Teen mothers at midlife: the long shadow of adversarial family caregiving.

ANS822

April 24, 2014

1:31

Advances in Nursing Science Vol. 37, No. 2, pp. 87–100 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright

Teen Mothers at Midlife The Long Shadow of Adversarial Family Caregiving Lee SmithBattle, PhD, RN; Victoria Leonard, PhD, RN, APRN Despite keen interest in teen mothers’ outcomes, few studies have followed teen mothers prospectively or examined how outcomes are shaped by family relationships and practices over time. This multigenerational, hermeneutic study began 21 years ago when 16 families were interviewed after the teen’s infant reached 8 to 10 months of age. Families were re-interviewed every 4 to 5 years. This article describes the 3 families who exemplified adversarial caregiving at the first study and how their relationships unfolded and shaped long-term outcomes. Findings alert clinicians to the importance of recognizing red flags and intervening early to interrupt adversarial caregiving. Key words: family research, grandparents, interpretive phenomenology, longitudinal research, teen mothers

D

ESPITE THE vast research on early childbearing, few studies have followed teen mothers prospectively and even fewer have examined their lives within the context of multigenerational relationships and practices. This gap is noteworthy since family members, especially grandmothers (of the teen’s child), provide the most consistent support to teen mothers,1 and their support is associated with improved maternal outcomes in mental health, education, and parenting.2 It is also known that family conflicts undermine parenting confidence and skill3,4 and are associated with depressive symptoms for teen Author Affiliations: School of Nursing, Saint Louis University, St Louis, Missouri (Dr SmithBattle); and Institute of Health and Aging, University of California, San Francisco (Dr Leonard). We are grateful to the families who have participated in this study. The sixth wave was funded by a Faculty Summer Scholar’s Award by the School of Nursing, Saint Louis University, and Delta Lambda of Sigma Theta Tau International to the first author. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Lee SmithBattle, PhD, RN, School of Nursing, Saint Louis University, 3525 Caroline St, St Louis, MO 63104 ([email protected]). DOI: 10.1097/ANS.0000000000000020

mothers2 and grandmothers.5 Because studies have primarily focused on the first 2 to 3 years postpartum, little is known about how patterns of family support or conflict unfold as teen mothers and their children grow up. Understanding of family caregiving processes is limited. Apfel and Seitz6 interviewed black teen mothers and grandmothers and discovered that 50% of grandmothers shared or supplemented infant care, about 10% completely replaced the mother, and another 10% mentored their “apprentice” daughters. In the remaining families, teen mothers acted as the primary parent with some family support. SmithBattle7 described 2 family patterns at the end of the first postpartum year. Families with adversarial practices exhibited intense competition and conflict over the baby, with grandparents either leaping in and taking over or standing on the sidelines as critical bystanders. Both forms of adversarial caregiving contributed to family resentment, maternal ambivalence, and the teen’s dependence and rebelliousness. In contrast, families with responsive caregiving practices were judged by teen mothers as providing just the right amount of support. These families avoided taking over the care of the baby and fostered the young mother’s parenting capabilities. Four years later, families identified 87

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

ANS822

April 24, 2014

88

1:31

ADVANCES

IN

NURSING SCIENCE/APRIL–JUNE 2014

as responsive in the initial study sustained that pattern.8 Adversarial families remained locked in competition and conflict over the care and discipline of the child when mothers remained at home. Leaving home improved family relationships, but mothers who later returned were frustrated to see conflicts resume and their gains in parenting evaporate. The study of teen mothers’ residential patterns (living with or apart from parents) intensified when welfare rules mandated that they live at home with a parent or guardian.9 Most of these studies point to relevant family issues but are limited to the first 2 years postpartum. For example, in a black sample followed for 2 years, the majority of teens (56%) remained home, almost a quarter (23%) moved in and out of home, and the remaining 21% left home and never returned.10 In a more diverse sample, the youngest mothers and black teen mothers were more likely to co-reside with grandparents than white or Hispanic teens whereas teens who were older, had more family conflicts, or came from large households were more likely to leave home.11 Teen mothers who remained at home 2 years after giving birth reported less parenting stress than those who lived apart,12 but resilient mothers were less likely to live at home or rely on grandmothers for emotional support or childcare assistance.13 Other researchers suggest that parenting may be difficult to negotiate for teens who live at home and conflicts may compromise children’s development.14,15 Very little is known about long-term residential patterns and their relationship to maternal-child outcomes, although there is some evidence to suggest that the quality of teen mothers’ relationships with their parents, not coresidence per se, is the more crucial factor in shaping outcomes.2,3 Several studies that examined teen mothers’ outcomes at midlife underscored childhood factors.16-18 Those with the greatest number of childhood adversities and traumas fared less well over the long term,19,20 whereas those who experienced few adversities as children did as well as older childbearers.17

To summarize, grandparents figure prominently in the lives of teen mothers and their children. Most studies of teen mothers have focused on the early years of parenting; are largely limited to black, low-income teens; and rarely investigate family processes. Little is known about how family processes and relationships evolve and how they impact teen mothers and family members over time. A study that began 21 years ago addressed this gap by identifying how early patterns of grandparent involvement shaped family relationships and outcomes over 2 decades. METHODS The original study examined the concerns, challenges, and caregiving practices of teen mothers and their families at the end of the first postpartum year.7,21 All waves of the study were based on hermeneutic assumptions that human lives and actions are always situated and developed in dialogue and interaction with others.22,23 According to Chesla,24 and following Heidegger, it was further assumed that shared meanings are expressed in families’ everyday practices and can be revealed through hermeneutic methods. Studying practices in the hermeneutic sense requires creating a context in which participants can demonstrate, in their words or actions, their everyday ways of being meaningfully involved in their worlds. Hermeneutic research enables participants’ narration of the everyday such that participants’ background understandings, which arise from local (cultural) worlds, become visible to the interpreter. It requires that we configure the research such that participants’ concerns in action can be apprehended. Practically, this means doing participant observation in meaningful contexts and conducting interviews to elicit participants’ everyday experience, preferably over time. These assumptions and methods have been detailed for each of the 6 waves8,21,25-28 and are referred to as Time 1 (T1 ) through Time 6 (T6 ). (see the Table for an overview of the studies, time intervals, and participants).


