- Email: [email protected]
Adolescent Mothers: Caregiving, Approval, and Family Functioning
K A T H R Y N A. R E C O R D S , R N , P H D
Adoksmat Mothers:
Caregiving, Approval, and Family Functioning Objective: This study tested the Adolescent Family A s s e b e n t Model, which describes the relationships between caregiving behaviors, caregiving knowledge, peer and family approval, and family functioning. Design: A descriptive correlational design was used along with causal modeling procedures to test the model. Setting: Subjects were recruited from teen parent programs and an obstetrician’s ojice. Subjects: A convenience sample of 134 adolescent mothers participated in the study. Each subject had not completed her high school education and was living in the same household as her child. Main Outcome Measures: Subjects completed a demographic questionnaire, the Infant Caregiving Inventory (caregiving knowledge), the Peer and Family Approval Instruments (social approval), and Smilkstein S Family APGAR gamily functioning). Instruments were completed twice by each subject, with a 2-week period between administration. Results: Fifeen percent of the variance of caregiving behaviors was explained by ethnicity (beta = -.30) and age of thejrst child (beta = -.26). Ten percent of the variance of family functioning was explained by age of the first child (beta = -.24) and ethnicity (beta = -.20). Conclusions: It appears that family functioning declines f o r theJirst 2 years afer the birth of the adolescent’s child. Accepted: July 1993
November/December 1994
he incorporation of an infant into a family requires adaptation on the part of all family members. As families learn to meet the infant’s needs and adjust to the time requirements of providing care for the infant, family functioning undergoes change. Becoming a parent during adolescence requires even more change than becoming one during adulthood. The adolescent mother needs to learn to provide care for her infant, a skill not routinely acquired during the teen years, and the family as a whole must adapt to welcome the new member. In 1990, 518,000 births in the United States (12.4%) occurred to teens younger than 19 years of age (U.S. Department of Commerce, Bureau of the Census, 1992). In Arizona (the site of this study), 9,767 births (14%) in 1990 were to teens (Arizona Department of Health Services,June 1990). Pima County, Arizona, reported 1530 births (13.4%) to adolescents 19 years of age or younger (Arizona Department of Health Services, June 1990). Furthermore, the pregnancy rate for adolescent girls in minority groups in Pima County exceeded the pregnancy rate for white, non-Hispanic adolescents. In 1990, the highest rate of adolescent pregnancy occurred to Mexican-American adolescents (35%). Because the majority of adolescents choose to keep their infants, the implications of adolescent parenting have become a focus of interest. Previous research focused on health outcomes for mother and child of white adolescent mothers (Becker, 1987; Mercer, 1986) and of black adolescent mothers (Ruff, 1987; Jarrett, 1982; Dougherty, 1978; Furstenberg & Crawford, 1978). Research also has been directed at adult Mexican-American women. Studies of stress, social support, and coping (Perez, 1983) and of predictors of pregnancy outcome (Norbeck & Anderson, 1989) have been conducted. Studies that have focused on Mexican-American adolescents include Becerra and deAnda’s (1984) study of pregnancy and motherhood and Speraw’s (1987) phenomenological study of adolescent perception of pregnancy. Caregiving behaviors of adolescent mothers have recently begun to be quantified (Parks & Srnerglio, 1986; 1983), whereas family functioning of families with an adolescent mother has not been quantitatively studied. It is necessary to examine the inJluence of teenage parenting on the functioning of the famity unit.
This study tested the Adolescent Family Assessment Model, which describes the relationships, from
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the adolescent mother’s perspective, of her caregiving knowledge, caregiving behaviors, approval received from family and friends, and family functioning. The proposed model delineates important variables that should be assessed by nurses who work with adolescent mothers.
Background Theoretical Model The proposed Adolescent Family Assessment Model (see Figure 1) is based on social learning theory and social exchange theory. According to social learning theory, learning occurs through modeling, imitation, and reinforcement (Bandura, 1977). The adolescent mother, then, learns to provide care for her infant by watching others in the household care for an infant and by being rewarded for providing such care herself. The reward for an adolescent mother is approval from family and friends as well as improved family functioning. Social exchange theory focuses on the social relation and the flow of benefits that occurs with social interaction. During social interaction, people act in ways to maximize benefits and minimize costs to themselves (Emerson, 1976). For the adolescent mother, the benefits and costs of an interaction are related to approval and family functioning, which occur when the mother performs care for her infant. Caregiving Successful parenting, n o matter what the age of the parents, requires interpretation and response to infant cues. To meet the needs of nonverbal infants, parents must have knowledge of infant care and the cognitive ability to solve problems Qulian, 1983): Studies have examined one component of caregiving knowledge, the knowledge of infant growth and development capabilities, and have yielded contradictory results (Becker, 1987; Parks & Smerglio, 1986; Aten, 1984; Jarrett, 1982). I t is not clear why some groups of ado Figure 1. Adolescent Furnr4r Assessment Model.
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lescent mothers overestimate their infants’ growth and development capabilities and other mothers underestimate them. However, it is accepted that caregiving knowledge is an integral component of parenting. Caregiving also involves a behavioral response, with the parent performing an activity to meet the infant’s needs. The behavioral component of caregiving has been studied primarily through qualitative methods. In general, adolescent mothers have been found to be less responsive and communicative to their infants than older mothers (Reis & Herz, 1987; Aten, 1984). For this study, caregiving was measured through quantitative estimation of both caregiving knowledge and behaviors. When caregiving is performed, the adolescent mother is rewarded with social approval and a family that functions well together.
