Comparison of maternal stress and psychiatric morbidity among mothers of children having psychiatric disorders and those of typically developing children.

INTRODUCTION: Motherhood is regarded to be stressful, but when the child has a psychiatric illness, the mother is affected more than the father since she is the primary caregiver. She gets affected not only emotionally but also psychologically. Increasing severity of stress in mothers may lead to negative outcome on a child's care. AIMS: The aim of this study was to evaluate the stress levels in mothers of children diagnosed with psychiatric disorder and to study the association between children having a psychiatric disorder and the psychiatric morbidity in their mothers.
MATERIALS AND METHODS: This was a case-control study with a total of 150 participants, in which 75 consecutive mothers of children were diagnosed with any psychiatric illness using ICD-10 criteria and compared to 75 mothers of typically developing children. The study was approved by the Institutional Ethics Committee. The Parental Stress Scale and the Mini-International Neuropsychiatric Interview-Plus questionnaire were used for assessments.
RESULTS: The study showed statistically significant stress scores (49.54) in mothers having children diagnosed with psychiatric illnesses as compared to scores (30.98) in mothers of normally developing children. Psychiatric morbidity in cases (n = 58; 77.3%) was statistically significant as compared to controls (n = 23; 30.6%). Depression and anxiety were among the most common psychiatric morbidities evaluated, and the highest was for mothers having children with severe mental retardation.
CONCLUSION: In all children with psychiatric disorders, mothers have to be screened for psychiatric morbidity to prevent, detect, and manage it at the earliest. Copyright:

INTRODUCTION

Motherhood is regarded to be stressful, but when the child has a psychiatric illness, the mother is affected more than the father since she is the primary caregiver.[1] The mother gets affected not only emotionally but also psychologically.[2] Childhood here is defined as a child born from birth until he/she attains 18 years of age and needing constant attention and nurturing. Childbirth is a major event, hugely affecting the family dynamics, and is associated with joy, dreams, aspirations, and hopes for themselves as well as the newborn. However, parenting is a demanding job which gets more so the case when the child is suffering from a mental illness.[2] In India, the majority of persons with mental disorders have traditionally been cared for by their families, especially by mothers. Taking care of a child with psychiatric illness such as autism, attention deficit, and hyperactive disorder, bipolar affective disorder or specific learning disability would put a lot of stress and anxiety on the mothers.

In India, many investigators have studied the prevalence of psychiatric disorders in children, and there is a wide range in prevalence rate from 0.48%[3] to 29.40%.[4] The weighted mean average prevalence rate of psychiatric disorder was found to be 6.46% (95% confidence interval: 6.08%–6.88%) for the community-based studies. For the school-based studies, the prevalence was found to be 23.33% (95% confidence interval: 22.25%–24.45%).[5]

The most common mental health consequences identified are anxiety and depression in mothers, which occur when they slip beyond exhaustion.[6] There is an increasing parental burden in the form of interferences in the family routine, which results in social, marital, familial, and emotional problems. Stress often appears to increase with the age of the afflicted child and is based on the daily caregiving demands of the child.[7] Other general factors affecting stress include parental locus of control, self-esteem, family support, social isolation,[89] as well as financial status of family,[7] whereas each parent has a unique style to cope with the situation they face. Emotion-based coping mechanism makes them prone to psychiatric illness, and the use of problem-based coping mechanism may have a positive impact on the stress of the parent.[7] We set out to look at the stress among mothers having child/children with any psychiatric illness and psychiatric morbidity among such mothers compared to mothers of a typically developing child.

Aims

The aim of this study was to evaluate the stress levels in mothers of children diagnosed with psychiatric disorder and also to study the association between children having a psychiatric disorder and the psychiatric morbidity in their mothers.

MATERIALS AND METHODS

It is a case–control study conducted in the Department of Psychiatry, Yenepoya Medical College and Hospital, after obtaining ethical clearance from the Institutional Ethics Committee from November 2017 to March 2019.

The sample was calculated using the formula, n = Z, at 95% confidence interval, standard normal deviate = 1.96 (Z), and power = 80%, a sample size of 150 was obtained. Typically developing children had no psychiatric diagnosis/ treatment based on history and on cross-sectional clinical examination had no psychiatric diagnosis. Out of the total 150 participants, 75 consecutive mothers of children diagnosed with any psychiatric illness in the outpatient department and inpatient department using ICD 10 criteria, mothers of children up to 18 years of age and who were able to understand and respond to the questionnaire were included as cases and 75 mothers of typically developing children were approached from the schools in the vicinity and visitors coming to the campus fulfilling the criteria were taken as controls. Mothers of children with predominant physical illnesses and children with primary caregivers other than mothers were excluded from this study. None of the mothers refused consent for the study among the control group; however, three mothers refused consent among the cases citing lack of time.

