- Email: [email protected]
A comparison of the psychological resources of adolescents at low and high risk of mistreating their children
ORIGINAL ARTICLE
PH C ABSTRACT Objective: Our objective was to compare the psychological resources of pregnant teenagers who are at low and high risk for mistreating their children. Method: We studied 71 participants in a comprehensive, adolescentoriented maternity program. During the prenatal period, the Family Stress Checklist was used to quantify child abuse potential, with scores ≥25 defining high risk. Information about the social context of the pregnancy and maternal psychological resources was obtained with selfadministered questionnaires. A composite psychological resource variable was computed by summing the z scores for intelligence, mental health, and mastery, with scores ≤0 defining the low-resource group. Results: Of the 71 teenagers, 26 (36.6%) were classified as high risk for child abuse and neglect. Compared with low-risk teens, highrisk teens had more behavioral problems, lower psychological resource scores (mean ± SD of z score: –0.98 ± 2.02 compared with 0.39 ± 1.79; P = .004), and were more likely to have low psychological resources (69.2% compared with 44.4%; P = .04). Conclusions: Pregnant teenagers who are at risk for child abuse and neglect exhibit fewer psychological resources than their low-risk peers do, and may therefore benefit preferentially from intensive, in-home intervention. J Pediatr Health Care. (2001). 15, 299-303.
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A Comparison of the Psychological Resources of Adolescents at Low and High Risk of Mistreating Their Children C a t h e r i n e S t e ve n s - S i m o n , M D, & Jo a n B a r r e t t , N P
W
omen who begin childbearing during their teens are overrepresented in child maltreatment and abandonment cases (Flanagan, Coll, Andreozzi, & Riggs, 1995; Flanagan, McGrath, Meyer, & Garcia-Coll, 1995; Stevens-Simon, Nelligan, & Kelly, 2001; Stevens-Simon & Reichert, 1994; Stier, Leventhal, Berg, Johnson, & Mezger, 1993; Zuravin, 1988). However, most adolescent parents do not abuse or neglect their children (Flanagan, Coll, et al., 1995; Flanagan, McGrath, et al., 1995; Stevens-Simon et al., 2001; Stevens-Simon & Reichert, 1994; Stier et al., 1993; Zuravin, 1988). The feasibility of predicting dysfunctional parenting practices during the prenatal and early postpartum periods has been investigated (Brayden et al., 1993; Gray, Cutler, Dean, & Kempe, 1979; Karoly, Greenwood, & Everingham, 1998; Korfmacher, 2000; Lealman, Haigh, Phillips, Stone, & Ord-Smith, 1983; Leventhal, Garber, & Brady, 1989; Murphy, Orkow, & Nicola, 1985; Olds & Henderson, 1989; Stevens-Simon & Nelligan, 1998; Wissow, 1995; Zuravin, 1988). Although the results of these studies suggest that it is possible for clinicians to use information obtained prenatally and during the Catherine Stevens-Simon is Associate Professor of Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, University of Colorado Health Sciences Center, The Children’s Hospital, Denver, Colo. Joan Barrett is Instructor of Nursing/Supervisor Trainer, Department of Pediatrics, Division of Adolescent Medicine, University of Colorado Health Sciences Center, The Children’s Hospital, Denver, Colo. Reprint requests: Catherine Stevens-Simon, MD, Department of Pediatrics, Division of Adolescent Medicine, University of Colorado Health Science Center, The Children’s Hospital, 1056 East 19th St, Denver, CO 80218. Copyright © 2001 by the National Association of Pediatric Nurse Practitioners. 0891-5245/2001/$35.00 + 0
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PH ORIGINAL ARTICLE C puerperium to identify parents who are at risk for mistreating their children, the specificity and negative predictive value of these predictions exceeds their sensitivity and positive predictive value (Brayden et al., 1993; Gray et al., 1979; Karoly et al., 1998; Korfmacher, 2000; Lealman et al., 1983; Leventhal et al., 1989; Murphy et al., 1985; Olds & Henderson, 1989; Stevens-Simon & Nelligan, 1998; Wissow, 1995; Zuravin, 1988). Nevertheless, the consensus is that concerns about overdiagnosis resulting in the mislabeling of healthy families as dysfunctional or potentially abusive should be tempered by awareness that the most serious, life-threatening forms of abuse can be predicted with greater accuracy than milder forms of neglect (Brayden et al., 1993; Korfmacher, 2000; Lealman et al., 1983; Leventhal et al., 1989; Olds & Henderson, 1989; Stevens-Simon & Nelligan, 1998; Wissow, 1995). Thus the current recommendation is that available screening tools be used as part of a comprehensive evaluation of a family’s need for additional abuse prevention services (Korfmacher, 2000). Within this context, the results of a previous study conducted at the University of Colorado Health Sciences Center demonstrate that one widely accepted risk-assessment tool, the Family Stress Checklist, helps health care and social service providers identify pregnant adolescents who are most likely to mistreat and abandon their infants and toddlers (StevensSimon, Nelligan, & Kelly, 2001). The Stress Checklist, a brief, 10-item questionnaire, was originally developed to guide and ensure the completeness of interviews conducted by health care and social service providers who wish to assess the abuse potential of families in their practices (Korfmacher, 2000). Although not originally intended to predict maltreatment, Murphy et al. (1985) demonstrated that the Family Stress Checklist did so, with a specificity of 89.4% (yielding a negative predictive value of 96.8%) and a sensitivity of 80% (yielding a positive predictive value of 52%). More recently, it was demonstrated that pregnant teenagers with high scores on the Family Stress Checklist were 8.41 (95% CI: 1.77 to 40.01) times more likely to mistreat their l-year-olds and 5.19 (95%
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CI: 1.99 to 13.60) times more likely to mistreat their 2-year-olds than were their lower scoring peers (Stevens-Simon et al., 2001). Taken together, these findings indicate that, at a minimum, the Family Stress Checklist facilitates the identification of a subgroup of adolescents and adults whose propensity for mistreating their children suggests the need for more intensive support services than those offered in most primary pediatric health care settings.
O
ne widely accepted
risk-assessment tool, the Family Stress Checklist, helps health care and social service providers identify pregnant adolescents who are most likely to mistreat and abandon their infants and toddlers.
