A Parenting and Life Skills Intervention for Teen Mothers: a Randomized Controlled Trial Joanne E

A Parenting and Life Skills Intervention for Teen Mothers: A Randomized Controlled Trial Joanne E. Cox, MD,a,b,c Sion Kim Harris, PhD,b,c Kathleen Conroy, MD, MS,a,c Talia Engelhart, MHS,a Anuradha Vyavaharkar, MSW, MPH,a Amy Federico, BSN,a Elizabeth R. Woods, MD, MPHb,c

BACKGROUND: Teen mothers often present with depression, social complexity, and inadequate abstract parenting skills. Many have rapid repeat pregnancy, which increases risk for poor outcomes. We conducted a randomized controlled trial of a parenting and life skills intervention for teen mothers aimed at impacting parenting and reproductive outcomes. METHODS: Teen mothers were recruited from a teen-tot clinic with integrated medical care and social services. Participants were randomly assigned 1:1 to receive (1) teen-tot services plus 5 interactive parenting and life skills modules adapted from the Nurturing and Ansell-Casey Life Skills curricula, delivered by a nurse and social worker over the infant’s first 15 months or (2) teen-tot services alone. A computerized questionnaire was self-administered at intake, 12, 24, and 36 months. Outcomes included maternal self-esteem, parenting attitudes associated with child maltreatment risk, maternal depression, life skills, and repeat pregnancy over a 36-month follow-up. We used generalized linear mixed modeling and logistic regression to examine intervention effects. RESULTS: Of 152 invited, 140 (92%) participated (intervention = 72; control = 68). At 36 months, maternal self-esteem was higher in the intervention group compared with controls (P = .011), with higher scores on preparedness for mothering role (P = .011), acceptance of infant (P = .008), and expected relationship with infant (P = .029). Repeat pregnancy by 36 months was significantly lower for intervention versus control participants. CONCLUSIONS: A brief parenting and/or life skills intervention paired with medical care for teens and their children has positive effects on maternal self-esteem and repeat pregnancy over 36 months.

’ Divisions of aGeneral Pediatrics and bAdolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, WHAT S KNOWN ON THIS SUBJECT: Teen parents and their Massachusetts; and cDepartment of Pediatrics, Harvard Medical School, Harvard University, Boston, children face multiple medical and social challenges. Massachusetts Promising interventions include home visiting, school-based interventions, and medical homes. Intervention outcomes Dr Cox conceptualized and designed the study, participated in design of the data collection include optimal medical care delivery, decreased repeat instruments, supervised the implementation of the protocol, drafted the initial manuscript, and pregnancy, and improved parenting skills. reviewed and revised the manuscript; Dr Harris performed the data analysis and reviewed and revised the manuscript; Dr Conroy supervised data collection, critically reviewed the manuscript for WHAT THIS STUDY ADDS: Longitudinal outcomes for important intellectual content, and revised the manuscript; Ms Engelhart coordinated and interventions used to target teen mothers and their children supervised data collection and reviewed and revised the manuscript; Ms Vyavaharkar and Ms have not been extensively studied. Our findings suggest that Federico participated in study design and implementation and revised and reviewed the a teen-tot model plus an enhanced parenting and life skills manuscript; Dr Woods conceptualized and designed the study, supervised study implementation, intervention shows promise for improving parenting and reviewed and revised the manuscript; and all authors approved the final manuscript as attributes and reducing repeat pregnancy. submitted and agree to be accountable for all aspects of the work. This trial has been registered at www.clinicaltrials.gov (identifier NCT01379924). To cite: Cox JE, Harris SK, Conroy K, et al. A Parenting and Life Skills Intervention for Teen Mothers: A Randomized DOI: https://doi.org/10.1542/peds.2018-2303 Controlled Trial. Pediatrics. 2019;143(3):e20182303

