The Need for Effective Teen Pregnancy Prevention Programs: A Critique of Baby Think It Over - Sarah S.

Research is now finding evidence that negative consequences associated with teen pregnancy are a result of the environment in which a teenager exists, rather than the pregnancy itself (1-7). This does not mean society should no longer implement programs to prevent teen pregnancy. Instead, the information should be used to create more effective teen pregnancy prevention programs. Rather than targeting only the problem of teen pregnancy itself, public health practitioners should create programs that also take into account the environment in which teenagers are embedded and use the program to help mitigate these factors. Practitioners can create effective programs by understanding how adolescents progress developmentally, grasping the effectiveness of different health promotion frameworks, and considering the effects of media on teens’ perceptions of sexual activity. One program, “Baby Think It Over” (BTIO) was implemented in schools starting in 1994 throughout the United States to prevent teen pregnancy (8). It has failed to take into account any of these environmental factors and program results show it to be ineffective (8-10). Analyzing the weaknesses in this program will aid future public health practitioners to understand how to create better, more effective programs.

The Problem

Past research has supported that a plethora of negative outcomes are associated with teen mothers and their children (11-15). Evidence has shown that adolescents who become parents are more likely than older mothers to drop out of school, be unemployed, use drugs and have a repeat pregnancy (13, 15-17). They are also more likely to have ineffective parenting styles and exhibit maltreatment or abuse to their children than mothers who have children at an older age (18, 19). Research has found that they are less likely to receive prenatal care than older mothers putting them at an increased risk for low birth weight babies, premature labor, cesarean sections, gestational morbidity, preeclampsia, eclampsia, post-neonatal death and other complications at birth (20-25). Evidence also suggests that even when teen mothers do receive prenatal care, they are still at a higher risk to have a low birth weight baby or premature labor than their older counterparts (12, 26, 27).

Children of teen mothers are more likely to have cognitive delays than children of older mothers (14, 28). Studies have shown that they are less likely to be in the normal range for intellectual-linguistic development, social-emotional functioning, or adaptive behavior compared to the children of older mothers (29). They perform worse on measures of math, reading, and general knowledge than children of older mothers (14, 30-32). They are also more likely to exhibit behavioral problems and are more likely to experiment with drugs, be involved with gangs, and face criminal charges (11, 33-35). In addition, they are at an increased risk to have a teen pregnancy themselves (16).

While recent literature does not dispute the fact that all of the above named outcomes are associated with teen pregnancy, it does argue that the negative outcomes are a result of the environment the teen is embedded in rather than the pregnancy itself (1-7). The environment therefore puts the teen at a higher risk for a teen pregnancy, as well as at a higher risk for the numerous negative outcomes. In fact, multiple studies show that when factors such as socio-economic status, family background, educational success, race/ethnicity, and future outcomes are controlled for, teen moms are just as likely as older mothers to raise healthy and successful children (7, 36).

The importance of recent findings is that programs to prevent teen pregnancy should not focus solely on sex and pregnancy. Rather, they should also account for the multiple factors that put teens at higher risk for a pregnancy. When creating a program, public health practitioners should take into account the development of adolescents and it’s affect on their reasoning and decision making. Particular attention should be paid to the health framework chosen for the program. Public health practitioners must ensure that the framework is right for the particular program and for the population being addressed. Finally, practitioners should create programs which consider the consumption of media by teenagers and how the media may affect adolescents’ perceptions of sexual activity and associated risks.

“Baby Think It Over”

The “Baby Think It Over” (BTIO) program is based on the Health Belief Model and was implemented starting in 1994 in schools across the United States (8, 37). Similar to the idea of a student taking care of an egg for a day as if it were a child, the BTIO program uses a life-like doll that simulates what it would be like to have a baby (9). The doll costs 500 dollars, is 20 inches in height, weighs eight pounds, and comes in varying skin colors; every detail is meant to make it seem like a real baby (8, 9). The doll is programmed to cry at irregular intervals for varying lengths of time. Students tend to BTIO’s baby’s “needs” by inserting and turning a key in BTIO’s baby’s back. There is an electronic monitoring device within the BTIO baby that records how long the student let the BTIO baby cry and if the student physically abused or handled the BTIO baby in a rough manner. The intention behind the BTIO program is that, if a student takes care of a BTIO baby for a few days, they will better understand the demands of parenthood and decide to delay sex and pregnancy (8-10, 37, 38).

