Counselor Manual
Counselor Manual
Counselor Manual
COUNSELOR MANUAL
CHOICES
COUNSELOR MANUAL
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Birth Defects and Developmental Disorders
Division of Birth Defects and Developmental Disabilities
Atlanta, GA
August 2011
ACKNOWLEDGEMENTS
The Project CHOICES Intervention Development
Team developed and wrote the CHOICES intervention
that included the Client Workbook and Counselor
Manual from which the Facilitator Guide for this
curriculum was developed. The Team included Mary
M. Velasquez, PhD, Karen Ingersoll, PhD, Mark B.
Sobell, PhD, ABPP, R. Louise Floyd, DSN, RN, Patricia
D. Mullen, DrPH, Mary Nettleman, MD, MS, Linda
Carter Sobell, PhD, ABPP, Deborah Gould, PhD,
Sherry Ceperich, PhD, and Kirk Von Sternberg PhD.
The following participated in the development of the
curriculum materials: Mary M. Velasquez, PhD, Karen
Ingersoll, PhD, Mark B. Sobell, PhD, ABPP, R. Louise
Floyd, DSN, RN, Linda Carter Sobell, PhD, ABPP, and
Sherry Ceperich, PhD.
Centers for Disease Control and Prevention (CDC)
provided oversight of the curriculum development
project and participated in all aspects of the process.
CDC participants were R. Louise Floyd, DSN, RN and
Catherine A. Hutsell, MPH.
The findings and conclusions in this report are those of the authors and do not necessarily represent this official position of
the Centers for Disease Control and Prevention.
This document is in the public domain and may be reproduced without permission. Photographic images are not public
property and may not be used exclusive of this document. Logos of the Federal Government, Departments, Bureaus, and
Independent Agencies are not in the public domain and cannot be used without specific authorization of the agency involved.
CONTENTS
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CHOICES: The Intervention Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Motivational Interviewing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Counseling Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Session 1: Introduction To CHOICES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
An Example of CHOICES Session 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Session 2: Reviewing Feedback and Setting Goals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
An Example of CHOICES Session 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Session 3: Reviewing Goals and Revisiting CHOICES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
An Example of CHOICES Session 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Session 4: Future Goals and Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
An Example of CHOICES Session 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Appendices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Appendix A: Risks of an Alcohol Exposed Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Appendix B: Assessments and Feedback. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Appendix C: Temptation and Confidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Appendix D: Contraceptive Methods, Facts, and Myths. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Appendix E: Glossary of Terms
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
66
Introduction
Prenatal alcohol exposure is a leading preventable cause of
birth defects and developmental disabilities in the United
States. Studies from the Centers for Disease Control and
Prevention (CDC) find that each year approximately 500,000
pregnant women report they drank alcohol in the past
month, and approximately 80,000 pregnant women report
binge drinking (five or more drinks on any one occasion).1
Fetal exposure to alcohol results in a spectrum of adverse
effects that has been termed Fetal Alcohol Spectrum
Disorders (FASDs), with the brain and central nervous
system being particularly sensitive to the effects of alcohol.
Alcohol exposure during pregnancy can have profound and
life-long consequences for children. Fetal Alcohol Syndrome
(FAS) is one of the most involved conditions along the
spectrum and affects up to two out of every 1,000 infants
born each year in the United States. The estimated lifetime
cost of FAS is $2 million per case, with an annual cost for all
cases of $4 billion to the nation.2
Most women reduce alcohol consumption after learning
they are pregnant. Others do not recognize they are
pregnant in the early weeks of gestation and continue to
drink at high levels. Among women of childbearing age
(1844 years), more than half report they drank alcohol in
the past month, and one in eight reports binge drinking
in the past month.3 Women who are planning to become
pregnant or are at risk of becoming pregnant should avoid
using alcohol if they are sexually active and not using
contraception. Studies find that about half of all pregnancies
in the U.S. are unplanned. About half of these unplanned
pregnancies occur in women who are using contraception
but not effectively. Enhancing effective contraception in
women who are drinking at risk levels could help them
avoid having an alcohol-exposed pregnancy (AEP).
Goal of CHOICES
The overall goal of the CHOICES intervention is to reduce
AEPs by identifying and intervening with at-risk women
in the preconception period or prior to pregnancy. To do
this, the intervention is designed to address both alcohol
reduction and pregnancy prevention.
