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Screening and recording of alcohol use among women of child-bearing age and pregnant women

February 2009
The Canadian journal of clinical pharmacology = Journal canadien de pharmacologie clinique 16(1):e242-63

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A woman's alcohol use during pregnancy is one of the top preventable causes of birth defects and developmental disabilities that are known as fetal alcohol spectrum disorders (FASD). The social and economic burden of FASD is substantial. Lifetime direct tangible costs per individual related to health care, education and social services in Canada have been estimated to be $1.4 million. Screening women of child-bearing age and pregnant women and recording their alcohol consumption is a practical process to identify and evaluate women at-risk and to identify potentially exposed infants. The FASD Advisory Workgroup proposes the following three levels of screenings which should be done on consenting women: Level I screening involves practice-based approaches that can be used by health care providers when talking to women about alcohol use, such as motivational interviewing and supportive dialogue. Level II screening includes a number of structured questionnaires that can be used with direct questioning (TLFB) or indirect /masked screening (AUDIT, BMAST / SMAST, CAGE, CRAFFT, T-ACE, TWEAK). Level III screening includes laboratory-based tools that can be used to confirm the presence of a drug, its level of exposure and determine the presence of multiple drugs. There are challenges and limitations in the use of the screening and assessment tools outlined. For example, the single question about alcohol use and the various questionnaires rely on a woman to provide details about her alcohol use. There is no consensus on the appropriate screening to use across Canada as each provincial / territorial jurisdiction, health care organization and healthcare provider uses a variety of formal and informal screening tool. In addition, there are inconsistent processes across Canada for the recording of the alcohol use in a woman's chart and the transfer of the information to the infant and the child's health records. The FASD Advisory Workgroup proposes eleven recommendations to improve the screening and recording processes for alcohol use in women of child-bearing age and pregnant women.

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Can J Clin Pharmacol Vol 16 (1) Winter 2009:e242-e263; April 16, 2009

242

SCREENING AND RECORDING OF ALCOHOL USE AMONG WOMEN

OF CHILD-BEARING AGE AND PREGNANT WOMEN

Moumita Sarkar, Toronto ON, Margaret Burnett, Winnipeg MB, Sarah Carrière, Ottawa ON, Lori Vitale

Cox, Elsipogtog NB, Colleen Ann Dell, Saskatoon SK, Holly Gammon, Winnipeg MB, Brian Geller,

Winnipeg MB, Lisa Graves, Montreal QC, Gideon Koren, Toronto ON, Lily Lee, Vancouver BC, Deana

Midmer, Toronto ON, Patricia Mousmanis, Richmond Hill ON, Nan Schuurmans, Edmonton AB, Vyta

Senikas, Ottawa ON, Danielle Soucy, Ottawa ON, Rebecca Wood, Winnipeg MB

ABSTRACT

woman’s alcohol use during pregnancy is

one of the top preventable causes of birth

defects and developmental disabilities that

are known as fetal alcohol spectrum disorders

(FASD). The social and economic burden of

FASD is substantial. Lifetime direct tangible costs

per individual related to health care, education and

social services in Canada have been estimated to

be $1.4 million.

Screening women of child-bearing age and

pregnant women and recording their alcohol

consumption is a practical process to identify and

evaluate women at-risk and to identify potentially

exposed infants.

The FASD Advisory Workgroup proposes

the following three levels of screenings which

should be done on consenting women:

Level I screening involves practice-based

approaches that can be used by health care

providers when talking to women about

alcohol use, such as motivational

interviewing and supportive dialogue.

Level II screening includes a number of

structured questionnaires that can be used

with direct questioning (TLFB) or indirect /

masked screening (AUDIT, BMAST /

SMAST, CAGE, CRAFFT, T-ACE,

TWEAK).

Level III screening includes laboratory-based

tools that can be used to confirm the presence

of a drug, its level of exposure and determine

the presence of multiple drugs.

There are challenges and limitations in the use of

the screening and assessment tools outlined. For

example, the single question about alcohol use

and the various questionnaires rely on a woman to

provide details about her alcohol use. There is no

consensus on the appropriate screening to use

across Canada as each provincial / territorial

jurisdiction, health care organization and health

care provider uses a variety of formal and

informal screening tool. In addition, there are

inconsistent processes across Canada for the

recording of the alcohol use in a woman’s chart

and the transfer of the information to the infant

and the child’s health records.

The FASD Advisory Workgroup proposes

eleven recommendations to improve the screening

and recording processes for alcohol use in women

of child-bearing age and pregnant women.

General Recommendations

1. Recognizing the importance of the health care

provider as an effective resource for harm

reduction, it is essential that adequate

community resources be made available for

women who require interventions beyond

primary interaction.

2. That research on the effects of alcohol use be

expanded to ensure there is sufficient

comparative evidence showing the effectiveness

of screening tools with particular cultural

groups.

3. That a public education / awareness program

be initiated to inform women they should

expect to be asked about the frequency and

amount of alcohol use and ensure that this

information is transmitted to all health care

providers involved in their care.

Screening and recording of alcohol use among women of child-bearing age and pregnant women

Can J Clin Pharmacol Vol 16 (1) Winter 2009:e242-e263; April 16, 2009

243

Recommendations Relative to Screening for

Alcohol Use:

4. That health care providers use a standardized,

universal set of questions routinely during

regular health exams that will include at least

Level I screening.

5. That Level II be adopted as the standard

screening process to identify alcohol use in all

women of child-bearing age and pregnant

women.

6. That health care providers be aware of the risk

factors that may inform their clinical

impression in combination with other

psychosocial assessment.

7. That health care providers access on-line

training tools for screening of FASD offered

by Best Start, Ontario’s maternal, newborn

and early child development resource centre

(www.beststart.org), and other resources offered

by programs such as PRIMA

(www.addictionpregnancy.ca), AADAC

(www.aadac.ca) and Motherisk

(www.motherisk.org). Resources are also

available from Healthy Choices in Pregnancy

program in British Columbia (www.hcip-

bc.org/resources_for_practice/default.htm)

and from the Canadian Centre for Substance

Abuse

(www.ccsa.ca/toolkit/introduction.htm).

8. That health care providers use Level III

screening methods when there is discordance

between Level I and Level II screening results

(e.g. frequency, perception of risk), or when

there are doubts unresolved by Levels I and

Level II screening.

Recommendations Relative to Recording Alcohol

Use:

9. That the frequency and amount of alcohol use

be recorded in a woman’s chart on a routine

basis and not only in relation to pregnancy.

10. That the information relative to frequency and

amount of alcohol use be recorded in the

woman’s chart and that this information be

transferred to appropriate health care

providers and health records to ensure a

continuum of care.

11. That information relative to frequency and

amount of a woman’s alcohol use during

pregnancy be routinely recorded in her

newborn’s chart and in her child’s health

records.

With this consensus report, the FASD Advisory

Workgroup aims to support health care

professionals in their role for the screening and

recording of alcohol use in all women of child-

bearing age and pregnant women. From this

document, health care providers will recognize the

importance of routinely asking women about

alcohol consumption, understand the need for and

effectiveness of using a screening tool to ask

women about alcohol use; recognize the

importance of recording information about a

woman’s alcohol consumption before, during and

after pregnancy; offer brief interventions to a

woman who is identified as drinking alcohol

during pregnancy or while planning a pregnancy;

and ensure appropriate documentation in a

newborn record and a child’s health record.

1. Introduction

Women’s use of alcohol is an important public

health and social issue in Canada. As alcohol use

during pregnancy is one of the leading

preventable causes of birth defects and

developmental delays in Canadian children. The

adverse effects of alcohol exposure during

pregnancy include fetal alcohol syndrome (FAS),

partial FAS, alcohol-related birth defects (ARBD)

and alcohol-related neurodevelopmental disorders

(ARND). These are diagnostic terms used to

describe conditions along this spectrum. Fetal

alcohol spectrum disorder is an umbrella term

used to describe all of the above related

conditions.1

Lemoine and colleagues first recognized a

variety of birth defects and developmental

disabilities in offspring born to alcoholic mothers

in 1968.1,2 The specific pattern of birth defects

associated with FAS consists of facial and

physical anomalies, impaired pre-natal or post-

natal growth (or both), and central nervous system

or neurobehavioral disorders. There is evidence

Screening and recording of alcohol use among women of child-bearing age and pregnant women

Can J Clin Pharmacol Vol 16 (1) Winter 2009:e242-e263; April 16, 2009

244

that alcohol acts through multiple mechanisms,

and a range of disabilities has been observed as a

result of damage during fetal development that

varies according to the timing, degree and pattern

of exposure.1

The diagnosis of FASD is complex. Because

it carries lifelong consequences, early recognition

of FASD can result in a better outcome for the

baby who receives a diagnosis. It is of utmost

importance to raise awareness of the impact of

alcohol use and to encourage the use of effective

screening tools and recording processes in order

to reduce the incidence of FASD.