Interventions designed to prevent child abuse have usually failed to do so (Brayden et al., 1993; Gray et al., 1979; Karoly et al., 1998; Korfmacher, 2000; Lealman et al., 1983; Leventhal et al., 1989; Olds & Henderson, 1989; Olds, Hill, Robinson, Song, & Little, 2000; Stevens-Simon & Nelligan, 1998; Wissow, 1995). However, studies conducted during the past two decades clearly identify the Pregnancy and Early Childhood Nurse Home Visitation Program as an exception (Kitzman et al., 1997; Olds et al., 1997; Olds, Henderson, Chamberlin, & Tatelbaum, 1986; Olds et al., 2000). First in Elmira, New York, then in Memphis, Tennessee, and most recently in Denver, Colorado, Olds and colleagues demonstrated that this intensive home-based intervention improves the safety of the home environ-
ment, decreases utilization of health care services for injuries and ingestions, improves the quality of mother-child interactions, reduces maternal self-reported use of harsh disciplinary strategies, promotes the use of educationally stimulating toys in the home, and reduces substantiated cases of child abuse (Kitzman et al., 1997; Olds et al., 1997; Olds et al., 1986; Olds et al., 2000). However, even within sociodemographically at-risk populations, the benefits of the Nurse Home Visitation Program have not been evenly distributed across all participants (Kitzman et al., 1997; Olds et al., 1997; Olds & Henderson, 1989; Olds et al., 2000; Olds & Korfmacher, 1998). Rather, positive program effects have consistently been concentrated within families headed by women who exhibit the fewest intrinsic psychological resources, the least sense of control over their lives, and the poorest social support (Kitzman et al., 1997; Olds et al., 1997; Olds & Henderson, 1989; Olds et al., 2000; Olds & Korfmacher, 1998). Because the Pregnancy and Early Childhood Nurse Home Visitation Program is costly and provides little benefit to the broader population (Kitzman et al., 1997; Olds et al., 1997; Olds & Henderson, 1989; Olds et al., 2000; Olds & Korfmacher, 1998), we compared the psychological resources of pregnant teenagers deemed to be at low and high risk for child abuse and neglect. Our goal was to determine if the high-risk cohort identified by the Family Stress Checklist exhibited a level of socioemotional functioning that is associated with positive Nurse Home Visitation Program effects.
METHODS Subjects The study sample consisted of 71 racially and ethnically diverse (42.3% White, 23.9% Black, 29.6% Hispanic, 4.2% other races), consecutively interviewed, poor (88.7% were Medicaid recipients), predominantly nulliparous (81.7%), unmarried (93%), pregnant, 14- through 19-year-olds (mean ± SD: 17.2 ± 1.4 years). At conception most of the young women who participated in the study lived with a supportive adult (64.8%; 46.5% lived with at least one biologic parent), were emotionally involved with the father of
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PH ORIGINAL ARTICLE C their child (70.4%; 35.2% of the couples were co-habitating), and were enrolled in school (54.9%). The study was approved by the Institutional Review Board at the University of Colorado Health Sciences Center.
Setting All of the study participants were patients in the Colorado Adolescent Maternity Program (CAMP), a comprehensive, multidisciplinary prenatal, delivery, and postnatal care program located in a large, urban, teaching hospital (Stevens-Simon, Kelly, & Kulick, 2000; Stevens-Simon et al., 2001). Briefly, the program integrates the professional services of health care providers trained in obstetrics, pediatrics, and adolescent medicine, a social worker, and a dietician. The goal is to reduce the incidence of adverse pregnancy outcomes and repeat teen pregnancies and to increase the number of young mothers and fathers who graduate from high school and become productive members of their communities and nurturing, nonabusive parents.
Data Collection and Definition of Variables As part of the enrollment procedure, all CAMP prenatal patients meet with a social worker and complete a precoded, self-administered, multiple choice questionnaire. The Family Stress Checklist (Murphy et al., 1985) is administered during the initial social worker assessment. To this end, specific questions designed to elicit information bearing on the 10 checklist items are interspersed in the intake interview. Each item of the Family Stress Checklist is scored as 0, no risk; 5, risk; and 10, high risk, and the 10 items are summed to yield a total scale score ranging from 0 to 100. The reliability (r = 0.93) and construct validity for the Family Stress Checklist have been established (Karoly et al., 1998; Korfmacher, 2000; Murphy et al., 1985). Studies of hospital and state child maltreatment records and studies comparing Family Stress Checklist scores with scores on other measures of child abuse potential have consistently demonstrated that high scores on the Family Stress Checklist are related to increased rates of abuse, increased potential for child abuse, and increased parenting difficulties (Karoly et al., 1998; Korf-
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macher, 2000; Murphy et al., 1985). However, the predictive validity of a high Family Stress Checklist score for individuals remains in question. Validity studies indicate that, like other scales of this type, the Family Stress Checklist overestimates the number of parents who may maltreat their children (Brayden et al., 1993; Korfmacher, 2000). The cutoff points on the Family Stress Checklist used to define “highrisk” parents were initially developed through clinical judgement, with scores of 25 or more (corresponding to approximately upper 40% of the population distribution) considered to be of concern and those of 40 or more (corresponding to approximately upper 10% of the population distribution) considered high risk for child abuse (Korfmacher, 2000; Murphy et al., 1985). Based on the results of our own stud-
T
he high-risk teenagers
were more apt than their low-risk peers to have been abused as children.