ANS822

April 24, 2014

1:31

The Long Shadow of Adversarial Caregiving

89

Table. Overview of Studies, Time Intervals, and Participants Participants

Study T1 : 1988-1989 T2 : 1993 T3 : 1997 T4 : 2001 T5 : 2005 T6 : 2010

a Children’s

Age of Firstborn Childa

Teen Mothers

8-10 mo 4-5 y 8-9 y 12-13 y 16-17 y 20-22 y

16 13 11 9 10 11

Grand- Partners of parents Teen Mother 19 11 10 9 9 12

3 3 2 3 1 1

Firstborn Children

6 8 11 (and wife of 1 child)

Younger Children Older Than 12 y

11

ages vary because families were recruited over 2 years.

Teens were recruited from programs serving teen mothers on the West Coast of the United States and were eligible for the study if they were between 15 and 19 years of ages, had given birth to a firstborn healthy child, were non-Latina white or black, and a parent (or surrogate) agreed to also participate in the study. Sixteen teen mothers, 3 partners, and 19 grandparents began the study in 19881989 once the baby reached 8 to 10 months of age. Families were black (n = 7) or white (n = 9) and were diverse with respect to income (US $10 800 to US $70 000), family structure (single vs married grandparents living in nuclear or extended families), and grandparents’ level of education (less than high school to master’s degree).21 The original study (T1 ) included 3 monthly interviews with individual family members, a conjoint family interview, and 3 monthly sessions of 4 to 6 hours each in which the first author observed members interacting with the infant and each other. Family members were reinterviewed separately and in person every 4 to 5 years, except for 1 family who was interviewed by phone at T5 . Beginning at T4 , firstborn children were invited to participate. At T6 , younger children were also invited to participate as long as they were 12 years or older. The sample at T6 included 47 participants from 11 of the 16 original families: 11 mothers, 1 partner, 12 grandparents, 22 offspring,

and the wife of 1 offspring. Mothers ranged in age from 37 to 40 years, and their firstborn children were 20 to 22 years of age. Six mothers were married and living with spouses; single mothers were living with partners (n = 2) or without partners (n = 3). Interview guides for mothers, grandparents, and children were developed and modified for each follow-up study. Adults were asked to describe life events, family history, caregiving practices, and instances of parenting/grandparenting that were meaningful, rewarding, and difficult. Children were asked to describe their activities and relationships. All participants described their relationships and involvement with each other. Human subjects approval was obtained for all studies, adults gave their informed consent, and children assented to the study. All participants received a monetary gift in appreciation of their time. Interviews for all waves of the study were recorded, transcribed, corrected for accuracy, and analyzed using hermeneutic strategies of paradigm, exemplar, and thematic analysis.29 The first author coded transcripts and field notes and moved blocks of coded text to summary files for each family with interpretive comments. These files condensed voluminous data from each family at each wave and facilitated the search for and comparison of family paradigms, themes, and exemplars across and between time periods. At


ANS822

April 24, 2014

90

1:31

ADVANCES

IN


T1 , vivid examples of adversarial and responsive caregiving emerged as paradigm cases by comparing family relationships and involvement in the care of the baby.7

as easily slide in there and take over without realizing what you’re doing . . . . Every time he’d cry, every time he needed to be changed, every time he needed a bath, anything to do with holding him, I was right there . . . . It was just like he was mine.7(p59)

RESULTS

As Joan and Rob usurped parenting, Ann withdrew from Drew and became increasingly rebellious and resentful. When she failed to meet her curfew one night, Joan and Rob moved Drew’s crib into their bedroom, chastised her for being an unfit mother, and requested custody. Ann refused. Ann’s family was lost to follow-up for 12 years. When they were located at T5 , Joan and Drew agreed to be interviewed but Ann did not respond to the recruitment letter. The first author learned from interviewing Joan at T5 that Ann had given birth to another son (Troy) and daughter (Liddy), that she had relinquished custody of Drew and Troy to Joan and Rob, and that Rob had died. At T6 , Ann, Joan, Drew (aged 22 years), and Troy (aged 18 years) were interviewed. Ann had recently left Joan’s household, but her daughter, Liddy (aged 15 years), was living in Joan’s home with her baby daughter. In piecing the family’s complicated story together with data from T5 and T6 , Ann gave birth to Troy 3 years after Drew was born. Neither of the boys’ fathers was ever involved. Except for Drew’s first 2 years when Ann lived at home, he, and later Troy, resided primarily with Joan and Rob. Ann gave her parents temporary guardianship of her sons about 6 months after Troy was born; she reluctantly agreed to her parents’ repeated requests to adopt them many years later, knowing that her parents offered her sons more stability and recognizing that “I was just messed up, mentally, physically, emotionally, all the way through . . . . I felt useless, horrible. I didn’t want to do it.” About 3 years after Troy was born, Ann entered a tumultuous marriage with an abusive man with a history of drug problems. The marriage eventually ended in divorce but only after Liddy, Ann’s third child, was born and both Liddy and Ann had been abused. Soon

Of the 16 families participating at T1 , 3 exemplified adversarial caregiving, a process that derails mothering as grandparents take over the care of the baby or become critical bystanders.7 These cases are presented with data from subsequent waves to show how family relationships and practices evolved over time. The first 2 cases depict the power struggles and poor outcomes associated with long-standing adversarial practices. The third family demonstrates that adversarial practices are difficult but not impossible to repair for families with less impaired relationships, with positive outcomes following the renegotiation of family relationships.