In 1979, the Canadian Task Force on the

Periodic Health Examination found there was fair

justification for recommending the inclusion of

counselling to reduce the alcohol intake of

pregnant women in the periodic health

examination. This was based on evidence that

counselling proved effective in reducing the

amount of drinking in pregnant women and the

rate of morbidity in their offspring.3The evidence

compiled since 1979 supports this original

recommendation.

In order to provide prevention and

intervention programs and strategies to reduce the

incidence of FASD, maternal alcohol

consumption must be identified. Asking questions

about alcohol use during pregnancy is necessary

for gathering accurate and reliable information

that will initiate an appropriate intervention

program, as well as early diagnosis of babies

affected by prenatal alcohol exposure.

Health care professionals play a critical role

in screening women for alcohol use during

pregnancy. There is general agreement that

improvements in the use and implementation of

screening tools for alcohol use among women will

have a significant impact in decreasing the

incidence of FASD. However, there are currently

no standard screening approaches or tools

available in the clinical setting in Canada and

there are no processes in place to ensure

consistency in the recording of this information.

In a study that involved the collection of

information from Canadian health care

professionals, the majority of health care

professionals (93.6%) reported that they routinely

discussed current drinking patterns with pregnant

patients. However, only 62% reported using a

standardized screening tool.4Within the

framework of a project funded by the Public

Health Agency of Canada, the Society of

Obstetricians and Gynaecologists of Canada

established the FASD Advisory Workgroup in

June 2007. The purpose of this multi-stakeholder

group, that includes individuals with expertise in

FASD, is to analyze current screening tools and

available recording systems and to make

recommendations on the most appropriate

screening and recording process for

implementation in the clinical setting. This

initiative is an important component of the multi-

faceted approach implemented by the Public

Health Agency of Canada to decrease the

incidence of FASD.

The intent of this report is to provide an

overview of the tools and processes available for

the screening of alcohol use in women of child-

bearing age and pregnant women. The authors

provide practical tips and wording to use when

interacting with mothers or expecting women.

2. Scope of the Problem

Approximately 20% of women report that they

consume some alcohol during pregnancy.5A

Health Canada study reveals that women most

likely to miss being identified include those over

35 years of age, social drinkers, those who are

highly-educated, those with a history of sexual

and emotional abuse, and those of high

socioeconomic status.4

It is estimated that the prevalence of FASD is

9.1 per 1000 live births in the United States.1

Prevalence studies in some Aboriginal

communities in Canada indicate prevalence rates

as high as 190 per 1000 live births. It is generally

recognized that prevalence rates are higher in any

community where women of childbearing age

regularly consume alcohol.6

Data from the 2003 Canadian Perinatal

Health Report indicate that 14.6% of children

under the age of 2 years have mothers who

reported alcohol use during pregnancy.4Most

early research has focused on pregnant drinkers

with heavy alcohol use or dependence problems,

as it was thought that only heavy or binge

drinking could harm the developing fetus.7Sokol

et al originally defined risk drinking in pregnancy

as an average of two or more drinks daily.8

However, the definition of risk drinking has

changed over the years with recent research

Screening and recording of alcohol use among women of child-bearing age and pregnant women

Can J Clin Pharmacol Vol 16 (1) Winter 2009:e242-e263; April 16, 2009

245

suggesting adverse outcomes associated with

much lower levels of alcohol consumption.9

Children affected by prenatal alcohol

exposure may present with prenatal or postnatal

growth deficit but many can have normal growth.

Many have other physical features including

characteristic facial anomalies that are important

diagnostically. The most serious consequence of

prenatal exposure to alcohol has to do with the

effect of alcohol on the developing brain.

Children who are exposed are at risk for

significant learning, behavioural and cognitive

deficits.1

A study by Stade et al reports that the burden

of prenatal exposure to alcohol on children and

their families is profound. This study shows that

children and youth with FASD have significantly

lower health and quality of life outcomes than

children and youth from the general Canadian

population. Children with FASD struggle with

depression and anxiety; experience difficulties in

social interactions and relationships; and are often

seen as “bad children”.10

The economic burden of FASD is substantial.

Lifetime direct tangible costs per individual

related to health care, education and social

services in Canada have been estimated to be $1.4

million.11 Stade et al report the societal costs

associated with FASD include: direct costs (i.e.

medical, education, social services), out-of-pocket

costs, and indirect costs (i.e. productivity losses).

The total adjusted expenditure per child with

FASD is estimated to be $14,342 per year. The

severity of a child’s condition, the age of a child,

and geographical setting are important

determinants of costs. It is estimated that the cost

of FASD annually to Canada of those 1 to 21

years old is $344,208,000.12

3. The ScreeningProcess

Pregnant women should be informed that no safe

level of alcohol consumption during pregnancy

has been established. The Public Health Agency

of Canada recommends abstaining from alcohol

use during pregnancy. Women who have

consumed small amounts of alcohol before they

knew they were pregnant can be reassured that the

risk to their baby is small if they abstain from

further alcohol consumption, eat a balanced and

nutritional diet, and adopt a healthy lifestyle,

throughoutthe course of their pregnancy.

Some groups and health professionals still

maintain that there are safe guidelines for drinking

while pregnant, but the safety of mild drinking

cannot be proven.19 While a systematic review of

the effects of pre-natal exposure to low levels of

alcohol by Henderson et al13 indicated no

significant effects on physical development pre-

or post-natally, a meta-analytical review of the

research literature by Testa et al14 indicated

significant effects on mental development at age

12 months. Therefore, abstaining from alcohol use

is the only responsible approach for women who

are, or may become pregnant.

While the importance of the health care

provider as an effective information resource for

harm reduction is recognized, it is essential that

adequate community resources also be made

available for women who require interventions

beyond this primary interaction.

Screening for alcohol use in childbearing

women should be part of a comprehensive

psychosocial assessment. Psychosocial risk

factors for substance use may be part of many

Canadian women’s life experiences.

The ALPHA form (Antenatal Psychological

Health Assessment) is a validated ante-natal

psychosocial assessment form available at

http://dfcm19.med.utoronto.ca/research/alpha.

The ALPHA form contains questions relating

to family factors (social support, recent stressful

life events, the relationship of the couple, etc.),

maternal factors (self-esteem, mood disorders,

relationship with parents, etc.), substance abuse

issues (including partner’s substance use, poly-

drug use, etc.), and family violence (childhood

Experience of family violence, childhood sexual

abuse, intimate partner violence, etc.). The form is

available as either a self-completing or provider-

completing version for each use. By asking a

woman about the totality of her psychosocial

health, a provider can better understand the issues

that may lead to alcohol use. Additionally, by

using a standardized psychosocial assessment

instrument, which includes a section on substance

use, the woman may feel less vulnerable

responding to personal questions.

Screening and recording of alcohol use among women of child-bearing age and pregnant women

Can J Clin Pharmacol Vol 16 (1) Winter 2009:e242-e263; April 16, 2009

246

3.1 Maternal Alcohol Screening

The Canadian guidelines for diagnosis of fetal

alcohol spectrum disorder recommends the

screening of all pregnant and post-partum women

for alcohol use.

What ? A process to identify and evaluate

alcohol use that might put the mother-

child well-being at risk.

Who ? Women who are pregnant or of child-

bearing age.

Why ? Improved maternal-child health

outcomes through:

Early identification and reduction of

problem maternal drinking

Recording of maternal alcohol history on

a newborn’s birth record and in a child’s

health record

Early identification of exposed infants

Earlier diagnosis of FASD.

Maternal alcohol screening and recording by

health care providers could lead to a reduction of

primary FASD disabilities as well as reduction of

secondary disabilities often related to FASD in the

absence of diagnosis and appropriate

interventions.

“The earlier in pregnancy a woman can stop

drinking, the better the outcome; the younger the

age at which the affected child is identified, the

lower the frequency of secondary disabilities.”

Source: Helen Barr, Ann Streissguth. Identifying Maternal

Self-Reported Alcohol Use Associated with Fetal Alcohol

Spectrum Disorders. Alcohol Clini Res. Vol 25, No. 2. 2001.

3.2 Benefits of Identification of Problem

MaternalAlcohol Consumption

Identification of women who would benefit

from information about Health Canada’s

recommendations regarding safe drinking

levels pre-pregnancy and abstinence during

pregnancy.

Identification of pregnant women who could

benefit from information about FASD and the

possible effects of pre-natal alcohol exposure.

Identification of pregnant women or women

of child-bearing age who should be referred

for varying levels of drug and alcohol services

– assessment, counselling, detox or inpatient

treatment.

Referral of women who’s drinking might be

related to depression, abuse or other mental

health issues to the appropriate mental health

service.

4. Level I Screening - Practice-based Screening

Recent surveys of health professionals indicate

that some clinicians feel uncomfortable asking

about alcohol use.15,16 They may avoid the subject

of alcohol use entirely because they do not know

how to identify women who engage in at-risk

drinking without embarrassing or offending their

clients who are not consuming alcohol. Others

lack knowledge of the alcohol treatment and

counselling services that are available or reside in

areas that simply lack adequate services. Still

others may hesitate to screen because they are

pressed for time and screening for alcohol use

may seem to be beyond the scope of their practice.

