The effectiveness of individual and group-based parenting programmes in improving outcomes for...

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Journal ofAdolescence

Journal of Adolescence 26 (2003) 79–103

The effectiveness of individual and group-based parentingprogrammes in improving outcomes for teenage mothers and

their children: a systematic review

Esther Corena, Jane Barlowb,*, Sarah Stewart-Brownb

aThe UK Cochrane Centre, Summertown Pavilion, Middle Way, Oxford OX2 7LG, UKb Institute of Health Sciences, Health Services Research Unit, University of Oxford, Old Road, Headington,

Oxford OX3 7LF, UK

Abstract

There is evidence from a range of studies showing adverse child outcomes for the children of teenageparents. Parenting programmes are increasingly being used to promote the well-being of parents andchildren, and this review aims to establish whether they can improve outcomes for teenage parents and theirchildren. The findings of the review are based on 14 studies that used varying study designs, and aretherefore limited. The results suggest, however, that parenting programmes can be effective in improving arange of psychosocial and developmental outcomes for teenage mothers and their children. Furtherresearch is needed.r 2002 The Association for Professionals in Services for Adolescents. Published by Elsevier Science Ltd.All rights reserved.

1. Introduction

Rates of live births to teenage women are high throughout the post-industrialized world, withthe USA having the highest rate (55/1000 women aged 15–19). The rate in the UK (23/1000women aged 15–19) is the highest in Western Europe (Social Exclusion Unit, 1999). Teenagepregnancy rates increase with deprivation levels, and the likelihood of teenage pregnanciescontinuing to term is greater among groups experiencing socio-economic deprivation (Boulton-Jones, McIlwaine, & McInneny, 1995; Social Exclusion Unit, 1999). This reflects the fact thatteenagers in more affluent environments are more likely to terminate the pregnancy (ibid).

*Corresponding author. Tel.: +44-1865-226930; fax: +44-1865-226711.

E-mail address: [email protected] (J. Barlow).

0140-1971/02/$ 30 r 2002 The Association for Professionals in Services for Adolescents. Published by Elsevier Science

Ltd. All rights reserved.

PII: S 0 1 4 0 - 1 9 7 1 ( 0 2 ) 0 0 1 1 9 - 7

Early parenthood involves a conflict between the adolescent parent’s developmental needs andthe needs of their child (Erf, 1981; Catrone & Sadler, 1984; Wakschlag & Hans, 2000). Itrepresents an ‘atypical early transition’ which may in itself cause stress (Whitman, Borkowski,Schellenbach, & Nath, 1987), and which can compromise the mother’s educational attainmentand longer term opportunities (Dawson, 1997). Teenage mothers are more likely to haveexperienced adverse childhood factors and lower educational attainment, compared with non-mothering adolescents (Oz & Fine, 1988). It is also suggested that some teenage mothers activelychoose parenthood having experienced lower academic achievement and school-related self-esteem than their peers. This suggests that some teenage mothers may have lower learningpotential compared to their peers, which may have implications regarding their ‘cognitivereadiness’ for parenting (Held, 1981; Whitman et al., 1987).There is some evidence of poorer outcomes for children of teenage parents including

developmental problems, intellectual deficiencies, developmental delays, behaviour problems andlower school attainment (Whitman et al., 1987; Wakschlag & Hans, 2000). There is also evidence,however, to show that some children of adolescent mothers do not differ from other childrendevelopmentally (Bucholz & Korn-Bursztyn, 1993). Younger parents may lack both knowledge ofchild development, and effective parenting skills (Bavolek, Kline, Mclaughlin, & Publicover, 1979;Reis & Herz, 1987; Whitman et al., 1987; Bucholz & Korn-Bursztyn, 1993), due partly to theirinexperience of life more generally (Utting, Bright, & Henricson, 1993). There is evidence tosuggest that maternal age can also have an impact on aspects of parenting such as maternal rolesatisfaction and mother–infant interaction (Ragozin, Basham, Crnic, Greenberg, & Robinson,1982), attitudes to child discipline (Reis & Herz, 1987), and on the development of realisticexpectations of infant behaviour and development (Field, Widmayer, Stringer, & Ignatoff, 1980;Roosa, 1984; Whitman et al., 1987; Haskett, Johnson, & Miller 1994).There is also a higher risk of child maltreatment among younger parents (Bucholz & Korn-

Bursztyn, 1993; Wakschlag & Hans, 2000), although it is recognized that this risk is confoundedby environmental factors, including socio-economic deprivation, lack of social support,depression, low self-esteem and emotional stress (Bolton, Laner, & Kane 1980; Utting et al.,1993). This suggests that in the absence of other factors, the age of the parent is not necessarily arisk factor for child maltreatment.The needs of adolescent parents differ from those of older parents. In particular, their

developmental needs set them apart as a specific group, and the potential for negative outcomesfor them and their children suggests the need for early intervention. The use of parentingprogrammes began in the 1960s, and they are now being offered in a variety of settings includingthe community. Parenting programmes differ in their philosophy and content. While there aremany variations, the objectives of most parenting programmes are to change parent’s attitudesand behaviour through the provision of new parenting skills, and to promote increased insight,within a framework that is based on respect for both children’s rights, and parental rights andresponsibilities.A recent systematic review of randomized controlled trials (RCTs) showed that parenting

programmes are effective in changing parenting practices and improving behaviour problems inyoung children (Barlow & Stewart-Brown, 2000). A further review showed that parentingprogrammes can be effective in improving aspects of maternal psychosocial health includinganxiety, depression and self-esteem (Barlow & Coren, 2000).

E. Coren et al. / Journal of Adolescence 26 (2003) 79–10380

There has been increased interest in the prevention of teenage pregnancy, and projects with thisgoal have been established in various countries (Bilodeau, Forget & Tetreault, 1994; Pierre & Cox,1997; Perez, San Lorenzo, & Perez, 1997; Social Exclusion Unit, 1999). However, suchintervention is unlikely to succeed in preventing teenage pregnancy entirely, and adolescentparents and their children will remain a high-risk group. In addition, prevention is a long-termstrategy, and the rate of births to teenage parents remains high. Interventions that are directed atmaximizing the parenting skills of adolescent parents may therefore be crucial in optimizingoutcomes for young parents and their children, and in breaking the cycle of disadvantage.The aim of this review was to examine the effectiveness of individual and/or group-based

parenting programmes in improving psychosocial and developmental outcomes in teenagemothers and their infants.

2. Methods of the review

The methods have been described in detail elsewhere (Coren & Barlow, 2001). A search wasconducted using electronic databases including MEDLINE, EMBASE, CINAHL, PsychLIT,Sociofile, Social Science Citation Index and ASSIA. Other information sources included theCochrane Library (SPECTR, CENTRAL), the National Research Register (NRR) and ERIC.Two reviewers independently selected the abstracts and articles. Parenting programmes which

met all of the following criteria were included in the review:

* individual or group-based format,* offered ante-or postnatally to pregnant or parenting teenagers (age less than 20 years),* based on the use of a structured format,* focusing on the improvement of parenting attitudes, practices, skills or knowledge.