“Climbing up a broken ladder” Ann’s family exemplified the first form of adversarial caregiving where grandparents derail mothering by taking over the care of the child. Ann was the third and only daughter of Rob and Joan, her married parents. Both Rob and Joan described difficult childhoods and issues of loss and abandonment from growing up in homes with parental alcoholism or mental illness. Their long-standing marital problems led to numerous separations during their many years of marriage; they were separated again and considering a divorce when Ann’s pregnancy was confirmed at 17 years of age. The pregnancy not only reunited Rob and Joan but Drew’s birth also provided a shared purpose that stabilized their marriage. As they leapt in and took over Drew’s care, Ann was sidelined, as Joan detailed in this passage at T1 : If you got a brand new mother, sometimes she can feel really easily pushed aside. And taken over. And when you’re the new grandma, you can just


ANS822

April 24, 2014

1:31

The Long Shadow of Adversarial Caregiving

91

after divorcing her first husband when Liddy was 3 years old, Ann married a man whose solid work history offered more stability. After 10 years of marriage, Ann’s second husband requested a divorce. Ann and Liddy lived with him or Joan after the divorce. Ann’s relationships with her children were complicated by unclear grandparent-parentchild boundaries that left her wondering where she fit in as a mother and a family member. To the first author’s surprise at T6 , Joan stated that Ann’s sons had only recently learned that Ann was their biological mother (as opposed to their adoptive sister) when a social worker reviewed their social security benefits (due to Rob’s death). The fact that the boys did not know that Ann was their mother seemed improbable but fully corroborated the blurring of generational boundaries. Ann’s relationships with her sons were further complicated by her longing to be their friend and by Joan’s unflinching criticism of Ann. For Ann, the boys’ older ages at T6 offered the possibility of having a more adultlike relationship with them:

Ann was asked to describe her initial reaction to Liddy’s pregnancy, she said,

. . . It’s better now that the kids are older. Because they’re their own individuals, they have a choice of going places with me. They can get to know who I am and see what I’m going through . . . I get to spend time with them. They’re actually adults now, so I can talk to them like people instead of worrying about how they feel or worrying about doing more harm to them.

L.S.: Did you ever talk with Ann about adopting Liddy?

Ann also yearned to be friends with her daughter: “I was Liddy’s friend. Everybody said you shouldn’t be friends with your children. But I was friends with her because she was the only thing I had.” Joan concurred in her private interview: “Ann will tell you she and Liddy are best friends . . . . And I say, ‘You cannot be best friends with your child.’ . . . Ann never says no to her on anything. I say no to her on a lot of things.” Poor boundaries precluded Ann from protecting and establishing limits for Liddy. Ann allowed an older, married neighbor to lavish Liddy with attention and gifts. Liddy became pregnant by this man at 14 years of age. When

. . . it didn’t bother me so much, [but] it’s like how do I tell my mom? My mother had been badgering me, telling me she’s gonna be pregnant . . . and it’s like that’s just slapping me in the face, you’ve failed.

The following excerpt revealed Ann’s sense of impotence in protecting Liddy or shaping her behavior: “I was kind of expecting [her pregnancy]. She was a troubled teen . . . . If she wouldn’t have gotten pregnant, I think she would be on the street.” Joan had stepped in multiple times to protect and shelter Liddy; she did so again when Liddy was expelled from a maternity home for problems at school: L.S.: So you’re essentially parenting her now? Joan: Forever. When Liddy would get into it with her mom/best friend, Liddy would call me and say, “Grandma I need you, I need you to come and get me.” I would go down there and bring her up here, feed her, let her spend the night, and then take her back.

Joan: Taking her? Yes. And she said no, you took my other two, you took them (in angry voice). We never took them. We tried so hard to get her to mother those babies.

Joan’s and Rob’s childhood histories of impaired family relationships preceded their children’s births. Ann’s pregnancy set the stage for them to reunite and take over Drew’s care at Ann’s expense.7 Family practices derailed mothering for Ann, which disrupted generational boundaries for the next generation and reinforced Ann’s dependence on her parents or on unreliable partners. To Ann’s chagrin, Liddy was following in her footsteps: Ann: Liddy’s kind of like me. She’s kind of dependent on somebody else’s emotions and how they feel about her and how they think about her. So she’s searching guys, like I did. I’ve tried to tell her, the guys are just gonna take it away from you. I mean look at me, every guy I’ve ever had, they


ANS822

April 24, 2014

92

1:31

ADVANCES

IN


haven’t helped me . . . . I mean when you’re dependent on people that aren’t reliable, it can undermine your own strength. L.S.: And what are your hopes and fears and concerns for Liddy? Ann: My fear is that she’ll end up like me.

Ann’s inability to parent Liddy set Liddy adrift. Despite the grandparents’ stability and financial resources, Drew and Troy were also somewhat adrift. While they had avoided trouble as teens, both had dropped out of high school (but received general equivalency diplomas [GED]) and neither had a driver’s license or had ever worked for more than a few days. At T6 , Joan was insisting that they find jobs, but her insistence often led to arguments, especially with Drew. Ann blamed Joan for her sons’ stalled development and lack of motivation. In Ann’s family, babies not only reconnect family members but also create distance and resentment. Ann’s comment at T6 that the birth of Liddy’s child “was like a new birth for me” mirrors her parents’ anticipation over Drew’s birth 22 years earlier. Just as Drew reunited Joan and Rob, Liddy’s daughter, according to Ann, “ . . . brought us closer together. It brought me and my mom and whole family together. The boys are even close to us now and they actually see what’s happening, what could be and should’ve been.” Ann’s feelings of closeness, however, were not echoed by Joan, Drew, or Troy in their private interviews. Ann aptly described her existential situation at T6 as “climbing up a broken ladder”: You’re lost . . . . Empty. And no power to yourself. Everything’s taken away from you and it’s not that you really did anything wrong, you just didn’t take the right steps or something. [I wonder], just what did I miss? So you’ve got to hold on to what you can.

Ann’s world is marked by false intimacies, ambiguous relationships, and a thin sense of self: I was a teen parent and my mother took my boys, like double do. That kind of made me think twice

about myself. It’s like, “Am I a parent or am I not a parent? Am I somebody? Am I important?”

When asked to evaluate her mother’s involvement in her life, she expressed gratitude and resentment for the series of events that filled her with remorse, shame, and hopelessness. Ann was disburdened from mothering within the first postpartum year because of impaired relationships descending from her parents’ adverse childhoods. Long-standing, circular family responses thwarted the development of maternal agency as Ann rebelled or submitted to her parents’ demands, criticism, and blame. Without the power and agency to act as a mother, to develop a sense of self, and to come to terms with her painful past, she remained dependent on and enmeshed with Joan and on unreliable men. She befriended her children to make up for emotional voids and a deep sense of failure and despair.