Screening for alcohol use need not be

complicated, time consuming, or difficult. One or

two interview questions concerning alcohol use

have been shown to be an effective way to screen

women by identifying those who are drinking and

in need of education or intervention.17,18 Most

pregnant women appreciate their practitioner’s

concern for their health and the health of their

unborn baby. Women are especially open to

changing their lifestyle when they are pregnant if

they know that it will help their baby.

This offers practitioners an opportunity in

terms of motivating women to change at-risk

behaviours. Practitioners should inquire about a

woman’s alcohol consumption and provide

information about the effects of alcohol on the

unborn baby at the very first pre-natal visit or at a

preconception counselling visit.

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Can J Clin Pharmacol Vol 16 (1) Winter 2009:e242-e263; April 16, 2009

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Many women do not know that alcohol could

affect their unborn child. They may have been

told in the past by friends, relatives, or even other

health providers that drinking moderately during

pregnancy was acceptable. Many people are not

aware of recent research studies of large

population samples of pregnant women that prove

a dose-response effect of pre-natal alcohol

exposure. The children of mothers who drank at

low levels (less than one drink a day) were shown

to be at significant risk for problem behaviour.9

This does not mean that a woman who is drinking

at low levels will necessarily have a child with

behavioural problems, but it does mean that they

increase the probability of a problem.

There are several approaches that health care

providers can use when talking to women about

alcohol use during pregnancy. The initial inquiry

can be included as part of routine pre-natal

questioning regarding a healthy lifestyle during

pregnancy in terms of nutrition, exercise, and the

avoidance of environmental toxins such as

nicotine and second-hand smoke. Some

physicians choose to have women fill out written

questionnaires while they are waiting in the office.

Health providers may include one or more questions

regarding alcohol or they may embed standardized

alcohol screens in their questionnaires. For the

practitioner who chooses to use the single

question method, the following are questions

identified as being effective for establishing a

rapport and introducing a discussion about alcohol

use:

“When was the last time you had a drink?”

“Do you ever enjoy a drink or two?”

“Do you sometimes drink beer, wine or other

alcoholic beverages?”

“Do you ever use alcohol?”

“In the past month or two have you ever enjoyed a

drink or two?”

If the woman indicates she does not consume

alcohol, then positive reinforcement of her

lifestyle choice is beneficial. Research shows that

it is helpful to provide brochures and other

information about a healthy lifestyle during

pregnancy that includes details about alcohol

abstinence and the effects of alcohol on the

fetus.19,20 Any written information should be

provided in a way that is linguistically and

culturally sensitive.

If a woman indicates that she does consume

alcohol, then a second stage of screening is

necessary. This can be done using standardized

screening questionnaires such as the T-ACE or

TWEAK. Practitioners can also use this opportunity

to help pregnant women who are using alcohol with

abrief intervention (BI) in the office.

Research has shown that BIs can be very

useful in helping pregnant women who drink

mild-to-moderate amounts of alcohol to reduce

their alcohol intake during pregnancy. BI’s are

cost effective and can be implemented in a variety

of clinical settings.

BI’s normally include four components:

1)assessment and direct feedback after assessment;

2)goal setting through establishing contracts;

3) positive reinforcement; and

4)education through pamphlets and hand-outs for

self-help.21

4.1 Motivational Interviewing

Motivational interviewing is a relational model

that is based on collaboration between the health

professional and the woman seeking care.

Research shows it to be especially effective in an

office setting when health providers are helping

women who are drinking when pregnant, but not

addicted to alcohol.22 Women who are alcohol

dependent can be more resistant to change and

should be referred to counsellors who can devote

the time it takes to establish a collaborative

relationship.

4.2 Supportive Dialogue

A woman-centered approach has been found to be

effective in engaging a woman in the decision to

change behaviours. A non-judgmental approach is

especially helpful for women who drink heavily

and who may have other problematic substance

use issues. Engaging a woman in the decision-

making concerning her own care can increase her

will to change while minimizing resistance. Open-

ended questions allow the woman to expand on

her life circumstances. Practitioners might begin

by simply asking a woman what she has heard

about using alcohol during pregnancy. They can

use this as an opportunity to provide information

as well as to correct any misinformation.

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Can J Clin Pharmacol Vol 16 (1) Winter 2009:e242-e263; April 16, 2009

248

This can be followed by questions such as:

“Can you tell me a bit about your drinking patterns

before you knew you were pregnant?”

“Have you been able to stop or cut down since

you found out?”

“Do you have any concerns about your drinking?”

The woman may have concerns about

drinking before she knew she was pregnant and it

is at this time that the practitioner can reassure her

that if she cuts down or stops, she can help her

baby. It is also at this time that the practitioner

can offer help on how to cut down or to stop

drinking.

4.3 Interview Techniques for Effective

Engagement - “Do’s and Don’ts”

Due to concerns surrounding fear, guilt and

stigma, it is essential to utilize effective interview

techniques to engage women of childbearing age

in order to obtain an accurate alcohol use report.

These include empathetic listening, and non-

judgemental, non-confrontational questions that are

woman-centered. The following examples suggest

interview techniques for effective engagement.23

The following is an example of an introductory

statement that can be used in women of child-

bearing age:

“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 a better understanding

of what your day-to-day life is like

(in terms of diet, exercise and

other lifestyle issues). It will help

me to know you, and that will help

me to provide better care.”

The following is an example of an introductory

statement for pregnant women:

“I ask all my patients these

questions because it is important

to their health and the health of

their babies.”

Unless otherwise reported, assume use of alcohol

by all women. Try to pose questions in the past

tense to avoid triggers associated with the stigma

of alcohol use during pregnancy.

“In a typical week, how many

occasions did you usually have

something to drink?”

Avoid questions such as:

“Do you drink often?”

“How much are you drinking?”

To encourage more accurate reporting, one can

suggest high levels of alcohol consumption:

“And on those days, would it be

something like 3 to 4 drinks or

about 8 to 10 drinks?”

It is important to avoid questions that require a

“yes” or “no” response. It is preferable to ask

open-ended questions to open a dialogue, such as:

“What do you know about the

effects of drinking in pregnancy?”

In cases of confirmed or suspected history of past

alcohol dependency / abuse, the following

questions are suggested17:

“Have you ever had a drinking

problem?” followed by

“When was your last drink?”

Avoid statements that increase guilt in women

who admit to continued alcohol use:

“You can have a healthier baby if

you stop drinking for the rest of

the pregnancy.”

Avoid statements such as:

“You may have already hurt

your baby.”

5. Level II Screening - Structured Questionnaires

5.1.1 Direct Questioning

5.1.2 Time Line Follow Back Tool (TLFB)

The timeline follow-back method (TLFB) is an

assessment interview developed to assist

individuals in their recollection of alcohol

consumption.24 As risky (high-volume / binge)

drinking can occur in the absence of any alcohol

problems, direct questions regarding the quantity

and frequency (QF) of alcohol intake in the TLFB

method aim to identify risky drinkers. This

interview can assist in identifying women who

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Can J Clin Pharmacol Vol 16 (1) Winter 2009:e242-e263; April 16, 2009

249

would be otherwise missed by indirect questions

focusing on the consequences of heavy drinking.

The TLFB provides information on various

characteristics of a given patient’s drinking habits

– the average number of drinking days at higher

levels of alcohol consumption, the number of

abstinent days, the mean number of drinks per

drinking day, the maximum number of alcoholic

beverages consumed, and temporal patterns such

as weekend versus weekday drinking. From this

information, alcohol exposure can be examined,

based on the dose of daily exposure and the period

of fetal development during which the exposure

occurred.25

The TLFB is considered a useful and

accurate retrospective assessment of drinking and

has been shown to be both highly reliable and

valid when individually administered by an

interviewer over the telephone.26,27 Sacks et al also

reliably assessed substance use in psychiatric

populations using the TLFB method.28 Moreover,

this method is quite reliable when administered to

various patient groups cross-culturally and with

abuse of recreational drugs, other than alcohol.27

5.2 Indirect / Masked Screening

Direct questions about quantity and frequency

may pose challenges to the pregnant patient due to

the stigma associated with alcohol use. In order to

overcome issues of possible under-reporting and

denial of alcohol exposure in early pregnancy,

brief screening instruments that include masked

questions regarding alcohol intake were

developedand are outlined in this section.

5.2.1 The AUDIT Tool

The Alcohol Use Disorders Identification Test

(AUDIT) includes 10 questions that may be used

to obtain more qualitative information about a

patient’s alcohol consumption. Validated in 6

countries, the AUDIT is useful for identifying

hazardous and dependent drinking as it asks about

quantity and frequency of alcohol use, drinking

behaviour (i.e. binge drinking), and alcohol-

related problems or reactions. An important

limitation is the lack of a cut-off point indicating

harmful use. A score of 8 is associated with

problem drinking, while 13 or more is indicative

of alcohol dependence.

Relevant Research

The AUDIT tool was found to be somewhat

less sensitive to female alcohol abuse and

dependence than the TWEAK (sensitivity of

65% and specificity of 94% for alcohol

dependence and a very low sensitivity of 42%

and specificity of 97% for any type of alcohol

use).29

As a self-administered questionnaire completed

by a woman waiting for her appointment, the

AUDIT offers the advantage of obtaining

specific information regarding her alcohol

consumption and any presence of dependence

symptoms.

