Screening for 

Substance Abuse 

During Pregnancy:

Improving Care,

Improving Health

Screening for 

Substance Abuse 

During Pregnancy:

Improving Care,

Improving Health

Published by

National Center for Education in Maternal and Child Health

Arlington, Virginia

By

Barbara Morse, Ph.D.,

Shelly Gehshan, M.P.P., and

Ellen Hutchins, Sc.D.
Cite as

Morse B, Gehshan S, Hutchins E. 1997. Screening for Substance Abuse During Pregnancy: Improving Care, Improving Health.

Arlington, VA: National Center for Education in Maternal and Child Health.

Screening for Substance Abuse During Pregnancy: Improving Care, Improving Health is not copyrighted. Readers are free to duplicate

and use all or part of the information contained in this publication. In accordance with accepted publishing standards, the

National Center for Education in Maternal and Child Health (NCEMCH) requests acknowledgment, in print, of any

information reproduced in another publication.

The mission of the National Center for Education in Maternal and Child Health (NCEMCH) is to promote and improve the

health, education, and well-being of children and families by leading a national effort to collect, develop, and disseminate

information and educational materials on maternal and child health; and by collaborating with public agencies, voluntary and

professional organizations, research and training programs, policy centers, and others to advance knowledge in programs, service

delivery, and policy development. Established in 1982 at Georgetown University, NCEMCH is part of the Georgetown Public

Policy Institute. NCEMCH is funded primarily by the U.S. Department of Health and Human Services through its Maternal and

Child Health Bureau.

ISBN 1-57285-042-6

Published by:

National Center for Education in Maternal and Child Health

2000 15th Street, North, Suite 701

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Single copies of this publication are available at no cost from:

National Maternal and Child Health Clearinghouse

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This publication has been produced by the National Center for Education in Maternal and Child Health under its cooperative

agreement (MCU-119301) with the Maternal and Child Health Bureau, Health Resources and Services Administration, Public Health

Service, U.S. Department of Health and Human Services.
The concept for this document came

out of a consensus meeting held in

July 1992 convened by the Center

for Substance Abuse Prevention under the

auspices of the National Resource Center for

the Prevention of Perinatal Abuse of Alcohol

and Other Drugs to examine substance

abuse screening and assessment instruments

and develop a reference manual. The

Maternal and Child Health Bureau would

like to thank the participants of that

meeting as well as the following persons for

reviewing drafts of this document and

assisting us in the selection of several

screening instruments appropriate for use

with pregnant women in the clinic setting:

Gene Burkett, M.D., Perinatal Division,

University of Miami, Miami, FL; Donna

Caldwell, Ph.D., National Perinatal

Information Center, Providence, RI; Grace

Chang, M.D., Harvard School of Medicine,

Boston, MA; Ira Chasnoff, M.D., National

Association for Families, Addiction Research

and Education, Chicago, IL; Wendy

Chavkin, M.D., M.P.H., Chemical

Dependency Institute, Beth Israel Medical

Center, New York, NY; Nancy Day, Ph.D.,

Western Psychiatric Institute and Clinic,

Pittsburgh, PA; Karol Kaltenbach, Ph.D.,

Family Center, Jefferson Medical College,

Thomas Jefferson University, Philadelphia,

PA; Sandra Lapham, M.D., Substance

Abuse Research Program, Lovelace Medical

Foundation, Albuquerque, NM; Susan

Martier, Ph.D., Hutzel Hospital, Detroit,

MI; Pat Paluzzi, C.N.M., American College

of Nurse-Midwives, Washington, DC;

Elizabeth Rahdert, Ph.D., Division of

Clinical and Services Research, NIDA,

Rockville, MD; Marcia Russell, Ph.D.,

Research Institute on Addictions, Buffalo,

NY; Sydney Schnoll, M.D., M.P.H.,

Division of Substance Abuse Medicine,

Virginia Commonwealth University,

Richmond, VA; and Robert A. Welch,

M.D., Department of OB/GYN, Providence

Hospital, Detroit, MI.

