- Email: [email protected]
Adolescents, Pregnancy, and Mental Health
Original Study Adolescents, Pregnancy, and Mental Health Rebecca S. Siegel PhD *, Anna R. Brandon PhD, ABPP The University of North Carolina at Chapel Hill, Chapel Hill, NC
a b s t r a c t Study Objective: Pregnancy during adolescence is a risk factor for adverse medical and psychosocial outcomes, including psychiatric illness. Psychiatric illness is linked with obstetric complications along with impaired maternal functioning in the postpartum period. This article provides a comprehensive review of the research examining the intersection of psychopathology and adolescent pregnancy and the postpartum period. Design: A literature search was conducted using PubMed (Medline), PsycINFO, and CINAHL for articles published between 1990 and 2013 that examined depression, anxiety, bipolar disorder, and psychosis during pregnancy and the postpartum period in adolescents age 21 years or younger. Articles were selected that covered the following topics: Prevalence or incidence, comorbidity, psychosocial correlates, birth outcomes, parenting, child outcomes, and psychosocial treatment. Forty articles were found and reviewed. Results: There is a substantial research base examining self-reported depressive symptoms in adolescents during pregnancy and the postpartum period. Existing research suggests that pregnant and parenting adolescents are at greater risk for experiencing depressive symptoms than pregnant and postpartum adult women. Depression in the perinatal period is also a risk factor for substance and alcohol abuse and a harsher parenting style in adolescents. Areas for future research in this population include investigating the prevalence, psychosocial correlates, and outcomes of clinically diagnosed Major Depressive Disorder, developing and empirically validating psychotherapeutic treatments, and focusing upon other psychiatric diagnoses such as bipolar disorder, anxiety, and psychosis. Key Words: Adolescents, Pregnancy, Postpartum, Depression, Anxiety
Introduction
Pregnant adolescents are at increased risk for adverse outcomes. These include medical complications during pregnancy and delivery, repeat pregnancies, harsher parenting techniques, and cognitive and behavioral difficulties in their children.1 In 2010 alone, 367,752 infants were born to adolescent mothers, indicating that 34.3 per 1,000 adolescent girls ages 15-19 years gave birth that year.2 Although these figures suggest that adolescent pregnancy is on the decline in the US, children having children remains a significant issue. In fact, the prevention of adolescent pregnancy is a stated priority by the Centers for Disease Control and Prevention.3 Adolescence is a developmental stage marked by significant biologic and psychosocial transitions. Biological changes include neurobiological development, substantial hormonal changes, and external physical changes. Psychological changes particularly relevant to mental health include an increase in novelty and sensation seeking without an accompanying increase in self-regulation.4 Social changes occur within societal expectations to take on greater responsibility with the transition to adulthood. Peer influences become increasingly important throughout adolescence, eventually surpassing family influence and becoming the
The authors indicate no conflicts of interest. * Address correspondence to: Rebecca S. Siegel, PhD, University of North Carolina at Chapel Hill, Department of Psychiatry, Women's Mood Disorders Center, Campus Box 7160, Chapel Hill, NC 27599-7160; Phone: (919) 962-9799; fax: (919) 966-9646 E-mail address: [email protected] (R.S. Siegel).
most important source of social support.5 Although these transitions are all developmentally normative, the combination presents unique risk factors during this time of development. For example, adolescents are at a significantly increased risk for injury and accidental death due to increased risk-taking behavior.4 When mental illness occurs during these changes, it can provoke an even greater risk for behavior that can lead to harmful consequences. In this context, therefore, adolescent pregnancy presents a unique set of challenges and risk factors differentiating the experience from pregnancy during adulthood. Psychiatric illness complicates pregnancy in adult populations by compromising maternal health, negatively impacting fetal development, and impairing mother-infant bonding. Prenatal depression is also associated with a greater risk of preterm birth,6 low birth weight,7 and behavioral differences (eg, increased fussiness, less time awake and alert) in the neonate (see Davalos et al8 for a review). Depression during pregnancy is the strongest risk factor for postpartum depression. It is also consistently associated with attachment difficulties, infant behavioral changes and, at worst, maternal suicide. Women with bipolar disorder during pregnancy are at significant risk for mood episode relapse9 and postpartum psychosis, which can also lead to maternal suicide and infanticide.10 In teenagers, psychopathology is a risk factor for early parenthood, highlighting the critical implications of adolescent mental illness for society.11 Therefore, given the adverse consequences of perinatal psychopathology demonstrated in the adult literature and the links between mental illness and the incidence of adolescent pregnancy,
1083-3188/$ - see front matter Ó 2014 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2013.09.008
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
mental illness in the context of adolescent pregnancy is a serious public health concern. Research surrounding the intersection of psychopathology and adolescent pregnancy is limited, but has shown growth in the last 2 decades. Understanding the specific challenges faced by pregnant and parenting adolescents with psychiatric illness is critical to design effective prevention strategies and interventions. This discussion will provide a comprehensive review of what has been learned about psychopathology during adolescent pregnancy and the postpartum period, followed by a discussion of areas for future direction. Method
A literature search was conducted using the following electronic databases: PubMed (Medline), PsycINFO, and CINAHL. Terms entered into the search in various combinations included “adolescent, pregnancy, postpartum, depression, bipolar disorder, anxiety, psychosis.” Limitations placed on each search included publication year between 1990 and 2013, Adolescents (age 21 and younger),12 and English language. The above search terms with the specified limitations produced the following results: 172 articles from PubMed, 397 articles from PsycINFO, and 146 articles from CINAHL. After removing duplicates, articles were read and were selected for inclusion based on the following themes related to adolescent mental illness during pregnancy or the postpartum period: prevalence or incidence, comorbidity, psychosocial correlates, birth outcomes, parenting, child outcomes, and psychosocial treatment. Along these themes, 40 articles met criteria and are included in this review (see Table 1). The majority (36) focused upon depression during pregnancy and the postpartum period with only 2 examining bipolar disorder, 2 examining anxiety, and none examining psychosis. Thus, the focus of this review will be on depression during pregnancy and the postpartum period in adolescents with information on bipolar disorder and anxiety presented where available. Results Prevalence
Only 1 known study comprehensively examined the prevalence of psychiatric disorders in perinatal adolescents. Mitsuhiro and colleagues13 used the Composite International Diagnostic Interview (CIDI),14 a structured clinical interview, to diagnose psychiatric disorders in adolescents (ages 11-19) in Brazil. Adolescents were interviewed in the hospital after giving birth and asked about psychiatric symptoms experienced over the previous 12 months. Investigators reported 32.5% of adolescents endorsed symptoms meeting criteria for a psychiatric disorder. Specific prevalence rates reported were: Substance use disorders: 13.7%, Psychotic disorders: 3.5%, Major depressive disorder: 12.9%,
139
Bipolar disorder: 0.8%, Anxiety disorders: 15.7%, and Eating disorders: 0.3%. Reported rates of depression during pregnancy and the postpartum period in adolescents are widely variable, in part due to the methods investigators use for establishing depression. Self-report measures of depression such as the Beck Depression Inventory (BDI) or Edinburgh Postnatal Depression Scale (EPDS) are widely used to identify symptoms but, as screening measures, are limited in diagnostic value. Other variables such as ethnicity and age (eg, younger vs older adolescents) may also account for some variability. In studies measuring self-reported depression in pregnant adolescents, prevalence rates range from 8%15 to 47%.16 Troutman and Cutrona17 were the only investigators found in this review who employed a clinician-administered structured interview to establish the diagnosis of Major Depressive Disorder (MDD) during pregnancy. The study reported a prevalence rate of 16% in the sample of pregnant adolescents (N 5 128; MDD diagnosed using the Schedule for Affective Disorders and Schizophrenia18). Investigators also established the prevalence of postpartum MDD, with 26% of the sample meeting criteria at 6 weeks postpartum and 20% at 1 year postpartum. Studies relying upon selfreport of postpartum depressive symptoms in adolescents suggest rates ranging from 7%15 to 37%.19 Prevalence rates of depression in perinatal adolescents are comparable to depression in non-perinatal adolescents. One study, however, found suicidal behavior to be increased in the perinatal population as compared to adolescents who were not pregnant or postpartum. In a study of inner-city adolescents, Steer, Scholl, and Beck15 administered the BDI to evaluate depressive symptoms during pregnancy, at 5 weeks postpartum, and again at 6 months postpartum. Mean BDI scores in this study were comparable to rates reported in 2 other studies of non-pregnant inner-city adolescents. In the previously mentioned Troutman and Cutrona17 study, no differences in diagnosed MDD or selfreported depressive symptoms (BDI) were found between pregnant and non-pregnant adolescents measured at the same time intervals. Finally, Freitas and colleagues20 studied suicidal behavior in pregnant and non-pregnant adolescents in Brazil, finding that 20% of pregnant adolescents had attempted suicide at least once prior to their pregnancy, while only 6.3% of non-pregnant adolescents had attempted suicide. Prevalence of self-reported depressive symptoms in perinatal adolescents appears to be higher than what is reported in samples of adult perinatal women. In a Portuguese sample, Figueiredo, Pacheco, and Costa21 compared an adolescent group to an adult group of mothers during pregnancy and again at 2-3 months postpartum, reporting that a greater percentage of adolescents endorsed high levels of depressive symptoms (measured by EPDS score O12) than adults. Lanzi and colleagues22 used the BDI to measure the severity of depressive symptoms in adolescents and lower- and higher-resource adults during pregnancy and later at 6 months postpartum, also finding higher levels of symptoms in adolescents than in either category of adults.
140
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
Extant literature includes 1 study examining the prevalence of self-reported anxiety and stress in pregnant adolescents. De Anda and colleagues23 found that 35% of their sample of pregnant adolescents felt “very upset, tense, or upset” “often” or “very often.” Additionally, the mean score on the self-report State-Trait Anxiety Inventory24 suggested anxiety was higher among the sample of pregnant adolescents than in benchmark scores from a community sample of adolescent females (study did not report significance tests). Self-reported symptoms of psychopathology (Youth Self Report, YSR)25 did not differ between pregnant versus non-pregnant adolescents.26 The YSR does not measure psychiatric diagnoses per se, but reports the following syndromal scales: Withdrawn behavior, anxiety/depression, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior. The ratings of pregnant adolescents were either not different or lower (indicating better functioning) than non-pregnant adolescents on all subscales. In sum, a substantial literature has examined prevalence rates of depression in pregnant and postpartum adolescents. Rates of depression vary widely across studies with estimates between 8%15 and 47%,16 possibly due to methodological factors. Compared to rates of depression in adolescents who are not pregnant or postpartum, depression rates in perinatal adolescents do not appear to differ. However, perinatal adolescents report significantly greater rates of depression than perinatal adults. In 1 study that examined rates of anxiety in pregnant adolescents,23 the prevalence estimate was 35% and more stress was reported among pregnant than nonpregnant adolescents. Regarding self-reported symptoms of psychopathology, no differences were found between pregnant versus non-pregnant adolescents. Comorbidity
Rates of comorbidity in perinatal adolescents are estimated at 33% among those experiencing any psychiatric disorder, with research in this area focusing upon substance and alcohol use or smoking.13 Barnet and colleagues27 examined substance and alcohol use in adolescents at 2 and 4 months postpartum. Self-reported depression and stress were examined as potential correlates of postpartum substance use. Use of alcohol in the postpartum period was significantly associated with depression. Additionally, adolescents with high levels of depression were 3.3 times more likely to use substances (alcohol or illicit drugs) at 4 months postpartum than those with lower levels of depression. In examining the association between smoking and selfreported depressive symptoms in pregnant adolescents, Bottomley and Lancaster28 did not find any mean differences in levels of depression between smokers and nonsmokers. However, the proportion of adolescents who scored above the cutoff score on the EPDS, suggesting probable depression, was higher in the smoking than nonsmoking group. Only 2 studies examined bipolar disorder in perinatal adolescents and both measured comorbid substance use. Bessa and colleagues29 examined correlates of cocaine and
marijuana use during the last trimester in pregnant adolescents in Brazil. Psychiatric diagnoses in this study were determined using the CIDI. Cocaine and marijuana use were associated with bipolar disorder in addition to posttraumatic stress disorder and somatoform disorder. In a study of adolescents with bipolar disorder, Goldstein and colleagues30 examined factors associated with substance use disorder (SUD) in this sample (diagnoses of bipolar disorder were made before SUD was reported in this study). Findings revealed that bipolar adolescents with SUD were more likely to have been pregnant and to have had an abortion in the past 12 months than bipolar adolescents without SUD. Overall, studies of comorbidity in pregnant and postpartum adolescents have focused on substance use and smoking. Depression was found to be strongly associated with substance and alcohol use and smoking in postpartum adolescents.27,28 Additionally, bipolar disorder is associated with substance use in pregnant and postpartum adolescents.29,30 Psychosocial Correlates
Research supports a strong association between social support and fewer depressive symptoms in perinatal adolescents.31e36 Findings suggest, however, that it might be adolescents' satisfaction with their social support, or the quality of their social support, rather than the quantity of social support that is associated with depressive symptoms.37,38 One investigative team, however, did not find a relationship between perceived or actual social support and postpartum depressive symptoms.39 Logsdon and colleagues40 divided the social support variable into 3 “levels,” (macrosystem [eg, socioeconomic status, exposure to community violence], mesosystem [eg, social network, postpartum support], and microsystem [eg, self-esteem, perceived stress]). The study then examined the associations between postpartum depression and each level of social support in adolescents. Deficiencies in all levels of support were found to be associated with postpartum depressive symptoms. Adolescents' experiences with their own parents, beliefs about themselves, and socioeconomic status are also associated with perinatal depression. Milan and colleagues41 examined adolescents' experiences with their own parents, finding that adolescents who perceived their mothers as more unavailable and their fathers as both more unavailable and more hostile experienced more depression during pregnancy. Birkeland and colleagues32 found that maternal self-efficacy, social isolation, and dissatisfaction with one's weight or body shape were predictive of depressive symptoms. Finally, Secco and colleagues39 found socioeconomic status to predict self-reported depressive symptoms in adolescent mothers. In sum, many psychosocial factors are associated with depression during pregnancy and the postpartum period in adolescents. Perceived social support is 1 factor that many,28e35 but not all,36 studies found was associated with depression. Other psychosocial factors associated with perinatal depression in adolescents include adolescents' own childhood experiences, self-efficacy, social isolation, body satisfaction, and socioeconomic status.29,36,38
Table 1 Summary of Studies Reviewed Authors, Year
n
Age
Participant Description
Study Design
Results
Mitsuhiro, Chalem, Carvalho, et al, 2009
1000
11-19
Postpartum adolescents in an obstetric center in Brazil.
