ACT for Youth Center of Excellence

A collaboration of Cornell University, University of Rochester, and New York State Center for School Safety

A World of Mixed Messages: Youth and Prevention of Fetal Spectrum Disorders

by Christine Heib and Mary Maley

Fetal Alcohol Spectrum Disorders (FASDs) are a range of disabilities that can affect a child whose mother drank during pregnancy. While many women are aware of the risks, nearly one in five pregnant women drink during the first trimester, likely before they know they are pregnant (Mattson & Lipari, 2014). Among most adolescents, both drinking and sex are new, and thinking of the consequences to a potential child may not be on a teen’s radar screen at all.

To better understand how best to communicate with adolescents about the risk of FASDs, the ACT for Youth Center of Excellence consulted with young women through focus groups and interviews. While drinking poses many risks to teens themselves, for the purposes of this article we look more narrowly at youth, pregnancy, and alcohol through the lens of FASD prevention. We include the insights of pregnant and parenting teens who participated in our data collection efforts.

Alcohol Use Among Youth Use of alcohol has declined fairly steadily in recent decades; however, alcohol remains the most widely used substance among America’s youth: a higher percentage of young people have used alcohol at some point in their lives than have used tobacco or illicit (Johnston, O’Malley, Bachman, & Schulenberg, 2013).

Why do adolescents drink? Some are at increased risk because of the genetic and psychological factors that are specific to the individual, or because of a February 2014

Christine Heib is a research aide and evaluation assistant with the ACT for Youth Center of Excellence at the Bronfenbrenner Center for Translational Research, Cornell University.

Mary Maley is an extension associate with the ACT for Youth Center of Excellence and directs the Research Synthesis Project at the Bronfenbrenner Center for Translational Research, Cornell University. preponderance of risk factors and lack of protective factors in their environments. However, changes common to all Drinking in Adolescence: A Few adolescents as they mature, as well as influences within the Statistics broader social and cultural environments, also make youth more vulnerable to drinking (Interagency Working Group on Youth Programs, 2013; U.S. Department of Health and Human • Many youth begin drinking well before Services, 2007). age 18. In 2012, one in five twelfth grade girls and one in four twelfth grade boys reported engaging in heavy (or “binge”) Adolescent development. Underage alcohol use is drinking (here defined as five or more partly the result of substantial neuro-biological changes drinks in a row in the two weeks before that occur in adolescence. Transformations in the brain’s the survey). limbic, or reward-controlling, system create a balance that is unique during this period. Brain regions controlling • Drinking, including , is more common among white students rational thought are less active, while regions controlling than among Hispanic or African American emotion are much more active and not completely mature. students. This makes adolescence inherently a risk-taking and reward-seeking developmental period. With the onset • Experimentation with alcohol is fairly of puberty, youth may increase their sensation-seeking common as early as eighth grade: in behaviors, including experimenting with alcohol. 2012, nearly one in three of eighth graders (30%) had tried “more than a few sips” of alcohol (Johnston et al., 2013). Media messages. Youth receive many messages about alcohol and drinking from the media. It is portrayed as • Pregnant teenagers age 15-17 are more fun, exciting, and popular – as if everybody their age is likely to drink than are pregnant women drinking. Coverage is not restricted to alcohol ads; one generally (Mattson & Lipari, 2014). of the most popular plot lines for TV shows or movies targeting young people is that of having access to alcohol at a party.

Extensive media portrayal of alcohol consumption contributes to alcohol use among young people. A systematic review by Anderson and colleagues (2009) found that exposure to media on alcohol is associated with the likelihood that adolescents will initiate or increase use of alcohol; this relationship is dose- responsive with more exposure leading to greater use. Furthermore, this relationship is also dose-related to the amount of money spent on . One study found that youth in markets with greater alcohol advertising expenditures drank more – for each additional dollar spent on advertising, the number of drinks consumed by young people increased by 3% (Snyder et al., 2006). Constant media exposure to drinking popularizes alcohol and its use in social situations with friends. It should not be surprising, then, that most adolescents overestimate how much their peers drink and how positively young people view drinking (National Institutes of Health).

This is exactly what we heard when we spoke directly to young people in focus groups and interviews. Youth reported getting most of their messages about drinking from their friends and the media. The term “binge drinking” did not resonate with these youth; they saw it as synonymous with “drinking.” Young people told us:

“The only reason young people drink is to get drunk.”

“Drinking and being drunk is fun and everyone does it.”

“[It’s always made] out to be the best thing out there.”

