You enter an exam room to meet 16-year-old Tria for her first prenatal appointment. She presents with a tough facade until you ask about her baby. You take her smile to be a good sign. In reviewing her intake forms, you notice that she checked off several childhood traumas and symptoms of psychological distress. You think to yourself, this girl has dealt with more than you can imagine. You fear that you'll contribute to her distress if you express your concern.

Figure. No caption available.

The Scope of the Problem

The teen birth rate in the United States is at its lowest level since 1991 (Ventura, Hamilton, & Matthews, 2014). This positive trend is overshadowed by the fact that the United States rate exceeds that of all other developed countries and by concerns for the vulnerabilities of teen mothers and their children. Psychological distress is one vulnerability that tends to be overlooked in the care of teen mothers, even though distress levels are often high. Depressive symptoms, for example, are two to four times higher in teen mothers than in their childless peers and in older mothers (Hodgkinson, Beers, Southammakosane, & Lewin, 2014; Mollborn & Morningstar, 2009). Of equal concern, depressive symptoms tend to persist and remain high as teen mothers enter mid-life (Mollborn & Morningstar). Although depression receives the most attention in the literature and clinical settings, depression in girls and women often co-occurs with other mental health conditions and trauma-related symptoms (Seng et al., 2013). In recognition of these comorbidities, psychological distress is the term used in this paper. We describe teen mothers' vulnerability to distress, effects of distress on mother and child, and factors protective of teen mothers' mental health. We also review what is known about the significant barriers to traditional mental healthcare for this group of parents and intervention studies that aim to improve their mental health. In light of this evidence, and the substantial role that nurses already play in serving pregnant and parenting teens, the second article in this two-part series will highlight what nurses in health clinics, schools, homes, and community agencies can do to reduce the toll of psychological distress on teen mothers and their children. The intent is that nurses who care for teen mothers like Tria will be less reluctant to screen for distress and more skillful in promoting their mental health.

Teen Mothers' Vulnerability to Psychological Distress

Teen mothers are a vulnerable group of parents for reasons other than young age. They often have experienced high levels of psychological distress as a child due to the social disadvantage and adversities that precede teen pregnancy (Hillis et al., 2004; Hodgkinson et al., 2014). Because teen mothers are disproportionately poor and of color, their childhoods are often characterized by family instability, chronic stress, and social inequities from attending inferior schools and living in unsafe neighborhoods with high unemployment and crime rates. Violence often permeates the social fabric, with children witnessing or personally experiencing violence. Child sexual abuse occurs in almost 50% of pregnant teens and co-occurs with other childhood traumas (Easterbrooks, Chaudhuri, Bartlett, & Copeman, 2011; Noll, Shenk, & Putnam, 2009). These assaults contribute to childhood distress and the risk of teen pregnancy (Hodgkinson et al.). When teens become mothers, early adversities are further compounded by the stress of parenting, economic hardships, intimate partner violence, and the stigma of early childbearing (Lindhorst & Oxford, 2008; SmithBattle, 2013). Challenges like these predispose mothers to depression (Lindhorst & Oxford) and symptoms of posttraumatic stress (Gapen et al., 2011).

What is at Stake?

The prevalence and severity of distress among teen mothers is troubling in light of the evidence that distress increases risk of maternal substance use and repeat pregnancy (Barnet, Liu, & Devoe, 2008; Chapman & Wu, 2013) and undermines maternal functioning. Depressed and traumatized mothers tend to be less responsive to infant cues and parent more harshly than their peers (Bartlett & Easterbrooks, 2012; Seng et al., 2013). Their children tend to be less securely attached (Cyr, Euser, Bakermans-Kranenburg, & Van Ijzendoorn, 2010), have more developmental delays (Huang, Costeines, Ayala, & Kaufman, 2014), and are at risk for behavioral problems and poor health (Mollborn & Dennis, 2012). Left untreated, adolescent and young adult offspring are also vulnerable to distress and depression (Hamilton, 2009).

The transmission of psychological vulnerability from one generation to the next begins prenatally and accumulates as mothers and children are exposed to toxic environments and adverse childhood experiences (ACEs) (Clarkson Freeman, 2014). Adverse childhood experiences are defined as growing up in families affected by mental illness, substance abuse, violence, or criminal activity (Felitti & Anda, 2010). The link between ACEs and poor health was first identified in a remarkable epidemiological study which showed that as the number of ACES increased, the risk for chronic diseases, mental illness, and impaired relationships also rose (Felitti & Anda). This pattern was also observed among teen mothers: those with more ACEs fared worse at mid-life than those with few ACEs (Hillis et al., 2004). Similarly, children with multiple ACEs were more likely to experience cognitive, behavioral, and health problems than those with few ACEs (Clarkson Freeman). These findings converge with the neurobiology and epigenetics of toxic stress (Shonkoff et al., 2012). In brief, if toxic stress is prolonged, the structure and functioning of the developing brain is altered as neuronal connections atrophy. Chronic stress activates a cascade of immunologic, neurochemical, and metabolic processes that contribute to phyical and mental health conditions over the life-span. Prolonged and high levels of stress also impair our ability to concentrate, learn, self-regulate, and form relationships.Thus, traumas and toxic environments profoundly shape our physiology and the ways we relate to the world and others, and may be expressed in trauma symptoms of withdrawal, hyper-arousal, or dissociation. The following review offers a thorough description of the science in this important area (Shonkoff et al.).

