The Journal of Primary Prevention, VoL 13, No. 1, 1992
Parent Education for Adolescent Mothers Nancy S. Dickinson 1,3 and Dorothea J. Cudaback 2
Adolescent parents are often ill prepared to provide their new babies with the care and stimulation they need for satisfactory development. A series of age-paced parent education booklets was designed to help these young parents acquire the information, knowledge, and confidence they need to improve their parenting practices. This is a report of a study designed to evaluate the impact of this parent education program on the parenting practices of adolescent mothers. The parenting practices of seventy young mothers who had received the parenting booklets monthly during their babies' first year of life were compared with those of a comparable group of eighty-five adolescent mothers who had not participated in the program. Results suggest that receiving the booklet series was associated with more positive parenting attitudes, beliefs, and practices. Implications for preventive services are discussed. KEY WORDS: Adolescence; parenting; education.
INTRODUCTION The social and economic consequences of adolescent parenthood are significant and long lasting (Furstenberg, Brooks-Gunn, & Morgan, 1987). Adolescent mothers are significantly less likely to complete high school (Mott and Maxwell, 1981) and more likely to be financially and medically dependent (Alan Guttmacher Institute, 1981; Baldwin, 1980; Swift, 1983) than women who delay childbearing until their twenties. Early childbearing 1Nancy S. Dickinson, Ph.D., is the Continuing Education Specialist, Center for Human Services Training and Development, University Extension, Davis, CA. ZDorothea J. Cudaback, Ph.D., is the Human Relations Specialist, University of California Cooperative Extension, Berkeley, CA. 3Address correspondence to: Nancy S. Dickinson, University Extension, Davis, CA 95616-8727. 23 © 1992HumanSciences Press, Inc.
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also leads to a higher risk of separation or divorce (McAnarney & Schreider, 1984). The most far reaching consequence of adolescent parenthood, however, is the heavy toll it takes on the children of these young parents. The implications of a number of studies are that adolescents may not provide the nurturing parent-infant interactions necessary for optimal child development (Elster, 1990). Compared with older parents, adolescent mothers appear to be inconsistent in their parenting behaviors and have less accurate knowledge of child development, less nurturing home environments, and less optimal child rearing attitudes (Elster et al., 1983; Baldwin & Cain, 1980). As a result, young offspring of adolescent parents fall significantly behind children of older parents on academic skills tests, although the differences are small (Brooks-Gunn & Furstenberg, 1986). By the time they are adolescents themselves, however, the differences between children of adolescent and older parents are startling and disturbing (Furstenberg, Brooks-Gunn, & Morgan, 1987). Academic failure, school maladjustment, delinquency and antisocial behavior, early sexual experience, and pregnancy are significantly more often the experiences of adolescents who were born to younger rather than later childbearers. The reasons adolescent mothers are likely to have parenting problems are many and tangled. These mothers are often single, are likely to come from poverty backgrounds, experience high rates of family instability, and usually have low educational achievement, all factors associated with parenting problems. Additionally, by virtue of limited experience and immaturity, they may be less prepared to provide for their babies' needs. Finally, adolescent mothers may lack the kind of information about child development and parenting needed to adequately promote their children's social and intellectual development (Bolton, 1980; Sparling & Lowman, 1983). With additional information and education, outcomes for the children of adolescent mothers are enhanced (Kinard & Reinherz, 1984). It is this need for parenting information that is addressed by the program described in this paper.
Parenting Information New mothers of any age experience the transition to parenthood as a major life change, both exciting and stressful (Mercer, 1986; Valentine, 1982). For adolescent mothers this transition may be particularly difficult, as they must struggle concurrently with conflicts between the developmental tasks of adolescence and the tasks of motherhood. At this time, they may be especially open to receiving and using parenting help and information
Parent Education for Adolescent Mothers
25
(Aslanian & Brickwell, 1980; Zitner & Miller, 1980). Although most expectant and new adolescent parents receive their parenting information through interpersonal channels, reading for most is an acceptable second choice (Sparling & Lowman, 1983). Unfortunately, the many teens who are poor readers may have difficulty finding parent education materials they can easily understand. Abram and Dowling (1979) used the Flesch Reading Ease Formula to classify the fifty most popular parenting books by reading level. None of the books they reviewed could be classified as "easy" (sixth grade reading level) or "very easy" (less than sixth grade reading level), and only six could be classified as "fairly easy" (seventh grade reading level). The parent education booklets described in this paper are classified as "very easy" to read. Age-paced parent education booklets seem to be a promising means of delivering written child development and care information to adolescent parents. These booklets, mailed to parents monthly during the baby's first year of life, are keyed to the baby's birth month so that the mother receives new information each month about development and care of babies exactly as old as hers. Such booklet series have enjoyed widespread use since Pierre the Pelican was written by Lloyd W. Rowland about 40 years ago (Rowland, 1977). The parent education booklet series which is the subject of this paper, is a series of 15 eight-page booklets mailed monthly to expectant and new parents (University of California Cooperative Extension, 1984). The first two booklets in the series are about prenatal development, the third is about birth, and the remaining 12 booklets, one for each month of the baby's first year, give month by month information about parenting and infant development. The program is available to all parents, but it was particularly designed for adolescent parents. Shaped by interviews with young mothers and professionals working with them, the booklets' content focuses on knowledge which has been shown to be predictive of good child development, including the importance of being responsive to baby's emotional and educational needs, playing with baby in ways that help the baby learn, monitoring baby's health, and promoting language development (Stevens, 1984). The booklets are written in simple, clear language at a fifth grade reading level with a supportive, encouraging tone and attractive format. This kind of program has distinct educational and practical advantages. Because information is keyed to the baby's birth month, parents receive the learning material when they are most ready to use it. They can read the booklets at their convenience, share them with others, and save them for future reference. Finally, and importantly, the program is a relatively inexpensive way to provide educational information for a large number of parents, some of whom might be otherwise inaccessible. In
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previous evaluations of the series, parents reported reading, valuing, using, and sharing the booklets' information, as well as improving their parenting practices as a result of reading the booklets (Cudaback et al., 1985; Cudaback, Dickinson, & Wiggins, 1990). While these evaluations included parents of all ages, results were more positive for those considered at risk of parenting difficulties, including low income, single, and adolescent parents. A previous article in this journal reported on the development of the series and one similar to it in a different state and their use with adolescent parents (Lamberts, Cudaback, & Claesgens, 1985). Major questions remained, however, about whether adolescent readers were handling their transitions to parenthood more successfully than their peers. The study reported in this paper extends previous research on the series by evaluating the impact of the parent education booklets on the parenting practices of young mothers who became pregnant while adolescents, compared with those practices of similar adolescents who did not read the series.
