PURPOSE OF THIS TRAINING

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4 PURPOSE OF THIS TRAINING The purpose of this training is to assist health providers who do not necessarily have prior experience in alcohol screening and brief intervention. The steps presented are intended to help practitioners carry out the important function of identifying and advising women who are drinking alcohol to cut down or abstain from using alcohol during pregnancy. 4

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7 BACKGROUND: Why reduce alcohol consumption during pregnancy? The prevalence of alcohol use among pregnant women is over 12% suggesting that approximately 1 in 8 fetuses is exposed to alcohol in utero. 1 The most devastating consequence of maternal alcohol consumption during pregnancy is Fetal Alcohol Syndrome (FAS), which is characterized by growth retardation, a distinct cluster of characteristic facial features, and central nervous system and neurodevelopmental deficits. 2 Estimates of the number of live births meeting criteria for a diagnosis of FAS range from.5 to 3 infants per 1,000 live births. 3 Moreover, it is estimated that about 1 in 100 children has a fetal alcohol spectrum disorder (FASD) which is associated with substantial life-long impairments in neurocognitive and socioemotional development. 3 Even low levels of alcohol consumption have been shown to be related to negative developmental sequelae. 4-5 Furthermore, children from low-income and ethnic minority populations are particularly vulnerable to the long-term effects of prenatal alcohol exposure because their mothers are less likely to receive appropriate counseling regarding alcohol l use during pregnancy. 6 For these reasons, effective prevention of alcohol l use by pregnant women has become an important public health priority. Currently, no amount of alcohol ingestion during pregnancy has been deemed safe, and the Surgeon General 7 recommends that pregnant women, women about to become pregnant, and those not using effective methods to avoid an unwanted pregnancy be counseled to avoid alcohol. 7

8 CNS PROBLEMS ASSOCIATED WITH PRENATAL ALCOHOL EXPOSURE Although not all children with FASDs are mentally retarded, prenatal alcohol exposure is the most common cause of mental retardation of known etiology. Both animal and human studies have revealed hyperactivity, problems with response inhibition, attention deficits, poor habituation, poor coordination, and poor state regulation to be associated with alcohol use during pregnancy. 8 Learning and memory problems in children have also been identified. Furthermore, recent studies of the socioemotional development of prenatally exposed children reveal problems in conduct, poor social judgment, higher levels of externalizing behavior, attachment problems, and ddepression. 9 Even more concerning for adaptive functioning i are the findings of problems in executive function on tasks involving the planning and execution of goal directed behaviors. 10 Problems in these areas lead to difficulties in social adaptation, as evidenced by the high number of mental health problems, substance abuse problems, and problems with the law in individuals exposed to alcohol prenatally. 11 Although h women who are alcoholics li are at highest h risk for having children with FAS, children of social drinkers also exhibit subtle but persistent neurodevelopmental problems. Studies of social drinkers reveal an increase in infant mortality, preterm birth, decreased birth weight, height and head circumference. Neonates show poorer habituation and state regulation, and impairments in information processing and mental functioning are evident as early as 12 months of age in infants who were prenatally exposed to levels of drinking as low as one drink per day. 12 8

9 ASSESSMENT OF QUANTITY AND FREQUENCY OF ALCOHOL USE The first step in prevention of an alcohol-exposed pregnancy is to ask the woman about her consumption behavior. Following are methods used to establish both consumption patterns and alcohol risk status. Quantitative methods and screening tools should be used in conjunction to increase the accuracy of self-report. Quantity-frequency measures (QF) inquire about average or typical consumption patterns. The simplest measures assess amount of drinking on average drinking days (Q), and the average number of days on which alcohol is consumed (F). It is also recommended to ask women about maximum intake on any drinking occasion to assess for binge drinking patterns. It is important to ask women about the time before they knew they were pregnant and current alcohol use after finding out they were pregnant. Prior to pregnancy recognition responses are most predictive of physical and developmental outcomes. 13 NIAAA guidelines suggest that non pregnant women drink no more than 7 drinks per week or 4 drinks per drinking occasion. For pregnant women, a binge of 3 or more drinks is significant and they should be advised not to drink any alcohol during pregnancy. 9

