1. The Maternal Drinking History Guide Presented by Moumita Sarkar, PhD Alcohol and Substance Use Helpline The Motherisk Program, Hospital for Sick Children Presented by Moumita Sarkar, PhD Alcohol and Substance Use Helpline The Motherisk Program, Hospital for Sick Children Based on a consensus report developed by the FASD Advisory Workgroup in collaboration with SOGC and PHAC

2. Infant born at 35 weeks of gestation with severe IUGR and APGAR score of 5 Poor tonus, poor suckling Infant born at 35 weeks of gestation with severe IUGR and APGAR score of 5 Poor tonus, poor suckling Case #1

3. Case #1 cont…. Medical history does not reflect any maternal exposure related to baby’s symptoms Patient denies the use of alcohol and substances Meconium test for Fatty Acid Ethyl Ester (combination of alcohol and fatty acids): 52nM/g (N=<2) Mother is a problem drinker, unknown to the GP or gynecologist Medical history does not reflect any maternal exposure related to baby’s symptoms Patient denies the use of alcohol and substances Meconium test for Fatty Acid Ethyl Ester (combination of alcohol and fatty acids): 52nM/g (N=<2) Mother is a problem drinker, unknown to the GP or gynecologist

4. Alcohol and Pregnancy 9-12% of women reported drinking throughout their pregnancies (Health Canada 2000) 1.4% of pregnant women reported binge drinking (CDC 2011) Health care providers do not systematically screen all pregnant women on their consumption of alcohol 19% of women reported not being ask about their alcohol use (Chang, 2011) 25% of pregnant women were not asked 9-12% of women reported drinking throughout their pregnancies (Health Canada 2000) 1.4% of pregnant women reported binge drinking (CDC 2011) Health care providers do not systematically screen all pregnant women on their consumption of alcohol 19% of women reported not being ask about their alcohol use (Chang, 2011) 25% of pregnant women were not asked

5. Prenatal Alcohol Use: widespread  Problem drinking:  refers to the amount of maternal drinking associated with harm to the fetus  Exceeds 3 drinks at one sitting or 7 drinks per week (NIAAA, 2005)  Pregnant or planning:  Any amount of drinking is risky for women who are pregnant or trying to become pregnant (USDHHS, 2005)  Problem drinking:  refers to the amount of maternal drinking associated with harm to the fetus  Exceeds 3 drinks at one sitting or 7 drinks per week (NIAAA, 2005)  Pregnant or planning:  Any amount of drinking is risky for women who are pregnant or trying to become pregnant (USDHHS, 2005)

6. Routine Screening Ask all women of childbearing age about alcohol/drug use (especially pregnant women) Advise all women planning/pregnant that no alcohol is the safest choice; women who consumed alcohol during their pregnancy to contact Motherisk Assist all women to stop drinking through information, counselling, care and referral to appropriate programs and services SCREEN TO PREVENT FASD Ask all women of childbearing age about alcohol/drug use (especially pregnant women) Advise all women planning/pregnant that no alcohol is the safest choice; women who consumed alcohol during their pregnancy to contact Motherisk Assist all women to stop drinking through information, counselling, care and referral to appropriate programs and services SCREEN TO PREVENT FASD

7. The Maternal Drinking Guide: Purpose  Determine if the mother drinks /has drank at a problem drinking level in pregnancy.  A Positive screen on TWEAK  Meets the NIAAA guidelines for problem drinker  Obtain accurate maternal alcohol use report  Knowledge of prenatal alcohol use is essential for  1) subsequent FASD diagnosis in the future and  2) harm reduction strategies  Determine if the mother drinks /has drank at a problem drinking level in pregnancy.  A Positive screen on TWEAK  Meets the NIAAA guidelines for problem drinker  Obtain accurate maternal alcohol use report  Knowledge of prenatal alcohol use is essential for  1) subsequent FASD diagnosis in the future and  2) harm reduction strategies

8. Benefits Validated methodology as effective means of eliciting maternal alcohol use Provides practitioner with options appropriate for different groups and circumstances No training/ expertise required to screen Integrate screening questions into standardized health questionnaires among innocuous questions related to lifestyle Validated methodology as effective means of eliciting maternal alcohol use Provides practitioner with options appropriate for different groups and circumstances No training/ expertise required to screen Integrate screening questions into standardized health questionnaires among innocuous questions related to lifestyle