This document was prepared by Barbara A.

Morse, Ph.D., Director, Fetal Alcohol

Education Program, Boston University

School of Medicine, Boston, MA; Shelly

Gehshan, M.P.P., Program Principal, Forum

for State Health Policy Leadership, National

Conference of State Legislatures,

Washington, DC; and Ellen Hutchins,

Sc.D., Health Care Administrator, Maternal

and Child Health Bureau, Health Resources

and Services Administration, U.S.

Department of Health and Human Services,

Rockville, MD. Editorial and graphic

design services were provided by Judith

Serevino, Editor, National Center for

Education in Maternal and Child Health

(NCEMCH), Arlington, VA; Oliver Green,

Senior Graphic Designer, NCEMCH; and

Carol Adams, M.A., Director of

Communications, NCEMCH.

1

ACKNOWLEDGMENTS
Substance Abuse Is a Major Problem During Pregnancy

• Five to 10 percent of all women have substance abuse problems during pregnancy

• Substance abuse contributes to obstetric and pediatric complications, including fetal

alcohol syndrome, prematurity, and abruptio placenta

• Treatment for substance abuse during pregnancy is significantly more effective than at

other times in a woman’s life

Screening Tools Are the Most Effective Way to Determine Risk

• Laboratory tests and urine toxicologies are ineffective tools for determining substance abuse

• Quick, brief questionnaires have been demonstrated to be effective in prenatal care for

assessing alcohol and drug use

• Pregnant women describe their health care providers as the best source of information and

will generally follow the provider’s advice

How to Use Screening Tools

• Choose a screen that fits your style

• Be nonjudgmental and supportive when asking about use

• Stress benefits of abstinence and offer to help the patient achieve it

• Know where to refer a patient for further assessment

Screening Example:T-ACE

• How many drinks does it take for you to feel high? (Tolerance)

• Have people Annoyed you by criticizing your drinking?

• Have you ever felt you ought to Cut down on your drinking?

• Have your ever had a drink first thing in the morning to steady your nerves or get rid of 

a hangover? (Eye-opener)

(Sokol et al. 1989)

2

SUMMARY
“Not in my practice.” This

statement describes the belief

of many health care providers

regarding the occurrence of domestic

violence, HIV, and substance abuse among

their patients (Schwartz 1993). Everyone

agrees that these problems exist—but not in

their practice. As a result, inquiring about

drug and alcohol use is often neglected when

providing prenatal care.

In today’s fiscal climate, it is difficult to hear of

one more problem that should be addressed in

the medical setting. Time allotted with each

patient is reduced, and successful practice is

measured by cost containment as often as by

patients’ health. Yet attention to substance

abuse problems during pregnancy is one area

in which patient health can be improved and

costs can be reduced. This manual was

developed to provide prenatal providers with

the background and skills to successfully

recognize alcohol and drug abuse among

patients, to institute protocols to improve the

health of both mother and newborn, and to

reduce the financial and physical costs

associated with prenatal substance abuse.

Alcohol abuse and/or drug abuse occurs in 5

to 10 percent of women in the childbearing

years, evenly spread across all ethnic,

geographic, and socioeconomic groups

(Stratton et al. 1996; Chasnoff et al. 1990).

There are multiple risks to both mother and

child when alcohol or drugs are abused

during pregnancy. Alcohol abuse is

associated with fetal alcohol syndrome (FAS)

or fetal alcohol effect (FAE), which represent

neurologic disorders and physical anomalies.

FAS and FAE affect as many as 30,000

births each year (Abel and Sokol 1991).

Cocaine or crack abuse contributes to

extreme prematurity and possible long-term

central nervous system disorders. Estimates

of the number of infants in the United

States born exposed to cocaine each year

range from 91,500 to 240,000 (GAO 1990;

Gomby and Shiono 1991). Opiate use can

cause physical addiction in the newborn,

requiring intensive medical intervention at

birth. Substance abuse can also contribute to

decreased birthweight and the risk of

increased obstetrical problems such as poor

weight gain, abruptio placenta, and HIV.

