Page 112

7
Prevention of Fetal Alcohol Syndrome

Fetal Alcohol Syndrome (FAS), alcohol-related birth defects (ARBD), and alcohol-related neurodevelopmental disorder (ARND), result from a complicated set of factors that influence exposure, whether a woman who abuses alcohol becomes pregnant and continues to drink throughout pregnancy, and vulnerability to adverse fetal effects at a given level of exposure. Some of these pose opportunities for prevention, others are impediments. Alcohol is a legal drug consumed by many people, but its abuse carries heavy costs—for the individual and for society—apart from costs associated with FAS. Many people who abuse alcohol do not get the help they need, either because they do not have access to the health care or social services system or because some health care or social services professionals are uncomfortable talking with patients about substance abuse problems. Finally, the use and abuse of alcohol have long been centered in emotional and moral debate. Women who abuse alcohol or other substances are particularly stigmatized.

The complicated interrelation among alcohol, women, pregnancy, the woman's spouse or other significant partner and community, and the health care profession means that the prevention of FAS, ARBD, and ARND requires a comprehensive program encompassing a variety of approaches. Because alcohol abuse during pregnancy most likely is associated with a number of different drinking patterns which have various characteristics and etiologies, concepts from cultural, sociological, behavioral, public health, and medical disciplines are relevant to the etiology and prevention of FAS and related conditions.

This chapter discusses prevention efforts aimed at the mother and people with whom she has close personal relationships, and relevant sectors of the community



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 112
Page 112 7 Prevention of Fetal Alcohol Syndrome Fetal Alcohol Syndrome (FAS), alcohol-related birth defects (ARBD), and alcohol-related neurodevelopmental disorder (ARND), result from a complicated set of factors that influence exposure, whether a woman who abuses alcohol becomes pregnant and continues to drink throughout pregnancy, and vulnerability to adverse fetal effects at a given level of exposure. Some of these pose opportunities for prevention, others are impediments. Alcohol is a legal drug consumed by many people, but its abuse carries heavy costs—for the individual and for society—apart from costs associated with FAS. Many people who abuse alcohol do not get the help they need, either because they do not have access to the health care or social services system or because some health care or social services professionals are uncomfortable talking with patients about substance abuse problems. Finally, the use and abuse of alcohol have long been centered in emotional and moral debate. Women who abuse alcohol or other substances are particularly stigmatized. The complicated interrelation among alcohol, women, pregnancy, the woman's spouse or other significant partner and community, and the health care profession means that the prevention of FAS, ARBD, and ARND requires a comprehensive program encompassing a variety of approaches. Because alcohol abuse during pregnancy most likely is associated with a number of different drinking patterns which have various characteristics and etiologies, concepts from cultural, sociological, behavioral, public health, and medical disciplines are relevant to the etiology and prevention of FAS and related conditions. This chapter discusses prevention efforts aimed at the mother and people with whom she has close personal relationships, and relevant sectors of the community

OCR for page 112
Page 113 prior to the birth of an affected baby. The next chapter describes prevention efforts that might be aimed at the baby and the family after the child is born to ameliorate the effects of prenatal exposure—that is, efforts aimed at preventing secondary disabilities once a child with FAS, ARBD, or ARND is born. The approach to prevention of FAS, ARBD, and ARND contained in this chapter is conceptually broad and includes treatment and maintenance for those few women who drink heavily during pregnancy. The chapter begins with a general framework for discussing prevention. This is followed by an in-depth description of prevention strategies for women at risk of giving birth to an FAS child. A PUBLIC HEALTH MODEL OF PREVENTION The challenge in broad-based prevention is to alter behavior within a variety of settings (Casswell and Gilmore, 1989; Mosher and Jernigan, 1989). Change that occurs in familial, religious, social, economic, judicial, educational, and health care institutions can affect individual and group behavior. Since all social institutions can be potential agents of change (Bloom, 1981), a broad-based approach seems to be most appropriate. A comprehensive FAS prevention program should provide multiple and overlapping levels of reinforcement, incentives, and controls. Most prevention efforts should be aimed at the mother, and to some degree at the father, of the child. Preventing the birth of a child with FAS may involve different actions affecting maternal behavior: broad-based prevention; targeted prevention efforts with the woman, her spouse or other significant partner(s), and additional significant family members; alcohol abuse treatments; contraceptive services; and aftercare. It is important to note that the committee was charged with discussing what is known from a research base about preventing FAS, ARBD, and ARND. There is a wealth of information being generated from communities concerned about the FAS problem. Many of these projects derive from common sense approaches and entail community support, general programs to increase protective factors and decrease risk factors for alcohol abuse, and the like. Reasonable and necessary services are provided to pregnant, substance-abusing women. As with many current health interventions, however, the utility and value of many of these programs as prevention efforts is unknown because of the limited evaluative component of the programs. As this chapter points out, controlled research on the prevention of FAS is scarce. Also, as discussed in greater detail in a subsequent section, it is not clear if these programs are available to, used by, or effective for those women who abuse alcohol in a manner that puts their fetus at risk for FAS, ARBD, or ARND. The committee found it helpful to think about and analyze the prevention of FAS and related problems within a conceptual framework. Two structures were considered by the committee—the classic framework of primary, secondary, and tertiary prevention and a framework developed by the IOM Committee on Prevention

OCR for page 112
Page 114 of Mental Disorders (IOM, 1994). In more classical terms, primary prevention refers to a focus on healthy persons and seeks to avoid the onset of disease processes (IOM, 1991). Secondary prevention involves early detection and treatment of persons with early or asymptomatic disease, and tertiary prevention concentrates on arresting the progression of a condition and on preventing or limiting additional impairment. The committee decided to use the latter framework (IOM, 1994), which describes a spectrum of seven levels of intervention, as a more appropriate tool, with some adaptation, to discuss prevention of FAS, ARBD, and ARND. The hallmark of this framework is that one enters into the continuum of interventions in a manner proportional to the certainty and severity of the risk involved. That is, the intervention becomes more specific and intensive as the risk is defined less by general population characteristics and more by individual characteristics. The model presented was originally described by Gordon (1983, 1987) and subsequently adapted for an IOM committee (IOM, 1994). The model includes a broad spectrum of prevention measures. The model also includes two related components—treatment and maintenance. Prevention activities vary from population-wide programs to efforts aimed at an individual at high risk. Prevention is divided into three levels (universal, selective, and indicated), treatment into two (case identification and standard treatment for known disorders), and maintenance into two (compliance with long-term treatment and aftercare). The model developed by the IOM in 1994 required slight modifications for applicability to FAS, but the general concepts remain the same (see Figure 7-1). This will be explained in the next section. The committee to study fetal alcohol syndrome also stresses that core research in fields such as biomedicine, behavioral and social sciences, and epidemiology support, inform, and are vital to research in FAS prevention. Because significant people in the life of a woman can play a crucial role in encouraging a healthy pregnancy or, unfortunately, encouraging unhealthy practices, the committee took a family-oriented approach to prevention. Clearly, a woman's partner and her community are appropriate targets for prevention interventions and subjects for prevention intervention research. After the birth of an FAS child, there are two targets for intervention—the mother and the child. Each of them is a patient in need of care; each is a target for treatment and maintenance as well as for prevention intervention for the birth of another FAS child. Case identification of FAS, ARBD, and ARND is described in Chapter 4. Treatment and maintenance of the person with FAS are discussed in Chapter 8. Definitions Universal prevention attempts to promote the health and well-being of all individuals in society or of a particular community. Universal prevention interventions are those targeted to the general public to or an entire population group