Interviewed using Composite International Diagnostic Interview (CIDI) at 4-48h after delivery. Asked about symptoms over past 12 months.
Prevalence rates: Substance use disorders e 13.7% Psychotic disorders e 3.5% Major depressive disorder e 12.9% Bipolar disorder e 0.8% Anxiety disorders e 15.7% Eating disorders e 0.3%
Steer, Scholl, Beck, 1990
158
13-18
Primarily Black and Hispanic pregnant and postpartum adolescent girls.
Beck Depression Inventory (BDI) administered at: - Week 28 of pregnancy - 5 weeks postpartum - 6 months postpartum
Rates of depression (cutoff score of 20): Never depressed e 84.8% Depressed during pregnancy e 8.2% Became depressed after delivery e 7% Ceased being depressed after delivery e 5.1% Depressed at all 3 time points e 3.1%
Ginsburg, Baker, Mullany, et al, 2008
53
12-19
Pregnant (#28 wks), reservation-based, American Indian adolescents participating in a home visiting program to promote positive parenting.
Center for Epidemiological Studies-Depression Scale (CES-D) administered one time during pregnancy.
Rates of depression: Scored $16 (clinical cutoff for CES-D) e 47% Scored $20 (elevated for adolescents) e 30% Scored $28 (1SD above mean) e 19%
Troutman, Cutrona, 1990
242
14-18
- Pregnant & postpartum adolescents (n 5 128). - Non-pregnant control adolescents (n 5 114)
Perinatal adolescents assessed using Schedule for Affective Disorders and Schizophrenia (SADS): - During pregnancy - 6 weeks postpartum - 1 year postpartum Controls assessed at similar time intervals.
No significant difference in rates of depression between perinatal adolescents and controls. Rates of MDD among perinatal adolescents: During pregnancy e 16% 6 wks postpartum e 26% 1 year postpartum e 20%
Schmidt, Wiemann, Rickert, et al, 2006
623
#18
Postpartum adolescents
BDI administered postpartum: - 3 months - 12 months - 24 months - 48 months Compared rates among different ethnicities as well as overall depression rates.
Rates of depression were lower overall for African Americans than Caucasians or Mexican Americans. Rates of depression across entire sample: 3 months postpartum e 36.7% 12 months postpartum e 28.4% 24 months postpartum e 23.6% 48 months postpartum e 21.1%
Freitas, 2008
220
14-18
Pregnant adolescents (n 5 110) & non-pregnant adolescents (n 5 110) in Sao Paulo, Brazil
Suicidality: Beck Scale for Suicide Ideation (BSI). Depression & anxiety: Hospital Anxiety and Depression Scale (HAD).
Prevalence rates: Attempted suicide Pregnant e 20% Non-pregnant e 6.3% Depression Pregnant e 26.3% Non-pregnant e 13.6% Anxiety Pregnant e 43.6% Non-pregnant e 28%
Prevalence
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
(continued on next page)
141
142
Table 1 (continued ) Authors, Year
Age
108
14-40
Portuguese sample - Adult mothers (age 19-40; n 5 54) - Adolescent mothers (age 14-18; n 5 54)
Participant Description
Edinburgh Postnatal Depression Scale (EPDS) administered: - During pregnancy (24-36 weeks) - Postpartum (2-3 months)
Study Design
Higher rate of depression (EPDSO12) in adolescents both during pregnancy and in the postpartum period -Rate of depression in adolescents: Pregnancy e 25.9% Postpartum e 25.9% -Rate of depression in adults: Pregnancy e 11.1% Postpartum e 9.3%
Results
Lanzi, Bert, Jacob, et al, 2009
682
15-35
First time mothers in the following categories: - Adolescents (age !19; n 5 396) - Lower-resource adults (age O21; n 5 169) - Higher-resource adults (age O21; n 5 117)
BDI administered: - During pregnancy - At 6 months postpartum
Higher rates of depression in adolescent mothers at both time points using both BDI clinical ratings of depression and mean BDI scores. -Rates of prenatal depression in adolescents: Mild-moderate e 41.8% Moderate-severe e 17.2% Severe e 4.1% -Rates of postpartum depression in adolescents: Mild-moderate e 26.9% Moderate-severe e 11.3% Severe e 3.8%
de Anda, Darroch, Davidson, et al, 1992
120
12-18
Pregnant adolescents, predominantly Latino/Hispanic
Administered during pregnancy: - Pregnant Adolescent and Adolescent Mother Stress Measure - Source of Stress Inventory - State-Trait Anxiety Inventory (STAI).
35% of adolescents reported feeling “very stressed, tense, or upset” often or very often. Mean STAI scores for pregnant sample: - A-Trait scale e 44.9 (SD 5 10.5) - A-State scale e 43.6 (SD 5 11.5) Mean STAI scores for non-pregnant high school sample (from a different study): - A-Trait scale e 41.6 (SD 5 11.3) - A-State scale e 37.6 (SD 5 11.8)
Wiemann, Berenson, Wagner, et al, 1996
311
!18
Pregnant (n 5 185) & never-pregnant (n 5 126) adolescents
- Youth Self Report (YSR) administered to both samples. - Used previously published normative samples of clinically referred and non-referred female adolescents.
Pregnant adolescents scored no different or significantly lower (indicating better functioning) on all scales. -YSR mean scores for pregnant adolescents Withdrawn Behavior e 4.0 (SD 5 2.5) Anxiety/depression e 6.3 (SD 5 4.8) Social Problems e 2.7 (SD 5 2.0) Thought Problems e 2.3 (SD 5 2.2) Attention Problems e 4.6 (SD 5 3.2) Delinquent Behavior e 3.2 (SD 5 2.5) Aggressive Behavior e 8.9 (SD 5 6.1) -YSR mean scores for non-pregnant adolescents Withdrawn Behavior e 4.4 (SD 5 2.7) Anxiety/depression e 6.9 (SD 5 5.9) Social Problems e 3.1 (SD 5 2.5) Thought Problems e 2.9 (SD 5 2.7) Attention Problems e 5.1 (SD 5 3.6) Delinquent Behavior e 4.8 (SD 5 3.4) Aggressive Behavior e 10.5 (SD 5 7.6)
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
n
Figueiedo, Pacheo, Costa, 2007
Comorbidity 12-18
Postpartum adolescents attending an adolescent pregnancy and parenting program.
- CES-D assessed depression - Self-report of alcohol use at 4 months postpartum. - Urine drug screens at 2 & 4 months postpartum
Rates of depression (CES-D $ 21): -Substance users e 44% -Non-substance users e 24% Illicit substance and/or alcohol use was 3.3 times greater for depressed than non-depressed.
Bottomley, Lancaster, 2008
81
13-20
Pregnant adolescents in Australia
Assessed at 2 time points, in early & late pregnancy: - Smoking Questionnaire - EPDS
-No mean differences in levels of depression between smokers and non-smokers. -Proportion of adolescents who scored above the cutoff score on the EPDS was higher in the smoking than non-smoking group.
Bessa, Mitsuhiro, Chalem, et al, 2010
1000
M 5 17.1
Pregnant adolescents in Brazil.
Assessed during 3rd trimester: - CIDI assessed depression - Analyzed hair samples to test for cocaine and marijuana use.
Diagnosis of bipolar disorder, post-traumatic stress disorder (PTSD) and somatoform disorder were associated with greater cocaine and/or marijuana use.
Goldstein, Strober, Birmaher, et al, 2008
249
12-17
Adolescents diagnosed with DSM-IV bipolar disorder.
- Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS) for diagnosis of bipolar disorder and substance use disorder (SUD). - Life Events Checklist to assess pregnancy and abortion.
In bipolar adolescents, having SUD was significantly associated with pregnancy and abortion over past 12 months. Bipolar disorder with SUD (n 5 40): Pregnancy e 20% Abortion e 12% Bipolar disorder without SUD (n 5 209): Pregnancy e 1% Abortion e 0%
Barnet, Joffe, Duggan, et al, 1996
125
12-18
Pregnant adolescents, predominantly African American sample.
Administered during pregnancy and at 2 & 4 months postpartum - CESD Children (CES-DC) to assess depression -Arizona Social Support Interview Schedule (ASSIS) -Life Events Scale to assess stress
-Stress levels significantly associated with depressive symptoms. -Social support from adolescent's mother or baby's father both significantly associated with lower levels of depression.
Birkeland, Thompson, Phares, 2005
149
15-19
Adolescent mothers 3-12 months postpartum.
Administered EPDS & Parenting Stress Index at one time point.
- Social isolation was significantly associated with depression levels in a multiple regression. -Other associations with depression included weight/shape disturbance & maternal self-efficacy.
Cox, Buman, Valenzuela, et al, 2008
168
!19
Adolescent mothers at 2 weeks postpartum
Administered: - CES-DC to assess depression - Duke-UNC Functional Social Support Questionnaire
-Depression associated with decreased perception of social support. -Depression also associated with lower maternal confidence in ability to parent. - Social isolation & dissatisfaction with one's weight or body shape also associated with depressive symptoms.
Psychosocial Correlates
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
125
Barnet, Duggan, Wilson, et al, 1995
(continued on next page) 143
144
Table 1 (continued ) Authors, Year
n
Age
Participant Description
Study Design
Results
21
16-19
Adolescent mothers at 3 months postpartum
Administered: - CES-DC to assess depression - UCLA Loneliness Scale - Social Support Questionnaire-Short Form
-Negative association found between levels of depression and social support. -Loneliness positively associated with depression.
Stevenson, Maton, Teti, 1999
110
13-18
Pregnant adolescents in their 2nd or 3rd trimester of pregnancy
Administered the following via clinical interview: - Social Support Scale - Marital Adjustment Scale (MAS) - Brief Symptom Inventory (BSI), - Rosenberg's Self-esteem scale
-Bi-directional support between pregnant adolescents and their parents associated with lower anxiety and depression. -Bi-directional support between pregnant adolescents and friends was not associated with lower levels of anxiety or depression. -Having a high-quality romantic relationship with the baby's father was associated with higher self-esteem and lower levels of depression.
Turner, Grindstaff, Phillips, 1990
268
M 5 17.6
Adolescents during pregnancy and four weeks postpartum.
- Assessed infant outcome by gestational age and birth weight. - Administered CES-D at 4 weeks postpartum. -Administered the Provisions of Social Relations (PSR) Scale to assess social support during early pregnancy.
- Family support positively associated with baby's birth weight, controlled for gestational age. -Friend support, family support, and living with parents were significantly associated with lower depressive scores (family support had the strongest association).
Panzarine, Slater, Sharps, 1995
50
13-18
Adolescent mothers 6 months postpartum.
- Administered BDI - Created a measure that assessed Coping with Motherhood, including a Seeking Social Support subscale. - Social support assessed using Barrera's Inventory of Social Supportive Behaviors.
- No difference in frequency of social support between depressed and non-depressed adolescents. - Adolescents with mild-moderate depressive symptoms were less satisfied with their social support than non-depressed adolescents.
Sacco, Macleod, 1990
61
12-19
Pregnant adolescents and their primary caregivers (mother or person in household with whom they felt the closest).
- Administered CES-D - Caregiver's affective response & attitude towards pregnancy assessed using Likert scales. - Perceived Social Support from Family (PSS-Fa) scale given to adolescents & caregivers.
-Adolescents' depression was not related to amount of social support reported by adolescents or caregivers. -Adolescents' depression was associated with more anger & concern and more negativity about pregnancy as expressed by their caregivers.
Secco, Profit, Kennedy, et al, 2007
78
M 5 16.8
Pregnant adolescents assessed during third trimester of pregnancy until 12-18 months postpartum.
- Administered BDI 4 weeks postpartum - Assessed perceived social support using PSS-Fa and PSS-Fr (assessing friendship support) during third trimester. - Assessed enacted social support using Inventory of Socially Supportive Behaviors (ISSB) 4 weeks postpartum.
- Perceived and actual social support from family and friends were not associated with postpartum depression. - Socioeconomic status (SES) was associated with depressive symptoms.
Logsdon, Hertweck, Ziegler, 2008
85
13-18
Adolescent mothers 4-6 weeks postpartum.