The most recent nationally cited estimates

report that 5.5 percent of all pregnant

women use an illicit drug during pregnancy

(National Pregnancy and Health Survey

1996). Abuse of drugs and alcohol among

pregnant women often remains unnoticed

and untreated. Outward signs of substance

abuse may be subtle. Pregnant women who

are abusing drugs or alcohol may not present

with the same stereotypical symptoms seen

in an older or late-stage abuse population.

Studies at Boston City Hospital in the late

1970s found that heavily drinking women

were no more likely than nonabusing

patients to miss appointments, register for

prenatal care late, or come in intoxicated.

They were, however, slightly older and more

likely to use other drugs and cigarettes

(Rosett et al. 1983). Early studies of alcohol

abuse among prenatal patients found that

clinic staff reported no alcohol abuse among

their patients, when, in fact, screening

identified between 9 and 11 percent

drinking at risk levels (Rosett et al. 1983;

Sokol 1980; Larsson 1983). Addiction

3

THE PROBLEM
specialists estimate that in the early stages of

heavy use as many as 90 percent of all

people who abuse drugs or alcohol are able

to maintain their normal lifestyle, keeping

appointments, jobs, and relationships.

It would be a rare professional today who

does not have someone in his or her practice

with drug or alcohol problems. Attention to

illicit drug abuse has alerted practitioners that

addictions are more widespread than might be

expected. However, many are still unclear

how to routinely and comfortably identify

women at risk, and how to provide effective

interventions.

4

THE SOLUTION

Anumber of clinical methods have

been developed to detect substance

abuse. These include blood tests,

urine toxicology screens, and educated

guessing based on clinical experience. Blood

tests (such as liver function tests) may detect

organ damage or malfunction, but only

identify those patients with long-term use in

whom secondary symptoms have occurred.

Early stage substance-abusing women are

rarely identified by this means. In spite of

the popularity of urine toxicologies (in

response to illicit drug use), these screens are

able to identify only fairly recent use of a

substance (i.e., cocaine may be detected for

no more than 36 hours after use) and

provide no information about frequency or

length of use. Women who have not used

drugs in the day or two prior to a prenatal

visit will not be identified. Urine, blood, and

breath tests are all unreliable indicators of

alcohol use, as alcohol is metabolized

quickly and is unlikely to be detected in

body fluids (Christmas 1992). Educated

guessing based on clinical experience may

identify some users, but is heavily dependent

on the practitioner’s attitudes and

experiences. The majority of at-risk women

who do not fit stereotypic molds will be

missed. The most effective method for

detecting substance abuse remains a

screening tool.

Screening tools are questionnaires designed to

be administered face-to-face, patient to

provider. They are not designed to diagnose a

substance abuse problem, but are intended to

determine if a patient may be at risk for

alcohol or drug problems and would benefit

from a more comprehensive evaluation by a

specialist. Effective screening tools in the

prenatal setting are those that:

• Can be administered in 5–10 minutes

• Are used routinely with every patient, not

just those in whom substance abuse is

“suspected”

• Can be adapted to fit a provider’s personal

history-taking style

• Can be administered multiple times across

a pregnancy, since patients may be more

forthcoming as they develop trust with a

provider

• Provide an opportunity to educate about

alcohol and drug abuse and the benefits of

stopping while pregnant

A screening tool for substance abuse should

be incorporated into every prenatal intake
and history form. Asking every patient

questions in a health context lessens the

stigma associated with the topic, and

expresses concern for the health of the

mother and baby. Just as screening for

diabetes is a routine and ongoing part of

prenatal care, questions about substance

abuse are most effective when used

consistently and routinely. Intervention can

be provided for problems as soon as they are

identified, reducing the chances of

obstetrical and newborn complications.

