Following in the footsteps of Edward Zigler, who had such a dramatic impact on US family and child policy, there has been a substantial increase in researchers and practitioners who are applying a human developmental science focus across non-WEIRD (Western, Educated, Industrialized, Rich, and Democratic; Henrich, Heine, & Norenzayan, Reference Henrich, Heine and Norenzayan2010) contexts, especially low- and middle-income countries (LMIC) and conflict-affected contexts. Developmental frameworks have been applied to the question of how global financial crises affect child and youth development (Lundberg & Wuermli, Reference Lundberg and Wuermli2012), to address early childhood development globally (Britto, Engle, & Super, Reference Britto, Engle and Super2013; Britto et al., Reference Britto, Lye, Proulx, Yousafzai, Matthews, Vaivada and Fernald2017a), to inform indicator frameworks (such as the Organisation for Economic Co-operation and Development (OECD)'s Program for International Student Assessment (PISA), PISA for Development Global Competence Framework, and the United Nations Sustainable Development Goals), and to advance the field of human developmental intervention research in LMIC (Wuermli, Tubbs, Petersen, & Aber, Reference Wuermli, Tubbs, Petersen and Aber2015).
Developmental frameworks, including bioecological, developmental niche, bioecocultural, and resilience frameworks (Bronfenbrenner & Morris, Reference Bronfenbrenner, Morris, Damon and Lerner2006; Garmezy & Masten, Reference Garmezy and Masten1986; Super & Harkness, Reference Super and Harkness1986; Weisner, Reference Weisner2002; Whiting, Reference Whiting1980; Worthman, Reference Worthman2010), facilitate efforts to trace how conditions of war and displacement interact with the mechanisms and processes underlying development at various levels of the human ecosystem. Although the pervasive adverse impacts of conflict exposure cannot be denied, coexisting resilience and promotive and protective factors offer potential levers for effective intervention (Cicchetti, Reference Cicchetti2010; Luthar & Zigler, Reference Luthar and Zigler1991; Masten & Wright, Reference Masten, Wright, Masten and Wright2010; Rutter, Reference Rutter2013). For example, a systematic review of studies investigating the effects of war and armed conflict on young children's development found that the family environment and parental mental health and functioning moderated the effects of exposure to conflict and child outcomes (Slone & Mann, Reference Slone and Mann2016). A number of studies have identified a range of social ecological factors that shape the meaning given to exposure to war events and mental health, including education, the social class of the community, individual coping mechanisms and meaning making, attachment relationships and caregiver health, family and social resources and support, and cultural and community norms and attitudes (Betancourt & Khan, Reference Betancourt and Khan2008; Kohrt et al., Reference Kohrt, Jordans, Tol, Perera, Karki, Koirala and Upadhaya2010). Global trends emphasize the importance of further investigating the mechanisms and processes underlying the effects of war and displacement on the development of children and youths and the potential intergenerational transmission of trauma and adversity.
Adolescent mothers may be at particularly high risk in contexts of war and displacement (Dillon & Cherry, Reference Dillon and Cherry2014; Urindwanayo & Richter, Reference Urindwanayo and Richter2020). Globally, approximately 12 million girls aged 15–19 years, and 777,000 girls younger than 15 give birth every year (WHO, 2020). In populations affected by conflict and displacement, adolescent girls have an increased likelihood of becoming mothers due to loss of family members, poverty, lack of security or alternative opportunity, gender-based violence, and poor access to health, including sexual and reproductive health (SRH), and education resources (UNFPA, 2018). As this paper will demonstrate, the strong evidence for developmental sensitivity during early childhood and adolescence provides reason to suspect that adolescent motherhood in contexts of war and displacement may be of particular concern as it can place a family at double jeopardy intergenerationally.
In this paper we present a developmental, intergenerational research framework to understand and support the development of adolescent mothers and their children affected by war and displacement. Our framework is informed by and integrates several disparate literatures: (a) the development of stress physiology in the developmentally sensitive windows of early life (prenatal and infancy) and adolescence; (b) the experiences of early parenthood and being an adolescent mother in international contexts of war and displacement; and (c) developmental cultural neurobiology. Based on these findings, we also investigate contextually meaningful sources of resilience that may serve as targets for intervention. In the tradition of Edward Zigler's groundbreaking life and career, we aim to integrate basic developmental science with applied intervention and policy.
We argue that, due to typical neuroendocrine developmental patterns, adolescent mothers are likely to show a more pronounced stress response in reaction to stressors than adult women. Furthermore, as an important period for the development of social-relational skills, war and displacement may disrupt important sources for social support, with significant effects on coping and parenting. Therefore, conflict and displacement may exert particularly disruptive effects on this group's development. In addition to interruptions to schooling and normal life activities, the stress of conflict and displacement influences the development of brain regions associated with cognitive and emotional regulatory functioning, learning, and mental health. Such neurological mechanisms can lead to poorer physical and mental health and functioning among adolescent mothers, with implications for parenting of the next generation. Through neuroendocrine channels, maternal stress affects the development of the fetus in ways that may have lasting effects on the child's physical and mental health and development. Moreover, early care shapes the development of the infant's stress physiology and is associated with health and wellbeing in later life. Although we know that the specifics of early neurobiological development render adolescents more sensitive to stress, we do not yet know the specifics of how adolescents’ stress physiology affects their offspring prenatally or their effectiveness as parents.
Effective interventions will need to target sources of strength, resilience, and protection for both generations, and to provide the specific supports adolescents need given their particular stage of development, while also supporting them in their role as caregivers. They will also require an understanding of neurobiological and stress physiological functioning to be expected from adolescents living in chronically and severely stressful contexts. Furthermore, an in-depth understanding of the sociocultural context will be required to better understand how such circumstances affect adolescents’ biopsychosocial functioning, and how interventions should be designed to appropriately support them, in particular in their role as mothers. How people make meaning of their lived experiences will shape both the development of their neurobiology and stress physiology, as well as how their bodies respond to these experiences. Drawing from the burgeoning field of cultural developmental neuroscience, we begin to unpack the interdependencies and interpenetration of culture and biology in ontogeny.
We commence by providing an introduction to stress physiology and its development, and illustrate how experiencing severely stressful events during the developmentally sensitive period of adolescence could have detrimental effects for the adolescent and – in the case of adolescent pregnancy and motherhood – for their offspring. We then discuss potential targets for intervention by reviewing the literature on factors contributing to resilience during adolescence, specifically for adolescent mothers experiencing war and displacement, and reflect on the interdependence and interpenetration of culture and biology. We conclude with an overview of the evidence on programs for adolescent mothers, emphasizing the importance of integrating intervention approaches to support the development of adolescent mothers as well as their children in a fully dual-generation approach with particular consideration given to the sociocultural environment.
