Transcript for EP101: Preventing Fetal Alcohol Spectrum Disorders
Announcer:
This episode is sponsored by Connect to End COVID-19.
Lorrie Appleton:
From the National Association of Social Workers, I'm your host, Lorrie Appleton, and this is Social Work Talks. In today's episode, we're going to discuss best practices for preventing and treating risky drinking and substance use in people of childbearing age. As the largest provider of mental and behavioral health services in a wide range of settings, social workers are integral to primary prevention of substance-exposed pregnancies. Nearly 14% of pregnant people reported currently drinking and about 5% reported binge drinking in the past 30 days. According to a recent study, another study found that 40% of those who drank during pregnancy said they also used one or more other substances, most frequently, tobacco and marijuana.
Today I'm joined by two esteemed presenters from the Health Behavior Research and Training Institute, HBRT, at Steve Hicks School of Social Work at the University of Texas in Austin. Dr. Mary Martin Velazquez is Centennial Professor in Leadership for Community Professional and Corporate Excellence and Director of HBRT. Anna Mangum is a Senior Health Strategist at the Institute. HBRT has over two decades of experience in working with the CDC and other federal and local partners to develop and disseminate programs. Also, Anna was previously the Chief of Programs at NASW. HBRT has been awarded $1.3 million by the Centers for Disease Control and Prevention to engage social workers in the prevention of alcohol and other substance use during pregnancy. The new four-year grant will continue a partnership that began in 2014 between HBRT and NASW of CDC's Collaborative for Alcohol-Free Pregnancy. In the new project, HBRT and NASW are participating in a multidisciplinary effort that includes partners in pediatrics, family medicine, obstetrics gynecology, nursing, and medical assisting.
Mary and Anna, you're doing such exciting and important work. Can you tell us more about the scope of the grant and the main objective?
Mary Velasquez:
This grant is really designed to reach out to social workers nationally and encourage them and give them some of the skills and some of the knowledge to work with women or people of childbearing age to prevent substance-exposed pregnancies. Given that social workers are in a variety of settings and that they're trained to do very thoughtful, sensitive work with the clients that they work with, they're really a natural group to do this work. Basically, what we would like for folks to do is have thoughtful conversations around drinking and other substance use if they are at risk of becoming pregnant. Most of our work really is not with women who are already pregnant, but it's really preventing the substance-exposed pregnancies and so we train them in certain counseling strategies and we really just educate them in a variety of ways about substance-exposed pregnancies.
Lorrie Appleton:
Anna, how has NASW partnered with your institute to assist in achieving successful outcomes?
Anna Mangum:
Thanks. Yes, it's a great partnership. NASW is the largest where I used to work. It's the largest membership association of social workers nationwide. A number of social workers are in lots and lots of different settings. As we know, the profession is really quite diverse in that regard and we are in probably more settings than... I'm a social worker, too. Probably more compared to than any other healthcare profession when we are considered a health profession, we're in a wider range of places and we work with individuals and families in all stages of the life cycle.
Social workers work with women a lot, and of course, a lot of women at some point in life may become pregnant or contemplating pregnancy and so we are really an important, or I'll say essential workforce in terms of not just substance use disorder prevention, which we know is a growing issue for women, but also this particular subpopulation of women who are pregnant or planning to become pregnant.
We also have a distinctive skillset as social workers. I think it's fair to say that all health providers are hopefully patient-focused, but we have a unique perspective as bringing the framework of the person in the environment, so looking at an individual client in the context of their family, in the context of their employment and all these other factors that are part of who a person is. These are things that need to be part of and are part of the calculation that people make when they are making decisions about their health and whether or not to drink alcohol is essentially a health decision, so we're just really essential in these spaces. We're really essential in these conversations, and as Mary mentioned, not always, but we sometimes have a little more time to talk with clients about their health decisions and to really hear where they're coming from. Mary's going to, I think, talk a little bit more about what those modalities look like.
