A Parenting and Life Skills Intervention

for Teen Mothers: A Randomized

Controlled Trial
Joanne E. Cox, MD,a,b,c Sion Kim Harris, PhD,b,c Kathleen Conroy, MD, MS,a,c Talia Engelhart, MHS,a
Anuradha Vyavaharkar, MSW, MPH,a Amy Federico, BSN,a Elizabeth R. Woods, MD, MPHb,c

BACKGROUND:Teen mothers often present with depression, social complexity, and inadequate abstract
parenting skills. Many have rapid repeat pregnancy, which increases risk for poor outcomes.
We conducted a randomized controlled trial of a parenting and life skills intervention for teen
mothers aimed at impacting parenting and reproductive outcomes.
METHODS: Teen mothers were recruited from a teen-tot clinic with integrated medical care and
social services. Participants were randomly assigned 1:1 to receive (1) teen-tot services plus 5
interactive parenting and life skills modules adapted from the Nurturing and Ansell-Casey Life
Skills curricula, delivered by a nurse and social worker over the infant’s first 15 months or (2)
teen-tot services alone. A computerized questionnaire was self-administered at intake, 12, 24,
and 36 months. Outcomes included maternal self-esteem, parenting attitudes associated
with child maltreatment risk, maternal depression, life skills, and repeat pregnancy over
a 36-month follow-up. We used generalized linear mixed modeling and logistic regression
to examine intervention effects.
RESULTS: Of
152 invited, 140 (92%) participated (intervention = 72; control = 68). At 36 months,
maternal self-esteem was higher in the intervention group compared with controls (P = .011),
with higher scores on preparedness for mothering role (P = .011), acceptance of infant
(P = .008), and expected relationship with infant (P = .029). Repeat pregnancy by 36 months
was significantly lower for intervention versus control participants.
CONCLUSIONS: Abrief parenting and/or life skills intervention paired with medical care for teens
and their children has positive effects on maternal self-esteem and repeat pregnancy over
36 months.

Divisions of aGeneral Pediatrics and bAdolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, WHAT’S KNOWN ON THIS SUBJECT: Teen parents and their
Massachusetts; and cDepartment of Pediatrics, Harvard Medical School, Harvard University, Boston, children face multiple medical and social challenges.
Massachusetts Promising interventions include home visiting, school-based
interventions, and medical homes. Intervention outcomes
Dr Cox conceptualized and designed the study, participated in design of the data collection include optimal medical care delivery, decreased repeat
instruments, supervised the implementation of the protocol, drafted the initial manuscript, and pregnancy, and improved parenting skills.
reviewed and revised the manuscript; Dr Harris performed the data analysis and reviewed and
revised the manuscript; Dr Conroy supervised data collection, critically reviewed the manuscript for WHAT THIS STUDY ADDS: Longitudinal outcomes for
important intellectual content, and revised the manuscript; Ms Engelhart coordinated and interventions used to target teen mothers and their children
supervised data collection and reviewed and revised the manuscript; Ms Vyavaharkar and Ms have not been extensively studied. Our findings suggest that
Federico participated in study design and implementation and revised and reviewed the a teen-tot model plus an enhanced parenting and life skills
manuscript; Dr Woods conceptualized and designed the study, supervised study implementation, intervention shows promise for improving parenting
and reviewed and revised the manuscript; and all authors approved the final manuscript as attributes and reducing repeat pregnancy.
submitted and agree to be accountable for all aspects of the work.
This trial has been registered at www.clinicaltrials.gov (identifier NCT01379924). To cite: Cox JE, Harris SK, Conroy K, et al. A Parenting and
Life Skills Intervention for Teen Mothers: A Randomized
DOI: https://doi.org/10.1542/peds.2018-2303 Controlled Trial. Pediatrics. 2019;143(3):e20182303

