PEDIATRICS Vol. 105 No. 3
March 2000,
p. e30
ELECTRONIC ARTICLE:
Does Mothering a Doll Change Teens' Thoughts About Pregnancy?
Judith Kralewski, RN, MSN, CPNP and
Catherine Stevens-Simon, MD
From University of Colorado, Health Sciences Center, Denver,
Colorado.
 |
ABSTRACT |
Objective. To determine the effect of
age on the efficacy of the computerized, infant simulator doll Baby
Think It Over (BTIO) for increasing middle school girls' knowledge
about the responsibilities of parenthood and discouraging plans for
teen childbearing. We hypothesized: 1) 8th grade students would be less
apt than 6th grade students to equate BTIO care with mothering because
they would rationalize that their infant would be easier to care
for than BTIO; and 2) BTIO would be a more effective teen pregnancy
prevention program with 6th grade students than with 8th grade
students.
Methods. Nulliparous 6th (n = 68) and
8th (n = 41) grade girls attending an urban middle
school in a predominantly lower socioeconomic, Hispanic, neighborhood
were asked to care for BTIO for 3 days and 2 nights. Responses to a
self-administered questionnaire were used to assess the girls'
understanding of the responsibilities and difficulties associated with
parenting, their feelings about the similarity of BTIO care and real
infant care, and their childbearing intentions before and after caring
for BTIO.
Results. Only 32 (29%) of the 109 girls thought that real
infant care would be like BTIO care. Although 8th grade students were
less apt than 6th grade students to equate BTIO care with real infant care (17% vs 37%), 6th grade students were more likely than
8th grade students to endorse statements suggesting that real infant care would be easier than BTIO care (37% vs 24%). Multivariate analyses revealed that this was largely because 6th grade students found BTIO care more difficult than did 8th grade students. Also, regardless of age or grade, the more difficult a girl found it to care
for BTIO than anticipated, the more likely she was to endorse
statements indicating that it would be easier to care for her own
infant than it had been for her to care for BTIO. Little learning about
the difficulties of parenting took place during the study. On average,
the 6th grade students did not find BTIO care more difficult than
anticipated and the 8th grade students actually found it easier than
anticipated. Finally, caring for BTIO had no affect on the intent of
students to become teen parents; 13 (12%) of the 109 students wanted
to be teen parents before they cared for BTIO and 16 (15%) wanted to
be teen parents after they cared for the doll.
Conclusion. The results of this study demonstrate that the
propensity of people this age for rationalizing their own immunity to
the nocuous aspects of potentially desirable situations (the personal
fable of omnipotence) allows those who perceive parenthood to be
attractive to overlook the negative aspects of any parenting experience
they have.
Key words:
adolescent pregnancy,
contraception,
adolescence.
The birth rate among American teenagers has declined
steadily since 1991.1 Nevertheless, the teen pregnancy
rate in this country remains one of the highest in the Western,
developed world.2 Preventing early teen pregnancy is a
highly sought after public health goal.3,4 Various efforts to achieve this goal have, on balance, failed over the past 4 decades.3-8
During the 1960s and 1970s, sex education was introduced to classrooms
with the expectation that more knowledge about human reproduction would
deter early conception.5-8 Despite the positive effect of
these programs on student knowledge, sex education has not had a
significant effect on teenagers' intended or actual sexual and
contraceptive behavior or the teen pregnancy rate in this
country.5-8 This is thought to be in part because people
this age have trouble applying the knowledge they acquire in the
classroom to real life situations.5-8 Thus, during the
1980s, sex education was expanded to include decision-making exercises
designed to give students the opportunity to apply their new knowledge
to simulated life conditions.6-11 These programs helped
prevent the untoward consequences of unprotected sexual activity,
particularly when linked to school-based or teen-oriented neighborhood
clinics.9-12 However, they were ineffective with
teenagers who had little intrinsic interest in obtaining or using
contraceptives.7-12 Thus, during the 1990s, several
programs were developed to address the motivational component of the
teen pregnancy problem. Educators who acknowledged that early
parenthood offered little in the way of opportunities for their most
impoverished students promoted incentive programs that rewarded
pregnancy-preventing behaviors. They also introduced classroom
exercises to help these students develop realistic, achievable,
future-oriented goals that would be more attractive than, and
incompatible with, early parenthood.3,6,9,12 In contrast,
other educators sought to deromanticize parenthood by implementing
classroom exercises that were supposed to teach students about the
onerous responsibilities associated with being a parent. These
activities required students to care for infant surrogates, such as
eggs, sacks of flour, and most recently, the Baby Think It Over (BTIO)
doll.13-16
BTIO, a 7-lb life-like doll, represents an advance over previous infant
surrogates because it contains an internal computer that simulates the
loud, hard cry of an infant at random intervals of 15 minutes to 4 hours, 24 hours a day.15,16 Because BTIO can only be
silenced with a probe that is attached to the caretaker's wrist with a
tamper-evident bracelet, the doll puts demands on its teenage caretaker
and interferes with her daily activities and sleep.