ies and those of other investigators, pregnant teenagers who scored 25 or higher on the Family Stress Checklist were classified as being at risk for dysfunctional parenting (Karoly et al., 1998; Korfmacher, 2000; Murphy et al., 1985; Stevens-Simon et al., 2001). Although using the higher cutoff (eg, a score of 40 or more) would have improved the specificity of our abuse predictions, it would have done so at the expense of a much larger loss of sensitivity (Korfmacher, 2000; Murphy et al., 1985), a disadvantageous tradeoff for this study. The intake questionnaire was written at a fourth-grade reading level and took approximately 20 minutes to complete. It collected information about the social context of the pregnancy, with emphasis on common demographic, psychosocial, and behavioral risk factors for dysfunctional parenting (Stevens-Simon et al., 2000; StevensSimon et al., 2001). The specific vari-
ables examined as potential confounders of the relationship between the Family Stress Checklist score and maternal psychological resources were identified a priori from a review of the adolescent parenting and child maltreatment literatures (Brayden et al., 1993; Flanagan et al., 1995; Flanagan, McGrath, et al., 1995; Kitzman et al., 1997; Murphy et al., 1985; Olds et al., 1997; Olds et al., 2000; Stevens-Simon et al. 2001; Stevens-Simon & Lowy, 1995; Stevens-Simon & Nelligan, 1998; Stevens-Simon et al., 2000; StevensSimon & Reichert, 1994; Stevens-Simon & White, 1991; Wissow, 1995; Zuravin, 1988). Specifically, the variables of interest included the following: • Sociodemographic factors such as age, race, and type of health insurance • Psychosocial factors such as living arrangements, school enrollment, involvement in socially problematic behaviors (fighting, delinquency, and illicit substance abuse, assessed by history and periodic urine toxicology screening), past or present physical or sexual abuse, suicide attempts, depression/stress (defined by the Center for Epidemiologic Studies–Depression scale and a checklist of negative life events adapted from Newton’s list of psychosocial stressors in pregnancy [Newton, Webster, Binu, Maskrey, & Phillips, 1979; Radloff, 1977; Stevens-Simon & McAnarney, 1995]), lack of support from adults (Flanagan, Coll, et al., 1995) and prime people (eg, their mother or the baby’s father [Barnet, Joffe, Duggan, Wilson, & Repke, 1996]), and inadequate family support (defined by the Family Apgar Scale [Smilkstein, Ashworth, & Montano, 1982]) • The degree to which the pregnancy was wanted (Stevens-Simon, Kelly, Singer, & Nelligan, 1998) Prospective participants were approached while they were waiting to be seen in the prenatal clinic. There were almost no refusals; however, some potential participants were probably missed because of time constraints. Written consent for participation was obtained from those who agreed to spend 10 to 15 minutes completing the 3 additional questionnaires needed to compute the Nurse Home Visitation Psychological Resource Index. Because sociodemographic characteristics by themselves provide little information
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when the outcome variable was continuous and Chi-square analyses when the outcome variable was categorical. All statistical analyses were performed with SPSS/PC+ (Nie, Hull, & Jenkins, 1989).
appointments, respectively; P = .004). These differences were not unanticipated, because parents receive points on the Family Stress Checklist for living in chaotic, unsupportive environments and engaging in antisocial behaviors. The two study groups also differed significantly with regard to psychological resources (Table). The high- and low-risk adolescents had similar intelligence quotient scores, but members of the high-risk group scored significantly lower than did members of the low-risk group on the mastery and affect scales. As a result, the high-risk cohort’s composite psychological resources score was significantly lower than that of the low-risk cohort. Indeed, 18 (69.2%) of the 26 high-risk teenagers had a psychological resource score ≤0, compared with only 20 (44.4%) of the 45 low-risk teenagers (χ2 ratio = 4.15; P = .04).
RESULTS
DISCUSSION
Scores on the Family Stress Checklist ranged from 0 to 50 (mean ± SD = 20.1 ± 10.5). The high-risk group included 26 (36.6%) of the 71 teenagers; their Checklist scores ranged from 25 to 50 (mean ± SD = 31.2 ± 7.4). The remaining 45 teenagers made up the low-risk group; their Checklist scores ranged from 0 to 20 (mean ± SD = 13.8 ± 5.5). The distribution of Checklist scores was almost identical to the one obtained in a prior study of this population (Stevens-Simon et al., 2001). This finding suggests that the teenagers who participated in this small study were representative of the larger CAMP clinic population from which they were drawn. The high- and low-risk teenage mothers did not differ significantly with regard to age, race, living arrangements, school status, the proportion of wanted pregnancies, or the timing of the first prenatal visit. However, the high-risk teenagers were more apt than their low-risk peers to have been abused as children (61.5% compared with 15.6%; χ2 ratio = 15.89; P < .0001 ), to have engaged in socially problematic behaviors in the past (69.2% compared with 31.1%; χ2 ratio = 9.84; P = .002), to report that food shortages at home limited their caloric intake during gestation (34.6% compared with 11.6%; χ2 ratio = 4.11; P = .04), and to miss prenatal appointments (attending 83.4% and 92.6% of their scheduled
The Family Stress Checklist can help prenatal health care and social service providers systematically identify a subgroup of pregnant adolescents and adults who are at increased risk for mistreating their children (Korfmacher, 2000; Murphy et al., 1985; StevensSimon et al., 2001). The Family Stress Checklist is a particularly attractive risk-assessment tool for clinicians because it has a high specificity and negative predictive value and because it was initially designed to guide treatment planning (Korfmacher, 2000). It therefore focuses on the identification of potentially remediable antecedents of dysfunctional parenting (Gray et al., 1979; Korfmacher, 2000; Murphy et al., 1985; Stevens-Simon & Nelligan, 1998). Most other abuse prediction scales focus on the identification of static sociodemographic characteristics, which do not include inherent mechanisms that necessarily compel parents to mistreat their children and therefore tend to be predictive of abuse in one setting but not in others (Brayden et al., 1993; Leventhal et al., 1989; Stevens-Simon & Nelligan, 1998). However, from the clinical standpoint, the value of this screening tool depends not only on its specificity, but also on what can be done to reduce the risk associated with a positive screening result. Within this context, home visiting is hypothesized to reduce the risk of child abuse and neglect directly by pro-
TABLE Group differences in psychological resources z scores Scale
Intelligence (mean ± SD) Affect (mean ± SD) Mastery (mean ± SD) Composite score (mean ± SD)§
High risk (N = 26)
Low risk (N = 45)
–0.18 ± 1.0 –0.47 ± 1.14 –0.32 ± 0.89 –0.98 ± 2.02
0.12 ± 0.82 0.14 ± 0.84† 0.13 ± 1.00* 0.39 ± 1.79‡
*P = .05. †P = .02. ‡P = .004. §Sum of the z scores obtained from the Shipley-Hartford test of intelligence, the RAND Corporation Mental Health Depression Scale, and the Pearlin Mastery Scale.
