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Too young to cope? Helping teenage parents

18 September 2020

Health visitor Julie Davidson describes techniques for working with often resistant teenage parents to make a real difference to the outcomes of young families.

Families referred to the Healthy Futures Team have complex vulnerabilities, are at higher risk of poor health and lack long-term wellbeing and life chances (Department of Health, 2009). The team – set up in 2017 and commissioned by Brighton and Hove City Council – acts early to enhance childhood outcomes in these families. Pregnant under-18s, refugees, asylum seekers, travellers and care leavers can be referred, as well as those in social care or living in emergency accommodation. The team’s specialist health visitor for teenage parents (SHVTP) works a caseload, and provides training and expertise within the health visiting service.

Early window

The SHVTP has supported more than 40 teenage parents who were referred at under 18 years old, and the Healthy Futures Team has supported nearly 70 teenage parents in all. Most referrals are from the young parent midwife from around 20 weeks’ gestation.

Research is clear that 80% of brain development takes place by three years old, so it is important to use this window of opportunity to identify needs early (Day, 2012). Families are offered as many as four antenatal visits to build a rapport and focus on the transition to parenthood. The team supports young parents in learning the skills to develop a secure attachment with their child. The families are offered a bespoke service, dependent on their specific needs, until their child is two years old.

Thirteen families have recently been transferred to the generic teams, and the children have had the full intervention from antenatal, finishing with a two-year developmental Ages and Stages questionnaire (ASQ) and family assessment.

Fathers figure

The Fatherhood Institute undertakes research and formulates policy to involve fathers in their children’s lives. All the fathers, where it was safe for them to be involved, had at least one antenatal contact. A Teenage Parent Pathway was developed by the SHVTP with the service manager to provide clarity on referral criteria and interventions. Families who did not complete the intervention have also had intensive support. They have moved either because of housing issues, or child protection issues resulting in a child being taken into care or adopted. The team is able to work city-wide and ensure continuity of care and robust handovers for families with high risk factors (see charts overleaf).

ACEs and teenagers

Teenage parents are more likely to have to have had adverse childhood experiences (ACEs) than other young people. ACEs increase the risk of health and social problems in adulthood: a person with four ACEs is 4.5 times more likely to get pregnant or get someone pregnant under the age of 18 years old. Health outcomes associated with ACEs include being 30.6 times more likely to have a sexually transmitted infection, 3.9 times more likely to smoke or have substance misuse problems, and 5.2 times more likely to have been hit in the last year (Blackburn with Darwen Council, 2012).

Children of teenage parents have a 75% higher risk of infant mortality than those born to women 20 and over (Public Health England (PHE), 2016). Infants have a three-times higher risk of sudden infant death syndrome (PHE, 2016).

Families are 63% more likely to live in poverty and have poorer mental health for up to three years after birth, which can often impacts negatively on child development. Looked-after children are three times more likely to be a parent by 18 and are likely to have had negative experiences at school (PHE, 2016). They may find it difficult to trust professionals and adults. Building a meaningful working relationship is crucial, but it is challenging, and takes time and skilled communication.

Behaviour change

Young parents are a high-risk group: nearly 60% of children involved in serious case reviews were born to mothers under 21 years (Department for Education, 2012). Their pre-birth social care assessment and social care interventions can create barriers and conflict when working with professionals.

Becoming a parent is a new chapter for them – sometimes exciting, sometimes frightening – with adults around them, asking them to change their lifestyle, circumstances or networks. I have experienced the impact of this, seeing young parents use various strategies to avoid change: from anger and rudeness – ‘I’ll scare her away’ – to silence, non-communication and just not being available at all. Even basic communication can be difficult, let alone imparting important health information or facilitating behaviour change. HVs must be skilled at using evidence-based techniques and skills to overcome barriers, manage the relationship and get the best outcomes (Norman et al, 2016).

Motivational interviewing

Motivational interviewing (MI) is an evidence-based approach to support best practice standards. Developed from more than 35 years of research, it is used in social work, and substance misuse and mental health services (Miller and Rollnick, 2002).