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11 EXAMPLE INTERVIEW FOR ALCOHOL USE When you interview a woman, think of questions concerning alcohol use as you would any questions on early history, not as something special or added on. If questions are asked in a neutral, matter of fact manner, women typically answer them without getting upset. You can ask questions using your own style and words but areas that should be covered are: Sample Interview for Quantity and Frequency (QF) of Alcohol Use How many weeks pregnant are you now? How many weeks pregnant were you when you found out you were pregnant? How many cigarettes do you smoke in a day? If the woman does not report daily smoking then ask: How often do you smoke cigarettes? Almost every day, 3-4 days a week, 1-2 days a week, 2-3 days a month, once a month, less than once a month, only on weekends? How many cups of caffeinated coffee or soft drinks do you drink daily? If the woman does not drink coffee daily, then ask: How often do you drink caffeinated drinks? Almost every day, 3-4 days a week, 1-2 days a week, 2-3 days a month, once a month, less than once a month, only on weekends? 11

12 PRELIMINARY QUESTIONS ON ALCOHOL USE Have you ever drunk wine, beer, or mixed drinks? This will let you know if the woman is abstinent or a drinker. If she says she never drank, you job is done. If she says that she has drunk alcohol in the past then go on with the interview. The majority of women drink alcohol before they know that they are pregnant. This is true, between 75% (young women) and 54% of women of child bearing age drink alcohol. This statement can reduce defensiveness. What type of alcoholic beverage do you prefer - wine, beer, wine coolers, or drinks containing liquor? This question allows you to estimate the amount of absolute alcohol consumed. The size of the drinking container should also be asked in order to better gauge consumption levels. Keep in mind that malt liquors have higher concentration of alcohol than regular beers (8% as opposed to 4% for beer). Wine coolers have the same amount of alcohol as one 12-ounce can of beer. 12

13 QUANTITY AND FREQUENCY QUESTIONS (PRIOR TO PREGNANCY RECOGNITION) Before you knew you were pregnant, on average, what was the number of drinks that you would typically drink at one sitting? During the time period before you knew you were pregnant, how often did you drink this amount? If the woman does not come up with an answer, you can suggest daily, almost every day, 3-4 days a week, 1-2 days a week, 2-3 days a month, once a month, less than once a month. Before you knew you were pregnant, what were the most drinks that you drank at any one sitting? For example at a celebration like a birthday party or wedding. This question gets at binge episodes. A binge of 3 drinks or more is considered high risk for the fetus. During this time period before you knew you were pregnant, how often did you drink this amount? If the woman does not come up with an answer, you can suggest daily, almost every day, 3-4 days a week, 1-2 days a week, 2-3 days a month, once a month, less than once a month. 13

14 QUANTITY AND FREQUENCY QUESTIONS (FOLLOWING PREGNANCY RECOGNITION) Right now, on average, what is the number of drinks that you typically drink at one sitting? This gives you information on the woman s current drinking without reminding her that she is continuing to drink after she found out she was pregnant. How often do you drink this amount? If she does not come up with an answer, you can suggest daily, almost every day, 3-4 days a week, 1-2 days a week, 2-3 days a month, once a month, less than once a month, only on weekends. Right now, what is the most number of drinks that you drink at one sitting? This question gets at current binge drinking. How often do you drink this amount? If she does not come up with an answer, you can suggest daily, almost every day, 3-4 days a week, 1-2 days a week, 2-3 days a month, once a month, less than once a month, only on weekends. 14

15 A STANDARD DRINK In order to get accurate assessments of levels of alcohol consumption and to help the woman understand just how much she is drinking, one must be able to explain the concept of a standard drink. A standard drink is considered to be.60 ounces of absolute alcohol (aa). Click on how to compute a standard drink One 12-ounce can of beer containing 5% aa (12 x.05 =.60 = 1 standard drink) One 5-ounce glass of wine containing 12% aa (5 x.12 =.60 = 1 standard drink) One 4-ounce glass of fortified wine containing 15% aa (4 x.15 =.60 = 1 standard drink) 1 ½ ounce hard liquor or spirits containing 40% aa (1 ½ x.40 =.60 = 1 standard drink) One 12-ounce bottle of wine cooler containing 5% aa (12 x.05 =.60 = 1 standard drink) One 16-ounce can of malt liquor containing 8% aa (16 x.075 = 1.20/.60 = 2 standard drinks) One 40-ounce bottle of malt liquor containing 8% aa (40 x.08 = 3.20/.60 = 5.33 standard drinks) One Colt 45 ounce bottle of beer containing 6% aa (40 x.06 = 2.40/.60 = 4.00 standard drinks) One Margarita bar drink (1 ½ x.40 =.60 = 1 standard drink) One Long Island Ice Tea bar drink (2 ¼ x.40 =.90/.60 = 1 ½ standard drink) One Cosmopolitan bar drink (1 ½ x.40 =.60 = 1 standard drink) 15