about individual differences in competency, Olds and colleagues created a composite variable (based on an assessment of intelligence, affect, and sense of mastery or control over life events) to index women’s psychological resources (Kitzman et al., 1997; Olds & Henderson, 1989; Olds & Korfmacher, 1998). The Nurse Home Visitation Psychological Resource Index is not a predictive scale and, therefore, has no intrinsic psychometric properties. However, it is computed by summing the z scores obtained from the following 3 scales, the reliability and construct and predictive validity of which are well established and widely accepted: (a) intelligence (this parameter is assessed by the Shipley-Hartford test, reliability coefficient 0.92 [Shipley, 1940] and validity coefficient 0.77 [Sines, 1958]); (b) mental health (this parameter is assessed by the 9-item RAND Corporation Mental Health Depression Scale [Cronbach α = .83 to .88] [Olds, unpublished; Ware, Veit, & Donald, 1985]) and (c) mastery (this parameter is assessed by the scale developed by Pearlin and Schooler [1967], [Cronbach α = .67, factor loading for the original instrument produced comparable results] [Olds, unpublished; Pearlin & Schooler, 1967]). For categorical analyses, the composite score was dichotomized at 0 because women who score below this level derive the most benefit from the Nurse Home Visitation Program (Kitzman et al., 1997; Olds & Korfmacher, 1998).
Data Analysis Summary statistics were used to describe the study population. Comparisons between the two abuse-risk groups were conducted with student t tests
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PH ORIGINAL ARTICLE C moting the use of nonviolent, ageappropriate childrearing techniques and environmental safety and indirectly by enhancing parental emotional well-being and life course development (American Academy of Pediatrics, 1998; Olds et al., 1997; Olds & Henderson, 1989; Olds et al, 2000; US Advisory Board on Child Abuse and Neglect, 1991). However, only one home visitation program, the Pregnancy and Early Childhood Nurse Home Visitation Program, has proven efficacious in randomized controlled trials, and then only for women who possess minimal intrinsic psychological resources (Kitzman et al., 1997; Olds et al., 1997; Olds et al., 2000; Olds & Korfmacher, 1998). Because both the implementation and effects of the Nurse Home Visitation Program are conditioned by the mother’s level of socioemotional functioning (Kitzman et al., 1997; Olds et al., 1997; Olds et al., 2000; Olds & Korfmacher, 1998), the results of this study suggest that incorporating this highly successful home visitation program into CAMP’s already intensive, clinic-based services might be a costeffective way to prevent child abuse and neglect in the easily identifiable subgroup of adolescent mothers who are at high risk for mistreating and abandoning their children. Studies are underway to test this hypothesis. We thank Grace Cisneros and the staff and patients of the Colorado Adolescent Maternity Program for their participation in this study and their help with data collection.
REFERENCES American Academy of Pediatrics. (1998). The role of home-visitation programs in improving health outcomes for children and families. Pediatrics, 101, 486-489. Barnet, B., Joffe, A., Duggan, A., Wilson, M., & Repke, J. (1996). Depressive symptoms, stress, and social support in pregnant and postpartum adolescents. Archives of Pediatrics & Adolescent Medicine, 150, 64-69. Brayden, R., Altemeier, W., Dietrich, M., Tucker, D., Christensen, M., McLaughlin, J., & Sherrod, K. (1993). A prospective study of secondary prevention of child maltreatment. Journal of Pediatrics, 122, 511-516. Flanagan, P., Coll, C. G., Andreozzi, L., & Riggs, S. (1995). Predicting maltreatment of children of teenage mothers. Archives of Pediatrics and Adolescent Medicine, 149, 451-455.
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Flanagan, P., McGrath, M., Meyer, E., & Garcia-Coll, C. (1995). Adolescent development and transitions to motherhood. Pediatrics, 96, 273-277. Gray, J. D., Cutler, C. A., Dean, J. G., & Kempe, C. H. (1979). Prediction and prevention of child abuse and neglect. Journal of Social Issues, 35, 127-139. Karoly, L. A., Greenwood, P. W., & Everingham, S. S. (1998). Investing in our children: What we know and don’t know about the costs and benefits of early childhood interventions. Santa Monica, CA: Rand Corporation. Kitzman, H., Olds, D. L., Henderson, C. R., Hanks, C., Cole, R., Tatelbaum, R., McConnochie, K. M., Sidora, K., Luckey, D. W., Shaver, D., Engelhardt, K., James, D., & Barnard, K. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeat childbearing: a randomized controlled trial. Journal of the American Medical Association, 278, 644-652. Korfmacher, J. (2000). The Kemp Family Stress Inventory: A review. Child Abuse & Neglect, 24, 129-140. Lealman, G., Haigh, D., Phillips, J., Stone, J., & OrdSmith, C. (1983). Prediction and prevention of child abuse—an empty hope? Lancet, 1, 14231424. Leventhal, J. M., Garber, R. B., & Brady, C. A. (1989). Identification during the postpartum period of infants who are at high risk of child maltreatment. Journal of Pediatrics, 114, 481487. Murphy, S., Orkow, B., & Nicola, R. M. (1985). Prenatal prediction of child abuse and neglect: A prospective study. Child Abuse and Neglect, 9, 225-235. Newton, R. W., Webster, P. A. C., Binu, P. S., Maskrey, N., & Phillips, A. B. (1979). Psychosocial stress in pregnancy and its relation to the onset of premature labour. Br Med J, 2, 411-413. Nie, N. H., Hull, C. H., & Jenkins, J. G. (1989). Statistical Package for the Social Sciences, 3rd edition (SPSSX). New York: McGraw-Hill. Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., Sidora, K., Morris, P., Pettitt, L. M., & Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: 15year follow-up of a randomized trial. Journal American Medical Association, 278, 637-643. Olds, D. L., Henderson, C. R., Chamberlin, R., & Tatelbaum, R. (1986). Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics, 78, 65-78. Olds, D. L., & Henderson, C. R. (1989). The prevention of maltreatment. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment—theory and research on the causes and consequences of child abuse and neglect (pp. 722-763). New York: Cambridge University Press. Olds, D., Hill, P., Robinson, J. A., Song, N., & Little, C. (2000). Update on home visiting from pregnant women and parents of young children. Current Problems in Pediatrics, 30, 109-147. Olds, D. L., & Korfmacher, J. (1998). Maternal psychological characteristics as influences on home visitation contact. Journal of Community Psychology, 26, 23-36.
