WHAT IS THE LIVED EMOTIONAL EXPERIENCE OF FIRST-TIME
ADOLESCENT MOTHERS?
By
NANCY A. AMOS
Submitted in partial fulfillment of the requirements for the degree of
Doctor of Philosophy
Dissertation Adviser: Elizabeth M. Tracy, PhD
Jack, Joseph and Morton Mandel
School of Applied Social Sciences
CASE WESTERN RESERVE UNIVERSITY
August 2016 i
CASE WESTERN RESERVE UNIVERSITY
SCHOOL OF GRADUATE STUDIES
We hereby approve the thesis/dissertation of
NANCY A. AMOS
candidate of the degree of Ph.D *.
Committee Chair
Elizabeth M. Tracy, Ph. D
Committee Member
Kathleen J. Farkas, Ph.D
Committee Member
Victor Groza, Ph. D
Committee Member
Julie Baylor, Ph.D., RN, CNE
Date of Defense
June 28, 2016
* We also certify that written approval has been obtained
for any proprietary material contained therein.
ii
Table of Contents
List of Tables ...... v
List of Figures ...... vi
Dedication ...... vii
Abstract ...... ix
CHAPTER 1: INTRODUCTION AND STUDY AIMS ...... 1
Introduction ...... 1
Postpartum Depression – History and Evolution ...... 1
Statement of the Problem ...... 3
Impact of Maternal Depression on Adolescents and Their Babies ...... 7
Research Epistemology and Ontology ...... 10
Purpose of the Study ...... 12
Relevance to Social Work Practice and Policy ...... 13
CHAPTER 2: LITERATURE REVIEW...... 15
Introduction ...... 15
Relational-Cultural Theory ...... 15
Emotional and Relational Female Adolescent Development ...... 17
RCT and the Construction of Adolescence ...... 21
RCT and Relationships by Level of Social Work Practice ...... 22
Empirical Literature Review ...... 25
Summary of Causal Process ...... 40
Concept Definitions ...... 41
Research Questions and Hypotheses ...... 46
iii
CHAPTER 3: RESEARCH METHODS ...... 48
Introduction ...... 48
Rationale for Choice of Phenomenology as a Method ...... 48
Sample Selection ...... 48
Participant Recruitment ...... 51
Research Methodology ...... 53
Date Collection...... 53
Data Analysis...... 54
Validity...... 57
Protection of Human Subjects...... 57
CHAPTER 4: RESEARCH FINDINGS ...... 59
Introduction ...... 59
The Story That the Findings Told ...... 59
Description of Sample ...... 61
Theme 1. Reaction to Pregnancy ...... 64
Theme 2. Knowledge ...... 67
Theme 3. Relationship to the Medical System ...... 69
Theme 4. Relationship to Child Care ...... 72
Theme 5. Relationship to School ...... 75
Theme 6. Legal System ...... 78
Theme 7. Relationship to Baby ...... 78
Theme 8. Relationships to Persons and Spiritual Concepts ...... 80
Findings in Relationship to Research Questions and Hypotheses ...... 87
iv
Summary of Findings in Relationship to Relational-Cultural Theory ...... 88
CHAPTER 5: DISCUSSION AND IMPLICATIONS ...... 90
Introduction ...... 90
Study Critique ...... 91
Study Strengths...... 91
Study Limitations...... 92
Difficulty in Recruiting a Sample for the Study...... 94
Implications ...... 95
Practice...... 95
Policy...... 97
Future research ...... 97
Appendix ...... 102
References ...... 116
v
List of Tables
Table 1. Expression of Depressive Symptoms ...... 43
Table 2. Description of the Sample ...... 63
Table 3. Self-Report of Race ...... 63
Table 4. Reaction to the Pregnancy ...... 66
Table 5. Knowledge of Pregnancy ...... 68
Table 6. Relationship to the Medical System ...... 70
Table 7. Relationship to Child Care ...... 74
Table 8. Connections to School ...... 76
Table 9. Disconnections to School ...... 77
Table 10. Relationship to Baby ...... 80
Table 11. Relationship with Father of Baby ...... 81
Table 12. What You Want Adults to Know ...... 85
vi
List of Figures
Figure 1. Data Collection in Phenomenology ...... 12
Figure 2. Experiences of Adolescent Mothers ...... 64
Figure 3. Conceptual Model ...... 90
vii
Dedication
The story of this dissertation and the story of my life are forever intertwined. I
dedicate my dissertation to
My God who gave me the call to be a social worker when I was 16 years old and
who has given me what I have needed.
And to
My mother, Dorothy M. Amos, who as she was dying tried to make me leave her
hospital room to go and work on this dissertation. Mom, you gave me a love of learning,
a commitment to excellence, and a heart for social justice. Thank you.
And to
Adolescent mothers – May society continue to work on all that is needed to bring
you justice and opportunity.
Thank you to so many also including
The faculty and staff of the Jack, Joseph and Morton Mandel School of Applied
Social Sciences who had the confidence in me to admit me to the doctoral program and who have supported and stood by me throughout the journey
Kathleen Wells, Ph.D., who began this journey with me and introduced me to
Relational-Cultural Theory and to The Stone Center for Developmental Services and
Studies at the Wellesley Centers for Women.
The Grace Brody Institute for Parent-Infant Studies that provided the funding for
my studies in Relational-Cultural Theory at The Stone Center for Developmental
Services and Studies at the Wellesley Centers for Women.
viii
Jerry Floersch, Ph.D., who taught me to understand the power of qualitative
research.
Katherine Betts Adams, Ph.D., who served on my dissertation committee through the prospectus stage.
The members of my dissertation committee, Kathleen Farkas, Ph.D., Victor
Groza, Ph.D, and Julie Baylor, Ph.D. Your investment in this research and dissertation
has been selfless and amazing. Thank you for your guidance and your teaching.
To Elizabeth Tracy, Ph.D., the Chair of my dissertation committee. There are not enough words to describe how much your guidance, teaching, expertise, and time have meant to me. You picked me up as an advisee after my previous two chairs had left the university. You helped me make sense of putting together what had been different visions of this study and allowed my vision to continue. You have been a teacher and a mentor and a role model in the very best meanings of those roles. I will be forever grateful.
To my students, clients, and friends and family who have encouraged me and done so many things that made this journey possible and have understood this journey.
And finally,
To Helen Moll, Valerie Radu, and Mary Rawlings, my “Ph.D. sisters.” We met
as this journey was beginning for all of us. We have bonded through shared living,
shared classes, and shared life experiences. My admiration for each one of you is beyond
measure. You have made me a better student and a better person. I love you all.
ix
What Is The Lived Emotional Experience of First-Time Adolescent Mothers?
Abstract
by
NANCY A. AMOS
In 2014 approximately 249,000 babies were born in the United States to young
women between the ages of 15 and 19. There are medical and psychological
complications associated with adolescent pregnancy. One problem is the presence of
maternal depression which is a serious condition with implications for both the mother and the child. Depression is experienced differently in adolescents than in adults, making it difficult to accurately assess and plan for services.
Guided by Relational-Cultural Theory, this qualitative study described the lived experience of adolescent mothers in the early postpartum period. The study also examined adolescent mothers classified as depressed compared to those as nondepressed using the Edinburgh Postnatal Depression Scale.
Eight adolescent mothers between the ages of 15 and 19 were interviewed using a semi-structured interview grounded in the theoretical and empirical literature. Questions were asked about risk factors for depression and to elicit the experiences of the participants as mothers. Data were analyzed using thematic analysis. Atlas.ti software was used to code and merge data. Two coders were used to increase reliability of the themes observed.
x
At the micro level, participants talked about their change of perception of themselves, change in school plans, lack of knowledge about pregnancy and delivery, and feeling the pressure of time and role conflict. At the mezzo level, participants described the loss of friends when they became mothers and about changing connections and disconnections with family members and with the father of their baby. At the macro level, participants talked about negotiating medical, daycare, and educational systems and about their perceptions of being treated differently as a reaction to their status as an adolescent mother. Participants described both connections and disconnections that improved their experience of being an adolescent mother. The participants described ways in which their connections with adults could be improved by listing ideas about what they wanted adults to know about their experience. The findings are discussed in relation to implications for social work practice, policy, and future research.
1
CHAPTER 1: INTRODUCTION AND STUDY AIMS
Introduction
This chapter begins with the scope and statement of the problem and then examines the history and evolution of postpartum depression and what is known about
postpartum depression in adolescents. Because the research on postpartum depression in
adolescents is limited, some of the background in this chapter will draw from literature
about postpartum depression in adult women. The chapter concludes with the purpose
and research questions for this study.
Postpartum Depression – History and Evolution
Psychiatric symptoms following the birth of a child have been termed postpartum symptoms and were first described by Hippocrates in the fourth century BC. In the 19th
century, the French physician Marce′ described a connection between physical changes
following pregnancy and symptoms such as delirium and confusion (Dunnewald, 1997).
However, a growing interest in categorizing mental illness and a focus on psychoanalytic
interpretations of psychiatric symptoms discredited this work. There is a gap in our
knowledge and the topic was not revisited until the 1960’s when large-scale studies
began to detail the epidemiology of postpartum depression in adult women (Dunnewald,
1997).
Depending on the severity and specific set of symptoms, the current literature
makes the distinction among “postpartum blues,” “postpartum psychotic depression” and
“postpartum nonpsychotic depression” commonly referred to as simply postpartum
depression (Miller, 2002). Each of these is described below.
2
Postpartum blues, sometimes referred to as the “baby blues”, is a “transient state of heightened emotional reactivity” (Miller, 2002, p. 762) that occurs in approximately
50% - 75% of women who have recently given birth (Miller, 2002; School of
Communication, Information & Library Studies at Rutgers University, 2001). Symptoms of postpartum blues are emotional lability, frequent crying, and irritability that usually peak 3 to 5 days after delivery and can last for several more days or weeks. Symptoms do not meet the criteria for Major Depression. Theories of the etiology include the rapidly changing levels of estrogens and progesterone following birth (Harris, Lovett, &
Newcombe, 1994) and the activation of biological systems in mammals that occurs following birth that biochemically triggers attachment behaviors and responses between the mother and child (Miller & Rukstalis, 1999). The development of postpartum blues has not been found to be related to a mother’s prior history of depression, parity, or cultural and environmental context (Hapgood, Elkind, & Wright, 1999).
Postpartum psychotic depression is defined as a mood disorder that includes psychotic symptoms such as delusions, hallucinations, or both. It usually begins within 3 weeks after giving birth. A woman may not show symptoms of psychotic postpartum depression in the first weeks after giving birth. When postpartum psychosis does develop, it is distinguished from postpartum blues by its psychotic symptoms and its lower level of emotional lability and from postpartum depression by its psychotic symptoms. Postpartum psychotic depression is rare (Miller, 2002, School of
Communication, Information & Library Studies at Rutgers University, 2001). The rate in the general population is approximately 1 in 1000 (Munk-Olsen, Laurent, Pedersen &
Mortensen (2006).
3
Postpartum depression, that is the relationship between depressive and other
mood disordered symptoms and the postpartum period, is the most common complication
of the postpartum, “having devastating and long lasting effects on mother and infant”
(Mezzacappa & Endicott, 2007, p. 259). Over the past twenty years, the rates of post-
partum depression have ranged from 10 to 28 percent of adult women who recently gave
birth (Beck, 1996; Hobfoll, Ritter, Lavin, Hulsizer, & Cameron, 1995; O’Hara & Swain,
1996; Pawlby, Sharp, Hay & O’Keane, 2008; Reid & Meadows-Oliver, 2007; Rutowski,
1992). The rates for postpartum depression in adolescent mothers are higher than rates
for older mothers (Barnet, Joffe, Duggan, Wilson, & Repke, 1996; Deal & Holt, 1998;
Miller, 1998; Reid & Meadows-Oliver, 2007). Research has even shown the rates of postpartum depression in adolescent mothers to be as high as 53% (Hudson, Elek, &
Campbell-Grossman, 2000) to 56% (Logsdon, Birkimer, Simpson, & Looney, 2005).
Postpartum depression entered the official nomenclature of the psychiatric
community when it was included in the Diagnostic and Statistical Manual, 4th edition, of
the American Psychiatric Association in 1994. Postpartum onset was added as a specifier
for mood disorders according to the following criteria: “onset of episode (of mood
disorder) within 4 weeks postpartum” (American Psychiatric Association, 2000, p. 387).
In the Diagnostic and Statistical Manual, 5th edition (DSM5) there is a peripartum onset
specifier. For DSM 5, onset can be either during pregnancy or in the 4 weeks following
delivery.
Statement of the Problem
Identifying adolescent postpartum depression accurately is a first step to
providing intervention and preventive services. However, identification and assessment
4
techniques for depression among pregnant and postpartum adolescents are limited. There
are quantitative instruments to identify depressed adolescents and there are instruments to
screen for postpartum depression in adult women. Thus, there is a gap in the social work
research literature about screening for postpartum depression among adolescents. This
study had as its aims to gain an understanding of the lived emotional experience of first- time adolescent mothers in the early postpartum period when the baby is six months of age or younger. An additional aim was to explore similarities and differences in the lived experience of first-time adolescent mothers who are classified as depressed versus those who weren’t classified as depressed using the Edinburgh Postnatal Depression Scale.
One impetus for this study was the fact that beginning January 1, 2008, all licensed health care professionals in Illinois were required by law to offer screening for mental health disorders to new mothers (IL Public Act 095-0469 “Perinatal Mental
Health Disorders Prevention and Treatment Act”). The law does not specify how that screening is to be offered or what screening instrument health care professionals should use. The fact that screening is required underlines the importance of an accurate and comprehensive view of postpartum depression in adolescent mothers. It is this legislation that gave impetus to this study, to better understand how adolescent mothers experience postpartum depression.
Birth rates to U.S. teenagers declined in the period from 1991 through 2005 but saw an increase in 2006 and 2007. The rate again declined in 2008 to 41.5 births per
1000 teenagers ages 15 to 19 (U.S. Department of Health and Human Services, 2010, p.
1). From 2013 – 2014, teen birth rates dropped nine percent in the United States.
Between 1991 and 2014, the teen birth rate in the United States decreased by more than
5
half. Still, in 2014, approximately 249,000 babies were born in the United States to
young women between the ages of 15 to 19 (Hamilton, Martin, Osterman, & Curtin,
2015).
The current study was conducted in Peoria, Illinois. The site was chosen because
it is the area in which the researcher has worked with adolescent mothers and a county in
Illinois that as described below has rates of adolescent pregnancy higher than the state
average. The trend in Illinois is consistent with the national trend although the rate is
lower; births in Illinois to mothers ages 15 to 19 decreased in 2008 to 38.1 births per
1,000 estimated female population (U.S. Department of Health and Human Services,
2010, Table B). The Guttmacher Institute’s 2013 publication (Kost & Henshaw 2013, p.
8) states the number of births to women ages 15 to 19 in Illinois in 2008 as 17,410.
Actual numbers of births in 2009 to women ages 15 to 19 in Peoria County, Illinois,
where the study was conducted, were 352 and in 2008 were 346 which represent 12.8 % of all births in Peoria County in 2008 and 12.5% in 2009. The total percentage of teen births in Illinois including those born to mothers younger than 15 was 10.0% in 2008 and
9.6 % in 2009 (Illinois Department of Public Health, 2016). Thus, the percentage of teen births in Peoria County is higher than the percent of teen births in Illinois during 2008 and 2009, the most recent year for which data were available.
The prevalence and incidence of births to adolescent mothers is important because of both physical and mental health difficulties associated with adolescents giving birth. Medical problems associated with adolescent pregnancy include anemia, premature birth, low birth weight babies, high blood pressure, poor nutrition, sexually transmitted infections, and higher risk of drug and alcohol used and eating disorders. The
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presence of depression in a mother is an additional serious condition because it has
consequences for both her child and for herself (Teen Pregnancy Statistics, 2009). As is
further discussed later in this chapter, the consequences for the child include lower levels
of maternal-child attachment, maternal labeling of normal infant behavior as “bad” which
increases the risk of child abuse, less interest in acquiring parenting information, and less
energy on the part of the mother to attend to her child’s medical and learning needs
(Field, 1984; Murray, 1992; Sharp, et al., 1995; Zajick-Farber, 2010; Zuckerman &
Beardslee, 1987). For the mother, the presence of postpartum depression decreases her
enjoyment of the mothering experience, may isolate her socially, negatively impacts her
mothering and attachment with her infant, and interferes with self-care and relationships
(Chaiton, Cohen, O’Loughlin & Rehm, 2010; Yolton, Khoury, Xu, Succop, Lanphear,
Bernert, & Lester, 2009). Also, women who become mothers while adolescents have a
greater risk for developing mental health problems, including depression, than do
mothers who delay childbearing (Thompson & Peebles-Wilkins, 1992, U.S. Department
of Health & Human Services, n.d). This may be understood in part by examining known
risk factors for depression in adolescence and in the postpartum period and by looking at
models of adolescent development (See Chapter 2 for further exploration of adolescent relational development).
The symptoms of depression in adolescents have a different configuration than symptoms in adults (Koplewicz, 2002), further discussed in Chapter 2. One of the reasons why the study of postpartum depression in adolescents is so important is that if members of the medical or social service professions do not understand this difference in
the way that adolescent depression is expressed, they may incorrectly assess and then
7
incorrectly treat a problem that they have identified with an adolescent mother.