War, displacement, stress physiology, and adolescent development
Refugees and other forcibly displaced populations constitute one of the largest current global crises. In 2019, there were an estimated 71 million forcibly displaced people globally, of whom 41 million were internally displaced, 26 million were refugees and 3.5 million were asylum seekers (UNHCR, 2019). Over half of refugees were under 18 years old – a much higher proportion than the one in seven overall migrants who are under 18 (UNHCR, 2019). Displacement ensuing from war and other disasters (including public health disasters such as the current Covid-19 pandemic) can negatively impact child and youth development and learning through manifold mechanisms. Direct exposure to trauma and stressful experiences, loss of caregivers or family members, the reduced capacity of adults to provide a stable and nurturing environment, the lack of quality educational and learning opportunities, poverty, and uncertainty about the future can each independently and in interaction undermine children's healthy development and learning (Murphy, Rodrigues, Costigan, & Annan, Reference Murphy, Rodrigues, Costigan and Annan2017; Waddoups, Yoshikawa, & Strouf, Reference Waddoups, Yoshikawa and Strouf2019; Yoshikawa, Wuermli, & Aber, Reference Yoshikawa, Wuermli, Aber and Suárez-Orozco2018; Yoshikawa et al., Reference Yoshikawa, Wuermli, Britto, Dreyer, Leckman, Lye and Stein2020).
While it is well established that early childhood development creates the foundation for lifelong health and development, adolescence is now widely recognized as a second sensitive period in brain development, involving dramatic changes in neuroendocrine functioning (Blakemore & Mills, Reference Blakemore and Mills2014; Crone & Dahl, Reference Crone and Dahl2012; Dahl & Gunnar, Reference Dahl and Gunnar2009). Adolescent pregnancy and motherhood often lead to disruptions in education and major shifts in social roles and expectations, with potentially dramatic implications for development. Furthermore, the World Health Organization reports higher perinatal complications and maternal mortality, and a 50% greater risk of stillbirths and infant deaths within the first weeks of life among adolescents and their infants, as compared with adult mothers and their children (WHO, 2014). Some of these increased risks to adolescent mothers and their infants can be attributed to confounding factors related to poverty and disadvantage, such as poorer prenatal care or more births outside of adequately equipped health clinics (Elster, Reference Elster1984). However, studies that control for these factors still find significantly increased risks of adverse pregnancy and birth-related outcomes among adolescent mothers (Conde-Agudelo, Belizan, & Lammers, Reference Conde-Agudelo, Belizan and Lammers2005; Fraser, Brockert, & Ward, Reference Fraser, Brockert and Ward1995). For instance, a study of primiparous mothers found that adolescent mothers tended to have less social support around child care and higher levels of stress, and showed less responsiveness to their infants and punished them more than their adult counterparts (Garcia Coll, Vohr, Hoffman, & Oh, Reference Garcia Coll, Vohr, Hoffman and Oh1986).
A substantial proportion of this increased risk to adolescent mothers and their children may stem from stress, conveyed prenatally through neuroendocrine mechanisms and postnatally prominently through the mother's capacity to provide nurturing care. Specific typical developmental changes in the adolescent brain make adolescents more susceptible to stressful experiences. Traumatic life events like war and the enduring adversity that refugees and the displaced are likely to experience have severe implications for adolescents’ development, and as such are likely to affect their offspring both prenatally and postnatally. Given the prevalence of, and risks associated with, adolescent motherhood in many parts of the world (particularly in contexts of conflict and displacement) and the extensive developmental plasticity of both adolescents and infants, greater understanding of the underlying mechanisms driving the development and adjustment of the two generations needs to be prioritized.
Stress physiology
Here we briefly review stress physiology, its changes during adolescent development, and the effects of exposure to chronic stressors on stress physiology. Stress physiology refers to the concerted interplay of multiple systems responding to and recovering from a threat or challenge. The stress response involves central nervous system (CNS) coordination of, and intricate molecular signaling pathways between, the sympathetic (epinephrine/neurepinephrine) and parasympathetic branches of the autonomic nervous system (ANS), the hypothalamic–pituitary–adrenal (HPA) axis system (e.g., cortisol), the immune system, and the metabolic system (Lupien, McEwen, Gunnar, & Heim, Reference Lupien, McEwen, Gunnar and Heim2009). A central aspect of mounting a response to an acute stressor, challenge, or threat involves an acceleration of energy metabolism in order to support the physiological ability to run from or fight the imminent threat. Metabolic processes shift toward pathways that increase levels of glucose and oxygen, the circulatory system directs these resources toward large muscles and the brain (supporting heightened attention to the source of danger and preparedness for defensive responding), and physiological processes not essential for action (such as digestion and the immune system) are suppressed.
Given the potency of its responses, this intricate network of systems maintains feedback loops that immediately signal a reversal of processes, for instance, to stop the release of glucocorticoids (e.g., cortisol). Binding of glucocorticoids to glucocorticoid and mineralocorticoid receptors in the hippocampus triggers a signaling cascade to down-regulate the stress response. Similarly, pro-inflammatory responses are triggered in order to heal “potential injuries.” Pro-inflammatory signals (e.g., NF-kB, IL-6, CRP) are also almost simultaneously accompanied by anti-inflammatory signals to prevent the immune system from attacking healthy cells in the body. When stressors or challenges are of fairly brief duration (e.g., running away from a lion, taking an exam), these systems are astoundingly effective at enabling a person to achieve high performance: the body flexibly adjusts to meet the immediate demands and effectively recovers thereafter. Disruptions to the regulatory dynamics among systems involved in the stress response, however, can have lifelong consequences for physical and mental health and functioning (McEwen & Wingfield, Reference McEwen, Wingfield and Fink2007).
Contexts of chronic stress
Persistent activation of the stress response can lead to alterations in how the various systems interact, leading to sustained activity levels and thus “imbalances” such as unusually high or low tonic (basal, resting) and phasic (acute responses) activation. Whereas normative, healthy functioning of stress physiology necessitates allostasis, or the ability to respond flexibly to changing conditions, the demand that chronic stressors place on bodily systems and resources can result in allostatic load, or a loss of flexibility evidenced by persistently exaggerated or diminished physiological activity (McEwen, Reference McEwen2017; McEwen & Wingfield, Reference McEwen and Wingfield2003). For example, the HPA axis may produce high (hyperactive) or low (hypoactive) basal levels of cortisol, flat diurnal patterns that fail to show the typical decrease over the day, and/or hypo- or hyper-responsiveness to acute challenges, which may then contribute to chronic and/or systemic inflammation (McEwen & Wingfield, Reference McEwen and Wingfield2003; Miller et al., Reference Miller, Chen, Fok, Walker, Lim, Nicholls and Kobor2009). Such disruptions to normative profiles of multi-system stress physiology have been linked to problematic cognitive and behavioral functioning (Lupien, Maheu, Tu, Fiocco, & Schramek, Reference Lupien, Maheu, Tu, Fiocco and Schramek2007; Lupien et al., Reference Luthar2009; Nederhof, Marceau, Shirtcliff, Hastings, & Oldehinkel, Reference Nederhof, Marceau, Shirtcliff, Hastings and Oldehinkel2015) and physical and mental health outcomes, including stunted growth, depression, obesity, type II diabetes, and cardiovascular disease (Juster, McEwen, & Lupien, Reference Juster, McEwen and Lupien2010; Juster et al., Reference Juster, Sindi, Marin, Perna, Hashemi, Pruessner and Lupien2011).