Pregnancy may be a window of opportunity

to intervene for substance abuse problems

(Weiner and Larsson 1987). It may be the

first time that a woman has sought medical

care (Woods 1993). Denial—a concern

whenever questions are asked about

substance abuse—may be less common

during pregnancy. Pregnant women as a

group are invested in the health of their

babies and can no longer deny that their

alcohol or drug abuse is hurting anyone but

themselves. Women in recovery have

reported that they wanted help during

pregnancy but didn’t know how to ask

(McElaney 1991). Pregnant women report

that they consider health care providers one

of their best sources of information, and are

likely to comply with advice given (Minor

and Van Dort 1982). This makes the

prenatal setting the ideal place for discussion

of substance abuse.

Even for women who do not have

substance abuse problems, a routine

screening offers the chance to discuss the

risks of alcohol and drug use, particularly

use that may have occurred prior to

knowledge of pregnancy. Substance abuse

problems in a partner may also be

discussed. Initiating this discussion in what

is generally a nonjudgmental, healthoriented setting conveys the message that

these issues are important to the healthiest

possible pregnancy.

5

THE BENEFITS OF SCREENING

S

creening can have several immediate

benefits:

1. Substance abuse during pregnancy is

placed as an issue critical to the health

of mothers and babies.

2. Education can be provided about the

risks of alcohol and illicit drugs, and

about behaviors that might have

occurred prior to the prenatal visit.

3. Identification of women whose

pregnancies are at risk due to their

substance abuse allows for the earliest

possible intervention or referral to

specialized treatment.

While each of these benefits is important,

the greatest one is identification of women

at risk. Over the past 20 years multiple

studies have demonstrated benefits to both

mothers and their infants when substance

abuse treatment was provided. Rosett et al.

(1983) demonstrated that women identified

as heavy drinkers in the prenatal setting were

responsive to treatment. Those who
completed at least three counseling sessions

(66 percent) had babies who were

significantly healthier at birth. Obstetrical

complications were also reduced. Larsson

(1983) and Smith et al. (1986) had similar

findings. Follow-up studies of children born

to heavily drinking women who responded

to treatment demonstrated a persistence of

the benefits observed at birth (Larsson

1985).

Chasnoff (1989) reported a reduction of

one-half in the incidence of abruptio

placenta and prematurity among a group of

women who reduced cocaine abuse during

pregnancy. Low birthweight was not

observed among the group participating in

treatment, but was 25 percent among those

who continued cocaine use.

Cost savings from screening and identification

of substance-abusing mothers are also

substantial. For every birth with cocaine

exposure that can be prevented, more than

$5,000 in medical costs can be saved.

Reductions in crack use, other drug use, or the

use of foster care can add substantially to the

savings. At the national level, the total medical

cost for neonatal cocaine exposure is estimated

to be $500 million (Phibbs et al. 1991).

Preventing FAS could save at least a portion

of the $74.6 million dollars estimated to be

the annual cost for the care of affected

individuals (Abel and Sokol 1991). Thus the

5–10 minutes of screening followed by an

appropriate intervention during prenatal

care is a relatively modest investment that

can result in enormous cost benefits.

6

THE ROLE OF THE

HEALTH CARE PROVIDER

Physicians, nurses, and others involved

in prenatal care can play a unique role

in the reduction of substance abuse

during pregnancy and its related problems.

In this positive, health-oriented context,

supportive inquiry about all aspects of a

woman’s life, including her use of drugs or

alcohol, can open the door to referral and

treatment. Many pregnant women will

reduce their use of drugs and/or alcohol

following supportive advice from a health

care professional, even if they never disclose

that use (Rosett and Weiner 1981). Health

care professionals can also help women see

the benefits of stopping through improved

sense of well-being, physical measures such

as weight gain, and better personal

relationships.

