Why is CAMP
different?
Click for details
about CAMP’s:
Postpartum Depression and
Violence Screening Program
Abuse & Neglect
Prevention Program
Little Sisters &
Daughters Program
The CAMP Prenatal Program
The selection of the various components of the CAMP
prenatal program was based on the results of studies which suggest that the
benefits of special, adolescent-oriented prenatal care are mediated by
improvements in compliance with prenatal appointments and maternal nutritional
status and by closer attention to the diagnosis and treatment of non-obstetric,
psychosocial problems and lower genital tract infections young, reproductively immature patients benefit from
this type of specialized prenatal care. Care is provided by certified nurse
midwives with sub-specialty experience in adolescent medicine, an obstetrician
with sub-specialty training in adolescent gynecology, a social worker, a
dietician, and paraprofessional home visiting case managers. To
promote staff-patient interaction and facilitate implementation of individual
care plans, clinic appointments are scheduled at least every 3 weeks until 34
weeks gestation and weekly thereafter. Periodic risk assessments help the staff
tailor the intervention to individual family needs and allocate scarce, costly
services to those most apt to benefit. To avoid duplicating services, numerous collaborations and linkages
with community service organizations and agencies have been established.
Click here for CAMP
publications about the reasons teens are such high-risk obstetrical patients
and here for CAMP research ideas on this topic.
To contend with the problem of late, inconsistent, prenatal care, the mechanics of obtaining care have been simplified. The referral process was streamlined to guarantee access to care within 7-to-10 days of first contact. Liaisons with school nurses, guidance counselors, and health care and social service providers in the community and direct telephone lines ensure immediate contact with a knowledgeable adult who enjoys teenagers and is willing to work with them to arrange appointments that are compatible with their school and work schedules. The availability of free bus tokens solves most transportation problems. Finally, patients who arrive late or walk in without appointments are never turned away. Rather, if a teenager is chronically late for appointments or begins to make a habit of arriving unannounced, her case manager works with her individually until she learns how to schedule appointments and to get to them on time. Similarly, if a patient does not call to reschedule a missed appointment within 24 hours, her case manager worker calls her. If her telephone is disconnected, there is no response, or she misses 2 consecutive prenatal visits the case manager investigates the cause of her poor clinic attendance by visiting her home.
This approach
clearly differs from the approach taken in traditional adult-oriented prenatal
clinics where patients are instructed to reschedule appointments if they arrive
late and missed appointments typically go unnoticed because patients are
expected to take responsibility for rescheduling them themselves. As a result of these efforts, approximately
half of CAMP patients enter prenatal care during the first trimester of
pregnancy and almost everyone obtains an adequate quantity of care.
Click here for CAMP publications
on prenatal care, here for CAMP research ideas on
prenatal care, and here for
patient information on adolescent-oriented prenatal care.
To contend with the problem of
maternal under-nutrition, the CAMP staff includes a dietician. At conception the average teenager weighs 10-to-15
pounds less than the average adult. This
is concerning because small mothers have small babies. Fortunately, underweight mothers can
compensate for their size by gaining additional weight during gestation. This means that adequate maternal weight gain
is a particularly important determinant of the birth weight of infants of
adolescent mothers (click here to see how maternal
size and weight gain are defined).
The CAMP dietician meets with each patient at least twice during
gestation. The purpose of these meetings
is to: identify patients who have poor dietary and or exercise habits or are
experiencing food shortages at home, expedite enrollment in food supplement
programs, like the Women, Infant, and Children (WIC) program, and design an
optimal gestational weight gain plan. That is one that maximizes the health of
both mother and infant (click here to see how the
adequacy of the maternal diet and physical activity are defined).
This approach clearly differs from the
approach taken in traditional adult-oriented prenatal clinics where the health
care provider may devote 3-to-5 minutes to nutrition counseling during the
initial visit. As a result of these efforts, most CAMP patients begin to
receive WIC supplements soon after enrollment for prenatal care and the number
of CAMP patients who state that food shortages at home limit their daily intake
of nutrients is practically eliminated by delivery. Most CAMP patients also gain an appropriate
amount of weight during gestation.
Click here for CAMP publications
on prenatal nutrition & exercise, here for CAMP research
ideas on prenatal nutrition & exercise, and here for patient information on
prenatal nutrition & exercise.
To contend with the problem of unmitigated
maternal psychological stress the CAMP staff includes a social worker and
paraprofessional, home-visiting, case manager. Adolescent mothers are more likely to live in
stressful environments than adult mothers.
