DR. BEERS is an assistant professor of pediatrics at Children's National Medical Center, Washington, DC.
DR. CHENG is an associate professor of pediatrics at Johns Hopkins University School of Medicine and Bloomberg School of Public
Health, Baltimore, Md.
The authors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may
have an interest in any part of this article.
The core concept of family-centered health care—an important component of the pediatric medical home—is that a child's primary
source of strength and support is his family, whose attitudes, beliefs, and knowledge have an important role in decisions
regarding the child's health (see Table 1).1,2 Some parents are, however, themselves adolescents, giving rise to unique parenting and development concerns for both the
young parent and child. Built on family-centered care, the teen-tot model that we describe in this article adapts the tenets
of family-centered care to recognize and address the distinct needs of a young family's physical and emotional health.2
Ideally, a clinic-based teen-tot program provides a range of services to the adolescent parent—typically the mother, although
sometimes the father—and her child, including primary health care for both in the same clinical setting, family planning services,
psychosocial support, encouragement to continue in school, and help obtaining services.3-6 Although many generalist pediatricians today care for teenage parents and their children together, further integration of
the family-centered care principles in practice may help optimize that care.
Despite the maturity that parenthood may confer on a teenager, she must continue to progress through normal stages of development
and master the skills of planning, prioritizing, and recognizing consequences. You, the primary care pediatrician, are well-positioned
to support the teenage parent during these trials of maturation, when seeing both the parent and child together in your office.
We offer a framework for integrating these principles into your practice.
An overview of teen pregnancy and parenting pitfalls
Good news about reduced adolescent pregnancy rates in the United States is tempered by worrisome statistics: The overall rate
declined during the last 50 years, yet remains higher than in other developed countries.7 In 2000, the pregnancy rate for women 15 to 19 years old was 83.6 pregnancies per 1000; 57% resulted in a live birth.8 Important racial and ethnic disparities exist—the pregnancy rates for African American and Hispanic women, for example,
are 2.8 and 2.5 times greater respectively, than their non-Hispanic white age peers. These rates have fallen during the past
10 years, by 32% among African Americans, 28% among non-Hispanic white women, and 15% among Hispanic women.8 Approximately one quarter of teenage mothers giving birth already have had at least one child. Less than 10% of children
born to unmarried teenage mothers are placed in an adoptive home.9
An examination of outcomes of children born to adolescent parents is complicated by confounding variables of socioeconomic
status, parental education, maternal depression, and prenatal care that is often sought late. Adverse childhood experiences,
for example, are more common among children raised by teenage mothers, and adverse childhood experiences have been found to
be a more important factor in poor childhood outcomes than the independent factor of having a teenage parent.10 A child of a teenage parent is at greater risk of prematurity, low birth weight, dying from intentional injury, and developmental
and behavioral disorders. This is true especially of second or third children born to teenagers.7 A teenage mother is likely to seek prenatal care later in subsequent pregnancies than her first pregnancy.11 Short pregnancy intervals also cause problems: A child born within two years of an older sibling is at greater risk of developmental
and educational underachievement.
In addition to the hurdles faced by her child, the teenage mother faces educational and financial hurdles and typically achieves
less academically compared with what her childless peers achieve—a difference that persists into adulthood.7 A parent's education is an important factor in the health and education outcomes of her child, and should be encouraged
and supported.
Overcoming obstacles, together
A family-centered approach helps the young parent see how her physical and emotional health and that of her baby are interdependent.
That link obliges you to address a young parent's health problems, including depression, and risk factors such as smoking.12-16 This interdependence is clearly exemplified with tobacco use: Helping the teenage parent stop smoking will have long-term
benefits for the young parent and her young child.
Poor adherence to your advice can, of course, thwart your best efforts, particularly when the teenager is caring for a child,
but interventions that focus on organization, education, and behavior modification—with family-centered care at the core—are
promising tools toward improving pediatric and adolescent adherence.17 A recent study demonstrated, for example, that glycemic control improved in adolescents with diabetes after a family-focused
intervention.18
An additional variable in adherence is the role of the child's parent and grandparent in the child's care.19,20 Some young parents surrender complete caregiving duties to the child's grandparent, whereas others take full responsibility
for raising the child; other families rely on a mix of shared responsibility. These relationships can affect adherence to,
and effectiveness of, the child's care plan. Counseling a teenage mother to put the infant to sleep on her back is misdirected
if the grandmother, as the primary caregiver, lays the infant on her stomach. Adherence to family-centered principles of care
ensures that all the child's caregivers share the same information.
