Meeting the needs of adolescent parents and their children

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Adolescent parenting and implications for health

There are nearly 13,000 infants born to adolescent parents each year in Canada.[1] Overall, Canada experienced a 47% decrease in adolescent births between 1990 and 2010, leveling with a birth rate of 13.5/1000. There are geographical exceptions to the general decline in adolescent birth rates, with some regions showing an increase, notably the Atlantic provinces.[2] The current practice point highlights the unique health needs of adolescent parents (<20 years of age) and their children and recommends some basic strategies to optimize outcomes.

There is substantial literature summarizing the adolescent pregnancy and parenting experience, as well as in-depth research exploring maternal and child outcomes over several decades.[3]-[6] Adolescent mothers have higher rates of mental health disorders,[7]-[11] repeat pregnancy,[12] substance use[13]-[14] and domestic violence,[15] often in the context of lower self-esteem, socio-economic status, income, educational attainment and social support.[4][8]-[10][16] The children of adolescents are at increased risk for prenatal death, premature birth and low birth weight.[5] These risks often co-exist or are accentuated among pregnant adolescents who, on average, have higher levels of substance use, smoking and sexually transmitted infections (STIs) along with lower levels of education, income, prenatal care and breastfeeding.[17] The children of adolescent mothers may also experience growth and development issues, particularly cognitive and speech and language delays,[18]-[19] have higher risk for accidental injury and neglect,[20] and encounter challenges with behaviour and in school.[21] Later, as adolescents, they are at higher risk for substance use, early sexual activity and becoming adolescent parents themselves.[22][23] They are more likely to struggle academically, which further limits their educational opportunities, vocational options and financial security.[14] At the same time, it must be emphasized that many adolescents excel as parents, and that some choose to parent at a young age for personal, cultural or familial reasons. Successful parenting is particularly evident in circumstances that include supportive social networks, a positive parenting environment and limited adversity.

More recent long-term studies have pointed less toward maternal age as a direct cause for negative outcomes than toward the impact of social determinants of health inequities, especially poverty.[14][19][21][24][25] Many adolescent parents live in poverty and continue to experience its many obstacles. Health care providers who have a thorough appreciation of the social issues at play and are mindful of the developmental challenges facing both children and their adolescent parents are ideally situated to help young families.

Health issues for adolescent parents and their children

Needs of the adolescent mother

Adolescents can be difficult to engage in preventive health care services, in part because they are basically physically healthy, do not anticipate needing a health intervention, are protective of their own privacy or on issues of confidentiality, and fear being judged. Because of early pregnancy or parenting, adolescent mothers are often cared for in a paediatric or family practice setting. It is common for adolescent mothers to have general health maintenance, sexual health and mental health needs, with more specific supports needed to access psychosocial and practical, everyday life resources.

Higher rates of psychosocial problems in the adolescent parenting population, such as interpersonal violence, relationship conflict, abuse and trauma as well as educational, employment and financial challenges are well described in the literature.[8][26]-[28] Mental health disorders are common, including depression (antenatal and postpartum), post-traumatic stress disorder, anxiety and substance misuse.[7]-[10][27] The estimated rate for depression in adolescent mothers falls between 16% and 44%; even this wide range is twice the estimated rates for nonpregnant adolescent or adult women.[7]

Prevalent sexual and reproductive health requirements include access to birth control, STI treatment, and preventing or managing repeat pregnancies.[29] The repeat pregnancy rate is as high as 23% within 24 months of a first birth[30] for this age group. Prevention requires seamless access to various birth control methods, including long-acting reversible contraceptives (LARC).[29] As with adult parents, health care providers must consider attachment, lactation and parenting factors as integrated and fundamental to appropriate paediatric care, but they also need to deliver such care in the context of adolescent development.