Centers for Disease Control and Prevention. (2009). Alcohol use among pregnant and
nonpregnant women of childbearing age-United States, 19912005. Morbidity and Mortality
Weekly Report, 58(19), 529532.
Lupton, C., Burd, L., & Harwood, R. (2004). Cost of fetal alcohol spectrum disorders.
American Journal of Medical Genetics, 127C, 4250.
CDC, 2009.
HHS. (2005, February 21[posted]; 2007, January 4 [last revised]). U.S. surgeon general
releases advisory on alcohol use in pregnancy: Urges women who are pregnant or who
may become pregnant to abstain from alcohol. Retrieved from www.surgeongeneral.
gov/pressreleases/sg02222005.html
Institute of Medicine. (1990). Broadening the base of treatment for alcohol problems.
Washington, DC: National Academy Press.
Dawson, D. A., Grant, B. F., Stinson, F. S., Chou, P. S., Huang, B., & Ruan, W. J. (2005).
Recovery from DSM-IV alcohol dependence: United States, 20012002. Addiction,
100(3), 281292.
CHOICES:
The Intervention Approach
Objectives
The objectives for this section are:
To provide an overview of CHOICES
To provide background on the origin of the
CHOICES study
To define the strategy used in CHOICES to address
alcohol use
To define the strategy used in CHOICES to address
birth control use
CHOICES: An Overview
CHOICES is a four-session counseling intervention, plus
a birth control consultation, that is offered to women
who are at risk for an alcohol-exposed pregnancy.
CHOICES is designed for delivery across health, mental
health, substance use treatment, and incarceration
settings. Using the MI spirit, components, and skills,
the CHOICES intervention is tailored to adapt to each
womans level of readiness to change her alcohol use
and contraceptive behaviors. The CHOICES intervention
includes three primary components:
1. Screen and assess women for drinking and
contraception use to identify those who are at risk
for an alcohol-exposed pregnancy
2. Provide each woman with a four-session
counseling intervention using the materials in this
training manual
3. Arrange a birth control consultation for each woman
This approach is unique in the field of alcoholexposed pregnancy prevention. Research shows brief
interventions that incorporate assessment, feedback,
consequences of behavior, and self-help materials
for goal-setting and behavior change can succeed in
reducing problem drinking among women in health
care settings.10
10
Sobell, M. B., & Sobell, L. C. (1995). Controlled drinking after 25 years: How important
was the great debate? Addiction, 90, 11491153.
11
Guidance in Contraception
Although CHOICES counselors are not expected to
be experts in contraception, they facilitate behavioral
changes in women who: are unable or unwilling to
drink at the advised levels to reduce the likelihood of
an alcohol-exposed pregnancy and therefore want to
focus on birth control as a means of AEP prevention,
or choose to focus on both limited drinking and
contraception effectiveness to prevent an AEP.
CHOICES counselors need basic knowledge about
contraception, including an understanding of:
Risks from drinking during pregnancy (see
Appendix A: Risks of an Alcohol-Exposed
Pregnancy)
Resources for contraception consultation and
services available to women in their community
How to listen to and explore myths about
contraception if a woman mentions them, and how
to provide accurate information to address these
myths (see Appendix D: Contraceptive Methods,
Facts, and Myths)
Bandura, A. (1997). Self-efficacy: The exercise of control (1st ed.). New York: Worth
Publishers.
12
Objectives
This section provides an overview of the counseling
techniques and approaches used in the CHOICES
intervention, focusing on Motivational Interviewing
(MI) as well as other strategies. The objectives of this
section are:
To provide an overview on how to use the MI
approach to motivate women to change their
drinking and contraceptive behaviors
To demonstrate how to apply MI to the CHOICES
intervention throughout each session
To illustrate MI skills and strategies so counselors
are prepared to use them to conduct the CHOICES
intervention
To provide an overview of the Stages of Change
model and how it can be applied to CHOICES
To demonstrate how to use the Readiness Ruler to
assess a womans readiness to change
To provide an overview on how to use decision
exercises throughout the CHOICES intervention
To illustrate the role and importance of temptation
and confidence in the womans process of change
13
Prochaska, J. O., Norcross, J., & DiClemente, C. (1995). Changing for good: A
revolutionary six-stage program for overcoming bad habits and moving your life
positively forward. Indiana: Collins Living.
14
15
Sobell, M. B., & Sobell, L. C. (2005). Guided Self-Change treatment for substance
abusers. Journal of Cognitive Psychotherapy, 19, 199210.
