Video Abstract

Video Abstract

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BACKGROUND:

Teen mothers often present with depression, social complexity, and inadequate 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.

What’s Known on This Subject:

Teen parents and their children face multiple medical and social challenges. Promising interventions include home visiting, school-based interventions, and medical homes. Intervention outcomes include optimal medical care delivery, decreased repeat pregnancy, and improved parenting skills.

What This Study Adds:

Longitudinal outcomes for interventions used to target teen mothers and their children have not been extensively studied. Our findings suggest that a teen-tot model plus an enhanced parenting and life skills intervention shows promise for improving parenting attributes and reducing repeat pregnancy.

Although the rates of teen pregnancy have declined nationally over the last 25 years, socioeconomic and racial disparities persist. Teen pregnancy and parenting remain a challenge in communities with high rates of poverty, low social capital, and inadequate access to contraception and among certain racial and/or ethnic populations.1,2 Teen parenting is associated with risk of depression, poor social supports, school failure, conflicted relationships, and inadequate family and community support.3,6 Women who were teen parents complete less education and are more likely to live in poverty.4 Teens with children are often unprepared for the stresses of raising young children; and those with histories of social isolation, violence, or other sources of toxic stress are more likely to parent using harsh, authoritarian methods.7,10 Their children lag developmentally and are at risk for poor educational outcomes that persist into adolescence.6,11,13 

Interventions for teen parents often focus on decreasing both repeat pregnancy and negative parenting behaviors associated with teen parents that place children and their mothers at risk for adverse long-term outcomes. Repeat teen pregnancy multiplies risk for both parental stress and harsh parenting that negatively affect child outcomes.14 In addition, the children are more likely to have behavioral problems. Educational and employment outcomes are better for teens without another pregnancy.8,14 Yet, almost 20% of teen births are repeat births.15 

Comprehensive programs have been aimed to address family planning while providing parenting and social support.16 Programs are used to address parenting behaviors, maternal attachment to the infant, and teen life skills to enhance child developmental outcomes and teen self-sufficiency.11,16,18 Promising interventions include school-based16,17 or home-visiting programs18,20 and mentoring.21,23 Other successful interventions have used the medical home or teen-tot model.24,27 

The Adolescent Family Life (AFL) demonstration projects, organized through the Office of Adolescent Pregnancy Programs (OAPP), are aimed to support young families through social support and medical care.28,31 The AFL funding required programs to deliver 10 core services, including pregnancy testing, adoption counseling, preventive and prenatal referrals for teens, nutritional counseling, well infant care, sexually transmitted infection screening, family life counseling, educational or vocational services, mental health services, and referrals for family planning. A multisite evaluation, which included our program, revealed increased use of long-acting contraceptives, child care, and decreased repeat pregnancy at 12 months.30 However, there is a paucity of scientific studies examining longer-term outcomes of these programs. Our aim with this study was to test the hypothesis that compared with the teen-tot model alone, adding a structured, comprehensive parenting curriculum to an AFL-funded teen-tot model would increase parenting self-esteem and reduce parenting attributes associated with child maltreatment, maternal depression, and repeat pregnancy over a 36-month follow-up.

This study was set in Boston, Massachusetts, in a teen-tot program within a pediatric hospital.24 Eligibility criteria included maternal age <19 years at delivery and willingness to receive maternal and infant care in a teen-tot program. Teens with infants ≥12 months were excluded. They were referred from prenatal clinics and community-based agencies between February 2008 and February 2012. At the first infant visit, every patient seen was asked to enroll in the study by trained program staff. Those agreeing to participate (140 of 152; 92%) were randomly assigned by the research assistant to the parenting and/or life skills intervention or control using a unique numeric identification number and computerized random number generator to determine assignment. It was indicated in power analysis that a sample of 48 participants in each arm had 80% power to detect a group difference in mean Maternal Self-Report Inventory (MSRI) total scores as found in our previous study.27 

Teens received $10 plus transportation for each intervention visit and study assessment, which were completed in the clinic. The majority of participants lived in the nearby neighborhoods where poverty reached 36%.32 All study participants attended the teen-tot clinic, receiving preventive care, urgent care, gynecologic services, and integrated social work. A nurse offered contraceptive counseling, and social workers provided brief check-ins plus intensive family support services when needed.24 All required AFL core services as outlined in Title XX were offered,31 and the Institutional Review Board of Boston Children’s Hospital approved the study with a waiver of parental consent.

