Preventing Fetal Alcohol Spectrum Disorders (FASDs)

­­Preventing Fetal Alcohol Spectrum Disorders

Steve Shuman: Right now, I get to introduce our really wonderful speaker. A person I call a friend and so lucky to have as a colleague, Candice Shelton. Candice?

Candice Shelton: Thank you, Steve. Appreciate that. And wow, I'm looking at all the people that are here, and it's very exciting. Before we begin, I would like to start our session in a good way. And I have found a reading that I would like to share with you from the meditations with Native American elders that I believe is appropriate to our work. And this book is written by Don Koyus.

The quote: “We Come All From the Same Root, But the Leaves Are All Different.” It's a quote from John Firelane. “Dear Lakotah, we all come from one creator, but we are all different and unique. Nothing in the great creation has a twin that is identical. Every single person is extremely special and unique. Each person has a unique purpose and a reason why they are on the Earth. Just like every leaf on a tree is different, each one is needed to make the tree look like it does. No leaf is better or worse than the other. All leaves are equal in worth and value and belong on the tree. It is the same with humans. We each belong here. And we will do things that will affect the greater whole. Creator, today, let me see myself as a contributor to the whole.”

Great. Well, I want to introduce myself. My name is Candice Shelton, and I'm a member of the Osage Tribe. In Arizona, where I live is … I am a licensed substance abuse counselor, and I maintain a private psychotherapy practice. For 12 years, I was the senior Native American specialist for SAMHSA, the Substance Abuse and Mental Health Services Administration Fetal Alcohol Spectrum Disorder Center for Excellence.

In those 12 years, I traveled all around Indian country, working with staff, individuals, and families around FASDs. Currently, as Steve said, I am the subject area expert for the American Indian and Alaska Native population for the National Center for Health, Behavioral Health, and Safety. And I am very honored to be here today to share this information with you. And I'm just excited when I look and people keep adding and adding and adding. Wow, we're almost at 950 people. And I'm very happy about that. Next slide.

What we're going to do now is I've introduced myself. Now, we would like to find some information about you. We are going to do a poll, and it's up on your screen. We want to know who is here today. If you would fill that out, we would appreciate that. Kate is going to bring up the poll. And we ask you to fill in one of the indicators that we have there of where … Who is here and what is your capacity?

Steve: Yes, I think we can bring up the results of the poll.

Candace: OK. Great. Wow. How wonderful. We've got … Our home visitors have won the race there. Not much more than the family engagement staff, but that is great. It's a great, great group of people. I'm so glad you're here.

We're going to do our second poll, which is to ask you where you work. It's Early Head Start program, Head Start program ages three to five, or Head Start program birth to five, or other. We'd like you to fill in where it is that you're working. And in a couple of seconds here, we'll get the results of that poll. Steve, are we just about there?

Steve: I think so. There's the results.

Candice: There's the results. OK, so the Head Start program serving ages birth to 5, again, wins the race with a close … with the Early Start Head Start program close second. That is wonderful. That is really great. Thank you very much for sharing that information with us so that we kind of know who is on our webinar today. And I am really excited because we are getting ready to just cross over 1,000 people on this website … in this webinar today.

We're going to look at our learning objectives. What are you … The participants are going to be able to define and know what FASD is, and we're going to explain the relationship between alcohol consumption during pregnancy and birth outcomes. We're also going to be able to talk about how you can discuss with a pregnant woman and expectant families about alcohol use. And again, the important thing is to know, what are the referrals in your community that support positive birth outcomes? Next slide, please.

Here is our goal. Our goal is a healthy baby. We know that pregnancy can be very scary, and it can be hard, and we need to support women during their pregnancy. And just as parenting can also be very difficult … Is this the first child? Is it a second, third, or fourth child? And we know that there are lots of demands on parents.

Our goal here is to be support and to deal and to help our expectant families and our pregnant mom to find ways to cope with any stressors that she may have going on in a healthy and supportive way. This is our goal. This is a healthy baby. Next slide, please.