Parenting programmes which met any of the following criteria were excluded from the review:

* standard antenatal programmes specifically addressing the pregnancy care needs of teenagers,* programmes not specifically aimed at adolescent parents,* programmes involving direct work with the children of teenage parents,* programmes that aimed exclusively to prevent or reduce teenage pregnancy,* programmes in which the parenting programme is combined with a home visiting intervention.

While ‘home visiting’ programmes and parenting programmes combined with ‘home visiting’programmes have been excluded from this review, parenting programmes that were delivered on aone-to-one basis in the home have not been excluded from the review. This reflects the fact that‘home-visiting’ programmes are qualitatively different interventions (i.e. broad-based supportwhich is provided on a frequent basis over an extended period of time) to parenting programmesthat are delivered in the home (i.e. brief structured programmes with a specific focus onparenting).A range of scales were used in the included studies to measure parent and child outcomes.

Where sufficient data were provided, effect sizes were calculated. In the case of RCTs, the effectfor each outcome in each study was standardized by dividing the mean difference in post-intervention scores for the intervention and control group by the pooled standard deviation. The

E. Coren et al. / Journal of Adolescence 26 (2003) 79–103 81

difference in post-intervention scores (as opposed to ‘change’ scores) was calculated for tworeasons: (i) the process of randomization should have ensured that there were no major differencesin baseline scores thereby precluding the need to calculate change scores; (ii) the calculation ofeffect sizes based on the changes between pre- and post-scores requires the availability ofindividual change data which were not available for any of the included studies.For the studies that used one- and two-group designs without randomization, the mean for each

outcome at pre-test was subtracted from the mean for each outcome at post-test and divided bythe pooled standard deviation. While this is a less reliable method of computing effect sizes thanthat which was used for the included RCTs, in the absence of randomization and the absence of asecond group (one-group designs) this appeared to be the best method of producing standardizedscores. No confidence intervals have been calculated for these effect sizes, and these results inparticular should be treated with caution.Where insufficient data were provided to calculate effect sizes, other test results such as p values,

have been provided. Due to significant heterogeneity, the results were not combined in a meta-analysis.

3. Results

A total of 291 abstracts were reviewed. Of the 291 abstracts reviewed, 267 proved to be of nodirect relevance. A total of 24 papers were obtained for further review. Ten studies were excludedbecause they included a home visiting component or because they were not parentingprogrammes. The final review included 14 studies of the effectiveness of parenting programmesfor teenage parents.A Cochrane Review (this is a summary of the best available evidence on a particular topic using

the most rigorous study designs) based on findings from the four RCTs included in this review,has been published in the Cochrane Library (Coren & Barlow, 2001) (The Cochrane Library is thebest single source of reliable information about the effects of health care and is available on theworld wide web).Table 1 describes the characteristics of the included studies and has been organized by study

design, i.e. RCTs; controlled studies and one-group designs. Table 2 provides a summary of theaims of the study and the content/method of delivery of the parenting programmes beingevaluated in the included studies.The results are presented in three sections based on the methodology that was used. Section 4

comprises randomized controlled trials. Section 5 comprises controlled studies, i.e. control group,but no randomization, and Section 6 comprises studies that used a one-group pre- and post-testdesign. Within each section, the results have been divided into parent and child outcomes. Itshould be noted that for the studies in Section 4, the effect size was calculated by subtracting thepost-test mean for the intervention group from the post-test mean for the control group. A minussign indicates a result favouring the intervention group. For the studies in Sections 5 and 6, theeffect sizes were calculated by subtracting the mean at time one from the mean at time two forboth the intervention and control groups (where applicable). In this case, a minus sign indicatesdeterioration in score. The effect sizes in Sections 5 and 6 should be treated with caution as achange standard deviation is required to calculate change scores, and these data were not


Table1

Characteristics

ofincluded

studies

Nameofstudy

Designand

intervention

Participants

Outcomes

measured

Results

Limitationsofstudy

Ra

nd

om

ized

con

tro

lled

tria

ls

Lagges

andGordon

(1999)USA

Des

ign

:Cluster

randomized

trialwith

pre-andpost-

measures

Sixty-twopregnant

orparenting

adolescentsenrolled

inschoolbased

‘GRADS’

programmerecruited

then

randomized

by

class

Parentingattitudes

andknowledge

1.Parentalattitudes:

ES=

�0.5[CI:�1.07to

0.07]

*Methodof

allocation

concealmentnot

specified

*Distributionof

confoundersnot

assessed

*Noaccounttaken

ofcluster

randomized

design

Inte

rven

tio

n:Group-

basedparenting

programme—

2

consecutiveweekly

classes

lasting2h

Meanage16.9

years.

Interventiongroup

(n=4)Controlgroup

(n=4).

2.Parentingknowledge

test:ES=

�0.95[CI:

�1.54to

�0.36]

Black

andTeti(1997)

USA

Des

ign

:RCTwith

pre-andpost-

measures

Fifty-ninefirsttime

African-American

adolescentmothersof

infantsrecruited

from

highschools,woman

andchildclinics

(WIC),andlow-

incomefamily

supportcentres.

Meanage>20years.

Interventiongroup

(n=26);control

group(n=33)

Maternalattitudes

to

mealtimes;maternal

mealtime

communication

1.Parentattitudes

to

mealtimes:ES=

�1.28

[CI:�1.84to

�0.02]

2.Maternalmealtime

communications:

ES=�0.54[CI:�1.07

to�0.02]

*Methodof

allocation

concealmentnot

specified

*Limited

generalizability

Inte

rven

tio

n:

1�15min

video

delivered

onaone-to-

onebasis


Koniak-G

riffin,

Verzemnieks,and

Cahill(1992)USA

Des

ign

:RCTwith

pre-andpost-

measures

Thirty-oneadolescent

mothersofhealthy

infantsrecruited

from

aresidential

maternityhome.

Maternalattitudes

andbehaviour

1.Responsivenessto

parent:ES=

�0.71[CI:

�1.44to

0.02]

2.Clarity

ofinfantcues:

ES=

�0.5[CI:�1.23to

0.21]

3.Mother–infant

interaction:ES=

�0.79

[CI:�1.53to

–0.06]

4.Maternalsensitivity:

ES=

�0.82[CI:�1.56

to–0.08]

5.Cognitivegrowth

fosteringcapacities:

ES=

�0.61[�1.34to

�0.11]

6.Maternalidentity:

ES=

�0.81[CI:�1.55

to�0.08]

7.Maternalmotivation:

ES=

�0.35[CI:�1.00

to0.35]

8.Self-confidence:

ES=

�0.42[CI:�1.13

to0.09]

*Methodof

allocation

concealmentnot

specified

*Drop-outsnot

accountedfor

*Methodof

allocation

concealmentnot

specified

*Limited

generalizability

Inte

rven

tio

n:

2�video

sessions

delivered

onaone-to-

onebasis

Meanage17years.