All health care professionals have the basic

skills to identify and refer at-risk women for

treatment. While the topic may be difficult

for patients and providers alike to discuss,

the basic skills of interviewing, being

empathic and supportive, providing

education on the risks of continuing the

adverse behaviors, and describing the

benefits of treatment, referral, and follow-up

are no different than they would be for any

other medical problem. Providers can make

the difference.
7

FINDING AND USING A

SCREENING TOOL

The first question that occurs to

most practitioners about screening

is, “When am I going to find the

time to do this?” followed by, “There’s really

no point in asking anyway. Denial is so

powerful that no one will tell you the

truth.” Finding time for any additional

procedure is a challenge for every provider.

Yet most screening will take a relatively

short amount of time—perhaps 30 seconds

for the majority of patients who do not

have a substance abuse problem and 5–10

minutes for the 10–15 percent of patients

who do. Many professionals find that the

time taken for the screening actually saves

time in other ways, either by answering

questions that might have come up at

another time, or in reduced care time for a

patient in whom obstetrical complications

can be prevented.

While denial may occur, routine screening

begins the discussion. For those patients in

whom you suspect substance abuse, even if

they have been unable to disclose it to you,

it is important to review the benefits of

reduction or abstinence. Some women may

seek help or cut down on their own, based

on your advice. However, statements such

as “Now that you’re pregnant, just don’t

drink” or “You don’t drink or use drugs, do

you?” may inadvertently reinforce denial

and may convey the message that there is

no benefit to be achieved by stopping now.

The purpose of the screening should be to

begin an open discussion about alcohol and

drug use.

HOW TO ASK AND HOW TO

RESPOND

1. Find an approach that is

comfortable for you.

Choose a screening tool that you can

use with all patients. For convenience,

five screens are listed in the back of this

document. Remember that there is no

one perfect way to ask, and that screens

can be adapted to fit each person’s

preferred style.

2. Be nonjudgmental.

Experience has shown that patients are

generally not offended by questions

about alcohol and drug use if they are

asked in a nonjudgmental,

nonmoralistic, nonthreatening manner,

and if the health implications and

benefits of reduction and abstinence are

stressed. As each of us comes with

experiences, attitudes, and beliefs that

may be intentionally or unintentionally

conveyed during an interview, it is

always important to recognize and

address personal attitudes that may

influence a patient’s response. In an

office or clinic setting, it is important

that all staff understand the reasons for

asking about substance abuse, even those

who may not be involved in the actual

interview. This helps reduce bias that

may be conveyed to patients.
3. Make it a routine part of 

prenatal care.

Just as women are routinely screened for

gestational diabetes, appropriate weight

gain, anemia, etc., screening for

substance abuse should be seen as

another low-cost way to provide optimal

prenatal care. Asking the same questions

of every patient reduces subjectivity in

deciding who should and should not be

screened.

4. Know how to respond.

Prepare yourself for patients’ questions

about why you are asking. Become

familiar with the risks of substance abuse

and the benefits of stopping during

pregnancy. Set the tone with introductory statements such as “I ask all my

patients these questions because it is

important to their health and the health

of their babies.” Know how to counsel

women with both negative and positive

screens.

For patients with a negative screen (no risk

determined): 

a. Review the benefits of abstinence

for the duration of the pregnancy. 

b. Reassure patients that small amounts

of alcohol (one drink or less in any

24-hour period) consumed prior to

the visit need not be a concern, that

occasional use before conception does

not pose a risk, and that foods

containing alcohol (such as Kahlua ice

cream or rum cake) are not a problem.

For patients who have a positive screen (risk

determined): 

a. Review for the patient what she has

just reported to you.

b. State your concern for the health of

the mother and the baby.

c. State your belief that you know the

mother wants her baby to be as

healthy as possible and that she can

improve the health of her baby by

stopping use of alcohol and drugs.

d. State the need for her to stop using

drugs and/or alcohol during

pregnancy, and that you and she will

work together to achieve this.

e. Discuss possible strategies for her to

stop—e.g., individual counseling,

12-step programs, and addiction

treatment programs.

f. Suggest a referral for a more indepth assessment by a specialist.