Helpful adolescent assessments and screens that can be incorporated effectively into an office visit include the HEEADSSS (Home / Education, Employment / Eating /Activities / Drugs / Sexuality/Suicide, Depression/Safety)[31]-[32] or SSHADESS (Strengths / School / Home / Activities / Drugs/substances / Emotions/eating / Depression / Sexuality / Safety[33] screens for obtaining a comprehensive strength-based psychosocial assessment, CRAFFT[34] for investigating substance abuse, and the Beck Depression Inventory[35] or Edinburgh Postnatal Depression Screen[36] for assessing mental health (Table 1). However, while many health and psychosocial risk factors undoubtedly exist before pregnancy, the decision to parent young is often deliberate and it can and commonly does bring new direction to family life, along with motivation to be a good parent, to pursue life goals, and to improve socio-economic circumstances and overall quality of life.[24]

Needs of the child

Although the children of adolescent parents need essentially the same things as children of adult parents, the context of their needs can differ considerably. The importance of providing anticipatory guidance, along with assessments and teaching around growth and development, nutrition, feeding, sleep, safety and immunizations remains paramount. Consideration needs to be given at the same time to factors specific to the child’s young parents, such as the developing adolescent brain, the obtainment of their own adolescent developmental tasks or milestones, the impact of social determinants of health and their (usually limited) access to social supports, because such factors inevitably impact parenting practices.[37][38]

Potential areas of vulnerability for the children of adolescents include difficulties in speech and language development,[18] less engagement in preventative health maintenance visits[37] and more frequent use of acute care services.[39] Neglect and unintentional injury,[20] disorders of attachment and regulation, and behaviour problems[11][40][41] may present as or result in feeding, sleep, growth or nutritional difficulties. Safety of the home environment should be considered, including assessment for maltreatment, exposure to interpersonal violence and the need to involve child protective services. Therefore, care for the children of adolescents should emphasize healthy parent-child interactions, mental health, early intervention and the facilitation of services (Table 2). A developmental screen (eg, the Nipissing District Developmental Screen [42] or the Ages and Stages Questionnaire (ASQ)[43] and Ages and Stages Questionnaire: Social-Emotional (ASQ:SE)[44]) along with a targeted speech and language screen should be incorporated into the 18-month or regular immunization visits to monitor potentially vulnerable areas and to ensure earlier identification and intervention.

Role of the adolescent father

Most fathers who parent with adolescent mothers are not adolescents themselves but are, on average, five years older than young mothers.[45] Over 80% of fathers do not live with their child, although up to one-half visit on a weekly basis. Their financial contribution to child-rearing is limited because they, too, are often living with poverty, limited education, tenuous employment or (potentially, at least) a criminal history.[3] Domestic violence and relationship problems can jeopardize family safety, and health care providers need to ask about psychosocial stressors and offer information and support in tenuous circumstances.[15]

It should also be noted, however, that paternal involvement has the potential to benefit both maternal and child outcomes. The literature has established that a father’s involvement can have positive impacts on maternal depression, breastfeeding rates, parenting practices and family functioning, as well as a child’s health and well-being, including psychosocial, cognitive and behavioural outcomes.[3][46] The early engagement of fathers, from the prenatal period onward, is essential to facilitating involvement in children’s lives. It is important for health care providers to actively include fathers in encounters along the continuum of care, whenever possible.

Recommended model of care for adolescent parents and their children

The population of adolescent parents and their parenting experience have been well studied in the United States. The American Academy of Pediatrics supports a ‘medical home’ model of care for adolescent parents: one where care for both parent and child is “accessible, family-centred, developmentally appropriate, continuous, comprehensive, coordinated, compassionate, and culturally sensitive”.[3] Philosophically, this approach is transferable to the Canadian context and has been incorporated into some hospital clinics (eg, The Hospital for Sick Children [Toronto, Ontario]), adolescent parent housing/resource centres and community health centres (eg, the Children’s Hospital of Eastern Ontario/St Mary’s home in Ottawa). Hospital or clinic-based models have proven successful due, in part, to the allocation of specialized interdisciplinary resources in places where mother and child can receive holistic care together. Central to this model’s foundation are the beliefs that social determinants of health for both the adolescent and her child can be addressed in a ‘medical home’ base and that health inequities can be reduced by facilitating interventions such as triaging needs, connecting patients with targeted resources, and using an interdisciplinary team approach to the full spectrum of care needs.[44] The medical home model should incorporate the extended family and each individual’s support system into care of the young family, always considering confidentiality and the adolescent’s autonomy. Creative educational and communication tools are being trialed or used with adolescents, including texting, apps and online tools, and should be incorporated as often as interest, effectiveness and accessibility allows.