Compared to T-ACE, the AUDIT tool was

found to be slightly less sensitive to pre-natal

alcohol consumption in a sample of pregnant

women.30,31

Given that the AUDIT questionnaire has been

well-validated in the male population, Torres

and colleagues investigated its usefulness in

female patients to determine the test cut-off

point for the diagnosis of alcohol problems in

women. From the 414 women recruited, the

AUDIT tool was determined to be a

questionnaire with good psychometrics

properties and valid for detecting dependence

and risk alcohol consumption in women.32

5.2.2 The BMAST Tool / SMAST Tool

The Michigan Alcoholism Screening Test

(MAST) is a long questionnaire of 25 questions

about drinking behaviour and alcohol-related

problems that was originally developed for use

with men. There are several variations of MAST,

including modified versions such as brief MAST

(BMAST) and short MAST (SMAST). The main

disadvantage of these tests is their focus on the

lifetime use of alcohol rather than recent use

which subsequently limits their ability to detect

problem drinking at an early stage.

Scoring: <3 points (non-alcoholic); 4

points (suggestive of problem

drinking); 5 or more points

(indicates alcohol dependence).

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Relevant Research

The BMAST was shown to be relatively less

sensitive in detecting alcohol problems in

female drinkers compared to men using a cut-

off point of 6, in the non-Caucasian American

population.33

Both CAGE and the brief MAST

questionnaires performed effectively in

screening for significant alcohol problems in a

high-risk sample composed of relatives of

alcoholic subjects and also in a community

sample consisting of families not selected for

alcohol dependence disorder.34

As serious mental illnesses are frequently

diagnosed along with alcohol dependence

(“dual diagnosis”), it is important for

clinicians to be able to recognize the presence

of alcohol dependence in people with mental

illnesses. Breakey et al utilized the CAGE and

the SMAST, and a clinical DSM-III-R

diagnosis of alcohol use disorder and found

that both had good sensitivity. The addition

of either screener enhanced the clinicians’

ability to detect alcohol use disorders.35

The T-ACE, the AUDIT and the SMAST

tools were completed by 350 women initiating

pre-natal care at a Boston hospital to compare

their accuracy with clinical predictors in the

identification of prenatal alcohol use. The T-

ACE, the AUDIT and clinical predictors alone

correctly identified 65 to 70% of current

drinkers, whereas the SMAST alone

performed only slightly better than chance.

The predictive ability of the T-ACE was

further improved with the addition of clinical

predictors.36

The standardized evaluation of alcoholism

and other psychopathologies in (non-

pregnant) minority populations, particularly

American Indians, has long been questioned.

This study investigated the validity of

SMAST in two distinct American Indian

tribal groups from large community

representative samples of 456 South Western

and 214 Plains Indians. The SMAST cut-off

score of greater than or equal to 3 had a

sensitivity of 86% to 95%, but had lower

specificity (23%-47%). Authors concluded

that the SMAST is not a valid tool for the

screening of alcohol use in these two tribal

populations due to the highly elevated and

different thresholds required from one

population to the next.37

5.2.3 The CAGE Tool

One of the oldest brief screening instruments, the

CAGE (Cut-down, Annoy, Guilty, Eye-Opener)

questionnaire has been widely used in a range of

cultures worldwide and is popular for screening in

the primary care setting.38 This 4-item screening

instrument is designed to identify and assess

potential alcohol abuse and dependence.

However, it primarily focuses on the

consequences of drinking rather than the quantity

or frequency of alcohol use, levels of

consumption, or episodes of binge drinking - all

factors that help identify patients in the early

stages of problem drinking. An affirmative

response to 2 or more questions is an indication

that a more thorough assessment is warranted.

Relevant Research

The mode of administration for the CAGE

tool (as a self-report, or as part of a clinical /

medical interview) was not shown to have an

influence on accuracy of the outcome.39

Two large studies of disadvantaged, minority,

obstetric patients reported that the calculated

sensitivity and specificity of the T-ACE and

TWEAK were superior to the CAGE in

identifying risk drinking (defined as 1 ounce

or more of alcohol consumption per day).40

The CAGE tool shows less sensitivity for

assessing dependence or harmful drinking in

non-Caucasian women.33

Due to its lack of ability in distinguishing

between heavy and non-heavy drinkers in the

general population, clinical use of the CAGE

tool is recommended among individuals

previously identified as alcohol users rather

than screening individuals in the general

population.41

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The CAGE tool outperformed both the

BMAST and the AUDIT in predicting

lifetime alcohol dependence (highest

sensitivity at 84%; specificity at 90%) in

trauma center populations. It should be used

in combination with alcohol testing to

identify patients at risk of alcohol use

problems.42

5.2.4 The CRAFFT Tool

Researchers at the Children's Hospital in Boston

refined a brief questionnaire, called CRAFFT

(Car, Relax, Alcohol, Forget, Friends, Trouble)

that primary care physicians can use to screen for

alcohol or substance abuse problems in

adolescents. By drawing on situations that are

more suitable to this age group,the purpose of this

tool is to identify which teens require more time

for comprehensive evaluation such as a diagnostic

interview. This test can be administered by any

health care professional who can maintain

confidentiality and can refer the teen to

appropriate resources. A score of two or more

positive items usually indicates the need for

further assessment. The CRAFFT screening tool

is included in a policy statement issued by the

American Academy of Paediatrics, and has been

part of a national case-based training curriculum

in some paediatric residency programs.

Relevant Research

To validate the CRAFFT instrument, project

investigators interviewed and screened 538

adolescents at a Boston outpatient adolescent

clinic and compared their CRAFFT scores

with scores on 2 longer questionnaires that

previously had been shown to reliably identify

adolescents with substance abuse problems or

diagnoses. Findings: A score of 2 or more

proved to be the optimal cut-off for

identifying adolescents with alcohol or drug

problems(sensitivity at 0.76; specificity at

0.94), while a score of 4 or higher indicated

that the adolescent may be dependent on

drugs or alcohol (sensitivity at 0.92;

specificity at 0.80). The investigators

concluded that the CRAFFT screening tool

offers primary care providers a valid and

practical means of quickly identifying

adolescent patients who need more

comprehensive assessment or referral to

substance abuse treatment.43

A second study by the same authors compared

the validity of the CRAFFT questionnaire, the

AUDIT tool, the Problem Oriented Screening

Instrument for Teenagers substance use/abuse

scale (POSIT), and the CAGE tool among

adolescents from a hospital-based adolescent

clinic. Findings: Sensitivities (95%

confidence intervals) were AUDIT 0.88 (0.83-

0.93), POSIT 0.84 (0.79-0.90), CAGE 0.37

(0.29-0.44), and CRAFFT 0.92 (0.88-0.96);

specificities were AUDIT 0.81 (0.77-0.85),

POSIT 0.89 (0.86-0.92), CAGE 0.96 (0.94-

0.98), and CRAFFT 0.64 (0.59-0.69).

Authors concluded the AUDIT, POSIT, and

CRAFFT have acceptable sensitivity for

identifying alcohol problems or disorders in

this age group but the CAGE is not

recommended for use among adolescents.44

5.2.5 The T-ACE Tool

As the first validated screening questionnaire for

risk drinking developed for pregnant women, the

T-ACE (Tolerance, Annoyed, Cut down, Eye-

Opener) has been established as a highly effective

screening tool, and is regularly used by

practitioners as part of routine care.45 Any woman

who answers “more than two drinks” on the

tolerance question, “how many drinks does it take

to make you feel high?” is scored 2 points. Each

“yes” to the additional 3 questions scores 1. A

score of 2 or more out of 5 indicates risk of a

drinking problem, and the woman should be

referred for further assessment.

Relevant Research

The first study looked at a population of

African-American inner-city women and

found T-ACE (76% sensitivity and 79%

specificity) to be superior to both MAST

(76% sensitivity and 76% specificity) and

CAGE (59% sensitivity and 82% specificity)

in identifying pre-natal risk drinking.45

Chang et al subsequently tested the T-ACE as

a self-administered, independent screening

tool embedded in a health-habits survey with

questions about smoking, stress, weight, and

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dietary habits. This was tested in a more

socially and ethnically diverse obstetric

population initiating pre-natal care at the

Women's Hospital in Boston.46 They

compared the sensitivity and specificity of

the T-ACE with the sensitivity and

specificity of three other popular methods of

screening for alcohol use in other clinical

settings, including the AUDIT47 and the

SMAST48, and a review of the patient’s

medical record. Researchers gave each

participant the AUDIT and SMAST

independently as well as reviewed the

participant’s medical record. T-ACE was

found to be more accurate than AUDIT in

detecting current risk drinking behaviour, as

well as a past history of alcoholism.46

The T-ACE was more effective in identifying

at-risk women for pre-natal alcohol use than

medical records.49

The T-ACE demonstrates acceptability and

accuracy in identifying a range of alcohol-use

levels in diverse obstetric populations.

