Substance use among adolescent mothers: A review
Highlights
► Adolescent mothers are at high risk for substance use. ► They reported greater substance use before pregnancy than other adolescent females. ► Girls stopped substance use in pregnancy, but they often resumed use postpartum. ► Postpartum substance use remained prevalent as adolescents transitioned to adults.
Introduction
Over the past 20 years, teenaged motherhood declined in the United States (US), decreasing from 59.9 live births per 1000 among girls aged 15–19 in 1990 to 34.3 live births per 1000 in 2010 (Hamilton, Martin, & Ventura, 2011). Although this population is smaller than it was, adolescent mothers remain a vulnerable group. Research shows a positive association between pregnancy before age 19 and problematic behaviors, such as substance abuse (Elster, Ketterlinus, & Lamb, 1990). In general, maternal substance abuse is a critical social and clinical problem (Pajulo et al., 2012). Population-based data suggest a reduced rate of substance use among women in pregnancy, but an elevated rate of use among women in the postpartum period (Substance Abuse and Mental Health Services Administration, 2007), implying a failed intervention opportunity. While substance use patterns differ between adolescent and adult women (De Genna, Cornelius, & Donovan, 2009), with use of most substances initiated before age 21 (e.g., marijuana) (Gfroerer and Epstein, 1999, Wu et al., 2005), differences in use patterns suggest adolescents may be at even greater risk than adult women for substance use once their children are born. In addition, teenage mothers may be likely to engage in long-term substance use, as teens who initiate use of psychoactive substances (e.g., marijuana) are more likely to use substances as adults and require related treatment (Gfroerer and Epstein, 1999, Merline et al., 2004). Continuing substance use from adolescence increases the likelihood of use escalating to abuse or dependence, which negatively affects multiple domains of postpartum adolescent life (e.g., health, parenting, and educational attainment). Little is known about substance use among postpartum adolescents, yet these girls constitute a high-risk and vulnerable population. Here, we describe demographic characteristics of adolescent mothers and conduct a literature review on postpartum adolescent substance use to identify research gaps and facilitate future investigation.
Most adolescent mothers are white; however, birth rates are disproportionately high among Latinos, Blacks, and girls in Southern states (e.g., Mississippi) (Mathews, Sutton, Hamilton, & Ventura, 2010). Differences in birth rates relate to multiple factors, such as low income and low educational attainment (Mathews et al., 2010). However, the overall decline in births is primarily attributed to greater contraception use, with a smaller proportion attributed to decreased sexual activity (Santelli, Orr, Lindberg, & Diaz, 2009). In 2006, 68% of teen births occurred to girls aged 18–19, just 50% of whom had graduated high school; of all teen mothers, most were unmarried (84%) and received prenatal care within the first trimester (70%) (National Campaign to Prevent Teen and Unplanned Pregnancy, 2008).
Teenage mothers are a vulnerable population. Adolescent sexual behavior and resulting parenthood are associated with an increased prevalence of substance use, including alcohol (Krohn, Lizotte, & Perez, 1997), marijuana, cocaine (Lowry et al., 1994), and methamphetamines (Zapata, Hillis, Marchbanks, Curtis, & Lowry, 2008). In addition, adolescent substance use elevates the odds of having difficult transitions to adulthood that negatively affect their success at engaging in adult roles and increase the likelihood of later problematic substance use (Krohn et al., 1997).
Although the focus is postpartum substance use, we include a brief description of the potential consequences of prenatal use to the fetus and of potential consequences of adolescent use to the mother as background. Some mothers continue substance use in pregnancy, and fetal effects could influence mother and infant life trajectories. Because girls who begin or resume substance use postpartum may not be able to quit in subsequent pregnancies, prenatal effects are also relevant to later children development (Jagodzinski & Fleming, 2007). Developmental changes made to maternal brain structure due to adolescent substance use could also negatively alter the maternal and infants life course.
Prenatal substance use confers multiple potentially lasting adverse effects on the neonate. Thompson, Levitt, and Stanwood (2009) reviewed animal and human studies that examined prenatal substance use effects on fetal brain development. These effects vary by substance and frequency of use. Alcohol exposure can have severe neuro-developmental consequences and result in fetal alcohol syndrome. Prenatal exposure to cigarettes is positively associated with attention deficit disorder, hyperactivity, antisocial behavior, and learning disabilities (Thompson et al., 2009). Children exposed to cocaine in utero may exhibit behaviors that mirror attention deficit hyperactivity disorder (ADHD). Children prenatally exposed to methamphetamines show decreased arousal, increased stress, lower scholastic achievement, decreased ability to sustain attention and less spatial and verbal memory than their non-exposed peers (Thompson et al., 2009). Children prenatally exposed to methamphetamines also may have increased anxiety, depression and ADHD related problems (LaGasse et al., 2012). Additional papers that address outcomes of prenatal substance exposure to offspring include, but are not limited to, Irner (2011), Sithisarn, Bada, Dai, Randall, and Legan (2011), and Cornelius and Day (2009).