What is FASD? For some of you that may have been working in this area for a long time, you may have heard of FAS and FAE. FAS is fetal alcohol syndrome, and FAE was fetal alcohol affects. Fetal alcohol affects was only not FAS, so no one really knew what that was. It didn't help anybody to understand what was an FAE.

What we're looking … What the field decided to do was look at a spectrum of disorders, so they came up with the term fetal alcohol spectrum disorder, and it really is an umbrella term that shows that … The range of disorders that can occur when a woman drinks alcohol during pregnancy. It is not the diagnosis. The problems that come from prenatal exposure to alcohol can be physical, mental, or behavioral, and they can be from mild to severe depending on the amount of alcohol that is consumed by mom. Next slide, please.

Here are the five types of disorders that fall under fetal alcohol spectrum disorders. The first one is fetal alcohol syndrome, which is the diagnosis. And that diagnosis covers three main things, which are growth deficiency, central nervous system abnormalities, and dysmorphic features. Actually, fetal alcohol syndrome was a term that was created by Dr. Smith and Jones from the University of Washington in 1973.

The second one is partial fetal alcohol syndrome, and that just means that in looking at the diagnosis that there's something missing, that they don't have all of the criteria to diagnose fetal alcohol syndrome. The third one is alcohol-related birth defects, ARBD, which basically describes the physical abnormalities that may happen with a child born. And the fourth is alcohol-related neural development disorder, ARND, and that basically describes the brain damage, as well as the fifth one, which is the neural behavior disorder associated with prenatal alcohol exposure. Next slide, please.

What is important to know is this is on a continuum. One end of the continuum is mild cognitive deficits that may be a result of the alcohol exposure. Along that continuum are the birth defects, the brain damage, and then there is the diagnosis of FAS. At the very end of that continuum is fetal death.

Let's look at some facts. The thing that has driven me and my desire to get information out about this is that FASDs are 100% preventable, which means that if no pregnant woman drank from this day forward, we would never have another child born with brain damage and a disability that will be lifelong. Other birth defects, such as Down syndrome, cystic fibrosis, cerebral palsy –those are birth defects that have a genetic component, and they will be in the population. But this, FASD, is –the only cause of an FASD is a mom drinking when she's pregnant.

It's also the leading known cause of preventable intellectual disability. And it's not caused on purpose. I worked in treatment where we had women that came to treatment and would bring their children. And I never have ever heard a woman say that she wants to harm her baby. But I have met many women who cannot stop drinking.

We have to realize that when we're working with women that are –pregnant women who are struggling with staying sober that we have to realize you're dealing with addiction. It's not just a simple process of just say no, and this can occur anywhere where women drink. Any pregnant women. This is not a Native American issue. It is not an issue for women of color. This is anywhere where a pregnant woman drinks, and it is an issue that is throughout the population.

And the next one is really we have said to people that dads cannot cause an FASD because dad doesn't drink. What we're finding with the new studies and the epigenetic studies showing that the chronic biological father using alcohol may alter his DNA, which can be passed down to their children. There's more studies going on about that, but what we have to know is that it's really about what women are drinking, because whatever a woman drinks or eats when she's pregnant, so does baby. This is not a new disorder. This is not something that was just discovered in 1973. We have observations from Aristotle and quotes in the Bible about the effects of pregnant women drinking during pregnancy. Next slide, please.

Let's look at, what do we talk about a drink? That all alcoholic beverages are harmful. Binge drinking is particularly harmful, and binge drinking is four or more drinks at one setting. We'll talk a little more about that, but there is no proven safe amount of alcohol. 0 is the best.

I was giving a presentation one time and I had a doctor raise his hand and said, you can't tell me that one drink of alcohol is going to cause an FASD. And I said, you're right, but you can't tell me that it won't, because we just don't know. It depends on the amount and timing, and we'll talk a little more about that. And then the other sad thing is that there are still some doctors in this country that are saying it's OK for a pregnant woman to drink. And our position on this is zero – none during pregnancy.