Many of these observable effects on cognition, behavior, and mental health may result from the effects of stress physiology on the CNS structure and function involved in threat perception and fear, memory consolidation and retrieval, and cognitive processing and regulation. For example, chronically elevated glucocorticoid levels, such as cortisol, can affect the development and activity of the amygdala (Mitra, Jadhav, McEwen, Vyas, & Chattarji, Reference Mitra, Jadhav, McEwen, Vyas and Chattarji2005), hippocampus (Anacker et al., Reference Anacker, Zunszain, Cattaneo, Carvalho, Garabedian, Thuret and Pariante2011), and the prefrontal cortex (PFC) (Arnsten, Reference Arnsten2009). Cumulatively, therefore, these biomarkers serve as both (a) reflections of the wear and tear on the body and brain of persistent activation of the multi-system stress response and (b) mechanisms by which contexts of chronic adversity undermine health and wellbeing. Studies have demonstrated that exposure to poverty and violence, which characterize the life contexts of individuals and families in regions of conflict and displacement, can trigger chronic physiological stress (Chen & Miller, Reference Chen and Miller2012; Evans & Kim, Reference Evans and Kim2013), with effects on brain function (Weissman, Conger, Robins, Hastings, & Guyer, Reference Weissman, Conger, Robins, Hastings and Guyer2018), neuroendocrine regulation (Ursache, Noble, & Blair, Reference Ursache, Noble and Blair2015), and patterns of DNA methylation (Kertes et al., Reference Kertes, Kamin, Hughes, Rodney, Bhatt and Mulligan2016; Kohrt et al., Reference Kohrt, Worthman, Adhikari, Luitel, Arevalo, Ma and Cole2016; Lam et al., Reference Lam, Emberly, Fraser, Neumann, Chen, Miller and Kobor2012). More positively, studies have also indicated a substantial amount of plasticity in stress physiology systems and potentially even reversibility of some stress-induced changes in the previously mentioned parts of the brain, namely the amygdala, hippocampus, and PFC (McEwen & Magarinos, Reference McEwen and Magarinos2001). For example, intervention studies to improve parental caregiving in families identified as maltreating have shown that children's HPA (Cicchetti, Rogosch, Toth, & Sturge-Apple, Reference Cicchetti, Rogosch, Toth and Sturge-Apple2011) and ANS (Hastings et al., Reference Hastings, Kahle, Fleming, Lohr, Katz and Oxford2019) regulation is improved.
Adolescent stress physiology
Adolescence has been recognized as a second developmental period of rapid neurobiological maturation and reorganization, with heightened plasticity of neural structure and function (Fuhrmann, Knoll, & Blakemore, Reference Fuhrmann, Knoll and Blakemore2015). This period is triggered by the pubertal transition and the rapid increase in circulating adrenal and gonadal hormones that occur as part of adrenarche and gonadarche, typically in late childhood to pre-adolescent years (Andersen & Teicher, Reference Andersen and Teicher2008; Byrne et al., Reference Byrne, Whittle, Vijayakumar, Dennison, Simmons and Allen2017). These circulating hormones influence the maturation of circuits connecting prefrontal and limbic regions, thereby contributing to stress regulation, as well as other hallmarks of adolescence such as social reorientation, risk-taking behavior, reward sensitivity, and emotional reactivity and regulation (Schriber & Guyer, Reference Schriber and Guyer2016).
Compared with younger children and adults, adolescents evince heightened acute stress and emotional reactivity (Dahl & Gunnar, Reference Dahl and Gunnar2009). Specifically, adolescents show a comparatively exaggerated amygdala response to threatening stimuli (Hare et al., Reference Hare, Tottenham, Galvan, Voss, Glover and Casey2008) and stronger HPA axis responses to socially evaluative challenges (Gunnar, Wewerka, Frenn, Long, & Griggs, Reference Gunnar, Wewerka, Frenn, Long and Griggs2009; Stroud et al., Reference Stroud, Foster, Papandonatos, Handwerger, Granger, Kivlighan and Niaura2009). Evidence that this may be potentiated by pubertal maturation stems from findings such as the earlier onset of puberty predicting stronger HPA responses (Natsuaki et al., Reference Natsuaki, Klimes-Dougan, Ge, Shirtcliff, Hastings and Zahn-Waxler2009), gonadal hormones affecting HPA axis activity (Viau, Reference Viau2002), and pubertal maturation and testosterone levels being more strongly predictive of subcortical brain development than chronological age (Wierenga et al., Reference Wierenga, Bos, Schreuders, vd Kamp, Peper, Tamnes and Crone2018).
The adolescent brain undergoes maturational changes beyond the neurobiological changes linked with puberty. Prefrontal myelination, synaptogenesis, and synaptic pruning continue throughout adolescence, as does maturation of the neural circuits affecting executive function and self-regulation, social cognition, and other competencies (Casey, Getz, & Galvan, Reference Casey, Getz and Galvan2008). However, PFC maturation is slower and lasts longer than subcortical, HPA axis, and pubertal maturation, such that – for much of adolescence – prefrontal down-regulatory capacities may be suboptimal for managing youths’ heightened stress physiology. With all of these changes, adolescence is a period of heightened susceptibility to the effects of stress on neurobiological development, with potential for programming effects with lasting consequences, similar to the very early years of development (Malter Cohen, Tottenham, & Casey, Reference Malter Cohen, Tottenham and Casey2013; McCormick, Mathews, Thomas, & Waters, Reference McCormick, Mathews, Thomas and Waters2010).
Adolescent development and stressful life circumstances
Adolescence is a time of major transitions: physical, cognitive, emotional, and social. Puberty is marked by substantial hormonal shifts and processes, resulting in marked changes from child-like physical appearance to adult-like characteristics. With these physiological changes come social expectations of behaviors and responsibilities (Petersen, Reference Petersen1988). Many cultures practice rituals pertaining to the transition to adulthood, though the timing as well as the content and scope of these rituals differ. In many countries, the onset of menarche is associated with a range of restrictions to what a girl can and cannot do. For example, menstruation can interfere with schooling in places where women are housebound during this period, and is a major reason for school drop-out (Sommer, Reference Sommer2010).