9. When to ask? Key times to assess alcohol use: Initial visit (to any new provider) Annual gynecological visit Preconception visit Visits for confirmation of pregnancy Mid-pregnancy (24-28 weeks) Exit visit (32-36 weeks) Key times to assess alcohol use: Initial visit (to any new provider) Annual gynecological visit Preconception visit Visits for confirmation of pregnancy Mid-pregnancy (24-28 weeks) Exit visit (32-36 weeks)

10. Level I Sarkar et al., CJCP 2009; 16 (1): e242-63

11. Level II Sarkar et al., CJCP 2009; 16 (1): e242-63

12. Level III Sarkar et al., CJCP 2009; 16 (1): e242-63

13. Case #1: Introduction Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health Intro #1: “I want to ask you a series of questions today about your lifestyle. I ask all my patients these questions because it helps me to get to know you better and provide better care.” Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health Intro #1: “I want to ask you a series of questions today about your lifestyle. I ask all my patients these questions because it helps me to get to know you better and provide better care.”

14. Level I: Practice-based When did you find out/suspect you were pregnant? Single-question method of screening Embed at least one question to identify prenatal alcohol use among other innocuous questions related to lifestyle e.g. Do you take any prenatal vitamins? Do you smoke any cigarettes? If so, how many?  Do you ever enjoy a drink or two? When was the last time?  Do you sometimes drink beer, wine or other alcoholic beverages?  In the past month or so, have you enjoyed a drink or two? What about taking medications? Did you exercise? When did you find out/suspect you were pregnant? Single-question method of screening Embed at least one question to identify prenatal alcohol use among other innocuous questions related to lifestyle e.g. Do you take any prenatal vitamins? Do you smoke any cigarettes? If so, how many?  Do you ever enjoy a drink or two? When was the last time?  Do you sometimes drink beer, wine or other alcoholic beverages?  In the past month or so, have you enjoyed a drink or two? What about taking medications? Did you exercise?

15. Case #1: Brief questionnaires Most effective method of screening (Stratton, 1996) Quick, practical, efficient and cost effective Direct questioning Timeline Follow Back Tool (TLFB) Indirect/masked screening Overcome issues of possible underreporting T-ACE, TWEAK Developed and validated for use among pregnant women TWEAK - Optimal for racially diverse groups, highly sensitive test Most effective method of screening (Stratton, 1996) Quick, practical, efficient and cost effective Direct questioning Timeline Follow Back Tool (TLFB) Indirect/masked screening Overcome issues of possible underreporting T-ACE, TWEAK Developed and validated for use among pregnant women TWEAK - Optimal for racially diverse groups, highly sensitive test

16. TWEAK QUESTIONSPOINTS ToleranceHow many drinks does it take to make you feel the first effect (before pregnancy)? _________ (3 or more = 2 points) WorryHave close friends worried or complained about your drinking in the past year? (yes = 2 points) Eye- opener Do you sometimes take a drink in the morning when you first get up? (yes = 1 point) AmnesiaHas a friend or family member ever told you about things you said or did while you were drinking that you could not remember? (yes = 1 point) Cut downDo you sometimes feel the need to cut down on your drinking? (yes = 1 point) Russell M. New assessment tools for risk drinking during pregnancy: T-ACE, TWEAK and Others. Alcohol Health and Research World (1994) 18 (1): 55-61

17. Case #1: Level III Screening (with consent) Postpartum case (  index of suspicion but deny use) If Level I and/or level II (TWEAK) screening is not successful  Level III screening (with consent) Why is this knowledge valuable? Postpartum case (  index of suspicion but deny use) If Level I and/or level II (TWEAK) screening is not successful  Level III screening (with consent) Why is this knowledge valuable?

