Demographic characteristics and needs of the Canadian urban adolescent mother and her child

Abstract

INTRODUCTION:

There is a paucity of Canadian-based literature on urban adolescent mothers and their children. To inform clinical assessment and interventions and to mitigate the risks that adolescent mothers and their children face, it is essential to understand the characteristics of this high-risk population.

METHODS:

A retrospective review of 116 adolescent mothers attending an urban academic hospital-based outpatient clinic in Canada from 2005 to 2009 was conducted. The following information was collected: demographic characteristics, maternal maltreatment history, substance use, postpartum depression symptoms, and child socioemotional and developmental functioning.

RESULTS:

The mean maternal age was 16.1 years and the mean education level was grade 9. Ninety-nine percent of adolescent mothers were single, 47% had a history of child welfare involvement and 18% had previous involvement with the judicial system. More than one-half of participants reported a history of both maltreatment and substance abuse, and 20% of adolescent mothers scored in the clinical range for postpartum depression. A substantial proportion of children scored in the clinical range for behavioural problems, regulatory difficulties and suspected developmental delays.

CONCLUSION:

The present study serves to illustrate the high-risk nature of urban adolescent mothers. These observations can be used to improve clinical practice for health care providers in community and hospital-based settings working with this population.

Adolescent parenthood is associated with demographic, health and developmental risks for both the mother and her child. For the purposes of the present study, ‘adolescent mothers’ are youth <20 years of age who provide the primary caregiving role for their child/children. In 2010, the birth rate among adolescents in Canada was 13.5 per 1000 (1). Research suggests that a large proportion of adolescent pregnancies are unplanned (2,3). Although there has been an overall decline in the rate of live births among adolescents in recent years (1), there has been an increasing trend among adolescents carrying pregnancies to term to undertake the primary parenting role. Therefore, a focus on the needs of adolescent parents and their children is important for those who provide their health care.

There is limited information on the characteristics of Canadian urban adolescent mothers and their children to guide current clinical practice (4). Data generated from studies in the United States indicate that adolescent pregnancy is associated with increased risk of inadequate prenatal care and greater risk of infant birth complications (1,5). Compared with women who delay childbearing beyond adolescence, adolescent parenthood is associated with increased rates of maternal postpartum depression (6,7), substance abuse and domestic violence (8). Social health inequalities that may accompany adolescent parenthood include poverty (6), lower levels of educational achievement (9) and more years as a single mother (10,11). The children of adolescent mothers are also at risk for adverse outcomes including developmental and behavioural problems, academic setbacks, substance abuse and becoming adolescent parents themselves (12,13). Contributing factors include toxic stress (ie, the resulting impact of cumulative exposure to childhood adversity without adequate adult support) (14), deficits in parenting knowledge, lack of social support and high-stress living environments that affect the mother’s ability to interact optimally with her child (15). Recently published Canadian data indicate high rates of social assistance, housing instability, mental health issues, substance abuse and withdrawal from school in an adolescent health outreach clinic (4).

To optimize outcomes for adolescent parents and their children, it is important to first understand the characteristics, risk factors and needs of this unique population. The objective of the present study was to describe a population of adolescent parents and their children assessed in a Canadian urban hospital-based clinic to better delineate the clinical needs of this high-risk patient population, with a goal to optimize short- and long-term outcomes. Findings generated from this research can be used as a resource for other practitioners and interdisciplinary teams to help serve pregnant adolescents, adolescent mothers and their children more effectively.

METHODS

Research subjects were recruited from The Young Families Program, an outpatient interprofessional clinical program within the Division of Adolescent Medicine in an urban, tertiary care academic children’s hospital in Toronto, Ontario. The Young Families Program serves youth 12 to 18 years of age, and their children from birth to two years of age. Youth are referred from the gynecology/obstetrical prenatal program at the hospital at which the program is based, as well as from family physicians, community agencies, the public health department, child welfare agencies, maternity homes and local shelters. Adolescent mother-infant dyads have frequently scheduled appointments during the infant’s first weeks of life, followed by monthly appointments until the infant’s first birthday and bimonthly appointments until the infant’s second birthday. The interprofessional team includes a paediatrician, a nurse practitioner, nurses, social workers, and medical and allied health trainees. The clinical assessments of patients include a standard history and physical examination. During the study period, clinical assessment included administration of a specific battery of standardized questionnaires. Maternal measures included assessment of maltreatment history, substance use history and postpartum depression. Details of the measures follow in the results section. Child measures included a developmental screen, and measures of socioemotional developmental and behavioural functioning.

