QUICK Abuse during Pregnancy LESSON ABOUT Description/Etiology No level of alcohol is known to be safe during pregnancy and drinking is not recommended. Many women do drink during pregnancy; sometimes this is because they are unaware they are pregnant. Many healthcare professionals believe that screening all pregnant clients for alcohol use and advising them of the dangers of drinking during pregnancy is critical. A clinical diagnosis of alcohol use disorder (AUD) using the criteria in theDiagnostic and Statistical Manual of Mental Disorders, 5th edition(DSM-5), requires exhibition of a recurrent pattern of use within a 12-month period that adversely affects personal functioning. A severity specifier (i.e., mild, moderate, severe) is then assigned based on the number of symptoms. Criteria for AUD include the manifestation of at least two of the following: consumption of alcohol in larger amounts over a longer period than was intended; a desire or unsuccessful attempts to cut down or controlalcohol use; spending large amounts of time on activities related to the obtaining of, use of, and recovery from alcohol; cravings; being unable to meet obligations at home, work, or school due to alcohol; continued use despite social or interpersonal problems caused by use; giving up social, recreational, or occupational activities; continued use even with physical or psychological problems; tolerance; and withdrawal. DSM-5 was published in 2013, replacing the DSM-IV. The DSM-IV chapter on “Substance-Related Disorders” included substance dependence, substance abuse, substance intoxication, and substance withdrawal, and then discussed specific substances (e.g., alcohol, amphetamines). The DSM-5 divides these disorders into two categories: substance use disorders (SUD) and substance-induced disorders (intoxication, withdrawal, and other substance/medication-induced mental disorders). Thus it removes the distinction between abuse and dependence and instead divides each disorder into mild, moderate, and severe subtypes. Drug craving has been added as a criterion for , whereas “recurrent legal problems” has been removed. In the DSM-5, substance abuse is referred to as substance use disorder whereas in the research literature and treatment field the terms substance abuse and substance dependence continue to be commonly used. Alcohol consumption may disrupt a woman’s menstrual cycle and increase her risk of infertility, miscarriage, stillbirth, and premature delivery. Biophysical effects of alcohol during pregnancy include nutritional deficiencies, , alcoholic ketoacidosis, , and . Fetal alcohol spectrum disorder (FASD) covers a range of effects of maternal alcohol consumption upon the fetus: it is a leading cause of birth Authors defects, developmental disabilities, and mental retardation in children. In the United Jan Wagstaff, MA, MSW States, an estimated 50,000 children are born each year with fetal alcohol effects. Many Cinahl Information Systems, Glendale, CA of these children will be of low birth weight and approximately 5,000 will have fetal Jessica Therivel, LMSW-IPR Cinahl Information Systems, Glendale, CA alcohol syndrome (FAS), a more severe pattern of problems caused by maternal alcohol consumption. Research also links sudden infant death (SID) with fetal exposure to alcohol. Reviewers Newborns of women who binge drank (defined as the consumption of 4 or more drinks Lynn B. Cooper, D. Criminology over the course of 2 hours or less) during their first trimester are at a substantially increased Chris Bates, MA, MSW risk of SID. Alcohol misuse additionally has been shown to disrupt maternal bonding and Cinahl Information Systems, Glendale, CA attachment after birth. Victimization by sexual assault is more common among women who drink, especially

July 31, 2015 younger women. The disinhibition that results from alcohol consumption may lead to

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2015, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206 risk-taking behavior, which can result in unplanned and/or unwanted pregnancy. Women with AUD are more likely to have personal trauma histories that predate their disorder than women without AUD, including being victims of physical and sexual assault and intimate partner violence (IPV). They also have a higher prevalence of eating disorders and addictions to prescription pain and sedative medications. If her AUD is not treated, a woman’s entire social support system and social network can break down. A common barrier to treatment is denial; many women with alcohol problems seek help only when their condition becomes chronic or they experience a traumatic event directly related to alcohol use. Society often judges women with alcohol disorders more harshly than men. Because of this many women will prioritize health- and family-related problems to avoid addressing any problematic alcohol use when seeing healthcare and social service professionals. Pregnant women can easily be screened as part of their routine treatment; the earlier this is completed, the better. In the United States, estimates are that between 5% and 30% of women are screened during pregnancy for alcohol use. The postpartum period, therefore, may represent a unique intervention opportunity for women with AUD.

