Association between parental psychiatric illness and psychological well-being of their children.

Background: Children and adolescents are the pillars of a healthy society. Researches have explored significantly higher rate of psychopathology in children whose parents (either) have psychiatric illness in comparison to the general community (25%-50% v/s. 20%). Parental psychiatric illness (PPI) has significant long-term consequences on child's development-general health, cognitive stimulation, social, emotional, and behavioral maturity.
Objectives: The objective of this study is to assess the cognitive, emotional, and behavioral problems of children of parents with psychiatric illness. Methodology: The present cross-sectional study attempted to evaluate the factors linked with the PPI and overall child's development. Two hundred and six parents with psychiatric illness (>1-year duration) were included in the research.
Results: A total of 206 families (either mother/father) and their children 353 in number (<18 years) were included in the study. Slightly higher percentage of mother as participant was observed (56.8% v/s. 43.2%). In 80% of the families, mother was the primary caregiver of the children. Marital discord was prevalent in these families (17.9% reported by mother v/s. 31.5% reported by father).
Conclusion: Early identification of the soft indicators of the children of PPI should be identified along with the treatment of their parents. Schools should be oriented to initiative an early assessment by the evaluation of the children with psychiatrist/psychologist. Copyright:

Globally, 12%–45% of patients using the mental health services are reported to be parents.[1] Researches have reported a significant impact of parental psychiatric illness (PPI) on their children with 25%–50% experiencing higher rates of psychopathology in their lifetime in comparison to 10%–20% in the general community.[2] Higher anxiety, depressive symptoms,[3] self-inflicting behaviors, and suicidal attempts[4] are noticed in children with PPI.

PPI has significant long-term consequences on child's development, for example,-general health, cognitive stimulation, social, emotional, and behavioral maturity.[5] Families, especially children in the families having psychiatric illness, are at risk for self-stigmatization, detachment from society, and shame.[6] Various problems have been reported when such children starts going to school like-frequent drop-outs due to the presence of anti-social behavior, exhibits difficulties with disciplines and attention.[7]

Various factors are responsible for the overall outcome of the PPI on their children-genetic over load, type of parenting, frequent familial discord, socioeconomic stress, severity and chronicity and the timing of the PPI, child's developmental age, coping style of each individual, and understanding regarding the parental illness.[8] Large argument is in the favor that mental illness early in life (especially mother) has more detrimental effect on children.[9] Such children can experience more fear (regarding parent's bizarre symptoms, their future, and fear of having similar illness), uncertainty, confusion, and self-blaming.[10]

Child characteristics act as an add-on factor with mutual influence between parental mental illness and child functioning.[11] The child temperament, gender, maladjustment to the circumstances, low intelligence, and poor social skills can modify the overall influence of the PPI.[2] Many models/theories have been proposed to explain the presence of higher psychopathology in children of PPI.[12] Research done so far strongly indicates influence (positive and negative) of PPI on their children.

Various studies have given evidence of parents reporting illness to be a significant barrier against healthy parenting and also parents with mental illness perceiving parenting to be demanding and bothersome.[1314] The present study attempts to enumerate the data profile of the association of PPI with the children's behavior in the Indian context since there is dearth of studies discussing these issues.

Aims and objectives

The present study aimed to assess the cognitive, emotional, and behavioral problems in the children of parents with psychiatric illness and to evaluate the role of variables (age of onset of illness of parents, gender of parents, marital discord, chronicity of illness, compliance to treatment, family relationships, child age at onset of illness, temperament of the child, etc.,) influencing the association of PPI and child mental health.

METHODOLOGY

This cross-sectional study recruited participants from the outpatient department of psychiatry at a tertiary care center in New Delhi, India.

Participants

Two hundred and six parents with psychiatric illness were included in the study. If the parent had more than one child (<18 years’ age), than one assessment form per child was filled out. A total of 353 minor children were assessed.

The inclusion criteria for parents were as follows: Age of parents ranging between 18 and 65 years, those giving the written informed consent, one or both the parents having chronic mental illness (for at least a year): F10--F19 mental and behavioral disorders due to psychoactive substance use; F20-F29 schizophrenia, schizotypal and delusional disorders; F30-F39 mood (affective) disorders; F40-F48 Neurotic, stress-related and somatoform disorders according to the International Classification of Diseases version 10 and the couple having at least one children from the marriage. The inclusion criteria for children in were age ranging between 6 and 18 years and children staying with the parents during the entire course of parent's illness. Primary informant (Mother/Father) having active psychiatric/medical symptoms were excluded from the study. Furthermore, children having siblings suffering from any psychiatric illness were also excluded from the study to decrease the chances of biasing.

