Connecting with the Pregnant Adolescent A Self-Study Guide Designed and written by Madeleine Sigman-Grant, PhD, RD Jamie Stang, PhD, RD Mary Story, PhD, RD A collaborative project between the University of Nevada, Reno; the University of Minnesota; and the US Department of Health and Human Services Modules • One – Adolescent Development • Two – Determinants of Food Choices by Adolescents • Three – Working toward Behavior Change Adolescent Development Section One Section One Average Ages of Pubertal, Cognitive, and Psychosocial Maturation Physical Development • Tanner Stages define pubertal growth • First signs - breast buds and sparse, fine pubic hair occurring on average between 8 - 13 years • Menarche occurs 2 to 4 years later • Linear growth occurs between 9.5 to 14.5 yrs. Sexual Maturity Rating for Females Sequence of Physiological Changes Body Composition and Weight • Females experience increases of 44% in lean body mass & 120% in body fat during puberty. • 50% of ideal adult body weight is gained during adolescence • During peak velocity of weight change (12.5 yrs) girls gain approx 18.3 lb (8.3 kg) per yr • As much as 14 lb (6.3 kg) can be gained during the latter half of adolescence • Peak accumulation of muscle mass occurs around or just after menses Skeletal Mass • Almost half of adult peak bone mass is accrued during adolescence • By age 18, more than 90% of adult skeletal mass has been formed Physical Changes • Weight gain • Breast size • Expanding waist and hips • GI disturbances The following video-clip provides insight into how a group of pregnant and parenting adolescents think and feel about the changes in their bodies and their weight Psychological and Social Changes The adolescent years requires balancing the needs for Self-identity vs. Peer Acceptance Psychological and Social Changes • Acceptance of pregnancy and parenting role is difficult for many mothers • Pregnant teens appear to have increased psychological responses Psychological and Social Changes • Self identity requires independence • Adolescents often express this normal developmental stage with defiance • This defiance can be interpreted by adults as demanding and self-centered Cognitive Changes • Develop global view • Master abstract concepts • Formulate own ideas Cognitive Changes • Pregnant teen learns appropriate health and nutrition choices but may not make them • Pregnant teen recognizes the conflict between knowledge and behavior Psychological, Social and Cognitive Changes The following clip demonstrates what adolescents say they want from their relationships with health care professionals Environmental factors • Family members • School accommodations • Health care • Socio-economic issues Conclusions To facilitate behavior change in pregnant teens, nutrition counselors must: integrate knowledge of the enormous challenges affecting the mother with a nutrition counseling style that accepts the mother where she is in her life Personal Counseling Philosophy Worksheet One will help you: • Choose components of your philosophy • Put that philosophy into operation • Prepare you for working with pregnant adolescents Determinants of Food Choice and Physical Activity Section Two Section Contents Determinants of Food and Physical Activity Continuum Individual Factors Personal Factors • Knowledge, attitudes and beliefs • Self-efficacy • Motivation to make change(s) • Psycho-social development • Literary and cognitive abilities Interpersonal Factors Parental and family influence • Family eating and activity attitudes and behaviors • Family views/knowledge of pregnancy • Family role modeling • Role of teen within family structure Community and Cultural Factors • Availability of socially acceptable food choices in reasonable portion sizes at reasonable prices • Cultural norms and beliefs regarding diet and activity during pregnancy and lactation • Social acceptability of teen pregnancy and of breastfeeding • Availability of appropriate, enjoyable physical activity options Population Factors • Economic incentives to purchase large portions of food high in fat, calories, sodium • Marketing and promotion of fast foods, snacks to teens • Promotion of formula feeding through hospitals and clinics
Modification of Risk Factors • Personal and interpersonal factors can be modified via nutrition education and counseling • Community and population factors must be modified through advocacy, policy development, legislation and industry regulation Assessing Determinants of Food Choice • Use of open ended questions to assess daily routines, knowledge, perceived barriers • Reflection of statements to engage adolescent and confirm information provided Assessing Determinants of Food Choice • Non-judgmental attitude and suggestions In the words of one teen “ Tell us to cut down on some foods, not to cut them out ” Working toward Behavior Change Section Three Section Contents • Acquiring information • Delivering nutrition education • Motivational Interviewing • Facilitated Discussion Groups Acquiring Information • In a group setting. • In an individual setting. Applying Information • Critical Thinking • Questioning The Dance -- Who Leads? The client is the expert in their behavior and lives Nutrition Education Strategies • Traditional approach: top down, expert driven, information overload • Newer techniques: client assumes active role, client drives the situation, client selects what information is appropriate and needed at that time What is Motivational Negotiation? • Term used for brief encounters with clients in an effort to promote behavior change • A client-centered approach to promoting positive changes in behavior based on the person’s own motivation to change Comparing Motivational Negotiation Traditional Counselor does all the work • Counselor is expert, period! • Counselor determines changes and how they should be made • Counselor jumps to action while client is still thinking • Counselor presents only positives of change to try to persuade client to do “right” thing Motivational Negotiation Counselor and client are a team • Client is expert of own life; counselor is expert of facts and experiences of others • Counselor provides information only when asked to or with permission of client • Client and counselor explore both the positive as well as the negative side of change Motivational Negotiation • Variety of strategies that elicit “change talk” from the client and enhance motivation to change behavior • Draws on values and goals of participants • Discrepancy