I talked a minute ago about a binge, and a binge is four or more drinks on one occasion. That is the most harmful in the sense that at that time, you are putting more alcohol into your body, which is then going into the baby. What is a drink? I get asked this all the time. A drink is 12 ounces of beer, four to Five ounces of regular wine … You have to be aware that there are fortified wines that can have as much as 20% of alcohol in them. And fortified wines are things like port, sherry, moderna, marsala, vermouth. Those are fortified wines. And again, a regular … just a wine that you would have, four to five ounces because it has 7% to 9% alcohol content.

And then one ounce of hard liquor. I would just like to make a note that we say one ounce of hard liquor. If you ever go to a bar and you watch someone free poor when they're making a drink, and they're pouring in there, and then they pour the little jigger into the glass, and then they pour again … Sometimes, a drink you might get may have two ounces of hard liquor in it so that if a woman has two drinks, she's having a binge at that point. it's very important to be mindful of, again, no alcohol during pregnancy, but to be mindful of what you would be drinking. Of what a drink is.

Steve: Candice, before you move to the next slide, could you define what an occasion is?

Candice:  That would be sitting and having an evening out. If you were sitting and you went to dinner, and then you went out to the bar afterwards, and you said, this is a four- or five-hour occasion where you would be drinking, like, have a drink, have another drink, have another drink. Did that answer that question?

Steve: Thank you. I appreciate that.

Candice: OK. What is the cause of FASD? The sole cause is a woman drinking alcohol beverages during pregnancy. Alcohol is a teratogen, which means it is a poison, and it causes a malformation of a developing fetus. What we have to look at is the report to Congress in 1996, which really hasn't changed much.

But the report said, of all substances of abuse, and that includes cocaine, heroin, and marijuana, alcohol produces by far the most serious neurobehavioral effects in the fetus. And that is really because alcohol easily goes through the blood-brain barrier, when these other drugs – cocaine, heroin, and marijuana – do not as easily. Next slide, please.

You have to look at, when a woman is out drinking, you have to check the labels for the alcohol content. You know, right now, we have wine spritzers. We have alcohol pops. These hard seltzers and the hard coolers that are available right now.

But a lot of times right now, because a lot of people are drinking the sparkling water. Some of these hard seltzers and hard coolers have a lot of fizz to them and can taste just like a glass of water, but you have to look at the alcohol content. Again, I'm going to say this, and I can't say it enough, is that a zero amount of alcohol during pregnancy is the safest for the developing fetus. Next slide, please.

This slide was adapted from Dr. Larry Bird of the University of North Dakota. And he took and wanted to give a visual, which I will tell you is very powerful, and I have used this when I've done trainings of what does the baby … What is the fetal exposure to alcohol in ounces? Let's say mom is having one drink a day for the nine months, which is the 270 days. And the fetal exposure … Let's say we cut it in half.

What that means is the baby at the end of nine months has received 15 baby bottles full of absolute alcohol. If mom is having two drinks a day, and again, we cut that in half so that she's having 540 drinks over the nine months, baby will have consumed 33 bottles of alcohol. And if mom is drinking at really a very high risk and probably an alcoholic level, she's having 10 drinks a day, at the end of nine months, the baby has received 168 baby bottles of alcohol.

I've always liked this slide because it's a very good visual of what is happening and what … the amount of alcohol that a baby can be receiving over nine months. And I've used this a lot with young people so that they really get an idea, because I think young people don't … Young mothers don't really get what's really happening. Next slide, please.

Let's look at some of the mediating factors. What are some of the differences? Why do … Some women are more likely to have an alcohol-affected child than others. And again, I just want to remind everybody, and you all know this. We're all chemistry sets. We look at –we could all take a medication. Right now, we've got over 1,000 people on this webinar right now, and we would probably get 1,000 different responses to that drug. We have to look at what are those factors that make a difference.