Procedure

Participants fulfilling the inclusion and exclusion criteria for the study were recruited from the psychiatry outpatient department in their steady state of illness after explaining the nature and benefit of the study and with their written consent to participate. Relevant information was collected through semistructured datasheet (includes biographical details of parents and their children and details regarding the illness) and relevant assessment tools (pediatric symptom checklist [PSC] and the Alabama parenting questionnaire [APQ]).

Pediatric symptom checklist

PSC is widely used caregiver report form identifying problem behavior in children and adolescents in terms of cognitive, emotional, and behavioral problems.[1516] In the present study, full-length parent-report version was used. It consists of 35 items, each item in Likert score 0, 1, and 2 as never, sometimes, or often. For age 4–5 years’ cutoff is 24 and above and for age 6 years and up, the scoring is 28 and above.[1718] Studies of the PSC have consistently found moderate to high test-retest reliability and correlation (r = 0.85).[1516]

The Alabama parenting questionnaire

APQ targets the parents of children and children with the age range of 6–18 years and measures the five dimensions of parenting that are relevant to the etiology and treatment of child externalizing problems: (1) Positive involvement with children, (2) supervision and monitoring, (3) use of positive discipline techniques, (4) consistency in the use of such discipline, and (5) use of corporal punishment.[19] The interpretation is based on the dominant scoring in the particular subtype. The average reliability across the APQ scales is 0.68. In the current study, the parent form was used.

Analysis

The results were analyzed using the Statistical Package for the Social Sciences (SPSS) SPSS Inc, IBM, Chicago, IL, software version 21. Descriptive analysis of the variables was carried out, making the appropriate correlations. Student t-test and the analysis of variance (ANOVA) test were used to analyze the continuous variables according to groups and Chi-square or Fisher exact test was used to analyze the proportions.

RESULTS

Sociodemographic and clinical attributes of parental psychiatric illness

A total of 206 families were recruited in the study comprising of 56.8% mothers as presenting patient (Group 1) and 43.2% fathers as presenting patient (Group 2). The mean age of the presentation of mothers was lower to that of fathers. There were no other significant differences among the groups for sociodemographic profile. In both groups, almost 60% patients were irregular in their treatment. Participants in Group 2 had more family history of psychiatric illness (12% v/s. 33.7%; P < 0.001) and higher duration of illness (5.44% v/s. 13.0%; P < 0.001). There were discrepancies in the differential distribution of diagnostic categories with Group 1 participants having more Schizophrenia, schizotypal and delusional disorder is abbreviated in the article as SSD, mood disorder (MD) and neurotic, stress-related and somatoform disorder (NSSD) but no substance use disorder (SUD) as compared to Group 2 participants [Table 1]. Group 1 had more frequency of severe mental illness in comparison to Group 2 (52% v/s. 27%) [Table 2].

Table 1

Diagnostic entities of parental psychiatric illness

Diagnostic category	Overall, n (%)	Group 1, n (%)	Group 2, n (%)	Inter group comparison
SUD	49 (23.8)	-	49 (55.1)	χ2=85.23, P<0.001
SSD	29 (14.1)	20 (17.1)	9 (10.1)
MD	56 (27.2)	41 (35)	15 (16.9)
NSSD	72 (35)	56 (47.9)	16 (18)

SUD – Substance use disorder; SSD – Schizophrenia, schizotypal and delusional disorder; MD – Mood disorder; NSSD – Neurotic, stress-related somatoform disorder; Group 1 – Mother as presenting patient; Group 2 – Father as presenting patient