Because of broad OAPP goals for improving teen parenting while enhancing youth and family development, elements of 3 validated curricula were incorporated into the intervention, which then underwent structured expert content review and pilot testing. Psychoeducational modules that were one-on-one used the Ansell-Casey Life Skills Assessment Curriculum,33, the Women’s Negotiation Project Curriculum for Teen Mothers,34 and the Nurturing Curriculum, which was previously studied by our group.27,35 The Nurturing Curriculum addresses child abuse risk within the following 4 constructs: inappropriate parental expectations of the child, lack of empathy toward the child’s needs, parental value of physical punishment, and parent-child role reversal.35 A series of five 1-hour long, structured, one-on-one interactive modules were aimed to help teens build positive, empathetic relationships with their children while enhancing self-efficacy and self-worth. Reproductive health goals and contraception were discussed at each session. The curriculum was approved by the OAPP and delivered in a confidential, private clinic setting. On the basis of competency learning principles, the intervention used informational lecture, vignette discussion, reflection, and interactive “practice” activities.33,35 Domains included child development, discipline, safety, house and money management, social relationships, career planning, substance abuse, and both community and interpersonal violence.33,34,36 This content is summarized in Table 1. Goals were focused on engaging teens in logical future planning while learning skills necessary for self-sufficient adulthood. A social worker or nurse content specialist with structured content training delivered each module. They were not blinded to intervention assignment and were teen-tot team members. Ongoing staff training with no staffing changes ensured the fidelity of topic content delivery. The first 10 teens received the intervention in a group of 2 to 4 participants over 12 sessions. This was modified to 5 individual sessions to improve flexibility with scheduling and compliance. The team met weekly to discuss intervention progress, barriers, and participant feedback.

TABLE 1

Intervention Modules and Facilitators

Module No.Module TopicFacilitatorDescription
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. 
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. 
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. 
Job and Education Readiness and Resume Social Worker In this module, teens focus on employment or career goals and practice 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. 
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. 
Module No.Module TopicFacilitatorDescription
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. 
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. 
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. 
Job and Education Readiness and Resume Social Worker In this module, teens focus on employment or career goals and practice 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. 
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. 

Self-administered computerized questionnaires were used to collect data at intake and child’s age of 12, 24, and 36 months. Because of a technical error, baseline data on measures were not collected on 40 of 140 participants. Measures have been previously described in detail.24 In addition to questions on demographics (eg, mother’s and infant’s age and race and/or ethnicity, mother’s educational and residential status) and social factors (eg, sources of social or economic support and child care), we used the following standardized instruments: MSRI37 to assess maternal parenting self-esteem, Adolescent Adult Parenting Inventory Version 2 (AAPI-2)38 to assess parenting and child-rearing attitudes associated with risk for child maltreatment, Center for Epidemiologic Studies Depression Scale for Children (CES-DC)39 to assess depressive symptoms, and the Ansell-Casey Life Skills Assessment33 to assess skills of daily living, communication, and relationships. Repeat pregnancy data were collected by patient report as well as review of medical records at 12, 24, and 36 months. Participants completed satisfaction questionnaires after completing each intervention session.

We analyzed variables using recommended scoring methods for all measures. For the AAPI-2, we used the scoring tool available at www.nurturingparenting.com with “sten” scores (scores standardized to a range of 1–10) in the current analysis, with scores 1 to 3 indicating high risk, 4 to 7 moderate risk, and 8 to 10 low risk for child maltreatment. On the Ansell-Casey Life Skills Inventory (ACLS), we examined raw scores (sum of item scores) and “mastery” scores (ie, percent of items with a response of “very much like me”). Because of skewed data or to preserve adequate cell sizes, we recoded demographic variables as outlined in Table 2.