The first is dose. How much alcohol is being consumed during pregnancy? Just gave you that slide that looks at to show if you're having one drink a day, two drinks a day, or if you're having 10 drinks a day. it makes a difference. Just as that doctor asked me, he said, you can't tell me that one drink is going to make a difference. And he was right. I couldn't. But I also couldn't tell you that it wouldn't. It's a … We go back to our zero – no amount of alcohol during pregnancy.

Let's look at the genetic sensitivity of the fetus. If there is a family history of alcoholism … You know, they have not found the alcoholic gene, but they certainly have found that there are predispositions to individuals who grow up in an alcoholic family. There are some fetuses that are certainly more sensitive.

We find from birth mothers who have given birth to a child that has an FASD that the amount of disability that is from one child to the other may be significant, and that is because of that particular fetus' sensitivity.

Gestational age. At what stage of the pregnancy is the drinking taking place? Well, if we think about it, early in the first trimester when baby is just forming, that can have the most impact because the baby is not able to process any of the alcohol on their own. If the drinking comes in the third trimester where baby now has a liver and a kidney, and they can begin to process some of the alcohol that's being received. It makes a difference. The thing that I tell people and encourage anyone to tell: As soon as a woman knows that she's pregnant for her to stop drinking at that moment is very helpful.

The next is maternal metabolism. how healthy is mom? How fast does her liver and her body detox the alcohol? You know, if she's young and it's her first pregnancy, she may be able to detox that, the alcohol, much quicker than an older pregnant woman who maybe is not. Or if they have been drinking for a long period of time, their health may be suffering, and they may not be able to metabolize the alcohol as quickly, which then would create more impact on the developing fetus.

The next one is maternal nutrition. Obviously, this is something that we all support with women who are pregnant. Healthy eating helps the metabolism. You know, I think for people who go out and drink, and if you haven't eaten something before you go out after work and have a drink, sometimes, you feel that much quicker than you do if you're drinking with your dinner or after a meal. it's important to know how mom … What is her nutrition, and how is she eating? And hopefully, she's eating in a healthy way.

And the last is parity, which means a number of previous pregnancies. For women that have given birth to multiple children that have an FASD, what we have found is that the older children are less impacted, and the younger children are more impacted. And that has to do a lot with what we were just talking about. If mom's health is deteriorating and her drinking has not stopped, her health, her ability to metabolize that alcohol is less and less and less so that the younger children usually have more of an impact than the older children.

What does alcohol do to this developing brain? The brain on the left is the normal brain of a baby six-week-old who died of unrelated alcohol causes. What you see there is a healthy brain. It's got two hemispheres. It has the creases. It is a healthy brain.

The brain on the right is the brain of a six-week-old baby that had failure to thrive. That brain could not sustain life. We see … And to remember that we're talking about brain damage, which is permanent and will be lifelong.

The alcohol's a teratogen. I said that earlier. It is a poison to the developing brain, meaning that it causes malformation. One of the things we see in what happens, what alcohol does to the developing brain, is it confuses the cells. What happens is that and eye cell, if it has been bathed in alcohol, instead of migrating to the area of the eye, it might migrate to the area of the ear. And it's going to die there because it's not an ear cell. What you see is what you see for this brain on the right, the malformation of the brain, because the cells were unable to go where they needed to go and create a healthy brain. Next slide.

This slide is a slide of looking at what is the total developmental cycle of a baby from inception to birth at 38 weeks. The question I want to ask is: When do you know you're pregnant? Some people know right away. Some people know when they have skipped their first period. Some people may wait and know at eight weeks when they skip their second period.

Depending on mom's health … And maybe she has intermittent periods. That can also happen. We've had women know … I mean, you read these stories of a woman who gives birth to a child and didn't know she was pregnant. I've never quite understood that, but I know it happens, and that's what women say.