“I’ve done so much that I’ve rendered her totally inept” The next family exemplifies the second form of adversarial care where the teen mother becomes overly dependent in response to the grandparent’s close scrutiny, hypercriticism, and under-involvement in infant care. Carol, the grandmother, raised 4 children as a single mother; Meg, the teen mother, was her youngest. Meg recalled few positive memories as a child and described Carol as preoccupied, “unhappy,” and harsh. Carol had been abused as a child by her mentally ill mother and acknowledged to her children that she had been verbally abusive to them. Both Carol and Meg yearned to avoid becoming like their mothers; Meg most feared “ . . . becoming an angry woman. That’s my biggest fear. My [maternal] grandmother is an angry, nasty, bitter woman.” Meg gave birth to Mike at 17 years of age and 3 additional sons as a single mother. Carol and Meg participated in all waves of the study. Mike refused to participate. Meg’s second son, 18-year-old Zack, participated at T6 .


ANS822

April 24, 2014

1:31

The Long Shadow of Adversarial Caregiving At T1 , Meg considered Carol a “lifesaver” as long as she followed Carol’s advice. But as Meg gained confidence as a mother, Carol struggled to not criticize and take over. By 8 months postpartum, intense conflicts over parenting Mike left Meg feeling like “I can’t do anything right.” Carol described the situation this way: You’re either an active participant or you’re a bystander and you’re going to go nuts watching this whole transaction go on. And I don’t think there’s any way to be the good guy . . . unless the girl comes home and gives the baby to the grandmother and says, “It’s all yours.”7(p60)

When Carol became unemployed at T1 , she deliberately stayed away from home and refused to help Meg for fear she would take over. She also reproached Meg and struggled with a hypercritical approach: What do you mean he hasn’t been fed yet? What do you mean he hasn’t been changed yet? What do you mean he hasn’t had a nap today? And I know I’m real quick to judge and step in there and want to take over and do it, so it’s a constant battle within myself, not to be judgmental and be dictatorial with Meg over the baby.7(p60)

In response to Carol’s criticism and refusal to help, Meg rebelled and was pulled back to the streets. By T2 , Meg had given birth to Zack and a positive but temporary shift occurred in Carol’s and Meg’s relationship. Carol attributed this change to learning boundaries and skills from her new position counseling drug users. As conflicts subsided, Meg felt more supported by Carol. By T3 , conflicts had resumed. Meg had given birth to a third son, and the child’s father was living with Carol, Meg, and her 3 boys. Meg described “a constant battle”: It’s hard raising kids with three adults in the house that aren’t on the same page. Because [partner] has his idea how a kid should be raised. I have mine and my mom has hers. So the kids get out of hand a lot, and they know that they can get away with a lot of stuff.

She felt impotent in changing Mike’s behavior because Carol consistently “spoiled” and

93

“rescued” him.26 By T4 , family relationships were so strained that both Meg and Carol wanted to “run away” from home. At T5 , Meg referred to “a black cloud hanging over this house constantly.” The household consisted of Meg, her 4 sons, the father of the 2 youngest boys, and Carol. The family was held together by the thinnest of threads only because Carol paid the bills, maintained the house and yard, bought groceries, and prepared dinner. Both Carol and Meg described chaos, resentment, and ongoing patterns of withdrawal, domination, and control between Carol and Meg as well as between Meg and her older sons. Because Meg also dominated her partner (just as she was dominated), their arguments sometimes erupted into physical fights and separations. Despite Meg’s yelling and threats, Mike refused to attend school and Zack was “disrespectful” and failing in school. Carol began retreating to her bedroom, hoping that her withdrawal would encourage Meg to parent her children. As Carol withdrew, she began to notice just how much she had taken over: “I keep wondering if I’m part of the problem because maybe I’ve done so much that I’ve rendered her totally inept.” She described this process as follows: I’ve isolated [myself] in my room. I quit socializing . . . . And it’s impacted the way the house operates . . . . I mean last night, the little one woke up from his nap and I said, “Do you want dinner?” Meg didn’t offer to get up and fix it. I made his dinner. Then, the next one woke up and it’s like wait a minute . . . . I’m gonna do it for the kids but there’s gonna come a day here real soon where I’m gonna quit cooking. (long description of dirty house). . . . The next move is I’m going to leave, because I don’t like living like a pig. My money is hard earned and I’m pouring it down the shit hole. It’s very discouraging.

The aforementioned passage at T5 echoes Carol’s words years earlier when she withdrew from Meg and young Mike to avoid taking over. As I learned at T6 , Carol and Meg had separated 4 years earlier after Meg had been hospitalized for a “nervous breakdown.” This event fueled Carol’s fears that she could end up raising her grandchildren. Here is how she


ANS822

April 24, 2014

94

1:31

ADVANCES

IN


described the situation: “So four years ago we all separated. Meg went her way and I went mine, and I’ve been working and learning how to not be involved in everybody’s life.” The mother-daughter “divorce” began a downward spiral for Meg. No longer able to depend on Carol for housing, she moved into several apartments in bad neighborhoods. During this time, Zack refused to go to school and Mike left home and refused contact with Meg because “He’s angry at me, he told me I fucked up his life.” With few friends and no car, Meg relied on Carol to take her for groceries. Meg described Carol “as very distant” and their relationship as Shaky, um, she tries to run my life I guess . . . . She wants me to raise my kids the way she wants me to raise my kids. She wants me to do the things she wants me to do, and if it’s not her way, it’s wrong.

Carol resented even her limited involvement with Meg and created further distance “by turning off my phone, not being available, and just setting some invisible boundaries.” Carol also divulged that upon her retirement in the next year, she intended to limit her involvement with Meg to 1 phone call per week. She remained very close to Mike, although she had refused to let him live with her: When we all broke up and left, Mike asked if he could come and stay with me, and I said no. I will not do to you what I did to your mother. I want you to learn some independence. . . . and I don’t want you to turn out like your mother.