Transferring components of care delivery into community practice

While specialized interdisciplinary models are ideal, there are many adolescent parents requiring tailored services who live beyond the reach of specialized urban centres. Certain components of care delivery are still transferable to a community-based practice, ideally when anticipatory guidance and the facilitation of care provide a smooth transition from the prenatal to postnatal period. Health care providers who can successfully promote positive outcomes for an adolescent, her baby and (possibly) her partner and extended family are also those who maintain close and sustained follow-up, have office or clinic staff who are engaging, nonjudgmental and educated in working with adolescents, and who emphasize contraception and family planning as well as encouraging continuing education.[48] The potential advantage of offering these optimal components of care to adolescent-led families is the active mitigation of risk: more and better employment, independence, stronger school engagement, adherence to condom and long-term contraceptive use, fewer repeat pregnancies and higher immunization rates.[48]

Ideally, an enhanced collaborative interdisciplinary network can be created by connecting traditional population health approaches with primary care responsibilities.[50] Meeting patient needs within the community will require outreach and communication with professionals and agencies that can work together to enhance youth-friendly patient care beyond the health care provider’s expertise. This linkage can offer an adolescent-focused approach in any setting, including a community office. Cultural norms and traditions relating to pregnancy, parenting and family structure may need to be assessed and integrated into individual care. Incorporating paediatric guidelines endorsed by the Canadian Paediatric Society such as the Rourke Baby Record[51] or the Greig Health Record[52] into regular office visits where a child’s well-being is understood in the context of family and community can provide a framework for optimal evidence-based care for both child and parent.

The use of developmental screens can be enhanced with screening for food security and housing, employment, child care, and education needs.[53] The health care provider must have a thorough working knowledge of community-based resources and supportive services, such as food banks, housing services, education, legal and job centres, child development and parenting centres, sexual health clinics, public health programs and, where available, resources specific to adolescent parents. In addition to enhancing child development, local programs may target infant mental health, reading skills, positive discipline and quality preschool learning (Tables 1,2).[54]-[58]

Consider educational and community resource information in waiting or exam rooms that addresses child and adolescent health issues, such as positive parenting, early literacy, speech and language, sexuality and healthy relationships. These materials should be written in clear, simple language and available in multiple languages, where appropriate. Consider referring vulnerable or isolated adolescents to outreach services such as home-based interventions, youth outreach or public health services. For example, a public health nurse is an ideal professional to connect with young parents in their home setting to further assess and link with pertinent resources within the family’s community.

TABLE 1
Meeting an adolescent mother’s basic health needs
Needs	Suggested screening tools, questions and resources
Growth and development	Greig Health Record[51] Body mass index (BMI)
Immunizations	Are all vaccines for parent and child up-to-date for your province or territory? Make sure at: www.phac-aspc.gc.ca/publication/cig-gci/index-eng.php
Nutrition/food security	Screen for body image concerns and nutrient deficiencies “How do you feel about your body changing?” “Do you worry about having enough money to buy food?”
Acute illness management	“Do you have the medications and equipment that you need in order to feel well?” “Do you have the funds or insurance coverage to be able to pay for this treatment?”
Lactation support	Refer to a local breastfeeding clinic or a public health unit/nurse
Psychosocial assessment	HEEADSSS[30]-[32] (Home / Education, employment / Eating / Activities / Drugs / Sexuality / Suicide, depression / Safety) SSHADESS[33] (Strengths / School / Home / Activities / Drugs/substances / Emotions/eating/depression / Sexuality / Safety) Refer to youth services/social services/local mental health agencies
Sexual health	“Do you have any sexual health needs? I can help with this care or I can tell you about local sexual health clinics. What would you prefer?”
Birth control	www.sexualityandu.ca
STI screening/treatment	www.cps.ca/en/documents/position/sexually-transmitted-infections
Mental health
Depression	Beck Depression Inventory (BDI)[35] Patient Health Questionnaire (PHQ-9)[55]: www.phqscreeners.com
Postpartum depression	Edinburgh Postnatal Depression Screen (EPDS)[36]: www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf
Substance use	CRAFFT substance abuse[34]: www.ceasar-boston.org/CRAFFT/index.php
Anxiety	SCARED[55]: www.psychiatry.pitt.edu/research/tools-research/assessment-instuments
Trauma/PTSD	The (abbreviated) UCLA PTSD Reaction Index[56][57]: www.nctsn.org/content/standardized-measures-assess-complex-trauma
Additional mental health screens	www.cps.ca/tools-outilis/mental-health-screening-tools-and-rating-scales Refer to youth services/social services/mental health agencies
Interpersonal violence/Safety	“Do you feel safe in your relationships with your partner and family members?” “Have you been physically hurt, threatened, afraid or forced sexually in any way in the last six months?”“Have you had any involvement with child protection services?” Develop a safety plan including assault help-line numbers and information about local shelters to have ready for quick mobilization in case of safety risk or crisis
Parenting support	“Do you have the supports and resources you need to parent in the ways that you would like?” Refer to adolescent-specific services whenever possible, including public health or young parent resources centres (formerly known as maternity homes), mental health services or support services offered by child protection agencies, as needed
Finances	“Do you have any concerns about having enough money to pay your bills or to buy what you need for you and your child?” Use region-specific practical tools to screen for child poverty in primary care: http://ocfp.on.ca/docs/default-source/cme/child-poverty—-a-practical-tool-for-primary-care-2013.pdf?sfvrsn=4
Housing	“Do you have any concerns about where you live? About being able to pay rent or becoming homeless?”
Education	“Do you have access to a school that helps you pursue your own educational goals?”
Employment	“Do you need help with securing employment or pursuing your career goals?”
Child care	“Do you have child care arrangements that are safe, affordable and reliable, and that allow you to attend work or school appointments?”
Legal	“Do you have any concerns about immigration or custody and access or other legal issues that may require the advice of a lawyer?”
Adapted from references [47][52]-[54].