- Administered CES-D - Macrosystem assessed by SES and Survey of Exposure to Community Violence Scale. - Mesosystem assessed by Postpartum Support Questionnaire & Social Network Index. - Microsystem assessed by Perceived Stress Scale-4, Rosenberg's Self-Esteem Scale, & Perlin's Sense of Mastery Scale.
- Deficiencies in 3 levels of social support were associated with depressive symptoms. - Levels examined were: macrosystem (e.g., SES, exposure to community violence), mesosystem (e.g., social network, postpartum support), and microsystem (e.g., self-esteem, perceived stress).
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
Hudson, Elek, Campbell-Grossman, 2000
Milan, Kershaw, Lewis, et al, 2007
700
14-24
-Pregnant adolescents (age 14-19; n 5 352) - Pregnant young adults (age 20-24; n 5 348). - Average gestational age was 18 weeks.
- Administered CES-D - Assessed prenatal social support using adapted scale. - Parental Caregiving Style assessed perceived quality of caregiving during childhood.
- Adolescents who perceived their mothers as more unavailable and their fathers as both more unavailable and more hostile experienced more depression during pregnancy.
Kabir, Sheeder, Stevens-Simon, 2008
1684
13-21
Pregnant adolescents assessed during each trimester.
- Administered CES-D during each trimester, when possible. vCollected total pregnancy weight gain from medical record. - Birth weight & gestational age of baby obtained by medical record.
- Higher depression scores during the 2nd and 3rd trimesters were predictive of inadequate weight gain during pregnancy, small for gestational age fetuses, and preterm delivery.
63
13-19
Adolescent mothers and their children from 3-4 weeks postpartum until 28-36 months postpartum.
- Administered BDI during first year postpartum and at 3 years postpartum. - Administered Child Behavior Checklist (CBCL) to assess preschoolers' behavior at age 2-3. - Coded interactions between mothers & toddlers according to contingent responses and conflict.
-Mothers' level of depression was associated with preschool problem behavior and poor interactions between the child and mother. -Depressive symptoms in the first 3 years postpartum accounted for a significant portion of the variance in child problem behaviors at two to three years of age.
Outcomes
Leadbeater, Bishop, Raver, 1996
5260
not reported
Adolescent (age #18) and adult (age O18) mothers and their teenaged children.
- Administered Delusions-Symptoms-States Inventory (DSSI) to assess maternal depression at 3-5 days postpartum, 6 months postpartum, and 14 years postpartum. Assessments of 14-year-old offspring: - Youth Self Report (YSR) - Raven's Standard Progressive Matrices - Wide Range of Achievements Test (WRAT3) - Asked adolescent & mother about health, smoking & alcohol use.
- Offspring of adolescent mothers demonstrated greater levels of psychopathology, poorer school performance, poorer reading ability, higher levels of criminal activity, greater use of tobacco, and more frequent consumption of alcohol than the offspring of adult mothers. - When adjusting for maternal depression during the postpartum period and when the child was 14 years old, most of these associations were attenuated.
Lee, 2009
1961
15-19 & O26
Postpartum - Adolescents (15-19; n 5 598) - Adults (O26; n 5 1363).
- Administered CIDI-SF at 1 year postpartum. - Parenting assessed during 3rd year postpartum using Conflict Tactics Scales (CTS).
- Adolescent motherhood was significant predictor of physical aggression, verbal aggression, and spanking. - Maternal depressive symptoms significantly predicted physical aggression in both adolescent and adult mothers.
260
M 5 18.0
Adolescent mothers with (n 5 160) and without (n 5 100) depressive symptoms.
Assessment -Administered BDI -Infants assessed using Bayley Scales of Infant Development and Early Social Communication Scales. Treatment - Adolescents at-risk for continuing depressive symptoms randomly assigned to treatment or control groups at 3 months postpartum. - Treatment lasted from 3-6 months postpartum. - Social/educational/vocational rehabilitation program and included free daycare.
- Mothers' BDI scores in the study did not decrease to the level of non-depressed control mothers. -Infant outcomes more favorable in the treatment group than in the depressed group that did not receive treatment.
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
Shaw, Lawlor, Najman, 2006
Psychosocial Treatment Field, Pickens, Prodromidis, 2000
145
(continued on next page)
146
Table 1 (continued ) Authors, Year
n
Participant Description
Study Design
Results
16
14-20
Pregnant and postpartum adolescents scoring above the clinical cutoff score on the BDI.
Assessment - Administered BDI before & after treatment. - Administered 2 measures to assess parental attributions about their children. Treatment - Randomized to treatment (n 5 9) and control (n 5 7) groups. - Intervention: classroom-based. Focus included increasing autonomy, bolstering social support, and addressing parenting attributions.
- Depressive symptoms decreased in treatment group significantly more than in control group. - Negative attributions were also improved in the treatment group.
Miller, Gur, Shanok, et al, 2008
25
13-18
Study 1: Pregnant adolescents of varying levels of depression (N 5 14). Study 2: Pregnant adolescents with diagnoses of depressive disorder or adjustment disorder (N 5 11).
Assessment: Study 1 - Administered BDI and EPDS before & after treatment. Assessment: Study 2 - Administered K-SADS - Administered BDI and EPDS before & after treatment and at 20 weeks postpartum. Treatment: Studies 1 & 2 - Used Interpersonal Therapy (IPT) in group format - No comparison group. - Adapted IPT manual for use with pregnant adolescents.
Study 1: -Significant decrease in depressive symptoms from pre- to post-treatment. Study 2: - Improvement in severity of disorder in all but one participant.
Logsdon, Birkimer, Simpton, et al, 2005
128
13-18
Pregnant and postpartum adolescents.
Assessment (administered at 32-36 weeks of pregnancy and 6 weeks postpartum): - CES-D - Postpartum Support Questionnaire (PSQ) - Rosenberg's Self-Esteem Scale Treatment: - Social support intervention administered during pregnancy to prevent postpartum depression. - Randomized into 4 groups based on how intervention was administered: 1. A videotape 2. A pamphlet 3. Both pamphlet & videotape 4. No treatment (control group).
-No statistical difference in postpartum depressive symptoms among the groups
Barnet, Liu, DeVoe, et al, 2007
84
12-18
Pregnant, African American adolescents followed from pregnancy until 2 years postpartum.
Assessment (conducted during pregnancy and 1 & 2 years postpartum): - CES-D - Adult-Adolescent Parenting Inventory Treatment: - Randomized to treatment or usual care conditions. - Treatment was a home visiting program beginning during pregnancy and extending through the child's 2nd birthday.
- Intervention group did not differ from usual care group with regard to depressive symptoms one or two years postpartum. - Parenting attitudes were improved in treatment group as compared to usual care.
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
Age
Stirtzinger, McDermid, Grusec , et al, 2002
147
- No difference in self-reported anxiety or stress between treatment and control group. Cognitive (e.g., concentration) and affective (e.g., frustration) manifestations of stress, were lower in treatment group after the intervention.
Birth and Child Outcomes
M, Mean age in studies that did not report an age range but only reported the mean.
Assessment (completed before and after treatment): - State-Trait Anxiety Inventory (STAI) - Pregnant Adolescent/Adolescent mother Stress Measure - Source of Stress Inventory (Short Form) Treatment: - 3/4 of participants were randomized into treatment or control groups. Remainder of participants self-selected their study group. - Treatment was a 5-week stress management group program using relaxation & cognitive techniques. Pregnant and postpartum adolescents. 35 de Anda, Darroch, Davidson, et al, 1990
14-18
58 Koniak-Griffin, 1994
14-20
Pregnant adolescents
Assessment (administered before and after intervention was completed): - CES-D - Self-Esteem Inventory Treatment: - Participants chose whether to participate in treatment (N 5 35) or not participate in treatment (comparison group; N 5 23). - Treatment was weekly exercise classes twice per week for six weeks.
- Symptoms of depression significantly reduced in treatment group as compared to control group.
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
Parallel to concerns about adolescent mothers are the concerns about birth and infant outcomes. One study team found that depression in the second and third trimesters in adolescent mothers predicted both small for gestational age (SGA) infants and preterm deliveries.42 Depression measured in the first trimester was not predictive of any adverse birth outcomes. Current findings suggest that postpartum depressive symptoms in adolescent mothers are associated with problem behavior and poorer academic achievement in offspring from toddlerhood through adolescence. Leadbeater and colleagues43 followed children of adolescent mothers from 3-4 weeks until 28-36 months after birth, assessing maternal depressive symptoms with the BDI. Mothers' level of depression was significantly associated with preschool problem behavior and poor interactions between the child and mother. In addition, depressive symptoms in the first 3 years postpartum accounted for a significant portion of the variance in child problem behaviors at 2 to 3 years of age. In an Australian sample of adolescent mothers, Shaw and colleagues44 examined whether being born to an adolescent mother affected psychological and behavioral outcomes when the child was 14 years old. The study also examined potential mediators of this association, including maternal self-reported depressive symptoms. Offspring of adolescent mothers demonstrated greater levels of psychopathology, poorer school performance, poorer reading ability, higher levels of criminal activity, greater use of tobacco, and more frequent consumption of alcohol than the offspring of adult mothers. However, when adjusting for maternal depression during the postpartum period and when the child was 14 years old, most of these associations were attenuated. Thus, higher levels of maternal depression in adolescent mothers may have accounted for the association between maternal age and adverse outcomes in their children, rather than adolescent parenthood alone. Adolescent mothers experiencing postpartum depression are more likely to use aggressive parenting behaviors with their children. Lee45 examined the influence of postpartum depressive symptoms (established by the Composite International Diagnostic Interview, Short Form)46 on harsh parenting behaviors (eg, physical and verbal aggression and spanking) at 3 years postpartum in both adolescent and adult mothers. Adolescent motherhood was a significant predictor of physical aggression, verbal aggression, and spanking. Maternal depressive symptoms, along with working, paternal support, expected social support, and attendance at religious services, significantly predicted physical aggression in both adolescent and adult mothers. Overall, studies have presented clear evidence for negative birth and child outcomes among depressed adolescent mothers. Negative birth outcomes include higher rates of SGA and preterm deliveries in pregnant adolescents experiencing depression.42 Many negative childhood outcomes are associated with maternal depressive symptoms in children of adolescent mothers.40 Depression is also associated with harsher parenting behaviors in adolescent
148
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
mothers.45 Interestingly, the negative childhood outcomes and harsher parenting behaviors associated with adolescent motherhood may be partially explained by a higher rate of depression, rather than age of the mothers alone.44 Psychosocial Treatment
Educational group interventions are successful treatments for adolescent depressive symptoms during pregnancy and the postpartum period. Field and colleagues47 conducted an intervention for adolescent mothers who were at risk for developing postpartum depression. Risk in this study was determined by neonatal predictors of 6month postpartum depression (right frontal EEG, elevated serotonin, elevated cortisol, less positive interaction behavior, elevated norepinephrine, and low vagal tone).47 Adolescents began the program when they were 3 months postpartum and continued through 6 months postpartum. The social/educational/vocational rehabilitation program, conducted at a vocational high school, included free daycare. Although mothers' BDI scores in the study did not decrease to the level of non-depressed control mothers, infant outcomes were more favorable in the treatment group than in the depressed group that did not receive treatment.47 Stirtzinger and colleagues48 also conducted psychoeducational groups for adolescents with depressive symptoms who were pregnant or had young children. The intervention emphasized the need for autonomy and selfrecognition in adolescent mothers, assisted adolescents with bolstering their social support networks, and addressed adolescents' parenting attributions based on their experiences in childhood and as parents. Depressive symptoms were decreased in the treatment group significantly more than in the control group. Negative attributions were also improved in the treatment group. Interpersonal Psychotherapy (IPT), an evidence-based treatment for MDD, has also demonstrated success with depressed, pregnant adolescents. Miller and colleagues49 conducted 2 studies using IPT in a group format to treat pregnant adolescents with depressive symptoms (first study) and pregnant adolescents with a depressive disorder or adjustment disorder (second study) with no comparison group in either study. The intervention adapted the IPT manual to the unique needs of pregnant adolescents. Goals were (1) clarifying the role transition to motherhood, (2) identifying resources for health during pregnancy, (3) getting social support from other mothers, and (4) practicing negotiating conflicts and avoiding danger to the infant. Findings revealed a significant decrease in depressive symptoms in the first study and improvement in the severity of disorder in all but 1 participant in the second study. Positive regard and validation by the therapist and reinforcement from group members and other health care professionals were the most effective components of treatment.50 Three separate studies tested a social support intervention, home visiting program, and exercise intervention in the treatment of perinatal adolescent depression. Logsdon and colleagues51 examined a social support intervention administered during pregnancy for the prevention of
postpartum depression in adolescents. Adolescents were randomized to receive the intervention using a videotape, a pamphlet, both the pamphlet and videotape, or no treatment (control condition). However, there was no statistical difference in postpartum depressive symptoms between the 3 groups. Barnet and colleagues52 conducted a study of a home visiting program beginning during pregnancy and extending through the child's second birthday in an urban, African American sample. As compared to a usual care control group, the intervention did not affect depressive symptoms 1 or 2 years postpartum, although parenting attitudes were improved. A 6-week aerobic exercise program was found to significantly reduce symptoms of depression in pregnant adolescents as compared to a control group who did not participate in the exercise program.53 One treatment study targeted anxiety and stress in perinatal adolescents reporting mixed results. De Anda and colleagues54 developed a 5-week stress management group program for pregnant and parenting adolescents, utilizing relaxation and cognitive techniques. After completion of the group, there was no difference in self-reported anxiety or stress between the group who received treatment and the no-treatment control group. Cognitive (eg, concentration) and affective (eg, frustration) manifestations of stress, however, were lower in the treatment group after the completion of the program. A wide variety of psychosocial treatments for depression during pregnancy and the postpartum period in adolescents have been tested, with variable findings. Success in improving infant outcomes and reducing symptoms has been demonstrated by some investigative teams44e46,50 but not by others.48,49 The 1 known intervention used to treat anxiety in pregnant and postpartum adolescents did not reduce self-reported anxiety. Cognitive and affective manifestations of anxiety were reduced, however.51 Conclusions
There is a developing body of literature examining adolescent mental health in the context of pregnancy and the postpartum period, primarily focusing upon depressive symptoms. Findings suggest that rates of depressive symptoms in pregnant and postpartum adolescents are comparable to non-pregnant adolescents, but higher than those reported in samples of pregnant adults. This is of serious concern, given the known risks of perinatal depression to mother and baby including increased substance use, poor social support, impaired parenting ability, birth complications, and maladaptive child behavior.6,7 Existing research is limited by the almost exclusive use of screening measures and the variable thresholds employed by study teams. Future research using rigorous clinicianrated diagnostic interviews to assess depressive disorders would provide a clearer clinical picture of adolescent maternal depression. Despite the focus on depression in pregnant and postpartum adolescents in the literature, psychosocial treatment research for this population has rarely moved beyond psychoeducation. In fact, of the 3 treatments demonstrating effectiveness in the reduction of depressive symptoms, only
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
1 evaluated an evidence-based psychotherapy treatment.49 Moreover, no treatment studies reviewed used the randomized controlled study design, the gold standard in evaluating treatment efficacy. Although beyond the scope of this review, there are no formal guidelines for the treatment of pregnant adolescents with antidepressants, and no known studies have examined the use of medication with pregnant adolescents.55 The reluctance to initiate formal research in this area may be provoked by the doubly “vulnerable” status of this population under human subjects protections.56 Given the prevalence rates of and serious consequences associated with perinatal depression in adolescents, there is a grave need for further treatment research with this population. Research on psychiatric disorders other than depression during pregnancy and the postpartum period in adolescents is also sorely lacking. The only study of anxiety in pregnant adolescents indicated that rates might be higher than in non-pregnant adolescents,23 indicating the necessity for future research. Only 2 studies examined pregnancy and bipolar disorder in adolescent samples, both finding substance and alcohol use to be significant correlates.29,30 These findings suggest that bipolar disorder might be a serious risk factor for pregnant adolescents and their babies. In fact, impulsivity, risk-taking, and increased sexual behavior are all symptoms of bipolar disorder, perhaps putting these adolescents at an even greater risk of becoming pregnant than the general adolescent population. Studies of bipolar disorder in pregnant and postpartum adults indicate severe risks including postpartum psychosis and even maternal suicide and infanticide.10 Given the increasing rates of bipolar disorder diagnoses, studying the impact of the illness during pregnancy and the postpartum period in adolescent samples is a clear priority for future research. In conclusion, there is a growing literature considering mental health during adolescent pregnancy and the early postpartum years. In particular, symptoms of depression in adolescents have been widely studied. We need future investigations that utilize randomized designs where possible, and study interventions for anxiety and bipolar disorder adapted to the unique characteristics of pregnant and postpartum adolescents. Perinatal adolescents are an underserved and often marginalized population in society. The identification of those vulnerable to psychiatric illness and the development of early, effective interventions for young mothers are essential steps toward better biopsychosocial outcomes for mother and baby.