Sibling relationships had also been damaged by years of family conflict. Mike and Zack had been intensely jealous of each other as children. At T6 , Zack reported that Carol had always favored Mike. Carol believed that Meg had deliberately poisoned her relationship with Mike by “humiliating” him and calling him “a grandma’s boy” in front of his friends as a teen. He had withdrawn from Carol for a couple of years, but their relationship had improved by T6 . Family members were caught in a vicious cycle of recrimination, resignation, and avoidance. When Meg was asked at T5 how parenting had changed her as a person, her

response confirmed that mothering had been derailed, “I would like to say it has but I don’t think it has.” At T6 , Meg described herself as isolated, depressed, and on disability for multiple health problems; her future prospects for gainful employment seemed poor. With no one holding the family together, Mike had left home and Zack had retreated from family life to avoid conflicts at home. According to Carol, Mike has had several “toxic” relationships with girlfriends. By T6 , he had received his GED, was working full-time, and considering community college. While these outcomes are positive, he has no relationship with his mother or siblings. Zack was also back in high school, but his learning disabilities and a history of truancy place him at risk for dropping out and returning to the streets. On a positive note, Meg returned to counseling after a long hiatus “because I’m messed up and I know I am.” Her problems have taken shape in the long shadow of Carol’s own grim childhood with a mentally ill mother. Despite Carol’s and Meg’s longing to flee or to repair a legacy of adversarial relationships, they “repeat” what they denounce. When I asked Meg, “How much are you like or unlike your mom as a parent?” she replied, “ . . . As much as I try to fight it, I think I’m like her a lot . . . . I’m not as mentally involved as I could be with my kids. My mom wasn’t mentally or physically there for us.” “She now looks to her mother as mommy” A third family that exemplified adversarial caregiving at T1 successfully developed responsive practices and relationship by T2 . Their example highlights the challenges in developing new practices and ways of relating that allow the teen mother to parent after mothering had been derailed. Several circumstances converged to make this shift possible: 2 years before the T2 interviews, when Jill was 19 years old and Dawn was 4 years old, Jill’s parents, Sally and Ed, moved 400 miles away and Jill and Dawn moved in with Jill’s fiancé. Although Sally and Ed had raised Dawn and


ANS822

April 24, 2014

1:31

The Long Shadow of Adversarial Caregiving offered to keep her until the couple was settled, Jill was adamant that Dawn stay with her: I didn’t want to leave her anymore. It was going to be our lives together and my parents weren’t going to be there for both of us always, and I figured it would be easier for me to try to change [our relationship] now than later.

Although Jill’s fiancé was not Dawn’s biological father, Jill believed that he was committed to parenting Dawn: I don’t think he would have let me move in without her . . . . He sees her as his responsibility also. This is his daughter, he’s really protective of her and he’s strict on her. He’s just like a father would be with their daughter.

He had also flatly rejected Jill’s parents’ hefty “bribe” to buy them a home in their new community. This family’s shift is remarkable, given the strong attachments between Dawn and her grandparents and her weak attachment to Jill as a parent. While Jill experienced a turbulent adolescence, this family drew on greater emotional and material resources than the first 2 families to reset their course after mothering had initially been derailed. Sally, for example, did not report a grim childhood or a troubled marriage. (Ed was not interviewed.) Sally described how “devastating” it was to relinquish Dawn to Jill when they moved away: At first it was very hard. I was jealous. I was feeling real sorry for myself. Wallowed in self-pity. And tried to make everybody feel guilty . . . . But then I realized that it wasn’t helping Dawn, and I think that probably the best thing that happened was that we did move away.

Two years later at T2 , Sally reported major shifts in family relationships: “I’m feeling a lot more like a grandmother than a mother. . . . I’m more comfortable with it. I mean I like being a grandmother. I think I liked being a mother more . . . . Dawn now looks to her mother as mommy.” Becoming Dawn’s mother involved setting limits for a child who had been indulged by Sally and Ed. Jill’s difficulty was exacerbated

95

by the fact that she had also been indulged as a child: “My parents didn’t discipline . . . . If I cried and threw a tantrum long enough, I would get [what I wanted].” In fact, when Jill’s parents attempted to set limits when she began getting into trouble at 14 years of age, Jill rebelled. Realizing that her parents’ permissiveness contributed to her risk-taking and rebelliousness, she relied on her fiancé’s greater skill in disciplining Dawn. But she was frustrated when her progress in creating new practices quickly evaporated after Dawn visited Sally and Ed. Rather than becoming passive and silent, Jill spoke up for Dawn’s needs and her authority as a parent: Dawn knows she can’t get away with something, but she’ll do it anyway when my mom’s visiting and I’ll tell her not to, and then she’ll say that she wants her nanny. My mom tries to keep her mouth shut, but she’ll be like, let her do it and I’ll look at my mom . . . . “Mom just stay out of it, she’s my child. I have to show her that she has to listen to me. You’re not the one that she lives with now and she has to start learning and abiding by my rules now.”

Sally eventually appreciated the gains from moving. Her relationships with Jill and her older daughter improved once she could no longer “bitch and nag. If I was still there, . . . you’re just so close that I’d just do it. ‘Why didn’t you do this? Or your bathroom’s dirty.’ It’s stupid, but I’d do that. So now that I’m not there, I can’t say anything.” Sally also appreciated that her daughters developed a closer relationship: It was good that I got away, because my two daughters always had a sense of rivalry toward me. They were jealous, competitive. So when I removed myself, they became friends, and they rely on each other and go shopping together.

Jill’s maternal engagement also earned her parents’ trust and respect. Ed told Sally, “I never thought I’d see the day that Jill would be such a good mother.” Not only did Dawn benefit from Jill’s limit setting but Jill no longer affiliated with peers who Sally perceived as “losers, they maybe smoked a little pot or they drank too much. Jill knew I disapproved and now she doesn’t want them


ANS822

April 24, 2014

96

1:31

ADVANCES

IN


in her house because she doesn’t want Dawn around them.” The development of healed relationships was confirmed by Jill at T2 : “I actually feel close to [my parents] now in a different way and not like a threatening manner with them trying to rule my life.” She added, I don’t think my mom thought I could do it when we first moved out. Now that she sees that we’re doing it and we’re making it and things are going good, I think she’s more trusting with the way I am because she looked at Dawn as her child.