For example, more than a third of CAMP patients have been, or are being,
physically or sexually abused and half are seriously depressed and/or have
inadequate family support. This is concerning because stressed mothers are more
likely to give birth to small, preterm infants.
Fortunately social support mitigates the adverse effect maternal stress
has on fetal growth. This means that adequate maternal support is a
particularly important determinant of the birth weight of infants of adolescent
mothers. Teens need dual support for their roles as mothers and adolescents (click here to see how adequate social support is defined).
The CAMP social worker meets with each patient at least twice during gestation
and all patients receive at least one prenatal home visit from the case
manager.
The purpose of these meetings and home visits is to address immediate
social and mental health problems and concerns, develop an effective support
network, and design achievable, educational, vocational, and lifestyle goals
that make the idea of a rapid repeat pregnancy less attractive (click here to see how maternal mood is defined). In addition, every effort is made to counter
environmental factors that have the potential to adversely affect pregnancy and
parenting outcomes ranging from preterm delivery to child abuse and neglect.
This approach clearly differs from the
approach taken in traditional adult-oriented prenatal clinics where the health
care provider may spend 3-to-5 minutes assessing psychosocial well-being during
the initial visit and 1-to-2 minutes at subsequent visits. Moreover, while health care providers can
usually identify the problems in teen-headed families, most cannot intervene
therapeutically. Alleviating the problems these young parents face requires
behavioral and life-style changes that go beyond traditional medical practice.
An on-site social worker and case managers who make home visits bridge this gap. As a result of these efforts, most CAMP
patients begin to receive new services from youth-serving, community agencies
during gestation, and the 
majority are
satisfied with the support they receive from family members, friends, and care
providers.
Click here for CAMP
publications on prenatal stress & life course development, here for CAMP research ideas on prenatal stress &
life course development, and here for patient information on
prenatal stress and life course development.
Finally, to
contend with the problem of genitourinary tract infections the CAMP
health care providers remain vigilant about the acquisition of these infections
during gestation. Pregnant teenagers
acquire more lower genital tract infections and have more alkaline vaginas and
shorter cervices than their adult counterparts. This is concerning because the
inflammatory response these infection engender can disrupt placentation
and cause the placental membranes to rupture prematurely, thereby precipitating
preterm labor. This is especially true
of women who have short cervices and women who are under physical and / or
psychological stress. Thus, at each visit patients are asked about vaginal
symptoms, abdominal pains, new sex partners, and fidelity of their steady sex
partner. Patients are routinely screened for
genitourinary tract infections when they enroll for prenatal care and during
the third trimester. Additional testing
is performed as needed (click here to see how these
infections other obstetrical complications, and the well-being of the pregnancy
are defined).
This clearly differs from the approach taken in traditional
adult-oriented prenatal clinics where healthcare providers usually only screen
for lower genital tract infections at the time of enrollment for care and
rarely inquire about new sexual contacts or sex partner behavior. As a result,
CAMP patients rarely harbor undiagnosed genitourinary tract infections for
long.
Click here for CAMP publications
on the prevention of prenatal medical complications, here
for CAMP research ideas on the prevention of prenatal medical complications,
and here for patient
information on the prevention of prenatal medical complications.
The "CAMP-approach" to prenatal care works. CAMP patients are demographically at significantly
higher risk for preterm and low birth weight delivery than other teenagers who
deliver their babies at the
Selection of
the various components of the postnatal program was based on the results of
studies which suggest that the benefits of special, teen-parent-and-infant
programs are mediated by interventions that simplify access to preventative
health care, discourage high-risk behaviors (such as unprotected sexual
activity and school drop-out), and promote protective behaviors (such as
high-school graduation and goal-setting) also influenced the design of the
postpartum intervention. Care is provided simultaneously to teenage parents and
their children by a pediatrician and a physician’s assistant and nurse
practitioner with sub-specialty training in pediatrics and adolescent medicine.
In addition, in keeping with the American Academy of Pediatrics' recommendation
that health care providers should try to integrate social service providers into
their practices. The CAMP social worker, dietician, and case managers are
always available to see patients who have pressing psychosocial problems or
immediate nutritional concerns. This
arrangement means that patients whom
providers deem to be at high-risk for repeat pregnancy, school drop out,
depression, interpersonal violence, child abuse and neglect, obesity, and
failure-to-thrive can b seen immediately.