SigniJcant variables afect not only the adolescent mother’s ability to care f o r her infant but also the functioning of the whole family.
Approval Approval can be considered as acceptance or positive affirmation received from another person for one’s actions. Approval also has elements of affection and belonging, needs that are basic to all people (Maslow, 1954). During adolescence, approval is a need that is met through interaction with two primary reference groups, the family and the peer group. Approval is gained through performance of roles in respect to each reference group. Peer approval and interactions for the adolescent mother are dependent on the norms of each peer group. Some peer groups consider teenage pregnancy and parenting to violate social norms, whereas other do not (Huttlinger, 1988). However, research has documented that, in general, parenthood isolates the adolescent mother from peers (Mercer, 1986; Thompson, 1986) and leads to a less cohesive network of friends and less approval. Peer approval was measured by the Peer Approval Instrument for this study. Mercer (1986) reported that although adolescent mothers had less supportive peer networks than adult mothers, this lack was not offset by increased acceptance and support from family members. Families exhibit a wide range of responses to pregnancy in an adolescent. They convey acceptance and support of the adolescent mother when a role-sharing relationship is developed, where all members assume part of
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the responsibility for infant care. Role-sharing allows the adolescent to accept the dual roles of mother and teen. Less accepting families may adopt roles that serve to bind the young mother to either the motherhood or adolescent role exclusively (Smith, 1983). Ethnicity plays a role in determining how a family will accept and support an adolescent mother. Becerra and deAnda (1984) found that white adolescents were likely to remain with their families of origin, whereas Mexican-American adolescent mothers were more likely to live with their spouses or boyfriends. For this study, approval of the family of origin and the new family unit was estimated by the Family Approval Instrument. When approval is received by the adolescent mother for her caregiving, she perceives her family functioning to be good.
Ethnicity and age of the child are signijcant variables to consider when assessing the fami{?!with an adolescent mother.
Family Functioning The link between high stress and illness has been well docomented (Holmes & Rahe, 1967). Pregnant adolescents who have high stress and low social network support have been found to have more neonatal and obstetric problems when compared with adolescents who have equally high stress and high social network support (Boyce, 1985). If lower levels of family functioning result in less network support and more stress, then physiologic effects such as illnesses are likely for adolescent mothers and their infants. Nathanson, Baird, and Jemail (1986) conducted a longitudinal study of interpersonal functioning within the family system of adolescent mothers. An adolescent who was a member of a family rated as enmeshed was likely to remain in that family after giving birth to her child. However, studies of family functioning after the birth of the adolescent’s child have been lacking. In this study, Smilkstein’sFamily APGAR (Smilkstein, Ashworth, & Montano, 1982) was used to measure family functioning, both of the family of origin and of the new family unit.
Methodology Design This study used a descriptive, correlational design with a convenience sample to describe the relation-
Nowmber/December 1994
ship between demographic variables, caregiving knowledge, caregiving behaviors, social approval, and family functioning in families with an adolescent mother. In addition, regression analysis was used to determine the impact of the independent variables on the outcome variables of caregiving behaviors and family functioning. Sample Subjects were recruited from teen parent programs of three school districts and an obstetrician’s practice. The researcher approached the subjects, explained the purpose of the study, and assured the teens of their rights as research participants. Those who agreed to participate in the study signed a consent form. The participants were 134 adolescent mothers, 19 years of age or younger, who were living in the southwest and had not completed high school. Subjects lived in the same household as their children. The age range of the sample was 13.2-19.7 years ( M = 17.4, SD = 1.41). Ethnic representation of the sample was 48% Mexican American ( n = 64), 37% white ( n = 5 0 ) , 12% native American ( n = 16), and 3% black ( n = 4 ) . The mean grade completed was 9.97 ( S D = 1.13). The range was 7th to 11th grade. The sample reported a mean income level of $16,777 ( S D = 9,212). The typical adolescent mother in the sample lived in a household with two other people, performed as primary caregiver for her infant, and relied on grandparents to be secondary caregivers. She had participated in a teen-parent program for 7 months and had n o babysitting experience before becoming pregnant. Instrumentation Instruments were administered to groups of subjects by the researcher in school classrooms ( n = 1141, through telephone interviews ( n = 12), or in the subjects’ homes ( n = 8). Five instruments were used to collect data for the study. The demographic questionnaire was administered first; the remaining instruments were randomly ordered. Data were collected from all subjects about their families of origin. Subjects no longer living with their families of origin completed an additional Family Approval Instrument and Family APGAR, relative to the new family unit. The Infant Caregiving Inventory (Parks & Smerglio, 1983) is a parenting-knowledge instrument that measures perceptions about the influences of caregiving practices on infants’ present and future well-being and on maternal well-being. The Peer and Family Approval instruments are two newly developed summated rating scales that measure the mother’s perception of social approval she received from family and friends. The Smilkstein et al. (1982) Family APGAR
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was used to measure family functioning. The five-item questionnaire addresses a single question to each of five areas: adaptation, partnership, growth, affection, and resolve. The Interpersonal Relationships Inventory (IPRI) (Tilden & Nelson, 1988) is a 30-item Likert scale that indexes network structure. The primary purpose of including the IPRI was to obtain an estimate of convergent validity with the social support subscale and the newly developed approval instruments. Data were analyzed using descriptive statistics, t-tests,analysis of variance, and regression analysis. The psychometric properties of each instrument were estimated using Cronbach’salpha to evaluate the internal consistency of the instruments. The criterion level for alpha was .70 for immature scales or scales not previously used with an adolescent population, and .80 for mature scales. Instruments were administered on two separate occasions, two weeks apart, to obtain an estimate of stability for the concepts (see Table 1). Alphas for all instruments met or exceeded the minimum criteria. The stability of the Infant Caregiving Inventory and the Peer Approval Instrument were not satisfactory. Convergent validity of the approval instruments as evaluated with the IPRI met the expected criterion of .40-.60.
