Addressing psychiatric and psychosocial issues related to children and adolescents
Great news: Teen pregnancy birth rates (i.e., the number of births per 1,000 individuals) for the United States are at an all-time low (Centers for Disease Control and Prevention [CDC], 2014; Cox et al., 2014). However, birth rates do not reflect actual pregnancy rates (i.e., births, abortions, and estimated fetal losses per 1,000 individuals) for teens ages 15 to 19 (American Academy of Pediatrics, 2014; Finer, 2010). Thus, other factors must be considered before celebrating lower birth rates. The impact of unintended teen pregnancies may include psychosocial, developmental, and physical risks; individuals younger than 15 usually incur higher risks (Hayatbakhsh et al., 2011). Fortunately, nurse practitioners, psychiatric–mental health nurses (PMHNs), school nurses, and other health care providers can play pivotal roles in providing support, guidance, and appropriate interventions for pregnant teens by encouraging them to seek appropriate physical and mental health care.
In recent years, the CDC (2014, 2015) and Cox et al. (2014) have reported a decline in teen birth rates. In 2013, a total of 273,105 births to teens ages 15 to 19 resulted in a birth rate of 26.5 per 1,000 girls (CDC, 2015). Analysis of the 1991–2012 National Vital Statistics System data and National Survey of Family Growth data from 2006–2010 revealed that birth rates (per 1,000 teens younger than 18) declined significantly. Birth rates for 15-, 16-, and 17-year-old girls decreased from 17.9 to 5.4, 36.9 to 12.9, and 60.6 to 23.7, respectively (Cox et al., 2014). Although declining, birth rates for U.S. teens are still higher than those for the rest of the Western world (CDC, 2015), and teen pregnancies continue to pose potential negative outcomes for teen mothers and their children.
Negative Correlates of Teen Pregnancy
Teen pregnancies and parenthood create risks for the psychosocial and physical health of the mother, and have adverse effects on fetal outcome, parenting, and long-term consequences on the mother and child (Chantrapanichkul & Chawanpaiboon, 2013). For example, the literature on fetal loss and teens reveals abortion, miscarriage, and unwanted pregnancy are significant risk factors for a variety of mental disorders (e.g., anxiety, depression, panic disorder, substance abuse, posttraumatic stress disorder, suicidal ideation) (Bellieni & Buonocore, 2013; Hayatbakhsh et al., 2011; Kong, Lok, Lam, Yip, & Chung, 2010). In addition, teen parents are more likely to be socially and economically disadvantaged and reside in more impoverished communities; pregnancy is likely to perpetuate these disadvantages (CDC, 2015; Hodgkinson, Beers, Southammakosane, & Lewin, 2014). Madigan, Wade, Tarabulsy, Jenkins, and Shouldice (2014) found an association between abuse history and teen pregnancy. In their meta-analysis of 38 independent studies, it was determined that the significance of this association differs as a function of type of abuse. For example, an increased risk of adolescent pregnancy was associated with physical and sexual abuse, but not emotional abuse and neglect. More specifically, they found that adolescent individuals who were physically abused were 1.5 times more likely to become pregnant than those who were not physically abused (Madigan et al., 2014).
Regardless of whether a teen chooses to have an abortion, experiences a fetal loss, or keeps the child, she is at risk for a variety of negative outcomes and needs continued care and follow up. Even teens who decide to continue the pregnancy and deliver the child often experience negative outcomes, which may include health-related complications (e.g., antepartal, intrapartal, postpartal, neonatal) or psychosocial-related problems (e.g., substance abuse, anxiety, depression) (Bellieni & Buonocore, 2013; Hayatbakhsh et al., 2011). Teens need additional support to optimize pregnancy outcomes (Chantrapanichkul & Chawanpaiboon, 2013; Hodgkinson et al., 2014). Providers are often challenged to meet the needs of these teens, as they face numerous barriers related to psychosocial and environmental stressors due to developmental, educational, and socioeconomic issues (Hodgkinson et al., 2014).