16
17
LISTEN REFLECTIVELY
Reflective listening is one of the most important skills
in MI. It involves forming a reasonable guess about
the meaning of the womans comments and giving
voice to this guess through a statement. Because
you may not fully understand what a woman means,
reflective listening provides an opportunity to clarify.
Reflect feelings as well as words. The intention is for
you to elicit arguments for change from the woman
rather than presenting them to her.
SUMMARIZE
Periodic summaries link together material already
discussed, demonstrate careful listening, prepare
women to move on, and examine ambivalence about
change. Its helpful to offer a major summary at the
end of a session. Summarizing helps to capture the
essence of the discussion, link topics, and make
transitions in the conversation.
Change Talk
The preceding four skills are fundamental to MI and
provide an important foundation. A fifth strategy helps
to guide the woman toward change by eliciting and
reinforcing her statements about it and helping her
resolve her ambivalence.
ELICIT CHANGE TALK:
Four general categories of change statements cover:
Desire to change
Ability to change
Reasons to change
Need to change
The counselor reinforces these statements through
reflective listening and supportive statements. Finally,
the counselor is careful to communicate acceptance
and reinforce the womans self-expression throughout
the session.
Using the training that accompanies this manual,
practicing with peers, and reviewing the
demonstration videos will prepare you to use MI in
your CHOICES sessions.
Readiness Ruler
Motivation can change over time. It is important for
the counselor to understand where a woman is in
her readiness to change. Lack of readiness can reflect
ambivalence.
The Stages of Change model has served as the
foundation for developing several different ways to
assess readiness.18 CHOICES uses a Readiness Ruler to
assess readiness to change.19 This is a simple method
that quickly provides a counselor with insight into
a womans motivation for change.20 The woman is
asked where she is on a scale from 0 to 10, with 10
indicating extremely ready to change.
Readiness Rulers are used in CHOICES sessions,
along with Importance and Confidence Rulers. In
CHOICES, these are called the Self-Evaluation Rulers.
These rulers also help you assess motivation, and
they can elicit change talk. For example, women are
asked to assess their readiness by marking the ruler
or verbalizing a number. Once a number is identified,
the next step is to ask why she chose a particular
number, say a 4, and not a lower number. You can
ask, Why a 4 and not a 1? This response elicits
Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing
traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin.
18
DOnofrio, G., Bernstein, E., & Rollnick, S. (1996). Motivating Clients for change: A
brief strategy for negotiation. In E. Bernstein & J. Bernstein (Eds.), Case studies in
emergency room medicine and the health of the public. (pp. 295303).
Boston: Jones & Bartlett.
19
Rollnick, S., Mason, P., & Butler, C. (1999). Health behavior change: A guide to
practitioners. Edinburgh: Churchill Livingston.
20
Counseling Guide
Decision Exercise
Decision exercises are used in CHOICES to provide
both the counselor and the woman important
information and strategies to help in goal-setting.
This exercise is oriented toward tipping the
motivational balance in favor of change.21,22 One side
of the scale favors the status quo; the other side favors
change. If the woman shows ambivalence about
changing, your task is to elicit information that will
reveal why. By discussing the good things and the
less good things about alcohol use and birth control
use, you help to elicit motivational factors for change
that she herself can identify.
Completing and discussing the exercise will help
identify which behavioralcohol use or birth control
usethe woman seems more ready to change.
Likewise, this will allow you to focus on the behavior
that the woman is more ready to change early in
the intervention.
Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of conflict,
choice, and commitment. New York: Free Press.
21
Center for Substance Abuse Treatment. (1999) Enhancing motivation for change in
substance abuse treatment: Treatment Improvement Protocol (TIP) Series 35. Vol. HHS
Publication No. (SMA) 99-3354. Rockville, MD: Substance Abuse and Mental Health
Services Administration.
22
Objectives
In this section you will be provided with a
background of the procedures, guidelines, and
overall structure to help you conduct the CHOICES
intervention. The objectives of this section are:
To demonstrate the importance of flexibility in the
CHOICES intervention and the ways in which MI
can facilitate this process
To provide tips on how counselors can guide
women through:
The process of conducting assessments
Analyzing drinking and contraceptive behaviors
Identifying risk factors and situations using the
daily journal and decision exercises
Transitioning through the activities in each
session
To provide strategies on how to introduce and
encourage a birth control visit and, in some cases,
a return visit
To provide information on how to promote
safer sex
To provide an overview of session content for the
four sessions in CHOICES
Witkiewitz, K., & Marlatt, G. A. (2004). Relapse prevention for alcohol and drug
problems: That was Zen, this is Tao. American Psychologist, 59 (4), 224-235.