Demographic details were collected using a specially designed pro forma for both the mother and the children. After this, the Parental Stress Scale was used to measure maternal stress[10] and theMini-International Neuropsychiatric Interview (M.I.N.I) Plus questionnaire version 5.0.0 (DSM-IV) 11 was used to measure the psychiatric morbidity in the mothers included in cases and controls by the principal investigator.

Data obtained were recorded in MS Excel worksheets, and statistical analysis was done using the Statistical Package for the Social Sciences version 23 (IBM Corporation, New York, USA) program running on Windows Operating System. Categorical variables were displayed in terms of percentages and proportions. Continuous variables were expressed as mean and standard deviation. Student's t-test and ANOVA were used to test the statistical significance. Post hoc analysis was done to analyze the difference between the means of specific groups.

RESULTS

Sociodemographic details: A total of 150 children and their mothers were included in the current study. They were divided as:

Cases: 75 mothers with psychiatrically ill children

Controls: 75 mothers with normal children.

Table 1 shows the sociodemographic details of the study population. Among the mothers, 25.3% were aged between 31 and 35 years, followed by the other age grouped mothers in both cases and controls. Out of 150 mothers included in the study, 101 were married, 23 were widows, 19 were separated, and 7 were divorced. According to our results, we also found that 72 (48%) mothers belonged to Hindu religion, 49 (32.7%) to Muslim, and 29 (19.3%) to Christian religion. Majority of them resided in urban areas (63; 42%) and belonged to the middle socioeconomic status (67; 44.7%). A comparative study with Chi square analysis was carried out, however the difference was not found to be significant [(Chi- square value= 1.076, P = 0.584)]. Among all the included children, 48.7% were aged between 7 and 12 years of age and the other 26% were in 1–6 years and 25.3% in 13–18 years. Out of the total children included, 86 (57.3%) were boys and 64 (42.7%) were girls.

Table 1

Sociodemographic distribution of mothers and children in the study

	Groups		Total
	Case	Control
Mother age (years)
18-25	8 (27.6)	21 (72.4)	29 (19.3)
26-30	12 (41.4)	17 (58.6)	29 (19.3)
31-35	21 (55.3)	17 (44.7)	38 (25.3)
36-40	18 (64.3)	10 (35.7)	28 (18.7)
41-45	16 (61.5)	10 (38.5)	26 (17.3)
Education status
Illiterate	5 (71.4)	2 (28.6)	7 (4.7)
Primary	34 (73.9)	12 (26.1)	46 (30.7)
High school	23 (39.7)	35 (60.3)	58 (38.7)
Higher secondary	11 (39.3)	17 (60.7)	28 (18.7)
Graduate	1 (12.5)	7 (87.5)	8 (5.3)
Postgraduate	1 (33.3)	2 (66.7)	3 (2)
Marital status
Married	49 (48.5)	52 (51.5)	101 (67.3)
Separated	9 (47.4)	10 (52.6)	19 (12.7)
Divorced	4 (57.1)	3 (42.9)	7 (4.7)
Widow	13 (56.5)	10 (43.5)	23 (15.3)
Socioeconomic status
Low	31 (56.4)	24 (43.6)	55 (36.7)
Middle	34 (50.7)	33 (49.3)	67 (44.7)
High	10 (35.7)	18 (64.3)	28 (18.6)
Other children in family
Yes	5 (100.0)	0 (0.0)	5 (3.3)
No	70 (48.3)	75 (51.7)	145 (96.7)
Showing distribution of children in the study
	Groups		Total
	Case	Control
Age group of children (years)
1-6	17 (43.6)	22 (56.4)	39 (26)
7-12	37 (50.7)	36 (49.3)	73 (48.7)
13-18	21 (55.3)	17 (44.7)	38 (25.3)
Gender of children
Male	50 (58.1)	36 (41.9)	86 (57.3)
Female	25 (39.1)	39 (60.9)	64 (42.7)
School-going status of children
Yes	38 (42.2)	52 (57.8)	90 (60)
No	37 (61.7)	23 (38.3)	60 (40)
		Cases, n (%)
Age at diagnosis (years)
1-6		37 (49.3)
7-12		23 (30.7)
13-18		15 (20)
Duration since diagnosis
Days		28 (37.3)
Years		47 (62.7)
Nature of child’s psychiatry illness
Temporary		27 (36)
Chronic		14 (18.7)
Permanent		34 (45.3)
Type of treatment given
Medication		41 (54.7)
Therapy		14 (18.7)
Medication + therapy		20 (26.6)