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 143, number 3, March 2019:e20182303 ARTICLE Although the rates of teen pregnancy interventions include school- prenatal clinics and community-based have declined nationally over the last based16,17 or home-visiting agencies between February 2008 and – – 25 years, socioeconomic and racial programs18 20 and mentoring.21 23 February 2012. At the first infant disparities persist. Teen pregnancy Other successful interventions have visit, every patient seen was asked to and parenting remain a challenge in used the medical home or teen-tot enroll in the study by trained – communities with high rates of model.24 27 program staff. Those agreeing to poverty, low social capital, and participate (140 of 152; 92%) were The Adolescent Family Life (AFL) inadequate access to contraception randomly assigned by the research demonstration projects, organized and among certain racial and/or assistant to the parenting and/or life through the Office of Adolescent ethnic populations.1,2 Teen parenting skills intervention or control using Pregnancy Programs (OAPP), are is associated with risk of depression, a unique numeric identification aimed to support young families poor social supports, school failure, number and computerized random through social support and medical conflicted relationships, and – number generator to determine care.28 31 The AFL funding required inadequate family and community assignment. It was indicated in power – programs to deliver 10 core services, support.3 6 Women who were teen analysis that a sample of 48 including pregnancy testing, adoption parents complete less education participants in each arm had 80% counseling, preventive and prenatal and are more likely to live in power to detect a group difference in referrals for teens, nutritional poverty.4 Teens with children are mean Maternal Self-Report Inventory counseling, well infant care, sexually often unprepared for the stresses of (MSRI) total scores as found in our transmitted infection screening, raising young children; and those previous study.27 family life counseling, educational or with histories of social isolation, vocational services, mental health Teens received $10 plus violence, or other sources of toxic services, and referrals for family transportation for each intervention stress are more likely to parent planning. A multisite evaluation, visit and study assessment, which using harsh, authoritarian – which included our program, were completed in the clinic. The methods.7 10 Their children lag revealed increased use of long-acting majority of participants lived in the developmentally and are at risk for contraceptives, child care, and nearby neighborhoods where poor educational outcomes that 32 – decreased repeat pregnancy at 12 poverty reached 36%. All study persist into adolescence.6,11 13 months.30 However, there is a paucity participants attended the teen-tot Interventions for teen parents often of scientific studies examining longer- clinic, receiving preventive care, focus on decreasing both repeat term outcomes of these programs. urgent care, gynecologic services, pregnancy and negative parenting Our aim with this study was to test and integrated social work. A nurse behaviors associated with teen the hypothesis that compared with offered contraceptive counseling, parents that place children and their the teen-tot model alone, adding and social workers provided brief mothers at risk for adverse long-term a structured, comprehensive check-ins plus intensive family outcomes. Repeat teen pregnancy parenting curriculum to an AFL- support services when needed.24 multiplies risk for both parental funded teen-tot model would increase All required AFL core services as stress and harsh parenting that parenting self-esteem and reduce outlined in Title XX were offered,31 negatively affect child outcomes.14 parenting attributes associated with and the Institutional Review Board In addition, the children are more child maltreatment, maternal of Boston Children’sHospital likely to have behavioral problems. depression, and repeat pregnancy approved the study with a waiver Educational and employment over a 36-month follow-up. of parental consent. outcomes are better for teens without another pregnancy.8,14 Yet, almost METHODS Intervention 20% of teen births are repeat Because of broad OAPP goals for births.15 Setting and Participants improving teen parenting while Comprehensive programs have been This study was set in Boston, enhancing youth and family aimed to address family planning Massachusetts, in a teen-tot program development, elements of 3 validated while providing parenting and social within a pediatric hospital.24 curricula were incorporated into the support.16 Programs are used to Eligibility criteria included maternal intervention, which then underwent address parenting behaviors, age ,19 years at delivery and structured expert content review and maternal attachment to the infant, willingness to receive maternal and pilot testing. Psychoeducational and teen life skills to enhance child infant care in a teen-tot program. modules that were one-on-one used developmental outcomes and teen Teens with infants $12 months were the Ansell-Casey Life Skills self-sufficiency.11,16–18 Promising excluded. They were referred from Assessment Curriculum,33, the

Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 COX et al Women’s Negotiation Project Data Collection and Measures me”). Because of skewed data or to 34 Curriculum for Teen Mothers, and Self-administered computerized preserve adequate cell sizes, we the Nurturing Curriculum, which was recoded demographic variables as 27,35 questionnaires were used to collect previously studied by our group. data at intake and child’sageof12, outlined in Table 2. The Nurturing Curriculum addresses 24, and 36 months. Because of We examined potential sample child abuse risk within the following a technical error, baseline data on selection bias by comparing baseline 4 constructs: inappropriate parental measures were not collected on 40 of characteristics of participants expectations of the child, lack of 140 participants. Measures have (n = 140) with nonparticipants empathy toward the child’sneeds, been previously described in (n = 12) and randomization success parental value of physical 24 detail. In addition to questions on by comparing baseline characteristics punishment, and parent-child role demographics (eg, mother’sand between randomized groups. To reversal.35 Aseriesoffive 1-hour infant’sageandraceand/or assess differential attrition between long, structured, one-on-one ethnicity, mother’s educational and groups, we compared rates of missing interactive modules were aimed to residential status) and social factors data at each time point and median help teens build positive, empathetic (eg, sources of social or economic number of missing time points relationships with their children support and child care), we used between groups. To determine while enhancing self-efficacy and the following standardized potential retention bias, we used self-worth. Reproductive health 37 instruments: MSRI to assess linear regression modeling to goals and contraception were maternal parenting self-esteem, evaluate whether baseline discussed at each session. The Adolescent Adult Parenting characteristics were independently curriculum was approved by the 38 Inventory Version 2 (AAPI-2) to associated with the number of OAPP and delivered in a confidential, assess parenting and child-rearing missing data points (0–3) across all private clinic setting. On the basis of attitudes associated with risk for time points. Any experimental group competency learning principles, the child maltreatment, Center for variables that differed at baseline or intervention used informational Epidemiologic Studies Depression that predicted differential retention lecture, vignette discussion, 39 Scale for Children (CES-DC) to across the follow-ups were controlled reflection, and interactive “practice” 33–35 assess depressive symptoms, and the for in subsequent analyses of the activities. Domains included 33 Ansell-Casey Life Skills Assessment intervention effect. We conducted child development, discipline, safety, to assess skills of daily living, bivariate analyses using 1-way house and money management, communication, and relationships. analysis of variance for continuous social relationships, career planning, Repeat pregnancy data were variables and x2 tests for categorical substance abuse, and both collected by patient report as variables. community and interpersonal 33,34,36 well as review of medical records violence. This content is at 12, 24, and 36 months. To evaluate intervention effects, we summarized in Table 1. Goals were Participants completed satisfaction compared experimental groups over focused on engaging teens in logical questionnaires after completing time, using intent-to-treat on each fi future planning while learning each intervention session. outcome measure, rst in unadjusted skills necessary for self-sufficient bivariate analyses and then, to adjust adulthood. A social worker or nurse for potential confounders, using content specialist with structured Data Analysis linear mixed-effects modeling with content training delivered each We analyzed variables using repeated measures nested within module. They were not blinded to recommended scoring methods for all participants.40 Intercepts of intervention assignment and were measures. For the AAPI-2, we used individual trajectories were treated as teen-tot team members. Ongoing the scoring tool available at www. random effects. We used maximum staff training with no staffing nurturingparenting.com with “sten” likelihood estimation of parameter changes ensured the fidelity of topic scores (scores standardized to estimates and specified an content delivery. The first 10 teens a range of 1–10) in the current unstructured covariance scheme. received the intervention in a group analysis, with scores 1 to 3 indicating Mixed-effects modeling was chosen of 2 to 4 participants over 12 high risk, 4 to 7 moderate risk, and 8 over traditional repeated measures sessions. This was modified to 5 to 10 low risk for child maltreatment. analysis of variance because of its individual sessions to improve On the Ansell-Casey Life Skills ability to calculate parameter flexibility with scheduling and Inventory (ACLS), we examined raw estimates even with some missing compliance. The team met weekly to scores (sum of item scores) and data points.40 To reduce discuss intervention progress, “mastery” scores (ie, percent of items multicollinearity, we used Cramér’sV barriers, and participant feedback. with a response of “very much like to assess association between

