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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