ACT for Youth Center of Excellence 2 www.actforyouth.net Mixing Alcohol with Sex Experimentation with alcohol and sex are expected and normal, but it is important to remember that use of substances such as alcohol may increase certain risky sexual behaviors. Early drinking is associated with early sexual initiation, for example, and some studies have shown that individuals who drink are more likely to have multiple sexual partners (Schantz, 2012).

Just over half of tenth graders and nearly 70% of high school ACT for Youth 2013 Focus Groups seniors have consumed alcohol (Johnston et al., 2013); by age 17, close to half of adolescents have had In 2013, the ACT for Youth Center of (Guttmacher Institute, 2013). The timing of alcohol and sexual Excellence conducted four focus groups and initiation suggests that many youth are already consuming two interviews with young women in New alcohol when they first have sex. Does this mean that teens York State. Three groups were conducted are mixing alcohol and sex? Researchers have looked at this upstate and one in New York City. A total of question in different ways. A Canadian study found that 38% 27 youth participated. Participants ranged of sexually active high school students had unplanned sex in age from 15-24 (average age 18), and 81% after they had been drinking or using drugs (Poulin & Graham, were currently pregnant or parenting. 2001). According to the 2011 Youth Risk Behavior Survey, 18% of sexually active female high school students reported Young women were asked what kinds of they had been drinking or using drugs before their last sexual messages they had heard about alcohol and intercourse (CDC, 2012). These studies suggest that a binge drinking, as well as messages about substantial number of sexually active high school students are drinking and pregnancy. They were asked using substances immediately prior to sexual intercourse. to react to a set of posters and flyers with FASD prevention messages, and they made recommendations about effective messaging. FASD and Public Health Recommendations Our thanks go to all of the participants, FASDs are a group of conditions that result from alcohol as well as to the staff of youth-serving exposure during pregnancy. Alcohol can cause problems agencies that supported this study. with fetal development throughout pregnancy. Effects on the child span physical and behavioral problems such as proper development, physical clumsiness, over- or under- sensitivity to stimuli, and difficulties learning and remembering, communicating, conducting daily life skills, controlling emotions, and following directions. Taken together FASDs, a major There is no level of alcohol use that is preventable cause of mental retardation, are more common guaranteed to be safe at any time during than autism. While some symptoms can be managed, the pregnancy. effects of FASDs last a lifetime (SAMHSA Fetal Alcohol Center for Excellence).

How much alcohol is too much? When it comes to low-to-moderate drinking, one systematic review was unable to conclude that it is harmful or that it is safe (Henderson & Gray, 2007). However, a more recent meta-analysis by Flak and colleagues (2014) found:

• At any time during pregnancy, binge drinking (here defined as four or more drinks on one occasion) is strongly associated with cognitive difficulties. • Moderate drinking (less than daily) during pregnancy is associated with behavior problems; specifically, social engagement, affect, and conduct. • Importantly, no amount of alcohol is known to be safe.

ACT for Youth Center of Excellence 3 www.actforyouth.net The state of the evidence is that there is no level of alcohol use that is guaranteed to be safe at any time during pregnancy, or when a woman is trying to get pregnant. For this reason, public health authorities recommend that a precautionary approach be taken both during, and prior to, pregnancy. The precautionary principle states that there is a social responsibility to protect the public from exposure to harm when scientific investigation has found a plausible harm. When there is no proof that an action is harmless, one should not act. Thus, consensus clinical guidelines state: “There is evidence that alcohol consumption in pregnancy can cause fetal harm; there is insufficient evidence regarding fetal safety or harm at low levels of alcohol consumption in pregnancy. There is insufficient evidence to define any threshold for low-level drinking in pregnancy. Abstinence is the prudent choice for a woman who is or might become pregnant” Formulating a Clear Message (Carson et al., 2010). It may be best to consistently present the message that “no alcohol is known to be safe Misconceptions and Media Messages during pregnancy,” rather than a range of negative consequences based on a spectrum The message that drinking and pregnancy don’t mix has of consumption levels. Any campaign should had significant impact. Surveys demonstrate that women include clear, consistent messages that: typically reduce or eliminate their drinking during pregnancy (Mattson & Lipari, 2014). In focus groups conducted by • Break down misconceptions; Elvira and colleagues (2013), women recognized the risks of • Encourage the use of contraceptives drinking during pregnancy; however, many still held common when drinking; misconceptions about its consequences. Popular myths • Stress that no amount of alcohol is include the ideas that certain kinds of alcohol are safe to drink during pregnancy; drinking during the third trimester safe to consume during pregnancy. does not harm the baby; and small amounts of alcohol during pregnancy are deemed acceptable by health care providers. These women reported that friends and family influenced their decisions during pregnancy. The Internet and health care providers were important sources of health information for them, but did not always deliver consistent messages about the risks of alcohol use during pregnancy.