Prejudices and stereotypes about adolescents may interfere with proper assessment and
treatment planning for adolescent mothers. As an example, social workers may label an adolescent mother’s failure to comply with a treatment plan as resistance to change when in fact the mother’s behavior may be an example of anhedonia (loss of ability to experience pleasure). Practitioners may also label the irritability and emotional lability of adolescent mothers as acting out behaviors, rather than depression.
The importance of valid screening tools for postpartum depression in adolescent women has become more critical because beginning January 1, 2008, when all licensed health care professionals in Illinois were required by law to offer screening for mental health disorders to new mothers (IL Public Act 095-0469 “Perinatal Mental Health
Disorders Prevention and Treatment Act”). The law does not specify how that screening is to be offered or what screening instrument health care professionals should use.
However, a commonly used screening instrument is the Edinburgh Postnatal Depression
Scale. This instrument was developed as a short 10-item screen for postpartum depression in adult women (Cox, Holden, & Sagovsky, 1987).
Impact of Maternal Depression on Adolescents and Their Babies
On the mother. If a mother who shows postpartum depression has also been depressed prenatally, the effect of the depression can begin antepartum. The empirical literature includes findings that associate depression during pregnancy with more smoking, greater consequences from alcohol use, and poorer overall health as well as less compliance with prenatal medical care (Chaiton, Cohen, O’Loughlin & Rehm, 2010). It should be noted that these antepartum behaviors in the mother are also associated with
8 behaviors in the infant such as increased arousal and excitability which also can interfere with mother-infant bonding (Yolton, Khoury, Xu, Succop, Lanphear, Bernert, & Lester,
2009).
When a mother is depressed in the postpartum period depression symptoms such as anhedonia (loss of ability to experience pleasure) poor concentration, irritability, and fatigue related to depression have a tremendous impact on her mothering. Problems discussed in Chapter 1 such as lower levels of maternal-child attachment, maternal labeling of normal infant behavior as “bad” which increases the risk of child abuse, less interest in acquiring parenting information, and less energy on the part of the mother to attend to her child’s medical and learning needs (Field, 1984; Murray, 1992; Sharp, et al.,
1995; Zajick-Farber, 2010; Zuckerman & Beardslee, 1987) are well documented in the literature.
For the mother, the presence of postpartum depression decreases her enjoyment of the mothering experience, may isolate her socially, negatively impacts her mothering and attachment with her infant, and interferes with self-care and relationships (Chaiton,
Cohen, O’Loughlin & Rehm, 2010, Yolton, Khoury, Xu, Succop, Lanphear, Bernert, &
Lester, 2009). Zajicek-Farber (2009) has documented that the presence of postpartum depression symptoms in the mother led to less interest in learning about mothering. Field
(2000b) describes how a depressed mother is disorganized in her interaction with her infant.
On the infant. When women experience depressive symptoms following the birth of a baby, the consequences become complex. One dimension of that complexity is that when a mother has symptoms of depression, studies have shown that the
9
development of her child is impacted negatively (Field, 1984; Murray, 1992; Sharp, et al.,
1995; Zuckerman & Beardslee, 1987). In a prospective study (Radke-Yarrow,
Cummings, Kuzynski, & Chapman, 1985) toddlers of depressed mothers showed less
affection, less speech, less exploratory behavior, and greater sadness than did toddlers of
nondepressed mothers. Children of depressed mothers have also been reported as
showing more insecure attachments, more poorly developed social skills, and more
difficulties in peer relationships when they are studied longitudinally (Campbell, Cohn, &
Neyers, 1995; Field et al., 1996; Dawson et al., 1997). And, Leadbeater and Bishop
(1994) have shown an effect on the interaction between an adolescent mother and her
infant when the mother shows symptoms of depression.
In a book chapter published in 2000 (Field, 2000b), Field reports on studies that
show that maternal depression negatively affects the infant in utero. She discusses how immediately after birth, infants of mothers depressed prenatally “show a Profile of dysregulation in their behavior, physiology, and biochemistry, which possibly derives from prenatal exposure to a biochemical imbalance in their mothers” (p. 3).
In addition to the negative effect on mother-infant bonding, research done since the mid-1980’s has been consistent in the findings that the infants of depressed mothers are at risk for other problems. Some of the adverse effects of maternal depression on infants found are higher stress levels, abnormal reflexes, withdrawal, irritability, decreased vocalization, lower activity level, and depressed emotional expression
(Rosenberg, Greening, & Windell, 2003; Ashman & Dawson, 2002; Goodman & Gotlieb,
1999; Field, et. al.1998; Radke-Yarrow, 1998). If the depression continues for the first six months of a child’s life, findings of the effect on the infant have included delayed
10
motor development, being more fussy and more drowsy, emotional difficulties, social
problems, and depression (Goodman & Gotlieb, 2002; Field, 1998; Hiscock & Wake,
2001; Murray, Woolgar, Cooper, & Hipwell, 2001).
Zajicke-Farber (2010) showed that postpartum depression in the mother was
correlated with slower language development in the child. In her study “Maternal
depressive symptoms…….. had a stronger impact on children’s involvement in
stimulation activities than parenting knowledge or practices alone” (p.206). Her study
also reported that when a mother was depressed postnatally, she was more likely to engage in risky parenting practice such as not using appropriate corporal punishment, not child proofing the home, and not following through with medical appointments for the child.
As Angela Davis points out in her introduction to the writings of Clara Zetkins,
these elements are interconnected in complex ways (Davis, 1981). An understanding of
the individual experience of adolescent mothers as they live these relationships will
provide an understanding of the common problems and coping mechanisms that
contribute to and ameliorate depression in this group.
Research Epistemology and Ontology
This research used the ontological assumption that the lived experiences of first-
time adolescent mothers was a dynamic experience based in the interplay of the
adolescent mother and her relationships both internal and external to multiple levels of
interaction, with family, friends, school and medical systems. The research used the
assumption that adolescent women are reliable reporters of their own experiences of
depression and motherhood. Likewise, the research used the experiences of the
11 participants in defining what is real and in understanding the kinds of things that constitute their world. The study was guided by the epistemological assumption that the best way to understand these dynamic experiences is to ask adolescent first-time
(primiparous) mothers to describe their experiences using a semi-structured interview with questions guided by the literature. Examining the lived experience of adolescent mothers will help to understand the unique aspects of their lives and mental health, particularly depression.
The method selected to capture the lived experience of first-time adolescent mothers was phenomenology. Phenomenology emphasizes the study of a concept, experience or idea (“the phenomenon”) with a group of individuals who have all experienced that phenomenon (Creswell, 2013, p.78). Data collection in phenomenology usually involves conducting interviews and then analyzing those interviews to search for the essence of the phenomenon as it is experienced by the study participants (Moustakas,
1994; van Manen, 1990). This relationship is summarized in Figure 1.
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Ontological Assumptions The lived experience of being a first- time adolescent mother is a dynamic experience of the interaction of internal and external relationships.
Epistemological Assumptions Oral evidence collected through interviews will provide data about the phenomenon.
Using semi-structured interviews Methodology/Method with first-time adolescent mothers to collect the data and then using Phenomenology as a method to focus on the direct experience of these mothers.
Figure 1. Data collection in phenomenology (Adapted from Jones, 1993, pp 114-117; Carey, 2009 as used in Carey, 2012)
Purpose of the Study
Using this methodology, data were gathered about the lived emotional experience
of first-time adolescent mothers and to look for themes and patterns in their responses
about their experiences. In this study, Relational-Cultural Theory was used to examine how having a baby as a teenager impacts the teenage mother’s relationship to herself, to the infant, and to other people in her environment and to also look at how the relationship of the adolescent mother to systems in the macro environment including the medical and social service establishment and social policy makers impacts her lived experience. The identified themes and patterns were then used to more completely understand the phenomenon of the participants’ experience.
13
The aim of the study was to elicit and describe the emotional experience of
depressed and non-depressed adolescent mothers during the early postpartum period. A
particular focus of the semi-structured interview was on connections and disconnections
experienced by the adolescent mothers in their relationships. The study was guided by
the following research aims:
1. What is the lived experience of first-time adolescent mothers in the early
postpartum period?
2. What are the similarities and differences in the lived experience of first-time adolescent mothers who are classified as depressed versus those who weren’t classified as depressed using the Edinburgh Postnatal Depression Scale?
Relevance to Social Work Practice and Policy
This study can use the experiences and voices of first-time adolescent mothers to inform social work practice, social work policy and social work research. The
assumptions are that this information can be used to improve understanding of adolescent
mothers both by social workers who encounter mothers who may be experiencing postpartum depression and by allied health professionals who will encounter these same
mothers; to mitigate the negative effects on the infant and mother that are the unintended consequences of an adolescent’s mother’s depression in the postpartum period; and to inform social work practice and public policy initiatives.
Of particular importance is that the literature reviewed is limited and showed no involvement of social work in the research about postpartum depression in adolescents but rather was based in other disciplines, most commonly in nursing. While treatment of depression in adolescent mothers will certainly require a multidisciplinary approach, the
14
absence of social work with its focus on person-in-environment seems to ignore an important aspect of that treatment. Social work is especially suitable to the study of a
condition that can have bio-psycho-social-spiritual causal pathways and consequences and of a condition that will be encountered by social workers and other providers of services to adolescent mothers and their children in settings such as child welfare agencies, hospitals, and services for adolescent mothers.
Social work brings a long history of experience in working in child welfare which
positions our profession to understand the consequences of undiagnosed postpartum
depression in adolescent mothers and their children and to assist other professionals such
as physicians and nurses in doing an adequate assessment of an adolescent mother and
her child’s needs. Social work also brings the necessary interview skills and
developmental knowledge needed to engage the adolescent mother. Social workers can
use knowledge of the problem to intervene at the macro level. Increased knowledge of
the lived experience of adolescent mothers, including mothers experiencing postpartum
depression, positions social work to develop appropriate services and resource for both
mother and child.
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CHAPTER 2: LITERATURE REVIEW
Introduction
This chapter presents the literature review for this study. Relational-Cultural
Theory is discussed first as it is the guiding theory for the study. The literature regarding the topic of depression in adolescent women is reviewed beginning with literature necessary to understand adolescent depression and then moving to the literature about postpartum depression. The effects on postpartum depression are reviewed as is the literature about parity since this study is only using adolescent women who are primiparous. Included in this review of adolescent depression is a review of the literature regarding risk factors for depression. The literature reviewed in this chapter guided the construction of the semi-structured interview used in the study. The definitions of terms and concepts used in this study are presented and the chapter ends with study hypotheses.
Relational-Cultural Theory
The theoretical model for this study is Relational-Cultural Theory (RCT). The theory and the resulting empirical studies began with the work of Miller (1976) who posited that the development of women is different than the development of men in ways other than physiologically and that this difference begins in infancy. She has written that
“almost every modern theorist who has tried to fit women into the prevalent models has had … obvious difficulty (Miller, 1991, p. 12) because the models ignore the use of relationships as critical to the development of self. While Miller argues that this oversight leads to a lack of understanding of how men develop the ability to be intimate, she believed that it has led to a much more comprehensive misunderstanding and incorrect understanding of women’s development (Miller, 1976).
16
Relational-Cultural Theory was originally known as Self-in Relation Theory and was renamed to take into account the influence of culture. As the work of Miller and her colleagues at the Stone Center continued to develop, “it brought phenomenological focus to the experience of women whose voices had been historically marginalized from the mainstream writing about women’s development.” (Jean Baker Miller Training Institute,
2016, p. 1). RCT focuses on human connections and disconnections to understand relationships and human behavior and development.
Relational-Cultural Theory (RCT) posits that inquiring into the nature of self is
“an organizational principal in human development” (Surrey, 1991, p.51) and that
“women’s core self-structure emerges out of experience of a relational process” (Kaplan,
Gleason, & Klein, 1991, p. 122). RCT describes that a sense of relational self begins in the mother-child bond and then continues to develop as women become involved in increasingly complex relationships. RCT looks at the interactions in relationships as the mechanism by which girls and women develop and create an understanding of their world. These interactions may be a time of connection or a time of disconnection and both have consequences for the development of the woman (Miller, 1976).
Connections and disconnections can and do occur at more than just the level of individual development. For example, connections and disconnections occur in mezzo relationships such as with extended families and in macro relationships such as interaction with schools and other community systems.
Relational-Cultural Theory has subsequently been studied in different areas. For example, Spencer (2000) focused on infancy research and completed a paper for the
Stone Center analyzing studies of infant development using relationship as the focus of
17 study. She concluded that relationships “are the mechanism through which psychological development occurs” (p.5). Likewise, the work of Schore (2003) who studied the neurology of connection supported the idea that the human brain is physically wired to develop in tandem with other. Miller (1976) makes the case that because of societal as well as genetic factors, this is even truer in women.
RCT is a theory of emotional and social development. It is not mutually exclusive to other theories regarding development. It is characterized by its dynamic quality in that connections and disconnections are continually affecting development.
RCT is not an epigenetic theory of development but posits that development is specific to the individual. As contrasted with the many theories that are reviewed in the next section, RCT is used in this study to understand adolescent relational development not as a task of individuation but as a task of reforming relationships. RCT does not view continued relationships with significant others such as parents as negative dependency as did previous theories.
Emotional and Relational Female Adolescent Development
Theories of adolescent development are multiple and varied. Some theories focus on the physical changes during adolescence; some theories focus on the psychological and social changes during adolescence; some theories define adolescence by its social and cultural context; and some theories use a combination of contexts. This section includes a summary of theories most applicable to female relational adolescent development followed by a discussion of how RCT informs our understanding of relational development in adolescence.
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Hall, an educator and a psychologist, first described adolescence as a discrete
developmental phase (Dahl & Hariri, 2005; Patton, 1997). Hall’s work (1904) was
historically influenced by the nature versus nurture arguments and debates about social
Darwinism and other attempts to merge the physical sciences with the growing field of
psychological inquiry. His theory of recapitulation was that the development of the
individual both psychically and somatically recapitulated the phylogeny of human beings.
Hall described normal adolescence as a period of stress and storm and emphasized the
biological predetermination of behaviors and abilities. However, Hall did include
discussions of how environmental influences can moderate the biology of adolescence
although he saw the stress and storm as a part in some way of normal adolescence. That
such turbulence was not seen in studies of adolescence in other cultures (Mead, 1928)
points out the importance of social context in defining and describing adolescence.
One of the interesting contributions of Hall is that he looked at the development
of the adolescent brain as one way of understanding the somatic and psychic changes
occurring (Hall, 1904). Sigmund Freud also began with a biological basis for his
discussion of adolescence. In his description of normal personality development Freud
used puberty as the time at which an individual moves from the latency period to the
genital stage. Freud described the tasks of the genital period as using the energy formally
employed in narcissism to seek out and form sexual relationships (in Freud’s writings of
normal development these were heterosexual relationships) and to extend the feelings developed into friendships and altruistic activities (Freud, 1933). Freud does write that
“the male sexual development is more consistent and easier to understand, while in the woman a sort of regression seems to appear” (Freud, 1938, p. 604).
19
Anna Freud saw adolescence as more conflict driven than did her father. She
wrote about “adolescence as a developmental disturbance” (1971) originating from the
alterations in body size and appearance, endocrinology and resulting changes in sexual
interest, advances in intellectual performance, and “reorientations with regard to object
attachments and to social relations” (Freud, 1971, p. 43). Her view of conflicts between
adolescents and their parents was that it was a necessary part of the child moving away from sexual urges toward the parents. Anna Freud believed that adolescents had to experience sadness and/or depression as part of these developmental tasks and that not experiencing them was evidence of an inability to deal with these internal struggles
(Freud, 1997; Koplewicz, 2002). It is important to note that Anna Freud did recognize the influence of culture and cultural pressures and expectations (Freud, 1971, pp. 46-47)
on the development of the adolescent. However, the emphasis was still on independence
rather than interdependence and connection.
Deutsch (1944) used the epigenetic model of Sigmund Freud (1933) but did subdivide the period between the latency and genital stages into prepuberty, early puberty, and finally adolescence which ends with the woman reaching the genital stage of development. In Deutsch’s model girls from ages 10 – 12 in prepuberty strive for liberation as they turn away from infantile fantasy and sexuality toward reality. Deutsch describes the ambivalence that the adolescent feels as she strives to be “liberated”
(Deustch, 1944, p.19) from the mother and still desires the nurturing of her mother.
Interestingly, Deustch describes the mutuality of these feelings by writing that “a corresponding process takes place in the mother” (Deutsch, 1944, p.20) as the mother struggles with desires to have her child grow up and still desires to be a caretaker for her
20
child. What Deutsch does not do, however, is describe how these struggles in both
mother and adolescent influence the development and behavior of the other.
Erikson’s model of individual development was a series of stages. Movement to the next stage required the successful completion of the tasks in the earlier stages. In
Erikson’s model, the tasks of adolescence required that the individual address the crisis of identity versus role diffusion (Erikson, 1959, 1968). Erikson described the normal tasks of adolescent development as moving away from the dependent relationships of childhood to the ability to rely on oneself so that the tasks of adulthood could be accomplished. Erikson’s work has been criticized for ignoring the social context of development (Hutchison & Charlesworth, 1998) and for ignoring differences of race, class, and gender (Carter & McGoldrick, 1988; George, 1993; Gillligan, 1982).
Similarly, his model does not include differences in sexual orientation that arise as an adolescent develops a sense of sexual identity.
Sarri and Finn (1992) describe the relationship to cultural understandings of normal adolescence in the United States to deeply held beliefs in the need for autonomous individualism. They argue that implicit in this belief system are values of individual sin and the need for salvation as well as a trust in a medical model of pathology that has the individual as the focus of problems and of intervention.