METHODS Study Design and Sample
A study group of 118 pregnant adolescents was recruited from 16 San Francisco Bay Area agencies and programs serving pregnant minors. These adolescent programs, distinct from each other and from the research project, offered a variety of health services, social services, and education for pregnant and parenting adolescents. Some of the programs were familiar with the project's parenting booklets, but none were distributing the booklets during the project year. An interviewer personally administered pre-test questionnaires to groups or individuals who agreed to participate in the study. The adolescents also agreed to receive the parenting booklets monthly until their babies were one year old and to participate in a follow-up interview. Approved human subjects procedures were used to ensure informed and voluntary consent by all participants. Eleven to 18 months after their babies were born, 70 of the study group mothers, or 59 percent, were interviewed again, most by telephone interviews. The remaining 48 adolescents could not be contacted. A comparison of teens who could not be recontacted with the study group shows that the two groups at the time of the first interview were similar in age, education, race, and living arrangements.
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Parent Education for Adolescent Mothers Table I. Respondent Characteristics
Study Group Characteristic
Pre-Test (n = 70)
Post-Test ControlGroup (n = 70) (n = 80)
Mean age
17.0
18.4
17.5
Percent single
90.0
80.0
85.7
Living arrangements: Alone Husband/partner Friends Parents Other
1.4% 15.7 8.6 57.1 17.1
5.8% 21.7 4.3 52.2 15.9
11.8% 25.9 2.4 54.1 5.9
Highest grade passed
some high school
11.4
10.8
In parent ed program
71.4%
24.0%
47.0%
21.4% 24.3
21.4% 24.3
23.5% 24.7
48.6 5.7
48.6 5.7
47.1 4.7
Race: Hispanic White nonHispanic Black Other
One year after the study began, information was collected from a comparable group of 85 young mothers of infants 11 to 18 months old who had become pregnant as adolescents but had not read the parenting booklet series. These control group mothers were recruited from 29 different a d o l e s c e n t p r o g r a m s in the San F r a n c i s c o Bay A r e a . T h e p o s t - t e s t questionnaires were administered to these young mothers by the study interviewer or by program staff. As shown in Table I, the study group mothers were older (t = 3.95; p < .001) and tended to have more years of schooling (t = 1.89; p < .06). They were less likely to be in parent e d u c a t i o n p r o g r a m s at the time of their second interview (t = 3.95; p < .001) than control group mothers. Measures Four instruments were used to collect information, three of which were designed for this study: the pre-program questionnaire and the parenting series evaluation, completed by the study group, and the post-
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program questionnaire, completed by study and control mothers. The preand post-program questionnaires were developed to assess respondents' sources of and need for information about baby care, attitudes about motherhood, and knowledge and beliefs about parenting and child development. The program evaluation questionnaire requested such information as reading patterns, helpfulness of specific topics covered by the booklets, degree to which parenting practices and attitudes were influenced by reading the booklets, and overall usefulness of the program. At the post-program interview, both study and control group mothers were given the Home Screening Questionnaire (HSQ) to assess parenting effectiveness (Coons et al., 1981). Based on the Home Observation for Measurement of the Environment (HOME) Inventory, the HSQ is a wellregarded and standardized screening instrument which identifies parents whose infants and young children may be at risk of delayed social and intellectual development due to inadequate parental and environmental influences (Caldwell & Bradley, 1979)).
RESULTS Program Use and hnpact
Study group mothers' evaluation of the parenting program was overwhelmingly positive. Almost all study group mothers (93%) indicated that they had read all or most of the booklets, more than half (57%) kept the booklets and referred back to them at least some of the time, and a large majority of the young mothers (83%) shared the booklets with others, usually their own parents, others, and spouses, in that order. In all, 81 percent indicated that reading the series increased their confidence as parents, and 93 percent of the respondents rated the programs as "very useful" overall. When respondents were asked about ways the booklets influenced their parenting practices, 95 percent reported they had increased at least one recommended practice as a result of reading the series. They reported that reading the booklets influenced them to provide more things for their babies to feel, look at, and listen to (83%), to play with their babies in ways that promoted learning (79%), to show their babies more affectionate attention (73%), to talk to their babies more frequently (70%), and to respond more quickly when their babies cried (69%). A summary score of respondents' answers to the five influence questions reflects the degree to which reading the parenting booklets influenced their parenting behavior (Alpha = .743). Scores ranged from a high of 5 (influenced in all five behaviors) to a low of 0 (no behaviors influenced).