Numerous studies have been conducted on the effectiveness of the BTIO program. While results vary slightly, the overall conclusion is that BTIO has little to no impact when it comes to altering an adolescent’s thinking in regards to sex and pregnancy (8-10). Interestingly, parents and teachers report that they feel the BTIO program is an effective intervention; student self reports, however, say differently (10).

Argument 1: The Developmental Perspective

The BTIO program assumes that adolescents are rational thinkers. The program is based on the assumption that adolescents, when in an emotionally charged state of mind, can think back to what it was like to “take care” of a pretend-baby and make the decision to not have sex. The model also assumes that, when faced with the choice to make a safe decision or take a risk, the adolescent will choose the safe decision. Unfortunately, literature on adolescent development states clearly that adolescents are not at a point developmentally or even biologically to make rational decisions in highly charged emotional environments and they are, by nature, risk takers (39-41).

It was once thought that brain development concluded during early adolescence. The advancement of technology has now allowed scientists to perform neuroimaging on adolescents. The results show that brain development does not conclude until around age twenty-four (39).

Research supports that the peak of total cerebral volume is reached at around ten and half years in girls and around fourteen and half years in boys. The cerebellum, which has a role in higher level cognitive functioning such as decision making, does not reach its peak until two years after the cerebrum (39). These findings suggest that higher cognitive functions are not fully developed in the teen years, but instead continue into young adulthood (39, 40). Additionally, the corpus callosum plays a role in the unification of sensory fields, memory storage, retrieval, attention and arousal. The basal ganglia have been shown to play a role in higher cognitive functions, attention and affective states. Similar to the cerebellum, the corpus callosum and basal ganglia continue to develop throughout adolescence and into young adulthood (39, 40).

It is important to understand brain development in adolescence because many of the areas that develop through young adulthood are fundamental to regulation of behavior, emotion, and evaluation of risk and reward (39, 40). Cognition appears to not only be affected by biological underpinnings but also by social and emotional circumstances (40, 41). Studies have shown that when in a laboratory setting, adolescents may have the same logical functioning as an adult. When presented with a particular problem in a laboratory setting, an adolescent can logically think through a problem and come to a decision in a similar manner as an adult. However, when they are presented with a real life situation, their desires, motives, and interests may illicit a different response than would be seen in a hypothetical situation (40).

It should also be understood that pubertal maturation brings on changes in arousal and motivation prior to an adolescent’s ability to regulate them. There is evidence that suggests that pubertal maturation is directly linked with the romantic interest, sexual motivation, sensation seeking, risk-taking and reckless behavior in adolescence (40, 41). Emotions affect decisions and pubertal maturation affects emotion. Therefore, is likely that there may be a link between pubertal maturation and decision making. While adolescents may understand the risks involved in a situation based on developmental maturity, they are not yet adept to weigh the risks and consequences when their emotions and social influences are involved (40).

The BTIO program is based on the assumption that an adolescent will learn in a few days, from a doll, the work that comes with being a parent (9, 10, 37, 38). The hope is that when an adolescent is later faced with a choice to engage in sexual intercourse that they remember the work involved in parenthood and make the decision to remain abstinent (8, 9, 37). Research on adolescent development makes it clear that such efforts will not be successful. Adolescents are still developing cognitively and emotionally. Developmentally they do not have the required tools to think back on a onetime, two-day program and recall what they learned when they are in a emotionally-charged situation. In addition, adolescents going through pubertal maturation are more likely to be sexually motivated and risk takers (40, 41). The BTIO program fails to take this into account and does not give them information on ways to protect themselves if they choose to participate in sexual activity.

Argument 2: The Health Belief Model

The BTIO program is based on the Health Belief Model (HBM). The HBM is rooted in the idea that health behavior is motivated by perceived susceptibility, severity, benefits of an action, barriers to taking that action, cue to action and self-efficacy (42, 43). The model fails to take into account the social and environmental factors. Additionally, the HBM assumes that individuals are rational decision makers. Finally, the HBM fails to take into account that intentions do not always equal behavior (42).

The BTIO program is based on the assumption that adolescents who go through the program will have a greater awareness of their personal susceptibility to an unplanned pregnancy (37). According to the Theory of Optimistic Bias, adolescents may overestimate someone else’s risk for a teen pregnancy but underestimate their own (44). Therefore, students who complete the program may have a greater understanding of the risks for a teen pregnancy, but it is likely they will still believe it could never happen to them. As discussed above, even if a teenager can understand the risks of a teen pregnancy when in a rational state of mind, when faced with sexual intercourse they may lack the ability to rationally think through the risks (40).