Enright, Levy, Jr., Harris, & Lapsley (1987) examine the construction of
adolescence from an economic perspective. Their look at adolescence from the 1980’s
through World War II focuses on the need of society to move or not move individuals
quickly into the category of “adult.” During times of economic prosperity, society has
less need for contributing adults. Consequently, the definition of adolescence can include
21 a wider age range. But during times of economic depression or times when part of the labor force is unavailable such as during war, society has a need to move adolescents in adult roles and responsibilities more quickly.
Some research findings demonstrate that when there is a disconnect between the developmental needs of the adolescent and the experiences of the adolescent, the psychological and behavioral development of the adolescent will be effected (Eccles, et al., 1996). And, when the adolescent lacks the needed resources to cope with this disconnect, the negative effect on psychological development is enhanced (Kloep &
Hendry, 1999). Hendry and Reid (2000) in their qualitative study of rural Scottish adolescents report that participants said that maintaining social support through friendships and knowing how to ask for social support were important components in mental as well as physical health. The next section examines how the theory was used to understand connections and disconnections such as these.
RCT and the Construction of Adolescence
RCT emphasizes relationships and movement in relationships as the way to understand development. Janet Surrey writes, “Connection has replaced self as the core element or the locus of the creative energy of development” (Surrey, 1991, p.10). Thus, the task of the adolescent female is not to separate and individuate from parents and adult caretakers but rather to move within those relationships to form a different kind of connection. Similarly, in regard to sexuality, the adolescent female moves within relationships from not having a sexual interest to including sexual interest in some of her relationships.
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This understanding of adolescent development does put the adolescent female at some disadvantage if her development is assessed by someone using a separation and individuation model. Dana Crowley Jack (1991) describes adolescence as a particularly vulnerable time for women because, “girls must struggle to reconcile their wish for continuing connection with the cultural command for separation” (p.14).
RCT and Relationships by Level of Social Work Practice
The use of Relational-Cultural Theory in the understanding of adolescent postpartum depression can be examined by looking at the application of the theory at the three levels of social work practice.
Micro. When adolescent mothers are depressed, they are more likely to show a flat affect and be unable to provide the infant with a positive role model for emotional expression. The depression may show in the lack of unexpressive tone of voice used when talking to the infant. This interferes with the positive stimulation that the infant needs to receive (Rosenberg, Greening, & Windell, 2003). Also, since one of the symptoms of depression is a withdrawal from social contact, adolescent depressed mothers exhibiting this symptom would be less responsive and interact less often with their infants.
Mezzo. The relationship of the adolescent mother and her peers in school, her friendship groups, and her extended family is also influenced by the mother’s level of depression. Wilkinson and Pickett (2009) suggest that the “threats to the social self” based on perceived assessments of differences and inequalities contribute to problems of depression and relationships (pp. 37-39). This is particularly true when examined in the context of adolescent development.
23
Macro. Kirk and Okazawa-Rey (1998) posit that much of western cultural history in terms of the approach of society to mental health characterizes women as more unstable than men. Using Merton’s (1948) theory of the self-fulfilling prophecy, the adolescent mother’s relationship to societal expectations would then predict higher rates of mental health problems including depression. Thus, “if the messages a young woman receives from her parents, community, and society reinforce the belief that she will be more prone to mental health problems, it should come as no surprise that she will grow to believe it as well” (Coggins & Hatchell, 2002, p. 100).
Misri (2005) writes about the role of culture in providing women with “Great
Expectations” (Misri, 2005, p.3) about motherhood. She describes motherhood as being both prized by society and a burden for women as they try to meet the demands of motherhood and of a society that may not provide esteem for women who take on the sole role of mother or that makes it financially impossible to do so. The portrayal of mothers in media and the arts as “blissful” and “pastel” (Misri, 2005, p. 3) sets up expectations that are unrealistic and not consistent with the demands that the mother experiences. Misri (2005) finds this to be especially true in the culture of the United
States with its emphasis on individuality that does not provide some of the social support that is built into the customs of other cultures. Using Beck’s (1963, 1964) theory of cognitive distortions and their role in the etiology of depression, the relationship of the mother to the societal expectations of the mothering role and the degree to which they are not realistic for her can be a contributing factor to postpartum depression. The adolescent mother experiences several role conflicts in relation to her role as a mother. For example, there is role conflict between the role of adolescent mother and the role of being a
24
daughter living in a parent’s home. Similarly, the adolescent mother also functions in relationship to the nation and community in which she lives. The ideology of the
dominant social and political groups of the state becomes the foundation for the
institutional structures that shape the lives of its citizens (Reitmeir, p. 216). Wilkinson
and Pickett (2009) looked at teenage birth rates in the context of the inequality of wealth.
They discuss a pattern of higher rates of teenage births in communities that have higher
disparity in wealth distribution – both internationally and domestically. Gold and
colleagues (2001) had similar findings showing that teen birth rates were highest in the
most unequal as well as the most relatively deprived counties in the United States.
Moreover, the effect of this inequality was highest with the youngest mothers, aged 15-
17. Thus, the experience of being an adolescent mother must be looked at in a way that
incorporates an understanding of the elements of racism, sexism, and classism as well as
the attitude toward adolescents in the macro environment of the mother.
Hoggart (2003), in discussing the political context of the debate about adolescent
pregnancy in the United Kingdom, writes that part of the emotional components that
surround policy debates about this issue are centered in the values of competing groups
about teenagers having sex and about unmarried persons having sex. When both these
situations intersect, Hoggart describes a condition in which adolescent mothers are in
conflict with the values of the powerful. She further describes the class issues in the
debate pointing out that limited access to birth control and socioeconomic deprivation
have been shown to increase the rate at which teenagers get pregnant. “Sexual behavior
and sexual decision-making do not exist in a vacuum” (Hoggart, 2003, p. 150). RCT
25 would emphasize that they exist in the relationship of the adolescent to her social and political environment.
In this study, RCT was used to: examine how having a baby as a teenager impacts the development in relation of the teenage mother to herself, to the infant, and to other people in her micro and mezzo environments; help describe the lived emotional experience of adolescent women; and guide the development of the semi- structured interview. It should also be noted that the research was conducted within the context of a relationship (as defined by Miller) between the study participant and the researcher. This researcher/participant relationship will be discussed further in Chapter 5.
Empirical Literature Review
Depression in adolescent women. The rates for adolescent depression have been documented in many places with similar findings that include the lifetime prevalence of major depression among adolescents up to age 19 to be between 15% (Birmaher et al.,
1996) and the 28% (Lewinshon, Rohde, & Seeley, 1998). The prevalence within a given year is cited as from 2% to 9% (Goodyer, 1995) up to 12.5% (Empfield & Bakalar,
2001). Even if the prevalence rate in a year is 8.3% of the adolescent population that will begin showing symptoms of major depression, this can be compared to the rate of 5.3% for the adult population (Kessler & Walters, 1998). A study published in June 2000 by the Centers for Disease Control found that annually, 3 million teenagers, 19 % of all U.S. high-schoolers, had thoughts of suicide, and more than 2 million of them made plans to carry it out (Centers for Disease Control, 2000, p.3.). Thoughts of suicide are one of the criteria for Major Depression (American Psychiatric Association, p.327).
26
While depression is certainly a problem that social work must continue to address
for both adolescent men and women, it is a problem that disproportionately affects
women. The Global Burden of Disease (GBD) study conducted by the World Health
Organization estimates that nonbipolar major depression is the leading cause of disease-
related disability among women in the world today (as cited in Kessler, 2003). The
National Comorbidity Survey (NCS) (Kessler et al., 1994), a large-scale epidemiological
study has reported that rates of depression are higher for women than for men (21.3%
lifetime, 12.9% in a 12-month period for women and 12.7% lifetime, 7.7% in a 12-month
period for men). These rates are similar to those given in the Diagnostic and Statistical
Manual, 4th edition, of the American Psychiatric Association (1994) that reports that “the
lifetime risk for Major Depressive Disorder in community samples has varied from 10%
to 25% for women and from 5% to 12% for men” (p. 341). Kessler (2003) cites rates of
major depression in women that range from one and one-half to three times the rate of men.
However, this gender difference in the rate of depression is not seen in young children. Studies show that the gender differences begin in the age range of 11 to 14 years, coinciding with puberty and menarche (the beginning of menstruation) (Angold,
Costello, & Worthman, 1998; Koplewicz, 2002). In a prospective study of 1073 children findings indicated that the gender divergence in depression occurred at mid-puberty.
Body changes predicted depression more than age but controlling for sex hormones eliminated the effects of body changes (Angold et al, 1998, 1998; Angold et al., 1999).
After age 15, the rate of depression for adolescent girls is at least two times the rate for adolescent boys (Koplewicz, 2002).
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As previously discussed, there is also literature that finds that adolescents and
women experience the symptoms of depression in unique ways. Harold S. Koplewicz,
M.D. (2002) summarizes the differences between adults and adolescents who are
depressed as depressed adolescents are more likely to be irritable and to act out than are
adults. Also, “while sad adults are apt to have trouble sleeping and lose their appetites,
teenagers are likely to sleep and eat more (Sic)” (p. 17) and are more likely to have a co-
occurring anxiety disorder (p. 17). The substitution of irritable mood for depressed mood
mentioned above is also recognized in the Diagnostic and Statistical Manual – TR
(American Psychiatric Association, 2000, p. 327).
Depression in adolescents is usually more unstable than in adults. Thus, an
adolescent can have the ability to “snap out of” the depression for short periods and then
return to her depressed state (Koplewicz, 2002, p. 17.) Also, an adolescent is more likely
to have short time periods during the depression in which she “feels fine” (Koplewicz,
2002, p. 9) and so the depressed adolescent may appear more reactive to life events than a
depressed adult would be. This characteristic would seem to indicate the need for
multiple measures at different time periods in order to confidently diagnosis depression in
adolescents. Shaila Kulkarni Misri, M.D. (2005) writes that women who suffer from depression “do so differently and in conjunction with more secondary conditions” (p. 27) than men. Women are more likely to experience increased drowsiness, increased appetite, inability to make decisions and to perform necessary tasks, and increased sensitivity to rejection (Misri, 2005; Cohen, 2003). Women also recover more slowly and have a greater tendency to relapse (Misri, p. 27). Women are also more likely to
28
develop anxiety and eating disorders as co-occurring mental health problems (Misri,
2005; Halbreich, 2003).
Among the consequences of adolescent depression described in the literature are individual suffering, delayed social and emotional development, family conflict, poor school performance, conduct disorders, suicide, somatic symptoms, and drug and alcohol use and abuse (Canino & Spurlock, 2000; Empfield & Bakalar; Henry, Stephenson,
Hanson, & Hargett, 1993; Sheeber, Hops, & Davis, 2001). The National Mental Health
Association factsheet entitled “Mental Health and Adolescent Girls in the Justice
System” (2003) cites mood disorders including depression as one of the factors that
“makes girls vulnerable to periods of crisis and negative life experiences, including juvenile justice involvement.”
Postpartum Depression in Adolescent Mothers. Postpartum depression has been shown to be experienced by 10% to 28% of adult women who have recently given birth (Beck, 1996; Hobfoll, Ritter, Lavin, Hulsizer, & Cameron, 1995; O’Hara & Swain,
1996; Pawlby, Sharp, Hay & O’Keane, 2008; Reid & Meadows-Oliver, 2007; Rutowski,
1992) with a meta-analysis by O’Hara and Swain (1996) determining a mean rate of 13% in the 59 studies analyzed. Differences in rates seem related to differences in samples, measuring instruments, and time frames.
These same factors affect outcomes in studies that look at depression in adolescent mothers. However, consistently, the rates for postpartum depression in adolescent mothers are higher than rates for older mothers. Deal and Holt (1998) report rates of postpartum depression in 15-17 year old study participants ranging from 48% in
African-American adolescents and 28% in Caucasian participants. Studies by Barnet,
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Joffe, Duggan, Wilson, & Repke (1996) and Miller (1998) also report rates of postpartum
depression up to 47% in adolescent mothers. Nancy DeRosa and M. Cynthia Logsdon
(2006) cite the rate of postpartum depression for adolescent mothers as up to 47% “in the
early postpartum period” (p.13). Hudson, Elek, & Campbell-Grossman, (2000) used a
small sample of 21 adolescent mothers ages 15 to 19 who were patients at health care
practices in the Midwest United States. They used the Center for Epidemiological
Studies Depression Scale for Children (CES-DC) (Faulstich, Carey, Ruggiero, Enyart, &
Gresham, 1986) and reported a rate of postpartum depression of 53% in study
participants. Logsdon, Birkimer, Simpson, & Looney (2005) used the same instrument to
study 128 adolescent mothers ages 13-18 with findings of a 56% rate of postpartum depression. Again, the differences in the instruments used complicates comparisons but the rates for postpartum depression in adolescent women are consistently higher than rates of postpartum depression in adult women regardless of instrument used.
Depression in adolescent mothers following birth has not received extensive study. Birkeland, Thompson, and Phares (2005) looked at depression in adolescent mothers ages 15 to 19 years in the time period 3 to 12 months postpartum. This study used the Edinburgh Postnatal Depression Scale. The study looked at the relationship among role restriction, social isolation, weight/shape disturbance, maternal self-efficacy and depression. Findings were that weight/shape concerns, social isolation, and maternal self-efficacy were connected to depression in their study participants. Two concerns with this study are the factors to be studied were laid out by the investigators and, therefore, could be ignoring other factors related to postpartum depression in adolescents, and the
30
measures were taken at different points in the mothering experience (3 to 12 months into
the experience) depending on when the data was collected for each study participant.
Four quantitative studies of adolescent postpartum depression have used the Beck
Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) as the measure
of depression (Field, Pickens, Prodromidis, Malphurs, Fox, Bendell, Yando, Schanberg,
& Kuhn, 2000; Leadbeater, Bishop, & Raver, 1996: Panzarine, Slater, & Sharps, 1995;
Troutman, & Cutrona, 1990). The results showed rates of moderate and severe depression ranging from 26% to 50% using this instrument. Some interesting findings
from these studies are that the maternal postpartum depression identified in the first three
weeks of the baby’s life was still seen in 50% of the mothers when their babies were
between 28 and 36 months old (Leadbetter & Bishop, 1996). When primiparous
adolescent mothers who were depressed were compared with a sample of adolescents
who were also depressed at the same rate, the mothers were likely to have somatic
symptoms of depression (Troutman & Cutrona, 1990). Finally, depressed adolescent
mothers were less likely to report confidence in their ability to parent than nondepressed
mothers (Panzarine, Slater, & Sharp, 1995).
Risk Factors for Postpartum Depression in Adolescents. Theories of
multifactorial etiology and/or stress diathesis have been used to understand postpartum depression in adult women. (Chrisler & Johnston-Robledo, 2002; DaCosta, Larouche,
Dritsa, & Brender, 2000). The etiology of depression in adolescent women is also
generally regarded as being multifactorial. For example, Hammen and Rudolph (2003)
developed a multi-factorial and transactional model of adolescent depression. This model
identified risk factors for depression, reviewed below, and is supported by other studies
31
of adolescent depression (Birmaher, Ryan, Williamson, Brant, Kaufman, Dahl, et al.,
1996; Emfield, 2001; Goodyer, 1995).
One way that Relational-Cultural Theory can be used to understand postpartum
depression in adolescents is to understand that the relationships of multiple identified risk
factors for depression and the risk factors encountered by being an adolescent mother
interact. Following is a discussion of risk factors for depression in adolescent women
that is useful as a background context in understanding postpartum depression in
adolescent women.
A History of Depression Prior to the Birth. One of those risk factors for developing postpartum depression is being depressed prenatally. This risk factor has been well established in both individual studies and in meta analyses of risk factors for postpartum depression (Banti, et al. 2009; Beck, 2001; Silverman & Loudon, 2010).
Gender. As discussed in the earlier section of this chapter, the rates for depression are higher for women than for men. After age 15, the rate of depression for adolescent girls is at least two times the rate for adolescent boys (Koplewicz, 2002).
Member of a nondominant group. The literature on the differences in rates of depression between Caucasian women and women who are members of a nondominant group supports the hypothesis that being a member of a nondominant group increases the risk for developing depression. For example, Dwight-Johnson, Unutzer, Sherbourne,
Tang, and Wells (2001) reported that in their study of primary care medical facilities,
African Americans presented with more depressive symptoms than any other group.
Borrell, Keife, Williams, Diez-Roux, and Gordon-Larsen (2006) found that the
“association of self-reported physical and mental health and of depressive symptoms with
32 self-reported racial discrimination were stronger among women than among men” (p.
1422) in their sample of 33-45 year old African-Americans from multiple urban sites.
Studies with adolescent participants also support a relationship between depressive symptoms and membership in a nondominant group. Ramos, Jaccard, and
Guilamo-Ramos (2003) used a sample of students in grades 7 through 12. They used four groups: European Americans, African Americans, Latinos, and Afro-Latinos. The highest levels of depression were found in Afro-Latino females. Across all fours groups, females showed higher levels of depression and older participants had higher levels of depression than younger participants. Likewise, Romero, Caravajal, Volle, and Orduña
(2007) found that in a sample of students in grade 8, bicultural stress was significantly associated with depressive symptoms. The authors suggest that exposure to prejudice and discrimination account for the stress that was related to depressive symptoms.