Retrospective chart reviews were conducted by a research assistant for all adolescent mothers and their children who presented to the Young Families Program between April 11, 2005 and April 11, 2009. The project was approved by the institutional research ethics board.

Data collection

The following demographic data were extracted from charts of adolescent mothers: maternal age at the time of delivery, last school grade completed, marital status, postpartum school attendance, post-partum living situation and community services accessed. Additional data collected included parental health, history of involvement with the judicial system, child welfare involvement and substance use. The results of formal assessment measures were also obtained from the charts of both adolescent mothers and their children.

Data analysis

Descriptive statistics (mean, SD, range, percentages) were used to summarize relevant data in the chart review.

RESULTS

Study participants

A total of 116 adolescent mother-child dyads were assessed by the Young Families Program during the study period. Demographic data were extracted from the clinical charts of all of these patients. Standardized measures were completed in varying portions of the patient population due to logistical challenges including missed appointments, crisis-focused appointments and intolerance of time requirement to complete questionnaires. Demographic characteristics of the adolescent mother-child dyads attending the Young Families Program are presented in Table 1. The mean (± SD) age of the adolescent mothers was 16.16±1.04 years and the mean educational level achieved was grade 9.32±1.19. Clinical characteristics of the adolescent mothers and children are presented in Figure 1.

TABLE 1.

Demographic characteristics

Characteristic	%	Mean ± SD
Maternal age at delivery, years		16.16±1.04
Paternal age at delivery, years		18.96±2.26
Pregnancy history
Gravida		1.53±0.78
Parity		1.10±0.30
Abortus		0.43±0.75
Gestational age, weeks
>40	45
>37–40	42
<37	13
Education
Education level, grade		9.32±1.19
Mother attending school postpartum	57
Marital status: single	99
Financial support
Mother employed	4
Support from infant’s father	9
Living arrangements at time of delivery
With infant’s maternal grandparents	45
With infant’s paternal grandparents	9
Maternity home	31
With unrelated friend(s)	5
With infant’s father	4
Independently	3
Other (eg, group home)	3
Agency involvement
Child welfare (as a youth)	47
Child welfare (with own child)	41
Young Parent Resource Center	66
Prenatal home	42
Public Health	33
Involvement with the judicial system	18

Figure 1).

Percent of sample above clinical (or ‘at risk’) cut-off on the Edinburgh Postpartum Depression Scale (EPDS), Substance Abuse Subtle Screening Inventory (SASSI), Child Behavior Checklist (CBCL), and Infant/Toddler Symptom Checklist (ITSC)

Maternal characteristics

A total of 37 mothers completed the Childhood Trauma Questionnaire (16), a self-report of child maltreatment history. Adolescent mothers reported high rates of moderate to extreme maltreatment during childhood, including emotional (29.7%), physical (23.3%) and sexual (29.7%) abuse, emotional neglect (24.3%) and physical neglect (24.3%) (Table 2). Approximately 38% of the sample was elevated on the CTQ’s minimization/denial scale.

TABLE 2.

Adolescent mothers’ severity of childhood maltreatment

Abuse subtype*	None to minimal†	Minimal to moderate	Moderate to severe	Severe to extreme
Emotional	48.6	21.6	13.5	16.2
Physical	62.0	13.5	5.4	18.9
Sexual	70.3	0.00	10.8	18.9
Emotional neglect	48.6	27.0	13.5	10.8
Physical neglect	70.3	5.4	13.5	10.8

Data presented as %.

^*As measured using Childhood Trauma Questionnaire;

^†38% of the sample was elevated on the minimization/denial scale of the Childhood Trauma Questionnaire, which suggests the possible under-reporting of maltreatment

The Edinburgh Postpartum Depression Scale (EPDS) (17), a widely used depression screening tool, was completed by mothers at three weeks (n=84) and three months (n=65) postpartum. At three weeks postpartum, 8.3% of adolescent mothers scored in the subclinical, and 10.7% in the clinical range for postpartum depression (ie, indicative of possible depression). Five (6%) mothers endorsed suicidal ideation. At three months postpartum, sub-clinical scores remained unchanged (7.8%), while clinical range scores increased, with 20% meeting the cutoff for postpartum depression. One (2%) mother endorsed thoughts of suicide.