The Family Nurse Partnership (FNP) uses MI techniques with first-time young mothers. In 2015, the results of Building Blocks, a randomised controlled trial, were published to increase understanding of the FNP. The trial showed that the FNP had positive effects on early child development and identified safeguarding risks at an earlier stage. It also showed that their clients engaged well and valued the relationship with their nurse (Cardiff University, 2015).

Prior to working in the Healthy Futures Team, I had briefly been a member for the FNP team in Brighton. There was the opportunity to experience a week’s residential training with the FNP for advanced communication skills, centred on MI techniques. Communication teaching had been limited in nurse and HV training. The Sussex Community Foundation Trust provided a two-day course for staff on solution-focused approaches and MI skills. I have revisited these crucial skills throughout my career and incorporate them into everyday practice.

Recently, I completed a two-day MI course from the National Centre for Behaviour Change. This allowed me to apply refreshed skills when planning visits with young people where there are obstacles to building rapport. Working on caseloads with high child protection and risk factors can test resilience, so training with these communication tools and skills can boost self-reflection and best practice. They can remind us about OARS (Open questions, Affirmations, Reflections and Summarising), and how scaling and simple and complex reflective listening can make a difference in a difficult visit (Miller and Rollnick, 2002).

Coaching skills promote respectful communication and overlap with MI skills. During a recent session of ‘The Coaching Leader’ training, I took part in a listening exercise. ‘Goldilocks and the Three Bears’ was read aloud, and participants were asked about the story. No one was able to answer all the questions correctly. It was clear that it is so easy to assume things and not remain open-minded. This could be caused by working with a certain client group or the same clients for some time and getting stuck in the same conversations, or switching off mentally because of overload or stress.

Communication breakdown

Practising and developing communication techniques has helped me maintain my own resilience. It has supported a positive working relationship with young parents who often have ambivalent feelings about the behaviour changes being asked of them (Local Government Association (LGA), 2019a). Understanding how teenage brain development affects behaviour and relationships can also support compassionate ways of working effectively with young people to reduce conflict and foster meaningful engagement (Blakemore, 2018).

Young people can be slower to understand their own and other people’s emotions. they are more vulnerable to stress and may overreact

Siegel (2014) describes young people’s brains as under construction until they are 25. During this time, the brain changes in important ways, creating challenges as well as opportunities for health professionals working with this client group. The prefrontal cortex is still developing at this age and is the last part of the brain to mature. This slow progress impacts on self-regulation, decision-making, judgement, insight and memory. Young people may be more likely to take risks and are excited by novel experiences, which gather a bigger dopamine reward (Morgan, 2013). They will be swayed by the reward bias offered by peers.

The risks and experimentation that many young people engage in as a normal part of growing up become child protection issues for some young parents.

Adolescents rely more on the amygdala (Blakemore, 2018). This is a small, almond-shaped part of the brain that helps us recognise emotions and is responsible for fight-flight-freeze responses. During this time of rapid brain change, young people can be slower to understand their own and other people’s emotions (Morgan, 2013). For example, mistaking concern for anger increases the likelihood of misunderstandings with partners and professionals. Young people are more vulnerable to stress, less likely to consider the consequences and may overreact.

Into their heads

How can HVs apply adolescent neuroscience to support young families? Remember, memory and organisation skills are still developing, so be prepared to be flexible regarding visits, to remind them about appointments, and to revisit information in different formats to keep it interesting and check understanding. Young families respond well to the use of technology such as the Baby Buddy app, and online resources such as Start4Life, Best Beginnings and Little Lullaby. Young parents respond well to the use of promotional guides from the Centre for Child and Parent Support, where they can focus on the areas of parenting most important to them. It is a strength-based approach using partnership and goal-orientated approaches on a wide range of topics (Day, 2012).

Educating young parents about the changes happening to their brain can also empower them: for example, exploring the ICON message, dealing with tantrums or understanding baby cues can be explored in relation to adolescent brain development .