TABLE 2

Sample Demographic and Social Characteristics at Program Enrollment

TotalControlInterventionP
Total sample, n (%) 140 (100.0) 68 (48.6) 72 (51.4) — 
Teen mother’s age, y, mean ± SD 17.3 ± 1.1 17.3 ± 1.2 17.4 ± 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 ± SD     
 Overall support 53.5 ± 18.7 54.1 ± 18.8 52.8 ± 18.7 .724 
  Family 61.1 ± 20.3 62.3 ± 18.2 59.9 ± 22.5 .556 
  Nonfamily 37.7 ± 21.4 37.5 ± 24.2 38.0 ± 19.3 .906 
 Overall stress 16.3 ± 17.2 15.6 ± 16.8 17.0 ± 17.7 .700 
  Family related  18.8 ± 19.8 17.6 ± 18.6 20.0 ± 21.0 .559 
  Non-family related  24.8 ± 13.4 25.7 ± 15.5 23.9 ± 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 
TotalControlInterventionP
Total sample, n (%) 140 (100.0) 68 (48.6) 72 (51.4) — 
Teen mother’s age, y, mean ± SD 17.3 ± 1.1 17.3 ± 1.2 17.4 ± 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 ± SD     
 Overall support 53.5 ± 18.7 54.1 ± 18.8 52.8 ± 18.7 .724 
  Family 61.1 ± 20.3 62.3 ± 18.2 59.9 ± 22.5 .556 
  Nonfamily 37.7 ± 21.4 37.5 ± 24.2 38.0 ± 19.3 .906 
 Overall stress 16.3 ± 17.2 15.6 ± 16.8 17.0 ± 17.7 .700 
  Family related  18.8 ± 19.8 17.6 ± 18.6 20.0 ± 21.0 .559 
  Non-family related  24.8 ± 13.4 25.7 ± 15.5 23.9 ± 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.”

We examined potential sample selection bias by comparing baseline characteristics of participants (n = 140) with nonparticipants (n = 12) and randomization success by comparing baseline characteristics between randomized groups. To assess differential attrition between groups, we compared rates of missing data at each time point and median number of missing time points between groups. To determine potential retention bias, we used linear regression modeling to evaluate whether baseline characteristics were independently associated with the number of missing data points (0–3) across all time points. Any experimental group variables that differed at baseline or that predicted differential retention across the follow-ups were controlled for in subsequent analyses of the intervention effect. We conducted bivariate analyses using 1-way analysis of variance for continuous variables and χ2 tests for categorical variables.

To evaluate intervention effects, we compared experimental groups over time, using intent-to-treat on each outcome measure, first in unadjusted bivariate analyses and then, to adjust for potential confounders, using linear mixed-effects modeling with repeated measures nested within participants.40 Intercepts of individual trajectories were treated as random effects. We used maximum likelihood estimation of parameter estimates and specified an unstructured covariance scheme. Mixed-effects modeling was chosen over traditional repeated measures analysis of variance because of its ability to calculate parameter estimates even with some missing data points.40 To reduce multicollinearity, we used Cramér’s V to assess association between predictor variables hypothesized to be intercorrelated. We found that the highest grade completed, educational status had a Cramér’s V of 0.550, and receiving public income assistance and receiving foods stamps had a Cramér’s V of 0.355. Thus, highest grade completed and participation in public income assistance were entered into subsequent models. For repeat pregnancy, we compared rates of any repeat pregnancy between groups by each follow-up time point (cumulative) using logistic regression modeling.

To address potential nonresponse bias due to missing data at baseline and follow-ups, we conducted multiple imputation of missing data (n = 10 imputation trials) for each of the outcome measures (MSRI, AAPI-2, ACLS, and CES-DC total scores) using the baseline predictor variables and reran analyses using pooled imputed data. These analyses results were similar to the nonimputed data set, so we present nonimputed data.

Participants were randomly assigned, with 72 in the intervention group and 68 in the control group. The Consolidated Standards of Reporting Trials diagram (Fig 1) summarizes sample recruitment and retention flow. Participant follow-up rates were similar between groups across the follow-up time points, except at 12 months, where the control group had higher response than the intervention group (88.2% [60 of 68] vs 68.1% [49 of 72]; P = .004). The median number of missing data time points in both groups was 1.0 (IQR 0–2). At baseline and 36 months, we found no significant differences between intervention and control groups in the characteristics of those with and without data. There was no difference in the number of teen-tot visits made by the 2 groups during the 36-month study period; the median (interquartile range) number of visits for control versus intervention group equaled 25 (18–38) vs 24 (16–34). There were no adverse events.

