One of the most difficult and frustrating scenarios faced by the practitioner who works with adolescents is the 15- or 16-year-old who comes to find out if she is pregnant. When asked what she will do if she is, she replies, "I dunno." When asked what she will do if she is not pregnant, one gets the same response - with perhaps a "nothin' different" added.
For many adults and for almost all health care providers facing the prospect of pregnancy, the expectation is filled with deep emotion. Indifference is an unexpected response to one of life's major events. How can that indifference be explained? Why are some teenagers active contraceptors when others rarely or never use contraceptives? Peer pressure, family structure, contraceptive knowledge and individual developmental factors have all been studied to understand adolescent sexual decision-making. This article reviews some of the developmental issues and presents a study related to this decision-making.
CONTRACEPTIVE BEHAVIOR OFADOLESCENTS
Today it is well known that the percent of adolescent females aged 15 to 17 who have had intercourse rose dramatically during the 1970s.1 Currently over 60% of family high school seniors report having had sexual intercourse.1 Concomitantly, the age of first intercourse fell during the last decade." When these two figures are combined with a third which indicates that over 50% of adolescent pregnancies occur within the first six months after initiating sexual activity then contraceptive behavior of youth becomes critically important in any attempt to contain unwanted and premature childrearing.'Zelnik and Kantner's data for 1979 are particularly troublesome in this regard. While there was a 20% rise during the 1970s in contraceptive use for most recent intercourse, the teenagers reporting regular contraceptive use represented only one-third of the sample. Thirty-nine percent said they sometimes used contraception and 27% said that they never did so. Furthermore, half the study population did not use contraception at first intercourse, an 11% increase since 1971.'
Of those who became pregnant, Shah et al4 reported only 23% had intended pregnancy, yet only one in five of those who did not wish to become pregnant used contraception. Approximately half of the contraceptive non-users who became pregnant did not consider pregnancy a likely outcome of unprotected intercourse.
The reasons given for contraceptive non-use are legend. The figure summarizes ZeI ni k and Kantner's findings/
Similar patterns of thinking exist for adolescent males regarding contraceptive use as for females. Finkel and Finkel6 reported that while 90% of adolescent males acknowledged the efficacy of condoms, only 15% regularly used them. Withdrawal, on the other hand, considered an effective contraceptive method by 70% of males surveyed, was regularly used by 30%. For adolescent males, however, the issue of contraception is not pressing since the majority view birth control as the sole responsibility of the female. In their nationwide survey of youth, Yankelovich et al7 found that almost half (43.2%) of adolescent males felt that contraception was the responsibility of the female and only one-fourth of the sample believed that males should regularly use contraception. Approximately two-thirds (63.4%) believed that abortion was the solution if they were to cause a partner to become pregnant; and almost one-third of the sample (29.6%) believed that it was not right to use any birth control. Finally, three out of five adolescent males believed it to be right to tell a girl you love her so as to encourage her to ha ve sex; one in five believed that getting a girl pregnant was proof of manhood.
Figure. Reason for last non-use of contraception given by females never having been and not trying to become pregnant, age 15-19 (N = 337). (Adapted with permission from Family Planning Perspectives, Volume 11, Number 5, 1978.)
With regard to adolescent contraceptive behavior, we are faced with national data which indicate that males continue to strongly regard contraception as the female's responsibility. Fifty percent of females do not use contraception during their first sexual experience; and two-thirds of all adolescent girls fail to routinely use birth control. Access to birth control technology and counseling appear to have a minimal impact on actual utilization. One is left to conclude that factors beyond availability are influencing adolescent decision-making around contraceptive use and sexual activity.
The following study was undertaken to define the contribution of developmental parameters to adolescent sexual decision-making. In this study only one aspect of sexual decision-making was examined, namely, once sexually active what developmental factors distinguish between those who are successful contraceptors* and those who become pregnant? Of those who become pregnant, the study explored differences among aborters, currently pregnant teenagers and adolescent mothers.
SAMPLE AND METHODS USED
Two hundred six sexually active adolescent females were identified in the Twin Cities with over 95% between the ages of 1 5 and 18 years with a mean age of 1 7. 1 years. Slightly less than two thirds were white, one third were black and 5% Native American. Twenty-nine percent were successful contraceptors; 24% were aborters,* 24% were currently pregnant, and 23% were mothers at the time of the study. There was no overall age difference among the four groups. All but four women were single.
The study focused on six developmental factors:
1. Ego Development (Loevinger Sentence Completion Form"): This aspect of development explores self-esteem as well as the capability of the individual to take multiple perspectives into account; and the extent to which one thinks complexly.
2. Locus of Control (Nowicki-Strickland*): This component of development refers to the extent one views herself to have control over her own life.
3. Future Time Perspective (Stein's Future Events Test10): This component of cognitive development refers to the extent to which an individual is able to project herself into the future and anticipate the occurrence of certain common events over the life cycle.
4. Moral Development (Rest's Defining Issues Test ' ' ): This aspect of cognitive development explores how an individual makes social and interpersonal (as different from intellectual) decisions.