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29
The largest percentage (48.6%) of young mothers responded that they had changed their parenting behavior in all five areas as a result of reading the booklets, while a low 4.3 percent reported no influence. Parenting Information Sources During pregnancy and parenthood, the largest percentage of both study and control group respondents reported relying most often on family and friends to provide them parenting information. Study group mothers, however, significantly increased their use of magazines and pamphlets from the pre-program to the post-program interview (t = 4.82; p < .001). Also, at this second interview significantly more study than control group mothers reported using written materials (t --- 5.30; p < .001) to obtain their parenting information. Parenting Information Needs At the first interview, the largest percentage of study group pregnant adolescents reported needing information about baby health and safety, followed by baby nutrition, ways to teach baby, and managing the stress of motherhood, in that order. At the post-program interview, significantly more of the study group reported needing additional information on five of the seven areas, including baby development, ways to teach, managing stress, and games and toys. At this interview, the number of study group mothers who reported needing information was significantly higher on all topics than the number of control group mothers who reported needing information. Also, significantly more control than study mothers reported that they did n o t need additional parenting information. Impact of Program Participation on Parenting Practices The findings from the Home Screening Questionnaire corroborate the self-reported impact of the program. Typically, when parents receive an HSQ score of 32 or l e s s - termed a risk s c o r e - these parents need further assessment to determine whether their children may experience developmental delays due to adverse parenting and environmental influences. In this study there was a significant relationship between group membership and respondents' scores (9~2 = 9.6; p < .01). Significantly more respondents who had read the parenting booklets (40%) had no-risk scores when compared with control group mothers (17%). The percentages of mothers
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receiving risk scores in both groups, however, were h i g h - 60 percent for the study group and 83 percent for the control g r o u p - so that program participation, quite understandably, was not sufficient to compensate for the difficulties of teen parenting. Chi-square analyses showed no significant relationships between score levels and participants' race (Z2 = 1.55) or participation in a parent education program (Z2 = .496). HSQ score levels were positively related to the mother's age (and to grade level and employment which are correlates of age). Analysis of covariance results showed that regardless of age, those adolescent mothers who read the parenting booklet series had significantly higher (better) HSQ scores than those who did not read it (F = 10.3; p < .01).
DISCUSSION An overwhelming majority of 70 young mothers who received parent education booklets during their babies' first year found the series to be beneficial and reported that their attitudes, beliefs, and parenting practices had been positively influenced by their program participation. Study group mothers may have exaggerated the extent to which they were affected by reading the booklets to please the interviewer. On the other hand, their spontaneous positive comments about the booklets and repeated requests for a toddler series highlight the program's positive impact. This study reinforces other research showing that expectant and parenting adolescents receive their parenting information primarily through interpersonal channels, which in this case included family and friends and professional advice. For mothers reading parenting booklets, however, the use of printed materials for parenting information increased significantly between pregnancy and post-test. This finding suggests that adolescent parents will find written materials enticing and useful when the writing is simple and clear, the format is attractive, and the delivery is timed to coincide with their baby's age in months. Interestingly, study group mothers reported that they needed more information on parenting at the second interview - - after reading parenting booklets for a y e a r - - t h a n they did at the first interview. At the post-test interview, these mothers also expressed higher information needs than those expressed by control group mothers at the post-test interview. There are several possible reasons for this finding. First, more study girls at the first interview and control mothers at the post-test were attending parent education classes than study group mothers at post-test. The information needs of these two groups may have been satisfied through these classes,
Parent Education for Adolescent Mothers
31
since those attending classes reported less need for parenting information. Perhaps study group mothers at post-test perceived a higher need for parenting information because they were not in parent education classes. Agepaced newsletters are obviously not a substitute for parent education classes but are useful supplements to their curriculum and may also follow adolescents who typically drop in and out of such programs. The finding also suggests the need for a parenting series for adolescent parents of toddlers, which is now available (University of California Cooperative Extension, 1989). A second possible explanation for the discrepancy between study and control mothers' felt needs for parenting information may be that some adolescents simply do not know what information they lack. Reading the parenting booklets may have helped study group mothers realize how much there is to know and stimulated their desire to learn more. The control group, on the other hand, may have continued to believe they had all the information they needed or that was available about parenting. Supporting this assertion is the finding that a large proportion of study group mothers reported wishing they had further information about topics emphasized in the booklet s e r i e s - ways to teach baby, games to play with baby, and toys for baby. These topics differ from the information-needed topics chosen by control group mothers at the post-test and study group teens during pregnancy. Parenting practices seem to have been positively affected by reading the parenting booklets, since significantly more study group mothers had not-at-risk HSQ scores. The higher positive HSQ scores for program participants persisted even when age differences and attendance at parent education classes were controlled. The fact that most study and control group respondents had risk scores, however, is quite disturbing and evidence of the tremendous difficulties facing adolescent parents and their offspring. This somber finding tempers program effects. The results of this study must be considered as suggestive only. The Home Screening Questionnaire has not been tested specifically on an adolescent population. While it was standardized on a low SES population, it is not known how many adolescents were part of that population. Thus, respondent scores in this study may be artificially low. Also, program and resource constraints made it impossible for us to administer a pre-test to the control group. In addition, 41 percent of the study group mothers could not be recontacted for post-program interviews. It was possible to control statistically for obvious differences between study and control group mothers and between those who remained and those who dropped out of the study group, but there may well have been other unknown factors which biased the results. Finally, we relied on respondents' self-
Dickinson and Cudaback
32
reports for the data; interviewers were known by our subjects to be employed by the same organization which had produced and sent the booklet series, factors which could well have influenced the mothers' responses. In sum, these concerns call for caution in interpreting the data and further replication of the study.
