Stigma as a Source of Stress for Adolescent Mothers and Their Babies by articles

StigmaasaSourceofStressforAdolescentMothersand TheirBabies

Jean-VictorP.Wittenberg,MD,*LoisT.Flaherty,MD,† DanielF.Becker,MD,‡ GordonHarper,MD,† JakeM.Crookall,MD,§andNatashaVianna,|| GroupfortheAdvancementofPsychiatry,CommitteeonAdolescence

Stigmatizingattitudesignorethestrengthsandpotentialsthatlie withinthesemothersandtheirbabies.Stigmacausesstress.Stresswhen itisoverwhelmingorchronichasatoxiceffect.Thesemothersand babiesmaybefightingtosucceed,buttheirattemptstoreachpositive goalsaresabotaged.Stressimpactsthelifeofthemotherandthelife andfunctioningofherchildpossiblyforthelifespan.

Althoughpregnancyrateshavebeendropping,in2015,almost 230,000babieswereborntomothersbetweentheagesof15to19years intheUnitedStates(CentersforDiseaseControlandPrevention, 2017),atrendthatisattributedtogreateravailabilityanduseofeffectivecontraception,comprehensivesexeducation,economicchanges, andlesssexualactivityinteens(PattenandLivingston,2016).Teen pregnancyandadolescentmotherhood,however,arealmostinvariably characterizedasaproblem(GroupfortheAdvancementofPsychiatry, CommitteeonAdolescence,1986;Mollborn,2017).EventheWebsite oftheAmericanAcademyofChildandAdolescentPsychiatrywrote “Ifpregnancyoccurs,teenagersandtheirfamiliesdeservehonestand sensitivecounselingaboutoptionsavailabletothem,fromabortionto adoption” (AmericanAcademyofChildandAdolescentPsychiatry, 2018).Thereisnothoughtthatpregnancymaybetheyoungwoman's choiceandthatitmayleadtobenefitforher.

herearemanyreportsofnegativeoutcomesforteenmothersand theirbabies.Manyofthestudiesareflawed,failingtoconsider baselineorprepregnancybackgroundfactors.Thesereportsarethe clinicalandscientificmanifestationsofsocialstigmathatispervasive inourcommunities.Thisstigmastressesteenmothersandmakesit harderforthemtosucceedasindividualsandasmothers.Professionals whorecognizethebiascanacttosupportthisvulnerablepopulation. Therecanbelifespanbenefitsforbothteenmothersandtheirbabies. Thisarticlereviewsstudiesthatilluminatethepotentiallypositiveexperienceofadolescentpregnancyandmotherhood.Italsoreviewstheconceptofstigma,itsmanifestations,andhowtheycontribute tomorenegativeoutcomes.Finally,wediscussapproachesthatmight supportratherthandistressthisvulnerablepopulation.

DOI:10.1097/NMD.0000000000001545

ISSN:0022-3018/22/21009 0650

(JNervMentDis 2022;210:650 654)

Mymotherrefusedtospeakwithmeandkickedmeoutof myhomewhenIwas17yearsoldand8weekspregnant.My schoolnursespreadthenewsofmypregnancytoteachersat school,whoeitherignoredmeentirelyorshooktheirheadindisapprovalasIwalkedby.Iwasremovedfromhonorsclassesanddiscouragedfromapplyingforcollege.Aftermydaughter'sbirth,the schoolrefusedtoprovidemewithaccommodationstopump breastmilk,ortoexcusemyabsencesforherdoctor'sappointments,eventothepointofaccusingmeoflyingormakingup herillnessessoIcouldskipschool.

650 www.jonmd.com TheJournalofNervousandMentalDisease • Volume210,Number9,September2022

Thefocusofpublicpolicyhasbeenprevention.Yetinmany cases,teenmothersdescribepregnancyandmotherhoodasopportunitiesforimportantpositivechangesintheirlives.Notinfrequently,they choosetobecomeorstaypregnant.Thereisalsoevidencethatsome teenmothersimprovetheirlivesbecauseofpregnancyandmotherhood (Mollborn,2017;SmithBattle,2009).