Become knowledgeable regarding

specialists and treatment centers for

appropriate referrals. If feasible, call

and make the appointment while

the patient is in the office.

g. Make a follow-up appointment to

see the patient after her drug/

alcohol assessment and keep an

ongoing interest in the problem.

Praise any reduction in use that she

reports to you.

h. Maintain communication with the

treatment provider to monitor

progress.

5. Be positive.

While no one can promise any woman a

perfect pregnancy outcome, you can

assure women that they will improve the

chances that their babies will be healthy

by discontinuing drug and alcohol use.

Emphasize that benefits will begin as

soon as the woman reduces or stops use,

and that the earlier she is able to stop

the better. It is never too late.

8
9

REFERRAL SOURCES

Most hospitals have substance

abuse treatment programs and

should be able to provide you

with patient assessments. If a program is not

available where you practice, contact your

state Division of Substance Abuse Services

(usually part of the Department of Public

Health) and ask for a referral. Pregnant

women have unique treatment needs, and

will do best in a program that can address

these needs. Most states now have programs

specifically designed for pregnant women

and for mothers. There are also numerous

private hospitals and counselors who treat

substance abuse. Twelve-step programs such

as Alcoholics (or Cocaine or Narcotics)

Anonymous can also provide useful support

to women addressing these problems. All of

these programs are listed in the Yellow 

Pages.

If you live in an area where no formal

treatment programs exist or access to them is

extremely limited, you may be the only

resource available to a woman to help her

reduce her substance use during pregnancy.

In these circumstances, meeting weekly or

even biweekly (as is done with other highrisk pregnancies) may be a first step towards

expressing your concern and the seriousness

of the situation. Suggest that the woman

reduce her use by one-half each day, over

several days until abstinence is achieved.

Determine if her use is related to other

problems in her life (depression, marital

problems or domestic violence, history of

sexual or physical abuse) and seek referrals

for these issues. Above all, maintain support

for her and affirm your belief that you know

she can reduce her use and improve the

health of her baby.

F

ive screening instruments are

presented on the following pages.

They were chosen from a large field 

of instruments for their brevity, validity,

specificity, and sensitivity in detecting

alcohol and drug problems. All have been

tested with populations of pregnant women.

While most substance abuse screens were

initially developed to inquire about alcohol

use, it is possible to add the term “drugs” (or

specifically list drugs of concern) to any of

the screens listed here. Some of these screens

inquire about the frequency and quantity of

use; others ask about problems associated

with substance abuse. Ideally the questions

are asked face-to-face while taking a history.

However, many providers have had success

screening for substance abuse by placing

these questions on an intake form that the

patient fills out, and then doing follow-up

when reviewing the history.

The screens are presented in alphabetical

order.

SCREENING INSTRUMENTS
1. How often do you have a drink containing

alcohol?

(0) Never

(1) Monthly

(2) 2–4 times a month

(3) 2–3 times a week

(4) 4 or more times a week

2. How many drinks containing alcohol do you

have on a typical day when you are drinking?

(0) 1–2

(1) 3 or 4

(2) 5 or 6

(3) 7–9

(4) 10 or more

3. How often do you have six or more drinks on

one occasion?

(0) never

(1) less than monthly

(2) monthly

(3) weekly

(4) daily or almost daily

4. How often during the last year have you found that

you were unable to stop drinking once you started?

(0) never

(1) less than monthly

(2) monthly

(3) weekly

(4) daily or almost daily

5. How often during the last year have you failed to

do what was normally expected of you because

of drinking?

(0) never

(1) less than monthly

(2) monthly

(3) weekly

(4) daily or almost daily

6. How often during the last year have you needed

a first drink in the morning to get yourself going

after a heavy drinking session?

