Young Parents Program Project Connect: Strengthening Teen Parents Parenting and Life Skills through Groups and Comprehensive Care

Joanne E. Cox, MD, Jennifer Valenzuela, MSW, MPH, Anthony Masiello
Division of General Pediatrics, Children’s Hospital Boston
Elizabeth R. Woods, MD, MPH
Division of Adolescent/Young Adult Medicine, Children’s Hospital Boston

Introduction:

Project Connect is a multidisciplinary care model embedded within the Young Parents Program (YPP) teen-tot medical clinic with the objectives to evaluate the effect of life skills/parenting groups for adolescent parents: 1) on parenting skills, empathy, non-violent discipline, role appropriateness and developmentally appropriate expectation using a randomized intervention-control design; 2) on adolescent skills of daily living, social relationships, and work/study at follow-up; 3) on depression and perceived social support and; 4) on repeat pregnancy rates at 12 and 24 months after first delivery. 
Parenting/life skills groups, nurse home visiting, toddler education forums, and intensive medical and mental health care are all components of the project creating a “one stop shopping” medical home as recommended by the American Academy of Pediatrics (AAP, 2001).  The project serves mothers aged < 18 years, fathers < 25 years, and their children.  Fathers are offered parenting groups. Nurse home visiting is also offered during the prenatal and newborn period to those parents who were interested.  Extended family members are also engaged when present at medical visits and are invited to the toddler educational forums.  These pregnant teens are from the poorer Boston neighborhoods, within close proximity to Children’s Hospital and are characterized by high social and environmental risks.  They commonly face housing instability or homelessness, exposure to violence, lack of social supports, and history of poor school performance.

Methods:

Project Connect is a randomized controlled trial of parenting/life skills groups for teen parents. This intervention is embedded within an integrated family based comprehensive medical home linked to home-based nurse visiting services. The medical home component of the project will be evaluated using a health services approach and qualitative methods. All program participants receive individual health care/education, mental health care, case management, and referral to community services regardless of whether they participate in a group. The parenting/life skills groups will be offered to mothers of infants randomized to the intervention arm. They will receive all intervention clinical components of YPP in addition to the parenting/life skills groups. Parents randomized to the control arm will receive all components of the project except for parenting/life skills groups.  Our hypothesis is that compared to controls, adolescent parents participating in the parenting/life skills groups will have higher scores on psychometric measures, skills of daily living and decreased repeat pregnancy at follow-up.

Data collection instruments used are: 1) Maternal Self-Report Inventory (MSRI); 2) Adult-Adolescent Parenting Inventory-2 (AAPI-2); 3) Duke-UNC Functional Social Support Questionnaire; 4) the Center for Epidemiological Studies Depression Scale for Children (CESD-C); 5) three sub-scales from the Ansell-Casey Life Skills Assessment Scale; 6) a new YPP Connectedness Measure; 7) AFL Care Core Instrument and; 8) Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD 2-question depression screener).  Participants complete the instruments through the self-administered computerized questionnaires system within the Patient Advocate program.  Data are collected at 2 months (or prior to first parenting/life skills group, if randomized into intervention group), 6, 12, 18, and 24 months.  For the control group, participants will complete the questionnaires 2, 6, 12, 18, and 24 months after enrollment.  Fathers complete the same instruments except the MSRI is replaced with the Young Fathers Assets Scale (YFAS) and the CESD is used instead of the CESD-C.  The CESD is similar to the CESD-C but is validated in an older population more representative of the father’s in the program. Research plan is approved by Children's Hospital, Boston IRB with informed consent.

For all analyses we will use the appropriate parametric or nonparametric statistical tests, depending on whether or not the data are normally distributed. Most measures have multiple sub-scales that have been validated separately during scale development.  Repeated measures analyses will be performed for each scale/sub-scale at time 0, 12 weeks and 1 year.  The final repeated measure analyses model and/or mixed effects modeling will be performed for each scale/sub-scale assessing the relationship with group status, and controlling for mother’s, baby’s age, ethnicity, Medicaid /welfare status, school/work status. These analyses will assess the relationship with group status and changes in the psychosocial measures while controlling for possible confounders and effect modifiers.