*DepartmentofPsychiatry,UniversityofToronto,Toronto,Ontario,Canada; †DepartmentofPsychiatry,HarvardMedicalSchool,Boston,Massachusetts; ‡DepartmentofPsychiatry,UniversityofCaliforniaSanFrancisco,SanFrancisco, California;§DepartmentofPsychiatry,NorthernOntarioSchoolofMedicine, Sudbury,Ontario,Canada;and||Co-Founder,NoTeenShame.org.

Duringmy2-weekpostnatalvisit,oneofthenursesspentthe entirevisitlecturingmeonteenagepregnancyandnotbeinglike “theseotherwelfaregirls” whogetpregnantbacktobackjust for “somefreegovernmenthandouts.” Onthatday,Iwasgiven thedeposhotandtoldthatitwasanecessarypartofmypostnatalcarebecauseshedidnotwanttoseemebackintheclinic withanotherpregnancyinafewmonths.

Abstract: Adolescentpregnancyandthebabiesofteenmothershavebeenafocusofattentionandconcernformanyyears.Theliteratureonthehealthofpregnant andparentingteens,however,islargelysilentabouttheimpactofstigmaonthem andtheirchildren.Stigmaisapervasiveculturalattitude,whichleadsustooverlook potentiallygoodoutcomesforthisvulnerablepopulationandcontributestopoor outcomesforthesemothersandbabies.Stigmaisacauseofstressleadingto well-knownadverseeffectsonhealthanddevelopmentforbothmothersand babies.Thisarticlereviewsmanifestationsofsocialstigmainourcommunities, intheofficesofprofessionals,andinpoliciesthatembedbiasinoursocialsystems. Theimpactofinequityhasbeenvividlyrevealedoverthecourseoftheglobal pandemic.Wereviewfindingsrelatedtointerventionsassociatedwithbetteroutcomesandoffersuggestionsformorehumanecareandpolicies.

REVIEW ARTICLE

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Mydaughter'sfatherwasoftenverballyabusive belittlingmeandtellingmeasateenmomIhadnowhereto go.Seekingassistanceatthechildcareassistanceofficeand theWICoffice,IneededtoprovethatIwastrulylivingin povertyandhadnosupport.

KeyWords: Adolescence,infancy,motherhood,stress,stigma

IwasabletocounterallthesemessagesthatIdidn'tmatter toanyoneanymore,byrememberingthefeelingofwhenmy daughterwasbornandIheldherforthefirsttime.Herbirth trulypromptedmetothinkmoredeeplyaboutthepersonI wantedtobecomeandhowIcouldmakeanimpactonthe worldaroundme.Iknewthattheoddswerestackedagainst me,butholdingherandthinkingaboutthekindofpersonI neededinmylifeencouragedmetobecomethatpersonfor mydaughter(Personalcommunication,2018).

SendreprintrequeststoJean-VictorP.Wittenberg,MD,DepartmentofPsychiatry,The HospitalforSickChildren,555UniversityAve,Toronto,Ontario,CanadaM5G 1X8.E mail:jean.wittenberg@sickkids.ca.

Powerdifferentialsarecentraltotheinfluenceofstigmaandhave lastingandnegativeimpactsbecauseofthatpower(Hatzenbuehler etal.,2013).Whenpowerrelationshipsarechanged,outcomesare changed.Teenbirthratesareaffectedbystatepolicies(Santelliand Kirby,2010).Ratesofdepressionarereducedinwomenversusmen whenwomenhavemorepowerwithinasociety(Seedatetal.,2009).

ADOLESCENTDEVELOPMENTANDOUTCOMES

Theimpactofstigmaissubtleanddifficulttorecognize,especiallybythosewhohavesocialpower,forexample,healthcareprofessionals.Professionalstendtoseeteenmothersasbadmothers(Breheny andStephens,2007).Itisinevitablethattheseattitudesinfluencetheir interactionswithteenmothers,whooftenexperiencehealthcareprovidersasdismissive,offensive,demeaning,orhurtful.Suchstressfulinteractionsnotonlyincreasetheoverallstressburdenthatayoung motherandherbabymayhavetobearbutarealsolikelytodiscourage prenatalcareandwell-babyvisits adirectimpactonhealth.