Finally, Wong, Eccles, and Sameroff (2003) using a longitudinal survey of students in grades 7 and 8 as part of the Maryland Adolescents in Context project found that when students experienced incidents of discrimination and prejudice at school, their reported levels of depression increased. However, this study also found that a strong connection to the student’s ethnic group moderated the effects of stress from discrimination and prejudice.
Poverty. Depression in an adult is positively correlated with lower educational attainment, substance abuse, chronic medical conditions, and social disadvantage in areas such as employment. Thus, depressed adults are more likely to live in poverty (Kessler, et. al 2006; National Research Council and Institute of Medicine, 2009). Yet, although depression does lead to lost income “…there is a growing consensus that socioeconomic
33
disadvantage precedes poor mental health” (Heflin & Iceland, 2009, p. 1052). This
hypothesis is supported by several longitudinal studies that have concluded that the
causal direction goes from socioeconomic status to depression (Muntaner, Eaton, Riech,
& O’Campo, 2004; Miech, Caspi, Moffitt, Wright., 1999; Johnson, Cohen, Dohrenwend,
Link, & Brook, 1999). In adolescents, poverty and depressed mood have been linked by
Hammack, Robinson, Crawford, and Li who found a significant relationship between poverty and depressed mood in their study of urban African-American female
adolescents (2004).
Vericker, Macomber, and Golden, writing in a report for the Urban Institute
(2010), used data from the 2001 Early Childhood Longitudinal Study to examine the
relationship between poverty and maternal depression. “…notably, all infants in poverty
have relatively young mothers. More than half of the mothers of nine-month old infants
living in poverty were younger than 25 and five percent of them were between the ages of
15 and 17” (p. 2). This report points out that infants living in poverty with mothers who
are depressed are also exposed to more risks such as domestic violence and binge
drinking by their mothers (p.3). These infants were also less likely to be breastfed for at
least nine months and to be given solid food before the recommended age (p.4).
Poor nutrition. The complexity of major depression “is unmistakable, yet a key
to its prevention and treatment may be a factor so fundamental it has been broadly
overlooked: dietary intake and overall nutritional status” (Bodnar & Wisner, 2005, p.
679). This would seem to be an important area to consider in understanding perinatal
adolescent depression since pregnancy, giving birth, and lactation all draw on the
nutritional resources of the mother.
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Cognitive pattern of rumination. Rumination is “engaging in behaviors and thoughts that passively focus attention on one’s symptoms of distress” (Nolen-Hoeksema,
S. & Jackson, B., 2001, p. 37). Studies have shown that women are more likely than men to respond to distress by ruminating (Nolen-Hoeksema, S., Morrow, J. & Fredrickson,
B.L., 1993). This same gender difference has been reported in adolescents (Abela,
Aydin, & Auerback, 2007; Allgood-Merten, B., Lewinsohn, P.M., & Hops, H., 1990).
These gender differences in using rumination in response to stress seem to mediate the observed gender differences. So, “women’s greater tendency to ruminate appears to contribute to their greater tendency toward depression compared to men”
(Nolen-Hoeksema & Jacson, 2001, p. 38).
Neurobiology. Biological Theory states that depression in adolescent women is caused by a process in the human body. It has as subtheories a group of conceptual models that share the belief that depression has its etiology in the body. These models differ as to the process in the body involved in the causal process. To remain within the scope of this study, three subtheories will be presented. They were selected because they have been studied in relationship to adolescents.
The concept of biological theory needs some clarification. Some authors include with biological the component of human genetics. Doing so is based on the studies that show that having a first-degree relative with depression is a risk factor for the development of depression (American Psychological Association, 2002). Other authors, for example, Ponirakis, Susman, and Stifter (1998) list genetics as one of the subtheories of biology. And, there is literature that categorizes biology and genetics as being two different theories (Sichel & Driscoll, 1999) based on the premise that there may be a
35 biological component without a genetic component to the etiology of depression, especially in women.
One subtheory has to do with changes in the gray matter in the brain. Jay Giedd, a researcher at the National Institute of Mental Health, has been studying adolescent brains using Structural Magnetic Resonance Imaging (SMRI). This technology has allowed for research into the brain that previously could only have been done postmortem
(which is difficult in adolescent depression research since adolescents do not die as frequently as, for example, clients with Alzheimer’s disease) or with less advanced equipment. Gield has found that the gray matter in the brain thickens until age 11 in girls and age 12 in boys. Then, just before puberty, the gray matter begins a chemical process that clears out unused brain connections. This process continues until about age 22 -25.
The highest rate of this process occurs between ages 14 and 17 (Geidd, Blumental,
Jeffries, et al., 1999; as cited in Sichel & Driscoll, 1999; as cited in Koplewicz, 2002).
Koplewicz (2002) points out that this is the period in which “rates of major psychiatric disorders, including depression, increase markedly” (p. 36).
A second subtheory has to do with the links between products of the hypothalamic-pituitary-adrenal axis (HPA) and depression. Two chemicals that the HPA produces in the body are corticotropin-releasing hormone (CRH) (an amino acid peptide) and cortisol. CRH is important in this process because it influences the production of adrenocorticotropic hormone (ACTH) that regulates the synthesis of cortisol. The causal process in adolescents is as follows:
36
CRH production in the body is low→Low production of ACTH→Low production
of cortisol→ Depression. In a study by Dorn, Susman, & Petersen (1993) lower
concentrations of cortisol in pregnant adolescents predicted depression.
The final subtheory also has to do with hormones, in this case with the hormones
estrogen and progesterone, the pubertal hormones. Estrogen begins to be produced in
higher levels by women when they reach puberty. And, there is a constant changing of
the levels of estrogen and progesterone during the adolescent years and especially during
pregnancy (Steiner, Dunn, and Born, 2003). The hormonal changes have been associated
with increases in mental health problems, such as depression.
Lack of Social Support. Research studies have shown a link between low social
support and the presence of postpartum depression in both adult women (Logsdon &
Usui, 2001) and adolescents (Barnet, Joffe, Duggan, Wilson & Repke, 1996). Social
support, although variously defined and studied using different research methods and in
different contexts, has also been found to mediate and/or moderate postpartum depression
in women (Barnard, et al., 1988; Norbeck, DeJoseph, & Smith, 1996). In fact, some
studies of adult women demonstrate that even the perception of positive social support
can influencer maternal behavior favorably (Reece, 1993; Baker & Taylor, 1997). These
findings are supported in a study by Secco, Profit, Kennedy, Walsh, Letourneau, and
Stewart (2007) in adolescent mothers where the “perceived family and friend social
support” (p. 47) was a moderator for adolescent mothers’ fears about their reactions to
their infant’s crying or fussing. However, in their sample, social support did not predict postpartum depressive symptoms. Rather the anticipated infant care emotionality and the socioeconomic status of the mother were stronger predictors. Panzarine, Slater, and
37
Sharp (1995) report that the adolescent mother’s perception of whether the social support received was helpful was the most important variable in determining if social support could mediate or moderate postpartum depression symptoms.
Logsdon, Hertweck, Ziegle, and Pinto-Folz (2008) studied whether lack of social support at the micro, mezzo, and macro levels could predict postpartum depression in adolescents. They present a bioecological model that looks at the social support that the adolescent mother is able to provide for herself through self-soothing and asking for help, the interactions of the adolescent mother with mezzo groups, and the stable community variables that can provide social support for the adolescent mother. All three levels of social support were shown to reduce the risk of postpartum depression in adolescent mothers. Their study is particularly important in that it highlights the importance of social context for postpartum depression symptoms in adolescent mothers.
Stressful life events have also been shown to play a role in the development of postpartum depression among adolescents Changes in relationships and other
“undesirable events” (O’Hara, Rehm, & Campblee, 1983, p. 336) can result in elevated stress levels. This stress has been linked to the decreased ability of the mother to care for her infant (Too, 1997; Kline, Martin, & Deyo, 1998) and in increased levels of postpartum depression (Brown & Shereshefsky, 1972; O’Hara et al.; Paykel, Emms,
Fletcher, & Rassaby, 1980) in adult women.
In the study by O’Hara, Rehm, and Campbell (1983), the participants who developed postpartum depression had a larger number of stressful events after the birth of the child occur than did participants who did not develop postpartum depression.
However, both the depressed and not depressed participants reported the need for both
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instrumental (help with physical care of the infant and of the house, financial assistance,
help with cooking meals) and emotional support during the postpartum period.
Depressed participants, though, reported less availability of the sources of social support
measured than did not depressed mothers. This gives additional support to the idea that
the lack of social support is associated with postpartum depression in adult women.
However, since depressed persons have been found to be relationally aversive to family
and friends (Coyne, 1976) and to not demonstrate effective social skills (Lewinsohn,
Mischel, Chaplin, & Barton, 1980), the direction of relationship and the question of
causality are not resolved. The African-American family has been presented in the
literature as having a value system that emphasizes family and informally adopting
community members as fictive kin. In fact, Carol Stack (1974) does suggest in her study
that the kin network operating in Black society functions as a mutual aid network by
assisting young and single mothers in the task of raising their children. However, Elaine
Bell Kaplan’s study (1997) of inner city Black women this kin network is described by
participants as overextended and without many of the informal sources of social support
seen in mothers of higher economic status.”
Koniak-Griffin, Lominska, and Brecht (1993) looked at differences in social support among three ethnic groups of adolescents. Differences were found in the number of persons in the social support of the network. The Black adolescents had fewer persons who they identified as sources of social support than the White and Hispanic adolescents in the study. Also, the members of the support systems were more likely to be family members in the Black and Hispanic mothers. This smaller number of members of the support system may be part of the explanation for the findings of the Kaplan study
39
(1997). However, Koniak-Griffin, Lominska, and Brecht used a convenience sample and did not account for differences in socioeconomic status.
Obstetrical Complications. The most consistent finding about the effect of obstetrical complications on postpartum depression is that obstetrical complications increase the risk for postpartum depression. This is especially true when obstetrical complications were defined as caesarean delivery, the use of forceps in delivery, and/or long labor (Boyce & Todd, 1992; Edwards, Porter, & Stein, 1994). In a study of adult women (mean age=29.6), Verdoux, Sutter, Glatigny-Dallay, & Minisini (2002), used a standardized scale to measure obstetrical complications and controlled for demographic characteristics, parity, marital adjustment, and a history of depressive or anxiety symptoms during the pregnancy. Their findings in this study of adult women were that obstetrical complications during pregnancy was an independent predictor of the severity of postnatal symptoms. This is an area that needs study with an adolescent population but does seem to be important enough to include in an assessment of risk factors. It is included in this study because listening for themes of obstetrical complications may shed light on the relationship of the adolescent mother to the medical community and on any changes in body image as a result of these complications.
Parity. One factor that research shows may have some influence on the development of postpartum depression is parity. This work began in animal studies
(Mann & Bridges, 1992) and has been continued in adult women. In human studies, there are data to support that oxytocin release is greater in multiparous than primiparous mother (Lucas, Drewett, & Mitchell, 1980; Holdcroft, Snidvongs, Cason, Dore, &
Berkley, 2003). Since the presence of oxytocin has been linked to less depressive
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symptoms postpartum (Mezzacapp & Endicaoo, 2007), the lesser amount in first time
mothers may be significant in an investigation of postpartum mood.
There are also studies that look at the stress of assimilating the new role of being a
mother which occurs with the birth of the first baby. Ferber (2004), for example, finds
that first time mothers are less confident in their role, have to adjust to the new role-
related tasks and relationships, and thus are more likely to show depressive symptoms.
These studies are all done using adult women as participants so it is not clear that this
same effect of parity is seen in adolescent mothers.
Summary of Causal Process
Thus, a summary of the theoretical and empirical literature would conclude that both depression and postpartum depression have multiple etiologies – what Misri labels
“A Confluence of Causes” (Misri, p. 28). Considering the many ways that risk factors can combine, the pathways to depression and postpartum depression are numerous and varied. In fact, this combination of multiple causal pathways and multiple and varied symptoms has probably influenced screening for depression in a negative manner. For example, it was not until 2002 that the U.S. Preventive Services Task Force and the
Agency for Healthcare Research and Quality began to recommend to medical professionals that screening for depression be done “because its symptoms were so amorphous” (Misri, p. 11).
What can be said is that depression has been shown to show increased incidence at times that coincide with changes in hormones – menstruation, perimenopause, menopause, and pregnancy (Misri, 2005). That these times also are times of increased
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stress for women (Misri, 2005) further adds to the conclusion that depression and
postpartum depression in women have multiple and intertwined causal pathways.
Concept Definitions
This section presents definitions of the concepts drawn from the theoretical and
empirical literature and used in this study.
Adolescence. Conceptually, the period of adolescence will be defined to begin at age 13 and to end at age 22. One reason this range was selected is from evidence that
depression is a significant problem among young adults in their early twenties (American
College Health Association, 2001). Another reason is the finding from neurobiology
research that the pathways in the brain continue to develop until age 21 or 22 thereby
having implications for the development of depression that has biology as at least part of
its etiology (Koplewicz, 2002). However, in order to be consistent with the population
used to develop the Edinburgh Postnatal Depression Scale instrument, the study
population will be limited to women 15 through 19 years of age.
Depression. The Diagnostic and Statistical Manual of Mental Disorders presents criteria used to diagnosis mental health disorders (American Psychiatric Association,
2013). The fifth edition (DSM 5) was published in 2013. This study was begun under the earlier version (DSM-IV-TR) of this typology and the concepts for both depression
and postpartum depression were drawn from the earlier edition. Diagnostic criteria for
Major Depression comes from the Diagnostic and Statistical Manual- IV – TR (American
Psychiatric Association, 2000). To receive a diagnosis of depression, one must meet five or more of the symptoms of major depressive episode within a two week time period. At least one of the symptoms must include depressed mood or loss of interest or pleasure.
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For children and adolescents, irritable mood can be substituted for depressed mood in the diagnosis. Additional symptoms include change in weight; change in sleep patterns; change in psychomotor agitation or retardation; fatigue; feelings of worthlessness or guilt; change in pattern of concentration; and suicidal ideation, plans or attempts.
Several points are important in regard to the definition of depression in adolescents. First, for adolescents, symptoms of depression may be expressed differently than symptoms of depression are expressed in adults. Using the definition for Major
Depression of the Diagnostic and Statistical Manual– IV –R (2000), the same symptoms of depression can be shared by both adults and adolescents. Certain depressive symptoms, particularly irritability, are more common among adolescents than adults
(Koplewicz, 2002, p. 14), and can confound the proper diagnosis of depressive episodes in adolescents. Koplewicz (2002. p. 18) provides the following summary of similarities and differences in depressive symptoms between adults and adolescents (Table 1). The last entry in Table 1 describes adolescent depression as being more reactive to the social environment. This provided another rationale for selecting Relational-Cultural Theory as the theoretical framework for this study.
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Table 1
Expression of Depressive Symptoms
Adults Adolescents
Depressed mood or loss of interest or Depressed mood, irritability, or loss of pleasure in nearly all activities pleasure in daily activities Decrease in appetite or weight Overeating, increased weight Decrease in sleep Increase in sleep Change in activity, either lethargy or Lethargy, decreased energy agitation Decrease in libido Little sexual impairment Social environment plays a small role Reactive to social environment
Second, depression in adolescents has been shown to be less stable than in adults;
viz., a depressed adolescent often has periods of apparent good mood without displaying
other depressive symptoms (Koplewicz, 2000). This pattern can lead to a failure to
recognize serious depression in adolescents, if the expectation is for a continuous,
depressed mood.
Third, there are differences in the most common symptoms of depression based
on gender; women are more likely than men to be depressed. These differences have been
shown in adult samples in multiple studies (Carter, Joyce, Mulder, Luty, & McKenzie,
2000; Silverstein, 2002; Wilhelm, Roy, Mitchell, Brownhill, & Parker, 2002). Bennett,
Ambrosini, Kudes, Metz, and Rabinovich (2005) studied 383 adolescents who were seen in a pediatric depression clinic at two different university medical centers. Consistent with findings from adult studies, Bennett et al. (2005) found that depressed girls
experienced more guilt, more body image dissatisfaction, and more difficulty
concentrating than did the depressed boys in their sample. Given the body changes that
44 pregnancy brings and the need for concentration inherent in parenting, this gender difference in the expression of depression symptoms would seem important.
Fourth, in regard to incidence of depression (number of new cases over a period of time), it is necessary to differentiate between first incidence of Major Depressive
Disorder (MDD) that occurs during the period under study and an incidence of MDD that occurs during the study period that is a recurrence of MDD. For example, in the Oregon
Adolescent Depression Project (OADP) sample, the first incidence of MDD in a one year period was 7.1% in girls and 4.4% in boys. The incidence of a recurrence of MDD during the same one year period was 21.1% for girls and only 9.1% for boys (Lewinsohn
& Essau, 2002). Since a previous MDD is a risk factor for postpartum depression in adult women (Beck, 2001), the OADP studies suggest that postpartum depression may be related to other experiences with depression for some of the adolescent mothers.
Finally, since assessment drives treatment, it is important that Major Depression be differentiated from other similar mood disorders. Thus, this study used a definition of depression that excludes Bipolar Disorder even though depression is one part of that disorder and may, in fact, be the primary way that the disease presents itself. Similarly, there is a distinction between Major Depression and Dysthymia that has less severe symptoms and is a more chronic condition. Major Depression must also be distinguished from the Adjustment Disorders. In an adjustment disorder, the adolescent reacts to a life event and may react with symptoms of depression. However, until the criteria for major depression are met, the reaction is still considered an adjustment reaction (American Psychiatric Association, 2000). Dr. Koplewicz (2002) calls adjustment reactions the “most common form of mood problem in...adolescents….It
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usually last anywhere from a few hours to a couple weeks” (p.15). This study also
excluded depression that is a normal part of the grieving process (American Psychiatric
Association, 2000) by excluding potential study participants who did not deliver a live
child. The interview also included a question about recent losses.