Interventiongroup

(n=15);control

group(n=16)

Table1(c

on

tin

ued

)

Nameofstudy

Designand

intervention

Participants

Outcomes

measured

Results

Limitationsofstudy


Truss,Benson,

Hirsch,andLickiss

(1977)USA

Des

ign

:RCTwith

pre-andpost-

measures

Onehundredand

twentyseven

pregnant

orparenting

adolescentswhose

babieswould

beaged

o6monthsatstartof

programmerecruited

from

outpatient

clinic.All‘teenage’

parents.Intervention

group(n=83);

controlgroup

(n=12);others:

(n=32)

Cognitive

development—

languageacquisition

1.Receptivelanguage:

ES=

�0.52[CI:�1.13

to0.09]

2.Emergentlanguage:

ES=

�0.24[CI:�0.84

to0.37]

3.Languagedevelopment:

ES=

�0.24[CI:�0.91

to0.50]

*Methodof

allocation

concealmentnot

specified

*Limited

generalizability

Inte

rven

tio

n:group-

basedparenting

programme—

3

hourlysessionsover

12weeks

Co

ntr

oll

edst

ud

ies

Britner

andReppucci

(1997)USA

Des

ign

:Two-group

pre-andpost-test

non-equivalent

controlgroupdesign

Urbanteen

unmarriedmothersat

risk

forchild

maltreatm

ent.

Recruited

from

hospitalaccordingto

risk

factorsfor

maltreatm

ent.

Parentalattitudes

andexpectations

Parentingattitudes

and

expectations:intervention

group—ES=0.7.No

resultsavailableforcontrol

group

*Norandom

allocationto

groups

*Nomatchingof

controlgroups

*Limited

generalizability

Inte

rven

tio

n:Group-

basedparenting

programme—

12

weekly

sessions

Meanage15years.

Interventiongroup

(n=125);control

group(n=410)


EmmonsandNystul

(1994)USA

Des

ign

:Two-group

pre-andpost-test

non-equivalent

controlgroupdesign

Volunteersrecruited

from

apre-natal

schoolprogramme.

All‘adolescent’

parents.Intervention

group(n=9);control

group(1)(n=9);

controlgroup(2)

(n=10)

Parentalattitudes

andself-esteem

1.Self-esteem

:

interventiongroup—

ES=1.1

controlgroup1

—ES=0.2

control

group2—

ES=�0.1

2.Maternalattitudes:


ES=1.2

controlgroup

1—

ES=

�0.5

control

group2—

ES=0.2

*Norandom

allocationto

groups

*Drop-outs/

attritionnot

accountedfor

Inte

rven

tio

n:Group-

basedparenting

programme—

16

weeklysessionsof1h

duration

Dickensonand

Cudaback

(1992)

USA

Des

ign

:Twogroup

pre-andpost-test

non-equivalent

controlgroupdesign

Onehundredand

eighteen

pregnant

adolescentsrecruited

via

variousagencies.

Meanage17years.

Interventiongroup

(n=118);control

group(n=85)

Parentingpractices

Significantlymore

interventiongroup

mothershad‘no-risk’

scores

po0.01(40%

comparedwith17%)

*Norandom

allocationto

groups

*Limited

generalizability

Inte

rven

tio

n:15�8

pagebooklets—

mailed

monthly

Kissm

an(1992)USA

Des

ign

:Two-group

pre-andpost-test

withmatched

control

group

Intervention

participants

randomly

selected

from

teen

mother

populationofschool.

Meanage16years.

Interventiongroup

(n=25);control

group(n=94)

Parentalattitudes;

socialsupport;

parentalwell-being

1.Satisfactionwithlife:


ES=1.12controlgroup

�ES=0

2.Maternalattitudes

interventiongroup

�ES=1.0control

group—ES=0.1

*Norandom

allocationto

groups

*Drop-outs/

attritionnot

accountedfor

Table1(c

on

tin

ued

)

Nameofstudy

Designand

intervention

Participants

Outcomes

measured

Results

Limitationsofstudy


Inte

rven

tio

n:Group-

basedparenting

programme—

1

year�1.5hsessions

Badger

(1981)USA

Des

ign:Random

assignmentto

oneof

twointervention

groups

Volunteer

teenage

mothersofinfants

recruited

postnatally

from

apaediatric

medicalcentre.Age

p16years.Group-

basedintervention

(n=24).Home

visitingintervention

(n=24)

Infantdevelopment

1.Infantdevelopment

significantlybetterin


p=

o0.01

2.Mentaldevelopment



p=0.01

3.Motordevelopment



po0.01

*Nocontrolgroup

Inte

rven

tio

n:Group-

basedparenting

programme—

provided

onweekly

basis(?duration)

On

e-g

rou

pp

re-

an

dp

ost

-tes

td

esig

ns

Treichel(1995)USA

Des

ign

:Onegroup

pre-andtestpost-test

design

Participantsrecruited

from

varioussites

where‘M

ELD

for

YoungMoms’

programmeoffered

(n=79).Meanage17

years

Parentalattitudes

andexpectations

1.Inappropriate

expectations:ES=0.5

2.Lack

ofem

pathy:

ES=0.4

3.Beliefin

corporal

punishment:ES=0.3

4.Parent–childrole

reversal:ES=0.3

*Norandomization

orcontrolgroup

Inte

rven

tio

n:Group-

basedparenting

programme—

2

hourlyweekly

sessions(?duration)


Censullo(1994)USA

Des

ign

:Onegroup

pre-andpost-test

design—

pilotstudy

Twelveteen

parents

andtheirinfants.

Volunteersfrom

participantsin

an

ongoingprogramme

(n=12).Meanage17

years.

Maternal

responsiveness;self-

esteem

;parentalself-

efficacy

1.Dyadicmutuality:

ES=2.2

2.Self-esteem

:ES=0.5

3.Self-efficacy:ES=0.2

*Norandomization

orcontrolgroup

*Limited

generalizability

Inte

rven

tio

n:Group-

basedparenting

programme—

3�weekly

sessions

Weinman,Schreiber,

andRobinson(1992)

USA

Des

ign

:Onegroup

pre

andpost-test

design

Referralinform

ation

notclear.

Participationwas

voluntary

(n=73).

Meanage17.7

years.