This new sense of trust contrasts sharply with intense family conflicts described by Sally and Jill at T1 . In retrospect, Jill conceded that she was a “rotten” teenager who “didn’t give my mom a chance to be close with me . . . . I was just one of those kids who rebelled . . . and I think when I finally moved out, I gave my mom the opportunity for us to be close again.” At T6 , Jill selected her mother as a good parent “because she is always there . . . . She’s still always the person I fall back on when I’m happy, angry, sad, always the person I turn to.” When I asked Sally what she was most proud of at T6 , she referred to her daughters and grandchildren and added, “I’m proud that Jill turned out to be a very good mother, very proud of that.” At T6 , Jill described close relationships with her parents; they talked regularly by phone and she visited when she could, since Ed was too ill to travel. Dawn reported being close to her mother, grandparents, and stepfather. She had not been a rebellious teen like Jill and, at T6 , had been in a 6-year relationship with her boyfriend. At Dawn’s insistence, they used condoms the first time they had sex. She recently graduated from college and was planning to attend graduate school. Jill took great pride in Dawn’s achievements and in her own resolve to defy the stereotypes of teen mothers. While Jill did not marry her first fiancé, she has been in a stable, 10-year marriage and has worked part-time since her 20s. Once Jill established herself as Dawn’s mother, she took advantage of the emotional and material resources from her parents and husband in ways that were never available to Ann or Meg. Jill’s only regret is that “I missed out on a

lot of Dawn’s raising. I look back at pictures of her as an infant and it’s always my mom or my sister with her. I’m in very few of the pictures . . . I missed that and I feel guilty about it.” Jill has not missed out on raising a second daughter with her husband, a difficult scenario to imagine if her family had remained locked in adversarial relationships. DISCUSSION Adversarial caregiving was identified at T1 as a family process that provides a precarious ground for mothering. For the first 2 families, adversarial practices preceded the teen’s pregnancy and reflected impaired relationships and ambiguous boundaries that descended from grandparents’ difficult childhood experiences. Ann and Meg became parents in troubled family situations that significantly undermined the development of maternal skills and their children’s development. Prospective data over 2 decades show that long-standing family practices not only derailed mothering but also led to a thin or failed sense of self for Ann and Meg. In both cases, their sense of failure and impotence as mothers rippled through other life domains and contributed to self-reported depression, abusive relationships with partners, unstable housing, poor work histories, and impaired family relationships. Ann’s metaphor of “climbing up a broken ladder” captured the hurdles in achieving other life goals when adverse childhood events shape a tenuous capacity for relationships and then damage one’s identity and competence as a mother. Grandparents and children also suffered from ongoing conflict, resentment, and ambiguous relational boundaries, transmitting the effects of a damaged maternal identity, broken relationships, and adverse childhood events across generations. Jill’s family provides a counterexample, showing that adversarial practices can be repaired with positive long-term results when the family has more emotional resources to draw upon and their relationships are less impaired. As family members renegotiated parenting and grandparenting after the


ANS822

April 24, 2014

1:31

The Long Shadow of Adversarial Caregiving grandparents’ fortuitous move, Jill reset her life course. The gains from reengaging as a mother extended to other life domains, including steady part-time work, a stable marriage, and supportive family relationships. Although initially raised by Jill’s parents, Jill’s daughter made a smooth transition to early adulthood, in contrast to Ann’s and Meg’s children. The 3 cases suggest that family practices that derail mothering bode poorly for teen mothers and family members unless relationships are repaired. These results are consistent with studies that describe the persistence of teen mothers’ family relationships over time19 and family patterns described by Apfel and Seitz.30 They found that teen mothers whose care was supplemented but not replaced by the grandmother by 18 months were more likely to be parenting the child at 6 and 12 years and doing better overall than the teens whose mothers had taken over the care of the baby or provided minimal support at 18 months. Several studies underscore the relationship between childhood risk factors and teen mothers’ poor outcomes in income, physical, and mental health at midlife.16,18 Krishnakumar and Black31 found that teen mothers with more risk factors had less support and more hostile relationships with parents than teens with fewer risk factors. Hillis et al17 described a dose-response relationship between childhood adversities and adult outcomes for women who had their first child as a teen; that is, teen mothers who had many childhood adversities had more problems as adults than those with few childhood adversities, a finding confirmed by others.19 Future studies of teen mothers’ outcomes should include the quality of family relationships as well as measures of childhood adversities for teen mothers and their parents. Kalil et al suggested that “negative family relations may take on more importance after, rather than during, young mother’s transition to parenthood.”2(p440) This conclusion downplays how adversarial practices and relationships extend backward as well as forward in time. The disconnection and de-

97

spair described by Ann and Meg reflect the long shadow of child and family adversities experienced by themselves and their parents. Rob, Joan, and Carol described difficult childhoods that included rejection, abandonment, or abuse by mentally ill or alcoholic parents. Sally, Jill’s mother, grew up very poor but did not describe an abusive childhood or a troubled marriage. Grandparents who fit the responsive pattern had either grown up in responsive families themselves or experienced corrective relationships with others. From the birth on, they supported their daughters as mothers without taking over or becoming critical bystanders. This study also clarifies possible links between coresidence and maternal outcomes. In the first 2 cases, long-term or intermittent coresidence amplified Ann’s and Meg’s impotence and family conflicts. When they left home, they were temporarily less dependent on their families but faced the problems associated with inadequate housing or unreliable men, which reinforced their dependence and powerlessness. Leaving home permanently, as Jill did at 19 years of age, may reflect more emotional resources on her part, less family enmeshment, and a more stable, reliable partner. Moving from home set the stage for Jill to become a mother and for the family to repair relationships. Other mothers in the study similarly succeeded in reorganizing their lives when they left home permanently and drew on positive relationships with partners or others in opposition to their pasts.25,32 As these findings suggest, residential patterns, family processes, and mothers’ outcomes are highly interrelated. Larger studies are needed to examine the links between adversarial family practices, adverse child and family experiences, and teen mothers’ longterm outcomes.