OCR for page 112
Page 115 FIGURE 7-1 The intervention spectrum for fetal alcohol syndrome. Adapted from Institute of Medicine (1994). that has not been identified on the basis of individual risk. The intervention is desirable for everyone in that group. Examples include universal childhood immunizations and water fluoridation. Selective prevention interventions are targeted to individuals or a subgroup of the population, whose risk of developing the condition is significantly higher than others by virtue of belonging to that subgroup. There is no assessment of individual risk in selective prevention interventions. An example would be routine mammograms for women over 40 to 50 years of age. Another example would be typhoid vaccine for Americans traveling to less developed countries. Indicated prevention interventions are targeted to high-risk individuals who are identified as having minimal but detectable signs or symptoms foreshadowing a condition or who have biological markers indicating predisposition (IOM, 1994). An example, in contrast to that offered for selective prevention interventions, would be frequent mammograms in a woman who has had breast cancer. Another example is rabies vaccination in someone bitten by a raccoon with unknown rabies status. Special considerations related to FAS necessitated some modification of this definition. That is, although prevention interventions are generally thought of as stopping short of treatment interventions, when thinking about a comprehensive prevention program for FAS, ARBD, and ARND, it is clear that treatment of alcohol problems in pregnant women (and their partners) is an appropriate indicated prevention intervention for the fetus being carried by the woman, as well as for future pregnancies. In addition, treatment of alcohol problems in the pregnant woman will improve her health and well-being.

OCR for page 112
Page 116 UNIVERSAL PREVENTION INTERVENTIONS Universal prevention interventions are directed to the general public or to an entire population group that has not been identified on the basis of increased risk. Interventions tailored specifically to pregnant women or preconceptional women could be included in this category. Universal prevention could include any activity that generally promotes responsible use of alcohol and discourages irresponsible use of alcohol, or it could be specific to fetal alcohol syndrome. As described later, it is not clear whether these general interventions have had, or could ever have, an impact on FAS, ARBD, or ARND. General universal prevention strives to ensure that all members of society understand that drinking alcohol can have hazardous consequences, and it promotes and supports positive, broadly shared attitudes and beliefs to protect the individual from harm due to alcohol consumption. The committee focused on FAS, ARBD, and ARND, which are related to consumption of very high levels of alcohol or to extreme patterns of alcohol consumption. They have not reviewed the literature on the health benefits (e.g., cardiovascular) of modest alcohol consumption except to note that there are some data to suggest such benefits for certain populations (Ashley et al., 1994; Fuchs et al., 1995). Moderate alcohol consumption as a substitute for abstinence or light drinking should not be encouraged as a public health measure (Addiction Research Foundation of Ontario and the Canadian Centre on Substance Abuse, 1994). Encouraging women to drink during pregnancy on this basis is unwarranted. The reader should consult the published literature for more information (Ashley et al., 1994; Fuchs et al., 1995; U.S. Department of Health and Human Services, 1993). One of the basic techniques used in universal prevention is public education. Television advertisements, public service announcements, pamphlets, posters, and the like, which serve to educate the public about the risks of alcohol abuse and to encourage responsible drinking are universal prevention interventions that indirectly discourage use of alcohol during pregnancy. Universal prevention could also involve changes to the social environment (Single, 1987; Wallack, 1984), such as laws and regulations reinforcing norms and practices that depict heavy drinking and alcohol abuse as unacceptable. The literature abuse indicates that higher socioeconomic status (SES), education, and access to meaningful employment are influential in decreasing the likelihood of alcohol abuse and, therefore, may lower FAS outcomes among women. Certainly low SES is correlated with FAS outcomes (Bingol et al., 1987; Sokol et al., 1980), ostensibly because the most highly abusive maternal drinking patterns are found among some individuals in low-SES groups. Although these problems may, in part, be generated by low SES, people who abuse alcohol might also drift to a lower SES. Consequently, universal prevention might be facilitated by improving social and economic opportunities for the entire population and reducing the prevalence of alcohol abuse. However, women

OCR for page 112
Page 117 of mid or high SES have given birth to children with FAS, ARBD, or ARND. No matter what the socioeconomic level, women who abuse alcohol are at risk for giving birth to an FAS baby. The above examples are the types of prevention activities undertaken to decrease risk factors and increase protective factors for alcohol abuse in general; they are not specific to FAS. Given the high cost of alcohol-related problems in the United States—$85 billion in 1985, (U.S. Department of Health and Human Services, 1993)—these measures are valuable in and of themselves, apart from whatever impact they might have on FAS. Most certainly, these messages could influence the drinking behavior of some pregnant or preconceptional women. Universal prevention of FAS further strives to ensure that all members of society understand that drinking during pregnancy can have hazardous consequences. Universal prevention promotes and supports positive, broadly shared attitudes and beliefs to protect the fetus from alcohol. Male partners and extended family members could play vital roles in the translation of these positive traits, as do peer groups (Wilsnack and Beckman, 1984; Wilsnack et al., 1991) and health care providers. No universally safe level of alcohol consumption has been identified for pregnant women. Neither a specific level of alcohol consumption nor precise information on the biological, experiential, and behavioral characteristics of the mother of an FAS child has been well defined. At present, there is uncertainty whether minimal alcohol intake during pregnancy could be associated with any degree of injury to the baby. Some of the large research studies conducted in various cities in the United States have shown statistical associations between less than heavy levels of alcohol consumption by pregnant women and the birth and developmental outcomes in their offspring, the vast majority of whom have not been diagnosed with FAS, ARBD, or ARND (see Russell, 1991, for a review). For example, a study in Pittsburgh reports deficits in height and weight at age 3 associated statistically with moderate drinking (Day et al., 1991). There are several issues relevant to the interpretation of these data related to relatively low levels of alcohol exposure and their translation into public health messages. First, statistical association is not proof of causality. That is, there are other factors associated with alcohol consumption during pregnancy that might be the cause of the abnormal outcome measures in the offspring. Some of the studies controlled for a variety of potential confounders, such as tobacco use, but not all of them did. As discussed in Chapter 1 it is not clear how clinically relevant some of the differences might be (Day et al., 1991; Russell, 1991). Finally, many of the more subtle differences in the child associated with low or moderate levels of alcohol intake during pregnancy are very common, and the association with alcohol exposure could be spurious. Assuming a causal relation with alcohol exposure could be erroneous. Although the effects of low levels of alcohol exposure during pregnancy are easier to study rigorously in one sense (the population of pregnant women who drink at low or moderate levels is much