Young parents have shown interest in the neuroscience that relates to them and how it might affect their parenting in group sessions and during home visits. Highlight to them and colleagues that, despite the challenges at this age, they also have a greater capacity to change, learn and access information. Celebrating the plasticity of their brain, and their ability to change, can help them concentrate on the strengths and advantages that they have to offer their children.

Ready for transition

Being part of a specialist team visiting earlier in pregnancy allows a good rapport to develop with teenage parents and helps to include fathers. It allows more time to prepare for the transition to parenthood and build trust with the HV (LGA, 2019b). Young families tend to be transient, so a city-wide service allows continuity of care. Do not underestimate the benefits of revisiting training such MI, coaching or solution-focused training, or the use of different tools. This can support resilience and reflection and refresh knowledge and develop new skills.

Finally, while acknowledging that teenage parenting presents many challenges, keep in mind that adolescence is a time of creativity, risk-taking and capacity to change. There will be many opportunities for professionals to make a difference to young families’ outcomes.  

 


Hard times 
Covid-19 and vulnerable families

Health visiting during Covid-19 has caused staff to be redeployed, a temporary end to home visits and fewer face-to-face contacts. It is a challenge to meet the needs of vulnerable families, where lockdown may have increased mental health, domestic abuse or financial problems. Our service has tried to overcome some of these obstacles and challenges. The growth in our technological skills has been significant, with staff working at home, using virtual contact with video call for professional meetings and all appointments with families where possible. For the most vulnerable families, with safeguarding issues or prematurity, we have several clinic hubs for face-to-face contacts using PPE. A new Parent Line texting service also started just prior to lockdown, which has had positive feedback from families. Changes continue, and staff have shown resilience and adaptability to try to continue to support children and families in these difficult times.


Resources  

Julie Davidson is an SHVTP at Sussex Community NHS Foundation Trust. With thanks to Linda Evans, clinical service manager for the Healthy Futures Team.


References:

Blackburn with Darwen Council. (2012) Childhood trauma: adverse childhood experiences (ACEs). See: blackburn.gov.uk/health/childhood-trauma (accessed 21 July 2020). 

Blakemore SJ. (2018) Inventing ourselves: the secret life of the teenage brain. Doubleday: London.  

Cardiff University. (2015) Building blocks trial executive summary. See: https://www.cardiff.ac.uk/__data/assets/pdf_file/0006/500649/Building-Blocks-Executive-Summary-Report.pdf (accessed 22 July 2020). 

Day C. (2012) Antenatal/postnatal promotional guide: guidance notes (4th edition). Centre for Child and Parent Support/South London & Maudsley NHS Foundation Trust: London. 

Department for Education. (2012) New learning from serious case reviews: a two year report for 2009-2011. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/184053/DFE-RR226_Report.pdf (accessed 22 July 2020).

Department of Health. (2009) Healthy child programme: pregnancy and the first five years of life. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Programme.pdf (accessed 27 July 2020).

Local Government Association. (2019a). Health visiting: giving children the best start in life. See: local.gov.uk/health-visiting-giving-children-best-start-life (accessed 22 July 2020).

Local Government Association. (2019b). Supporting young parents to reach their full potential. See: local.gov.uk/supporting-young-parents-reach-their-full-potential (accessed 22 July 2020).

Miller WR, Rollnick S. (2002) Motivational interviewing: preparing people for change (2nd edition). Guilford Press: New York. 

Morgan N. (2013) Blame my brain: the amazing teenage brain revealed. Walker: London.

Norman C, Moffatt S, Rankin J. (2016) Young parents’ views and experiences of interactions with health professionals. Journal of Family Planning and Reproductive Health Care 42(3): 179-86.

Public Health England. (2016) A framework for supporting teenage mothers and young fathers. See: gov.uk/government/publications/teenage-mothers-and-young-fathers-support-framework (accessed 27 July 2020).

Siegel DJ. (2014) Brainstorm: the power and purpose of the teenage brain. Scribe Publications: London.

 

 

 

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