23
11
What happened sounds like what we call a highrisk situation where there is a strong likelihood that
you might drink heavily or drink more than you
intended. In this program, you can develop your
own plans for how to deal with situations like that
without drinking heavily.
12
14
SESSION 1:
INTRODUCTION TO CHOICES
Session 1 Objectives
Components of Session 1
To
To
To
To
16
Implementation: The 12
Activities of Session 1
Activity 1: Introduce yourself and explain
your role.
Objective: Establish a collaborative, respectful, and
warm style to set the stage for what is to come in
CHOICES.
Tell the woman you are looking forward to working
with her, and that changing is her choice.
17
18
19
20
There are two main ways to avoid an alcoholexposed pregnancy. The first is to not drink alcohol
at all or reduce your drinking to below risky levels.
The second is to use birth control effectively so you
dont become pregnant in the first place. The best
thing, of course, would be to abstain from or reduce
your drinking below risky levels and to use birth
control effectively so you dont become pregnant.
SESSION 2:
Session 2 Objectives
Components of Session 2
To
To
To
To
24
Implementation: The 12
Activities of Session 2
Activity 1: Review session activities.
Objective: Review the upcoming session activities to
provide a guide for what will be covered during this
session, to give the woman a sense of the structure for
the remaining sessions, and to introduce anything else
she would like to discuss or ask.
Discuss any outstanding issues from the last session
or anything that appears pressing to her. She may
want to talk about her journal immediately; this is a
good way to open the session. If she does not want to
talk about her journal, show her the session activities
list, review the activities together, and ask if there
is anything else she would like to add. If she does
add something to the list, you can let her know it is
OK to return to further discussion of that issue after
you cover the session activitiesunless she needs to
discuss it first.
25
26
Righting reflex
The tendency of the
counselor to try to solve the
problem for the client or
improve what the client says.
For example
[NOTE: Review two situations, preferably one where
temptation exceeds confidence and one where
confidence exceeds temptation.]
29
30
SESSION 3:
Session 3 Objectives
Components of Session 3
32
33
34
Last time you were here, the goal you had for birth
control use was _______. If you were to make a goal
now, what would it be? Remember, you can change
your goal any time.
Activity 5: Review and update
decision exercises.
Lets use your decision exercises to take another look
at the good things and less good things about your
current drinking and your use of birth control.
Lets go to the drinking one. As you look at that
now, how does it fit with where you are now? What
changes, if any, would you like to make?
You also wrote some good things and less good
things about using birth control. Looking at those
statements today, what changes do you want to
make on this exercise?
[NOTE: Summarize briefly.]
Activity 6: Review and update
self-evaluation exercises.
Last time, you filled out some Readiness Rulers. Lets
look at them again and see where you are now.
Lets start with your drinking. Using this ruler, please
make a mark anywhere from 1 to 10 to show how
important it is for you today to make a change in
your drinking.
You marked a ___, which shows this is ____ (not/
somewhat/pretty/very) important.
Why did you select a ____ and not a____?
[NOTE: Always make the second number lower than
the one the woman chose. Be sure to use reflective
listening skills. This is a good opportunity to elicit and
reinforce change talk.]
35
36
SESSION 4:
Session 4 Objectives
Components of Session 4
1.
2.
3.
4.
38
Implementation: The 11
Activities of Session 4
Activity 1: Review session activities.
Objective: Review the session activities to provide a
guide for what will be covered during this session, to
discuss any outstanding issues from previous sessions,
and to give the woman an opportunity to introduce
anything else she would like to discuss or ask.
If she came in with something to discuss, let her know
you can discuss her issue further after you cover the
session activities.
OARS
1. Open-ended questions
2. Affirm the person
3. Reflect what the person says
4. Summarize
39
Activity 7: Problem solve, reinforce goals, revisit temptation and confidence, and work to
strengthen commitment for birth control.
Objective: Discuss where she had difficulty meeting
her birth control goals, explore the challenges that
came up, and help her find alternative strategies for
moving forward.
If she identifies obstacles, assess whether the problem
is a lack of confidence or a lack of importance
attributed to this goal. Respond accordingly.
