By Dr. Pamela Gillen. Dr. Pamela Gillen

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1 By Dr. Pamela Gillen Dr. Pamela Gillen

2 Working with every woman to prevent FASDs: Dr. Pamela Gillen

3 Participants will be able to do the following: Discuss the risks of an alcohol-exposed pregnancy (AEP) Discuss ways to prevent an AEP Describe components of the Motivational Interviewing (MI) spirit that are fundamental to SBIRT and the CHOICES program Demonstrate some key MI strategies Discuss the key components of SBIRT and CHOICES intervention sessions

4 Why some women are more likely to have an alcohol affected child Mediating Factors Dose - 4 or more drinks at one time» Drinking heavily throughout pregnancy Genetic sensitivity» Family history of alcoholism» Some fetuses are more sensitive Gestational stage» At one stage of pregnancy is drinking taking place Maternal metabolism» How fast does the liver/body detox the alcohol Maternal nutrition- Choline, Zinc, Iron deficiencies Parity - number of previous pregnancies

5 FASD 100% Preventable No known amount of ETOH is safe during pregnancy If you re pregnant Don t Drink If you Drink Don t get pregnant If a woman is of child bearing age drink below risk levels Dr. Pamela Gillen

6 Fetal Alcohol Spectrum Disorders (FASD) Effects of FASD include physical, mental, behavioral, and/or learning disabilities. Severity of effects depends on: The amount of alcohol consumed Timing of exposure Possibly maternal/fetal genetics FASDs are estimated to occur about three times more often than the full Fetal Alcohol Syndrome alone. An estimated 36,000 babies are born with an FASD each year.

7 What s the Difference between FAS and FASD? Fetal Alcohol Spectrum Disorders (FASD) Not a clinical diagnosis Umbrella term Describes range of effects in an individual who is prenatally exposed to alcohol and includes the following conditions: Fetal Alcohol Syndrome (FAS) Partial FAS Alcohol-related neurodevelopmental disorders (ARND) Alcohol-related birth defects (ARBD) Fetal Alcohol Syndrome (FAS) A clinical diagnosis with specific physical and neurodevelopmental criteria One of the most involved effects of alcohol exposure in pregnancy

8 FAS Facial Dysmorphia To be diagnosed with FAS, an individual must demonstrate three facial malformations: 1. Smooth philtrum: divot or groove between the nose and the lip; flattened upper lip 2. Thin vermillion: thin upper lip 3. Small palpebral fissures: decreased eye width

9 FAS Growth Problems Growth deficiency is defined as height and/or weight that is significantly below average. Deficiencies are documented when height or weight falls at or below the 10th percentile of standardized growth charts appropriate to the patient s age, gender, and population. Growth deficiencies can occur during pregnancy (small for gestational age), at birth, or at any time.

10 FAS Central Nervous System Deficits Structural impairments: Observable physical damage to the brain or brain structures Neurological impairments: Assessed when structural impairments are not observable or do not exist Functional impairments: Deficits, problems, delays, or abnormalities, such as: Decreased IQ Specific learning problems in reading, spelling, and/or math Fine or gross motor problems Communication or social interaction problems Attention problems and/or hyperactivity Memory deficits Executive functioning

11 Long-Term Consequences of FAS (N=473, age range 6 51 years)* Mental health problems 94 Disrupted school experience Trouble with the law Confinement Inappropriate sexual behavior Alcohol/drug problems *All numbers are percentages. For example, 94% experienced mental health problems. Source: Streissguth, A.P., et al. (1996). Final report (CDC Grant R04/CCR008515).

12 Less Severe Outcomes of Alcohol Use during Pregnancy Drinking 7 drinks a week or fewer can have effects on the developing fetus that may not be readily identified at birth, but show up over time as the child develops. Bailey, B., Sokol, R., Effects can include: learning problems in reading and math, attention problems, difficulties with memory and organizing, and a wide range of behavioral problems such as impulsivity, aggression, and social problems. CDC, Women who are pregnant or could become pregnant should not drink any amount of alcohol. HHS, Bailey, B., Sokol,R. (2008). Pregnancy and alcohol use: Evidence and recommendations for prenatal care. Clinical Obstetrics and Gynecology, 51(2), CDC, National Center on Birth Defects and Developmental Disabilities. ( 2004). Fetal alcohol syndrome: Guidelines for referral and diagnosis. Retrieved from HHS. (2005, February 21 [posted];2007, January 4 [last revised]). U.S. Surgeon General releases advisory on alcohol use in pregnancy: Urges women who are pregnant or who may become pregnant to abstain from alcohol. Retrieved from

