case study of an adolescent problems and needs

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• April 01, 2024 | VOL. 75, NO. 4 CURRENT ISSUE pp.307-398
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Behavioral Management for Children and Adolescents: Assessing the Evidence

• Melissa H. Johnson , M.A., M.P.H. ,
• Preethy George , Ph.D. ,
• Mary I. Armstrong , Ph.D. ,
• D. Russell Lyman , Ph.D. ,
• Richard H. Dougherty , Ph.D. ,
• Allen S. Daniels , Ed.D. ,
• Sushmita Shoma Ghose , Ph.D. , and
• Miriam E. Delphin-Rittmon , Ph.D.

Search for more papers by this author

Behavioral management services for children and adolescents are important components of the mental health service system. Behavioral management is a direct service designed to help develop or maintain prosocial behaviors in the home, school, or community. This review examined evidence for the effectiveness of family-centered, school-based, and integrated interventions.

Literature reviews and individual studies published from 1995 through 2012 were identified by searching PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. Authors chose from three levels of evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness.

The level of evidence for behavioral management was rated as high because of the number of well-designed randomized controlled trials across settings, particularly for family-centered and integrated family- and school-based interventions. Results for the effectiveness of behavioral management interventions were strong, depending on the type of intervention and mode of implementation. Evidence for school-based interventions as an isolated service was mixed, partly because complexities of evaluating group interventions in schools resulted in somewhat less rigor.

Conclusions

Behavioral management services should be considered for inclusion in covered plans. Further research addressing the mechanisms of effect and specific populations, particularly at the school level, will assist in bolstering the evidence base for this important category of clinical intervention.

Problem behavior early in life can be related to later development of negative outcomes, such as school dropout, academic problems, violence, delinquency, and substance use; in addition, early childhood delinquent behavior may predict criminal activity in adulthood ( 1 – 7 ). Therefore, interventions designed to address problem behavior and increase prosocial behavior are important for children and adolescents and for families, teachers, school officials, community members, and policy makers. This article provides an assessment of behavioral management interventions for children and adolescents who have behavior problems.

This article reports the results of a literature review that was undertaken as part of the Assessing the Evidence Base Series (see box on next page). For purposes of this series, the Substance Abuse and Mental Health Services Administration (SAMHSA) has described behavioral management as a direct service that is designed to help a child or adolescent develop or maintain prosocial behaviors in the home, school, or community. Examples of these behaviors include demonstrating positive, nonaggressive relationships with parents, teachers, and peers; showing empathy and concern for others; and complying with rules and authority figures. Table 1 presents a description of the service and its components. Behavioral management interventions are individualized to the person’s needs.

About the AEB Series

The Assessing the Evidence Base (AEB) Series presents literature reviews for 13 commonly used, recovery-focused mental health and substance use services. Authors evaluated research articles and reviews specific to each service that were published from 1995 through 2012 or 2013. Each AEB Series article presents ratings of the strength of the evidence for the service, descriptions of service effectiveness, and recommendations for future implementation and research. The target audience includes state mental health and substance use program directors and their senior staff, Medicaid staff, other purchasers of health care services (for example, managed care organizations and commercial insurance), leaders in community health organizations, providers, consumers and family members, and others interested in the empirical evidence base for these services. The research was sponsored by the Substance Abuse and Mental Health Services Administration to help inform decisions about which services should be covered in public and commercially funded plans. Details about the research methodology and bases for the conclusions are included in the introduction to the AEB Series ( 26 ).

The treatment literature includes a variety of behavioral management interventions that are designed to address problem behaviors (for example, externalizing or acting-out behaviors) of children and adolescents when implemented in various settings. Given the breadth and variations of these interventions, behavioral health policy makers, providers, and family members may benefit from a brief review of specific behavioral management interventions and their value as covered services in a benefit package.

The purposes of this article are to describe behavioral management services and highlight specific behavioral management interventions that are implemented in community settings, rate the level of evidence (methodological quality) of existing studies, and describe the effectiveness of these services on the basis of the research. We identify three models of behavioral management interventions that can be implemented, depending on the intervention setting and the needs of children or groups of children and their families. To facilitate use by a broad audience of mental health services personnel and policy makers, we provide an overall assessment of research quality and briefly highlight key findings. The results will provide state mental health directors and staff, policy officials, purchasers of health services, and community health care administrators with a simple summary of the evidence for a range of behavioral management services and implications for research and practice.

Description of behavioral management

Behavioral management for children and adolescents is a general category of intervention that is often incorporated as part of a variety of clinical practices that differ by setting and populations of focus. These interventions share common goals, which are listed in Table 1 . Behavioral management interventions for children and adolescents included in this review address various problem behaviors, including noncompliance at home or at school, disruptive behavior, aggressive behavior, rule breaking, and delinquent behaviors. For purposes of this article, clinical components of behavioral management interventions for children were compiled from various practice-relevant sources ( 8 – 11 ).

Behavioral management is grounded in social learning theory and applied behavior analysis. Social learning theory asserts that people learn within a social context, primarily by observing and imitating the actions of others, and that learning is also influenced by being rewarded or punished for particular behaviors ( 12 ). Based on the principles of social learning theory, applied behavior analysis uses general learning principles, direct observation, objective measurement, and analytic assessment to shape behavior and solve problems that are clinically significant for an individual or family ( 11 ). The approach often is used for children with autism spectrum disorders; however, applied behavior analysis principles and techniques can be used more generally with behavioral management interventions for various child behavior problems.

Examples of specific behavioral management treatment activities include observing and documenting child behaviors, identifying antecedents of behaviors, utilizing motivating factors in reinforcement strategies, developing behavioral plans to address identified problem behaviors, coordinating interventions across different settings in which children function, and training other individuals in a child’s life to address specific behavioral objectives or goals. Behavioral management services typically are delivered through an individualized plan that is based on a clinical assessment. An assessment identifies the needs of the child or adolescent and the family and establishes goals, intervention plans, discharge criteria, and a discharge plan. Behavioral management plans are implemented through teaching, training, and coaching activities that are designed to help individuals establish and maintain developmentally appropriate social and behavioral competencies. Services may involve coordination of other care or referral to complementary services.

Behavioral management interventions may be delivered by family members, teachers, professional therapists, or a team of individuals working in concert to address the needs of a child or adolescent. A behavioral management therapist collaborates with the child or adolescent and the family to develop specific, mutually agreed-upon behavioral objectives and interventions to alter or improve specific behaviors. The resulting behavioral management treatment plan may also include a risk management or safety plan to identify risks that are specific to the individual. In some cases, a contingency plan is developed to address specific risks should they arise. Behavioral management professionals work in partnership with family members or teachers to implement a behavioral plan and monitor the child’s behavior and progress.

Three basic models of behavioral management interventions in the research literature are family-centered behavioral interventions, school-based behavioral interventions that can include services implemented across grades or classrooms or as individually targeted services, and integrated home-school programs. We focus on behavioral management interventions for children who are evidencing problem behavior and on interventions that include families and have some level of personalization that addresses the child’s needs.

Family-centered behavioral interventions

Family-centered interventions emphasize the role of parents or other caregivers in helping to manage problem behaviors of children, and they frequently focus on parenting practices. The interventions can be clinic based or offered in community settings or in the home. Behavioral parent training interventions are among the more commonly used family-centered behavioral management models. These interventions specifically target individual children with identified behavior problems and their families and generally teach parents to increase positive interactions with children and reduce harsh and inconsistent discipline practices. Behavioral parent training programs are delivered in a variety of formats. For example, some behavioral parenting interventions may involve parents, children, or teachers, and some may be delivered only to parents. Behavioral parent training interventions also vary in the extent to which they are customized to specific needs of the child. For purposes of this article, we focus on behavioral parent training interventions that involve planning for specific behavior problems that are expressed by a child and working with the parent and child, rather than group-based parent training programs that do not involve the child or are not customized based on specific behavioral needs.

Two family-centered behavioral interventions that meet the criteria for this review are Parent-Child Interaction Therapy (PCIT) and the Incredible Years programs. PCIT uses live coaching of parents during parent-child interactions to help parents establish nurturing relationships with their children, clear parent-child communication and limit setting, and consistent contingencies for child behavior ( 13 , 14 ). The Incredible Years parent training and child training programs involve addressing problem behavior of children aged two to ten years who have a diagnosis of a disruptive behavior disorder or are exhibiting subclinical levels of problem behavior ( 15 , 16 ). During treatment, a therapist works with parents and children in group settings and uses vignettes, focused discussions, role plays, and problem-solving approaches to illustrate and discuss specific behavioral management techniques. Both of these interventions incorporate behavioral management strategies of rewarding prosocial behavior, limiting reinforcement of inappropriate behavior, and delivering appropriate consequences for misbehavior.

School-based behavioral interventions

School-based behavioral interventions specifically target problem behaviors that occur in the school setting, and they use teachers and school staff as interveners in the management of student behaviors. One model that is commonly used in school settings is Positive Behavior Support (PBS). This model describes strategies that are implemented with the whole school to improve behavior and school climate and to prevent or change patterns of problem behavior ( 17 ). Based on applied behavior analysis, person-centered planning (an approach designed to assist the individual in planning his or her life and supports, often to increase self-determination and independence), and inclusion principles, PBS aims to support behavioral success by implementing nonpunitive behavioral management techniques in a systematic and consistent manner ( 18 , 19 ). PBS models of intervention seek to prevent problem behavior by altering conflict-inducing situations before problems escalate while concurrently teaching appropriate alternative behaviors ( 8 ).

Specific school-based interventions developed based on the PBS model include Positive Behavioral Interventions and Supports ( 20 ) and Safe & Civil Schools ( 21 ). These school-based interventions implement behavioral management strategies and tailor the level of intervention for the unique needs of a child or adolescent. PBS interventions utilize three levels of treatment: a primary tier, applied to the entire school setting to prevent challenging behaviors; a secondary tier, targeting individuals who display emerging or moderate behavior problems; and a tertiary tier for students who evidence more significant behavior problems and require complex and individualized team-based support beyond what is delivered at the primary and secondary levels ( 10 ). Interventions at the tertiary level involve tailored behavioral management strategies outlined in a behavioral management plan ( 22 ). To direct this review to treatment approaches for children with identified behavior problems, we focused on school-based behavioral management interventions that fall within the tertiary tier of intensity.

Integrated behavioral interventions

Integrated interventions combine school- and family-centered treatment components to create cohesive programs that address child behaviors in school and home settings. Three integrated programs are assessed in this review: Fast Track, Child Life and Attention Skills (CLAS), and the Adolescent Transitions Program (ATP). The Fast Track program is a long-term intervention that is designed to prevent antisocial behavior and psychiatric disorders among children identified as demonstrating disruptive behavior by parents and teachers. It uses a combination of parent behavioral management training, child social cognitive skills training, tutoring or mentoring, individualized home visits, and a classroom curriculum ( 23 ). The CLAS program is designed to reduce inattention symptoms and improve organizational and social skills among children with attention-deficit hyperactivity disorder (ADHD), inattentive type, through a combination of teacher consultation, parent training, and child skills training ( 24 ). ATP is a communitywide, family-centered intervention delivered through schools that takes a multilevel approach to addressing adolescent behavior problems ( 25 ). Similar to the three-tiered system of intervention described with school-based PBS, ATP uses tiered universal, selected, and indicated interventions to address different groups of children and families, depending on the child’s level of symptom expression. That is, universal interventions are designed for all parents and children in a school setting, selected interventions are for families and children at elevated risk, and indicated interventions are for families of children with early signs of problem behavior that do not yet meet clinically diagnosable levels of a mental disorder. The indicated level of intervention entails a variety of family treatment services, including brief family intervention, a school monitoring system, parent groups, behavioral family therapy, and case management services. These components vary depending on the individual needs of the child and family.

Search strategy

To provide a summary of the evidence and effectiveness for behavioral management, we conducted a survey of major databases: PubMed (U.S. National Library of Medicine and National Institutes of Health), PsycINFO (American Psychological Association), Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature.