40
41
Activity 7: Problem solve, reinforce goals, revisit temptation and confidence, and work to
strengthen commitment for birth control.
[NOTE: Use motivational interviewing techniques to
summarize her progress and obstacles, and to reinforce
changes she has made.]
In what additional areas do you feel you need
some help?
Based on your goals and how you have worked
to reach your goals, lets discuss more ways to get
support and maintain those goals.
[NOTE: Use goals and other points from Activity 6.]
42
APPENDICES:
APPENDIX A: RISKS OF
AN ALCOHOL-EXPOSED
PREGNANCY
Objectives
This section provides an overview of the research
and evidence on alcohol-exposed pregnancies.
The objectives of this section are:
To identify the risks and dangers of alcohol use
during pregnancy:
Fetal Alcohol Syndrome
Fetal Alcohol Spectrum Disorders
Other adverse outcomes
To provide an overview of the public health
implications of alcohol-exposed pregnancies in
the United States
To identify the risk factors for an alcoholexposed pregnancy
An estimated 12% of
pregnant women 1544
years of age drank alcohol
the past monthmeaning
approximately 1 in 8 women
put their children at risk for an
alcohol-exposed pregnancy.
Overview
Alcohol consumption during pregnancy is frequently
cited as one of the leading preventable causes of
birth defects and childhood disabilities in the United
States.24,25 Children who are exposed to alcohol
during fetal development can suffer a range of
negative life-long effects that vary in quantity and
severity. Alcohol use during pregnancy can result
in physical and mental birth defects, preterm births,
and miscarriages.26 Consequently, both the Surgeon
General and the March of Dimes Foundation
recommend women do not consume any alcohol
while pregnant.27,28
Alcohol is a known teratogen, meaning it can harm
an unborn child. When a pregnant woman drinks
alcohol, it crosses the placenta barrier and moves into
the bloodstream of the fetus. So the alcohol content in
CDC. (2002). Alcohol use among childbearing-age womenUnited States, 19911999.
Addiction, 90, Morbidity and Mortality Weekly Report, 51, 2736.
24
Ebrahim, S. H., Luman, E. T., Floyd, R. L., Murphy, C. C., Bennett, E. M., & Boyle, C.
A. (1998). Alcohol consumption by pregnant women in the United States during
19881995. Obstetrics & Gynecology 92, 18792.
25
26
HHS, 2005.
30
SAMHSA, 2008
HHS, 2005.
31
32
27
28
44
29
CDC, National Center on Birth Defects and Developmental Disabilities. (2004). Fetal
alcohol syndrome: Guidelines for referral and diagnosis. Retrieved from www.cdc.gov/
ncbddd/fasd/documents/FAS_guidelines_accessible.pdf
33
FETAL ALCOHOL
SPECTRUM DISORDERS
FAS, included under the umbrella of FASDs, is one of
the most involved and least common effects of alcohol
exposure during pregnancy. According to CDC, an
estimated 1,000 to 6,000 of the 4 million babies born
each year will have FAS.36
36
CDC, (2005).
37
34
35
Sampson, P. D., Streissguth, A. P., Bookstein, F. L., Little, R. E., Clarren, S. K., Dehaene,
P., Hanson, J. W., & Graham, J. M. (1997). Incidence of fetal alcohol syndrome and
prevalence of alcohol-related neurodevelopmental disorder. Teratology, 56, 317326.
Egeland, G. M., Katherine, P. H., Gessner, B. D., Ingle, D., Berner, J. E., & Middaugh, J. P. (1998).
Fetal alcohol syndrome in Alaska, 1977 through 1992: An administrative prevalence
derived from multiple data sources. American Journal of Public Health, 88, 781786.
38
Chavez, G. F., Cordero, J. F., & Becerra, J. E. (1988). Leading major congenital
malformations among minority groups in the United States, 19811986. Morbidity
and Mortality Weekly Report, 37 (SS-3), 1724.
39
40
41
CDC, (2004).
42
45
Facial Dysmorphia
To be diagnosed with FAS, an individual must exhibit
all three of the following characteristic facial features:
Smooth philtrumabsence of a groove or divot
running between the nose and upper lip
Thin vermillion borderthin upper lip
Small palpebral fissuresdecreased eye width
Growth Deficits
Growth retardation has been documented consistently
in individuals with FAS. Growth deficiencies are
defined as height, weight, or both that is/are
significantly below average. To meet the growth
retardation criteria for FAS, an individuals height
or weight falls at or below the 10th percentile on
standardized growth charts appropriate to the patients
population. Growth retardation can occur during
pregnancy, at birth (known as small for gestational
age), or at any time after birth.