FIGURE 1

Study flow diagram.

FIGURE 1

Study flow diagram.

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Table 2 summarizes group demographic and social characteristics at baseline. Participants were majority African American or Hispanic (93.4%) and first-time mothers (98%), and at baseline had infants age ≤2 months (68.6%), were in high school (65.7%), living with their own parent(s) (52.2%), and receiving Medicaid insurance (94.3%) and Supplemental Nutrition Program for Women, Infants, and Children (WIC) (84.3%). The intervention and control groups differed only with respect to education variables at baseline, with control group participants having a higher percentage still in high school. Participants were younger than those declining to participate (17.3 ± 1.1 vs 18.1 ± 0.7 years; P = .021), were more likely to be Hispanic (60.1% vs 33.3%; P = .043), to score lower on maternal self-esteem (mean [SE] = 114.0 [1.1] vs 121.4 [1.8]; P = .046) and overall social support (53.5 [8.9] vs 66.2 [5.8]; P = .052), and score marginally higher on overall social stress (16.3 [1.7] vs 6.6 [3.3]; P = .98) and on depressive symptoms (17.3 [1.1] vs 10.1 [2.6]; P = .068).

Unadjusted group mean scores over time for each of our outcome measures and the results of mixed-effects modeling adjusting for covariates are presented in Tables 3 and 4, respectively. In adjusted analysis comparing group trends over time, we found a significant decline by 36 months in overall maternal self-esteem scores in both groups (main effect of time P = .009) but less in the intervention group (group by time interaction effect P = .011). Significant intervention subscale effects were seen for preparedness for mothering role (P = .011), acceptance of infant (P = .008), and expected relationship with infant (P = .029). There was a marginal effect on caretaking ability (P = .052).

