Case Management for Teenage Parents: Lessons from the Teenage Parent Demonstration. HOW CAN CASE MANAGEMENT STAFF PROMOTE CLIENT PARTICIPATION?

12/01/1991

Some teenage parents came to the demonstration programs already strongly motivated to continue their education, or to find and succeed in a suitable training course, and had a strong personal sense of direction and purpose.  They needed no prodding or coaxing by case managers to pursue a path off AFDC and towards self-sufficiency, and appreciated the program's help with child care and expense subsidies.  In the view of case managers, these very motivated participants were likely to succeed even without the program.  In the program, given access to educational opportunities, a training course, or employment guidance, these clients generally applied themselves and succeeded, without the need for case managers to spend very much time working with them.  Case managers described such cases as relatively rare, however.

The potential impacts of a program for teenage parents on AFDC are therefore more likely to be achieved by the staff's work with the larger segment of the target population who are less motivated and have less sense of direction, or who face severe countervailing pressures that can overwhelm their own strengths and ambitions.  Case managers spent most of their time working with such clients, although levels of motivation, direction, and personal problems -- and the attention required of staff -- were of course a matter of degree.  The case managers worked case-by-case to find the right combination of supportiveness and helpfulness, on the one hand, and pressure and clear expectations, on the other, that could draw clients into sustained contact with the program staff, and guide them into activities that were motivating and rewarding and could potentially lead towards decent future employment.

It Was Important to Persist in Efforts to Draw Less Motivated Teenagers into Productive Activities

Among the less motivated or less self-directed clients, a variety of factors interfered with their ability or willingness to take part in demonstration activities, and case managers had to take a persistent approach to identifying these factors and helping clients overcome them.  Many participants suffered from general lack of confidence and self-esteem, and lacked the kinds of supportive relationships that could help them develop these strengths.  In some instances clients' families objected to their pursuing education or training.  Some participants' boyfriends interfered with their involvement in the demonstration.  Crime and drug abuse in their neighborhoods threatened their security and could make them uneasy traveling to program activities or jobs.

Case managers had to use a variety of approaches to overcoming clients' reluctance to participate.  They reasoned with clients -- trying to help them understand the connection between efforts to improve their skills and their long-term prospects for employment and a better life for themselves and their children.  They encouraged them, reassuring them that they would make friends in the new environment of the class they were to enter, and that they could succeed.  In some instances case managers spoke to clients' mothers to win their support for their daughters' participation or to cooperate in joint efforts to persuade them to participate.  Case managers chided clients when they missed appointments or slacked off in their attendance at education or training classes, and reminded them that they had to choose between participating and the possibility of a sanction that would reduce their AFDC grant.  They used the formal tools they had for enforcing participation requirements -- sanction warning notices and, when necessary, grant reductions.  These efforts were often made over extended periods, because some clients went through recurrent cycles of participation and resistance.

Case managers found that these persistent and varied efforts to involve less motivated clients had the desired effects with some of them.  They reported cases in which teenage parents who were at first very reluctant to participate in the program, and even resisted participating for long periods, eventually showed a striking turnaround in their attitude and behavior.  In in-depth interviews, some teenage parents clearly reported their initial skepticism about and resistance to the program, and attributed their decision to participate to the persistent, caring, but insistent attention paid to them by the demonstration staff.  Inevitably, however, some teenage parents chose to accept ongoing sanctions rather than participate, and some -- according to case managers' perceptions -- may have chosen to leave AFDC rather than attend program activities.

Formal Participation Requirements and Sanction Rules Were an Important Foundation for Staff Efforts to Promote Participation

The threat of a sanction or the actual financial effects of a sanction were clearly an important foundation for the varied approaches described above that case managers took to get reluctant clients to participate.  The premise of sanction policy in the demonstration -- and in JOBS -- is that the reduction of an AFDC grant, or the possibility of such a reduction, is an effective financial incentive to comply with program requirements and participate in program activities.  In New Jersey, teenage parents of one child with their own AFDC cases lost $160 off their monthly $322 grant when they were sanctioned.  In Chicago, a mother of one child lost $56 per month off her $268 grant.(5)  The States followed their own individual policies with regard to continuation of Medicaid eligibility and adjustment of Food Stamp benefits associated with an AFDC sanction.

These financial incentives were clearly at work in the demonstration.  In the New Jersey programs, for example, large proportions of the teenage parents who completed intake -- 26 percent in Camden and 49 percent in Newark -- were later either warned of a sanction or were sanctioned.  In about half of these cases the action led to at least some further program activity -- either completing a workshop or some other activity.  In one illustrative case, a client was at first very depressed and insecure, lacking in self- confidence, and very reluctant to participate.  She failed to appear for program workshops, but eventually complied after receiving several sanction warnings.  By the time she had completed a few workshops, she had become more comfortable and interested in the program.  She expressed an interest in working with computers, received data entry training, got a job with a major insurance company, and within a short time was promoted -- which she reported with great pride to the program staff.