Central Nervous System (Abnormalities)
Central nervous system abnormalities produce a range
of short- and long-term cognitive and behavioral
outcomes observed among individuals with FAS. As a
result of these abnormalities, many adults affected by
FAS have complex mental health disorders, are affected
by neurobehavioral deficits, and are unable to live
independently.43 These deficits are typically life-long.
The following structural, neurological, and/or
functional deficits are caused by central nervous
system abnormalities that are identified in persons
with FAS.
1. Structural: Observable physical damage to the
brain or brain structures such as a smaller than
normal brain (microcephaly) or damage to the
connections between the two sides of the brain
(malformed corpus callosum)
2. Neurological: Assessed when structural
impairments are not observable or do not exist;
may be indicated by seizures, coordination
problems, motor difficulties, etc.
Streissguth, A. P., & OMalley, K. (2000). Neuropsychiatric implications and longterm consequences of fetal alcohol spectrum disorders. Seminars in Clinical
Neuropsychiatry, 5, 177190.
43
46
52
53
Astley, S. J., Bailey, D., Talbot, C., et al. (2000). Fetal alcohol syndrome (FAS) primary
prevention through FAS diagnosis: II: A comprehensive profile of 80 birth mothers of
children with FAS. Alcohol & Alcoholism, 35 (5), 509519.
54
CDC. (2005). Alcohol consumption among women who are pregnant or who might
become pregnantUnited States, 2002. Morbidity and Mortality Weekly Report, 58, 529-532.
44
45
Office of Applied Studies. (2007). Results from the 2006 National Survey on Drug Use
and Health: National findings (HHS Publication No. SMA 07-4293, NSDUH Series H-32).
Rockville, MD: Substance Abuse and Mental Health Services Administration.
46
CDC, 2004.
55
56
SAMHSA, 2007.
47
CDC 2002.
48
49
Floyd, R. L., Decoufle, P., & Hungerford, D. W. (1999). Alcohol use prior to pregnancy
recognition. American Journal of Preventative Medicine, 17, 101107.
50
CDC, 2004.
51
47
Average #
of Alcoholic
Drinks on Days
Alcohol Was
Consumed
1517
15.8
3.6
1825
9.8
3.6
2644
12.5
1.7
White
14.5
1.9
Black
15.7
3.1
4.1
4.6
8.9
4.5
8.3
2.6
Some college
11.7
2.1
College graduate
15.8
1.6
11.7
3.7
$20,000$49,999
9.2
2.2
$50,000$74,999
9.5
2.3
$75,000 or higher
16.3
1.6
Demographic
Characteristics
Age
According to the National Survey on Drug Use and
Health, pregnant women 1517 years of age show
the highest levels of alcohol consumption compared
across age groups. Nearly 16% of pregnant women
in this age group used alcohol in the past month
and, on average, they consumed 24 drinks in the past
month. This means they drank on an average of six
days in the past month and drank an average of four
drinks on each of those days.
AGE
RACE/ETHNICITY
Hispanic
EDUCATION STATUS
INCOME
SAMHSA, 2008.
57
48
16
14
12
10
8
6
4
2
0
15 - 17
18 - 25
26 - 44
Age
% of Pregnant Women
Reporting Alcohol Use
in the Past Month
Average # of Alcoholic
Drinks on Days Alcohol
Was Consumed
Race
The National Survey on Drug Use and Health also
revealed differences by race/ethnicity in alcohol use
among pregnant women. White and black pregnant
women had the highest rates of alcohol use in the
past month, at 14.5% and 15.7% respectively. Only 4%
of Hispanic pregnant women reported alcohol use in
the past month. However, on the days alcohol was
consumed, Hispanic women drank the largest quantity
of alcoholan average of five drinks, compared with
two drinks consumed by white women and three
drinks consumed by black women.