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17 One of the main challenges to identifying a group of at-risk pregnant alcohol users is to effectively screen for alcohol use and related problems using reliable methods. Several short questionnaires currently exist that have been used to screen for problematic alcohol use and have been evaluated in multiple settings. Of these screening tools, the two that have been used most effectively with pregnant women are the T-ACE and the TWEAK. The tool shown to be effective with adolescents is the CRAFFT. The screening questions can be presented orally during interview or the woman can fill them out while waiting to meet with you. 17

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19 T-TOLERANCE How many drinks does it take before you begin to feel the first effects of alcohol? [3 or more drinks constitutes a positive answer = 2 points] W- WORRY Do close friends or relatives worry or complain about your drinking? [ yes constitutes a positive answer = 2 points] E-EYE OPENER Do you sometimes take a drink in the morning when you first get up? [ yes constitutes a positive answer = 1 point] A-AMNESIA Has a friend or family member ever told you about things you said or did when you were drinking that t you could not remember? [ yes constitutes t a positive answer = 1 point] K-CUT DOWN Do you sometimes feel the need to cut down on your drinking? [ yes constitutes a positive answer = 1 point] Scores on the TWEAK range from 0 to 7. Investigators have suggested that a cut point total score on the TWEAK of 2 or more should be used to optimize sensitivity/specificity in identifying pregnant women who may not be alcohol dependent but who may, nevertheless, be drinking at levels that place the fetus at risk. 19

20 C- Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? R- Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? A- Do you ever use alcohol or drugs while you are by yourself, ALONE? F- Do you ever FORGET things you did while using alcohol or drugs? F- Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? T- Have you ever gotten into TROUBLE while you were using alcohol or drugs? Each question on the CRAFFT is given a score of 1. The authors recommend that any positive answer on the CRAFFT be followed by further inquiry and possible brief intervention. 20

21 Despite growing understanding of the impact of alcohol use during pregnancy on fetal outcomes, with results highlighting that no level of consumption can be considered safe, the majority of intervention programs that have been designed to prevent fetal alcohol exposure have either been informational campaigns or alcoholism treatment programs, of which few have been specifically designed for pregnant women. These types of interventions reach women at two ends of the drinking continuum: women who drink infrequently or women who are alcohol dependent. Few prevention programs have specifically targeted pregnant women who drink frequently but at lower levels, or who periodically drink excessively but would not be identified as alcohol dependent. Thus, women who drink at levels potentially harmful to the developing fetus, but who are not identified as problem drinkers, are often neglected in intervention efforts. 21

22 Derived from principals of social learning theory, brief intervention (BI) is an effective methodology that has been empirically validated to reduce consumption in a number of alcohol studies. 17 A recent randomized controlled trial suggests that pregnant women are particularly responsive to BI. 18 The approach employs the use of brief counseling (10 TO 15 MINUTES) and can be delivered by personnel who are not specialists in the treatment of alcohol abuse or dependence. BI has been shown to be a low-cost, effective treatment alternative for alcohol use problems that uses time-limited, self-help strategies to promote reductions in alcohol use in nondependent individuals, and in the case of dependent persons, to facilitate referral to specialized treatment programs