The BTIO program is flawed for two reasons. First, turning a key in a baby’s back when it cries is not a realistic response to meeting a baby’s needs (8-10, 37, 38). Adolescents are unlikely to make a strong association between this and the implications of pregnancy and parenthood. Second, even if an adolescent was able to grasp the magnitude of the potential pregnancy from the BTIO program, it does not mean they will be able to make the decision to not have sex when faced with a highly emotional situation (40, 41).

The BTIO program presumes that if an adolescent cares for a simulated baby for a few days and realizes the work involved that they will then be able to appreciate the perceived benefits of not having a baby. It also assumes that students will come to the decision that deciding to not have sex outweighs the potential risk of pregnancy (8, 9). The program fails to provide students with benefits associated with abstinence and protected sex. Depending on the adolescent’s community, they may not even think of college, a successful career, etc as a viable option for their future. In this instance, they may conclude that pregnancy is their best option. They may thrive on the attention they get from others when they carry around the BTIO baby and begin to perceive having a baby as a benefit, or at the very least decide the cost of not having sex does not outweigh the risk of becoming pregnant.

Finally, the BTIO program makes the assumption that having a simulated baby for a few days will act as a cue to action to adolescents. It also assumes that adolescents will have the belief in themselves that they have the ability to remain abstinent (8-10, 37, 38). However, the program fails to give adolescents the tools they need to take action and does nothing to promote their self-efficacy. It is unlikely that carrying around a doll will encourage self-efficacy and cue to action. Rather, it might be more effective to promote students’ power to engage in discussions with their significant other about if and when to engage in sexual activities, and discussions around protection.

Argument 3: Modeling the Media

The BTIO program fails to take into account the environment in which an adolescent is embedded and how that environment can affect them (8-10, 37, 38). Today’s adolescents are constantly surrounded by the media. Music, television, internet, and movies all inundate teens with sexually explicit images (45). The Social Learning Theory would suggest that teenagers are likely to model the behaviors they see (46). Therefore, it is important that a program implemented to reduce teen pregnancy accounts for the media in an adolescent’s environment.

A recent study conducted by the Kaiser Family Foundation found that youth spend an average of 7 hours and 38 minutes using entertainment media on a typical day. A similar study conducted prior to the Kaiser study found that out of the top twenty television shows watched by teens, an average of eight out of ten episodes include some sexual content (47). Only 15 percent of episodes that contained sexually explicit content illustrated any consequences of sex. They also did not discuss using contraceptives or show the concept of waiting to have sex (47). Finally, one analysis of television found that teens may watch up to 143 incidents of sexual behavior on prime time shows each week (48).

Parents seldom speak with their children about sex (47). Thus, when adolescents become curious about sexual relationships, they often turn to the media. Media is easy for adolescents to access and depicts sex as exciting and free from risk (47). Some researchers even posit that the media may act as a sexual “super peer” because it is right at an adolescent’s fingertips and the messages are delivered by attractive and well-known actors/actresses playing teenage roles (49).

Studies conducted on the effects of sex in the media on adolescents have supported that consumption of highly sexual imagery increases sexual activity and intentions to have sex in teens (47, 50). Research suggests that adolescents who view greater amounts of media containing sexual images are more likely to engage in sexual activity than those adolescents who view lesser amounts of sexually explicit media (47). Some suggest that media may not only act upon teens’ initial perceptions of sex, but may continually reinforce them (51). Researchers posit that a plethora of risk-free sexual activity in the media may act to diminish any effects of school based sexual education programs (50).

The amount of a time an adolescent “parents” a BTIO baby normally ranges from 2 to 5 days (8, 9). In comparison, adolescents are exposed to the media daily (45). It is likely that any possible effects that the BTIO program had during the 2 to 5 day period will be greatly diminished by the sexual explicit material that adolescents view in the media (45). To have an effect on reducing sexually risky behaviors and preventing teen pregnancy, the BTIO program would need to account for the influence of the media. This could be done by extending the length of the program greatly so that teens are reminded daily of the consequences of a teen pregnancy. Another method would be to encourage parents to talk often with their children about how realistic the portrayals of sex in the media really are.