Lorrie Appleton:
Well, that's a good lead-in. Social workers use a variety of modalities in providing services to clients. Can you summarize for us, what's screening brief intervention and referral to treatment, SBIRT, and why do we know about its effectiveness?
Mary Velasquez:
Let me tell you about SBIRT in just a minute, but I wanted to say just a tiny bit more about the reason we're using SBIRT and what we're wanting to convey to the social work audience and having them convey to their clients. Social workers know, for the most part, highly educated and well-trained group oftentimes about the dangers of drinking alcohol during pregnancy. What we want to get across, for example, when you think about alcohol use, most women don't know they're pregnant, or most people don't know they're pregnant until about three months into the pregnancy, so really into that first trimester, so they may decide when they're pregnant, "I won't drink," but they don't know they're pregnant for quite a while.
When we think about fetal alcohol spectrum disorder or fetal alcohol syndrome, we think about children who are born with the facial abnormalities, and you can really tell when someone has FAS, but alcohol use across the pregnancy, during the pregnancy, depending on the time of gestation, can really impact a fetus. What happens is that, we call it a spectrum, a fetal alcohol spectrum disorder. It's not fetal alcohol syndrome, it's a spectrum, so it could be early. I'm here, I'm using my hands, but early in a pregnancy. Sometimes when a child is having behavioral disorders or learning disabilities, there can be a lot of things that are caused through that substance use that we're not really recognizing as fetal alcohol syndrome, but it's somewhere along the spectrum. That's one of the things that we really are hoping to get across to young people if they're having sex, not using contraception and are at risk is that it's not just the full-blown syndrome that we're trying to prevent, but it's all these things across that spectrum. We'll talk in a few minutes, I think, about other substances as well.
Sometimes people don't realize that or they don't have those kind of conversations with people because it just hasn't been part of their work or they haven't really recognized it or thought about it. Screening brief intervention, which is often known, SBIRT, is a highly effective with a very, very strong evidence base. It's really a way of having a conversation with someone, a brief conversation with someone about, as Anna said, about a health behavior. The S stands for screening in relation to alcohol.
For example, if a social worker were in a medical setting, what we do with medical settings is we encourage people to screen everyone. It's called universal screening. Basically, it's one question, "Do you drink alcohol?" If you have, then we ask about three questions about quantity and frequency, and that's called a measure called the audit, and so when we know that someone is drinking, there's a range of risk drinking. We ask a social worker to have a conversation with the person about their drinking and maybe probe a little bit about the potential of having an alcohol-exposed pregnancy. That's the screening part. It's identifying someone who might need a brief intervention. I'm going to talk about motivational interviewing in just a minute, but a brief intervention, the way we define it uses a particular strategy called motivational interviewing, a particular approach. That's the screening piece. You're identifying the person and it takes just one or two questions.
The brief intervention piece is really, there's a sort of an algorithm or a model that we use. It's asking the woman or the person, "Tell me a little bit more about your drinking," whatever the behavior is, and what are maybe some of the good things and some of the not-so-good things, so you're engaging this person using what we call motivational interviewing. It's a very empathic way to work with clients and it's perfect for social workers because that's the way they're trained. They think about people holistically, "Tell me a little bit more about your drinking," and then we ask them, "Would it be okay?" Ask them for permission to give them some information, so we'd always ask permission. Then the brief intervention, "How important is this drinking to you perhaps and how ready might you be to change it?" Some very sensitive questions around their motivation. Then we ask permission to give them some information. That's the brief intervention piece of it.
