About Us




September 2008


Book Review:
The Moon Children by Beverley Brenna

Reviewed by Tracy Jirikowic

Billy Ray is an 11-year-old with a Fetal Alcohol Spectrum Disorder (FASD). Ms. Brenna takes readers inside the head of Billy Ray as he struggles with friendship, family and his personal sense of self. The author does a wonderful job describing how Billy Ray perceives the people and events in his life as he tries to make sense of and cope with learning difficulties, school bullies, an alcoholic father, and a mother trying to make ends meet. Through Billy Ray’s friendship with Natasha, his neighbor across the street, we learn how Billy Ray yearns to do the right thing, be a good friend and reach out to this silent, reticent international adoptee.

The story provides an honest, first person account of the day-to-day thoughts, misunderstandings and triumphs of a young boy who possesses some very unique talents, but who struggles with a mind affected by prenatal alcohol exposure, a body that “won’t sit still” and an urgent need to belong and succeed. This work of young adult fiction could help introduce young readers to FASD and serve as a basis for discussing the risks associated with alcohol use during pregnancy and for understanding learning differences.

return to top

Preventing an Alcohol Exposed Pregnancy through Preconception Care

By Mary O’Connor, PhD, ABPP

Although there have been substantial gains in improving the health of women and children in the United States, much remains to be done. Of specific concern is the continued use of alcohol by women of childbearing age and the need for preconception counseling (PCC) in order to prevent an alcohol exposed pregnancy (AEP).

Prenatal exposure to alcohol remains a leading preventable cause of birth defects and developmental disabilities in the United States with the prevalence of alcohol consumption by women of childbearing age remaining high and unchanged over the last decade.1 Each year, half a million women report alcohol use in the past month, and 80,000 report heavy episodic drinking of 5 or more drinks per drinking occasion. About 8 percent are sexually active, fertile, not using any form of birth control and at risk of having an AEP.2 For many women, pregnancy recognition does not occur until the sixth week of gestation (a time of great vulnerability for the developing fetus) and yet they frequently do not receive counseling on the dangers of alcohol until their first prenatal visit, if at all.2 Furthermore, there is a high probability of post-pregnancy alcohol use thus endangering subsequent pregnancies.3

Women of childbearing age visit their physicians an average of about three times a year and these visits represent opportunities to deliver PCC messages.4 However, the literature on clinical practice reveals that these opportunities are often missed by health care professionals.5 In a recent study of OB/GYN practitioners, 87 percent viewed PCC as specialized pre-pregnancy care focusing on issues not typically addressed during a routine examination. Although the majority agreed that PCC is an important issue and has positive effects on pregnancy outcomes, only 21 percent agreed that it is a high priority in their own practices.6

In contrast to the beliefs of providers, a recent survey of women of childbearing age revealed that 98 percent realized the importance of optimizing their health prior to a pregnancy and thought that the best time to receive health related information was before conception.7 Only 39 percent of women could recall their physicians ever discussing their preconception health.

In 2004, the U.S. Preventive Services Task Force recommended screening and behavioral interventions to reduce alcohol misuse in women in primary care settings. Likewise, the Surgeon General released a report in 2005, stating that health providers should a) inquire routinely about alcohol consumption by all women of childbearing age, b) inform them of the risks of consumption during pregnancy, and c) advise them to abstain from alcohol use during pregnancy. In spite of these recommendations, a recent study found that only 49 percent of OB/GYNs report that they discuss alcohol consumption during routine examinations. In contrast, 89 percent report that they discuss the dangers of smoking.6

One reason that many providers do not routinely counsel women concerning their alcohol use may relate to their unfamiliarity with validated screening tools and efficacious intervention techniques. Currently, the most commonly recommended screening questionnaires for women are the T-ACE, the TWEAK, and the National Epidemiologic Survey on Alcohol and Related Conditions AUDIT-C (NESARC AUDIT-C). (link each to figures)8 Wording and scoring keys for these screeners are presented in Figure 1, Figure 2 and Figure 3. Quantity and frequency measures have also been employed, and the National Institute on Alcohol Abuse and Alcoholism (NIAAA)9 recommends that women who are not pregnant drink no more than 7 drinks per week and no more than 3 drinks per drinking occasion. Abstinence is recommended for women who are planning on becoming pregnant, women who are not using effective contraception, and women who are pregnant or nursing.