Facts and Figures Treatment admission data indicate that approximately 20% of pregnant women entering treatment for substance use disorders were being treated for alcohol use disorder (McCabe & Arndt, 2012). Using 11 years of treatment admission data, researchers found that the rate of referrals from primary care went down in the period of years studied whereas referrals from the criminal justice system increased (McCabe & Arndt, 2012).One in 30 U.S. women is estimated to drink during pregnancy at high enough levels to cause FASD (National Center on Birth Defects and Developmental Disabilities, 2004). The Behavioral Risk Factor Surveillance System survey found that between 2006 and 2010, 7.6% of pregnant women in the United States used alcohol and 1.4% engaged in (CDC Morbidity and Mortality Report, 2012).

Risk Factors Pregnant girls ages 15-17 years have an increased risk of developing AUD and thus are especially in need of prevention services. Among women who are pregnant, those ages 35 to 44, White,and have a college education or are employed are the most likely to use at least some alcohol. Women with the greatest risk of having a baby with FASD are those who are under 30, living in poverty, have mental health issues, and have a history of substance dependency and/or incarceration. Women with little or no social supportcan be at higher risk. Women living in environments in which alcohol use is common and accepted may also be vulnerable. Women with parents with AUD are at greater risk for developing AUD. Women with mental health issues, especially depression, and those with high levels of brought on by life stressors (e.g., unemployment, being the victim of IPV or sexual assault) can also be at increased risk.

Signs and Symptoms/Clinical Presentation Smelling of alcohol; having glazed or bloodshot eyes; changes in mood; drowsiness; sleep problems; blackouts; and unusual passivity or argumentativeness can be symptoms of AUD. Deterioration in appearance or hygiene may be a sign. An intoxicated person may have flushed skin, a decreased ability to pay attention, and/or forgetfulness.

Social Work Assessment 1.Client History • Conduct a biopsychosocialspiritual assessment with the client, covering her developmental, emotional, psychological, and medical history and that of her family. Women with severe are more likely to deny alcohol use than women who consume moderate amounts of alcohol. It is important to note that when designing interventions for women whose histories include depression and post-traumatic stress disorder (PTSD) related to physical or sexual assault or abuse, the confrontational approach traditionally used to deal with denial in addiction is unlikely to work 2.Relevant Diagnostic Assessments and Screening Tools • The Alcohol Use Disorders Identification Test (AUDIT) has 10 questions; research has shown it to be especially useful for screening women and persons who are non-White • The CAGE questionnaire is a commonly used screening tool for AUD because it has 4 questions that are simple and thus easy to remember • The TWEAK survey detects harmful drinking during pregnancy; it has 5 questions and can be administered in less than 2 minutes • The Prenatal Risk Overview (PRO) is a 10- to 15-minute structured interview that screens pregnant women for psychosocial risk factors that can pregnancy. Ithas been shown to have high specificity (i.e., identifying who is not at risk)and sensitivity in detecting AUD in pregnant women 3.Laboratory Tests of Interest to the Social Worker • Dependent on setting, it may be appropriate to have blood alcohol or breathalyzertesting completed • Fetal monitoring and/or ultrasounds may be indicated

Social Work Treatment Summary Any reduction in drinking during pregnancy is considered beneficial (Armstrong et al., 2009). Screening all pregnant women is recommended; this can be combined with motivational interviewing techniques to educate women about the dangers of drinking during pregnancy and to reinforce abstinence (Kotrla & Martin, 2009; Armstrong et al., 2009). Motivational interviewing (MI) creates a positive, empathic relationship between the client and social worker that avoids argumentation, facilitates mutual trust, and encourages self-efficacy as the client engages in risk-benefit analysis (Hepworth et al., 2010). Women-only support or therapy groups and meetings may be beneficial since researchers have found that women with a history of trauma have more difficulty trusting male staff (Carlson, 2006). Cognitive behavioral therapy (CBT) addresses skills deficits and assists in the development and rehearsal of new skills, which can help women manage stress (Sampl & Kadden, 2001; Carlson, 2006; González-Prendes, 2008). Spirituality or religiosity can play a role in recovery; (AA) is a 12-stepprogram that incorporates spirituality for anyone with a past or present AUD. However, AA may not work for everyone, and Secular Organizations for (SOS) is an alternative (Bliss, 2007; Kaskutas, 2009). In one study,Native Americans had better outcomes when they were matched with motivational enhancement therapy (a derivative of MI) than with the AA model (Miller et al., 2007). Interventions that offer childcare help women attend programs (Welsh et al., 2008). Social workers should be aware of their own cultural values, beliefs, and biases and develop specialized knowledge about the histories, traditions, and values of their clients. Social workers should adopt treatment methodologies that reflect their knowledge of the cultural diversity of the communities in which they practice.

