Video: Treating Substance Abuse among Prenatally Exposed Persons

This video will explore traditional and alternative treatment approaches for substance abuse in those with FASD.

About this video

Production date: October 2009
Length: 1 hour 23 minutes
Presenter: Sara Jo Nixon, PhD
Download slide notes for this video (PDF, 15 pages)

Dr. Nixon is a Professor, Chief of Addiction Research and Director of the Neurocognitive Laboratory at the University of Florida Department of Psychiatry. She is the current President of the Research Society on Alcoholism, and a Fellow in Addiction and Substance Use and Psychopharmacology for the American Psychological Association. Dr. Nixon is an experienced clinical researcher in the area of substance abuse and dependence. Her research team focuses on the cognitive, psychological and social effects of substance misuse. Dr. Nixon is a respected author, educator and presenter.


This video will help you to:

  • examine traditional treatment approaches and their limitations
  • identify alternative approaches


  1. Traditional approach (10:19)
  2. Brain changes and their impact (12:45)
  3. Alternative approaches (55:51)

Traditional approach

12-Step approach

The most common is Alcoholics Anonymous

  • no dues and fees, not allied with any sect, denomination, organization or institution, apolitical
  • the primary purpose is to stay sober and help other alcoholics to achieve sobriety


Progresses in 3 stages:

Stage 1 (Steps 1-3)

  • admission and acceptance of powerlessness over alcohol
  • unmanageability of life
  • surrender of will

Stage 2 (Steps 4-10)

  • self-examination
  • amends and restitution

Stage 3 (Steps 11-12)

  • service

AA is a program of recovery, NOT treatment.

Most treatment programs use some sort of 12 step approach. May not work for individuals exposed to alcohol in utero.


  • capacity for successful interpersonal relationships
  • capacity to review actions and consider impact on others (both in present and in past)
  • capacity to engage abstract concepts and thinking
  • capacity for self-disclosure and to hold self-accountable to others through community
  • a high level of cognitive capability
  • requires use of frontal lobe that may have been damaged
  • traditional approaches rely on assumptions that the individual's systems and capabilities are intact

Brain changes and their impact

Studies demonstrate that children who were prenatally exposed to alcohol were less successful than the ‘control’ group in following categories:

  • switching between tasks
  • incorporating feedback
    • perseverance (when told answer was wrong, they continued to use the same approach and continued to be wrong)
  • incorporating direction
    • executing directed sorts (reduced ability when directed)
  • verbalization of principles
    • unable to answer why they did something the way they did

Behavioural effect of deficits means the person is unable to:

  • see alternatives
  • change behaviour when told it’s not effective
  • integrate/act on concepts provided by others
  • answer questions

Even in high functioning individuals with FASD, there were still major deficits. These individuals would be unable to navigate the 12 step program, because it relies heavily on abstract thinking.

Alternative approaches

Contingency management approach

A direct relationship between behaviour and reward.


  • Provide urine sample
  • Clean urine
  • Get a reward

A graduated program with increased rewards for sustaining desired behaviours. Motivation eventually shifts from external rewards to internal.

Contingency management programs are often 12 weeks long, but this is too short.

  • limited applicability to FASD individuals due to short-term nature
  • persons with FASD require rewards long-term


For meaningful outcomes:

  • be concrete
  • sobriety may be an abstract term to them
  • not drinking is a concrete action
  • engage the community
  • if walking by a bar or liquor store every day, one can get distracted
  • meeting the bar or liquor store owner and talking to them might be an option
  • this treatment is going to engage more than the individual with a substance abuse issue
  • ensure meaningful, immediate, consistent learning
  • learn what motivates the individual
  • for example: watching movies
  • use context-specific rewards
    • what works in the home as a reward may not work in the workplace
    • each step has to be rewarded immediately – not later
  • use monitoring and reminders
    • in any learning situation there is continual monitoring, checking and reminding
  • towards need to change with developmental changes to remain relevant
  • apply contingencies consistently

Don't develop a system that can’t be implemented. Ask yourself:

  • is the behaviour observable?
  • is the contingency observable?
  • does the behaviour linked to all settings?

You need a way to monitor behaviour across environments. This can be very difficult because you can’t always control behavior (for example: work versus social situations).

Use both costs and rewards:

  • punishment can work when it’s there to keep a person safe
  • we need to have a cost associated with a transgression that is life threatening
  • time-limited intervention isn’t realistic; it has to be ongoing
  • plan must be reviewed periodically
    • the framework may not have changed, but the players will or might over time
Modified: 2015-09-09
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