18. FASD assessment referral Referral by a doctor required Assessment involves physical, neurological, psychiatric, genetic examination Confirmation of prenatal alcohol exposure required Confirmation of prenatal alcohol exposure required Referral by a doctor required Assessment involves physical, neurological, psychiatric, genetic examination Confirmation of prenatal alcohol exposure required Confirmation of prenatal alcohol exposure required

19. Screening and Intervention What can be done? Early Dx = Early Intervention Early diagnosis - evidence based Stimulation in early ages - important Parenting support materials

21. Case #2 BJ has been your patient for a year. She is very private and can be both defensive and combative by nature She has a 5 yr old child with both developmental and behavioural issues She is now pregnant and has previously never been asked about her alcohol use During her prenatal screening, her provider asks: “I’m sure you know alcohol and pregnancy don’t go well together. You don’t drink, do you?” She responds: “No” Few weeks later, her partner mentions his concern for her continued drinking BJ has been your patient for a year. She is very private and can be both defensive and combative by nature She has a 5 yr old child with both developmental and behavioural issues She is now pregnant and has previously never been asked about her alcohol use During her prenatal screening, her provider asks: “I’m sure you know alcohol and pregnancy don’t go well together. You don’t drink, do you?” She responds: “No” Few weeks later, her partner mentions his concern for her continued drinking

22. Case #2: Introduction Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health Intro example: “I want to ask you a series of questions today about your lifestyle. I ask all my patients these questions because it helps me to get to know you better and provide better care of your pregnancy.” Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health Intro example: “I want to ask you a series of questions today about your lifestyle. I ask all my patients these questions because it helps me to get to know you better and provide better care of your pregnancy.”

23. Level I: Practice-based Begin Innocuous questions: When did you find out/suspect you were pregnant? Single-question method of screening e.g. Do you take any prenatal vitamins? Do you smoke any cigarettes? How is your diet?  Do you ever enjoy a drink or two? When was the last time?  Do you sometimes drink beer, wine or other alcoholic beverages?  In the past month or so, have you enjoyed a drink or two? What about taking medications? Did you exercise? Begin Innocuous questions: When did you find out/suspect you were pregnant? Single-question method of screening e.g. Do you take any prenatal vitamins? Do you smoke any cigarettes? How is your diet?  Do you ever enjoy a drink or two? When was the last time?  Do you sometimes drink beer, wine or other alcoholic beverages?  In the past month or so, have you enjoyed a drink or two? What about taking medications? Did you exercise?

24. Case #2 BJ has been your patient for a year. She is very private and can be both defensive and combative by nature She has a 5 yr old child with both developmental and behavioural issues She is now pregnant and has previously never been asked about her alcohol use During her prenatal screening, her provider asks: “I’m sure you know alcohol and pregnancy don’t go well together. You don’t drink, do you?” She responds: “No” Few weeks later, her partner mentions his concern for her continued drinking BJ has been your patient for a year. She is very private and can be both defensive and combative by nature She has a 5 yr old child with both developmental and behavioural issues She is now pregnant and has previously never been asked about her alcohol use During her prenatal screening, her provider asks: “I’m sure you know alcohol and pregnancy don’t go well together. You don’t drink, do you?” She responds: “No” Few weeks later, her partner mentions his concern for her continued drinking

25. Avoid questions that suggest that you want a negative response:  Negative: You don’t drink, do you?  Positive: Many women wind down the day with a glass of wine or a few drinks on a night out…..do you sometimes enjoy a drink or two?”  Avoid many closed or dead-ended questions:  Negative: Do you drink since you found out? Yes or No  How has your alcohol consumption evolved since finding out your pregnancy? a) I continue my usual habit b) I have cut down c) I am trying to abstain but find it difficult Avoid questions that suggest that you want a negative response:  Negative: You don’t drink, do you?  Positive: Many women wind down the day with a glass of wine or a few drinks on a night out…..do you sometimes enjoy a drink or two?”  Avoid many closed or dead-ended questions:  Negative: Do you drink since you found out? Yes or No  How has your alcohol consumption evolved since finding out your pregnancy? a) I continue my usual habit b) I have cut down c) I am trying to abstain but find it difficult Case #2: Motivational Interviewing Techniques

26. Case #2: Supportive Dialogue Supportive dialogue (Without any moral connotation & empathetic listening)  Can you tell me a bit about your drinking pattern before you knew you were pregnant?  Have you been able to stop or cut down since you found out? Supportive dialogue (Without any moral connotation & empathetic listening)  Can you tell me a bit about your drinking pattern before you knew you were pregnant?  Have you been able to stop or cut down since you found out?