6.
7. 8.
9.
10. 11. 12.
13. 14.
15. 16.
17. 18. 19.
20.
21.
22. 23. 24. 25.
26. 27.
28. 29. 30. 31.
32. 33.
References 34. 1. Elfenbein DS, Felice ME: Adolescent pregnancy. Pediatr Clin North Am 2003; 50:781 2. Martinez G, Copen CE, Abma JC: Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2006-2010 national survey of family growth. Vital Health Stat 2011; 31:1 3. Centers for Disease Control and Prevention: Teen Pregnancy Prevention 2010-2015: Available: http://www.cdc.gov/TeenPregnancy/PreventTeenPreg. htm. Accessed May 27, 2012 4. Steinberg L: Risk taking in adolescence: what changes, and why? Ann N Y Acad Sci 2004; 1021:51 5. Furman W, McDunn C, Young B: Peer relations, friendships, and romantic relationships: implications for the development and maintenance of depression in adolescents. In: Allen N, Sheeber L, editors. Adolescent emotional
35. 36. 37. 38.
39.
149
development and the emergence of depressive disorders. New York, Cambridge University Press, 2009, pp 299e317 Li D, Liu L, Odouli R: Presence of depressive symptoms during early pregnancy and the risk of preterm delivery: a prospective cohort study. Hum Reprod 2009; 24:146 Diego MA, Field T, Hernandez-Reif M, et al: Prenatal depression restricts fetal growth. Early Hum Dev 2009; 85:65 Davalos DB, Yadon CA, Tregellas HC: Untreated prenatal maternal depression and the potential risks to offspring: a review. Arch Womens Ment Health 2012; 15:1 Viguera AC, Whitfield T, Baldessarini RJ, et al: Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Am J Psychiatry 1817; 2007:164 Jones I, Craddock N: Bipolar disorder and childbirth: the importance of recognising risk. Br J Psychiatry 2005; 186:453 Kessler RC, Berglund PA, Foster CL, et al: Social consequences of psychiatric disorders, II: Teenage parenthood. Am J Psychiatry 1997; 154:1405 National Institute of Health: NIH Policy on the Inclusion of Children in Clinical Research: Evaluation of Policy Implementation at the NICHD. Available: http:// opasi.nih.gov/eo/documents/NICHD-Pediatric-Inclusion-report-FINAL-(06-703R-NICHD).pdf. Accessed August 31, 2013 Mitsuhiro SS, Chalem E, Barros MC, et al: Brief report: prevalence of psychiatric disorders in pregnant teenagers. J Adolesc 2009; 32:747 € n TB: The World Mental Health (WMH) Survey Initiative Kessler RC, Ustu Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res 2004; 13:93 Steer RA, Scholl TO, Beck AT: Revised Beck Depression Inventory scores of inner-city adolescents: pre- and postpartum. Psychol Rep 1990; 66:315 Ginsburg GS, Baker EV, Mullany BC, et al: Depressive symptoms among reservation-based pregnant American Indian adolescents. Matern Child Health J 2008; 12(Suppl 1):110 Troutman BR, Cutrona CE: Nonpsychotic postpartum depression among adolescent mothers. J Abnorm Psychol 1990; 99:69 Endicott J, Spitzer RL: A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch Gen Psychiatry 1978; 35:837 Schmidt RM, Wiemann CM, Rickert VI, et al: Moderate to severe depressive symptoms among adolescent mothers followed four years postpartum. J Adolesc Health 2006; 38:712 Freitas GV, Cais CF, Stefanello S, et al: Psychosocial conditions and suicidal behavior in pregnant teenagers: a case-control study in Brazil. Eur Child Adolesc Psychiatry 2008; 17:336 Figueiredo B, Pacheco A, Costa R: Depression during pregnancy and the postpartum period in adolescent and adult Portuguese mothers. Arch Womens Ment Health 2007; 10:103 Lanzi RG, Bert SC, Jacobs BK: Depression among a sample of first-time adolescent and adult mothers. J Child Adolesc Psychiatr Nurs 2009; 22:194 de Anda D, Darroch P, Davidson M, et al: Stress and coping among pregnant adolescents. J Adolesc Res 1992; 7:94 Spielberger CD, Gorsuch RL, Lushene RE: Manual for the State-Trait Anxiety Inventory. Palo Alto, CA, Consulting Psychologists Press, 1970 Achenbach TM, Rescorla LA: Manual for the ASEBA School-Age Forms & Profiles. Burlington, VT, University of Vermont Research Center for Children, Youth & Families, 2001 Wiemann CM, Berenson AB, Wagner KD, et al: Prevalence and correlates of psychopathology in pregnant adolescents. J Adolesc Health 1996; 18:35 Barnet B, Duggan AK, Wilson MD, et al: Association between postpartum substance use and depressive symptoms, stress, and social support in adolescent mothers. Pediatrics 1995; 96:659 Bottomley KL, Lancaster SJ: The association between depressive symptoms and smoking in pregnant adolescents. Psychol Health Med 2008; 13:574 Bessa MA, Mitsuhiro SS, Chalem E, et al: Correlates of substance use during ~o Paulo, Brazil. Rev Bras Psiquiatr 2010; 32:66 adolescent pregnancy in Sa Goldstein BI, Strober MA, Birmaher B, et al: Substance use disorders among adolescents with bipolar spectrum disorders. Bipolar Disord 2008; 10:469 Barnet B, Joffe A, Duggan AK, et al: Depressive symptoms, stress, and social support in pregnant and postpartum adolescents. Arch Pediatr Adolesc Med 1996; 150:64 Birkeland R, Thompson JK, Phares V: Adolescent motherhood and postpartum depression. J Clin Child Adolesc Psychol 2005; 34:292 Cox JE, Buman M, Valenzuela J, et al: Depression, parenting attributes, and social support among adolescent mothers attending a teen tot program. J Pediatr Adolesc Gynecol 2008; 21:275 Hudson DB, Elek SM, Campbell-Grossman C: Depression, self-esteem, loneliness, and social support among adolescent mothers participating in the new parents project. Adolescence 2000; 35:445 Stevenson W, Maton KI, Teti DM: Social support, relationship quality, and well-being among pregnant adolescents. J Adolesc 1999; 22:109 Turner RJ, Grindstaff CF, Phillips N: Social support and outcome in teenage pregnancy. J Health Social Behav 1990; 31:43 Panzarine S, Slater E, Sharps P: Coping, social support, and depressive symptoms in adolescent mothers. J Adolesc Health 1995; 17:113 Sacco WP, MacLeod VA: Interpersonal responses of primary caregivers to pregnant adolescents differeing on depression level. J Clin Child Psychol 1990; 19:265 Secco ML, Profit S, Kennedy E, et al: Factors affecting postpartum depressive symptoms of adolescent mothers. J Obstet Gynecol Neonatal Nurs 2007; 36:47
150
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
40. Logsdon MC, Ziegler C, Hertweck P, et al: Testing a bioecological model to examine social support in postpartum adolescents. J Nurs Scholarsh 2008; 40:116 41. Milan S, Kershaw T, Lewis J, et al: Caregiving history and prenatal depressive symptoms in low income adolescent and young adult women: Moderating and Mediating Effects. Psychol Women Q 2007; 31:241 42. Kabir K, Sheeder J, Stevens-Simon C: Depression, weight gain, and low birth weight adolescent delivery: do somatic symptoms strengthen or weaken the relationship? J Pediatr Adolesc Gynecol 2008; 21:335 43. Leadbeater BJ, Bishop SJ, Raver CC: Quality of mother-toddler interactions, maternal depressive symptoms, and behavior problems in preschoolers of adolescent mothers. Dev Psychol 1996; 32:280 44. Shaw M, Lawlor DA, Najman JM: Teenage children of teenage mothers: psychological, behavioural and health outcomes from an Australian prospective longitudinal study. Soc Sci Med 2006; 62:2526 45. Lee Y: Early motherhood and harsh parenting: the role of human, social, and cultural capital. Child Abuse Negl 2009; 33:625 46. Kessler RC, Andrews G, Colpe LJ, et al: Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002; 32:959 47. Field T, Pickens J, Prodromidis M, et al: Targeting adolescent mothers with depressive symptoms for early intervention. Adolescence 2000; 35:381
48. Stirtzinger R, McDermid S, Grusec J, et al: Interrupting the inter-generational cycle in high risk adolescent pregnancy. J Primary Prev 2002; 23:7 49. Miller L, Gur M, Shanok A, et al: Interpersonal psychotherapy with pregnant adolescents: two pilot studies. J Child Psychol Psychiatr 2008; 49:733 50. Shanok AF, Miller L: Depression and treatment with inner city pregnant and parenting teens. Arch Womens Ment Health 2007; 10:199 51. Logsdon MC, Birkimer JC, Simpson T, et al: Postpartum depression and social support in adolescents. J Obstet Gynecol Neonatal Nurs 2005; 34:46 52. Barnet B, Liu J, Devoe M, et al: Home visiting for adolescent mothers: effects on parenting, maternal life course, and primary care linkage. Ann Fam Med 2007; 5:224 53. Koniak-Griffin D: Aerobic exercise, psychological well-being, and physical discomforts during adolescent pregnancy. Res Nurs Health 1994; 17:253 54. de Anda D, Darroch P, Davidson M, et al: Stress management for pregnant adolescents and adolescent mothers: a pilot study. Child Adolesc Soc Work 1990; 7:53 55. McClanahan KK: Depression in pregnant adolescents: considerations for treatment. J Pediatr Adolesc Gynecol 2009; 22:59 56. Brandon AR, Shivakumar G, Inrig SJ, et al: Ethical challenges in designing, conducting, and reporting research to improve the mental health of pregnant women: The voices of investigators and IRB members. American Journal of Bioethics Primary Research. 2013 [epub ahead of print]
a b s t r a c t Study Objective: Pregnancy during adolescence is a risk factor for adverse medical and psychosocial outcomes, including psychiatric illness. Psychiatric illness is linked with obstetric complications along with impaired maternal functioning in the postpartum period. This article provides a comprehensive review of the research examining the intersection of psychopathology and adolescent pregnancy and the postpartum period. Design: A literature search was conducted using PubMed (Medline), PsycINFO, and CINAHL for articles published between 1990 and 2013 that examined depression, anxiety, bipolar disorder, and psychosis during pregnancy and the postpartum period in adolescents age 21 years or younger. Articles were selected that covered the following topics: Prevalence or incidence, comorbidity, psychosocial correlates, birth outcomes, parenting, child outcomes, and psychosocial treatment. Forty articles were found and reviewed. Results: There is a substantial research base examining self-reported depressive symptoms in adolescents during pregnancy and the postpartum period. Existing research suggests that pregnant and parenting adolescents are at greater risk for experiencing depressive symptoms than pregnant and postpartum adult women. Depression in the perinatal period is also a risk factor for substance and alcohol abuse and a harsher parenting style in adolescents. Areas for future research in this population include investigating the prevalence, psychosocial correlates, and outcomes of clinically diagnosed Major Depressive Disorder, developing and empirically validating psychotherapeutic treatments, and focusing upon other psychiatric diagnoses such as bipolar disorder, anxiety, and psychosis. Key Words: Adolescents, Pregnancy, Postpartum, Depression, Anxiety
Introduction
Pregnant adolescents are at increased risk for adverse outcomes. These include medical complications during pregnancy and delivery, repeat pregnancies, harsher parenting techniques, and cognitive and behavioral difficulties in their children.1 In 2010 alone, 367,752 infants were born to adolescent mothers, indicating that 34.3 per 1,000 adolescent girls ages 15-19 years gave birth that year.2 Although these figures suggest that adolescent pregnancy is on the decline in the US, children having children remains a significant issue. In fact, the prevention of adolescent pregnancy is a stated priority by the Centers for Disease Control and Prevention.3 Adolescence is a developmental stage marked by significant biologic and psychosocial transitions. Biological changes include neurobiological development, substantial hormonal changes, and external physical changes. Psychological changes particularly relevant to mental health include an increase in novelty and sensation seeking without an accompanying increase in self-regulation.4 Social changes occur within societal expectations to take on greater responsibility with the transition to adulthood. Peer influences become increasingly important throughout adolescence, eventually surpassing family influence and becoming the
The authors indicate no conflicts of interest. * Address correspondence to: Rebecca S. Siegel, PhD, University of North Carolina at Chapel Hill, Department of Psychiatry, Women's Mood Disorders Center, Campus Box 7160, Chapel Hill, NC 27599-7160; Phone: (919) 962-9799; fax: (919) 966-9646 E-mail address: [email protected] (R.S. Siegel).
