Early Pregnancy in Adolescents: Diagnosis, Assessment, Options Counseling, and Referral

Mary M. Aruda, PhD, RN, PNP-BC; Kathleen Waddicor, RN, BSN; Liesl Frese, MSW, LICSW; Joanna C.M. Cole, PhD; Pamela Burke, PhD, RN, FNP, PNP-BC

Disclosures

J Pediatr Health Care. 2010;24(1):4-13. 

In This Article

Psychosocial Assessment

Once a pregnancy is confirmed, it is important to assess the adolescent's emotional response, coping skills, and social resources. Having a protocol or practice guideline is very helpful to structure the visit and ensure a comprehensive assessment of a pregnant adolescent. One way to introduce such a protocol is by saying, "We use this intake form for all adolescents who have a positive pregnancy test. It helps us get a more complete picture of your circumstances. Many patients also have found that it helped them to think through their situation and choices. Deciding what to do about a pregnancy is a process that takes time, and we do not expect you to decide today. Our role is to make sure you are healthy and to provide you with information and support. We will work with you as you decide what option will be best for you."

Regardless of whether they already knew or are just finding out that they are pregnant, adolescents need time to grasp the news and begin to express their feelings. Providers can start off by stating, "Learning that you are pregnant can trigger many thoughts and feelings. What reactions are you experiencing at this point?" Because their interpersonal relationships will affect decision making, clinicians can begin assessment of partner influences through gentle probing questions. A clinician can start with the circumstances surrounding her becoming pregnant: "By whom did you become pregnant?" and using the teen's perceptions of his reaction to the pregnancy: "What reaction do you think your partner will have to your being pregnant?" Using open-ended and non-biased questions sets the tone for further screening for intimate partner violence, abuse, and sexual assault, which is especially important for pregnant adolescents who may be involved with older partners (Gold & Delisi, 2008; Kriepe, 2008). Research indicates that when adolescent females have sex at a young age with much older partners, there is a greater chance that their first sexual experience was involuntary or unwanted and that they can become pregnant (Kirby, 2007). Drawing from American College of Obstetricians and Gynecologists (ACOG) 2008 screening recommendations for domestic violence and sexual assault, it is useful to preface questions with the statement, "Because violence is so common in many women's lives and because there is help available for women being abused, we ask every patient about domestic violence." It also is important to assess for safety by asking questions such as, "Do you feel safe going home?" The common adolescent response of, "My mother is going to kill me!" needs further exploration to see if indeed there is the potential of violence within the home.

For assessment of social resources, it often is helpful to begin with less sensitive information such as verifying demographic information, confirming the adolescent's date of birth, obtaining a confidential phone number where she can be reached for follow-up, and confirming with whom she currently lives. It is important to ask if it is safe to call her home number and to clearly identify the best phone number (including working cell phone number) and best time to reach her. One should encourage the adolescent to give contact information for a significant other whom they trust, especially a person older than 18 years, to help the clinician reach her. Some teens give their partner's cell phone number; if so, there needs to be a discussion about what information may or may not be shared with that person. It is vital to document the school that the adolescent attends, because school nurses play a critical role in helping clinicians follow up if the teen does not keep return appointments.

Further assessment of the adolescent's social resources includes asking about household/family members and their social networks. The following questions can probe for this information: "Who came with you to the clinic today?" "Who knows you are pregnant?" and "Who is your main support person?" For minors as defined by state statutes (most commonly those younger than 18 years), the clinician should clarify the identity of their current legal guardian for future reference. Inquiring about involvement (past or present) with the Department of Child & Family Services/Social Services (e.g., child abuse, foster care) or with the court system (e.g., probation, youth detention) provides additional context.

It is important to establish whether the teen is able to include family in the pregnancy discussion, especially if the youth is younger than 18 years. Asking, "Do you need help telling parents/guardian about your pregnancy?" lets them know you can help them with disclosure if that is their intention. The teen can be asked about their mother's, father's, and partner's actual or anticipated reactions, what option they would want them to choose, and how supportive they think they will be. This approach helps identify key influences, sources of support, and potential pressures affecting the teen's decision making. Similarly, asking about their spiritual or religious beliefs and how they have handled major decisions in the past reveals their personal resources and inner strengths for dealing with this pregnancy decision.

Other environmental factors that can affect the adolescent's decision include her educational and employment status. Inquiring about whether the teen has ever repeated a grade or participated in special education alerts the clinician to possible learning disabilities. Cognitive limitations can affect adolescents' ability to understand their options and fully engage in options counseling. Employment status, career goals, and education goals provide a context for understanding the adolescent's life course and future plans. Asking about what they hope to do in the future and how they think this pregnancy might affect those plans encourages the adolescent to think about possible long-term results of their decision.

Additional barriers to care include limited financial resources and lack of insurance. For adolescents who opt to continue their pregnancy, Medicaid coverage for obstetrical care is usually readily available. However, those who decide to terminate the pregnancy can have financial constraints, which also may influence their decision. Thus, it is important that clinicians be aware of the financial resources, adolescent prenatal programs, and termination options within their community. Creative strategies to cover termination costs include exploring discrete community funds (e.g., through Planned Parenthood or their city hospital) or cost sharing with their partner or supportive family members.

Emotional response to a pregnancy and coping skills can vary among adolescents. Responses may be related to the adolescent's stage of psychosocial development, with early adolescents manifesting disbelief and denial; middle adolescents displaying denial, fear of consequences, and ambivalence; and late adolescents being more objective about decisions regarding the pregnancy outcome (Wildey, 1987). These responses are not necessarily predictable based on whether the pregnancy was planned or unintended. The psychosocial assessment identifies how the adolescent functions within her family and school environment, revealing her resilience and supports available during the decision-making process.

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