Results:

At the end of the second year of Project Connect, 66 participants have been enrolled in Project Connect.  Of the 66, 55 are mothers and 11 are fathers.  Randomization scheme was set to have a balanced assignment of mothers in intervention and comparison groups. Only one mother has refused to be placed in the randomized control trial therefore she was placed in the non-randomized component and will not be offered the parenting/life skills groups.  This one participant will receive all other services.  Mothers’ mean age at time of enrollment is 17.8 + 1.07 SD years with 64% reporting Medicaid as primary insurance; 36% self-report as Black/African-American/African, 4% White, 56% Hispanic or Latino/a, and 4% Biracial; 92% of mothers report English as the primary language, 6% report Spanish; 73% are in school or a GED program, 18% have graduated high school or completed a GED and 9% have dropped out of school. There were insufficient numbers to test for statistical differences between groups.

At baseline demographic collection, numerous mental health questions are asked to assess previous mental health or child protection concerns.  Over 60% of young mothers replied “yes” to the question “have you ever been depressed?” Only 7% of those respondents stated they currently felt depressed and 3% reported “I don’t know.” Using the PRIME-MD 2-question depression screener, 20% of respondents stated during the last month, they felt bothered by feeling down, depressed or hopeless, and 11% reported they had “often been bothered by little interest or pleasure in doing things.” Almost 50% reported ever being in therapy or counseling during their lifetime.  When child protection involvement was asked, 25% of participants reported having child protection services involved as a child and 7% reported current child protection involvement. Over 70% of respondents report being in a committed relationship with the father of their child and 83% report having someone to support them emotionally and “with things like babysitting.” 

Two infant parenting/life skills groups have been completed during the second year with the third group slated to begin November, 2008.  A total of 28 mothers were randomized into the intervention arm of the project and 9 have completed the group. One year data collection will not be available until 2009. Over 23% of participants   accepted and are currently receiving home visiting from our Healthy Baby/Healthy Child (HB/HC) partner.  Number of individual visits, who was present at each visit, time spent with the family, tracking of referrals and other case management information is being tracked.  Monthly meetings occur between the Project Connect team and the HB/HC nurse to discuss shared families.  The fathers enrolled in Project Connect have also been engaged throughout the project.  One fathers group has been completed with our partner agency, Families First.  This was an eight-week curriculum based group focusing on fatherhood and relationships.  Also, “Rock it Out,” a rock-climbing program, was offered for our young fathers this summer.  Fathers were given free access to Boston University’s new state-of-the-art rock climbing facilities where instructors taught the basic fundamentals of rock climbing.  Fathers are also included at all of their child’s medical visits as an equal partner and parent.  These fathers’ groups are offered to all fathers of the children receiving care in YPP. 

We recently completed our first year of monthly Toddler Family Forum Workshops.  A total of ten topics are offered to Project Connect families throughout the year.  The workshops are scheduled to begin again October, 2008.  Monthly workshops are offered for all families with a child over one- year discussing toddler behavior, development and the many other challenges our young families face when their child becomes a toddler.  These workshops are open to all young parents and their family members. Qualitative feedback from patients has shown that they have become more interested in the research since they are answering all questions on a computer.  We look forward to seeing how patients self-report and in what way outcomes change over time. 

Discussion:

Project Connect has successfully initiated data collections systems and has completed two series of parenting/skills building groups and has used the data for initial analysis. Evaluation of a comprehensive medical home with multiple components remains challenging.  While we believe our data collection is being developed with all aspects in mind, capturing every component to know what is significant is difficult.  Realizing a randomized control trial is the gold-standard of evaluation, it comes with difficulty at times when high-risk participants are not randomized to the intervention arm. Some teens are specifically referred to the program fro groups but this cannot be guaranteed with current design. In addition, not all parents initially assigned to parenting groups agreed to ultimately participate.  To optimize participation, clinical and research staff have now energized the response when a participant is randomized into the “green group” (group participant) and defined participant in more detail.  Letters are sent to “green” participants weeks before a new group begins reminding them they were chosen to be in group followed by phone calls and reminders at clinic visits of the upcoming group.

Implications:

We are excited to continue with the innovative data collection in progress for our randomized control trial.  There are high expectations that important research will result to discuss implications of parenting/life skills groups for adolescent parents. 

Contact Information:

Contact person during abstract review:  Joanne Cox, MD
Telephone:  (617) 355-5227
E-Mail Address:  Joanne.Cox@childrens.harvard.edu