For women who screen positive for alcohol use or abuse, brief intervention (BI) has been shown to be a low-cost, effective treatment approach that uses time-limited, self-help, and preventative strategies to promote reductions in alcohol use in nondependent individuals, and in the case of dependent individuals, to facilitate referral to specialized treatment programs.10 The approach employs the use of motivational counseling and can be delivered by providers who are not specialists in the treatment of alcohol abuse or dependence. The main components of the intervention involve feedback of personal risk, responsibility for personal control, advice to change, ways to reduce or stop drinking, an empathetic counseling style, and self-efficacy or optimism for behavior change. BI also involves establishing a drinking goal and follow up of progress with ongoing support.10

The most effective use of BI in PCC is demonstrated in Project CHOICES, which was designed to prevent AEPs among high-risk women in various community settings.11 A unique aspect of the intervention was that it focused not only on reducing high risk drinking, but also addressed pregnancy postponement. Findings were that at the 3, 6, and 9 month follow-ups, women in the intervention group were twice as likely to reduce their risk for an AEP as those in the control group either through a reduction in their risk drinking, an increase in the use of effective contraception, or both.

Similar cognitive behavioral approaches have also demonstrated reductions in alcohol use in pregnant women, resulting in more positive newborn outcomes.12, 13 An example of such an intervention is provided in Figure 4. In recognition of the importance of screening and BI, a tool kit was developed by the American College of Obstetricians and Gynecologists (ACOG) under the auspices of the Centers for Disease Control and Prevention (CDC) to enhance formal screening and BI in preconception and pregnant women. The toolkit can be accessed through the CDC’s Web site.


The greatest opportunities for healthy pregnancy outcomes lie in prevention strategies implemented prior to conception. Importantly, health care providers should understand that early prenatal care is often too late for many women and babies. With regard to alcohol, the only definitive way of promoting the prevention of an AEP is to advise women to stop drinking before conception. Brief clinician-delivered behavioral interventions to women, counseling regarding effective contraceptive options when not planning a pregnancy, and improved access to treatment for those women who are unable to reduce their alcohol intake are all effective methods aimed at preventing an AEP and the devastating developmental outcomes associated with such exposure.

Note: If you print this newsletter, the Figures and References will be printed.

Mary J. O’Connor, PhD, ABPP, is an adjunct professor of Psychiatry and Biobehavioral Sciences at the Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles.

The writing of this manuscript was supported by the Centers for Disease Control and Prevention Grant #CCU925033. The contents do not necessarily represent the positions or policies of the Centers for Disease Control and Prevention and endorsement by the federal government should not be assumed.

Figure 1. T-ACE

T- TOLERANCE – How many drinks does it take to make you feel high? [3 or more drinks constitutes a positive answer = 2 points]
A- Have people ANNOYED you by criticizing your drinking? [“yes” constitutes a positive answer = 1 point]
C- Have you ever felt you ought to CUT DOWN on your drinking? [“yes” constitutes a positive answer = 1 point]
E- EYE OPENER – Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? [“yes” constitutes a positive answer = 1 point]

A positive screen is a score of 2 or more points.