OCR for page 112
Page 118 greater than the population who drinks very heavily), the subtle nature of some of the outcomes makes it difficult. The committee focused on conditions more closely associated with heavier levels of alcohol consumption. The reader is referred to the many excellent reviews of the effect of lower levels of prenatal exposure for further information (see for example, Jacobson and Jacobson, 1994; Russell, 1991). Whether or not further research clarifies the relation between low to moderate levels of alcohol during pregnancy and adverse birth outcomes, the universal prevention message for FAS is a conservative one that encourages abstinence prior to conception and throughout pregnancy as the safest course. This was articulated by the Surgeon General in 1981 (U.S. Public Health Service, 1981). One can understand that the public health message encourages total abstinence. However, this message is potentially problematic for some individuals—women, their partners, and even some in the medical community—because it seems to contradict years of experience. Current data from three separate surveys suggest that approximately 20 percent of pregnant women drink alcohol at some level during pregnancy (CDC, 1995b; NIDA, 1994; Serdula et al., 1991). The vast majority of the babies born to these women show no overt signs of damage. Therefore, it is sometimes hard to convince these women that they should not have consumed alcohol or that they should not consume it during the next pregnancy. Public health messages must be simple and can never fully explain the scientific and medical facts and uncertainties behind the message. If further research demonstrates a causal relation between low or moderate levels of alcohol consumption and less severe or complete manifestations of neurobehavioral damage than seen in FAS, ARBD, or ARND, as has been hypothesized, then this most conservative message of total abstinence will have been wise and reasonable. An obvious example of a universal prevention intervention specific to FAS is warning labels on alcoholic beverages (see Box 7-1) or similar signs posted in restaurants or bars. These interventions are mandated by federal and state law. They are delivered to and accessible to everyone who drinks alcohol, including all pregnant women, not just those at high risk based on either population-based factors (selective prevention interventions) or individual factors (indicated prevention interventions) of delivering a baby with FAS. Many groups, such as the March of Dimes, the American College of Obstetrics and Gynecology, and drug store chains, have put out pamphlets with information about FAS; the National Organization on Fetal Alcohol Syndrome recently sponsored public service announcements about FAS by popular musicians Bonnie Raitt and Queen Latifah. Health care providers can and should engage in universal prevention interventions. Visits to family practitioners and to obstetrician gynecologists offer the opportunity for brief messages about the importance of responsible alcohol use and for providing general information about the risks of alcohol to the fetus (American College of Obstetricians and Gynecologists, 1994). It should be standard

OCR for page 112
Page 119 BOX 7-1 Warning Label on Alcoholic Beverages GOVERNMENT WARNING: (1) ACCORDING TO THE SURGEON GENERAL, WOMEN SHOULD NOT DRINK ALCOHOLIC BEVERAGES DURING PREGNANCY BECAUSE OF THE RISK OF BIRTH DEFECTS. (2) CONSUMPTION OF ALCOHOLIC BEVERAGES IMPAIRS YOUR ABILITY TO DRIVE A CAR OR OPERATE MACHINERY AND MAY CAUSE HEALTH PROBLEMS. SOURCE: Public Law 100-690, Section 204. medical practice to talk to women about their alcohol consumption (Cefalo and Moos, 1995; Mullen and Glenday, 1990) and this appears to be more common now than in the past. An increase in these activities is part of the Healthy People 2000 goals (see Table 1-1). As universal interventions such messages would be brief, delivered to every patient, and almost generic. More targeted messages and questioning would depend on whether the woman drinks and is pregnant. These are discussed under selective interventions. While universal prevention activities in isolation may have had some effects, there has been no data found that demonstrates a change in the prevalence of FAS in response to such efforts. As discussed in Chapter 5, there are no definitive data on the prevalence or incidence of FAS. According to some surveys, its incidence appears to have increased (CDC, 1995a). This is most likely due to improvements in case identification, rather than a true increase in incidence. Therefore, as discussed in Chapter 5, proxy measures of the impact of prevention activities are appropriate to consider. Relevant proxy measures might include knowledge, attitudes, and beliefs, as well as prevalence of drinking by pregnant women. Universal interventions seem to have increased the general knowledge of FAS and related problems. Data from the National Health Interview Survey indicate a statistically significant increase between 1985 and 1990 in the number of people ages 18 to 44 who had heard of FAS, who agreed that heavy drinking (as defined by each respondent) carries pregnancy-related risks, and who could correctly identify FAS as a birth defect (other choices were that the baby was born drunk or addicted to alcohol) (Dufour et al., 1994). However, those same data show that in 1990, a small percentage of people believe that FAS means that a baby is born drunk, 60 percent of all men and women between 18 and 44 years of age who had heard of FAS thought it referred to an alcohol-addicted baby, and only 29 percent of all women of childbearing age could correctly describe FAS as a birth defect. Careful analysis of a study on the impact of the alcoholic beverage warning label on the drinking of approximately 3,500 pregnant women shows that after

OCR for page 112
Page 120 introduction of the warning label, pregnant women who drank very little (the equivalent of less than one mixed drink per day) decreased their alcohol consumption by an amount equivalent to 1 ounce of beer per week (Hankin, 1994). Pregnant women who drank more (the equivalent of more than one mixed drink per day) did not change their drinking behavior. These data suggest that universal prevention interventions might have little direct impact on FAS, ARBD, or ARND. Data suggest that many women cut down their consumption of alcohol while pregnant (Serdula et al., 1991). Some pregnant women do not drink simply because the state of pregnancy decreases the palatability of alcohol for them. However, it is possible that increasing awareness of FAS and risks to the fetus have contributed to the decreases. Nevertheless, data indicate that women who drink heavily do not cut down their consumption of alcohol while pregnant. Because it is these women who are at risk for giving birth to an FAS child, it seems that universal prevention activities would have had little impact on the incidence of FAS. If future research suggests that low or modest levels of alcohol are associated with damage to the fetus other than FAS, ARBD, or ARND, then universal prevention interventions might decrease the incidence of those more subtle effects. SELECTIVE PREVENTION INTERVENTIONS Selective prevention interventions are targeted to people who are at greater risk for a particular outcome because they are members of a subgroup known to be at higher risk than the general population. These interventions involve different levels of targeting and intensity compared to universal prevention interventions. Some selective prevention is stimulated by general public information (universal prevention). A trickle-down effect of information may occur among those who are in a vulnerable state and thus at higher risk; and thus, the broadly dispersed universal prevention information on alcohol and pregnancy may or may not have a greater effect on vulnerable populations than on the general population. However, a trickle-down effect is not sufficient (Fitzgerald, 1988), and effective interventions must be devised to specifically target people who are members of high-risk groups. Targets of selective prevention for FAS, ARBD, and ARND include women in the reproductive age range who drink alcohol. This is a very large and heterogeneous population. Chapter 6 includes a discussion on women's drinking and relevant risk factors. In general, a risk reduction approach to prevention and treatment of alcohol abuse in pregnancy would be strengthened by increased scientific knowledge about personal and social risk factors for drinking by pregnant women.