IMPLICATIONS FOR PRACTICE These 3 cases highlight the importance of intervening early to strengthen family relationships, maternal identity, and emotionally


ANS822

April 24, 2014

98

1:31

ADVANCES

IN


healthy parenting practices. Family interventions with teen mothers have shown some promise in reducing conflict and fostering generational boundaries,33 but they are challenging to conduct,34 which may partly explain why home visiting and mental health interventions for teen mothers rarely focus on relationships beyond the mother-child dyad. Adopting a family focus in serving pregnant and parenting teens is a pressing concern in light of federal welfare provisions that require that teen mothers reside with a parent (or guardian) to receive cash benefits. This rule is based on the assumption that living with parents improves mothers’ life chances and strengthens parenting skills.12 While teen mothers residing in abusive homes can petition for an exemption to the rule, welfare rules do not recognize that long-standing adversarial practices also impair maternal skill and long-term outcomes. The perinatal period is a crucial time to identify adversarial caregiving. Red flags arise when grandparents report that they are more excited in preparing for the baby’s birth than the teen, the infant has become the focal point of their lives, they consider the teen to be unfit or irresponsible, or they refuse to participate in infant care. Intense power struggles over infant care and grandparents seeking adoption are particularly pernicious signs. Teens who report the following should also raise red flags: teens feel excluded and criticized by parents; they report few gains over time in maternal confidence and skill; they describe their parents as doing too much or too little; and they express anger or depression by rebelling. Signs of rebelliousness may surface in truancy, inconsistent use or nonuse of contraception, or resuming risky activities after giving birth. Threats to leave home with or without the baby may also indicate intense family conflicts and adversarial caregiving. Taking a family history prenatally and discussing family members’ expectations about their future involvement in caring for the baby may uncover red flags. When red flags surface, the clinician can engage grandparents in a

dialogue about the strong pull they may feel to care for the baby, with the warning that taking over infant care or becoming critical bystanders may derail mothering. Helping teens to identify their aspirations and challenges in being a good parent and asking grandparents what they can do to support the teen mother’s aspirations and capacities can facilitate a dialogue about their respective roles. When red flags are identified, interdisciplinary team meetings are indicated to pull together family members and involved others (eg, childcare providers, social workers, nurses, teachers) to identify their concerns and perspectives. If not already involved, the family should be referred to a home visiting program with a family/mental health focus. Home visitors are in an ideal position to gain the trust of family members, but such programs are unlikely to effectively address the multigenerational problems identified in the first 2 cases without a strong family/mental health component. Family therapy may be indicated, but a family’s lack of receptivity or insurance coverage, especially when the teen mother has already been identified by parents or professionals as “the problem,” may preclude this option. Referring the teen mother to alternative housing and advocating for an exemption from the welfare rule that she live with a parent may be a critical option when family enmeshment and acrimony prevail.

STRENGTHS AND LIMITATIONS OF THE STUDY Rich narratives were obtained from intensive interviews with multiple family members to identify family caregiving practices and shifts in relationships over 2 decades. Families were economically diverse and non-Latina white or black. Data were analyzed systematically using hermeneutic approaches. Summary files for all families were created at each wave to condense the data; these files also provided an audit trail of the first author’s decisions and interpretations. At T6 , the second author read the transcripts of 5 families to


ANS822

April 24, 2014

1:31

The Long Shadow of Adversarial Caregiving challenge and refine the first author’s interpretations. By T6 , 5 of the 16 families were lost to follow-up and few grandfathers or partners had ever participated in the study. Their perspectives may have extended or refined these interpretations. Studies with diverse and contemporary families are needed to confirm or expand on these findings. While the transferability of findings may be questionable since participants became teen mothers 2 decades ago, it is also possible that findings are especially relevant, given the welfare mandate that teens live at home or in supervised settings.

CONCLUSION The prospective and multigenerational nature of this study identified long-standing family caregiving practices that derail mothering

99

and contribute to poor outcomes for teen mothers at midlife. In the context of multiple adverse childhood events, adversarial practices, when not repaired, contribute to a vicious cycle that erodes the teen mother’s identity, compromises her life course, impairs family relationships, and limits the gains that are often made when a teen mother is supported and affirmed.32 Intense conflicts and persistent over- or underinvolvement in the care of the child by grandparents, and long or intermittent periods of coresidence, reinforce teen mothers’ dependence, disengagement, and impotence. Since families at highest risk of adversarial practices may have an intergenerational history of troubled family relationships, clinicians are urged to identify early warning signs and refer families to services that include family/mental health consultants to interrupt the long shadow of adversarial family practices and relationships.

REFERENCES 1. DeVito J. Self-perceptions of parenting among adolescent mothers. J Perinat Educ. 2007;16:16-23. 2. Kalil A, Spencer MS, Spieker SJ, Gilchrist LD. Effects of grandmother coresidence and quality of family relationships on depressive symptoms in adolescent mothers. Fam Relat. 1998;47:433-441. 3. Sellers K, Black MM, Boris NW, Oberlander SE, Myers L. Adolescent mothers’ relationships with their own mothers: impact on parenting outcomes. J Fam Psychol. 2011;25(1):117-126. 4. SmithBattle L. Learning the baby: findings from an interpretive study of teen mothers. J Pediatr Nurs. 2007;22:261-271. 5. Caldwell CH, Antonucci TC, Jackson JS. Supportive/conflictual family relations and depressive symptomatology: teenage mother and grandmother perspectives. Fam Relat. 1998;47:395-402. 6. Apfel N, Seitz V. Four models of adolescent mothergrandmother relationships in black inner-city families. Fam Relat. 1991;40:421-429. 7. SmithBattle L. Intergenerational ethics of caring for adolescent mothers and their children. Fam Relat. 1996;45:56-64. 8. SmithBattle L. Change and continuity in family caregiving practices with young mothers and their children. J Nurs Scholarsh. 1997;29:145-149. 9. Eshbaugh EM. Potential positive and negative consequences of coresidence for teen mothers and their

10.

11.

12.

13.

14.

15.