In many parts of the world, adolescence has been characterized as a time of identity development, burgeoning interest in romantic relationships, growing importance of peers, and a desire to explore meaning in life. This time of heightened awareness and exposure to new social settings and situations brings both risks and opportunities. Evidence points toward the possibility that adolescence is a sensitive period for social and cultural development, highlighting how changes in structure and organization of the brain may underlie sociocultural development (Blakemore & Mills, Reference Blakemore and Mills2014; Choudhury, Reference Choudhury2009). However, adolescence as a period is, in and of itself, a cultural construct deserving of culturally valid investigations, and may have very different implications in different parts of the world (Worthman & Trang, Reference Worthman and Trang2018). Of course these realities need to be considered when using biopsychosocial frameworks to investigate the particulars of this stage of development (Choudhury, Reference Choudhury2009).
Regardless of culturally rooted changes in roles and expectations, pubertal processes lead to a variety of neurobiological, cognitive, emotional, and social shifts that can present both risks and opportunities (Steinberg, Reference Steinberg2005). Adolescence is a time when many mental health problems first begin to surface or become exacerbated. The source is likely a confluence of genetic factors, early exposure to stress and adversity prenatally and/or postnatally, and current events and circumstances. At the same time, however, these shifts or changes in processing capacity and responsiveness, including heightened sensitivity to rewards, render adolescents inherently more curious, exploratory, and creative in supportive environments. Adolescents often try to seek the meaning of life and explore their identity, position, and function in their communities and beyond (Côté, Reference Côté, Lerner and Steinberg2009; Eisenberg, Morris, McDaniel, & Spinrad, Reference Eisenberg, Morris, McDaniel, Spinrad, Lerner and Steinberg2009).
War, displacement, and transition to motherhood during adolescence
War and displacement, as well as the protracted sequelae often experienced by refugees, represent sources of stress above and beyond those more often studied, such as poverty. There is evidence showing elevated rates of mental health problems among refugee youth compared with nonrefugee peers (Betancourt et al., Reference Betancourt, Borisova, Williams, Meyers-Ohki, Rubin-Smith, Annan and Kohrt2013; Sirin & Rogers-Sirin, Reference Sirin and Rogers-Sirin2015); for example, experiences of conflict and violence during adolescence are associated with increases in anxiety (Kohrt et al., Reference Kohrt, Hruschka, Worthman, Kunz, Baldwin, Upadhaya and Tol2012). However, commonly, other risk factors for mental health problems follow war and displacement, and studies have shown gender differences in both responses to risk factors (e.g., stressful life events) as well as protective factors (e.g., social support). For example, a study in Nepal found higher rates of anxiety in females in response to stressful life events; for males, this association was moderated by social support (Kohrt & Worthman, Reference Kohrt and Worthman2009). Interruptions to and lack of quality educational opportunities can further undermine positive development post-displacement (Burde, Kapit, Wahl, Guven, & Skarpeteig, Reference Burde, Kapit, Wahl, Guven and Skarpeteig2016).
Early pregnancy is likely to trigger additional major events and transitions, depending on the context, including transitioning into adult roles and responsibilities such as primary caregiver, home keeper, and spouse. Adolescent mothers’ still-developing capacity to self-regulate and manage stressful situations could make them more susceptible to the stress of parenting, affecting their ability to provide responsive and sensitive care and stimulation to their child. However, aside from the general stresses that any woman at any age might experience when transitioning to motherhood, adolescent motherhood may not be a particularly stressful life event where early marriage is normative and deeply ingrained in the culture and, as such, desired by all parties involved (Lancaster & Hamburg, Reference Lancaster, Hamburg, Lancaster and Hamburg2008).
To better understand the developmental consequences of early marriage and childbearing across cultures and contexts requires a bioecocultural lens (Worthman, Reference Worthman2010). Globally, it is estimated that 12 million girls under the age of 18 are married every year (UNICEF, 2019). Commonly, marriage traditions are culturally potent and politically sensitive. The question of whether early marriage and motherhood is perceived as unduly stressful needs to be explored within the sociocultural context. In contexts where adolescent motherhood carries stigma, or where laws mandate school leaving and other social shifts when pregnant, girls are likely to experience more stress (social exclusion, bullying). Too often, early marriage and motherhood conflicts with universal education goals and changes opportunities and life-course trajectories.
Studies focusing on adolescent pregnancy in refugee camps have found a general lack of appropriate SRH and family planning services available to adolescent girls, alongside high rates of gender-based violence and poverty-driven transactional sex typical of camp settings (Asnong et al., Reference Asnong, Fellmeth, Plugge, San Wai, Pimanpanarak, Paw and McGready2018; Urindwanayo & Richter, Reference Urindwanayo and Richter2020). Researchers working with Rohingya refugees in Cox's Bazar, Bangladesh, conducted in-depth interviews and focus group discussions with female and male adolescents and young adults, program managers, service providers, and members of the host communities, asking about their perceptions of marriage practices pre- and post-displacement (Melnikas, Ainul, Ehsan, Haque, & Amin, Reference Melnikas, Ainul, Ehsan, Haque and Amin2020). The findings indicated a strong cultural preference for early marriage (before 18 years of age), linked to beliefs about optimal fertility windows and readiness for marriage. These preferences were equally expressed by adolescent girls, both married and unmarried. While this preference existed before displacement, Myanmar military forces prevented underage marriages unless the family had the means to pay a bribe. Early marriages are now more common because such barriers seem to have been lifted (Melnikas et al., Reference Melnikas, Ainul, Ehsan, Haque and Amin2020). However, education may alter attitudes and therefore cultural norms. Across four South Asian nations in the period 1991–2011, secondary education attainment reduced the odds of getting married for girls age 17 years and younger in Bangladesh, Nepal, and India, but only for girls under the age of 14 in Pakistan (Raj, McDougal, Silverman, & Rusch, Reference Raj, McDougal, Silverman and Rusch2014).
Even in the event that adolescent motherhood is considered culturally normative or is not considered stressful, the stress and trauma of conflict and displacement during adolescence could be transmitted to the next generation – prenatally through molecular mechanisms related to stress physiology and postnatally predominantly through caregiving. We argue that a stress physiology perspective may allow us to learn more about the developmental origins and factors perpetuating known epidemiological, demographic, and socioeconomic challenges, including intergenerational transmission of poverty and noncommunicable disease prevalence globally.