5. Sex Role Socialization (Bern's Sex Role Inventory'2): This aspect of social development and selfconcept examines how an individual sees herself regarding traditional and non-traditional sex role stereotypes.
6. Irrational Belief S (Jones1 Irrational Beliefs Testn): This instrument examines such factors as anxiety, helplessness, dependency, rationality in decisionmaking, and the tendency to catastrophize as components of individual cognitive style.
All subjects were asked to complete the six pencil and paper tasks followed by an interview of between 60 and 90 minutes which focused on critical incidents of sexual decision-making together with associated family and peer "pressure."
Aborters were found to have the most developed future time perspective (the capacity to understand future consequences) of all groups studied. Furthermore, this group had the lowest demand for external approval and lowest dependency needs.
Comments from this group typically included such remarks as, "I wasn't ready for it" or "I wasn't ready to have a child." The aborters in this sample more frequently discussed how having a baby would interfere with their plans for school and career. Several also reflected on what they saw as the probable outcome of themselves becoming mothers for their infants. As one 15-year-old remarked: "I knew that I wasn't ready to become a mother ... I knew that I didn't want to become a mother. I was afraid that I would take this out on my baby, even though I knew that she really had nothing to do with it." As the group which evidenced the most well developed future time perspective, it came as no surprise that many of the aborters' comments and explanations for their decision to abort rested on consideration of the future consequences of childbearing both to themselves and others.
Interestingly, the aborters' low levels of dependence and demand for approval were also reflected in many comments. Those who had received an abortion against the advice and warnings of others, particularly parents or boyfriends, tended to explain their decision less in terms of overt defiance and more in light of their own belief that the abortion decision ultimately was their own. A 16year-old girl commented: "My mother told me I'd better keep the baby, that if I didn't I might regret it for the rest of my life, and then what would I do? I told her that I respected her point of view, but that I had the right to make up my own mind ..."
A 17-year-old adolescent also remarked: "When I found out I was pregnant, and I got over the shock of it all, I realized one morning that I really had to make a decision. It was really scary, but I knew I had to do what was best for me because I was the one who would live with it, live with my decision about what I did. That means 1 had to listen to myself before anyone else."
Teen mothers were found to have the least developed conceptualization of the future. They had the highest level of anxiety and rumination, the most external locus of control and had internalized the most traditional notion of female sex roles of all groups studied.
Our data indicate that teenage mothers are less aware of the future implications of childrearing (for both themselves and their offspring) than either contraceptors or aborters. In a population which sees fate "in the winds" and for which rumination is a major coping mechanism, there is a strong tendency toward inaction, passivity, and an inclination to let "whatever happens, happen." This non-interventionist attitude toward the course of life events is also reinforced by the traditional interpretation of the female sex role by teenage mothers which views passivity as appropriate.
Contraceptors were significant in the present study less in terms of what was found and more in relation to what was not identified as characteristic of this group. Previous comparative studies have tended to dichotomize their study population into contraceptors and noncon t racept ors. In such a comparison, contraceptors have been shown to have a more highly developed future time perspective, more internal locus of control, higher levels of ego development and a more modern sex role orientation than their n on-cont racept ing counterparts.'4 While in our study these observations were substantiated when contraceptors were compared with teenager mothers, they did not hold when compared with other non-contraceptors (i.e., aborters). What is learned from this is that "non-contraceptors" as a group are quite heterogeneous, consisting of those who choose abortion, parenting, and adoption as pregnancy outcomes.
This heterogeneity of the non-contraceptor group was evident in our fourth study sub-sample of those currently pregnant. There were no distinguishing characteristics evident in this group; and we hypothesize that this is because pregnancy is a transitional status with a number of viable options remaining as potential outcomes.
Experimentation and Locus of Control
Piaget15 characterized the cognitive shift of adolescence as a movement from concrete to abstract reasoning. One component of abstract reasoning, or formal operations as Piaget labelled it, is the capacity to extrapolate - to draw upon old experiences to solve new problems not previously encountered. We tend to view adolescence as a period of experimentation, of seeking new experiences. From a developmental perspective such experimentation becomes the substrate for cognitive growth. The more restricted one's range of experiences the fewer resources one has to draw upon for problem-solving. One psychological device which allows youth to sample more broadly from life's experiences is the "personal fable" or the myth of invulnerability.16
We tend to view such a belief as the malignant extension of an overactive denial system. On the other hand , such a belief is also the reflection of one with few life experiences who has interpreted the physiologic changes of puberty as sy nono mous with limitless potential. It is only through comparing that potential with actual experiences that one develops a reality-based notion of competency and limitations. The more vulnerable one sees oneself, the less one is willing to experiment. The myth of invulnerability allows the adolescent to experiment with more of life's options. It is from experimentation thai the boundaries of one's potential are learned. Such is the nature of reality testing. It is through this same process of experimentation that one begins to develop an internal locus of control, for as the teenager tries on new roles she does so as if standing in a Hall of Mirrors - aware of the reflections back onto herself from peers, family, teachers and all whom she encounters.1 She begins to become aware that a given action will please some and anger others; that certain appearances will entice some and repel others; that a given phrase will attract some and alienate others. Over time, as one role is rejected and a new one assumed, the teenager anticipates the impact it will have on those around her.