The “hold” version of the tolerance question

was examined by Russell et al who gave it a

positive scoring when women reported being

able to consume more than 5 drinks without

passing out. The T-ACE performed even

better with increased sensitivity (91%) and

specificity (81%). More recent studies using

a cut-off point of ≥2 for T-ACE very clearly

distinguished the women at risk of pre-natal

alcohol use from those who are not (88%

sensitivity and 79% specificity).50

5.2.6 The TWEAK Tool (Tolerance, Worry,

Eye-opener, Amnesia, Cut down)

TWEAK (Tolerance, Worry, Eye-opener,

Amnesia, Cut down) is a 5-item screening tool

that combines questions from other tests including

MAST, CAGE, and T-ACE, which were found to

be effective in identifying at-risk drinkers.51 These

questions address tolerance, feeling the need to

cut down on drinking, and having close friends or

relatives worry or complain aboutthe drinking.52

On the tolerance question, 2 points are given if a

woman reports that she can consume more than 5

drinks without falling asleep or passing out (“hold

version”) or reports that she needs 3 or more

drinks to feel the effect of alcohol (“high

version”). A positive response to the worry

question yields 2 points and positive responses to

the last 3 questions yield 1 point each. Scored on a

7-point scale, a woman who has a total score of 2

or more points is likely to be an at-risk drinker.

Relevant Research

The TWEAK was first tested in three male

and female samples randomly selected from

three groups: 1) alcoholics in treatment at a

county medical center; 2) patients at two

primary health care centers; and 3) the general

population of the Buffalo, New York,

metropolitan area.53 Subsequent evaluation of

the TWEAK has revealed its promise as a

screening tool for identifying pregnant women

who are at-risk drinkers, defined as those

consuming 1 ounce of alcohol or more

daily.50,31,29

In a study of 4,743 African-American women

of low socioeconomic status who were also

given the MAST, the CAGE, and the T-ACE

tolerance question, the calculated sensitivity

and specificity of the TWEAK were 79% and

83%, respectively, in contrast to the

calculated 70% sensitivity and 85%

specificity of the T-ACE.50

The utility of items included in the TWEAK

was demonstrated in studies of obstetric and

gynecologic outpatients, the general

household population, hospital in-patients and

in emergency room settings. Chang et al

assessed the efficacy of TWEAK to identify

alcohol use in pregnant patients.30 They found

that TWEAK performed similar to T-ACE in

detecting a range of drinking patterns from

moderate to high-risk drinking, but performed

better than T-ACE in predicting lifetime

ethanol diagnosis and risk drinking. It is well-

documented that the TWEAK questionnaire

has an approximately 90% sensitivity and

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78% specificity to detect women who are

problem drinkers and is therefore considered

to be more appropriate for use during

pregnancy.

Subsequent research suggests that TWEAK is

well-established as a sensitive instrument for

detecting alcohol problems not only among

pregnant women, but in the general

population as well using different cut-off

points.33

It is important to note that many of the studies

investigating the TWEAK’s performance have

relied on the older definition of risk drinking ( ≥1

ounce alcohol daily) rather than the current

definition (≥0.5 ounce alcohol daily).

Nonetheless, it offers another option for

clinicians.

The TWEAK screening tool is recommended for

use with pregnant women by:

Institut national de santé publique du Québec

(April & Bourret, 2004).

Alberta Alcohol and Drug Abuse Commission

(AADAC) (Watkins, 2004).

United States National Institute on Alcohol

Abuse and Alcoholism (Allen, 2003).

TABLE 1 Structured Questionnaires (Indirect / Masked Screening)

Tool Advantages Limitations Validation

AUDIT • 10 item questions

(2 minutes)

• Easy to administer

• Detects problem drinking;

dependence / abuse

• Validated for cross-cultural

applicability and ability to

identify people who have

problems with alcohol but

who may not be dependent

Shown to be especially

useful when screening

women, minorities and

adolescents.54,55

• Not well examined in prenatal

settings

• Less sensitive to female alcohol

abuse and dependence than the

TWEAK.29

• Definition of a positive score

on the AUDIT for drinking

pregnant women remains to be

established

• Developed for use in men and

therefore less effective in

identifying drinking problems

among women

• Fails to distinguish between

problem drinking and

dependence

Validated for

use in women

BMAST • 10 item questions

(2 minutes)

Detects harmful use of

alcohol

• Focuses on lifetime rather than

current drinking47 Validated for

use in women

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Tool Advantages Limitations Validation

CAGE • Routinely incorporated into

clinical assessments as it is

short and very easily

administered (takes ≤1

min)

• Validated for use in general

population (primary

setting), minority ethnic

groups, and adolescents

• Detects alcohol dependence

/ abuse

• Has been proven effective

for detecting a range of

alcohol problems

• No cut-off point to differentiate

dependence and abuse

• Focuses on lifetime rather than

current drinking 47

• Developed for use in men and

therefore less effective in

identifying drinking problems

among women

Validated in

women of

childbearing

age,

including

pregnant

women

CRAFFT • Validated as the most

sensitive tool for detecting

a range of alcohol problems

among adolescents

• Limited research conducted

specifically in pregnancy Validated for

use in

adolescents

T-ACE • Instrument developed

specifically for use with

pregnant women

• Questions are easy to

remember and score and

can be asked by an

obstetrician or a nurse (1

min)

• Emerging research suggests

TWEAK outperforms the T-

ACE

• Validity of the tool varies

across different ethnic

populations

Validated for

use in

pregnant

women

TWEAK • Instrument developed

specifically for use with

pregnant women

• Short and very easily

administered (takes ≤1

min)

• Optimal tool for racially

diverse groups, superior in

sensitivity compared to

other tools as it has been

extensively validated in

different obstetric

populations.29

• Emerging research suggests

TWEAK outperforms the

T-ACE

• Validity of the tool varies

across different ethnic

populations

Validated for

use in

pregnant

women

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TABLE 2 Summary of Provincial Prenatal Records in Canada

Maternal Alcohol Use Screening Questions

Summary of Drinking Patterns

NWT BC AB SK MN ON QC NB NS PEI NFLD

Drinking Patterns

“Amount” X X X X X

“Frequency” X

# drinks/day X X X X X X X

# drinks/wk X

#drinking

days/wk

X X X X

Max # per

occasion

X X

Quit Date X X X X

T-ACE Score X X X X X

TWEAK Score X

TABLE 3 Use of Tools in the International Environment

Countries General Population Screening Special Population Screening

(Pregnancy)

United Kingdom CAGE

Scotland AUDIT TWEAK

Australia CAGE followed by

TLFB or QF; AUDIT; TWEAK TWEAK followed by AUDIT

Indigenous

Australians AUDIT

CAGE AUDIT

CAGE

United States CAGE

AUDIT

BMAST

T-ACE, TWEAK, CAGE

in combination with TLFB and QF

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5.3 Summary: An Overview of Findings

The T-ACE and TWEAK tools were

developed specifically to identify at-risk

drinking in pregnant women. Common to

both, the tolerance question appears to be

most sensitive for indicating problem drinking

in women as it places less emphasis on issues

of guilt related to drinking. There are two

different versions of the tolerance question,

with one focusing on the number of drinks to

feel “high”: “How many drinks does it take to

make you feel the first effect of alcohol?”

while the second focuses on the number of

drinks one can “hold”:

The high question works well for

women who often have 3 or 4

drinks at most but never to the point

of passing out. On the other hand,

the hold question detects binge

drinking patterns where large

amounts of alcohol are consumed.

Overall, the TWEAK questionnaire appears to

be superior for identifying heavy drinking

patterns, alcohol dependence or abuse across a

range of socio-economically and ethnically

diverse populations.A cut-off point of 2 or

more was found to have optimal sensitivity

and specificity for detecting alcohol problems

in women with sensitivities ranging from

89%-91% and specificity ranging from 77%-

87%.29

However, since both of these tools fail to

provide a picture of the woman’s pattern of

consumption, a positive screen may be

supplemented by the TLFB tool which

includes quantity-frequency questions.

5.4 Knowledge Gaps and Challenges of

Structured Questionnaires

There is no consensus on the appropriate

questionnaire to use across Canada as each

provincial / territorial jurisdiction, health care

organization and health care provider uses a

variety of formal and informal screening

questionnaires. It is interesting to note that

only 6 of the 11 provinces have a screening

tool; however, some provinces use tools that

do not ask specific questions in the screening

process.

There are inconsistent recording processes

across Canada. The information collected in

the clinical setting by the health care

professional is not consistently noted in all

records of the women and not necessarily

connected to the records of the child.

Health care professionals are not trained in

motivational interviewing techniques.

Motivational interviewing is a scientifically

tested method of counselling people in the

treatment of lifestyle problems and motivates

them to change their behaviour without

evoking resistance.

Health care professionals may not be

motivated to screen for alcohol use if there are

no facilities or programs available to refer the

woman for intervention and / or counselling

on alcohol use.

