Medicaid Instability and Mental Health of Teen Parent Families.

This study examines the effect of inconsistent Medicaid coverage on parenting stress, maternal depression, and child behavior in a sample of teen mothers and their children. The majority (54%) of mothers experienced inconsistent coverage. After 24 months, mothers experiencing inconsistent coverage had significantly higher parenting stress and depressive symptoms, and their children had more internalizing behaviors than families with consistent Medicaid. These differences existed despite no initial differences and controlling for numerous covariates. Policies and practices that stabilize Medicaid coverage for teen parent families may reduce unnecessary stress, depressive symptoms, and early childhood behavior problems.

The protective effects of father involvement for infants of teen mothers with depressive symptoms.

The purpose of this study is to examine the role of father involvement on infant distress among children born to teen mothers, particularly those who are depressed. 119 teen mothers (<20 years) and their infants (<6 months) enrolled in a quasi-experimental trial of a comprehensive pediatric primary care program. Data were drawn from mother-reported questionnaires administered at baseline, before participation in the intervention or comparison conditions. 29 % of teen mothers screened positive for depression. Mothers reported that 78 % of fathers were engaged with their children, typically seeing them a few times per month, and 71 % took financial responsibility for their children. In a multiple linear regression, father responsibility predicted lower infant distress, maternal depression predicted higher infant distress, and there was a significant interaction in which father engagement buffered the effect of maternal depression on infant distress. Fathers may be a protective resource for children born to teen mothers, even as early as the first 6 months of life, potentially mitigating the heightened risk associated with maternal depression in the postpartum period.

Strengthening positive coparenting in teen parents: a cultural adaptation of an evidence-based intervention.

Teen childbearing is associated with a range of adverse outcomes for both mothers and children, and perpetuates an intergenerational cycle of socioeconomic disadvantage. Fathers may be an underappreciated source of support to teen mothers and their children. The strongest and most consistent predictor of positive father involvement is a positive coparenting relationship between the mother and father. Thus, strengthening the coparenting relationship of teen parents may be protective for both parents and children. This paper describes the rationale, the intervention model, and the cultural adaptation of Strong Foundations, an intervention designed to facilitate and enhance positive coparenting in teen parents. Adapted from an evidence-based coparenting program for adult, cohabiting parents, this intervention was modified to be developmentally and culturally appropriate, acceptable, and feasible for use with urban, low-income, minority expectant teen mothers and their male partners. The authors present lessons learned from the cultural adaptation of this innovative intervention. Pilot testing has shown that this model is both acceptable and feasible in this traditionally hard to reach population. Although recruitment and engagement in this population present specific challenges, young, urban minority parents are deeply interested in being effective coparents, and were open to learning skills to support this goal.

"The thing in my arm": Providing contraceptive services for adolescents in primary care.

BACKGROUND: Due to high rates of unintended pregnancies in Delaware, the state launched a public health initiative in 2014 to increase access to contraceptive services. OBJECTIVES: This study was designed to assess the practice-level barriers and facilitators to providing contraceptive care, particularly long-acting reversible contraceptives (LARCs), to adolescents in primary care settings. DESIGN: This qualitative study was part of a larger process evaluation of the Delaware Contraceptive Access Now (DelCAN) initiative. METHODS: In-depth, semi-structured qualitative interviews were conducted with 16 practice administrators at 13 adolescent-serving primary care sites across the state of Delaware. A process of open, axial, and selective coding was used to analyze the data. RESULTS: Despite the interest in LARC among their adolescent patients, administrators described numerous barriers to providing LARC for adolescents including confidentiality in patient visits and billing, preceptorship, and provider discomfort and assumptions about the need for contraception among adolescent patients. CONCLUSION: Findings from this study reveal substantial barriers to providing contraception to adolescents, even in primary care practices that were committed to comprehensive contraceptive access for their adolescent patients. This study supports the need for contraceptive care to be integrated into training of pediatricians at every stage of their education. Such training must go beyond education about contraceptive options and the clinical skills necessary for LARC insertion and removal, to include counseling skills based in a reproductive justice framework. Additional changes in policies and practices for adolescent patients would further increase access to contraceptive care.