Although the prospect of the financial effects of a sanction -- or an actual sanction -- could be expected to be one factor in encouraging teenage parents to cooperate, demonstration staff pointed out that the mandatory nature of the program promoted participation in ways other than simple financial incentives.  Persistent insistence on participation was beneficial in some instances because it maintained contact with the client over a long enough time for the client to become acquainted with the program staff, recognize that they were supportive and helpful, and overcome fears of the unknown.  Before imposing sanctions, case managers used the formal notices and conferences with clients as prescribed in demonstration rules, and in some cases these succeeded in drawing reluctant clients into the initial stages of program involvement such as assessment and workshops.  Such program exposure could overcome some clients' reservations and lead them into further activities.

Patient adherence to program participation requirements could also, according to some staff, be a useful ingredient in the search for the right activity that would spark a client's interest.  When a client repeatedly missed a particular class despite several warnings, or dropped out of a course but professed a general willingness to participate in the program, the participation requirement pressed program staff to reexamine what other paths the client might take, rather than accepting non-participation as an acceptable status.  The case manager had to continue to communicate -- and often struggle -- with the client over the program participation requirement.  This sustained communication could increase the chances of identifying an activity that would engage the client and help her make progress.  One Newark client, for example, entered the program with a cooperative, willing attitude; she had already graduated from high school and started a BA program at Rutgers University.  She seemed unsure of what she wanted out of school, however, and ended up dropping out of college.  The program staff quickly insisted that she attend Teen Progress workshops; she missed some classes and was warned to keep up her attendance.  By coming to the program offices, she was exposed to an allied health training program available in the same building, and ended up enrolling there and doing very well in a medical technician course.  Demonstration case managers have pointed out that some clients visited them for company or advice even when they were sanctioned; such visits were continued opportunities to guide and persuade clients towards later participation.

According to staff, continued efforts to gain compliance, or simply the long application of a sanction, had a positive effect in some cases by keeping the client aware that there was a program to turn to when it eventually became more attractive to her.  One client, for example, refused to complete intake and had been sanctioned for about 18 months when she finally showed up and said she wanted to participate in the program because, in her own words, she had become "ashamed" of being on AFDC.  Within two months she had entered an office skills training program, which she completed successfully.

The Threat of Sanctions is Often Ineffective When Clients are Less Dependent on AFDC, but Circumstances Can Change

The prospect or the reality of a sanction seemed to program staff to work in inconsistent ways, depending on client circumstances.  Based on staff perceptions of clients' circumstances and behavior, sanctions seemed least effective when AFDC was relatively unimportant to the client.  Demonstration staff pointed out that some teenage clients who were included in their mothers' AFDC grants seemed insensitive to the financial consequences of their actions because they did not have to manage their own household budget.  Some clients were unresponsive because, it appeared to the case manager, they had other non-AFDC sources of income, such as support from a boyfriend or their own unreported earnings or other income.(6)

The lives of teenage parents change, however, and some changes made clients more sensitive to the financial loss they incurred by not participating in the program or simply motivated them to pursue some productive activity.  Most obviously, teenage parents get older and in some cases become more aware of the life choices they have to make.  For example, one client described by program staff completed program intake at 14, but was then sanctioned for about a year for non-participation.  After this extended period of non-compliance, however, she came back to the program exhibiting a completely different attitude and even greater attention to her personal grooming and dress.  She completed program workshops and began attending ABE classes regularly and looking for a part-time job.

This kind of turnaround after a period of sanction largely depends on changes in the teenage parent's life and personal initiative.  For the most part, once clients were sanctioned the case managers could not devote any substantial effort to repeated attempts to persuade them to rejoin the program.  In some cases, however, ongoing contact was possible, and in a few instances even sought by sanctioned clients who resisted program activities but seemed anxious to maintain contact with program staff.  Continued contact with the teenage parent's mother sometimes helped prod a client into action -- perhaps due only to the older mother's concern about sanctions resulting from the teenage parent's noncompliance, but in some cases because the mother was earnestly seeking an ally in her own efforts to guide and motivate her daughter. 