Reasons for Declined Teen Birth Rates
Changes in pregnancy and birth rates have been attributed to two factors: teens are (a) using more effective contraceptives and/or (b) having less sex (Boonstra, 2014). Evidence exists that supports teens are using either more effective (long-term) contraceptive (e.g., intrauterine devices) or dual (e.g., condoms and another method) methods (Boonstra, 2014; CDC, 2014). Other factors may also be at play, including prevention education, the economy, childbearing norms (e.g., holding off childbearing until later may be becoming a new “normal” for many teens), fear of being diagnosed with HIV, the media (e.g., more messages about sex and contraception), and/or medical recommendations from health providers regarding contraception (e.g., intrauterine devices, hormonal methods) (Boonstra, 2014; Cox et al., 2014). Currently, there is a lack of longitudinal evidence to support which specific factors, or combinations thereof, are most significant in the support of a change in the sexual behaviors of teens.
Evidence-Based Interventions and Prevention Programs
A number of interventions and prevention programs have had an impact on the declining teen birth rates.
MTV®'s show, “16 and Pregnant,” has had a positive impact on the teen birth rate based on its realistic depiction of the negative consequences of teen pregnancy and parenting. Findings from Kearney and Levine (2014, 2015) noted that this show may have led to a 5.7% decline in birth rates in the 1.5-year timeframe since the show began. According to the researchers, the content of this reality show, which highlights sex, contraception, abortion, and parenting, has had an influence on teens considering the use of birth control and the option of abortion.
Three states are exemplary in the development of initiatives to curb high teen pregnancy rates: Georgia, North Carolina, and Colorado.
Georgia. This state has aimed to prepare teens and parents with the most accurate information to help them make the best informed decisions regarding their health (Georgia Campaign for Adolescent Power & Potential, 2013) by targeting high-risk youth and standardizing sexual health education in public school curricula.
North Carolina. This state has made an effort to assist medical providers of teens and young adults with contraceptive education and health care access by clinic outreach and social marketing. Such initiatives inform teens about resources and providers in their communities (Sexual Health Initiative for Teens, n.d.).
Colorado. This state has made a significant effort to improve access to and advocate for funding of the provision of more effective contraception methods for teens. Teen birth rates decreased 40% from 2009–2013 when the state secured funding to offer teens and poor women intrauterine devices and hormonal implants for pregnancy prevention (Tavernise, 2015).
Evidence-Based and Community Prevention Programs
Although a variety of other programs have had variable results, all of the following yield significant improvements in declining teen pregnancy and birth rates:
- Enhancing teen pregnancy prevention with text messaging (Devine, Bull, Dreisbach, & Shlay, 2014);
- Peer education programs delivering reliable sexual health promotion messages in schools (Layzer, Rosapep, & Barr, 2014);
- Community participation in teen pregnancy prevention through collaboration with community stakeholders to achieve successes among community programs (Oluwaseyi, Wright, & Maja, 2015); and
- School completion programs (e.g., vocational training, alternative schooling, social–emotional training, college-oriented program, case management, mentoring and counseling) for teen moms to be better educated, which may decrease the likelihood of a second teen pregnancy (Hahn et al., 2015).
Manlove, Fish, and Moore (2015) completed an evidence review of programs purporting to improve adolescent sexual and reproductive health in the United States and determined that although many programs may be effective, they are isolated; the authors recommended replication studies to determine long-term success.
PMHNs, nurse practitioners, and other care providers have major responsibilities when caring for pregnant teens. Specific nursing implications are listed in the Table.
Implications for Nursing Practice, Education, and Research Regarding Teen Pregnancy
It is too early to celebrate the trend indicating teen birth rates are declining. Regardless of the number, the majority of teen pregnancies pose risks to girls' mental and physical health. Potential negative outcomes for the teen and the fetus/child are significant; therefore, PMHNs, advanced nurse practitioners, and other care providers must educate, support, and guide this at-risk population.
- American Academy of Pediatrics. (2014). Addendum—Adolescent pregnancy: Current trends and issues. Pediatrics, 133, 954–957. doi:10.1542/peds.2014-0450 [CrossRef]
- Bellieni, C.V. & Buonocore, G. (2013). Abortion and subsequent mental health: Review of the literature. Psychiatry and Clinical Neurosciences, 67, 301–310. doi:10.1111/pcn.12067 [CrossRef]
- Boonstra, H.D. (2014). What is behind the declines in teen pregnancy rates?Guttmacher Policy Review, 17, 15–21.