Intervention

My proposed intervention is to have a school based national curriculum for 12 through 18 year olds throughout the country. The proposed curriculum would be developmentally appropriate and would contain contraceptive education, identification of risks and consequences of teen pregnancy, identification of alternatives to sex and teen pregnancy, and education regarding sexually explicit images in the media. Curriculum would be taught by teachers once a week during health or science class year round. Parents would be encouraged to be active participants and to discuss sexual health information with their child at home.

Evidence supports that in 2009, six percent of students reported having sex before age 13 (52). To be effective, a program should begin at least by age 12. This may sound young to some communities, but because kids are beginning to have sex as early as age 13; there is a need to implement programs before they put themselves at risk (52).

The proposed program will include both education on contraceptives and role playing between students to learn how to communicate effectively about sexual activities and contraceptives. The education will be taught by teachers during health or science class. Teachers will teach about the risks of each form of contraceptive and how effective each type is. They will educate students on the proper methods for using various types of contraceptives. The message promoted will be, “Abstaining from sex is the safest method to prevent pregnancy and STIs, but if you choose to have sex these are ways you can protect yourself.” In addition, students will be asked to role play so that they can learn how to effectively communicate about contraceptives and sexual expectations with their peers. For example, students will be given a pretend situation where they are getting ready to engage in sexual intercourse. They will be asked to practice how they would communicate their wants and needs around contraceptives. It is believed that by practicing, when faced with the actual situation, adolescents will be more prepared to discuss the use of protection or their desire to wait to engage in sexual activities with their sexual partner.

To increase students’ awareness of the risks and consequences of teen pregnancy the proposed program would include a component in which teen parents came into the classroom and talked with students. The teen parents would tell students about what their own risk perception of becoming pregnant was and how they felt when they discovered they were pregnant. They would describe to students what it is like to be a teen parent including both the joys of being a parent and the great deal of work associated with it.

To show students the alternatives to sex and pregnancy the proposed program would also have college students come and talk to teens; there would also be field trips to different colleges. This piece of the program would allow students to get excited about their potential future and the prospect of going to school and living on their own. For some students, a typical four-year college may not be an option. This program would not want to make them believe that, since they cannot go to a typical college, they have no future. Therefore, information would also be presented on alternatives such as technical and vocational schools. Students would also have the chance to visit these schools so they could experience the different opportunities available to them.

To mitigate the effects of the media, the proposed program would offer educational classes for parents. In these classes parents would be taught the effects that the media can have on their children. Rather than encourage parents to ban their children from watching prime time television shows, the program would encourage parents to watch the shows with their children. Teachers would suggest that at commercial breaks, parents talk with their children about the scenes they just watched. The intervention would encourage parents to discuss with their children how realistic the sexual relationships on the show or movie were, give their child information on healthy sexual relationships, and communicate to their child their expectations about their child participating in sexual activities.

The proposed program would also include a component in which students would be asked to analyze a show they watched for sexual imagery on a bi-weekly basis. They would bring in their thoughts about what was portrayed to class and there would be a classroom discussion. Students could discuss what was realistic or unrealistic about the portrayal. If the portrayal was unrealistic, teachers would ask students to think about what would make the scene more realistic.

Intervention Argument 1: Contraceptive Education

The BTIO program makes the assumption that teens are not going to have sex and based on that assumption chooses to not educate students about contraceptives (8, 9). Adolescents are entering puberty which changes adolescents’ levels of arousal before they have the ability to regulate them cognitively (40, 41). One researcher has suggested that the discord between emotional experience and the ability to regulate arousal and motivation results in a situation in which an adolescent is “starting an engine without yet having a skilled driver behind the wheel” (40). Research has supported that this can lead to teenagers acting irrationally and partaking in high risk behaviors (41).

The BTIO program made the assumption that after completion of the program students would make the decision to refrain from sexual intercourse. However, even if students expressed the desire to abstain from sex at the end of the program, research has supported that decisions made in a cold state of mind may be very different from those in a heated circumstances (53). When faced with a highly emotional situation, such as the prospect of sex, teens are unlikely to think through all of the negative consequences as they may do in a classroom setting (40). They are apt in these instances to think with their feelings rather than their head (53). It is a likely possibility that teens will in engage in sexual activities. The lack of contraceptive education puts students that choose to have sex at risk. Without the knowledge of what methods of contraceptives are available, how effective they are and how to use them students engaging in sexual activities could potentially place themselves at a higher risk for pregnancy or STIs.