Parentalattitudes

andexpectations;

self-image;locus-of-

control;viewofthe

future

1.Emotionaltone:

ES=0.4

2.Vocationaland

educationalgoals:

ES=0.3

3.Sexualattitudes:

ES=0.3

4.Masteryofexternal

world:ES=0.4

5.Superioradjustment:

ES=0.4

6.Inappropriate

expectations:ES=0.4

7.Lack

ofem

pathy:

ES=0.3

8.Beliefin

corporal

punishment:ES=0.7

9.Parent–childrole-

reversal:ES=0.6

1.Norandomization

orcontrolgroup

Limited

generalizability

Inte

rven

tio

n:Group-

basedparenting

programme—

7hper

dayfor3daysover

8

weeks

Table1(c

on

tin

ued

)

Nameofstudy

Designand

intervention

Participants

Outcomes

measured

Results

Limitationsofstudy


Fulton,Murphy,and

Anderson(1991)

USA

Des

ign

:Onegroup

pre-testpost-test

design

Seventy-six

teenage

parentsrecruited

voluntarily

through

variousagencies.

Meanage17years

Parentingattitudes;

parentingknowledge;

self-esteem

1.Parentingattitudes

significantlyimproved

post-intervention:

po0.03

2.Parentingknowledgeof

childdevelopmentand

behavioursignificantly

improved

post-

intervention:

po0.016

3.Self-esteem

:no

significantchange

*Norandomization

orcontrolgroup

*Limited

generalizability

Inte

rven

tio

n:Weekly

sessionsfor4–6

monthsdelivered

on

aone-to-onebasis

Roosa

(1984)USA

Des

ign

:Onegroup

pre-testpost-test

design.Retrospective

study

Participantsrecruited

from

threeschool-

basedurbanteenage

parenting

programmes

in

Arizona(n=79).

Meanage16years

Maternalattitudes;

maternalanxiety;

maternalsatisfaction;

knowledgeofhuman

reproductionand

childdevelopment

1.Maternalsatisfaction:

ES=0.2

2.Encouragem

entof

interaction:ES=0.1

3.Maternalanxiety:

ES=0.2

4.Knowledgeofhuman

reproduction


post-intervention:

po0.01

5.Knowledgeofchild

development


post-intervention:

po0.05

*Norandomization

orcontrolgroup

*Retrospective

study

*Limited

generalizability

Inte

rven

tio

n:

Delivered

aspartof

schoolcurriculum—

nofurther

details

provided

n.b.In

thecase

ofRCTsaminussignindicatesaresultfavouringtheinterventiongroup.In

thecase

ofcontrolled

studiesandtheone-designsa

minussignindicatesdeteriorationin

score.ES=effect

size

andCI=

confidence

interval.


Table2

Contentoftheincluded

parentingprogrammes

StudyID

Aim

ofthestudy

Contentanddeliveryofintervention

Ra

nd

om

ized

con

tro

lled

tria

ls

LaggesandGordon(1999)

Toevaluate

theuse

ofaninteractivevideodisc

programmebasedontheParentingAdolescents

Wisely(PAW)programme(thetheoreticalpremise

underpinningtheprogrammewasnotspecified)in

reducingtherisk

ofchildmaltreatm

entor

developmentaldelay

Parentingprogrammeprovided

onanindividual

basisdelivered

byinteractivevideodiscaddressing

communicationskills,problem

solvingandadaptive

parentingskills.Twoconsecutiveweeklyclasses

lasting2heach

Black

andTeti(1997)

Toexaminetheeffectivenessofavideotaped

parentingprogrammebasedonsociallearningtheory

inchangingmaternalmealtimebehaviour


onanindividual

basisusingvideotaped

vignettesto

modelmealtime

behaviour.One15-m

invideo

Truss

etal.(1997)

Toexaminetheeffectivenessofagroup-based

parentingprogrammein

enablingparentsto

enhance

infantcognitivedevelopmentandpreventor

minimizedevelopmentaldelays

Group-basedparentingprogrammefocusedonchild

managem

entandeffectivestimulationofinfants.

Alsodevelopmentallyappropriatebookletsmailed

toparentsover

48months.Threehourlysessionsover

thecourseof12weeks

Koniak-G

riffinet

al.

(1992)

Toexaminetheeffectivenessofaparenting

programmein

improvingthematernalbehaviourof

adolescentmothersthroughavideo-tapemodelling

programme


onanindividual

basisinvolvingstructuredtasksrecorded

on

videotapewithfeedback

from

anursingprofessional.

Twovideo-tapesessionswithinstructionand

feedback.

Co

ntr

oll

edst

ud

ies

Britner

andReppucci

(1997)



reducingtherisksofchild

maltreatm

entandpromotingpositiveoutcomes

for

teenagemothersandtheirchildren

Group-basedprogrammeofparenteducationand

supportwithafocusonbonding,communication,

responsibleparenting,discipline,childdevelopment,

continuingeducation,familyplanningandhealthand

relationship

issues.Twelveweekly

sessions

EmmonsandNystul

(1994)

ToexaminetheeffectivenessofPREPin

promoting

dem

ocraticparentingattitudes

withadolescents

enrolled

inanante-natalprogramme

‘PREPforeffectiveliving’programme.Adlerian

group-basedparentingprogramme—

focuson

communication,self-esteem,relationshipsand

parentingskills.Hourlygroup-basedsessionsfora

periodof16weeks

DickensonandCudaback

(1992)

Toexaminetheeffectivenessofabibliotherapy-based

parentingprogrammeprovided

onanindividual

basis,ontheparentingskillsandpractices

of

adolescentmothers

Fifteen

eight-pagebookletsmailed

monthly—three

focusingonante-natalandbirth

issues

and12

focusingonparentingandchilddevelopment


Kissm

an(1992)



enhancingparentingskills

andincreasingtheuse

ofsocialsupport.Toprovide

supportalongsidethatoffered

bytheschool

Group-basedparentingprogrammecomplementary

tothatoffered

bytheschool.Designed

toenhance

parentingskillsandincrease

use

ofsocialsupport.

Cognitivebehaviouralapproach

focusedonchild

managem

entskills,childneedsandinteraction.One

andahalfhourweeklysessionsoverthecourseofan

academ

icyear

Badger

(1981)



reinforcingthematernal

role,increasingrolesatisfaction,andpreventing

deficitsanddevelopmentaldelaysin

infants

Group-basedparentingintervention.Focuson

mother–infantinteractioncoachingandinfant

development.Group-basedprogrammeprovided

on

aweekly

basisandhomevisitingprogrammeona

monthlybasis(nofurther

details)

On

e-g

rou

pp

re-

an

dp

ost

-tes

t

Treichel(1995)



promotingdevelopmentof

appropriateparentingbehavioursin

teenagemothers

Supportandinform

ationaboutparentingin

agroup

runbyex-teenmothers.Two-hourweekly

sessions

(noinform

ationaboutduration)

Censullo(1994)

Toexaminetheeffectivenessofresponsiveness

coachingprovided

bynurses,in

improving

responsivenessin

themother–infantrelationship

and

increasingparentalself-esteem

andconfidence

Group-basedparentingprogrammeusingICAP.

(‘InteractionCoachingforAdolescentParents’).