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PEDIATRICS Volume 143, number 3, March 2019:e20182303 ARTICLE
Although the rates of teen pregnancy
have declined nationally over the last
25 years, socioeconomic and racial
disparities persist. Teen pregnancy
and parenting remain a challenge in
communities with high rates of
poverty, low social capital, and
inadequate access to contraception
and among certain racial and/or
ethnic populations.1,2 Teen parenting
is associated with risk of depression,
poor social supports, school failure,
conflicted relationships, and
inadequate family and community
support.3–6 Women who were teen
parents complete less education
and are more likely to live in
poverty.4 Teens with children are
often unprepared for the stresses of
raising young children; and those
with histories of social isolation,
violence, or other sources of toxic
stress are more likely to parent
using harsh, authoritarian
methods.7–10 Their children lag
developmentally and are at risk for
poor educational outcomes that
persist into adolescence.6,11–13
Interventions for teen parents often
focus on decreasing both repeat
pregnancy and negative parenting
behaviors associated with teen
parents that place children and their
mothers at risk for adverse long-term
outcomes. Repeat teen pregnancy
multiplies risk for both parental
stress and harsh parenting that
negatively affect child outcomes.14
In addition, the children are more
likely to have behavioral problems.
Educational and employment
outcomes are better for teens without
another pregnancy.8,14 Yet, almost
20% of teen births are repeat
births.15
Comprehensive programs have been
aimed to address family planning
while providing parenting and social
support.16 Programs are used to
address parenting behaviors,
maternal attachment to the infant,
and teen life skills to enhance child
developmental outcomes and teen
self-sufficiency.11,16–18 Promising
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2 COX et al
interventions include school-
based16,17 or home-visiting
programs18–20 and mentoring.21–23
Other successful interventions have
used the medical home or teen-tot
model.24–27
The Adolescent Family Life (AFL)
demonstration projects, organized
through the Office of Adolescent
Pregnancy Programs (OAPP), are
aimed to support young families
through social support and medical
care.28–31 The AFL funding required
programs to deliver 10 core services,
including pregnancy testing, adoption
counseling, preventive and prenatal
referrals for teens, nutritional
counseling, well infant care, sexually
transmitted infection screening,
family life counseling, educational or
vocational services, mental health
services, and referrals for family
planning. A multisite evaluation,
which included our program,
revealed increased use of long-acting
contraceptives, child care, and
decreased repeat pregnancy at 12
months.30 However, there is a paucity
of scientific studies examining longer-
term outcomes of these programs.
Our aim with this study was to test
the hypothesis that compared with
the teen-tot model alone, adding
a structured, comprehensive
parenting curriculum to an AFL-
funded teen-tot model would increase
parenting self-esteem and reduce
parenting attributes associated with
child maltreatment, maternal
depression, and repeat pregnancy
over a 36-month follow-up.
METHODS
Setting and Participants
This study was set in Boston,
Massachusetts, in a teen-tot program
within a pediatric hospital.24
Eligibility criteria included maternal
age ,19 years at delivery and
willingness to receive maternal and
infant care in a teen-tot program.
Teens with infants $12 months were
excluded. They were referred from
prenatal clinics and community-based
agencies between February 2008 and
February 2012. At the first infant
visit, every patient seen was asked to
enroll in the study by trained
program staff. Those agreeing to
participate (140 of 152; 92%) were
randomly assigned by the research
assistant to the parenting and/or life
skills intervention or control using
a unique numeric identification
number and computerized random
number generator to determine
assignment. It was indicated in power
analysis that a sample of 48
participants in each arm had 80%
power to detect a group difference in
mean Maternal Self-Report Inventory
(MSRI) total scores as found in our
previous study.27
Teens received $10 plus
transportation for each intervention
visit and study assessment, which
were completed in the clinic. The
majority of participants lived in the
nearby neighborhoods where
poverty reached 36%.32 All study
participants attended the teen-tot
clinic, receiving preventive care,
urgent care, gynecologic services,
and integrated social work. A nurse
offered contraceptive counseling,
and social workers provided brief
check-ins plus intensive family
support services when needed.24
All required AFL core services as
outlined in Title XX were offered,31
and the Institutional Review Board
of Boston Children’s Hospital
approved the study with a waiver
of parental consent.
Intervention
Because of broad OAPP goals for
improving teen parenting while
enhancing youth and family
development, elements of 3 validated
curricula were incorporated into the
intervention, which then underwent
structured expert content review and
pilot testing. Psychoeducational
modules that were one-on-one used
the Ansell-Casey Life Skills
Assessment Curriculum,33, the
Women’s Negotiation Project
Curriculum for Teen Mothers,34 and
the Nurturing Curriculum, which was
previously studied by our group.27,35
The Nurturing Curriculum addresses
child abuse risk within the following
4 constructs: inappropriate parental
expectations of the child, lack of
empathy toward the child’s needs,
parental value of physical
punishment, and parent-child role
reversal.35 A series of five 1-hour
long, structured, one-on-one
interactive modules were aimed to
help teens build positive, empathetic
relationships with their children
while enhancing self-efficacy and
self-worth. Reproductive health
goals and contraception were
discussed at each session. The
curriculum was approved by the
OAPP and delivered in a confidential,
private clinic setting. On the basis of
competency learning principles, the
intervention used informational
lecture, vignette discussion,
reflection, and interactive “practice”
activities.33–35 Domains included
child development, discipline, safety,
house and money management,
social relationships, career planning,
substance abuse, and both
community and interpersonal
violence.33,34,36 This content is
summarized in Table 1. Goals were
focused on engaging teens in logical
future planning while learning
skills necessary for self-sufficient
adulthood. A social worker or nurse
content specialist with structured
content training delivered each
module. They were not blinded to
intervention assignment and were
teen-tot team members. Ongoing
staff training with no staffing
changes ensured the fidelity of topic
content delivery. The first 10 teens
received the intervention in a group
of 2 to 4 participants over 12
sessions. This was modified to 5
individual sessions to improve
flexibility with scheduling and
compliance. The team met weekly to
discuss intervention progress,
barriers, and participant feedback.
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PEDIATRICS Volume 143, number 3, March 2019
Data Collection and Measures
Self-administered computerized
questionnaires were used to collect
data at intake and child’s age of 12,
24, and 36 months. Because of
a technical error, baseline data on
measures were not collected on 40 of
140 participants. Measures have
been previously described in
detail.24 In addition to questions on
demographics (eg, mother’s and
infant’s age and race and/or
ethnicity, mother’s educational and
residential status) and social factors
(eg, sources of social or economic
support and child care), we used
the following standardized
instruments: MSRI37 to assess
maternal parenting self-esteem,
Adolescent Adult Parenting
Inventory Version 2 (AAPI-2)38 to
assess parenting and child-rearing
attitudes associated with risk for
child maltreatment, Center for
Epidemiologic Studies Depression
Scale for Children (CES-DC)39 to
assess depressive symptoms, and the
Ansell-Casey Life Skills Assessment33
to assess skills of daily living,
communication, and relationships.
Repeat pregnancy data were
collected by patient report as
well as review of medical records
at 12, 24, and 36 months.
Participants completed satisfaction
questionnaires after completing
each intervention session.
Data Analysis
We analyzed variables using
recommended scoring methods for all
measures. For the AAPI-2, we used
the scoring tool available at www.
nurturingparenting.com with “sten”
scores (scores standardized to
a range of 1–10) in the current
analysis, with scores 1 to 3 indicating
high risk, 4 to 7 moderate risk, and 8
to 10 low risk for child maltreatment.
On the Ansell-Casey Life Skills
Inventory (ACLS), we examined raw
scores (sum of item scores) and
“mastery” scores (ie, percent of items
with a response of “very much like
me”). Because of skewed data or to
preserve adequate cell sizes, we
recoded demographic variables as
outlined in Table 2.
We examined potential sample
selection bias by comparing baseline
characteristics of participants
(n = 140) with nonparticipants
(n = 12) and randomization success
by comparing baseline characteristics
between randomized groups. To
assess differential attrition between
groups, we compared rates of missing
data at each time point and median
number of missing time points
between groups. To determine
potential retention bias, we used
linear regression modeling to
evaluate whether baseline
characteristics were independently
associated with the number of
missing data points (0–3) across all
time points. Any experimental group
variables that differed at baseline or
that predicted differential retention
across the follow-ups were controlled
for in subsequent analyses of the
intervention effect. We conducted
bivariate analyses using 1-way
analysis of variance for continuous
variables and x 2 tests for categorical
variables.
To evaluate intervention effects, we
compared experimental groups over
time, using intent-to-treat on each
outcome measure, first in unadjusted
bivariate analyses and then, to adjust
for potential confounders, using
linear mixed-effects modeling with
repeated measures nested within
participants.40 Intercepts of
individual trajectories were treated as
random effects. We used maximum
likelihood estimation of parameter
estimates and specified an
unstructured covariance scheme.
Mixed-effects modeling was chosen
over traditional repeated measures
analysis of variance because of its
ability to calculate parameter
estimates even with some missing
data points.40 To reduce
multicollinearity, we used Cramér’s V
to assess association between
3
TABLE 1 Intervention Modules and Facilitators
Module No. Module Topic
1 Child Development and discipline
2 Safety
3 Budgeting and/or Bank Account
4 Job and Education Readiness and
Resume
5 Healthy Living
Facilitator Description
Social Worker This module focuses on child development and discipline. Participants
play a developmental card game that reviews children’s developmental
milestones and engage in a discussion about age-appropriate
expectations and learning styles. They also talk about how they were
raised, how they hope to raise their child, the goal of discipline, and
what discipline looks like at different ages and/or stages. Participant
contraceptive plan is reviewed and appointments in clinic made if
needed.
Nurse This module focuses on prevention of potential hazards in the home and
the community. Teens receive a safety bag that includes
a thermometer, list of important phone numbers, poison control
magnet, outlet covers, choke tube, and items for personal safety, such
as emergency contraception and condoms. Participant contraceptive
plan is reviewed and appointments in clinic made if needed.
Social Worker In this module, teens learn about finances and budgeting. They discuss
current income as well as expenses and look at what are realistic
goals for current income. At the end of the session, they have the
option to go to the neighborhood bank and open a personal checking
account. Participant contraceptive plan is reviewed and appointments
in clinic made if needed.
Social Worker In this module, teens focus on employment or career goals and practice
some skills that help them find and keep a job. They create an
appropriate email account if they do not already have one, work on
a resume, and have a practice interview. Participant contraceptive plan
is reviewed and appointments in clinic made if needed.
Social Worker In this module, they discuss the importance of healthy living, including
exercise and a healthy diet. They review the health hazards of smoking,
drug use, and how drug use can negatively impact how one parents
their child. They also discuss violence and how exposure to violence
can impact your life and the child’s development. Participant
contraceptive plan is reviewed and appointments in clinic made if
needed.