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 143, number 3, March 2019 3 TABLE 1 Intervention Modules and Facilitators Module No. Module Topic Facilitator Description 1 Child Development and discipline Social Worker This module focuses on child development and discipline. Participants play a developmental card game that reviews children’s developmental milestones and engage in a discussion about age-appropriate expectations and learning styles. They also talk about how they were raised, how they hope to raise their child, the goal of discipline, and what discipline looks like at different ages and/or stages. Participant contraceptive plan is reviewed and appointments in clinic made if needed. 2 Safety Nurse This module focuses on prevention of potential hazards in the home and the community. Teens receive a safety bag that includes a thermometer, list of important phone numbers, poison control magnet, outlet covers, choke tube, and items for personal safety, such as emergency contraception and condoms. Participant contraceptive plan is reviewed and appointments in clinic made if needed. 3 Budgeting and/or Bank Account Social Worker In this module, teens learn about finances and budgeting. They discuss current income as well as expenses and look at what are realistic goals for current income. At the end of the session, they have the option to go to the neighborhood bank and open a personal checking account. Participant contraceptive plan is reviewed and appointments in clinic made if needed. 4 Job and Education Readiness and Social Worker In this module, teens focus on employment or career goals and practice Resume some skills that help them find and keep a job. They create an appropriate email account if they do not already have one, work on a resume, and have a practice interview. Participant contraceptive plan is reviewed and appointments in clinic made if needed. 5 Healthy Living Social Worker In this module, they discuss the importance of healthy living, including exercise and a healthy diet. They review the health hazards of smoking, drug use, and how drug use can negatively impact how one parents their child. They also discuss violence and how exposure to violence can impact your life and the child’s development. Participant contraceptive plan is reviewed and appointments in clinic made if needed.

predictor variables hypothesized to reran analyses using pooled imputed groups was 1.0 (IQR 0–2). At be intercorrelated. We found that the data. These analyses results were baseline and 36 months, we found highest grade completed, educational similar to the nonimputed data set, so no significant differences between status had a Cramér’s V of 0.550, and we present nonimputed data. intervention and control groups in receiving public income assistance the characteristics of those with and receiving foods stamps had RESULTS and without data. There was no a Cramér’s V of 0.355. Thus, highest difference in the number of teen- grade completed and participation in Sample Characteristics tot visits made by the 2 groups public income assistance were Participants were randomly during the 36-month study period; entered into subsequent models. For assigned, with 72 in the intervention the median (interquartile range) repeat pregnancy, we compared rates group and 68 in the control group. number of visits for control versus of any repeat pregnancy between The Consolidated Standards of intervention group equaled 25 – – groups by each follow-up time point Reporting Trials diagram (Fig 1) (18 38) vs 24 (16 34). There were (cumulative) using logistic regression summarizes sample recruitment and no adverse events. modeling. retention flow. Participant follow-up Table 2 summarizes group To address potential nonresponse rates were similar between groups demographic and social characteristics bias due to missing data at baseline across the follow-up time points, at baseline. Participants were and follow-ups, we conducted except at 12 months, where the majority African American or multiple imputation of missing data control group had higher response Hispanic (93.4%) and first-time (n = 10 imputation trials) for each of than the intervention group (88.2% mothers (98%), and at baseline had the outcome measures (MSRI, AAPI-2, [60 of 68] vs 68.1% [49 of 72]; infants age #2months(68.6%), ACLS, and CES-DC total scores) using P = .004). The median number of were in high school (65.7%), living the baseline predictor variables and missing data time points in both with their own parent(s) (52.2%),