16.

children in adult-supervised households. J Child Fam Stud. 2008;17:98-108. Oberlander SE, Shebl FM, Magder LS, Black MM. Adolescent mothers leaving multigenerational households. J Clin Child Adolesc Psychol. 2009;38:62-74. Eshbaugh EM, Luze GJ. Adolescent and adult lowincome mothers: how do needs and resources differ? J Commun Psychol. 2007;35:1037-1052. Spencer MS, Kalil A, Larson NC, Spieker SJ, Gilchrist L. Multigenerational coresidence and childbearing conflict: links to parenting stress in teenage mothers across the first two years postpartum. Appl Dev Sci. 2002;6:157-170. Easterbrooks MA, Chaudhuri JH, Bartlett JD, Copeman A. Resilience in parenting among young mothers: family and ecological risks and opportunities. Child Youth Serv Rev. 2011;33:42-50. Mollborn S, Dennis JA. Investigating the life situations and development of teenage mothers’ children: evidence from the ECLS-B. Popul Res Policy Rev. 2012;31:31-66. Arnold A, Lewis J, Maximovich A, Ickovics J, Kershaw T. Antecedents and consequences of caregiving structure on young mothers and their infants. Matern Child Health J. 2011;15:1037-1045. Furstenberg FF Jr. Destinies of the Disadvantaged: The Politics of Teenage Childbearing. New York, NY: Russell Sage Foundation; 2007.


ANS822

April 24, 2014

100

1:31

ADVANCES

IN


17. Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, longterm psychosocial consequences, and fetal death. Pediatrics. 2004;113:320-327. 18. Taylor JL. Midlife impacts of adolescent parenthood. J Fam Issues. 2009;30:484-510. 19. Dalla RL, Jacobs-Hagen SB, Jareske BK, Sukup JL. Examining the lives of Navajo Native American teenage mothers in context: a 12- to 15-year follow-up. Fam Relat. 2009;58:148-161. 20. SmithBattle L. Legacies of advantage and disadvantage: the case of teen mothers. Public Health Nurs. 2007;24:409-420. 21. SmithBattle L. Teenage mothers’ narratives of self: an examination of risking the future. Adv Nurs Sci. 1995;17:22-36. 22. Heidegger M. Being and Time. New York, NY: Harper & Row; 1962. Original work published in 1935. 23. Gadamer H. Truth and Method. New York, NY: Seabury Press; 1975. Original work published 1960. 24. Chesla C. Hermeneutic phenomenology: an approach to understanding families. J Fam Nurs. 1995; 1:68-78. 25. SmithBattle L. Developing a caregiving tradition in opposition to one’s past: lessons from a longitudinal study of teenage mothers. Public Health Nurs. 2000;17:85-93. 26. SmithBattle L. Family legacies in shaping teen mothers’ caregiving practices over 12 years. Qual Health Res. 2006;16:1129-1144. 27. SmithBattle L, Leonard V. Inequities compounded: explaining variations in the transition to adulthood

28.

29.

30.

31.

32.

33.

34.

for teen mothers’ offspring. J Fam Nurs. 2012;18: 409-431. SmithBattle L. Gaining ground from a cultural tradition: a teen mother’s story of repairing the world. Fam Process. 2008;47:521-535. Benner P. The tradition and skill of interpretive phenomenology in studying health, illness, and caring practices. In: Benner P, ed. Interpretive Phenomenology: Embodiment, Caring, and Ethics in Health and Illness. Thousand Oaks, CA: Sage; 1994:99-127. Apfel N, Seitz V. African American adolescent mothers, their families, and their daughters: a longitudinal perspective over twelve years. In:Leadbeater BJR, Way N, eds. Urban Girls: Resisting Stereotypes, Creating Identities. New York, NY: New York University Press; 1996:149-170. Krishnakumar A, Black MM. Family processes within three-generation households and adolescent mothers’ satisfaction with father involvement. J Fam Psychol. 2003;17:488-498. SmithBattle L. Listening with care to teen mothers and their families. In: Chan GK, Brykczynski KA, Malone RE, Benner P, eds. Interpretive Phenomenology in Health Care Research. Indianapolis, IN: Sigma Theta Tau International; 2010:217-241. McDonald L, Conrad T, Fairlough A, et al. An evaluation of a groupwork intervention for teenage mothers and their families. Child Fam Soc Work. 2009;14:45-57. Stiles AS. A pilot study to test the feasibility and effectiveness of an intervention to help teen mothers and their mothers clarify relational boundaries. J Pediatr Nurs. 2008;23:415-428.


What teen mothers know.

The turning point: family caregiving and residential long-term care.

Friends, family, and caregiving among midlife and older lesbian, gay, bisexual, and transgender adults.

Thalidomide's long shadow.

Parenting satisfaction of mothers during midlife.

Differential social evaluation of pregnant teens, teen mothers and teen fathers by university students.

Acceptability and initial efficacy of education for teen mothers.

The life narrative at midlife.

Mothers' characteristics as predictors of adolescents' ethnic-racial identity: An examination of Mexican-origin teen mothers.

The Motherhood Penalty at Midlife: Long-Term Effects of Children on Women's Careers.

Experiences of "endless" caregiving of impaired elderly at home by family caregivers: a qualitative study.

The relationship between family obligation and religiosity on caregiving.

Long-term effects of staying connected with your teen® on drug use frequency at age 20.

Marital Strain Exacerbates Health Risks of Filial Caregiving: Evidence from the 2005 National Survey of Midlife in the U.S.

A feasibility study to assess the effectiveness of safe dates for teen mothers.

The Effects of Spiritual Self-Care Training on Caregiving Strain in Mothers of Mentally Retarded Children.

The Effects of Intranasal Oxytocin Administration on Sensitive Caregiving in Mothers with Postnatal Depression.

Multidimensional Caregiving Burden of Female Family Caregivers in Korea.

Children's Provision of Family Caregiving: Benefit or Burden?

Filial Caregiving is Associated with Greater Neuroendocrine Dysfunction: Evidence from the 2005 National Survey of Midlife in the U.S.

Distance caregiving a family member with cancer: A review of the literature on distance caregiving and recommendations for future research.

How Do Family Caregivers of Older People Give Up Caregiving?

The meaning of time: Mohawk women at midlife.

Age at menarche, androgen concentrations, and midlife obesity: findings from the Midlife Women's Health Study.