- Centers for Disease Control and Prevention. (2014). NCHS data on teenage pregnancy. Retrieved from http://www.cdc.gov/nchs/data/factsheets/factsheet_teenage_pregnancy.pdf
- Centers for Disease Control and Prevention. (2015). Teen pregnancy in the United States. Retrieved from http://www.cdc.gov/teenpregnancy/about/index.htm
- Chantrapanichkul, P. & Chawanpaiboon, S. (2013). Adverse pregnancy outcomes in cases involving extremely young maternal age. International Journal of Gynecology and Obstetrics, 120, 160–164. doi:10.1016/j.ijgo.2012.08.024 [CrossRef]
- Clayton, S., Chin, T., Blackburn, S. & Echeverria, C. (2010). Different setting different care: Integrating prevention and clinical care in school-based health centers. American Journal of Public Health, 100, 1592–1596. doi:10.2105/AJPH.2009.186668 [CrossRef]
- Cox, S., Pazol, K., Warner, L., Romero, L., Spitz, A., Gavin, L. & Barfield, W. (2014). Vital signs: Birth to teens aged 15 to 17 years–United States, 1991–2012. Morbidity and Mortality Weekly Report, 63, 312–318.
- Devine, S., Bull, S., Dreisbach, S. & Shlay, J. (2014). Enhancing a teen pregnancy prevention program with text messaging: Engaging minority youth to develop TOP® Plus text. Journal of Adolescent Health, 54, s78–s83. doi:10.1016/j.jadohealth.2013.12.005 [CrossRef]
- Finer, L.B. (2010). Unintended pregnancy among U.S. adolescents: Accounting for sexual activity. Journal of Adolescent Health, 47, 312–314. doi:10.1016/j.jadohealth.2010.02.002 [CrossRef]
- Georgia Campaign for Adolescent Power & Potential. (2013). Georgia teen pregnancy rates hit historic low. Retrieved from http://www.gcapp.org/news/georgia-teen-pregnancy-rates-hit-historic-low
- Hahn, R.A., Knopf, J.A., Wilson, S.J., Truman, B.I., Milstein, B., Johnson, R.L. & Hunt, P.C. (2015). Programs to increase high school completion: A community guide systematic health equity review. American Journal of Preventive Medicine, 48, 599–608. doi:10.1016/j.amepre.2014.12.005 [CrossRef]
- Hayatbakhsh, M.R., Najman, J.M., Khatun, M., Al Mamun, A., Bor, W. & Clavarino, A. (2011). A longitudinal study of child mental health and problem behaviours at 14 years of age following unplanned pregnancy. Psychiatry Research, 185, 200–204. doi:10.1016/j.psychres.2010.05.019 [CrossRef]
- Hodgkinson, S., Beers, L., Southammakosane, C. & Lewin, A. (2014). Addressing the mental health needs of pregnant and parenting adolescents. Pediatrics, 133, 114–122. doi:10.1542/peds.2013-0927 [CrossRef]
- Kearney, M.S. & Levine, P.B. (2014). Media influences on social outcomes: The impact of MTV's 16 and pregnant on teen childbearing. Retrieved from http://www.nber.org/papers/w19795
- Kearney, M.S. & Levine, P.B. (2015). Investigating recent trends in the U.S. teen birth rate. Journal of Health Economics, 41, 15–29. doi:10.1016/j.jhealeco.2015.01.003 [CrossRef]
- Kogan, S.M., Cho, J., Allen, K., Lei, M., Beach, S.H., Gibbons, F.X. & Brody, G.H. (2013). Avoiding adolescent pregnancy: A longitudinal analysis of African-American youth. Journal of Adolescent Health, 53, 14–20. doi:10.1016/j.jadohealth.2013.01.024 [CrossRef]
- Kong, G.W., Lok, I.H., Lam, P.M., Yip, A.S. & Chung, T.K. (2010). Conflicting perceptions between health care professionals and patients on the psychological morbidity following miscarriage. Australian and New Zealand Journal of Obstetrics and Gynecology, 50, 562–567. doi:10.1111/j.1479-828X.2010.01229.x [CrossRef]
- Layzer, C., Rosapep, L. & Barr, S. (2014). A peer education program: Delivering highly reliable sexual health promotion messages in schools. Journal of Adolescent Health, 54, s70–s77. doi:10.1016/j.jadohealth.2013.12.023 [CrossRef]
- Long-Middleton, E.R., Burke, P.J., Lawrence, C.A., Blanchard, L.B., Amudala, N.H. & Rankin, S.H. (2013). Understanding motivations for abstinence among adolescent young women: Insights into effective sexual risk reduction strategies. Journal of Pediatric Health Care, 27, 342–350. doi:10.1016/j.pedhc.2012.02.010 [CrossRef]