Focusonexplanation,modelling,andindividual

trial,errorandreward.Threexweekly

sessions

Weinmanet

al.(1992)

Toexaminetheeffectivenessofagroup-basedparent

educationprogrammedeveloped

foradolescent

mothersin

theprimary

preventionofchildabuse

Group-basedparentingprogrammefocusingon

concreteskillsacquisitionandabstractinternal

resourcebuilding—

childdevelopmentandparenting

skills,healthandsafety,survival,personalgrowth

andself-esteem.Programmeprovided

for7hoursper

dayfor3daysover

8weeks

Fultonet

al.(1991)

Toexaminetheeffectivenessofaparenting

programmein

increasingknowledgeofchildgrowth

anddevelopment.Toassessifanincrease

inknowledgeisrelatedto

adecrease

intendencies

toinappropriate

interactionswithchildren.Alsoto

assessifmothers’self-esteem

wasinfluencedby

changes

inknowledgeofchildgrowth

and

development

Parentingprogrammedelivered

onanindividual

basisathomeandatclinicalternately.Content

included

prenatalcare,parentingskills,service

availability,supportto

mothers.Mothersencouraged

toidentify

curriculum

topics.Variousmedia

usedas

appropriate.Weekly

sessionsover

thecourseof4–6

monthsalternatinghomeandcommunitycentrevisits

Roosa

(1984)

Toexaminetheshortterm

effectivenessofthree

group-basedparentingprogrammes

onthe

knowledgeandattitudes

ofpregnantteenagers

Retrospectivestudythatrecruited

participantsfrom

threeparentingprogrammes.Noinform

ationon

programmecontent.Allprogrammesincluded

family

livingandparent–childdevelopmentcomponents.

Delivered

aspartoflocalschoolsystem

asan

alternativeto

attendingmainstream

classes.No

detailsaboutfrequency

ordurationprovided


available for any of the included studies. Confidence intervals have not therefore been calculatedfor the studies in Sections 5 and 6. See methods section for further details.

4. Randomized controlled trials

4.1. Child outcomes

4.1.1. Responsiveness to parent and clarity of infant cuesKoniak-Griffin et al. (1992) evaluated a parenting programme which was delivered on an

individual basis in the home, using video-tape instruction with feedback. The study assessedmother–infant interaction using the Nursing Child Assessment Teaching Scale (NCATS). TheNCATS measures mother–infant interaction using six subscales, four of which assess thecaregiver’s behaviour in interactions, and two of which measure aspects of infant interaction. TheResponsiveness to Parent Subscale measures the extent to which the infant responds positively tothe parent. The results for this subscale show a non-significant effect favouring the infants in theintervention group �0.71 [�1.44, 0.02]. An evaluation was also conducted of the effectiveness ofthe programme in improving the clarity of infant cues in interaction using the Baby Subscale ofthe NCATS. The results show a moderately non-significant difference favouring the infants in theintervention group �0.5 [�1.23, 0.21].

4.1.2. Language developmentTruss et al. (1977) evaluated the effectiveness of a 10–12 week, group-based parenting

programme, focusing on the promotion of infant language development. In addition, participantsin the intervention group were sent booklets designed to enhance mother–infant interaction, every2 months for the first 48 months of the child’s life. The infant’s ability to understand and respondto language was measured using the Receptive Language Score of the Bzoch-League Receptive-Expressive Emergent Language Scale. The results show a non-significant effect favouring theinfants in the intervention group �0.52 [�1.13, 0.09]. The development of the infant’s expressivelanguage abilities was measured using the Bzoch-League Receptive-Expressive EmergentLanguage Scale. The results show a non-significant effect favouring the infants in the interventiongroup �0.24 [�0.84, 0.37]. The child’s general language development was measured using theUtah Test of Language Development. It should be noted that this was measured at 2 years of age,i.e. 1 year later than the other included measures from this study. The results show a non-significant effect favouring the infants in the intervention group �0.24 [�0.91, 0.50].

4.2. Parent outcomes

4.2.1. Parenting attitudes and knowledgeLagges and Gordon (1999) evaluated a brief interactive laser-disc parent-training programme

with group discussion. Parental attitudes were assessed using the Parent Attitudes Questionnaire.The results show a non-significant effect favouring the intervention group �0.50 [�1.07, 0.07].They also evaluated the effectiveness of the programme in improving parenting knowledge using


the Parenting Knowledge Test. The results show a significant effect favouring the interventiongroup �0.95 [�1.54, �0.36].

4.2.2. Parental mealtime communicationBlack and Teti (1997) used a 15-min, culturally sensitive video-tape to model appropriate

mealtime behaviours for African-American adolescent mothers. Changes in parent attitudes tomealtimes were assessed using ‘About Your Child’s Eating’ Questionnaire. The results show asignificant effect favouring the intervention group �1.28 [�1.84, �0.71]. A modified version of theParent–Child Early Relational Assessment was used to measure changes in maternal mealtimecommunication. The results show a significant effect favouring the intervention group �0.54[�1.07, �0.02].

4.2.3. Nursing child assessment teaching scale (maternal subscales)

Koniak-Griffin et al. (1992) evaluated the effectiveness of the parenting programme describedin Section 4.1.1 above, in improving mother–infant interaction using the Nursing ChildAssessment Teaching Scale. The results for the Total Score show a significant effect favouring theintervention group �0.79 [�1.53, �0.06]. The NCATS was used to evaluate the effectiveness ofthe programme in improving maternal sensitivity in interaction. The results show a significanteffect favouring the parents in the intervention group �0.82 [�1.56, �0.08]. The cognitive growthfostering capacities of mothers were measured using the Cognitive Growth Fostering Subscale ofthe NCATS. The results show a significant effect favouring the parents in the intervention group�0.61[�1.34, �0.11].

4.2.4. Maternal identityKoniak-Griffin et al. (1992) evaluated the effectiveness of the parenting programme described

in Section 4.1.1 above in improving aspects of maternal identity using the Semantic DifferentialsMeasure. The ‘Myself As Mother’ Subscale measures the evaluative dimension of the concept‘myself as mother’. The results show a significant effect favouring the intervention group�0.81[�1.55, �0.08]. The ‘My Baby’ Subscale measures aspects of maternal identity that relatespecifically to maternal beliefs or attitudes about their child. The results for this subscale show asignificant effect favouring the intervention group �0.78 [�0.51, �0.04].

4.2.5. Self-confidence

Koniak-Griffin et al. (1992) used the Pharis Self-Confidence Scale, to evaluate the effectivenessof the parenting programme described in Section 4.1.1 above, in improving maternal self-confidence in regular child-care tasks. The results show a non-significant effect favouring theintervention group �0.42 [�1.13, 0.29].

4.2.6. Maternal involvement with the child

Truss et al. (1977) evaluated the effectiveness of the parenting programme described in Section4.1 above, in improving maternal involvement with the child using the Caldwell Home Inventory.The results show a non-significant effect favouring the intervention group �0.35 [�1.00, 0.31].