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 Mean (SE), n = 10012 mo Mean (SE), n = 10924 mo Mean (SE), n = 11536 mo Mean (SE), n = 109Change From Baseline to 12 moaChange From Baseline to 24 moaChange From Baseline 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) −0.2 −1.7 −6.7 
  Intervention 27.0 (0.6) 27.5 (0.4) 26.3 (0.7) 23.7 (1.1) +0.5 −0.7 −3.3 
 Preparedness for mothering role        
  Control 37.3 (0.4) 36.2 (0.6) 36.1 (0.6) 33.7 (0.7) −1.1 −1.2 −3.6 
  Intervention 37.2 (0.5) 36.9 (0.6) 36.3 (0.5) 35.9 (0.5) −0.3 −0.9 −1.3 
 Acceptance of infant        
  Control 13.7 (0.2) 13.7 (0.3) 13.2 (0.4) 11.1 (0.5) 0.0 −0.5 −2.6 
  Intervention 13.6 (0.3) 13.9 (0.3) 13.3 (0.3) 12.5 (0.4) +0.3 −0.3 −1.1 
 Expected relationship with infant        
  Control 21.8 (0.4) 21.8 (0.4) 21.3 (0.5) 19.5 (0.6) 0.0 −0.5 −2.3 
  Intervention 21.9 (0.4) 22.6 (0.4) 21.6 (0.4) 21.1 (0.4) +0.7 −0.3 −0.8 
 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) −0.9 −3.3 −14.3 
  Intervention 114.3 (1.7) 116.2 (1.8) 112.8 (1.9) 108.5 (2.6) +1.9 −1.5 −5.8 
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 −0.2 −0.4 
 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) −0.1 −0.4 −1.5 
  Intervention 5.9 (0.3) 6.0 (0.3) 5.2 (0.3) 4.6 (0.3) +0.1 −0.7 −1.3 
 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 −1.0 
  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) −0.5 −0.9 −2.8 
  Intervention 6.2 (0.3) 5.5 (0.3) 5.2 (0.3) 4.3 (0.3) −0.7 −1.0 −1.9 
 Total score        
  Control 22.8 (0.7) 24.1 (0.7) 22.4 (0.8) 18.9 (0.8) +1.3 −0.4 −3.9 
  Intervention 24.1 (0.6) 24.7 (0.8) 23.0 (0.9) 20.8 (0.8) +0.6 −1.1 −3.3 
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) −0.5 −0.8 −0.1 
  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) −2.5 −10.2 −1.2 
  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 
 Total: mastery score        
  Control 51.6 (3.6) 54.1 (4.1) 49.3 (4.8) 60.0 (4.9) +2.5 −2.3 +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 −1.7 +0.8 
 Intervention 17.9 (1.7) 21.2 (1.9) 18.0 (1.6) 16.4 (1.4) +2.3 +0.1 −1.5 
Baseline Mean (SE), n = 10012 mo Mean (SE), n = 10924 mo Mean (SE), n = 11536 mo Mean (SE), n = 109Change From Baseline to 12 moaChange From Baseline to 24 moaChange From Baseline 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) −0.2 −1.7 −6.7 
  Intervention 27.0 (0.6) 27.5 (0.4) 26.3 (0.7) 23.7 (1.1) +0.5 −0.7 −3.3 
 Preparedness for mothering role        
  Control 37.3 (0.4) 36.2 (0.6) 36.1 (0.6) 33.7 (0.7) −1.1 −1.2 −3.6 
  Intervention 37.2 (0.5) 36.9 (0.6) 36.3 (0.5) 35.9 (0.5) −0.3 −0.9 −1.3 
 Acceptance of infant        
  Control 13.7 (0.2) 13.7 (0.3) 13.2 (0.4) 11.1 (0.5) 0.0 −0.5 −2.6 
  Intervention 13.6 (0.3) 13.9 (0.3) 13.3 (0.3) 12.5 (0.4) +0.3 −0.3 −1.1 
 Expected relationship with infant        
  Control 21.8 (0.4) 21.8 (0.4) 21.3 (0.5) 19.5 (0.6) 0.0 −0.5 −2.3 
  Intervention 21.9 (0.4) 22.6 (0.4) 21.6 (0.4) 21.1 (0.4) +0.7 −0.3 −0.8 
 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) −0.9 −3.3 −14.3 
  Intervention 114.3 (1.7) 116.2 (1.8) 112.8 (1.9) 108.5 (2.6) +1.9 −1.5 −5.8 
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 −0.2 −0.4 
 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) −0.1 −0.4 −1.5 
  Intervention 5.9 (0.3) 6.0 (0.3) 5.2 (0.3) 4.6 (0.3) +0.1 −0.7 −1.3 
 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 −1.0 
  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) −0.5 −0.9 −2.8 
  Intervention 6.2 (0.3) 5.5 (0.3) 5.2 (0.3) 4.3 (0.3) −0.7 −1.0 −1.9 
 Total score        
  Control 22.8 (0.7) 24.1 (0.7) 22.4 (0.8) 18.9 (0.8) +1.3 −0.4 −3.9 
  Intervention 24.1 (0.6) 24.7 (0.8) 23.0 (0.9) 20.8 (0.8) +0.6 −1.1 −3.3 
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) −0.5 −0.8 −0.1 
  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) −2.5 −10.2 −1.2 
  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 
 Total: mastery score        
  Control 51.6 (3.6) 54.1 (4.1) 49.3 (4.8) 60.0 (4.9) +2.5 −2.3 +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 −1.7 +0.8 
 Intervention 17.9 (1.7) 21.2 (1.9) 18.0 (1.6) 16.4 (1.4) +2.3 +0.1 −1.5 

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.

TABLE 4

Results From Mixed-Effects Modeling When Comparing Intervention and Control Groups on Outcomes at 12, 24, and 36 Months

