(p. 386) Interventions with Adolescent and Young Adult Mothers
Adolescent and young adult women who are pregnant or parenting are at high risk for a host of poor psychosocial outcomes, such as multiple pregnancies, parenting difficulties, disrupted mother–infant interactions, partner violence, and increased rates of psychological disorders (particularly depression), as well as being more likely to face poverty, receive welfare, and face residency instability (Garrett & Tidwell, 1999; Harden, Lynch, Turkheimer, Emery, D’Onofrio, Slutske, et al., 2007; Key, Gebregziabher, Marsh, & O’Rourke, 2008; Lindhorst & Oxford, 2007; Moran, Forbes, Evans, Tarabulsy, & Madigan, 2007; Oxford, Lee, & Lohr, 2010). Difficulties associated with these vulnerabilities are often further exacerbated by the adolescents’ and young adults’ life inexperience as it relates to their ability to manage responsibilities, such as difficulty managing finances and school responsibilities; indeed, adolescent mothers are less likely to complete high school, attend college, find stable employment, marry, or be self-supporting (Letourneau, Stewart, & Barnfather, 2004). Of particular relevance as a risk factor for poor outcomes is substance use in this population (DiClemente, Santelli, & Crosby, 2009). Adolescent, unmarried pregnant women with less than a high school education have been identified as a group at highest risk for frequent substance use (Ebrahim & Gfroerer, 2003). Although studies have suggested young adults typically “mature out” of substance use (Bachman, O’Malley, & Schulenberg, 2002), substance-using mothers who are in early and mid-adolescence typically continue to use into and following pregnancy; compared to a nationally representative sample of same-aged adolescent women who are not mothers, the prevalence of substance use has been found to be much higher among adolescent mothers (Gillmore, Gilchrist, Lee, & Oxford, 2006).
Substance use among adult mothers, as well as adolescent and young adult mothers, has been shown to be associated with a host of poor child outcomes, from lower birthweight and head circumference (Shankaran, Das, Bauer, Bada, Lester, & Wright, 2004) to infants’ acoustic cry characteristics that reflect reactivity, respiratory, and neural control of the cry sound being compromised by prenatal substance use (Lester, Boukydis, & Tworney, 2002). Furthermore, pregnant adolescent and young adult mothers are already at the highest risk for infant mortality and low birthweight compared to all other maternal ages (p. 387) (Mathews, Menacker, & MacDorman, 2003), and this risk is further exacerbated when the mothers are using substances, as maternal substance use among adult mothers has been shown to have detrimental effects on the mother–infant interaction (Goldman-Fraser, Harris-Britt, Thakkallapalli, Kurtz-Costes, & Martin, 2010).
Despite its high-risk status, the intersection of substance use and teen pregnancy has surprisingly received little research attention, and few empirically based treatment models have been developed to meet the unique needs of substance using adolescent and young adult mothers. Of particular concern is the lack of consideration of developmental context when delivering intervention programs, as targeting adolescent and young adult substance-using mothers’ needs is distinct from those of adult populations. Unique factors that must be taken into consideration include social influences (i.e., in relation to peers and parents), demands to juggle personal responsibilities (i.e., related to continued schooling and financial pressures), and issues related to “dual-development” processes (i.e., teenage mothers themselves are in many ways still developing).
In order to address limitations in understanding the treatment needs of substance-using adolescent and young adult mothers and the scarcity of effective treatment approaches to meet these needs, this chapter aims to provide an overview of the specific vulnerabilities of this group, as well as a discussion of components of empirically supported interventions that may provide a potential framework to inform age-appropriate intervention development. The first section outlines specific developmental considerations unique to adolescent and young adult mothers. The second section presents a detailed overview of the very few treatment models designed for pregnant and/or parenting adolescents and young adults with substance use problems. Empirical evidence is presented where available, and particular attention is focused on the specific components of these intervention programs that are tailored specifically to the adolescent and young adult age group. In the final sections, recommendations are provided to guide future directions of work in this area, drawing from the evidence reviewed throughout the chapter, as well as components of integrated parenting and substance use interventions developed for adult mothers that may be useful for future application to younger mothers. Rather than implying that these interventions could be simply extended to the adolescent and young adult populations without modification, the adult interventions are reviewed through a developmental lens, and only components that match the specific vulnerabilities of adolescent and young adult substance using mothers are discussed.
Adolescent and Young Adult Mothers: Developmental Considerations
Factors that influence parenting as an adolescent or young adult are often distinct from factors that adult mothers typically face, and these factors cut across numerous domains, including family factors, peer influences, and other forms of social support, as well as intra-individual factors related to one’s own development, substance use, and psychological comorbidity (Roberts, Roberts, & Xing, 2007). (p. 388) Stressors related to being a young mother, coping with one’s own developmental issues, and the high rates of psychopathology found in this population contribute to high rates of substance use (Black, Nair, Kight, Waschtel, Roby, & Schuler, 1994; Huebner, 2002) which further increase the risk of poor parenting (Nair et al., 2003).