findings Caregiving KnowZedge and Behaviors The adolescent mothers reported a moderate level of caregiving knowledge ( M = 116.5, SD = 14.18). The range was 43-136, with a possible response range of 34-136. A moderately high level of knowledge was expected because the majority of the sample participated in teen-parent programs. However, the measurement instrument for caregiving knowledge did not exhibit stability. Because knowledge should be a stable concept for a 2-week period, the results are questionable. The main problem identified by the subjects was that the scale was difficult to complete. Revision of the scale is recommended. An unexpected finding was the amount of time reported as active caregiving. Eleven ( S D = 4.57) and 12.7 ( S D = 4.89) hours were reported as time spent in performing care on weekdays and weekends, respect ive1y . Family and Peer Approval The mothers in the sample reported a moderately high level of peer approval ( M = 29.95, SD = 5.49) and family approval ( M = 38.23, SD = .69). The possible response ranges were 8-45 and 5-50, respectively.
Table 1. Psycbometric Estimates Initial psychometrics
Resultant psychometrics
Instrument
Reliability
Validity
Alpha
Stability
Infant Caregiving Inventory
.90-.94*
>.54#
.93
.66$
Validity
.73* Family APGAR Peer Approval Instrument
.80-.86*
.80$
.90
.74#
.85*
.75tlf
.73
.31#
.46* *
Family Approval Instrument
.87*
.68ll .75tl
.83
.83$
.48* *
Interpersonal Relationships Inventory
.81-.92* .81-.91#
.87
.71$
>.8911
>.30#
* internal consistency. t apparent internal consistency
* test-retest.
$, construct validity. 11 content validity. # criterion-related validity 7 clarity. * * convergent validity.
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instrument development activities are needed for the Native American J
measurement of caregiving knowledge.
-
caregiving Behavior
b=-.30
White
Age of 1st Child
’
Family Functioning
w- .To) A
b = -24
t
Figure 2. Empirical Adoobcent Family Assessment Model. b = beta.
Family approval of the new family units and the family of origin did not differ significantly. Family Functioning The adolescents reported a moderate level of family functioning ( M = 18.4, SD = 5.11). Response range was 5-25. Family functioning did not differ significantly between the new family units and families of origin.
Model Testing Results Multiple regression used forward entry, with the criterion level of significance set at .05, following the theoretical relationships proposed in the Adolescent Family Assessment Model. Results are shown in Figure 2. Fifteen percent of the variance of caregiving behavior was explained by white ethnicity (beta = -.30) and age of the first child (beta = -.26). Ten percent of the variance of family functioning was explained by age of the first child (beta = -.24) and native American ethnicity (beta = -.20). Caregiving knowledge could not be explained by the study variables, and family approval did not help to explain family functioning.
Adolescent mothers experience a signif cant amount of caregiving burden.
When responding to the two caregiving behavior questions, the adolescent mothers in this study reported providing a high number of hours of direct care to their infants. It is unlikely that an average of 12 hours of care per day was provided because most of the mothers were attending school for part of the day. There are several possible explanations for the results. The high number of caregiving hours reported could reflect the strong feeling of burden felt by the mothers. The results also could be due to social acceptance or inability to differentiate active from passive caregiving activities. Results indicate that as the infant of the adolescent mother grows, family functioning decreases. The period of time after an infant is brought home has been termed a honeymoon phase. Further exploration may reveal what difficulties are encountered by the family in the 1st 1-2 years after the birth of the adolescent’s child and after the honeymoon phase has passed. Ethnicity contributes to the explained variance of both caregiving behaviors and family functioning. White mothers reported significantly less time performing caregiving behaviors than mothers in other ethnic groups, whereas native American mothers reported lower levels of family functioning. As future studies attempt to explain more of the variance of these concepts, ethnicity may remain a significant variable.