Table 2

Sociodemographic and clinical variables of parental psychiatric illness

Variable	Group 1 (mother)	Group 2 (father)	t/χ2	P
Frequency (%)	117 (56.8)	89 (43.2)
Age (mean±SD)	36.43±6.48	39.64±8.16	−3.14#	0.002
Spouse age (mean±SD)	41.04±7.28	34.62±6.38	6.47#	<0.001
Religion (%)
Hindu	79.5	80.9	2.85*	0.41
Muslim	17.1	13.5
Sikh	-	2.2
Christian	2.6	3.4
Marital status (%)
Together	91.5	94.4	1.36*	0.71
Separated	4.3	3.4
Divorced	-	1.1
Widower	4.3	1.1
Marital discord (%)
Present	17.9	31.5	5.09*	0.05
Absent	76.9	67.4
Missing data	4.3	1.1
Education (%)
Illiterate	29.1	13.5	10.02*	0.11
Primary school	7.7	5.6
Middle school	21.4	32.6
High school	24.8	27.0
Posthigh school diploma	5.1	7.9
Graduate or postgraduate	11.1	13.5
Professional or honors	0.9	-
Occupation (%)
Unemployed or housewife	73.5	21.3	62.16*	<0.001
Unskilled worker	6.0	20.2
Semi-skilled worker	6.8	15.7
Skilled worker	7.7	22.5
Clerical, shop owner, farmer=	2.6	15.7
Semi-profession	-	2.2
Profession	3.4	2.2
Residence (%)
Urban	82.1	78.7	0.37*	0.59
Rural	17.9	21.3
Family type (%)
Nuclear	69.2	69.7	0.01*	0.94
Joint	30.8	30.3
Primary caregiver (%)
Mother	81.2	84.3	5.89*	0.05
Father	15.4	6.7
Others	3.4	9.0
Spouse (%)
Alive	94.9	96.6	1.73*	0.24
Dead	4.3	1.1
Missing	0.9	2.2
Treatment compliance (%)
Yes	33.3	25.8	2.23*	0.26
No	57.3	60.7
Missing	9.4	13.5
Presence of family history of psychiatric illness (%)
Yes	12.0	33.7	14.23*	<0.001
No	88.0	66.3
Number of children (mean±SD)	2,81±1.35	2.85±1.36	−0.22#	0.82
Mean monthly family income (INR)	23119.65±32628.04	19292.13±22137.20	0.95#	0.34
Mean duration of illness (years)	5.44±4.98	13.01±8.98	−7.69#	<0.001
Mean treatment duration (months)	1052.81±1359.26	1166.16±2181.26	−0.45#	0.64

#Student t-test; *Chi-square test (Fischer’s exact test if expected cell count <5). SD – Standard deviation; INR – Indian rupee

Characteristics of children of parental psychiatric illness

Age/gender

There were 188 (53.3%) male children and 165 (46.7%) female children. The mean age of children was 11.56 ± 3.71 years

Children awareness of parental psychiatric illness

About 70% (n = 247) children were aware of psychiatric illness in their parents and in 11.6% (n = 41) of child cases, parents did not know whether their children know about the illness or not.

Temperament

About 65.7% were categorized as easy child; 11.6% were slow to warm up, and 22.7% were found to be having difficult child.

Pediatric symptom checklist assessment

The total PSC scores were variably distributed (mean: 11.56 ± 10.4, median: 8.0, range: 0–50) with significant scores (i.e., >28) present in 31 (8.8%) children. No differences were observed on comparing significant total PSC scores between children of PPI Group 1 and 2 (U = 0.38, P = 0.71).

Parental psychiatric illness diagnostic category-based comparison

Overall, no differences were observed among the four diagnostic categories of PPI, apart for the presence of marital discord and family h/o psychiatric illness [Table 3].

Table 3

Differences among diagnostic entities of parental psychiatric illness

Parameter	SUD	SSD	MD	NSSD	χ 2	P
Number of children, n (%)	89 (25.2)	47 (13.3)	96 (27.2)	121 (34.3)	42.16	0.004
Boys (%)	52.8	57.4	45.8	57.9	3.11	0.32
Presence of marital discord (%)	52.8	23.4	14.6	13.2	52.68	<0.001
Presence of family history of psychiatric illness (%)	55.1	21.3	19.8	3.3	78.22	<0.001
Presence of pregnancy complications (%)	10.1	6.4	5.2	14.9	8.11	0.23
Children’s awareness of illness (%)	75.3	70.2	71.9	64.5	3.34	0.76
Temperament of child (%)
Easy child	55.1	68.1	72.9	66.9	16.68	0.11
Slow to warm up	11.2	10.6	5.2	17.4
Difficult child	33.7	21.3	21.9	15.7