5. Controlled studies

5.1. Child outcomes

5.1.1. Infant developmentBadger (1981) used the Uzgiris-Hunt Ordinal Scales of Infant Development to assess the

effectiveness of a group-based parenting programme compared with a home visiting programmein promoting infant development. The Uzgiris-Hunt Ordinal Scales of Infant Developmentinclude measures of infant cognitive development such as object permanence, development ofmeans and vocal imitation. Participants were divided into high-risk and low-risk groups. Theresults show a significant difference between the infants in the group-based parenting programmecompared with the home visiting programme (p ¼ o0:01). The treatment effect was especiallyapparent in the group of high-risk mothers, although no data were reported.Badger (1981) used the Bayley Scales of Infant Development (Mental Scale) to measure the

effectiveness of the programme in promoting infant development. The Bayley scales are standardmeasures of infant developmental progress and comprise three scales measuring mental, motorand behavioural development. The results show that the infants of the high-risk mothers in thegroup-based programme had better mean mental scores than the infants of the high-risk mothersin the home visiting group (p ¼ o0:05). There were no other significant inter-group differences.Badger (1981) used the Bayley Scales of Infant Development (Motor Scale) to measure the

effectiveness of the above programme in promoting motor development. The results show that theinfants of high-risk mothers in the group-based programme had significantly improved meanmotor scores compared with the infants of the high-risk mothers in the home visiting group(p ¼ o0:05). The motor scores of these infants were significantly better than those of lower riskmothers who attended the group-based programme.


5.2.1. Satisfaction with life

Kissman (1992) evaluated the effectiveness of a group-based parenting programme based on acognitive-behavioural approach in improving maternal well-being using the Satisfaction with LifeScale. This scale was used to evaluate the mother’s perception of the condition of her life. Theresults show an improvement in maternal well-being for the intervention group (ES ¼ 1:1) but nochange for the control group (ES ¼ 0).

5.2.2. Maternal attitudesKissman (1992) evaluated the effectiveness of a group-based programme in improving maternal

attitudes using the Segal Scale. This scale measures maternal attitudes to the parental role, i.e.disciplinarian vs. child-centredness. The results show an improvement in maternal attitudes for theintervention group (ES ¼ 1:0) and no change for the control group (ES ¼ 0:1).Emmons and Nystul (1994) evaluated the effectiveness of the ‘PREP for family living’, group-

based, Adlerian parenting programme on teenage mothers’ attitudes towards discipline andauthority using the Attitude Towards the Freedom of Children Scale. The authors compared theintervention group with two comparison groups. The first of these (adolescent mothers—AM)


had attended the prenatal course the previous year, but had not received the PREP programme.The second comparison group comprised adolescents who had never been pregnant (adolescentswithout children—AWC). The Attitude Towards the Freedom of Children Scale measuresparenting attitudes ranging from authoritarian to democratic. The results show a largeimprovement in parental attitudes for the intervention group (ES ¼ 1:2), deterioration for theAM comparison group (ES ¼ �0:5) and no improvement for the AWC comparison group(ES ¼ 0:2).Britner and Reppucci (1997) evaluated the effectiveness of a group-based parenting programme

aimed at preventing child maltreatment, in changing parental attitudes and expectations using theAdult Adolescent Parenting Inventory (AAPI). This scale measures parental attitudes as regardsappropriate/inappropriate expectations of children, empathy, discipline and parent–child roles.The results show a moderate improvement in parenting attitudes for the intervention group(ES ¼ 0:4). The results for the comparison group were not reported.

5.2.3. Self-esteemEmmons and Nystul (1994) evaluated the effectiveness of the PREP for family living group-

based Adlerian parenting programme described in B2.2 above, on the self-esteem of teenagemothers using the Coopersmith Self-Esteem Inventory. The results show a large change in self-esteem for the intervention group (ES ¼ 1:1), a small change for the AM comparison group(ES ¼ 0:2), and no improvement for the AWC comparison group (ES ¼ �0:1).

5.2.4. Maternal involvement with the childDickenson and Cudaback (1992) evaluated the effectiveness of a bibliotherapy-based parenting

programme in improving the parenting effectiveness of teenage mothers using the HOMEScreening Questionnaire. This questionnaire is based on the HOME Observation forMeasurement of the Environment (HOME) Inventory, which measures the quality of the infant’shome environment and comprises six subscales—acceptance of the child; provision of learningmaterials; parental involvement; parental responsibility; variety in experience and organization ofthe environment. The results show that a significantly higher proportion of mothers in theintervention group (40%) had ‘no risk’ scores at post-test compared with mothers in the controlgroup (17%) po0:01:

6. One-group pre- and post-test design

6.1. Child outcomes

None of the one-group pre- and post-test design studies reported child outcomes.


6.2.1. Parenting attitudesBoth Weinman et al. (1992) and Treichel (1995) evaluated the effectiveness of group-based

parenting programmes, in changing parental attitudes and expectations using the AAPI. This


scale measures parental attitudes as regards appropriate/inappropriate expectations of children,empathy, discipline and parent–child roles. The findings for the four subscales or constructs of theAAPI are reported below—6.2.1.1–6.2.1.4.

6.2.1.1. Inappropriate expectations. The Weinman et al. (1992) study shows a moderately largeimprovement in inappropriate expectations post-intervention (ES ¼ 0:4). The Treichel (1995)study also shows a moderately large improvement in inappropriate expectations post-intervention(ES ¼ 0:5).

6.2.1.2. Lack of empathy. Weinman et al. (1992) study shows a small improvement in levels ofempathy post-intervention (ES ¼ 0:3). The Treichel (1995) study showed a moderate improve-ment in levels of empathy post-intervention (ES ¼ 0:4).

6.2.1.3. Belief in corporal punishment. The Weinman et al. (1992) study shows a fairly largeimprovement in beliefs about the use of corporal punishment post-intervention (ES ¼ 0:7). TheTreichel (1995) study showed a small improvement in beliefs about the use of corporalpunishment post-intervention (ES ¼ 0:3).

6.2.1.4. Parent–child role reversal. The Weinman et al. (1992) study showed a moderately largeimprovement in attitudes to role reversal post-intervention (ES ¼ 0:6). The Treichel (1995) studyshowed a small improvement in attitudes to role reversal post-intervention (ES ¼ 0:3).

6.2.1.5. Overall parenting attitudes. Fulton et al. (1991) evaluated the effectiveness of a parentingprogramme focused on antenatal care, parenting skills, and support and service access, which wasdelivered individually both in the home and at a clinic, in improving parenting attitudes using theChild Abuse Potential Inventory. The results show a significant improvement in parentingattitudes post-intervention po0:01:Roosa (1984) undertook a retrospective study of the effectiveness of three school-based

parenting programmes for adolescent parents in which alternative classes were provided forpregnant school pupils. Effectiveness was assessed using three subscales of the Maternal AttitudeScale (Cohler, Weiss & Greenbaum, 1967). This instrument is designed to measure emotionalresponses to aspects of mother–child interaction. The findings are reported below.