The varied diagnosis of the children is providing in Table 2, with 16% of the children with mild mental retardation (MR) and 13.3% with autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). On Student t test, this study found a higher mean stress scores among the cases (49.5 ± 12.1) compared to controls (30.9 ± 7.5), [t(148) = 11.24, P = 0.00]

Table 2

The varied diagnosis in included children

	n (%)
Mild MR	12 (16)
Moderate MR	6 (8)
Severe MR	6 (8)
ASD	10 (13.3)
ADHD	10 (13.3)
ADHD + conduct disorders	4 (5.3)
Specific learning disorders	4 (5.3)
Tic disorder	2 (2.7)
Dissociation	4 (5.3)
BPAD	2 (2.7)
Depression	3 (4)
Substance use disorder	7 (9.3)
Substance use + conduct disorder	3 (4)
Nocturnal enuresis	2 (2.7)

MR – Mental retardation; ASD – Autism spectrum disorder; ADHD – Attention-deficit/hyperactivity disorder; BPAD – Bipolar affective disorder

Table 3 reveals that among the included mothers, 58 mothers had psychiatric morbidity in the children diagnosed with psychiatric disorders and 23 had psychiatric morbidity among mothers of normal children. There was a significantly high level of stress score in the cases when compared to the controls. The mothers with psychiatrically children had a significant high-stress level in comparison with the mothers having normal children.

Table 3

The mean difference between stress scores of mothers in cases vs. controls using ANOVA

	n	Mean	SD	Minimum	Maximum	Significant
Psychiatric morbidity in mothers (cases)
Present	58	53.06	10.88	29.00	71.00	<0.001
Absent	17	37.52	8.15	27.00	52.00
Psychiatric morbidity in mothers (controls)
Present	23	39.91	5.34	32.00	54.00
Absent	52	27.03	4.20	20.00	39.00

P<0.05 considered statistically significant, P<0.001 is statistically highly significant. SD – Standard deviation

There was a statistically significant difference of mean stress scores between groups as determined by one-way ANOVA in them F (3,146) = 98.06, P = 0.001 [psychiatric morbidity among cases present (A), psychiatric morbidity among cases absent (B), psychiatric morbidity among controls present (C), psychiatric morbidity among controls absent (D)]. The psychiatric morbidity among the mothers had a significant effect on the mean stress score. A post hoc Tukey's analysis [Table 4] revealed that the mean stress score for psychiatric morbidity among cases present group (53.06 ± 10.8) was significantly higher than the psychiatric morbidity among cases absent group (37.52 ± 8.15), psychiatric morbidity among controls present group (39.91 ± 5.34), and psychiatric morbidity among controls absent group (27.03 ± 4.20). There was statistical significant difference in mean stress score among psychiatric morbidity among cases absent group with psychiatric morbidity among controls absent group.

Table 4

The post hoc analysis of Tukey for the significance among mothers with psychiatric morbidity in case and control groups

	Mean difference (I-J)	SE	Significant
Mothers’ morbidity in cases present
Mothers’ morbidity in cases absent	15.53*	2.20	<0.001*
Mothers’ morbidity in controls present	13.15*	1.96	<0.001*
Mothers’ morbidity in controls absent	26.03*	1.52	<0.001*
Mothers’ morbidity in cases absent
Morbidity in controls present	−2.38	2.55	0.787
Morbidity in controls absent	10.49*	2.22	<0.001*
Morbidity in controls present
Morbidity in controls absent	12.87*	2.0	<0.001*

*- Denotes the statistically significant resultsP<0.05 considered statistically significant, P<0.001 is statistically highly significant. SE – Standard deviation

Table 5 lists the psychiatric morbidities that were screened in the mothers among both the case and control groups.

Table 5

Distribution of morbidities among the mothers of cases and controls

	Groups, n (%)		Total
	Case	Control
No morbidity	17 (24.6)	52 (75.4)	69 (46)
Current major depression	10 (90.9)	1 (9.1)	11 (7.3)
Major depression episode of melancholia	9 (100.0)	0	9 (6)
Dysthymia	12 (60.0)	8 (40.0)	20 (13.3)
Panic disorder current	11 (61.1)	7 (38.9)	18 (12)
Generalized anxiety disorder	16 (72.7)	7 (27.3)	23 (14.7)

Stress level among the mothers with a child diagnosed with psychiatric illness in the family is higher, and increase level is found in different age groups, with a significant difference of stress level with children between 1 and 6 years compared to children with 13–18 years.