13 Other Adverse Outcomes of Alcohol Use during Pregnancy Miscarriage/spontaneous abortion Prenatal and postnatal growth restriction Prematurity Birth defects (cardiac, skeletal, renal, ocular, auditory)

14 Alcohol Use during Pregnancy: Impact on a National Level Prenatal alcohol exposure is one of the leading preventable causes of birth defects and developmental disabilities in the United States. An estimated 1,200 to 6,100 babies in the United States are born with FAS each year. FASDs may affect as many as 36,000 babies born each year. The annual cost of FAS in the United States is estimated at $4 billion and the cost of FASDs may be as much as $6 billion annually, accounting for the cost of care, developmental disabilities services, special education, and other service systems.

15 Prevalence* of binge drinking among adults Behavioral Risk Factor Surveillance System combined landline and cellular telephone developmental dataset, United States, 2010

16 Intensity* of binge drinking among adults Behavioral Risk Factor Surveillance System combined landline and cellular telephone developmental dataset, United States, 2010 Average largest number of drinks consumed by binge drinkers on any occasion in the past month.

17 US Drinking Patterns High-risk drinking: a brief or short intervention (such as CHOICES) is appropriate 71% 25% Low-risk: reinforce safe limits including recommendation of no alcohol at all if planning on or at risk of pregnancy 4% Alcohol dependent: referral to treatment needed

18 What is one drink? 0.6 Oz. Absolute Alcohol

19 What are recommended limits? Single occasion Women: no more than 3 standard drinks 4 or more drinks on a single occasion is a binge (Non-Pregnant) Men: no more than 4 standard drinks 5 or more drinks on a single occasion is a binge

20 What are recommended limits? Weekly: Women: no more than 7 standard drinks 8 or more drinks/week is heavy drinking (risky to health)(non-pregnant) Men: no more than 14 standard drinks 14 or more drinks/week is heavy drinking (risky to health)

21 Who Supports Screening & Brief Advice for All Patients AAP ACOG CDC SAMHSA NIAAA WHO USPSTF

22 Spectrum of Use and Misuse lifetime abstinence current abstinence 71% low risk drinking hazardous drinking harmful drinking dependence symptoms 25% dependence 4%

23 What Can Be Done to Prevent FASD? Screen women for risk of an AEP (alcohol-exposed pregnancy) Offer at-risk women an evidence-based intervention such as SBIRT and CHOICES. If she declines, advise her of the consequences of an AEP and recommend that she discuss her alcohol use with her physician or another health care provider who is familiar with programs that assist in reducing alcohol use. *

25 Decision Tree for effective contraception 1st _ Ask The last time you had vaginal intercourse, what did you use? IF none: ineffective contraception If contracepting then ask: What type of contraception are you currently using? You used this contraception when you had vaginal intercourse: Every time Most of the time Sometimes Never If Every time -> Go to contraception questions to determine effectiveness If most, sometimes or never then : ineffective contraception

26 Adapted from: WHO. Family Planning: A Global Handbook Tier 1 Tier 2 Tier 3 Tier 4

28 Preventing AEPs Avoid high-risk drinking, or abstain and/or Use birth control effectively Many women choose to do both.

29 Why Reduce Drinking and Improve Contraception among Women? Many women continue to drink alcohol before they realize they are pregnant. Alcohol can damage an unborn child at any time during pregnancy, particularly in the first trimester. If a woman of childbearing age is sexually active and chooses to drink alcohol at risk levels, she should practice effective contraception.

30 Why Intervene? (Reproductive Age Women/Girls) 51% of pregnancies are intended, in women managing contraception/fertility effectively 50% of pregnancies are unintended ½ of those in women using contraception, but ineffectively ½ of those in women not using contraception at all

31 Why Intervene, cont. Most women don t realize they are pregnant until 6-8 weeks Most women continue to drink until they are aware of the pregnancy 7.6% continue to drink even after they are aware of the pregnancy * Most women do not enter prenatal care until well into the first trimester * MMWR July 20, 2012 / 61(28);

Surgeon General Releases Updated Advisory on Alcohol Use in Pregnancy* There is no known safe level of alcohol use during pregnancy. Alcohol can cause damage at any stage of pregnancy.