SUD – Substance use disorder; SSD – Schizophrenia, schizotypal and delusional disorder; MD – Mood disorder; NSSD – Neurotic, stress-related somatoform disorder

On individual group comparisons using the Mann–Whitney U-test, there were no differences observed except between MD and NSSD participants for treatment compliance (U: 3984.00, P = 0.007), family h/o psychiatric illness (U: 4850.50, P < 0.001) and pregnancy complications (U: 5195.00, P = 0.014), and between SSD and NSSD participants for family h/o psychiatric illness (U: 2332.50, P < 0.001).

Using ANOVA, it was found that the mean illness duration (F [3]: 39.42, P < 0.001) and treatment duration (F [3]: 6.94, P < 0.001) were different among the diagnostic categories, but the PSC total scores were similar (F [3]: 0.69, P = 0.55). As shown in Table 4, a post hoc Tukey honestly significant difference (HSD) test revealed that the illness duration was more among SUD than other three groups and more in SSD than NSSD. Duration for treatment was less among SUD than SSD and MD and more in SSD than NSSD.

Table 4

Post hoc Tukey honestly significant difference among the parental psychiatric illness diagnostic categories

Dependent variable	Diagnosis (I)	Diagnosis (J)	Mean difference (I-J)	SE	Significant	95% CI
						Lower bound	Upper bound
Duration of illness	1.0	2.0	5.97*	1.22	0.00	2.83	9.12
		3.0	8.47*	0.99	0.00	5.91	11.04
		4.0	9.71*	0.94	0.00	7.27	12.15
	2.0	1.0	−5.97*	1.22	0.00	−9.11	−2.83
		3.0	2.50	1.20	0.16	−0.59	5.61
		4.0	3.73*	1.16	0.01	0.74	6.74
	3.0	1.0	−8.47*	0.99	0.00	−11.04	−5.91
		2.0	−2.50	1.20	0.16	−5.61	0.59
		4.0	1.23	0.9231	0.54	−1.15	3.62
	4.0	1.0	−9.71*	0.9432	0.00	−12.14	−7.27
		2.0	−3.73*	1.16	0.01	−6.74	−0.74
		3.0	−1.23	0.92	0.54	−3.62	1.15
T/T duration	1.0	2.0	−1227.41*	302.29	0.00	−2007.78	−447.04
		3.0	−861.21*	246.69	0.00	−1498.05	−224.38
		4.0	−470.21	234.12	0.18	−1074.57	134.14
	2.0	1.0	1227.41*	302.29	0.00	447.04	2007.77
		3.0	366.19	298.46	0.61	−404.28	1136.66
		4.0	757.19*	288.15	0.04	13.34	1501.04
	3.0	1.0	861.21*	246.69	0.00	224.38	1498.05
		2.0	−366.19	298.46	0.61	−1136.66	404.28
		4.0	391.01	229.14	0.32	−200.52	982.53
	4.0	1.0	470.21	234.12	0.18	−134.14	1074.57
		2.0	−757.19*	288.15	0.04	−1501.04	−13.34
		3.0	−391.01	229.14	0.32	−982.53	200.52
PSC_total score	1.0	2.0	−0.27	1.87	0.99	−5.10	4.55
		3.0	1.51	1.53	0.76	−2.44	5.44
		4.0	1.56	1.45	0.70	−2.18	5.30
	2.0	1.0	0.27	1.87	0.99	−4.55	5.10
		3.0	1.77	1.84	0.77	−2.99	6.54
		4.0	1.83	1.78	0.73	−2.77	6.44
	3.0	1.0	−1.50	1.53	0.76	−5.44	2.44
		2.0	−1.77	1.85	0.77	−6.54	2.99
		4.0	0.05	1.42	1.00	−3.60	3.72
	4.0	1.0	−1.56	1.45	0.70	−5.30	2.18
		2.0	−1.83	1.78	0.73	−6.44	2.77
		3.0	−0.05	1.42	1.00	−3.72	3.60