Downloaded from www.aappublications.org/news by guest on September 24, 2021 4 COX et al TABLE 2 Sample Demographic and Social Characteristics at Program Enrollment Total Control Intervention P Total sample, n (%) 140 (100.0) 68 (48.6) 72 (51.4) — Teen mother’s age, y, mean 6 SD 17.3 6 1.1 17.3 6 1.2 17.4 6 1.0 .511 Infant’s age, mo, n (%) .256 #2 96 (68.6) 50 (73.5) 46 (63.9) — 3–5 20 (14.3) 10 (14.7) 10 (13.9) — 6+ 24 (17.1) 8 (11.8) 16 (22.2) — Race and/or Hispanic ethnicity, n (%) .178 African American 46 (33.3) 18 (26.5) 28 (40.0) — Hispanic 83 (60.1) 44 (64.7) 39 (55.7) — Other 9 (6.5) 6 (8.8) 3 (4.3) — School status, n (%) .038 In high school and/or GED program 92 (65.7) 51 (75.0) 41 (56.9) — Completed high school and/or GED or in college 28 (20.0) 12 (17.6) 16 (22.2) — Not currently in school or other 20 (14.3) 5 (7.4) 15 (20.8) — Highest grade completed, n (%) .053 #10th grade 49 (38.6) 30 (46.9) 19 (30.2) — 11th or higher 78 (61.4) 34 (53.1) 44 (69.8) — Residential status, n (%) Lives with own parent(s) 71 (52.2) 36 (55.4) 35 (49.3) .478 Lives with FOI, partner, or spouse 31 (22.8) 18 (27.7) 13 (18.3) .193 Lives with FOI’s parents 26 (19.1) 13 (20.0) 13 (18.3) .802 Income support, n (%) Own parent(s) 39 (27.9) 18 (26.5) 21 (29.2) .722 FOI, partner, or spouse 101 (73.7) 46 (69.7) 55 (77.5) .302 Social support and/or child care, n (%) Own parent(s) 125 (94.0) 63 (95.5) 62 (92.5) .479 FOI, partner, or spouse 114 (87.7) 54 (87.1) 60 (88.2) .844 FOI’s family 104 (81.9) 52 (86.7) 52 (77.6) .186 Duke Social Support and Stress Scales, mean 6 SD Overall support 53.5 6 18.7 54.1 6 18.8 52.8 6 18.7 .724 Family 61.1 6 20.3 62.3 6 18.2 59.9 6 22.5 .556 Nonfamily 37.7 6 21.4 37.5 6 24.2 38.0 6 19.3 .906 Overall stress 16.3 6 17.2 15.6 6 16.8 17.0 6 17.7 .700 Family related 18.8 6 19.8 17.6 6 18.6 20.0 6 21.0 .559 Non-family related 24.8 6 13.4 25.7 6 15.5 23.9 6 10.8 .502 Other support, n (%) Medicaid insurance 132 (94.3) 63 (92.6) 69 (95.8) .417 Public cash assistancea 48 (34.3) 22 (32.4) 26 (36.1) .640 Employed 8 (5.7) 3 (4.4) 5 (6.9) .519 WIC program participant 118 (84.3) 59 (86.8) 59 (81.9) .433 Food stamps 54 (38.6) 25 (36.8) 29 (40.3) .670 FOI, father of infant; GED, general equivalency diploma; —, not applicable. a Responded “yes” to receiving Transitional Aid to Needy Families, social security, or “other public aid.” and receiving Medicaid insurance esteem (mean [SE] = 114.0 [1.1] vs and 4, respectively. In adjusted (94.3%) and Supplemental Nutrition 121.4 [1.8]; P = .046) and overall analysis comparing group trends over Program for Women, Infants, and social support (53.5 [8.9] vs 66.2 time, we found a significant decline by Children (WIC) (84.3%). The [5.8]; P = .052), and score marginally 36 months in overall maternal self- intervention and control groups higher on overall social stress (16.3 esteem scores in both groups (main differed only with respect to [1.7] vs 6.6 [3.3]; P = .98) and on effect of time P = .009) but less in the education variables at baseline, with depressive symptoms (17.3 [1.1] vs intervention group (group by time control group participants having 10.1 [2.6]; P = .068). interaction effect P =.011).Significant a higher percentage still in high intervention subscale effects were school. Participants were younger Intervention Effects seen for preparedness for mothering than those declining to participate Unadjusted group mean scores over role (P = .011), acceptance of infant (17.3 6 1.1 vs 18.1 6 0.7 years; time for each of our outcome (P = .008), and expected relationship P = .021), were more likely to be measures and the results of mixed- with infant (P = .029). There was Hispanic (60.1% vs 33.3%; P =.043), effects modeling adjusting for a marginal effect on caretaking ability to score lower on maternal self- covariates are presented in Tables 3 (P =.052).

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 143, number 3, March 2019 5 FIGURE 1 Study flow diagram.