predictor variables hypothesized to
be intercorrelated. We found that the
highest grade completed, educational
status had a Cramér’s V of 0.550, and
receiving public income assistance
and receiving foods stamps had
a Cramér’s V of 0.355. Thus, highest
grade completed and participation in
public income assistance were
entered into subsequent models. For
repeat pregnancy, we compared rates
of any repeat pregnancy between
groups by each follow-up time point
(cumulative) using logistic regression
modeling.
To address potential nonresponse
bias due to missing data at baseline
and follow-ups, we conducted
multiple imputation of missing data
(n = 10 imputation trials) for each of
the outcome measures (MSRI, AAPI-2,
ACLS, and CES-DC total scores) using
the baseline predictor variables and
reran analyses using pooled imputed
data. These analyses results were
similar to the nonimputed data set, so
we present nonimputed data.
RESULTS
Sample Characteristics
Participants were randomly
assigned, with 72 in the intervention
group and 68 in the control group.
The Consolidated Standards of
Reporting Trials diagram (Fig 1)
summarizes sample recruitment and
retention flow. Participant follow-up
rates were similar between groups
across the follow-up time points,
except at 12 months, where the
control group had higher response
than the intervention group (88.2%
[60 of 68] vs 68.1% [49 of 72];
P = .004). The median number of
missing data time points in both
groups was 1.0 (IQR 0–2). At
baseline and 36 months, we found
no significant differences between
intervention and control groups in
the characteristics of those with
and without data. There was no
difference in the number of teen-
tot visits made by the 2 groups
during the 36-month study period;
the median (interquartile range)
number of visits for control versus
intervention group equaled 25
(18–38) vs 24 (16–34). There were
no adverse events.
Table 2 summarizes group
demographic and social characteristics
at baseline. Participants were
majority African American or
Hispanic (93.4%) and first-time
mothers (98%), and at baseline had
infants age #2 months (68.6%),
were in high school (65.7%), living
with their own parent(s) (52.2%),

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4 COX et al
TABLE 2 Sample Demographic and Social Characteristics at Program Enrollment
Total Control Intervention P
Total sample, n (%) 140 (100.0) 68 (48.6) 72 (51.4) —
Teen mother’s age, y, mean 6 SD 17.3 6 1.1 17.3 6 1.2 17.4 6 1.0 .511
Infant’s age, mo, n (%) .256
#2 96 (68.6) 50 (73.5) 46 (63.9) —
3–5 20 (14.3) 10 (14.7) 10 (13.9) —
6+ 24 (17.1) 8 (11.8) 16 (22.2) —
Race and/or Hispanic ethnicity, n (%) .178
African American 46 (33.3) 18 (26.5) 28 (40.0) —
Hispanic 83 (60.1) 44 (64.7) 39 (55.7) —
Other 9 (6.5) 6 (8.8) 3 (4.3) —
School status, n (%) .038
In high school and/or GED program 92 (65.7) 51 (75.0) 41 (56.9) —
Completed high school and/or GED or in college 28 (20.0) 12 (17.6) 16 (22.2) —
Not currently in school or other 20 (14.3) 5 (7.4) 15 (20.8) —
Highest grade completed, n (%) .053
#10th grade 49 (38.6) 30 (46.9) 19 (30.2) —
11th or higher 78 (61.4) 34 (53.1) 44 (69.8) —
Residential status, n (%)
Lives with own parent(s) 71 (52.2) 36 (55.4) 35 (49.3) .478
Lives with FOI, partner, or spouse 31 (22.8) 18 (27.7) 13 (18.3) .193
Lives with FOI’s parents 26 (19.1) 13 (20.0) 13 (18.3) .802
Income support, n (%)
Own parent(s) 39 (27.9) 18 (26.5) 21 (29.2) .722
FOI, partner, or spouse 101 (73.7) 46 (69.7) 55 (77.5) .302
Social support and/or child care, n (%)
Own parent(s) 125 (94.0) 63 (95.5) 62 (92.5) .479
FOI, partner, or spouse 114 (87.7) 54 (87.1) 60 (88.2) .844
FOI’s family 104 (81.9) 52 (86.7) 52 (77.6) .186
Duke Social Support and Stress Scales, mean 6 SD
Overall support 53.5 6 18.7 54.1 6 18.8 52.8 6 18.7 .724
Family 61.1 6 20.3 62.3 6 18.2 59.9 6 22.5 .556
Nonfamily 37.7 6 21.4 37.5 6 24.2 38.0 6 19.3 .906
Overall stress 16.3 6 17.2 15.6 6 16.8 17.0 6 17.7 .700
Family related 18.8 6 19.8 17.6 6 18.6 20.0 6 21.0 .559
Non-family related 24.8 6 13.4 25.7 6 15.5 23.9 6 10.8 .502
Other support, n (%)
Medicaid insurance 132 (94.3) 63 (92.6) 69 (95.8) .417
Public cash assistancea 48 (34.3) 22 (32.4) 26 (36.1) .640
Employed 8 (5.7) 3 (4.4) 5 (6.9) .519
WIC program participant 118 (84.3) 59 (86.8) 59 (81.9) .433
Food stamps 54 (38.6) 25 (36.8) 29 (40.3) .670
FOI, father of infant; GED, general equivalency diploma; —, not applicable.
a Responded “yes” to receiving Transitional Aid to Needy Families, social security, or “other public aid.”