16
14
12
10
8
6
4
2
0
White
Black
Hispanic
Race
% of Pregnant Women
Reporting Alcohol Use
in the Past Month
Average # of Alcoholic
Drinks on Days Alcohol
Was Consumed
49
16
14
12
10
8
6
4
2
0
Less than
$20,000
$20,000
$49,999
$50,000
$74,999
$75,000
or Higher
Income
% of Pregnant Women
Reporting Alcohol Use
in the Past Month
Average # of Alcoholic
Drinks on Days Alcohol
Was Consumed
16
14
12
10
8
6
4
2
0
Less than
High School
High School
Graduate
Some
College
College
Graduate
Education
% of Pregnant Women
Reporting Alcohol Use
in the Past Month
50
Average # of Alcoholic
Drinks on Days Alcohol
Was Consumed
HHS, 2005.
58
51
APPENDIX B: ASSESSMENTS
AND FEEDBACK
The CHOICES CORE Assessment is designed
to provide (1) information about a womans
appropriateness for the CHOICES intervention,
and (2) information about her alcohol risk and
contraception behavior for the standardized feedback
to be delivered in Session 2.
7. Effective
(Show Perfect Use Cards and ask: Did
you use [method] exactly as directed
each time you had vaginal sex?)
Condoms
Diaphragm/
Yes
Yes
No
No
Yes
Yes
No
No
Patch
Emergency
Yes
Yes
No
No
Depo-Provera shot
IUD
Yes
Yes
No
No
contraception
Core Assessment
1. What is your date of birth?
Month Day
Year
No
Tubes tied
Yes
Yes
No Hysterectomy
No Menopause
Yes
Yes
No
(NuvaRing)
contraception
Implanon
Yes
Other ________________
Yes
No
Yes
If yes in #3 STOP
The woman is not appropriate for CHOICES
No
Yes
If no in #4 STOP
The woman is not appropriate for CHOICES
5. If you have had vaginal sex in the last
3 months, have you used birth control?
Yes
Go to #6 and #7)
No
(Go to #8)
52
No
No
No
Yes
No
Yes
If no to #8 and #9 STOP
The woman is not appropriate for CHOICES
Diaphragm/cervical cap
Must be taken on time every day, at the same time each day.
Missing one pill/doubling up on the next day is still effective.
It is ineffective until the following menstrual cycle if another,
second pill is missed/doubled up on within the same pack.
NuvaRing
Patch
Must be inserted for three whole weeks, and taken out for
one week for bleeding.
Depo-Provera shot
Implanon
Given every 1113 weeks; schedule must be monitored by a Should have been inserted within the past
doctor, use limited to two years.
three years.
Spermicide
53
54
50% No drinking
(7 out of 20)
(3 out of 20)
Pregnancy Risk
In this section of the CHOICES feedback, you will
discuss the risk of pregnancy with the woman.
As with the drinking risk, because the woman
was screened and assessed as appropriate for the
CHOICES intervention, she is at risk of pregnancy.
Therefore, of the low-risk and the risky categories
on your feedback form, the woman will always fall
into the risky category. You will need to respond
to the open-ended item You are at risk because by
taking the information the woman reported to you
on the Screening and Assessment Questionnaire.
Specifically, items 5, 6, and 7 will be used. These items
establish the type of birth control, if any, and the
lack of effective use, respectively. Typical examples
might read:
You reported using condoms as your sole method
of birth control and not using the condoms regularly
with one of your partners.
You reported using birth control pills but missed taking
the pill more than three times in a 30-day period.
55
2 - Not very
TEMPTED
3 - Moderately
TEMPTED
4 - Very
TEMPTED
5 - Extremely
TEMPTED
Again, we want to know how tempted you would be at the present time
to drink alcohol in each of these types of situations.
SITUATION
Not at all
Not very
Moderately
Very
Extremely
1. UNPLEASANT EMOTIONS
If I were depressed in general; if
everything were going badly for me
2. PHYSICAL DISCOMFORT
If I were having trouble sleeping; if I
felt jumpy and physically tense
3. PLEASANT EMOTIONS
If something good happened and
I felt like celebrating; if things were
going well
56
HOW TEMPTED
Temptation: CONTRACEPTION
Listed below are a number of situations that might affect someones use of birth control when having sex.
We would like to know how tempted you would be to have sex without the use of birth control in each of
these situations. Choose the response that best describes the feelings of temptation you would have for each
situation, at the present time, according to the following scale:
1 - Not at all
TEMPTED
2 - Not very
TEMPTED
3 - Moderately
TEMPTED
4 - Very
TEMPTED
5 - Extremely
TEMPTED
Again, we want to know how tempted you would be at the present time to
have sex without the use of birth control in each of these situations.