At six months postpartum, 42 adolescents completed the Adolescent version of the Substance Abuse Subtle Screening Inventory (SASSI-A2) (18). Approximately 19% of mothers reported using drugs or alcohol since the birth of their child, two with a high probability of a diagnosis of substance abuse. Thirty percent reported that they smoked cigarettes regularly and 32% reported that they were friends with people who sell drugs. When adolescents were asked about their lifetime experience of alcohol and drug abuse, 22 (51%) of the 43 respondents’ scores indicated a high probability of substance use disorder. Of note, 35% had elevated scores on the defensiveness scale, which measures the adolescents’ inability or unwillingness to acknowledge personal problems.

Child functioning

Fifteen adolescent mothers completed the Child Behavior Checklist (19) when their infants were 24 months of age. Based on parent report, 26% of children scored in the subclinical or clinical range for internalizing behaviour problems (ie, emotionally reactive, anxious/depressed, somatic complaints and withdrawn), and 53% of children scored in the subclinical or clinical range for externalizing problems (attention and aggression problems); ie, 26% and 53% of the children scored at or above the 93rd percentile on internalizing and externalizing behaviour, respectively.

The Infant/Toddler Symptom Checklist (20), was used to sample for regulatory disorders (eg, behavioural difficulty, and disturbances in sleep, feeding, self-calming and mood regulation). At seven to nine months of age, 20 of the 56 (34%) scored in the ‘at-risk’ range (ie, identified as having severe deficit) for regulatory disorders. When assessed again between 19 and 24 months of age, seven of the 16 (44%) children scored in the clinical range.

The Nipissing District Developmental Screen (21) was completed at four, six, nine, 12, 15 and 18 months. The following number (and percentage) of children had not mastered the developmental skills expected of the child by the associated age, indicating a possible area of developmental delay: four months, two of 68 (3%); six months, one of 52 (2%); nine months, six of 48 (13%); 12 months, three of 47 (6%); 15 months, 13 of 32 (41%); and 18 months, eight of 27 (30%).

DISCUSSION

Demographic findings from the current study indicate that the majority (99%) of adolescent mothers were single, with approximately one-third residing with their own parents or in maternity homes. Of interest, an adolescent mother’s own history of involvement with child welfare was common (47%), with a similar number of mothers (41%) having current involvement with child welfare (voluntary or mandated) with their own child(ren). A history of involvement with the judicial system was reported by 18% of the adolescents in our sample.

With regard to depression at three weeks’ postpartum, approximately 8% and 11% of the sample were in the subclinical or clinical range, respectively. Although the number of mothers in the subclinical range (7.8%) remained stable at three months post-partum, the percentage of mothers falling in the clinical range of postpartum depression rose to 20%. This increase in postpartum depression may not be surprising because the prevalence of major and minor depression in adult samples gradually rises following delivery and peaks three months postpartum (22). However, the elevated estimated rates of subclinical and clinical depression in the current sample are alarming, and are in striking contrast to prevalence estimates of subclinical and clinical postpartum depression in adult samples (23). Recent research demonstrates that adolescent mothers’ history of maltreatment can exacerbate mental health difficulties during their transition to parenthood (24). Collectively, these findings underscore the need for clinicians to have a heightened awareness of assessing postpartum depression and, when necessary, providing the adolescent mother with intervention services. The assessment of postpartum depression can be facilitated by routine administration of the EPDS as a screening tool. The EPDS is available for use free of charge and is simple to administer.

A notable finding that emerged from the present study was the urban adolescent mothers’ high rate of maltreatment history, with between 24% and 30% reporting moderate to severe abuse history, a finding commensurate with previous research (25). It is important to note that 38% of our respondents had elevated scores on the minimization/denial scale of the CTQ, which suggests that more than one-third of the sample likely under-reported their history of abuse and neglect, a common finding in retrospective studies investigating abuse history (26). A recent meta-analysis demonstrated that, compared with their nonparenting peers, pregnant adolescents have a two- and 1.5-fold risk of having a history of sexual and physical abuse, respectively (27). In addition to dealing with past maltreatment and victimization experiences, adolescent mothers are also coping with the stress that often accompanies the transition to parenthood, not only in terms of shifting roles and responsibilities, but also in terms of the sociodemographic changes that are often associated with adolescent parenthood (eg, financial hardship, single parenthood, low education attainment) (28). The cumulative toll of these psychosocial factors can have a substantial impact on adolescent mothers’ effective transition into the role of caregiver (24).