We reviewed meta-analyses, research reviews, and individual studies from 1995 through 2012. We also examined bibliographies of major reviews and meta-analyses. We used combinations of the following search terms: behavioral management, behavior management, behavioral management therapy, behavior specialist, mental health, substance abuse, children, and adolescents. Additional citations were gathered from reference sections of articles. We used an independent consensus process when reviewing abstracts found through the literature search to determine whether a study used a behavioral management approach, on the basis of the conceptual definition of behavioral management provided above.

Inclusion and exclusion criteria

This review included U.S. and international studies in English of the following types: randomized controlled trials (RCTs), quasi-experimental studies, and review articles, such as meta-analyses and systematic reviews. The focus of this review was on clinical intervention approaches for children or adolescents who presented with problem behaviors or elevated risk at the beginning of the intervention. Included in the search were studies of family-focused parent training interventions that involved individualization based on the needs of the child and that involved the child and family members. Also included were studies of interventions in which the child or adolescent was selected for inclusion on the basis of the presence of problem behaviors that were targeted for change during the active treatment period.

Some populations and intervention programs were excluded to ensure basic similarities of the participants, interventions, and outcome measures and to be able to draw conclusions about whether the behavioral management intervention itself (as opposed to other intervention components) was associated with the outcomes. Studies that focused on children with autism spectrum disorders or other pervasive developmental disorders, intellectual disabilities, or fetal alcohol spectrum disorder were excluded. There is a large body of literature on behavioral management interventions for children with autism spectrum disorders and developmental disabilities, which we believe would be more appropriately reviewed in a separate article. Also excluded were universal preventive interventions that are not part of a multitiered program, because of our focus on individualized clinical intervention approaches. Universal preventive interventions address all individuals in a population, regardless of symptom severity or level of risk; as a result, the strategies and approaches used are distinct from those of more targeted interventions and more appropriately reviewed in a separate article. Finally, we excluded intervention models that may incorporate behavioral management components but are not exclusively behavioral management interventions or do not explicitly focus on child and adolescent behavior problems, such as Homebuilders, Multisystemic Therapy, Functional Family Therapy, individual cognitive-behavioral therapy, and behavioral management interventions in residential treatment centers and psychiatric hospitals.

Strength of the evidence

The methodology used to rate the strength of the evidence is described in detail in the introduction to this series ( 26 ). The research designs of the studies identified by the literature search were examined. Three levels of evidence (high, moderate, and low) were used to indicate the overall research quality of the collection of studies. Ratings were based on predefined benchmarks that considered the number and quality of the studies. If ratings were dissimilar, a consensus opinion was reached.

In general, high ratings indicate confidence in the reported outcomes and are based on three or more RCTs with adequate designs or two RCTs plus two quasi-experimental studies with adequate designs. Moderate ratings indicate that there is some adequate research to judge the service, although it is possible that future research could influence initial conclusions. Moderate ratings are based on the following three options: two or more quasi-experimental studies with adequate design; one quasi-experimental study plus one RCT with adequate design; or at least two RCTs with some methodological weaknesses or at least three quasi-experimental studies with some methodological weaknesses. Low ratings indicate that research for this service is not adequate to draw evidence-based conclusions. Low ratings indicate that studies have nonexperimental designs, there are no RCTs, or there is no more than one adequately designed quasi-experimental study.

We accounted for other design factors that could increase or decrease the evidence rating, such as how the service, populations, and interventions were defined; use of statistical methods to account for baseline differences between experimental and comparison groups; identification of moderating or confounding variables with appropriate statistical controls; examination of attrition and follow-up; use of psychometrically sound measures; and indications of potential research bias.

Effectiveness of the service

We described the effectiveness of the service—that is, how well the outcomes of the studies met the service goals. We compiled the findings for separate outcome measures and study populations, summarized the results, and noted differences across investigations. We considered the quality of the research design in our conclusions about the strength of the evidence and the effectiveness of the service.

Results and discussion

Level of evidence.

Five reviews of family-centered behavioral interventions ( 16 , 27 – 30 ), two reviews of school-based behavioral interventions ( 9 , 19 ), and one review of integrated behavioral interventions ( 25 ) were identified. Twelve RCTs that had been published after the previous reviews had been conducted were also identified. Their topics were family-centered behavioral interventions ( 31 – 34 ), school-based behavioral interventions ( 35 – 37 ), and integrated behavioral interventions ( 23 , 24 , 38 – 40 ). Tables 2 and 3 summarize the reviews and the RCTs, respectively.

a Articles are in chronological order by intervention type. Review articles sometimes included citations for interventions not described in this article. Only studies of interventions included in this article are described in the table. Abbreviations: ADHD, attention-deficit hyperactivity disorder; CD, conduct disorder; ODD, oppositional defiant disorder; PCIT, Parent-Child Interaction Therapy; RCT, randomized controlled trial

a Articles are in chronological order by intervention type. Abbreviations: ADHD, attention-deficit hyperactivity disorder; CD, conduct disorder; CLAS, Child Life and Attention Skills; ODD, oppositional defiant disorder; PCIT, Parent-Child Interaction Therapy;

b Multiple publications based on the same randomized controlled trial

Participants who received behavioral management interventions included children in preschool, elementary, middle, and high school grades. Studies included a range of racial-ethnic groups and rural and urban populations. Across studies, children who received behavioral management interventions typically were described as exhibiting problem behaviors or externalizing behaviors.

Overall, given the strength of the research designs in more than three RCTs, the level of evidence for the various types of behavioral management interventions was rated as high. However, the complexities of evaluating school-based interventions have resulted in somewhat less rigor in that area of behavioral management research. Reviews and individual studies of family-based and integrated family- and school-based behavioral management interventions included in this review used strong RCT designs, and several included intent-to-treat analyses.

RCTs of family-centered behavioral interventions (as defined for this article) have been examined in multiple review articles ( 27 – 30 ) and individual studies. Across both types of publications, the evaluations examining the effects of PCIT and Incredible Years behavioral parenting programs had adequate statistical power to detect treatment effects, used well-designed RCTs, utilized interventions with treatment manuals and fidelity data, and measured clinical outcomes with reliable and valid assessment instruments. Findings for both programs have also been replicated in multiple RCTs conducted by independent investigators.

Researchers have noted that most studies evaluating the effectiveness of tertiary-level school-based interventions have included students with significant disabilities in self-contained classrooms, which limits the generalizability of the evidence to general education students in typical classroom settings ( 37 , 41 ). Researchers also noted that studies in this body of literature generally have small samples, lack RCTs, use single-subject or within-group research designs, do not always use standardized behavioral management protocols, and are limited in their ability to report whether school personnel were implementing the interventions with fidelity ( 37 , 41 – 43 ). However, in this review we included three studies of tertiary-level school-based interventions using RCTs ( 35 – 37 ). Researchers indicated various limitations of the design (which varied across studies), including the lack of fidelity measures of team implementation of the intervention, attrition over time, limited measurement of interrater reliability of observational data, lack of validated assessment measurement, and lack of statistical analyses to account for school-level differences.

Integrated behavioral management intervention studies included in this review used strong RCT designs, had adequate statistical power to detect treatment effects, and used intent-to-treat analyses ( 23 – 25 ). One limitation is that these integrated behavioral management interventions have been studied primarily by program developers. The literature would be strengthened if these RCTs were replicated by independent researchers and demonstrated similar results.

Family-centered behavioral interventions.

Family-centered parent training interventions have been reviewed extensively and have demonstrated strong effects in reducing and preventing problem behaviors across a range of ages and populations when compared with wait-list control groups ( 16 , 28 – 30 ). Reviews found PCIT to be effective in reducing disruptive behavior of young children. Eyberg and colleagues ( 16 ) reviewed two well-designed RCTs with wait-list control groups and indicated that PCIT was superior in reducing disruptive behavior of children aged three to six years. The comparison groups in the two studies were not active controls or placebo treatment conditions, which resulted in a “probably efficacious” rating for PCIT ( 16 ). A meta-analysis of PCIT included 13 studies from eight cohorts and three research groups ( 28 ). The researchers compared children who received PCIT with children in nonclinical comparison groups and concluded that mothers of children who received PCIT reported greater declines in problem behaviors. There were large effects for positive behaviors observed in the classroom.

Adaptations and abbreviated versions of PCIT and the Incredible Years program showed preliminary positive effects in various populations, including Mexican-American families ( 44 ), Chinese families ( 33 , 45 ), African-American families ( 46 ), children in Head Start ( 47 , 48 ), and children identified in pediatric medical settings ( 31 , 32 , 49 ). Various forms of the Incredible Years program implemented for children with significant needs reduced problem behaviors among children with a diagnosis of ADHD ( 34 ) and oppositional defiant disorder ( 50 ) six months after the intervention. Overall, compared with control groups, these family-centered parent training programs had strong effects in reducing externalizing behaviors (immediately after the intervention and at follow-up) among children across a range of ages.

School-based interventions.

Research findings were mixed on the effectiveness of tertiary-level school-based interventions. Two meta-analyses of tertiary-level interventions that used functional behavioral assessments found that these interventions were effective in reducing problem behavior across a range of disabilities and grades ( 9 , 19 ). However, these results should be interpreted with caution, because the studies evaluated in these reviews had methodological limitations (for example, single-participant research designs and small samples). Two RCTs with elementary school students found effects in reducing externalizing behavior, compared with control groups, at the end of the intervention ( 36 ) and at the follow-up 14 months after the pretest ( 37 ), as indicated by self-reported scores on standardized instruments and observer ratings of student behavior. Compared with students in control groups, students in the intervention group also evidenced higher ratings of self-reported social skills; improvements were also seen in time engaged in academic activities, as measured by independent observational assessment ( 36 ). These positive effects were not replicated in a rigorous RCT that examined the effects of a three-tiered, schoolwide aggression intervention in early- and late-grade elementary schools in an inner city and in an urban poor community ( 35 ). Researchers found that compared with the control condition, the tertiary-level intervention had significant effects on aggressive behavior when it was delivered to children during the early school years in the urban poor community. Aggressive behavior was measured through a composite of standardized assessment instruments. However, none of the interventions were effective in preventing aggression among older elementary school children.

Integrated behavioral management interventions.

Integrated interventions demonstrated promising findings in preventing and reducing problem behaviors among diagnosed and at-risk children. The Fast Track program had a significant impact on lowering the likelihood of diagnosis of conduct disorder and externalizing behavior among children identified as being at the highest risk of antisocial behavior; however, the intervention did not have an impact on the resulting diagnoses of children who had moderate baseline risk levels ( 23 ). In a recent article that assessed the impact on the onset of various disorders of random assignment to the Fast Track intervention, researchers found that the intervention implemented over a ten-year period prevented externalizing psychiatric disorders among the highest risk group, including during the two years after the intervention ended ( 40 ). In another study, youths who had participated in the Fast Track program had reduced use of professional general medical, pediatric, and emergency department services for health-related problems, compared with youths in a control group, ten years after the first year of the intervention ( 39 ). These findings indicate that this program could be very beneficial and cost-effective if targeted to high-risk children.

The CLAS program also demonstrated significant positive results; children receiving this intervention showed decreased inattention symptoms and increased social and organizational skills compared with peers who were assigned randomly to a control group ( 24 ). For families randomly assigned to ATP, adolescents had lower rates of antisocial behavior and substance use, and families reported stronger parent-child interactions and parenting practices, compared with those in control conditions ( 25 , 38 ). Overall, the effectiveness of integrated behavioral management interventions can be characterized as relatively strong.