Results were mixed across the AAPI-2 baseline in both groups, revealed range. Scores on all other AAPI-2 parenting profile subscales. Scores on significant improvement (main time subscales in both groups were in the “empathy towards children’s needs” effect P = .019) (Table 4), although “medium risk” range at baseline subscale, which were “high risk” at sten scores remained in the high risk without improvement over time,

Downloaded from www.aappublications.org/news by guest on September 24, 2021 6 COX et al TABLE 3 Adolescent Mothers’ Self-Reported Self-Esteem, Parenting Profile, Life Skills, and Depressive Symptoms by Group at Baseline and 12, 24, and 36 Months Follow-up Baseline 12 mo 24 mo 36 mo Change From Change From Change From Mean (SE), Mean (SE), Mean (SE), Mean (SE), Baseline Baseline Baseline n = 100 n = 109 n = 115 n = 109 to 12 moa to 24 moa to 36 moa Maternal self-esteemb Caretaking ability Control 27.2 (0.5) 27.0 (0.5) 25.5 (0.9) 20.5 (1.4) 20.2 21.7 26.7 Intervention 27.0 (0.6) 27.5 (0.4) 26.3 (0.7) 23.7 (1.1) +0.5 20.7 23.3 Preparedness for mothering role Control 37.3 (0.4) 36.2 (0.6) 36.1 (0.6) 33.7 (0.7) 21.1 21.2 23.6 Intervention 37.2 (0.5) 36.9 (0.6) 36.3 (0.5) 35.9 (0.5) 20.3 20.9 21.3 Acceptance of infant Control 13.7 (0.2) 13.7 (0.3) 13.2 (0.4) 11.1 (0.5) 0.0 20.5 22.6 Intervention 13.6 (0.3) 13.9 (0.3) 13.3 (0.3) 12.5 (0.4) +0.3 20.3 21.1 Expected relationship with infant Control 21.8 (0.4) 21.8 (0.4) 21.3 (0.5) 19.5 (0.6) 0.0 20.5 22.3 Intervention 21.9 (0.4) 22.6 (0.4) 21.6 (0.4) 21.1 (0.4) +0.7 20.3 20.8 Perceptions of childbearing experience Control 13.6 (0.7) 14.2 (0.5) 14.4 (0.6) 13.7 (0.5) +0.6 +0.8 +0.1 Intervention 14.6 (0.6) 15.3 (0.7) 15.2 (0.6) 15.4 (0.5) +0.7 +0.6 +0.8 Total score Control 113.7 (1.4) 112.8 (1.7) 110.4 (2.4) 99.4 (3.1) 20.9 23.3 214.3 Intervention 114.3 (1.7) 116.2 (1.8) 112.8 (1.9) 108.5 (2.6) +1.9 21.5 25.8 Parenting profilec Inappropriate expectations Control 4.9 (0.3) 5.6 (0.3) 5.0 (0.3) 5.1 (0.3) +0.7 +0.1 +0.2 Intervention 5.5 (0.4) 5.8 (0.3) 5.3 (0.3) 5.1 (0.3) +0.3 20.2 20.4 Empathy toward child’s needs Control 1.4 (0.2) 1.7 (0.2) 2.1 (0.3) 2.5 (0.3) +0.3 +0.7 +1.1 Intervention 1.7 (0.2) 1.6 (0.2) 2.0 (0.3) 1.7 (0.2) 0.0 +0.3 0.0 Use of corporal punishment Control 5.8 (0.3) 5.7 (0.3) 5.4 (0.3) 4.3 (0.3) 20.1 20.4 21.5 Intervention 5.9 (0.3) 6.0 (0.3) 5.2 (0.3) 4.6 (0.3) +0.1 20.7 21.3 Parent-child role responsibilities Control 4.7 (0.3) 5.6 (0.3) 4.8 (0.4) 3.7 (0.4) +0.9 +0.1 21.0 Intervention 4.8 (0.3) 5.9 (0.4) 5.4 (0.4) 5.1 (0.3) +1.1 +0.6 +0.3 Child’s power and independence Control 6.0 (0.3) 5.5 (0.3) 5.1 (0.3) 3.2 (0.3) 20.5 20.9 22.8 Intervention 6.2 (0.3) 5.5 (0.3) 5.2 (0.3) 4.3 (0.3) 20.7 21.0 21.9 Total score Control 22.8 (0.7) 24.1 (0.7) 22.4 (0.8) 18.9 (0.8) +1.3 20.4 23.9 Intervention 24.1 (0.6) 24.7 (0.8) 23.0 (0.9) 20.8 (0.8) +0.6 21.1 23.3 Life skillsd Housing and/or money management: raw score Control 57.0 (1.9) 60.4 (2.1) 62.8 (2.0) 66.2 (2.3) +3.4 +5.8 +9.2 Intervention 57.5 (2.1) 60.6 (1.8) 65.1 (1.9) 68.3 (1.8) +3.1 +7.6 +10.8 Housing and/or money management: mastery score Control 30.8 (3.7) 38.4 (4.4) 36.5 (4.7) 49.0 (5.1) +7.6 +5.7 +18.2 Intervention 33.6 (4.0) 37.7 (3.9) 47.1 (4.2) 50.8 (4.6) +4.1 +13.5 +17.2 Work life: raw score Control 21.5 (0.4) 21.0 (0.5) 20.7 (0.5) 21.4 (0.5) 20.5 20.8 20.1 Intervention 21.6 (0.5) 22.4 (0.4) 22.0 (0.4) 22.4 (0.4) +0.8 +0.4 +0.8 Work life: mastery score Control 72.3 (4.7) 69.8 (4.7) 62.1 (5.8) 71.1 (5.5) 22.5 210.2 21.2 Intervention 76.8 (4.8) 82.7 (4.0) 77.8 (4.3) 82.1 (4.1) +5.9 +1.0 +5.3 Total: raw score Control 78.5 (2.1) 81.4 (2.5) 83.4 (2.3) 87.5 (2.7) +2.9 +4.9 +9.0 Intervention 79.1 (2.4) 83.0 (2.0) 87.0 (2.2) 90.6 (2.1) +3.9 +7.9 +11.5