It is also found that the mean stress score in mothers was higher with increase in the age of the child on doing a post hoc analysis using Games-Howell. Mothers having a first child diagnosed with a psychiatric illness had a significantly higher level of mean stress scores as compared to a child of other birth orders being affected.

Mothers having more than one child being diagnosed with a psychiatric illness have higher stress scores. Stress level among the mothers whose child's diagnosis is made recent was significantly lower compared to mothers having a long-standing diagnosed psychiatrically ill child. It is also assessed that stress scores in the mothers having children diagnosed with severe MR were highest, followed with children having substance use disorders, substance use with conduct disorder, and ADHD with conduct disorder.

In the mothers assessed, it is found that among the ones who had a child diagnosed with mental illness, majority were diagnosed with generalized anxiety disorder (n = 16), followed by dysthymia (n = 12) and panic disorder current (n = 11).

DISCUSSION

Stress among parents and mothers is not an inevitable consequence of having a psychiatrically ill child in the family. It is a combination of multiple stressors playing a predictable experience of stress and morbidity in mothers. One hundred and fifty mothers included in this study were assessed for stress and psychiatric morbidity and compared to the controls.

The sociodemographic distribution reveals that the children of mothers included in the current study were aged between 1 and 18 years. Among them, majority of the children were falling in the age range of 7–12 years both in cases and controls. Out of the 150 children, 90 were school going and 60 nonschool going (61.7% in cases). Mothers belonged to the age group ranging between 18 and 45 years, with majority of them aged between 31 and 35 years. In cases, a major portion of the mothers belonged to the age of 31–35 years (n = 21). This was similar to the findings in another researcher's study.[12]67.3% of the mothers belonged to joint family, and 32.67% belonged to the nuclear family type.

Most of the mothers were educated till high school (n = 58), followed by primary schooling (n = 46), only seven mothers were illiterate, and three had done postgraduate as the highest educational qualification. It is explained in previous studies that mothers' level of education influences treatment and care of such children in family.[12]50% of the mothers were unskilled and 26% were unemployed and were dependent on the family head for economic stability of the family. Sixty-seven mothers belonged to middle class of socioeconomic status, 55 were in low status, and 28 in high status. A self-earning mother shows a positive strength of care and independence to care children as explained in a survey by the National Mental Health.[13]

Family life of mothers showed that 101 mothers in cases and controls were presently married at the time of inclusion in the study, and the child was taken care by both husband and wife together, 23 were widows, 19 of them were separated from husband, and 7 were divorced. The broken families always have a negative impact on children and mothers, which is exaggerated by the fact that household responsibility cannot be shared with any.[8] The presence of another child having a psychiatric illness was found in five mothers, which further increases, the stress as well as makes them prone to a greater risk of developing a psychiatric illness themselves.

Psychiatric illness in children

A major portion of the children diagnosed with psychiatric illness were in the age group of 16 years (n = 37) and 7–12 years (n = 23). These findings were similar to the study conducted by Majumdar et al.[8]

Among the case group of mothers, a pattern of psychiatric diagnosis made in their children included the following: mild MR (n = 12), ASDs (n = 10), and ADHD (n = 10). Seven children were with the substance abuse and 8 children had moderate and severe MR, respectively. Other diagnoses made in the child included ADHD + conduct disorders, specific learning disorders, tic disorders, dissociation, bipolar affective disorders, depression, and nocturnal enuresis. A similar pattern of disorders in children was documented by various authors in their studies.[121415]

Treatment modalities in children

Forty one children required medication as treatment and the other 14 required therapy and 20 children required medication + therapy. Among all the 75 children with psychiatric disorders, 34 had permanent illness, 27 had temporary disorder, and 14 had chronic illness. Previous studies suggest that chronic psychiatric illness in children had an added burden on their families. It also caused stress, anxiety, and morbidities in their mothers.[1617]

Stress score and morbidity in mothers

Stress score analysis was done using questionnaire to all the mothers. Mean stress scores in mothers belonging to the case group (49.54 ± 12.16), which was significantly high compared to the mothers with normal developing children (30.98 ± 7.5) [Table 3]. This clearly showed that mothers who had children with psychiatric illness had a higher stress level. This finding is very similar to the study done in the past.[8] Studies have also documented the same findings with various psychiatric illnesses that have a strong association with morbidities in mothers.[101218]