Otherstudiesandreviews,includingquiteanumberfromthe UnitedStates,havecometosimilarconclusionsandacknowledgethat outcomesaremorecomplexlydeterminedthanwaspreviouslybelieved. Individualdifferencesareoftencitedasdistinguishingpositiveversus negativeoutcomesfordifferentteenmothers(e.g.,Mollborn,2017).

Teenswithpsychiatricdisordersarethreetimesmorelikelyto havebabiesthanthosewhoarehealthy(Vigodetal.,2014).Theseconditionsmaywellpredisposetobecomingpregnant,theymayariseduringpregnancyorinthepostpartumperiodastheydoformanywomen, andtheyarelikelytoadverselyaffectteenswhoaretryingtocarefora youngbaby.

Stigmahasbeenidentifiedevenintheconstructionandconclusionsinresearchonpregnantadolescents.Researchhastendedinthe pasttocharacterizepregnancyandmotherhoodforteensasadeterminantofanundesirablelifetrajectory,whereasmorecarefulstudieshave showntheoppositeinmanycases.Evidencesuggeststhatteenmothers aremorelikelytocomefrompopulationsmarkedbypovertyandthat teenmotherscandobetterthantheirsocialpeersafterhavingbabies (SmithBattle,2009).

Güneş (2016)foundsignificantadversechangesinhealthbehaviors andineconomicimpactsforteenmothers,especiallyforminoritygroups whobeartheburdenofmorepovertyandgreaterstigma;however,nonminorityteenmothersstruggledearlierintheyearsafterchildbearingbut werenotdisadvantagedcomparedwithpeersbytheirmid-40s.

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SOCIALSTIGMA

Manyreportsdescribenegativeoutcomesforteenmothers;however,manyareflawed.Theyfailtoconsiderbaselineorprepregnancy backgroundfactors.Therearestudiesthatshowpositiveoutcomesfor teenswhobecomemothers.Characteristicssuchaspoverty,deprivation, poorhealth,education,andsoonarenothigherwhentheseteensare comparedwithteenswhoaretheirsocialpeers(reviewedinJutteetal., 2010;Mollborn,2017).Insomecases,teenmothersmayhaveoutcomes thatsurpasstheirpeers(SmithBattle,2009).AnAustriansamplefound thatconsiderablenumbersachievedhighereducationandweremoresatisfiedthansocialpeerswhodidnothavebabies(Zecketal.,2007).

The1964CivilRightsActprohibitedsegregationinhealthcarefacilities,decreasedthepowerdifferential,increasedaccesstoservices,and substantiallyreducednumbersofinfantdeaths(Almondetal.,2006).

OberlanderandBlack(2011)foundthatteenmotherscontinuedto attendschoolatratesequivalentorhigherthanthosefortheirsocialpeers. Theyspeculatedaboutarelationshiptopolicychangesthatallowedmore educationalopportunitiesforteenmothersleadingtothisimprovement.

Amongtheirstudygroupof925adolescentmothersinthedays afterdelivery,Wiemannetal.(2005)foundthat39%identifiedthemselvesashavingexperiencedsocialstigmatizationduringtheirpregnancies.Zeidersetal.(2016)foundthatstigmainthefirst2yearspredicted maternaldepression,insensitivematernal-childinteractions,andlower childsocioemotionalandacademicperformanceat5yearsofageina populationofMexicanAmericansintheUnitedStates.Theyfoundthat theoutcomeswererelatedtotheamountofdiscriminationandstress thesefamiliesenduredandthatearlystresses(first2 3years)ledto laterdifficulties(age5years).