Evidence is promising regarding the effectiveness of specific behavioral management interventions. Although these effects vary depending on setting and intervention type and some studies had methodological limitations, a number of reviews and subsequent studies have reported positive results of these interventions for improving child behavior in multiple settings. The level of evidence is in the high range, particularly among family-centered and integrated family-school program models (see box on this page). The benefits of integrated family-school models include service access for families. If implemented early, such interventions may assist in early detection and treatment of problem behaviors before they become more severe. Children and adolescents have been shown to benefit from these interventions, and given the importance of early intervention to reduce the potentially negative consequences of disruptive behavior later in life, these findings are encouraging. In addition, integrated family-school approaches appear to allow strategies that are implemented in the home to be reinforced in school settings, thus providing an additional level of collaboration and support between the school and family.

Evidence for the effectiveness of behavioral management for children and adolescents: high

Overall, positive outcomes found in the literature:

For policy makers and payers (for example, state mental health and substance use directors, managed care companies, and county behavioral health administrators), the findings of this review suggest a number of benefits to the implementation of behavioral management interventions. Detection and intervention at early stages of problem behavior generally are less costly than intensive services for severe problem behavior. Implementation of effective treatment when children exhibit early signs of problem behavior may prevent future engagement in criminal activity, substance use, and juvenile justice system involvement. It may also reduce the need for costly emergency services or residential treatment. There has been limited research examining the long-term outcomes of behavioral management interventions; however, some studies—such as those investigating Fast Track ( 39 , 40 )—have shown positive long-term results into young adulthood. There could be considerable cost savings if these interventions demonstrate long-lasting impacts; thus, future research should continue to examine the long-term outcomes of these types of behavioral management programs.

Studies need to be replicated by independent investigators in ethnically and racially diverse populations to confirm the strength of the evidence base and generalizability of the results. The level of evidence is somewhat dependent on the implementation setting assessed, and research findings are mixed on the effectiveness of school-based interventions that are not integrated with family interventions. There is a need for further research to examine for whom and under what conditions tertiary school-based interventions are effective, and research suggests that starting early in development may be a particularly effective approach.

For decision makers, research has established the value of behavioral management approaches to address problem behavior, and we recommend that behavioral management be considered as part of covered services. However, additional research is needed to examine the effects of behavioral management interventions implemented in school settings, given various methodological limitations in the literature. Current limitations of research conducted in this area are related to generalizability, measurement, study design, and long-term outcomes. Also, as researchers have highlighted, interventions that are designed to address the behavioral needs of children in school settings should examine not only the treatment effects but also the conditions under which an intervention in a school setting is most effective ( 35 ). Factors such as symptom severity, school characteristics, and the child’s race, ethnicity, language (including language fluency of the parents), and sex are important moderating variables to examine when determining the effects of a school-based intervention. In addition, future research on behavioral management interventions should specifically examine the various treatment components included in the intervention to determine whether there are “key ingredients” associated with particular outcomes that are effective without commercial packaging or whether the specific combinations of practices contained in these intervention packages are required to produce the reported results.

Acknowledgments and disclosures

Development of the Assessing the Evidence Base Series was supported by contracts HHSS283200700029I/HHSS28342002T, HHSS283200700006I/HHSS28342003T, and HHSS2832007000171/HHSS28300001T from 2010 through 2013 from the Substance Abuse and Mental Health Services Administration (SAMHSA). The authors acknowledge the contributions of Paolo del Vecchio, M.S.W., Kevin Malone, B.A., and Suzanne Fields, M.S.W., from SAMHSA; John O’Brien, M.A., from the Centers for Medicare & Medicaid Services; Garrett Moran, Ph.D., from Westat; and John Easterday, Ph.D., Linda Lee, Ph.D., Rosanna Coffey, Ph.D., and Tami Mark, Ph.D., from Truven Health Analytics. The views expressed in this article are those of the authors and do not necessarily represent the views of SAMHSA.

The authors report no competing interests.

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Health Risks in Adolescence

Unique biological and psychosocial changes occurring during adolescence, brain development, sexual orientation and gender identification, legal status, mental health and emotional well-being, morbidity from high-risk sexual activity, the adolescent medical home, recommendations, appendix: online resources, lead authors, committee on adolescence, 2017–2018, unique needs of the adolescent.

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Elizabeth M. Alderman , Cora C. Breuner , COMMITTEE ON ADOLESCENCE , Laura K. Grubb , Makia E. Powers , Krishna Upadhya , Stephenie B. Wallace; Unique Needs of the Adolescent. Pediatrics December 2019; 144 (6): e20193150. 10.1542/peds.2019-3150

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Adolescence is the transitional bridge between childhood and adulthood; it encompasses developmental milestones that are unique to this age group. Healthy cognitive, physical, sexual, and psychosocial development is both a right and a responsibility that must be guaranteed for all adolescents to successfully enter adulthood. There is consensus among national and international organizations that the unique needs of adolescents must be addressed and promoted to ensure the health of all adolescents. This policy statement outlines the special health challenges that adolescents face on their journey and transition to adulthood and provides recommendations for those who care for adolescents, their families, and the communities in which they live.

Adolescence, defined as 11 through 21 years of age, 1   is a critical period of development in a young person’s life, one filled with distinctive and pivotal biological, cognitive, emotional, and social changes. 2   The World Health Organization 3   ; the Office of Adolescent Health of the US Department of Health and Human Services 4   ; the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) 5 , 6   ; the Lancet , 7   with 4 international academic institutions 8   ; and the Society for Adolescent Health and Medicine 9   have called for a closer examination of the unique health needs of adolescents. In 2018, Nature devoted an issue to the advances in the science of adolescence and called for ongoing further study of this important population. 10   As a leader in adolescent health care, the American Academy of Pediatrics (AAP) is motivated to describe why adolescents are a unique and vulnerable population and why it is crucial that the AAP focus on adolescents’ health concerns to optimize healthy development during the transition to adulthood. Addressing the unique needs of adolescents with disabilities is outside the scope of this statement; several statements specific to this population are available at https://pediatrics.aappublications.org/collection/council-children-disabilities . In addition, specific guidance around the transition to adult health care is not covered in this statement; please refer to the list of transition resources at the end of this document.

The need for comprehensive health services for teenagers has been well documented since the 1990s. 11 – 13   The AAP advocates for the pediatrician to provide the medical home for adolescent primary care. 14   Other professional societies, such as the Society for Adolescent Health and Medicine, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists and school-based health initiatives ( https://www.sbh4all.org/ ), recognize the unique needs of adolescents. These organizations recommend an increase in adolescent medicine training, along with the Accreditation Committee for Graduate Medical Education. The Accreditation Committee for Graduate Medical Education currently requires only 1 month of adolescent medicine training from a board-certified adolescent medicine specialist for all pediatric residency programs (adolescent medicine; [Core] IV.A.6.[b].[3].[a].[i]); there must be one educational unit). 15   The importance of addressing the physical and mental health of adolescents has become more evident, with investigators in recent studies pointing to the fact that unmet health needs during adolescence and in the transition to adulthood predict not only poor health outcomes as adults but also lower quality of life in adulthood. 16  

A hallmark of adolescence is a gradual development toward autonomy and individual adult decision-making. However, adolescents are often faced with situations for which they may not be prepared, and many are likely to be involved in risk-taking behaviors, such as use of alcohol, tobacco, and other drugs and engaging in unprotected sex. Most recently, there is increased concern about the rise in electronic cigarette use among adolescence. 17   In fact, most health care visits by adolescents to their pediatricians or other health care providers are to seek treatment of conditions or injuries that could have been prevented if screened for and addressed at an earlier comprehensive visit. 18   Although some risk-taking behavior is considered normal in adolescence, engaging in certain types of risky behavior can have adverse and potentially long-term health consequences. The majority of mortality and morbidity during adolescence, which can be prevented, is attributable to unintentional injuries, suicide, and homicide. 19   Approximately 72% of deaths among adolescents are attributable to injuries from motor vehicle crashes, other unintentional and intentional injuries, injuries caused by firearms, injuries influenced by use of alcohol and illicit substances, homicide, or suicide. 20 , 21   These causes of death greatly surpass medical etiologies such as cancer, HIV infection, and heart disease in the United States and other industrialized nations. 21  

The AAP Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents recommends a strength-based approach to screening and counseling around these behaviors that lead to mortality and morbidity in adolescents. 1 , 22   However, according to the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, only 39% of adolescents received any type of preventive counseling during ambulatory visits. 23   Seventy-one percent of teenagers reported at least 1 potential health risk, yet only 37% of these teenagers reported discussing any of these risks with their pediatrician or primary care physician. Clearly, screening for and counseling around these high-risk behaviors needs to be improved. 24  

New screening codes for depression, substance use, and alcohol and tobacco use as well as brief intervention services may provide opportunities to receive payment for the services pediatricians are providing to adolescents. These include 96127, brief emotional and behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder scale) with scoring and documentation, per standardized instrument, and 96150, health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires). 25   However, it is important to recognize that coding for specific diagnoses may be challenging if the patient does not want his or her parent(s) to know the reasons for the clinical visit. Adolescent visits and documentation of visits are confidential to promote better access and to protect the rights of adolescents. 26  

Another trend in the health status of adolescents (reflecting technological advances in pediatric medical care) is the increasing number of pediatric patients with chronic medical conditions and developmental challenges who enter adolescence. Adolescents with chronic conditions face developmental challenges similar to their healthy peers but may have special educational, vocational, and transitional concerns because of their medical issues. 27  

The prevalence of chronic medical conditions and developmental and physical disabilities in adolescents is difficult to assess because of the variation of study methodologies and categorical versus noncategorical approaches to the epidemiology of chronic illness. 28   According to the National Survey of Children’s Health, funded by the US Department of Health and Human Services, almost 31% of adolescents have 1 moderate to severe chronic illness, such as asthma or a mental health condition. 29   Other common chronic illnesses include obesity, cancer, cardiac disease, HIV infection, spastic quadriplegia, and developmental disabilities. 30 – 32   One in 4 adolescents with chronic illness has at least 1 unmet health need that may affect physical growth and development, including puberty and overall health status as well as future adult health. 33  

Within pediatric practice, integrating adolescent-centered, family-involved approaches into the care of adolescents as well as culturally competent and effective approaches (as outlined in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents ) has the potential not only to identify threats to well-being but also to create a space to work with families to bolster opportunities for optimal development of all children. 1   When considering the health challenges adolescents face, it is imperative to take into account not only the ethnic and racial diversity of the adolescent population in the United States but also the social and ecologic factors (eg, socioeconomic status, family composition, parental education and engagement, neighborhood and school environment, religion, earlier childhood trauma and toxic stress, and access to health care).

The Search Foundation has conducted research that suggests that for minority youth, a positive ethnic identity is a critical spark for emergence of the required developmental assets to enable adolescents to develop into successful and contributing adults. 34 , 35   This theory is supported by a recent study in The Journal of Pediatrics that suggests minority youth are still prone to depression because of isolation and discrimination faced during adolescence while navigating neighborhood and school environments, even when they have educated and supportive parents. 36   African American male adolescents have the highest rates of mortality, followed by American Indian, white, Hispanic, and Asian American or Pacific Islander male adolescents, pointing to racial and ethnic disparities in adolescent health and the potential to achieve a healthy adulthood. 37  

The AAP has previously published policy statements addressing the unique strengths and health disparities that exist for specific groups of adolescents, such as lesbian, gay, bisexual, and transgender youth and those in the juvenile justice system, foster care, and the military. 38 – 42   Pediatricians must pay attention to how care is delivered to the increasingly diverse adolescent populations to prevent a decline in health status and increase in health care disparities.

Biological and psychosocial changes that occur during adolescence make this age group unique. Research describing the timing and physiology of puberty has been invaluable in revealing not only differences between racial groups but also between adolescents with different chronic conditions. 43 – 46  

Puberty is the hallmark of physiologic progression from child to adult body habitus. Chronic conditions, such as obesity and intracranial lesions, or trauma may cause early puberty, which may put the adolescent at risk for engagement in higher-risk behaviors at an earlier age. 44   Delayed puberty is often a variant of normal development but may also be seen in adolescents with inflammatory bowel disease, eating disorders, and chronic conditions that create malnutrition as well as adolescents who have undergone treatment of malignancies. Comorbid mental disease (eg, an eating disorder that causes delayed puberty) or medication for psychiatric illness that causes obesity, which may cause early puberty, can complicate optimal adolescent psychosocial development.