most important source of social support.5 Although these transitions are all developmentally normative, the combination presents unique risk factors during this time of development. For example, adolescents are at a significantly increased risk for injury and accidental death due to increased risk-taking behavior.4 When mental illness occurs during these changes, it can provoke an even greater risk for behavior that can lead to harmful consequences. In this context, therefore, adolescent pregnancy presents a unique set of challenges and risk factors differentiating the experience from pregnancy during adulthood. Psychiatric illness complicates pregnancy in adult populations by compromising maternal health, negatively impacting fetal development, and impairing mother-infant bonding. Prenatal depression is also associated with a greater risk of preterm birth,6 low birth weight,7 and behavioral differences (eg, increased fussiness, less time awake and alert) in the neonate (see Davalos et al8 for a review). Depression during pregnancy is the strongest risk factor for postpartum depression. It is also consistently associated with attachment difficulties, infant behavioral changes and, at worst, maternal suicide. Women with bipolar disorder during pregnancy are at significant risk for mood episode relapse9 and postpartum psychosis, which can also lead to maternal suicide and infanticide.10 In teenagers, psychopathology is a risk factor for early parenthood, highlighting the critical implications of adolescent mental illness for society.11 Therefore, given the adverse consequences of perinatal psychopathology demonstrated in the adult literature and the links between mental illness and the incidence of adolescent pregnancy,
1083-3188/$ - see front matter Ó 2014 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2013.09.008
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
mental illness in the context of adolescent pregnancy is a serious public health concern. Research surrounding the intersection of psychopathology and adolescent pregnancy is limited, but has shown growth in the last 2 decades. Understanding the specific challenges faced by pregnant and parenting adolescents with psychiatric illness is critical to design effective prevention strategies and interventions. This discussion will provide a comprehensive review of what has been learned about psychopathology during adolescent pregnancy and the postpartum period, followed by a discussion of areas for future direction. Method
A literature search was conducted using the following electronic databases: PubMed (Medline), PsycINFO, and CINAHL. Terms entered into the search in various combinations included “adolescent, pregnancy, postpartum, depression, bipolar disorder, anxiety, psychosis.” Limitations placed on each search included publication year between 1990 and 2013, Adolescents (age 21 and younger),12 and English language. The above search terms with the specified limitations produced the following results: 172 articles from PubMed, 397 articles from PsycINFO, and 146 articles from CINAHL. After removing duplicates, articles were read and were selected for inclusion based on the following themes related to adolescent mental illness during pregnancy or the postpartum period: prevalence or incidence, comorbidity, psychosocial correlates, birth outcomes, parenting, child outcomes, and psychosocial treatment. Along these themes, 40 articles met criteria and are included in this review (see Table 1). The majority (36) focused upon depression during pregnancy and the postpartum period with only 2 examining bipolar disorder, 2 examining anxiety, and none examining psychosis. Thus, the focus of this review will be on depression during pregnancy and the postpartum period in adolescents with information on bipolar disorder and anxiety presented where available. Results Prevalence
Only 1 known study comprehensively examined the prevalence of psychiatric disorders in perinatal adolescents. Mitsuhiro and colleagues13 used the Composite International Diagnostic Interview (CIDI),14 a structured clinical interview, to diagnose psychiatric disorders in adolescents (ages 11-19) in Brazil. Adolescents were interviewed in the hospital after giving birth and asked about psychiatric symptoms experienced over the previous 12 months. Investigators reported 32.5% of adolescents endorsed symptoms meeting criteria for a psychiatric disorder. Specific prevalence rates reported were: Substance use disorders: 13.7%, Psychotic disorders: 3.5%, Major depressive disorder: 12.9%,
139
Bipolar disorder: 0.8%, Anxiety disorders: 15.7%, and Eating disorders: 0.3%. Reported rates of depression during pregnancy and the postpartum period in adolescents are widely variable, in part due to the methods investigators use for establishing depression. Self-report measures of depression such as the Beck Depression Inventory (BDI) or Edinburgh Postnatal Depression Scale (EPDS) are widely used to identify symptoms but, as screening measures, are limited in diagnostic value. Other variables such as ethnicity and age (eg, younger vs older adolescents) may also account for some variability. In studies measuring self-reported depression in pregnant adolescents, prevalence rates range from 8%15 to 47%.16 Troutman and Cutrona17 were the only investigators found in this review who employed a clinician-administered structured interview to establish the diagnosis of Major Depressive Disorder (MDD) during pregnancy. The study reported a prevalence rate of 16% in the sample of pregnant adolescents (N 5 128; MDD diagnosed using the Schedule for Affective Disorders and Schizophrenia18). Investigators also established the prevalence of postpartum MDD, with 26% of the sample meeting criteria at 6 weeks postpartum and 20% at 1 year postpartum. Studies relying upon selfreport of postpartum depressive symptoms in adolescents suggest rates ranging from 7%15 to 37%.19 Prevalence rates of depression in perinatal adolescents are comparable to depression in non-perinatal adolescents. One study, however, found suicidal behavior to be increased in the perinatal population as compared to adolescents who were not pregnant or postpartum. In a study of inner-city adolescents, Steer, Scholl, and Beck15 administered the BDI to evaluate depressive symptoms during pregnancy, at 5 weeks postpartum, and again at 6 months postpartum. Mean BDI scores in this study were comparable to rates reported in 2 other studies of non-pregnant inner-city adolescents. In the previously mentioned Troutman and Cutrona17 study, no differences in diagnosed MDD or selfreported depressive symptoms (BDI) were found between pregnant and non-pregnant adolescents measured at the same time intervals. Finally, Freitas and colleagues20 studied suicidal behavior in pregnant and non-pregnant adolescents in Brazil, finding that 20% of pregnant adolescents had attempted suicide at least once prior to their pregnancy, while only 6.3% of non-pregnant adolescents had attempted suicide. Prevalence of self-reported depressive symptoms in perinatal adolescents appears to be higher than what is reported in samples of adult perinatal women. In a Portuguese sample, Figueiredo, Pacheco, and Costa21 compared an adolescent group to an adult group of mothers during pregnancy and again at 2-3 months postpartum, reporting that a greater percentage of adolescents endorsed high levels of depressive symptoms (measured by EPDS score O12) than adults. Lanzi and colleagues22 used the BDI to measure the severity of depressive symptoms in adolescents and lower- and higher-resource adults during pregnancy and later at 6 months postpartum, also finding higher levels of symptoms in adolescents than in either category of adults.
140
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
Extant literature includes 1 study examining the prevalence of self-reported anxiety and stress in pregnant adolescents. De Anda and colleagues23 found that 35% of their sample of pregnant adolescents felt “very upset, tense, or upset” “often” or “very often.” Additionally, the mean score on the self-report State-Trait Anxiety Inventory24 suggested anxiety was higher among the sample of pregnant adolescents than in benchmark scores from a community sample of adolescent females (study did not report significance tests). Self-reported symptoms of psychopathology (Youth Self Report, YSR)25 did not differ between pregnant versus non-pregnant adolescents.26 The YSR does not measure psychiatric diagnoses per se, but reports the following syndromal scales: Withdrawn behavior, anxiety/depression, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior. The ratings of pregnant adolescents were either not different or lower (indicating better functioning) than non-pregnant adolescents on all subscales. In sum, a substantial literature has examined prevalence rates of depression in pregnant and postpartum adolescents. Rates of depression vary widely across studies with estimates between 8%15 and 47%,16 possibly due to methodological factors. Compared to rates of depression in adolescents who are not pregnant or postpartum, depression rates in perinatal adolescents do not appear to differ. However, perinatal adolescents report significantly greater rates of depression than perinatal adults. In 1 study that examined rates of anxiety in pregnant adolescents,23 the prevalence estimate was 35% and more stress was reported among pregnant than nonpregnant adolescents. Regarding self-reported symptoms of psychopathology, no differences were found between pregnant versus non-pregnant adolescents. Comorbidity
Rates of comorbidity in perinatal adolescents are estimated at 33% among those experiencing any psychiatric disorder, with research in this area focusing upon substance and alcohol use or smoking.13 Barnet and colleagues27 examined substance and alcohol use in adolescents at 2 and 4 months postpartum. Self-reported depression and stress were examined as potential correlates of postpartum substance use. Use of alcohol in the postpartum period was significantly associated with depression. Additionally, adolescents with high levels of depression were 3.3 times more likely to use substances (alcohol or illicit drugs) at 4 months postpartum than those with lower levels of depression. In examining the association between smoking and selfreported depressive symptoms in pregnant adolescents, Bottomley and Lancaster28 did not find any mean differences in levels of depression between smokers and nonsmokers. However, the proportion of adolescents who scored above the cutoff score on the EPDS, suggesting probable depression, was higher in the smoking than nonsmoking group. Only 2 studies examined bipolar disorder in perinatal adolescents and both measured comorbid substance use. Bessa and colleagues29 examined correlates of cocaine and
marijuana use during the last trimester in pregnant adolescents in Brazil. Psychiatric diagnoses in this study were determined using the CIDI. Cocaine and marijuana use were associated with bipolar disorder in addition to posttraumatic stress disorder and somatoform disorder. In a study of adolescents with bipolar disorder, Goldstein and colleagues30 examined factors associated with substance use disorder (SUD) in this sample (diagnoses of bipolar disorder were made before SUD was reported in this study). Findings revealed that bipolar adolescents with SUD were more likely to have been pregnant and to have had an abortion in the past 12 months than bipolar adolescents without SUD. Overall, studies of comorbidity in pregnant and postpartum adolescents have focused on substance use and smoking. Depression was found to be strongly associated with substance and alcohol use and smoking in postpartum adolescents.27,28 Additionally, bipolar disorder is associated with substance use in pregnant and postpartum adolescents.29,30 Psychosocial Correlates
Research supports a strong association between social support and fewer depressive symptoms in perinatal adolescents.31e36 Findings suggest, however, that it might be adolescents' satisfaction with their social support, or the quality of their social support, rather than the quantity of social support that is associated with depressive symptoms.37,38 One investigative team, however, did not find a relationship between perceived or actual social support and postpartum depressive symptoms.39 Logsdon and colleagues40 divided the social support variable into 3 “levels,” (macrosystem [eg, socioeconomic status, exposure to community violence], mesosystem [eg, social network, postpartum support], and microsystem [eg, self-esteem, perceived stress]). The study then examined the associations between postpartum depression and each level of social support in adolescents. Deficiencies in all levels of support were found to be associated with postpartum depressive symptoms. Adolescents' experiences with their own parents, beliefs about themselves, and socioeconomic status are also associated with perinatal depression. Milan and colleagues41 examined adolescents' experiences with their own parents, finding that adolescents who perceived their mothers as more unavailable and their fathers as both more unavailable and more hostile experienced more depression during pregnancy. Birkeland and colleagues32 found that maternal self-efficacy, social isolation, and dissatisfaction with one's weight or body shape were predictive of depressive symptoms. Finally, Secco and colleagues39 found socioeconomic status to predict self-reported depressive symptoms in adolescent mothers. In sum, many psychosocial factors are associated with depression during pregnancy and the postpartum period in adolescents. Perceived social support is 1 factor that many,28e35 but not all,36 studies found was associated with depression. Other psychosocial factors associated with perinatal depression in adolescents include adolescents' own childhood experiences, self-efficacy, social isolation, body satisfaction, and socioeconomic status.29,36,38
Table 1 Summary of Studies Reviewed Authors, Year
n
Age
Participant Description
Study Design
Results
Mitsuhiro, Chalem, Carvalho, et al, 2009
1000
11-19
Postpartum adolescents in an obstetric center in Brazil.