Manyoftheseinteractcreatingamultipliereffecttoincrease stressforindividualswhoaretargetedbystigma.Beingpartofastigmatizedgroupincreasestherateofpregnancyinadolescence.Birth ratesarehigheramongthoseyoungwomenwhoaresociallyandeconomicallydisadvantaged,forexample,throughpoverty,identifiableminoritystatus,beinginthechildprotectionsystem,andsoon(Goodman etal.,2008;Mollborn,2017;SmithBattle,2009).Theyarethenfurther stigmatizedbecausetheyarepregnantteensorteenmothers.That stigmahasbeenseenasdiscouragingteensfromattendingprenatal visits(Güneş,2016)andthusputtingthematriskofadversehealthoutcomes.Theadversehealthoutcomesthemselvesattractstigma.

Adolescentsarecapableofmaturereasoninganddecisionmakingwhentheyarecalmandemotionalresponsesareregulated. However,theabilitytousethosecapacities,especiallyattimesofemotionalarousal,isstillintheprocessofdevelopment(Steinberg,2010). Teensaremorelikelythanadultstomakemoreautomaticandimpulsive decisionsinthefaceofstrongemotions,includingthoseevokedby stigma,whichcontributestohigherlevelsofstressindisadvantagedpopulationsandthusmaycompromiseeffectiveproblem-solving(executive function)atabrainlevel,particularlyforadolescents.

Pregnancyandmotherhoodprovidestrongmotivationstosucceedinbeingagoodmother.Succeedinginmotherhood,eventheexperienceofhavingresponsibilityforababy,canmotivateteenstoorganizeandimprovetheirlives(Goodmanetal.,2008).Sheeranetal. (2016)foundthatadolescentsreconstructedtheirsenseofselfbecause ofteenmotherhood.Theymovedtowardmoreadaptivebehaviorsanda strongersenseofpersonalresourcesandidentity.

PSYCHIATRICDISORDERSANDTEENPREGNANCY

Earlychildhoodexperiencesanddisorderspredisposetoteen pregnancy.Ratesofpregnancyandofpsychiatricdisordersarehigher inadolescentswhohavebeenexposedtohigherlevelsofadversechildhoodexperiences(Hardenetal.,2009)andinteengirlswhohadexternalizingproblemsinchildhood(Lehtietal.,2012).

Psychiatricdisordersinfluenceongoingfunctioningand decision-makinginadolescence.Higherstressinteenmothersisassociatedwithdepression,althoughthatoutcomeismitigatedbyaccessto socialsupport(Brownetal.,2012).Huangetal.(2014)foundthata combinationofstress,depression,andtheabsenceofsocialsupports inteenmotherswereassociatedwithdevelopmentaldelaysintheir babiesatage1year.Ateen'ssenseofcompetencyinthematernalrole, however,wasfoundtobuffertheeffectsofmaternaldepressiononchild development(Knocheetal.,2007).Addingstresstothechallengesthat teenmothersfaceislikelytodecreasethesenseofcompetence.Stigma

Hatzenbuehleretal.(2013)definestigmaasthe “co-occurrence oflabeling,stereotyping,separation,statusloss,anddiscriminationina contextwithinwhichpowerisexercised.” Theyconceptualizeitasa fundamentalsocialcauseofhealthinequalities.MajorandO'Brien (2005)writethat “stigmahasbeenlinkedtopoormentalhealth,physicalhealth,academicunderachievement,infantmortality,lowsocial status,poverty,andreducedaccesstohousing,education,andjobs.”

Withindisadvantagedgroups,therearecharacteristicsthatpredisposesomegirlstobemorelikelytobecomepregnantasteens.These includeexposuretoviolence,psychiatricdisorders,historyofmaltreatment,lackofeducation,andofknowledgeandaccesstocontraception (Goodmanetal.,2008;JozkowskiandCrawford,2016;Vigodetal., 2014).Mollborn(2017)referstogirlswhoaremorelikelytobecome pregnantasdescendinginto “lifeworldsofchaos” evenbeforebecomingpregnant;pregnancyandmotherhoodarebothoutcomesofand contributorstothedegreeofdisorganization,disadvantage,andchaos.

AttachmentTheory

SocialSupports

2009).Monketal.(2016)foundanepigeneticeffectontheplacenta thataffectsplacentalmetabolismofcortisolthatinturnisassociated withsubsequentpsychopathologyinchildren.