Feasibility of Implementing a Mindfulness-Based Online Program for Latina Immigrants and the Staff that Work with Them.

Objective: Post-migration stress and trauma impact the way Latino/a immigrants in the USA experience everyday life. Mindfulness-based interventions (MBIs) reduce stress and strengthen mental health by improving the response to stressors and promoting physical and psychological well-being; however, they have not been tested extensively with Latino/a immigrants in the USA, particularly MBIs implemented online. Thus, more information is needed about the feasibility of online MBIs adapted for Latino/a immigrants. Method: This study focuses on the feasibility of an online MBI for Latina mothers and community staff members working with them (n = 41). Qualitative (three focus groups) data were collected to assess feasibility, appropriateness, acceptability, and quantitative (questionnaires) data asking about self-reported changes on stress, mindfulness, mind-body connection, subjective well-being, and perceived physical and mental health after the program. Results: Participants in the three groups indicated the program was appropriate, feasible, and acceptable for Latina immigrant mothers and the staff serving them. Mothers' and Promotoras' (community health workers) mean scores for subjective well-being and perceived physical and mental health increased significantly from baseline to post-test. No significant changes were observed in surveys completed by the staff, even though focus group participants reported meaningful improvement. Conclusion: Overall, the feasibility study was well received and relevant for the organization and the population they serve. The study's findings provide guidance to others who are implementing online mindfulness practices with Latina immigrants and the staff that work with them. Preregistration: This study is not preregistered. Supplementary Information: The online version contains supplementary material available at 10.1007/s12671-023-02123-6.

Variations in the relationship between maternal depression, maternal sensitivity, and child attachment by race/ethnicity and nativity: findings from a nationally representative cohort study.

This study uses data from the nationally representative Early Childhood Longitudinal Study-Birth Cohort to examine the relationship between maternal depression, maternal sensitivity, and child attachment, specifically among Hispanic and Asian American mothers and their young children, and to explore the role of cultural variation and nativity in the associations between these variables. Data used in this study were collected from biological mothers on two occasions, when their children were approximately 9 and 24 months of age. Trained observers completed a direct assessment of child attachment security and an observational measure of maternal sensitivity, data on maternal depression was obtained via maternal report. Hierarchical logistic regression models were used to predict odds of child insecure attachment. The risk of child insecure attachment associated with chronic maternal depression was found to be much higher for Hispanic mothers than for Asians. In contrast, mothers' foreign-born status was a stronger risk factor than depression for insecure child attachment among Asian Americans. Maternal sensitivity significantly reduced the odds of Asian American children being insecurely attached by more than half. Among the full sample of mothers, which included U.S.-born non-Hispanic White mothers and U.S.-born non-Hispanic Black mothers, decreased maternal sensitivity mediated the association between chronic depression and child insecure attachment. However, this mediation was not found in stratified analyses of Hispanic and Asian mothers. Finally, mothers' nativity did not influence the extent to which maternal depression or sensitivity was associated with child attachment. These findings suggest that the associations between maternal depression, sensitivity, and child attachment are culturally specific, and that mothers' immigrant status may be a risk factor in some racial/ethnic groups but protective in others.

Development and psychometric properties of the ACE-I: Measuring adverse childhood experiences among Latino immigrant youth.