Intergenerational transmission of stress physiology
Exposure to severe levels of stress early in life has been linked to disparities in health and wellbeing at the societal level (Charil, Laplante, Vaillancourt, & King, Reference Charil, Laplante, Vaillancourt and King2010; Shonkoff, Reference Shonkoff2012), accounting for a significant proportion of the noncommunicable disease burden globally (Nyirenda, Reference Nyirenda2006). Studies have identified links between exposure to stress in utero and in the first few years of life to poorer cognitive performance, impulsive behavior, aggression, and poor self-regulation (Bell & Deater-Deckard, Reference Bell and Deater-Deckard2007; Juster et al., Reference Juster, McEwen and Lupien2010; Lupien et al., Reference Luthar2009).
Conceived and gestated during crises
Studies of natural experiments have documented the long-term effects of exposure in utero to different types of stressors and how these outcomes differ depending on the age of the fetus at exposure. While the exact vector of stress transmission often cannot be identified (e.g., stress hormones, infection and inflammation, psychosocial, nutrition), studies of natural disasters, pandemics, and war-related famines demonstrate that exposure in utero to severe maternal stress has persistent effects on lifelong health, wellbeing, and other socioeconomic outcomes, and that the specific outcomes differ depending on when during gestation exposure occurred (Almond, Reference Almond2006; King & Laplante, Reference King and Laplante2015; Lumey et al., Reference Lumey, Stein, Kahn, van der Pal-de Bruin, Blauw, Zybert and Susser2007). Furthermore, the effects have been identified in DNA methylation patterns (Cao-Lei et al., Reference Cao-Lei, Massart, Suderman, Machnes, Elgbeili, Laplante and King2014), potentially indicative of fetal programming effects.
Born and raised during crises
Many of these studies do not account for continuity in adversity and risk experienced after birth, and there is an ongoing debate about short- versus long-term effects of prenatal exposure to stress (DiPietro, Reference DiPietro2012). Crises – including wars or the current Covid-19 pandemic – are often accompanied and followed by myriad other risk factors. These can include separation from or loss of caregivers and family networks, displacement and/or severe restrictions on movement, increases in domestic and societal tensions and violence, deep economic recession and unemployment associated with food insecurity and loss of home, and poor healthcare – just to mention a few (Yoshikawa et al., Reference Yoshikawa, Wuermli, Britto, Dreyer, Leckman, Lye and Stein2020).
Infants are dependent on caregivers to provide nurture, which includes the provision of protection and security, as well as sensitive, responsive, and stimulating care (Britto et al., Reference Britto, Lye, Proulx, Yousafzai, Matthews, Vaivada and Fernald2017a). The quality of these early relationships is extraordinarily important for lifelong health, development, and learning. However, studies investigating maternal mental health and wellbeing after birth among young mothers have found substantial continuity in self-report measures of anxiety, stress, and depressive symptoms from pregnancy to 2 years post-partum (Dipietro, Costigan, & Sipsma, Reference Dipietro, Costigan and Sipsma2008; Pesonen, Räikkönen, Strandberg, & Järvenpää, Reference Pesonen, Räikkönen, Strandberg and Järvenpää2005).
Postnatally, stress can be transmitted to the infant through multiple channels. On the physiological side, cortisol levels in human breast milk have been linked to infant negative affectivity (Grey, Davis, Sandman, & Glynn, Reference Grey, Davis, Sandman and Glynn2013). Stress and mental health have been shown to be transmitted through more overt and observable caregiving behaviors (responsiveness, sensitivity, stimulation), as well as through less visible channels, such as contagion of physiological states, and potentially a mix between overt behaviors and physiological signaling (Debiec & Sullivan, Reference Debiec and Sullivan2014; Mills-Koonce et al., Reference Mills-Koonce, Propper, Gariepy, Barnett, Moore, Calkins and Cox2009; Waters, West, & Mendes, Reference Waters, West and Mendes2014).
In contexts of war and displacement, the caregiver–infant relationship serves as an important source of resilience, with higher quality caregiver–child interactions buffering external sources of risk and adversity (Gunnar & Quevedo, Reference Gunnar and Quevedo2008; Murphy et al., Reference Murphy, Rodrigues, Costigan and Annan2017). These caregiver effects have been demonstrated in experimental studies using interventions (Bakermans-Kranenburg, Van Ijzendoorn, Mesman, Alink, & Juffer, Reference Bakermans-Kranenburg, Van Ijzendoorn, Mesman, Alink and Juffer2008; Nelson et al., Reference Nelson, Zeanah, Fox, Marshall, Smyke and Guthrie2007). Furthermore, in many cultures, parenting does not take place in an isolated nuclear setting, but within an extended family network that can be a source of support and thus resilience. Positive or negative, such mechanisms lead to an intergenerational transmission of physiological and behavioral characteristics linked to learning and development, and later life physical and mental health.
Supporting Adolescent Mothers and Building a Foundation for Healthy Development and Learning of Present and Future Generations
Because adolescence demarcates a protracted period of neural maturation that persists into the third decade of life, it also offers an opportunity for interventions to “reverse” the vestiges of earlier life stress and redirect the developmental trajectory for the better. When considering how interventions may best support adolescent mothers affected by war and displacement and their children, one first needs to understand sources of resilience, or protective and promotive factors, in the specific context. Resilience is defined as positive adaptation and development despite exposure to substantial risk and/or adversity (Garmezy & Masten, Reference Garmezy and Masten1986; Luthar, Reference Luthar1993; Luthar & Zigler, Reference Luthar and Zigler1991; Masten, Reference Masten2019). Of particular interest are factors that are malleable – in other words, factors that can be targets of interventions.
Sources of resilience in adolescent mothers
Studies in the USA and other wealthy countries have found that, counter to the assumption that adolescent mothers’ lives are overwhelmed by negative factors and that their children may show correspondingly overwhelmingly negative outcomes, the life-course outcomes of both adolescent mothers and their children are highly variable. Important sources of resilience include both contextual and individual factors that predict (a) better parenting during the early years or (b) better child behavioral or cognitive outcomes in early childhood. Among the contextual factors, social support from a variety of sources appears to buffer the developing child from the negative effects of adversity (Sroufe, Egeland, Carlson, & Collins, Reference Sroufe, Egeland, Carlson and Collins2005). Such support for adolescent mothers often comes from the parents of the mother (Apfel & Seitz, Reference Apfel and Seitz1991) and is accentuated in later benefits for both mothers and children when the resource levels of the parents are higher, as is the case in Sweden and the USA (Ekéus, Christensson, & Hjern, Reference Ekéus, Christensson and Hjern2004; Furstenberg Jr, Brooks-Gunn, & Morgan, Reference Furstenberg, Brooks-Gunn and Morgan1987). Support from a partner is also associated with better indicators of early parenting (Huang & Lee, Reference Huang and Lee2008). Natural mentors of adolescent mothers can also provide a positive influence (Hurd & Zimmerman, Reference Hurd and Zimmerman2010). Access to stable housing is predictive of better early child development among children of adolescent mothers (Leadbeater & Way, Reference Leadbeater and Way2001). Individual-level factors associated with better outcomes for the children of adolescent mothers include higher educational aspirations and ambitions of the mother, and autonomy and agency in acting on those ambitions (Furstenberg Jr et al., Reference Furstenberg, Brooks-Gunn and Morgan1987; Leadbeater & Way, Reference Leadbeater and Way2001).