Implications for Prevention The results of this study imply that the children of adolescent parents benefit as a result of their mothers' program participation. For example, when adolescent mothers share the booklets with o t h e r s - - t h e i r own parents, partners, and other parents - - they strengthen their social support network. Such use of social support can improve the mother-child relationship (Crockenberg, 1981) and cut through the social isolation, experienced by many adolescent mothers, which contributes to child maltreatment (Salzinger, Kaplan, & Artemyeff, 1983). In addition, depression and low self-esteem seem to affect a disproportionate number of adolescent mothers (Colleta, 1983). Increasing their self-confidence, one result of program participation, enhances the adolescent mothers' caregiving abilities and thus their children's well-being (Lyons-Ruth et al., 1986). Moreover, children of adolescent mothers who improve their parenting practices are less likely to experience developmental delays due to adverse parenting and environmental influences. One way that the parent education program helped adolescent parents improve their parenting practices was to expose them to reading materials which are appealing, timely, easy to read, and, therefore, useful. As a result of this exposure, adolescent parents were more eager to continue learning about parenting and child development and more open to using printed materials. The motivation to learn and the ability to use written materials to learn are necessary components of acquiring academic skills which can mediate the long-term negative consequences of adolescent pregnancy for mothers and their children (Furstenberg, Brooks-Gunn, & Morgan, 19887). Clearly most adolescent parents, and their children, need a range of clinical and educational services. Printed materials cannot substitute for these. The results of this study indicate, however, that such materials may help adolescents reduce the risk of providing their infants with inadequate care and could, therefore, valuably supplement available programs. For example, Elster (1990) discusses a range of preventive strategies which may promote improved parental behaviors of adolescents: (1) office-based, private-practice models usually operating within a physician's office; (2) post-
Parent Education for Adolescent Mothers
33
partum intervention models which attempt to increase positive maternalinfant contact; (3) integrated services model using a comprehensive care approach in one setting; and (4) home-based models providing services within the home. Age-paced parent education materials are relevant for each of these particular service categories, as well as others typically used with adolescent parents. In addition, printed materials could also provide some measure of help to those adolescents who cannot or will not use more extensive or intensive services. That such a program benefits adolescent m o t h e r s - who are known to confront significant problems with few r e s o u r c e s - is grounds for optimism about similar efforts with other at-risk groups. Many people look to printed materials for personal help. Self-help books proliferate. Advice columns, magazines, news features, and pamphlets which deal with personal and interpersonal problems are read by millions. Human service workers already use bibliotherapy with benefit to clients (Pardeck & Pardeck, 1987). Shaping the written materials more precisely for carefully selected audiences and designing the delivery of the program so that it reaches this audience at a time and in a way that is most likely to be useful to them will increase the benefit of such materials. The parent education program described in this paper was successful partly because it reached people who were experiencing a life transition and, therefore, not only needed assistance but were also open to using it. During the course of a lifetime, people face many such transitions - - family dislocation, job loss, divorce, bereavement, retirement - - all times when serious repercussions could occur if prevention services were not available. Some of these people could be helped by written materials which provide them with information about their distress, give them ideas on ways to cope, and suggest resources and services which could provide further help. With limited numbers of human service workers and inadequate social and health budgets, society cannot provide for all who need help. Prevention is a cost effective way of serving large numbers of vulnerable people. We can very possibly expand our effectiveness in providing these services if we hone our ability to use written materials.
ACKNOWLEDGMENTS The authors thank Mary Zernicke, Gail Splaver, Victoria Leonard, and Judy Pope for their assistance with the project and Richard Barth for his help with the manuscript preparation.
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REFERENCES Abram, M. J., & Dowling, W. D. (1979). How readable are parenting books? The Family Coordinator, 28, 365-368. Alan Guttmacher Institute. (1981). Teenage pregnancy: The problem that hasn't gone away. New York: Author. Aslanian, C. B., & Brickwell, H. M. (1980). Americans in transitions: Life changes as reasons for adult learning. New York: Future Directions for a Learning Society, College Board. Baldwin, W. (1980). Adolescent pregnancy and childbearing--growing concerns for Americans. Population Bulletin, 31, 1-37. Baldwin, W., & Cain, V. S. (1980). The children of teenage parents. Family Planning Perspective (January-February), 344-433. Bolton, F. G. (1980). The pregnant adolescent: Problems of premature parenthood. Beverly Hills: Sage Publications. Brooks-Gunn, J., & Furstenberg, F. F., Jr. (1986). The children of adolescent mothers: Physical, academic and psychological outcomes. Developmental Review, 6, 224-251. Caldwell, B. M., & Bradley, R. H. (1979). Home observation for measurement of the environment. Little Rock, AK: University of Arkansas at Little Rock. Colletta, N. D. (1983). At risk for depression: A study of young mothers. Journal of General Psychology, 142, 301-310. Coons, C. E., Gay, E. C., Fanda, A. W., Ker, C., & Frankenburg, W. K. (1981). The home screening questionnah'e reference manual. Denver, CO: John F. Kennedy Child Development Center, School of Medicine, University of Colorado Health Sciences Center. Crockenberg, S. B. (1981). Infant irritability, mother responsiveness, and social support influences on the security of infant-mother attachment. Child Development, 52, 857-865. Cudaback, D. J., Darden, C., Nelson, P., O'Brien, S., Pinsky, D., & Wiggins, E. (1985). Becoming successful parents: Can age-paced newsletters help? Family Relations, 344, 271-275. Cudaback, D. J., Dickinson, N. S., & Wiggins, E. (1990). Parent education by mail. Families in Society, 71, 172-175. Elster, A. B. (1990). Conceptual issues related to promotion of improved parental behaviors and health in adolescents. In Children's Trust Fund of Texas (Ed.), Critical issues in prevention of child abuse and neglect - - adolescent parenting and life skills for children. Austin, TX: Children's Trust Fund of Texas. Elster, A. B., McAnarney, E. R., & Lamb, M. E, (1983). Parental behavior of adolescent mothers. Pediatrics, 71, 494-503. Furstenberg, F. F., Jr., Brooks-Gunn, J., & Morgan, S. P. (1987). Adolescent mothers in later life. Cambridge: Cambridge University Press. Kinard, E. M., & Reinherz, H. (1984). Behavioral and emotional functioning in children of adolescent mothers. American Journal of Orthopsychiatry, 54, 578-594. Lamberts, M. B., Cudaback, D. J., & Claesgens, M. A. (1985). Helping teenage parents: Use of age-paced parent education newsletters. Journal of Primaly Prevention, 5, 26-32. Lyons-Ruth, K., Zoll, D., Connel, D., & Gruenbaum, H. U. (1986). The depressed mother and her one-year-old infant: Environment, interaction, attachment, and infant development. In E. Z. Troniek & T. Field (Eds.), Maternal depression and infant disturbance. San Francisco: Jossey-Bass. McAnarney, E. R., & Schreider, C. (1984). Identifying social and psychological antecedents of adolescent pregnancy: The contribution of research to concepts of prevention. New York: William T. Grant Foundation. Mercer, R. T. (1986). First-time motherhood (experiences from teens to forties). New York: Springer Publishing Company. Mott, F. L., & Maxwell, N. L. (1981). School-age mothers: 1968 and 1979. Family Planning Perspectives, 13, 287-292. Pardeck, J. T., & Pardeck, J. A. (1987). Using bibliotherapy to help children cope with the changing family. Social Work h~ Education, 9, 107-116.