OCR for page 112
Page 121 Population-Based Risk Factors for Giving Birth to an FAS Child The epidemiologic literature related to FAS clearly identifies several risk factors for giving birth to an FAS child. First, and most obviously, is consumption while pregnant of large quantities of alcohol—either continuously or in risky patterns, such as bingeing–although there are many children diagnosed with FAS for whom a good history of maternal alcohol consumption is not available. For those women who have had a baby with FAS and for whom alcohol consumption is known, the levels, pattern, and frequency of alcohol consumed have typically been high. However, as described in Chapter 5, a high proportion of women who abuse alcohol while pregnant do not give birth to a child with FAS. Alcohol is not unlike most teratogens in that not all fetuses, not even dizygotic twins, are equally affected by the same amount of exposure. The epidemiologic literature identifies other risk factors for alcohol use during pregnancy: age, race, marital status, smoking level, and SES (see Chapter 6). Special selective prevention interventions could be designed based on these factors. Role of the Father Because the Committee to Study Fetal Alcohol Syndrome views the targets of FAS prevention activities as appropriately including more than just women, the partners of women who drink could be included in selective prevention activities as well. In contrast to the attention devoted to the influence of maternal factors on pregnancy outcome, data on the possible role of paternal factors are sparse. The association between alcohol exposure in utero and FAS, ARBD, and ARND is well established. Maternal alcohol exposure causes FAS. Similarly, the important social, psychological, and behaviorally supportive role that the male partner plays in a healthy pregnancy is well established and cannot be emphasized too strongly. However, the possible biophysiological contribution of paternal alcohol consumption to an adverse pregnancy outcome is not well understood. The animal literature suggests that male exposure to alcohol might result in some damage to sperm, and thus affect the fetus. Data from animal models suggest that paternal alcohol exposure may affect organ weights, hormone secretion, and immune response in the offspring (Abel, 1993; Abel and Blitzke, 1990; Abel and Tan, 1986; Cicero, 1994; Hazlett et al., 1989), but paternal consumption of alcohol does not cause FAS. Since women who drink heavily tend to associate with men who also drink heavily (Jacob and Premer, 1986; Russell, 1991), and many children with FAS have fathers who abuse alcohol (Abel, 1983), there is a possibility that some of the anomalies now attributed to the teratogenic effects of maternal drinking may be exacerbated by paternal drinking. Clarification of this issue, including the possible mechanisms of paternal alcohol effects, awaits further research.

OCR for page 112
Page 122 Regardless of whether future research indicates a direct role for prenatal paternal alcohol exposure in birth defects other than FAS, ARBD, and ARND, prevention efforts directed at men are appropriate and important for the influences that men have on women's drinking. For men, emphasis could be placed on the important social, psychological, and behavioral role they can play in supporting a healthy pregnancy. When appropriate, men should be encouraged to enter treatment for alcohol abuse, both for their own health and well-being and to make it easier for the pregnant woman to stop drinking. However, since many women who are at high risk for FAS are unmarried, in very unstable relationships, or both, it is important to tailor interventions to these situations. Contracts with other significant persons or with an entire at-risk community might be useful, including extended family, influential peers, and possibly bartenders. Boxes 7-2 and 7-3 represent family- and community-wide pledges related to drinking during pregnancy that are used by two Native American communities. These approaches seem to have promise for some communities but have not been evaluated. BOX 7-2 Sample Vision and Mission Statements Here is an excellent example of a vision and mission statement developed by the prevention leaders of the American Indian reservation community of Zuni Pueblo, New Mexico. It is positive, uplifting, value-oriented, and it encapsulates the cultural and humanitarian reasons for their FAS prevention efforts. It is also accompanied by a four-page list of problem statements, goals, objectives, barriers to overcome, and outcome measures. Vision Statement Zuni will be a community that affirms and accepts the cultural values of the sanctity of life and the values of women's and men's roles in nurturing the healthy development of infants and children. Young people will promote supportive roles for each other in developing healthy lifestyles with a sense of unity within the community. Mission Statement ''Keep the tradition by working together for generations of healthy babies." The FAS Coalition will promote the coordination of community services for prenatals and their families. Community resources will be committed to helping young people create healthy lifestyles within the Zuni culture. (Pueblo of Zuni, 1993)

OCR for page 112
Page 143 Post Partum Women and Their Infants (PPWI) program, administered by Substance Abuse and Mental Health Service Administration (SAMHSA) with funds contributed also by the Maternal and Child Health Bureau (MCHB) of Health Resources and Services Administration (HRSA), sponsored 147 demonstration-type programs for substance-abusing pregnant or postpartum women (National Center for Education in Maternal and Child Health, 1993). The types of interventions used in these programs were common sense approaches that seem, on consideration, to be reasonable. However, the program evaluation components are typically weak. For example, only half of the projects in existence in fiscal year 1993 had any type of evaluation. Most of these were pre- and posttest assessments of knowledge, attitudes, and beliefs. Of those, only half had a comparison group. Of those with a comparison group, a common comparison was with women who refused to participate in the program. Obviously, these programs provide important services to women in need but contribute little to a firm understanding of whether a program of interventions is effective at improving maternal and infant outcome or not. Setting up an FAS prevention initiative with programmatic goals and objectives will facilitate evaluation of programs with multiple outcome measures, e.g., maternal outcome such as reducing alcohol consumption and infant outcome such as birth weight or FAS symptoms. Many prevention activities are evaluated for process outcomes only. In these cases, FAS is not the outcome measure. Rather, process evaluations focus on the number of women who enroll in the program, how many complete the program, and the like. The outcome measure of prime importance, however, would be changes in the incidence of FAS. Establishing the baseline prevalence of FAS in a community is the ideal first step in directly assessing the outcome of prevention efforts (May and Hymbaugh, 1983; May et al., 1983; Plaisier, 1989). This is a difficult outcome measure to use for several reasons. First, FAS is not very common. As described in Chapters 4 and 5, FAS is frequently difficult to diagnose except by highly trained persons. Thus, only large prevention programs with solid financial resources to include assessment by trained medical personnel would be able to detect changes in FAS incidence. Therefore, proxy measures must frequently be used. As described in Chapter 5, proxy measures of infant outcome could be used. These might include the components most recognizable or easy to measure of the FAS diagnosis, such as head circumference or birth weight. Measuring knowledge gain and retention (Little et al., 1981, 1983; May and Hymbaugh, 1989), opinion and attitude changes, and surveys of behavior change all are possible proxy measures of success or failure in maternal outcome. However, they frequently represent measures of success with that part of the population at least risk for FAS, the moderate or minimal drinkers. For those at high risk, changes in relevant behavior are the most reasonable proxy measures. Thus, levels of drinking during

OCR for page 112
Page 144 pregnancy must be assessed reliably and routinely. Research is needed to suggest the most sensitive and cost-effective proxy measures of FAS for these purposes. PUBLIC HEALTH SERVICE-FUNDED RESEARCH The National Institute of Alcohol Abuse and Alcoholism (NIAAA) funds or has funded several projects that would provide fundamental information necessary for the design of prevention intervention projects (e.g., on health beliefs and knowledge about alcohol use in pregnancy, the impact of alcohol warning labels, the development of laboratory tests to detect alcohol abuse). Many of the projects funded through the NIAAA alcohol and pregnancy program are more basic studies using animal models or human in vitro methods. The importance and utility of these clinical and animal studies is explained throughout the report. The mainstays of clinical research projects have been the long-term follow-up studies of alcohol exposure during pregnancy (i.e., the Cleveland, Pittsburgh, Seattle, Detroit, and Atlanta projects referred to repeatedly in the text of this report). These projects have provided much important information used for diagnosis and for the epidemiologic study of the effects of less than heavy alcohol consumption. Identifying women who have given birth to a child affected by alcohol, even if not affected by FAS, ARBD, or ARND, is an important component of indicated prevention efforts. Other programs within NIAAA provide or could provide information potentially relevant to FAS prevention. For example, many of the prevention and treatment projects aimed at alcohol abuse in general, and epidemiological studies of women in the general population, might provide information translatable to pregnant women. Most of the prevention and treatment projects, however, as pointed out in the previous section, do not currently focus on pregnant women or even on women. Nevertheless, NIAAA-funded research has elucidated fundamentals of alcohol abuse prevention and treatment in general, and some projects funded in the future could focus on or at least include women and pregnant women. Several of the CDC state-based prevention projects are involved in what the committee would consider universal prevention activities. The Colorado project is embarking on developing statewide media campaigns about FAS. The Alaska project is identifying statewide information and awareness needs about FAS and is working to identify how prepared health care providers feel about discussing alcohol issues with patients, including their comfort level with referring those in need for treatment. FAS workers in Oklahoma are developing and implementing education programs about FAS targeted to health care providers. The project in South Dakota, which is conducted in conjunction with the Indian Health Service, is working to change community attitudes toward drinking during pregnancy. There are currently no firm data from any of these projects with which to ascertain