and receiving Medicaid insurance
(94.3%) and Supplemental Nutrition
Program for Women, Infants, and
Children (WIC) (84.3%). The
intervention and control groups
differed only with respect to
education variables at baseline, with
control group participants having
a higher percentage still in high
school. Participants were younger
than those declining to participate
(17.3 6 1.1 vs 18.1 6 0.7 years;
P = .021), were more likely to be
Hispanic (60.1% vs 33.3%; P = .043),
to score lower on maternal self-
esteem (mean [SE] = 114.0 [1.1] vs
121.4 [1.8]; P = .046) and overall
social support (53.5 [8.9] vs 66.2
[5.8]; P = .052), and score marginally
higher on overall social stress (16.3
[1.7] vs 6.6 [3.3]; P = .98) and on
depressive symptoms (17.3 [1.1] vs
10.1 [2.6]; P = .068).
Intervention Effects
Unadjusted group mean scores over
time for each of our outcome
measures and the results of mixed-
effects modeling adjusting for
covariates are presented in Tables 3
and 4, respectively. In adjusted
analysis comparing group trends over
time, we found a significant decline by
36 months in overall maternal self-
esteem scores in both groups (main
effect of time P = .009) but less in the
intervention group (group by time
interaction effect P = .011). Significant
intervention subscale effects were
seen for preparedness for mothering
role (P = .011), acceptance of infant
(P = .008), and expected relationship
with infant (P = .029). There was
a marginal effect on caretaking ability
(P = .052).

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PEDIATRICS Volume 143, number 3, March 2019 5
FIGURE 1
Study flow diagram.

Results were mixed across the AAPI-2 baseline in both groups, revealed range. Scores on all other AAPI-2
parenting profile subscales. Scores on significant improvement (main time subscales in both groups were in the
“empathy towards children’s needs” effect P = .019) (Table 4), although “medium risk” range at baseline
subscale, which were “high risk” at sten scores remained in the high risk without improvement over time,

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6 COX et al
TABLE 3 Adolescent Mothers’ Self-Reported Self-Esteem, Parenting Profile, Life Skills, and Depressive Symptoms by Group at Baseline and 12, 24, and
36 Months Follow-up
Baseline 12 mo 24 mo 36 mo Change From Change From Change From
Mean (SE), Mean (SE), Mean (SE), Mean (SE), Baseline Baseline Baseline
n = 100 n = 109 n = 115 n = 109 to 12 moa to 24 moa to 36 moa
Maternal self-esteemb
Caretaking ability
Control 27.2 (0.5) 27.0 (0.5) 25.5 (0.9) 20.5 (1.4) 20.2 21.7 26.7
Intervention 27.0 (0.6) 27.5 (0.4) 26.3 (0.7) 23.7 (1.1) +0.5 20.7 23.3
Preparedness for mothering role
Control 37.3 (0.4) 36.2 (0.6) 36.1 (0.6) 33.7 (0.7) 21.1 21.2 23.6
Intervention 37.2 (0.5) 36.9 (0.6) 36.3 (0.5) 35.9 (0.5) 20.3 20.9 21.3
Acceptance of infant
Control 13.7 (0.2) 13.7 (0.3) 13.2 (0.4) 11.1 (0.5) 0.0 20.5 22.6
Intervention 13.6 (0.3) 13.9 (0.3) 13.3 (0.3) 12.5 (0.4) +0.3 20.3 21.1
Expected relationship with infant
Control 21.8 (0.4) 21.8 (0.4) 21.3 (0.5) 19.5 (0.6) 0.0 20.5 22.3
Intervention 21.9 (0.4) 22.6 (0.4) 21.6 (0.4) 21.1 (0.4) +0.7 20.3 20.8
Perceptions of childbearing
experience
Control 13.6 (0.7) 14.2 (0.5) 14.4 (0.6) 13.7 (0.5) +0.6 +0.8 +0.1
Intervention 14.6 (0.6) 15.3 (0.7) 15.2 (0.6) 15.4 (0.5) +0.7 +0.6 +0.8
Total score
Control 113.7 (1.4) 112.8 (1.7) 110.4 (2.4) 99.4 (3.1) 20.9 23.3 214.3
Intervention 114.3 (1.7) 116.2 (1.8) 112.8 (1.9) 108.5 (2.6) +1.9 21.5 25.8
Parenting profilec
Inappropriate expectations
Control 4.9 (0.3) 5.6 (0.3) 5.0 (0.3) 5.1 (0.3) +0.7 +0.1 +0.2
Intervention 5.5 (0.4) 5.8 (0.3) 5.3 (0.3) 5.1 (0.3) +0.3 20.2 20.4
Empathy toward child’s needs
Control 1.4 (0.2) 1.7 (0.2) 2.1 (0.3) 2.5 (0.3) +0.3 +0.7 +1.1
Intervention 1.7 (0.2) 1.6 (0.2) 2.0 (0.3) 1.7 (0.2) 0.0 +0.3 0.0
Use of corporal punishment
Control 5.8 (0.3) 5.7 (0.3) 5.4 (0.3) 4.3 (0.3) 20.1 20.4 21.5
Intervention 5.9 (0.3) 6.0 (0.3) 5.2 (0.3) 4.6 (0.3) +0.1 20.7 21.3
Parent-child role responsibilities
Control 4.7 (0.3) 5.6 (0.3) 4.8 (0.4) 3.7 (0.4) +0.9 +0.1 21.0
Intervention 4.8 (0.3) 5.9 (0.4) 5.4 (0.4) 5.1 (0.3) +1.1 +0.6 +0.3
Child’s power and independence
Control 6.0 (0.3) 5.5 (0.3) 5.1 (0.3) 3.2 (0.3) 20.5 20.9 22.8
Intervention 6.2 (0.3) 5.5 (0.3) 5.2 (0.3) 4.3 (0.3) 20.7 21.0 21.9
Total score
Control 22.8 (0.7) 24.1 (0.7) 22.4 (0.8) 18.9 (0.8) +1.3 20.4 23.9
Intervention 24.1 (0.6) 24.7 (0.8) 23.0 (0.9) 20.8 (0.8) +0.6 21.1 23.3
Life skillsd
Housing and/or money management:
raw score
Control 57.0 (1.9) 60.4 (2.1) 62.8 (2.0) 66.2 (2.3) +3.4 +5.8 +9.2
Intervention 57.5 (2.1) 60.6 (1.8) 65.1 (1.9) 68.3 (1.8) +3.1 +7.6 +10.8
Housing and/or money management:
mastery score
Control 30.8 (3.7) 38.4 (4.4) 36.5 (4.7) 49.0 (5.1) +7.6 +5.7 +18.2
Intervention 33.6 (4.0) 37.7 (3.9) 47.1 (4.2) 50.8 (4.6) +4.1 +13.5 +17.2
Work life: raw score
Control 21.5 (0.4) 21.0 (0.5) 20.7 (0.5) 21.4 (0.5) 20.5 20.8 20.1
Intervention 21.6 (0.5) 22.4 (0.4) 22.0 (0.4) 22.4 (0.4) +0.8 +0.4 +0.8
Work life: mastery score
Control 72.3 (4.7) 69.8 (4.7) 62.1 (5.8) 71.1 (5.5) 22.5 210.2 21.2
Intervention 76.8 (4.8) 82.7 (4.0) 77.8 (4.3) 82.1 (4.1) +5.9 +1.0 +5.3
Total: raw score
Control 78.5 (2.1) 81.4 (2.5) 83.4 (2.3) 87.5 (2.7) +2.9 +4.9 +9.0
Intervention 79.1 (2.4) 83.0 (2.0) 87.0 (2.2) 90.6 (2.1) +3.9 +7.9 +11.5