- Madigan, S., Wade, M., Tarabulsy, G., Jenkins, J.M. & Shouldice, M. (2014). Association between abuse history and adolescent pregnancy: A meta-analysis. Journal of Adolescent Health, 55, 151–159. doi:10.1016/j.jadohealth.2014.05.002 [CrossRef]
- Manlove, J., Fish, H. & Moore, K.A. (2015). Programs to improve adolescent sexual health in the US: A review of the evidence. Adolescent Health, Medicine and Therapeutics, 2015, 47–79. doi:10.2147/AHMT.S48054 [CrossRef]
- Oluwaseyi, O., Wright, S. & Maja, T.M. (2015). Community participation in teenage pregnancy prevention programmes: A systematic review. International Journal of Nursing Didactics, 5, 26–38. doi:10.15520/ijnd.2015.vol5.iss05.57.26-38 [CrossRef]
- Sexual Health Initiative for Teens. (n.d.). North Carolina teen pregnancies drop to new historic low. Retrieved from http://www.shiftnc.org/spotlight-story/north-carolina-teen-pregnancies-drop-to-new-historic-lows
- Sipsma, H.L., Ickovics, J.R., Lewis, J.B., Ethier, K.A. & Kershaw, T.S. (2011). Adolescent pregnancy desire and pregnancy incidence. Women's Health Issues, 21, 110–116. doi:10.1016/j.whi.2010.09.004 [CrossRef]
- Smith, M.K. & Stepanov, N. (2014). School-based youth health nurses and adolescent decision making concerning reproductive and sexual health advice: How can the law guide healthcare practitioners in this context?Contemporary Nurse, 47, 42–50. doi:10.1080/10376178.2014.11081905 [CrossRef]
- Tavernise, S. (2015). Colorado's effort against teenage pregnancies is a startling success. Retrieved from http://www.nytimes.com/2015/07/06/science/colorados-push-against-teenage-pregnancies-is-a-startling-success.html?_r=0
Implications for Nursing Practice, Education, and Research Regarding Teen Pregnancy
Conduct mental health screening for depression and other disorders, as indicated (e.g., if the teen is pregnant or experiences a perinatal loss) (Hodgkinson et al., 2014).
Be cognizant that fetal loss of any kind can be a risk factor for mental health disorders (Bellieni & Buonocore, 2013).
Offer guidance to pregnant teens regarding medical care and community resources, making referrals as needed (Clayton, Chin, Blackburn, & Echeverria, 2010).
Maintain confidentiality at all times and follow the federal, state, and institutional guidelines and laws governing provision of care to teens (Smith & Stepanov, 2014).
Refer teen mothers to Public Health for follow-up home visits or clinical follow up (per available state and county services) (Hodgkinson et al., 2014).
Intervene early in teen high-risk pregnancies, with close monitoring for physical and mental health complications and abuse history, which may involve alternative schooling, counseling, or removal of the teen from the home and placement in foster care or a residential facility (Chantrapanichkul & Chawanpaiboon, 2013; Kogan et al., 2013; Madigan et al., 2014).
Teach teens about sexuality and making responsible choices (Long-Middleton et al., 2013).
Educate teens about safe sex and contraception choices (Chantrapanichkul & Chawanpaiboon, 2013).
Conduct longitudinal studies to determine long-term impact of pregnancy on psychosocial and physical outcomes (Hayatbakhsh et al., 2011).
Test interventions using text messaging to reach teens for pregnancy prevention (Devine, Bull, Dreisbach, & Shlay, 2014).
Inform teens that desiring pregnancy adds a greater risk to actually becoming pregnant (Sipsma, Ickovics, Lewis, Ethier, & Kershaw, 2011).
Encourage students to stay in school and seek supplemental academic support (Hahn et al., 2015).
Guide teens to seek birth control education and methods (Layzer, Rosapep, & Barr, 2014).
Be aware of teens' needs to better understand their sexuality and choices regarding contraception (Centers for Disease Control and Prevention [CDC], 2015).
Understand the need to support teens' desires to prevent pregnancy (CDC, 2015).
Support the use of school-based clinics in the community, which can provide guidance and support to pregnant teens (Hahn et al., 2015; Smith & Stepanov, 2014).
Develop community prevention programs to support teens (Hahn et al., 2015).