. Problem Goal Intervention During screening, pregnant Client will be counseled on Advise client about the risks client discloses alcohol use alcohol use during pregnancy involved in drinking during pregnancy. If the client meets criteria for an AUD, conduct a biopsychosocialspiritual assessment and work together on devising an appropriate intervention. If client meets criteria for inpatient treatment for AUD, assist in referral to appropriate program

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Applicable Laws and Regulations › The vast majority of countries set a legal age at which individuals can buy and consume alcohol. The most common is age 18 years, in a few countries it is age 16, and in a small number, including the United States, it is age 21. In a small number of countries drinking is forbidden, and about a dozen countries have no laws limiting alcohol consumption or purchase by age › Each country has its own standards for cultural competency and diversity in social work practice. Social workers must be aware of the standards of practice set forth by their governing body (e.g., National Association of Social Workers in the United States, British Association of Social Workers in England) and practice accordingly

Available Services and Resources › World Health Organization (WHO), http://www.who.int/substance_abuse/en/ › National Institute on Alcohol Abuse and (NIAAA), http://www.niaaa.nih.gov › U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), http://www.samhsa.gov › U.S. Centers for Disease Control and Prevention, http://www.cdc.gov › Alcoholics Anonymous, http://www.aa.org › Harm Reduction Coalition, http://harmreduction.org/ › Secular Organizations for Sobriety (SOS), http://www.cfiwest.org/sos/index.htm

Food for Thought › AUD in women is less likely to be identified by social workers than AUD in men › Although social networks generally are considered a protective factor against AUD, in some cases they can be detrimental by encouraging excessive alcohol use › Removal of a child who had been exposed to alcohol or drugs during pregnancy from the custody of the mother was found to increase the likelihood of a subsequent birth by two-fold, and to increase the likelihood of the mother’s consumption of alcohol or drugs during that pregnancy by three-fold(Grant et al., 2014) › In one survey 2.6% of women who had abortions stated that alcohol use was the reason for termination. 84% of these women reported heavy binge drinking or having experienced blackouts (Roberts et al., 2012) › Older pregnant women (i.e., age 35 and over) are more likely to drink than younger pregnant women. This may be a result of an increase in both physical and psychological stress felt by older pregnant women, although other risk factors for alcohol use disorder are likely to decrease with age (Meschke& Messelt, 2013)

Red Flags › No level of alcohol consumption is known to be safe during pregnancy › Symptoms of and withdrawal can mimic those of many major psychiatric disorders; therefore, accurate screening and assessment are critical › Research suggests that consuming alcohol while pregnant increases the risk of SID › Cigarette smoking has been identified as a significant predictor of alcohol use during pregnancy across ethnicities › Alcohol use during mid-pregnancy can increase the risk that the mother will be non-responsive to the infant in the 12 months after birth (Pearson et al., 2012) › Heavy maternal alcohol consumption has been found to negatively affect fetal brain function. Evidence of diminished information processing may indicate the presence of structural damage to the brain (Hepper et al., 2012)

Discharge Planning Whenever possible, follow up with the client and continue with support. Case management is recommended by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) for reaching the optimal level of care for substance-abusingpregnant women. Refer client to community-based peer support group (e.g., AA or appropriate 12-step program)