Protective Factors

Although teen mothers as a group are at high risk for distress, distress is by no means universal. Variations in the occurrence, severity, and persistence of distress are partly explained by factors that protect mental health and reduce the impact of childhood adversities. These protective factors include family and partner support, positive childhood experiences, and mothers' aspirations to improve their lives and be good parents. These factors contribute to the strengths and resilience that are often observed among teen mothers (Easterbrooks et al., 2011; Hurd & Zimmerman, 2010; SmithBattle, 2009).

Support: Family and partner support fosters young African American mothers' mental health (Edwards et al., 2012) and protects teen mothers' offspring from emotional and behavioral problems (Mollborn & Dennis, 2012). Support also buffers the relationship between stressful life events and depression for teen and low-income mothers (Divney et al., 2012; Edwards et al.). Grandmothers (of the baby) are often identified as teen mothers' most reliable source of support (Pires, Araujo-Pedrosa, & Canavarro, 2013), but their support can introduce problems (Caldwell, Antonucci, & Jackson, 1998). For example, support that is intrusive or laden with criticism contributes to family conflicts, and undermines the teen's mental health (Caldwell et al.; SmithBattle & Leonard, 2014) and the child's development (Mollborn & Dennis). Family conflicts may also ensue when grandmothers resent childcare or financial burdens (Caldwell et al.).

Although supportive partners decrease maternal distress and improve child outcomes, partner support may be constrained by meager finances or by the limited relational skills of either partner (Kershaw et al., 2013). Given that many young fathers have experienced childhood traumas, they are also at risk for depression and trauma-related symptoms (Divney et al.).

Positive Experiences: Even teen mothers with childhood traumas do well if nurturing experiences were available. Positive childhood experiences reduce the risk of depressive symptoms among disadvantaged pregnant women (Chung, Mathew, Elo, Coyne, & Culhane, 2008) and spare teen mothers from poor psychosocial outcomes (Bartlett & Easterbrooks, 2012; Hillis et al., 2010). Positive and corrective experiences with supportive adults also helps to repair difficult childhoods and promote mothers' resilience (Hurd & Zimmerman, 2010).

Aspirations: In the context of social and economic inequities, mothering offers an adult identity, confers meaning, and deepens aspirations. Yearning for a better future and drawing strength from their children, many teens return to school, develop healthy habits, and forsake risky relationships (SmithBattle, 2009). Depressed teens also report that mothering motivates them to improve their lives and protect their children from harm (Clemmens, 2002). Teens' aspirations for a better life represent untapped resources for promoting their mental health, but it is also the case that their strengths and aspirations can be threatened by stigma, ongoing distress, and limited support (Pires et al., 2013; SmithBattle, 2013).

Psychosocial Treatment

In spite of high levels of distress, teen mothers rarely seek mental healthcare (Logsdon, Foltz, Stein, Usui, & Josephson, 2010). Barriers to treatment include cost, stigma of mental illness, and lack of time, because the demands of parenting, work, and school take priority and trump self-care (Boath, Henshaw, & Bradley, 2013). Lack of transportation, childcare, and insurance pose additional barriers (Miller, Gur, Shanok, & Weissman, 2008). Teen mothers also fear losing custody of their children if they seek treatment (Boath et al.). The limited effectiveness of a phone-based intervention to help depressed teen mothers' obtain care underscores the barriers to treatment (Logsdon et al.).

The pressing need for mental healthcare for mothers in general, and teen mothers in particular, is evident in the growing number of studies that test interventions to improve mental health. The few that target teen mothers test novel approaches for reducing symptoms of depression (Hodgkinson et al., 2014). For example, group therapy, massage for teens' infants, and relaxation or massage for teens as components of a larger program have reduced depressive maternal symptoms relative to controls (Field, Grizzle, Scafidi, & Schanberg, 1996; Field et al., 2000; Miller et al., 2008; Oswalt, Biasini, Wilson, & Mrug, 2009). Compared to traditional mental healthcare, these programs offer teen-friendly approaches located at trusted, convenient sites that are more easily integrated into teen mothers' hectic schedules. Group therapy approaches have the additional benefit of fostering peer support and reducing teen mothers' social isolation.

Although home visiting interventions (HVIs) provide emotional support with health and parenting education to vulnerable families, these programs have rarely been effective in improving maternal mental health (Azzi-Lessing, 2013). The Family Spirit Intervention represents a notable exception in reducing depressive symptoms and drug use among American Indian teen mothers who were visited by paraprofessionals in their homes (Barlow et al., 2015). Improvements in mothers' mental health extended to their young children, who had fewer externalizing and internalizing problems than children of mothers in the control group. Two additional clinical trials have also shown promise in reducing depression in young, low-income mothers who received home-based psychotherapy as an adjunct to the home visits they received as participants of an established HVI (Ammerman et al., 2013; Beeber et al., 2013). In these studies, mothers with mild or moderate levels of depression received a fairly short course (10-15 sessions) of therapy from master's-prepared mental healthcare professionals. Because these studies did not measure child outcomes, we do not know if children benefitted from mothers' symptom reduction. Although home-based programs such as these do not offer peer support, they eliminate the expense of transportation and child care that hinder teen mothers' access to traditional care.