23 The six elements of BI are summarized by the acronym FRAMES: feedback, responsibility, advice, menu of strategies, empathy, and self-efficacy. Goal setting and follow up have been identified as important to the effectiveness of BI. F-Feedback F F kof Personal lrisk. Most health professionals delivering i brief intervention ti provide patients t with feedback on their risks for alcohol problems. For pregnant women, the risk to the developing fetus and child is explained. R-Responsibility of the Patient. Perceived personal control has been recognized to motivate behavior change. Therefore, brief intervention commonly emphasizes the patient's responsibility and choice for reducing drinking. For example, you may tell a woman that "No one can make you change or make you decide to change. What you do about your drinking is up to you. But you can have a healthier baby if you stop drinking now." A-Advice To Change. In some types of brief intervention, professionals give patients explicit advice to reduce or stop drinking. When working with a pregnant woman, the best advice is to abstain from alcohol l use entirely. M-Menu of Ways To Reduce Drinking. Health professionals providing brief intervention may offer patients a variety of strategies from which to choose. These may include learning to recognize the antecedents of drinking (risky situations) and developing skills to avoid drinking in high-risk situations (ways to avoid risky situations); planning ahead to limit drinking; pacing one's drinking (e.g., sipping, measuring, diluting, and spacing drinks); and learning to cope with the everyday problems that may lead to drinking. Health care professionals often give their patients self-help materials to present such strategies and to help them carry these strategies out. Self-help materials often include drinking diaries to help patients monitor their abstinent days and the number of drinks consumed on drinking days, record instances when they are tempted to drink or experience social pressure to drink, and note the alternatives to drinking that they use. E-Empathetic Counseling Style. A warm, reflective, and understanding style of delivering BI is more effective than an aggressive, confrontational, or coercive style. S-Self-Efficacy or Optimism of the Patient. Health professionals delivering brief intervention commonly encourage women to rely on their own resources to bring about change and to be optimistic about their ability to change their drinking behavior. BI often includes motivation-enhancing techniques (e.g., eliciting and reinforcing self-motivating statements, such as "I am confident that t I can stop drinking," to encourage patients t to develop, implement, and commit to plans to stop drinking). OTHER IMPORTANT ELEMENTS OF BRIEF INTERVENTION Establishing a Drinking Goal. Patients are more likely to change their drinking behavior when they are involved in goal setting. The drinking goal usually is negotiated between the patient and health provider and may be presented in writing as a contract. Follow up. The health care professional continues to follow up on the patient's progress and to provide ongoing support. Follow up may take the form of telephone calls from office staff or repeat visits to the provider. The woman is to be congratulated and encouraged at each follow up visit for her attempts to abstain from alcohol use or to cut down on her use.

24 FEEDBACK AND RESPONSIBILITY You have already done many good things to help your baby be healthy. You mentioned that you are having drinks on occasion. Did you know that there is no safe amount of drinking when you are pregnant because alcohol exposure can hurt a developing baby. No one can make you decide to change your drinking. What you do about your drinking is up to you. But you can have a healthier baby if you stop drinking now. A baby who has been exposed to alcohol during pregnancy might have some problems. MAJOR PROBLEMS: Small Size, Mental Retardation, Facial Deformities, Heart Problems OTHER PROBLEMS: Eating and Sleeping, Hyperactivity it and Inattention, ti Language Delays, Memory and Learning, Hearing and Vision, Social Problems, Motor Delays ADVICE TO CHANGE The best advice for a pregnant woman is to not drink any alcohol. Ask for a response to your advice to make sure the patient understands the need to take action: What do you think about what I have just said? Would you like to work with me to quit or reduce your drinking? MENU OF WAYS TO REDUCE DRINKING-RISKY SITUATIONS People drink for different reasons. Here are some examples of risky situations for some people: At a party, On weekends, Following arguments, When feeling uptight or stressed, When feeling angry, When smoking, When friends are drinking, When feeling sad, Wanting to fit in. Are there situations in which you feel like you want to drink? MENU OF WAYS TO REDUCE DRINKING-DEALING WITH RISKY SITUATIONS It is important to figure out how you can resist drinking in risky situations. Here are some examples of ways in which people cope with a desire to drink: Go for a walk, Call a friend, Grab a snack, Listen to music. Can you tell me some ways you think you can avoid drinking in these risky situations? ESTABLISHING A DRINKING GOAL Now, thinking about how much alcohol you have told me that you drink, would you like to set a drinking goal? Would you like to stop or lower your alcohol use? A reasonable goal for someone who is pregnant is abstinence not drinking any alcohol. I know that some people find that total abstinence is difficult. What would you like to do? What goal would you like to set for yourself? Stop drinking altogether or cutting down? SET YOUR GOAL: Encourage abstinence. Agree on number of drinks per week. SELF EFFICACY On a scale of 1 to 5, how sure are you that you can stop (lower) your drinking? 1 means you think you CANNOT stop (cut down) your drinking and 5 means you are sure you CAN stop (cut down) your drinking. If you feel that you cannot stop drinking right now, here are ways to cut down. Add water to hard liquor (whiskey, rum, gin) Drink no more than one drink per hour Eat food when you drink Sip your drinks Do not drink from the bottle Drink water or juice instead of alcohol Do not drink 3 or more drinks per drinking occasion ENCOURAGEMENT N AND FOLLOW OW UP Changing one's behavior can be hard. It will become easier. Remember your drinking goal Some people have days when they drink too much. If this happens to you, DO NOT GIVE UP At the end of each week, think about how many days you did not drink and congratulate yourself Your follow up visit is important. Please remember to come see me. 24