We heard similar reports from the young women in our focus groups. When asked about drinking during pregnancy, most reported hearing that it was not a good idea and could cause problems with the baby. Consequently, many stopped drinking during their pregnancy. However, some youth reported hearing mixed messages about the effect of alcohol on the baby and that “a glass of red wine is okay.”

Should we be expecting these misconceptions? The Centers for Disease Control and Prevention, departments of health, and clinical guidelines for physicians all promote completely abstaining from alcohol use during pregnancy (CDC, 2010; Carson et al., 2010). However, this is not always the message that reaches the public. Media sources highlight new and surprising reports with headlines such as: “Pregnancy Wisdom Questioned: Are Alcohol, Caffeine Really Off Limits?” (Keegan, 2013). Articles like this, designed to catch attention, do just that – but may be based solely on one research study, one new claim by an individual, or one person’s radical opinion. Catchy titles and headlines are easily taken for granted, without reading the fine print or further investigating the evidence.

ACT for Youth Center of Excellence 4 www.actforyouth.net Sending the Right Message Misconceptions are likely to be even more impactful on adolescents because of their developing brain structure: mixed and confusing messages are not as easily sorted out in a rational way, and the potential risks of the behavior are outweighed by the in-the-moment benefits. How then can we prevent these misunderstandings?

In our focus groups, we asked young women about the types Sample Messages of messages that would resonate with their peers and younger teens. We learned that they would like to see messages that: Using the insights of teens in our focus groups and working with • Include personal stories the ACT Youth Network - NYC, we developed several FASD prevention • Connect alcohol consumption to its effect on the baby messages for youth. • Target middle-school youth before they become sexually active “My friends know I’m pregnant so they support my choice not • Appear in public places, including media outlets to drink.” Alcohol can harm the way your In their words, baby learns and behaves.

“I don’t think people pay enough attention or take it seriously “If I drink, I make sure that I when it is just on a poster; the message isn’t strong enough am protected.” because you can’t connect alcohol to harming the baby…. Alcohol can hurt a baby before a You should get an actual person who experienced a baby with woman knows she is pregnant. birth defects, that would make it real. You could see the actual Always use birth control. birth defects that happened to the baby.” “When it comes to my baby, “The first year of high school, that is when it all starts happening I always make the healthy – drinking and partying – in 9th grade it would be too late.” choice. People say different things about drinking during “[Youth] should know before they become sexually active.” pregnancy, but I know I wouldn’t give my baby alcohol. That’s “Needs to be more on TV – everybody watches TV – they why I didn’t drink when I was need to put it on the right channels like MTV. They talk about pregnant.” abusive relationships and teen pregnancy but not drinking.”

In a world of mixed messages, youth are left to sort out all that they are hearing: drinking is fun and everyone does it, alcohol may hurt your baby, it is okay to drink a little. There is confusion over what the healthiest decision is as well as the impact of not making that choice; for some youth, this makes it extraordinarily difficult to make the healthiest decision. We will only fully address the problem of FASD and teen pregnancy when we create healthy, genuinely empowering environments for youth. In the meantime, we can help by sending clear, timely, relatable messages according to the advice of pregnant and parenting youth themselves.

ACT for Youth Center of Excellence 5 www.actforyouth.net References

Anderson, P., de Bruijn, A., Angus, K., Gordon, R., & Hastings, G. (2009). Impact of alcohol advertising and media exposure on adolescent alcohol use: A systematic review of longitudinal studies. Alcohol & , 44(3), 229-243.

Carson, G., Cox, L. V., Crane, J., Graves, L., Kluka, S., Koren, G., . . . Wood, R. (2010). Alcohol use and pregnancy consensus clinical guidelines. Journal of Obstetrics and Gynaecology Canada, 32(8), S1-31.