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PEDIATRICS Volume 143, number 3, March 2019 7
TABLE 3 Continued
Mean (SE),
Total: mastery score
Control
Intervention
Depressive symptomse
Control
Intervention
Unadjusted data.
a Difference in each group’s means for this comparison period.
b MSRI; total score is sum of all subdomain scores.
c AAPI-2, Form A: standardized scores (ie, sten) relative to norms with scores of 1–3 indicating high risk, 4–7 medium risk, and 8–10 low risk.
d Ansell-Casey Life Skills Assessment Youth Level 4: raw score is the sum of all item scores; mastery score is the percent of items with a score of 3 indicating mastery; total raw score is
the sum of all housing and/or money management and work item scores; total mastery score is the average of mastery scores for housing and/or money and work.
e CES-DC.
except for worsening in “children’s
power and independence” scores
(P = .013). Sten scores for “parent-
child role responsibilities” worsened
between 12 and 36 months in the
control compared with intervention
group (group by time interaction
effect P = .024).
Scores on the ACLS domains
increased over time in unadjusted
analysis (Table 3); however, after
adjustment for teen mother’s age, the
time effect disappeared, indicating
teen’s age mediated the increasing
scores over time (Table 4). Overall,
over one-third (37.3%) of teens were
employed at the 36-month follow-up,
and 59.1% had completed high
school without group differences.
Of note, baseline CES-DC mean
scores in both groups were above
the cut point of 16, indicating
depressive symptomatology, and
revealed significant increase over
time after adjusting for covariates
(36-month time effect, P = .02)
(Tables 3 and 4).
Repeat pregnancy data at 36-month
follow-up was available for 70.6% of
participants in the control group and
72.2% of intervention group
participants. The intervention group
had significantly lower unadjusted
rates of any repeat pregnancy than
the control group by each follow-up
time point, which remained
significant in logistic regression
modeling, controlling for group
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8 COX et al
Baseline 12 mo 24 mo 36 mo
Mean (SE), Mean (SE), Mean (SE),
n = 100 n = 109 n = 115 n = 109
51.6 (3.6) 54.1 (4.1) 49.3 (4.8) 60.0 (4.9)
55.2 (3.8) 60.2 (3.4) 61.9 (3.8) 66.4 (3.8)
16.2 (1.4) 17.6 (1.7) 14.5 (1.2) 17.0 (1.7)
17.9 (1.7) 21.2 (1.9) 18.0 (1.6) 16.4 (1.4)
differences at baseline or variables
associated with differential study
retention (Table 5).
At 12 months, 61.1% of intervention
participants used longer-acting
contraceptives (Depo Provera,
intrauterine device or implant)
versus 43.5% of participants in the
control group (P = .059). In
multivariate logistic regression,
adjusting for the same variables as in
repeat pregnancy analyses, adjusted
odds ratio at 12-month follow-up for
group difference in any use of longer-
acting contraceptive methods was
2.31 (95% confidence interval
1.02–5.23; P = .044), comparing
intervention group to control group.
There were no significant differences
in reported contraceptive use at
subsequent follow-up assessments.
Intervention participants provided
universally positive qualitative
feedback. Examples are “they taught
me to build my picture frame, they
showed techniques on how to give
your child praise, and how to read to
your child, a lot of things you
wouldn’t even think of” and “good
outlet for stress and thoughts.”
DISCUSSION
Our previous pre- and poststudy of
the teen-tot model revealed
successful delivery of preventive
health and social services.24 With this
study, we build on that work by
Change From Change From Change From
Baseline Baseline Baseline
to 12 moa to 24 moa to 36 moa
+2.5 22.3 +8.4
+5.0 +6.7 +11.2
+1.4 21.7 +0.8
+2.3 +0.1 21.5
randomly assigning teens to an added
parenting and life skills intervention.
Our findings suggest that a teen-tot
model plus an enhanced parenting
and life skills intervention shows
promise for improving parenting
attributes and reducing repeat
pregnancy. Compared with
participants in the control group,
intervention participants
demonstrated less worsening of
maternal parenting self-esteem,
caretaking ability, acceptance of
infant, and had lower rates of repeat
pregnancy over a 36-month follow-up
as the children became toddlers. All
participants revealed risk for child
maltreatment, with some worsening
of risk over 36 months in both
groups. Life skills improved over
time, with no difference between
groups. Our intervention also had no
effect on depressive symptoms, which
increased for both groups even after
controlling for family-related social
stress. This finding is consistent with
our earlier work3 and highlights the
high prevalence and importance of
addressing mental health concerns
when caring for teen parents.41
Our study is unique in that
participants were managed for
36 months with positive outcomes
across parenting and reproductive
health constructs. These findings are
consistent with other interventions
with shorter follow-up.25 In
a randomized controlled trial,
TABLE 4 Results From Mixed-Effects Modeling When Comparing Intervention and Control Groups on Outcomes at 12, 24, and 36 Months
12 mo 24 mo 36 mo
Estimate (SE) P Estimate (SE) P Estimate (SE) P
a
Maternal self-esteem
Caretaking ability
Time 23.39 (2.25) .133 27.39 (3.76) .050 215.19 (5.56) .007
Group by time 1.11 (1.64) .678 0.80 (1.61) .621 3.17 (1.63) .052
Preparedness for mothering role
Time 22.06 (1.33) .122 23.09 (2.24) .169 26.32 (3.32) .058
Group by time 1.22 (0.93) .193 0.64 (0.92) .490 2.38 (0.93) .011
Acceptance of infant
Time 20.64 (0.86) .457 21.72 (1.44) .235 24.35 (2.14) .043
Group by time 0.60 (0.62) .333 0.47 (0.61) .435 1.65 (0.61) .008
Expected relationship with infant
Time 21.68 (1.11) .131 23.49 (1.86) .061 26.65 (2.75) .016
Group by time 1.22 (0.79) .124 .60 (0.78) .442 1.72 (0.78) .029
Perceptions of childbearing experience
Time 20.98 (1.25) .433 22.72 (2.10) .197 24.95 (3.13) .115
Group by time 0.58 (0.86) .503 0.34 (0.85) .691 0.81 (0.86) .350
Total score
Time 28.03 (5.40) .138 217.05 (9.08) .061 235.38 (13.45) .009
Group by time 4.75 (3.84) .217 2.89 (3.77) .444 9.76 (3.82) .011
Parenting profileb
Inappropriate expectations
Time 20.01 (0.80) .989 20.99 (1.33) .459 21.39 (1.97) .482
Group by time 20.29 (0.59) .608 20.33 (0.57) .554 20.54 (0.57) .341
Empathy toward children’s needs
Time 1.30 (0.65) .047 2.51 (1.08) .021 3.76 (1.59) .019
Group by time 20.49 (0.47) .301 20.38 (0.47) .413 20.97 (0.47) .039
Use of corporal punishment
Time 20.21 (0.62) .731 20.46 (1.04) .657 21.38 (1.53) .369
Group by time 0.40 (0.42) .345 20.17 (0.42) .680 0.26 (0.43) .550
Parent-child role responsibilities
Time 0.86 (0.86) .317 0.11 (1.44) .937 20.69 (2.14) .747
Group by time 0.18 (0.60) .758 0.64 (0.59) .281 1.36 (0.60) .024
Children’s power and independence
Time 21.48 (0.85) .083 22.58 (1.41) .068 25.18 (2.09) .013
Group by time 20.21 (0.61) .725 20.19 (0.60) .751 0.92 (0.61) .129
Life skillsc
Housing and/or money management: raw score
Time 2.87 (3.59) .424 5.00 (6.09) .412 7.46 (9.04) .410
Group by time 0.77 (2.45) .755 3.02 (2.43) .215 2.52 (2.46) .307
Housing and/or money management: mastery score
Time 2.64 (8.14) .745 23.24 (13.80) .814 3.80 (20.48) .853
Group by time 0.17 (5.57) .975 8.60 (5.52) .120 20.12 (5.59) .982
Work life: raw score
Time 22.14 (1.11) .055 23.57 (1.87) .057 24.34 (2.77) .118
Group by time 1.84 (0.78) .019 1.33 (0.77) .085 1.08 (0.78) .169
Work life: mastery score
Time 218.31 (11.23) .104 236.20 (18.93) .057 241.16 (28.05) .143
Group by time 13.51 (7.89) .088 11.45 (7.77) .142 7.26 (7.86) .356
Total: raw score
Time 0.83 (4.21) .843 1.72 (7.14) .810 3.61 (10.59) .734
Group by time 2.67 (2.88) .354 4.43 (2.85) .121 3.67 (2.89) .205
Total: mastery score
Time 28.10 (8.49) .341 220.02 (14.36) .164 219.01 (21.31) .373
Group by time 27.09 (5.87) .228 10.23 (5.80) .079 3.73 (5.86) .525
Depressive symptomsd
Time 8.93 (3.67) .016 11.68 (6.18) .060 21.38 (9.16) .020