between behavior and values is acknowledged as “normal” and is used to explore strategies for change Essential Principles • Express empathy • Avoid argumentation • Roll with resistance • Support self-efficacy • Develop discrepancy Reflective Listening • THE fundamental skill required of educators • Relies on open-ended questions • Counselor reflects back what the client says Phrases for Open-Ended Questions • Tell me why… • What other things… • How often do you… • Why do you think… • Let me see if I understand correctly… • Give me some examples of… • Tell me about… • What is a typical day like for you? Reflective Listening Phrases • It sounds like you… • It’s difficult/easy for you to… • You realize that… • You’re having trouble/success with… • You understand that… • You feel that… • You do/don’t see the need to … Reflective Listening Responses • Content “You know that you need to gain weight during pregnancy to have a healthy baby.” • Perceived feelings “You are worried that if you gain too much weight you will not be able to lose it after the pregnancy.” • Perceived meanings “Being thin after your pregnancy is more important to you than the risk of preterm delivery.” Reflective Listening Practice • “I know that I need to drink more milk. But it’s hard when all my friends are drinking soda. I feel out of place.” • Content • Feelings • Meaning Reflective Listening Practice • Content: You realize that milk is an important part of being a healthy mom and having a healthy baby. • Feelings: You are worried about fitting in with your friends if you are the only person drinking milk. • Meaning: It is very important to you to be accepted by your friends, perhaps more important than your health and that of your baby. Resistance • Tension between educator and client • Two people with two different points of view and wills • Absence of collaborative direction towards goal Choice of Words • Sensitive to teens – problem, concerns, issues • More responsive with teens – choices, behaviors, and sometimes, risk Signs of Resistance • Challenges or discounts counselor’s advice • Interrupts or cuts off counselor’s advice • Minimizes need to change, making excuses, blaming others, or pessimism (yes, but…) • Inattentiveness or nonresponsiveness Dealing with Resistance • Acknowledge it exists • Reflect discrepancy • Change the focus or the subject • Change meaning • Emphasize personal control • Allow teen to leave with pride Determining Motivations and Barriers to Behavior Change Basic question: “On a scale of 0-10, with 0 being not at all behavior of interest* , and 10 being extremely behavior of interest , how would you rate your behavior of interest ?” Determining Motivations and Barriers to Change when working with Individuals Follow-up Questions To determine barriers: “You could have chosen 9 or 10 but you chose 5. Tell me why you didn’t choose 9 or 10.” To determine motivators and knowledge: “You could have chosen 0 or 1 but you chose 5. Tell me why you didn’t choose 0 or 1.” Determining Motivations and Barriers to Behavior Change Basic question: “On a scale of 0-10, with 0 being not at all confident, and 10 being extremely confident, how confident do you feel that you will be able to breastfeed your baby?” • “You could have chosen 9 or 10 but you chose 5. Tell me why you didn’t choose 9 or 10.” • “You could have chosen 0 or 1 but you chose 5. Tell me why you didn’t choose 0 or 1.” Determining Motivations and Barriers to Change when working with Groups Follow-up Questions To determine barriers: “Suppose someone who could have chosen 9 or 10 chose a 5. Why would she not choose 9 or 10?” To determine motivators and knowledge: “She could have chosen 0 or 1 but she chose 5. Tell me why you think she didn’t choose 0 or 1.” Values and Discrepancy The counselor’s role is to help teen moms discover the link between their eating and physical activity behaviors and what is most important to them. • “How does your lack of exercise affect your ability to go to school, work and feel good?” • “What do you think the relationship is between gaining weight and how confident a pregnant teens feels?” Values and Discrepancy When teens have difficulty seeing relationship between values and behaviors, try to use extreme consequence situations. “Let’s suppose that you don’t change your diet and that your blood sugar levels continue to be as high as they are now. Based on what we have discussed, what would you expect the effect on your baby to be?” The Final Negotiation Use a double-sided reflection to summarize the session and ask about next step. • “You have mentioned some reasons why you don’t want to change your eating habits, such as _____. On the other hand, you have also talked about how your current habits might be a problem for your unborn child. Does that sound about right?” • “In thinking about these choices, is there anything that I can do to help you?” Or, “ What do you think is the next step?” What about TIME? Behavior Change Counseling • Takes about 5-30 minutes • Requires a listening environment • Allow teen to tell you why and how she might change • Don’t jump ahead Behavior Change • Communicate risk • Provide information • Initiate a behavior change sequence • Identify client’s goals and readiness • Present a menu of choices Videotape: The Situation • 17 yr old • 3 months pregnant • senior in high school • still nauseated • boyfriend distant but involved • parents ambivalent to her situation The Situation • MD concerned about rapid weight gain • Gained 3 pounds since last visit • During diet recall, high fat intake noted • She really wants healthy baby View Video Group-Based Counseling Pros • Powerful resource system • Reassurance that person not alone • Reduction in individual resistance • Group pressure might pull in less-interested Cons • Group interactions are complex • Non-participation • Group resistance • Collective augmentation Facilitated Discussions • Clients freely discuss their own approaches to behaviors brought up in the group • Counselors are facilitators who create comfortable atmospheres; encourage participation; interject only to correct misinformation and to manage group dynamics Facilitated Discussions Options • Clients can determine a topic for the day OR can choose a topic from a menu presented by the counselor • During the discussion, the counselor asks permission to correct errors in understanding and information • At the conclusion, group summarizes learning and intentions |
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