12 mo24 mo36 mo
Estimate (SE)PEstimate (SE)PEstimate (SE)P
Maternal self-esteema       
 Caretaking ability       
  Time −3.39 (2.25) .133 −7.39 (3.76) .050 −15.19 (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 −2.06 (1.33) .122 −3.09 (2.24) .169 −6.32 (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 −0.64 (0.86) .457 −1.72 (1.44) .235 −4.35 (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 −1.68 (1.11) .131 −3.49 (1.86) .061 −6.65 (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 −0.98 (1.25) .433 −2.72 (2.10) .197 −4.95 (3.13) .115 
  Group by time 0.58 (0.86) .503 0.34 (0.85) .691 0.81 (0.86) .350 
 Total score       
  Time −8.03 (5.40) .138 −17.05 (9.08) .061 −35.38 (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 −0.01 (0.80) .989 −0.99 (1.33) .459 −1.39 (1.97) .482 
  Group by time −0.29 (0.59)  .608 −0.33 (0.57) .554  −0.54 (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 −0.49 (0.47) .301 −0.38 (0.47) .413 −0.97 (0.47) .039 
 Use of corporal punishment       
  Time −0.21 (0.62) .731 −0.46 (1.04) .657 −1.38 (1.53) .369 
  Group by time 0.40 (0.42) .345 −0.17 (0.42) .680 0.26 (0.43) .550 
 Parent-child role responsibilities       
  Time 0.86 (0.86) .317 0.11 (1.44) .937 −0.69 (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 −1.48 (0.85) .083 −2.58 (1.41) .068 −5.18 (2.09) .013 
  Group by time −0.21 (0.61) .725 −0.19 (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 −3.24 (13.80) .814 3.80 (20.48) .853 
  Group by time 0.17 (5.57) .975 8.60 (5.52) .120 −0.12 (5.59) .982 
 Work life: raw score       
  Time −2.14 (1.11) .055 −3.57 (1.87) .057 −4.34 (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 −18.31 (11.23) .104 −36.20 (18.93) .057 −41.16 (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 −8.10 (8.49) .341 −20.02 (14.36) .164 −19.01 (21.31) .373 
  Group by time −7.09 (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 
  Group by time 0.65 (2.60) .803 2.41 (2.56) .347 −1.39 (2.59) .591 
12 mo24 mo36 mo
Estimate (SE)PEstimate (SE)PEstimate (SE)P
Maternal self-esteema       
 Caretaking ability       
  Time −3.39 (2.25) .133 −7.39 (3.76) .050 −15.19 (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 −2.06 (1.33) .122 −3.09 (2.24) .169 −6.32 (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 −0.64 (0.86) .457 −1.72 (1.44) .235 −4.35 (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 −1.68 (1.11) .131 −3.49 (1.86) .061 −6.65 (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 −0.98 (1.25) .433 −2.72 (2.10) .197 −4.95 (3.13) .115 
  Group by time 0.58 (0.86) .503 0.34 (0.85) .691 0.81 (0.86) .350 
 Total score       
  Time −8.03 (5.40) .138 −17.05 (9.08) .061 −35.38 (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 −0.01 (0.80) .989 −0.99 (1.33) .459 −1.39 (1.97) .482 
  Group by time −0.29 (0.59)  .608 −0.33 (0.57) .554  −0.54 (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 −0.49 (0.47) .301 −0.38 (0.47) .413 −0.97 (0.47) .039 
 Use of corporal punishment       
  Time −0.21 (0.62) .731 −0.46 (1.04) .657 −1.38 (1.53) .369 
  Group by time 0.40 (0.42) .345 −0.17 (0.42) .680 0.26 (0.43) .550 
 Parent-child role responsibilities       
  Time 0.86 (0.86) .317 0.11 (1.44) .937 −0.69 (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 −1.48 (0.85) .083 −2.58 (1.41) .068 −5.18 (2.09) .013 
  Group by time −0.21 (0.61) .725 −0.19 (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 −3.24 (13.80) .814 3.80 (20.48) .853 
  Group by time 0.17 (5.57) .975 8.60 (5.52) .120 −0.12 (5.59) .982 
 Work life: raw score       
  Time −2.14 (1.11) .055 −3.57 (1.87) .057 −4.34 (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 −18.31 (11.23) .104 −36.20 (18.93) .057 −41.16 (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 −8.10 (8.49) .341 −20.02 (14.36) .164 −19.01 (21.31) .373 
  Group by time −7.09 (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 
  Group by time 0.65 (2.60) .803 2.41 (2.56) .347 −1.39 (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.