Figure 2. TWEAK

T-TOLERANCE – How many drinks does it take before you begin to feel the first effects of alcohol? [3 or more drinks constitutes a positive answer = 2 points]
W- WORRY – Do close friends or relatives worry or complain about your drinking? [“yes” constitutes a positive answer = 2 points]
E-EYE OPENER – Do you sometimes take a drink in the morning when you first get up? [“yes” constitutes a positive answer = 1 point]
A-AMNESIA – Has a friend or family member ever told you about things you said or did when you were drinking that you could not remember? [“yes” constitutes a positive answer = 1 point]
K-CUT DOWN – Do you sometimes feel the need to cut down on your drinking? [“yes” constitutes a positive answer = 1 point]

Scores on the TWEAK range from 0 to 7. Investigators have suggested that a cut point total score on the TWEAK of 2 or more should be used to optimize sensitivity/specificity in identifying pregnant women who may not be alcohol-dependent but who may, nevertheless, be drinking at levels that place the fetus at risk.



During the last 12 months, about how often did you drink ANY alcoholic beverage?

Counting all types of alcohol combined, how many drinks did you USUALLY have on days when you drank during the last 12 months?

During the last 12 months, about how often did you drink FIVE OR MORE drinks in a single day?

Scores range from 0 to 4 on each question. Good sensitivity and specificity is reached at a cut point of 3 or greater for identifying risk drinking in non-pregnant and pregnant women.


  1. Alcohol use among women of childbearing age. United States, 1991-1999, MMWR, 2002;52:273-6.
  2. Floyd RL, Decoufle P, Hungerford DW. Alcohol use prior to pregnancy recognition. Am J Prev Med 1999;17:101-7.
  3. Ebrahim SH, Gfreoerer J. Pregnancy related substance use in the United States during 1996-1998. Obstet Gynecol 2003;101:374-9.
  4. Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey: 2000 Summary. Adv Data 2002;1-32.
  5. Moos MK. Preconceptional Health Promotion: Progress in changing a prevention paradigm. J. Perinat Neonat Nurs 2004;18:2-13.
  6. Morgan MA, Hawks D, Zinberg S, Schulkin J. What obstetrician-gynecologists think of preconception care. Matern Child Health J 2006;10:S59-S65.
  7. Frewy KA, Files JA. Preconception healthcare: What women know and believe. Matern Child Health J 2006;10:S73-S77.
  8. Floyd RL, O’Connor MJ, Sokol RJ, Bertrand J. Cordero JF. Recognition and prevention of Fetal Alcohol Syndrome. Obstet Gynecol 2005;106:1059-64.
  9. Dawson DA, Grant BF, Li TK. Quantifying the risks associated with exceeding recommended drinking limits. Alcohol Clin Exp Res. 2005;29(5):902-908,.
  10. Floyd RL, O’Connor MJ, Bertrand J, Sokol, R. Reducing adverse outcomes from prenatal alcohol exposure: A clinical plan of action. Alcohol Clin Exp Res 2006;30:1-5.
  11. Floyd RL, Sobell, M, Velasquez MM et al. Preventing alcohol-exposed pregnancies: A randomized controlled trial. Amer J Prev Med 2007;32:1-9.
  12. Chang G, McNamara TK, Orav EJ et al. Brief intervention for prenatal alcohol use: A randomized trial. Obstet Gynecol 2005;105:991-8.
  13. O’Connor MJ, Whaley SE. Brief intervention for alcohol use with pregnant women in the WIC setting. AM J Public Health 2007;63:773-83.

return to top

You are invited to attend the Fetal Alcohol Awareness Candlelight Vigil

Fetal Alcohol Awaremenss Candlelight Vigil

Tuesday, September 9th at 8:45 pm in Victoria Park (corner of Central & Richmond Street) Meet and greet to follow at Williams
Coffee Pub.

International FASD Awareness Day is set aside
each year to raise awareness about Fetal Alcohol Spectrum Disorder (FASD). On the ninth minute of the ninth hour of the ninth day of the ninth month, SEPTEMBER 9TH, organizations and agencies across Canada plan events in their own community to raise
awareness that during the nine months of pregnancy, a woman should not drink

For more information please call Laura Spero @ 519 963 1402

Sponsored by the London FASD Network


return to top
view other newsletters


FASIS - Iceberg
P.O. Box 95597
Seattle, WA 698145-2597