Since teen mothers' relationships with grandmothers and partners can contribute to maternal distress, early interventions that strengthen these relationships represent another avenue for improving mental health. The few interventions targeting teen mothers and grandmothers reduced interpersonal conflicts, clarified generational boundaries, and improved mother-child relationships (Fletcher, Fairtlough, & McDonald, 2013; McDonald et al., 2009). Other researchers designed interventions to improve the interpersonal skills of teen mothers and their partners, and partners' involvement with their children. Coparenting interventions with young couples improved fathers' paternal engagement (Florsheim et al., 2012), but initial reductions in intimate partner violence were not sustained in one study (Florsheim, McArthur, Hudak, Heavin, & Burrow-Sanchez, 2011).

Clinical Implications

Toxic stress and childhood trauma are woven into the lives of many teen mothers. We also know that neglecting ACEs and toxic stress has a lasting and perverse impact on the health and development of teen mothers and their children. It is ironic, then, that teen mothers' distress receives little attention in the clinics, schools, and home visiting programs that serve them (Brand, Morrison, & Down, 2014).

Nurses are on the front lines in caring for teen mothers and their children. Although mental health screenings are routinely conducted by nurses in diverse settings, screenings are of dubious value when high scores are used exclusively to initiate referrals to traditional mental healthcare. Because referring teen mothers to traditional care is rarely effective (Logsdon et al., 2010), too many teen mothers may continue to suffer in silence. A different approach is clearly indicated. Nurses often miss a golden opportunity to intervene when interacting with teen mothers. Nurses may feel ill prepared to respond to disclosures of distress and trauma, even though a therapeutic presence conveys to the teen that she is worthy of care and respect, that her concerns and experiences are taken seriously, and that even the most disturbing events are approachable. Responding to teens' disclosures with skill and sensitivity makes it possible for the nurse to counter what a teen may fear but is too frightened to acknowledge, that past traumas inevitably curtail their chances to improve their lives and to be the good parents they want to be (SmithBattle & Leonard, 2012).

Mothering is a striking example of a turning point that alters a woman's identity and life course. For those who have suffered past traumas, this turning point can be augmented with positive experiences and supportive relationships that facilitate growth and healing (Kennedy, Agbenyiga, Kasiborski, & Gladden, 2010). Conversely, negative experiences after giving birth to a child can compound and reinforce the effects of early adversities and deepen emotional scars from childhood. Nurse researchers have improved our understanding of teen mothers' vulnerabilities and resilience (Clemmens, 2003; SmithBattle, 2013). Further research is needed to advance nursing skills and teen-friendly services that promote teen mothers' mental health (Logsdon et al., 2010).

Nurses cultivate the transformative potential of mothering when they adopt principles of strength-based and trauma-informed care. In the second article in this two-part series, we describe these principles and how they create a link in a positive chain when nurses respond to teen mothers' distress and promote protective factors in their lives. Moving in this direction has the potential to alter the physiological cascade and habituated responses to chronic stress that impair neurodevelopment, attachment, learning, and health over the life course. Teen mothers and their children deserve no less.

Acknowledgment

Funding from the Group Foundation for Advancing Mental Health is gratefully acknowledged. The funder played no role in developing this article.

Clinical Implications for Nurses

* Assess pregnant and parenting teens for childhood adversities and current distress.

* Validate their aspirations and their use of resources.

* Refer psychologically vulnerable teens to teen-friendly mental health resources.

Instructions for Taking the CE Test Online An Overview of Teen Mothers' Mental Health

* Read the article. The test for this CE activity can be taken online at http://www.nursingcenter.com/ce/MCN. Tests can no longer be mailed or faxed.

* You will need to create a free login to your personal CE Planner account before taking online tests. Your planner will keep track of all your Lippincott Williams & Wilkins online CE activities for you.

* There is only one correct answer for each question. A passing score for this test is 12 correct answers. If you pass, you can print your certificate of earned contact hours and the answer key. If you fail, you have the option of taking the test again at no additional cost.

* For questions, contact Lippincott Williams & Wilkins: 1-800-787-8985.

Registration Deadline: February 28, 2018

Disclosure Statement:

The authors received an educational grant from the Group Foundation for Advancing Mental Health. The funder played no role in developing this article. The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

Provider Accreditation:

Lippincott Williams & Wilkins, publisher of MCN, The American Journal of Maternal/Child Nursing, will award 2.0 contact hours for this continuing nursing education activity.

Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.0 contact hours. Lippincott Williams & Wilkins is also an approved provider of continuing nursing education by the District of Columbia, Georgia, and Florida CE Broker #50-1223. Your certificate is valid in all states.

Payment:

* The registration fee for this test is $21.95.

References