OBJECTIVE: Despite the well-established relationship between Adverse Childhood Experiences (ACEs) and health and well-being across the life course, there is a limited understanding of ACEs among diverse populations. The purpose of this study was to develop a new measure, the ACE-I, which consists of adversities that may be more relevant among immigrant populations, and to compare these rates to those of traditionally studied ACEs. METHOD: Data for this study comes from a community sample of 338 Latino immigrant adolescents who completed an 11-item measure of traditional ACEs and a novel 13-item measure of immigrant-specific ACEs (ACE-I) as part of the intake process for a positive youth development program. RESULTS: While the scores of the two ACEs measure were correlated (r = .16), immigrant youth, on average, reported more adversities on the ACE-I measure than the traditional ACEs measure (3.6 vs. 1.6). Overall, individual ACE-I items were more likely to be endorsed than traditional ACE items. Fit indexes from a confirmatory factor analysis suggested that the ACE-I hypothesized three-factor structure (experiences of violence/unrest in one's home country, danger encountered on the migration journey, and instability of life as an immigrant) represents a satisfactory solution. CONCLUSIONS: These findings suggest that there are essential early adverse experiences for immigrants that have not previously been considered in ACEs research. Broadening our conceptualization and measurement of ACEs among immigrant populations could provide valuable insight into social determinants of health and avenues for intervention for immigrant youth and families. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Family-Centered Care and Flourishing in Early Childhood.

INTRODUCTION: Flourishing reflects a child's ability to cope with stress and have positive relationships, which are critical to health and well-being. Pediatricians may increase flourishing in children through family-centered care, which is perceived as sensitive and responsive to specific child needs and family circumstances. The purpose of this study was to examine the relationship between family-centered care and flourishing in young children. METHODS: Data from the 2019-2020 National Survey of Children's Health were used to examine the relationship among children aged 1-5 years (n=17,826). The relationship was explored using chi-square tests and sequential logistic regression modeling, controlling for family socioeconomics and adversity, race/ethnicity, child health, and other measures of healthcare quality. Analyses were conducted in January 2022. RESULTS: Approximately 82% of young children were flourishing. After adjusting for all variables, receipt of family-centered care was the only measure of quality health care associated with an increased likelihood of flourishing in young children (adjusted prevalence rate ratio=1.14; 95% CI=1.01, 1.29; p=0.02). Disparities in flourishing by child sex, race/ethnicity, parental education, income, and insurance type were mitigated after adjustment. However, a decreased likelihood of flourishing continued to be associated with having a special healthcare need (adjusted prevalence rate ratio=0.74; 95% CI=0.68, 0.82) and experiencing multiple adverse childhood experiences (adjusted prevalence rate ratio=0.78; 95% CI=0.66, 0.92). CONCLUSIONS: Expanding receipt of family-centered care may support flourishing and help to reduce disparities in flourishing during early childhood. Future research should evaluate the strategies to overcome barriers to delivering and receiving family-centered care, especially among children with special healthcare needs and children who experienced multiple adverse childhood experiences.

Family Health Development: A Theoretical Framework.

In recognition of the family as central to health, the concept of family, rather than individual, health has been an important area of research and, increasingly, clinical practice. There is a need to leverage existing theories of family health to align with our evolving understanding of Life Course Health Development, including the opportunities and constraints of the family context for promoting lifelong individual and population health. The purpose of this article is to propose an integrative model of family health development within a Life Course Health Development lens to facilitate conceptualization, research, and clinical practice. This model provides an organizing heuristic model for understanding the dynamic interactions between family structures, processes, cognitions, and behaviors across development. Potential applications of this model are discussed.

Evaluation of the Delaware Contraceptive Access Now (DelCAN) initiative: A qualitative analysis of site leaders' implementation recommendations.

OBJECTIVES: In 2014, Delaware launched a statewide initiative to reduce the rate of unintended pregnancies and increase access to contraception services. Our study objective was to understand the implementation experiences, barriers, and successes across health care practice settings and to provide recommendations for future, similar initiatives. STUDY DESIGN: As part of a larger multicomponent process evaluation, we conducted semistructured interviews with 32 leaders from 26 practice settings implementing the initiative across the state. We analyzed the qualitative data through iterative open, axial, and selective coding using grounded theory methods, employing thematic analysis to identify common themes in implementation experiences. RESULTS: Most practices perceived that patient demand for methods of long-acting reversible contraception (LARC) increased. Many practices had to adapt the intervention to fit the needs and constraints of their settings and patient populations. Primary care practices, smaller practices, and practices that served large numbers of adolescents experienced more barriers compared to obstetrics and gynecology or women's health practices. For current and future iterations of the initiative, leaders emphasized: (1) the need for greater implementation flexibility, (2) the importance of inclusive communication at multiple levels, and (3) attending to logistical challenges, particularly around billing. CONCLUSION: Varied practice settings required significant flexibility and responsiveness to context in order to implement the initiative. Organizations with greater pre-existing capacity were able to offer the full range of contraceptive care, as the initiative intended, in contrast to practices with less pre-existing capacity for providing methods of LARC and other types of contraception. IMPLICATIONS: To meet the specific but heterogenous needs of various practices, it is crucial for future contraceptive access initiatives to conduct a comprehensive pre-implementation assessment. Preceding any training, this assessment should gather input from participants across all roles in a medical practice (e.g., providers, medical assistants, office staff, billing department).