The work of Giedd 47   and others shows that brain development during adolescence is ongoing and affects behavior and health. Because of changes in signaling that relate to the reward system in which the brain motivates behavior and the continuing maturation of the parts of the brain that regulate impulse control, adolescents may have a propensity to be involved with high-risk behaviors and have heightened response to emotionally loaded situations. In addition, adverse childhood experiences can have an impact on brain development, affecting behaviors and health during adolescence. 48   During adolescence, there is a “pruning” of gray matter and synapses, which makes the brain more efficient. 47   White matter increases throughout adolescence, which allows the older adolescent and adult brain to conduct more-complex cognitive tasks and adaptive behavior. 49  

Increasingly, studies show that the adolescent brain responds to alcohol and illicit substances differently than adults. 50 , 51   This difference may explain the increased risk of binge drinking as well as greater untoward cognitive effects of alcohol and marijuana.

Sexual (and gender) development is a process that starts early in childhood and involves negotiating and experimenting with identity, relationships, and roles. In early adolescence, people begin to recognize or become aware of their sexual orientation. 52 , 53  

However, some adolescents are still unsure of their sexual attractions, and others struggle with their known sexual attraction. Adolescence is a time of identity formation and experimentation, so labels that one uses for their sexual orientation (eg, gay, straight, bisexual, etc) often do not correlate to actual sexual behaviors and partners. Sexual orientation and behaviors should be assessed by the pediatrician without making assumptions. Adolescents should be allowed to apply and explain the labels they choose to use for sexuality and gender using open-ended questions. 54 – 56  

Sexual minority adolescents may engage in heterosexual practices, and heterosexual adolescents may engage in same-sex sexual activity. Depending on their specific behaviors and the gender of various partners, all sexually active adolescents may be at risk for sexually transmitted infections and unplanned pregnancy. Sexual minority youth are at higher risk of sexually transmitted infections and unplanned pregnancy, often because they do not receive education that applies to their sexual behaviors and are less likely to be screened appropriately ( http://www.cdc.gov/healthyyouth/disparities/smy.htm ). 57 , 58  

Sexual minority and transgender youth, because of the stigma they face, are also at higher risk of mental health problems, including depression and suicidality, altered body image, and substance use. 38  

There is strong evidence that when sexual minority and transgender youth feel they cannot express their true selves, they go underground by either hiding or denying their attractions and identity. 59   When this is combined with reinforcing parental rejection, bullying, etc, it is believed to lead to internalization, low self-esteem, and ultimately, depression and suicide. 59   Using an explanation like this places the problem on the societal context, not the adolescent or his or her identity. 38 , 39 , 60 , 61  

A relatively higher proportion of homeless adolescents are lesbian, gay, bisexual, transgender, and queer or questioning youth. 61   They leave their family homes because of abuse or having been thrown out. These adolescents are at high risk for victimization and often need to engage in unsafe sexual practices to provide themselves food and shelter. 61  

Mental health problems may become more pronounced when sexual minority teenagers come out during adolescence to unsupportive family members and friends or health care providers. 38   These youth are more likely to experience violence both in their homes and in their schools and communities. Studies have shown that sexual minority youth reveal higher rates of tobacco, alcohol, marijuana, and other illicit substance use. 62  

Most adolescents identify by and express a gender that conforms to their anatomic sex. However, some adolescents experience gender dysphoria with their anatomic sex when entering puberty. As they consider transgender options, they are at an increased risk of mental or emotional health problems, including depression and suicidality, victimization and violence, eating disorders, substance use, and unaccepting or intolerant family members and peers. Crucial to the successful navigation of gender dysphoria issues are health care providers who can assist transgender youth and families to achieve safe, healthy transitioning both in the postponement of puberty, when indicated, and in transitioning to preferred gender with psychosocial and behavioral support. 59  

Adolescence heralds a change of legal status, in which the age of 18 or 19 years transforms legal status from minors to adults with full legal privileges and obligations related to health care. However, certain states afford minors the right to confidentiality and consent to or for reproductive and mental health and substance use treatment confidential health services. 26 , 63   Generally, minors may receive confidential screening and care for sexually transmitted infections in all 50 states and the District of Columbia. However, accessing contraception to prevent unwanted pregnancy as well as the ability to self-consent to pregnancy options counseling, prenatal care, and termination of pregnancy vary between states. 64   These discrepancies also exist in accessing outpatient mental health and substance use services. Many adolescents in need of these services do not know they may have the right to access them on their own and may avoid interaction with the health care system to assist with reproductive and mental health concerns. 16   Delaying such care leads to adverse health outcomes. 16   A recent survey confirms that adolescents value private time with their health care providers, with confidentiality assurances by health care providers. 65   The need for office policies in negotiating private time was suggested. Moreover, health care providers reported needing more education in the provision of confidential services. 66   Adolescents in foster care may also be limited in their autonomous access to confidential services, which varies state to state. 41   In certain states, pregnant and parenting adolescents may have the right to consent for their care and the care of their child ( https://www.guttmacher.org/state-policy/explore/minors-rights-parents , https://www.schoolhouseconnection.org/state-laws-on-minor-consent-for-routine-medical-care/ ). Few adolescents are considered emancipated minors and, thereby, entitled to all legal privileges of adults. 67  

Mental health and emotional well-being, in combination with issues pertaining to sexual and reproductive health, violence and unintentional injury, substance use, eating disorders, and obesity, create potential challenges to adolescents’ healthy emotional and physical development. 68   Approximately 20% of adolescents have a diagnosable mental health disorder. 69   Many mental health disorders present initially during adolescence. Twenty-five percent of adults with mood disorder had their first major depressive episode during adolescence. 70  

Suicide is the second leading cause of death in adolescents, resulting in more than 5700 deaths in 2016. 71   Between 2007 and 2016, the overall suicide rate for children and adolescents ages 10 to 19 years increased by 56%. 71   Older adolescents (15–19 years of age) are at an increased risk of suicide, with a rate of 5 in 100 000 for girls and 20 in 100 000 for boys. 71   According to the 2017 Youth Risk Behavior Survey of high school students, 7.4% of high school students attempted suicide in the last 12 months, and 13.6% made a suicide plan. 72   Adolescents with parents in the military were at increased risk of suicidal ideation (odds ratio [OR]: 1.43; 95% confidence interval [CI]: 1.37–1.49), making a plan to harm themselves (OR: 1.19; 95% CI: 1.06–1.34), attempting suicide (OR: 1.67; 95% CI: 1.43–1.95), and an attempted suicide that required medical treatment. 73  

Eating disorders typically present in the adolescent years. Although the incidence of eating disorders is low compared with depression, anxiety, and other mental health problems, these problems are often comorbid with eating disorders. 74   Moreover, the incidence of anorexia nervosa, bulimia nervosa, and other disordered eating is becoming more prevalent in formerly obese teenagers, male teenagers, and teenagers from lower socioeconomic groups. 75 – 77  

Teenagers with mental health issues may have subsequent poor school performance, school dropout, difficult family relationships, involvement in the juvenile justice system, substance use, and high-risk sexual behaviors. 78   Almost 70% of youth in the juvenile justice system have a diagnosed mental health disorder. 79 , 80  

Rates of serious mental health disorders among homeless youth range from 19% to 50%. 81 , 82   Homeless youth have a high need for treatment but rarely use formal treatment programs for medical, mental, and substance use services. 81   Confidentiality is also an issue for adolescents, as evidenced by the fact that in adolescents to whom confidentiality is not assured, there is a higher prevalence of depressive symptoms, suicidal thoughts, and suicide attempts. 83   There is a paucity of adequately trained mental health professionals to care for adolescents with these mental health challenges. 84   In addition, coverage for mental health services by insurance plans can be variable. 78  

Multiple factors, including the increase in use of long-acting reversible contraception, have resulted in the teenage pregnancy rate decreasing in the United States over the past 20 years. 85 , 86   However, pregnancy still contributes to delays in educational and career success for adolescents. Moreover, pregnant teenagers are more likely to delay seeking medical care, putting them at risk for pregnancy-related health problems and putting their children at risk for prematurity and other negative birth outcomes. 87  

Adolescents continue to have the highest rates of sexually transmitted infections (eg, gonorrhea and Chlamydia ). 88   Although screening most sexually active adolescents for Chlamydia infection is covered by the Patient Protection and Affordable Care Act (Pub L No. 111–148 [2010]) and recommended by the AAP Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents , adolescent concerns about billing and confidentiality are obstacles to medical screening. 1 , 89   Pediatricians can refer to AAP guidance to find appropriate codes for payment for providing adolescent health services ( https://www.aap.org/en-us/Documents/coding_factsheet_adolescenthealth.pdf ).

Consideration of the unique health risks as well as the biological and psychosocial elements of adolescence allows the AAP-endorsed patient-centered medical home (PCMH) to serve as an ideal conceptual framework by which a primary care practice can maximize the quality, efficiency, and patient experience of care. In 2007, the AAP joined the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association to endorse the “Joint Principals of the Patient-Centered Medical Home,” which describes 7 core characteristics: (1) personal physician for every patient; (2) physician-directed medical practice; (3) whole person orientation; (4) care is coordinated and/or integrated; (5) quality and safety are hallmarks of PCMH care; (6) enhanced access to care; and (7) appropriate payment for providing PCMH care. 90   The AAP, American Academy of Family Physicians, and American College of Physicians assert that optimal health care is achieved when each person, at every age, receives developmentally appropriate care. 91   Pediatricians provide quality adolescent care when they maintain relationships with families and with their patients and, thus, help patients develop autonomy, responsibility, and an adult identity. 92   Issues unique to adolescence to consider within the PCMH model include the following: adolescent-oriented developmentally appropriate care, which may require longer appointment times; confidentiality of health care visits, health records, billing, and the location where adolescents receive care; providers who offer such care; and the transition to adult care. 91 , 93   Moreover, using a strengths-based approach in the care of adolescents, as well as capitalizing on resiliency, is instrumental to maintaining the health of the individual adolescent. 94  

Schools have an important role for adolescents who either do not have access to a PCMH or do not use their access to receive recommended preventive services. School-based health centers and school-based mental health services can meet the needs of adolescents who do not have a PCMH or can coordinate school-based health services with the PCMH if the student has one. School nurses can help identify and refer adolescents who need these services. 95  

Financing health care of the adolescent can be challenging. Please see the detailed AAP policy statement on reforms in health care financing with the ultimate goal to improve the health care of all adolescents. 92  

On the basis of the unique biological and psychosocial aspects of adolescence, the AAP supports the following:

continued recognition by international and national organizations, including the AAP, the Society for Adolescent Health and Medicine, the American College of Obstetricians and Gynecologists, the North American Society for Pediatric and Adolescent Gynecology, and the American Academy of Family Physicians, of the need for policies and advocacy related to adolescent health and well-being;

sustained funding for research to further elucidate the biological basis of the growth and development of adolescents and how they affect adolescent behavior;

educational programs and adequate financial compensation for pediatricians and other health care professionals to support them in providing evidence-based, quality primary care for adolescents;

pediatricians receiving training on how to maintain the clinical setting as a “safe space,” particularly in terms of confidentiality, especially when working with lesbian, gay, bisexual, transgender, and queer or questioning adolescents;

the role of schools, including school nurses and school-based health centers, and their role in promoting healthy adolescent development and providing access to health care;

further education, training, and advocacy for mental health care services that specifically address the needs of adolescents, preferably as part of a medical home model, stressing the importance of mental health for all youth;

federal confidentiality protection for mental health and reproductive services, as is currently provided in many states;

innovative postresidency training programs to increase the number of adolescent-trained pediatric providers in the workforce;

improved access to medical homes for all adolescents to ensure access to preventive medical care;

affiliation of middle and high schools with a physician trained to care for adolescents, unless the student already has access to comprehensive adolescent health services;

education for pediatricians so that they are aware of the laws regarding confidential care of adolescents in their states; and

familiarity with community resources for confidential reproductive and mental health care if they cannot provide confidential care themselves. Pediatricians who are unable to provide these services should learn about local community resources that provide confidential reproductive and mental health care.