Discussion Implications f o r Nursing The instruments measuring peer approval and caregiving knowledge did not meet the criteria for stability. Peer approval may not be a concept that exhibits stability for a period of weeks because of the volatile nature of adolescent peer relationships. However, knowledge should be a characteristic exhibiting stability over time. Therefore, the reliability of the Infant Caregiving Inventory with this sample is questioned, despite the respectable coefficient alpha obtained. Furthermore, when responding to the Infant Caregiving Inventory, mothers tended to answer that almost everything could affect their infant. It appears that adolescent mothers have difficulty differentiating valid from extraneous influences o n their infant’s growth and development. It is clear that additional
November/Decenzber 1994
Findings provide direction for future research about adolescent mothers: definition of the family unit, conceptualization of peer group relations, and measurement of caregiving behaviors. The family unit needs to be defined for measurement because the adolescent parent lives in a wide variety of kinship networks. Some of the living arrangements were begun as a result of premature pregnancy and parenthood; others were long-standing living arrangements. Regardless of the origin of the family unit, measurement of the adolescent mother’s family must take into account the various family forms encountered. Nursing also can work to conceptualize peer group relations for future studies. It is probable that
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the subjects’ peer groups had changed because of pregnancy; the students were participants in teen-parent programs or were not attending school. Therefore, it may be necessary to measure recent changes in peer group affiliation and peer approval. Measurement of caregiving behaviors and knowledge should be improved. Items need to be developed that can more easily and more validly be answered by adolescent mothers who may still be in the concrete stage of thinking. The findings also contribute to nursing’s understanding of the caregiving and family functioning of adolescent mothers, which can be used when counseling new mothers and their families. Nurses may need to intervene with families to help them confront problems arising in the period after the initial incorporation of the adolescent mother and her infant into the group. Many families d o not receive ongoing care and assessment after the postpartum period has ended. Assessment of communication patterns, role expectations, and satisfaction within the family unit at intervals throughout the first 2 years is necessary. Interventions should be designed to address concerns of the entire family. Nurses have the ability to affect the health of all family members by helping them identify issues negatively affecting family functioning and by assisting them to resolve the issues identified. This can be done when the adolescent or her infant is brought to the clinic for checkups or routine care, or during home visits.
Conclusion This study described the caregiving and family functioning of 134 adolescent mothers who were participating in teen-parent programs. The study tested the relationships in a proposed Adolescent Family Assessment Model and resulted in a new model identifying ethnicity and age of the adolescent’s child as significant variables to assess when intervening with the family of an adolescent mother. It appears that family functioning declines during the first 2 years after the birth of the adolescent’s infant. Use of a family approach when intervening with the family of an adolescent mother is necessary and should occur beyond the initial postpartum period.
Acknowledgment Supported by 11istitutic)nal Instrumentation Fellowship (NRSA) grant 5T32~NLJO7029-04and by a NAACOG Research Award.
References
Nurses also need to understand differences in family functioning of the various ethnic groups. Consideration of the family as a whole and of the cultural expectations of the group must be recognized if interventions are to be accepted. As nurses interact with each family, they will be able to compare the responses of the teen mother with that of other family members. Differences that are noted can be used as guides for intervention. For example, the adolescent mother may feel that she is always taking care of the infant and never has time for herself, yet her mother may feel that her teenage daughter never responds to the infant’s needs. The nurse can help the family to discuss different perceptions and to solve problems effectively.
Arizona Department of Health Services. (1990). Teenage p r e g m n cy report. P hoe i i ix. Aten, M. J. (1984). Adolescent mothers: The early niotherinfant relationship. In The adolescentfamily: The report of thefifteerith Ross Roundtable ( p p 43-52). Columbus, O H : Ross Laboratories. Bandura, A. (1977). Social learriivzg theory. Englewood Cliffs, NJ: Prentice-Hall. Becerra, R. M., bi deAnda, D. (1984). Pregnancyand motherhood among Mexican American adolescents. Health a d Social Work, 9, 106-123. Becker, P. T. (1987). Sensitivity to infant development and behavior: A comparison of adolescent and adult single mothers. Research iiz Nursing arid Health, 10, 119-127. Boyce, W. T. (1985). Social support, family relations, and children. In S. Cohen bi S. L. Syme (Eds.), Socialsupport and health. New York: Academic Press. Dougherty, M. C. (1978). Becoming a womaii in rural black culture. New York: Holt, Rinehart bi Winston. Emerson, R . M. (1976). Social exchange theory. Avivzual Review of Sociologl: 2, 335-362. Furstenberg, F. F., bi Crawford, A. G . (1978). Family support: Helping teenage mothers to cope. Fami41 Plavzn irzg Perspectives, 10, 322-33 3. Holmes, T. H., M: Rahe, R. H. (1967). The social reacljustment rating scale. Journal of Psjchosomatic Research, 11, 213-218. Huttlinger, K. (1988). Preggnarq,: Arz adolesceizt experience. Unpublished doctoral dissertation. University of Arizona, Tucson. Tarrett. G . E. (1982). Childrearine tmterns o f v o i i i i ~
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Nurses have the ability to injuence family functioning positively f o r all members of the adolescent parent’s fami&.
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mothers: Expectations, knowledge, and practices. Maternal-Child Nursing, 7, 119-124. Julian, K. C. (1983). A comparison of perceived and demonstrated maternal role competence of adolescent mothers. Issues in Health Care of Women, 4, 223-236. Maslow, A. H. (1954). Motivation and personality. New York: Harper. Mercer, R. T. (1986). First-time motherhood: Experiences from teens to forties. New York: Springer.. Nathanson, M., Baird, A,, bi Jemail, J. (1986). Family functioning and the adolescent mother: A systems approach. Adolescence, 21, 827-841. Norbeck, J. S., bi Anderson, N . J. (1989). Psychosocial predictors of pregnancy outcomes in low-income black, hispanic, and white women. Nursing Research, 38, 204209. Parks, P. L., & Smerglio, V. L. (1983). Parenting knowledge among adolescent mothers. Journal of Adolescent Health Care, 4, 163-167. Parks, P. L., bi Smerglio, V. L. (1986). Relationships among parenting knowledge, quality of stimulation in the home and infant development. Family Relations, 35, 41 1-416. Perez, R. (1983). Effects of stress, social support and coping style on adjustment to pregnancy among hispanic women. Hispanic Journal of Behavioral Sciences, 5(2), 141-161. Reis, J . S., bi Herz, E. J. (1987). Correlates of adolescent parenting. Adolescence, 22, 599-609. Ruff, C. C . (1987). How well d o adolescents mother? Maternal Child Nursing, 12, 249-253.