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Rowland, L. W. (1977). The story of Pierre the Pelican. In Depth Reports, New York Mental Health. Salzinger, S., Kaplan, S., & Artemyeff, C. (1983). Mothers' personal social networks and child maltreatment. Journal of Abnormal Psychology, 922, 68-76. Sparling, J., & Lowman, B. (1983). Parent information needs as revealed through interests, problems, attitudes, and preferences. In R. Haskins & D. Adams (Eds.), Parent education and public policy. Norwood, NJ: Albex Publishing Co. Stevens, J. H. (1984). Child development knowledge and parenting skills, Family Relations, 33, 237-244. Swift, G. A. (1983). Schoolage parents: Statistics as action weapons. Unpublished data (Contact author, United States Department of Education, Region X, 2901 3rd Ave., Seattle, WA 98052). University of California Cooperative Extension. (1984). Parent Express Infant Series. Oakland, CA: Agriculture and Natural Resources Publications. University of California Cooperative Extension. (1989). Parent Express Toddler Series. Oakland, CA: Agriculture and Natural Resources Publications. Valentine, D. P. (1982). The experience of pregnancy: A developmental process. Family Relations 31, 243-248. Zitner, R., & Miller, S. H. (1980). Our youngest parents: A study of the use of support services by adolescent mothers. New York: Child Welfare League of America.
Parent Education for Adolescent Mothers Nancy S. Dickinson 1,3 and Dorothea J. Cudaback 2
Adolescent parents are often ill prepared to provide their new babies with the care and stimulation they need for satisfactory development. A series of age-paced parent education booklets was designed to help these young parents acquire the information, knowledge, and confidence they need to improve their parenting practices. This is a report of a study designed to evaluate the impact of this parent education program on the parenting practices of adolescent mothers. The parenting practices of seventy young mothers who had received the parenting booklets monthly during their babies' first year of life were compared with those of a comparable group of eighty-five adolescent mothers who had not participated in the program. Results suggest that receiving the booklet series was associated with more positive parenting attitudes, beliefs, and practices. Implications for preventive services are discussed. KEY WORDS: Adolescence; parenting; education.
INTRODUCTION The social and economic consequences of adolescent parenthood are significant and long lasting (Furstenberg, Brooks-Gunn, & Morgan, 1987). Adolescent mothers are significantly less likely to complete high school (Mott and Maxwell, 1981) and more likely to be financially and medically dependent (Alan Guttmacher Institute, 1981; Baldwin, 1980; Swift, 1983) than women who delay childbearing until their twenties. Early childbearing 1Nancy S. Dickinson, Ph.D., is the Continuing Education Specialist, Center for Human Services Training and Development, University Extension, Davis, CA. ZDorothea J. Cudaback, Ph.D., is the Human Relations Specialist, University of California Cooperative Extension, Berkeley, CA. 3Address correspondence to: Nancy S. Dickinson, University Extension, Davis, CA 95616-8727. 23 © 1992HumanSciences Press, Inc.
24
Dickinson and Cudaback
also leads to a higher risk of separation or divorce (McAnarney & Schreider, 1984). The most far reaching consequence of adolescent parenthood, however, is the heavy toll it takes on the children of these young parents. The implications of a number of studies are that adolescents may not provide the nurturing parent-infant interactions necessary for optimal child development (Elster, 1990). Compared with older parents, adolescent mothers appear to be inconsistent in their parenting behaviors and have less accurate knowledge of child development, less nurturing home environments, and less optimal child rearing attitudes (Elster et al., 1983; Baldwin & Cain, 1980). As a result, young offspring of adolescent parents fall significantly behind children of older parents on academic skills tests, although the differences are small (Brooks-Gunn & Furstenberg, 1986). By the time they are adolescents themselves, however, the differences between children of adolescent and older parents are startling and disturbing (Furstenberg, Brooks-Gunn, & Morgan, 1987). Academic failure, school maladjustment, delinquency and antisocial behavior, early sexual experience, and pregnancy are significantly more often the experiences of adolescents who were born to younger rather than later childbearers. The reasons adolescent mothers are likely to have parenting problems are many and tangled. These mothers are often single, are likely to come from poverty backgrounds, experience high rates of family instability, and usually have low educational achievement, all factors associated with parenting problems. Additionally, by virtue of limited experience and immaturity, they may be less prepared to provide for their babies' needs. Finally, adolescent mothers may lack the kind of information about child development and parenting needed to adequately promote their children's social and intellectual development (Bolton, 1980; Sparling & Lowman, 1983). With additional information and education, outcomes for the children of adolescent mothers are enhanced (Kinard & Reinherz, 1984). It is this need for parenting information that is addressed by the program described in this paper.