The AAP recommends the following strategies targeted at improving financing for the health care of adolescents:

Federal and state agencies should increase their efforts to further reduce the number of adolescents who are not insured or who lack comprehensive and affordable health insurance.

The Centers for Medicare and Medicaid Services should implement its regulatory authority to update its standards for essential health benefits, as defined in the Patient Protection and Affordable Care Act, in the 2 categories of mental and behavioral health services and pediatric services. These essential health benefits should be consistent with the full scope of benefits outlined in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (including health supervision visits, recommended immunizations, screening for high-risk conditions, and adequate counseling and treatment of conditions related to sexual, reproductive, mental, and behavioral health and substance use disorder). In this way, all adolescents can access the full range of services needed during this developmentally critical period to secure optimal physical and mental health on entry into midadulthood.

All health plans should provide preventive services without member cost sharing. In addition, to reduce financial barriers to care for adolescents, payers should limit the burden on families by reducing or eliminating copayments and eliminating coinsurance for visits related to anticipatory guidance and/or treatment of sexual and reproductive health, behavioral health, and immunization visits.

To provide sufficient payment to physicians and other health care providers for medical services to adolescents, insurers’ claims systems should recognize and pay for all preventive medicine Current Procedural Terminology codes related to services for health and behavior assessment, counseling, risk screening, and/or appropriate interventions recommended in Bright Futures : Guidelines for Health Supervision of Infants, Children, and Adolescents. These services should not be bundled under a single health maintenance Current Procedural Terminology code.

Government and private insurance payers should increase the relative value unit allocation and level of payment for pediatricians delivering care and clinical preventive services to adolescents to a level that is commensurate with the time and effort expended, including health maintenance services, screening, and counseling.

The Centers for Medicare and Medicaid Services should mandate that payers provide enhanced access to cost-effective and clinically sound behavioral health services for adolescents, ensure that payment for all mental health services is more equitable with payment provided for medical and surgical services, and ensure that pediatricians are paid for mental health services provided during health maintenance and follow-up visits.

American Academy of Pediatrics

Confidentiality Protections for Adolescents and Young Adults in the Health Care Billing and Insurance Claims Process: http://pediatrics.aappublications.org/content/137/5/e20160593

Office-Based Care for Lesbian, Gay, Bisexual, Transgender, and Questioning Youth: http://pediatrics.aappublications.org/content/pediatrics/132/1/e297.full.pdf

Society for Adolescent Health and Medicine

Resources for adolescents and parents are online resources aimed specifically at adolescents and their parents. Health care providers and youth-serving professionals can offer these additional resources or print a 1-page reference sheet (PDF) for adolescents and parents looking for additional information, including support groups, peer networks, helplines, treatment locators, and advocacy opportunities.

Mental Health Resources for Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Mental-Health/Mental-Health-Resources-For-Adolesc.aspx

Mental Health Resources for Parents of Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Mental-Health/Mental-Health-Resources-For-Parents-of-Adolescents.aspx

Substance Use Resources for Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Substance-Use/Substance-Use-Resources-For-Adolesc.aspx

Substance Use Resources for Parents of Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Substance-Use/Substance-Use-Resources-For-Parents-of-Adolesc.aspx

Confidentiality in Health Care Resources for Adolescents and Parents of Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Confidentiality/Confidentiality-Resources-For-Adolesc.aspx

Sexual and Reproductive Health Resources for Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Sexual-Reproductive-Health/Sexual-Reproductive-Health-Resources-For-Adolesc.aspx

Sexual and Reproductive Health Resources for Parents of Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Sexual-Reproductive-Health/SandRH-Resources-For-Parents-of-Adolesc.aspx

Physical and Psychosocial Development Resources for Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Physical-and-Psychosocial-Development/Physical-Pschosocial-Develop-Resources-For-Adolesc.aspx

Physical and Psychosocial Development Resources for Parents of Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Physical-and-Psychosocial-Development/Physical-Psych-Resources-For-Parents-of-Adolesc.aspx

Transition Resources

General resources.

National Health Care Transition Center ( www.gottransition.org )

Family Voices, Inc ( www.familyvoices.org )

National Alliance to Advance Adolescent Health ( www.thenationalalliance.org )

Transition Care Plans

AAP/National Center for Medical Home Implementation ( www.medicalhomeinfo.org/how/care_delivery/transitions.aspx )

British Columbia Ministry of Children and Family Development, “Transition Planning for Youth With Special Needs” ( www.mcf.gov.bc.ca/spec_needs/pdf/support_guide.pdf )

University of Washington, Adolescent Health Transition Project ( http://depts.washington.edu/healthtr )

Transition Assessment and Evaluation Tools

AAP/National Center for Medical Home Implementation ( www.medicalhomeinfo.org/health/trans.html )

JaxHATS, evaluation tools for youth and caregivers and training materials for medical providers ( www.jaxhats.ufl.edu/docs )

Texas Children's Hospital transition template ( http://leah.mchtraining.net/bcm/resources/tracs )

Carolina Health and Transition Project ( www.mahec.net/quality/chat.aspx?a=10 )

Wisconsin Community of Practice on Transition ( www.waisman.wisc.edu/wrc/pdf/pubs/THCL.pdf )

National Alliance to End Homelessness

• http://www.endhomelessness.org/

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

Drs Alderman and Breuner were equally responsible for writing and revising this policy statement with input from various internal and external reviewers as well as the Board of Directors, and both authors approved the final manuscript as submitted.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

FUNDING: No external funding.

confidence interval

Patient-Centered Medical Home

Elizabeth M. Alderman, MD, FSAHM, FAAP

Cora C. Breuner, MD, MPH, FAAP

Cora Breuner, MD, MPH, FAAP, Chairperson

Laura K. Grubb, MD, MPH, FAAP

Makia E. Powers, MD, MPH, FAAP

Krishna Upadhya, MD, FAAP

Stephenie B. Wallace, MD, FAAP

Laurie Hornberger, MD, MPH, FAAP – Section on Adolescent Health

Liwei L. Hua, MD, PhD – American Academy of Child and Adolescent Psychiatry

Margo A. Lane, MD, FRCPC, FAAP – Canadian Paediatric Society

Meredith Loveless, MD, FACOG – American College of Obstetricians and Gynecologists

Seema Menon, MD – North American Society of Pediatric and Adolescent Gynecology

CDR Lauren B. Zapata, PhD, MSPH – Centers for Disease Control and Prevention

Karen S. Smith

James D. Baumberger, MPP

Competing Interests

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Stress and Well-Being: A Systematic Case Study of Adolescents’ Experiences in a Mindfulness-Based Program

• Original Paper
• Published: 28 November 2020
• Volume 30 , pages 431–446, ( 2021 )

Cite this article

• Deborah L. Schussler   ORCID: orcid.org/0000-0001-5970-4326 1 ,
• Yoonkyung Oh 2 ,
• Julia Mahfouz 3 ,
• Joseph Levitan 4 ,
• Jennifer L. Frank 1 ,
• Patricia C. Broderick 1 ,
• Joy L. Mitra 1 ,
• Elaine Berrena 1 ,
• Kimberly Kohler 1 &
• Mark T. Greenberg 1  

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Research on mindfulness-based programs (MBPs) for adolescents suggests improvements in stress, emotion regulation, and ability to perform some cognitive tasks. However, there is little research examining the contextual factors impacting why specific students experience particular changes and the process by which these changes occur. Responding to the NIH call for “n-of-1 studies” that examine how individuals respond to interventions, we conducted a systematic case study, following an intervention trial (Learning to BREATHE), to investigate how individual students experienced an MBP. Specifically, we examined how students’ participation impacted their perceived stress and well-being and why students chose to implement practices in their daily lives. Students in health classes at two diverse high schools completed quantitative self-report measures (pre-, post-, follow-up), qualitative interviews, and open-ended survey questions. We analyzed self-report data to examine whether and to what extent student performance on measures of psychological functioning, stress, attention, and well-being changed before and after participation in an MBP. We analyzed qualitative data to investigate contextual information about why those changes may have occurred and why individuals chose to adopt or disregard mindfulness practices outside the classroom. Results suggest that, particularly for high-risk adolescents and those who integrated program practices into their daily lives, the intervention impacted internalizing symptoms, stress management, mindfulness, and emotion regulation. Mindful breathing was found to be a feasible practice easily incorporated into school routines. Contextual factors impacted practice uptake and program outcomes. Implications for practitioners aiming to help high school students manage stress are discussed.

Systematic case study provides nuanced data about how individuals respond to a mindfulness-based program (MBP).

High-risk adolescents received the most benefit from MBP participation.

Students who practiced were more likely to experience change across outcomes.

The MBP most impacted the way students responded to stress.

Mindful breathing may be the most accessible practice for students.

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Author Contributions

All authors contributed to the study conception and design. Qualitative data collection and analysis were performed by D.L.S., J.M., and J.L. Quantitative analysis was performed by Y.O., while J.L.M., E.B., and K.K. led the quantitative data collection. The first draft of the manuscript was written by D.L.S. and Y.O., and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

The project described was supported by Award Number R305A140113 from the Institute of Education Sciences (IES). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Institute of Education Sciences or the U.S. Department of Education.

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Pennsylvania State University, University Park, PA, USA

Deborah L. Schussler, Jennifer L. Frank, Patricia C. Broderick, Joy L. Mitra, Elaine Berrena, Kimberly Kohler & Mark T. Greenberg

University of Texas Health Science Center, Houston, TX, USA

Yoonkyung Oh

University of Colorado, Denver, CO, USA

Julia Mahfouz

McGill University, Montreal, QC, Canada

Joseph Levitan

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Correspondence to Deborah L. Schussler .

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Conflict of interest.

In accordance with ethical obligations, P.C.B., developer of Learning to Breathe, is reporting a financial interest that may be affected by the research reported in the enclosed paper.

Ethics Approval

This study was approved by the Human Research Ethics committee of Pennsylvania State University (Study 00000492; initial approval 2/24/2015).

Informed Consent

(1) Consent to Participate—Informed consent was obtained from all individual participants included in the study. Parents of minors provided passive consent to participate. (2) Consent to Publish—Participants provided informed consent for publication of their de-identified data.

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Schussler, D.L., Oh, Y., Mahfouz, J. et al. Stress and Well-Being: A Systematic Case Study of Adolescents’ Experiences in a Mindfulness-Based Program. J Child Fam Stud 30 , 431–446 (2021). https://doi.org/10.1007/s10826-020-01864-5

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Accepted : 08 November 2020

Published : 28 November 2020

Issue Date : February 2021

DOI : https://doi.org/10.1007/s10826-020-01864-5

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Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
• Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
• Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
• Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright

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Understanding Troubled Young Adolescents Who Have Problems at School: Case Studies

Related Papers

Travis McCoy

Journal of High Institute of Public Health

Dr Safaa Rabea Osman

Background & Objective(s): Emotional and behavioral problems among adolescents represent a considerable public health problem in developing countries. These problems are considered a source of stress for adolescents as well as their families, schools and community. Emotional health and well-being of young people have implications on their self-esteem, behavior, school attendance, educational achievement, social cohesion and future health and life chances. To estimate the prevalence of emotional and behavioral problems and to determine the association between these problems and socio-demographic variables among adolescent students in Assiut district. Methods: A cross sectional study was conducted in randomly selected secondary schools (2 urban and 2 rural) in Assiut district, and 400 students were included in the study. Self-administered questionnaires were used to collect study data which included: personal data, socioeconomic status scale and self-reported version of Strengths and Difficulties Questionnaire (SDQ) (Arabic version) which included 25 items divided into 5 subscales (conduct problems, hyperactivity, emotional symptoms, peer problems and prosocial behavior) Results: About 45 % of adolescents were identified with emotional and/or behavioral problems using the SDQ. These problems included conduct, emotional, peer problems, prosocial and hyperactivity difficulties (36.0%, 42.3%, 5.0%, 28.5% and 24.8% respectively). Emotional difficulties were significantly higher (p value= 0.02) among females (40.4%), while conduct difficulties were more prevalent among males (47.5%). The majority of students with emotional/ behavioral problems (90%) reported high negative impact of such problems that was significantly associated with female sex, rural residents, students of low socioeconomic level and whose mothers were housewives. Conclusion: Screening secondary school adolescents in Assiut district revealed high prevalence of emotional and behavioral problems that was associated with perceived enormous negative impact. Further studies and intervention programs are greatly needed to address adolescent mental health needs.

