and stress
|Sensory Integration (e.g., difficulty modulating incoming stimuli)||· Reduce distracting stimuli in the environment
· Reduce auditory distractions
Gelb and colleagues (2011) reported on the perspectives of women who have FASD discussing their experiences accessing and succeeding in treatment. There were multiple barriers identified for these women in obtaining substance use treatment including:
- Fear of children’s apprehension and/or concerns regarding stigmatization
- Presence of co-occurring issues requiring integrated care that is not always available
- Lack of transportation or high cost of travel to programs/appointments
- Lack of childcare in order to access care
- Lack of locally available programs for women
Considering these barriers in your practice and referrals may allow for more appropriate and effective support for clients with FASD. In addition, the following variables were found to be effective practices that allowed for women to succeed in substance use treatment4:
- Meeting people where they are at (i.e., their goals, their abilities)
- Using a relationship-based, culturally safe approach
- Programs that are holistic and consider integrated care
- Having a combination of one-to-one and peer-based support
- Having professionals who are knowledgeable about FASD
In the context of mental health support, we can work to incorporate these into our practice. For example, increasing our knowledge of FASD, engaging with clients about their needs, goals, and strengths, and finding resources and referrals to FASD-appropriate substance use treatment are appropriate and helpful options.
Practices for Supporting People with FASD and Substance Use Challenges
The following are practices related to supporting people with FASD regarding substance use challenges. However, as discussed throughout this Guide, it is important to consider each client’s unique strengths, needs, and capabilities when developing treatment plans and goals. This section is meant to serve as a guide to potential options that may work for some clients.
- Understanding FASD as a brain-based lifelong disability can pave the way for flexibility and accommodation in treatment5. This approach may also involve reframing how one thinks about behaviours in people with FASD1.
- Understanding the brain-based differences in memory, learning, language, adaptive functioning, attention, sensory processing, and executive functioning and how these differences can impact treatment can support you in adapting your approaches and practices1.
- Using simple, clear, and concrete language may help with difficulties around communication and memory. Examples of changes that can be made in support include using repetition, slowing down when speaking, breaking down instructions into smaller pieces, using journals/notes, and including reminders1,5.
- In addition, attending to the language we use and moving to person-first language can help reduce stigma surrounding FASD6.
Flexibility and Creativity
- Like supporting people with other challenges, a “one size fits all” approach is not effective for people with FASD1. It is important to have a willingness to be flexible and creative in your approach to care and support. For example, consider changing any homework or techniques that involve writing, developing manageable and realistic goals, and allowing for movement during a session1.
- Making accommodations to the physical environment may help a person with FASD feel safe and comfortable during mental health supports. For example, accommodations could include keeping the environment uncluttered and calm, including visual cues related to treatment, and changing the environment based on each client’s needs/challenges4,5,7.
- Using a harm-reduction approach allows for mental health practitioners to focus on substance use practices that put their clients at the highest risk of harm or danger, rather than solely focusing on abstinence5. Recognizing that there can be solutions beyond abstinence and working from a non-punitive approach may allow for a more supportive, safe, and appropriate treatment1,5.
- Some examples of this may include education around the dangers of using substance alone and using safe supplies/paraphernalia.
Goals and Treatments
- Individuals with FASD know themselves best and are aware of how their strengths and challenges impact their lives. As such, they have likely developed some effective strategies and accommodations that work for them. Listening to your clients and co-creating treatment plans and goals for mental health support is an important aspect of meeting people where they are and being person-centered1.
Supporting Youth with FASD who have Substance Use Challenges
Although the promising practices above may also work for youth with FASD, there are also important considerations when specifically supporting children and youth with substance and alcohol challenges. There are many reasons why youth may engage in substance and alcohol use including a desire to belong, growing up in an environment where substance use was normalized, boredom, escaping challenges and problems, and alleviating feelings of depression, ADHD, and/or anxiety8. There are also significant barriers for youth with FASD in accessing substance use support or treatment, including a lack of appropriate programming that considers the brain-based differences youth with FASD may have8. There are some promising practices that were identified by Peled and Smith (2014) through interviews with youth with FASD, including:
- Individualized Support to support the unique strengths and needs of each youth, and the ability to tailor treatment to each person.