Results were mixed across the AAPI-2 parenting profile subscales. Scores on “empathy towards children’s needs” subscale, which were “high risk” at baseline in both groups, revealed significant improvement (main time effect P = .019) (Table 4), although sten scores remained in the high risk range. Scores on all other AAPI-2 subscales in both groups were in the “medium risk” range at baseline without improvement over time, except for worsening in “children’s power and independence” scores (P = .013). Sten scores for “parent-child role responsibilities” worsened between 12 and 36 months in the control compared with intervention group (group by time interaction effect P = .024).

Scores on the ACLS domains increased over time in unadjusted analysis (Table 3); however, after adjustment for teen mother’s age, the time effect disappeared, indicating teen’s age mediated the increasing scores over time (Table 4). Overall, over one-third (37.3%) of teens were employed at the 36-month follow-up, and 59.1% had completed high school without group differences. Of note, baseline CES-DC mean scores in both groups were above the cut point of 16, indicating depressive symptomatology, and revealed significant increase over time after adjusting for covariates (36-month time effect, P = .02) (Tables 3 and 4).

Repeat pregnancy data at 36-month follow-up was available for 70.6% of participants in the control group and 72.2% of intervention group participants. The intervention group had significantly lower unadjusted rates of any repeat pregnancy than the control group by each follow-up time point, which remained significant in logistic regression modeling, controlling for group differences at baseline or variables associated with differential study retention (Table 5).

TABLE 5

Comparison of Group Rates of Any Repeat Pregnancy by Each Follow-up Time Point

Follow-up, moNControl, %Intervention, %Unadjusted Comparison, PaOR (95% CI)aaOR, P
12 117 29.1 12.9 .030 0.25 (0.07–0.92) .037 
24 107 46.2 30.9 .105 0.24 (0.07–0.86) .029 
36 100 66.7 42.3 .015 0.20 (0.06–0.75) .017 
Follow-up, moNControl, %Intervention, %Unadjusted Comparison, PaOR (95% CI)aaOR, P
12 117 29.1 12.9 .030 0.25 (0.07–0.92) .037 
24 107 46.2 30.9 .105 0.24 (0.07–0.86) .029 
36 100 66.7 42.3 .015 0.20 (0.06–0.75) .017 

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 grade completed, whether received public income assistance, overall social support, family-related social stress.

At 12 months, 61.1% of intervention participants used longer-acting contraceptives (Depo Provera, intrauterine device or implant) versus 43.5% of participants in the control group (P = .059). In multivariate logistic regression, adjusting for the same variables as in repeat pregnancy analyses, adjusted odds ratio at 12-month follow-up for group difference in any use of longer-acting contraceptive methods was 2.31 (95% confidence interval 1.02–5.23; P = .044), comparing intervention group to control group. There were no significant differences in reported contraceptive use at subsequent follow-up assessments.

Intervention participants provided universally positive qualitative feedback. Examples are “they taught me to build my picture frame, they showed techniques on how to give your child praise, and how to read to your child, a lot of things you wouldn’t even think of” and “good outlet for stress and thoughts.”

Our previous pre- and poststudy of the teen-tot model revealed successful delivery of preventive health and social services.24 With this study, we build on that work by randomly assigning teens to an added parenting and life skills intervention. Our findings suggest that a teen-tot model plus an enhanced parenting and life skills intervention shows promise for improving parenting attributes and reducing repeat pregnancy. Compared with participants in the control group, intervention participants demonstrated less worsening of maternal parenting self-esteem, caretaking ability, acceptance of infant, and had lower rates of repeat pregnancy over a 36-month follow-up as the children became toddlers. All participants revealed risk for child maltreatment, with some worsening of risk over 36 months in both groups. Life skills improved over time, with no difference between groups. Our intervention also had no effect on depressive symptoms, which increased for both groups even after controlling for family-related social stress. This finding is consistent with our earlier work3 and highlights the high prevalence and importance of addressing mental health concerns when caring for teen parents.41 

