Minnesota Chapter of the American Academy of Pediatrics

Emily Ruedinger, MD, FAAP

By Emily Ruedinger, MD, Adolescent Medicine Fellow at the University of Minnesota and Abigail Johnson, MSW, MPH
On a national level, the teen birth rate has been steadily declining over the past 20 years. However, the U.S. teen birth rate remains substantially higher than most other developed countries, including nearly all European nations, Canada, and Australia. Although Minnesota boasts one of the lowest teen birth rates in the country, in 2012 there were still approximately 20 births per 1,000 adolescent females ages 15-19.
Despite best efforts to reduce unintended teen pregnancies, however, it is likely that most pediatricians practicing in Minnesota will care for more than one adolescent- 
headed family throughout their career. It is important to understand the unique needs of this population and to serve these families using known best and promising practices.

Challenges of Adolescent Childbearing
Many of the negative outcomes associated with adolescent childbearing that were previously attributed to maternal age may actually be more attributable to the social, economic, and environmental factors that increased the risk of the teen becoming pregnant in the first place. Studies that have controlled for these factors reveal smaller gaps between adolescent mothers and their same-age peers who delay childbearing. Pediatricians should keep in mind that, like most parents of any age, most adolescent parents possess both the desire and the capability to be excellent parents, if they are adequately supported.
Nonetheless, adolescent-headed families are undoubtedly a high-risk population. Adolescent mothers are disproportionately affected by depression and poor self-esteem. They are also more likely to live in poverty, and tend to have lower educational attainment. Pregnant and parenting teens are more likely to engage in substance abuse and to be involved in intimate partner violence. Data consistently show that the majority of parenting teens are on public assistance and live in conditions that make them highly mobile. Young mothers are also less likely to receive adequate prenatal care. Roughly one in five adolescent parents will experience a rapid repeat pregnancy; subsequent births serve to compound the challenges these young families face.
Children of adolescent mothers also suffer negative consequences &#8212; though again it is unclear how many of these are related to maternal age versus pre-existing social, economic and environmental factors. Regardless, these children are more likely to be born prematurely; to suffer from abuse and neglect; to have lower language and cognitive skills; and they are more likely to have behavioral difficulties and acute and chronic medical conditions. As adults, individuals born to adolescent mothers show lower educational attainment; are more likely to live in poverty; are at higher risk of mental illness; and are more likely to be involved with the criminal justice system. Further, they are more likely to become teen parents themselves.
Adolescent-headed families face a number of challenges specific to healthcare. Systemic access issues related to poverty affect the majority of adolescent-headed families. These include lack of health insurance, homelessness and housing insecurity, leading to high levels of mobility, and unreliable transportation. On an individual level, adolescence is a time of immense emotional, cognitive and physical growth.
Young people, including teen parents, experience varying levels of resilience, and of coping and stress management skills. The normal developmental process of adolescence can create developmental barriers to accessing a system typically designed for the &#8220;adult&#8221; user. Furthermore, adolescents are less likely to have developed the health literacy skills to advocate for themselves and their families within the traditional medical system. Many of these young families also lack the social support that can facilitate health care access. Many do not have consistent relationships with supportive adults to help them know how and when to access the healthcare system.
Parenting in isolation, as so often happens, creates logistic difficulties, such as not having anyone to babysit during the mother’s appointment. Most adolescent-headed families also face barriers related to the cultural stigma of teen parenting. This may include a history of being treated poorly by health care providers. This can lead to a general aversion around interacting with the healthcare system, and concerns about perpetuating the stigma by asking for help.
How To Optimize Your Care for Adolescent-Headed Families
Given these many disparities, adolescent-headed families often have a high level of need. The pediatrician serves as an important touch-point for these families, and can play a pivotal role in increasing their odds of success.
Numerous interventions directed at improving outcomes for adolescent-headed families have been studied. These include programs based in the home, school, community and clinic. In general, programs that are multi-disciplinary, culturally sensitive and tailored to the developmental stage of adolescence have been most successful. Whenever possible, it is optimal to coordinate care within a team that works together towards addressing the family’s health, mental health, educational, and resource needs. Although team-based care can be challenging &#8212; especially if all team members are not located within your clinic &#8212; there are a number of clinic-based models around the country that have achieved significant improvements in repeat pregnancy rates, immunization rates, educational attainment and other positive outcomes. As many clinics move towards the medical home model, this level of comprehensive, family-centered care will become more attainable, and certainly the extra investment of time and efforts appears to be worthwhile.
The following article describes one such model, though others exist as well: Joanne E. Cox, Matthew P. Buman, Elizabeth R. Woods, Olatokunbo Famakinwa, and Sion Kim Harris. Evaluation of Raising Adolescent Families Together Program: A Medical Home for Adolescent Mothers and Their Children. American Journal of Public Health: October 2012, Vol. 102, No. 10, pp. 1879-1885.
What Can You Do Today
• Create policies in your clinic that account for the unique needs of adolescent families and maximize young families’ access to your services. This may include ensuring they have quick and easy access to last-minute, walk-in, evening and weekend appointments for both urgent and routine health visits; waiving or relaxing policies that require patients to reschedule if they arrive late for an appointment; and personal (rather than automatic) appointment reminder calls or text messages.
• Point out that all parents, regardless of their age, benefit from having a robust support system. Talk with your teens to help them identify potential sources of emotional support within their family or community.
• Provide a warm referral whenever possible, keeping in mind that adolescent parents often benefit from more directed assistance than older parents might require. It is best when you or another staff person from your office can make a referral phone call with the teen, rather than just giving him or her a number or information.
• Help build their self-efficacy as a parent. Praise positive parenting techniques and interactions that you witness during the visit.
• Use every visit &#8212; whether you are seeing the mother or the baby &#8212; as an opportunity to discuss family planning. This should start at the very first newborn check with the baby. A good place to start is by asking, &#8220;Do you plan to have another child right away?&#8221; If the answer is no, follow up with, &#8220;What do you plan to do to prevent another pregnancy?&#8221;
According to both AAP and ACOG, long-acting reversible contraception (LARC), such as the implantable rod and intrauterine devices, is the recommended first-line form of contraception for most adolescents, including adolescent mothers.
For further information on LARC and other contraceptive methods, as well as further suggestions for contraceptive counseling with adolescents, the AAP released a policy statement in October 2014 that can be accessed at: http://pediatrics.aappublications.org/content/134/4/e1244.full.html
• Screen for symptoms of post partum mood disturbances at every visit, whether the visit is for the parent or the child. Remember that post partum mood changes can manifest months after the birth of a child and teen parents are at higher risk.
What’s On The Horizon
Given the importance of care coordination, advocates are working to create streamlined systems that will make it more efficient and feasible for pediatricians to coordinate with the many other agencies and individuals that serve young families. One such model involves a coordinated, online referral system that directly connects healthcare providers and other service providers that care for adolescent-headed families.
A group in Hennepin County is working to more clearly identify the practice patterns of various state and local agencies that work with adolescent-headed families. This will hopefully allow families first referral to be to the agency that is most qualified to meet their level of need. Still others are working towards creation of a standard, universal release of information form that will allow coordination of care for young families across multiple domains.

Supporting Teen Parents and Preventing Teen Pregnancies

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BC/BE Pediatrician

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Emily Ruedinger, MD, FAAP Category