According to program staff, some teenage mothers' relationships with men -- and changes in those relationships -- affected their willingness to engage in the program.  Case managers perceived the role of men in some clients' lives as undermining the goals of the program and the chances for their clients' progress.  In some instances, case managers saw the teenage women they worked with entering into or remaining in exploitative or abusive relationships.  Some male partners discouraged the teenage mothers from pursuing education or training.  Case managers could discuss the effects of such relationships with some clients, but more often it was their natural deterioration and dissolution, and the loss of the financial support from male partners, that led clients to respond to sanctions and reconsider the possibility of participating in the program.  Persistent contact with clients to enforce the program participation requirement can maximize chances that when such changes occur the teenage mothers will turn back to the program.  Periodic reminders while sanctions are in effect were not consistently used in the demonstration, but they might be helpful in encouraging such changes in response to the program.

Program Pressures Did Not Always Get Clients to Participate

Even the prodding of case managers and financial sanctions did not prevent some teenage parents from refusing all program activities or complying only temporarily.  Some of the teenage parents in the demonstration sample seemed to be trapped in family behavior patterns that created insurmountable barriers to participating in or benefitting from the program.  Some came from severely troubled families and lacked the personal skills and strengths to escape them.  In some such instances, case managers reported that clients were responsive to the caring attention of program staff, but that family pressures interfered with effective participation.  Case managers found clients like these to be impossible to help through a program that could not remove them from the home and neighborhood environment that had so affected their lives.

Some teenage mothers seemed to case managers to be entrenched in their dependence on public assistance.  For example, one client, whose mother was herself a long-term welfare recipient with six children, some already with their own AFDC cases, took continued evasive action over a period of two- and-a-half years to avoid any meaningful involvement with the program.  She repeatedly refused to participate, allowed sanction action to proceed against her, then agreed to comply just long enough to have the sanction lifted at least for a probationary period, and then resisted participation again, filing repeated but unsuccessful fair-hearing petitions along the way to delay or minimize her loss of AFDC benefits.  She devoted great energy and considerable intelligence to resisting the program and preserving the stability of her AFDC-based life, and seemed to have no idea of the possibility of a different life.

In some instances, neither available program services nor the pressures of demonstration sanction policy could overcome family and community views about the roles of women in society; this obstacle to participation was reported by case managers to be somewhat more common among Hispanic clients.  Hispanic teenage parents were described as more likely to emphasize their roles as mothers to the exclusion of other pursuits, and to be wary of leaving their children in child care to pursue education or training.  In addition, they more often came from an extended family in which their role as breadwinners was discounted, and when in relationships with men they were often pressured not to pursue education or training.

Creating a Setting for Open, Informal Communication Helps Make Opportunities for Case Managers to Guide and Motivate

Not surprisingly, case managers found that guiding and motivating their teenage parent clients entailed a great deal of listening, not just telling clients what to do.  A willingness to be patient and receptive and to engage in a lot of informal conversation was important for several reasons.  First, it was often only through repeated conversations, sometimes over the course of months and numerous turns in a client's commitment, that case managers became aware of the full range of home circumstances and personal strengths and weaknesses that explained the client's behavior and identified issues to be addressed.  Second, some clients developed trust in their case managers only over extended periods, and thus only slowly became willing to talk openly about important concerns.  Finally, program managers pointed out that ongoing, informal contact was important if staff were to serve in any measure as role models for clients.  Informal conversation created natural opportunities for case managers to reveal something of their own lives and, in an unforced way, to present themselves to their clients as real people whose lives offered some examples they could follow.

Much of the success of case management, therefore, is likely to hinge on the atmosphere created by the case managers, their supervisors, and the physical place where they work, and the degree to which these factors combine to encourage open and informal communication between staff and clients.  Demonstration staff in one site described their ideal of creating a "clubhouse" atmosphere at the case management unit.

Several program factors can promote such an atmosphere.  Fostering a close-knit, cooperative working relationship among staff is one important ingredient.  Case managers have to be willing to help each other, deal with each others' clients when necessary, and generally avoid "compartmentalizing" themselves and the program clients, so that clients feel they have a group of friends rather than just an "assigned worker."  Group activities at the case management offices, particularly early in clients' experience with the program, also contribute by helping them forge supportive relationships with their peers in the program.  The initial workshops that new demonstration participants went through as a group -- particularly the four-week "boot camp" regimen used in the Camden program -- were particularly useful in this respect.  Case managers reported that clients often dropped by the case management office to chat with the staff, and to meet new-found friends.  This kind of atmosphere is probably most readily created if the case management unit is housed in its own location, rather than being in a few assigned offices or cubicles in a maze of welfare offices.  Physical facilities -- such as the attractive kitchen facility installed at the Chicago demonstration program to allow preparation of healthy snacks and nutrition demonstrations -- can promote the informal clubhouse atmosphere that demonstration case managers sought to maintain.