6. Level III Screening - Laboratory-based

Screening Tools

6.1 Biological Markers

Unlike brief questionnaires, biochemical markers

address concerns of many researchers who feel

that self-reporting underestimates alcohol

consumption. In the pregnant patient, current

alcohol use can be detected by urine toxicology,

blood, saliva or breath, to follow-up a positive

interview screen. Gamma-glutamyl transferase

(GGT) and carbohydrate-deficient trans-ferin

(CDT) have been used as biochemical measures

of detecting long-term heavy drinking.56,57,58 they

are not specific. Among the benefits of toxicology

tests is that they confirm the presence of a drug

and determine the use of multiple drugs. The

disadvantages include the high costs associated

with lab analysis.

There are limitations to lab testing - alcohol,

which is the most widely used substance and has

the greatest impact on the fetus, is hard to detect

due to its short time in the blood streams so

negative results do not rule out alcohol / substance

use; a positive test fails to reveal information

regarding pattern of drug use; urine toxicology is

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also limited by the short window of appearance.

Fatty acid ethyl esters (FAEEs) are metabolic

products that result from the interaction between

alcohol and fatty acids. FAEEs can be detected in

blood, hair, placenta, cord blood, and meconium

(i.e. first stool of newborns).

Over the last few years, a revolutionary test

using adult hair has been developed and validated

to measure FAEEs. The test can accurately

separate chronic alcohol abuse from moderate and

non-drinking status. Six centimetres of hair are

needed, representing 6 months of growth of hair

(hence, the recent 6 months in the life of the

individual).57,58

The following are the cut-offs for the test:

FAEE levels above 1 ng/mg are 100%

specific for regular, excessive alcohol

consumption. At this level 25% of chronic

alcohol abusers will test below (i.e. 75%

sensitivity).

FAEE levels between 0.5-0,99 ng/ml are 90%

specific for regular, excessive alcohol

consumption. At this level 10% of chronic

alcohol abusers will be missed, and 10% of

moderate drinkers will show results in this

range.

FAEE levels below 0.49ng/mg indicate no

evidence of excessive alcohol consumption

(up to 2 drinks per day).

FAEE levels between 0.2-0.4ng/mg mean no

evidence of alcohol consumption.59

6.2 Knowledge Gaps and Challenges of

Laboratory-based Screening Tools

Traditional methods of measuring alcohol in

blood or through breath test reflect only

drinking in the last few hours, and hence do

not assist in defining problem drinking.

There are limitations of laboratory testing as

negative results do not rule out alcohol use.

The hair test overcomes this shortcoming, as a

level above 0.5 ng/mg would not miss

excessive drinkers, and levels below 0.49

ng/mg indicate no evidence of excessive

alcohol drinking. These characteristics make

the test very relevant in the context of

drinking patterns associated with FASD.

While positive test results provide separation

between excessive alcohol consumption and

milder intake, information regarding pattern

of alcohol use (e.g. binge vs. chronic

continuous use) is not revealed.

Laboratory tests of liver function usually only

identify those patients with long-term use in

whom secondary symptoms have occurred,

e.g. liver function tests.

Urine toxicology has no value in identifying

teratogenic effects that occur early in

pregnancy.

The hair test has been found to accurately

separate chronic alcohol abuse from

moderate-non drinkers and is likely to become

gold standard of corroborating alcohol use.

Ethical considerations: as with any other test,

respect to the autonomy of the woman, to her

rights for confidentiality and for refusal, must

be strictly adhered to.

7. Challenges of Implementation of Screening

and Assessment Tools

The task of identifying and managing health

issues in a pregnant woman who uses alcohol

during pregnancy can be difficult. Universal

screening would mean that all child-bearing

women will be asked about the amount of alcohol

they consume. A positive response to the

screening question(s) should be followed by

further in-depth assessment.

7.1 Level 1: Screening with Interviewing

Techniques

Asking a woman a single question about alcohol

use is the first step in the screening process. A

woman may admit to drinking on occasion or

deny any use of alcohol. Any denial of use should

be sieved through the provider’s impressions of

the woman, ascertained by a non-judgmental

observation of her body language, general

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deportment, and eye contact, as well as through

past interactions with her. Asking about alcohol

use at other times during the pregnancy would be

prudent.

7.2 Level II: Screening/Assessment with

Standardized Questionnaires

The least challenging (Level II) screening strategy

would be the use of open-ended interviewing

techniques (the Timeline Follow Back Method

and Quantity-Frequency Tool), wherein the

provider asks the woman to provide details about

her recent consumption of alcohol. If the provider

is respectful and non-judgemental, a woman will

often respond positively. However, women may

not accurately recall the amount or frequency of

their alcohol consumption. Women may also

underestimate, minimize or deny their alcohol

intake. The provider must also clarify the amount

of alcohol in a standard drink and ask for details

on amounts consumed (e.g., a bottle of wine can

vary in size). Consequently, a screening interview

may not elicit an accurate record of alcohol

consumption and medical records may not be

accurate.

Standardized questionnaires (AUDIT,

BMAST, CAGE, TWEAK, T-ACE, CRAFFT)

are sometimes used as screening tools and can

also be used for further in-depth assessment of

alcohol consumption. However, the questionnaires

have limitations because they do not perform

equally well in heterogeneous populations. They

do provide a structured way to elicit alcohol

consumption, yet require that providers know

their individual components and also know the

scoring system.

Some providers include a questionnaire for

completion by the woman in the waiting room.

There are difficulties with this approach; for

example, if the woman is not literate, speaks

English as a second language, is accompanied by

her spouse, or is lacking privacy. The responses

on these “pen and paper” versions need to be

reviewed carefully with the woman during a pre-

natal visit, wherein the provider can observe the

woman’s responses. The questionnaires also need to

be used in a respectful and non-judgemental manner

in order to engage the pregnant woman. Some

questionnaires, e.g. the T-ACE, have been validated

in pregnant populations but the overlay of

cultural, ethnic and socio-economic factors may

interfere with their accuracy. The ideal screening

test should be both highly sensitive and highly

specific. However, there is often a trade-off

between sensitivity and specificity for any given

test. A tool with high sensitivity will identify all

pregnant women with problematic alcohol

consumption (a positive result) while a tool with

high specificity will exclude all women who are

not consuming risky levels of alcohol, (a negative

test result).60 Typically, given the importance of

identifying problematic alcohol use, priority is

placed on high sensitivity. In communities with a

paucity of resources for follow-up, a tool with

high specificity may prove more cost-effective, as

false positive scores are reduced.

In the absence of a “gold standard”,

clinicians are limited by the characteristics of a

particular tool. The challenge for providers is the

variability in screening instruments to detect

women at-risk and to eliminate false positives,

especially in different subpopulations of women,

e.g., immigrant or refugee women.61 Additionally,

providers need to ask the questions with cultural

competency and sensitivity to each woman’s

circumstance.

7.3 Level III: Assessment for Biological

Markers

In-depth biomedical assessment with a laboratory-

based test, such as maternal hair testing for FAEE

(fatty acid ethyl esters), provides quantifiable

results that can inform the clinician about the

woman’s alcohol consumption. However this test

can be invasive for women. Full and informed

consent must be obtained before this test is

conducted. Although hair-testing offers a more

accurate understanding of the woman’s alcohol

use, it is not available in all centres and its clinical

use is not yet wide-spread. Currently hair testing

is usually ordered for legal reasons. Additionally,

some providers may be disinclined to use such

tests because of a woman-centered philosophy

towards caring for pregnant women, which

advocates belief in a woman and acceptance of

her reports of alcohol use as the truth.

7.4 Summary

The task of identifying and managing a pregnant

woman who uses alcohol during pregnancy can be

difficult. Each level of screening or assessment

presents some challenges and limitations. A

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negative response to screening questions does not

warrant further investigation, although it is

prudent to ask about alcohol use during each

trimester. A positive response to screening for

alcohol consumption should be followed by

further assessment and recording as well as

providing assistance and resources as required.

As recommended by the Public Health Agency

of Canada, and as reflected in the goal of this

project, there is a need for the development and

validation of screening tools that are specific and

sensitive to pre-natal alcohol exposure. These

tools should be adaptable for use in various

contexts, they should be culturally appropriate and

they should lead to further assessment.

Additionally, providers must be trained to

accurately record the alcohol history of the

mother, which can facilitate diagnostic referral of

the infant if necessary.

8. Recording Alcohol Use

Specific recommendations for documentation of

alcohol and other substance use during pregnancy

on the maternal, newborn and child health records

are crucial.

Primary health care providers (family

doctors, nurse practitioners, midwives, family

practice nurses, public health nurses, physician

assistants etc.) are encouraged to include

questions about alcohol and other substance use a

routine part of well-woman visits (Pap smears,

birth control renewals, annual checkups etc.).

Ideally this information is gathered in contexts

before, during and after pregnancy.

The answers to screening questions regarding

alcohol use should always be documented in the

chart for future reference. Recording alcohol use

in pregnancy is important for the woman, her

developing fetus, the newborn infant and the child

who may have fetal alcohol spectrum disorder. It

is useful to ask these questions at multiple visits

so that they become part of the standard of care.