StressinPregnancy

Poverty

Behaviorproblemsinchildrenandparentalstresshavebeen notedtoexacerbateeachother.Hastingsetal.(2006)providedevidence ofabidirectionalrelationship,wherebyincreasedmaternalstressleads toincreasedchildbehaviorproblems,andchildbehaviorproblemslead toincreasedmaternalstressovertime,independentofmaternalmental health.Teenmothersandbabiesareparticularlyvulnerabletostressand thusmorelikelytohavetheirinteractionsderailed.

Exposuretomaternalstresssuchasateenmothermightexperienceduetostigmaduringpregnancyhasbeenshowntohavedeleteriouseffectsonbabies:atbirth lowerbirthweight,lowerAPGAR scores,increasedlevelsofresuscitationneeded;ininfancyand childhood problemswithstressmanagement,higherratesofpsychopathology,difficultieswithexecutivefunction,andsoon(Lupienetal.,

Studieshavereporteddifferingfrequenciesofinsecurityinchildrenofteenmothers.Teenmothersofinsecurebabiescomparedwith peersreporthigherlevelsofstressandlowerlevelsofsocialsupport. Whenateenmotherreportedlowstressandsatisfactionwithsocial supportat10months,herbabywasmorelikelytoshowsecureattachment(Emeryetal.,2008).Maternalexperiencesofstresstendtobe transmittedtothebaby.

Maltreatment

Wittenbergetal. TheJournalofNervousandMentalDisease • Volume210,Number9,September2022 652 www.jonmd.com

MaternalAge

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Attachmenttheory,perhapsthemostinfluentialtheoryunderpinningourunderstandingofinfancy,isatheoryofrelationshipsandof stressregulation.Attachmentclassificationsreflectaninternalized strategyfordealingwithandregulatingstress,learnedthroughrelationshipsinthefirst12to18monthsoflife.Secureattachmentisassociated withbettersocialfunctioning,betterlearning,betterphysicalandmentalhealth,andlesspsychopathologyinchildren,teens,andadults (Sroufe,2005),aswellaswithmoredesirablephysiologicalreactions tostress(Gunnaretal.,1996).

Teenmothersaredescribedaslessresponsiveandinsensitive, moredetached,andmorelikelytobeinappropriatelyintrusivewith theirbabies(FlahertyandSadler,2011).Theyarealsodescribedas morelikelytobeabusive,athi gherriskforpsychologicalandphysicalaggression,morelikelytospanktheirchildren,andmorelikely toberestrictive(LeeandGuterman,2010).Alongsidemultiplereportsofincreasedratesofchildmaltreatmentbyteenmothers,however,atleastonestudyf oundthatwhenothersocialriskfactorswere controlledfor,therewasnoevidenceforhigherrates(Corenand Barlow,2001).

INTERVENTIONS

Thereisevidencethatinterventionscanleadtobetteroutcomes includingimprovedlifecircumstancesfortheteenmothersandbetter outcomes(developmental,behavioral,etc.)forthebabies.Programs mustbetailoredtotargetedpopulationsandcanbedeliveredinschools, inclassrooms,inclinics,andsoon.School-basedinterventionsthat provideguidance,socialsupportsoftenassociatedwithchildcareservices,therapy,andeducationadaptedtotheschedulesanddemands ofyoungmothersandbabiesareparticularlyefficacious(Kelseyand Layzer,2014).

Effectivepregnancypreventionprogramsarecharacterizedby provisionofsexeducationandaccesstobirthcontrol.Programsthateffectivelyreducefirstandrepeatpregnanciesareassociatedwithempowermentandeducationofyoungwomensometimesfrommuchearlierchildhood(CentersforDiseaseControlandPrevention,2017; Hardenetal.,2009).

BidirectionalInfluences

Teenmothersshowconsiderablevariabilityinparentingtheirinfantsandyoungchildren.Byandlarge,however,theyhavebeendescribedmorenegativelythanoldermothers.Thehigherfrequencyof psychiatricdisordersinteenmothersandtheirimpactonthebabies havebeenreferredtopreviously.