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PEDIATRICS Volume 143, number 3, March 2019 9
TABLE 4 Continued
12 mo 24 mo 36 mo
Estimate (SE) P Estimate (SE) P Estimate (SE) P
Group by time 0.65 (2.60) .803 2.41 (2.56) .347 21.39 (2.59) .591
Mixed-effects modeling controlled for mother’s age, child’s age, mother’s highest grade completed and whether she received public income assistance, participated in WIC program,
overall social support, and family-related social stress. —, not applicable.
a MSRI; total score is the sum of all subdomain scores.
b AAPI-2, Form A: standardized scores (ie, sten) relative to norms with scores of 1–3 indicating high risk, 4–7 medium risk, and 8–10 low risk.
c Ansell-Casey Life Skills Assessment Youth Level 4: raw score is the sum of all item scores; mastery score is the percent of items with score of 3 indicating mastery; total raw score is the

sum of all housing and/or money management and work item scores; total mastery score is the average of mastery scores for housing and/or money and work.
d CES-DC.

a home-based mentorship model teens and their children increases Many teen parents have a history of
used to addressed teen development with each additional repeat teen trauma and/or depression.
and negotiation skills decreased birth. Our qualitative study of repeat Integrating mental health treatment
repeat pregnancy at 24 months.21 pregnancy highlighted the with parenting education may also
Likewise, a motivational intervention importance of teen control and reduce risk of child maltreatment.
that was focused on relationships and independent decision-making as
contraceptive-use intentions showed important factors in reducing There were some study limitations.
decreased repeat pregnancies at 24 pregnancy risk.43 To decrease Data were obtained through self-
months.23 Data from our study were subsequent pregnancy, counseling on report, although repeat pregnancies
included in a meta-analysis of 13 AFL the use of long-acting contraceptives, were verified by chart review. At
projects with variable study designs not extensively available during this entry into the study, there was 1
that revealed improved use of study period, should be started significant difference between
contraceptives and decreased repeat during the prenatal period.44 The intervention and control participants.
pregnancy at 12 months; however, intervention provided teens time with Control participants were more likely
parenting outcomes were not program staff in which they could to be in high school. This potentially
studied.30 Other interventions with discuss future plans and the affected their decisions about repeat
repeat pregnancy improvements experience of parenting. This may pregnancy either to delay or continue
include school-based case have affected their decisions around another pregnancy but did not
management16 and immediate planning another pregnancy, although positively affect their parenting
postpartum insertion of long-acting this effect was not directly measured. attributes over time. Engaging and
reversible contraceptives.42 An Because teens are often unprepared retaining teens in the intervention
evaluation of a home-visiting for parenting, their children are at was challenging. The complex social
intervention showed positive effects risk for maltreatment.8 This risk was needs of the teens often overwhelmed
on parenting stress, engagement in not attenuated by the intervention, program staff making module
high risk behaviors, and college suggesting the need for interventions completion difficult in the face of
attendance at 24 months.19 that more intensely targeted harsh these urgent needs. Adherence was
parenting practices. The Healthy similar to other AFL teen parenting
Positive effects on both parenting and Families New York home-visiting programs.46 Early in the intervention,
repeat pregnancies are critical program demonstrated significant there were some missing baseline
outcomes for teen parenting decreases in harsh parenting in data, but it was evenly distributed
programs. Risk for poor outcomes for a group of teen first-time mothers.45 and managed statistically. Because
the study design nested the parenting
and life skills intervention within
TABLE 5 Comparison of Group Rates of Any Repeat Pregnancy by Each Follow-up Time Point a teen-tot model, effects may have
Follow- N Control, Intervention, Unadjusted aOR (95% CI)a aOR, P been attenuated because the control
up, mo % % Comparison, P condition also received substantial
12 117 29.1 12.9 .030 0.25 .037 teen-tot care, which may have
(0.07–0.92) included the nurse or social worker
24 107 46.2 30.9 .105 0.24 .029 who delivered the intervention.
(0.07–0.86) Participants in the intervention group
36 100 66.7 42.3 .015 0.20 .017
(0.06–0.75)
received more contacts from staff
through recruitment phone calls and
aOR, adjusted odds ratio; CI, confidence interval.
a Multiple logistic regression modeling for each time point controlled for mother’s age, child’s age, mother’s highest reminders and frequently asked to
grade completed, whether received public income assistance, overall social support, family-related social stress. speak to their social worker or nurse