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 143, number 3, March 2019 7 TABLE 3 Continued Baseline 12 mo 24 mo 36 mo Change From Change From Change From Mean (SE), Mean (SE), Mean (SE), Mean (SE), Baseline Baseline Baseline n = 100 n = 109 n = 115 n = 109 to 12 moa to 24 moa to 36 moa Total: mastery score Control 51.6 (3.6) 54.1 (4.1) 49.3 (4.8) 60.0 (4.9) +2.5 22.3 +8.4 Intervention 55.2 (3.8) 60.2 (3.4) 61.9 (3.8) 66.4 (3.8) +5.0 +6.7 +11.2 Depressive symptomse Control 16.2 (1.4) 17.6 (1.7) 14.5 (1.2) 17.0 (1.7) +1.4 21.7 +0.8 Intervention 17.9 (1.7) 21.2 (1.9) 18.0 (1.6) 16.4 (1.4) +2.3 +0.1 21.5 Unadjusted data. a Difference in each group’s means for this comparison period. b MSRI; total score is sum of all subdomain scores. c AAPI-2, Form A: standardized scores (ie, sten) relative to norms with scores of 1–3 indicating high risk, 4–7 medium risk, and 8–10 low risk. d Ansell-Casey Life Skills Assessment Youth Level 4: raw score is the sum of all item scores; mastery score is the percent of items with a score of 3 indicating mastery; total raw score is the sum of all housing and/or money management and work item scores; total mastery score is the average of mastery scores for housing and/or money and work. e CES-DC. except for worsening in “children’s differences at baseline or variables randomly assigning teens to an added power and independence” scores associated with differential study parenting and life skills intervention. (P = .013). Sten scores for “parent- retention (Table 5). Our findings suggest that a teen-tot child role responsibilities” worsened model plus an enhanced parenting At 12 months, 61.1% of intervention between 12 and 36 months in the and life skills intervention shows participants used longer-acting control compared with intervention promise for improving parenting contraceptives (Depo Provera, group (group by time interaction attributes and reducing repeat intrauterine device or implant) effect P = .024). pregnancy. Compared with versus 43.5% of participants in the participants in the control group, Scores on the ACLS domains control group (P = .059). In intervention participants increased over time in unadjusted multivariate logistic regression, demonstrated less worsening of analysis (Table 3); however, after adjusting for the same variables as in maternal parenting self-esteem, adjustment for teen mother’sage,the repeat pregnancy analyses, adjusted caretaking ability, acceptance of time effect disappeared, indicating odds ratio at 12-month follow-up for infant, and had lower rates of repeat teen’s age mediated the increasing group difference in any use of longer- pregnancy over a 36-month follow-up scores over time (Table 4). Overall, acting contraceptive methods was as the children became toddlers. All over one-third (37.3%) of teens were 2.31 (95% confidence interval participants revealed risk for child employed at the 36-month follow-up, 1.02–5.23; P = .044), comparing maltreatment, with some worsening and 59.1% had completed high intervention group to control group. of risk over 36 months in both school without group differences. There were no significant differences groups. Life skills improved over Of note, baseline CES-DC mean in reported contraceptive use at time, with no difference between scores in both groups were above subsequent follow-up assessments. groups. Our intervention also had no the cut point of 16, indicating Intervention participants provided effect on depressive symptoms, which depressive symptomatology, and universally positive qualitative increased for both groups even after revealed significant increase over feedback. Examples are “they taught controlling for family-related social time after adjusting for covariates me to build my picture frame, they stress. This finding is consistent with (36-month time effect, P = .02) showed techniques on how to give our earlier work3 and highlights the (Tables 3 and 4). your child praise, and how to read to high prevalence and importance of Repeat pregnancy data at 36-month your child, a lot of things you addressing mental health concerns follow-up was available for 70.6% of wouldn’t even think of” and “good when caring for teen parents.41 participants in the control group and outlet for stress and thoughts.” 72.2% of intervention group Our study is unique in that participants. The intervention group participants were managed for had significantly lower unadjusted DISCUSSION 36 months with positive outcomes rates of any repeat pregnancy than Our previous pre- and poststudy of across parenting and reproductive the control group by each follow-up the teen-tot model revealed health constructs. These findings are time point, which remained successful delivery of preventive consistent with other interventions significant in logistic regression health and social services.24 With this with shorter follow-up.25 In modeling, controlling for group study, we build on that work by a randomized controlled trial,