In this way, pregnant women will not feel

stigmatized by questions that are only linked to

their pregnancy. Documentation should be on the

Standardized Antenatal Record so that obstetrical

providers and hospital labour and delivery staff

are able to access the information. Tables 2 and 3

summarize the current Canadian and international

practices in recording alcohol use.

Equally important is the recording of important

risk factors present during the pregnancy on the

chart of the newborn infant. Contents of the

newborn’s hospital or midwifery care chart should

be easily and routinely available to the family

physician or paediatrician caring for the infant.

Subsequently, the relevant information about

maternal alcohol and substance use is available to

be transferred to the child’s health record.

It is important to note that there is some

sensitivity surrounding a woman’s consent to the

recording of this information in her and her

child’s health records, as a woman is aware of the

potential discriminatory actions of hospital staff

and others in response to her use of alcohol use

during pregnancy.

The diagnosis of FASD is challenging and

not always possible in the immediate newborn

period. Many children do not have the typical

facial features of FASD. Some children will

present with developmental delays in the toddler

period, behavioral issues in the preschool period

or learning difficulties in the childhood years.

Health care practitioners providing care for

children and adolescents must consider FASD in

the differential diagnosis of any cognitive or

emotional problem.

8.1 Benefits of Recording Maternal Alcohol

History on Infant Birth Records

Identification of infants who might be at-risk

for FASD through the recording of specific

information regarding maternal drinking.

Earlier and more accurate FASD diagnosis in

terms of ARND and PFAS.

Earlier implementation of appropriate

interventions.

Decreased levels of secondary disabilities

related to in-utero exposure to alcohol.

9. Recommendations

The implementation of a consistent and effective

screening process for the assessment of pre-natal

alcohol exposure is an important measure and

allows the establishment of a blueprint for early

intervention. The following recommendations are

intended to improve the screening process and

recording process for alcohol use in women of

Screening and recording of alcohol use among women of child-bearing age and pregnant women

Can J Clin Pharmacol Vol 16 (1) Winter 2009:e242-e263; April 16, 2009

260

child-bearing age and pregnant women, thereby

improving diagnosis and intervention for all

women and their families.

9.1 General Recommendations

1. Recognizing the importance of the health care

provider as an effective resource for harm

reduction, it is essential that adequate

community resources be made available for

women who require interventions beyond a

primary interaction.

2. That research on the effects of alcohol use be

expanded to ensure there is sufficient

comparative evidence showing the

effectiveness of screening tools with

particular cultural groups.

3. That a public education / awareness program

be initiated to inform women they should

expect to be asked about the frequency and

amount of alcohol use and ensure this

information is transmitted to all health care

providers involved in their care.

9.2 Recommendations Relative to Screening

for Alcohol Use:

4. That health care providers use a standardized,

universal set of questions routinely during

regular health exams that will include at least

Level I screening.

5. That Level II be adopted as the standard

screening process to identify alcohol use in all

women of child-bearing age and pregnant

women.

6. That health care providers be aware of the risk

factors that may inform their clinical

impression in combination with other

psychosocial assessment.

7. That health care providers access on-line

training tools for screening of FASD offered

by Best Start, Ontario’s maternal, newborn

and early child development resource centre

(www.beststart.org), and other resources

offered by programs such as PRIMA

(www.addictionpregnancy.ca) and Motherisk

(www.motherisk.org). Resources are also

available from Healthy Choices in Pregnancy

program in British Columbia (www.hcip-

bc.org/resources_for_practice/default.htm)

and from the Canadian Centre for Substance

Abuse (www.ccsa.ca/toolkit/introduction.htm).

8. That health care providers use Level III

screening methods when there is discordance

between Level I and Level II screening results

(e.g. frequency, perception of risk), or when

there are doubts unresolved by Levels I and II.

9.3 Recommendations Relative to Recording

Alcohol Use:

9. That the frequency and amount of alcohol use

be recorded in a woman’s chart on a routine

basis and not only in relation to pregnancy.

10. That the information relative to frequency and

amount of alcohol use be recorded in the

woman’s chart and that this information be

transferred to appropriate health care

providers and health records to ensure a

continuum of care.

11. That information relative to frequency and

amount of a woman’s alcohol use be routinely

recorded in her newborn’s chart and in her

child’s health records.

Corresponding Author: gkoren@sickkids.ca

Acknowledgements

This consensus report was developed and

approved by the Fetal Alcohol Spectrum Disorder

(FASD) Advisory Workgroup, a group of health

professionals and stakeholders with expertise in

the screening and recording of FASD.

Funding Source

This production of this report had been made

possible through a financial contribution from the

Public Health Agency of Canada (PHAC Project

No. 6789-15-2007/0870002). The views expressed

herein do not necessarily represent the views of

Public Health Agency of Canada.

Screening and recording of alcohol use among women of child-bearing age and pregnant women

Can J Clin Pharmacol Vol 16 (1) Winter 2009:e242-e263; April 16, 2009

261

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Alcohol use, pregnancy and associated risk factors: a pilot cross-sectional study of pregnant women attending antenatal care in an urban city

Preprint

Full-text available

Aug 2019

Imelda K. Moise

Background Alcohol consumption during pregnancy can cause adverse pregnancy outcomes such as preventable alcohol-related developmental disability fetal alcohol syndrome. This study examined the prevalence of alcohol use in a representative sample of pregnant women attending prenatal care at two urban clinics in Lusaka, Zambia. Methods A cross-sectional facility based survey evaluated self-reported alcohol use in the periconceptional period and pregnancy recognition (outcomes). Bivariate analyses were performed using the χ2 test for dichotomous variables and the t-test for continuous variables. Mixed-effects linear models were used to evaluate the effect of outcome variables with patient-level variables. Results About 40 (21.2%) pregnant women were identified by the T-ACE as at-risk for problem drinking during pregnancy. Except for regular prenatal care and distance, there was no difference in the demographic factors between pregnant women who scored 2 points (all p’s > 0.05). A small proportional of women at both clinics reported binge drinking during the periconceptional period (12.7% vs. 3.2%, p=0.003) and beyond periconception period. Excluding employed women, no significant relationships were observed between alcohol use and demographic factors. Conclusion These findings underscore the need for targeted screening and intervention for alcohol use in all pregnant women in Zambia.

Alcohol use, pregnancy and associated risk factors: a pilot cross-sectional study of pregnant women attending antenatal care in an urban city

Preprint

Full-text available

Dec 2019

Imelda K. Moise

Background Alcohol consumption during pregnancy is associated with adverse pregnancy outcomes such as preventable alcohol-related developmental disability fetal alcohol syndrome. In Zambia, alcohol use and associated risk factors have not been investigated, and screening in prenatal care is nonexistent. This study determined individual correlates and the prevalence of alcohol use in pregnant women attending prenatal care at two health clinics in Lusaka, Zambia. Methods A study adopted a cross-sectional design and recruited 188 pregnant women after seeking their informed consent from July 19 to 31, 2017. Participants aged 18 or over completed the T-ACE (Tolerance, Annoyance, Cut Down and Eye Opener) screening tool and validated alcohol-screening questionnaires on self-reported alcohol use periconceptional and during conception period while at their regular prenatal visit. The T-ACE screening tool assessed the risk of alcohol dependence in four short questions. The questionnaires included demographic questions. Bivariate analyses were performed using the χ2 test for dichotomous variables and the t-test for continuous variables. Mixed-effects linear models were used to evaluate the effect of outcome variables with patient-level variables. Results About 40 (21.2%) pregnant women were identified by the T-ACE as at-risk for problem drinking during pregnancy. Except for regular prenatal care and distance, there was no difference in the demographic factors between pregnant women who scored 2 points (all p’s > 0.05). A small proportional of women at both clinics reported binge drinking during the periconceptional period (12.7% vs. 3.2%, p=0.003) and beyond periconception period. Excluding employed women, no significant relationships were observed between alcohol use and demographic factors. Conclusion Alcohol consumption is prevalent in the periconceptional period and during pregnancy in pregnant women attending prenatal care in Zambia. Findings underscore the need for targeted alcohol use screening and intervention for pregnant women.

Alcohol use, pregnancy and associated risk factors: a pilot cross-sectional study of pregnant women attending antenatal care in an urban city

Preprint

Full-text available

Oct 2019

Imelda K. Moise

Background Alcohol consumption during pregnancy is associated with adverse pregnancy outcomes such as preventable alcohol-related developmental disability fetal alcohol syndrome. In Zambia, alcohol use and associated risk factors have not been investigated, and screening in prenatal care is nonexistent. This study determined individual correlates and the prevalence of alcohol use in pregnant women attending prenatal care at two health clinics in Lusaka, Zambia. Methods A study adopted a cross-sectional design and recruited 188 pregnant women after seeking their informed consent from July 19 to 31, 2017. Participants aged 18 or over completed validated alcohol screening questionnaires on self-reported alcohol use periconceptional and during conception period while at their regular prenatal visit. The questionnaires included demographic questions. Bivariate analyses were performed using the χ2 test for dichotomous variables and the t-test for continuous variables. Mixed-effects linear models were used to evaluate the effect of outcome variables with patient-level variables. Results About 40 (21.2%) pregnant women were identified by the T-ACE as at-risk for problem drinking during pregnancy. Except for regular prenatal care and distance, there was no difference in the demographic factors between pregnant women who scored 2 points (all p’s > 0.05). A small proportional of women at both clinics reported binge drinking during the periconceptional period (12.7% vs. 3.2%, p=0.003) and beyond periconception period. Excluding employed women, no significant relationships were observed between alcohol use and demographic factors. Conclusion These findings underscore the need for targeted screening and intervention for alcohol use in all pregnant women in Zambia.