Types of Lifetime Reproductive Coercion and Current Contraceptive Use.

Background: Intimate partner violence and differential power dynamics are associated with contraceptive behaviors. This study examines the role of reproductive coercion (RC) by an intimate partner in women's decisions about contraceptive use. Materials and Methods: A self-report survey was administered to a probability sample of a diverse group of women of reproductive age in Delaware's Title X health care facilities. Currently used contraceptive methods were categorized into three effectiveness levels based on typical use failure rates: no method or low effectiveness (>10% failure), moderate effectiveness (>1% and <10% failure), and high effectiveness (<1% failure). The short-form RC scale was used to categorize RC experiences: no RC, verbal only, or behavioral. We conducted multinomial logistic regression to examine the association between types of RC and effectiveness level of current contraceptive method, taking our sampling design into account and adjusting for covariates. Results: Among 240 women (weighted n = 6529) included in the sample, 13.9% reported experiencing only verbal RC, and 16.1% reported behavioral RC. Women who reported behavioral RC were more likely to currently be using highly versus moderately (adjusted relative risk ratio [aRRR]: 26.71, 95% confidence interval [CI]: 4.59-156.0) and low effective methods (aRRR: 3.08, 95% CI: 0.97-9.82), but less likely to be using moderately (aRRR: 0.12, 95% CI: 0.02-0.77) than low effective methods. Conclusions: Using highly and low effective methods may indicate two opposing ways of managing behavioral RC experiences: controlling fertility by choosing less detectable but highly effective methods or feeling disempowered and using no or low effective partner-dependent methods.

Family factors associated with emerging adults' human papillomavirus vaccine behavior.

Objective: The current study examined the role of family influences on the vaccine behavior of emerging adults. Participants: In Spring 2017, we conducted anonymous online surveys of undergraduate students (n = 608) at a large, public university in the mid-Atlantic. Methods: Logistic regression was used to examine associations between family factors and students' awareness of the HPV vaccine, vaccine receipt, and vaccine intentions. Family factors included sex communication, religiosity, parental monitoring, family structure, and parents' birthplace. Results: More comprehensive family sex communication is associated with less uncertainty regarding HPV vaccine receipt and greater likelihood of being already vaccinated. More frequent family religiosity and more parental monitoring are associated with greater likelihood of having decided against vaccination rather than already being vaccinated. Significant gender and racial disparities exist. Conclusion: Further research, policy, and programmatic intervention are needed to reduce disparities and to improve emerging adults' compliance with HPV vaccine recommendations.

Exploring gender differences in the association between young African American mothers' reports of preschoolers' violence exposure and problem behavior.

The prevalence of children's violence exposure, particularly among ethnic minorities living in urban areas, is troubling. Gender differences in the rates and effects of violence exposure on behavior have been found for older children, and the current study extends this research to preschool-age children. We draw on data collected from a sample of 3- to 5-year-olds born to 230 adolescent African American mothers living in Washington, DC. Girls and boys were exposed to comparable levels of witnessed and directly experienced violence. In contrast to findings from studies of older children, preschool-age boys' and girls' externalizing and internalizing behavior were comparably associated with directly experienced and witnessed violence. These findings highlight the importance of further developmental research to differentiate the effects of violence exposure as children grow older.