Anecdotal newspaper reports and the results of 1 published study
indicate that teenagers find BTIO difficult to care
for.15,16 However, there is no evidence that teenagers
equate doll care with real infant care or that their sentiments about
the former affect their motivation to avoid the latter. Rather, studies
of the pattern of cognitive development during adolescence raise serious concerns about the validity of the premise that they will do
so.17,18 Indeed, the egocentrism and sense of personal
invulnerability that permeates cognitive processes at this age (the
personal fable of omnipotence), enables teenagers to rationalize their
own immunity to the onerous aspects of a potentially desirable
situation.
We prospectively compared the reactions of 6th and 8th grade girls to
BTIO. We chose this population for study because the middle school
years are pivotal in the formation of life-long reproductive
behavior.19 Also, we reasoned that the growing sense of
personal invulnerability that is characteristic of this stage of
adolescent cognitive development would influence the efficacy of the
BTIO approach to preventing teen pregnancy.
Specifically, we hypothesized that: 1) 8th grade students would be less
apt than 6th grade students to equate BTIO care with mothering because
they would rationalize that their infants would be easier to care for;
2) BTIO would be a more effective teen pregnancy prevention program
with 6th grade students than with 8th grade students.
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METHODS |
Study Subjects
All the girls in one 6th and one 8th grade class in an urban
middle school located in a lower socioeconomic, predominantly Hispanic,
neighborhood in Denver, CO, were invited to obtain written parental
permission to participate in the study. This neighborhood was chosen
because vital statistic data indicate that it has one of the highest
teen pregnancy rates in the Denver metropolitan area.
Sixth grade students were more enthusiastic about the prospect of
caring for BTIO than were 8th grade students. Many of the 8th grade
students declined to participate for reasons that reflected their
concern about the "imaginary audience."17 That is on
the grounds that "they were too old to play with dolls" or that
"people would stare at someone my age carrying a doll." As a
result, 68 (75%) of the 91 sixth grade students but only 41 (57%) of
the 72 eighth grade students obtained parental permission to
participate. Because teenagers who express these types of concerns about the imaginary audience are typically at the same stage of cognitive development as those who endorse the personal
fable,17,18 this selective loss of 8th grade students
could have resulted in an under estimation of the effects of cognitive
maturation in the population we studied.
The study was approved by the Committee on Investigations Involving
Human Subjects at the University of Colorado Health Sciences Center.
Intervention
Participants spent 3 days and 2 nights with BTIO. Each girl had
a care key attached to her wrist with a tamper-evident armband and
carried a diaper bag along with BTIO.
Data Collection
The principal assessment instrument was a 3-part,
self-administered questionnaire developed for this investigation and
written at a 4th grade reading level. The questionnaire was distributed to the students during class time and explained to them. Part 1 (completed before the BTIO experience) collected background information
including personal and environmental characteristics that have the
potential to influence feelings and knowledge about parenting, such as
exposure to relatives and close friends who were or had been teen
parents, baby-sitting experience, and educational and career goals.