References 1. American Psychiatric Association. (2013). Substance-related and addictive disorders. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, VA: American Psychiatric Association. 2. Armstrong, M. A., Kaskutas, L. A., Witbrodt, J., Taillac, C. J., Hung, Y. Y., Osejo, V. M., & Escobar, G. J. (2009). Using drink size to talk about drinking during pregnancy: A randomized clinical trial of Early Start Plus. Social Work in Health Care, 48(1), 90-103. 3. Austin, E. L., & Irwin, J. A. (2010). Age differences in the correlates of problematic alcohol use among southern lesbians. Journal of Studies on Alcohol and Drugs, 71(2), 295-298. 4. Bailey, J. A., Hill, K. G., Hawkins, J. D., Catalano, R. F., & Abbott, R. D. (2008). Men's and women's patterns of substance use around pregnancy. Birth, 35(1), 50-59. 5. Bliss, D. L. (2007). Empirical research on spirituality and alcoholism: A review of the literature. Journal of Social Work Practice in the Addictions, 7(4), 5-25. 6. Brienza, R. S., & Stein, M. D. (2002). Alcohol use disorders in primary care: Do gender-specific differences exist?. Journal of General Internal Medicine, 17(5), 387-397. 7. British Association of Social Workers. (2012). The code of ethics for social work: Statement of principles. Retrieved from http://cdn.basw.co.uk/upload/basw_112315-7.pdf 8. Carlson, B. E. (2006). Best practices in the treatment of substance-abusing women in the child welfare system. Journal of Social Work Practice in the Addictions, 6(3), 97-115. 9. Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities. (n.d.). Preventing alcohol-exposed pregnancies. Retrieved June 16, 2015, from http://www.cdc.gov/ncbddd/fasd/pastactivities-preventing.html 10. Centers for Disease Control and Prevention. (2012). Alcohol use and binge drinking among women of childbearing age – United States, 2006-2010. Morbidity and Mortality Weekly Report , 61(28), 534-538. Retrieved from 11. Cummings, S. M., Bride, B., & Rawlins-Shaw, A. M. (2006). Alcohol abuse treatment for older adults: A review of recent empirical research. Journal of Evidence-Based Social Work, 3(1), 79-99. 12. Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., ... Sheffield, J. S. (2014). Prenatal care. In Williams Obstetrics (24th ed., pp. 167-173). New York: McGraw Hill Medical. 13. Davis, K. C., Hendershot, C. S., George, W. H., Norris, J., & Heiman, J. R. (2007). Alcohol's effects on sexual decision making: An integration of alcohol myopia and individual differences. Journal of Studies on Alcohol and Drugs, 68(6), 843-851. 14. Ebert, M. H., Loosen, P. T., Nurcombe, B., & Leckman, J. F. (Eds.). (2008). Current diagnosis & treatment: Psychiatry (2nd ed.). New York: McGraw-Hill Medical. 15. Ferri, F. F. (2012). Alcoholism. In F. F. Ferri (Ed.), 2012 Ferri's clinical advisor: 5 books in 1 (pp. 38-40). Philadelphia, PA: Elsevier Mosby. 16. Goecke, T. W., Burger, P., Fasching, P. A., Bakdash, A., Engel, A., Haberle, L., ... Kornhuber, J. (2014). Meconium indicators of maternal alcohol abuse during pregnancy and association with patient characteristics. BioMed Research International, 702848. doi:10.1155/2014/702848 17. González-Prendes, A. A. (2008). Anger-control group counseling for women recovering from alcohol or drug addiction. Research on Social Work Practice, 18(6), 616-625. 18. Grant, T., Graham, J. C., Ernst, C. C., Peavy, K. M., & Brown, N. N. (2014). Improving pregnancy outcomes among high-risk mothers who abuse alcohol and drugs: Factors associated with subsequent exposed births. Children and Youth Services Review, 46, 11-18. doi:10.1016/j.childyouth.2014.07.014 19. Harrison, P. A., Godecker, A., & Sidebottom, A. C. (2012). Validation of the alcohol use module from a multidimensional prenatal psychosocial risk screening instrument. Maternal and Child Health Journal, 16(9), 1791-1800. doi:10.1007/s10995-011-0926-2 20. Hepper, P. G., Dornan, J. C., & Lynch, C. (2012). Fetal brain function in response to maternal alcohol consumption: Early evidence of damage. Alcoholism, Clinical and Experimental Research, 36(12), 2168-2175. doi:10.1111/j.1530-0277.2012.01832.x 21. Hepworth, D. H., Rooney, R. H., Dewberry Rooney, G., Strom-Gottfried, K., & Larsen, J. (2010). Direct social work practice: Theory and skills (8th ed.). Belmont, CA: Brooks/ Cole. 22. I. S. Obot, & R. Room (Eds.), Alcohol, gender, drinking problems: Perspectives from low and middle-income countries. Geneva, Switzerland: World Health Organization. 