Implementing the teen-tot model of family-centered care
Table 1: How to engage in family-centered care
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In 1987, the Association for the Care of Children's Health outlined the principles of family-centered care in Elements of Family-Centered Care, which provided the foundation for the American Academy of Pediatrics's 2003 policy statement, Family-Centered Care and the Pediatrician's Role.2,21 The document offers guidance and a framework for integrating family-centered care principles into your practice, which are
outlined in Table 1.21
Table 2: How to provide effective care for the adolescent parent and child
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Built on the principles of family-centered care, health care programs for young families that employ the teen-tot model focus
on the unique concerns of teenage parents outlined in the 2001 AAP policy statement, "Care of adolescent parents and their children" (Table 2).22 These programs address the reproductive care needs of the mother and primary care needs of the teenage parent and her child,
with both seen during the same office visit, often by the same provider (see "A comprehensive teen-tot program in action").
Some practices provide medical care and additional services such as social work, case management, mental health evaluation
and treatment, and career counseling. Others, equipped only to offer medical care, generally provide referrals to community
agencies for needed social services.
A comprehensive teen-tot program in action
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The principles of the teen-tot model of care are easily integrated into a traditional pediatric practice. When your staff
schedules an appointment for a young mother's child, have them encourage her to also schedule time for herself at the same
visit. Setting aside specific times each week to see young parents and their children is an efficient way to care for these
patients and encourages frequent contacts for follow-up.
Although the number of providers using the teen-tot model of care is unknown, evidence suggests that these programs keep the
rapid repeat pregnancy rate in check and increase the rates of immunization, contraceptive use, and school enrollment among
the young parent.3 Caring for the parent and child in the same medical setting encourages you to inquire about the teenager's health, education,
and family planning during frequent routine well child visits—thereby increasing the teenage parent's access to care.
How you approach a teenage parent is important; providers who see a young family together in the office are often more sensitive
to the developmental needs of the teenage parent, and that sensitivity is a key to developing a long-standing and trusting
relationship with the parent. A review of interventions to decrease the documented rapid repeat pregnancy rate among adolescent
mothers found that the characteristics of successful interventions are a close, sustained relationship between the teenage
mother and health care provider; effective, professional providers; an emphasis on family planning; and encouragement of the
parent's continued education.11
Caring for a teenage parent together with her child allows you to develop rewarding relationships across generations and,
ultimately, helps strengthen young families. The significant health and educational risks that adolescent parents and their
children face, compounded by barriers to care within our system of health care, underscore the need for comprehensive, family-centered
care. Helping a young parent navigate these challenges can exert a positive influence on her parenting skills and health behaviors.
Witnessing the strength and resilience of these young families can be very rewarding. Establishing a medical home is vitally
important for these young families to develop the trust and relationships that are requisite for improving outcomes.
REFERENCES
1. American Academy of Pediatrics Medical Home Initiatives for Children with Special Needs Project Advisory Committee: The
Medical Home: Policy Statement. Pediatrics 2002;110(1):184
2. American Academy of Pediatrics Committee on Hospital Care and Institute of Family Centered Care: Family-Centered Care and
the Pediatrician's Role. Pediatrics 2003;112(3):691
3. Akinbami LJ, Cheng TL, Kornfeld D: A review of teen-tot programs: Comprehensive clinical care for young parents and their
children. Adolescence 2001;36(142):381
4. Elster AB, Lamb ME, Tavare J, et al: The medical and psychosocial impact of comprehensive care on adolescent pregnancy
and parenthood. JAMA 1987;258:1187
5. Nelson KG, Key D, Fletcher JK: The teen-tot clinic: An alternative to traditional care for infants of teenaged mothers.
Journal of Adolescent Health Care 1982;3:19
6. O'Sullivan AL: Tertiary prevention with adolescent mothers: Rehabilitation after the first pregnancy. Birth Defects 1991;27(1):57
7. Elfenbein DS, Felice ME: Adolescent Pregnancy. Pediatric Clinics of North America 2003;50(4):781
8. The Alan Guttmacher Institute: U.S. Teenage Pregnancy Statistics: Overall Trends, Trends by Race and Ethnicity and State-by-State
Information. New York, NY, The Alan Guttmacher Institute, 2004
9. National Committee for Adoption: Adoption factbook: US data, issues, regulations, and resources. Washington, DC, National
Committee for Adoption, 1989;127
10. Hillis SD, Anda RF, Dube SR, et al: The association between adverse childhood experiences and adolescent pregnancy, long-term
psychosocial consequences, and fetal death. Pediatrics 2004;113:320
11. Klerman LV: Another Chance: Preventing Additional Births to Teen Mothers. Washington DC, The National Campaign to Prevent
Teen Pregnancy and National Organization on Adolescent Pregnancy, Parenting and Prevention, Inc. 2004
12. Schor EL: Family pediatrics: Report of the Task Force on the Family. Pediatrics 2003;111(6 Pt 2):1541
13. Casey P, Goolsby S, Berkowitz C: Maternal depression, changing public assistance, food security and child health status.