Part 2, entitled "My Feelings About Doll Care," was completed both
before and after the BTIO experience. It consisted of a series of 10 statements about caring for BTIO. For example, "it will be (was) hard
to wake up at night and feed the doll" and "it will be (was) hard
to get ready for school and care for the doll." The respondent was
asked to rate each statement on a 4-point Likert scale, ranging from
"not true at all for me" (score = 1) to "very true for me"
(score = 4). Cornbauch-
s were .92 and .89, respectively, for
the pre- and post-BTIO testing. Part 3, entitled "My Feelings About
Real Baby Care," was completed after the BTIO experience. It
consisted of a series of 8 statements about the similarity of doll care
to real infant care. The respondent was asked to rate these statements
on the same 4-point Likert scale. In an effort to appeal to the
participants' egocentrism and feelings of personal omnipotence, each
statement was phrased "my baby would be easier than (the same as) the
doll because... . " The Cornbauch- for Part 3 was .82. Finally, both before and after the BTIO experience, the participants
were asked how old they hoped to be when they had their first child.
Those who indicated that they planned to be <20 years old when they
had their first child defined the subgroup that intended to become teen
parents.
Definition of Efficacy
Although the long-term efficacy of the BTIO program can only be
assessed by measuring adherence to safe sexual practices throughout adolescence and the avoidance of teen pregnancy, the more immediate effects of the experience on knowledge and behavioral intention can be
assessed as potential first steps toward long-term behavioral change.
Although knowledge alone has not been found to be sufficient to change
behavior, it is certainly a necessary prerequisite. To assess the
efficacy of the BTIO experience for teaching teenagers the depth of the
responsibility involved in parenting, we compared the participants'
pre- and post-BTIO scores on the "My Feelings About Doll Care"
questionnaire. A higher post-BTIO score, indicating that the teenager
had found the actual experience of caring for BTIO more difficult than
she had anticipated, was taken as evidence of increased knowledge
(learning) about the difficulties associated with parenting a child.
Because the results of previous studies suggest that an individual's
intention to behave a certain way is an important predictor of their
actual behavior,20,21 we assessed the efficacy of the BTIO
experience for changing intended childbearing behavior by comparing the
age at which the participants stated they hoped to have their first
child before and after the caring for BTIO. The intent to become a teen
parent before, but not after, caring for BTIO was interpreted as
evidence of a positive change in childbearing intentions.
Data Analysis
Univariate analyses were used to describe the study population
and to report on the frequency with which the study subjects endorsed
various statements about the ease and difficulty of caring for BTIO and
the similarity of the BTIO experience to that of parenting a real
infant. Relationships between the various background variables, scale
scores, and childbearing intentions were examined using Pearson
Correlations. The initial comparisons between 6th and 8th grade
students were conducted with bivariate analyses ( t
tests and 
2). Multivariate analyses using
forward stepwise regression were conducted to determine whether
findings at the bivariate level would be supported after adjusting for
relevant background characteristics, expectations about the
difficulties of doll care, and preexisting childbearing intentions. All
statistical analyses were performed with SPSS/PC+.22
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RESULTS |
The students participating in this study ranged in age from 10.3 to 15.3 years (mean ± standard deviation [SD]: 12.9 ± 1.2 years). Most (94%) were Hispanic, lived with at least 1 biologic parent (96%) and had some baby-sitting experience (80%). Although most students responded that they wanted to attend college (81%) and
to delay parenting until they were in their twenties (mean ± SD = 22.7 ± 2.9 years), these girls live in a neighborhood
in which the high school graduation rate is only ~60% and the teen pregnancy rate is one of the highest in the state. Other investigators have also noted discrepancies of this type between expectations for the
future and the reality of the living environment in populations of
teenagers who are at high risk for pregnancy.8,9 With the
exception of the anticipated difference in age, Table
1 shows that the only significant
difference between the 6th and 8th grade students was that the latter
were more likely to have boyfriends.
Only a minority 32 (29%) of the 109 students thought that real infant
care would be like BTIO care. As hypothesized, 8th grade students were
less apt to equate BTIO care with real infant care than were 6th grade
students (17% compared with 37%; P = .02). However
this was not because 8th grade students were more likely to expect that
caring for their own infant would be easier than caring for BTIO. In
fact, 6th grade students were more likely than 8th grade students to
endorse statements suggesting that real infant care would be easier
than BTIO care (37% compared with 24%; P = .02).