Pearlin, L. I., & Schooler, C. (1967). The structure of coping. Journal of Health Social Behavior, 19, 2-21. Radloff, L. (1977). The CES-D scale: A self-report depression scale for research in the general population. Journal of Applied Psychologic Measures, 1, 385-401. Shipley, W. (1940). A self-administered scale for measuring intellectual impairment and deterioration. Journal of Psychology, 9, 371-377. Sines, L. (1958). Intellectual test correlates of Shipley-Hartford performance. Journal of Clinical Psychology, 14, 399-404. Smilkstein, G., Ashworth, C., & Montano, D. (1982). Validity and reliability of the Family APGAR as a test of family function Journal of Family Practice, 15, 309-311. Stevens-Simon, C., Kelly, L., & Kulick, R. (2000). A village would be nice but it takes a long-acting contraceptive to prevent repeat adolescent pregnancies. Pediatric Research, 47, 13A. Stevens-Simon, C., Kelly, L. S., Singer, D., & Nelligan, D. (1998). Reasons for first teen pregnancies predict the rate of subsequent teen conceptions. Pediatrics, 101, e8. Stevens-Simon, C., & Lowy, R. (1995). Is teenage childbearing an adaptive strategy for the socioeconomically disadvantaged or a strategy for adapting to socioeconomic disadvantage? Archives of Pediatrics and Adolescent Medicine, 149, 912-915. Stevens-Simon, C., & McAnarney, E. R. (1995). Change in depressive symptoms during pregnancy: Relationship to birth outcome. Journal of Pediatrics and Adolescent Gynecology, 8, 29-33. Stevens-Simon, C., & Nelligan, D. (1998). Identification and treatment of adolescent parents at risk for child abuse in a comprehensive adolescent-oriented maternity program. Aggressive & Violent Behavior, 3, 197-217. Stevens-Simon, C., Nelligan, D., & Kelly, L. (2001). Adolescents at risk for mistreating their children (in press, Child Abuse & Neglect). Stevens-Simon, C., & Reichert, S. (1994). Child sexual abuse and adolescent pregnancy. Archives of Pediatrics and Adolescent Medicine, 148, 23-27. Stevens-Simon, C., & White, M. (1991). Adolescent pregnancy. Pediatric Annals, 20, 322-331. Stier, D. M., Leventhal, J. M., Berg, A. T., Johnson, L., & Mezger, J. (1993). Are children born to young mothers at increased risk of maltreatment? Pediatrics, 91, 642-648. US Advisory Board on Child Abuse and Neglect. (1991). Creating caring communities. Blueprint for an effective federal policy on child abuse and neglect. Washington, DC: US Department of Health and Human Services, Administration for Children and Families. Ware, J. E., Veit, C. T., & Donald, C. A. (1985). Refinements in the measurement of mental health for adults in the health insurance study. Santa Monica, CA: Rand Corporation. Wissow, L. S. (1995). Child abuse and neglect. New England Journal of Medicine, 332, 1425-1431. Zuravin, S. J. (1988). Child maltreatment and teenage first births: A relationship mediated by chronic sociodemographic stress? American Journal of Orthopsychiatry, 58, 91-103.
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PH C ABSTRACT Objective: Our objective was to compare the psychological resources of pregnant teenagers who are at low and high risk for mistreating their children. Method: We studied 71 participants in a comprehensive, adolescentoriented maternity program. During the prenatal period, the Family Stress Checklist was used to quantify child abuse potential, with scores ≥25 defining high risk. Information about the social context of the pregnancy and maternal psychological resources was obtained with selfadministered questionnaires. A composite psychological resource variable was computed by summing the z scores for intelligence, mental health, and mastery, with scores ≤0 defining the low-resource group. Results: Of the 71 teenagers, 26 (36.6%) were classified as high risk for child abuse and neglect. Compared with low-risk teens, highrisk teens had more behavioral problems, lower psychological resource scores (mean ± SD of z score: –0.98 ± 2.02 compared with 0.39 ± 1.79; P = .004), and were more likely to have low psychological resources (69.2% compared with 44.4%; P = .04). Conclusions: Pregnant teenagers who are at risk for child abuse and neglect exhibit fewer psychological resources than their low-risk peers do, and may therefore benefit preferentially from intensive, in-home intervention. J Pediatr Health Care. (2001). 15, 299-303.