Journal of Child and Family Studies

Douglas Cullinan , Edward J Sabornie

Evidence-Based Practice in Child and Adolescent Mental Health

Jennifer Keenan

Fariha Iram

Present study was conducted to find the profiles and patterns of emotional and behavioral problems in adolescents from general population who had never been reported or diagnosed. A sample of 300 adolescents from public and private schools of Lahore, (13 to 17 years old, Mean=14.8) participated in the study. Participants completed the self-report standardized questionnaires, Youth Self-Report (YSR: Achenbach, & Rescorla, 2001) in Urdu language. The study revealed that majority of the adolescents was found to have normal behavior but a noticeable number of adolescents show emotional and behavioral problems. About 2 to 15% adolescents were found in clinical range and 3 to 10% in border line range of problems. Findings also suggest that in broadband scales externalizing problems were most prevalent in adolescents i.e. 15% and among DSM oriented problems conduct problem and anxiety problem were found most common in adolescents.

Revija za elementarno izobraževanje

Katja Vrhunc Pfeifer

Employees in education, especially in residential treatment centres, face crisis situations as a result of emotional and behavioural problems/disorders of children and adolescents. They most often face various types of violence, self-aggression, use of illicit substances and abuse. Cases of children and adolescents with mental health problems are frequent. Crisis interventions differ with the complexity of the situation, and regardless of the approach, an appropriate relationship is crucial to any solution. The purpose of this article is to present and elaborate the most common crisis situations and some successful interventions in such cases.

International Research Journal Commerce arts science

Adolescents are highly vulnerable to psychiatric disorders. This study aimed to explore the prevalence and patterns of behavioural and emotional problems in adolescents. It was also aimed to explore associations between socio environmental stressors and maladaptive outcomes. A school based cross-sectional study was conducted between January and July 2008. A stratified random sampling was done. 1150 adolescents in 12 to 18 year age group in grades 7 to 12 in 10 co-educational schools (government run and private) were the subjects of the study. Behavioural and emotional problems were assessed using Youth Self-Report (2001) questionnaire. Family stressors were assessed using a pre-tested 23 item questionnaire. Univariate and multivariate analysis were performed. Multiple logistic regression analysis was also done.

Science Park Research Organization & Counselling

The aim of this study is to find out numerous situations and counseling approaches that school counselors are likely to encounter during their training and the first five years of practice. We believe that attention to the various theoretical approaches that can be applied to resolve different cases will better prepare school counselors to deal with each dilemma using an efficient approach to school counseling. Thus it is important to know the most common cases seen and counseling approaches used in school counseling to prepare school counseling students to the profession. In order to achieve data about school counseling cases and approaches, fourteen high school counselors from public and private schools are interviewed with semi structured questionnaire prepared by researchers. School counselors are asked about the cases that they see the most, the approaches that they use with these cases, support systems that they seek for and therapy trainings that they take after their graduation from college. Study group is settled with random sampling from schools in different districts of Istanbul that have school counselor with at least one year experience. The results are analyzed with thematic analysis.

Child Development Perspectives

Armando Pina

Jeanne Bleuer

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Explore the experiences of children and families with these interdisciplinary case studies. Designed to help professionals and students explore the strengths and needs of children and their families, each case presents a detailed situation, related research, problem-solving questions and feedback for the user. Use these cases on your own or in classes and training events

Each case study:

• Explores the experiences of a child and family over time.
• Introduces theories, research and practice ideas about children's mental health.
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• Invites users to “try on the hat” of different specific professionals.

By completing a case study participants will:

• Examine the needs of children from an interdisciplinary perspective.
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• Apply ecological and developmental perspectives to children’s mental health.
• Predict probable outcomes for children based on services they receive.

Case studies prompt users to practice making decisions that are:

• Research-based.
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• Best to meet a child and family's needs in that moment.

Children’s mental health service delivery systems often face significant challenges.

• Services can be disconnected and hard to access.
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• Parents, teachers and other direct providers can become overwhelmed with piecing together a system of care that meets the needs of an individual child.
• Professionals can be unaware of the theories and perspectives under which others serving the same family work
• Professionals may face challenges doing interdisciplinary work.
• Limited funding promotes competition between organizations trying to serve families.

These case studies help explore life-like mental health situations and decision-making. Case studies introduce characters with history, relationships and real-life problems. They offer users the opportunity to:

• Examine all these details, as well as pertinent research.
• Make informed decisions about intervention based on the available information.

The case study also allows users to see how preventive decisions can change outcomes later on. At every step, the case content and learning format encourages users to review the research to inform their decisions.

Each case study emphasizes the need to consider a growing child within ecological, developmental, and interdisciplinary frameworks.

• Ecological approaches consider all the levels of influence on a child.
• Developmental approaches recognize that children are constantly growing and developing. They may learn some things before other things.
• Interdisciplinary perspectives recognize that the needs of children will not be met within the perspectives and theories of a single discipline.

There are currently two different case students available. Each case study reflects a set of themes that the child and family experience.

The About Steven case study addresses:

• Adolescent depression.
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The Brianna and Tanya case study reflects themes of:

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• Educational disparities.
• Trauma and toxic stress.
• Financial insecurity.
• Intergenerational issues.

The case studies are designed with many audiences in mind:

Practitioners from a variety of fields. This includes social work, education, nursing, public health, mental health, and others.

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Each case is based on the research, theories, practices and perspectives of people in all these areas. The case studies emphasize the importance of considering an interdisciplinary framework. Children’s needs cannot be met within the perspective of a single discipline.

The complex problems children face need solutions that integrate many and diverse ways of knowing. The case studies also help everyone better understand the mental health needs of children. We all have a role to play.

These case has been piloted within:

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Currently, the case studies are being offered to instructors and their staff and students in graduate and undergraduate level courses. They are designed to supplement existing course curricula.

Instructors have used the case study effectively by:

• Assigning the entire case at one time as homework. This is followed by in-class discussion or a reflective writing assignment relevant to a course.
• Assigning sections of the case throughout the course. Instructors then require students to prepare for in-class discussion pertinent to that section.
• Creating writing, research or presentation assignments based on specific sections of course content.
• Focusing on a specific theme present in the case that is pertinent to the course. Instructors use this as a launching point for deeper study.
• Constructing other in-class creative experiences with the case.
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To get started with a particular case, visit the related web page and follow the instructions to register. Once you register as an instructor, you will receive information for your co-instructors, teaching assistants and students. Get more information on the following web pages.

• Brianna and Tanya: A case study about infant and early childhood mental health
• About Steven: A children’s mental health case study about depression

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Advancing child-centred public policy in brazil through adolescent civic engagement in local governance, mainstreaming adolescent mental health & suicide prevention, adolescents take action to mitigate air pollution in vietnam, adolescent mental health knowledge summary: time for action.

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Case Study: Adolescence

Helping young people say 'no': the prevalence of risk-taking behaviour and what works to reduce it.

How many adolescents smoke, drink and take drugs and what kind of interventions work best to stop them?

Adolescent years are a notoriously challenging time, as children go through the biggest changes since their first year of life. It's this life stage that presents the greatest risk to future health, with damaging habits most often picked up between the ages of 11 and 19.

Research under the adolescent theme has examined the trends in health risk behaviours and reviewed interventions designed to prevent them, in order to inform UK health policy for this susceptible group.

Key Points:

• Two studies looked at trends in risky behaviours in adolescents and interventions designed to prevent them
• Smoking, drinking and drug use have individually declined, but a core of young people remain who engage in all three
• School-based interventions designed to empower young people to say 'no' have proved most effective at reducing multiple harmful behaviours

This case study is for the  Adolescence  theme.

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Parenting a Problem Adolescent: Aaron’s Case Study

Aaron is a 15 year old boy who attends a local public high school in an industrialised area of the city. He lives with his mum, dad and two brothers, Will aged 9 and Brad aged 11 years. Aaron has recently been in trouble with the law (a year ago), having stolen some goods from the local bike shop but was let off as this was his first offence and he had previously been of good behaviour. Aaron has not been doing well at school and has been aggressive to his mum and younger brothers over the past year.

His dad works various shifts (lots of night shifts) at the local glass factory and Aaron doesn’t get to see him much. When he does his dad usually tells him to get lost because his dad is too tired and needs his sleep. His dad constantly tells the family that he hates his job and isolates himself from the family in his bedroom. His dad is always moody and negative about things.

Aaron’s mum works at the local grocery store also on shift work. She is the powerhouse of the family, always working and cleaning up around the house, making sure the bills are paid and that the kids are fed cleaned and ready for school each day. On the rare occasion that Aaron’s mum and dad are at home together with the kids the activities around the house are not shared and everyone does their own thing. Aaron’s mum and dad sometimes yell at each other about bills and household chores.

Aaron often hears his mum berate his dad about being lazy and that he should fix up the house or mow the lawn or do some exercise and his dad swears and curses about working hard all week but rarely does any chores. Aaron has some older mates that his mum disapproves of as they are always getting into trouble, but Aaron thinks they are cool and tough and they have motor bikes, beer, drugs and girlfriends. Aaron’s brothers look up to him as a role model and Aaron often brags and tells them stories about being tough, fighting with other kids and pinching things from other peoples’ houses.

So what is problematic here?

Well Aaron has had to start growing up in early adolescence with few role models to guide him. His dad has little or no time for him as his dad is too engrossed in his own problems and his own world, is overly negative and seems not to value his son’s needs.

Aaron dislikes him because his dad tells him he is stupid and a menace when they go to talk with one another. His mum is so overworked and busy making sure that the family is provided for that there is little quality time to spend with her sons. His mum constantly screams at he and his brothers to hurry up for school, to clean their bedrooms and to stop making a mess about the house. Aaron has received little intimacy from his family and has chosen to seek anyone outside the family that can be his friend and mentor.

In this case he has not chosen wisely and is in the company of older and very questionable mates who appear to be leading him in the direction of trouble. It is clear from this example that the family is under a lot of stress, and that the parents are not providing much guidance, care or love to Aaron and probably have little idea about how to cope effectively with their own lives let alone their children’s’ lives.

Family communication is almost non-existent and there is little or no scope for sharing ideas, feelings and learning about each other and how to be happy and contented with and supportive of one another. Aaron’s dad has withdrawn from the family except for just the very basics of interactions and has isolated himself from Aaron so much so that he is like a stranger to Aaron, and not very likeable at that, trying to demolish Aaron’s self-worth and self-esteem whenever they meet with verbal abuse. Aaron’s dad may well be depressed, his mum is constantly stressed and the family is functioning only at a very basic level. Aaron’s brothers are also at risk of being led into trouble and the family certainly needs some sort of support and professional help.

• December 18, 2007
• Adolescents , Case Study , Families , Parenting , Self-Esteem
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Exploring the Dilemmas, Challenges, and Opportunities of Adolescent Fatherhood: An Exploratory Case Study

Eugene musiiwa makhavhu.