Research has suggested the importance of considering the “social context” of adolescent and young adult parenting, given that, particularly for this group, parenting effectiveness is often challenged without appropriate social support (Luster, Bates, & Fitzgerald, 2000). Furthermore, it is also common for adolescent mothers to have a second child before the end of young adulthood; research has found that teenage mothers who have already given birth are five times more likely to have another child before age 20 than are other adolescent girls (Key, Gebregziabher, Marsh, & O’Rourke, 2008). Given that young, substance-using mothers are often single mothers with limited resources and more than one child, effects of social support are crucial in terms of managing multiple responsibilities (Gillmore et al., 2006). Limited psychosocial resources have been shown to be associated with an increased likelihood of harmful parenting practices and other risks to their child’s development; however, these threats are often found to be “buffered” by a supportive social network, either family, partner, or professional support (Luster, Bates, & Fitzgerald, 2000; Schellenbach, Whitman, & Borkowski, 1992).
In addition to direct effects on parenting practices, positive social support has been shown to be related to the adolescent and young adult mother’s well-being, which has clear implications for parenting abilities and child outcomes. Multiple sources of support (e.g., family, partner, friends) have been shown to decrease rates of depression as well as substance use among adolescent mothers, which in turn improves parent–infant interactions (Stewart, 1993; Stewart, 2000). Support in coping with the daily life of raising a child as a teenager may also reduce rates of relapse for the young mother, given the clearly documented link between stress, as well as parenting stress more specifically, and substance use (Sheinkopf, LaGasse, Lester, Liu, Seifer, Bauer, et al., 2006). Research has shown that specific parental stressors (e.g., infant crying, child deviant behaviors) could be a distinct type of stressor that leads mothers to have an increased desire to use substances (Lang, Pelham, Johnston, & Gelernter, 1989; Pelham, Lang, Atkeson, Murphy, Gnagy, Greiner, et al., 1997). Moreover, mothers who experience high levels of distress may be less effective at responding to their infant, thus worsening the effects of parental stress and further highlighting the importance of support for these young mothers in their daily lives (Sheinkopf et al., 2006).
Lastly, the social context has been shown to change following birth for adolescent and young adult mothers, such that having a baby may “convince” a young mother that she is now an “adult” and can be independent (Morrison, Spencer, & Gillmore, 1998). Thus, in weighing the role of the various forms of social support that may be present in the adolescent’s network, it is crucial to consider how the adolescent may receive this support, and what effects this may have on parenting. (p. 389) The following sections address specific types of social influences and how they may relate to young mothers’ needs.
A clear distinction between adolescent/young adult and adult mothers is the role of family involvement. Although not specific to substance users, adolescent mothers tend to rely more on their family for support than do adult mothers. Support from family appears to reduce stress, engender a positive parent–child relationship for the adolescent mother and her child, and promote infant development (Collins, 2005; Logsdon, Birkimer, Ratterman, Cahill, & Cahill, 2001). The child’s grandmother has been suggested to be a particularly important source of support for the adolescent mother (Gee & Rhodes, 2003; Dallas, 2004) and may have direct effects on the child’s intellectual and linguistic development (Sommer, Whitman, & Borkowski, 2000).
However, it is crucial to note young mothers’ “dual role” as both mother and child (Whitman, Borkowski, Keogh, & Weed, 2001; Sadler & Cowlin, 2003). Although adolescents may rate their mothers as the most helpful sources of child-related support, they also often report resentment towards this help; the support may foster a sense of identity confusion for adolescent mothers who are stuck in dual roles, simultaneously acting as a mother and as a child (Morrison, Spencer, & Gillmore, 1998). Conflict with the adolescent’s mother may take away from her self-confidence in her parenting abilities and often results in mother–daughter conflict, which has also been shown to have a direct impact on the adolescent’s child’s functioning (East & Felice, 1996).
Of particular relevance to adolescents is the role of peer influence. Compared to adults, adolescents are much more affected by peer pressure, peer attitudes and socialization, and peer substance use (DiClemente, Santelli, & Crosby, 2009). Peer substance-using networks are commonly cited as one of the strongest correlates of adolescent substance use (Bauman & Ennett, 1996; Kobus, 2003). However, pregnancy and parenting also force adolescents to alter their social network; adolescent friendships have been shown to change during the postpartum period, as the young mothers are forced to spend more time on childrearing than on social activities (Morrison, Spencer, & Gillmore, 1998). Adolescent mothers often report feeling less support from their peers as a result of inadequate day care services, high rates of school dropout, and increased financial pressures (Collins, 2005). Furthermore, this can contribute to increased substance use as a means to fit in by mimicking peer group use (Lundborg, 2006), or to cope with this distress (Englund, Egeland, Oliva, & Collins, 2008; Fergusson, Horwood, & Ridder, 2007; Shelton & Harold, 2008; Zucker, 2008). Although most pregnant substance-using adolescents stop or at least limit their substance use while pregnant, some do continue into pregnancy (Gillmore, Gilchrist, Lee, & Oxford, 2006). For this latter group, research indicates continued use may be (p. 390) associated with peer substance use as well as school dropout (Gillmore, Butler, Lohr, & Gilchrist, 1992; Haynie, Giordano, Manning, & Longmore, 2005; Spears et al., 2010). Similar factors also appear to influence re-initiation into substance use patterns after giving birth for those who limit their substance use during pregnancy (Gillmore et al., 2006).