Postpartum Depression. The scholarly literature contains definitions of the
concept of postpartum depression although the definition is not entirely consistent across
studies. The Diagnostic and Statistical Manual 5 treats postpartum onset of depression
as a specifier to the category major depressive disorder (American Psychiatric
Association, 2000, 2013). For DSM-IV-TR, the period of postpartum depression can begin at childbirth and continue for four weeks after the birth. Revisions to the postpartum specifier for depression in the DSM5 changed the label to peripartum onset and widened the time period to either during pregnancy or during the four weeks after birth. Other studies have defined postpartum depression onset from birth to 3 to 6 months (Miller, 2002; O’Hara, Zekoski, Philipps, & Wright, 1990).
Postpartum depression has received increased public attention from the media
(Butler, New York Times, 2002 April 13; Yardley, New York Times, 2002, March 13;
Yardley, New York Times, 2002, February 28). However, studies in the medical literature indicate that it is still underdiagnosed (Georgi, 2001; Miller, 2002). There is “evidence that most births in the United States are complicated by a mood disturbance of some kind for the mother” (Rosenberg, Greening, & Windell, 2003, p. 324).
Connection. Relational-Cultural Theory defines connection as an interaction
“between two or more people that is mutually empathic and mutually empowering”
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(Miller & Stiver, 1997, p. 26). These connections occur at micro, mezzo, and macro levels of interaction.
Disconnection. In contrast, Relational-Cultural Theory defines a disconnection as “an encounter that works against mutual empathy and mutual empowerment” (Miller
& Stiver, 1997, p. 26) that also can occur at all levels of interaction, micro, mezzo, and macro.
Relationship. As used in Relational-Cultural Theory, relationship refers to a set of social, emotional and physical interactions that occur over time (Miller & Stiver, 1997, p, 26). Relationships are seen as dynamic and occurring along a continuum of connection to disconnection. “In reality, most of us struggle with various mixtures of connection and disconnection” (Miller & Stiver, 1997, p.23).
Research Questions and Hypotheses
Using the theoretical and empirical literature, the following research questions and hypotheses for this study were developed.
Research question 1. What is the lived experience of first-time adolescent mothers who are experiencing depression in the postpartum period?
Hypothesis 1-1. The experiences will be able to be understood by looking at micro, mezzo, and macro relationships including connections and disconnections of the participants.
Hypothesis 1-2. The risk factors for depression in adolescent women will emerge as themes in adolescent mothers who scored as depressed on the Edinburgh Postnatal
Depression Scale.
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Hypothesis 1-3. Participants will describe a fluctuating experience of mood postpartum.
Research question 2. What is the lived experience of first-time adolescent mothers who are not experiencing depression in the postpartum period?
Hypothesis 2-1. The participants who scored as not depressed on the Edinburgh
Postnatal Depression Scale will share experiences and themes with participants who have scored as depressed.
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CHAPTER 3: RESEARCH METHODS
Introduction
This chapter describes the research methodology used in this study. The chapter
begins with a rationale for a phenomenological approach and then discusses the study
sample inclusion/exclusion criteria and methods for participant recruitment. The steps in
data collection and data analysis are presented.
Rationale for Choice of Phenomenology as a Method
This study used the ontology that the lived experience of a participant is what is real and that the way to learn about the lived experience is to ask the participant. Georgi
(1985) describes the way to “go back to the things themselves” (Husserl, 1970/1900, p.
252) is to use as the research base a phenomenological approach that studies the everyday world of the participants so the experience of participants can be understood. Since the aim was to understand the lived experience of the participants, the answers of the participants will not be used to construct the next question for the participant as would be done in a narrative analysis approach (Riessman, 1993). Instead, a semi-structured interview was developed drawn from Relational-Cultural Theory concepts and based on the theoretical and empirical literature on postpartum depression in adolescent mothers.
Sample Selection
Study participants were first-time adolescent mothers who were ages 15 to 19 at the time of the interview. Inclusion/Exclusion criteria for the sample were the following:
1. First time mothers between the ages of 15 and 19 were included.
Rationale: This controlled for the effects of parity as described in the literature
review.
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2. Mothers who had babies in the last six months were included.
Rationale: This set a timeframe commonly used in studies of postpartum
depression.
3. Mothers who delivered a stillborn baby or a baby with anomalies severe
enough to have generated a referral to Easter Seals or the Illinois Division of
Crippled Children were excluded.
Rationale: This is an exclusion generally included in the adult studies that
were used to compare findings. This exclusion also helped control for loss
experienced by the mother.
4. Mothers who had active psychosis that was not controlled by medication as
determined by the medical record were excluded.
Rationale: The study required that participants be oriented to time, place, and
situation. The focus of this study was postpartum depression and not
postpartum psychosis.
5. Mothers who were themselves wards of the Illinois Department of Children
and Family Services (DCFS) were excluded.
Rationale: DCFS had its own research center and its practice was not to give
consent to outside researchers to include wards in outside studies.
6. Mothers whose school history showed they have attended special education
classes based on low I.Q. were excluded.
Rationale: While it is important to study this group of adolescent mothers,
their cognitive functioning was assumed to be different from adolescents who
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have not attended special education classes that they will be excluded from
this study.
7. Mothers must speak English.
Rationale: The researcher did not speak any other language well enough to
conduct the research interviews in any language other than English. A body
of literature exists that supports the hypothesis that the use of a language
interpreter changes the clinical process. For example, Marcos (1979) did
content analyses of interpreter-mediated psychiatric interviews and found that
“interpreter related distortions could lead to misevaluation of the patient’s
mental status (p. 171). Other problems associated with the use of a language
interpreter have been listed as hesitancy to divulge mental health information
to another person other than the clinician, misunderstandings that arise when
language is translated literally and then loses its nuances, interpreters using
the participant’s nonverbal behavior to guide interpretation based on the
interpreter’s understanding of nonverbal behavior, interpreters who share a
language but not a culture with the participant and thus misinterpret, and
difficulties in making the boundaries clear for interpreters who may try to
advocate for participants (Singh, McKay, & Singh, 1999; Trivasse, 2006).
And, particularly important to this study, Bot and Wadensjo (2004) described
how the addition of a language interpreter changes the communication
process. Thus, although the literature is particularly relevant to clinical
settings, the findings seemed important enough to justify this limitation in the
current study.
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Marital status was not considered as it has not been found to be a significant variable in studies of adolescent depression and/or it is not even included in studies of depression and postpartum depression (Koniak-Griffin, Lominska, & Brecht, 1993,
Troutman, & Cutrona, 1990).
Participant Recruitment
The sample was selected from adolescent mothers who met the research criteria and were patients at a multi-site federally funded medical care clinic (Clinic), or clients of a private, not-for-profit child welfare agency (Agency) both located in Peoria, Illinois.
Both agencies served adolescent mothers and both screened for postpartum depression in all postpartum women who accepted postpartum screening including adolescents. Letters of Support were obtained from the Executive Directors of the Clinic and from the
Program Director of the Agency. Recruitment began June 1, 2012, and ended May 30,
2014. The original recruitment plan was to interview mothers at the infant’s six week
Clinic visit; however, many of the adolescent mothers did not make it to the six week visit in a timely fashion. There, a change in protocol was approved to interview women with babies up to six months old. When this change still did not yield sufficient participant, then a child welfare setting, the Agency, was added and approved for recruitment. Recruitment, however, continued to remain problematic so an additional question was approved for addition to the interview, that of asking participants for the names of other adolescent mothers who they thought might be interested in participating in the study (for the purpose of snowball sampling). Lessons learned during this lengthy recruitment period are discussed in Chapter 5.
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The researcher met with the Director of Clinical Services and with the Medical
Director of the Clinic on December 5, 2009, for their input into the process of obtaining
research participants and with the Program Director of the Agency on September 8, 2013,
to obtain her input and support. The researcher met with the nursing staff at both sites to
train them on procedures to inform potential study participants of the study using a
standard script (See Appendix A).
A flyer (See Appendix A) was created to make potential participants for the study
aware of the opportunity to participate. The flyer defined basic criteria for inclusion in
the study. All eligible patients/clients were given an informational flyer about the study
by the clinic or program casework staff. The flyer was also displayed at both sites with a
tear-off part that could be put in a secure box in the waiting area to be returned to the
researcher. The researcher obtained a second dedicated line on her telephone through
which potential participants could contact her by text for further information. The
researcher distributed flyers personally by going to both sites during times that potential
study participants would be present. A script for the first telephone contact is attached in
the Appendix A. When participants agreed to participate and met the criteria for
inclusion in the study, an interview was scheduled.
Recruitment to the study stopped when 8 participants were obtained; while the
original plan was to interview 15 adolescent mothers, the overwhelming problems with
recruitment, in spite of several alternate strategies used, prevented this from happening.
Thus, the sample represents a convenience sample of adolescent mothers meeting the research criteria who are patients of the Clinic or of the Agency and who agreed to
participate in the study during the time that the study was conducted. It represents what
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Patton calls information-rich cases (Patton, 2002). It is obviously skewed toward
mothers of a lower economic class given the populations served by both programs from which participants were recruited.
Research Methodology
Date Collection.
Participants were interviewed when their child was 6 months of age or younger. A room was available at the Clinic but the researcher also used other venues such as the participant’s home or school if meeting at the Clinic was not practical. Interviews ranged
in time from 45 to 90 minutes. The interview was audio recorded for transcription later.
A semi-structured interview guideline was used (See Appendix A). Questions were
based on the literature about postpartum depression in adolescent mothers and were
informed by Relational-Cultural Theory. The semi-structured interview covered questions about risk factors for depression, reactions to pregnancy, connections and disconnections with self, family, and macro systems, and the lived experience of being an adolescent mother. The first interview served as the pre-test. The participant understood the questions and subsequently no further changes were made in the research interview questions. After the semi-structured interview was conducted, the Edinburgh Postnatal
Depression Scale was administered verbally by the researcher to all participants.
The Edinburgh Postnatal Depression Scale was developed as a screening instrument for postpartum depression that could be used in both office visits and home visits (Cox, Holden, & Sagovsky, 1987). It consists of 10 questions. Responses are scored on a scale of 0 to 3. Some items are reverse scored. Validation studies have used different scores as threshold levels for referral and further assessment, ranging from 9 to
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13 with all authors recommending referral if the woman answers that she has had thoughts of harming herself in Question 10 (American Academy of Pediatrics, 2010).
Scores above 10 are considered to be a positive screen for depression. It is important to note that the Edinburgh Postnatal Scale is only a screen and not a diagnostic tool. This allows it to be used by persons not specially trained in mental health counseling and in a variety of settings. The authors give specific permission for its reproduction without permission as long as the copyright is protected by giving credit for the Scale to the authors (American Academy of Pediatrics, 2010; Cox, Holden, & Sagovsky, 1987). Cox and his colleagues found the Edinburgh Postnatal Depression Scale to “have satisfactory sensitivity and specificity, and was also sensitive to change in the severity of depression over time” (Cox, Holden, & Sagovsky, 1987, p. 782). A copy of the Edinburgh Postnatal
Depression Scale and the semi-structured interview are in the Appendix A. Its use in this study was to screen for evidence of postpartum depression questions in relation to addressing research question two.
At the completion of the interview, as approved by the IRB protocol, participants were able to choose a piece of costume jewelry and were given a $10.00 gift card to a major discount store.
Data Analysis.
Data were analyzed using a thematic analysis (Aronson, 1994; Braun & Clark,
2006). Steps in the data analysis were as follows:
Step 1. Collect data. Responses to the interview questions were transcribed into a word processing program. Atlas.ti software was used to code and merge data.
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Step 2. Patterns of experiences either from direct quotes or from a paraphrasing of
common expressed experiences were identified. Responses of participants who scored
greater than or equal to 10 on the Edinburgh Postnatal Depression Scale were compared
to responses of participants with scores indicating no evidence of depression. The
responses were examined separately and then as an aggregate to see whether there were
themes specific to each and/or themes that were present in both groups. It is important to
note that the two coders, the researcher and another professionally trained social worker
were blind to the results of the EPDS.
Step 3. All data that related to the identified patterns were identified. The
researcher used initial impressions to identify patterns. Themes or patterns were
identified using an inductive method (Boyatzia, 1998). Codes were defined as “a word or
short phase that symbolically assigns a summative, salient, essence capturing, and/or
evocative attribute for a portion of language based on visual data” (Saldaña, p.3).
Patterns consistent with relationships were examined using Relational-Cultural
Theory to guide the analysis. Specifically, patterns of connection and disconnection were
identified using the participant’s viewpoint about what constitutes a positive connection
vs. a negative disconnection and how connections contributed to the experience of being
a first-time adolescent mother.
Step 4. Combine and code related patterns into subthemes and then into themes.
Braun and Clarke (2006) define a theme as capturing “something important about the data in relation to the research question, and that represents some level of patterned
response or meaning within the data set (p. 82).
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Step 5. Themes were “pieced together to form a comprehensive picture of their collective experience” (Aronson, 1994, p. 2). This was a reiterative process of merging and organizing codes. The final code book that emerged is included in Appendix B.
Step 6. Following the recommendation of Barbour (2001) against multiple coding of entire datasets, a subset of the interviews were chosen at random (Interviews 1, 3, and
5), and a second coder was used to determine reliability of coding. The researcher provided the second coder with information about the theory and about the process of thematic analysis prior to meeting to code the interviews. Since the researcher was working independently conducting data analysis, it seemed important to have a second person read the data and look for themes of connection and disconnection. As Barbour
(2001) points out, the ultimate value of having the second coder was for the insights into the data that evolved from the discussion of codes. Issues such as the adultism (assuming adult reasons for adolescent behavior) of the researcher were bracketed (Tufford &
Newman, 2012); the use of a second reader of the transcripts increased the likelihood that bracketing was carried out. As a result of working with the second coder, several additional themes were added to the code book. Descriptive information (age, risk factors for description) asked in the first six interview questions was used to describe the characteristics of the sample (See Tables 2 and 3 in Chapter 4). The decision to begin coding after the descriptive questions in the semi-structured interview were asked was done to maintain consistency in coding across all interviews as prescribed by Braun and
Clarke (2006). The agreement between the researcher and the second coder was very close; there were 11 disagreements in the three interviews coded. All disagreements were resolved through discussion.
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Validity.
There is research to support that when interviews rather than a checklist are used
to gather data from depressed adolescents, the information gained is more complete and accurate. Duggal et al. (2000), for example, used a subject/control group design of adolescents to gather information about stress life events from a checklist and from an interview given to all participants. Particularly in the group of depressed adolescents, the interview gathered more information, information not on the checklist, and information about the relationship of mood symptoms and specific life events. The original study protocol included conducting a focus group as a means of triangulation to establish member checking and thereby corroborate the validity of the themes generated in the data analysis (Barbour, 2001); however, the long period of time (two years) between participant interviews made this not a feasible option.
Protection of Human Subjects.
The study protocol was reviewed and approved by two university-based institutional review boards (IRB) for the protection of human research participants. One
IRB was based at the university where the researcher was a student and the other IRB was based at the university where the researcher is a faculty member. The study was classified as minimal risk and special review was done for adolescents. All participants signed an Informed Consent Form (See Appendix). At the beginning of the face-to-face scheduled meeting with the participant, the researcher again explained the purpose of the study. If the participant was willing to continue with the interview, she was given a consent form to sign and the interview was conducted. The consent form was careful to document the limits of confidentiality since the researcher is a mandated reporter under
58
Illinois law. Under Illinois law, minors who are parents may consent to their own
medical treatment (Illinois Hospital Association, 410 ILCS 210/1). Using the model of
the Institutional Review Board at John Hopkins University, “in the absence of specific
law or regulations addressing consent for research” the state law regarding consent for medical treatment will be used as the guide for determining effective informed consent for research studies under the Common Rule (Informed Consent for Minors in Research
Studies, 2005) and therefore, a consent rather than an assent form was used for this study.
As stated in the IRB protocol, all identifying information (e.g. names and birthdates of babies) were deleted from the interviews during transcription and the audio recordings were erased within two weeks of the date of the interview. Only de-identified transcripts were reviewed and coded.
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CHAPTER 4: RESEARCH FINDINGS
Introduction
The purpose of this study was to describe the lived experience of first-time
adolescent mothers and to look for themes and patterns in responses informed by
Relational-Cultural Theory. Themes and patterns were analyzed using a thematic
analysis approach. Themes and patterns were also compared to scores of research
participants on the Edinburgh Postnatal Depression Screen. The identified themes and
patterns were then used to more completely understand the phenomenon of the
participants’ experience. Answers to the last question in the interview which was “What
do you want adults to know about the experience of being an adolescent mother?” were
coded and analyzed separately from other data.
Results will be presented as follows: overall phenomena or story revealed,
description of sample, analysis of data for each theme identified showing data by research
question. This study used the following research questions:
1. What is the lived experience of first-time adolescent mothers in the early
postpartum period?
2. What are the similarities and differences in the lived experience of first-time
adolescent mothers who are classified as depressed versus those who weren’t
classified as depressed using the Edinburgh Postnatal Depression Scale?