Interviewed using Composite International Diagnostic Interview (CIDI) at 4-48h after delivery. Asked about symptoms over past 12 months.
Prevalence rates: Substance use disorders e 13.7% Psychotic disorders e 3.5% Major depressive disorder e 12.9% Bipolar disorder e 0.8% Anxiety disorders e 15.7% Eating disorders e 0.3%
Steer, Scholl, Beck, 1990
158
13-18
Primarily Black and Hispanic pregnant and postpartum adolescent girls.
Beck Depression Inventory (BDI) administered at: - Week 28 of pregnancy - 5 weeks postpartum - 6 months postpartum
Rates of depression (cutoff score of 20): Never depressed e 84.8% Depressed during pregnancy e 8.2% Became depressed after delivery e 7% Ceased being depressed after delivery e 5.1% Depressed at all 3 time points e 3.1%
Ginsburg, Baker, Mullany, et al, 2008
53
12-19
Pregnant (#28 wks), reservation-based, American Indian adolescents participating in a home visiting program to promote positive parenting.
Center for Epidemiological Studies-Depression Scale (CES-D) administered one time during pregnancy.
Rates of depression: Scored $16 (clinical cutoff for CES-D) e 47% Scored $20 (elevated for adolescents) e 30% Scored $28 (1SD above mean) e 19%
Troutman, Cutrona, 1990
242
14-18
- Pregnant & postpartum adolescents (n 5 128). - Non-pregnant control adolescents (n 5 114)
Perinatal adolescents assessed using Schedule for Affective Disorders and Schizophrenia (SADS): - During pregnancy - 6 weeks postpartum - 1 year postpartum Controls assessed at similar time intervals.
No significant difference in rates of depression between perinatal adolescents and controls. Rates of MDD among perinatal adolescents: During pregnancy e 16% 6 wks postpartum e 26% 1 year postpartum e 20%
Schmidt, Wiemann, Rickert, et al, 2006
623
#18
Postpartum adolescents
BDI administered postpartum: - 3 months - 12 months - 24 months - 48 months Compared rates among different ethnicities as well as overall depression rates.
Rates of depression were lower overall for African Americans than Caucasians or Mexican Americans. Rates of depression across entire sample: 3 months postpartum e 36.7% 12 months postpartum e 28.4% 24 months postpartum e 23.6% 48 months postpartum e 21.1%
Freitas, 2008
220
14-18
Pregnant adolescents (n 5 110) & non-pregnant adolescents (n 5 110) in Sao Paulo, Brazil
Suicidality: Beck Scale for Suicide Ideation (BSI). Depression & anxiety: Hospital Anxiety and Depression Scale (HAD).
Prevalence rates: Attempted suicide Pregnant e 20% Non-pregnant e 6.3% Depression Pregnant e 26.3% Non-pregnant e 13.6% Anxiety Pregnant e 43.6% Non-pregnant e 28%
Prevalence
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
(continued on next page)
141
142
Table 1 (continued ) Authors, Year
Age
108
14-40
Portuguese sample - Adult mothers (age 19-40; n 5 54) - Adolescent mothers (age 14-18; n 5 54)
Participant Description
Edinburgh Postnatal Depression Scale (EPDS) administered: - During pregnancy (24-36 weeks) - Postpartum (2-3 months)
Study Design
Higher rate of depression (EPDSO12) in adolescents both during pregnancy and in the postpartum period -Rate of depression in adolescents: Pregnancy e 25.9% Postpartum e 25.9% -Rate of depression in adults: Pregnancy e 11.1% Postpartum e 9.3%
Results
Lanzi, Bert, Jacob, et al, 2009
682
15-35
First time mothers in the following categories: - Adolescents (age !19; n 5 396) - Lower-resource adults (age O21; n 5 169) - Higher-resource adults (age O21; n 5 117)
BDI administered: - During pregnancy - At 6 months postpartum
Higher rates of depression in adolescent mothers at both time points using both BDI clinical ratings of depression and mean BDI scores. -Rates of prenatal depression in adolescents: Mild-moderate e 41.8% Moderate-severe e 17.2% Severe e 4.1% -Rates of postpartum depression in adolescents: Mild-moderate e 26.9% Moderate-severe e 11.3% Severe e 3.8%
de Anda, Darroch, Davidson, et al, 1992
120
12-18
Pregnant adolescents, predominantly Latino/Hispanic
Administered during pregnancy: - Pregnant Adolescent and Adolescent Mother Stress Measure - Source of Stress Inventory - State-Trait Anxiety Inventory (STAI).
35% of adolescents reported feeling “very stressed, tense, or upset” often or very often. Mean STAI scores for pregnant sample: - A-Trait scale e 44.9 (SD 5 10.5) - A-State scale e 43.6 (SD 5 11.5) Mean STAI scores for non-pregnant high school sample (from a different study): - A-Trait scale e 41.6 (SD 5 11.3) - A-State scale e 37.6 (SD 5 11.8)
Wiemann, Berenson, Wagner, et al, 1996
311
!18
Pregnant (n 5 185) & never-pregnant (n 5 126) adolescents
- Youth Self Report (YSR) administered to both samples. - Used previously published normative samples of clinically referred and non-referred female adolescents.
Pregnant adolescents scored no different or significantly lower (indicating better functioning) on all scales. -YSR mean scores for pregnant adolescents Withdrawn Behavior e 4.0 (SD 5 2.5) Anxiety/depression e 6.3 (SD 5 4.8) Social Problems e 2.7 (SD 5 2.0) Thought Problems e 2.3 (SD 5 2.2) Attention Problems e 4.6 (SD 5 3.2) Delinquent Behavior e 3.2 (SD 5 2.5) Aggressive Behavior e 8.9 (SD 5 6.1) -YSR mean scores for non-pregnant adolescents Withdrawn Behavior e 4.4 (SD 5 2.7) Anxiety/depression e 6.9 (SD 5 5.9) Social Problems e 3.1 (SD 5 2.5) Thought Problems e 2.9 (SD 5 2.7) Attention Problems e 5.1 (SD 5 3.6) Delinquent Behavior e 4.8 (SD 5 3.4) Aggressive Behavior e 10.5 (SD 5 7.6)
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
n
Figueiedo, Pacheo, Costa, 2007
Comorbidity 12-18
Postpartum adolescents attending an adolescent pregnancy and parenting program.
- CES-D assessed depression - Self-report of alcohol use at 4 months postpartum. - Urine drug screens at 2 & 4 months postpartum
Rates of depression (CES-D $ 21): -Substance users e 44% -Non-substance users e 24% Illicit substance and/or alcohol use was 3.3 times greater for depressed than non-depressed.
Bottomley, Lancaster, 2008
81
13-20
Pregnant adolescents in Australia
Assessed at 2 time points, in early & late pregnancy: - Smoking Questionnaire - EPDS
-No mean differences in levels of depression between smokers and non-smokers. -Proportion of adolescents who scored above the cutoff score on the EPDS was higher in the smoking than non-smoking group.
Bessa, Mitsuhiro, Chalem, et al, 2010
1000
M 5 17.1
Pregnant adolescents in Brazil.
Assessed during 3rd trimester: - CIDI assessed depression - Analyzed hair samples to test for cocaine and marijuana use.
Diagnosis of bipolar disorder, post-traumatic stress disorder (PTSD) and somatoform disorder were associated with greater cocaine and/or marijuana use.
Goldstein, Strober, Birmaher, et al, 2008
249
12-17
Adolescents diagnosed with DSM-IV bipolar disorder.
- Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS) for diagnosis of bipolar disorder and substance use disorder (SUD). - Life Events Checklist to assess pregnancy and abortion.
In bipolar adolescents, having SUD was significantly associated with pregnancy and abortion over past 12 months. Bipolar disorder with SUD (n 5 40): Pregnancy e 20% Abortion e 12% Bipolar disorder without SUD (n 5 209): Pregnancy e 1% Abortion e 0%
Barnet, Joffe, Duggan, et al, 1996
125
12-18
Pregnant adolescents, predominantly African American sample.
Administered during pregnancy and at 2 & 4 months postpartum - CESD Children (CES-DC) to assess depression -Arizona Social Support Interview Schedule (ASSIS) -Life Events Scale to assess stress
-Stress levels significantly associated with depressive symptoms. -Social support from adolescent's mother or baby's father both significantly associated with lower levels of depression.
Birkeland, Thompson, Phares, 2005
149
15-19
Adolescent mothers 3-12 months postpartum.
Administered EPDS & Parenting Stress Index at one time point.
- Social isolation was significantly associated with depression levels in a multiple regression. -Other associations with depression included weight/shape disturbance & maternal self-efficacy.
Cox, Buman, Valenzuela, et al, 2008
168
!19
Adolescent mothers at 2 weeks postpartum
Administered: - CES-DC to assess depression - Duke-UNC Functional Social Support Questionnaire
-Depression associated with decreased perception of social support. -Depression also associated with lower maternal confidence in ability to parent. - Social isolation & dissatisfaction with one's weight or body shape also associated with depressive symptoms.
Psychosocial Correlates
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
125
Barnet, Duggan, Wilson, et al, 1995
(continued on next page) 143
144
Table 1 (continued ) Authors, Year
n
Age
Participant Description
Study Design
Results
21
16-19
Adolescent mothers at 3 months postpartum
Administered: - CES-DC to assess depression - UCLA Loneliness Scale - Social Support Questionnaire-Short Form
-Negative association found between levels of depression and social support. -Loneliness positively associated with depression.
Stevenson, Maton, Teti, 1999
110
13-18
Pregnant adolescents in their 2nd or 3rd trimester of pregnancy
Administered the following via clinical interview: - Social Support Scale - Marital Adjustment Scale (MAS) - Brief Symptom Inventory (BSI), - Rosenberg's Self-esteem scale
-Bi-directional support between pregnant adolescents and their parents associated with lower anxiety and depression. -Bi-directional support between pregnant adolescents and friends was not associated with lower levels of anxiety or depression. -Having a high-quality romantic relationship with the baby's father was associated with higher self-esteem and lower levels of depression.
Turner, Grindstaff, Phillips, 1990
268
M 5 17.6
Adolescents during pregnancy and four weeks postpartum.
- Assessed infant outcome by gestational age and birth weight. - Administered CES-D at 4 weeks postpartum. -Administered the Provisions of Social Relations (PSR) Scale to assess social support during early pregnancy.
- Family support positively associated with baby's birth weight, controlled for gestational age. -Friend support, family support, and living with parents were significantly associated with lower depressive scores (family support had the strongest association).
Panzarine, Slater, Sharps, 1995
50
13-18
Adolescent mothers 6 months postpartum.
- Administered BDI - Created a measure that assessed Coping with Motherhood, including a Seeking Social Support subscale. - Social support assessed using Barrera's Inventory of Social Supportive Behaviors.
- No difference in frequency of social support between depressed and non-depressed adolescents. - Adolescents with mild-moderate depressive symptoms were less satisfied with their social support than non-depressed adolescents.
Sacco, Macleod, 1990
61
12-19
Pregnant adolescents and their primary caregivers (mother or person in household with whom they felt the closest).
- Administered CES-D - Caregiver's affective response & attitude towards pregnancy assessed using Likert scales. - Perceived Social Support from Family (PSS-Fa) scale given to adolescents & caregivers.
-Adolescents' depression was not related to amount of social support reported by adolescents or caregivers. -Adolescents' depression was associated with more anger & concern and more negativity about pregnancy as expressed by their caregivers.
Secco, Profit, Kennedy, et al, 2007
78
M 5 16.8
Pregnant adolescents assessed during third trimester of pregnancy until 12-18 months postpartum.
- Administered BDI 4 weeks postpartum - Assessed perceived social support using PSS-Fa and PSS-Fr (assessing friendship support) during third trimester. - Assessed enacted social support using Inventory of Socially Supportive Behaviors (ISSB) 4 weeks postpartum.
- Perceived and actual social support from family and friends were not associated with postpartum depression. - Socioeconomic status (SES) was associated with depressive symptoms.
Logsdon, Hertweck, Ziegler, 2008
85
13-18
Adolescent mothers 4-6 weeks postpartum.