Parenting Information New mothers of any age experience the transition to parenthood as a major life change, both exciting and stressful (Mercer, 1986; Valentine, 1982). For adolescent mothers this transition may be particularly difficult, as they must struggle concurrently with conflicts between the developmental tasks of adolescence and the tasks of motherhood. At this time, they may be especially open to receiving and using parenting help and information
Parent Education for Adolescent Mothers
25
(Aslanian & Brickwell, 1980; Zitner & Miller, 1980). Although most expectant and new adolescent parents receive their parenting information through interpersonal channels, reading for most is an acceptable second choice (Sparling & Lowman, 1983). Unfortunately, the many teens who are poor readers may have difficulty finding parent education materials they can easily understand. Abram and Dowling (1979) used the Flesch Reading Ease Formula to classify the fifty most popular parenting books by reading level. None of the books they reviewed could be classified as "easy" (sixth grade reading level) or "very easy" (less than sixth grade reading level), and only six could be classified as "fairly easy" (seventh grade reading level). The parent education booklets described in this paper are classified as "very easy" to read. Age-paced parent education booklets seem to be a promising means of delivering written child development and care information to adolescent parents. These booklets, mailed to parents monthly during the baby's first year of life, are keyed to the baby's birth month so that the mother receives new information each month about development and care of babies exactly as old as hers. Such booklet series have enjoyed widespread use since Pierre the Pelican was written by Lloyd W. Rowland about 40 years ago (Rowland, 1977). The parent education booklet series which is the subject of this paper, is a series of 15 eight-page booklets mailed monthly to expectant and new parents (University of California Cooperative Extension, 1984). The first two booklets in the series are about prenatal development, the third is about birth, and the remaining 12 booklets, one for each month of the baby's first year, give month by month information about parenting and infant development. The program is available to all parents, but it was particularly designed for adolescent parents. Shaped by interviews with young mothers and professionals working with them, the booklets' content focuses on knowledge which has been shown to be predictive of good child development, including the importance of being responsive to baby's emotional and educational needs, playing with baby in ways that help the baby learn, monitoring baby's health, and promoting language development (Stevens, 1984). The booklets are written in simple, clear language at a fifth grade reading level with a supportive, encouraging tone and attractive format. This kind of program has distinct educational and practical advantages. Because information is keyed to the baby's birth month, parents receive the learning material when they are most ready to use it. They can read the booklets at their convenience, share them with others, and save them for future reference. Finally, and importantly, the program is a relatively inexpensive way to provide educational information for a large number of parents, some of whom might be otherwise inaccessible. In
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previous evaluations of the series, parents reported reading, valuing, using, and sharing the booklets' information, as well as improving their parenting practices as a result of reading the booklets (Cudaback et al., 1985; Cudaback, Dickinson, & Wiggins, 1990). While these evaluations included parents of all ages, results were more positive for those considered at risk of parenting difficulties, including low income, single, and adolescent parents. A previous article in this journal reported on the development of the series and one similar to it in a different state and their use with adolescent parents (Lamberts, Cudaback, & Claesgens, 1985). Major questions remained, however, about whether adolescent readers were handling their transitions to parenthood more successfully than their peers. The study reported in this paper extends previous research on the series by evaluating the impact of the parent education booklets on the parenting practices of young mothers who became pregnant while adolescents, compared with those practices of similar adolescents who did not read the series.
METHODS Study Design and Sample
A study group of 118 pregnant adolescents was recruited from 16 San Francisco Bay Area agencies and programs serving pregnant minors. These adolescent programs, distinct from each other and from the research project, offered a variety of health services, social services, and education for pregnant and parenting adolescents. Some of the programs were familiar with the project's parenting booklets, but none were distributing the booklets during the project year. An interviewer personally administered pre-test questionnaires to groups or individuals who agreed to participate in the study. The adolescents also agreed to receive the parenting booklets monthly until their babies were one year old and to participate in a follow-up interview. Approved human subjects procedures were used to ensure informed and voluntary consent by all participants. Eleven to 18 months after their babies were born, 70 of the study group mothers, or 59 percent, were interviewed again, most by telephone interviews. The remaining 48 adolescents could not be contacted. A comparison of teens who could not be recontacted with the study group shows that the two groups at the time of the first interview were similar in age, education, race, and living arrangements.
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Parent Education for Adolescent Mothers Table I. Respondent Characteristics
Study Group Characteristic
Pre-Test (n = 70)
Post-Test ControlGroup (n = 70) (n = 80)
Mean age
17.0
18.4
17.5
Percent single
90.0
80.0
85.7
Living arrangements: Alone Husband/partner Friends Parents Other
1.4% 15.7 8.6 57.1 17.1
5.8% 21.7 4.3 52.2 15.9
11.8% 25.9 2.4 54.1 5.9
Highest grade passed
some high school
11.4
10.8
In parent ed program
71.4%
24.0%
47.0%
21.4% 24.3
21.4% 24.3
23.5% 24.7
48.6 5.7
48.6 5.7
47.1 4.7
Race: Hispanic White nonHispanic Black Other
One year after the study began, information was collected from a comparable group of 85 young mothers of infants 11 to 18 months old who had become pregnant as adolescents but had not read the parenting booklet series. These control group mothers were recruited from 29 different a d o l e s c e n t p r o g r a m s in the San F r a n c i s c o Bay A r e a . T h e p o s t - t e s t questionnaires were administered to these young mothers by the study interviewer or by program staff. As shown in Table I, the study group mothers were older (t = 3.95; p < .001) and tended to have more years of schooling (t = 1.89; p < .06). They were less likely to be in parent e d u c a t i o n p r o g r a m s at the time of their second interview (t = 3.95; p < .001) than control group mothers. Measures Four instruments were used to collect information, three of which were designed for this study: the pre-program questionnaire and the parenting series evaluation, completed by the study group, and the post-
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program questionnaire, completed by study and control mothers. The preand post-program questionnaires were developed to assess respondents' sources of and need for information about baby care, attitudes about motherhood, and knowledge and beliefs about parenting and child development. The program evaluation questionnaire requested such information as reading patterns, helpfulness of specific topics covered by the booklets, degree to which parenting practices and attitudes were influenced by reading the booklets, and overall usefulness of the program. At the post-program interview, both study and control group mothers were given the Home Screening Questionnaire (HSQ) to assess parenting effectiveness (Coons et al., 1981). Based on the Home Observation for Measurement of the Environment (HOME) Inventory, the HSQ is a wellregarded and standardized screening instrument which identifies parents whose infants and young children may be at risk of delayed social and intellectual development due to inadequate parental and environmental influences (Caldwell & Bradley, 1979)).