*The mean difference is significant at the 0.05 level. Diagnostic Category: 1 - SUD, 2 - SSD, 3 - MD, 4 - NSSD. SUD – Substance use disorder; SSD – Schizophrenia, schizotypal and delusional disorder; MD – Mood disorder; NSSD – Neurotic, stress-related somatoform disorder; CI – Confidence interval; PSC – Pediatric symptom checklist; SE – Standard error

Parenting assessment

Table 5 provides mean scores of parenting style among PPI for gender and diagnostic category-based groups. There was significant difference noted using Independent student t-test among ill mother and ill father groups for positive parenting parameters of involvement (t = 3.63, P < 0.001, mean difference [md]: 3.21, 95% confidence interval [CI]: 1.47–4.95) and positive parenting (t = 2.08, P = 0.03, md: 1.22, 95% CI: 0.07–2.38] but not for any of the negative parenting styles – poor monitoring, inconsistent discipline, corporal punishment, or other disciplinary practices. The group with ill mother's had more positive parenting styles as compared to ill father's group.

Table 5

Mean scores on parenting style among parental psychiatric illness based upon gender and diagnosis

Parameters	IN	PP	PM	ID	CP	ODP
Overall (n=353) (mean±SD)	31.39±8.42	21.60±5.54	20.52±7.61	17.67±3.97	8.67±2.92	14.29±2.92
Ill mother (n=192) (mean±SD)	32.86±8.34	22.16±4.96	20.36±7.82	17.87±4.18	8.77±2.96	14.39±3.20
Ill father (n=161) (mean±SD)	29.64±8.21	20.93±6.11	20.71±7.38	17.44±3.71	8.55±2.86	14.18±2.56
SUD (n=89) (mean±SD)	29.92±8.54	20.86±6.32	20.96±8.08	17.84±3.01	8.71±2.89	14.47±2.62
SSD (n=47) (mean±SD)	26.78±9.22	19.41±6.34	21.04±7.21	16.06±3.97	9.25±3.91	14.08±2.95
MD (n=96) (mean±SD)	33.57±8.01	22.67±5.07	19.31±7.06	18.19±4.63	8.64±2.91	13.86±3.27
NSSD (n=121) (mean±SD)	32.54±7.45	22.14±4.63	20.96±7.82	17.76±3.91	8.43±2.46	14.59±2.82

IN – Involvement; PP – Positive parenting; PM – Poor monitoring; ID – Inconsistent discipline; CP – Corporal punishment; ODP – Other discipline practice; SUD – Substance use disorder; SSD – Schizophrenia, schizotypal and delusional disorder; MD – Mood disorder; NSSD – Neurotic, stress-related somatoform disorder; SD – Standard deviation

Significant differences were observed between diagnostic categories using ANOVA test for positive parenting parameters of involvement (F[3] =9.07, P < 0.001) and positive parenting (F[3] =4.71, P = 0.003) and only for inconsistent discipline subscale of negative parenting style (F[3] =3.27, P = 0.02) but not for any other negative parenting styles – poor monitoring, corporal punishment, or other disciplinary practices. Post hoc Tukey HSD test revealed significant differences between the diagnostic categories for involvement among participants with SUD and MD (md:-3.65, P = 0.013, 95% CI:-6.47 to-0.55), SSD and MD (md:-6.78, P < 0.001, 95% CI:-10.53 to-3.04), and SSD and NSSD (md:-5.75, P < 0.001, 95% CI:-9.37 to-2.14); for positive parenting between SSD and MD (md:-3.26, P = 0.005, 95% CI:-5.77 to-0.75) and SSD and NSSD (md:-2.74, P = 0.01, 95% CI:-5.16 to-0.32) and for inconsistent discipline between SSD and MD (md:-2.13, P = 0.01, 95% CI:-3.94 to-0.32). Thus, there was more positive parenting style in participants with MD as compared to SUD or SSD and in participants with NSSD as compared to SSD. In the negative parenting style dimension, only inconsistent discipline was found to be higher in participants with MD as compared to SSD [Table 5].

Increasing PSC scores were negatively correlated to positive parenting style dimension of involvement and positive parenting [Figure 1] and positively correlated to negative parenting style dimension of poor monitoring and corporal punishment. Difficult temperamental characteristic of children was negatively correlated to positive parenting dimension of involvement and positively correlated to negative parenting dimension of inconsistent discipline. Higher PSC scores were positively associated with difficult temperament of children.