Intervention Argument 2: Realization of Risks, Consequences and Rewards

BTIO is based on the HBM, which makes the assumption that by “parenting” a doll students will realize their risk for becoming a teen parent (42). For an individual of any age this is somewhat of a stretch. A doll in which you turn a key in its back to make it stop crying is not a very realistic situation. Furthermore, even if the doll was able to increase students understanding of the risks involved with sexual intercourse there is still the issue of optimistic bias. Students are likely to think that other teens are at a high risk of teen pregnancy if they engage in sexual intercourse, but that they themselves are at lower risk (44). Bringing teen parents into the classroom to tell their stories will make the situation more real for teens and demonstrate to them that when they engage in sexual intercourse that they too could become pregnant.

Using the HBM, BTIO also assumes that the doll will allow youth to understand and remember the consequences of being a teen parent (42). First, this is debatable due to the unrealistic situation. Next, even if it does make students aware of the consequences of having a teen pregnancy it only lasts for a short duration. Adolescents are bombarded everyday with sexually explicit messages from the media. BTIO only lasts 2 to 5 days (8-10, 37, 45). The proposed program will last year-round for students ages 12 to 18 which will ensure that students are bombarded with healthy sexual information in order to mitigate the effects of inaccurate information in the media.

The BTIO program assumes that, through the program, students will comprehend why it is worth it to say no to sex in order to not get pregnant. However, the program gives students a doll that they are likely to get a lot of attention for, and then fails to show them alternatives to having sex and becoming pregnant. The proposed intervention would not have simulation dolls. It is felt that in some rare instances students may relish the attention that they get from having the doll, which in turn may make them more likely to have sex and possibly become pregnant. In addition, the proposed program will emphasize college and vocational schools to demonstrate to students the exciting future that lies ahead of them. It is thought that if students are excited about a future that does not involve a teen pregnancy that they may refrain from sex or at least take the proper precautions when engaging in sexual intercourse.

Intervention Argument 3: The Media

Finally, the BTIO program does not take into account the sexually explicit images adolescents are exposed to in the media every day. Research supports that youth often look to the media for information on sexual relationships (47, 49). More often than not individuals are seen on television and movies engaging in risky sex behaviors with no foreseen consequences (49). Students may see these images in the media and believe that “everyone is having unprotected sex with no consequences.” According to the Social Learning Theory students may mimic the behavior they see on television which could potentially put them at risk for a teen pregnancy (46). The proposed program would not advocate for students to stop watching such programs, but instead would make efforts to help students understand that the images displayed in the media are not realistic sexual relationships. Such efforts should help students to realize that in reality “everyone” is not engaging in unsafe sexual relationships. It is thought that if students realize that the social norm is not to participate in unsafe sexual behaviors, that they will be more likely to abstain from, or practice safe, sexual behaviors.

Conclusion

Teen pregnancy is a continuing problem in the United States. Programs such as BTIO focus only on the outcome of teen pregnancy and fail to consider the entire context which puts an adolescent at risk for becoming pregnant. The BTIO intervention is flawed in many ways. The program fails to take into account how adolescents think developmentally and how the development of their brain, emotions, and puberty affect their decision-making capabilities. Additionally, BTIO uses the Health Belief Model (37). This model is based on many assumptions of how adolescents will act (42). Given an individual’s irrationalities and where adolescents are developmentally, these assumptions are often incorrect. Finally, BTIO fails to account for the effects of the media on adolescents and their actions. In order to make an effective program to reduce teen pregnancy, all of the above named factors must be considered. It is felt that implementing the proposed program which addresses the named downfalls in BTIO could greatly reduce teen pregnancies and their associated negative outcomes.

REFERENCES

1. Geronimus A. Damned if you do: Culture, Identity, Privilege, and Teenage Childbearing in the United States. Social Science and Medicine 2003;57:881-893.

2. Reichman N, Pagnini D. Maternal Age and Birth Outcomes: Data from New Jersey. Family Planning Perspectives 1997;29(6):268-272.

3. Makinson C. The Health Consequences of Teenage Fertility. Family Planning Perspectives 1985;17(3):132-139.

4. Gueorguieva R, Carter R, Ariet M, Roth J, Mahan C, Resnick M. Effect of Teenage Pregnancy on Educational Disabilities in Kindergarten. American Journal of Epidemiology 2001;154(3):212-220.