1 Nursing Science Department Sefako Makgatho Health Sciences University, Pretoria, South Africa

Tendani Sara Ramukumba

2 Adelaide Tambo School of Nursing Sciences, Tshwane University of Technology, Pretoria, South Africa

Mmajapi Elizabeth Masala-Chokwe

Teenage pregnancy is a significant concern for society, and the effect on education is immense. In South Africa, policies were thus introduced allowing pregnant school-going children to continue attending class until the baby’s birth. However, research on adolescent pregnancy generally ignores teenage fathers and focuses mostly on teenage mothers. Parents of teenage girls are also encouraged to offer support to their children, but the same cannot be said about adolescent fathers. They confront numerous barriers in fulfilling their parenting roles. A qualitative exploratory study was conducted to explore adolescent fathers’ dilemmas, challenges, and opportunities. Interviews were conducted to collect data from 5 adolescent fathers in 1 township in South Africa. Findings indicate that adolescent fathers face various challenges and experience fatherhood differently. The phenomenon’s effects on education are immense and unavoidable, yet some opportunities accompany the fathering role. Adolescent fathers are exposed to several complex situations that impact their lives. To understand these, further research studies into adolescent fatherhood still need to be conducted, and reproductive health education efforts should equally be directed toward empowering boys to the same extent as girls.

What is already known about this topic?

Adolescent fatherhood is a topic not widely researched; in fact, when speaking of adolescent parenting, it is a norm that the topic mostly refers to teenage motherhood. As a result, adolescent fathers’ navigation through fatherhood is not widely covered.

How does this research contribute to the field?

This research offers insight into adolescent fatherhood in a low-resourced community from the fathers’ perspectives.

What are your research’s implications toward theory, practice, or policy?

This research can promote policy change, particularly in terms of the educational and social support adolescent fathers require.

Introduction

Discussions on teenage parenting often focus on teenage mothers to the exclusion of teen fathers. There is also literature on teenage mothers’ influence on children’s outcomes, but the relationship between teenage fatherhood and children’s health and development is less documented. 1 Moreover, although research is available about adolescent parenting, it generally ignores the father’s involvement and focuses more on the teenage mother. This may be attributed to data suggesting teenage girls are often impregnated by older men. 2

Some negative societal perceptions regarding adolescent fathers reflect these young men are never ready to take on the parental role and are seldom involved in their children’s lives. These adolescents often deny paternity and remain absent from their children’s lives. However, it has also been reported that many adolescent fathers have a strong need to be active parents. 3 Thus, while they are initially typically reluctant to come forward, some do so over time; others remain uninvolved and uninterested. Literature on adolescent fathers has highlighted negative life outcomes that may lead to adolescent fathers’ absenteeism from their children’s lives.

Some perceptions are that mothers’ presence influences the child’s development to a greater extent than the father’s. However, it has also been argued that a father or father figure’s presence in a child’s life positively affects the child’s life prospects, academic achievement, physical and emotional health, and linguistic, literary, and cognitive development. 4 Moreover, adolescent fathers’ lives are often complicated, and they face many harsh realities. 5 Some of these negative life outcomes include delinquency, lower levels of education, and reduced or lack of employment opportunities. 6

It is well understood that adolescent parenting is not ideal as it is frequently characterized by negative outcomes. 7 Researchers further report that adolescent fatherhood decreases years of schooling and the likelihood of receiving a high school diploma. Adolescent fathers often do not attend school, are unemployed, and seldom receive formal training compared to their childless peers. 8 It is within this context that the investigation of dilemmas, challenges, and opportunities related to adolescent fatherhood (particularly in a low-resourced community) was pertinent.

Study Design and Setting

A qualitative exploratory design was employed in this study. Five participants aged between 18 and 25 who had fathered children before their 20th birthday were recruited from a mobile clinic operated by the university where the primary investigator was employed. The community did not have any other healthcare facilities within a 5-km radius. 9 The clinic was funded by a philanthropic group and was the only source of healthcare in the community. The clinic has been operating since 2005 and offers primary healthcare services, including sexual health services and free condoms. A semi-structured interview, 10 which was self-developed based on the available literature, was used to collect data. Participants were permanent residents of the low-resourced community of Soshanguve extensions 12 and 13 in the City of Tshwane, South Africa, where the mobile clinic was in operation. The area is in an extremely disadvantaged and recently formalized region with extensive informal settlements around its periphery. 11

Population and Sampling

Participants were sampled because they fit the study’s inclusion criteria. One participant who had attended the clinic for healthcare services was contacted to take part in the study and assisted the primary investigator in recruiting another participant known to him. This process resulted in snowball sampling, 12 which ensued until the last participant was selected.

Data Collection

Information leaflets were distributed to all participants to read and sign prior to data collection. Participants were prepared and informed of what the study entails and how interviews would be conducted. Data were collected by the primary investigator in English and translated to Setswana for participants who required such translation; Setswana is a dominant language in the community. Face-to-face semi-structured interviews were conducted and audio recorded with participants’ permission. Data were collected until data saturation was achieved 13 - 15 and the research focus was met. It was challenging to sample adolescent fathers, as they are typically hard to identify, contact, and recruit to participate in research for several reasons. 16 - 18

Data Analysis

The primary investigator verbatim transcribed and analyzed the data using Tesch’s approach to content analysis. It is defined as a data analysis method that examines communication messages that are usually in written form. 19 The main approach to data analysis involved a detailed exploration and review of each interview. Initial findings were coded to find the deeper meaning of the participant’s responses. Each new interview transcript was compared to the previous one to confirm or disapprove evidence, and common themes and subthemes were noted during the analysis. An independent coder also assisted to confirm or contradict the common emergent themes from analyzed data.

Ethical Considerations

Ethical principles of nursing research were applied in the study. Informed consent was obtained from participants, and a copy of the information leaflet was shared with them for reference. Interviews were conducted in a private room provided by the mobile clinic to ensure privacy during data collection. Participants’ identities were protected, and recorded interviews were kept confidential. Anonymity was ensured by not identifying participants and using codes to report on the data. Information and arrangements contained in the participants’ information leaflet were adhered to and no changes or adaptations were made during the study period. Participants were assured of their right to self-determination and were further informed that interviews would be audio rerecorded.

Socio-Demographic Information

Dilemmas of fatherhood.

Upon finding out about the pregnancy, the adolescent fathers’ reactions differed. Their dilemmas reflected the choices participants faced between undesirable alternatives, and included denial of the pregnancy and refusal of paternity.

Denial of pregnancy and refusal of paternity

Upon being informed of the pregnancy, some participants in this study denied the situation, although having engaged in sexual intercourse with the mother. They denied being responsible for the pregnancy when it was first announced. Participants were also unprepared to become fathers, as illustrated by their initial request to terminate the pregnancy.

P2: It was tough. In the beginning I refused and told my partner that I am not the father of that child, and that maybe she was busy with other men. But you have to understand, though I knew the child was mine, I was just scared.

P3: I refused paternity and only accepted after seven months when I was calm. I think I was just scared and unsure.

P4: The first time she told me she was pregnant; we had a very serious and long fight and lots of disagreements. I was not ready then to have a child, I was pushing her to have an abortion and telling her that we are still very young to become parents and that we were not ready.

Confusion and shock

Some participants indicated confusion after the pregnancy announcement as there was no expectation of a pregnancy at the time. They further mentioned feeling shocked at having had sex only once and were confounded about how that could lead to a pregnancy.

P1: I was confused and uncertain. I did not know how I was going to tell my family and I was asking myself how they [the family] would respond to the pregnancy, especially because I am still at school but I had to accept the matter and took a decision to change

P5: I froze just after she said it, it’s not something I expected at that time. We had only done it [had sex] once, so I was a bit surprised that she could be pregnant already

Failed relationships with the partners

The study’s findings further indicated that adolescent fathers separated from the mothers of their children after the baby’s birth. Participants highlighted no longer being involved with the mothers of their children; they said the only reason they remained in contact was due to co-parenting responsibilities. In some cases, this included participants financially supporting the child. One participant emphasized that although they had no relationship, he had to be courteous to the mother of his child so he could maintain access to the child. Another participant indicated that his partner and child had moved to another province. Explanations for the failed relationships were not shared.

P1: We are no longer together; the only thing that brings us together now is the child we have. And because I love my child, I have to see her, but only through her mother.

P3: Even though we do not have a ‘romantic’ relationship with the mother, but because I am still supporting my child financially, I have to see her through her mother. That is the only way that we relate, as mother and father not boyfriend and girlfriend

P4: She and I are no longer together. We broke up about 3 years ago, but for the sake of the child, we still keep communication. If we don’t do that, then I might not be able to see my child

P5: It [the relationship] ended after the child was born. But we still maintain contact so I can see the child

P2: We are in a distant relationship because she stays in another province now. So I go see her and the child now and then, like end of the month, I went to see them. We have a civil relationship considering that she stays on the other side of the country and I am here. We try our best to keep it that way for the sake of the child. If I don’t, I will not be able to see my child

Challenges of Fatherhood

The study’s findings highlighted some challenges that adolescent fathers experienced. Some reported educational challenges, family challenges, financial challenges, and challenges in accessing their child.

Educational challenges

The difficulty of not successfully completing their schooling was a common theme that emerged from participants. The primary reason cited for their interrupted schooling was the pressure of feeling the need to support their child financially. This implies that the adolescent fathers’ educational prospects and ability to complete school are affected by their parental roles. The balance between schooling and being a parent is difficult for adolescent fathers to maintain. One participant indicated a loss of concentration in school contributed to his decision to discontinue schooling, with the aim of seeking employment.

P1: Schooling and parenting becomes very challenging. I’m still at school. I am in the 9 th grade now. It’s even harder now because at my age, I should have finished high school already.

P2: I was still at school at the time of the pregnancy, but I had to drop out from the 9 th grade when the child was born, I started looking at small businesses in order to be able to provide for my child. I knew I had a responsibility and I couldn’t put it on someone else.

P3: When my child was born, I had already passed my 12 th grade. I was in college about to complete and get my diploma. My father then said he will not be able to support both me and the child and that as a man I had to make a plan. I was then forced to drop out of college to go look for a job and be able to support my child.

P4: Having a child and being at school did eventually affect me because the mother of the baby was later unable to manage on her own, I then started losing concentration at school and I eventually dropped out to look for a job so I can help her.

P5: It is difficult to continue with school not knowing if your child is okay, and if she had something to eat or not. I had to leave school and look for odd jobs like doing people’s gardens in order to make a little money to send to my child. That makes any father feel like a man

Effects on family relations

In addition to adolescent parenthood’s challenging impact on education, adolescent fathers also mentioned how the pregnancy announcement affected their family relations. Participants shared that family reactions toward the pregnancy varied from disappointment, punitive responses, acceptance of the pregnancy and, in some cases, families reacted as though they did not care.

P1: I stay with my mother only. Her response was just OK. It was as though she did not care, but I could see the disappointment in her eyes when she looks at me

P2: Informing the family of what you had done is very challenging. My family was very disappointed then. However, in the end they accepted because there was not much they could do. The child was already there when they found out and we could not ‘return the child’

P3: I faced so much difficulty at home. Although my family eventually accepted that I had a child, they cut me off financially in order to support my child. Therefore, they could not help me complete college and at the same time support my child. My father said in his own words that he will not support me and my child at the same time

P4: You went and had this child, so it means you are now a man and have to take responsibility. Those are the words my father told me, so then I accepted the ‘punishment’ as it were.

P5: Telling my family about the pregnancy was difficult, but to my surprise they [the family] didn’t react very negatively, they just told me that now that things are the way they are [with the pregnancy], I needed to get a job so I can support my child and they would help me where I couldn’t reach and wherever they could.

Financial challenges

The lack of parental and family support ultimately strained the adolescent fathers’ financial situation. They reported financial difficulty when their children were born. They were typically unable to financially provide for their children’s needs, as most participants were not formally employed.

Adolescent fathers’ lack of financial income may also influence their ability or inability to maintain access to the child. In certain cases, it is the adolescent mother’s family that prohibits the adolescent father from having access to the child.

P1: Mostly, financial challenges, not being able to provide for my child since I am still in school. Otherwise everything was fine.