Figure 1

Dual-axis plot displaying distribution of pediatric symptom checklist scores amongst the various diagnostic categories and the relationship with positive parenting style

Increased illness awareness was observed in children with higher PSC scores. Increasing age of children was observed to be negatively associated to positive parenting dimension of involvement and illness awareness. From a gender perspective, boys were more positively correlated to higher PSC scores and difficult temperament. A low positive correlation was found between family history of psychiatric illness and illness awareness. Treatment compliance was observed to be poor with decreasing positive parenting style dimension of involvement and increasing negative dimension of poor monitoring [Table 6].

Table 6

Correlation among parenting style and other variables

	IN	PP	PM	ID	CP	ODP	PSC#	TEMP	IA	CA	CS	FHPI	TC
IN	-	0.71**	−0.43**	0.24**	−0.31**	0.02	−0.11*	−0.12*	0.07	−0.13*	0.05	0.06	−0.11*
PP		-	−0.40**	0.32**	−0.25**	−0.01	−0.15**	−0.07	0.03	−0.09	0.01	−0.01	−0.03
PM			-	−0.06	0.21**	0.14**	0.15**	0.09	−0.01	0.07	0.04	−0.05	0.12*
ID				-	0.10	0.13**	0.08	0.14**	−0.15**	0.07	−0.01	−0.11*	0.06
CP					-	0.17**	0.19**	0.12*	−0.04	−0.03	−0.04	0.01	0.03
ODP						-	0.08	−0.03	−0.01	−0.01	0.05	0.03	−0.08
PSC							-	0.60**	0.16**	−0.07	−0.13*	−0.10	0.06
TEMP								-	0.09	−0.09	−0.15**	−0.16**	0.05
IA									-	−0.36**	−0.05	0.11*	0.02
CA										-	−0.01	0.01	0.01
CS											-	−0.07	−0.06
FHPI												-	−0.21**
TC													-

#Using Pearson’s correlation, **Correlation is significant at 0.01 level (2-tailed), *Correlation is significant at 0.05 level (2-tailed). IN – Involvement; PP – Positive parenting; PM – Poor monitoring; ID – Inconsistent discipline; CP – Corporal punishment; ODP – Other discipline practice; PSC – Pediatric symptom checklist; TEMP – Temperament; IA – Illness awareness in children; CA – Childs age; CS – Child sex/gender; FHPI – Family history of psychiatric illness; TC – Treatment continuity

DISCUSSION

Child rearing

In the current study, majority of the parents were raising their child together, whereas previous studies have reported very high percentage of single parents (~4% in the present study v/s ~ 50% in previous study).[20] In Indian culture, divorce/separation is still stigmatized/not encouraged; this might be the reason for the low rate of single parent in the present study despite the higher rates of marital discord in these parent profiles.

A slightly larger proportion of mother as a representative parent with mental illness was reported, consistent with the previous studies reporting more female group consulting the health setup in comparison to their male counterpart.[20]

Difference in psychiatric diagnosis among parents

Almost half of the group 1 (mothers) presented with neurotic spectrum of illness (dissociative disorder and somatoform disorder), whereas more than half of the group 2 (fathers) presented with SUD, inconsistent with the previous studies reporting MDs to be most prevalent in both groups.[20]

The higher prevalence of family history of psychiatric illness in Group 2 was attributable to higher prevalence of SUD in the latter group as compared to the Group 1 mothers. Most of the parents had serious psychiatric illness in Group 1 − Mother (53%), which could act as a significant high risk factor in their children's overall development consistent with the studies done so far.[21]

Awareness of parental illness in their children

Majority of the children were aware of their PPI in contrary to the studies done previously (70% v/s. 30%).[22] Reasons for this discrepancy could be (1) Majority of the children were staying in the nuclear family with the parents, (2) mother was the main caregiver of the children who was suffering from mental illness, and (3) majority of the parents were not on regular treatment leading to increase in the severity and in turn identification of the illness symptoms. Studies on the needs of child of parents with mental illness have reported following concerns-lack of information of their parent's illness, lack of knowledge to deal with parent's illness, strained family dynamics, and lack of support system. Therefore, it is very important to discuss parent's mental illness with their children to improve the overall family development.