SITUATION
HOW TEMPTED
Not at all
Not very
Moderately
Very
Extremely
57
2 - Not very
CONFIDENT
3 - Moderately
CONFIDENT
4 - Very
CONFIDENT
5 - Extremely
CONFIDENT
Again, we want to know how confident you are that you would not drink
alcohol in each of these types of situations at the present time.
SITUATION
Not at all
Not very
Moderately
Very
Extremely
1. UNPLEASANT EMOTIONS
If I were depressed in general; if
everything were going badly for me
2. PHYSICAL DISCOMFORT
If I were having trouble sleeping; if I felt
jumpy and physically tense
3. PLEASANT EMOTIONS
If something good happened and I felt
like celebrating; if things were going
well
58
HOW CONFIDENT
2 - Not very
3 - Moderately
4 - Very
5 - Extremely
CONFIDENT
CONFIDENT
CONFIDENT
CONFIDENT
CONFIDENT
Again, we want to know how confident you would be at the present time to
use birth control when having sex in each of these situations.
SITUATION
HOW CONFIDENT
Not at all
Not very
Moderately
Very
Extremely
59
2 - Not very
TEMPTED
3 - Moderately
TEMPTED
4 - Very
TEMPTED
5 - Extremely
TEMPTED
4 - Very
CONFIDENT
5 - Extremely
60
2 - Not very
CONFIDENT
3 - Moderately
CONFIDENT
CONFIDENT
This is a graphic template for providing feedback on temptation and confidence for both the alcohol and the
birth control measures. It is simple to produce the graphs. The numbers on the feedback template graphs
correspond to the response categories on the measures. Using two different colored markers, you simply draw a
line to represent how far along the scale of temptation or confidence the woman responded. Starting at the left
side of the graph, for an item response of 3 (e.g., Moderately Tempted), you would draw a line up to the third
line on the graph (labeled 3 at the bottom). See examples:
Example:
TEMPTATION AND CONFIDENCE ALCOHOL
T
C
T
C
T
C
T
C
T
C
T
C
T
C
T
C
Unpleasant emotions
Physical discomfort
Pleasant emotions
Testing control over my use of alcohol
Urges and temptations
Conflict with others
Social pressure to drink
Pleasant times with others
T
C
T
C
T
C
T
C
T
C
T
C
T
C
T
C
Unpleasant emotions
Physical discomfort
Pleasant emotions
Testing control over my use of alcohol
Urges and temptations
Conflict with others
Social pressure to drink
Pleasant times with others
61
Example:
TEMPTATION AND CONFIDENCE BIRTH CONTROL
T
C
T
C
T
C
T
C
T
C
T
C
T
C
T
C
T
C
T
C
62
APPENDIX D: CONTRACEPTIVE
METHODS, FACTS, AND MYTHS
A wide variety of contraceptive methods can be used
to prevent pregnancy. They vary in availability, cost,
effectiveness, risks, and benefits. Some contraceptive
methods protect women from contracting HIV and
other sexually transmitted infections, while others
only prevent pregnancy. Planned Parenthood
offers up-to-date information and details for each
contraceptive method (www.plannedparenthood.org/
health-topics/birth-control-4211.htm).
Diaphragm/Cervical Cap
A latex thimble-shaped device, it is inserted into the
vagina and fits snugly over the cervix.
Spermicide must be spread around the cup.
Must be in place before intercourse.
Must be kept in place six hours after intercourse.
63
Spermicide
A substance that prevents pregnancy by stopping
sperm from moving and fertilizing an egg.
Available in creams, film, foams, gels, and
suppositories.
Can be used alone but is more effective when used
with other birth control methods.
It must always used with the diaphragm and
cervical cap
Implanon
A matchstick-sized rod containing the hormone
progestin that is inserted in the arm to prevent
pregnancy.
Must be administered by a health care provider.
Effective for 3 years after insertion.
Emergency Contraception
(Morning-After Pill)
Two pills taken to prevent pregnancy up to five days
(120 hours) after unprotected sex.
Available at health centers and drugstores/
pharmacies.
Made of the same hormones found in birth
control pills.
First pill recommended to be taken within 72 hours
(three days) after unprotected sex for increased
effectiveness, but may be taken up to 120 hours
(five days); second pill is taken 12 hours after the
fPlanned Parenthood affiliate or other trusted source.
Encourage women to talk about these beliefs when
they have their birth control appointment if they have
questions.
66
67
68
219815-C