Studies of resilience in adolescent mothers in LMIC and conflict-affected contexts are few and far between. We generally know that older age, higher education, and more income-earning opportunities of mothers predict higher investments in children's development, lower levels of domestic violence, and better access to SRH services (Aizer, Reference Aizer2010; Beegle, Frankenberg, & Thomas, Reference Beegle, Frankenberg and Thomas2001; Kabeer, Reference Kabeer1997; Richards et al., Reference Richards, Theobald, George, Kim, Rudert, Jehan and Tolhurst2013). While age is not malleable, education and livelihood opportunities, knowledge about SRH, and social support and networks are, and these are likely to provide much needed resources for adolescent mothers. A substantial body of research has investigated resilience in adolescents affected by war and displacement more generally (Betancourt & Khan, Reference Betancourt and Khan2008; Masten & Narayan, Reference Masten and Narayan2012; Tol, Song, & Jordans, Reference Tol, Song and Jordans2013). However, specific sources of resilience will vary depending on culture and other contextual specifics.
Culture, resilience, and stress physiology
Resilience needs to be investigated as a complex dynamic system embedded within the “bioecocultural micro-niche” (Worthman, Reference Worthman2010). Both what is seen as resilience and what supports that resilience may vary across cultures (Tol et al., 2013), and a substantial body of literature has explored resilience across diverse cultures and contexts, including in children and families affected by war and displacement (Panter-Brick & Eggerman, Reference Panter-Brick, Eggerman and Ungar2012; Theron, Liebenberg, & Ungar, Reference Theron, Liebenberg and Ungar2015; Tol et al., 2013). Culture is a lens through which we experience and make meaning of events around us. A pregnant woman's appraisal of an event, for instance a natural disaster, can be linked to methylation patterns in her child 13 years later (Cao-Lei et al., Reference Cao-Lei, Elgbeili, Massart, Laplante, Szyf and King2015). It extends from this that culturally salient factors and processes of resilience would be reflected in biological processes, specifically processes associated with stress physiology.
The link between culture and the embodiment of experiences (e.g. trauma) is not a new discovery; however, earlier work was dominated by biological and medical anthropology (Worthman, Reference Worthman2019; Worthman & Costello, Reference Worthman and Costello2009). There is a growing understanding of the relations between culture and biology and how they dynamically interact to shape lifelong health and wellbeing (Worthman & Costello, Reference Worthman and Costello2009). Recent works have increasingly integrated culture, neuroscience, and genomics in the study of physical/mental health and behavioral development (Causadias, Telzer, & Gonzales, Reference Causadias, Telzer and Gonzales2018; Chiao, Li, Seligman, & Turner, Reference Chiao, Li, Seligman and Turner2016; Worthman, Reference Worthman2019). Applying this framework to resilience – if war and displacement are reflected in hyper- or hypo-reactivity of the HPA axis or the sympathetic nervous system, or high levels of chronic inflammation – then resilience should show a reversal or readjustment of these systems and their functioning.
The use of specific biomarkers of stress physiology can thus inform our hypotheses of culturally specific sources of resilience. These associations can further be confirmed with rigorous experimental intervention studies incorporating a range of relevant biomarkers. Intervention studies have demonstrated the usefulness of incorporating biological measures of stress in order to better understand how and why interventions effect change (Bakermans-Kranenburg et al., Reference Bakermans-Kranenburg, Van Ijzendoorn, Mesman, Alink and Juffer2008; Cicchetti & Gunnar, Reference Cicchetti and Gunnar2008; Cicchetti et al., Reference Cicchetti, Rogosch, Toth and Sturge-Apple2011; Hastings et al., Reference Hastings, Kahle, Fleming, Lohr, Katz and Oxford2019). Biological markers can also help us understand cross-cultural differences in somatization, or physiological manifestations of mental health problems, and further disentangle the physical and psychological contributions to observed psychiatric disorders and overall mental and behavioral functioning (Kohrt et al., Reference Kohrt, Kunz, Baldwin, Koirala, Sharma and Nepal2005). In summary, investigating the particular factors of risk and resilience for adolescent mothers and their young children in contexts of war and displacement will require a deep investigation of cultural and contextual characteristics and how these characteristics moderate the embodiment of the stress and trauma they have endured, and often continue to experience.
Integration of evidence from Adolescent programming in LMIC and early childhood programs in conflict-affected contexts
Have program models for adolescent mothers been successful in bolstering these sources of resilience and thereby reducing risk? Unfortunately, the two primary literatures in humanitarian and post-conflict settings that may be useful – on early childhood development and later child and youth development – generally ignore the population of adolescent mothers. A systematic review of interventions to improve the mental health of pregnant adolescents and adolescent parents identified zero studies in LMIC, let alone conflict-affected contexts (Laurenzi et al., Reference Laurenzi, Gordon, Abrahams, du Toit, Bradshaw, Brand and Servili2020). To our knowledge there are only two evaluations of programs to support adolescent mothers from LMIC – one experimental and one nonexperimental. The Meseret Hiwott program, implemented in the rural Amhara region of Ethiopia, combined group discussions facilitated by mentor community women for adolescent married mothers with separate groups for their husbands, with the goals of increasing voluntary counseling and testing (VCT) for HIV, as well as awareness of and skills related to SRH, family planning, motherhood, gender and power dynamics, and financial literacy. A parallel program was developed for husbands of any age (not just those of the participating mothers), with groups discussing a parallel set of topics and male mentors from each village facilitating those groups. In a nonexperimental comparison across levels of participation in the groups, participating mothers reported increased family planning behaviors, HIV VCT, and accompaniment to health clinics by their spouses (Erulkar & Tamrat, Reference Erulkar and Tamrat2014). A recent randomized controlled trial of home visiting services to low-income adolescent mothers in urban Brazil found positive effects on both parent–child stimulation and mothers’ wellbeing (Fatori et al., Reference Fatori, Argeu, Brentani, Chiesa, Fracolli, Matijasevich and Polanczyk2020).