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Smilkstein, F., Ashworth, C., & Montano, D. (1982). Validity and reliability of the Family APGAR as a test of family function. Journal of Family Practice, 15, 303-31 1 . Smith, L. (1983). A conceptual model of families incorporating an adolescent mother and child into the household. Advances in Nursing Science, 6 45-60. Speraw, S. (1987). Adolescents’ perceptions of pregnancy: A cross-cultural perspective. Western Journal of Nursing Research, 9 ( 2 ) , 180-202. Thompson, M. S. (1986). The influence of supportive relations on the psychological well-being of teenage mothers. Social Forces, 64, 1006-1023. Tilden, V. P., bi Nelson, C. (1988, May). Cost and reciprocity index: A measure of intelpersonal exchange. Paper presented at the 21st Annual Communicating Nursing Research Conference, Western Society for Research in Nursing, Salt Lake City, UT. U.S. Department of Commerce, Bureau of the Census (1992). Statisticalabstract of the Unitedstates. Washington DC: U.S. Government Printing Office.
Address for correspondence: Kathryn Records, RN, PhD, ICNE, West 2917 Fort Wright Drive, Spokane, WA 99204.
Kathryn A . Records is an assistant professor at the Intercollegiate Center for Nursing Education, Spokane, WA.
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Adoksmat Mothers:
Caregiving, Approval, and Family Functioning Objective: This study tested the Adolescent Family A s s e b e n t Model, which describes the relationships between caregiving behaviors, caregiving knowledge, peer and family approval, and family functioning. Design: A descriptive correlational design was used along with causal modeling procedures to test the model. Setting: Subjects were recruited from teen parent programs and an obstetrician’s ojice. Subjects: A convenience sample of 134 adolescent mothers participated in the study. Each subject had not completed her high school education and was living in the same household as her child. Main Outcome Measures: Subjects completed a demographic questionnaire, the Infant Caregiving Inventory (caregiving knowledge), the Peer and Family Approval Instruments (social approval), and Smilkstein S Family APGAR gamily functioning). Instruments were completed twice by each subject, with a 2-week period between administration. Results: Fifeen percent of the variance of caregiving behaviors was explained by ethnicity (beta = -.30) and age of thejrst child (beta = -.26). Ten percent of the variance of family functioning was explained by age of the first child (beta = -.24) and ethnicity (beta = -.20). Conclusions: It appears that family functioning declines f o r theJirst 2 years afer the birth of the adolescent’s child. Accepted: July 1993
November/December 1994
he incorporation of an infant into a family requires adaptation on the part of all family members. As families learn to meet the infant’s needs and adjust to the time requirements of providing care for the infant, family functioning undergoes change. Becoming a parent during adolescence requires even more change than becoming one during adulthood. The adolescent mother needs to learn to provide care for her infant, a skill not routinely acquired during the teen years, and the family as a whole must adapt to welcome the new member. In 1990, 518,000 births in the United States (12.4%) occurred to teens younger than 19 years of age (U.S. Department of Commerce, Bureau of the Census, 1992). In Arizona (the site of this study), 9,767 births (14%) in 1990 were to teens (Arizona Department of Health Services,June 1990). Pima County, Arizona, reported 1530 births (13.4%) to adolescents 19 years of age or younger (Arizona Department of Health Services, June 1990). Furthermore, the pregnancy rate for adolescent girls in minority groups in Pima County exceeded the pregnancy rate for white, non-Hispanic adolescents. In 1990, the highest rate of adolescent pregnancy occurred to Mexican-American adolescents (35%). Because the majority of adolescents choose to keep their infants, the implications of adolescent parenting have become a focus of interest. Previous research focused on health outcomes for mother and child of white adolescent mothers (Becker, 1987; Mercer, 1986) and of black adolescent mothers (Ruff, 1987; Jarrett, 1982; Dougherty, 1978; Furstenberg & Crawford, 1978). Research also has been directed at adult Mexican-American women. Studies of stress, social support, and coping (Perez, 1983) and of predictors of pregnancy outcome (Norbeck & Anderson, 1989) have been conducted. Studies that have focused on Mexican-American adolescents include Becerra and deAnda’s (1984) study of pregnancy and motherhood and Speraw’s (1987) phenomenological study of adolescent perception of pregnancy. Caregiving behaviors of adolescent mothers have recently begun to be quantified (Parks & Srnerglio, 1986; 1983), whereas family functioning of families with an adolescent mother has not been quantitatively studied. It is necessary to examine the inJluence of teenage parenting on the functioning of the famity unit.
This study tested the Adolescent Family Assessment Model, which describes the relationships, from
J O G N N
791
C L I N I C A L
S T U D I E S
the adolescent mother’s perspective, of her caregiving knowledge, caregiving behaviors, approval received from family and friends, and family functioning. The proposed model delineates important variables that should be assessed by nurses who work with adolescent mothers.