TABLE 2
Meeting the basic health needs of children of adolescent mothers
Needs: Standard paediatric care with areas of emphasis	Suggested screening tools, questions and resources
Infant mental health	Observe and discuss mother-child relationship, attachment, interactions, emotional regulation, sleep, feeding and developmentally appropriate behaviours ASQ-SE[44]
Early intervention	Promote early literacy and communication: Use CPS “Read, speak, sing” information as yourstarting point: www.cps.ca/en/issues-questions/literacy Refer to preschool speech and language services, as needed Provide contact information for child development centres, children’s mental health centres, local public library programs, nursery schools, child care centres and subsidy information, as needed
Safety	Offer developmentally appropriate anticipatory guidance Refer to Health Canada’s consumer product safety website (www.hc-sc.gc.ca/cps-spc/index-eng.php) for essential equipment information such as crib safety, and to Transport Canada for safe car seat practices (www.tc.gc.ca/eng/motorvehiclesafety/safedrivers-childsafety-index-53.htm) Assess for child maltreatment and exposure to interpersonal violence. Consult with child protection services as required.
Behaviour	Observe and ask about parenting strategies, approaches to discipline, parent-child interactions, stress factors
	Provide contact information for adolescent-specific community supports and family services, whenever possible

There should be youth-centred nonjudgmental staff and a welcoming atmosphere in the office setting with, preferably, some allowance made for the occasional late or missed appointment. Such lapses may be better understood in this age group, who are also contending with conflicting demands, immature executive function, limited resources and high requirements for care. Access to supports and information is hugely important to adolescent parents, who are often inhibited by fears of judgment or stigmatization.[38] Your practice’s readiness to make reminder calls, waive administrative fees for photocopying or completing medical forms, and to provide advocacy letters or donated items are just a few practical ways to engage an adolescent who is learning basic life skills at the same time as parenting, often in difficult social and financial circumstances. Sustaining a long-term positive relationship and encouraging autonomous decision-making, along with reassurance as needed, can contribute to resiliency and positive health outcomes for young families.

Acknowledgements

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CPS ADOLESCENT HEALTH COMMITTEE

Members: Giuseppina Di Meglio MD, Johanne Harvey MD (past member), Natasha Johnson MD, Margo Lane MD (Chair), Karen Leis MD (Board Representative), Mark Norris MD, Gillian Thompson NP-Paediatrics
Liaison: Christina Grant MD, CPS Adolescent Health Section
Principal author: Gillian Thompson RN(EC),BScN,MN,NP-Paediatrics

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.