The Story That the Findings Told
The birth of a baby to the adolescent mothers in this study clearly occurred within the contexts of the lives that they were living and of their development as adolescents.
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Relational-Cultural Theory assisted in understanding the contexts of their lives as they included multiple connections and disconnections at all levels of interaction.
At the micro level, participants talked about their change of perception of themselves, the reactions to being a victim of a violent crime, their change in school plans, their lack of knowledge about pregnancy and child care, and their feeling the pressure of a lack of time. They had to negotiate new relationships with parents and with siblings. Sometimes these resulted in disconnections and sometimes they resulted in new connections. The birth of the baby fostered new or renewed connections for some participants. They described connections and disconnections with the fathers of their babies. At the time of the interview, only two participants had a connected relationship with the father of the baby.
At the mezzo level all participants talked about the loss of social support from their friends after the birth of their babies. They had to form new relationships with other people including the family of the father of the baby. They had to navigate new relationships with members of their own families as they were put in the role conflict of child/mother.
At the macro level, the participants’ experience of being a mother was influenced by systems in which they were involved – school, medical, day care, and legal. They talked about the difficulty of being students and mothers. They sometimes showed a lack of knowledge about pregnancy and delivery and sometimes felt that they were treated differently because of their status as teen mom when using parts of the medical system.
They sometimes described connections with school or the medical system and with day care that improved their experience of being an adolescent mother. They struggled to
61 maintain relationships with the fathers of their babies who were incarcerated. They wanted to work but some were too young to even get a work permit. They all described some type of plan for their baby to have a better life than they had in whatever way they defined a better life.
Risk factors for depression were distributed with frequency throughout the sample of mothers. However, those participants who scored as depressed on the Edinburgh
Postnatal Depression Scale did not have any different distribution of these risk factors than did the participants who did not score as depressed on the Edinburgh Postnatal
Depression Scale.
The adolescent mothers in this study were ready and willing to talk about what they wanted adults to know about their lived experiences. Their enthusiasm to share these experiences showed in their words and in their nonverbal expressions. Following is a description of the eight participants.
Description of Sample
Eight first-time adolescent mothers participated in the study. Their ages ranged from 15 to 19 years and all had babies six months of age or younger. Questions from the semi-structured interview elicited information about risk factors for depression including poverty, being a member of a nondominant race, having a history of recent loss, and having a history of abuse. Results are shown in Table 2. Seven of the eight participants were determined to be living in poverty as determined by their receiving free lunches at school. The eighth participant at the time of the interview was taking online college classes while receiving low income services such as Medicaid for her child while also continuing to receive financial assistance from her family.
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Five of the eight participants described recent losses that were defined as deaths.
These included the loss of a sister to cancer, the loss of a grandfather who had sexually abused the participant, the loss of a friend, the loss of a friend in a street gang fight, and losses of other relatives including grandparents and uncles.
Five of the eight participants also described examples of being abused. These included two participants who described verbal abuse and three participants who described being sexually abused. In addition, one participant who had been sexually abused had also recently been sexually assaulted. In that case, the paternity of her baby was determined from the DNA sample obtained at the County Jail where the man who was charged with the sexual assault was being held and who was determined to be the father of the participant’s child.
Participants were asked the question “How would you describe your race?” during the semi-structured interview and their responses are presented in Table 3 as their direct quotes. This data will be further discussed in Chapter 5.
Scores on the Edinburgh Postnatal Scale can range from 0 to 30. In this study, participants’ scores on the Edinburgh Postnatal Depression Scale ranged from 3 to 10. A score of 10 or higher is considered a positive screen for depression. Participants 3 and 6 scored 10 indicating a positive screen for depression and other participants scored within the range of not depressed on the screen. Data were analyzed by considering participants
3 and 6 to be depressed at the time of the interview and the other participants to not be depressed at the time of the interview. These distinctions are further discussed in Chapter
5.
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Table 2
Description of the Sample
EPDS Recent History Participant Age Race Poverty Score Loss of Abuse 1 19 Caucasian 3 N N N 2 19 Caucasian 7 Y Y Y 3 15 African-American/White 10 Y Y Y 4 16 Cherokee/African-American 4 Y Y Y 5 17 African-American 4 Y Y N 6 15 African-American 10 Y N Y 7 15 Mulatto 0 Y N N 8 19 Black 6 Y Y Y Note. Age is represented in years. Race is self-described. EPDS scores had a range of 0-10, with scores > 10 indicating PPD. "Y" = yes; "N" = no.
Table 3
Self-Report of Race
Participant
1 Caucasian 2 Caucasian African American and I would describe it as a little bit white because my 3 grandmother is white. 4 My grandmother is Cherokee so I guess Cherokee and African-American. 5 African-American 6 African-American My dad’s black and my mom’s white. So that’s what they call me 7 “mulatto.” 8 Black. I think of myself as Black.
Seven out of the eight participants were attending school. The type of school that they attended differed and included middle school (1 participant), high school (5 participants), and online college classes (1 participant). Three of the participants
(participants 5, 6, and 7) had premature deliveries. Five of the participants (participants
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4, 5, 6, 7, and 8) described the fathers of their babies as having spent some time incarcerated either while they were pregnant or after the birth of the baby.
Interviews were analyzed using a thematic analysis approach by coding into
Atlas.ti. A network map was created that shows the Themes that will be discussed in this chapter. The network map appears as Figure 2 below.
Figure 2. Experiences of Adolescent Mothers
In the analysis of themes, the research questions will be referred to as Question 1
Lived Experiences and Question 2 Depressed Compared to Nondepressed
Theme 1. Reaction to Pregnancy
Question 1: Lived Experience.
All participants described some feelings of surprise at being pregnant. Their reactions were often tied into their relationships with their family and sometimes with their relationships with their peers and with the father of the baby. Family members were generally not pleased with the pregnancy. Numerous examples of disconnections with
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family members were described as reactions to the participant’s pregnancy. Two of the
participants were forced out of the home where they were living when their pregnancy
was announced.
There were also examples of connections with peers. One participant said, “A
couple of my friends knew that I was pregnant and had brought me the book What to
Expect When You’re Expecting. She told me to just take my time and look it over and
don’t make any drastic decisions.” Four of the eight participants discussed considering abortion as an option when they learned that they were pregnant and one participant considered placing her baby for adoption. These were determined to be disconnections
with the baby at the time including the possible adoption plan since that participant said,
“I thought that maybe I should just give him up for adoption.”
Reactions of the fathers of the babies were varied. Some were shocked and
questioned their paternity (2/8). This is an example of disconnection between the
participant and the father of her baby. However, some fathers of the babies were happy
and showed connection with the participant and some were incarcerated and had no
reaction that the participants shared. Table 4 shows additional quotations from the
participants about the Theme of Reaction to Pregnancy.
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Table 4
Reaction to the Pregnancy
Of Peers and the Father of Of the Participant Of Family the Baby
• "Surprised" "I just didn't • "I told my mom and I • "I was the last one of my think that it would thought that she was friends to have a baby." happen. Not so soon going to break down but • "He was like shocked." anyway." she didn’t. She was like, • "He was at the point of • "I was crying." you know 'Well, can’t saying that we needed a • "I just stayed in my room really do anything about DNA test." for days and days and it. 'She was scared but not • "He was happy." days and days." really upset." • "He was like happy and • "I got pregnant. I didn't • "After she found out that everything." care." I was pregnant, it was • "It was a big surprise and I over with. From then to was excited about it." now, my life has really • "I had done the deed so changed. And she was it's hard to be surprised." really not involved in it • "You have to get all the because she put me out baby stuff." when I told her. A little after – when I was 5 months, she put me out." • "My sister’s dad was mad • "My grandma kept putting me out."
Question 2: Depressed Compared to Nondepressed.
In looking at the responses for the two participants who scored within the depressed range on the EPDS, there were few differences in their reactions to the pregnancy as compared to the nondepressed participants. One participant talked about the relationship to being pregnant and her self- image – “I was crying and I was hurt.” “I was a good girl.” Neither of the depressed participants discussed the reaction of the father of the baby when asked about it in the interview. Participant 3 continued to talk
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about the reaction of her family and Participant 6 told her experience with being abused
and sexually assaulted.
Theme 2. Knowledge
Question 1: Lived Experiences.
Participants talked about both connections with knowledge about pregnancy and delivery and with knowledge of the medical resources available. Table 5 shows examples of disconnections from pregnancy knowledge but it also shows an example of a connection with pregnancy knowledge by the participant who knew that when her water broke with a yellow color, she needed to get medical attention immediately. Five of the participants were attending a class in their high school for pregnant and parenting teens.
They discussed learning about pregnancy in this class. One participant said that “you learn things about being pregnant.” Another said the “You learn from each other about what to expect.” These were connections that showed the knowledge that participants were gaining from the in-school classes and about the connections with peers that were developing in those classes.
One participant described her experience at the hospital as a disconnection of knowledge about delivery and a disconnection with the medical system when she said,
“When I got to the hospital, I didn’t want them to put no IV in me. I was standing up pushing. Mom said that they had to. Finally, they told me that the baby would fall on the floor. (Interviewer: And why didn’t you want the IV?). It was hurting too bad. They couldn’t find a vein.” It was a connection with her mother who convinced the participant to let medical personnel put in the IV and the participant to get into bed.
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Table 5
Knowledge of pregnancy
Knowledge of pregnancy Knowledge of pregnancy Knowledge of and Access and preparation for and preparation for to Medical Services delivery delivery (Continued) Available • "I kept having pain in my • • "...my water broke at 3 • "I was supposed to be back. I thought that o’clock in the morning induced on my due date. maybe it was just an upset and I saw that it was They ended up sending me stomach. Sometimes my yellow-colored and I home because the OB was back will hurt. But the knew that it wasn’t full. " pains were coming every 5 supposed to be yellow- • "I decided to have sex. I minutes or so nothing colored so I said that we told my mother and asked strong. I wondered if had to get going." her for birth control. She these are contractions. I • "My baby had a lot of said that I was not having had just changed the bed hair when she was born sex. She always set my and the sheets and so that’s why I had appointment. I didn’t everything and if heartburn." know how. I asked her 3 something were to happen, times to get birth control." I didn’t want to be sleeping in the bed so we both slept on the couch that night." • ...they say to get into the bathtub and if the contractions get worse, you are in labor. So I go into the bathroom and I fall asleep in there. All of a sudden the contractions were worse. So I don’t want to tell myself that they are contractions because I had been having pain throughout the pregnancy." • "You have to learn a lot – like how fast the baby grows."
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Question 2: Depressed Compared to Nondepressed.
The data showed no differences between the depressed and nondepressed participants with respect to knowledge about pregnancy and delivery and to knowledge and access to medical services.
Theme 3. Relationship to the Medical System
Question 1: Lived Experiences.
One of the participants described a particularly strong connection to her physician but then described feeling disconnected to the allied health personnel who worked in her doctor’s office. She said that they treated her “like a kid.”
Three participants described having disconnections with the medical system because they did not have a consistent relationship with a doctor. The participant’s statement in Table 6 about having to retell her history every office visit is indicative of this kind of disconnection.
Participants were particularly lengthy in their descriptions of disconnections with the medical system in the form of poor medical outcomes. Two of the participants described situations in they were told that they “almost died” during delivery. One participant said that her baby’s “heart stopped” in the Neonatal Intensive Nursery. This is one participant’s description of a poor medical outcome: “It was hard pushing and I was tired because I have low iron so they vacuumed her out and her eye was cock-eyed. I didn’t feel it because I had the epidural but when she came out I saw a whole lot of blood drop to the floor when they was pulling her. They asked me did I want to hold her but at the time I didn’t know that I had a baby; I was out of it. Then, I woke up again and my mom was crying. She said that they had been working on me and they said that they had
70 to rush me to surgery. They put me to sleep but I woke up during surgery and then I asked if I was going to die and the lady said, “We don’t know because you’re losing so much blood and we’re going to put you back to sleep.” And then, when I woke up I was in my room and my iron was at a 7 but normally for teenagers you are supposed to be at
13 or 14. And then they kept giving me blood transfusions. I had 3.” Table 6 shows further data on this theme.
Table 6
Relationship to the medical system
Relationships to Allied Provider Relationships Medical Outcomes Health Professionals • "I went to the doctor. My • "I had a lot of visits at the • "I went to the hospital 7 days mom took me to the doctor hospital. It was pretty cool. in a row because I knew that but the doctor said that I had They treated me good. " there was something wrong. hemorrhoids. She poked me • "when they was offering me Then on that 7th day, the in the front and all the while I to use the bathroom she was doctor said 'Well you keep was pregnant. So I went like 'here’s your cup and I coming and you’re not back to school the next day. want you to go in the dilated.' I said, “But I know And, the school called my bathroom.' But I could tell that there is something mother and said that I was that when she talked to wrong.” And the doctor said hurting; I was underneath the older people, she made sure that he didn’t think that there table. So my mom took me to greet them and this and was anything wrong but he back to the doctor at the that like I was a kid. I know was just going to do an emergency room and they that I’m a kid but treat me ultrasound just to see the did a machine and the whole like you treat other people." baby. And they did the time there was a baby.""And ultrasound and there was no my doctor, Denise, I loved fluid around her. So the her. " doctor told me that I wasn’t • "And I had different doctors going to leave the hospital all the time. And every time without the baby. So they I had a visit, I had a new needed to hurry up and doctor, I had to reexplain my induce me." whole history about me being pregnant and all over again and I was “Dang. You should know this stuff. I don’t got time to keep telling you the same stuff all the time and ask the same questions every time I come.”
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Two participants described having feelings of sadness or depression. One participant said that she had screened as depressed and suicidal when she was given the
Edinburgh Postnatal Depression Scale at her doctor’s office. When the researcher used this as a prompt to ask her if she had received any offer of help with her mood from her physician’s office, she replied, “Yeah. But not immediately after they gave me the score.
But weeks after that they asked me about it and asked me if I needed help or any pills or anything and I told them “No.” Because by that time I had moved out of my sister’s house. “
In a similar disconnection, participant 2 described calling her physician’s office after the birth of her baby to ask for help with her mood. Her words were as follows: “I was an emotional wreck. I asked for help through my doctor’s office and they said they felt that it was postpartum depression and it will subside and every mother has it, just give it time.” (Interviewer: They called it postpartum depression?) “Yeah. They called it postpartum depression and said that most mothers have it and to give it time. ‘Cause I was feeling anxious. I had been on anxiety medicine before (the baby) and I had asked to be put back on it and they said, ‘We can’t do that because you’re in the range of something or other’ and I said, ‘So you’re not going to give me anxiety medicine because
I’m feeling anxious and I’m just supposed to deal with it.’ And she was like ‘Pretty much. Ask for help and if you’re still feeling the way after the weekend, we’ll go from there.’ And, I’m like, ‘Great, great, great.’ So I wasn’t getting any of the help that I needed nor wanted so I just told myself – Just deal with it. Just deal with it. It will go away. Make it go away.”
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Question 2: Depressed Compared to Nondepressed.
When the data were compared between depressed and nondepressed participants
in the theme Relationship to Medical System, both groups describe connections and
disconnections in similar ways.
Theme 4. Relationship to Child Care
Question 1: Lived Experiences.
Five of the eight participants used a day care center for their child care while they were in school. All five described positive connections with the day care as shown by one participant who said. “It’s a good day care. It’s a one room day care. The van picks
up me and (the baby) in the morning and takes us to the day care. Then I sign her in.
The only thing that I have to provide is that I have to bring an outfit to put in her cubbie
so if she has an accident, then it will be there. I only have to bring diapers. They provide
all her formula and food and wipes while she is there. If I don’t have any diapers, then they will give her diapers. There be lots of times that (the baby) has no diapers. I just tell
them and they give her a box of diapers.”
Other quotes showed that the participants were connected to the day care by their
commitment to get the baby to the day care and by their perceived need for day care as
shown in shown in Table 7.
Other participants made child care arrangements with other people. One
participant decided to use the father of the baby and a relative as her day care plan. She
said, “He’s (the father of the baby) got her now. (Interviewer: He has her now while
you’re at school?) This is the first day that he has had her ‘cause he just got out (of jail)
on Friday. Before he got out, my stepdad was taking care of him (the baby).” She
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showed a connection to both the father of the baby and to her stepdad. One participant
used her mother and the mother of the father of the baby for day care while the attended
school.
One participant talked about her desire to be the primary caretaker for her baby
when the participant was not in school. She said, “Me personally I believe that when you
have a child it’s best to sit and take care of the child when you have it at a young age. I
understand that you have a life to live but you don’t want your son or your daughter
growing up to call anyone in your family – your siblings, your mom, your aunties,
‘mom’…Or dad. Because I know that that would be – I know that it would be heart
breaking. Because when I was confused who my mom was. My mom had me when she
was 20. She was always at work; she had 2 jobs. And my grandma and my uncle
watched me. And I got confused that my uncle was my dad. I knew that my grandma
was my grandma but I called her mom. And that hurted my mom so bad because I saw her cry when I called her that. It was heartbreaking for her I could tell. Then she quit her second job and noticed that we started calling her mom. I know that in so many stories that people tell me I know that that hurts.” This is a participant that shows a
connection to her baby as well as some of the context into which she places her
adolescent pregnancy.