A Primary Care Intervention to Prevent Repeat Pregnancy Among Teen Mothers.

INTRODUCTION: The purpose of this study is to determine the effectiveness of a patient-centered medical home intervention for teen parent families in reducing rates of unintended repeat pregnancy in the first 2 years postpartum. METHODS: A prospective quasi-experimental evaluation was conducted with 98 African American, low-income, teen mother (aged <20 years) participants who received either the intervention or standard pediatric primary care. All participants completed structured interviews at baseline (child aged 2 months) and at follow-ups 12 and 24 months later. Data were collected from 2011 to 2015. Participants reported number of pregnancies, contraception used at last intercourse, depressive symptoms, and romantic status of the relationship with the baby's father. Analyses were conducted from 2015 to 2017. RESULTS: Logistic regression showed that mothers in the intervention group were half as likely as mothers who received standard pediatric primary care to have a repeat pregnancy within 2 years (OR=0.55, p=0.16). The main effect of the intervention on lower rates of repeat pregnancy was mediated by higher rates of contraceptive use. Depression was associated with higher odds of repeat pregnancy, but did not appear to mediate the intervention effect. CONCLUSIONS: This comprehensive and integrated model of care for teen parents may be an effective method to prevent rapid repeat pregnancies in this vulnerable population.

Improving Mental Health Access for Low-Income Children and Families in the Primary Care Setting.

Poverty is a common experience for many children and families in the United States. Children <18 years old are disproportionately affected by poverty, making up 33% of all people in poverty. Living in a poor or low-income household has been linked to poor health and increased risk for mental health problems in both children and adults that can persist across the life span. Despite their high need for mental health services, children and families living in poverty are least likely to be connected with high-quality mental health care. Pediatric primary care providers are in a unique position to take a leading role in addressing disparities in access to mental health care, because many low-income families come to them first to address mental health concerns. In this report, we discuss the impact of poverty on mental health, barriers to care, and integrated behavioral health care models that show promise in improving access and outcomes for children and families residing in the contexts of poverty. We also offer practice recommendations, relevant to providers in the primary care setting, that can help improve access to mental health care in this population.

The Role of Teen Mothers' Support Relationships in Maintenance of Contraceptive Use.

STUDY OBJECTIVE: To explore interpersonal factors associated with maintaining contraceptive use over time among urban, African American teen mothers. DESIGN: Longitudinal study, 2011-2015. SETTING: Six pediatric primary care sites in the same city, all of which primarily serve urban, low-income, African American families. PARTICIPANTS: Teen mothers accessing health services for their child at one of the six study sites. INTERVENTIONS: The current study was a secondary data analysis of data that were collected as part of a patient-centered medical home model intervention, that compared a group of teen mothers and their children who were participants in the intervention with mother-child dyads who were enrolled in standard community-based pediatric primary care. Structured interviews were conducted with teen mothers at baseline/enrollment, when their children were, on average, 3 months old, and again 12 months later. MAIN OUTCOME MEASURES: Maintenance of contraceptive use over time. RESULTS: Teen mothers who perceived any tangible support from their own mothers were significantly less likely to maintain contraceptive use over time (adjusted odds ratio [AOR] = .27). However, teens who perceived any emotional support from their own mothers were nearly four times more likely to maintain contraceptive use (AOR = 3.74). Teens who lived with their own mothers were more than 5 times more likely to maintain contraceptive use over time (AOR = 5.49). CONCLUSION: To better understand contraceptive discontinuation and thus to prevent repeat pregnancies among teen mothers, it might be necessary to further examine the role of support relationships in teen mothers' contraceptive decision-making. Secondary pregnancy prevention programs should include key support persons.

The use of AAP-recommended disciplinary practice guidelines among African American caregivers of children in Head Start programs.