Then we give them the information, whatever they seem to be lacking. Sometimes it's materials such as brochures, sometimes it's just a little bit of education, but it's delivered in a way using this motivational approach so the woman doesn't feel like they're being lectured to. They don't feel like you're trying to force them into doing anything. In fact, we tell folks, we say, "I'm not trying to talk you into anything. Any changes you make are completely up to you, but would it be okay if I give you this information?" We give them the information about the risks of their substance use potentially on a pregnancy and have a thoughtful conversation about, is that person using contraception? If they're going to be drinking, are they being careful about not getting pregnant? That's the brief intervention piece in SBIRT. That's the S-B-I and that's really the bulk of our work.
The RT piece is what we call referral to treatment, so if the person perhaps was drinking at really high levels or using other substances and needed referral to additional treatment, that's the RT piece. But for our work, we really focus on the screening and the brief intervention part of it. This project is really designed to reach as many social workers in the field working in all different settings, reach as many people as we can to encourage them to have these kind of conversations with people to prevent substance-exposed pregnancies and to really bring it to the forefront of their mind how important it is to have these kind of conversations among all the other things that they're working with the client.
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Lorrie Appleton:
You've talked about the linkage between motivational interviewing and SBIRT. What's the role of social workers in deploying these tools?
Anna Mangum:
Social workers use a lot of different modalities in our work, and of course, we customize our approach depending on what the issues that are presenting and who we're working with. As I mentioned earlier, social workers kind of bring to the work a certain distinctive set of skills and we, of course, have a certain set of values. I'll mention here, very important to really, I mentioned earlier, really being where the client is, and this is really about the client's journey, meeting them where they are in their own journey.
There's a piece that has to do with health equity, too, and health disparities, and these are contributing factors in health decisions in general, in healthcare. We recognize more and more, I mean, I think our profession has long understood that, but society is starting to, and other leaders are starting to recognize the essential steps that are needed in terms of closing some of the gaps around healthcare and health access and so forth, so there is an equity piece here that has a lot of dimensions to it that we can't really get into in this one podcast that is absolutely a key dimension of the project and another place where social workers are so important because we do bring that orientation, the ability to work with lots of different kinds of populations who come to us for support and services.
Mary Velasquez:
No, I just wanted to add, again, the role of motivational interviewing. This approach was developed, I guess in the '80s. It started to become popular by two psychologists, William Miller and Stephen Rollnick. Bill Miller began to look at the way you talk with people about, for example, their alcohol use. Many years ago, the approach used to be very punitive and confrontive and motivational interviewing really in so many ways changed the field and became a way of working with people who were working with substance users, helping them to approach it in a much more sensitive, much more thoughtful way.
There are a number of what we would call strategies. Really, in motivational interviewing. It's more about the spirit, but it's a very skills-based approach, and so people don't just learn it in a minute. It's kind of like learning a piano or learning a sport. There are a lot of steps in learning motivational interviewing, and it's a skill that can be developed, but it really is something that takes didactic pieces. It takes a lot of practice. That's what we're doing here and that's the cool thing is that in the work that we're doing is we are teaching these motivation interviewing skills or building on them from the social workers maybe that already have them and that there's been a really big appeal for that. Social workers seem to resonate to this approach and our team is able, we're trained in motivational interviewing, we're trained as trainers, and so we're able to bring that to this CDC project along with the SBIRT piece.
That's had quite a big appeal to social workers. They've been very excited about what we've done so far in some of our other initiatives and we fully expect that this'll be exciting to them as well. We have a number of other activities planned that we can talk about in just a minute. That's the exciting part of it. In addition to using these skills to prevent substance-exposed pregnancies, these are skills that can be used across any behavior in working with clients.
Lorrie Appleton:
Did you want to say any more about that, Anna?
Anna Mangum:
I was just going to add that if you think about it, a person's decisions in many ways about their health is really fundamental and foundational to who they are. It's not like health decisions are over in the corner somewhere, they're often quite central to someone's daily experience, and so that's why these modalities are so important to understand what... Health decisions are slightly different than other decisions we might make about, for example, buying a house or buying a car or whether to have a child, so there's different aspects, and I think the science around these modalities is really important to recognize the growing body of science that we have around these modalities and motivational interviewing and SBIRT and why and how health decisions work and how to help people process those decisions effectively for themselves.