Continuity between the prenatal and postnatal portions of the program is
maintained by the nurse practitioner, social worker, dietician, and home
visiting case managers. To promote staff-patient interaction and
facilitate implementation of individual care plans health maintenance visits
are scheduled at least every other month during the first six postpartum months
and every 3-to-6 months until the child is two years old. Periodic risk
assessments help the staff tailor the intervention to individual family needs
and allocate scarce, costly services to those most apt to benefit. Finally, to
avoid duplicating services, numerous collaborations and linkages with community service organizations and
agencies have been established.
This approach to primary care clearly differs from the approach taken in traditional “stand-alone” medical or social service offices. In such settings, health care providers usually find it impossible to help teens change their risky sexual behavior. When teenagers do not believe that the consequence of inconsistent contraceptive use (i.e., pregnancy) is incompatible with the lifestyle they want and the life course trajectory they envision for themselves, they are rarely willing to take the steps that are necessary to avoid conceiving by default. Similarly, social workers, dieticians, and case managers who are not an integral part of an existing health care system rarely have resources greater than their own energy and enthusiasm to work with. Since teenagers cannot be case-managed into non-existent family planning services and weight-loss programs, these providers are often unable to help them overcome the system-related barriers and logistical that make it so difficult for them to use contraceptives consistently and maintain a healthy weight after delivery.
Click here for CAMP
publications on why teenagers are at such high risk for personal &
parenting problems, here for CAMP research ideas
on why teenagers are at high risk for personal & parenting problems,
and here for patient
information on this topic
To contend with the problem of late,
inconsistent well-child and teen care access-to-care has been
simplified. Specifically, CAMP offers:
1) same-day appointments and a waiting time of less than one week for
pre-scheduled appointments; 2) coordinated medical and psychosocial care for
parents and children; 3) follow-up of missed health and contraceptive
maintenance visits by telephone, mail, or home visit and rescheduling within
one week of contact; 4) appointments that are scheduled to avoid conflicts with
the parents' school and/or work schedules; 5) clinic fees and contraceptive
supplies on a sliding payment scale, with free care and supplies available for
uninsured and under-insured patients; and 6) free bus tokens and help with
accessing other forms of free transportation.
This approach clearly differs from the
approach taken in traditional adult-oriented pediatric and family practices
where walk-in visits are rarely allowed, waiting times for health maintenance
visits average 3-to-4 months, and parents with acute medical or mental health
needs can not expect to be seen during their children’s appointments. As a
result of these efforts CAMP is one of the few clinics that serves a
predominantly lower socioeconomic status patient population that has achieved
the immunization and continuity of care goals set forth in Healthy People 2010.
Access to care is critical as the under-immunization and emergency department
(ED) visit rates in the CAMP clinic are inversely related to the number of well
teen-and-child visits. On average those
who are behind on shots and visit the ED, have two-thirds of the recommended
number of health maintenance visits and those whose immunizations are
up-to-date and do not routinely use the ED have more than the recommended
number of well-child visits during the first postpartum year.
Click here for CAMP publications
on the care of teen families, here for CAMP
research ideas on the care of teen families, and here for patient information on
this topic
To contend with the problem of rapid
repeat conception the CAMP postpartum program was designed to help teenage
mothers delay the birth of their next child in two ways. Directly, by
simplifying access to the medical and social services that make it easy for
less socially disadvantaged women to use contraceptives effectively. But
also indirectly by encouraging the pursuit of goals that foster the sense of
competency and self-sufficiency that makes career-oriented teenagers want to
try to postpone childbearing beyond adolescence - not because they think they
are suppose to do so, but because they understand that having babies during
their teens will make it harder for them to excel personally and
professionally. The goal is to help them learn that there are better ways
to solve the multitude of problems discrimination, poverty, and social
deprivation create in their lives than having numerous closely spaced children
before they graduate from high school and to give them the opportunity to do
so. While the
intervention is provider-directed, it is designed to be client-centered and
supportive and as well as therapeutic. Specifically, during the prenatal and postnatal period a heavy emphasis is placed on
the importance of consistent contraceptive use, regular school attendance, and
future oriented family, career, and lifestyle planning. Providers emphasize the
advantages of delaying further childbearing beyond adolescence, rather than the
disadvantages of additional teen pregnancies. Counseling begins at the prenatal
enrollment visit
and is part of all subsequent encounters. At each visit pre- and
postnatal providers assess the teen mother’s risk of
conception and stress that pregnancy prevention is not an end in itself,
but means of attaining goals and a life style the desirability of which is likely
to endure longer than the strength of the otherwise fickled
desire to remain non-pregnant. In addition, they make every effort to identify
and counter environmental pressures and experiences
that have the potential to make repeat pregnancy a more attractive option than
contraception. To this end they discuss concerns about contraceptive
side-effects and social taboos that make it difficult for single women to plan
ahead for sex. This information is used to develop a differential
diagnosis for inconsistent contraceptive use and to tailor subsequent
counseling to meet individual reproductive health care needs. Because accidents are inevitable, patients
are provided with a prescription for the emergency
contraceptive pill, Plan B and questioned about their use at each visit.