- Administered CES-D - Macrosystem assessed by SES and Survey of Exposure to Community Violence Scale. - Mesosystem assessed by Postpartum Support Questionnaire & Social Network Index. - Microsystem assessed by Perceived Stress Scale-4, Rosenberg's Self-Esteem Scale, & Perlin's Sense of Mastery Scale.
- Deficiencies in 3 levels of social support were associated with depressive symptoms. - Levels examined were: macrosystem (e.g., SES, exposure to community violence), mesosystem (e.g., social network, postpartum support), and microsystem (e.g., self-esteem, perceived stress).
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
Hudson, Elek, Campbell-Grossman, 2000
Milan, Kershaw, Lewis, et al, 2007
700
14-24
-Pregnant adolescents (age 14-19; n 5 352) - Pregnant young adults (age 20-24; n 5 348). - Average gestational age was 18 weeks.
- Administered CES-D - Assessed prenatal social support using adapted scale. - Parental Caregiving Style assessed perceived quality of caregiving during childhood.
- Adolescents who perceived their mothers as more unavailable and their fathers as both more unavailable and more hostile experienced more depression during pregnancy.
Kabir, Sheeder, Stevens-Simon, 2008
1684
13-21
Pregnant adolescents assessed during each trimester.
- Administered CES-D during each trimester, when possible. vCollected total pregnancy weight gain from medical record. - Birth weight & gestational age of baby obtained by medical record.
- Higher depression scores during the 2nd and 3rd trimesters were predictive of inadequate weight gain during pregnancy, small for gestational age fetuses, and preterm delivery.
63
13-19
Adolescent mothers and their children from 3-4 weeks postpartum until 28-36 months postpartum.
- Administered BDI during first year postpartum and at 3 years postpartum. - Administered Child Behavior Checklist (CBCL) to assess preschoolers' behavior at age 2-3. - Coded interactions between mothers & toddlers according to contingent responses and conflict.
-Mothers' level of depression was associated with preschool problem behavior and poor interactions between the child and mother. -Depressive symptoms in the first 3 years postpartum accounted for a significant portion of the variance in child problem behaviors at two to three years of age.
Outcomes
Leadbeater, Bishop, Raver, 1996
5260
not reported
Adolescent (age #18) and adult (age O18) mothers and their teenaged children.
- Administered Delusions-Symptoms-States Inventory (DSSI) to assess maternal depression at 3-5 days postpartum, 6 months postpartum, and 14 years postpartum. Assessments of 14-year-old offspring: - Youth Self Report (YSR) - Raven's Standard Progressive Matrices - Wide Range of Achievements Test (WRAT3) - Asked adolescent & mother about health, smoking & alcohol use.
- Offspring of adolescent mothers demonstrated greater levels of psychopathology, poorer school performance, poorer reading ability, higher levels of criminal activity, greater use of tobacco, and more frequent consumption of alcohol than the offspring of adult mothers. - When adjusting for maternal depression during the postpartum period and when the child was 14 years old, most of these associations were attenuated.
Lee, 2009
1961
15-19 & O26
Postpartum - Adolescents (15-19; n 5 598) - Adults (O26; n 5 1363).
- Administered CIDI-SF at 1 year postpartum. - Parenting assessed during 3rd year postpartum using Conflict Tactics Scales (CTS).
- Adolescent motherhood was significant predictor of physical aggression, verbal aggression, and spanking. - Maternal depressive symptoms significantly predicted physical aggression in both adolescent and adult mothers.
260
M 5 18.0
Adolescent mothers with (n 5 160) and without (n 5 100) depressive symptoms.
Assessment -Administered BDI -Infants assessed using Bayley Scales of Infant Development and Early Social Communication Scales. Treatment - Adolescents at-risk for continuing depressive symptoms randomly assigned to treatment or control groups at 3 months postpartum. - Treatment lasted from 3-6 months postpartum. - Social/educational/vocational rehabilitation program and included free daycare.
- Mothers' BDI scores in the study did not decrease to the level of non-depressed control mothers. -Infant outcomes more favorable in the treatment group than in the depressed group that did not receive treatment.
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
Shaw, Lawlor, Najman, 2006
Psychosocial Treatment Field, Pickens, Prodromidis, 2000
145
(continued on next page)
146
Table 1 (continued ) Authors, Year
n
Participant Description
Study Design
Results
16
14-20
Pregnant and postpartum adolescents scoring above the clinical cutoff score on the BDI.
Assessment - Administered BDI before & after treatment. - Administered 2 measures to assess parental attributions about their children. Treatment - Randomized to treatment (n 5 9) and control (n 5 7) groups. - Intervention: classroom-based. Focus included increasing autonomy, bolstering social support, and addressing parenting attributions.
- Depressive symptoms decreased in treatment group significantly more than in control group. - Negative attributions were also improved in the treatment group.
Miller, Gur, Shanok, et al, 2008
25
13-18
Study 1: Pregnant adolescents of varying levels of depression (N 5 14). Study 2: Pregnant adolescents with diagnoses of depressive disorder or adjustment disorder (N 5 11).
Assessment: Study 1 - Administered BDI and EPDS before & after treatment. Assessment: Study 2 - Administered K-SADS - Administered BDI and EPDS before & after treatment and at 20 weeks postpartum. Treatment: Studies 1 & 2 - Used Interpersonal Therapy (IPT) in group format - No comparison group. - Adapted IPT manual for use with pregnant adolescents.
Study 1: -Significant decrease in depressive symptoms from pre- to post-treatment. Study 2: - Improvement in severity of disorder in all but one participant.
Logsdon, Birkimer, Simpton, et al, 2005
128
13-18
Pregnant and postpartum adolescents.
Assessment (administered at 32-36 weeks of pregnancy and 6 weeks postpartum): - CES-D - Postpartum Support Questionnaire (PSQ) - Rosenberg's Self-Esteem Scale Treatment: - Social support intervention administered during pregnancy to prevent postpartum depression. - Randomized into 4 groups based on how intervention was administered: 1. A videotape 2. A pamphlet 3. Both pamphlet & videotape 4. No treatment (control group).
-No statistical difference in postpartum depressive symptoms among the groups
Barnet, Liu, DeVoe, et al, 2007
84
12-18
Pregnant, African American adolescents followed from pregnancy until 2 years postpartum.
Assessment (conducted during pregnancy and 1 & 2 years postpartum): - CES-D - Adult-Adolescent Parenting Inventory Treatment: - Randomized to treatment or usual care conditions. - Treatment was a home visiting program beginning during pregnancy and extending through the child's 2nd birthday.
- Intervention group did not differ from usual care group with regard to depressive symptoms one or two years postpartum. - Parenting attitudes were improved in treatment group as compared to usual care.
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
Age
Stirtzinger, McDermid, Grusec , et al, 2002
147
- No difference in self-reported anxiety or stress between treatment and control group. Cognitive (e.g., concentration) and affective (e.g., frustration) manifestations of stress, were lower in treatment group after the intervention.
Birth and Child Outcomes
M, Mean age in studies that did not report an age range but only reported the mean.
Assessment (completed before and after treatment): - State-Trait Anxiety Inventory (STAI) - Pregnant Adolescent/Adolescent mother Stress Measure - Source of Stress Inventory (Short Form) Treatment: - 3/4 of participants were randomized into treatment or control groups. Remainder of participants self-selected their study group. - Treatment was a 5-week stress management group program using relaxation & cognitive techniques. Pregnant and postpartum adolescents. 35 de Anda, Darroch, Davidson, et al, 1990
14-18
58 Koniak-Griffin, 1994
14-20
Pregnant adolescents
Assessment (administered before and after intervention was completed): - CES-D - Self-Esteem Inventory Treatment: - Participants chose whether to participate in treatment (N 5 35) or not participate in treatment (comparison group; N 5 23). - Treatment was weekly exercise classes twice per week for six weeks.
- Symptoms of depression significantly reduced in treatment group as compared to control group.
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
Parallel to concerns about adolescent mothers are the concerns about birth and infant outcomes. One study team found that depression in the second and third trimesters in adolescent mothers predicted both small for gestational age (SGA) infants and preterm deliveries.42 Depression measured in the first trimester was not predictive of any adverse birth outcomes. Current findings suggest that postpartum depressive symptoms in adolescent mothers are associated with problem behavior and poorer academic achievement in offspring from toddlerhood through adolescence. Leadbeater and colleagues43 followed children of adolescent mothers from 3-4 weeks until 28-36 months after birth, assessing maternal depressive symptoms with the BDI. Mothers' level of depression was significantly associated with preschool problem behavior and poor interactions between the child and mother. In addition, depressive symptoms in the first 3 years postpartum accounted for a significant portion of the variance in child problem behaviors at 2 to 3 years of age. In an Australian sample of adolescent mothers, Shaw and colleagues44 examined whether being born to an adolescent mother affected psychological and behavioral outcomes when the child was 14 years old. The study also examined potential mediators of this association, including maternal self-reported depressive symptoms. Offspring of adolescent mothers demonstrated greater levels of psychopathology, poorer school performance, poorer reading ability, higher levels of criminal activity, greater use of tobacco, and more frequent consumption of alcohol than the offspring of adult mothers. However, when adjusting for maternal depression during the postpartum period and when the child was 14 years old, most of these associations were attenuated. Thus, higher levels of maternal depression in adolescent mothers may have accounted for the association between maternal age and adverse outcomes in their children, rather than adolescent parenthood alone. Adolescent mothers experiencing postpartum depression are more likely to use aggressive parenting behaviors with their children. Lee45 examined the influence of postpartum depressive symptoms (established by the Composite International Diagnostic Interview, Short Form)46 on harsh parenting behaviors (eg, physical and verbal aggression and spanking) at 3 years postpartum in both adolescent and adult mothers. Adolescent motherhood was a significant predictor of physical aggression, verbal aggression, and spanking. Maternal depressive symptoms, along with working, paternal support, expected social support, and attendance at religious services, significantly predicted physical aggression in both adolescent and adult mothers. Overall, studies have presented clear evidence for negative birth and child outcomes among depressed adolescent mothers. Negative birth outcomes include higher rates of SGA and preterm deliveries in pregnant adolescents experiencing depression.42 Many negative childhood outcomes are associated with maternal depressive symptoms in children of adolescent mothers.40 Depression is also associated with harsher parenting behaviors in adolescent
148
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
mothers.45 Interestingly, the negative childhood outcomes and harsher parenting behaviors associated with adolescent motherhood may be partially explained by a higher rate of depression, rather than age of the mothers alone.44 Psychosocial Treatment
Educational group interventions are successful treatments for adolescent depressive symptoms during pregnancy and the postpartum period. Field and colleagues47 conducted an intervention for adolescent mothers who were at risk for developing postpartum depression. Risk in this study was determined by neonatal predictors of 6month postpartum depression (right frontal EEG, elevated serotonin, elevated cortisol, less positive interaction behavior, elevated norepinephrine, and low vagal tone).47 Adolescents began the program when they were 3 months postpartum and continued through 6 months postpartum. The social/educational/vocational rehabilitation program, conducted at a vocational high school, included free daycare. Although mothers' BDI scores in the study did not decrease to the level of non-depressed control mothers, infant outcomes were more favorable in the treatment group than in the depressed group that did not receive treatment.47 Stirtzinger and colleagues48 also conducted psychoeducational groups for adolescents with depressive symptoms who were pregnant or had young children. The intervention emphasized the need for autonomy and selfrecognition in adolescent mothers, assisted adolescents with bolstering their social support networks, and addressed adolescents' parenting attributions based on their experiences in childhood and as parents. Depressive symptoms were decreased in the treatment group significantly more than in the control group. Negative attributions were also improved in the treatment group. Interpersonal Psychotherapy (IPT), an evidence-based treatment for MDD, has also demonstrated success with depressed, pregnant adolescents. Miller and colleagues49 conducted 2 studies using IPT in a group format to treat pregnant adolescents with depressive symptoms (first study) and pregnant adolescents with a depressive disorder or adjustment disorder (second study) with no comparison group in either study. The intervention adapted the IPT manual to the unique needs of pregnant adolescents. Goals were (1) clarifying the role transition to motherhood, (2) identifying resources for health during pregnancy, (3) getting social support from other mothers, and (4) practicing negotiating conflicts and avoiding danger to the infant. Findings revealed a significant decrease in depressive symptoms in the first study and improvement in the severity of disorder in all but 1 participant in the second study. Positive regard and validation by the therapist and reinforcement from group members and other health care professionals were the most effective components of treatment.50 Three separate studies tested a social support intervention, home visiting program, and exercise intervention in the treatment of perinatal adolescent depression. Logsdon and colleagues51 examined a social support intervention administered during pregnancy for the prevention of
postpartum depression in adolescents. Adolescents were randomized to receive the intervention using a videotape, a pamphlet, both the pamphlet and videotape, or no treatment (control condition). However, there was no statistical difference in postpartum depressive symptoms between the 3 groups. Barnet and colleagues52 conducted a study of a home visiting program beginning during pregnancy and extending through the child's second birthday in an urban, African American sample. As compared to a usual care control group, the intervention did not affect depressive symptoms 1 or 2 years postpartum, although parenting attitudes were improved. A 6-week aerobic exercise program was found to significantly reduce symptoms of depression in pregnant adolescents as compared to a control group who did not participate in the exercise program.53 One treatment study targeted anxiety and stress in perinatal adolescents reporting mixed results. De Anda and colleagues54 developed a 5-week stress management group program for pregnant and parenting adolescents, utilizing relaxation and cognitive techniques. After completion of the group, there was no difference in self-reported anxiety or stress between the group who received treatment and the no-treatment control group. Cognitive (eg, concentration) and affective (eg, frustration) manifestations of stress, however, were lower in the treatment group after the completion of the program. A wide variety of psychosocial treatments for depression during pregnancy and the postpartum period in adolescents have been tested, with variable findings. Success in improving infant outcomes and reducing symptoms has been demonstrated by some investigative teams44e46,50 but not by others.48,49 The 1 known intervention used to treat anxiety in pregnant and postpartum adolescents did not reduce self-reported anxiety. Cognitive and affective manifestations of anxiety were reduced, however.51 Conclusions
There is a developing body of literature examining adolescent mental health in the context of pregnancy and the postpartum period, primarily focusing upon depressive symptoms. Findings suggest that rates of depressive symptoms in pregnant and postpartum adolescents are comparable to non-pregnant adolescents, but higher than those reported in samples of pregnant adults. This is of serious concern, given the known risks of perinatal depression to mother and baby including increased substance use, poor social support, impaired parenting ability, birth complications, and maladaptive child behavior.6,7 Existing research is limited by the almost exclusive use of screening measures and the variable thresholds employed by study teams. Future research using rigorous clinicianrated diagnostic interviews to assess depressive disorders would provide a clearer clinical picture of adolescent maternal depression. Despite the focus on depression in pregnant and postpartum adolescents in the literature, psychosocial treatment research for this population has rarely moved beyond psychoeducation. In fact, of the 3 treatments demonstrating effectiveness in the reduction of depressive symptoms, only
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
1 evaluated an evidence-based psychotherapy treatment.49 Moreover, no treatment studies reviewed used the randomized controlled study design, the gold standard in evaluating treatment efficacy. Although beyond the scope of this review, there are no formal guidelines for the treatment of pregnant adolescents with antidepressants, and no known studies have examined the use of medication with pregnant adolescents.55 The reluctance to initiate formal research in this area may be provoked by the doubly “vulnerable” status of this population under human subjects protections.56 Given the prevalence rates of and serious consequences associated with perinatal depression in adolescents, there is a grave need for further treatment research with this population. Research on psychiatric disorders other than depression during pregnancy and the postpartum period in adolescents is also sorely lacking. The only study of anxiety in pregnant adolescents indicated that rates might be higher than in non-pregnant adolescents,23 indicating the necessity for future research. Only 2 studies examined pregnancy and bipolar disorder in adolescent samples, both finding substance and alcohol use to be significant correlates.29,30 These findings suggest that bipolar disorder might be a serious risk factor for pregnant adolescents and their babies. In fact, impulsivity, risk-taking, and increased sexual behavior are all symptoms of bipolar disorder, perhaps putting these adolescents at an even greater risk of becoming pregnant than the general adolescent population. Studies of bipolar disorder in pregnant and postpartum adults indicate severe risks including postpartum psychosis and even maternal suicide and infanticide.10 Given the increasing rates of bipolar disorder diagnoses, studying the impact of the illness during pregnancy and the postpartum period in adolescent samples is a clear priority for future research. In conclusion, there is a growing literature considering mental health during adolescent pregnancy and the early postpartum years. In particular, symptoms of depression in adolescents have been widely studied. We need future investigations that utilize randomized designs where possible, and study interventions for anxiety and bipolar disorder adapted to the unique characteristics of pregnant and postpartum adolescents. Perinatal adolescents are an underserved and often marginalized population in society. The identification of those vulnerable to psychiatric illness and the development of early, effective interventions for young mothers are essential steps toward better biopsychosocial outcomes for mother and baby.