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W
omen who begin childbearing during their teens are overrepresented in child maltreatment and abandonment cases (Flanagan, Coll, Andreozzi, & Riggs, 1995; Flanagan, McGrath, Meyer, & Garcia-Coll, 1995; Stevens-Simon, Nelligan, & Kelly, 2001; Stevens-Simon & Reichert, 1994; Stier, Leventhal, Berg, Johnson, & Mezger, 1993; Zuravin, 1988). However, most adolescent parents do not abuse or neglect their children (Flanagan, Coll, et al., 1995; Flanagan, McGrath, et al., 1995; Stevens-Simon et al., 2001; Stevens-Simon & Reichert, 1994; Stier et al., 1993; Zuravin, 1988). The feasibility of predicting dysfunctional parenting practices during the prenatal and early postpartum periods has been investigated (Brayden et al., 1993; Gray, Cutler, Dean, & Kempe, 1979; Karoly, Greenwood, & Everingham, 1998; Korfmacher, 2000; Lealman, Haigh, Phillips, Stone, & Ord-Smith, 1983; Leventhal, Garber, & Brady, 1989; Murphy, Orkow, & Nicola, 1985; Olds & Henderson, 1989; Stevens-Simon & Nelligan, 1998; Wissow, 1995; Zuravin, 1988). Although the results of these studies suggest that it is possible for clinicians to use information obtained prenatally and during the Catherine Stevens-Simon is Associate Professor of Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, University of Colorado Health Sciences Center, The Children’s Hospital, Denver, Colo. Joan Barrett is Instructor of Nursing/Supervisor Trainer, Department of Pediatrics, Division of Adolescent Medicine, University of Colorado Health Sciences Center, The Children’s Hospital, Denver, Colo. Reprint requests: Catherine Stevens-Simon, MD, Department of Pediatrics, Division of Adolescent Medicine, University of Colorado Health Science Center, The Children’s Hospital, 1056 East 19th St, Denver, CO 80218. Copyright © 2001 by the National Association of Pediatric Nurse Practitioners. 0891-5245/2001/$35.00 + 0
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PH ORIGINAL ARTICLE C puerperium to identify parents who are at risk for mistreating their children, the specificity and negative predictive value of these predictions exceeds their sensitivity and positive predictive value (Brayden et al., 1993; Gray et al., 1979; Karoly et al., 1998; Korfmacher, 2000; Lealman et al., 1983; Leventhal et al., 1989; Murphy et al., 1985; Olds & Henderson, 1989; Stevens-Simon & Nelligan, 1998; Wissow, 1995; Zuravin, 1988). Nevertheless, the consensus is that concerns about overdiagnosis resulting in the mislabeling of healthy families as dysfunctional or potentially abusive should be tempered by awareness that the most serious, life-threatening forms of abuse can be predicted with greater accuracy than milder forms of neglect (Brayden et al., 1993; Korfmacher, 2000; Lealman et al., 1983; Leventhal et al., 1989; Olds & Henderson, 1989; Stevens-Simon & Nelligan, 1998; Wissow, 1995). Thus the current recommendation is that available screening tools be used as part of a comprehensive evaluation of a family’s need for additional abuse prevention services (Korfmacher, 2000). Within this context, the results of a previous study conducted at the University of Colorado Health Sciences Center demonstrate that one widely accepted risk-assessment tool, the Family Stress Checklist, helps health care and social service providers identify pregnant adolescents who are most likely to mistreat and abandon their infants and toddlers (StevensSimon, Nelligan, & Kelly, 2001). The Stress Checklist, a brief, 10-item questionnaire, was originally developed to guide and ensure the completeness of interviews conducted by health care and social service providers who wish to assess the abuse potential of families in their practices (Korfmacher, 2000). Although not originally intended to predict maltreatment, Murphy et al. (1985) demonstrated that the Family Stress Checklist did so, with a specificity of 89.4% (yielding a negative predictive value of 96.8%) and a sensitivity of 80% (yielding a positive predictive value of 52%). More recently, it was demonstrated that pregnant teenagers with high scores on the Family Stress Checklist were 8.41 (95% CI: 1.77 to 40.01) times more likely to mistreat their l-year-olds and 5.19 (95%
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CI: 1.99 to 13.60) times more likely to mistreat their 2-year-olds than were their lower scoring peers (Stevens-Simon et al., 2001). Taken together, these findings indicate that, at a minimum, the Family Stress Checklist facilitates the identification of a subgroup of adolescents and adults whose propensity for mistreating their children suggests the need for more intensive support services than those offered in most primary pediatric health care settings.
O
ne widely accepted
risk-assessment tool, the Family Stress Checklist, helps health care and social service providers identify pregnant adolescents who are most likely to mistreat and abandon their infants and toddlers.
Interventions designed to prevent child abuse have usually failed to do so (Brayden et al., 1993; Gray et al., 1979; Karoly et al., 1998; Korfmacher, 2000; Lealman et al., 1983; Leventhal et al., 1989; Olds & Henderson, 1989; Olds, Hill, Robinson, Song, & Little, 2000; Stevens-Simon & Nelligan, 1998; Wissow, 1995). However, studies conducted during the past two decades clearly identify the Pregnancy and Early Childhood Nurse Home Visitation Program as an exception (Kitzman et al., 1997; Olds et al., 1997; Olds, Henderson, Chamberlin, & Tatelbaum, 1986; Olds et al., 2000). First in Elmira, New York, then in Memphis, Tennessee, and most recently in Denver, Colorado, Olds and colleagues demonstrated that this intensive home-based intervention improves the safety of the home environ-
ment, decreases utilization of health care services for injuries and ingestions, improves the quality of mother-child interactions, reduces maternal self-reported use of harsh disciplinary strategies, promotes the use of educationally stimulating toys in the home, and reduces substantiated cases of child abuse (Kitzman et al., 1997; Olds et al., 1997; Olds et al., 1986; Olds et al., 2000). However, even within sociodemographically at-risk populations, the benefits of the Nurse Home Visitation Program have not been evenly distributed across all participants (Kitzman et al., 1997; Olds et al., 1997; Olds & Henderson, 1989; Olds et al., 2000; Olds & Korfmacher, 1998). Rather, positive program effects have consistently been concentrated within families headed by women who exhibit the fewest intrinsic psychological resources, the least sense of control over their lives, and the poorest social support (Kitzman et al., 1997; Olds et al., 1997; Olds & Henderson, 1989; Olds et al., 2000; Olds & Korfmacher, 1998). Because the Pregnancy and Early Childhood Nurse Home Visitation Program is costly and provides little benefit to the broader population (Kitzman et al., 1997; Olds et al., 1997; Olds & Henderson, 1989; Olds et al., 2000; Olds & Korfmacher, 1998), we compared the psychological resources of pregnant teenagers deemed to be at low and high risk for child abuse and neglect. Our goal was to determine if the high-risk cohort identified by the Family Stress Checklist exhibited a level of socioemotional functioning that is associated with positive Nurse Home Visitation Program effects.
METHODS Subjects The study sample consisted of 71 racially and ethnically diverse (42.3% White, 23.9% Black, 29.6% Hispanic, 4.2% other races), consecutively interviewed, poor (88.7% were Medicaid recipients), predominantly nulliparous (81.7%), unmarried (93%), pregnant, 14- through 19-year-olds (mean ± SD: 17.2 ± 1.4 years). At conception most of the young women who participated in the study lived with a supportive adult (64.8%; 46.5% lived with at least one biologic parent), were emotionally involved with the father of
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PH ORIGINAL ARTICLE C their child (70.4%; 35.2% of the couples were co-habitating), and were enrolled in school (54.9%). The study was approved by the Institutional Review Board at the University of Colorado Health Sciences Center.