Lorrie Appleton:
You added other substances to the scope of the grant. What are those substances and why did the Centers for Disease Control and Prevention include them?
Mary Velasquez:
I'm really excited about this, actually, because the CDC has been at the forefront of addressing these issues for quite a long time. We have worked with them for almost 30 years working around fetal alcohol spectrum disorder, yet we've all recognized that other substances are also very problematic during pregnancy. I do want to stress that alcohol is the number one preventable cause of birth defects, so alcohol is the forerunner here, but other substances, example, for example, opioid use during pregnancy, it's been linked to preterm birth, stillbirth, specific birth defects, and something called neonatal abstinence syndrome, which is when a baby is born addicted to opioids. That is obviously something that affects the whole family, obviously, so that's problematic. Cigarette smoking has long been linked to things like preterm birth problems with the mouth in a newborn, lots of problems there, and then marijuana, and we really have a lot to learn about that. It has been linked to growth problems. It's been linked to other things such as problems with attention and learning in young children, so marijuana use, and especially given that there's so much more societal acceptance of marijuana use, it's being legalized.
Sometimes during pregnancy, I've had women tell me, "Well, my physician said it's okay to have one glass of alcohol a day." We're trying to dispel some of that, not only with social workers, but with other healthcare providers. Oftentimes they'll say, "Well, I'm having morning sickness, and so I smoke a little pot because that calms me down and it helps me get over the morning sickness," so again, that's something that we're trying to dispel and the workforce of social workers is really such an effective way of reaching these folks and helping them learn a little bit more about the problems of substance use during pregnancy.
Lorrie Appleton:
Now, I'm intrigued about engaging a network of social workers who can serve as champions on this initiative. Can you tell us more about this?
Anna Mangum:
Sure. Yes, we're developing that program right now. It's a pillar of this initiative. It's a very important one. We'll be having a webinar in the next few months. We invite all of you to attend, all of our listeners, and you'll get free CEs at this webinar, which is hopefully attractive to you. But in addition to the subject matter, we're going to really do more of a deep dive into what we talked about today. It'll be interactive, which I think people really appreciate. If you attend, you can sign up to become a champion in this program. Whether this is playing a role in your practice setting, for example, as someone who can promote the use of SBIRT and motivational interviewing and other modalities, just helping raise the awareness of social workers in your setting, or even other healthcare professionals, just really leveraging those relationships that you have. Social workers or relationship people in my experience and so you'll have those relationships and you'll be a person who can kind of share updated information about this topic and opportunities for other people to become champions as well.
Lorrie Appleton:
Do you have anything else that either one of you would like to add regarding this topic?
Mary Velasquez:
Just to add a little bit to what Anna was saying, I'm very excited, we are very excited about developing this champion network. If social workers attend the webinar, they will have an opportunity to become champions. It's not a big ask in terms of what they would be doing other than talking with their clients about substance-exposed pregnancies and perhaps participating in some continuing ed, watching videos, or things like that. We'll give you a certificate as a champion. We will stay in touch with you as there are updates around this and you can put on your resume that you're a CDC/NASW champion in this area. Again, social workers have found that very appealing and you'll learn more about motivational interviewing, more about SBIRT, and how to deliver SBIRT in social workers and in their various settings, so we'll be very intentional about conveying those skills in this work. We're hoping we get lots of people signing up to be champions.
Lorrie Appleton:
Yeah, I hope so, too. I think it expands in terms of not only the work that we would be doing generally, but also in our own practices, so that's really exciting. Mary and Anna, we thank you for the much-needed work you're doing to prevent substance abuse during pregnancy and I'm pleased to have the opportunity to spotlight your initiative today. Listeners, we'd like to thank you for joining us. You can find details about the topic in the show notes and resources section of our website.
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