In addition to peer influences, romantic partners in particular have been shown to have a significant effect on adolescent and young adult mothers’ participation in substance use and other risky behaviors; the more involved the partner tends to be in substance use and risky behaviors, the stronger his influence on the mother (Amaro, Zuckerman, & Cabral, 1989; Spears et al., 2010). Compared to older mothers, adolescent mothers are often single mothers, reducing their likelihood of being involved in reciprocally supportive relationships (Neufeld & Harrison, 1995). In addition to supportive partners’ providing resources to young mothers, being in a relationship with reciprocal interaction also may model for adolescents how to meet the demands of child interaction (Letourneau et al., 2004). However, for adolescent and young adult mothers, particularly those who use substances, it is even less likely that these populations will reap the benefits of being in a reciprocal, supportive relationship (Dormire, Strauss, & Clarke, 2006; Neufeld & Harrison, 1995). Indeed, scarce partner support following birth has been shown to be associated with anger and punitive maternal behavior towards the child (Crockenberg, 1987).
Community support for childbearing needs is critical to enhance support from friends, family, and partners, particularly when support in these areas is lacking. Among adolescent mothers, professional support from healthcare professionals has been shown to be valued similarly to that of familial support (Burke & Liston, 1994), and was shown to be particularly beneficial when the professional support involved specific skill-building or further parenting education (Schinke, Barth, Maxwell, & Gilchrist, 1986). Although the availability of multiple forms of social support is important for this high-risk, vulnerable group of mothers, access to professional support, as well as appropriate healthcare services, may often be a challenge in this population. For instance, young, low-income substance-using mothers are at high risk for being uninsured at the beginning of their pregnancy; they are often excluded from private insurance agencies due to mental health and substance abuse issues, and Medicaid coverage may not be sufficient for their own as well as child’s health care and mental health needs (Aday, 2001). Additionally, fear of stigma and legal implications of admitting to substance use may prevent pregnant, substance-using adolescents and young adults from seeking help in the first place (Fonseca, 2010), which highlights the importance of professionals in the community being sensitive and taking into account the safety of the young mother (Kaiser & Hays, 2005).
(p. 391) Perceived Social Norms
Beyond the practical, financial, and emotional support provided by family and professional support figures, numerous lines of research also suggest the importance of these forms of social support in determining social norms regarding substance use. Exposure to social norms regarding substance use, often dictated by messages delivered by family and professional support figures, has been shown to predict continued substance use and severity of use among adolescent and young adult mothers. Morrison and colleagues (1998) found that adolescent mothers’ attitudes and perceived social norms regarding substance use became increasingly less unfavorable in this postpartum period. These attitudes were in line with the messages they were receiving from loved ones and health professionals who stressed the negative effects of substance use during pregnancy but did not continue to stress the negative impact of substance use in the postpartum period. In this way, perceived social norms can be a protective factor when they support positive parenting behaviors, including limiting one’s substance use; however, in the same way, they can be a great detriment to those who are surrounded by norms that are less critical of substance use and problematic parenting practices, which may be a particular risk factor in the postpartum period (Morrison et al., 1998).
Individual Risk Factors Affecting Parenting: “Dual-Development Hypothesis”
Unique to adolescent and young adult mothers is the idea that developmental tasks of adolescence may conflict with the tasks of early parenthood; young mothers may face a “developmental crisis” that can lead to a lack of emotional availability to their children (Sadler & Cantrone, 1983). This developmental crisis may consist of identity diffusion, difficulties with trust, lower self-esteem, depressive symptoms, and being less likely to initiate verbal interaction with or show responsiveness to the child, which may all be associated with limited emotional availability and positive affect expressed to the child (Osofsky, Hann, & Peebles, 1993). Adolescent mothers in a developmental crisis are more likely to be punitive with discipline (Garcia-Coll, Vohr, Hoffman, & Oh, 1986), and furthermore, for substance-using mothers, this punitive parenting style may increase the likelihood of problematic conduct and control behaviors in their children (Kandel, 1990). Social support has been shown to help mitigate the effects of this “developmental crisis” on adolescent and young adult mothers’ well-being and parenting practice by providing support and resources to make abusive patterns less likely and to promote positive parenting practices. However, this pervasive need for self-identity development remains a key obstacle in successful parenting for young mothers.