25 INTERVIEWING TECHNIQUES Your approach should be: Impartial. As an interviewer,,your job is to elicit information, regardless of whether you think it good or bad. Don t, by word or reaction, indicate surprise, pleasure, or disapproval of any answer. Even a slight intake of breath will cue a woman that you have reacted to her answer. Don t attempt to influence responses. The truth is all that really counts what the woman really thinks or feels about drinking. Remember the object of the intervention is to get honest, uninfluenced answers. None of your opinions should be conveyed during the interview. Confident. As a trained professional, you should appear confident. No one knows your job better than you do. If you convey insecurity or hesitancy the woman may become defensive. Casual. If you pursue the interview too earnestly, too grimly, the woman may not want to share information with you. She won t tell you what she honestly thinks. Approach the interview pleasurably, and let the client enjoy it too. Conversational. Use a less formal manner of speaking, natural to you. Know the questions you will be asking so that you never sound as though you re reading them. Friendly. A major objective is to put the client at ease. Your attitude must be sympathetic and understanding. Emphasize that there are no correct answers. Rather, encourage the woman that what she thinks really is what counts. An opinion can never be wrong. Empathetic. Use an empathic, nonconfrontational style when asking questions. Try to avoid the following interviewer pitfalls: Try not to rush the woman. Let her understand the questions fully. Don t show impatience. Remember, that you must instill confidence and trust, rushing may make her not want to disclose information to you. Avoid doing anything that suggests to the woman that an answer is right or wrong. Do not use pejorative pj labels such as alcoholic or problem drinker. Do not allow another family member to sit in on the interview. 25

26 These are some examples of concerns that many health providers have when talking to women about their use of alcohol. Following each question is a list of some of the possible responses. Concern: Will women become upset with me, if I start asking personal questions about their alcohol use? Responses: Reassure the woman that the alcohol screening procedures are a part of the routine for all clients. Women who become irritable with alcohol screening questions often have personal or family problems associated with alcohol use. Concern: Who should be advised d to become totally t abstinent? t? Responses: Pregnant women. Women who are trying to become pregnant. Damage to the fetus can occur prior to pregnancy recognition. Women who are not using effective contraception. The chances of an unplanned pregnancy for someone who is drinking are quite high, so it is best to advise women to use effective contraception if continuing to drink. Women who are breastfeeding. Alcohol l can be passed to the infant in breast milk. Some research shows that t infants exposed to alcohol tainted breast milk actually prefer the taste when given a choice between it and regular breast milk. Concern: What do I do if a woman states that she would like to cut down or stop drinking, but does not believe she can? Responses: Talk to her about trying to stop drinking during her pregnancy for the health of her baby, provide brief intervention. Ask her if she would like to get help for her drinking. If she agrees to seek help, make an appointment for her at a local alcohol treatment program while she is still in your office. Concern: What if the woman says she does not want to cut down or stop drinking when I am conducting a brief intervention with her? Responses: It is your choice to reduce or abstain from alcohol but there is risk to your baby if you continue to drink. Concern: What if a woman is worried that it is too late to stop drinking because the harm has already been done to her baby. Responses: It is never too late to stop drinking and the sooner you stop drinking, the better the outcome for the baby. 26