I would like for you to look and see, if you look on your screen there, and between 8 and 12 is 10 weeks. By 10 weeks, the heart, the arms, and the legs are already formed. And you also see that the pallet and the teeth … Teeth continue to develop all the way throughout the end of the pregnancy.

But the other thing to notice here is that the central nervous system, which is the brain, continues to develop throughout pregnancy. The recent research tells us that our brains continue to develop until we're about 25 years old, which is new information for us because a lot of times, we heard before that, oh, your brain stops developing around five, six, seven years old, which is not true.

Looking at this, this is one of the reasons that we're talking about pregnant women right now. But there's also another piece of this that I really believe is important, which is to have a discussion with women of childbearing age. If you have women in your program and you're working with women who maybe are not pregnant, but to let them know that if they're having sex and they're drinking and they're not using birth control, that there is a possibility of getting pregnant.

And potentially, if they don't know they're pregnant for 10 weeks or 12 weeks, the damage may already be done. we try to work with women of childbearing age to let them know that they have to be aware of when they're drinking, and to be aware that they don't want to have a child that may have an FASD. I've always felt that this is a powerful slide to use when we're working with women because it tells you how the baby develops. And there's only about seven days of total protection for the fetus. And that's the first seven days that it has been fertilized.

When the egg travels down the fallopian tube and then implanted in the uterus, there is a coating on that that protects it so that even if there is alcohol exposure, that little zygote will not have any impact. But once the baby implants in the uterus and whatever mom eats or drinks, so does baby. Next slide, please.

We look at the possible effects of alcohol on mom and baby. What happens to mom if she's drinking at at-risk levels? At-risk levels are binge drinking, which is four drinks at one sitting, and the other at risk is seven or more drinks in a week. Those are considered to be at risk levels of women who are drinking alcohol to have a potential alcohol exposed pregnancy without some intervention in them.

We look at mom. What can happen? Miscarriage, still birth, preterm labor, and preterm birth …. can have early births with … because of what the alcohol is doing to the body and to the uterus. And then what I want to say … Of course, preterm birth is miscarriage. What I want to say is the effects on the developing fetus are permanent, and they will last a lifetime, which is different than other drugs that we were talking about.

Let's say a baby is born addicted to cocaine, which … the cocaine babies. And we all heard the stories. What happens with the baby is that the baby will be detoxed and will get the cocaine out of its system. It has not had brain damage. The longitudinal studies of some of these cocaine babies, what they're finding is that the impact has been more on the nervous system than it has been on the brain.

It's letting, again, women of childbearing age, as well as pregnant women, that this is a permanent condition and will last a lifetime. This individual, depending on the level of severity, will need support and help throughout their lifetime.

Let's look at what happens with baby. The possible effects of happens on baby: low birth weight, small head size, poor coordination, learning difficulties, speech and language delays. vision and hearing problems, difficulty with attention, poor memory, and lack of focus.

These issues are what you will see as these children come in to Early Head Start and Head Start. These are the issues that create lots of problems for these kids once they get into school. And we're going to talk about working with these kids. I'm going to do another webinar … I believe it's June 9th. And we're going to look at how to work with these individuals because they really need support in order to be able to succeed in school and in other settings.

You will see these, and not all of these mean that there is an FASD. But I think the one thing that I tell staff is when they're doing this, if they're working with a child and they get this feeling like they just don't get it because you've helped them, you've supported them, they say yes, and then they go out and do the exact opposite thing again, I ask you to trust your gut about that. Sometimes, that means that there's something else going on besides just learning how to do different things, and that these things don't always mean to have an FASD. You'll look at them together and see that there are other problems. Next slide, please.

What we want to do is look at, how do we support our expectant families to have a healthy baby? The most important thing is education and information. Check with the family. What do they know? Is this the first baby? Is it the third or fourth or fifth baby? What do they know about taking care of themselves in the process of this pregnancy?