The importance of social support for adolescent mothers is particularly relevant when considering these mothers’ need to balance their individual needs for treatment and other personal goals with parenting responsibilities. For instance, Fonseca (2010) interviewed adolescent mothers, many of whom were dealing with substance abuse issues, as they partook in a comprehensive, school-based intervention program in order to understand the challenges of adolescent substance-using (p. 392) mothers from both the adolescents’ and treatment staff members’ points of view. As a result, a few key themes emerged. The need for child care was particularly salient when adolescent mothers were considering their own treatment needs. For instance, adolescent, unwed mothers may not be able to enter into substance abuse treatment, particularly residential programs, if they do not have a familial support network that may be able to take care of the child, often citing the fear of losing their child to child protective services (CPS) as the main concern. Similarly, young mothers without appropriate social support had difficulty juggling parenting with the demands of school, which has clear implications for long-term outcomes of both the young mother and her child. Yet, substance using mothers also reported a renewed interest in returning or completing school after giving birth, as well as other more concrete goals and aspirations for the future compared to pre-pregnancy. Although giving birth may inspire a desire for longer-term changes, young mothers are in a difficult position in having to balance caring for themselves and their own identity development with the need to care for their child. Underlining the importance of social support as delineated in the previous section, without child care or family support to care for the child, the young mother is unable to follow through on her own aspirations and self-development (Fonseca, 2010).
Severity of Substance Use
As indicated in the previous section, some adolescent and young adult mothers may fully desist from substance use upon pregnancy, yet many resume substance use in the postpartum period. Morrison and colleagues (1998) examined substance use, as well as cognitions related to use, among a large sample of pregnant and parenting adolescents from pregnancy to 12 months postpartum. Their findings demonstrated that adolescent mothers tended to reduce rates of substance use during pregnancy; however, they often reinitiated and increased use substantially by six months postpartum and then leveled off to rates similar to pre-pregnancy by 12 months postpartum. Common predictors of greater resumption and/or greater level of substance use included greater history of use before pregnancy, depressive symptoms, partner substance use, childhood abuse, and a longer time period since the child’s birth (Morrison et al., 1998; Spears et al., 2010).
Continued use and severity of substance use among teen mothers have numerous implications for the effectiveness of their parenting practices. Particularly among younger, inexperienced mothers, substance users are more likely to provide inappropriate developmental support to meet their child’s needs (Spieker et al., 2001). Severity of the mother’s substance use, as well as associated stress and health issues, contribute to the quality of her parenting practices and beliefs about parenting, which have direct effects on the mother–infant interaction. Substance using mothers have been shown to be less sensitive and more likely to demonstrate subtly hostile behaviors when interacting with their infants compared with non-substance using mothers (Spieker et al., 2001), and this is a particular risk factor for younger mothers. Adolescent mothers, specifically those who experience rejection and low social support, have also been shown to be more likely to exhibit angry and punitive parenting (Crockenberg, 1987). Compounded by the (p. 393) pharmacological effects of substance use, studies have found a range of negative characteristics common among substance using mothers—ranging from memory and attention deficits, to aggression, impulsivity, depression, and unpredictable behavior—each having the potential to greatly interfere with parenting capability (Clark, Robbins, Ersche, & Sahakian, 2006; Indlekofer, Piechatzek, Daamen, Glasmacher, Lieb, & Pfister et al., 2009; Lori, Akihito, Jason, & Frazier, 2008).
Rates of comorbid psychopathology are high among adolescent mothers (Cassidy, Zoccolillo, & Hughes, 1996), particularly those with substance use problems (Quinlivan, Box, & Evans, 2003). One of the most common comorbid conditions in this population that also has significant effects on parenting is major depressive disorder (MDD). Studies have reported over 50% of substance using teenage mothers experience clinically elevated rates of depression, and these mothers demonstrate less spontaneous, cheerful, proximal, and reciprocal interactions with their infants (Field et al., 1998). Substance use and depression have been shown to have synergistic negative effects on the mother–child interaction and are associated with significant social, emotional, and cognitive deficits for their children (Field et al., 1998). Beyond direct effects on parenting, both depression and substance abuse put children at increased risk for other risk factors, such as exposure to violence, academic problems, and early sexual risk activity and risk-taking (Spears et al., 2010). Adolescent mothers who are younger (16 and under) and those who are depressed represent two high-risk groups who are less responsive and stimulating to their infants and respond poorly to intervention (Letourneau et al., 2004).
Knowledge of Child Development
Lack of experience with parenting practices and knowledge of child developmental progression has been identified as one of the greatest challenges for young substance-using mothers (Fonseca, 2010; Spieker et al., 2001). Adolescent and young adult substance-using mothers have been shown to have unrealistic development expectations about their child’s behavior (Spieker et al., 2001) and also have less knowledge of child’s developmental milestones (Letourneau et al., 2004). This suggests that young substance-using mothers are often not well prepared or educated in terms of knowledge and expectations about child development, and further education on parenting and basic child developmental processes is needed (Letourneau et al., 2004; Spieker et al., 2001). The mismatch between maternal expectations and realistic child development has been shown to lead adolescent mothers to form negative attributions towards their child as well as themselves as mothers, particularly when comorbid substance use is present (Spieker et al., 2001).