OUTCOMESFORBABIESOFTEENMOTHERS

anditsnegativeattributionsoftenleadindividualstodevelopnegative self-perceptions(Hatzenbuehleretal.,2013);theyaremorelikelyto loseasenseofconfidenceandcompetence.

ADOLESCENTSASMOTHERS

Adolescentparentstendtobepoor.Theyhavefewertoysandaccesstofewerprogramsforinfantandchildstimulation.Theabsenceof toysandprogramsreducesthenumberanddurationofparent-childinteractions.Teenparentsareseenashavinglesspatienceormotivationto engagetheirbabies;theabsenceoftoysmayevenfurtherreducetheir interactions.Thebabiesareslowerdevelopmentally;theyarelesslikely tobeschool-ready.Theyaremorelikelytobeseenbyteachersasless capableandlessintelligent(Jahromietal.,2016).

Childrenofadolescentmothershavehigherratesofdevelopmentaldelays,behaviorproblems,healthproblems,higherratesof childprotectioninvolvement,earlymortality,mentalhealthproblems andsubstanceabuse,educationalandvocationalunderachievement,relianceonsocialsupportinadulthood,juveniledelinquencyandcriminality,lesslifesatisfaction,andlessincomethanchildrenborntoolder mothers(e.g.,Jutteetal.,2010;OberlanderandBlack,2011).These undesirableoutcomesaretheresultofmanydifferentfactors.Adding stressthroughstigmaislikelytocontributetotheseundesirableoutcomesforbabies.

Thereisevidencethatmanyoftheproblemsseeninthechildren ofteenmotherscanbemitigatedbypostnatalexperiences.Thequality ofthoseexperiencesisdeterminedbytheirmothers'senseofsupport. Teensareparticularlysusceptibletothestress-inducingeffectsofsocial interactions(eg,ÖstbergandHagekull,2013).Manyinfantsofteen mothersfunctionwithinreferencerangesondevelopmentalassessmentsandsocioemotionalmeasuresinthefirstyear;however, socioemotionaldifficultiesbecomeapparentbytheendofthefirstyear anddelaysinintellectualfunctioningthereafter(Zeidersetal.,2016). Infantswhoshoweddelaysaremorelikelytocomefromhomeswhere therearemorestresses:poverty,fewerlearningmaterials,maternaldepression,andconflict(Jahromietal.,2016).Evenwhentheremaybe earlystresses,betteremotionalandcognitivedevelopmentarepredicted bysupportivefamilyenvironments.

Jutteetal.(2010)foundthattheiroffspring'sproblemsdidnot arisefromtheteenmothers'relativeimmaturity.Childrentheyborelater (i.e.,afteradolescence)didnotfarebetterthantheonestheyboreearlier.Thissuggeststhattheproblemslaynotwithbeingateenage mother,butwithotherfactorsintheirlives(e.g.,poverty,depression, etc.),perhapsthesamefactorsthatledthemtohavebabiesinadolescence.Thosefactorscanbeeasilyunderstoodasstress-inducingfor babiesandchildrenandareindependentlyassociatedwithdevelopmentaldelays,behavioralproblems,andsooninthebabies.

JahromiLB,Umaña-TaylorAJ,UpdegraffKA,ZeidersKH(2016)Trajectoriesofdevelopmentalfunctioningamongchildrenofadolescentmothers:Factorsassociatedwithriskfordelay. AmJIntellectDevDisabil.121:346 363. ©2022WoltersKluwerHealth,Inc.Allrightsreserved.

HardenA,BruntonG,FletcherA,OakleyA(2009)Teenagepregnancyandsocialdisadvantage:Systematicreviewintegratingcontrolledtrialsandqualitativestudies. BMJ.339:b4254.

Therearenoresearchdataasthisisareviewofpublishedliterature.Personalstoriesarebyauthors.Thusthird-partyethicalreview andclearancearenotneeded.