Part of the experimentation process is the identification of the control and influence one's behavior exerts upon self and others. Over time the sense of control and limits of influence are internalized and the need to continually validate it through testing behavior diminishes. From this perspective, it would be anticipated that those with a less internalized locus of control would be more likely not to use contraception since they would believe there is little they could do to diminish their chances of pregnancy. If in their past experiences their actions were not seen to have an impact on the course of events then perhaps it would be extreme ?? expect them to view contraception differently. Teen mothers repeatedly expressed this perspective:
When I found out I was pregnant I couldn't believe it ... I sort of felt like this thing was happening to me but I wasn't really there... I mean that there really wasn't nothing I could do about it because the baby was already growing when 1 found out about it. . . Like it really didn't matter what I thought about it ... it's almost like I wasn't even there.
Cognitive Development and Time
One aspect of the transition from concrete to abstract reasoning is the understanding of time as an abstraction and the development of a personal sense of future. One is not born with a notion of time; rather, it develops from early childhood. Initially, the child learns of the past - what Jife was like when she \vasa babyand before she was born. There are many concrete landmarks for the past such as photographs and adult recollections. There are few comparable markers for the future. It is late in childhood and throughout adolescence that one begins to understand time as an abstract concept which we artificially structure through seconds, minutes, hours, and days. Not only is time understood as an abstract concept, but the teenager begins to perceive herself as a being who will live in the future as weli as in the present and past.1" The child and early adolescent rooted in the present is unable to conceptualize, let alone plan for the future.
The notion of prevention, on the other hand, is predicated upon a personal conception of future. If there is no future, there is nothing to prevent. Most of the current contraceptive technologies are predicated upon taking an action today to prevent a statistical event from occurring nine months from now. It is not surpris ing t hat those with the least developed future perspective would be most at risk for unanticipated pregnancy.19 Furthermore, from this perspective, neither is it surprising that those who as teenagers have one child are most at risk for repeat pregnancy, for it is the same dynamic which placed them at risk initially (i.e., the inability to project themselves into the future) which is still at work. Without an understanding of the future implications of one's actions there is little reason to expect one to "learn from her mistakes." Child rearing does not change that dynamic; rather, it is the product of the dynamic.
So far we have commented upon two components of the concept of future: 1) time as an abstract notion, and 2) the development of a personal sense of time. There is a third component which is interwoven with the others and must be teased apart lest we place all the focus upon developmental risk factors for contraceptive failure. Luker contends that contracepting is like saving money. To do so you must not only have a personal sense of future, but that future must be worth investing in. Without future possibilities, which are both attainable and worth attaining, motherhood may be the best alternative available. If motherhood is seen as the best possible alternative, there is little impetus to defer it to a later age even if one has the cognitive capability to do so.
The interweaving of the three components of future time perspective was illuminated by a 17-year-old discussing her decision to abort:
I was afraid when I found out 1 was pregnant . . . what it might do to my life. 1 knew I wasn't ready to have a kid right now and I didn't know how I was going to take care of it. I want to go to college and I knew that if I had a baby, I would never get around to doing it ...
Not only does this young woman see herself in the future, but her vision of the future is worth attaining and thus competitive with the present reality of pregnancy. If, on the other hand, she either saw no future for herself or the future envisioned was bleak, there would be little incentive not to carry the pregnancy to term and parent the infant.
In both adoption and abortion the teenager relinquishes the concrete reality of an infant for an abstract belief that the future promises something better. Likewise, through regular contraception, the adolescent is implicitly making plans for the future. What we must face when looking at the entire problem of premature parenting is that for a sizable segment of our adolescent population we as a society offer few viable alternatives to parenting and thus little impetus to delay childbearing.~l When adolescents' cognitive complexity in conjunction with their self-perceived life choices and options are considered together, a powerful framework emerges for understanding the dynamics and underlying logic of sexual decision-making.
Psychological as well as physical developmental considerations are crucial when working with adolescents around sexual decisions. Whether working in the aggregate, such as a classroom setting or on a one-to-one basis in the office or clinic, both the information provided and the guidance offered to teens must be grounded in an understanding of youth development. To assume that a 13-year-old with a physical appearance of someone five years her senior has advanced cognitive skills is to run the risk of failing to reach the patient: it is akin to a misdiagnosis. Does the individual see herself as having control over her life or is fate "in the winds"? Does she have future goals and desires - or is life "here and now"? Are problems seen in shades of grey - or is everything black or white? Clinically, the cues to these and other developmental questions lie less in the answers given and more in how our questions are answered. Is there evidence of complexity of thought or predominantly simplistic, dichotomized thinking? Does the individual have the capacity to take another's perspective into account as well as her own? How much and what kinds of information does the individual use in making a decision? Once we have an understanding of how the individual processes information and makes decisions, we will be in a better position to provide information and guidance with which to meet her needs at an appropriate and understandable development level.
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