32 Surgeon General Releases Updated Advisory on Alcohol Use in Pregnancy* There is no known safe level of alcohol use during pregnancy. Alcohol can cause damage at any stage of pregnancy. Alcohol use can cause a broad spectrum of effects. The effect of fetal alcohol exposure is lifelong. Women who are pregnant or considering becoming pregnant should not consume alcohol. February 21, 2005

33 When Is an Ideal Time to Prevent an AEP? FIGURE Prevalence of women aged years who reported alcohol use * Behavioral Risk Factor Surveillance System, United States, Percentage Any use, not pregnant Binge drinking, not pregnant Year Data not collected in 1994, 1996, 1998, and 2000.

34 Timeline of Fetal Development Week Central Nervous System Heart Arms Legs Ears Eyes Teeth Palate External Genitalia Missed Period Noted Typical time of first prenatal visit

35 Brief to short interventions SBIRT Brief Intervention CHOICES 1 session (front load session one and two in one session) CHOICES 2 Session model CHOICES 4 Session model based off original researched Project Choices

36 SBIRT Universal screening assesses substance use and identifies people with substance use problems Brief intervention is provided with a screening indicates moderate risk or higher. Brief intervention utilized motivational interviewing techniques to raise awareness of substance use and its consequences and motivating them towards positive behavior change. Brief Therapy continues motivational discussion for persons needing more than brief intervention. Referral to Treatment provides a referral to specialty care persons at high risk.

38 Brief Screen Question Drinks per week: How many drinks do you have per week? Positive Screen Criteria If female or a male over the age of 65 = More than 7 drinks If a male age 65 and younger = More than 14 drinks Drinks per day: When was the last time you had 4 or more drinks per day? (Asked of all females and males over the age of 65) OR When was the last time you had 5 or more drinks per day? (Asked of males age 65 and younger) In the past year, how many times have you used marijuana? In the past year, have you used or experimented with an illegal drug or a prescription drug for nonmedical reasons? Do you currently smoke or use any form of tobacco? Other positive screen criteria For those age For pregnant women If female or a male over the age of 65 = 4 or more drinks in one day in the past three months. OR If male age 65 and younger = 5 or more drinks in one day in the past three months If one or more times = Yes If = Yes If = Yes Any alcohol use Any alcohol use

39 Adolescents Half of high school students are current drinkers One third binge drink One fourth smoke marijuana YET Less than one half of physicians report screening all adolescent patients for substance use, and less than one fourth report screening for drinking and driving Dr. Pamela Gillen

40 CHOICES Intervention Changing High-Risk AlcOhol use and Increasing Contraceptive Effectiveness Study

41 What is CHOICES? A short term prevention intervention for women who are at risk for an alcohol-exposed pregnancy Focuses on avoiding an alcohol-exposed pregnancy Tailored to meet each client s level of readiness to change her alcohol use and/or contraceptive behaviors Designed for delivery in health care, addiction treatment, and correctional settings Uses motivational interviewing skills and brief intervention components 2 or 4 session model

42 Project CHOICES Series of Studies Epidemiological studies showing that proposed settings had high proportions of women at risk for an AEP were completed Evidence-based intervention components developed and evaluated in a successful feasibility (pilot) research study completed in Efficacy study completed 2006 and published Showed that more women receiving the intervention lowered their risk for an AEP than did so in the control group

43 Project CHOICES Intervention Study CHOICES: Changing High-Risk Alcohol Use and Increasing Contraceptive Effectiveness Study Began as a research project with three universities Three goals of the study: To identify settings with high proportions of women at high risk for an AEP To characterize this population to identify the level of risk and predictors of risk To design and offer an intervention to reduce their risk for an AEP

44 How did women reduce AEP risk?

45 Goal of CHOICES To avoid alcohol-exposed pregnancies (AEPs) How? By providing information that helps women at risk of an AEP learn how to reduce their drinking or abstain from alcohol altogether and/or use birth control methods effectively