GoodmanD,MazzucaA,MarkleB,CheungC,TitusA,JellinekA(2008)Partnershipsforpositiveoutcomes:Supportingyoungmothersincare.Children’sMental HealthOntario&OntarioAssociationforChildren’sAidSocietiesJointConference.

CentersforDiseaseControlandPrevention(2017)Teenpregnancy.Availableat:https://www. cdc.gov/teenpregnancy/about/index.com.Published2017.AccessedJanuary31,2018.

HuangCY,CosteinesJ,KaufmanJS,AyalaC(2014)Parentingstress,socialsupport, anddepressionforethnicminorityadolescentmothers:Impactonchilddevelopment. JChildFamStud.23:255 262.

AlmondDV,ChayKY,GreenstoneM(2006)Civilrights,thewaronpoverty,and Black-WhiteconvergenceininfantmortalityintheruralSouthandMississippi. MITDepartmentofEconomicsWorkingPaperNo.07-04.Availableat:https:// dx.doi.org/10.2139/ssrn.961021.AccessedMay24,2022.

REFERENCES

Otherinterventionsthatsupportself-esteemandefficacyintheir day-to-daylivesinyoungwomenandespeciallyinyoungmothersare likelytohavesomepositiveimpactonthemandtheirchildren,although muchremainstobeinvestigated.

CorenE,BarlowJ(2001)Individualandgroup-basedparentingprogrammesforimprovingpsychosocialoutcomesforteenageparentsandtheirchildren. Cochrane DatabaseSystRev.CD002964.

Psychiatricdisordersareverycommoninpregnantandparentingteensandareamultiplierforstigmaandstress.Itisimportantfor healthcareserviceproviderstopayparticularattentiontopregnantor parentingteensfordiagnosesofpsychiatricdisordersandfortheirexperiencesofstigma.Itisalsoimportanttoaddressissuesofsexualactivity,aswellasaccesstoandunderstandingofbirthcontrolandapproachestoproblem-solvinginteenswhohavepsychiatricdiagnoses.

FlahertySC,SadlerLS(2011)Areviewofattachmenttheoryinthecontextofadolescentparenting. JPediatrHealthCare.25:114 121.

BrehenyM,StephensC(2007)Irreconcilabledifferences:Healthprofessionals'constructionsofadolescenceandmotherhood. SocSciMed.64:112 124.

DISCLOSURE

Adolescentmothersandtheirbabiesareavulnerablegroup,predisposedtoundesirableoutcomesbythesamefactorsthatinmany casesleadtheyoungwomentobecomepregnant:poverty,mental healthdisorders,alackofsocialsupports,andsoon.Adolescentsas wellasbabiesandyoungchildrenaredevelopmentallyvulnerablewhen excessivelystressed.

HastingsRP,DaleyD,BurnsC,BeckA(2006)Maternaldistressandexpressedemotion:Cross-sectionalandlongitudinalrelationshipswithbehaviorproblemsof childrenwithintellectualdisabilities. AmJMentRetard.111:48 61.

AmericanAcademyofChildandAdolescentPsychiatry(2018)Whenchildrenhave children.Availableat:https://www.aacap.org/aacap/families_and_youth/facts_ for_families/Facts_for_Families_Pages/When_Children_Have_Children_31. aspx.AccessedJanuary31,2018.

Insummary,stressinmothersduringpregnancy,afterbabiesare born,andstressdirectlyimposedonbabiesandtoddlershavelifespan consequences.Stigmaplaysasignificantpartinaggravatingandcreatingthatstress.

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TheJournalofNervousandMentalDisease • Volume210,Number9,September2022 StigmaasStressforTeenMothers

Itisimportantforustobeawareoftheperspectiveoftheteen mothersinthecontextoftheirlives.Formanyteenmothers,havinga babyisaturningpointintheirlivesleadingtoanimprovedsenseofself, moreorganizedandregulatedlives,moreeducationandbetteremployment,greatersatisfactioninlife,andsoon.Thisisdespitethechallenges andstressesthatstigmaimposesonthem.Someyoungmothersimprove theirlifetrajectoriesbutarestressedandstrugglingwhentheirbabies needthemmost.Insomecases,stigmamayselectivelyharmbabies.