Centers for Disease Control and Prevention. (2010). Alcohol use in pregnancy. Retrieved from http://www.cdc.gov/NCBDDD/fasd/alcohol-use.html

Centers for Disease Control and Prevention. (2012). Youth risk behavior surveillance--United States, 2011. Morbidity and Mortality Weekly Report, 61(4). Retrieved from http://www. cdc.gov/mmwr/pdf/ss/ss6104.pdf

Elvira, E., Harris, S. L., Squire, C. M., Margolis, M., Weber, M. K., Dang, E. P., & Mitchell, B. (July 2013). Women’s knowledge, views and experiences regarding alcohol use and pregnancy: Opportunities to improve health messages. American Journal of Health Education, 44(4), 177-190.

Flak, A. L., Su, S., Bertrand, J., Denny, C. H., Kesmodel, U. S., & Cogswell, M. E. (2014). The association of mild, moderate, and binge prenatal alcohol exposure and child neuropsychological outcomes: A meta-analysis. Alcoholism: Clinical and Experimental Research, 38(1), 214-226. doi:10.1111/acer.12214

Guttmacher Institute. (June 2013). Facts on American teens’ sexual and reproductive health. Retrieved from http://www.guttmacher.org/pubs/FB-ATSRH.html

Henderson, J., & Gray, R. (2007). Systematic review of effects of low-moderate prenatal alcohol exposure on pregnancy outcome. British Journal of Obstetrics and Gynaecology, 114(3), 243-252.

Interagency Working Group on Youth Programs. (2013). Substance abuse: Risk and protective factors. Retrieved from http://findyouthinfo.gov/youth-topics/substance-abuse/risk-and- protective-factors-substance-use-abuse-and-dependence

Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2013). Monitoring the Future national survey results on use, 1975–2012: Volume I, Secondary school students. Ann Arbor: Institute for Social Research, The University of Michigan. Retrieved from http://www.monitoringthefuture.org/pubs/monographs/mtf-vol1_2012.pdf

Keegan, A. (2013, August 12). Pregnancy wisdom questioned: Are alcohol, caffeine really off limits? Retreived from ABC News website http://abcnews.go.com/blogs/lifestyle/2013/08/ pregnancy-wisdom-questioned-are-alcohol-caffeine-really-off-limits/

Mattson, M., & Lipari, R. (2014, January). Ask the expert: Survey finds ongoing concerns with alcohol use during pregnancy. Retrieved from the Fetal Alcohol Spectrum Disorders Center for Excellence website: http://fasdcenter.samhsa.gov/askTheExpert/Jan2014. aspx

National Institutes of Health, National Institute on and Alcoholism. (n.d.). Underage drinking: A growing health care concern. Retrieved from http://pubs.niaaa. nih.gov/publications/PSA/underagepg2.htm

Poulin, C., & Graham, L. (2001). The association between substance use, unplanned sexual intercourse and other sexual behaviours among adolescent students. Addiction, 96, 607-621. doi:10.1080/09652140020031656

ACT for Youth Center of Excellence 6 www.actforyouth.net SAMHSA Fetal Alcohol Center for Excellence. (n.d.). Fetal Alcohol Spectrum Disorders: The basics. Retrieved from http://fasdcenter.samhsa.gov/educationTraining/fasdBasics. aspx

Schantz, K. (2012). Substance use and sexual risk taking in adolescence. Research fACTs and Findings. Retrieved from http://www.actforyouth.net/resources/rf/rf_substance_0712. pdf

Snyder, L. B., Milici, F., Slater, M., Sun, H., & Strizhakova, Y. (2006). Effects of alcohol advertising exposure on drinking among youth. Archives of Pediatric and Adolescent Medicine, 160(1), 18-24.

U.S. Department of Health and Human Services. (2007). The Surgeon General’s call to action to prevent and reduce underage drinking. Retrieved from http://www.surgeongeneral. gov/library/calls/underagedrinking/index.html

More from the ACT for Youth Center of Excellence

The ACT for Youth Center of Excellence connects youth development research to practice in New York State and beyond. Areas of focus include the positive youth development approach in programs and communities, adolescent development, and adolescent sexual health.You can receive announcements of new publications and youth development resources by subscribing to the ACT for Youth Update, an e-letter that appears 1-2 times each month. To subscribe, visit: www.actforyouth.net/publications/update.cfm

The ACT for Youth Center of Excellence is a partnership among Cornell University Bronfenbrenner Center for Translational Research, Cornell Cooperative Extension of New York City, the New York State Center for School Safety, and the University of Rochester Medical Center.

ACT for Youth Center of Excellence Bronfenbrenner Center for Translational Research Beebe Hall • Cornell University • Ithaca, New York 14853 607.255.7736 • [email protected] www.actforyouth.net www.nysyouth.net

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