When analyzed in various subgroups (four subgroups) of mothers (cases with and without psychiatric morbidity versus controls with and without psychiatric morbidity), there was a significant difference in mean stress level [Table 4]. Post hoc Tukey's between-group analysis revealed the following findings that mothers with psychiatric morbidity in cases had a significantly higher mean stress score compared to those who were not morbid. In controls, mothers with psychiatric morbidity showed a significantly high-stress score compared to mothers with no morbidity. There was no significant difference in mean stress score of mothers without morbidity in cases against morbid mothers in controls. Regardless of having children diagnosed with psychiatric illness, mothers with psychiatric morbidity had a higher stress level compared to mothers who were not morbid. This clearly shows that the presence of psychiatric morbidity increases stress levels independently.

When analyzed for mean stress score according to the age group of the children, the mean stress score in mothers was increasing with increase in the age of children. There was a significant difference in mean stress scores in mothers of children aged 1–6 years (43.58 ± 8.79) when compared to 13–18 years (54.52 ± 13.80). This difference can be due to various factors, which include peer children and their development in social and educational status. Mothers being the sole caretaker of the children in Indian setup, they are under high stress about the future of their children including their marriage. These findings are in line with the studies of Beckman,[19] Burden,[20] and Bradshaw and Lawton.[21]

Similar to the other studies, our study had a mean Stress score significantly high in mothers caring for a child diagnosed with psychiatric illness for many years compared to the ones diagnosed very recently, as the mothers of a newly diagnosed child had no forethought of children's future and the special care required.[21]

In our study, mothers having their first child diagnosed with a psychiatric illness had a significantly higher level of mean stress scores when compared to the mothers whose second or third ordered child was having a psychiatric illness. These findings were similar to another study in the past.[22]

There is a high level of mean stress score in mothers with children having severe MR (65.5 ± 4.8) compared to other disorders, followed by substance use disorders (63.42 ± 7.48) and ADHD with conduct disorders (59.75 ± 6.84). A similar pattern was discussed by Beckman in their study.[19]

Morbidity among mothers

Psychiatric morbidity among cases

Fifty eight mothers having a child diagnosed with a psychiatric illness showed psychiatric morbidity compared to 23 mothers with normally developing children. Similar findings were observed in other studies.[1623]

In the present study, various morbidities were found in mothers. Among them, majority suffered with generalized anxiety disorders (GAD) (n = 16 cases and n = 7 controls), followed by dysthymia (n = 12 cases and n = 8 controls), panic disorder current (n = 11 cases and n = 8 controls), major depression (n = 10 cases and n = 1 control), and major depression with melancholia (n = 9 cases). A similar finding was seen in a study done by Babu and Eliza, in which depression and anxiety disorders were major morbidities suffered by mothers with psychiatric children.[14] It was also seen that mothers whose children were diagnosed with MR and ASD had dysthymia and depression, whereas those with children having ADHD and substance use disorders had GAD and panic disorders.

A study from The Netherlands by Middeldorp et al. reported that both fathers and mothers are at increased risk for psychiatric problems at the time of a child's evaluation and that their problems are equally associated with their offspring problems.[24] Wesseldijk et al. also concluded that families of children with psychopathology are at higher risk of having affected parents, and it is necessary to screen both parents.[25]

The significant results of this study were that mean stress scores in mothers belonging to cases were significantly high compared to the control population, the mean stress score in mothers was higher with increase in the age of child, mothers having a first child diagnosed with a psychiatric illness had a significantly higher level of mean stress scores, and mothers having more than one child being diagnosed with a psychiatric illness have more stress.

The strengths of this study are that it has a good sample size of 150, validated standardized questionnaires used, minimal refusal of consents, included all children with ICD-10 coded psychiatric illnesses, mothers included were the primary caregivers, children with predominant physical problems were excluded and an equal control group.

However, limitations are that it is a cross-sectional study design, a study done in a tertiary care hospital setting which may include more severe cases, past psychiatric morbidity in mothers was not formally assessed. Future directions to improve the study would be to have an interventional study design in order to see improvement in stress scores with treatment and to have samples for the study taken from the community.

CONCLUSION

In management of children with psychiatric illnesses, mothers have to be screened for psychiatric morbidity to prevent, detect, and manage it at the earliest.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.