They also encourage the teens to set
small achievable goals the accomplishment of which not only alleviates an
immediate, personally relevant problems, but also gives them the
self-confidence and sense of mastery they need to tackle other problems in
their lives. To this end providers guide the teens toward the appropriate use
of health and human services, and help them develop strong supportive
relationships with key family members and friends. To increase the motivation to stay in school at each clinic visits,
parents are given an information sheet about a career option that has the potential to be as attractive
and rewarding as parenting. The sheet
explains the job, the educational requirements, and gives names of people in
the community who would enjoy having a teen shadow them on the job. This
collaboration is critical. It ensures that the counseling and support the CAMP
staff provides are accompanied by substantive changes in the young parents'
daily living environment. Thus, all program participants have both the
resources and the reasons needed to delay childbearing. In addition to being at increased risk for
conception, teenage mothers are more likely to acquire sexually transmitted
diseases than their nulliparous peers. Hence, periodic urine-based screening is a
routine part of their postpartum care.
This
approach clearly differs from the approach taken in traditional adult-oriented
gynecology or family planning clinics where providers
do not address family health and social needs as a whole or counsel patients
about contraception and the importance and desirability of spacing subsequent
children within the context of their life course development. This approach also differs from that taken by
most family doctors as the care is truly designed to meet the immediate health
and mental health care needs of the entire family.
Click here for CAMP publications
on prevention of repeat pregnancy, here for
CAMP research ideas on the prevention of repeat pregnancy, here for patient information on prevention of repeat
pregnancy, here to see the career options CAMP providers discuss, here for more information on the
CAMP postpartum
depression and violence screening program and,
here for more information on the
CAMP Chlamydia and infidelity screening program.
Preventing rapid repeat conception is one of the ways
the CAMP staff contends with the problem of child abuse and neglect.
Formal screening for postpartum depression and exposure to interpersonal
violence is another routine part of the care CAMP patients receive during the
first six postpartum months. Helping young parents learn how to provide a safe,
stimulating, development promoting home environment for their children is the
third way the CAMP staff tries to prevent child abuse and neglect. At each
clinic visit parents are counseled about normal child development and
age-appropriate disciplinary and feeding tactics. Parents are also given
a set of development promoting games to play with their children. Finally,
providers make every effort to identify and counter misunderstandings
about child development, diet, and disciplinary and feeding styles that set the
stage for poor growth and child abuse and neglect and failure to thrive. During these discussions providers emphasize that
adequate child-spacing is a critically important component of raising healthy
children.
This approach clearly differs from the approach taken in most traditional
adult-oriented clinics where there is almost never a formal procedure for
identifying depressed and abused mothers, child spacing is rarely
discussed as an important component of raising healthy children and organized,
multidisciplinary mechanisms for preventing and treating child abuse and
neglect and failure to thrive are not available on-site.
Click here for CAMP publications
on parenting, here for CAMP research ideas on
parenting, here for
patient information on parenting, here for
more information about the CAMP postpartum depression and violence screening
program , here for more information about the
CAMP abuse & neglect prevention program, here for
more information about the CAMP failure-to-thrive treatment program, and here to see
the development-promoting games CAMP providers discuss.
The
"CAMP-approach" to postpartum care works. CAMP patients are no more likely than other
teenage mothers in
The CAMP Little Sisters and
Daughters Program
Selection of the various components of the
The goal is to help
families who have experienced one teen pregnancy avoid others.
The younger never pregnant, middle-school aged
sisters and daughters of teenage mothers are a particularly vulnerable
group. These young women often share
numerous characteristics that collectively foster negative attitudes about
using contraception and positive feelings about the ways in which having a baby
will affect their lives. Few teenage mothers and their younger sisters and
daughters actually want or plan to become teen parents. However, most lack the
adult role models and daily living, learning, and work experiences that
motivate women to take the steps necessary to avoid conceiving by default.
Participants engage in loosely structured, one-on-one discussions about future
life options with an adult mentor who can arrange for teens to have a hands-on
introduction to a career of their choice.