RESULTS Program Use and hnpact
Study group mothers' evaluation of the parenting program was overwhelmingly positive. Almost all study group mothers (93%) indicated that they had read all or most of the booklets, more than half (57%) kept the booklets and referred back to them at least some of the time, and a large majority of the young mothers (83%) shared the booklets with others, usually their own parents, others, and spouses, in that order. In all, 81 percent indicated that reading the series increased their confidence as parents, and 93 percent of the respondents rated the programs as "very useful" overall. When respondents were asked about ways the booklets influenced their parenting practices, 95 percent reported they had increased at least one recommended practice as a result of reading the series. They reported that reading the booklets influenced them to provide more things for their babies to feel, look at, and listen to (83%), to play with their babies in ways that promoted learning (79%), to show their babies more affectionate attention (73%), to talk to their babies more frequently (70%), and to respond more quickly when their babies cried (69%). A summary score of respondents' answers to the five influence questions reflects the degree to which reading the parenting booklets influenced their parenting behavior (Alpha = .743). Scores ranged from a high of 5 (influenced in all five behaviors) to a low of 0 (no behaviors influenced).
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The largest percentage (48.6%) of young mothers responded that they had changed their parenting behavior in all five areas as a result of reading the booklets, while a low 4.3 percent reported no influence. Parenting Information Sources During pregnancy and parenthood, the largest percentage of both study and control group respondents reported relying most often on family and friends to provide them parenting information. Study group mothers, however, significantly increased their use of magazines and pamphlets from the pre-program to the post-program interview (t = 4.82; p < .001). Also, at this second interview significantly more study than control group mothers reported using written materials (t --- 5.30; p < .001) to obtain their parenting information. Parenting Information Needs At the first interview, the largest percentage of study group pregnant adolescents reported needing information about baby health and safety, followed by baby nutrition, ways to teach baby, and managing the stress of motherhood, in that order. At the post-program interview, significantly more of the study group reported needing additional information on five of the seven areas, including baby development, ways to teach, managing stress, and games and toys. At this interview, the number of study group mothers who reported needing information was significantly higher on all topics than the number of control group mothers who reported needing information. Also, significantly more control than study mothers reported that they did n o t need additional parenting information. Impact of Program Participation on Parenting Practices The findings from the Home Screening Questionnaire corroborate the self-reported impact of the program. Typically, when parents receive an HSQ score of 32 or l e s s - termed a risk s c o r e - these parents need further assessment to determine whether their children may experience developmental delays due to adverse parenting and environmental influences. In this study there was a significant relationship between group membership and respondents' scores (9~2 = 9.6; p < .01). Significantly more respondents who had read the parenting booklets (40%) had no-risk scores when compared with control group mothers (17%). The percentages of mothers
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receiving risk scores in both groups, however, were h i g h - 60 percent for the study group and 83 percent for the control g r o u p - so that program participation, quite understandably, was not sufficient to compensate for the difficulties of teen parenting. Chi-square analyses showed no significant relationships between score levels and participants' race (Z2 = 1.55) or participation in a parent education program (Z2 = .496). HSQ score levels were positively related to the mother's age (and to grade level and employment which are correlates of age). Analysis of covariance results showed that regardless of age, those adolescent mothers who read the parenting booklet series had significantly higher (better) HSQ scores than those who did not read it (F = 10.3; p < .01).
DISCUSSION An overwhelming majority of 70 young mothers who received parent education booklets during their babies' first year found the series to be beneficial and reported that their attitudes, beliefs, and parenting practices had been positively influenced by their program participation. Study group mothers may have exaggerated the extent to which they were affected by reading the booklets to please the interviewer. On the other hand, their spontaneous positive comments about the booklets and repeated requests for a toddler series highlight the program's positive impact. This study reinforces other research showing that expectant and parenting adolescents receive their parenting information primarily through interpersonal channels, which in this case included family and friends and professional advice. For mothers reading parenting booklets, however, the use of printed materials for parenting information increased significantly between pregnancy and post-test. This finding suggests that adolescent parents will find written materials enticing and useful when the writing is simple and clear, the format is attractive, and the delivery is timed to coincide with their baby's age in months. Interestingly, study group mothers reported that they needed more information on parenting at the second interview - - after reading parenting booklets for a y e a r - - t h a n they did at the first interview. At the post-test interview, these mothers also expressed higher information needs than those expressed by control group mothers at the post-test interview. There are several possible reasons for this finding. First, more study girls at the first interview and control mothers at the post-test were attending parent education classes than study group mothers at post-test. The information needs of these two groups may have been satisfied through these classes,
Parent Education for Adolescent Mothers
31
since those attending classes reported less need for parenting information. Perhaps study group mothers at post-test perceived a higher need for parenting information because they were not in parent education classes. Agepaced newsletters are obviously not a substitute for parent education classes but are useful supplements to their curriculum and may also follow adolescents who typically drop in and out of such programs. The finding also suggests the need for a parenting series for adolescent parents of toddlers, which is now available (University of California Cooperative Extension, 1989). A second possible explanation for the discrepancy between study and control mothers' felt needs for parenting information may be that some adolescents simply do not know what information they lack. Reading the parenting booklets may have helped study group mothers realize how much there is to know and stimulated their desire to learn more. The control group, on the other hand, may have continued to believe they had all the information they needed or that was available about parenting. Supporting this assertion is the finding that a large proportion of study group mothers reported wishing they had further information about topics emphasized in the booklet s e r i e s - ways to teach baby, games to play with baby, and toys for baby. These topics differ from the information-needed topics chosen by control group mothers at the post-test and study group teens during pregnancy. Parenting practices seem to have been positively affected by reading the parenting booklets, since significantly more study group mothers had not-at-risk HSQ scores. The higher positive HSQ scores for program participants persisted even when age differences and attendance at parent education classes were controlled. The fact that most study and control group respondents had risk scores, however, is quite disturbing and evidence of the tremendous difficulties facing adolescent parents and their offspring. This somber finding tempers program effects. The results of this study must be considered as suggestive only. The Home Screening Questionnaire has not been tested specifically on an adolescent population. While it was standardized on a low SES population, it is not known how many adolescents were part of that population. Thus, respondent scores in this study may be artificially low. Also, program and resource constraints made it impossible for us to administer a pre-test to the control group. In addition, 41 percent of the study group mothers could not be recontacted for post-program interviews. It was possible to control statistically for obvious differences between study and control group mothers and between those who remained and those who dropped out of the study group, but there may well have been other unknown factors which biased the results. Finally, we relied on respondents' self-
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reports for the data; interviewers were known by our subjects to be employed by the same organization which had produced and sent the booklet series, factors which could well have influenced the mothers' responses. In sum, these concerns call for caution in interpreting the data and further replication of the study.