Substance using mothers more generally exhibit higher levels of parenting distress than non-substance-using mothers (Sheinkopf et al., 2006), and adolescent (p. 394) mothers, who often have less parental knowledge and even fewer support resources than adult mothers, are even more likely to exhibit high levels of parenting distress (Mollborn & Morningstar, 2009). Teenage and substance-using mothers, representing the intersection of both high-risk groups, may be most vulnerable to experiencing parenting-related distress. Parenting-related distress has been found to explain a significant degree of maladaptive parenting practices among high-risk substance-using adult mothers (Suchman & Luthar, 2001) and is also highly relevant for adolescent mothers who commonly have to juggle multiple responsibilities and also have a less mature understanding of how to effectively cope with distress (Golder, Gillmore, Spieker, & Morrison, 2005).
There are numerous factors that may contribute to the increased parenting stress among substance using mothers, stemming both from actual infant cues as well as mothers’ maladaptive cognitions related to child cues. Cocaine-exposed infants often demonstrate increased reactivity compared with non-cocaine-exposed infants (Lester et al., 2002), and these behaviors (e.g., excessive crying, irritability, jitteriness, tone abnormalities, and attention problems) can be considered particularly distressing to mothers (Papousek & von Hofacker, 1998; Porter & Porter, 2004; Nair et al., 2003; Singer et al., 2000). In addition to visible or audible cues that may trigger stress in a parent, an absence of certain cues in cocaine-exposed infants (e.g., times of lethargy, unresponsiveness, lack of enjoyment during play) can also lead to increased frustration and guilt in mothers (Porter & Porter, 2004; Nair et al., 2003; Bendersky & Lewis, 1998). Postnatal effects of drug exposure interfere with an infant’s ability to send healthy, positive cues to the mother that normally define the mother–infant attachment, thus feeding the guilt and decreased parenting confidence experienced by substance using mothers (Porter & Porter, 2004; Suchman & Luthar, 2001). Mothers also experience stress from cues related to premature birth characteristics (e.g., low birthweight or irritability) and these often foster maternal cognitions of failure, inadequacy, or guilt (Suchman & Luthar, 2001). Younger mothers may be even more vulnerable to these patterns, given the overall tendency to have lower levels of parenting knowledge, understanding of infant cues, and parenting confidence (Ryan-Krause, Meadows-Oliver, Sadler, & Swarts, 2008; Osofsky, Hann, & Peebles, 1993).
Substance using mothers have reported guilt and shame, not only about the biological consequences of their substance abuse, but also the concomitant lifestyle—often filled with violence and abuse brought on by drug involvement—that their children may face (Suchman & Luthar, 2001; Baker & Carson, 1999), which is often coupled with low rates of school completion and employment among teenage mothers (Hoffman & Maynard, 2008; Bradley, Cupples, & Irvine, 2002). The cognitions of fear, shame, guilt, and frustration associated with parenting for substance using mothers have serious implications, as they are often cited as reasons to not seek external help or resources (Pajulo, Savonlahti, & Sourander, 2001; Suchman & Luthar, 2001; Davis, 1990) and have also been associated with increased parenting stress, depression, hopelessness, and low self-esteem (Porter & Porter, 2004; Kettinger, Nair, & Schuler, 2000).
(p. 395) Existing Treatment Approaches
Despite the numerous individual and environmental risk factors facing substance-using adolescent and young adult mothers, there has been surprisingly scarce research attention paid to treatment approaches for this population, particularly those that simultaneously address parenting and substance use. This section outlines the very few interventions that were identified that address both concerns. Given the lack of research specific to this area, the following section also discusses characteristics of successful parenting interventions for adult substance-using mothers that have components that may hold promise for adolescent mothers. Although these components may not be developmentally informed initially, they may be useful starting points to guide future intervention development and to consider which components may be most applicable to the adolescent developmental context.