- Flexibility and involvement in goal setting allows youth to make mistakes without penalization, allowing for future success. Youths expressed the importance of being involved in their own treatment planning and goal setting.
- Structure and clear boundaries helped youth stay on a healthy path, but within this structure, flexibility is also needed. Youth expressed that structure also included supervision to identify and address problematic behaviours.
- Supportive relationships with adults including those providing support. Youth expressed the importance of adult relationships outside of their immediate family and appreciation for adults who were open and honest.
- Strengths-based approaches that emphasize the abilities of youth with FASD, as low self-confidence and a sense of competence are important risk factors for substance use
- Life-skills development to enhance independent living skills (e.g., budgeting, banking, shopping, eating, hygiene).
- Meaningful activities to support healthy and meaningful alternatives to drug and alcohol use.
- Community and cultural connectedness can increase support and help with mental health.
- Work and employment programs can support connections to community and provide motivation to engage in activities that are meaningful and fulfilling.
- Physical activity and time outdoors to increase other activities, healthier alternatives, and a sense of calm and happiness.
- Prosocial peers can impact youth greatly having positive impacts on mental health, increased self-confidence and lower rates of self-harming behaviour.
- Collaboration among services and professionals can help youth feel more connected to their community and ensure the youth are getting the services and supports they need.
- Life-long support considers that FASD is a lifelong disability, and that youth may require support beyond the age of 18.
When supporting someone with FASD who struggles with substance use it is important to consider how we as mental health service providers can support people’s growth by adapting our practices and approaches to people’s unique strengths and challenges.
In the following video Dr. Aamena Kapasi and Elizabeth Carlson discuss substance use and treatment in FASD populations: Substance Use Treatment in FASD Populations.
- Moving Towards FASD-Informed Care in Substance Use Treatment
- Decolonizing Substance Use & Addiction | Len Pierre | TEDxSFU
- Substance Using Women with FASD and FASD Prevention
- Brief Intervention on Substance Use with Girls and Women
- A Systematic Review of Interventions to Improve Mental Health and Substance Use Outcomes for Individuals with Prenatal Alcohol Exposure and Fetal Alcohol Spectrum Disorder
For a summary of information, download the Mental Health Resource and Practice Guide Section 6 Summary.
1Kapasi, A., Tremblay, M., Pei, J., Rorem, D., Makowecki, E., Wuest, V., Regier, M., McLachlan, K., Dunleavy, B., Mela, M., Benjamin, M., & DesRoches, A. (2022). Moving Towards FASD-Informed Care in Substance Use Treatment. Canada FASD Research Network.
2Pei J., Denys K., Hughes J., Rasmussen C. (2011). Mental health issues in Fetal Alcohol Spectrum Disorder. Journal Mental Health, 20, 473–483. https://doi.org/10.3109/09638237.2011.577113
3Flannigan, K., Coons‐Harding, K. D., Anderson, T., Wolfson, L., Campbell, A., Mela, M., & Pei, J. (2020). A systematic review of interventions to improve mental health and substance use outcomes for individuals with prenatal alcohol exposure and fetal alcohol spectrum disorder. Alcoholism: Clinical and Experimental Research, 44(12), 2401-2430. https://doi.org/10.1111%2Facer.14490
4Rutman, D. (2013). Voices of women living with FASD: Perspectives on promising approaches in substance use treatment, programs, and care. First Peoples Child & Family Review, 8(1), 107-121.
5Rutman, D. (2011). Substance Using Women with FASD and FASD Prevention: Service Providers’ Perspectives on Promising Approaches in Substance Use Treatment and Care for Women with FASD. Victoria, BC: University of Victoria.
6Gelb, K. & Rutman, D. (2011). Substance Using Women with FASD and FASD Prevention: A Literature Review on Promising Approaches in Substance Use Treatment and Care for Women with FASD. Victoria, BC: University of Victoria.
7Grant, T. M., Brown, N. N., Dubovsky, D., Sparrow, J., & Ries, R. (2013). The impact of prenatal alcohol exposure on addiction treatment. Journal of addiction medicine, 7(2), 87-95.
8Peled, M., Smith, A., & McCreary Centre Society (2014). Breaking Through the Barriers: Supporting Youth with FASD who have Substance Use Challenges. Vancouver, BC: McCreary Centre Society.