Our study is unique in that participants were managed for 36 months with positive outcomes across parenting and reproductive health constructs. These findings are consistent with other interventions with shorter follow-up.25 In a randomized controlled trial, a home-based mentorship model used to addressed teen development and negotiation skills decreased repeat pregnancy at 24 months.21 Likewise, a motivational intervention that was focused on relationships and contraceptive-use intentions showed decreased repeat pregnancies at 24 months.23 Data from our study were included in a meta-analysis of 13 AFL projects with variable study designs that revealed improved use of contraceptives and decreased repeat pregnancy at 12 months; however, parenting outcomes were not studied.30 Other interventions with repeat pregnancy improvements include school-based case management16 and immediate postpartum insertion of long-acting reversible contraceptives.42 An evaluation of a home-visiting intervention showed positive effects on parenting stress, engagement in high risk behaviors, and college attendance at 24 months.19 

Positive effects on both parenting and repeat pregnancies are critical outcomes for teen parenting programs. Risk for poor outcomes for teens and their children increases with each additional repeat teen birth. Our qualitative study of repeat pregnancy highlighted the importance of teen control and independent decision-making as important factors in reducing pregnancy risk.43 To decrease subsequent pregnancy, counseling on the use of long-acting contraceptives, not extensively available during this study period, should be started during the prenatal period.44 The intervention provided teens time with program staff in which they could discuss future plans and the experience of parenting. This may have affected their decisions around planning another pregnancy, although this effect was not directly measured. Because teens are often unprepared for parenting, their children are at risk for maltreatment.8 This risk was not attenuated by the intervention, suggesting the need for interventions that more intensely targeted harsh parenting practices. The Healthy Families New York home-visiting program demonstrated significant decreases in harsh parenting in a group of teen first-time mothers.45 Many teen parents have a history of trauma and/or depression. Integrating mental health treatment with parenting education may also reduce risk of child maltreatment.

There were some study limitations. Data were obtained through self-report, although repeat pregnancies were verified by chart review. At entry into the study, there was 1 significant difference between intervention and control participants. Control participants were more likely to be in high school. This potentially affected their decisions about repeat pregnancy either to delay or continue another pregnancy but did not positively affect their parenting attributes over time. Engaging and retaining teens in the intervention was challenging. The complex social needs of the teens often overwhelmed program staff making module completion difficult in the face of these urgent needs. Adherence was similar to other AFL teen parenting programs.46 Early in the intervention, there were some missing baseline data, but it was evenly distributed and managed statistically. Because the study design nested the parenting and life skills intervention within a teen-tot model, effects may have been attenuated because the control condition also received substantial teen-tot care, which may have included the nurse or social worker who delivered the intervention. Participants in the intervention group received more contacts from staff through recruitment phone calls and reminders and frequently asked to speak to their social worker or nurse during these calls. Because the study was conducted in 1 program in the northeast, generalizability of findings to other regions and settings may be limited.

This randomized controlled trial of a multifaceted intervention that paired medical care for teen and child with brief parenting and life skills training revealed positive effects on maternal self-esteem, including caretaking ability, acceptance of and expected relationship with infant, and decreased risk of repeat pregnancy over 36 months. With these findings, we highlight the positive impact of pairing medical services with comprehensive social services and parenting education and can inform future policy and services for teen parents. These positive effects also have potential to improve long-term outcomes for teens and their children.

Dr Cox conceptualized and designed the study, participated in design of the data collection instruments, supervised the implementation of the protocol, drafted the initial manuscript, and 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 important intellectual content, and revised the manuscript; Ms Engelhart coordinated and supervised data collection and reviewed and revised the manuscript; Ms Vyavaharkar and Ms Federico participated in study design and implementation and revised and reviewed the manuscript; Dr Woods conceptualized and designed the study, supervised study implementation, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

This trial has been registered at www.clinicaltrials.gov (identifier NCT01379924).

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.

We thank our patients who repeatedly answered our questionnaires, Jennifer Valenzuela for her work leading early implementation of our study, the Young Parents Program team, and Dr Eric Fleegler and his computerized data collection system.

     
  • AAPI-2

    Adolescent Adult Parenting Inventory Version 2

  •  
  • ACLS

    Ansell-Casey Life Skills Inventory

  •  
  • AFL

    Adolescent Family Life

  •  
  • CES-DC

    Center for Epidemiologic Studies Depression Scale for Children

  •  
  • MSRI

    Maternal Self-Report Inventory

  •  
  • OAPP

    Office of Adolescent Pregnancy Programs

  •  
  • WIC

    Supplemental Nutrition Program for Women, Infants, and Children

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.