Background Theoretical Model The proposed Adolescent Family Assessment Model (see Figure 1) is based on social learning theory and social exchange theory. According to social learning theory, learning occurs through modeling, imitation, and reinforcement (Bandura, 1977). The adolescent mother, then, learns to provide care for her infant by watching others in the household care for an infant and by being rewarded for providing such care herself. The reward for an adolescent mother is approval from family and friends as well as improved family functioning. Social exchange theory focuses on the social relation and the flow of benefits that occurs with social interaction. During social interaction, people act in ways to maximize benefits and minimize costs to themselves (Emerson, 1976). For the adolescent mother, the benefits and costs of an interaction are related to approval and family functioning, which occur when the mother performs care for her infant. Caregiving Successful parenting, n o matter what the age of the parents, requires interpretation and response to infant cues. To meet the needs of nonverbal infants, parents must have knowledge of infant care and the cognitive ability to solve problems Qulian, 1983): Studies have examined one component of caregiving knowledge, the knowledge of infant growth and development capabilities, and have yielded contradictory results (Becker, 1987; Parks & Smerglio, 1986; Aten, 1984; Jarrett, 1982). I t is not clear why some groups of ado Figure 1. Adolescent Furnr4r Assessment Model.
792 J O C N N
lescent mothers overestimate their infants’ growth and development capabilities and other mothers underestimate them. However, it is accepted that caregiving knowledge is an integral component of parenting. Caregiving also involves a behavioral response, with the parent performing an activity to meet the infant’s needs. The behavioral component of caregiving has been studied primarily through qualitative methods. In general, adolescent mothers have been found to be less responsive and communicative to their infants than older mothers (Reis & Herz, 1987; Aten, 1984). For this study, caregiving was measured through quantitative estimation of both caregiving knowledge and behaviors. When caregiving is performed, the adolescent mother is rewarded with social approval and a family that functions well together.
SigniJcant variables afect not only the adolescent mother’s ability to care f o r her infant but also the functioning of the whole family.
Approval Approval can be considered as acceptance or positive affirmation received from another person for one’s actions. Approval also has elements of affection and belonging, needs that are basic to all people (Maslow, 1954). During adolescence, approval is a need that is met through interaction with two primary reference groups, the family and the peer group. Approval is gained through performance of roles in respect to each reference group. Peer approval and interactions for the adolescent mother are dependent on the norms of each peer group. Some peer groups consider teenage pregnancy and parenting to violate social norms, whereas other do not (Huttlinger, 1988). However, research has documented that, in general, parenthood isolates the adolescent mother from peers (Mercer, 1986; Thompson, 1986) and leads to a less cohesive network of friends and less approval. Peer approval was measured by the Peer Approval Instrument for this study. Mercer (1986) reported that although adolescent mothers had less supportive peer networks than adult mothers, this lack was not offset by increased acceptance and support from family members. Families exhibit a wide range of responses to pregnancy in an adolescent. They convey acceptance and support of the adolescent mother when a role-sharing relationship is developed, where all members assume part of
Volume 23 Number 9
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the responsibility for infant care. Role-sharing allows the adolescent to accept the dual roles of mother and teen. Less accepting families may adopt roles that serve to bind the young mother to either the motherhood or adolescent role exclusively (Smith, 1983). Ethnicity plays a role in determining how a family will accept and support an adolescent mother. Becerra and deAnda (1984) found that white adolescents were likely to remain with their families of origin, whereas Mexican-American adolescent mothers were more likely to live with their spouses or boyfriends. For this study, approval of the family of origin and the new family unit was estimated by the Family Approval Instrument. When approval is received by the adolescent mother for her caregiving, she perceives her family functioning to be good.
Ethnicity and age of the child are signijcant variables to consider when assessing the fami{?!with an adolescent mother.
Family Functioning The link between high stress and illness has been well docomented (Holmes & Rahe, 1967). Pregnant adolescents who have high stress and low social network support have been found to have more neonatal and obstetric problems when compared with adolescents who have equally high stress and high social network support (Boyce, 1985). If lower levels of family functioning result in less network support and more stress, then physiologic effects such as illnesses are likely for adolescent mothers and their infants. Nathanson, Baird, and Jemail (1986) conducted a longitudinal study of interpersonal functioning within the family system of adolescent mothers. An adolescent who was a member of a family rated as enmeshed was likely to remain in that family after giving birth to her child. However, studies of family functioning after the birth of the adolescent’s child have been lacking. In this study, Smilkstein’sFamily APGAR (Smilkstein, Ashworth, & Montano, 1982) was used to measure family functioning, both of the family of origin and of the new family unit.