Alcohol use, pregnancy and associated risk factors: a pilot cross-sectional study of pregnant women attending antenatal care in an urban city

Preprint

Full-text available

Nov 2019

Imelda K. Moise

Background Alcohol consumption during pregnancy is associated with adverse pregnancy outcomes such as preventable alcohol-related developmental disability fetal alcohol syndrome. In Zambia, alcohol use and associated risk factors have not been investigated, and screening in prenatal care is nonexistent. This study determined individual correlates and the prevalence of alcohol use in pregnant women attending prenatal care at two health clinics in Lusaka, Zambia. Methods A study adopted a cross-sectional design and recruited 188 pregnant women after seeking their informed consent from July 19 to 31, 2017. Participants aged 18 or over completed the T-ACE (Tolerance, Annoyance, Cut Down and Eye Opener) screening tool and validated alcohol-screening questionnaires on self-reported alcohol use periconceptional and during conception period while at their regular prenatal visit. The T-ACE screening tool assessed the risk of alcohol dependence in four short questions. The questionnaires included demographic questions. Bivariate analyses were performed using the χ2 test for dichotomous variables and the t-test for continuous variables. Mixed-effects linear models were used to evaluate the effect of outcome variables with patient-level variables. Results About 40 (21.2%) pregnant women were identified by the T-ACE as at-risk for problem drinking during pregnancy. Except for regular prenatal care and distance, there was no difference in the demographic factors between pregnant women who scored <2 on the T-ACE and those that scored > 2 points (all p’s > 0.05). A small proportional of women at both clinics reported binge drinking during the periconceptional period (12.7% vs. 3.2%, p=0.003) and beyond periconception period. Excluding employed women, no significant relationships were observed between alcohol use and demographic factors. Conclusion These findings underscore the need for targeted screening and intervention for alcohol use in all pregnant women in Zambia.

Alcohol use, pregnancy and associated risk factors: A pilot cross-sectional study of pregnant women attending prenatal care in an urban city

Article

Full-text available

Dec 2019

Imelda K. Moise

Background: Alcohol consumption during pregnancy is associated with adverse pregnancy outcomes such as preventable alcohol-related developmental disability fetal alcohol syndrome. In Zambia, alcohol use and associated risk factors have not been investigated, and screening in prenatal care is nonexistent. This study determined individual correlates and the prevalence of alcohol use in pregnant women attending prenatal care at two health clinics in Lusaka, Zambia. Methods: A study adopted a cross-sectional design and recruited 188 pregnant women after seeking their informed consent from July 19 to 31, 2017. Participants aged 18 or over completed the T-ACE (Tolerance, Annoyance, Cut Down and Eye Opener) screening tool and validated alcohol-screening questionnaires on self-reported alcohol use periconceptional and during conception period while at their regular prenatal visit. The T-ACE screening tool assessed the risk of alcohol dependence in four short questions. The questionnaires included demographic questions. Bivariate analyses were performed using the χ2 test for dichotomous variables and the t-test for continuous variables. Mixed-effects linear models were used to evaluate the effect of outcome variables with patient-level variables. Results: About 40 (21.2%) pregnant women were identified by the T-ACE as at-risk for problem drinking during pregnancy. Except for regular prenatal care and distance, there was no difference in the demographic factors between pregnant women who scored < 2 on the T-ACE and those that scored > 2 points (all p's > 0.05). A small proportional of women at both clinics reported binge drinking during the periconceptional period (12.7% vs. 3.2%, p = 0.003) and beyond periconception period. Excluding employed women, no significant relationships were observed between alcohol use and demographic factors. Conclusion: Alcohol consumption is prevalent in the periconceptional period and during pregnancy in pregnant women attending prenatal care in Zambia. Findings underscore the need for targeted alcohol use screening and intervention for pregnant women.

Quantifying fetal alcohol exposure by meconium fatty acid ethyl esters (FAEE); association with adverse fetal outcomes and population estimates of fetal alcohol exposure

Article

Oct 2019

Fetal Alcohol Spectrum Disorder (FASD) describes the wide range of adverse physical, behavioral and cognitive effects resulting from ethanol exposure during embryonic and fetal development. Identification of children suffering from FASD is often difficult, as abuse of ethanol during pregnancy is a heavily stigmatized behavior that receives little prenatal screening attention in routine care. Over the last 3 decades, measurement of the ethanol metabolites fatty acid ethyl esters (FAEE) has emerged as a useful tool to detect in the neonatal period fetal alcohol exposure starting from mid gestation. This review aims at updating clinicians and researchers on the validity and utility of this biological marker in two aspects: The association with adverse fetal outcomes and in generating population estimates of fetal alcohol exposure.

New assessment tools for risk drinking during pregnancy: T-ACE, TWEAK, and others

Article

Full-text available

Jan 1994
Alcohol Health Res World

Marcia Russell

Effective screening of pregnant women for drinking that puts the fetus at risk for developing fetal alcohol syndrome is an essential part of prenatal care. Screening tools such as questionnaires have demonstrated varying degrees of accuracy in identifying risk drinkers among pregnant women.

Les enfants de parents alcooliques: Anomalies observees. A propos de 127 cas [Children of alcoholic parents: Abnormalities observed in 127 cases]

Article

Jan 1968

Timeline follow-back: A technique for assessing self-reported alcohol consumption

Article

Jan 1992

Utility of the Time-Line Follow-Back to assess substance use among homeless adults

Article

Mar 2003

Assessing substance use of homeless persons is a critical task. This study examines the test-retest reliability, concurrent validity, and sensitivity to change of the Time-Line Follow-Back interview, a calendar instrument used to assess days and quantities of alcohol use and days of illicit drug use, in the multisite, Collaborative Program to Prevent Homelessness (CPPH). The Time-Line Follow-Back was reliable for assessing use during the past month and the recent 6 months. Results from the Time-Line Follow-Back were correlated with other self-reports of use, with research diagnoses of substance use disorder, and with clinician ratings of severity of substance abuse. The Time-Line Follow-Back detected changes in clients with severe mental illness and in those with less severe psychiatric problems.

Validity of brief alcohol screening tests among adolescents: A comparison of AUDIT, POSIT

Article

Jan 2002

Fundamentals of Biostatistics

Article

Jan 1995

Rosner BA

Performance of Screening Instruments for Identifying Alcohol Dependence in the General Population, Compared with Clinical Populations

Article

Oct 1998

Cheryl J. Cherpitel

Screening instruments for problem drinking have been developed in clinical populations, and little is known of their performance In the general population. Sensitivity and specificity of the CAGE and the TWEAK for ICD-10 and/or DSM-IV criteria for alcohol dependence are compared among those sampled from the southern region in the 1995 National Alcohol Survey (n = 776), and from emergency room (ER) (n = 1327) and primary care clinic (n = 767) samples in Jackson, MS. Sensitivity of the CAGE was higher in both the ER (85%) and primary care (82%) samples than in the general population (75%), although differences were not significant, and this held for males and females alike. Sensitivity of the TWEAK was lower in the general population sample (83%) than in the ER sample (89%), but higher than in the primary care sample (75%). In the general population, sensitivity of both screeners was better (although not significantly so) among those making an ER or primary care visit during the last year than among those not doing so, with the largest difference found for the CAGE (85% vs. 65%, respectively). In a merged sample of the three sites, the interaction of site by screening instrument was not a significant predictor of alcohol dependence for either the CAGE or TWEAK. Data suggest that screening instruments may not perform as well in the general population as in some clinical populations, with more variation apparent across groups for some screeners than for others. Although further analysis is necessary to explore this issue further, attention should be given to selection of the best instrument for use in a given population.

Motivational interviewing preparing people for change (2nd edition)

Article

Jun 2006
ADDICT BIOL

Michael Farrell

An abstract is unavailable. This article is available as HTML full text and PDF.

The Periodic Health Examination: 1980 ??? Approach of the Canadian Task Force to the Periodic Health Examination(Editorials and Notes)

Article

Oct 1980

H R H

Measuring Alcohol Consumption

Article

Jan 1992

more than two decades ago, the timeline was developed as a procedure to aid recall of past drinking / that method, first referred to as the gathering of daily drinking disposition data and later labeled as the timeline follow-back (TLFB) method, is the focus of this chapter / TLFB appears to provide a relatively accurate portrayal of drinking and has both clinical and research utility administration of the TLFB technique / psychometric properties / test–retest reliability / subject-collateral comparisons / concurrent validity (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Screening and recording of alcohol use among women of child-bearing age and pregnant women

Abstract

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