Interventions for children and youths exposed to armed conflict have been successful in improving mental health outcomes, though again they have not focused on adolescent mothers. The bulk of successful programs have been small-group interventions targeting mental health outcomes such as post-traumatic stress disorder (PTSD), internalizing symptoms such as depression and anxiety, and externalizing and conduct problems. Interventions ranged from psychoeducation with an emphasis on coping, arts-based expression of trauma, and cognitive behavioral therapy principles. Most have been implemented in schools (Jordans, Pigott, & Tol, Reference Jordans, Pigott and Tol2016; Yoshikawa et al., Reference Yoshikawa, Wuermli, Aber and Suárez-Orozco2018), which may limit the extent to which adolescent mothers have access to such programs if pregnancy precipitates early termination of schooling. Of note, while 40% of the evaluations reported adaptations of programs “imported” from another country, very few of these described the adaptation in detail beyond translation (Jordans et al., Reference Jordans, Pigott and Tol2016). This suggests a critical need to examine processes of cultural adaptation at deeper levels than translation and back-translation of intervention manuals and training materials.
Interventions targeting girls’ education, labor market and livelihoods skills, SRH, psychosocial wellbeing, and violence prevention for adolescents in LMIC not specific to conflict or displacement show promise. There is now a strong evidence base on the effectiveness of livelihoods and training programs for adolescent girls from a number of LMIC (Adoho, Chakravarty, Korkoyah, Lundberg, & Tasneem, Reference Adoho, Chakravarty, Korkoyah, Lundberg and Tasneem2014; Singla et al., Reference Singla, Waqas, Hamdani, Suleman, Zafar, Saeed and Rahman2019). Livelihoods training programs with stronger positive impacts on employment and income for young people are more likely to combine a focus on technical training in occupations with local demand, practical on-the-job internships, and the addition of social skills (“soft skills”) training for success (Singla et al., Reference Singla, Waqas, Hamdani, Suleman, Zafar, Saeed and Rahman2019).
Mental health and life skills programs, overlapping with social–emotional learning programs as they are conceptualized in rich countries, have been found to be effective in a recent meta-analysis that included 50 controlled trials in LMIC (Barry, Clarke, Jenkins, & Patel, Reference Barry, Clarke, Jenkins and Patel2013). Overall, these programs were found to reduce the symptoms of depression, anxiety, and PTSD. Programs with positive impacts were likely to focus on a combination of stress management, interpersonal skills, and improving parent–child communication and interaction (although in these cases the parent was the parent of a youth, not the youth as a parent). Here, too, it is important to understand local idioms of distress and mental health and to ascertain the cultural validity of more commonly used assessment tools (Hinton, Kredlow, Bui, Pollack, & Hofmann, Reference Hinton, Kredlow, Bui, Pollack and Hofmann2012).
A systematic review of SRH interventions for young people in humanitarian and LMIC contexts found that several appear to be effective, including education on SRH, gender-based violence, contraception use, and behavioral training targeting assertiveness, communication, and problem-solving skills (Desrosiers et al., Reference Desrosiers, Betancourt, Kergoat, Servilli, Say and Kobeissi2020). Another systematic review of reviews of evaluated violence-reduction programs for young women and girls aged 10–24 found that successful programs were more likely to include focus on skills, peer network support, education, and community engagement (Yount, Krause, & Miedema, Reference Yount, Krause and Miedema2017).
Broader emphasis on cash transfers and education may also be relevant. A systematic review of interventions to prevent adolescent childbearing in LMIC found that cash transfers to incentivize school attendance and other programs that encourage school enrollment and attendance for adolescent girls can reduce adolescent childbearing (McQueston, Silverman, & Glassman, Reference McQueston, Silverman and Glassman2013). A subsequent national randomized control trial in Kenya found that exposure to a cash transfer program resulted in reductions in early pregnancy (Handa et al., Reference Handa, Peterman, Huang, Halpern, Pettifor and Thirumurthy2015). Other promising approaches include interventions for men to transform inequitable gender attitudes, with some promising results from the Democratic Republic of Congo (Vaillant et al., Reference Vaillant, Koussoubé, Roth, Pierotti, Hossain and Falb2020).
Successful programs to improve adolescent mental health and livelihoods and reduce gender-based violence in LMIC thus suggest several principles that might be considered in programs for adolescent mothers. These include emphases on peer support, community mentorship and engagement, the inclusion of life skills and coping into livelihoods training, and recognition of the larger household dynamics experienced by youth at home. Each of these are also implicated in the basic literature on resilience among adolescent mothers previously reviewed (Furstenberg Jr et al., Reference Furstenberg, Brooks-Gunn and Morgan1987; Huang & Lee, Reference Huang and Lee2008; Hurd & Zimmerman, Reference Hurd and Zimmerman2010).
Overall, despite the extensive evidence base about Early Childhood Development (ECD) interventions in LMIC (Britto et al., Reference Britto, Lye, Proulx, Yousafzai, Matthews, Vaivada and Bhutta2017b), there are few rigorous studies of such programs in humanitarian contexts. Murphy, Yoshikawa, and Wuermli (Reference Murphy, Yoshikawa and Wuermli2018) identified only four completed early childhood intervention evaluation studies in LMIC that met their inclusion criteria (in particular, inclusion of control or comparison groups, and focused on parenting, caregiving, stimulation, and/or early learning programs) (Murphy et al., Reference Murphy, Yoshikawa and Wuermli2018). Three of these (in Liberia, Northern Uganda, and Bosnia) targeted caregiver–child dyads with a combination of activities addressing caregiver psychosocial support and wellbeing, early child development information, and positive parenting approaches (play, reduced harsh discipline, stimulation etc.). Only one (Northern Uganda) targeted caregivers of children under the age of 3 years, and found positive effects on caregiver self-reported wellbeing, involvement, and availability of play materials. Examples of contextually and culturally grounded ECD programs that have proven effective and sustainable at national scale include the Te Whāriki in New Zealand, which incorporated Maori cultural principles into a national preschool curriculum, and the Modalidad Propia of the Colombian De Cero a Siempre policy, which allows for the incorporation of locally developed program content, implementation, and budgeting on part of indigenous populations within a national child development policy (Lee, Carr, Soutar, & Mitch, Reference Lee, Carr, Soutar and Mitch2013; Motta & Yoshikawa, Reference Motta, Yoshikawa, Verma and Petersen2018).
Conclusions: The Promise of Dual-generation Programming for Adolescent Mothers and their Young Children
As Allen, Seitz, and Apfel (Reference Allen, Seitz, Apfel, Aber, Bishop-Joseph, Jones, McLearn and Phillips2007) pointed out in a prior tribute volume to Edward Zigler, from an intervention perspective, adolescent mothers in many places fall through the cracks in programming, even in wealthy countries such as the USA. Given the virtually complete absence of rigorous impact evaluations of programs for adolescent mothers and their children, what directions may be promising in conflict or disaster-affected contexts?