Moreover, maternal substance use continues to have significant consequences after birth. For example, alcohol may pass through breast milk and complicate infant development (Little, Anderson, Ervin, Worthington-Roberts, & Clarren, 1989). Exposure to second hand smoke is positively associated with respiratory infections, ear infections, and asthma (Carlsen & Carlsen, 2008); and it has been suggested to be a primary risk for sudden infant death syndrome (SIDS) (Alvik et al., 2006, Carlsen and Carlsen, 2008). Mothers using substances may have difficulty reading infant cues and meeting the interactional needs of children (Pajulo, Savonlahti, Sourander, Ahlqvist Helenius, & Piha, 2001). Further, alcohol and drug use contribute to child neglect and abuse and, because child abuse can be a precursor to substance abuse, may create generational cycles of abuse (Dunn et al., 2002, Romero et al., 2010).
Adolescence is also a critical time for brain development, and repeated substance use by adolescent mothers can alter their brain structure. Associated changes may contribute to increased risk taking and explain partly why early substance use often leads to continued use and addiction in adulthood (Squeglia, Jacobus, & Tapert, 2009). Although changes vary by substance and frequency of use, adolescent substance use may result in deficits in executive functioning, abstract reasoning, problem solving (Squeglia et al., 2009), and later substance and other psychiatric disorders (Brook et al., 2000, Gfroerer et al., 2002, National Institute on Drug Abuse (NIDA), 2007). Hence, adolescent mothers are uniquely vulnerable to current and future problematic substance use. They and their children face severe consequences from substance use, yet little research addresses postpartum use.
Flanagan and Kokotailo (1999) reviewed prenatal substance use among adolescent mothers and found that adolescents at risk for pregnancy were also often at risk for substance use, likely related to common socioeconomic factors that increased vulnerability. However, reductions observed in prenatal and early postpartum use suggested that pregnancy might be protective, particularly in contexts where motherhood offered an alternative life course to girls affected by poverty, low education, and high rates of substance use. Flanagan and Kokotailo (1999) concluded that there was a need for research to determine if prenatal substance use declines held through the postpartum period and into the parenting years. To understand whether there is an increase in substance use after these young women give birth and facilitate future studies, we conducted a literature review and present identified gaps in adolescent postpartum substance use research.
Section snippets
Methods
We selected Google Scholar, PsychInfo, and PubMed to search for studies on postpartum adolescent substance use. PubMed focuses on the medical literature and was used to identify articles related to the postpartum period and to substance abuse treatment. PsychInfo focuses on psychology studies and was used to identify articles related to substance use, substance abuse, and substance abuse treatment. Google Scholar covers a wide range of topics and was used to find articles on topic but not
Results
Nearly all reported studies relied on moderately small samples (N < 344) (Table 1). Of the 12 identified studies, five were cross-sectional and seven used longitudinal designs. Longitudinal studies often followed samples from earlier cross-sectional studies. For comparative purposes, we present data reported by studies on pre-pregnancy and prenatal use first. Provided for comparison, Table 2 shows substance use prevalences for girls aged 12–17 in the US, as determined by the 2010 National Survey
Discussion
Adolescent mothers report greater substance use before pregnancy compared to other adolescent females. While many stop using substances during pregnancy, an important proportion continue to use. Once babies are born, many girls self-report that they begin to use substances again, often within the first six months. In addition, multiple authors (e.g., Amaro et al., 1989, Barnet et al., 1995, Gilchrist et al., 1996, and Morrison et al., 1998) used assay measures to correct or confirm
Conclusions
Adolescent mothers are uniquely vulnerable and at risk for increased substance use compared with their nulliparous peers. Due to their young age, they are likely to have subsequent pregnancies that substance use could affect pervasively (Cornelius et al., 2004). Even removing the biological consequences of prenatal substance use, postpartum use remains a precursor of child abuse (US Department of Health and Human Services, 1999). The consistent finding that substance use rates rise once babies
Acknowledgements
The authors have received research support from the U.S. National Institute on Drug Abuse of the National Institutes of Health (R33DA027503, R01DA019623, and R01DA019901; PI: Li-Tzy Wu). The sponsoring agency had no further role in the writing of this paper or the decision to submit the paper for publication. The opinions expressed in this paper are solely those of the authors.
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