OCR for page 112
Page 145 their effectiveness—data that are crucial for decisionmakers who need to prioritize their increasingly sparse public health prevention resources. Several of the CDC state and university projects involve activities that the committee would consider selective interventions. Many (e.g., Colorado, Kansas, and South Dakota) are explicitly working on identification of women at risk for substance abuse. The projects in Georgia, Colorado, and Oklahoma include the development of training materials for professionals to identify women at high risk for FAS. Two demonstration projects in Missouri offer alcohol education to high-risk women (i.e., women encountered in the Division of Family Services Alternate Care Program). The Missouri project will also offer family planning services to women in substance abuse treatment programs. The University of Cincinnati project is using a randomized controlled methodology comparing standard care versus intensive, prenatal intervention with pregnant drinkers. The outcome measures in this project will include maternal and infant characteristics. The committee identified at least two CDC FAS prevention projects that are involved in gathering fundamental information relevant for what the committee defines as indicated prevention programs. The Alaska project is examining the social, medical, and reproductive histories of women who have given birth to at least one FAS child. The data could then be used as a framework for developing interventions aimed at these highest-risk mothers. The state-based program in Washington also includes efforts to identify characteristics of the biological mothers of FAS children and to identify, locate, track, and follow-up the biological mothers of children identified in the University of Washington FAS clinic. SUMMARY The detailed prevention measures described above represent a progression through a spectrum. Universal prevention is used to promote general knowledge and social conditions that serve to reduce substance abuse and to promote healthy pregnancy practices. Selective prevention targets groups that include people at risk. Indicated prevention is applied to individuals identified as at risk for adverse outcomes. The effects of heavy and persistent alcohol abuse on pregnancy are already established. If a woman or couple has diagnosed problems of alcohol or substance abuse, specific steps, indicated prevention action, must be taken to break the causal chain and to adapt to the needs and problems created by the maternal behavior. Such treatment steps for the mother are preventive for FAS. The women who drink most heavily are the least likely to lower their alcohol consumption on their own during pregnancy, and they compromise their own welfare as well as the well-being of the larger community (May, 1991). Women who continue to participate in substance abuse and risky pregnancy practices, despite attempts at motivation and empathic approaches to change, are candidates for very intensive treatment. At advanced stages of heavy drinking and alcohol abuse, a woman may no

OCR for page 112
Page 146 longer be able to control her own health status (due to social, economic, medical, and psychological barriers). For such a woman, treatment for alcohol abuse as a means to prevent FAS could also be a means to enhance her ability to reduce her disability and to reenter a state of health, healthy behavior, and mainstream society. Many women who drink heavily are ostracized, which may discourage their entry into treatment or reentry to mainstream society (Blume, in press; May et al., 1983). The indicated level of prevention, alcohol treatment, and maintenance, when facilitated by well-trained case managers, can provide such a vehicle. If one wants to reduce the prevalence of FAS in a short period of time, using case-managers to institute indicated prevention, treatment, and aftercare might effect such change (Masis and May, 1991). Recent studies show that while approximately 20 percent of all women continue to drink during pregnancy, most women reduce their consumption during pregnancy. Furthermore, women who abuse alcohol are a small subset of drinking women (Grant et al., 1994; Serdula et al., 1991). Therefore, indicated prevention, treatment, and aftercare are considered necessary only for a small proportion of the population. RECOMMENDATIONS • The committee recommends that until such time as clear dose-response relationships are established, pregnant women and those about to become pregnant be counseled to avoid alcohol consumption throughout pregnancy. • The committee recommends greatly increased attention among sponsors of prevention initiatives, independent of the target population, to evaluating the effectiveness of programs implemented. This recommendation applies to all levels of prevention interventions. • The committee recommends that research efforts include comparisons of prevention methods at all levels in order to provide information to policy makers about relative costs and benefits. Indicated prevention interventions: • The committee recommends that a high priority be placed on research efforts to design, implement, and evaluate prevention interventions that can effectively guide pregnant women who drink heavily to alcohol treatment. Research or programs should also include:   — implementation of appropriate screening tools, including biomarkers of alcohol exposure, to identify women who are drinking moderate to heavy amounts of alcohol during pregnancy;   — assessment of methods to involve women's partners and family members in interventions to decrease or stop drinking;   — incorporation of comprehensive reproductive counseling and contraceptive

OCR for page 112
Page 147     services in prevention and treatment programs for substance-abusing women;   — assessment of the effectiveness and economic benefits of protocols for case management and follow-up of women, and of their families, who have given birth to a child affected by fetal alcohol exposure;   — development of training programs for professionals in the identification of heavy drinking, and referral to appropriate regional centers or prevention services;   — use of multiple outcome measures to assess the effectiveness of prevention initiatives; and   — basic research in animal models to elucidate further the mechanisms of alcohol teratogenesis, which might lead to pharmacologic or other strategies for amelioration of the effects of alcohol exposure in utero. Selective prevention interventions: • The committee recommends increased research efforts to design, implement, and evaluate selective prevention interventions to decrease risks of FAS, ARND, and ARBD through programs aimed toward women who are pregnant or may become pregnant, and who drink alcohol. Designing such interventions will be aided by further research assessing the contribution of personal and socio-environmental risk and protective factors that affect levels of drinking by women during pregnancy. • Where the utility of specific intervention programs has been established, the committee recommends broad implementation of successful prevention interventions. Programs developed or studied should include the following:   — specific demographic groups that have been demonstrated to be at higher risk for FAS, ARBD, and ARND, as well as those who exhibit risk factors associated with moderate to heavy alcohol consumption during pregnancy; and   — implementation of prevention efforts in a wide range of communities and media; Universal prevention interventions: • The committee recommends that although data are insufficient regarding the effectiveness of universal prevention interventions, such interventions should be continued to raise awareness about the risks of FAS, ARBD, and ARND. However, the most important approach to universal prevention is probably the development of a medical environment in which concepts of the risk of FAS, ARBD, and ARND are incorporated into routine health care. Further education efforts to reach children and adults about FAS, ARBD, and ARND through health educational curricula and other means are recommended.

