Alcohol-Screening Instruments for Pregnant Women

 
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Alcohol-Screening Instruments
               for Pregnant Women
                                                 Grace Chang, M.D., M.P.H.

           According to new studies, even low levels of prenatal alcohol exposure can negatively affect the
           developing fetus, thereby increasing the importance of identifying women who drink during
           pregnancy. In response, researchers have developed several simple alcohol-screening
           instruments for use with pregnant women. These instruments, which can be administered
           quickly and easily, have been evaluated and found to be effective. Because of the potential
           adverse consequences of prenatal alcohol exposure, short screening questionnaires are
           worthwhile preventive measures when combined with appropriate followup. KEY WORDS: prenatal
           alcohol exposure; prenatal diagnosis; alcohol use test; identification and screening for AOD
           (alcohol or other drug) use; specificity and sensitivity of measurement; breath alcohol analysis;
           AODR (alcohol- or other drug-related) biological markers

S
       creening pregnant women for             five or more drinks per occasion) by          3.5 drinks per week) demonstrated that
       alcohol use has become of increasing    pregnant women has increased substan­         the women who drank more than 3.0
       importance, because new research        tially, from 0.8 percent in 1991 to 3.5       drinks per week increased significantly
indicates that even low levels of prenatal     percent in 1995 (Ebrahim et al. 1998;         their risk of first-trimester spontaneous
alcohol exposure can negatively affect         Centers for Disease Control and               abortion (Windham et al. 1997).
the developing fetus. Adverse effects of       Prevention 1997). This rise in the rate           Identifying women who drink at
prenatal alcohol exposure can range from       of alcohol consumption among pregnant         risky levels during pregnancy poses spe­
subtle developmental problems, or fetal        women coincides with growing evidence         cial challenges, however, particularly
alcohol effects, to full-blown fetal alcohol   of the negative effects of low-to-moderate    because the definition of pregnancy risk
syndrome. In addition, scientists and          alcohol consumption during pregnancy.         drinking has been refined over time. In
clinicians have found that certain neuro­          Increasingly sophisticated research       addition, screening for any alcohol use
behavioral outcomes associated with            has improved scientific and clinical under-   during pregnancy is difficult. This arti­
prenatal alcohol exposure can persist in       standing of the adverse consequences          cle discusses the difficulties involved in
the affected person into adolescence           of prenatal alcohol exposure. The term        screening pregnant women for alcohol
(Sampson et al. 1994) and adulthood            “pregnancy risk drinking” (i.e., drink­       use; details some of the questionnaires,
(Kelly et al. 2000).                           ing during pregnancy at levels consid­        or instruments, available to facilitate
    Because no universally safe level of       ered risky to the fetus) was previously
alcohol consumption during pregnancy           defined as the consumption of 1 ounce
has been identified (Stratton et al. 1996),    or more of alcohol (i.e., two or more         GRACE CHANG, M.D., M.P.H., is an
the U.S. Surgeon General and the               drinks) per day (Sokol et al. 1989), but      associate professor of psychiatry at Harvard
Secretary of Health and Human Services         more recent findings show that even           Medical School, Department of Psychiatry,
recommend abstinence both before con­          lower levels of alcohol consumption can       Brigham and Women’s Hospital, Boston,
ception and throughout pregnancy               lead to negative pregnancy outcomes           Massachusetts.
(Stratton et al. 1996; Ebrahim et al. 1998).   (Charness et al. 1994; Wong et al. 1995;
However, approximately 20 percent of           Ikonomidou et al. 2000; Jacobson and          Preparation of this article was supported
women drink some alcohol during preg­          Jacobson 1994). A study of more than          in part by National Institute on Alcohol
nancy, and the rate of frequent drinking       5,000 pregnant women who consumed             Abuse and Alcoholism grants K24–AA–
(i.e., seven or more drinks per week or        alcohol moderately (defined as at least       00289 and R01–AA–12548.