6.2.1.6. Maternal Attitude Scale (MAS). The Maternal Satisfaction Subscale measures maternalsatisfaction vs. feelings of depletion and hostility. The Roosa (1984) study shows a smallimprovement in maternal satisfaction post-intervention (ES ¼ 0:2). The Encouragement ofInteraction Subscale measures encouragement of positive interaction vs. hostility towardschildren. The Roosa study shows no real improvement in encouragement of interaction post-intervention (ES ¼ 0:1). The Maternal Anxiety Subscale measures maternal anxiety. The studyshows a very small improvement in maternal anxiety post-intervention (ES ¼ 0:2).

6.2.2. Maternal self-image (Offer Scale)Weinman et al. (1992) evaluated the effectiveness of the programme described in 6.2.1 above, in

improving the self-image of adolescent mothers using the Offer Scale. This scale measures


self-image and is divided into 11 subscales which comprise impulse control, emotional tone, bodyand self-image, social relationships, morals, vocational and educational goals, sexual attitudes,family relationships, mastery of the external world in relation to the immediate environment,psychopathology, superior adjustment, and coping with self, others and the world. The authorsreport findings for only five subscales. The data for the remaining scales were not reported due toa lack of significance.The study shows a moderate improvement in emotional tone post-intervention (ES ¼ 0:4),

and a small improvement in both vocational and educational goals (ES ¼ 0:3), and in sexualattitudes, post-intervention (ES ¼ 0:3). The study also shows a moderate improvement in bothmastery of the external world (ES ¼ 0:4), and in superior adjustment, post-intervention(ES ¼ 0:4).

6.2.3. Maternal knowledge of human reproduction and child developmentRoosa (1984) evaluated the effectiveness of the three parenting programmes described in 6.2.1.4

above in improving maternal knowledge of human reproduction and child development usingnon-standardized instruments that were designed specifically for the study. The results showsignificant improvements in maternal knowledge about human reproduction post-interventionpo0:01 and in maternal knowledge about child development po0:05:Fulton et al. (1991) evaluated the effectiveness of the parenting programme described in 6.2.1.4

above, in improving parenting knowledge of child development and behaviour using theKnowledge Inventory of Child Development and Behaviour. The results show a significantimprovement in parenting knowledge post-intervention po0:016:

6.2.4. Mother–infant responsiveness

Censullo (1994) evaluated the effectiveness of a programme entitled ‘Interaction Coachingfor Adolescent Parents’. This programme aims to improve mother–infant interaction,increase sensitive maternal responsiveness and enhance the mother’s self-confidence in herparenting ability using feedback from the infant and the programme coach. Responsivenessin mother–infant interaction was evaluated using the Dyadic Mutuality Code, which isdesigned to measure responsiveness in early mother–infant interaction. Observed individualinfant and mother behaviours are scored, in addition to the interaction behaviour of thepair. The study shows a very large improvement in mother–infant interaction post-intervention(ES ¼ 2:2).

6.2.5. Self-esteem

Censullo (1994) evaluated the effectiveness of the programme described in 6.2.1.4 above onmaternal self-esteem, using the Rosenberg Self-Esteem Scale, which measures the self-acceptancecomponent of self-esteem. The findings show a moderate improvement in maternal self-esteempost-intervention (ES ¼ 0:5).Fulton et al. (1991) evaluated the effectiveness of the parenting programme described in

C2.1 (d) above, in improving the self-esteem of teenage mothers. The CoopersmithSelf-Esteem Inventory measures subjects’ attitudes to themselves in social, academic,family and personal contexts. This study shows no significant differences in maternal self-esteempost-intervention.


6.2.6. Parental self-efficacy

Censullo (1994) evaluated the effectiveness of the programme described in C2.4 above, onconfidence in the parental role, using the Parental Self-Efficacy Scale. Responses to the items inthis scale indicate the level of competence the subject feels about infant care and the parental role.The study shows a small improvement in maternal self-efficacy post-intervention (ES ¼ 0:2)

7. Discussion

The results of this review are necessarily limited due to the small number of included studies andthe varying methodologies used. However, the results indicate that parenting programmes areeffective in improving a range of outcomes for both teenage parents and their infants includingmaternal sensitivity, identity, self-confidence and the infants’ responsiveness to their parents.This review reflects the paucity of rigorous research evaluating the effectiveness of parenting

programmes for teenage parents and the conclusions that can be reached are limited due to thesmall number of outcomes that were measured and the lack of rigorous methodology. One of thefour RCTs utilized a cluster randomized controlled design in which random allocation wasundertaken using classes rather than individuals (Lagges & Gordon, 1999). No allowance wasmade in this study for the ‘design effect’, which is defined as the ratio of the total number ofparticipants required using cluster randomization, to the number required using individualrandomization. Furthermore, no account was taken of the cluster design at the analysis stage ofthe study. Failure to take account of the cluster design can result in a Type I error, or an increasedlikelihood of a positive treatment effect (Cornfield, 1978, Donner, 1982, Murray et al., 1994;Rooney & Murray, 1996). The results of this study should therefore be treated with caution. Theresults of the studies in Sections 5 and 6 of this review should also be treated with caution. Thisprimarily reflects the fact that the controlled studies did not randomize participants tointervention groups, and the results of these studies may well be confounded by other factors.Furthermore, in the absence of a control group (the one-group pre- and post-test studies) it is notpossible to know whether the results were attributable to the intervention rather than changeswhich occurred naturally over time.There was considerable diversity in the parenting programmes that were evaluated in this

review as regards (i) whether they were delivered on a group or one-to-one basis and; (ii) theintensity/duration of the programmes. Of the 14 included studies ten evaluated group-basedparenting programmes (Badger, 1981; Roosa, 1984; Kissman, 1992; Weinman et al., 1992;Censullo, 1994; Emmons & Nystul, 1994; Treichel, 1995; Britner & Reppucci, 1997; Truss et al.,1997; Lagges & Gordon, 1999), three evaluated programmes that were delivered on an one-to-onebasis (Black & Teti, 1997; Koniak-Griffin et al., 1992; Fulton et al., 1991), and one programmeevaluated the effectiveness of booklets which were mailed to parents (Dickenson & Cudaback,1992). Only one study directly compared a group-based programme with a programme deliveredon a one-to-one basis (Badger, 1981). The results of this study showed that the group-basedprogramme produced more changes than the individual programme, especially in the case of high-risk mothers. It is hypothesized that group processes and peer-group support may have played asignificant role in producing the change. Overall, while there is insufficient evidence available toreach any firm conclusion about the comparative effectiveness of individual and group-based


programmes for teenage parents, it seems likely that a group-based intervention may be a moresupportive and helpful strategy with younger mothers.A number of the included studies evaluated the effectiveness of brief (i.e. one to two sessions)