OCR for page 112
Page 148 REFERENCES Abel EL. Marihuana, Tobacco, Alcohol, and Reproduction. Boca Raton, FL: CRC Press, 1983. Abel EL. Fetal alcohol syndrome in families (Commentary). Neurotoxicology and Teratology 1988; 10:12. Abel EL. Rat offspring aired by males treated with alcohol. Alcohol 1993; 10:237-242. Abel EL, Bilitzke PB. Paternal alcohol exposure: Paradoxical effect in mice and rats. Psychopharmacology 1990; 100:159-164. Abel EL, Sokol RJ. Maternal and fetal characteristics affecting alcohol's teratogenicity. Neurobehavioral Toxicology and Teratology 1986; 8:329-334. Abel EL, Tan SE. Effects of paternal alcohol consumption on pregnancy outcome in rats. Neurotoxicology and Teratology 1986; 10:167-192. Addiction Research Foundation of Ontario, Canadian Centre on Substance Abuse. Appendix 1—Moderate drinking and health: A joint policy statement based on the International Symposium on Moderate Drinking and Health, April 30-May 1, 1993, in Toronto, Canada. Canadian Medical Association Journal 1994; 151:821-824. Adger H, McDonald EM, DeAngelis C. Substance abuse education in pediatrics. Pediatrics 1990; 86:555-560. American College of Obstetricians and Gynecologists. Substance Abuse in Pregnancy. ACOG Technical Bulletin 195:1994. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: 3rd Edition. Washington, DC: APA, 1980. Anton RF, Moak DH. Carbohydrate-deficient transferrin and -glutamyltransferase as markers of heavy alcohol consumption: gender differences. Alcoholism: Clinical and Experimental Research 1994; 18:747-754. Ashley MJ, Ferrence R, Room R, Rankin J, Single E. Moderate drinking and health: Report of an international symposium. Canadian Medical Association Journal 1994; 151:809-828. Babor TF. Avoiding the horrid and beastly sin of drunkenness: Does dissuasion make a difference? Journal of Consulting and Clinical Psychology 1994; 62:1127-1140. Bacon FS. Counseling aspects of alcohol use in pregnancy—Beyond primary prevention. Alcoholism treatment quarterly 1988; 5:257-267. Bingol N, Schuster C, Fuchs J, Iosub S, Turner G, Stone RK et al. Influence of socio-economic factors on the occurrence of Fetal Alcohol Syndrome. Advances in Alcohol and Substance Abuse 1987; 6:105-118. Bloom M. Primary Prevention: The Possible Science. Englewood Cliffs, New Jersey: Prentice-Hall, Inc., 1981. Blume SB. Women and Alcohol: Issues in Social Policy in Alcohol and Gender. R. W. Wilsnack and S. C. Wilsnack (eds.). New Brunswick, New Jersey: Rutgers University Center of Alcohol Studies, in press. Bowen OR, Sammons JH. The alcohol-abusing patient: A challenge to the profession. Journal of the American Medical Association 1988; 260:2267-2270. Bradley KA, Larson EB. Training physicians to help patients who drink too much [editorial; comment]. Journal of General Internal Medicine 1994; 9:296-298. Brown RT, Coles CD, Smith IE, Platzman KA, Silverstein J, Erickson S et al. Effects of prenatal alcohol exposure at school age. II. Attention and behavior. Neurotoxicology and Teratology 1991; 13:369-376. Carroll KD, Change G, Behr H, Clinton B, Kosten TR. Improving treatment outcome in pregnant methadone-maintained women: Results from a randomized clinical trial. American Journal on Addictions 1995; 4:56-59. Casswell S, Gilmore L. An evaluated community action project on alcohol. Journal of Studies in Alcohol 1989; 50:339-346.

OCR for page 112
Page 149 Cefalo RC, Moos MK. Preconceptional Health: A Practical Guide. St. Louis: Mosby, 1995. Centers for Disease Control and Prevention. Update: Trends in fetal alcohol syndrome—United States, 1979-1993. Morbidity and Mortality Weekly Report 1995a;44:249-251. Centers for Disease Control and Prevention. Sociodemographic and behavioral characteristics associated with alcohol consumption during pregnancy—United States, 1988. MMWR 1995b; 44:261-264. Chavkin W. Mandatory treatment for drug use during pregnancy. Journal of the American Medical Association 1991; 266:1556-1561. Chavkin W, Kandall SR. Between a "Rock" and a hard place: Perinatal drug abuse. Pediatrics 1990; 85:223-225. Cicero TJ. Effects of paternal exposure to alcohol on offspring development. Alcohol Health & Research World 1994; 18:37-41. Clarren SK. Recognition of fetal alcohol syndrome. Journal of the American Medical Association 1981; 245:2436-2439. Coles CD, Smith IE, Fernhoff PM, Falek A. Neonatal ethanol withdrawal: Characteristics in clinically normal, nondysmorphic neonates. Journal of Pediatrics 1984; 105:445-451. Coles CD, Smith I, Fernhoff PM, Falek A. Neonatal neurobehavioral characteristics as correlates of maternal alcohol use during gestation. Alcoholism: Clinical and Experimental Research 1985; 9:454-460. Coles CD, Smith IE, Lancaster JS, Falek A. Persistence over the first month of neurobehavioral alterations in infants exposed to alcohol prenatally. Infant Behavior and Development 1987; 10:23-37. Coles CD, Brown RT, Smith IE, Platzman KA, Erickson S, Falek A. Effects of prenatal alcohol exposure at 6 years: I. Physical and cognitive development. Neurotoxicology 1991; 13:1-11. Davis A, Lipson A. A challenge in managing a family with Fetal Alcohol Syndrome. Clinical Pediatrics 1984; 23:304. Davis JH, Frost WA. Fetal Alcohol Syndrome: A challenge for the community health nurse. Journal of Community Health Nursing 1984; 1:99-110. Day NL, Cottreau CM, Richardson GA. The epidemiology of alcohol, marijuana, and cocaine use among women of childbearing age and pregnant women. Clinical Obstetrics and Gynecology 1993; 36:232-245. Day NL, Robles N, Richardson G, Geva D, Taylor P, Scher M et al. The effects of prenatal alcohol use in the growth of children at three years of age. Alcoholism: Clinical and Experimental Research 1991; 15:67-71. Day N, Richardson G, Robles N et al. Effect of prenatal alcohol exposure on growth and morphology of the offspring at age three. Poster presented at ISBRA/RSA Congress, June 17-22, 1990, Toronto, Canada. Dahlgren L, Willander A. Are special facilities for female alcoholics needed? A controlled 2-year follow-up study from a specialized female unit (EWA) versus a mixed male/female treatment facility. Alcoholism: Clinical and Experimental Research 1989; 11:499-504. Dorris M. The Broken Cord. New York: Harper & Row, 1989. Dufour MC, Williams GD, Campbell KE, Aitken SS. Knowledge of FAS and the risks of heavy drinking during pregnancy, 1985 and 1990 [NIAAA's Epidemiologic Bulletin No. 33]. Alcohol Health & Research World 1994; 18:86-92. Ewing JA. Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association 1984; 252:1905-1907. Faden VB, Graubard BI, Dufour M. Drinking by expectant mothers—What does it mean for their babies? Working paper, Division of Biometry and Epidemiology, National Institute on Alcohol Abuse and Alcoholism 1994.