204                                                                                                         Alcohol Research & Health
Screening Instruments for Pregnant Women

alcohol screening in this population; and                      inquiries about drinking patterns before       1996). Progress toward this goal has
briefly describes a few laboratory tests                       pregnancy confirmation are potentially         not yet been reported.
used for detecting alcohol use among                           more accurate measures of first-trimester          In response to the need for increased
pregnant women.                                                drinking (Day et al. 1993). Women are          alcohol screening among pregnant women,
                                                               also likely to deny or minimize their          researchers have developed several alcohol-
                                                               drinking during pregnancy out of embar­        screening instruments specifically for
Complications of                                               rassment (Morrow-Tlucak et al. 1989).          use with this population.
Screening Pregnant                                             Even moderate drinkers may underreport
Women for Alcohol Use                                          alcohol consumption during pregnancy
                                                               (Verkerk 1992). Data from a sample of          Screening Instruments
A key complication in screening preg­                          361 mothers suggest that women who
nant women for alcohol use arises from                         report drinking more than 1.3 drinks           The screening instruments described in
the fact that the traditional alcohol-                         per week during pregnancy actually may         this section were tested in diverse clini­
screening questionnaires—such as the                           be drinking at levels high enough to           cal populations and may help identify
Michigan Alcoholism Screening Test                             incur risk for alcohol-related birth defects   women using alcohol during pregnancy.
(MAST) (Selzer 1971) and the CAGE1                             (Jacobson et al. 1991). For example, 53        These instruments vary in that they
(Ewing 1984)—are less effective in                             percent of the women who reported              were designed to detect different levels
identifying drinking problems among                            drinking more than 1.3 drinks per week         of alcohol use and, therefore, differ in
women than among men. This discrep­                            during pregnancy reported higher lev­          how they define pregnancy risk drinking.
ancy is attributable to the fact that these                    els of consumption when interviewed                In general, a positive screen does not
instruments were developed among men,                          retrospectively.                               indicate an alcoholism diagnosis; rather,
who have different patterns of alcohol                             A third complication is that standard      it may signal to a physician or other
consumption and different thresholds                           questions about quantity and frequency         health care practitioner the need to discuss
for problem drinking than women                                of alcohol consumption are unlikely            pregnancy risk drinking with a patient.
(Babor et al. 1989). In addition, these                        to be helpful when screening pregnant          Routine use of screening questionnaires
instruments were developed to detect                           women for alcohol use. The widely              in clinical practices may reduce the
alcohol dependence, which is relatively                        used American College of Obstetricians         stigmatization of asking patients about
uncommon among pregnant women                                  and Gynecologists (ACOG) Antepartum            alcohol use and result in more accurate
(Ebrahim et al. 1998). Because of bio­                         Record poses three questions about alco­       and consistent evaluation.
logical differences between women and                          hol use: (1) the amount of alcohol con­            Sensitivity and specificity are two
men, the same quantity of alcohol con­                         sumed per day before pregnancy, (2) the        important properties of every screening
sumed over the same time period pro­                           amount of alcohol consumed per day             instrument. The sensitivity of a screen­
duces higher blood alcohol levels in                           during pregnancy, and (3) the number           ing test refers to the probability that a
women than in men (Graham et al.                               of years of alcohol use. The Antepartum        person who should test positive, does
1998). Women are also more sensitive                           Record has a fill-in-the-boxes format          so (i.e., the sensitivity of a screen for
than men to alcohol-related organ dam-                         designed to gather standard clinical           pregnancy risk drinking is the probabil­
age, such as cardiomyopathy and myopa­                         information on obstetric patients. How-        ity that a woman who is a risk drinker
thy (Urbano-Marquez et al. 1995;                               ever, compared with the 13-item Prenatal       tests positive). The specificity of a
Hanna et al. 1992). Therefore, alcohol-                        Alcohol Use Interview, the ACOG                screening test is the probability that a
screening-instrument cutoff scores (i.e.,                      Antepartum Record is less successful           person who should test negative, does
the values that clinicians use to define                       in identifying prenatal alcohol use.           so (i.e., the probability that a woman
a positive result from a screening instru­                     Researchers suggest that the difference        who is not a risk drinker tests negative)
ment) most likely need to be set differ­                       in findings between the two instruments        (Rosner 1990).
ently for men and women and particu­                           may be attributable to the format of
larly for pregnant women (Bradley et                           the ACOG Antepartum Record and its
al. 1998).                                                     lack of guiding questions: the ACOG
                                                                                                              The T-ACE
    A second complication faced by                             instrument requires a skilled interviewer      The T-ACE was the first validated sen­
researchers is that many women alter their                     in order to elicit accurate responses about    sitive screen for risk drinking (defined
alcohol consumption once they learn                            drinking during pregnancy (Budd et al.         as alcohol consumption of 1 ounce or
that they are pregnant. Consequently,                          2000).                                         more per day) developed for use in
                                                                   A final complication is that obstetri­     obstetric-gynecologic practices (Sokol
1
                                                               cians inconsistently screen their patients     et al. 1989). An obstetrician developed
 The CAGE screening instrument (Ewing 1984) consists
of four questions: (1) Have you ever felt you should Cut
                                                               for alcohol use during pregnancy. One          the T-ACE after observing that asking
down on your drinking?, (2) Have people Annoyed you by         goal of Healthy People 2000 was to             patients about their tolerance to the
criticizing your drinking?, (3) Have you ever felt bad or      increase obstetricians’ rate of screening      intoxicating effects of alcohol did not
Guilty about your drinking?, and (4) Have you ever had a
drink first thing in the morning to steady your nerves or to   for alcohol use to 75 percent, from the        trigger denial. The “socially correct”
get rid of a hangover (Eye opener)?                            1987 rate of 34 percent (Stratton et al.       answer is not known (patients do not