Studies have reported awareness of illness in children to be increasing with the age, i.e., older children to be more aware of the illness, whereas in the present study, younger children were more aware of the illness. Reason could be different children profile of the present study with higher younger child participants.[22]

Awareness of PPI was more common in parents with severe mental illnesses (though not significantly high), similar to previous studies. Reasons explained are more functional impairment in parents leading to the early identification of the illness.[20] Severe mental illness used in the present study meant the mental illness considered as severe in accordance to National Institute of Mental Health, i.e., schizophrenia, severe major depression, and bipolar disorder.

Temperament

More of difficult temperament was observed in children of SUD parents. Evidence of the studies done so far favors higher prevalence of temperamental disturbances with the parental psychopathology but other factors influencing the same cannot be ruled out-low socioeconomic status, marital discord, poor parenting, and positive family history of psychiatric illness. The PPI, duration of the illness, and treatment duration did not contribute to the temperament variation in the children.[23]

In the present study, association was found between parenting style and the temperament of the child-difficult temperament to be associated with negative parenting dimension of inconsistent discipline. Studies on parenting and temperamental behavior have reported poor sociability and emotional response in families which adapt low demand and high responsiveness as there parenting style.[24]

Nezhad et al., reported low and high negative emotions with mother's behavioral and father's psychological control, respectively.[25] The present study reported more inconsistent discipline and less positive parenting in child with difficult temperament (and High PSC score) indicating toward correlation between negative parenting worsening/leading to difficult temperament. Study on off springs of bipolar disorder parents (6–18 years) observed slow to warm up/difficult child to be more prevailing with negative parenting.[26]

More difficult temperament is observed in depressed parents in previous literature and in SUD in the present study in male child and psychosis and MD in female child.[27] The difference in the findings might be due to the difference in the distribution of the illness in the two studies. The present study reported more of difficult temperament in males with increasing behavioral symptoms.[28]

Parenting style

It was observed that positive parenting was more prevalent in families having psychiatric illness in mothers. Reason could be (1) presence of more of neurotic spectrum of disorder in comparison to families having psychiatric illness in father, (2) mothers are more emotionally attached to their children in comparison to father despite the presence of illness, and (3) majority of the mothers being house wife tend to spend more time with their children. Researches have reported mixed result regarding correlation of parenting style with the type of diagnosis. Studies have reported association between parenting style and the mental health of the child.[29] Poor parenting style has been linked with behavioral problems such as conduct disorders, externalizing behaviors, and indulgence in risk taking behaviors (substance).[30]

In the present study, positive parenting was less prevalent in parents diagnosed with psychosis similar to previous studies with lesser degree of involvement, harsh punishment in patients with psychosis/depression.[31] In the present study, all diagnostic entities had more involvement and lesser corporeal punishment to children that could be due to the attitude of Indian parents to support their children at every stage of their life.

Similar to current findings, Hasumi et al., assessed parental involvement and mental well-being on adolescents in Indian set up and noted parental involvement to be decreasing with age of the child.[32] Studies on SUD in father have reported more of indifference, abuse and over control on their children in concordance with the current findings.[32] Sunju et al., studied correlation of parent's depressive symptoms with the parenting style and found no association between the two, whereas the current study found MD to be associated with more positive parenting in comparison to other psychiatric illnesses.[33]

Mental health services should also focus on assessment of the off springs of PPI. Specific guidelines should be developed for the proper assessment and treatment of high risk children. Future research would benefit from studies on the association of temperament and parenting style with varied PPIs. Existing preventive measures for the children of parents suffering from psychiatric illness also need up gradation.

Limitations of the present study

Small sample size with no comparison with health group was the major limitation. Therefore, this restricts the generalizability of findings and the interpretation with regard to specificity Information regarding the children (temperament, illness awareness details, details of emotional and behavioral domains, etc.,) were taken from the parents only due to the ethical issues and were not measured on a standard instrument limiting the generalizability of findings.

CONCLUSION

The present study has attempted to provide platform for more elaborative research on potential risk factors attributing to unusual behavior in off springs of PPI. The following are the main highlights of the present study – Higher psychopathology was observed in children having difficult temperament. On screening, about 8% of children were screened positive through PSC. Families with poor parenting styles had more children with difficult temperament. Awareness of PPI was associated with negative impact on the children (higher PSC scoring). Poor treatment compliance was associated with poor child monitoring.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.