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10 COX et al
during these calls. Because the study pairing medical services with
was conducted in 1 program in the comprehensive social services and
ABBREVIATIONS
northeast, generalizability of findings parenting education and can inform AAPI-2: Adolescent Adult
to other regions and settings may be future policy and services for teen Parenting Inventory
limited. parents. These positive effects also Version 2
have potential to improve long-term ACLS: Ansell-Casey Life Skills
outcomes for teens and their children. Inventory
CONCLUSIONS
AFL: Adolescent Family Life
This randomized controlled trial of CES-DC: Center for Epidemiologic
a multifaceted intervention that Studies Depression Scale
paired medical care for teen and child ACKNOWLEDGMENTS
for Children
with brief parenting and life skills We thank our patients who MSRI: Maternal Self-Report
training revealed positive effects on repeatedly answered our Inventory
maternal self-esteem, including questionnaires, Jennifer Valenzuela OAPP: Office of Adolescent
caretaking ability, acceptance of and for her work leading early Pregnancy Programs
expected relationship with infant, and implementation of our study, the WIC: Supplemental Nutrition
decreased risk of repeat pregnancy Young Parents Program team, and Dr Program for Women, Infants,
over 36 months. With these findings, Eric Fleegler and his computerized and Children
we highlight the positive impact of data collection system.

Accepted for publication Dec 18, 2018

Address correspondence to Joanne E. Cox, MD, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: joanne.cox@childrens.harvard.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2019 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported in part by the Office of Adolescent Pregnancy Programs (grant APHPA0020033-08-01), the Edgerly Family Endowment, and Leadership Education
in Adolescent Health training grant T71MC00009, the Maternal and Child Health Bureau, and the Health Resources and Services Administration. This content and
conclusions are those of the authors and should not be considered as nor should any endorsements be inferred by an official position or policy of Health Resources
and Services Administration, US Department of Health and Human Services, or the US Government.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES
1. Martin JA, Hamilton BE, Osterman MJK,
Driscoll AK, Mathews TJ. Births: final
data for 2015. Natl Vital Stat Rep. 2017;
66(1):1
2. Kost K, Maddow-Zimet I. U.S. Teenage
Pregnancies, Births and Abortions,
2011: National Trends by Age, Race and
Ethnicity. New York, NY: Guttmacher
Institute. 2016
3. Brown JD, Harris SK, Woods ER, Buman
MP, Cox JE. Longitudinal study of
depressive symptoms and social
support in adolescent mothers.
Matern Child Health J. 2012;16(4):
894–901
4. Assini-Meytin LC, Green KM. Long-term
consequences of adolescent
parenthood among African-American
urban youth: a propensity score
matching approach. J Adolesc Health.
2015;56(5):529–535
5. Lavin C, Cox JE. Teen pregnancy
prevention: current perspectives. Curr
Opin Pediatr. 2012;24(4):462–469
6. Jutte DP, Roos NP, Brownell MD, Briggs
G, MacWilliam L, Roos LL. The ripples of
adolescent motherhood: social,
educational, and medical outcomes for
children of teen and prior teen
mothers. Acad Pediatr. 2010;10(5):
293–301
7. Coley RL, Chase-Lansdale PL. Adolescent
pregnancy and parenthood. Recent
evidence and future directions. Am
Psychol. 1998;53(2):152–166
8. Savio Beers LA, Hollo RE. Approaching
the adolescent-headed family: a review
of teen parenting. Curr Probl Pediatr
Adolesc Health Care. 2009;39(9):
216–233
9. Mitchell SJ, Lewin A, Horn IB, et al.
Violence exposure and the association
between young African American
mothers’ discipline and child problem
behavior. Acad Pediatr. 2009;9(3):157–163
10. Wiemann CM, Rickert VI, Berenson AB,
Volk RJ. Are pregnant adolescents
stigmatized by pregnancy? J Adolesc
Health. 2005;36(4):352.e1–352.e8
11. Levine JA, Pollack H, Comfort ME.
Academic and behavioral outcomes
among the children of young mothers.
J Marriage Fam. 2001;63(2):355–369
12. Pogarsky G, Thornberry TP, Lizotte AJ.
Developmental outcomes for children of