Integrated Interventions that Address both Parenting and Substance use Among Adolescent and Young Adult Mothers
Multicomponent Intervention for Teen Mothers and Their Infants
As one of the few interventions specifically targeting parenting and substance use among adolescent mothers, Field and colleagues (1998) developed an intervention that took place at a vocational school: the intervention was a four-month program that integrated substance abuse treatment, parenting classes, job training, and schooling for poly-substance-using adolescent mothers with infant children. Day care was also provided for infants during schooling. The drug and social rehab program consisted of psychoeducation, frequent urine monitoring, group therapy, Narcotics Anonymous or Alcoholics Anonymous (NA, AA) groups, as well as individual substance-abuse counseling. Individualized treatment plans were developed for each participant based on their substance abuse history, and psychiatric, educational, and vocational evaluations. Psycho-educational material consisted of subjects related to theories of addiction, medical complications, family relationships, male–female interactions, interpersonal and communication skills, assertiveness training, HIV/AIDS and sexually transmitted disease (STD) risk education, spirituality, accessing health care, social and vocational services, as well as additional information on 12-Step programs. The group therapy portion of the intervention focused on themes related to patterns of a substance using lifestyle, such as breaking down denial of substance use, teaching effective problem-solving and coping skills, and focusing on the 12-Step philosophy. Social rehabilitation was conducted two hours per week and addressed problems with daily living, social support, school, parenting, and interpersonal relationships; members of one’s support network, such as parents, boyfriends, and friends, were encouraged to attend this aspect of the intervention. Regarding the vocational aspect of the program, mothers had to agree to complete high school or a General Educational Development certificate (GED) in order to participate in program. Mothers attended classes in the morning and received educational counseling. For vocational help, mothers were provided (p. 396) with job counseling, referrals for job training, assistance with placement in vocational training programs, and assistance in finding stable living arrangements and affordable day care at the end of the program.
Although somewhat separate from the substance abuse treatment and vocational and educational rehabilitation, mothers also attended parenting classes two hours per week. The classes were designed to provide education on developmental milestones, child-rearing practices, and exercises for age-appropriate sensorimotor/cognitive development, and to facilitate mother–infant interactions. Infants were in the nursery school day care program while mothers were in school for the majority of the intervention, but mothers also spent one to two hours per day in the nursery school helping, in order to learn how to care for the infants. The nursery was staffed by a head teacher, two teaching assistants, and three mothers, who each served time as teacher-aid trainees. Lastly (having positive implications for both parenting abilities and substance abuse recovery), mothers were also involved in relaxation therapy, which included aerobics, progressive muscle relaxation, music mood-induction, and massage therapy—all techniques that have been previously shown to reduce anxiety, depression, and cortisol reactivity in adolescent psychiatric patients.
Field et al. (1998) examined outcomes among 126 substance using mothers (16–21 years of age) receiving the intervention program compared to a group of non-substance-using adolescent and young adult mothers who participated in the intervention program and a group of substance-using control mothers who did not participate in the program. Mothers of all three groups were similar across the variables of age, education, socioeconomic status, and ethnicity. Six months after participating in the intervention, results demonstrated a differential effect of treatment on numerous positive outcomes related to the mothers’ well-being. For instance, by six months, levels of self-reported depressive symptoms in the substance-using mothers’ group receiving the intervention approached levels reported by non-substance-using mothers and fell below levels reported by the substance using mothers in the control group. Following participation in the intervention, the substance using adolescent mothers demonstrated lower rates of repeat pregnancy and lower rates of substance use compared to the no-treatment substance using controls. There were also positive effects on education and vocational outcomes: mothers in the program were more likely to receive their high school diploma and obtain employment.
Similar positive effects of treatment were documented for mother–infant interactions and infant outcomes. Mother–infant interactions were videotaped during feeding at the newborn period and during play when infants were three and six months old. The substance using mothers in the intervention demonstrated significant improvements in their coded interactions by three months post-intervention, and by six months, the interactions resembled those of the non-substance-using comparison condition. Regarding infant outcomes, the intervention group’s infants demonstrated positive effects on infants’ head circumference, developmental complexity of early infant interactions (measured by the Early Social Communication Scales; Seibert & Hogan, 1982; Seibert, Hogan, & Mundy, 1987), and infant mental status development measured using the Mental Status Scale of the Bayley Scales of Infant Development (Bayley, 1969). At 12 (p. 397) months following the intervention, the infants of the adolescent substance-using mothers receiving the intervention had improved Early Social Communication Scales scores and Bayley Mental Scale scores, significantly greater head circumference, and fewer pediatric complications, compared to the substance-using control group.
The intervention program developed by Field and colleagues has numerous strengths, notably its comprehensiveness through addressing education, job training, parenting, substance abuse treatment, social support, and overall mental health and well-being. The techniques are largely derived from empirically supported research and incorporate a developmental perspective; the components are focused on the unique needs of an adolescent/young adult population (ages 16–21). For instance, particular emphasis is placed on school and vocational needs, social rehabilitation and support necessary for adolescents, and relaxation techniques with empirical support specifically in an adolescent population. Parent training focused on basic education that is often deficient in young mothers (e.g., knowledge of developmental milestones).
This intervention program appears to be the most clearly documented integrated approach for substance use and parenting developed specifically for this age group (Field et al., 1998). Meanwhile, it is also important to acknowledge some limitations, such as the potential implications for generalizability and dissemination given the time- and resource-intensive nature of the program. Future research is needed to replicate these findings, to compare the intervention to a closer comparison treatment, as well as to begin to tease apart which components of the multifaceted intervention are the most necessary.