Methodology Design This study used a descriptive, correlational design with a convenience sample to describe the relation-
Nowmber/December 1994
ship between demographic variables, caregiving knowledge, caregiving behaviors, social approval, and family functioning in families with an adolescent mother. In addition, regression analysis was used to determine the impact of the independent variables on the outcome variables of caregiving behaviors and family functioning. Sample Subjects were recruited from teen parent programs of three school districts and an obstetrician’s practice. The researcher approached the subjects, explained the purpose of the study, and assured the teens of their rights as research participants. Those who agreed to participate in the study signed a consent form. The participants were 134 adolescent mothers, 19 years of age or younger, who were living in the southwest and had not completed high school. Subjects lived in the same household as their children. The age range of the sample was 13.2-19.7 years ( M = 17.4, SD = 1.41). Ethnic representation of the sample was 48% Mexican American ( n = 64), 37% white ( n = 5 0 ) , 12% native American ( n = 16), and 3% black ( n = 4 ) . The mean grade completed was 9.97 ( S D = 1.13). The range was 7th to 11th grade. The sample reported a mean income level of $16,777 ( S D = 9,212). The typical adolescent mother in the sample lived in a household with two other people, performed as primary caregiver for her infant, and relied on grandparents to be secondary caregivers. She had participated in a teen-parent program for 7 months and had n o babysitting experience before becoming pregnant. Instrumentation Instruments were administered to groups of subjects by the researcher in school classrooms ( n = 1141, through telephone interviews ( n = 12), or in the subjects’ homes ( n = 8). Five instruments were used to collect data for the study. The demographic questionnaire was administered first; the remaining instruments were randomly ordered. Data were collected from all subjects about their families of origin. Subjects no longer living with their families of origin completed an additional Family Approval Instrument and Family APGAR, relative to the new family unit. The Infant Caregiving Inventory (Parks & Smerglio, 1983) is a parenting-knowledge instrument that measures perceptions about the influences of caregiving practices on infants’ present and future well-being and on maternal well-being. The Peer and Family Approval instruments are two newly developed summated rating scales that measure the mother’s perception of social approval she received from family and friends. The Smilkstein et al. (1982) Family APGAR
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was used to measure family functioning. The five-item questionnaire addresses a single question to each of five areas: adaptation, partnership, growth, affection, and resolve. The Interpersonal Relationships Inventory (IPRI) (Tilden & Nelson, 1988) is a 30-item Likert scale that indexes network structure. The primary purpose of including the IPRI was to obtain an estimate of convergent validity with the social support subscale and the newly developed approval instruments. Data were analyzed using descriptive statistics, t-tests,analysis of variance, and regression analysis. The psychometric properties of each instrument were estimated using Cronbach’salpha to evaluate the internal consistency of the instruments. The criterion level for alpha was .70 for immature scales or scales not previously used with an adolescent population, and .80 for mature scales. Instruments were administered on two separate occasions, two weeks apart, to obtain an estimate of stability for the concepts (see Table 1). Alphas for all instruments met or exceeded the minimum criteria. The stability of the Infant Caregiving Inventory and the Peer Approval Instrument were not satisfactory. Convergent validity of the approval instruments as evaluated with the IPRI met the expected criterion of .40-.60.
findings Caregiving KnowZedge and Behaviors The adolescent mothers reported a moderate level of caregiving knowledge ( M = 116.5, SD = 14.18). The range was 43-136, with a possible response range of 34-136. A moderately high level of knowledge was expected because the majority of the sample participated in teen-parent programs. However, the measurement instrument for caregiving knowledge did not exhibit stability. Because knowledge should be a stable concept for a 2-week period, the results are questionable. The main problem identified by the subjects was that the scale was difficult to complete. Revision of the scale is recommended. An unexpected finding was the amount of time reported as active caregiving. Eleven ( S D = 4.57) and 12.7 ( S D = 4.89) hours were reported as time spent in performing care on weekdays and weekends, respect ive1y . Family and Peer Approval The mothers in the sample reported a moderately high level of peer approval ( M = 29.95, SD = 5.49) and family approval ( M = 38.23, SD = .69). The possible response ranges were 8-45 and 5-50, respectively.
Table 1. Psycbometric Estimates Initial psychometrics
Resultant psychometrics
Instrument
Reliability
Validity
Alpha
Stability
Infant Caregiving Inventory
.90-.94*
>.54#
.93
.66$
Validity
.73* Family APGAR Peer Approval Instrument
.80-.86*
.80$
.90
.74#
.85*
.75tlf
.73
.31#
.46* *
Family Approval Instrument
.87*
.68ll .75tl
.83
.83$
.48* *
Interpersonal Relationships Inventory
.81-.92* .81-.91#
.87
.71$
>.8911
>.30#
* internal consistency. t apparent internal consistency
* test-retest.
$, construct validity. 11 content validity. # criterion-related validity 7 clarity. * * convergent validity.
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instrument development activities are needed for the Native American J
measurement of caregiving knowledge.
-
caregiving Behavior
b=-.30
White
Age of 1st Child
’
Family Functioning
w- .To) A
b = -24
t
Figure 2. Empirical Adoobcent Family Assessment Model. b = beta.
Family approval of the new family units and the family of origin did not differ significantly. Family Functioning The adolescents reported a moderate level of family functioning ( M = 18.4, SD = 5.11). Response range was 5-25. Family functioning did not differ significantly between the new family units and families of origin.
Model Testing Results Multiple regression used forward entry, with the criterion level of significance set at .05, following the theoretical relationships proposed in the Adolescent Family Assessment Model. Results are shown in Figure 2. Fifteen percent of the variance of caregiving behavior was explained by white ethnicity (beta = -.30) and age of the first child (beta = -.26). Ten percent of the variance of family functioning was explained by age of the first child (beta = -.24) and native American ethnicity (beta = -.20). Caregiving knowledge could not be explained by the study variables, and family approval did not help to explain family functioning.
Adolescent mothers experience a signif cant amount of caregiving burden.