OCR for page 112
Page 150 Faden VB, Hanna EZ. Alcohol and pregnancy—To drink or not to drink? Paper Presented at the Conference on Psychosocial and Behavioral Factors in Women's Health. American Psychological Association, Washington, DC 1994. Fetal Alcohol Prevention and Education Family Album, Developed by the Spokane Tribe of Indians Fetal Alcohol Program; Spokane Tribal Community Action Team, Wellpinit, Washington. Finkelstein N. Treatment programming for alcohol and drug-dependent pregnant women. International Journal of the Addictions 1993; 28:1275-1309. Fitzgerald P. FAS persists despite broad public awareness. Michigan Medicine 1988; May, 262-268. Fuchs CW, Stampfer MD, Colditz GA, Giovannucci EL, Manson JE, Kawachi I et al. Alcohol consumption and mortality among women. New England Journal of Medicine 1995; 19:1245-1250. Galanter M. (ed.) Recent Developments in Alcoholism. Volume XII: Alcoholism in Women: The effect of gender. New York: Plenum, in press. Geshan S. A Step Toward Recovery: Improving Access to Substance Abuse Treatment for Pregnant and Parenting Women. DC: Southern Regional Project on Infant Mortality, 1993. Gjerde H, Johnson J, Bjorneboe A, Bjorneboe GEA, Morland J. A comparison of serum carbohydrate-deficient transferrin with other biological markers of excessive drinking. Scandinavian Journal of Clinical Laboratory Investigation 1988; 48:106. Gomberg ESL, Nirenberg RD (eds.). Women and Substance Abuse. Norwood, New Jersey: Ablex, 1993. Gordon RS, Jr. An operations classification of disease prevention. Public Health Reports 1983; 98:107-109. Gordon R. An Operational Classification of Disease Prevention. Preventing Mental Disorders. J. A. Steinberg and M. M. Silverman (eds.). Rockville, MD: National Institute of Mental Health, 1987. Grant BF, Harford TC, Dawson DA, Chou P, DuFour M, Pickering R. Prevalence of DSM-IV alcohol abuse and dependence United States, 1992. Alcohol Health and Research World 1994; 18:243-248. Halvorson MR, Campbell JL, Sprague G, Slater K, Noffsinger JK, Peterson CM. Comparative evaluation of the clinical utility of three markers of ethanol intake: The effect of gender. Alcoholism: Clinical and Experimental Research 1993a; 17:225. Halvorson MR, Noffsinger JK, Peterson CM. Studies of whole blood-associated acetaldehyde levels in teetotalers. Alcohol 1993b; 19:409-413. Hankin JR. FAS prevention strategies: Passive and active measures. Alcohol Health & Research World 1994; 18:62-66. Harouki R, Chobert MN, Finidori J, Aggerbeck M, Nalpas B, Hanoune J. Ethanol effects in a rat hepatoma cell line: Induction of gamma glutamyl transferase. Hepatology 1983; 3:323-329. Hazlett LD, Barrett RP, Berk RS, Abel EL. Maternal and paternal alcohol consumption increase offspring susceptibility to P. aeruginosa ocular infection. Ophthalmic Research 1989; 21:381-387. Higgins ST, Budney AJ, Bickel WK, Hughes JR. Achieving cocaine abstinence with a behavioral approach. American Journal of Psychiatry 1993; 150:763-769. Higgins ST, Budney AJ, Bickel WK, Foerg FE, Donham R, Budger GJ. Incentives improve outcome in out-patient behavioral treatment of cocaine dependence. Archives of General Psychiatry 1994; 51:568-576. Holder HD, Longabaugh R, Miller WR, Robonis AV. The cost effectiveness of treatment for alcohol problems: A first approximation. Journal of Studies on Alcohol 1991; 52:517-540. Humphrey K, Marvis B, Stofflemavr B. Factors predicting attendance at self-help after substance abuse treatment: Preliminary findings. Journal of Consulting and Clinical Psychology 1991; 59:591-593.

OCR for page 112
Page 151 Institute of Medicine. Broadening the Base of Treatment of Alcohol Problems. Washington, DC: National Academy Press, 1990. Institute of Medicine. Disability in American. Washington, DC: National Academy Press, 1991. Institute of Medicine. Reducing Risks for Mental Disorders: Frontiers for Prevention Intervention Research. Washington, DC: National Academy Press, 1994. Institute of Medicine. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: National Academy Press, 1995. Jacob T., Premer DA. Assortive mating among men and women alcoholics. Journal of Studies on Alcohol 1986; 47:219-222. Jacobson JL, Jacobson SW. Prenatal alcohol exposure and neurobehavioral development: Where is the Threshold? Alcohol Health & Research World—[Special Focus: Alcohol-Related Birth Defects]. Dianne M. Welsh (ed.). 18. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism: 1994:30-36. Jessup M, Green JR. Treatment of the pregnant alcohol-dependent woman. Journal of Psychoactive Drugs 1987; 19:193-203. Kadden RM, Cooney NL, Getter H, Litt M. Matching alcoholics to coping skills or interactional therapies: Posttreatment results. Journal of Consulting and Clinical Psychology 1989; 57:698-704. Korri UM, Nuutinen H, Salaspuro M. Increased blood acetate: A new laboratory marker of alcoholism and heavy drinking. Alcoholism: Clinical and Experimental Research 1985; 9:468-471. Little R, Grathwohl HL, Streissguth AP, McIntyre C. Public knowledge about the risks of drinking during pregnancy in Multnomah County, Oregon. American Journal of Public Health 1981; 71:312-314. Little RE, Streissguth AP, Guzenski GM, Grathwohl HL, Blumhagne JM, McIntyre CE. Change in obstetrician advice following a two-year community educational program on alcohol use and pregnancy. American Journal of Obstetrics and Gynecology 1983; 146:23-28. Masis KB, May PA. A comprehensive local program for the prevention of fetal alcohol syndrome. Public Health Reports 1991; 106:484-489. Mausner JS, Kramer S. Epidemiology: An introductory text. Philadelphia: W. B. Saunders Co., 1985. May PA. Fetal alcohol effects among North American Indians: Evidence and implications for society. Alcohol Health & Research World 1991: 15(3):239-248. May PA. The epidemiology of alcohol abuse among American Indians: The mythical and real properties. Journal of American Indian Culture 1994; 18:121-143. May PA. Research issues in the prevention of fetal alcohol syndrome (FAS) and alcohol-related birth defects (ARBD). Prevention Research on Women and Alcohol. E. Taylor, J. Howard, P. Mail, M. Hilton (eds.). Washington, DC: U.S. Government Printing Office, in press. May PA, Hymbaugh KJ, Aase JM, Samet JM. Epidemiology of fetal alcohol syndrome among American Indians of the Southwest. Social Biology 1983; 30:374-387. May PA, Hymbaugh KJ. A macro-level fetal alcohol syndrome prevention program for Native Americans and Alaska Natives: Description and evaluation. Journal of Studies on Alcoholism 1989; 50:508-518. May PA, Hymbaugh KJ. A pilot project on fetal alcohol syndrome among American Indians. Alcohol Health & Research World 1983; 7:3-9. McLellan AT, Alterman AI, Metzger DS, Grissom GR, Woody GE, Luborsky L, O'Brien CP. Similarity of outcome predictors across opiate, cocaine, and alcohol treatments: Role of treatment services. Journal of Consulting and Clinical Psychology 1994; 62:1141-1158. Mihas AA, Tavassoli M. Laboratory markers of ethanol intake and abuse: A critical appraisal. American Journal of Medical Sciences 1992; 303:415-428. Miller WR, Hester RK. The effectiveness of alcoholism treatment: What research reveals. Treating additive behaviors: Processes of change. W.R. Miller and R.K. Hester (eds.). New York: Plenum, 1986:121-174.