Implications for Prevention The results of this study imply that the children of adolescent parents benefit as a result of their mothers' program participation. For example, when adolescent mothers share the booklets with o t h e r s - - t h e i r own parents, partners, and other parents - - they strengthen their social support network. Such use of social support can improve the mother-child relationship (Crockenberg, 1981) and cut through the social isolation, experienced by many adolescent mothers, which contributes to child maltreatment (Salzinger, Kaplan, & Artemyeff, 1983). In addition, depression and low self-esteem seem to affect a disproportionate number of adolescent mothers (Colleta, 1983). Increasing their self-confidence, one result of program participation, enhances the adolescent mothers' caregiving abilities and thus their children's well-being (Lyons-Ruth et al., 1986). Moreover, children of adolescent mothers who improve their parenting practices are less likely to experience developmental delays due to adverse parenting and environmental influences. One way that the parent education program helped adolescent parents improve their parenting practices was to expose them to reading materials which are appealing, timely, easy to read, and, therefore, useful. As a result of this exposure, adolescent parents were more eager to continue learning about parenting and child development and more open to using printed materials. The motivation to learn and the ability to use written materials to learn are necessary components of acquiring academic skills which can mediate the long-term negative consequences of adolescent pregnancy for mothers and their children (Furstenberg, Brooks-Gunn, & Morgan, 19887). Clearly most adolescent parents, and their children, need a range of clinical and educational services. Printed materials cannot substitute for these. The results of this study indicate, however, that such materials may help adolescents reduce the risk of providing their infants with inadequate care and could, therefore, valuably supplement available programs. For example, Elster (1990) discusses a range of preventive strategies which may promote improved parental behaviors of adolescents: (1) office-based, private-practice models usually operating within a physician's office; (2) post-
Parent Education for Adolescent Mothers
33
partum intervention models which attempt to increase positive maternalinfant contact; (3) integrated services model using a comprehensive care approach in one setting; and (4) home-based models providing services within the home. Age-paced parent education materials are relevant for each of these particular service categories, as well as others typically used with adolescent parents. In addition, printed materials could also provide some measure of help to those adolescents who cannot or will not use more extensive or intensive services. That such a program benefits adolescent m o t h e r s - who are known to confront significant problems with few r e s o u r c e s - is grounds for optimism about similar efforts with other at-risk groups. Many people look to printed materials for personal help. Self-help books proliferate. Advice columns, magazines, news features, and pamphlets which deal with personal and interpersonal problems are read by millions. Human service workers already use bibliotherapy with benefit to clients (Pardeck & Pardeck, 1987). Shaping the written materials more precisely for carefully selected audiences and designing the delivery of the program so that it reaches this audience at a time and in a way that is most likely to be useful to them will increase the benefit of such materials. The parent education program described in this paper was successful partly because it reached people who were experiencing a life transition and, therefore, not only needed assistance but were also open to using it. During the course of a lifetime, people face many such transitions - - family dislocation, job loss, divorce, bereavement, retirement - - all times when serious repercussions could occur if prevention services were not available. Some of these people could be helped by written materials which provide them with information about their distress, give them ideas on ways to cope, and suggest resources and services which could provide further help. With limited numbers of human service workers and inadequate social and health budgets, society cannot provide for all who need help. Prevention is a cost effective way of serving large numbers of vulnerable people. We can very possibly expand our effectiveness in providing these services if we hone our ability to use written materials.
ACKNOWLEDGMENTS The authors thank Mary Zernicke, Gail Splaver, Victoria Leonard, and Judy Pope for their assistance with the project and Richard Barth for his help with the manuscript preparation.
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Rowland, L. W. (1977). The story of Pierre the Pelican. In Depth Reports, New York Mental Health. Salzinger, S., Kaplan, S., & Artemyeff, C. (1983). Mothers' personal social networks and child maltreatment. Journal of Abnormal Psychology, 922, 68-76. Sparling, J., & Lowman, B. (1983). Parent information needs as revealed through interests, problems, attitudes, and preferences. In R. Haskins & D. Adams (Eds.), Parent education and public policy. Norwood, NJ: Albex Publishing Co. Stevens, J. H. (1984). Child development knowledge and parenting skills, Family Relations, 33, 237-244. Swift, G. A. (1983). Schoolage parents: Statistics as action weapons. Unpublished data (Contact author, United States Department of Education, Region X, 2901 3rd Ave., Seattle, WA 98052). University of California Cooperative Extension. (1984). Parent Express Infant Series. Oakland, CA: Agriculture and Natural Resources Publications. University of California Cooperative Extension. (1989). Parent Express Toddler Series. Oakland, CA: Agriculture and Natural Resources Publications. Valentine, D. P. (1982). The experience of pregnancy: A developmental process. Family Relations 31, 243-248. Zitner, R., & Miller, S. H. (1980). Our youngest parents: A study of the use of support services by adolescent mothers. New York: Child Welfare League of America.