Pediatrics 2004;113(2):298
14. Leiferman J: The effect of maternal depressive symptomatology on maternal behaviors associated with child health. Health Educ Behav 2002;29(5):596
15. Brennan PA, LeBrocque R, Hammen C: Maternal depression, parent-child relationships and resilient outcomes in adolescence.
J Am Acad Child Adolesc Psychiatry 2003;42(12):1469
16. Ireys HT, Chernoff R, DeVet KA: Maternal outcomes of a randomized controlled trial of a community-based support program
for families of children with chronic illnesses. Arch Pediatr Adolesc Med 2001;155:771
17. LeBlanc LA, Goldsmith T, Patel DR: Behavioral aspects of chronic illness in children and adolescents. Pediatric Clinics of North America 2003;50(4):859
18. Laffel LM, Vangsness L, Connell A, et al: Impact of ambulatory, family-focused teamwork intervention on glycemic control
in youth with type I diabetes. J Pediatr 2003;142(4):409
19. Rich OJ: Family-focused tertiary prevention with the adolescent mother and her child. Birth Defects 1991;27(1):137
20. Brooks-Gunn J, Chase-Lansdale L: Children having children: Effects on the family system. Pediatric Annals 1991;20(9):467
21. Cooley WC, McAllister JW: Putting family-centered care into practice—a response to the adaptive practice model. J Dev Behav Pediatr 1999;20(2):117
22. American Academy of Pediatrics: Care of adolescent parents and their children. Committee on Adolescence and Committee
on Early Childhood and Adoption, and Dependent Care. Pediatrics 2001;107:429
Tips and encouragement for young parents
Being a parent is one of the best things that can happen to someone.
Although parenting can sometimes seem very hard, you can be a terrific
parent. Remember to always give your baby lots of love, and to ask for
help when you need it. Learn as much as you can about babies and
parenting—ask your doctor, go to the library, and ask other people you
know who are parents. Here are some tips to help you raise a happy
and healthy child.
- The most important thing that you can give
your child is lots of love. Every day, give her
a hug and say, “I love you.” Even when your
child is very young, tell her at least three
things each day that you love about her
and that she is doing well.
- Take care of yourself! You need to be
healthy and happy to be able to take the
best care of your baby. Eat healthfully,
exercise regularly, and see your doctor for
regular checkups. If you feel sad or
depressed, talk to someone you trust at
home, school, the doctor’s office, church, or youth center.
- No alcohol, no smoking, and no drugs. Not only are these bad for you, but your
use of them is bad for your baby, and may cause you to make poor decisions. If
you need help quitting, ask your doctor.
- Bring your baby to the pediatrician for all of his regular checkups. Ask the doctor
what to expect next in your baby’s development, and also how to handle any
challenges these developments may present. Raising a baby isn’t easy, and there
are many people who can help you.
- Babies don’t know how to tell you things, or how to listen. Read a parenting
book and talk to your baby’s pediatrician to learn what is normal for babies
and toddlers at different ages.
- Think about if and when you want to have another child. Studies show that
families do best if they wait at least two years between pregnancies—just think
about what it would be like to have two children in diapers at the same time! If
you are still having sex and you aren’t ready for another baby, talk to your
doctor about ways to prevent pregnancy.
- Not only is breast milk the best nutrition for babies, breastfeeding is good for
mothers and is a great way to bond with your baby. Your doctor can give you
tips on how to manage breastfeeding and also go to work or school. If you
decide not to breastfeed, always hold your baby when you give her a bottle so
that she can feel close to you when she eats.
- One of the most important things you can do for yourself and your baby is to
finish your education and follow your dreams. Completing your education will
enable you to do things that make you feel good about yourself, and to support
your family. Finishing your education will also set a good example for your
child.
- Read to your child every day, even when she is very young and shows little
interest—she will show more interest as she grows. Babies like books with lots of
colors and pictures and few words. Toddlers and older children like books with
fun pictures and more words. Children younger than two years old shouldn’t
watch any TV, and older children should have no more than an hour or two a
day of TV or videos.
- Have fun! Babies learn by playing, so get down on the floor with your baby to
play and have a good time!