Vol. 25, No. 3, 2001                                                                                                                                  205
feel stigmatized to answer honestly), and   make you feel high?” The T-ACE was                             the AUDIT and SMAST independently
tolerance reflects a pattern of drinking.   not administered as an independent                             as well as reviewed the participant’s
    The four T-ACE questions (see T­        instrument; instead, both the sensitivity                      medical record. The three criteria used
ACE textbox) take less than 1 minute        and specificity of the T-ACE were cal­                         to evaluate the T-ACE, AUDIT, SMAST,
to ask. The T-ACE is positive with a        culated from the subjects’ responses to                        and medical record were as follows: (1)
score of 2 or more points. One point is     the tolerance question as well as to the                       alcohol abuse or dependence diagnoses
given for each affirmative answer to the    annoyed, cut-down, and eye-opener                              as defined according to the Diagnostic
A, C, or E questions. Two points are        questions from the CAGE questionnaire.                         and Statistical Manual of Mental Disorders,
given when a pregnant woman reports         The T-ACE proved to be superior to                             Third Edition, Revised (DSM-III-R)
that more than two drinks are necessary     both the MAST and CAGE in identi­                              (American Psychiatric Association 1987),
for her to feel “high” or experience the    fying pregnancy risk drinking (i.e.,                           which the subject could meet at any
intoxicating effects of alcohol.            defined as alcohol consumption of more                         point in her lifetime; (2) risk drinking,
    Researchers initially evaluated the     than 1 ounce daily). Table 1 summa­                            defined as having more than two drinks
T-ACE in a sample of 971 African-           rizes the study’s findings.                                    per drinking day before pregnancy; and
American women attending an inner-city          We subsequently tested the T-ACE                           (3) current drinking (i.e., any alcohol
antenatal clinic. The researchers admin­    as a self-administered, independent                            consumption during pregnancy).
istered both the MAST and CAGE as           screening tool embedded in a health-                               Table 2 summarizes the sensitivity
well as asked the T-ACE tolerance ques­     habits survey with questions about smok­                       and specificity of the T-ACE, AUDIT,
tion, “How many drinks does it take to      ing, stress, weight, and dietary habits in                     SMAST, and medical record for the
                                            a more socially and ethnically diverse                         three criteria. In addition, sensitivity
                                            obstetric population—350 women ini­                            and specificity for varying cut-off scores
                   T-ACE                    tiating prenatal care at the Brigham and                       for the T-ACE and AUDIT are listed
                                            Women’s Hospital in Boston, Massa­                             (e.g., in response to the tolerance question
                                            chusetts (Chang et al. 1998).                                  in the T-ACE, “more than 2 drinks”
   T Tolerance: How many drinks                 We compared the sensitivity and                            would be a positive response in one
       does it take to make you feel        specificity of the T-ACE with the sensi­                       scoring method and “2 or more drinks”
       high?                                tivity and specificity of three other pop­                     would be a positive response when
                                            ular methods of screening for alcohol                          using a different scoring method). With
   A Have people Annoyed you by             use in other clinical settings: (1) the                        “tolerance” defined as “2 or more drinks
       criticizing your drinking?           Alcohol Use Disorders Identification                           to feel intoxicated,” the T-ACE was the
                                            Test (AUDIT) (Babor et al. 1992), (2)                          most sensitive instrument to detect cur-
   C Have you ever felt you ought           the Short Michigan Alcoholism Screening                        rent alcohol consumption, risk drink­
       to Cut down on your drinking?        Test (SMAST) (Selzer et al. 1975), and                         ing, and lifetime DSM-III-R alcohol
                                            (3) a review of the patient’s medical                          diagnoses. However, it was also the
   E Eye opener: Have you ever              record. Researchers gave each participant                      least specific.
       had a drink first thing in the
       morning to steady your nerves
       or get rid of a hangover?               Table 1       Comparison of the T-ACE, CAGE, and MAST in Identifying Pregnancy
                                                             Risk Drinking
   The T-ACE is used to screen for
   pregnancy risk drinking, defined                                        Screening for Pregnancy Risk Drinking*
   here as the consumption of
   1 ounce or more of alcohol per
                                                                        Positive Test Score                   Sensitivity                Specificity
   day while pregnant. Scores are              Instrument                (points accrued)                        (%)                        (%)
   calculated as follows: a reply of
   “More than two drinks” to ques­
   tion T is considered a positive             T-ACE                               (> 2)                            69                         89
   response and scores 2 points, and           CAGE                                (> 2)                            38                         92
                                               MAST                                (> 5)                            36                         96
   an affirmative answer to question
   A, C, or E scores 1 point, respec­
   tively. A total score of 2 or more
                                               MAST = Michigan Alcoholism Screening Test.
   points on the T-ACE indicates a             *Pregnancy risk drinking is defined as the consumption of 1 ounce or more of alcohol per day during pregnancy.
   positive outcome for pregnancy              NOTE: The sensitivity of a screening test is the probability that a person who should test positive, does so (i.e.,
   risk drinking.                              the sensitivity of a screen for pregnancy risk drinking is the probability that a woman who is a risk drinker tests
                                               positive). The specificity of a screening test is the probability that a person who should test negative, does so
                                               (i.e., the probability that a woman who is not a risk drinker tests negative) (Rosner 1990).
   SOURCE: Sokol et al. 1989.
                                               SOURCE: Sokol et al. 1989.