Theconsequencesofstigmaarecostlytousall.Toreduceor eradicatetheadverseeffectsofstigma,powerdifferentialsmustbeaddressed.Healthcareprofessionalshavesomesocialinfluence.Intheinterestsofhealth,wemustadvocateforequalandjusttreatmentandserviceprovisionatthelevelofpolicyaswellaspractice.Thiscannotbe morerelevantthanitistodayinmiddleofaglobalpandemicthathas forcedustoconfronttheimpactofouroften-unconsciousbeliefson themostvulnerableamongus.Interventionsthatreducestigma,reduce

HatzenbuehlerML,PhelanJC,LinkBG(2013)Stigmaasafundamentalcauseofpopulationhealthinequalities. AmJPublicHealth.103:813 821.

GunnarMR,BrodersenL,NachmiasM,BussK,RigatusoJ(1996)Stressreactivity andattachmentsecurity. DevPsychobiol.29:191 204.

Generally,weseemothersandyoungchildrenasvaluedmembersofourcommunities.Wemakespecialeffortstohelpthem.Communitysupportisanimportantfactorinhelpingyoungfamiliesestablishhealthytrajectoriesforthemselvesandtheirchildren.Thisisoften lostwhenthemotherisseenasbelongingtoanundesirablegroup.Itis likelythatsuboptimalmotherandinfantoutcomesaresecondaryat least,inpart,tothestressofsocialstigma.

Güneş PM(2016)Theeffectsofteenagechildbearingonlong-termhealthintheUS:A twin-fixed-effectsapproach. RevEconHousehold.14:891 920.

EmeryJ,PaquetteD,BigrasM(2008)Factorspredictingattachmentpatternsininfants ofadolescentmothers. JFamStud.14:65 90.

DISCUSSION

Socialstigmaexertsstressonthisvulnerablepopulationofteen mothersandtheirbabiesinmanyifnotallcontexts,inschools,the workplace,thebureaucracy,shops,inthehealthcaresystem,andso on.Stigmareducestheresourcesavailabletothemothersandbabies. Itmakesthemothersfeellikeoutcasts,untrusted,andshameful.Itleads otherstomisinterprettheirbehaviorinnegativeways.

Healthcareserviceprovidersincludingphysicians,nurses,social workers,childprotectionworkers,andsoonmustbesensitivetoconsideringthepossibilityofbiasintheirworkwithteenmothersand babies.Itiscriticaltothedeliveryofgoodclinicalcarethattheyexaminetheirbeliefsandtheirpracticesaswellasthoseoftheircolleagues andofficestaff,andthattheysearchforevidenceofstigmainthehistoriestheytakefromtheseteenmothersandintheirapproachestoservicedelivery.Healthcareserviceprovidersmustdevelopcollaborative, family-centeredapproacheswithadolescentmothersandtheirchildren toimproveourpractices.Wemustrecognizeabasictenetoffamilycenteredcare;weaddtothehealthofourpatientswhenwerecognize andsupportthestrengthoftheirfamilies.

Allauthorsparticipatedintheconceptualization,drafting,and editingofthismanuscript;eachisaccountableforthecontentandapprovesitssubmissionforpublication.

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BrownJD,HarrisSK,WoodsER,BumanMP,CoxJE(2012)Longitudinalstudyof depressivesymptomsandsocialsupportinadolescentmothers. MaternChild HealthJ.16:894 901.

GroupfortheAdvancementofPsychiatry,CommitteeonAdolescence(1986) Crisis ofAdolescence,TeenagePregnancy:ImpactonAdolescentDevelopment (No.118). NewYork,NY:Brunner-Routledge.

stress,andcreateequityofaccesstoresourcesarelikelytohelp.Itisvitalthatweidentifystigma,theinequityitpromotes,andtheadverse consequencesthispopulationendures.Appropriateadjustments,interventions,andsupportsatalllevelsofpolicyandpracticecouldlead tolastingimprovedqualityoflifeandreducedsocialcosts.

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