P2: Financial challenges are also there. If the child is sick at any time of the day, one needs to arrange transport to take him to the hospital and wake neighbours who have cars and pay them. If I don’t have money, then what happens to my child?

P3: Sometimes money talks. Not being able to support my child financially was my biggest challenge.

P4: I faced so many challenges, I saw after I left school that my priority is that I have a child. I was not getting anything [financial assistance] at home anymore; all they [were] offering me is food. Everything else is for the child. I then asked myself, who will buy me shoes, who will buy me clothes? I needed to make a plan to get money

P5: Although there were a lot of challenges at that time, but the most difficult part was financial problems. The child needs diapers, clothes, medications, and other things and if I cannot supply that then I feel I have failed as a father, but again how do you provide the things if you are not working

Access to the child

Conflict with the mothers sometimes hindered adolescent fathers’ access to the child. Although the participants in this study had access, not all had unlimited access to their children. Some participants said that their access to their child was primarily impacted by their financial means. They consequently physically delivered money or other necessities for the child and were then in a position to see the child during these deliveries. For 1 participant, access was difficult as the mother and child had moved to a distant province, and it was problematic for him to travel since he was unemployed. However, he did manage to visit them at the end of each month.

P1: I still see my child fulltime, anytime actually

P3: Yes, I do still see my child every now and then. I do everything for my child. From preschool fees, to her clothes, I am doing my bit as a father. Next year she will start school, I will still continue with that as my duty

P4: It is difficult sometimes to see the child. Since the relationship with the mother ended, I have to see my child through her and only if her family agrees for me to see the child you see.

P2: We are in a distant relationship because she stays in another province now. So I go see her and the child now and then, like end of the month, I went to see them.

Opportunities

Although challenging, adolescent fatherhood may also provide opportunities for these young men. In this study, adolescent fathers noted that their situation taught them how to adapt to the pressures of fatherhood.

Transition to fatherhood

The sudden transition from childhood to adulthood—and ultimately fatherhood—prepared them for sudden growth and responsibilities. There was an unexpected need to change after the birth of their children.

P1: Fatherhood to me means changing from a stage of childhood to a stage of fatherhood so that I can be able to raise my child in a proper manner. It is difficult already, so one needs to grow.

P2: Now life is not as it was before the child was born. A lot has changed since then. Back then when you have some cents you would think of buying a nice pair of jeans or some nice T-shirts. Now, it is not like that anymore. When you have 10 Rands, you remember that you have a child. So responsibility is a lot on you to take care of the little one. Life is just not as free as it was before I had a child. So yeah, one has to grow in that manner.

P3: Fatherhood to me means being there for my child. Not necessarily by financial means. I’m willing to do anything and everything just to see my child survive.

P4: Being a father to me means being more involved in my child’s life. It means I have to be a more responsible person now. Be a good father to my child, a better one than my own father was to me and learning how to take care of myself as an adult [now] and learning to take care of others [My child].

P5: To me, being a father is more about availability and accessibility to my child. It is no longer about me alone anymore; it means I have to grow up now. I need to be strong and be there for my child. It means I have to be present in my child’s life and play a fatherhood role

Growth and the meaning of fatherhood

Adolescent fathers defined fatherhood as central to their personal experiences and gave it meaning. There was also an opportunity to learn from their circumstances and teach other adolescent males who might potentially find themselves in a similar situation. There was an element of growth and a change in behavior that participants experienced, followed by emotions that come with parenting. Participants also learned that they could care for someone other than themselves. Being able to define fatherhood and give it meaning gave adolescent fathers an opportunity to learn and grow from what others may term “their mistakes.” For the 1 participant still in school, it further created an opportunity to focus more on his education.

P1: Being a father at my age taught me a lot about caring for another person. I would say that my child has taught me to be softer than I was [laughing]. I am now much more serious at school than I ever was because my child depends on it

P2: Being able to love someone and learning how to take care of them and knowing you can do anything and everything to protect them. That is real love and that is what my child taught me

P3: You learn a lot from your mistakes. I cannot begin to explain just how much my situation has taught me but now I know I am an example to other young people and they can see that there is no need to rush in life. I hope my mistakes teaches someone something out there

P5: Having a child taught me a lot about responsibility, love, and caring. I am trying to be a much better person now so I can be a good role model for my child. I know now how it feels like to put someone first

There was a further unintended lesson on financial literacy. Participants learned to take care of the little money they received through odd jobs due to the sudden emergence of a new dependent.

P4: I had to grow up very quickly, and now I am also learning to use money wisely whenever I have done some work somewhere because my child comes first

The study explored the dilemmas, challenges, and opportunities of fatherhood from the perspective of adolescent fathers in a low-resourced community. It was a common finding that adolescent fathers, upon discovering the pregnancy, did not immediately accept it. There was an instantaneous decision not to father the child by rejecting paternity. Research in South Africa also reported that teen fathers have difficulty accepting they were to be fathers, and the first reaction is often denial. 16 This phenomenon is also common in other African countries, particularly among unmarried couples. Ultimately, the fact that women in consensual unions are not legally married may give the fathers room to deny their children. 20 Reasons for denying the pregnancy were not further investigated, but another study suggested that the denial of paternity on the part of the father was a way to evade responsibility. It illustrated a lack of maturity, and also related to gender commitment and societal norms depicting expectations. 21 In this case, denying paternity may be associated with the societal norms and expectations of fathers as providers.

The pregnancy announcement elicited different reactions from participants. As an unexpected change in their lives, at the time of hearing about the pregnancy for the first time, shock was expressed. This is further supported by data on unmarried fathers that found when pregnancy was unexpected, there was a typical reaction of surprise, anger, and confusion. 22 Anxiety and stress were also common among adolescent fathers when they discovered they were to be parents. 2 Adolescent fathers are likely to be scared and shocked due to being unprepared for the pregnancy. 23 This unpreparedness can further be followed by the unavoidable task of having to inform their parents and other family members that they had fathered a child.

Adolescent fathers’ biggest fear was informing their parents about the pregnancy and fathering a child at that age. The fear, in some cases, was not of physical punishment but rather emotional conflicts between them and their families. 24 This was particularly prominent among participants from a low-resourced community where poverty is rife; the announcement of a new member to the family means an extra person will need to be fed, and accepting that may be challenging. The lack of parental support was one of the challenges adolescent fathers experienced during their journey to fatherhood, and their fear of not receiving support prevailed.

For those parents who eventually accepted the pregnancy, there was a likelihood that their family could take over and support the child financially. However, financial support would typically come at the expense of the young men’s education. 24 This study also found that families who chose to support their adolescent son’s child did so by no longer providing for the adolescent father’s basic needs. This is a punitive response that the family displays toward the adolescent father, perhaps to discourage these young men from repeating the same mistake.

The study’s findings also reflected that adolescent fathers separated from the mothers of their children once the child was born. The lack of preparedness to become fathers may be a contributory factor to the separation or the end of the relationship that this study established. However, the study’s focus was not on the reasons for separation, and it is unclear why the adolescent fathers separated from the mothers of their children after childbirth. Still, separation was almost imminent and is similarly reported in literature. For the adolescent fathers in this study, despite their separation from the child’s mother, this did not always translate into an absence from the child’s life. Participants maintained a courteous relationship with the mothers of their children primarily to maintain access to the child. This finding is corroborated in literature, which found that although adolescent fathers maintained a civil relationship for the sake of the child, they were no longer in relationships with the mothers of their children. 25 This dilemma is faced by most adolescent fathers and may play a crucial role in their ultimate access to the child. Financial difficulties may be a potential reason for the separation, as other researchers found that the young fathers’ inability to financially provide hampered relationships in 56% of study samples. 25 The inability to financially support the child may result in access to the child being denied.

Various factors may impact adolescent fathers’ access to the child after birth regardless of the status of the relationship between them and the mother. This may include the maternal family denying the adolescent father’s access to the child based on their perceived belief of his inability to be a financial provider, or as a result of the young man’s initial denial of paternity. A study on young fatherhood and child support found that active fatherhood can be encouraged or discouraged by the maternal family controlling access to the child. 26 The mother’s side of the family would immediately assume kinship and guardianship of the child at the thought that the father may fail as a provider since the mother is a teenager herself. This indicates the amount of power the maternal family may possess in the relationship between father and child.

It was further reported that unemployment among adolescent fathers challenged the idea of their role as a provider. 26 Societal norms relating to gender roles place child-support responsibilities on men as fathers; therefore, the expectation from the mother’s family can be seen as morally acceptable in society. Ultimately, access to the child is not always prohibited, although it is sometimes restricted.

Adolescent fathers also have certain opportunities as a result of being a father. Participants were positively involved with their children except those who desired to be involved but were prohibited by the child’s mother. 24 However, such involvement also requires adolescent fathers to appreciate and accept their transition to fatherhood, which presents an opportunity for growth. The transition to parenthood can be a challenging time, in which both mothers and fathers experience an increased risk of distress and depression. 7 However, the participants in this study indicated that their transition to fatherhood came with opportunities for growth and financial education.

Although the main focus of this study was not on gender roles and societal expectations of fatherhood, the adolescent fathers’ transition to adulthood was affected by cultural and societal norms. These transitions were highlighted when some adolescent fathers discontinued schooling in order to seek work and provide for their children.

Literature indicates that adolescent mothers are most affected when it comes to their education. However, this does not exclude adolescent fathers. Adolescent fathers are less likely to finish high school than their childless peers, and they frequently feel they have to get a job. 27 Furthermore, adolescent fathers had significantly higher failure rates in completing secondary education. 23

Due to the cessation of schooling, adolescent fathers find it more difficult to secure employment in the future than their childless peers who likely completed tertiary education and may have good employment prospects. Difficult financial situations made it very hard for participants to play an active role in their children’s lives. The desperation of being financially viable and the societal expectations and gender roles that state men are providers may place a severe strain on adolescent fathers and be a promoter of criminal behavior in a crime-ridden and competitive low-resourced community.

This study followed 5 adolescent fathers in a low-resourced, recently formalized community in the City of Tshwane, South Africa. The objectives were to assess the dilemmas, challenges, and opportunities adolescent fathers faced from the beginning of the pregnancy to after the child was born. The study’s findings showed that adolescent fathers go through complex situations and the complexities have an impact on their lives.

Research into adolescent pregnancy and parenting focuses mostly on adolescent mothers and less on fathers. Further research studies into adolescent fatherhood need to be conducted, and reproductive health education efforts should equally be directed toward empowering boys as much as girls. More needs to be done to establish support structures for adolescent fathers to assist them in continuing their education.

Limitations

• The study only focused on a small context of a low-resourced community; therefore, the results may not be transferrable to a different context. A broader study covering other parts of the townships may potentially yield different results.
• The sample size in this study may be considered a limitation due to the challenges experienced in sampling teenage fathers. Thus, the study was more dependent on data adequacy coupled with literature support, and the information collected from the participants was adequate to meet the study’s objectives.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors disclose that funding was received for this research from the Tshwane University of Technology in Tshwane, South Africa, and the paper’s publication was funded by the Sefako Makgatho Health Sciences University, Tshwane, South Africa.

Ethical Approval: The Departmental Committee for Research and Innovation and the Research Ethics Committee of the Tshwane University of Technology in Pretoria, South Africa approved the study protocol and granted permission before the study could be carried out.

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Lisa's journalism career spans two decades, and she currently serves as the Americas Day Editor for the Global News Desk. She played a pivotal role in tracking the COVID pandemic and leading initiatives in speed, headline writing and multimedia. She has worked closely with the finance and company news teams on major stories, such as the departures of Twitter CEO Jack Dorsey and Amazon’s Jeff Bezos and significant developments at Apple, Alphabet, Facebook and Tesla. Her dedication and hard work have been recognized with the 2010 Desk Editor of the Year award and a Journalist of the Year nomination in 2020. Lisa is passionate about visual and long-form storytelling. She holds a degree in both psychology and journalism from Penn State University.

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