Downloaded from www.aappublications.org/news by guest on September 24, 2021 8 COX et al TABLE 4 Results From Mixed-Effects Modeling When Comparing Intervention and Control Groups on Outcomes at 12, 24, and 36 Months 12 mo 24 mo 36 mo Estimate (SE) P Estimate (SE) P Estimate (SE) P Maternal self-esteema Caretaking ability Time 23.39 (2.25) .133 27.39 (3.76) .050 215.19 (5.56) .007 Group by time 1.11 (1.64) .678 0.80 (1.61) .621 3.17 (1.63) .052 Preparedness for mothering role Time 22.06 (1.33) .122 23.09 (2.24) .169 26.32 (3.32) .058 Group by time 1.22 (0.93) .193 0.64 (0.92) .490 2.38 (0.93) .011 Acceptance of infant Time 20.64 (0.86) .457 21.72 (1.44) .235 24.35 (2.14) .043 Group by time 0.60 (0.62) .333 0.47 (0.61) .435 1.65 (0.61) .008 Expected relationship with infant Time 21.68 (1.11) .131 23.49 (1.86) .061 26.65 (2.75) .016 Group by time 1.22 (0.79) .124 .60 (0.78) .442 1.72 (0.78) .029 Perceptions of childbearing experience Time 20.98 (1.25) .433 22.72 (2.10) .197 24.95 (3.13) .115 Group by time 0.58 (0.86) .503 0.34 (0.85) .691 0.81 (0.86) .350 Total score Time 28.03 (5.40) .138 217.05 (9.08) .061 235.38 (13.45) .009 Group by time 4.75 (3.84) .217 2.89 (3.77) .444 9.76 (3.82) .011 Parenting profileb Inappropriate expectations Time 20.01 (0.80) .989 20.99 (1.33) .459 21.39 (1.97) .482 Group by time 20.29 (0.59) .608 20.33 (0.57) .554 20.54 (0.57) .341 Empathy toward children’s needs Time 1.30 (0.65) .047 2.51 (1.08) .021 3.76 (1.59) .019 Group by time 20.49 (0.47) .301 20.38 (0.47) .413 20.97 (0.47) .039 Use of corporal punishment Time 20.21 (0.62) .731 20.46 (1.04) .657 21.38 (1.53) .369 Group by time 0.40 (0.42) .345 20.17 (0.42) .680 0.26 (0.43) .550 Parent-child role responsibilities Time 0.86 (0.86) .317 0.11 (1.44) .937 20.69 (2.14) .747 Group by time 0.18 (0.60) .758 0.64 (0.59) .281 1.36 (0.60) .024 Children’s power and independence Time 21.48 (0.85) .083 22.58 (1.41) .068 25.18 (2.09) .013 Group by time 20.21 (0.61) .725 20.19 (0.60) .751 0.92 (0.61) .129 Life skillsc Housing and/or money management: raw score Time 2.87 (3.59) .424 5.00 (6.09) .412 7.46 (9.04) .410 Group by time 0.77 (2.45) .755 3.02 (2.43) .215 2.52 (2.46) .307 Housing and/or money management: mastery score Time 2.64 (8.14) .745 23.24 (13.80) .814 3.80 (20.48) .853 Group by time 0.17 (5.57) .975 8.60 (5.52) .120 20.12 (5.59) .982 Work life: raw score Time 22.14 (1.11) .055 23.57 (1.87) .057 24.34 (2.77) .118 Group by time 1.84 (0.78) .019 1.33 (0.77) .085 1.08 (0.78) .169 Work life: mastery score Time 218.31 (11.23) .104 236.20 (18.93) .057 241.16 (28.05) .143 Group by time 13.51 (7.89) .088 11.45 (7.77) .142 7.26 (7.86) .356 Total: raw score Time 0.83 (4.21) .843 1.72 (7.14) .810 3.61 (10.59) .734 Group by time 2.67 (2.88) .354 4.43 (2.85) .121 3.67 (2.89) .205 Total: mastery score Time 28.10 (8.49) .341 220.02 (14.36) .164 219.01 (21.31) .373 Group by time 27.09 (5.87) .228 10.23 (5.80) .079 3.73 (5.86) .525 Depressive symptomsd Time 8.93 (3.67) .016 11.68 (6.18) .060 21.38 (9.16) .020