46 CHOICES Materials Assessment tools Interventionist Manual Client Workbook Additional materials to be provided by interventionist: Pamphlet on birth control options Instructions for women on how to contact birth control providers working with your agency

47 Self-Evaluation: Alcohol On the line below, please make a slash mark (/) at the point that best reflects how important it is for you to drink below Risky levels Not important Very important On the line below, please make a slash mark (/) at the point that best reflects how confident you are that you can drink below Risky levels Not Confident Very Confident On the following scale, which point best reflects how ready you are at the present time to drink below Risky level? (Below risky levels means having 7 or fewer drinks per week, 3 or fewer drinks per day, or none if you become pregnant Not at all ready to drink below risky levels Thinking about drinking below risky levels Planning and making a commitment to drink below risky levels Actively drinking below risky levels

48 Self-Evaluation: Birth Control On the line below, please make a slash mark (/) at the point that best reflects how important it is for you to use birth control every time you have sex. Not important Very important On the line below, please make a slash mark (/) at the point that best reflects how confident you are that you can use birth control every time you have sex. Not Confident Very Confident On the following scale, which point best reflects how ready you are at the present time to use birth control every time you have sex? Not at all ready to use birth control every time I have sex Thinking about using birth control every time I have sex Planning and making a commitment to use birth control every time I have sex Actively using birth control every time I have sex

49 You said that you drink drinks per week. You also said that on occasions you may drink drinks in a single day. Personal Feedback Moderate Drinking: 7 drinks per week AND no more than 3 drinks in any one day Risky Drinking: 8 or more drinks per week, or 4 or more drinks in any one day How does your drinking compare with other women? Your current drinking level falls into the risk group. You are drinking more than % of women aged Your Pregnancy Risk Low: You use birth control correctly every time you have vaginal intercourse. Risky: You never use birth control or you sometimes have vaginal intercourse without using birth control correctly. Your Risk for an Alcohol- Exposed Pregnancy Not at risk At risk You are at risk because: Moderate Drinking (3 out of 10) 20% 30% No Drinking (5 out of 10) 50% Risky Drinking (2 out of 10)

50 Goal Statement and Change Plan for Birth Control Choice 1: I plan not to have vaginal intercourse at all The ways other people can help me are Choice 2: I plan to have vaginal intercourse and not to use any birth control Choice 3: I plan to use birth control every time I have vaginal intercourse. (Specify methods) Person: Possible ways to help: Choice 4: I plan to use birth control sometimes, but not with every vaginal intercourse. (Specify) The most important reasons why I chose this goal I will know that my plan is working if The steps I plan to take in reaching my goal are Some things that could interfere with my plan are:

Goal Statement and Change Plan for Alcohol Choice 1: I plan not to drink at all The ways other people can help me are Choice 2: My plans for drinking are A.

51 Goal Statement and Change Plan for Alcohol Choice 1: I plan not to drink at all The ways other people can help me are Choice 2: My plans for drinking are A. On the average day when I drink, to drink no more than drinks. B. During the average week, to drink no more than days. C. Never to drink more than drinks on any one day. D. Other (specify) Person: Possible ways to help: The most important reasons why I chose this goal I will know that my plan is working if The steps I plan to take in reaching my goal are Some things that could interfere with my plan are:

52 Summary: Effects of Alcohol Use on Pregnancy Alcohol consumed during pregnancy can result in many harmful effects. There is no safe level of drinking during pregnancy. Potential effects under umbrella of FASDs range from mild learning and/or behavioral problems to severe, lifelong brain damage & physical problems. One of leading preventable causes of birth defects and developmental disabilities in US; FAS is one of the most severe FASDs Estimated annual cost of FASD is up to $6 billion

53 Why MI? Evidence-based Theory-based Can address a variety of health behaviors Relatively brief Complementary to other methods Verifiable Appropriate for those not presenting for treatment

54 What is MI? A goal-oriented, client-centered counseling style Enhances motivation for change Specific communication skills that increase a client s motivation to change

55 Goals of MI Prepare people to consider changing Maintain motivation to change Not push people to change

56 Characteristics of MI Client-centered Goal-oriented Focuses on guiding versus advising Enhances internal motivation for change Explores and resolves ambivalence Involves the MI spirit

57 Exercise Closed vs. Open-ended Questions Do you use birth control methods? How many times have you used birth control methods in the past three months? What birth control methods you have used in the past three months?