Setting All of the study participants were patients in the Colorado Adolescent Maternity Program (CAMP), a comprehensive, multidisciplinary prenatal, delivery, and postnatal care program located in a large, urban, teaching hospital (Stevens-Simon, Kelly, & Kulick, 2000; Stevens-Simon et al., 2001). Briefly, the program integrates the professional services of health care providers trained in obstetrics, pediatrics, and adolescent medicine, a social worker, and a dietician. The goal is to reduce the incidence of adverse pregnancy outcomes and repeat teen pregnancies and to increase the number of young mothers and fathers who graduate from high school and become productive members of their communities and nurturing, nonabusive parents.
Data Collection and Definition of Variables As part of the enrollment procedure, all CAMP prenatal patients meet with a social worker and complete a precoded, self-administered, multiple choice questionnaire. The Family Stress Checklist (Murphy et al., 1985) is administered during the initial social worker assessment. To this end, specific questions designed to elicit information bearing on the 10 checklist items are interspersed in the intake interview. Each item of the Family Stress Checklist is scored as 0, no risk; 5, risk; and 10, high risk, and the 10 items are summed to yield a total scale score ranging from 0 to 100. The reliability (r = 0.93) and construct validity for the Family Stress Checklist have been established (Karoly et al., 1998; Korfmacher, 2000; Murphy et al., 1985). Studies of hospital and state child maltreatment records and studies comparing Family Stress Checklist scores with scores on other measures of child abuse potential have consistently demonstrated that high scores on the Family Stress Checklist are related to increased rates of abuse, increased potential for child abuse, and increased parenting difficulties (Karoly et al., 1998; Korf-
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macher, 2000; Murphy et al., 1985). However, the predictive validity of a high Family Stress Checklist score for individuals remains in question. Validity studies indicate that, like other scales of this type, the Family Stress Checklist overestimates the number of parents who may maltreat their children (Brayden et al., 1993; Korfmacher, 2000). The cutoff points on the Family Stress Checklist used to define “highrisk” parents were initially developed through clinical judgement, with scores of 25 or more (corresponding to approximately upper 40% of the population distribution) considered to be of concern and those of 40 or more (corresponding to approximately upper 10% of the population distribution) considered high risk for child abuse (Korfmacher, 2000; Murphy et al., 1985). Based on the results of our own stud-
T
he high-risk teenagers
were more apt than their low-risk peers to have been abused as children.
ies and those of other investigators, pregnant teenagers who scored 25 or higher on the Family Stress Checklist were classified as being at risk for dysfunctional parenting (Karoly et al., 1998; Korfmacher, 2000; Murphy et al., 1985; Stevens-Simon et al., 2001). Although using the higher cutoff (eg, a score of 40 or more) would have improved the specificity of our abuse predictions, it would have done so at the expense of a much larger loss of sensitivity (Korfmacher, 2000; Murphy et al., 1985), a disadvantageous tradeoff for this study. The intake questionnaire was written at a fourth-grade reading level and took approximately 20 minutes to complete. It collected information about the social context of the pregnancy, with emphasis on common demographic, psychosocial, and behavioral risk factors for dysfunctional parenting (Stevens-Simon et al., 2000; StevensSimon et al., 2001). The specific vari-
ables examined as potential confounders of the relationship between the Family Stress Checklist score and maternal psychological resources were identified a priori from a review of the adolescent parenting and child maltreatment literatures (Brayden et al., 1993; Flanagan et al., 1995; Flanagan, McGrath, et al., 1995; Kitzman et al., 1997; Murphy et al., 1985; Olds et al., 1997; Olds et al., 2000; Stevens-Simon et al. 2001; Stevens-Simon & Lowy, 1995; Stevens-Simon & Nelligan, 1998; Stevens-Simon et al., 2000; StevensSimon & Reichert, 1994; Stevens-Simon & White, 1991; Wissow, 1995; Zuravin, 1988). Specifically, the variables of interest included the following: • Sociodemographic factors such as age, race, and type of health insurance • Psychosocial factors such as living arrangements, school enrollment, involvement in socially problematic behaviors (fighting, delinquency, and illicit substance abuse, assessed by history and periodic urine toxicology screening), past or present physical or sexual abuse, suicide attempts, depression/stress (defined by the Center for Epidemiologic Studies–Depression scale and a checklist of negative life events adapted from Newton’s list of psychosocial stressors in pregnancy [Newton, Webster, Binu, Maskrey, & Phillips, 1979; Radloff, 1977; Stevens-Simon & McAnarney, 1995]), lack of support from adults (Flanagan, Coll, et al., 1995) and prime people (eg, their mother or the baby’s father [Barnet, Joffe, Duggan, Wilson, & Repke, 1996]), and inadequate family support (defined by the Family Apgar Scale [Smilkstein, Ashworth, & Montano, 1982]) • The degree to which the pregnancy was wanted (Stevens-Simon, Kelly, Singer, & Nelligan, 1998) Prospective participants were approached while they were waiting to be seen in the prenatal clinic. There were almost no refusals; however, some potential participants were probably missed because of time constraints. Written consent for participation was obtained from those who agreed to spend 10 to 15 minutes completing the 3 additional questionnaires needed to compute the Nurse Home Visitation Psychological Resource Index. Because sociodemographic characteristics by themselves provide little information
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when the outcome variable was continuous and Chi-square analyses when the outcome variable was categorical. All statistical analyses were performed with SPSS/PC+ (Nie, Hull, & Jenkins, 1989).
appointments, respectively; P = .004). These differences were not unanticipated, because parents receive points on the Family Stress Checklist for living in chaotic, unsupportive environments and engaging in antisocial behaviors. The two study groups also differed significantly with regard to psychological resources (Table). The high- and low-risk adolescents had similar intelligence quotient scores, but members of the high-risk group scored significantly lower than did members of the low-risk group on the mastery and affect scales. As a result, the high-risk cohort’s composite psychological resources score was significantly lower than that of the low-risk cohort. Indeed, 18 (69.2%) of the 26 high-risk teenagers had a psychological resource score ≤0, compared with only 20 (44.4%) of the 45 low-risk teenagers (χ2 ratio = 4.15; P = .04).