One of the things we know is that when … Pregnancy can be a time that families are open to make some healthy choices. They maybe realize, especially if it's a first pregnancy, they may begin to realize we need to change some things in our lifestyle because now we have a child, and we're bringing a child into our family. And we keep saying all the time, this is about having a healthy baby, healthy family member.

In-home visitors and center staff, you can give information on healthy practices, and I know that many of you do. But it's important to include in those –so what is healthy nutrition for mom and baby? We need to look at, what does she need to be eating? How does she need to be eating? It's a chance to go over with those individuals and say, you know, how much sugar are you eating? If you have other health issues that can give information out about healthy food. Sometimes, it's hard for us to eat those vegetables and fruits when we're used to eating all of our donuts and our carbohydrates.

The other is regular prenatal checkups. This is really important, and we need to make sure that she's in that place, and she has someone that she's seeing, because that is really important to maintain her health as well as to be able to check up on the baby's health and the baby's development.

Exercise – this is an important one. You know, they say to us that walking is the best exercise that you can do. I think that's great. I think for pregnant women … This is not about going out and running, or climbing a mountain, or doing something that is very strenuous. But to go out and walk and just to get some exercise is healthy for mom, and it's also healthy for the baby.

Then the other thing … information about is to be aware of the risks of alcohol and other drug use. To tell you the truth, there are some women that are not aware of what happens. It's just information. There are pamphlets and information that you can give that are nonjudgmental, and just be aware that these risks are present. Next slide, please.

Let's look at the health risks that are associated with substances in general. The column on the left is really about mom. Smoking … There's a lot of information about smoking, the effects of smoking during pregnancy and other drugs. But it can cause, as we said earlier, early labor, early birth, problems with the placenta, stillbirth, heart problems, and low birth weight.

Then, if we look at what happens to the baby … The column on the right is about the baby. As I said earlier, alcohol, the EPOH crosses the blood brain barrier much easier than other drugs do. That's how the brain damage happens, and it causes the brain damage. And then, the dysmorphic features, which I've already explained. And then, of course, fetal death.

Those are the health risks and for expectant families to be aware of that. Those can all be presented in a nonjudgmental, nonthreatening way just so that they know what is happening and what is expected of them as a pregnant family to be healthy. Next slide, please.

One of the things that … This is a standard from the Head Start program, the performance standards. These are federal regulations and I'm assuming that a lot of you know this. But if you don't, it's really important to pay attention to them and the first one is the Family Support Services for Health, Nutrition, and Mental Health.

This is about collaboration. This is about working with parents – not working at parents or to parents but with parents – to promote a child's health and well-being. They're looking at different parts of that which can be medical. We talked about the prenatal checkups. We talked about oral and nutrition, mental health education.

These are surfaces and support that are really important for all families, and especially expectant families. And B, many of these opportunities … And you're going to collaborate. Again, it's about collaboration and working with the family to include opportunities for parents to learn about healthy pregnancy. Postpartum care and things like breast feeding. Also, what is in this federal regulation is about the treatment options for parental mental health and substance use problems. This applies to all families in Early Head Start and Head Start. Next slide, please.

How to address alcohol use during pregnancy. It's about building a relationship with the expectant family. My guess is that most of you do this in a really good way. It's about: How do you have a relationship with this family? Know again that we go back to what we're saying … that this is about having a healthy baby. This is what we're here to support you. A healthy child.

One of the ways to do that is to look at what are the strengths that this family has? Especially for home visitors, you're able to see what goes on in the home. For staff that's at the agency, you also know what they do well. To start with that, which is a nonjudgmental, supportive way of saying, you're doing something really positive, and we want you to look at what may happen if you're drinking during your pregnancy. And then, the earlier the discussion you can have of alcohol, the better it is for the mother, baby, and family. Let's go to the next slide.

This performance is 1302.80, and .81, we're going to talk about. These are specific to Early Head Start and the enrollment of pregnant women. Again, this is to have access to comprehensive services to referrals. That's a minimum that include nutritional counseling, food assistance, mental health, and again, here is substance abuse prevention and treatment.