Downloaded from www.aappublications.org/news by guest on February 13, 2019

PEDIATRICS Volume 143, number 3, March 2019 11
 young mothers. J Marriage Fam. 2006;
68(2):332–344
13. Pinzon JL, Jones VF; Committee on
Adolescence; Committee on Early
Childhood. Care of adolescent parents
and their children. Pediatrics. 2012;
130(6). Available at: www.pediatrics.
org/cgi/content/full/130/6/e1743
14. El-Kamary SS, Higman SM, Fuddy L,
McFarlane E, Sia C, Duggan AK. Hawaii’s
healthy start home visiting program:
determinants and impact of rapid
repeat birth. Pediatrics. 2004;114(3).
Available at: www.pediatrics.org/cgi/
content/full/114/3/e317
15. Gavin L, Warner L, O’Neil ME, et al.
Vital signs: repeat births among
teens–United States, 2007-2010. MMWR
Morb Mortal Wkly Rep. 2013;62(13):
249–255
16. Key JD, Gebregziabher MG, Marsh LD,
O’Rourke KM. Effectiveness of an
intensive, school-based intervention for
teen mothers. J Adolesc Health. 2008;
42(4):394–400
17. Letourneau NL, Stewart MJ, Barnfather
AK. Adolescent mothers: support needs,
resources, and support-education
interventions. J Adolesc Health. 2004;
35(6):509–525
18. McKelvey LM, Burrow NA, Balamurugan
A, Whiteside-Mansell L, Plummer P.
Effects of home visiting on adolescent
mothers’ parenting attitudes. Am
J Public Health. 2012;102(10):1860–1862
19. Jacobs F, Easterbrooks MA, Goldberg J,
et al. Improving adolescent parenting:
results from a randomized controlled
trial of a home visiting program for
young families. Am J Public Health.
2016;106(2):342–349
20. Barnet B, Liu J, DeVoe M, Alperovitz-
Bichell K, Duggan AK. Home visiting
for adolescent mothers: effects on
parenting, maternal life course, and
primary care linkage. Ann Fam Med.
2007;5(3):224–232
21. Black MM, Bentley ME, Papas MA, et al.
Delaying second births among
adolescent mothers: a randomized,
controlled trial of a home-based
mentoring program. Pediatrics. 2006;
118(4). Available at: www.pediatrics.
org/cgi/content/full/118/4/e1087
22. Barnet B, Rapp T, DeVoe M, Mullins CD.
Cost-effectiveness of a motivational
Downloaded from www.aappublications.org/news by guest on February 13, 2019
12
intervention to reduce rapid repeated
childbearing in high-risk adolescent
mothers: a rebirth of economic and
policy considerations. Arch Pediatr
Adolesc Med. 2010;164(4):370–376
23. Barnet B, Liu J, DeVoe M, Duggan AK,
Gold MA, Pecukonis E. Motivational
intervention to reduce rapid subsequent
births to adolescent mothers:
a community-based randomized trial.
Ann Fam Med. 2009;7(5):436–445
24. Cox JE, Buman MP, Woods ER,
Famakinwa O, Harris SK. Evaluation of
raising adolescent families together
program: a medical home for
adolescent mothers and their children.
Am J Public Health. 2012;102(10):
1879–1885
25. Lewin A, Mitchell S, Beers L, Schmitz K,
Boudreaux M. Improved contraceptive
use among teen mothers in a patient-
centered medical home. J Adolesc
Health. 2016;59(2):171–176
26. Beers LS, Cheng TL. When a teen has
a tot: a model of care for the
adolescent parent and her child.
Contemp Pediatr. 2006;23(4):47–56
27. Woods ER, Obeidallah-Davis D, Sherry
MK, et al. The parenting project for teen
mothers: the impact of a nurturing
curriculum on adolescent parenting
skills and life hassles. Ambul Pediatr.
2003;3(5):240–245
28. Barnet B. Supporting adolescent
mothers: a journey through policies,
programs, and research. Am J Public
Health. 2012;102(12):2201–2203
29. Ruedinger E, Cox JE. Adolescent
childbearing: consequences and
interventions. Curr Opin Pediatr. 2012;
24(4):446–452
30. Kan ML, Ashley OS, LeTourneau KL, et al.
The adolescent family life program:
a multisite evaluation of federally
funded projects serving pregnant and
parenting adolescents. Am J Public
Health. 2012;102(10):1872–1878
31. Office of the Law Revision Counsel.
Subchapter XIII—adolescent family life
demonstration projects. Available at:
http://uscode.house.gov/view.xhtml?pa
th=/prelim@title42/chapter6A/subcha
pter18&edition=prelim. Accessed
November 4, 2017
32. Boston Planning and Development
Agency, Research Division. Boston in
Context: Neighborhoods 2011-2015
American Community Survey. 2017
33. Nollan KA, Wolf M, Ansell D, et al. Ready
or not: assessing youths’ preparedness
for independent living. Child Welfare.
2000;79(2):159–176
34. Clawson HJ, Sheldon S. Teen parents
and the lase (TPAL) program outcome
report. In: Social Science Education
Consortium eds. Compendium of
Research Supporting Law-Related
Education, Part II: Alternative
Conceptions/Application of Law-Related
Education. 1998
35. Bavolek SJ. Assessing and treating
high-risk parenting attitudes. Early
Child Dev Care. 1989;42(1):99–112
36. Cowen PS. Effectiveness of a parent
education intervention for at-risk
families. J Soc Pediatr Nurs. 2001;6(2):
73–82
37. Shea EA, Tronick EZ. The maternal
self-report inventory: a research and
clinical instrument for assessing
maternal self-esteem. In: Fitzgerald HE,
Lester BM, Yogman MH, eds. Theory and
Research in Behavioral Pediatrics. Vol
4. New York, NY: Springer; 1988:101–139
38. McDonell JR, Limber SP, Connor-Godbey
J. Pathways teen mother support
project: longitudinal findings. Child
Youth Serv Rev. 2007;29(7):840–855
39. Faulstich ME, Carey MP, Ruggiero L,
Enyart P, Gresham F. Assessment of
depression in childhood and
adolescence: an evaluation of the
Center for Epidemiological Studies
Depression Scale for Children (CES-DC).
Am J Psychiatry. 1986;143(8):1024–1027
40. Palmgren J. Analysis of longitudinal
data. Stat Med. 1996;15(11):1231–1232
41. Hodgkinson S, Beers L,
Southammakosane C, Lewin A.
Addressing the mental health needs of
pregnant and parenting adolescents.
Pediatrics. 2014;133(1):114–122
42. Tocce KM, Sheeder JL, Teal SB. Rapid
repeat pregnancy in adolescents: do
immediate postpartum contraceptive
implants make a difference? Am
J Obstet Gynecol. 2012;206(6):481.
e1–481.e7
43. Conroy KN, Engelhart TG, Martins Y,
et al. The enigma of rapid repeat
pregnancy: a qualitative study of teen
COX et al
 mothers. J Pediatr Adolesc Gynecol.
2016;29(3):312–317
44. Damle LF, Gohari AC, McEvoy AK, Desale
SY, Gomez-Lobo V. Early initiation of
postpartum contraception: does it
decrease rapid repeat pregnancy in
adolescents? J Pediatr Adolesc Gynecol.
2015;28(1):57–62
Downloaded from www.aappublications.org/news by guest on February 13, 2019
PEDIATRICS Volume 143, number 3, March 2019
45. Rodriguez ML, Dumont K, Mitchell-
Herzfeld SD, Walden NJ, Greene R.
Effects of Healthy Families New York
on the promotion of maternal
parenting competencies and the
prevention of harsh parenting.
Child Abuse Negl. 2010;34(10):
711–723
46. Asheer S, Berger A, Meckstroth A,
Kisker E, Keating B. Engaging
pregnant and parenting teens: early
challenges and lessons learned
from the evaluation of adolescent
pregnancy prevention approaches.
J Adolesc Health. 2014;54(suppl 3):
S84–S91
13
 A Parenting and Life Skills Intervention for Teen Mothers: A Randomized
Controlled Trial
Joanne E. Cox, Sion Kim Harris, Kathleen Conroy, Talia Engelhart, Anuradha
Vyavaharkar, Amy Federico and Elizabeth R. Woods
Pediatrics originally published online February 12, 2019;

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 A Parenting and Life Skills Intervention for Teen Mothers: A Randomized
Controlled Trial
Joanne E. Cox, Sion Kim Harris, Kathleen Conroy, Talia Engelhart, Anuradha
Vyavaharkar, Amy Federico and Elizabeth R. Woods
Pediatrics originally published online February 12, 2019;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2019/02/08/peds.2018-2303

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