23. International Federation of Social Workers. (2012, March 3). Statement of ethical principles. Retrieved from http://ifsw.org/policies/statement-of-ethical-principles/ 24. Karoll, B. R. (2002). Women and alcohol-use disorders: A review of important knowledge and its implications for social work practitioners. Journal of Social Work, 2(3), 337-356. 25. Kaskutas, L. A. (2009). Alcoholics Anonymous effectiveness: Faith meets science. Journal of Addictive Diseases, 28(2), 145-157. 26. Kim, W., & Kim, S. (2008). Women's alcohol use and alcoholism in Korea. Substance Use & Misuse, 43(8-9), 1078-1087. 27. Kotrla, K. (2008). Predicting alcohol use during pregnancy: Analysis of national survey data and implications for practice and the church. Social Work & Christianity, 35(1), 12-32. 28. Kotrla, K., & Martin, S. (2009). Fetal alcohol spectrum disorders: A social worker's guide for prevention and intervention. Social Work in Mental Health, 7(5), 494-507. 29. Manuel, J. K., McCrady, B. S., Epstein, E. E., Cook, S., & Tonigan, J. S. (2007). The pretreatment social networks of women with . Journal of Studies on Alcohol and Drugs, 68(6), 871-878. 30. McCabe, J. E., & Arndt, S. (2012). Demographic and substance abuse trends among pregnant and non-pregnant women: Eleven years of treatment admission data. Maternal and Child Health Journal , 16(8), 1696-1702. doi:10.1007/s10995-011-0872-z 31. Meschke, L. L., Holl, J., & Messelt, S. (2013). Older not wiser: Risk of prenatal alcohol use by maternal age. Maternal and Child Health Journal, 17(1), 147-155. doi:10.1007/s10995-012-0953-7 32. Miller, W. R., Villanueva, M., Tonigan, J. S., & Cuzmar, I. (2007). Are special treatments needed for special populations?. Alcoholism Treatment Quarterly, 25(4), 63-78. 33. Mizrahi, T., & Mayden, R. W. (2001). NASW standards for cultural competency in social work practice. Retrieved December 15, 2014, from http://www.socialworkers.org/ practice/standards/NASWCulturalStandards.pdf 34. Pardasani, M. (2005). A context-specific community practice model of women's empowerment: Lessons learned from rural India. Journal of Community Practice, 13(1), 87-103. 35. Pearson, R. M., Heron, J., Melotti, R., Joinson, C., & Evans, J. (2012). The impact of alcohol use during pregnancy on maternal responses after birth. Archives of Women’s Mental Health, 15(6), 433-443. doi:10.1007/s00737-012-0305-z 36. Roberts, S., Avalos, L., Sinkford, D., & Foster, D. G. (2012). Alcohol, tobacco, and drug use as reasons for abortion. Alcohol & Alcoholism, 47(6), 1-9. doi:10.1093/alcalc/ ags095 37. Sadock, B. J., & Sadock, V. A. (2007). Synopsis of psychiatry: Behavioral sciences/clinical psychiatry (10th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. 38. Sampl, S., & Kadden, R. (2001). Motivational enhancement therapy and cognitive behavior therapy for adolescent cannabis users. Retrieved April 3, 2014, from http:// kap.samhsa.gov/products/manuals/cyt/ 39. Shaw, C., & Palattiyil, G. (2008). Issues of alcohol misuse among older people: Attitudes and experiences of social work practitioners. Social Work in Action, 20(3), 181-193. 40. Substance Abuse & Mental Health Services Administration (SAMHSA). Quick guide for clinicians: Based on tip 2: Pregnant, substance-using women. Retrieved from http:// kap.samhsa.gov/ 41. Substance Abuse and Mental Health Services Administration. (2008). The NSDUH report: Alcohol use among pregnant women and recent mothers: 2002 to 2007. Retrieved from http://www.oas.samhsa.gov/2k8/pregnantAlc/pregnantAlc.cfm 42. Welsh, J., Precey, G., & Lambert, P. (2008). Parents of children at risk - a multi-agency initiative to address substance misuse amongst parents whose children are at risk of neglect. Child Abuse Review, 17(6), 454-462.