For example, the subsequent pregnancy risk reduction interventions from which Dr. Barnet and her colleagues drew data for their secondary analysis comprised weekly or monthly home visits beginning during the index pregnancy and continuing for two years. The interventions were facilitated by trained paraprofessionals who provided parenting instruction, case management, and motivational interviewing. Neither of the consecutive interventions achieved their primary intervention goal, nor were maternal depressive symptoms affected, she said.
In contrast, research has shown that treating depression in mothers can improve mother and child outcomes. Findings from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial showed that remission of maternal depression has a significant positive effect on the health and well-being of both mothers and children (JAMA 2006;295:1389–98).
Although it is not known whether treating depression in adolescent mothers will decrease the risk of rapid subsequent pregnancies, “our findings suggest that depression may be an important malleable risk factor,” Dr. Barnet said. As such, she noted, depression in this group needs to be identified and treated, and doing so requires the implementation of a model of health care in which multidisciplinary primary care teams provide care coordination across clinic and community settings.
Schools might be an important front-line resource in this regard. For example, although it was not developed to prevent subsequent teen pregnancies or to address maternal depression, the Cradle to Classroom program, piloted successfully in the Chicago Public Schools, might affect both. The comprehensive program, designed to develop parenting skills in adolescent parents, help them finish high school, and promote healthy outcomes for the teens and their offspring, includes extensive in-school academic, social, and health supports for young mothers and an intensive home visiting program for the adolescent parents and their babies.
Of the 2,000 or so teens from 54 Chicago schools who had babies in 2002 and who participated in the program, only five had a repeat pregnancy while still in school. Also, all 495 seniors in the program graduated, and more than 75% went on to 2- or 4-year colleges (JAMA 2003;290:586).
Improving outcomes for teen mothers and their children requires this type of comprehensive strategy, according to Dr. Barnet. She and her colleagues stress the need for protocols that incorporate systematic practice changes and collaborative care teams.
Perspective
Risk factors are not predictive factors because of the presence of protective factors. This truism should be the mantra of preventive mental health.
Depression in adolescent girls has been linked to an increase in high-risk sex behavior and, consequently, pregnancy. Yet, not all girls with depression engage in high-risk sex and become pregnant.
Much attention has been focused on determining whether depression leads to an increased risk of high-risk sex and pregnancy among adolescents or whether it is a consequence of such outcomes. But the more practical research question in terms of designing an effective teen pregnancy-prevention intervention should be this: “What protective factors are keeping the nonpregnant adolescent girls who are depressed from getting pregnant?”
The answer, I suspect, will be the same protective factors that foster resilience in some trauma-exposed teens, and the same ones that keep some low-income, underprivileged nonwhite teens out of trouble: a strong social fabric, self-esteem, self-efficacy, a sense of belonging, and access to community resources.
Interventions designed to optimize these factors will likely have the most benefit across outcomes. The Cradle to Classroom initiative is a perfect example. Developed as a tool to keep pregnant teens in school through high school graduation, the program not only is associated with reduced dropout rates among participants. It also has been linked to increased personal growth and development in terms of college enrollment, improved parent/child interactions, and the prevention of rapid subsequent pregnancies. It succeeds by fortifying the protective factors necessary to keeping these kids on track.
In contrast, interventions designed to educate depressed teen mothers about how not to be depressed or how not to get pregnant again don't work. The fact that there are still academics who believe that education alone can change behavior is laughable. Of course, it is easier to throw education at a problem than it is to design a comprehensive and thorough intervention. But easier isn't better; in most cases, it's not nearly enough.