OBJECTIVE: The American Academy of Pediatrics (AAP) recommends that parents not use harsh disciplinary practices. Previous studies have characterized the disciplinary practices of African American parents as harsh, with reliance on more aggressive techniques not currently recommended by the AAP. However, recent research has indicated more disciplinary practice diversity among African Americans. This study describes factors associated with the use of AAP-recommended disciplinary practices among lower-income African American caregivers of children in Head Start. METHODS: Subjects were caregivers of children at three Head Start sites. Participants were eligible for inclusion if the biological mother, biological father, or target child was identified as African American. Using consensus methods, responses to the Parental Discipline Methods Interview (PDMI) were described as consistent or inconsistent with AAP guidelines regarding use of negative disciplinary practices (e.g., spanking, yelling). Caregivers avoiding any of these inconsistent methods were referred to as "adherent." RESULTS: "Adherent" caregivers were older (32.5 years vs. 30.4 years) and had more education (86.0% vs. 75.4% high school graduates). They were also less likely to report that their child had behavioral problems (12.9% vs. 25.2%) or deficient social skills (1.7% vs. 8.0%). CONCLUSIONS: Lower-income African American caregivers were more likely to use disciplinary practices consistent with AAP guidelines if they had higher levels of education and were living in an urban setting. Caregivers describing their child as having fewer behavior problems, better social skills, or themselves as less stressed were also more likely to be "adherent."

Improved Contraceptive Use Among Teen Mothers in a Patient-Centered Medical Home.

PURPOSE: The Generations program, a patient-centered medical home, providing primary medical care, social work, and mental health services to teen mothers and their children, offers a promising approach to pregnancy prevention for teen mothers. This study tested whether the Generations intervention was associated with improved rates of contraceptive and condom use among participants 12 months after program entry. METHODS: This study compared teen mothers enrolled in Generations to those receiving standard community-based pediatric primary care over 12 months. Participants included African-American mothers ages 19 and younger, with infants under 6 months, living in Washington DC. A total of 83% of the baseline sample (150 mother-child dyads) was retained at follow-up. RESULTS: Generations participants had over three times the odds of contraceptive use, with an odds ratio (OR) of 3.35, and twice the odds of condom use (OR = 2.29) after 12 months, compared to participants receiving standard pediatric care. The odds remained comparable and significant when adjusting for differences in baseline use. Once additional covariates were entered into the model, the association was reduced to OR = 2.59 because being in a relationship with the baby's father was significantly associated with reduced contraceptive use. The same pattern was evident for condom use. Mothers in Generations had steady use of contraceptives over time, but there was a decline in use among comparison mothers, indicating that Generations prevented contraceptive discontinuation. CONCLUSIONS: Findings from this study suggest that the Generations program is an effective intervention for improving contraceptive use among teen mothers, a group at especially high risk for pregnancy.

Mental health service use in a community head start population.

BACKGROUND: Evaluating access to and delivery of mental health services for young children was a primary objective of the national research demonstration program Starting Early Starting Smart (SESS). OBJECTIVE: To present preliminary findings on family mental health and use of services in a community Head Start population at time of entry into a longitudinal study as part of the SESS program. SUBJECTS: Children enrolled for Head Start entry in 1998 and 1999 (N = 290; mean age, 4.3 years). Of these children, 52% were boys. METHODS: Data on demographic factors, child and parent mental health, and service use were collected from the sample at baseline. Information was gathered from primary caregivers and teachers using standardized questionnaires and structured interviews. RESULTS: There was low concordance between parent and teacher ratings of child behavior. Factors predicting behavior problems in young children varied according to whether the parent or teacher rated the child as having behavior problems. Sex (male) and home environment were associated with teachers rating the child as having a behavior problem. Parent mental health problems and problems in the parent-child relationship were associated with parent ratings. Only home environment was associated with child-focused service utilization (services that help parents manage children's behavior). CONCLUSIONS: Demographic risk factors were not associated with child behavior problems or use of mental health services in this group of Head Start children. Findings suggest that children with behavioral problems have unmet mental health service needs. Interventions designed to address both parent mental health needs and sensitivity to the developmental needs of children may increase child-focused mental health service utilization.