An example of disconnection occurred when a participant had left her baby with
the father of the baby. She describes the situation by saying, “I guess that after the baby I
saw the real (father of the baby). Like his mom when I was at his house, (father of the
baby) was like ‘Let me keep the baby because you need some sleep.’ But after a while,
his mom started telling me when the baby slept and when she fed him. His little sister
74 was like ‘You didn’t know that the whole time that he is over here, me and my mother take care of him.’ I said, ‘No, I thought that (father of the baby) had him. ‘She said,
‘No.’ He making it look like he’s doing all these things when really it is his mom and sister.” There are also in her statement, the evidence of some connection around day care with the relatives of the father of the baby.
Participants raised the topic of macro connections by saying that the day care center used by five of the participants was in a church. One participant talked about the absence of day care in her school.
Table 7
Relationship to child care
Who Watches the Baby When Mother in Day Care Macro Issues School or at Work
• "Day Care...It’s by the bus line. So every • "Day care is at the church." day I get up, dress my baby, comb her hair, • "There's no day care at school." take her to the day care, and be at school by 7:30 a.m." • "You gotta know the future. You got your future and your baby’s future. Why would you want your baby’s future to be looking like yours. No. People are stressed and struggle with stuff but I don’t get these people like they say it’s hard. Get your baby in day care. There are a bunch of day cares for teen moms who go to high school."
Question 2: Depressed compared to Nondepressed.
No differences were able to be detected between participants who scored as depressed on the Edinburgh Postnatal Depression Scale and participants who did not score as depressed on the Edinburgh Postnatal Depression Scale. One of the two
75 participants who scored as depressed used the same day care center as four other participants and the other participant who scored as depressed used her mother for day care. This participant described a strong connection with her mother.
Theme 5. Relationship to School
Question 1: Lived Experiences.
Connections described by study participants about school are organized into two subthemes – Connections to Personnel Within the School and Connections to the Macro
System of the School.
All six participants that were in public middle or high school talked about positive connections with school in the form of positive connections with personnel within the school system –teachers, counselors, a principal, a school social worker. The other two participants were either not in school or taking online classes. Some of the participants’ comments about school personnel are contained in Table 8.
Connections to the macro system included the Peoria Public Schools offering classes for pregnant and parenting adolescents. Five of the participants attended these classes. One of those participants described her experience with the class as “I love that class. I came so close with Miss Moss (the teacher). She’s the sweetest lady. She have people to come in and talk to us and give us so much information that we didn’t know and think about. ‘Cause I was clueless in half the things I know now I would never have known. (Interviewer: Like what?) Breast feeding, know how to swaddle the baby, how to shush, ways to calm the baby down, things that they be doing with certain months, certain years, a whole lot. There are peoples in there who have kids so you know when we get time, and we don’t have visitors that day or Miss Moss doesn’t feel like talking,
76 you know we’ll talk and we’ll ask each other questions about the birth or the pregnancy you know with the moms that’s early in their pregnancy, they like to ask questions like
What am I looking forward to, How’s the labor going to be? And that’s what they need.
And that’s what I needed. It was great.”
Two of the participants were no longer in high school and the eighth participant was still in middle school. One of the high schools also offered bus transportation from the day care center at the church to the school and back for the participants.
Table 8
Connections to school
Connections with School Personnel
• "The teacher and one student were very helpful." • "...when (the baby) came home, I was up because she was on a monitor and the monitor went off and I was trying to do my homework and stuff. ‘Cause I had to take finals right when I came home. And my tutor had brought all my printouts so I could study for them. She let me cheat which was awesome. She let me use my study guides. I had an awesome tutor." • (After she had been put out of her family home) "I was in my senior year of high school and my counselor at school and my principal at the time were wonderful and got all my mail sent to the school including college things and regular mail sent to the school. I stayed in Tuscola with one of my mother’s friends who she dropped out when she got married but I was classified as homeless so I could finish school. Note. Disconnections to School included having to drop out or alter plans for schooling. See Table 9.
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Table 9
Disconnections to school
Disconnection with School - Change in Educational Plans
• "That’s when we started fighting and she said that she could take me any time that she wanted and that she was pregnant by (the father of participant's baby). But, she’s not pregnant. And they said that they felt like they should expel me. I was 5 months pregnant by then. But they said that I should really calm down because I was pregnant and fighting. And they said that I should go to Woodruff Academy." • "A staff, he said, 'What’s wrong with you. You’re always getting sick. You’re always sleeping in class. Every time I come in your class you’re always sleep. You’re looking pale.' So then he told my principal and my principal called me down to the office and she was asking me questions. Is there ….And then she took me down to the nurse office and run a pregnancy test and she said I was pregnant." • "I was going to school last fall and then due to me being pregnant and like morning sickness was way too hard. I couldn’t finish out the semester. (Interviewer: So you quit last fall is that what you said?) Yes, it was kind of a bummer because I got accepted into the practical nursing program. And, yeah But I figured that I can go to school any time any time and I won’t miss the – it’s not any option to you know (Interviewer: Not to stay home and be a mom?) Yeah, it can happen and I still have the drive to go back to school anyway so which is very different since my family they were so afraid of me not wanting to go back to school and just work but I still want to go back to school. But, time will tell."
Question 2: Depressed compared to nondepressed.
In this small sample, there were no differences in connection/disconnections to school between participants who scored as depressed on the Edinburgh Postnatal
Depression Scale and those who did not score as depressed on the Edinburgh Postnatal
Depression Scale except that those who scored as depressed did not discuss any disconnections with school.
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Theme 6. Legal System
Question 1: Lived Experiences.
There were few quotes about the relationship to the legal system by the participants. However, those that were made serve to highlight a part of the participants’ experience. The father of the baby for five of the participants was incarcerated at one point in his relationship with the participant. One disconnect that the legal system fostered was when the father of the baby was incarcerated at a location distant from the participant. In describing this, one participant said, “First he was here and then he got sent to (another prison in another town). Then he got transferred again from there.” This makes connection with the participant and with the baby more difficult.
Question 2: Depressed Compared to Nondepressed.
One of the two participants who scored as depressed on the Edinburgh Postnatal
Depression Scale had been sexually abused and assaulted. Thus she had involvement
with the legal system. She said, “My mom has made me talk to the detectives,”
indicating that she did not want to be involved with the legal system. She did not want to
discuss her involvement any more during the interview.
Theme 7. Relationship to Baby
Question 1: Lived Experiences.
Some examples of connections to the baby were seen in what participants
described as their perceptions of problems in the way that medical personnel handled the
birth of the baby. One participant explained, “And then I had her and it took them
forever to clean her up. I only got to see her for a couple minutes and then they took me
upstairs to recovery and I was in recovery for an hour and I still didn’t get to see her.
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Then they took me back to the room and I waited at least a half an hour to 45 minutes and they brought her in and the student nurse was there. And she was supposed to have a number on her bracelet that matched mine and she didn’t. My number wasn’t there - The bed number wasn’t there, something. She didn’t know what she was doing; she was a student nurse. So everyone was around and I couldn’t hold the baby. Everyone was surrounding her and looking at her and I couldn’t see her. I asked if I could just see her.
I had a meltdown. They couldn’t take her out of her bed. (Interviewer: So how did they get that corrected?) So the nurse came in and said that the number was not supposed to match mine. It’s supposed to match the bed that she’s in. I was like “Oh my gosh, just let me hold her.” So finally that happened.” [Baby coos. Participant tends to her and says
“Mama just wanted to hold you.”] It was horrible.”
Participants talked about disconnection with their babies using descriptions such as they weren’t excited about the baby or that they cried when they “looked at the baby.”
Examples of connections and disconnections with the baby are included in Table 10.
Another subtheme that was found was that participants talked about the lack of time in their lives since the baby was born. One participant went back to work within the first weeks after the birth of the baby and talked about the difficulty of getting her own needs met. One participant talked about not having time to do “high school things.”
Other participants talked about the role conflict of being a mother and a student and four participants talked about the difficulty with time in the morning when they had to dress themselves and their babies, get the babies to day care, and be at school by 7:30 a.m.
Examples of this data are also included in Table 10.
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Table 10
Relationship to baby
Relationship with Baby Relationship with Baby Lack of Time Connection Disconnection
• "The first time that I heard • "I wasn’t too excited to • ...he (the baby) requires so my daughter’s heartbeat I have a baby. I was like Oh much time and since I don’t was crying and stuff." well there’s a baby in my have that other parent • "But you notice when you stomach." helping out, I probably only have that baby that is your • "It was very overwhelming. eat like about you know best friend." I had the baby blues." about once a day." • "...I knew what I was having • "It’s just the simple fact that and it was exciting shopping being a single mother and a for him. I was thinking that I young mother, that’s like a was going to be a mom. I double whammy. There’s could get a car seat. just no time. " Something that was mine."
Question 2: Depressed Compared to Nondepressed.
Again, a analysis of the data show no difference between mother who scored as depressed on the Edinburgh Postnatal Depression Scale and those mothers who did not score as depressed on the Postnatal Depression Scale. Both groups had a mixture of connections and disconnections with their babies and participants in both groups talked about the time pressure that they felt now that they were mothers.
Theme 8. Relationships to Persons and Spiritual Concepts
Question 1: Lived Experiences.
Participants described relationships to a number of different persons and spiritual concepts as part of their lived experience of being an adolescent mother. There were connections and disconnections discussed in each group of relationships. As discussed in
Chapter 3, the reactions of the persons in the participants’ lives to their pregnancy was
81 sometimes a part of or influenced their relationships to those persons while pregnant and after the birth of the baby.
Relationship to Father of the Baby. Participants described connections and disconnections with the fathers of their babies (Table 11). Sometimes both occurred in a
short period of time. For example, one participant described how she was afraid when
she went to the hospital for delivery and wanted the father of the baby there. But when
he came “he and his friends were all drunk and stuff” and so she told him to leave. But
then she wanted him back in the delivery room and was upset when he didn’t get to cut
the umbilical cord.
Table 11
Relationship with father of baby
Relationship to Father of the Baby Relationship to Father of the Baby Connections Disconnections
• "Ever since she was born it’s just been me and • "Like one time I went to get my nails done with her father. Ever since she was born she (my his mom and he got mad because we was gone mother) has not bought her one pack of Pampers. so long. We left at 12 and got back at 7. I told And we bought her clothes and her coat. It’s just him that I don’t say anything when you are out me and the dad right now." so long. He said that he didn’t think that it was • "I’m living with my boyfriend now. We’re fair that I left him with the baby. I told him that talking about marriage. Me and him. We deal I didn’t think that it was fair that I had surgery with the baby together. It’s 50-50. We wake up and he left me here with the baby." in the night together. We take turns feeding her • "We didn’t talk until 2 weeks before I gave you know but it’s like that’s my life partner right birth to (the baby) and he came back into the there. " picture and you know it was a rocky road but you know he came to the hospital when I was delivering (the baby). He was 2 hours late. But I guess that it’s not on my time; it’s on his time.
Relationships to Peers. The strongest theme identified measured by it being consistent in all eight interviews, was the lack of social support that the participants experienced from their friends and peers after the baby was born. This disconnection
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from people that they had previously felt connected to resulted in feelings on sadness,
loneliness, anger, and resignation depending on the participant but all were affected by
the change in their social system. Examples of the way that participants described this
are
“When you think that you have friends as a young person, and you get pregnant,
you go from having 100 friends before you get pregnant, to having maybe 50
friends during your pregnancy, to when the baby is born to the first week having
30 and then when life settles in, having maybe 10.”
“We all changed. One of my friends she had a baby who’s going to be 1 next
month and she’s pregnant now. She’s about 8 months now. And my other friend,
she got a baby and she’s 7 months now. And my other friend, she moved about of
town. She’ll be back. (Interviewer: So your friends had babies already. I was
the last one to have one. (Interviewer: So everyone is busier with their babies
and your relationships changed?) Right.”
Relationship to Community. Participants made less than ten comments about relationship to the larger community outside of the medical, school, and daycare systems.
In those few comments there were examples of connections and disconnections and an insight that her perceived reaction from the community may be tied to her self-talk and self-perception and experiences of shame and guilt. She said, “I even a got a few looks
going out to eat or to the grocery store. But in the medical office, everyone is there
because they are either pregnant or they have a child and the medical professionals keep it professional and I never felt like everyone is looking at me and they probably think that
I’m like 16. But it was definitely something that you struggle with because you think that
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people are looking at me and thinking that I was 16 when in reality I am out of high
school and 19 and providing for myself. (Interviewer: You said that you were ashamed?)
That played a big part in it. I feel like if you feel ashamed of yourself, you feel like everybody is ashamed of you. And you feel like if you’re looking at yourself and asking
“Why are you pregnant; What are you doing?”, then you feel like other people feel or think that way.”
There were three participants who described particularly helpful connections to community agencies – one to the Agency, one to a worker from the Women, Infant, and
Children’s Program, and one to the school social worker at her school.
Relationship to Self. Participants’ discussion of their relationship to themselves throughout the time that they learned of the pregnancy, were pregnant, and were mothers was varied and the themes identified had less than three comments for each theme. These themes included:
A disconnection with changing body imagine and not wanting to wear maternity clothes.
A disconnection and then a connection as they changed their self-image from a teenager to a mother. One participant said, “I’m a mom now. (Interviewer: So your image of yourself has changed?) Yeah – It’s like you’re grown now. You can’t just be putting your baby off with everybody.”
A discussion that their mood changed while pregnant and after the baby was born.
One participant said, (Interviewer: Tell me about your mood when you were pregnant.)
“It was all over the place. (Interviewer: All over the place?) Part of that depended on how the other people in my life were treating me.” This demonstrates the importance of
84 understanding the lived experience of the adolescent mother in the context of her environment.
Question 2: Depressed Compared to Nondepressed.
Participants who were depressed on the Edinburgh Postnatal Depression Scale and those who were not depressed on the Edinburgh Postnatal Depression Scale did not show differences in connections and disconnections in relationships with the following exception:
One participant who scored as depressed and one participant who did not score as depressed but said that she had only recently not felt suicidal both described not having friends before, during, or after their pregnancy. One said, “I don’t have many friends.
Just some of the people that I’ve come to school with, that I’m graduating with – I have to sit in the classroom and look at them every day. I associate with them but I don’t hang with people outside of school. I didn’t do it before my pregnancy, during my pregnancy, or even now. It’s not that I don’t want friends.” And the other said, “I only have one friend. (Interviewer: Did you have more friends before the baby?) I had associates. I didn’t really talk to anybody. Nowadays people are a mess. I only had conversations with one person.
Final Question.
The final question asked of the participants in the interview was “What do you want adults to know about the experience of being an adolescent mother.” Their answers were analyzed separately and the following themes were seen: Disappointment with
Peers, It’s Hard, Our Life is Not Over, We Really Need Jobs, It Don't Seem So Bad as
People Say, Don’t Have a Stereotype, It Affects How I Thought About Myself, and
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Effect of Being Young. These themes use the actual quotes of the study participants.
Data that support the themes are summarized in Table 12. It was the researcher’s observation that only one participant asked for clarification of the question. The other participants began immediately to give voice to what they wanted adults to know about their lived experience.
Table 12
What you want adults to know
Disappointment with Peers It's Hard Our Life is Not Over
• "We take life for granted." • It's very hard." • "It doesn't stop here." • "We are going to school but • “It's hard because if you're • "I cried when I decided that we have no drive to work. living in a situation with your I couldn't play professional mom and your basketball. I'm going to be grandmother...you want to lawyer." change some of the things that they did and they get mad and frustrated because they feel like you're not listening to them." • "If you have a teen daughter who that's pregnant, then help them out...and don't be their child's mother." • "It's busy." • In my eye I may be a teenager but I have so much ambition that it's just crazy. I'm NOT a teenager. ...I done did things. I done overcome things. I've come a long way. It's hard."
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Table 12 (cont.)
"We really need jobs." "It don't seem so bad as people say.
• "Sometimes your parent doesn't help you." • "...it's not that hard doing it by myself. Except • "Can't get a job at 14. I wish that the state I'm not really doing it by myself. I have my people would have to have a baby at 14 and mom and dad." know what we go through before they make the laws."
"It affects how I thought "Don't have a stereotype." Effect of "Being Young" about myself"
• "We're not all immature." • "It only takes one time." • "...it's the pressure now of • Not all teen moms are "wild • "I tried to follow my religion we're young" and crazy." but (my boyfriend) didn't • "..I think that it is way more • "It's not a teen mom status; want to." hard for teenagers because it's a mom status." • "It changes your life some." these be the years that you • "No one knows what the be having fun but you're not teenage mom has gone a kid no more once you be through - rape, sexual abuse." having this baby." • "A teenager has to pretend to be an adult but still act like a kid to the adults." • "We have to remember everything; All an adult has to remember is that I have to work in the morning." • "I was young and didn't know what I was getting myself into." • "I don't consider myself grown but I consider myself s an adult because I have adult responsibilities."
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Findings in Relationship to Research Questions and Hypotheses
Research questions, hypotheses, and findings are summarized as follows:
Research question 1. What is the lived experience of first-time adolescent mothers who are experiencing depression in the postpartum period?
Hypothesis 1. The experiences will be able to be understood by looking at micro, mezzo, and macro relationships including connections and disconnections of the participants.
Relational-Cultural Theory helped to understand the lived experience of the adolescent mothers in this study by looking at their connections and disconnections at multiple levels of interaction.
Hypothesis 2. The risk factors for depression in adolescent women will emerge as themes in adolescent mothers who scored as depressed on the Edinburgh Postnatal
Depression Scale.
Some of the risk factors for depression were present in the lived experience of all study participants including those participants who scored as depressed on the Edinburgh
Postnatal Depression Scale and were used to name and examine the themes presented by the participants.