5. Rothenberg P, Varga P. The Relationship between Age of Mother and Child Health and Development. American Journal of Public Health 1981;71:810-817.

6. Geronimus A. The Weathering Hypothesis and the Health of African-American Women and Infants: Evidence and Speculations. Ethnicity and Disease 1992;2(3):207-221.

7. Lawlor D, Shaw M. Too much too young? Teenage Pregnancy is not a Public Health Problem. International Journal of Epidemiology 2002;31:552-554.

8. Somers C, Fahlman M. Effectiveness of the "Baby Think It Over" teen pregnancy prevention program. Journal of School Health 2001;71(5):188-195.

9. Barnett J. Evaluating "Baby Think It Over" infant simulators: A comparison group study. Adolescence 2006;41(161):103-110.

10. Tingle L. Evaluation of the North Carolina "Baby Think It Over" project. Journal of School Health 2002;72(5):178-183.

11. Pogarsky G, Thornberry T, Lizotte A. Developmental Outcomes for Children of Young Mothers. Journal of Marriage and Family 2006;68:332-344.

12. Grady M, Bloom K. Pregnancy Outcomes of Adolescensts Enrolled in a CenteringPregnancy Program. Journal of Midwifery and Women's Health 2004;49(5):412-420.

13. Omar H, Fowler A, McClanahan K. Significant Reduction of Repeat Teen Pregnancy in a Comprehensive Young Parent Program. Journal of Pediatric and Adolescent Gynecology 2008;21:283-287.

14. Terry-Humen E, Manlove J, Moore K. Playing Catch-Up: How Children Born to Teen Mothers Fare: The National Campaign to Prevent Teen Pregnancy; 2005.

15. Hoffman S, Maynard, RA. Kids having kids: Economic costs and social consequences of teen pregnancy. Washington DC: Urban Institute Press, 2008.

16. Furstenberg, F. F., Brooks-Gunn, J., & Morgan, S.P. Adolescent mothers in later life. Cambridge, UK: Cambridge University Press, 1987.

17. Conger R, Conger K, Elder GJ, Lorenz F, Simons R, Whitbeck L. A Family Process Model of Economic Hardship and Adjustment of Early Adolescent Boys. Child Development 1992;63:526-541.

18. Stier D, Leventhal J, Berg A, Johnson L, Mezger J. Are Children Born to Young Mothers at Increased Risk of Maltreatment? Pediatrics 1993;91(3):642-648.

19. Lee B, Goerge R. Poverty, Early Childbearing, and Child Maltreatment: A Multinomial Analysis. Children and Youth Services Review 1999;21(9-10):755-780.

20. Fraser A, Brockert J, Ward R. Association of Young Maternal Age with Adverse Reproductive Outcomes. New England Journal of Medicine 1995;27(332):1113-1117.

21. Jolly M, Sebire N, Harris J, Robinson S, Regan L. Obstetric Risks of Pregnancy in Women Less than 18 Years Old. Obstetrics & Gynecology 2000;96:962-966.

22. Gortzak-Uzan L, Hallak M, Press F, Katz M, Shoham-Vardi I. Teenage Pregnancy: Risk Factors for Adverse Perinatal Outcome. The Journal of Maternal-Fetal Medicine 2001;10:393-397.

23. Vintzileos A, Ananth C, Smulian J, Scorza W, Knuppel R. The Impact of Prenatal Care on Postneonatal Deaths in the Presence and Absence of Antenatal High-Risk Conditions. American Journal of Obstetrics and Gynecology 2002;187(5).

24. Vintzileos A, Ananth C, Smulian J, Scorza W, Knuppel R. Prenatal Care and Black- White Fetal Death Disparity in the United States: Heterogenetiy by High-Risk Conditions. The American College of Obstetricians and Gynecologists 2002;99(3):483-489.

25. Kogan M, Alexander G, Kotelchuck M, Nagey D. Relation of the Content of Prenatal Care to the Risk of Low Birth Weight: Maternal Reports of Health Behavior Advice and Initial Prenatal Care Procedures. JAMA 1994;271(17):1340-1345.

26. Corcoran J, Pillai V. Effectiveness of Secondary Pregnancy Prevention Programs: A Meta-Analysis. Research on Social Work Practice 2007;17(1):5-18.