206                                                                                                                             Alcohol Research & Health
Screening Instruments for Pregnant Women

    The ideal screening test would be                      in diverse obstetric populations. The                  patients at two primary health care cen­
both highly sensitive and highly spe­                      questions are easy to both remember                    ters; and (3) the general population of
cific; however, any given test usually                     and score and can be asked by an obste­                the Buffalo, New York, metropolitan area
has a trade off. Screeners typically give                  trician or nurse in 1 minute. Women                    (Chan et al. 1993). Subsequent evaluation
priority to sensitivity if it is important                 waiting for their prenatal appointments,               of the TWEAK has revealed its promise
to identify a condition, even if more                      for example, could be asked to complete                as a screening tool for identifying preg­
false positives are subsequently identi­                   the T-ACE as part of a routine patient                 nant women who are at-risk drinkers,
fied. However, if insufficient resources                   questionnaire to be reviewed during                    defined as those consuming 1 ounce of
are available to evaluate all patients who                 the visit.                                             alcohol or more daily (Russell et al. 1994).
screen positive, then specificity may be                                                                              The TWEAK is scored on a 7-point
considered more important (Russell                                                                                scale. On the tolerance question, 2 points
1994). Thus, the T-ACE, with a posi­
                                                           The TWEAK
                                                                                                                  are given if a woman reports that she
tive response to the tolerance question                    The TWEAK is a five-item screening                     can consume more than five drinks
defined as “more than 2 drinks,” offers                    tool that includes questions from the                  without falling asleep or passing out. A
the best balance of sensitivity and                        MAST, CAGE, and T-ACE (see TWEAK                       positive response to the worry question
specificity.                                               textbox). The TWEAK is designed to                     yields 2 points, and positive responses
    The T-ACE is a valuable and efficient                  detect alcoholism or heavy drinking                    to the last three questions yield 1 point
tool for identifying alcohol use among                     and was first tested in three male and                 each. A woman who has a total score of
pregnant women; in addition, it demon­                     female samples randomly selected from                  2 or more points is likely to be an at-
strates acceptability and accuracy in                      three groups: (1) alcoholics in treat­                 risk drinker.
identifying a range of alcohol-use levels                  ment at a county medical center; (2)                       Like the T-ACE, the TWEAK asks
                                                                                                                  about tolerance to the effects of alcohol.
                                                                                                                  In one study of 4,743 African-American
   Table 2      Sensitivity and Specificity of the T-ACE, AUDIT, SMAST,                                           women of low socioeconomic status
                and Medical Record                                                                                who were given the MAST, the CAGE,
                                                                                                                  and the T-ACE tolerance question, the
   Criterion                                                          Sensitivity*         Specificity**          calculated sensitivity and specificity of
   Standard                        Instrument                            (%)                  (%)                 the TWEAK were 79 percent and 83
                                                                                                                  percent, respectively, in contrast to the
   DSM-III-R                       T-ACE (tolerance > 2)                   87.8                  36.6             calculated 70-percent sensitivity and