OCR for page 112
Page 152 Miller WR, Rollnick S. Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford, 1991. Mosher JF, Jernigan DW. New directions in alcohol policy. Annual Review of Public Health 1989; 10:245-279. Mullen PC, Glenday MA. Alcohol Avoidance Counseling in Prenatal Care. New Perspectives on Prenatal Care. I. R. Merkatz, J. E. Thompason (eds.), P. D. Mullen and R. L. Goldenberg, (Assoc. eds.). New York: Elsevier, 1990. National Center for Education in Maternal and Child Health. Prevention of Perinatal Substance Use: Pregnant and Postpartum Women and Their Infants Demonstration Grant Program—Abstracts of Active Projects Fiscal Year 1993. Arlington, VA: National Center for Education in Maternal and Child Health. 1993. National Institute on Alcohol Abuse and Alcoholism. Alcoholism and alcohol abuse among women: Research issues (NIAAA Research Monograph No. 1). Washington, DC: U. S. Department of Health, Education and Welfare (Publication No. ADM 80-835), 1980. National Institute on Drug Abuse. NIDA survey examines extent of women's drug use during pregnancy. NIDA Media Advisory. Rockville, MD: NIDA, 1994. Niemelä O, Halmemake E, Jlikorkala O. Hemoglobin-acetaldehyde adducts are elevated in women carrying alcohol-damaged fetuses. Alcohol: Clinical and Experimental Research 1991; 15:1007-1010. Peterson CM, Ross SL, Scott BK. Correlation of self-administered alcoholism screening test with hemoglobin-associated acetaldehyde. Alcohol 1990; 7:289-293. Plaisier KJ. Fetal alcohol syndrome prevention in American Indian communities of Michigan's upper peninsula. American Indian and Alaska Native Mental Health Research 1989; 3:16-33. Rosett HL, Weiner L. Identifying and treating pregnant patient at risk from alcohol. Canadian Medical Journal 1981a; 125:149-154. Rosett HL, Weiner L, Edelin KC. Strategies for prevention of fetal alcohol effects. Obstetrics and Gynecology 1981b; 57:1-7. Russell M. Clinical implications of recent research on the fetal alcohol syndrome. Bulletin of the New York Academy of Medicine 1991; 67:207-222. Russell M. New assessment tools for risk drinking during pregnancy. Alcohol Health and Research World 1994; 18:55-61. Savitz DA, Schwingl PJ, Keels MA. Influence of paternal age, smoking, and alcohol consumption on congenital anomalies. Teratology 1991; 44:429-440. Savitz DA, Zhang J, Schwingl P, John EM. Association of paternal alcohol use with gestational age and birth weight. Teratology 1992; 46:465-471. Selzer ML. The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry 1971; 127:1653-1658. Serdula M, Williamson DF, Kendrick JS, Anda RF, Byers T. Trends in alcohol consumption by pregnant women: 1985 through 1988. Journal of the American Medical Association 1991; 265:876-879. Single E. The control of public drinking: The impact of the environment on alcohol problems. Control Issues in Alcohol Abuse Prevention: Strategies for States and Communities. H.D. Holder (ed.). Greenwich, CT: JAI Press, 1987. Smith IE, Coles CD, Lancaster JS, Fernhoff PM, Falek A. The effect of volume and duration of prenatal ethanol exposure on neonatal physical and behavioral development. Neurobehavioral Toxicology and Teratology 1986;8:375-381. Smith IE, Lancaster JS, Moss-Wells S, Coles CD, Falek A. Identifying high-risk pregnant drinkers: biological and behavioral correlates of continuous heavy drinking during pregnancy. Journal of Studies on Alcohol 1987; 48:304-309. Sokol RJ, Martier SS, Ager JW. The T-ACE questions: Practical prenatal detection of risk-drinking. American Journal of Obstetrics and Gynecology 1989; 160:863-868.

OCR for page 112
Page 153 Sokol RJ, Miller SI, Reed G. Alcohol abuse during pregnancy: An epidemiological study. Alcoholism: Clinical and Experimental Research 1980; 4:135-145. Sokol RJ, Miller SI, Martier S. Identifying the alcohol-abusing obstetric/gynecologic patient: A practical approach. Washington, DC: U.S. Department of Health and Human Services, NIAAA, (Publication No. ADM 81-1163), 1991. Stibler H, Borg S. Allgulander C. Clinical significance of abnormal microheterogeneity of transferrin in relation to alcohol consumption. Acta Medica Scandinavica 1979; 206:275-281. Stitzer ML, Iguchi MY, Kidorf M, Bigelow GE. Contingency management in methadone treatment: The case for positive incentives. Behavioral treatments for drug abuse and dependence. L.S. Onken, J.D. Blaine, J.J. Boren (eds.). Rockville, Maryland: National Institute on Drug Abuse, 1993. Storey EL, Anderson GJ, Mack U, Powell LW, Halliday JW. Desialylated transferrin as a serological marker of chronic excessive alcohol ingestion. Lancet 1987; 1:1292-1294. Streissguth AP, Aase JM, Clarren SK, Randels SP, LaDue RA, Smith DF. Fetal alcohol syndrome in adolescents and adults. Journal of the American Medical Association 1991; 265:1961-1967. Streissguth AP, Grant T, Ernst CC, Phipps P. Reaching out to the highest risk mothers: the Birth to 3 Project. Pregnancy & Health Studies, University of Washington, Seattle, Technical Report No. 93-02. April 27, 1993. Streissguth AP, LaDue RA, Randels SP. A Manual on Adolescents and Adults with FAS with Special Reference to American Indians. Rockville, MD: U.S. Indian Health Service, 1986. Toneatto A, Sobell LC, Sobell MB. Gender differences in the treatment of abusers of alcohol and other drugs. Journal of Substance Abuse 1992; 4:209-218. U.S. Department of Health and Human Services, Public Health Service, Office of Disease Prevention and Health Promotion (ODPHP). Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Conference Edition. U.S. DHHS: Washington, D.C., September 1990. U.S. Department of Health and Human Services. Alcohol and Health [Eighth Special Report to the U.S. Congress]. Washington, DC: U.S. Department of Health and Human Services, 1993. U.S. Public Health Service. Surgeon General's Advisory on Alcohol and Pregnancy. Food and Drug Administration Bulletin 1981; 11:9-10. Vanicelli M. Treatment outcome of alcoholic women. The state of art in relation to sex bias and expectancy effects. Alcohol Problems in Women. S.C. Wilsnack and L.J. Beclanan (eds.). New York: Guilford, 1984:369-412. Wallack L. Practical issues, ethical concerns and future directions in the prevention of alcohol-related problems. Journal of Primary Prevention 1984; 4:199-224. Waterson EJ, Murray-Lyon IM. Alcohol, smoking and pregnancy: Some observations on ethnic minorities in the United Kingdom. British Journal of Addiction 1989; 84:323-325. Waterson EJ, Murray-Lyon IM. Preventing alcohol related birth damage: A review. Social Science and Medicine 1990; 30:349-364. Weiner L, Morse BA, Garrido P. FAS/FAE: Focusing prevention on women at risk. International Journal of the Addictions 1989; 24:385-395. Wilsnack SC. Alcohol Use and Alcohol Problems in Women. Psychology of Women's Health: Progress and Challenges in Research and Application. A. L. Stanton and S. J. Gallant (eds.). Washington, DC: American Psychological Association, in press. Wilsnack SC. Patterns and trends in women's drinking: Recent findings and some implications for prevention. Prevention Research on Women and Alcohol. E. Taylor, J. Howard, P. Mail, M. Hilton (eds.). Washington, DC: U.S. Government Printing Office, in press. Wilsnack SC, Beckman LJ. Alcohol Problems in Women: Antecedents, Consequences, and Intervention. New York: Guilford Press, 1984. Wilsnack SC, Klassen AD, Schur BE, Wilsnack RW. Predicting onset and chronicity of women's problem drinking: A five-year longitudinal analysis. American Journal of Public Health 1991; 81:305-318.