27. Roth J, Hendrickson J, Schilling M, Stowell D. The Risk of Teen Mothers Having Low Birth Weight Babies: Implications of Recent Medical Research for School Health Personnel. Jounal of School Health 1998;68(7).

28. Kewon L, Woodward L, Field J. Language Development of Pre-School Children Born to Teenage Mothers. Infant and Child Development 2001;10:129-145.

29. Sommer K, Whitman T, Borkowski J, Gondoli D, Burke J, Maxwell S, et al. Prenatal Maternal Predictors of Cognitive and Emotional Delays in Children of Adolescent Mothers. Adolescence 2000;35(137):87-112.

30. Hayes C. Risking the future: Adolescent sexuality, pregnancy, and childbearing. Washington, DC: National Academy Press, 1987.

31. Maynard R. Kids having kids. Washington DC: Urban Institue Press, 1997.

32. Coley R, Chase-Lansdale P. Adolescent pregnancy and parenthood: Recent evidence and future directions. American Psychologist 1998;53:152-166.

33. Nagin D. Adolescent Mothers and the Criminal Behavior of Their Children. Law and Society Review 1997;31(1):137-162.

34. Eshbaugh E, Luze G. Adolescent and Adult Low-Income Mothers: How Do Needs and Resources Differ? Journal of Community Psychology 2007;35(8):1037-1052.

35. Fergusson D, Woodward L. Maternal Age and Psychosocial Outcomes in Early Adulthood. Journal of Child Psychology and Psychiatry 1999;40(3):479-489.

36. Geronimus A, Korenman S. Maternal Youth or Family Background? On the Health Disadvantages of Infants with Teenage Mothers American Journal of Epidemiology 1993;137:213-225.

37. Out J, Lafreniere K. Baby Think It Over: Using Role-Play to Prevent Teen Pregnancy. Adolescence 2001;36(143):571-582.

38. Barnett J, Hurst C. Do Adolescents Take "Baby Think It Over" Seriously? Adolescence 2004;39(153):65-75.

39. Giedd J. The Teen Brain: Insights From Neuroimaging. Journal of Adolescent Health 2008;42(4):335-343.

40. Steinberg L. Cognitive and Affective Development in Adolescence. Trends in Cognitive Science 2005;9(2):69-74.

41. Steinberg L. Risk Taking in Adolescence New Perspectives from Brain and Behavioral Science. Current Directions in Psychological Science 2007;16(2):55-59.

42. Edberg M. Individual Health Behavior Theories (p. 35-49). In: Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

43. Rosenstock I. Historical Origins of the Health Belief Model. Health Education Monographs 1974;2:328-335.

44. Weinstein N. Unrealistic Optimism about Susceptibility to Health Problems: Conclusions from a Community-Wide Sample. Journal of Behavioral Medicine 1987;10:481-500.

45. Ladin L'Engle K, Brown J, Kenneavy K. The Mass Media are an Important Context for Adolescents' Sexual Behavior. Journal of Adolescent Health 2006;38:186-192.

46. Bandura A. Social Learning Theory. New York, NY: General Learning Press, 1977.

47. Brown J, L'Engle Ladin K, Pardun C, Guo G, Kenneavy K, Jackson C. Sexy Media Matter: Exposure to Sexual Content in Music, Movies, Television, and Magazines Predicts Black and White Adolescents' Sexual Behavior. Pediatrics 2006;117:1018-1027.

48. Gruber E, Grube J. Adolescent Sexuality and the Media: A Review of Current Knowledge and Implications. The Western Journal of Medicine 2000;172:210-214.

49. Brown J, Tucker Halpern C, Ladin L'Engle K. Mass Media as a Sexual Super Peer for Early Maturing Girls. Journal of Adolescent Health 2005;36:420-427.

50. L'Engle K, Brown J, Kenneavy K. The Mass Media are an Important Context for Adolescents' Sexual Behavior. Journal of Adolescent Health 2006;38:186-192.

51. Klein J, Brown J, Dykers C, Walsh Childers K, Oliveri J, Porter C. Adolescents' Risky Behavior and Mass Media Use. Pediatrics 1993;92:24-31.

52. Centers for Disease Control and Prevention. 2009 Youth Risk Behavior Survey. Available at: www.cdc.gov/yrbss.

53. Ariely D. The influence of arousal: Why hot is much hotter than we realize (pp. 89-108). In: Predictably irrational: The hidden forces that shape our decisions. New York, NY: HarperCollins Publishers, 2008.