58 Closed vs. Open-Ended Questions Closed questions can be answered finitely, often with yes or no. Questions are restrictive and can be answered in a few words. Open-ended questions will solicit additional information from women. Questions are broad and require more than one- or two-word answers.

59 Summary: Open-Ended Questions Foster a dialogue, not an interrogation Establish rapport Provide more information than closed questions Allow your clients to tell their stories - you talk less and listen more Permit a better understanding of the issues and build empathy

60 Responding to Change Talk Listen to and reflect the client s perspectives: Pro-change Anti-current behavior Reasons Confidence Desire Go beyond reflecting change talk to evoking it: Explore existing readiness for change Explore possible first steps towards change

61 Using Rulers to Assess Readiness Which point best reflects how ready you are to change your [drinking or use of birth control]? Not at all ready to change Thinking about changing Planning and making a commitment to change Actively changing

Summary Key principles of MI that are used in SBIRT and CHOICES MI Spirit Encourages your client to give reasons for change Collaboration, Evocation, Autonomy, OARS skills Allow you to stay focused,

62 Summary Key principles of MI that are used in SBIRT and CHOICES MI Spirit Encourages your client to give reasons for change Collaboration, Evocation, Autonomy, OARS skills Allow you to stay focused, provide direction, and express empathy Open-ended questions, Affirmations, Reflection, and Summary Change talk Helps your client build her readiness to change Desire, Ability, Reasons, Need Commitment Activation Taking Steps

63 DARN-CAT The Flow of Change Talk Desire Ability Reasons Need Commitment Activation Taking steps Source: Miller, 2005

64 Reflective Listening Leads to Change Talk Change Talk Sample Desire I want to... Ability Reasons Need Commitment Taking steps I could I know I would feel better if I ought to I am going to This week I started

65 MI and Non-MI Comparison Role Plays To compare and contrast effectiveness of talking with a woman about her risky problem behavior(s) birth control and drinking using two very different interviewing approaches: MI and Non MI

66 Reflective Listening MI requires a special type of listening Listening reflectively involves observing verbal and nonverbal cues

67 Reflective Listening Statements Mirror the client s perspectives Can be simple repeat a word or two depressed or angry Can be sophisticated - substitute new words for what your client said or guess about unspoken meaning It sounds like you are uncertain about whether you will remember to take your birth control pills regularly Encourage exploration and establish rapport

68 Summary: Reflective Listening Demonstrates that you understand what your client says Validates your client s concerns and feelings Is an important way to express empathy High levels of empathy are associated with positive outcomes

69 First MI-Non MI Role Play: 90 seconds Persuade vs Motivational Interviewing

70 First MI-Non MI Role Play: 90 seconds Debrief of Role Plays

71 The Spirit of MI Partnership Evocation Compassion Acceptance

72 MI Spirit in Practice (cont.) Acceptance and Compassion Responsibility for change is the client s Respect her autonomy Support her freedom to make the final decision about change Support her choices Promote her confidence

73 Four Processes of MI Engage Focus Evoke Plan

74 OARS Techniques for Establishing Good Rapport O = Open-ended questions Elicit and explore topics and extended answers A = Affirm the person Focus on client strengths, efforts, patience, etc. R = Reflect what the person says Nondirective initially, then directive S = Summarize Capture essence, link topics, transition conversation

75 Summary MI is different and feels different from persuading or arguing. MI is a goal-oriented, client-centered counseling style that enhances motivation by helping your client resolve ambivalence about behavior change. The goal of MI is to prepare people to consider changing and to maintain their motivation for change, but not to push them into it.

76 Questions?

77 Resources COFAS Dr. Pamela Gillen amareas/cofas/pages/cofas.aspx Dr. Pamela Gillen

Understanding Prenatal Alcohol Exposure

Understanding Prenatal Alcohol Exposure Prenatal Alcohol Exposure Causes Birth Defects Alcohol and pregnancy do not mix. Slide 2 The U.S. Surgeon General s Warning The dangers of consuming alcohol during