And it is important to know also … One of the other things that's important here is emergency shelter or transitional housing in case of domestic violence. This is completely about supporting the woman, the pregnant woman, so that she can have a healthy pregnancy. Next slide, please.

This one is about the postpartum information, prenatal and postpartum information, education, and services. We've talked about this is that … how information is so important to these families. This standard is about getting information to the pregnant women, fathers, and partners, or any other relevant family members that may be supportive to having a healthy baby.

They're going to address fetal development, and again, the importance of nutrition, the risk of alcohol and drugs, and smoking, again, which are all of those at-risk factors that can impact a healthy pregnancy. And then B, which I think is really wonderful, is that it addresses the need for appropriate support and well-being for the father.

You know, this is, hopefully … This is a woman's issue about her taking care of herself and not drinking alcohol while she's pregnant. But it's also a man's issue. If he can support her and help her to not drink, that is really, really important. Looking at how is dad doing? Is dad maybe –maybe dad is drinking too much, and maybe dad needs some help. It's really important we look at the woman, but it is about a family, and it is about two people. This is not just a woman's issue, and sometimes, it's a fine line you have to walk with that. Next slide, please.

Let's look at how do you begin the conversation? First of all, the information that you get on your intake and your health history is really important. And at that time, people come into programs, and they know they have to fill out this paperwork. It's a really good time to ask questions about alcohol use. If there are no questions in your current intake or health history, I would support you to consider adding them.

This is about being able to guide and enroll pregnant woman to comprehensive services that begin with nonjudgmental inquiry about substance use, and that's important to say. We need to be not judgmental. Next slide, please.

When I say that –for us to do this, we need to check our own biases and attitudes in relation to alcohol and other substances before we engage with the family. We need to know, how we feel about that? How do we feel about pregnant women drinking? There's a lot of people that are wagging their finger and say, you shouldn't be drinking. Well, that isn't helpful, and if this woman is addicted, it's certainly not helpful because what we have to do in that case is we have to reach out to her and realize that she has an addiction, and we need to help her to stop drinking, at least while she's pregnant. Your relationship with the family and your stated desire to help the family have a happy and healthy baby will allow you to begin to ask questions about the healthy and unhealthy practices.

Know that you are the agent of change, and you're the agent of change for children and families that you work with. Know that this is an important part of your job. I know that most of you do know that, but to realize that you can be very helpful in helping this expectant family and you can begin supporting the family by asking open-ended questions about pregnancy and alcohol use. Next slide, please.

Let's say our conversation. Here are just some examples of things that you might say. Our conversation will help me to support you and your baby. Our goal is to have a happy and healthy baby. What do you want from your pregnancy? That question can bring up lots of responses. What do they want? Is this first baby? Is this the fourth baby? What is happening for them in their pregnancy?

When did you realize you were pregnant? Again, that is open-ended. You can find out when they found out they were pregnant. Was it right away? Was it the third month? As we talked earlier about what impact it might have if she was drinking up until the third or fourth month of her pregnancy.

Before you were pregnant, were you drinking alcoholic beverages? What was your pattern of drinking? Now that you are pregnant, are you still drinking alcoholic beverages? Then you know that there are resources in the community to help you have a healthy and safe pregnancy, and I'm happy to help you find those resources. Again, we're talking to mom, and we're saying, we want to help you. We want to help you have a healthy baby. We realize that sometimes that's difficult. It's hard. Next slide, please.

It's important to know your community resources and your treatment options within your community. The reason I say this is because if a woman is drinking, and she's pregnant, and she's having difficulty stopping, she may need to go to treatment and in many communities, there are … Many treatment centers will set aside beds just for pregnant women, so that if you call the treatment center and said, “I have a pregnant woman who needs to come into treatment,” she can go immediately. Because the best treatment for a pregnant woman drinking is inpatient treatment. But you also need to know what are the intensive outpatient treatment services? What are your social services? I believe that most of you are aware of what's happening in your community, but it's very important to know what is happening in the area of treatment and support for a pregnant woman to stop drinking. Next slide, please.

