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NIDA. (2014, February 7). Intervention Strengthens American Indian Teen Mothers’ Parenting. Retrieved from

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February 07, 2014

Teen mothers on three American Indian reservations improved on several measures of parenting capability after participating in Family Spirit, a home-visiting intervention developed with NIDA support. At 12 months postpartum, the women’s children exhibited reduced rates of emotional difficulties that predict later drug abuse and other serious behavioral problems. The infants at highest risk—those whose mothers had histories of drug abuse—benefited the most.

Study leaders Allison Barlow, M.P.H., Ph.D., associate director of Johns Hopkins Center for American Indian Health, and John T. Walkup, M.D., adjunct professor at Johns Hopkins and director of child and adolescent psychiatry at Weill Cornell Medical College, and their colleagues expect the intervention’s benefits to compound as the children traverse childhood and grow into the teen years of heightened emotional and behavioral risks. The researchers suggest that the Family Spirit design and approach can be applied widely and adapted to mitigate the risks of teen pregnancy in diverse populations with limited resources for health promotion.

Young Mothers, Helping Neighbors

Some 40 percent of American Indian women give birth while still in their teens, a much higher percentage than among women in the general population. As a group, children of teen mothers bear heightened risks for delinquency, teen pregnancy, substance abuse, and other problems.

The picture shows an interaction between an American Indian health educator and a teen mother during a parenting lesson. The home-visiting educator uses a tabletop flip chart depicting a typical parenting situation to engage the mother in a discussion about what steps are required to address or resolve the situation.Figure 1. A Native American Family Health Educator Uses a Flip Chart to Engage Teen Mothers in Discussions of Parenting

The Family Spirit intervention aims to reduce these risks by enhancing adolescent mothers’ parenting skills and psychosocial development. The intervention comprises 43 structured lessons that take place in the adolescent mother’s home (see Figure 1), weekly while she is pregnant and with tapering frequency during her child’s first 3 years.

Testing and implementing health services in American Indian communities generally are complicated by two considerations: scarcity of resources and strong cultural sensitivities. To mitigate the impact of these issues, Dr. Barlow and colleagues trained and employed American Indian family health educators to deliver the Family Spirit curriculum. These women, from the same three Arizona reservations as the intervention’s recipients, attended more than 80 hours of instruction and passed written and oral examinations before making any home visits. They also received weekly supervision and quarterly quality assurance observational assessments.

“These Native American paraprofessional women are culturally competent, bilingual, and extremely compassionate concerning their participants’ needs,” Dr. Barlow says. “They have the potential to fill gaps in the health care system, especially in communities that are very underserved.”

Enhanced Mothering and Better Behaved Infants

The researchers recruited 322 pregnant adolescents, aged 12 to 19, to participate in the study. Three-fourths of the young women were pregnant for the first time, and all but a few were unmarried. The researchers randomly assigned 159 of the women to receive Family Spirit and the remaining 163 to a control group. Both groups received transportation to prenatal and well-baby visits, informational pamphlets on child care, and referrals to community resources.

At 12 months postpartum, the researchers assessed the teen mothers’ parenting knowledge and found that the mothers in the Family Spirit group had made greater gains than those in the control group. The Family Spirit group also scored higher on standardized measures of self-confidence about childrearing, on commitment and ability to manage their child’s behavior, and on attitudes toward home safety.

Also at the 12-month mark, the mothers completed a standardized assessment of their children’s emotional development (the Infant and Toddler Social Emotional Assessment; ITSEA). The results indicated that the Family Spirit children exhibited better adjustment across the board. Most reduced were externalizing behaviors, which generally manifest as defiance, temper tantrums, and/or hyperactivity.

The Family Spirit advantage was greatest for the 145 children of women who had entered the study with histories of substance use. On average, these infants were only about half as likely as those in the control group to have ITSEA scores predictive of future clinically significant externalizing or internalizing problems (see Figure 2).

See text description belowFigure 2. Family Spirit Children Exhibit Fewer Risks for Future Emotional Problems Compared with a control group, fewer Family Spirit infants received ITSEA assessment scores that indicate risk for future problems of an externalizing (aggression, impulsivity) or internalizing (anxiety, depression) nature. The Family Spirit infants also showed fewer signs of emotional dysregulation (difficulties sleeping or eating, or sensory hypersensitivity) than controls, but this decrease was not statistically significant.
Text description of Figure 2

The figure shows a bar graph indicating the proportion of children clinically at risk for emotional problems. The vertical (y)-axis shows the percentage of children clinically at risk for these emotional problems; the horizontal (x)-axis shows the types of emotional problems, that is, externalizing symptoms, internalizing symptoms, and dysregulation symptoms. The green bars represent the percentage values for the children of teen mothers in the Family Spirit intervention group (145 participants) and the blue bars for the children of the control group of mothers receiving a standard-of-care intervention (140 participants). As shown by the differences in bar heights between the two groups, the percentage of children at risk for each of the three emotional problems was lower in the intervention group than in the control group. As shown by the lines above the bars for externalizing symptoms and internalizing symptoms, the differences between the two groups in these two symptoms were statistically significant, indicated by probability (p) values of equal or less than 0.05.

The researchers suggest that Family Spirit’s greater efficacy for children of women with drug abuse histories indicates that improved parenting skills may buffer children against negative effects of their mothers’ substance abuse. Although the differences attributable to the intervention were small (the effect size for externalizing behaviors was –0.26), Dr. Walkup says they are significant from a public health perspective.

“The intervention is doable, reasonably affordable, and has the capacity to multiply itself over time,” Dr. Walkup says. He notes that once a mother has learned the skills taught by the intervention, she can apply them in raising subsequent children.

Adjusting and Advancing

Although more than three-fourths of the mothers in the study reported having used drugs in the past, only 10 percent reported that they were currently doing so when they enrolled during their pregnancy. However, at 12 months postpartum, 21 percent of the women reported having used an illicit drug during the past month. To address this negative trend, the researchers added new content focusing on substance abuse prevention to the curriculum for the next 2 years of the intervention. “In future replication, we will start the substance use prevention lessons as soon as mothers enroll,” says Dr. Barlow.

“So many things make this work hard to do: very rural settings, the mothers’ economic disadvantage, and tribes’ mistrust of outsiders arising in part from a history of exploitation,” says NIDA Program Officer Dr. Aria Crump. “I’m incredibly impressed with this team; they recognize the potential obstacles but don’t shy away from doing the work.”

Nineteen other tribes are implementing the Family Spirit curriculum and delivery model, and the Indian Health Service, serving 561 tribal nations, plans to scale it up even further. The Family Spirit trial in Arizona has now completed its 36-month assessments. In a paper pending publication, the researchers report further evidence that the intervention can help to interrupt the cycle of teen pregnancy and inadequate prenatal and child care among Native Americans.

“It’s a multigenerational challenge,” Dr. Walkup says. “We hope to break the cycle with this generation of mothers.”

This study was supported by NIH grant DA019042.


Barlow, A.; Mullany, B.; Neault, N.; Compton, S.; Carter, A.; Hastings, R.; Billy, T.; Coho-Mescal, V.; Lorenzo, S.; Walkup, J.T. Effect of a paraprofessional home-visiting intervention on American Indian teen mothers’ and infants’ behavioral risks: a randomized controlled trial. American Journal of Psychiatry 170(1): 83-93, 2013. Abstract