27. Case #2: Supportive Dialogue If alcohol problem suspected, but denied, Important to engage women to improve trust Use empathy "it is recommended to abstain from alcohol during pregnancy, if you are having hard time stopping, or even if you drink occasionally, do not hesitate to discuss it with me" If alcohol problem suspected, but denied, Important to engage women to improve trust Use empathy "it is recommended to abstain from alcohol during pregnancy, if you are having hard time stopping, or even if you drink occasionally, do not hesitate to discuss it with me"

28. Advise/ Feedback  If screen positive as problem drinker, or report continued prenatal alcohol use, begin the process by:  Here is some information that has been learned through research; I’d like to share it with you, if I may.  What is your understanding about alcohol use in pregnancy?  Do you have any questions about your alcohol use?  Provide feedback that allows clients to compare their behavior to others so they know how their behavior relates to national norms “Many women drink on a regular basis, and since half of all pregnancies are unplanned, many women are exposed to alcohol prior to pregnancy knowledge.”  Do you mind if we spend a few minutes talking about…..?  Are you interested in learning more about……..?  If screen positive as problem drinker, or report continued prenatal alcohol use, begin the process by:  Here is some information that has been learned through research; I’d like to share it with you, if I may.  What is your understanding about alcohol use in pregnancy?  Do you have any questions about your alcohol use?  Provide feedback that allows clients to compare their behavior to others so they know how their behavior relates to national norms “Many women drink on a regular basis, and since half of all pregnancies are unplanned, many women are exposed to alcohol prior to pregnancy knowledge.”  Do you mind if we spend a few minutes talking about…..?  Are you interested in learning more about……..?

30. Recommendations: Screening During regular health exams, health care providers should use standardized questions that should include at least Level I screening Early identification and reduction of maternal drinking No known safe limit for alcohol use in pregnancy Level II should be adopted as standard screening process to identify alcohol use in all women of childbearing age and pregnant women Upon screening, women need to be linked to services if required by their providers During regular health exams, health care providers should use standardized questions that should include at least Level I screening Early identification and reduction of maternal drinking No known safe limit for alcohol use in pregnancy Level II should be adopted as standard screening process to identify alcohol use in all women of childbearing age and pregnant women Upon screening, women need to be linked to services if required by their providers

31. Health care provider role in harm reduction is vital advise patients that the safest choice is not to consume alcohol during pregnancy Adequate resources should be made available to women requiring interventions beyond primary interaction Recording of maternal alcohol use in newborn’s birth record and child’s health record Early identification and subsequently early FASD Dx = intervention can occur Health care provider role in harm reduction is vital advise patients that the safest choice is not to consume alcohol during pregnancy Adequate resources should be made available to women requiring interventions beyond primary interaction Recording of maternal alcohol use in newborn’s birth record and child’s health record Early identification and subsequently early FASD Dx = intervention can occur Take Home Message

32. FASD programs/resources Best Start (www.beststart.org)www.beststart.org Provides online training tools for screening alcohol Motherisk Alcohol and Substance Abuse Helpline (www.motherisk.org) National toll-free helpline 1 877 FAS-INFO providing evidence-based info and referrals on alcohol/drugswww.motherisk.org Canadian Centre on Substance Abuse (www.ccsa.ca)www.ccsa.ca PRIMA (www.addictionpregnancy.ca)www.addictionpregnancy.ca Alberta Health Services (www.albertahealthservices.ca)www.albertahealthservices.ca Healthy Choices in Pregnancy in BC (www.hcip-bc.org)www.hcip-bc.org Best Start (www.beststart.org)www.beststart.org Provides online training tools for screening alcohol Motherisk Alcohol and Substance Abuse Helpline (www.motherisk.org) National toll-free helpline 1 877 FAS-INFO providing evidence-based info and referrals on alcohol/drugswww.motherisk.org Canadian Centre on Substance Abuse (www.ccsa.ca)www.ccsa.ca PRIMA (www.addictionpregnancy.ca)www.addictionpregnancy.ca Alberta Health Services (www.albertahealthservices.ca)www.albertahealthservices.ca Healthy Choices in Pregnancy in BC (www.hcip-bc.org)www.hcip-bc.org

33. Acknowledgments Dr. Gideon Koren Motherisk Alcohol and Substance Use Helpline Counselors The National Taskforce for FASD Screening Canadian Association for Paediatric Health Science Centre Public Health Agency of Canada Dr. Gideon Koren Motherisk Alcohol and Substance Use Helpline Counselors The National Taskforce for FASD Screening Canadian Association for Paediatric Health Science Centre Public Health Agency of Canada

34. The Maternal Drinking History Guide Thank you for listening! Thank You!