The interventions just reviewed from LMIC provide principles for youth programming – that is, single-generation programming. For adolescent mothers and their families, in particular, the developmental potential of taking a dual-generation approach to intervention may be high, given the potential benefits for two generations of intervening with the mother (Wuermli & Yoshikawa, Reference Wuermli, Yoshikawa, Petersen, Koller, Motti-Stefanidi and Verma2016). Some of the successful interventions for adolescent mothers and their children in rich countries took a dual-generation focus. The Yale Child Welfare Project incorporated parenting and social support for young low-income mothers with high-quality child care. In a quasi-experimental evaluation, Seitz, Rosenbaum, and Apfel (Reference Seitz, Rosenbaum and Apfel1985) showed that the program increased school attainment and earnings among mothers, reduced subsequent childbearing (increasing sibling spacing), and reduced their children's behavior problems and improved their achievement. Intriguingly, there were some sibling diffusion effects such that later-born siblings of the adolescent mothers’ target infants also benefited (Seitz & Apfel, Reference Seitz and Apfel1994). In a separate evaluation, access to education for adolescent mothers was found to reduce subsequent childbearing (Seitz & Apfel, Reference Seitz and Apfel1993). By facilitating naturally occurring support processes among peer networks of adolescent mothers, opportunities for returns to school after interruptions, and supporting their parenting and child care responsibilities, it appears possible to produce long-term impacts on both academic and social competence outcomes – an integrated approach that Zigler long called for (Zigler & Seitz, Reference Zigler and Muenchow1980). Although scaling such interventions has been a challenge, from a policy perspective, the UK implemented a national education policy explicitly aimed at reintegrating young mothers into schooling as part of its policies to address social exclusion (Hosie & Selman, Reference Hosie, Selman, Holgate, Evans and Yuen2006).
To our knowledge, dual-generation interventions for adolescent mothers that integrate foci on peer support, continued education, parenting support, and (if needed) child care support have rarely, if ever, been evaluated in low-income or conflict-affected country contexts. Yet each of these principles has an evidence base. For example, peer support is facilitated in many programs for adolescent girls and women, with some evidence of the positive impacts of such programs on outcomes such as reduced gender-based violence (Yount et al., Reference Yount, Krause and Miedema2017). Educational attendance and enrollment appear to be associated with lower adolescent pregnancy (Yakubu & Salisu, Reference Yakubu and Salisu2018), suggesting that interventions to boost girls’ education may benefit adolescent mothers as well. Further, parenting programs with a focus on nurturing care and responsive stimulation appear to be effective for mothers in LMIC (Knerr, Gardner, & Cluver, Reference Knerr, Gardner and Cluver2013) but, as noted previously, very few have focused on conflict-affected or displaced populations.
Beyond the two generations of adolescent mother and child, there is a third generation that is quite influential in the lives of adolescent mothers – their own parents’ generation. This is particularly the case in cultures where childrearing does not happen in a nuclear family setting, but within multi-generational extended family households. The influence of in-laws on young mothers’ development can be immense, but quite culturally and historically dynamic. For example, a recent study showed that, with urbanization and the implementation of the one-child policy, the traditionally patrilineal patterns of grandparent care of infant grandchildren in urban China had shifted to a matrilineal pattern (Zhang et al., Reference Zhang, Fong, Yoshikawa, Way, Chen and Lu2019). Interventions that include some emphasis on the role of grandparents, if present, in adolescent mothers’ lives may be a promising future direction. In some countries, “skip-generation” families – grandparents raising their grandchildren without the biological parents present (due to migration, urban violence or loss, for example) – are highly prevalent (e.g., in the northern triangle countries of El Salvador, Honduras, and Guatemala (Duryea, Reference Duryea2016; Sheppard & Sear, Reference Sheppard and Sear2016)).
Given the multiple and cumulative risks associated with adolescent motherhood for two generations, it may be that multi-component interventions addressing different and complementary pathways of risk are required. This has been termed the “cumulative protection” model for programming (Yoshikawa, Reference Yoshikawa1994). Indeed, the Yale Child Welfare Project arguably targeted mothers’ education and parenting as well as children's development directly through quality child care – an approach that has recently shown positive effects when integrated with the US Head Start program (Chase-Lansdale et al., Reference Chase-Lansdale, Sabol, Sommer, Chor, Cooperman, Brooks-Gunn and Morris2019). Such multi-component programs have been suggested as effective for adolescent girls in LMIC generally, but they have not been tested in conflict- or disaster-affected populations. Given Edward Zigler's call for multi-component interventions focused on strengthening both child learning environments such as early care and education and family health, mental health, and nutrition support (Yoshikawa & Zigler, Reference Yoshikawa and Zigler2000; Zigler & Muenchow, Reference Zigler and Muenchow1992), this direction for research in situations of conflict and displacement is more than ripe for exploration, from research, practice, and policy perspectives.
As mentioned previously, adolescent mothers often fall through the cracks in programming. In some cases, programs may intentionally exclude adolescent mothers. It is commonly understood that programs often fail to reach the most vulnerable and in need, and adolescent mothers in LMIC and contexts of war and displacement tend to be among the most vulnerable. There have, however, been efforts to extend reach to the most vulnerable girls. One such example is Girl RosterTM, which is a tool to better understand the local context and ensure that programs reach their intended beneficiaries. Inclusive program implementation will be critical in ensuring maximum impact as the agency and potential contributions of these mothers themselves to programming is often overlooked. One peer sex education program in the UK integrated adolescent mothers into the delivery of SRH messages in school contexts (Kidger, Reference Kidger, Holgate, Evans and Yuen2006). Ambition, aspirations, and agency are frequently identified as protective factors in both the qualitative and quantitative literature on adolescent mothers, and could be facilitated in youth-led intervention models (Speer, Reference Speer, Shinn and Yoshikawa2008). Youth-led approaches combined with in-depth ecocultural investigations of social norms and local idioms of distress and resilience, juxtaposed with standardized measures and physiological manifestations of mental health and functioning, yield potential for substantial and meaningful impacts on the lives of families and communities (Worthman & Costello, Reference Worthman and Costello2009).
In this paper we have endeavored to present a developmental framework for how adolescent motherhood may affect developmental outcomes for both adolescents and their young children experiencing war and displacement across the diversity of LMIC. We have further outlined directions for two- and three-generation interventions, and begun to outline a multi-dimensional research agenda that incorporates culture and biology to better understand contextually relevant risks and resilience, and if and how interventions effect change by juxtaposing local idioms of distress and resilience and markers of stress physiological functioning. Rooted in a bioecocultural framework, we believe that the legacy of Edward Zigler can be extended far beyond the USA to integrate basic and applied developmental science to maximize developmental potential across generations.
Financial Statement
This paper was supported by funding from the MacArthur and LEGO Foundations to Sesame Workshop and NYU Global TIES for Children. Hirokazu Yoshikawa's effort on this paper was partially supported by a grant from NYU Abu Dhabi Research Institute to the Global TIES for Children Center.
Conflicts of Interest
None.