6.
7. 8.
9.
10. 11. 12.
13. 14.
15. 16.
17. 18. 19.
20.
21.
22. 23. 24. 25.
26. 27.
28. 29. 30. 31.
32. 33.
References 34. 1. Elfenbein DS, Felice ME: Adolescent pregnancy. Pediatr Clin North Am 2003; 50:781 2. Martinez G, Copen CE, Abma JC: Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2006-2010 national survey of family growth. Vital Health Stat 2011; 31:1 3. Centers for Disease Control and Prevention: Teen Pregnancy Prevention 2010-2015: Available: http://www.cdc.gov/TeenPregnancy/PreventTeenPreg. htm. Accessed May 27, 2012 4. Steinberg L: Risk taking in adolescence: what changes, and why? Ann N Y Acad Sci 2004; 1021:51 5. Furman W, McDunn C, Young B: Peer relations, friendships, and romantic relationships: implications for the development and maintenance of depression in adolescents. In: Allen N, Sheeber L, editors. Adolescent emotional
35. 36. 37. 38.
39.
149
development and the emergence of depressive disorders. New York, Cambridge University Press, 2009, pp 299e317 Li D, Liu L, Odouli R: Presence of depressive symptoms during early pregnancy and the risk of preterm delivery: a prospective cohort study. Hum Reprod 2009; 24:146 Diego MA, Field T, Hernandez-Reif M, et al: Prenatal depression restricts fetal growth. Early Hum Dev 2009; 85:65 Davalos DB, Yadon CA, Tregellas HC: Untreated prenatal maternal depression and the potential risks to offspring: a review. Arch Womens Ment Health 2012; 15:1 Viguera AC, Whitfield T, Baldessarini RJ, et al: Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Am J Psychiatry 1817; 2007:164 Jones I, Craddock N: Bipolar disorder and childbirth: the importance of recognising risk. Br J Psychiatry 2005; 186:453 Kessler RC, Berglund PA, Foster CL, et al: Social consequences of psychiatric disorders, II: Teenage parenthood. Am J Psychiatry 1997; 154:1405 National Institute of Health: NIH Policy on the Inclusion of Children in Clinical Research: Evaluation of Policy Implementation at the NICHD. Available: http:// opasi.nih.gov/eo/documents/NICHD-Pediatric-Inclusion-report-FINAL-(06-703R-NICHD).pdf. Accessed August 31, 2013 Mitsuhiro SS, Chalem E, Barros MC, et al: Brief report: prevalence of psychiatric disorders in pregnant teenagers. J Adolesc 2009; 32:747 € n TB: The World Mental Health (WMH) Survey Initiative Kessler RC, Ustu Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res 2004; 13:93 Steer RA, Scholl TO, Beck AT: Revised Beck Depression Inventory scores of inner-city adolescents: pre- and postpartum. Psychol Rep 1990; 66:315 Ginsburg GS, Baker EV, Mullany BC, et al: Depressive symptoms among reservation-based pregnant American Indian adolescents. Matern Child Health J 2008; 12(Suppl 1):110 Troutman BR, Cutrona CE: Nonpsychotic postpartum depression among adolescent mothers. J Abnorm Psychol 1990; 99:69 Endicott J, Spitzer RL: A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch Gen Psychiatry 1978; 35:837 Schmidt RM, Wiemann CM, Rickert VI, et al: Moderate to severe depressive symptoms among adolescent mothers followed four years postpartum. J Adolesc Health 2006; 38:712 Freitas GV, Cais CF, Stefanello S, et al: Psychosocial conditions and suicidal behavior in pregnant teenagers: a case-control study in Brazil. Eur Child Adolesc Psychiatry 2008; 17:336 Figueiredo B, Pacheco A, Costa R: Depression during pregnancy and the postpartum period in adolescent and adult Portuguese mothers. Arch Womens Ment Health 2007; 10:103 Lanzi RG, Bert SC, Jacobs BK: Depression among a sample of first-time adolescent and adult mothers. J Child Adolesc Psychiatr Nurs 2009; 22:194 de Anda D, Darroch P, Davidson M, et al: Stress and coping among pregnant adolescents. J Adolesc Res 1992; 7:94 Spielberger CD, Gorsuch RL, Lushene RE: Manual for the State-Trait Anxiety Inventory. Palo Alto, CA, Consulting Psychologists Press, 1970 Achenbach TM, Rescorla LA: Manual for the ASEBA School-Age Forms & Profiles. Burlington, VT, University of Vermont Research Center for Children, Youth & Families, 2001 Wiemann CM, Berenson AB, Wagner KD, et al: Prevalence and correlates of psychopathology in pregnant adolescents. J Adolesc Health 1996; 18:35 Barnet B, Duggan AK, Wilson MD, et al: Association between postpartum substance use and depressive symptoms, stress, and social support in adolescent mothers. Pediatrics 1995; 96:659 Bottomley KL, Lancaster SJ: The association between depressive symptoms and smoking in pregnant adolescents. Psychol Health Med 2008; 13:574 Bessa MA, Mitsuhiro SS, Chalem E, et al: Correlates of substance use during ~o Paulo, Brazil. Rev Bras Psiquiatr 2010; 32:66 adolescent pregnancy in Sa Goldstein BI, Strober MA, Birmaher B, et al: Substance use disorders among adolescents with bipolar spectrum disorders. Bipolar Disord 2008; 10:469 Barnet B, Joffe A, Duggan AK, et al: Depressive symptoms, stress, and social support in pregnant and postpartum adolescents. Arch Pediatr Adolesc Med 1996; 150:64 Birkeland R, Thompson JK, Phares V: Adolescent motherhood and postpartum depression. J Clin Child Adolesc Psychol 2005; 34:292 Cox JE, Buman M, Valenzuela J, et al: Depression, parenting attributes, and social support among adolescent mothers attending a teen tot program. J Pediatr Adolesc Gynecol 2008; 21:275 Hudson DB, Elek SM, Campbell-Grossman C: Depression, self-esteem, loneliness, and social support among adolescent mothers participating in the new parents project. Adolescence 2000; 35:445 Stevenson W, Maton KI, Teti DM: Social support, relationship quality, and well-being among pregnant adolescents. J Adolesc 1999; 22:109 Turner RJ, Grindstaff CF, Phillips N: Social support and outcome in teenage pregnancy. J Health Social Behav 1990; 31:43 Panzarine S, Slater E, Sharps P: Coping, social support, and depressive symptoms in adolescent mothers. J Adolesc Health 1995; 17:113 Sacco WP, MacLeod VA: Interpersonal responses of primary caregivers to pregnant adolescents differeing on depression level. J Clin Child Psychol 1990; 19:265 Secco ML, Profit S, Kennedy E, et al: Factors affecting postpartum depressive symptoms of adolescent mothers. J Obstet Gynecol Neonatal Nurs 2007; 36:47
150
R.S. Siegel, A.R. Brandon / J Pediatr Adolesc Gynecol 27 (2014) 138e150
40. Logsdon MC, Ziegler C, Hertweck P, et al: Testing a bioecological model to examine social support in postpartum adolescents. J Nurs Scholarsh 2008; 40:116 41. Milan S, Kershaw T, Lewis J, et al: Caregiving history and prenatal depressive symptoms in low income adolescent and young adult women: Moderating and Mediating Effects. Psychol Women Q 2007; 31:241 42. Kabir K, Sheeder J, Stevens-Simon C: Depression, weight gain, and low birth weight adolescent delivery: do somatic symptoms strengthen or weaken the relationship? J Pediatr Adolesc Gynecol 2008; 21:335 43. Leadbeater BJ, Bishop SJ, Raver CC: Quality of mother-toddler interactions, maternal depressive symptoms, and behavior problems in preschoolers of adolescent mothers. Dev Psychol 1996; 32:280 44. Shaw M, Lawlor DA, Najman JM: Teenage children of teenage mothers: psychological, behavioural and health outcomes from an Australian prospective longitudinal study. Soc Sci Med 2006; 62:2526 45. Lee Y: Early motherhood and harsh parenting: the role of human, social, and cultural capital. Child Abuse Negl 2009; 33:625 46. Kessler RC, Andrews G, Colpe LJ, et al: Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002; 32:959 47. Field T, Pickens J, Prodromidis M, et al: Targeting adolescent mothers with depressive symptoms for early intervention. Adolescence 2000; 35:381
48. Stirtzinger R, McDermid S, Grusec J, et al: Interrupting the inter-generational cycle in high risk adolescent pregnancy. J Primary Prev 2002; 23:7 49. Miller L, Gur M, Shanok A, et al: Interpersonal psychotherapy with pregnant adolescents: two pilot studies. J Child Psychol Psychiatr 2008; 49:733 50. Shanok AF, Miller L: Depression and treatment with inner city pregnant and parenting teens. Arch Womens Ment Health 2007; 10:199 51. Logsdon MC, Birkimer JC, Simpson T, et al: Postpartum depression and social support in adolescents. J Obstet Gynecol Neonatal Nurs 2005; 34:46 52. Barnet B, Liu J, Devoe M, et al: Home visiting for adolescent mothers: effects on parenting, maternal life course, and primary care linkage. Ann Fam Med 2007; 5:224 53. Koniak-Griffin D: Aerobic exercise, psychological well-being, and physical discomforts during adolescent pregnancy. Res Nurs Health 1994; 17:253 54. de Anda D, Darroch P, Davidson M, et al: Stress management for pregnant adolescents and adolescent mothers: a pilot study. Child Adolesc Soc Work 1990; 7:53 55. McClanahan KK: Depression in pregnant adolescents: considerations for treatment. J Pediatr Adolesc Gynecol 2009; 22:59 56. Brandon AR, Shivakumar G, Inrig SJ, et al: Ethical challenges in designing, conducting, and reporting research to improve the mental health of pregnant women: The voices of investigators and IRB members. American Journal of Bioethics Primary Research. 2013 [epub ahead of print]