Correlational analyses revealed that, in addition to grade and age, the
feeling that it would be easier to take care of one's own infant than
BTIO was directly related to learning about the difficulties of
parenthood (the difference between the anticipated and actual
difficulty of BTIO care; P = .002). Feelings about the
relative ease of real infant care and BTIO care were unrelated to the
intent to become a teen parent. A multivariate analysis that controlled
for statistically significant grade-group differences in background
characteristics (age and boyfriend status), revealed that learning
about the difficulties of parenthood was the only significant predictor
of the feeling that it would be easier to take care of one's own
infant than BTIO (P = .002). Thus, regardless of age or
grade, the more difficult a girl found it to care for BTIO than
anticipated, the more likely she was to endorse statements indicating
that it would be easier for her to care for her own infant than it had
been for her to care for BTIO.
Table 2 examines the relative efficacy of
BTIO for teaching 6th and 8th grade girls that it is difficult to be a parent. The data show that little learning took place during the study
period. On average, 6th grade students did not find BTIO care
significantly more difficult than anticipated and 8th grade students
actually found it easier to care for BTIO than they anticipated it
would be. As a result, 8th grade students were less likely to learn
about the difficulties of parenting than 6th grade students. Indeed,
only 32% of the 8th grade students compared with 51% of the 6th grade
students found BTIO care more difficult than they anticipated it would
be (P = .04). Correlational analyses showed that, in
addition to grade and age, learning about the difficulties associated
with parenting (eg, the difference between the anticipated and actual
difficulty of BTIO care) was inversely related to the anticipated
difficulty of doll care (P < .0001) and directly
related to the actual difficulty of doll care (r = .45;
P < .0001) and the intent to become a teen parent
(P = .02). In multivariate analyses controlling for
statistically significant grade-group differences in background
characteristics (eg, age and boyfriend status) and childbearing
intentions, the anticipated difficulty of doll care emerged as the only
significant, independent, predictor of learning about the difficulties
of parenthood (eg, the difference between the anticipated and actual
difficulty of BTIO care; P < .001). In other words,
regardless of age, grade, or initial childbearing intentions, the
easier a girl thought it would be to care for BTIO, the more she
learned about the difficulties of being a parent.
The data presented in Table 3 show that
there were no grade-related differences in intended childbearing
behavior either before or after the BTIO experience. Both correlational and regression analyses revealed that intended childbearing behavior before caring for BTIO was the only significant predictor of intended childbearing behavior after caring for BTIO (P < .0001). Thus, caring for BTIO had almost no effect on the study
participants' intent to become teen parents.
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DISCUSSION |
The primary purpose of this study was to determine the effect of
grade level (and by extension, age and cognitive maturity) on the
efficacy of a computerized, infant simulator doll (BTIO) for increasing
middle school girls' knowledge and understanding of the difficulties
involved in parenting a child, thus discouraging them from planning to
be teen parents. We hypothesized that, attributable to their allegiance
to "the personal fable of omnipotence," 8th grade students would be
less apt than 6th grade students to equate BTIO care with mothering.
That is, more 8th grade students would rationalize that their infants
would be easier to care for than BTIO. Thus, we anticipated that BTIO
would be a more effective teen-pregnancy prevention program with 6th
grade students than with 8th grade students. Instead, we found that
grade level was not a significant independent predictor of perceptions
about BTIO or the efficacy of the BTIO program. This may have been in
part because concerns about the "imaginary audience" ("I don't
want to participate because people will stare at someone my age
carrying a doll") prevented a disproportionately large number of the
8th grade students from signing up for the study. Those 8th grade students are the teens who we expected might be most apt to believe in
the personal fable. With this in mind, the results of this study
indicate that, regardless of grade, only a minority (29%) of the
students thought that BTIO care would be like real infant care. Little
learning about the difficulties of parenting took place (eg, there was
no significant difference between anticipated and actual difficulty of
doll care), and BTIO had almost no effect on the student's
childbearing intentions.