Very few adolescent mothers reported current clinical problems with substance use, although 19% and 30% of the sample reported the use of substances and cigarettes regularly in the postnatal period, respectively. These findings are in stark contrast to recently published Canadian data from an adolescent health outreach clinic (4), which suggests much higher histories of substance use. Possible explanations for this finding are that adolescent mothers were under-reporting substance use due to the social stigma associated with substance use when providing care for newborns or their concern of our duty to report to child welfare services. Of interest, >35% of our sample had elevated scores on the defensiveness scale, suggesting the adolescents’ unwillingness to acknowledge problems with substance use. In contrast to current reports of substance use, when adolescent mothers were asked about their lifetime history of substance use, >50% reported a pattern of substance use that was likely clinically significant and higher than percentages found among nonparenting adolescents (40%) (29). Another possible source of discrepancy between our data and other published Canadian data (4) in this area is the manner in which information regarding substance use was extracted (yes/no format versus our use of a standardized measure).

Adolescent mothers in the current sample had elevated concerns regarding their children’s behavioural and regulatory disorders when compared with a nationally representative sample. For example, in a general population of children <5 years of age, typically 17% are scored by parents as having clinically elevated scores (ie, above the 93rd percentile) in the domain of externalizing problems, such as disruptive and aggressive behaviours. In contrast, 53% of children in the current sample were scored by their mothers as being in the subclinical or clinical range for these problems. This finding suggests that a substantial proportion of the toddlers presenting to the Young Families Program are struggling with emotional, behavioural and regulatory issues that warrant clinical attention.

The developmental screen questionnaire identified concerns that escalated with increasing age of the child. By 15 months of age, the proportion of children with developmental concerns was well above expected (41%). Of note, the most prominent domain of developmental delay was speech and language. This finding is consistent with previous literature describing children of adolescent mothers (30) and emphasizes the need for developmental screening and careful follow-up of children of adolescent mothers, and implementation of early intervention services to prevent long-term impacts, such as language skills, school readiness, academic achievement and, ultimately, employment and earning potential (31).

Limitations

One of the most significant challenges faced by the present study, and by the hospital outpatient clinic in general, is the transient nature of the adolescent mother’s lifestyle. Adolescent mothers’ lives and support systems changed considerably, both pre- and postnatally, causing upheaval in living conditions, employment, family and intimate relationships, and education arrangements. These unique challenges were often cited by program staff as the primary cause for failing to collect a complete battery of standardized measures, and limiting discussions of current and ongoing issues with the adolescent superseded the collection of standardized measures during the clinic visits. Another factor contributing to the low completion on some measures was the cited concern of the participants that child welfare services may become involved depending on the content of the answers. These factors may have also contributed to under-reporting of maltreatment and substance abuse, as evidenced by the high scores on the defensiveness scales of these measures. Finally, data regarding the adolescent’s ethnicity and potential partner support, as well as repeat pregnancies were not available in our case review. However, these factors warrant consideration in treatment planning and evaluation with pregnant adolescents.

CONCLUSIONS

The study serves to illustrate the high-risk nature of the urban adolescent mother. The program in which the study was completed consists of an interprofessional team, in which time was allocated within its model of care to identify mothers and children who may be more at risk for adverse outcomes. However, many practitioners who work independently without these resources will encounter adolescent mothers. In such cases, we stress the importance of comprehensive and frequent prenatal and postnatal visits. We encourage a flexible and supportive approach that considers the developmental and psychosocial needs of both the adolescent parent and her child(ren), and one that works to minimize barriers that may challenge the integration of health services. The areas of particular clinical significance have been identified as maternal mental health, substance use, and trauma and victimization. It is also important to appreciate the potential vulnerabilities in behaviour, regulation, and speech and language development in children of adolescent parents. A model of care that focuses on establishing rapport with the adolescent coupled with an awareness of the potential difficulties associated with adolescent parenthood will ultimately enable more effective care for the adolescent mother and her child(ren) (32,33).

Questionnaires to assess the various characteristics of the adolescent parent may not be practical for primary health care providers and consultants. However, the information garnered from the current study should alert paediatricians to the characteristics of the adolescent mother and her child that should be routinely examined. An understanding of these issues is essential for practitioners working with this population. To effectively promote and optimize the health of the adolescent mother and her child, knowledge of their psychosocial and mental health is essential.