Hypothesis 3. Participants will describe a fluctuating experience of mood postpartum.
Participants described both connections and disconnections in ways that showed that their mood fluctuated in that these connections and disconnections changed at points during their experience of being pregnant and being a mother.
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Research question 2. What is the lived experience of first-time adolescent mothers who are not experiencing depression in the postpartum period?
Hypothesis 1. The participants who scored as not depressed on the Edinburgh
Postnatal Depression Scale will share experiences and themes with participants who have scored as depressed.
Participants who scored as nondepressed and participants who scored as depressed on the Edinburgh Postnatal Depression Scale shared connections and disconnections and no reportable difference was found in these connections and disconnections between the two groups.
Summary of Findings in Relationship to Relational-Cultural Theory
The sample did not produce results that allowed prediction of a score on the
Edinburgh Postnatal Depression Scale from the participant’s discussion of connections and disconnections in their lived experience. However, the participants did discuss how connections fostered their growth and development as individuals and as mothers. And, conversely, their comments showed how disconnections inhibited their growth and development as individuals and as mothers. For example, the participant who said, “I decided to have sex. I told my mother and asked her for birth control. She said that I was not having sex. She always set my appointment. I didn’t know how. I asked her three times to get birth control” illustrated disconnections with her mother and with her knowledge about the medical system and how to access services. These disconnects had consequences for her lived experience.
Participants who described connections also demonstrated how those connections influenced their lived experience as mothers. As an example, participants who attended
89 in-school classes for pregnant and parenting teens described increasing their knowledge about pregnancy and child development. Two of the participants further described a relationship with a person who taught that class as being an important part of why the class was so helpful to them in developing knowledge and encouraging social support.
Thus, the results do assist in understanding the lived experience of first-time adolescent mothers by highlighting the importance of listening to their connections and disconnections as they live their lives. And, because depression in adolescents is dynamic, this understanding of connections and disconnections provides a point in time place to understand the lived experience at over time and in the particular moment.
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CHAPTER 5: DISCUSSION AND IMPLICATIONS
Introduction
This study focused on the place where adolescent depression, postpartum depression, and the lived experience of the research participants intersected (See Figure
3). Previous chapters have presented theoretical and empirical literature related to adolescent depression as distinguished from depression in adults. Postpartum depression and its consequences for mothers and children have been presented. The design used in this study was intended to capture the lived experience of adolescent postpartum depression. As stated in Chapter 4, only two of the participants scored as depressed as measured by the Edinburgh Postnatal Depression Scale. However, some participants who did not score as depressed expressed feelings of depression and/or were told by a health care professional that they were depressed.
Adolescent Depression
Lived Postpartum Experience of Depression Adolescent Mothers
Figure 3. Conceptual Model
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The findings from this study remind social workers and others who work with
adolescent mothers to have empathy for the context of each mother. The findings show
how Relational-Cultural Theory can be used to understand the lived experience of the adolescent mothers who participated in the study. The study did have strengths and limitations. And, finally, the study had implications for social work practice, social work policy, and further social work research.
Study Critique
Study Strengths.
A strength of this study was that the data were the actual words of the study
participants as they described their lived experience of being an adolescent mother. In regard to methodology, the semi-structured interview was created from the empirical and theoretical literature regarding risk factors for depression, postpartum depression, and adolescent development. The interview was further guided by Relational-Cultural
Theory as the questions emphasized relationships with their connections and
disconnections at micro, mezzo, and macro levels of the lived experiences of the study
participants.
The study used two coders. Both coders were experienced social workers who
have worked with adolescent women in their social work practice. The second coder was
given information about Relational-Cultural Theory and about the analysis method for
the study two weeks before the second coding process and she indicated that she
understood both.
The researcher has had working with adolescents as a major focus of her social
work practice for more than 30 years. This meant that the researcher had knowledge
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about the different contexts of the participants such as their school and neighborhood,
was comfortable in the high school setting where five of the eight interviews were
conducted, and was comfortable with making home visits to the neighborhoods of varied
socioeconomic status in which the other three interviews were conducted. The researcher
was also comfortable in what could be called the adolescent culture that the participants
often used to describe their lived experience.
The researcher made multiple efforts to bracket (self-reflect upon and remove
personal bias) her experience during the research process. This started before the study
began by taking an adolescent young woman with the researcher to buy the costume
jewelry that was given to participants as a thank-you gift. The researcher kept a journal after every interview of her thoughts and impressions. This allowed the researcher to include the extra step of looking back at the coding to try to be certain that bracketing was in place.
Study Limitations.
Any time that any screen is administered including the Edinburgh Postnatal
Depression Scale (EPDS), it is a point in time instrument. This combined with the fact
that the Edinburgh Postnatal Depression Scale is a self-report instrument would add some possibilities for both internal and external threats to validity. Examples of such threats are described below.
Participant’s mood on the day of the screen could be influenced by hormonal changes (internal). Participant’s answers could be influenced by current events in her life
(external). For example, Participant 8 had just learned a few minutes before the interview that she was going to be allowed to graduate from high school in a few days. Even
93 though, her score on the EPDS scale (10) did put her in the depressed range, her interview included her discussion of how she just recently didn’t feel suicidal.
It has been a common practice in the Peoria community to use the EPDS as the tool for postpartum depression screening. It is the tool being used at the Clinic and the
Agency. Thus, there is a test-retest threat to validity. Several of the participants expressed remembering some of the questions when the EPDS was administered. And, one, Participant 4, was very clear that she remembered this instrument. Her nonverbal response was that she was excited to know about the instrument. She smiled and had an excited tone in her voice. She scored a 0 on the EPDS. One question here is whether she wanted to “do well” on this “test.”
Another external threat may be the desire of the participants to please the researcher. By the time of the administration of the EPDS at the end of the interviews, in the researcher’s opinion, a relationship had developed with all participants. That relationship could have influenced the manner in which participants responded to the questions.
Another limitation of the study was the small size of the sample and the fact that participants shared living in a small geographic area. All study participants lived in an urban setting. There were no participants from a rural area. This raises the question of generalizability which is receiving discussion in the qualitative literature. Trochin (2009) does add a perspective that even though qualitative research is designed to be a point in time understanding of a participant’s experience some “researchers espouse the approach of analytical generalization where one judges the extent to which the findings in one study can be generalized to another under similar theoretical, and the proximal similarity
94
model, where generalizability of one study to another is judged by similarities between
the time, place, people and other social contexts” (p. 325).
Another limitation of this study is that connections and disconnections were coded dichotomously. In analyzing the transcripts, a relationship was coded as either a connection or a disconnection. Relational-Cultural Theory would not dictate such a dichotomous coding but rather view relationships along a continuous continuum. For example, when participants described breaking up and subsequently making up with the father of the baby, both a connection and disconnection and nuances of both were present.
Difficulty in Recruiting a Sample for the Study.
As described in Chapter 3, the research used a multiple targeted approach to recruit study participants. And yet, recruitment continued for two years. As the study progressed, the researcher began to hand study flyers to participants after the interview in a snowball sampling technique. Study participants expressed an eagerness to help. They even mentioned women who they were going to ask to participant. However, there was never a contact from anyone from this snowball sampling.
Every study participant had someone in her life who knew the researcher and who encouraged the adolescent mother to sign up for the study at either the Clinic or the
Agency. It was as if the participant had to have that “stamp of approval” about the researcher by someone that the participant trusted before she would agree to be in the study. Using Relational-Cultural Theory, this would say that a connection with someone whom a potential research participant trusted had to be present before she was willing to
explore any kind of connection with this study or with the researcher. This emphasis on
95
relationship is consistent with social work theory and practice. The difficulties in
recruitment represent an important area for future research.
There are some specific strategies that could be tested in future research. One
strategy might be using a peer recruiter closer in age to the potential study participants.
The peer recruiter could let other adolescent mothers know about the study. Another
method for increasing involvement in this type of research might to partner with a
practice agency or investigate ways that the researcher could become part of the
parenting class curriculum. Another area to explore is to examine ways in which the
father of the baby might either facilitate or inhibit the mother’s participation in such a
study.
In this study one of the inclusion criteria was that participants be between the ages
of 15 and 19. Even with the small sample in this study, differences were seen between
the younger and older participants in their responses and their processing of their lived
experience. Suggestions for future research would be to either restrict inclusion to a narrower age range or to have a larger sample so that distinctions could be made between different age groups.
Implications
Practice.
Social workers need to take the time to build a relationship and to do a thorough assessment of the environment of adolescent mothers which must include giving adolescent mothers a chance to describe their lived experience. This is a difficult task given the current limitations on time for child welfare workers as they are expected to have increased caseloads and increased paperwork.
96
Professionals who work with adolescent mothers need to ask questions about whether they have food to eat, where they live, and their mood. As participants 2 and 8 taught, getting an indication of a problem (in their cases depression) and then not offering services until sometime later means that an adolescent mother has to make do in the best way that she can. This would seem to further isolate the mother and to discourage her from reaching out for help in the future.
Since all participants described an absence of and/or a loss of social support from friends and peers after the birth of the baby, social work needs to continue to develop ways to facilitate connection of adolescent mothers. It is important to note that mothers who might be least receptive to this type of connection (for example the mothers who said that they had no friends) may be the ones that need to be asked what would facilitate their involvement. It is important to also note that both of those mothers who said that they had no friends were involved in the same in-school program for pregnant and parenting teens. The program provided a great deal of support and education, but the participants did not describe friends coming from this program. The woman who ran that group personally provided transportation for them if they needed it, made an effort to go and visit their babies in the daycare during school so that she could talk with the mothers about them, and bought baby books for the mothers to complete. Her connections with the mothers and her efforts to make the connection seemed to be an important example of what kept those mothers engaged.
In this study, the eight participants described their race in six different ways. This demonstrates that the participants experience race in ways that are more than discrete categories. Social workers need to understand the concept of race from the viewpoint of
97
their clients. This means that they need to first ask how a client defines her race and then
to ask how that definition affects both the self-image of the client and how the client views interactions with persons and systems. This is consistent with the NASW Code of
Ethics Standard 1.05 Cultural Competence and Social Diversity that requires social workers to seek education about and practice competently regarding issues of diversity
(National Association of Social Workers, 2008).
By asking for the client’s definition of race, there may be discovered policy implications for practice. For example, Participant 4 described her race as “My grandmother is Cherokee so I guess Cherokee and African-American.” This means that in certain legal and child welfare scenarios, if this definition is accurate, this participant will be eligible for services defined by the Indian Child Welfare Act of 1978.
Policy.
Participants raised the issue of not being able to work when they became a mother because of their young age. Perhaps adolescent mothers could be funneled into programs that do exist for young people to work and be paid and such work opportunities will need to include day care. All subsidized daycare that participants attended was only available to them while they were in school. This raises the need for not only daycare while adolescent mothers work but also the need for daycare on second and third shift time periods since adolescent mothers such as participant 8 can find themselves working in industries that work more than the normal first shift.
Future research
As mentioned in Chapter 1, social work has not been a part of facilitating the study of postpartum depression in adolescents because social workers have not done the
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research. This study gives the social work community an opportunity to bring social
work knowledge, perspective, and research into the area of working with adolescent
mothers around understanding their lived experience and including an understanding of
how connections and disconnections are related to mood changes. Topics for further
research include:
Finding ways to get information to adolescents about pregnancy, delivery,
and child development.
The findings illustrated multiple examples of how the adolescent mothers in this
study had limited or incorrect knowledge about pregnancy, what to expect during the
delivery of their babies, and/or child development. Those mothers who did attend a class
at their school for pregnant and parenting mothers demonstrated a higher level of
knowledge although there were examples of lack of knowledge from those participants
also. Thus, one implication seems to be the need to ask adolescent mothers what would
help them to understand these areas and then to look at what obstacles are present. One
participant, for example, talked about seeing a different doctor each time she went for a
prenatal visit. She was annoyed that she had to repeat her history each time. This might
have interfered with her learning about pregnancy, delivery and child care.
Social workers, medical personnel, and others who work with pregnant and
parenting adolescents should incorporate knowledge about learning and about the
adolescent culture and look at current empirical studies of teaching adolescents about
pregnancy, delivery, and child care and development. For example, perhaps videos or
applications (apps) could be sent to pregnant and parenting adolescents’ telephones.
Research could examine different modalities and ways of reaching adolescent mothers.
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Questions That Need To Be Asked.
Since 25% of the participants in this study were forced to leave their living situation when they became pregnant, questions about housing need to be asked at the time of and soon after a pregnancy is confirmed. This could most easily be done in the medical facility when an adolescent mother finds out that she is pregnant and in subsequent prenatal visits. Future research needs to examine the impact of housing on the mother and baby.
Partnering with Physicians, Nurses, and Other Providers of Physical Health
Care.
More than one participant discussed not feeling that medical providers understood her description of depression or anxiety and was not provided treatment in a timely fashion. Social work can have an impact on improving the delivery of services to depressed adolescent mothers when social workers are able to be seen as viable members of the health care team and of teams of educators in medical education settings. Using the theoretical frameworks of social work such as Person-in-Environment and Strengths as well as Relational-Cultural Theory, social work can then recommend and model new ways to understand, give voice to, and treat depressed adolescents during the perinatal period. Specific strategies include the following:
1. Use nontraditional vehicles to help members of the medical community
develop an increased sensitivity to the experience of depression. Donohoe
(2005) suggests using stories of the disenfranchised in literature for this
purpose. This would have the added benefit of giving readers a chance to
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absorb and contemplate the depression experience without the pressures of
time limits imposed on patient contact and feelings about any specific patient.
2. Help members of the medical community see the relationship between the
experiences of their patients and the need for review of public policy.
Donohoe (2005) suggests that the medical community should have a role in
confronting the effects of poor environment and social injustice issues on the
health of individuals.
Change in Definition of Postpartum Depression in Diagnostic Statistical
Manual.
In 2013 the American Psychiatric Association published the latest edition of the
Diagnostic and Statistical Manual – DSM – 5. In this newest edition, postpartum depression was included as a new specifier for Major Depressive Disorder; viz., “With peripartum onset” (p. 186). This new specifier is described as “This specifier can be applied to current, or if full criteria are not currently met for a major depressive episode, most recent episode of major depression if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery” (American Psychiatric Association,
2013, p. 186).
This definition does serve to include at least some of prenatal depression which has been shown in Chapter 2 to be a risk factor for postpartum depression (Banti, et. al.
2009; Beck, 2001; Silverman & Loudon, 2010). However, this short time period – four weeks – does raise some concern. One of the themes in the study participants’ data was the decreasing social support over time following the birth of the baby. Since lack of social support has been shown to be a risk factor for maternal depression following the
101 birth of a child, decreased social support would seem to increase the risk for postpartum depression. In a poster presentation in 1999 (Follett, Dayton, Simonds, & Rosenblum), mothers of young infants were studied longitudinally. When the infants were seven months old, “mothers’ perceived need for social support had an additive effect on depression when combined with environmental risk, resulting in elevated levels of depression.”
Need for Research That is a Merging of Psychological, Behavior, and
Biological.
“Probably the most influential effort in this area has been the change in research funding policy, announced by the National Institutes of Mental Health in 2013. The awarding of research funding now favors use of the Research Domain Criteria (RDoC) over DSM diagnostic categories (including MDD). RDoC marks a major conceptual shift in that it reorganizes the way we categorize our observations, parsing behaviors and mental status findings into groupings that are believed to correspond more directly with underlying biological processes. RDoC promises to facilitate exploration of the underlying neural, genetic, cellular, molecular, and physiologic bases of the various component features of what we call major depression” (Schildkrout, 2015, p. 3). The participants in this study show that it is important to study their lived experience from a multifactorial perspective.
102
Appendix
Appendix A. Study Recruitment and Informed Consent
Appendix B. Codebook
103
Appendix A. Study Recruitment and Informed Consent
104
105
106
107
108
109
110
111
112
113
Appendix B. Codebook
Code List & Hierarchy: The Lived Experience of First-Time Adolescent Mothers
Thematic and Axial Codes:
a. Connection
i. Connection
ii. Disconnection
b. Timing
i. Before Pregnant
ii. While Pregnant
iii. After Baby Born
c. Reaction to Pregnancy
i. Participant
ii. Father of the Baby
iii. Participant's Mother
iv. Participant's Father
v. Friends
vi. Participant's Other Relatives
vii. Peers
viii. Relatives and/or Friends of Father
ix. Housing Difficulties
d. Knowledge
i. Pregnancy Knowledge
1. Preparation for Delivery
114
ii. Child Care and Development
iii. Healthy Relationships
iv. Medical System Access
v. Medical System Resources
vi. Social Service Access
vii. Social Service Resources e. Relationship to the Medical System
i. Provider Relationships
ii. Allied Health Professionals
iii. Macro Access
iv. Medical Outcomes f. Relationship to Child Care
i. Macro Issues
ii. Micro Issues g. Relationship to School
i. Macro System
ii. Relationships h. Relationship to Work i. Relationship to the Legal System j. Relationship to the Baby
i. Lack of Time k. Relationships to Persons and Spiritual Concepts
i. Relationship to Mother
115 ii. Relationship to Father iii. Relationship to Father of Baby iv. Relationship to Friends v. Relationship to Other Relatives vi. Relationship to Peers vii. Recent Losses or Deaths viii. Relationship to God ix. Relationship to Community x. Relationship to Self
1. Mood
2. Body Image
3. Shame/Guilt
4. Self Care
5. Self Image
6. Health
7. History of Abuse
8. Impact of Age
116
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