Suchman and colleagues (2006) emphasized in a review of parenting interventions for predominantly adult substance-dependent mothers that the intervention evaluated in Field et al. (1998) demonstrated sustained effects on parent–child interactions—effects that were not found in the other interventions evaluated in the review. Suchman and colleagues suggested that the unique components of the Field intervention that may explain these sustained outcomes include an emphasis on reciprocity, mutual regulation, and harmony in the mother–infant interactions, as the intervention included a significant focus on recognizing infant cues and coaching mothers’ sensitive, contingent responses. Suchman and colleagues suggested that “mutual regulatory processes in the mother–child dyad” may be “critical mechanisms” to target in parenting interventions for substance abusing mothers. This may be a particular vulnerability for adolescent mothers, as adolescence is a critical period for the developmental of key brain regions associated with emotion and behavior regulation; furthermore, heightened changes in emotion and arousal associated with puberty may precede full development of these regions, thereby creating a “disjunction” between regulatory abilities and heightened emotional states (Steinberg, 2005), potentially impacting mutual regulatory processes relevant to the mother–child dyad.
Parenting Enhancement Program
One intervention that was developed initially for adult substance-using mothers but has also been evaluated among unwed adolescent mothers (who were (p. 398) not substance users) is Porter’s Parenting Enhancement Program (PEP), a program aimed at improving parenting skills and knowledge about infant health, developmental milestones, and safety issues, as well as self-care and relaxation (Porter & Porter, 2004). Studies have adapted PEP for pregnant teens and unwed adolescent mothers, and showed positive effects on maternal and infant health outcomes (Porter & Knicely, 1985). Studies have also evaluated a PEP intervention that combines infant massage, the Blended Infant Massage–Parenting Enhancement Program (IMPEP), and this has been piloted in an adolescent/young adult population. Porter, Bongo-Sanchez, and Kissel (1996) recruited 19 substance-using mothers from a hospital-based Maternal Addiction Program; their sample ranged in age from 14 to 20 years. Half of their sample was assigned to an IMPEP condition (four weekly sessions), and half was assigned to a control condition. The intervention showed perfect treatment retention, which is noteworthy given the high levels of treatment resistance and dropout in this population. Although it was a small sample and results were not statistically significant, the authors argued there was sufficient support to suggest further exploring the gains in attachment-related outcomes, including improved eye contact, more interaction, and active interest in learning more about developmental considerations for parenting.
While the pilot results proved promising, future work is clearly needed to build on an IMPEP intervention for adolescent mothers, specifically those who also are substance users. Research seems only to have continued to build on the efficacy of the IMPEP intervention delivered in adult populations, and interestingly, little differentiation seems to have been made when applying IMPEP to adults versus adolescents. It is unclear whether and how the intervention was modified based on developmental needs of adult versus young adult populations.
Recommendations and Future Directions based on Previous Research
Numerous studies have pointed to the need to develop interventions for substance using adolescents who are parenting (Morrison et al., 1998; Spears et al., 2010); however, this is a difficult endeavor with a clear need for continued research. This final section outlines recommendations for future intervention-development efforts based on knowledge of both the developmental needs of adolescent substance-using mothers, as outlined above, and on empirically supported interventions that have been evaluated among adult substance-using mothers that have components that may also hold promise for younger mothers. Rather than implying that interventions for adult substance-using mothers could simply be extended to adolescents, which would neglect important developmental considerations, this section focuses on the pieces of available interventions that may best fit the needs of adolescent and young adult mothers described in the previous sections.
Targeting Beliefs Related to Substance use and Parenting
Given that substance use has consistently been shown to decrease during pregnancy, albeit it often resumes in the postpartum period, researchers have suggested that a (p. 399) desire to protect the baby’s health may be a key motivation for reducing substance use during the postpartum period. This is further supported by the fact that adolescents have been shown to respond to clear messages they receive from family and professional support regarding the negative effects on child outcomes of the mother’s substance use while pregnant. Researchers have suggested that effective intervention programs may be able to capitalize on these messages in later stages of parenting: efforts must continue to focus on addressing adolescent mothers’ beliefs related to how their substance use can also harm the baby in later developmental periods and on the effects of substance use on parent–child interactions and parenting abilities (Morrison et al., 1998). Also related to addressing cognitions and beliefs related to substance use during pregnancy and in the postpartum period, interventions can focus on building relationships with others who are also parenting, which may increase support for resisting substance use during the postpartum period (Morrison et al., 1998). Although research has suggested that cognitive interventions that involve other young substance-using adolescent mothers may be promising, it remains unclear the degree to which these directions have been pursued in intervention-development efforts.