   lifetime alcohol                T-ACE (tolerance > 2)                   60.0                  66.4
                                                                                                                  85-percent specificity of the T-ACE.
   diagnosis                       AUDIT (> 11)                             7.0                  99.6
                                   AUDIT (> 10)                            11.0                  99.0
                                                                                                                  Periconceptional risk drinking, defined
                                   AUDIT (> 8)                             22.6                  97.4             as 1 ounce or more of alcohol consump­
                                   SMAST                                   14.8                  97.9             tion per day or 14 drinks per week dur­
                                   Medical record                          15.6                  93.6             ing a typical week before pregnancy
                                                                                                                  (Russell et al. 1994), was the criterion
   Risk drinking                   T-ACE (tolerance > 2)                   92.4                  37.6             standard (i.e., this was the level of
   (two drinks per day             T-ACE (tolerance > 2)                   74.3                  71.4             drinking that the instruments were try­
   before pregnancy)               SMAST                                   11.4                  95.9
                                                                                                                  ing to detect). The ability to generalize
                                   Medical record                           6.7                  89.4
                                                                                                                  these findings is limited. This is attribut­
   Current alcohol                 T-ACE (tolerance > 2)                   89.2                  37.8             able to the homogenous makeup of the
   consumption                     T-ACE (tolerance > 2)                   60.0                  66.9             sample, the fact that neither the T-ACE
   (while pregnant)                AUDIT (> 11)                             3.3                  97.8             nor the TWEAK were administered
                                   AUDIT (> 10)                             6.7                  96.9             as independent instruments, and the
                                   AUDIT (> 8)                             15.0                  93.9             definition of periconceptional risk
                                   SMAST                                    7.5                  94.3             drinking, which other researchers have
                                   Medical record                          20.0                  96.1             subsequently updated to 0.5 ounces of
   SMAST = Short Michigan Alcoholism Screening Test.
                                                                                                                  alcohol per day (Hankin and Sokol 1995).
   *Sensitivity is the probability that a person who should test positive, does so (Rosner 1990).                     The TWEAK does not appear to
   **Specificity is the probability that a person who should test negative, does so (Rosner 1990).                offer any significant advantages over
   NOTE: The sensitivity and specificity for varying cutoff scores for the T-ACE and AUDIT are listed (e.g., in
   response to the tolerance question in the T-ACE, “more than two drinks” would be a positive response in one
                                                                                                                  the T-ACE. Most studies investigating
   scoring method and “two or more drinks” would be a positive response under a different scoring method). With   the TWEAK’s performance have relied
   tolerance defined as two or more drinks to feel intoxicated, the T-ACE was the most sensitive instrument to
   detect current alcohol consumption, risk drinking, and lifetime DSM-III-R alcohol diagnoses. However, it was
                                                                                                                  on a definition of risk drinking that
   also the least specific.                                                                                       does not reflect more current research.
   SOURCE: Chang et al. 1998.                                                                                     Nonetheless, it offers another option
                                                                                                                  for clinicians.