Several factors may have contributed to our inability to demonstrate
the efficacy of BTIO in this population. First, only a minority (29%)
of the students equated doll care with real infant care. Regardless of
grade, those students who learned the most about the difficulties of
parenting from the BTIO experience were also the least apt to equate
BTIO care with real infant care. Indeed, they showed the strongest
tendency to discount the difficulties they experienced caring for BTIO
by rationalizing that they would find it easier to care for an infant
of their own.
This finding challenges one of the key assumptions in the conceptual
model underlying the BTIO program and many other adolescent pregnancy
prevention programs, eg, programs that use eggs and sacks of flower as
infant simulators12-16: that it is possible to discourage
teenagers from engaging in unprotected sexual activity by creating
simulated classroom experiences that emphasize the adverse consequences
of such behavior. Unfortunately, there are only 2 published studies
evaluating the efficacy of this approach to the prevention of teen
pregnancy.14,16 In 1 study, the investigators did show
that teens find it difficult to care for BTIO and their findings
implied that teenagers might equate their experience with BTIO with
real infant care.16 However, the results of our study
demonstrate that, in this context, the propensity of young people to
believe in the personal fable of omnipotence may allow them to simply
overlook the negative aspects of any parenting experience they have.
This is a very important finding because it suggests that, during
adolescence, the link between knowledge and behavioral intention is not
as tight as theories of behavioral change suggest. In part, this may be
because the personal fable of omnipotence has a powerful impact on
cognitive processes at this age.
A second factor that may have contributed to our inability to
demonstrate the efficacy of BTIO is shown in Table 2. Because most
students expected BTIO care to be difficult, there may have been little
room for learning. We found it encouraging that, within this context,
the students who anticipated that doll care would be easiest learned
the most about the onerous nature of parenting by caring for BTIO. This
is particularly true because girls who wanted to be teen parents tended
to anticipate that it would be easier to care for BTIO than their peers
who planned to postpone parenthood. Unfortunately, because those who
learned the most about the difficulties of parenting were least apt to equate doll care with real infant care and most apt to think their infant would be easier to care for, the experience did not translate into a change in childbearing plans. Nevertheless, our finding that the
anticipated difficulty of doll care was the only significant predictor
of learning about the difficulties of parenthood may help educators
target future intervention toward those who are most apt to benefit
from the experience.
Finally, it is important to note that the manufacturer intended that
BTIO should be part of a sex education program that includes the doll,
worksheets, discussions, and written assignments. In contrast, we
implemented the doll portion of the program in isolation. We did this
because the students who participated in the study had already been
exposed to a sex education program as part of their regular curriculum.
Our finding that most students found BTIO difficult to care for
supports the manufacturer's claim that caring for BTIO allows teens to
experience the responsibilities of parenthood.15 Because
the students we studied were already participating in sex education and
life skills courses, it is difficult to know if implementing the rest
of the BTIO program would have helped them overcome their allegiance to
the personal fable of omnipotence and improved the efficacy of the
intervention. This issue could be explored in future studies of more
racially and ethnically diverse populations. However, in light of our
findings concerning the strength of the personal fable at this age, the results of this study suggest that during adolescence, pregnancy prevention programs that only try to discourage parenthood are apt to
be ineffective. Therefore, it might be preferable to focus future
research efforts on intervention strategies that work with the personal
fable and help adolescents develop future-oriented goals that are more
desirable than, and incompatible with, early childbearing.23
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ACKNOWLEDGMENTS |
We thank the staff and students of Horace Mann Middle School and
the staff of the Quigg Newton Health Center for their help with this
study; BTIO Inc for loaning us the dolls; and Dr Harter for her review
and critique of the study design and questionnaires.
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FOOTNOTES |
Received for publication May 11, 1999; accepted Oct 18, 1999.
This work was presented in part at the Pediatric Academic
Societies' Annual Meeting; May 1-5, 1998; New Orleans, LA.
Reprint requests to (J.K.) 630 Redwood Ave, Corte Madera, CA
94925.
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ABBREVIATIONS |
BTIO, Baby Think It Over;
SD, standard deviation.
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Pediatrics (ISSN 0031 4005). Copyright ©2000 by the American Academy of Pediatrics
Top
Abstract
Methods