Incorporating Family Involvement
Although not specific to substance using mothers, research has demonstrated that successful parenting interventions with adolescent mothers require family involvement. Family involvement may be incorporated through support groups on how to improve relations with family, as well as interventions that include family members taking part in the treatment process. In this context, educators would work with the mother and family to improve their relations and demonstrate how the young mother can best be supported by family (DiClemente et al., 2009). When a young mother lacks family support or resources, interventions must find ways to creatively incorporate extended family or other means of social support (Letourneau, 2004). Partner-specific support may also play an important role, particularly in relation to the mother’s overall well-being, which has key implications for the implementation of effective parenting practices (Gee & Rhodes, 2003). Family and partner involvement may also be crucial in order to allow for young mothers’ engagement and entry into the program itself, as daily responsibilities related to school, child care, and access to financial resources may be factors that preclude mothers’ ability to participate in intervention programs. However, the incorporation of family into treatment efforts needs to be conveyed to the adolescent in light of her own perception of her developmental stage, as she may view herself as an independent mother not in need of the support of others. In sum, although familial support during parenting has been consistently demonstrated to be important and predictive of better outcomes, this help may not be wholly welcomed, and the indirect conflict and arguments that often result may also be important predictors of adolescent and young adult mothers’ parenting confidence and subsequent effects on child outcomes.
Reducing Psychological Barriers to Treatment
A unique challenge to treatment efforts directed at adolescent substance-using mothers is engagement in treatment. Adolescents may perceive intervention (p. 400) efforts as “competing” with peer influences; during a developmental period in which peer influence tends to be most salient, an intervention program must incorporate efforts to address any ambivalence toward change. The Seattle “Birth to Three” program (Ernst, Grant, Streissguth, & Sampson, 1999), although developed for adult populations (mean age = 27 years old), may provide useful strategies to incorporate in an adolescent-focused program. This approach incorporated Motivational Enhancement strategies (Miller & Rollnick, 2002) specifically to target treatment engagement. The approach directly acknowledges maternal ambivalence toward change in substance use and parenting responsibility. Although in the ideal situation an intervention could effectively target ambivalence toward substance use, many adolescents may not be at a stage in which they are ready to change. Moreover, the stigma of being a young, substance-using mother has been reported as a barrier to entry into an integrated substance-use and parenting program (Fonseca, 2010). Efforts targeted at increasing entry into treatment programs must not only incorporate reduction in practical barriers to attendance in intervention programs, but also address the psychological barriers. Research involving adult substance-using mothers has suggested that first engaging an individual in a parenting intervention may also show reductions in substance use behaviors. For example, Suchman and her colleagues (2006) pinpointed reductions in substance use following parenting interventions alone, even when substance-abuse treatment was not a requirement or core focus of the intervention. This is in line with previous theories showing that psycho-education in parenting interventions may also reduce maternal substance use and other maladaptive behaviors by encouraging young mothers to consider how their behavior is harmful to their children, their families, and themselves (Moore & Finkelstein, 2001). Thus, even when comprehensive substance abuse treatment is not available, feasible, or tolerable for adolescent and young adult mothers, openly discussing substance use and other behaviors as they relate to parenting may have positive effects in reducing rates of substance use (Suchman et al., 2006).
Addressing Affect Regulation
An attachment-based approach as a parenting intervention for substance using mothers stresses the importance of accurate perception of and sensitive response to infant emotional cues, as well as the link between misattribution of one’s own affective states and insensitive or intrusive parental responding (Suchman et al., 2006). The focus on awareness of affective states, and regulation of these states in particular, has clear relevance to adolescent substance-using mothers, as adolescence is a developmental period in which the “disjunction” between full regulatory capacity and heightened affect during puberty creates a “situation in which one is starting an engine without yet having a skilled driver behind the wheel” (Dahl, 2001; Steinberg, 2005, p. 70). Although an attachment-based framework holds promise, given the heightened vulnerabilities related to affective awareness and regulation in adolescence, continued research is still needed to develop and test an attachment-based intervention tailored to the needs of young substance-using mothers. Preliminary work modifying an attachment-based intervention (p. 401) for adolescent mothers emphasized a particular need to establish rapport with and gain trust from adolescent mothers, to reduce barriers to treatment (e.g., using a home-visiting program; not referring to treatment as an “intervention” or “therapy”), and to carefully consider other factors that may impact the effectiveness of attachment-based interventions, such as a maternal history of trauma or unresolved attachment status (Moran, Pederson, & Krupka, 2005). Future work in this area may consider other developmental modifications to attachment-based interventions, including emphasizing the roles of social influences and dual-developmental processes in contributing to affective distress, as well as a particular focus on strategies to improve self-regulation.
There are clear ways intervention programs can target the specific needs of adolescent and young adult substance-using mothers, incorporating both the powerful social influences on treatment entry and success, as well as the need to balance personal needs and goals related to continued schooling and independence. Intervention programs must focus not only on effective parenting practices, but also on the adolescents’ own developmental issues related to self-esteem, identity formation, emotion regulation, relationships, and personal goals as they also may relate to parenting, substance use, and child outcomes. Effective programs must simultaneously address the needs of the developing adolescent together with components of both effective substance use treatment and parenting interventions. However, future research cannot simply extend findings from adults to adolescent and young adult mothers. Rather, a thoughtful consideration of the unique developmental context of adolescence and young adulthood is necessary.
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