(0) never

(1) less than monthly

(2) monthly

(3) weekly

(4) daily or almost daily

7. How often during the last year have you felt

guilt or remorse after drinking?

(0) never

(1) less than monthly

(2) monthly

(3) weekly

(4) daily or almost daily

8. How often during the last year have you been

unable to remember what happened the night

before because of drinking?

(0) never

(1) less than monthly

(2) monthly

(3) weekly

(4) daily or almost daily

9. Have you or someone else been injured as the

result of your drinking?

(0) no

(2) yes, but not in the last year

(4) yes, during the last year

10. Has a friend, relative, or doctor or other health

worker been concerned about your drinking or

suggested you cut down?

(0) no

(2) yes, but not in the last year

(4) yes, during the last year

Scores are in parentheses. A score of 8 or more is

considered a positive screen.

10

AUDIT

Saunders JB, Aasland OG, Babor TF, De La Fuente JR, Grant M. 1993. Development of the Alcohol Use Disorders Identification Test

(AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption—II. Addiction 88(6).
11

Have you ever used drugs or alcohol during this Pregnancy?

Have you had a problem with drugs or alcohol in the Past?

Does your Partner have a problem with drugs or alcohol?

Do you consider one of your Parents to be an addict or alcoholic?

This screening device is often used as a way to begin a discussion about drug or alcohol use. Any woman

who answers yes to one or more questions should be referred for further assessment.

4PS

Ewing H. Medical Director, Born Free Project, Contra Costa County, 111 Allen Street, Martinez, CA 94553. Phone: (510) 646-1165.

How many drinks does it take for you to feel high? (Tolerance)

Have people Annoyed you by criticizing your drinking?

Have you ever felt you ought to Cut down on your drinking?

Have your ever had a drink first thing in the morning to steady your nerves or get rid of a 

hangover? (Eye-opener)

Any woman who answers more than two drinks on the tolerance question is scored 2 points. Each yes 

to the additional three questions scores 1. A score of 2 or more is considered a positive screen, and the

woman should be referred to a specialist for further assessment.

T-ACE

Sokol RJ, Martier SS, Ager JW. 1989. The T-ACE questions: Practical prenatal detection of risk drinking. American Journal of Obstetrics and

Gynecology 160(4).
12

How many drinks does it take for you to feel high? (Tolerance)

Does your partner (or do your parents) ever Worry or complain about your drinking?

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

(Eye-opener)

Have you ever Awakened the morning after some drinking the night before and found that you

could not remember part of the evening before?

Have you ever felt that you ought to K/Cut down on your drinking?

A woman receives 2 points on the tolerance questions if she reports that she can hold more than five

drinks without falling asleep or passing out. A positive response to the worry question scores 2 points, and

a positive response to each of the last three questions scores 1 point each. A total score of 2 or more

indicates that the woman is a risk drinker and requires further assessment.

TWEAK

Russell M. 1994. New assessment tools for risk drinking during pregnancy. Alcohol Health and Research World 18(1).

TEN-QUESTION DRINKING HISTORY (TQDH)

Weiner L, Rosett HL, Edelin KC. 1982. Behavioral evaluation of fetal alcohol education for physicians. Alcoholism: Clinical and Experimental

Research 6(2).

Beer: How many times a week do you drink beer?

How many cans do you have at one time?

Do you ever drink more?

Wine: How many times per week do you drink wine?

How many glasses do you have at one time?

Do you ever drink more?

Liquor: How many times per week do you drink liquor?

How many drinks do you have at one time?

Do you ever drink more?

Has your drinking changed during the past year?

Any woman who reports drinking more than four drinks once a week or more is considered at risk and

requires further evaluation.
13

Abel EL, Sokol RJ. 1991. A revised

conservative estimate of the incidence of

FAS and its economic impact. Alcoholism:

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14
Maternal and Child Health Bureau

National Center for Education

in Maternal and Child Health ISBN 1-57285-042-6