RESULTS
DISCUSSION
Scores on the Family Stress Checklist ranged from 0 to 50 (mean ± SD = 20.1 ± 10.5). The high-risk group included 26 (36.6%) of the 71 teenagers; their Checklist scores ranged from 25 to 50 (mean ± SD = 31.2 ± 7.4). The remaining 45 teenagers made up the low-risk group; their Checklist scores ranged from 0 to 20 (mean ± SD = 13.8 ± 5.5). The distribution of Checklist scores was almost identical to the one obtained in a prior study of this population (Stevens-Simon et al., 2001). This finding suggests that the teenagers who participated in this small study were representative of the larger CAMP clinic population from which they were drawn. The high- and low-risk teenage mothers did not differ significantly with regard to age, race, living arrangements, school status, the proportion of wanted pregnancies, or the timing of the first prenatal visit. However, the high-risk teenagers were more apt than their low-risk peers to have been abused as children (61.5% compared with 15.6%; χ2 ratio = 15.89; P < .0001 ), to have engaged in socially problematic behaviors in the past (69.2% compared with 31.1%; χ2 ratio = 9.84; P = .002), to report that food shortages at home limited their caloric intake during gestation (34.6% compared with 11.6%; χ2 ratio = 4.11; P = .04), and to miss prenatal appointments (attending 83.4% and 92.6% of their scheduled
The Family Stress Checklist can help prenatal health care and social service providers systematically identify a subgroup of pregnant adolescents and adults who are at increased risk for mistreating their children (Korfmacher, 2000; Murphy et al., 1985; StevensSimon et al., 2001). The Family Stress Checklist is a particularly attractive risk-assessment tool for clinicians because it has a high specificity and negative predictive value and because it was initially designed to guide treatment planning (Korfmacher, 2000). It therefore focuses on the identification of potentially remediable antecedents of dysfunctional parenting (Gray et al., 1979; Korfmacher, 2000; Murphy et al., 1985; Stevens-Simon & Nelligan, 1998). Most other abuse prediction scales focus on the identification of static sociodemographic characteristics, which do not include inherent mechanisms that necessarily compel parents to mistreat their children and therefore tend to be predictive of abuse in one setting but not in others (Brayden et al., 1993; Leventhal et al., 1989; Stevens-Simon & Nelligan, 1998). However, from the clinical standpoint, the value of this screening tool depends not only on its specificity, but also on what can be done to reduce the risk associated with a positive screening result. Within this context, home visiting is hypothesized to reduce the risk of child abuse and neglect directly by pro-
TABLE Group differences in psychological resources z scores Scale
Intelligence (mean ± SD) Affect (mean ± SD) Mastery (mean ± SD) Composite score (mean ± SD)§
High risk (N = 26)
Low risk (N = 45)
–0.18 ± 1.0 –0.47 ± 1.14 –0.32 ± 0.89 –0.98 ± 2.02
0.12 ± 0.82 0.14 ± 0.84† 0.13 ± 1.00* 0.39 ± 1.79‡
*P = .05. †P = .02. ‡P = .004. §Sum of the z scores obtained from the Shipley-Hartford test of intelligence, the RAND Corporation Mental Health Depression Scale, and the Pearlin Mastery Scale.
about individual differences in competency, Olds and colleagues created a composite variable (based on an assessment of intelligence, affect, and sense of mastery or control over life events) to index women’s psychological resources (Kitzman et al., 1997; Olds & Henderson, 1989; Olds & Korfmacher, 1998). The Nurse Home Visitation Psychological Resource Index is not a predictive scale and, therefore, has no intrinsic psychometric properties. However, it is computed by summing the z scores obtained from the following 3 scales, the reliability and construct and predictive validity of which are well established and widely accepted: (a) intelligence (this parameter is assessed by the Shipley-Hartford test, reliability coefficient 0.92 [Shipley, 1940] and validity coefficient 0.77 [Sines, 1958]); (b) mental health (this parameter is assessed by the 9-item RAND Corporation Mental Health Depression Scale [Cronbach α = .83 to .88] [Olds, unpublished; Ware, Veit, & Donald, 1985]) and (c) mastery (this parameter is assessed by the scale developed by Pearlin and Schooler [1967], [Cronbach α = .67, factor loading for the original instrument produced comparable results] [Olds, unpublished; Pearlin & Schooler, 1967]). For categorical analyses, the composite score was dichotomized at 0 because women who score below this level derive the most benefit from the Nurse Home Visitation Program (Kitzman et al., 1997; Olds & Korfmacher, 1998).
Data Analysis Summary statistics were used to describe the study population. Comparisons between the two abuse-risk groups were conducted with student t tests
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PH ORIGINAL ARTICLE C moting the use of nonviolent, ageappropriate childrearing techniques and environmental safety and indirectly by enhancing parental emotional well-being and life course development (American Academy of Pediatrics, 1998; Olds et al., 1997; Olds & Henderson, 1989; Olds et al, 2000; US Advisory Board on Child Abuse and Neglect, 1991). However, only one home visitation program, the Pregnancy and Early Childhood Nurse Home Visitation Program, has proven efficacious in randomized controlled trials, and then only for women who possess minimal intrinsic psychological resources (Kitzman et al., 1997; Olds et al., 1997; Olds et al., 2000; Olds & Korfmacher, 1998). Because both the implementation and effects of the Nurse Home Visitation Program are conditioned by the mother’s level of socioemotional functioning (Kitzman et al., 1997; Olds et al., 1997; Olds et al., 2000; Olds & Korfmacher, 1998), the results of this study suggest that incorporating this highly successful home visitation program into CAMP’s already intensive, clinic-based services might be a costeffective way to prevent child abuse and neglect in the easily identifiable subgroup of adolescent mothers who are at high risk for mistreating and abandoning their children. Studies are underway to test this hypothesis. We thank Grace Cisneros and the staff and patients of the Colorado Adolescent Maternity Program for their participation in this study and their help with data collection.
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