When responding to the two caregiving behavior questions, the adolescent mothers in this study reported providing a high number of hours of direct care to their infants. It is unlikely that an average of 12 hours of care per day was provided because most of the mothers were attending school for part of the day. There are several possible explanations for the results. The high number of caregiving hours reported could reflect the strong feeling of burden felt by the mothers. The results also could be due to social acceptance or inability to differentiate active from passive caregiving activities. Results indicate that as the infant of the adolescent mother grows, family functioning decreases. The period of time after an infant is brought home has been termed a honeymoon phase. Further exploration may reveal what difficulties are encountered by the family in the 1st 1-2 years after the birth of the adolescent’s child and after the honeymoon phase has passed. Ethnicity contributes to the explained variance of both caregiving behaviors and family functioning. White mothers reported significantly less time performing caregiving behaviors than mothers in other ethnic groups, whereas native American mothers reported lower levels of family functioning. As future studies attempt to explain more of the variance of these concepts, ethnicity may remain a significant variable.
Discussion Implications f o r Nursing The instruments measuring peer approval and caregiving knowledge did not meet the criteria for stability. Peer approval may not be a concept that exhibits stability for a period of weeks because of the volatile nature of adolescent peer relationships. However, knowledge should be a characteristic exhibiting stability over time. Therefore, the reliability of the Infant Caregiving Inventory with this sample is questioned, despite the respectable coefficient alpha obtained. Furthermore, when responding to the Infant Caregiving Inventory, mothers tended to answer that almost everything could affect their infant. It appears that adolescent mothers have difficulty differentiating valid from extraneous influences o n their infant’s growth and development. It is clear that additional
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Findings provide direction for future research about adolescent mothers: definition of the family unit, conceptualization of peer group relations, and measurement of caregiving behaviors. The family unit needs to be defined for measurement because the adolescent parent lives in a wide variety of kinship networks. Some of the living arrangements were begun as a result of premature pregnancy and parenthood; others were long-standing living arrangements. Regardless of the origin of the family unit, measurement of the adolescent mother’s family must take into account the various family forms encountered. Nursing also can work to conceptualize peer group relations for future studies. It is probable that
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the subjects’ peer groups had changed because of pregnancy; the students were participants in teen-parent programs or were not attending school. Therefore, it may be necessary to measure recent changes in peer group affiliation and peer approval. Measurement of caregiving behaviors and knowledge should be improved. Items need to be developed that can more easily and more validly be answered by adolescent mothers who may still be in the concrete stage of thinking. The findings also contribute to nursing’s understanding of the caregiving and family functioning of adolescent mothers, which can be used when counseling new mothers and their families. Nurses may need to intervene with families to help them confront problems arising in the period after the initial incorporation of the adolescent mother and her infant into the group. Many families d o not receive ongoing care and assessment after the postpartum period has ended. Assessment of communication patterns, role expectations, and satisfaction within the family unit at intervals throughout the first 2 years is necessary. Interventions should be designed to address concerns of the entire family. Nurses have the ability to affect the health of all family members by helping them identify issues negatively affecting family functioning and by assisting them to resolve the issues identified. This can be done when the adolescent or her infant is brought to the clinic for checkups or routine care, or during home visits.
Conclusion This study described the caregiving and family functioning of 134 adolescent mothers who were participating in teen-parent programs. The study tested the relationships in a proposed Adolescent Family Assessment Model and resulted in a new model identifying ethnicity and age of the adolescent’s child as significant variables to assess when intervening with the family of an adolescent mother. It appears that family functioning declines during the first 2 years after the birth of the adolescent’s infant. Use of a family approach when intervening with the family of an adolescent mother is necessary and should occur beyond the initial postpartum period.
Acknowledgment Supported by 11istitutic)nal Instrumentation Fellowship (NRSA) grant 5T32~NLJO7029-04and by a NAACOG Research Award.
References
Nurses also need to understand differences in family functioning of the various ethnic groups. Consideration of the family as a whole and of the cultural expectations of the group must be recognized if interventions are to be accepted. As nurses interact with each family, they will be able to compare the responses of the teen mother with that of other family members. Differences that are noted can be used as guides for intervention. For example, the adolescent mother may feel that she is always taking care of the infant and never has time for herself, yet her mother may feel that her teenage daughter never responds to the infant’s needs. The nurse can help the family to discuss different perceptions and to solve problems effectively.
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Smilkstein, F., Ashworth, C., & Montano, D. (1982). Validity and reliability of the Family APGAR as a test of family function. Journal of Family Practice, 15, 303-31 1 . Smith, L. (1983). A conceptual model of families incorporating an adolescent mother and child into the household. Advances in Nursing Science, 6 45-60. Speraw, S. (1987). Adolescents’ perceptions of pregnancy: A cross-cultural perspective. Western Journal of Nursing Research, 9 ( 2 ) , 180-202. Thompson, M. S. (1986). The influence of supportive relations on the psychological well-being of teenage mothers. Social Forces, 64, 1006-1023. Tilden, V. P., bi Nelson, C. (1988, May). Cost and reciprocity index: A measure of intelpersonal exchange. Paper presented at the 21st Annual Communicating Nursing Research Conference, Western Society for Research in Nursing, Salt Lake City, UT. U.S. Department of Commerce, Bureau of the Census (1992). Statisticalabstract of the Unitedstates. Washington DC: U.S. Government Printing Office.
Address for correspondence: Kathryn Records, RN, PhD, ICNE, West 2917 Fort Wright Drive, Spokane, WA 99204.
Kathryn A . Records is an assistant professor at the Intercollegiate Center for Nursing Education, Spokane, WA.
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