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 143, number 3, March 2019 9 TABLE 4 Continued 12 mo 24 mo 36 mo Estimate (SE) P Estimate (SE) P Estimate (SE) P Group by time 0.65 (2.60) .803 2.41 (2.56) .347 21.39 (2.59) .591 Mixed-effects modeling controlled for mother’s age, child’s age, mother’s highest grade completed and whether she received public income assistance, participated in WIC program, overall social support, and family-related social stress. —, not applicable. a MSRI; total score is the sum of all subdomain scores. b AAPI-2, Form A: standardized scores (ie, sten) relative to norms with scores of 1–3 indicating high risk, 4–7 medium risk, and 8–10 low risk. c Ansell-Casey Life Skills Assessment Youth Level 4: raw score is the sum of all item scores; mastery score is the percent of items with score of 3 indicating mastery; total raw score is the sum of all housing and/or money management and work item scores; total mastery score is the average of mastery scores for housing and/or money and work. d CES-DC. a home-based mentorship model teens and their children increases Many teen parents have a history of used to addressed teen development with each additional repeat teen trauma and/or depression. and negotiation skills decreased birth. Our qualitative study of repeat Integrating mental health treatment repeat pregnancy at 24 months.21 pregnancy highlighted the with parenting education may also Likewise, a motivational intervention importance of teen control and reduce risk of child maltreatment. that was focused on relationships and independent decision-making as contraceptive-use intentions showed important factors in reducing There were some study limitations. decreased repeat pregnancies at 24 pregnancy risk.43 To decrease Data were obtained through self- months.23 Data from our study were subsequent pregnancy, counseling on report, although repeat pregnancies included in a meta-analysis of 13 AFL the use of long-acting contraceptives, were verified by chart review. At projects with variable study designs not extensively available during this entry into the study, there was 1 that revealed improved use of study period, should be started significant difference between contraceptives and decreased repeat during the prenatal period.44 The intervention and control participants. pregnancy at 12 months; however, intervention provided teens time with Control participants were more likely parenting outcomes were not program staff in which they could to be in high school. This potentially studied.30 Other interventions with discuss future plans and the affected their decisions about repeat repeat pregnancy improvements experience of parenting. This may pregnancy either to delay or continue include school-based case have affected their decisions around another pregnancy but did not management16 and immediate planning another pregnancy, although positively affect their parenting postpartum insertion of long-acting this effect was not directly measured. attributes over time. Engaging and reversible contraceptives.42 An Because teens are often unprepared retaining teens in the intervention evaluation of a home-visiting for parenting, their children are at was challenging. The complex social intervention showed positive effects risk for maltreatment.8 This risk was needs of the teens often overwhelmed on parenting stress, engagement in not attenuated by the intervention, program staff making module high risk behaviors, and college suggesting the need for interventions completion difficult in the face of attendance at 24 months.19 that more intensely targeted harsh these urgent needs. Adherence was parenting practices. The Healthy similar to other AFL teen parenting 46 Positive effects on both parenting and Families New York home-visiting programs. Early in the intervention, repeat pregnancies are critical program demonstrated significant there were some missing baseline outcomes for teen parenting decreases in harsh parenting in data, but it was evenly distributed programs. Risk for poor outcomes for a group of teen first-time mothers.45 and managed statistically. Because the study design nested the parenting and life skills intervention within TABLE 5 Comparison of Group Rates of Any Repeat Pregnancy by Each Follow-up Time Point a teen-tot model, effects may have Follow- N Control, Intervention, Unadjusted aOR (95% CI)a aOR, P been attenuated because the control up, mo % % Comparison, P condition also received substantial 12 117 29.1 12.9 .030 0.25 .037 teen-tot care, which may have (0.07–0.92) included the nurse or social worker 24 107 46.2 30.9 .105 0.24 .029 who delivered the intervention. (0.07–0.86) Participants in the intervention group 36 100 66.7 42.3 .015 0.20 .017 (0.06–0.75) received more contacts from staff through recruitment phone calls and aOR, adjusted odds ratio; CI, confidence interval. a Multiple logistic regression modeling for each time point controlled for mother’s age, child’s age, mother’s highest reminders and frequently asked to grade completed, whether received public income assistance, overall social support, family-related social stress. speak to their social worker or nurse

Downloaded from www.aappublications.org/news by guest on September 24, 2021 10 COX et al during these calls. Because the study pairing medical services with ABBREVIATIONS was conducted in 1 program in the comprehensive social services and northeast, generalizability of findings parenting education and can inform AAPI-2: Adolescent Adult to other regions and settings may be future policy and services for teen Parenting Inventory limited. parents. These positive effects also Version 2 have potential to improve long-term ACLS: Ansell-Casey Life Skills outcomes for teens and their children. Inventory CONCLUSIONS AFL: Adolescent Family Life This randomized controlled trial of CES-DC: Center for Epidemiologic a multifaceted intervention that Studies Depression Scale ACKNOWLEDGMENTS paired medical care for teen and child for Children with brief parenting and life skills We thank our patients who MSRI: Maternal Self-Report training revealed positive effects on repeatedly answered our Inventory maternal self-esteem, including questionnaires, Jennifer Valenzuela OAPP: Office of Adolescent caretaking ability, acceptance of and for her work leading early Pregnancy Programs expected relationship with infant, and implementation of our study, the WIC: Supplemental Nutrition decreased risk of repeat pregnancy Young Parents Program team, and Dr Program for Women, Infants, over 36 months. With these findings, Eric Fleegler and his computerized and Children we highlight the positive impact of data collection system.

Accepted for publication Dec 18, 2018 Address correspondence to Joanne E. Cox, MD, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2019 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Supported in part by the Office of Adolescent Pregnancy Programs (grant APHPA0020033-08-01), the Edgerly Family Endowment, and Leadership Education in Adolescent Health training grant T71MC00009, the Maternal and Child Health Bureau, and the Health Resources and Services Administration. This content and conclusions are those of the authors and should not be considered as nor should any endorsements be inferred by an official position or policy of Health Resources and Services Administration, US Department of Health and Human Services, or the US Government. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 A Parenting and Life Skills Intervention for Teen Mothers: A Randomized Controlled Trial Joanne E. Cox, Sion Kim Harris, Kathleen Conroy, Talia Engelhart, Anuradha Vyavaharkar, Amy Federico and Elizabeth R. Woods Pediatrics 2019;143; DOI: 10.1542/peds.2018-2303 originally published online February 12, 2019;

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