Here it is. This is our healthy baby. This is our goal. Our goal is to have a healthy baby and to have a child that will grow up and not have any disabilities. I want to say thank you for paying attention today and I know that a lot of you are really aware of these issues. I hope this was helpful for you today.

Steve: Thank you so much, Candice. Barbara, if you could bring us to the next slide. We have a number of resources. They are on the resource list handout that Livia and I have been putting into the chat, so please go to them. All these resources are linked. Barbara, next slide. As well as these resources, as well as the certificate, the evaluation, a copy of today's slides.

We have time for just a few questions, and there are so, so many. Next slide, please. Candice, if you don't mind, I'm just going to ask you a few of them. We've been responding to questions throughout today's session, and we have so many questions, we're not going to be able to get to them all. But is it possible for a mom who is drinking to pass the effects on to her children? In other words, will her own eggs be affected so that that child then would pass on the effect of her drinking? In other words, her grandchildren?

Candice: That's more of a predisposition question, Steve, and is about DNA. We don't have a lot of information about that. But it is –when you realize that alcohol being the teratogen that it is and the poison that it is, it can affect … Especially in an older woman who has been drinking for a longer period of time, it can have an impact on her eggs. And that's why for older women who have been drinking a lot, they may have a miscarriage or have … and not be able to carry the child to term.

Steve: Thank you. How about, is there one trimester that's more sensitive to alcohol intake than another?

Candice: Yes. The first trimester. The first trimester because you've got a very small, little zygote that's growing into a baby, and the first trimester is the most sensitive, although all of them are, but the first trimester is the most sensitive to the alcohol consumption.

Steve: And that may be the one, the trimester, where people are not aware that they're pregnant yet.

Candice: That's right, and that's why this information is really important to get out to women of childbearing age to know that again, if they're being sexual and they're drinking, that they need to be aware that they could be pregnant.

Steve: There were a lot of questions about children with FASD. How to diagnose them, how to work with them. I want to remind people that on June 9th, Candice is coming back to do a webinar about identifying and working with children with FASD. Please, go to ECLKC and register for that webinar to get those questions answered.

Candice: We'll answer a lot of those questions, Steve, in the next webinar about how to work with these kids, because it's really important.

Steve: Thank you. We have so many more questions. And I'm going … Can you go to the next slide, Barbara? Thank you. This is the evaluation link that we want you to go to. And that evaluation will bring you to the certificate.

Once you submit the evaluation, I'm going to put it into the chat for everybody, and Livya will repeat it. It will be here for you to access after the webinar closes. Next slide, please.

We want to thank you all for your incredible participation, but especially to Candace for really trying to make this very complicated and difficult information so accessible to so many of us who are working with families. And there were so many of you who identified in your questions and in your chat the kind of work that you were doing. thank you for that. And then, next slide, please.

This is how you reach us. If you have questions that didn't get answered today, go to MyPeers, or write to health@ecetta.info. We work closely with all of our subject matter experts and partners to make sure you get the best possible answer. Our resources are on ECLKC at that URL, and we really, really thank you for such incredible attention to this very important issue. You are on the front lines. You are there working with pregnant women and families, expectant families, and we really want this information to go out there.

There are a lot of you that shared so much in the chat, and we thank you for that. But really, really, the work is hard. The work needs, as Candice said, needs to be delivered in a nonjudgmental way. And really knowing that you are – Candice used these words – you are an agent of change here. You and we can all do our part to prevent fetal alcohol syndrome disorders.

I thank you all. Thank you, Candice. Thank you back of the stage, Livia, Barbara, and Kate for making the show run. We know that some of you have questions that didn't get answered. We encourage you to write them again on MyPeers or health@ecetta.info, and we will get you those answers.