Vol. 25, No. 3, 2001                                                                                                                                      207
Other Screening                                of drinking by most pregnant women            2000), brief interventions (i.e., short
Questionnaires                                 (i.e., it is unlikely that pregnant women     counseling sessions) may be especially
                                               will consume alcohol right before their       effective in this population. Given the
Research has not established the utility       obstetric appointment) (Testa and             potential adverse consequences of pre-
of other screening questionnaires—the          Reifman 1996; Lundberg et al. 1997;           natal alcohol exposure, short screening
CAGE, SMAST, AUDIT, and Prenatal               Strano-Rossi 1999). However, recent           questionnaires are worthwhile preven­
Alcohol Use Interview—for pregnant             research has demonstrated the potential
                                                                                             tive measures. ■
women. The CAGE and the SMAST                  value of maternal blood markers for
are popular self-report measures of            detecting levels of alcohol use during
alcoholism and are well studied in alco­       pregnancy that may result in overt
holic and nonalcoholic subjects and            alcohol-related deficits in newborns.
among males (Bradley et al. 1998). The         However, the most significant and most                         TWEAK
AUDIT is a 10-item questionnaire that          common result of prenatal alcohol expo-
identifies harmful and hazardous drink­        sure, neurobehavioral dysfunction, is
ing during the past year and has been          not an outcome recognized in the new-
                                                                                                T        Tolerance: How many
                                                                                                         drinks can you hold?
validated in six countries (Cherpitel 1995).   born period. Therefore, research has yet
The Prenatal Alcohol Use Interview is          to establish the relevance of these blood
a 13-item questionnaire that has been          markers to the more common fetal alco­
                                                                                                W        Have close friends or rela­
                                                                                                         tives Worried or com­
tested in a sample of 56 women thus far        hol effects (Jones and Chambers 1998;
                                                                                                         plained about your drink­
and requires further evaluation (Budd          Stoller et al. 1998). (See the article by
                                                                                                         ing in the past year?
et al. 2000).                                  Bearer on pp. xx-xx of this issue for more
    Two large studies of disadvantaged,        information on potential biomarkers to
minority, obstetric patients (Hankin and       detect alcohol use during pregnancy.)
                                                                                                E        Eye Opener: Do you
                                                                                                         sometimes take a drink in
Sokol 1995; Russell et al. 1996) reported
                                                                                                         the morning when you
that the calculated sensitivity and speci­
                                                                                                         get up?
ficity of the T-ACE and TWEAK were             Summary
superior to the CAGE in identifying
risk drinking (defined as 1 ounce or           Simple screening questionnaires, such
                                                                                                A        Amnesia: Has a friend or
                                                                                                         family member ever told
more of alcohol consumption per day).          as the T-ACE, provide valuable tools
                                                                                                         you about things you said
In another study, we gave the SMAST,           for identifying women who are using
                                                                                                         or did while you were
AUDIT, and T-ACE questions inde­               alcohol during pregnancy. The T-ACE
                                                                                                         drinking that you could
pendently to 350 pregnant women                has been shown to identify any alcohol
                                                                                                         not remember?
(Chang et al. 1998) and calculated how         consumption during pregnancy as well
well each of the three instruments could       as higher amounts of drinking. Research
predict lifetime DSM-III-R alcohol diag­       has demonstrated that any alcohol con­
                                                                                                K(C) Do you sometimes feel
                                                                                                         the need to Cut down on
noses and any drinking during pregnancy.       sumption during pregnancy increases
                                                                                                         your drinking?
The SMAST did not perform better               the risk of continued drinking during
than chance as a predictor for either of       pregnancy (Chang et al. 1999).
                                                                                                The TWEAK is used to screen
the two drinking categories. Although              The T-ACE is administered easily.
                                                                                                for pregnancy risk drinking,
the AUDIT had good predictive abil­            A clinician may either ask the T-ACE
                                                                                                defined here as the consumption
ity, the definition of a “positive” score      questions directly or request that the
                                                                                                of 1 ounce or more of alcohol
on the AUDIT for drinking pregnant             patient complete the questionnaire while
                                                                                                per day while pregnant. Scores
women remains to be identified and             waiting for her appointment. The T­
                                                                                                are calculated as follows: A positive
confirmed through further research.            ACE has been tested and demonstrated
                                                                                                response to question T on
                                               to be acceptable and effective in both
                                                                                                Tolerance (i.e., consumption of
                                               formats.
                                                                                                more than five drinks) or question
Laboratory Tests for                               A positive screen is not an indict­
                                                                                                W on Worry yields 2 points
Detecting Alcohol Use                          ment. Rather, it is an opportunity for
                                                                                                each; an affirmative reply to
                                               the clinician and patient to discuss pre-
                                                                                                question E, A, or K scores 1 point
Although the central focus of this arti­       natal alcohol exposure. The discussion
                                                                                                each. A total score of 2 or more
cle is on screening questionnaires, other      may lead the clinician to refer the patient
                                                                                                points on the TWEAK indicates
methods of detecting alcohol use dur­          for a diagnostic assessment. Or the
                                                                                                a positive outcome for pregnancy
ing pregnancy deserve some comment.            clinician may offer a brief intervention
                                                                                                risk drinking.
Use of breath analysis or urinalysis in        if the patient does not have a severe
pregnant patients is not likely to be fea­     alcohol problem. Because most preg­              SOURCE: Chan et al. 1993.
sible or acceptable, given the rapid           nant women are highly motivated to
metabolism of alcohol and the pattern          change their behaviors (Hankin et al.

208                                                                                                          Alcohol Research & Health
Screening Instruments for Pregnant Women

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