The goal is to help the teenagers weigh the personal and societal
advantages and disadvantages finishing high school and delaying conception
beyond adolescence. The teens are
encouraged to discuss a wide array of topics with their mentor. They have the
opportunity to raise topics of immediate personal concern, and are then helped
to generalize the discussion to a more global consideration of the antecedents
of school failure and early childbearing within their family and community. To
ensure participants feel appreciated and valued, special events such as
birthdays, graduations, and the receipt of scholastic, sporting, or community
service awards are acknowledged with gift certificates to local clothing or
music stores. Finally, program participants and their parents are invited to
attend a monthly meeting with the CAMP social worker. The goal is to establish
channels of communication that foster mutual trust and respect, and make it
easy and desirable for the teens to be open and share their daily experiences
with their parents. This minimizes the
need for the direct monitoring their parents find so difficult to implement and
enhance parental knowledge of their children’s activities and where-a-bouts.
Because the sisters program is an integral part of CAMP, participants have
access to the full range of medical, nutritional, and social services the
clinic offers. This includes routine well and sick care, contraceptive care,
and nutritional, social service, and mental health counseling. To familiarize
program participants with factors that are longitudinally linked to adolescent
pregnancy and school drop out, they receive a monthly "Health Note From
Your Doctor" or "Mental Health Note From Your Social Worker" in
the mail. These are short discussions of medical (i.e., acne, menstrual cramps)
or mental health (i.e., emotional liability, substance use) topics.
This approach to
preventing teen pregnancy and school drop-out clearly differs from the
traditional one in which the focus tends to be on deterring socially
problematic behaviors with sanctions rather than fostering pro-social ones by
rewarding the efforts teens make to negotiate the hazards in their daily living
environments.
Click
here for CAMP publications on the CAMP Little Sisters & Daughters Program,
here for CAMP research ideas on little sisters
& daughters, here
for patient information for little sisters & daughters of teen mothers,
here
to see what the CAMP health care providers discuss with the little sisters and
daughters of teen mothers, and here to see the
monthly discussions the Mentor has with program participants.
The CAMP Graduate Program
In
accordance with the recommendation of the American Academy of Pediatrics, CAMP
only provides care to individuals who are less than 22 years of age. Older mothers are referred to new health
care providers but may continue to use CAMP as their pediatric
health care provider.
CAMP is more than a unique
adolescent-oriented family practice. It is also an active forum for teaching
and research. Since its inception, the CAMP staff has taken a leadership role
in educating the community and the next generation of health and social service
care providers about the unique needs of teenage parents and their
children. Staff members speak at high
schools, community service organizations, and professional seminars, distribute
the CAMPNews (a
monthly publication devoted to new research findings pertinent to the care of teen-headed
families), to more than 150 youth serving groups and agencies in Colorado and
maintain this interactive website, (http://www.uchsc.edu/CAMP). In
addition, they teach medical, nursing, physician assistant, nutritional
sciences, and public health students and maintain an on-line curriculum that
serves as a forum
for the scholarly exchange of ideas about adolescent health. Prenatal research
studies focus on the effects that physiological and psychological differences
between pregnant adolescents and adults have on fetal growth and development.
After delivery, the focus of investigation shifts to preventing the pregnancies
that occur when sexually active teens lack the motivation to use contraceptives
consistently enough to avoid conceiving by default. All data required to carry
out this type of research is stored on the CAMP database – The
Electronic Report on Adolescent Pregnancy (ERAP). To ensure that the required data is
collected consistently and uniformly, a computer-based
decision support system, “Electronic
Tips for Interviewing Pregnant and Parenting Teens (ETIPPT)”
walks the staff through key portions of the prenatal and postpartum
psychosocial and behavioral history. Obtaining accurate information from a teenager is an art
that requires years of clinical experience. E-TIPPT
was created to embed the knowledge that is required to incorporate these skills
into the daily work of professionals who do not have subspecialty training
in adolescent medicine or significant clinical experience with teenagers.
Click here for a list of
CAMP publications, here for a
list of future research ideas, here
for CAMP Institutional Review Board (IRB) information,
here to see E-TIPPT,
here for a description of
the CAMP database, and here for definitions of
variables included in the CAMP database.
Thus, in summary, the long and vast
experience of the Departments of Pediatrics and Obstetrics-Gynecology at the
University of Colorado Denver in caring for high-risk
adolescent parents and their families, the interdisciplinary nature of the
program, the strong commitment to teaching and research, and the large number
of racially and ethnically diverse patients makes CAMP a unique demonstration
program.