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Indicators of Possible Alcohol Use/Dependence

Adapted from the Missouri Department of Health's Maternal Screening to Prevent Fetal Alcohol Syndrome: a training module for WIC program employees. For ordering information, contact Missouri Department of Health, Division of MCFH, Bureau of Disabilities Prevention and Injury Control, P.O. Box 570, Jefferson City, MO 65102-0570, (573) 751-6253.

Each of the following may have explanations other than alcohol use. Keep in mind that these may be warning signs of possible alcohol use and/or dependence:

Physical Appearance of client:

  • Has pupils that do not react to changes in light levels.
  • Nods and/or appears sleepy.
  • Looks much older than stated age.
  • Appears unkempt.
  • Smells of cigarettes or alcohol, especially on breath.

Behavior of client:

  • Frequently misses appointments.
  • Appears agitated, irritable, nervous, forgetful, and/or confused.
  • Constantly plays with objects.
  • Turns body away from interviewer.
  • Maintains no eye contact (this can vary by culture).
  • Leaves awkward periods of silence between responses.
  • Frowns intensely and/or grimaces.
  • Leaves a seated position to walk, pace, etc.
  • "Rocks" while responding.
  • Trembles or has uncoordinated movements.
  • Makes abrupt, intense gestures toward interviewer.

Verbal Cues of client:

  • Impaired speech.
  • Changes in conversational pace (faster, slower).
  • Jokes about questions , and/or inappropriate laughter.
  • Quick answers denying use (no time taken to think).
  • Inconsistency in responses.
  • Hostile , angry responses.
  • Refuses to answer some (or all) questions.
  • Blames others for her drinking.
  • Attempts to change the subject.

Building Rapport to Honest Answers

Adapted from the Missouri Department of Health's Maternal Screening to Prevent Fetal Alcohol Syndrome: a training module for WIC program employees. For ordering information, contact Missouri Department of Health, Division of MCFH, Bureau of Disabilities Prevention and Injury Control, P.O. Box 570, Jefferson City, MO 65102-0570, (573) 751-6253.

Positive rapport is key to getting honest answers to questions. It is based on treating clients with respect and value, and it starts with the first interaction. Your personal attitudes toward alcohol use and women who drink can either enhance or diminish your relationship with the client and the screening process. Left unidentified, negative attitudes will be conveyed to your client through: content, voice tone, and body language. Negative attitudes include judgement, condescension, disinterest, and fear.

Ways to Establish Positive Rapport with the Client:

  • Develop an atmosphere of warmth and trust.
  • Maintain a friendly manner.
  • Exhibit genuine concern and caring.
  • Demonstrate empathy and understanding.
  • Use appropriate eye contact , posture and gestures.

Techniques For Asking the Tough Questions:

  • Review your responsibilities as a medical provider regarding patient confidentiality.
  • Ask questions that are straightforward, non-threatening, non-judgmental, and open-ended.

If a client becomes defensive or resistant, try:

  • emphasizing confidentiality again
  • softening your voice tone
  • active listening (i.e. nodding head, leaning forward)
  • reflective listening (i.e. reflect back to the client what she has told you in her own words)


Use the following progression to ask about the least threatening substances first:

  • Over-the-counter medications
  • Prescription medications
  • Caffeine
  • Cigarettes
  • Alcohol


Talking with High-Risk Pregnant Clients About Alcohol and Other Drugs

  • Be non-judgmental
  • Work toward building client's self-esteem
  • Be culturally sensitive and age appropriate
  • Use patience and persistence
  • Encourage new interests and participation in healthy leisure time activities that the person enjoys
  • Reinforce client's coping skills
  • Encourage her to spend time with friends and family who support a healthy lifestyle and, if she doesn't have such a support system, suggest how she might develop one
  • Connect alcohol/drugs with their consequences by explaining effects on how they pass through the placenta and affect the fetus
  • Emphasize that abstinence will improve chances of a healthy baby
  • Avoid guilt-provoking criticism
  • Tell her to be patient and live one day at a time

Use positive statements:

"If you stop drinking, you have a better chance of having a healthy baby"

rather than

"Your drinking has already damaged your baby"


"Both you and Your baby will feel better when you are sober"

rather than

"If you continue to drink you will ruin your health and your baby won't develop normally"

"Your concern for your baby will help you be a good mother"

rather than

" If you really loved your baby you won't drink so much"

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