27 Concern: What if a woman says that her best friend drank throughout pregnancy and her child is fine. Responses: Women metabolize alcohol at different rates based upon their genetic makeup so that one woman may be able to drink more than another woman with fewer ill effects to the fetus, but at this point, we have no reliable way of testing for this so there are no guarantees that your baby will have no ill effects. The best advice that we have to date is not to drink during pregnancy. Concern: What should I tell my friends when they offer me a drink? Responses: I am pregnant and there is no safe level of drinking during pregnancy. Concern: I don t really want to stop drinking. Responses: I understand your reluctance to stop, how about trying to stop for the next week and we will meet again and discuss your progress. It may not be as hard as you think to make a change. Concern: What should I do if I get the urge to drink? Responses: Remember the coping steps we went over when we talked about risky situations. Try practicing those steps until we meet again. If you do have a drink, don t be discouraged. Start each day anew and tell yourself that you will not drink today. Take it day by day. If you have the urge to drink and you do not drink, reward yourself for a job well done. Concern: Do you think I should have an abortion if my baby is already damaged? Responses: While having an abortion is a personal choice, it is important to stop now to minimize any potential problems to your baby. If you are worried, you can have the baby followed by a pediatrician to make sure that everything is okay. 27

28 CONCLUSIONS Fetal alcohol spectrum disorders are the leading cause of developmental problems but they can be prevented through the use of standardized screening tools and brief intervention for alcohol reduction or cessation. It was the goal of this training to encourage the use of these techniques by all health practitioners who provide services to women of childbearing age and to pregnant women in particular. REFERENCES 1 CDC (2002) Alcohol consumption among pregnant and childbearing-aged women-united States MMWR 51 (13): Jones KL, Smith DW (1993) Recognition of the fetal alcohol syndrome in early infancy. Lancet 2: May PA, Gossage PJ (2001) Estimating the prevalence of fetal alcohol syndrome: a summary. Alcohol Res Health 25(3): Sayal K, Heron J, Golding J, Edmond, A (2007) Prenatal alcohol exposure and gender differences in childhood mental health problems: A longitudinal population-based study. Pediatrics, 19, Sood, B., Delancey-Black, V., Covington, C. et al. (2001) Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. Doseresponse effect. Pediatrics, 108(2): Abel EL (1995) An update on incidence of FAS: FAS is not an equal opportunity birth defect. Neurotoxicol Teratol 17: Office of the Surgeon General (2005) Press Release: US Surgeon General releases advisory on alcohol luse in pregnancy, February 21, Available at FAS guidelines accessible.pdf. 8 Mattson, S.N., & Riley, E.P. (1998). A review of the neurobehavioral deficits in children with fetal alcohol syndrome or prenatal exposure to alcohol. Alcohol Clini Exp Res, 22: O Connor MJ, Kasari C. (2000) Prenatal alcohol exposure and depressive features in children. Alcohol Clin Exp Res, 24(7): Rasmussen, C. (2005) Executive functioning and working memory in fetal alcohol spectrum disorder. Alcohol Clin Exp Res, 29(8): Streissguth AP, Barr HM, Kogan J, Bookstein, F.L. (1996) Understanding the Occurrence of Secondary Disabilities in Clients with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE): Final Report to the Center for Disease Control. Seattle: University of Washington, Fetal Alcohol and Drug Unit. 13 Jacobson JL, Jacobson, SW (2002) Effects of prenatal alcohol exposure on child development. Alcohol Research and Health, 26: Sokol RJ, Martier SS, Ager JW (1989) The T-ACE questions: practical prenatal detection of risk-drinking. Am J Obstet Gynecol. 160: Russell M, Martier S, Sokol R, Mudar P, et al (1994) Screening for pregnancy risk drinking. Alcohol Clin Exp Res 18: Knight JR, Shrier LA, Bravender TD (1999) A new brief screen for adolescent substance abuse. Arch Pediat Adol Medi 153: Fleming MF (2003) Brief interventions and the treatment of alcohol use disorders: current evidence. Rev Dev in Alcohol 16: O Connor, MJ, Whaley, SE (2007) Brief intervention for alcohol use by pregnant women. American Journal of Public Health 97, Bien TH, Miller WR, Tonigan JS (1993) Brief interventions of alcohol problems: A review. Addiction 88: Miller WR, Rollnick S (1991) Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press. 21 National Institute on Alcohol Abuse and Alcoholism and Alcoholism Office of Research on Minority Health (1999) Identification of at-risk drinking and intervention with women of childbearing age: A guide for primary-care providers. National Institutes of Health, Rockville, MD. NIH Publication No