interventions, two of which involved the use of videos that were delivered on a one-to-one basis(Black & Teti, 1997; Fulton et al., 1991). Despite their brevity, these interventions producedpositive changes in a range of parent and child outcomes. The majority of the group-basedprogrammes that were evaluated was provided on a weekly basis over the course of 12–16 weeks.All of these programmes produced positive outcomes. Three further studies evaluated theeffectiveness of programmes that were provided more intensively, i.e. 7 hours a day for 3 days over8 weeks (Weinman et al., 1992) or over a longer period of time, i.e. over the course of a year(Kissman, 1992). While these studies also provided positive outcomes, it seems likely that shorterprogrammes could have produced similar results. One study evaluated the effectiveness of aparenting programme that was provided as part of the school curriculum as an alternative toattending mainstream classes (intensity and duration unspecified) (Roosa, 1984). While this studyshowed significant changes in maternal knowledge there were no changes post-intervention inmaternal attitudes. Overall, there were many methodological problems with this study, and toofew details were provided about the nature of the curriculum or the method of delivery to assesswhy there was no change in maternal attitudes. Finally, one study evaluated the effectiveness of aseries of booklets that were mailed to teenage parents (Dickenson & Cudaback, 1992). While thisintervention also produced positive changes, as was suggested earlier, it seems likely that group-based interventions that offer peer support to isolated teenage mothers may be a moreappropriate intervention.None of the included studies provided any evidence of the cost-effectiveness of the interventions

being evaluated, but there is some evidence to indicate that group-based parenting programmes ofmedium duration, i.e. 10–12 weeks are more cost-effective than parenting programmes which areadministered on a one-to-one basis (Barlow and Stewart-Brown, 2000). There is no availableevidence, however, concerning the cost benefit ratio of mailing booklets to parents compared withthe use of groups.The included studies reflect the wide range of settings in which interventions for teenage parents

are provided, e.g. schools (Roosa, 1984; Kissman, 1992; Emmons & Nystul, 1994; Lagges &Gordon, 1999), health settings (Truss et al., 1977; Badger, 1981; Britner & Reppucci, 1997), aresidential maternity home (Koniak-Griffin et al., 1992), and community health clinics and familysupport centres (Weinman et al., 1992; Black & Teti, 1997). In addition, three programmes wereprovided in the home (Dickenson & Cudaback, 1992; Koniak-Griffin et al., 1992; Black & Teti,1997), and one programme was provided in both the home and a community health setting(Fulton et al., 1991). None of the studies discuss the rationale for the location of the serviceprovision and the reasons may have been pragmatic. The range of settings identified in this studypoints to the need for service providers to consider in which settings programmes can best beprovided, in order to maximize beneficial outcomes. In view of the small numbers of participantsand the high level of dropout and attrition in some of the included studies, consideration shouldalso be given to methods of recruiting and retaining teenage participants in parentingprogrammes. Furthermore, whilst there appears to be considerable development of services forteenage parents across a range of different settings, there is very little discussion in the literatureconcerning coordination between the different providers.


The generalizability of the results obtained from the included studies was compromised by anumber of factors. First, while the upper limit for parental drop-out was 33% in the RCTs (Trusset al., 1977), the drop-out rate was as high as 41% for the controlled studies (Dickenson &Cudaback, 1992) and 47% for the one group pre- and post-test designs (Weinman et al., 1992).Furthermore, in the retrospective study by Roosa (1984) only 31 of 79 participants completingmeasures at pre- and post-test, were the same at both time points.Research concerning the factors that predict drop-out from parenting programmes has shown

that teenagers are more likely to drop-out than older parents (Danoff, Kemper, & Sherry 1994). Ithas also been suggested that mothers reporting greater stress from their relations with the child,their own role functioning, and life events; and families being at greater socio-economicdisadvantage (Kazdin, 1990) have a higher likelihood of attrition. Other studies have identifiedindividuals more likely to drop out as including those from a lower social class or an ethnicminority (Strain, Young, & Horowitz 1981; Holden, Lavigne, & Cameron, 1990; Farrington,1991). In view of the prevalence of these social circumstances among the teenage parentingpopulation, the above attrition rates may be seen as encouragingly low. The problemssurrounding the issue of attrition and dropouts point to the importance of evaluating the resultsof such trials on an intention-to-treat basis.Second, all of the included studies were based on samples of parents who had volunteered to

participate. Parents who self-refer or who volunteer to take part in parenting programmes are notrepresentative of the wider group of parents, perhaps most importantly due to the fact thatvolunteers are very often better motivated than parents who have been referred by professionalagencies. This, once again, limits the generalizability of the results.Third, the studies included in this review were all directed at teenage mothers. While one study

recruited fathers, it did not include the results obtained from fathers in the analysis (Lagges &Gordon, 1999). The findings from this review should not therefore be generalized to both parents.While there is some evidence to indicate the important role that may be played by teenage fathersin the transition to parenthood of a teenage mother (Westney, Cole, & Munford 1987), fathershave on the whole tended to be ‘neglected or misunderstood’ in the development of serviceprovision (Kiselica, 1999). However, a number of studies have demonstrated the benefits ofinvolving fathers in programme provision for both fathers in general (McBride, 1991), andteenage fathers in particular (Westney et al., 1987), and the evidence points to the need for greaterinvolvement of teenage fathers in parenting programmes.Finally, only one study was specifically directed at parents from a non-caucasian ethnic group,

i.e. African-Carribean mothers, and this study was restricted to one aspect of parenting, i.e. infantfeeding (Black & Teti, 1997). All of the remaining studies, however, included a mixed ethnicprofile of mothers, and this suggests that the findings may be relevant to parents from a range ofethnic groups. All of the studies were conducted in the USA, and caution should therefore beexercised before the findings are generalized to other social and cultural contexts.None of the included studies discuss the role of process factors, eg. group processes or

facilitator skills, as regards the outcomes obtained. Peer group relations may be an importantconsideration for teenage parents, and it would be useful for service evaluators to consider thebenefits of group-based programmes from this perspective. The potential role of the group processin interventions with teenage mothers has been acknowledged (Schamess, 1990; Parekh & de laRey, 1997). There is very little research available to date, however, that addresses the role of group


processes in producing positive outcomes with regard to parental functioning. It seems likely,nevertheless, that the group facilitator/leader has an important part to play in helping parents notonly to persist with a particular programme (Frankel & Simmons, 1992), but in facilitating anatmosphere of openness and trust between the participating parents, and in helping parents to feelrespected, understood, and supported.In addition, future studies would ideally include the evaluation of a wider range of outcomes, in

particular those for which there is existing evidence of poorer outcomes for children of teenageparents, including developmental problems, intellectual deficiencies, developmental delays, andlife chances generally. Many of the negative outcomes identified in the literature on teenageparents have implications not only for infants but also for older children. This points to the needfor longer-term follow-up studies.

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