| Abstract|| |
Aim of the Study: This study aims to evaluate the parenting skills of patients with schizophrenia as perceived by themselves and their children and compare the same with a matched healthy control group of parents and their children.
Materials and Methods: Fifty-one patients with schizophrenia and their 51 children were assessed on the Alabama Parenting Scale. A healthy control group of 51 parents and their children were also assessed for parenting.
Results: The mean age of parents with schizophrenia was 45.23 years. Compared to the parents in the healthy control group, patients with schizophrenia reported deficits in the domains of positive involvement, positive parenting; more often report poor monitoring/supervision, and inconsistent discipline. When the children of patients with schizophrenia and children of healthy parents were compared, children of healthy control parents reported higher positive involvement, positive parenting; and lower corporal punishment and inconsistent discipline. Except for few associations, parenting was not affected by demographic and clinical profile of the patients with schizophrenia.
Conclusion: The present study suggests that patients with schizophrenia have deficits in parenting and there is a need to improve the parenting skills of the patients with schizophrenia.
Keywords: Deficits, mental illness, parents
|How to cite this article:|
Rabha A, Padhy SK, Grover S. Parenting skills of patients with chronic schizophrenia. Indian J Psychiatry 2021;63:58-65
| Introduction|| |
Schizophrenia is a severe mental illness, which is often associated with deficit in functioning even after resolution of symptoms. The persistent deficits seen in the personal, social, and occupational spheres can interfere in role functioning.,, Schizophrenia is primarily an illness, which starts at a young age, either before marriage or in some cases onset is after marriage. Available data also suggest that persons who experience psychotic disorder become parents on an average at 20 years of age, with 35% developing psychotic illness before becoming parent. Although schizophrenia starts prior to marriage in some of the cases, a significant proportion of these patients get married and have children in long run., Available data suggest that more than half of the women and around a quarter of men with psychotic disorders are parents.
Managing symptoms and meeting parental role obligations places immense pressure on people with severe mental illnesses, their family and friends., A diagnosis of schizophrenia is considered to be a stronger predictor of poor mother–infant interaction than severity, duration of illness, higher medication dosage, socioeconomic status, or poor social stability/support. Illness severity assessed by longer duration of illness and lifetime presence of symptoms such as hallucinations, delusions, subjective thought disorder, and self-harm have also been shown to be associated with lower quality of care of children. Available evidence suggests that women with schizophrenia do not bond well with their infants., Children are most severely affected when the parental mental disorder is recurrent and chronic. Paternal psychotic illness induces chaotic ambivalent communication, severe impairments in the ability of parenting, parenting stress, disorganized and disrupted parenting as well as maladjusted relationship.
Children of patients with schizophrenia face double jeopardy, i.e., genetic and environmental (parenting) vulnerability to have adverse outcome. Infants of women with schizophrenia are described as poorly developed when compared with infants of healthy mothers. Parental behavior such as distorted expressions of reality or strange behaviours/beliefs is considered as the root cause for children experiencing anxious, confused, perplexed relationship with their parents and attachment problems. Children of patients with schizophrenia have also been shown to more often experience psychiatric disturbances, have more problems associated with school, less contact with relatives and more at-home time. Further, as the child grows up, inconsistencies in parenting puts extra responsibilities on children of ill mothers. Children of mothers with schizophrenia have also been shown to be abused by their mothers and abandoned by their fathers. Further, the marital/live-in relationships are often fragile and many children witness the divorce or separation of their parents. Children of parents with a mental disorder are often in fear of stigmatization; the children also experience fear, anger, abandonment, isolation, guilt, and shame. The impact on children can last until adulthood, in the form of problems with work and marriage, lower self-esteem, increased consumption of alcohol, increased tendency of isolation, and the development of mental disorders.
Accordingly, it is suggested that, clinicians managing patients of schizophrenia, should not limit themselves to the management of clinical issues of the patients, but also focus on their parenting skills, so as to minimize the negative impact on their children. Very few studies from India have evaluated the parenting skills of patients with schizophrenia and its impact on their offspring. A study from Delhi reported psychosocial environment in families, in which mother was suffering with schizophrenia and showed that the familial environment is characterized by distorted intrafamilial relationship and communication along with abnormal upbringing. However, none of these studies from India have evaluated the parenting skills of patients with schizophrenia. In this background, this study aimed to evaluate the parenting skills (positive involvement, positive parenting, poor monitoring and supervision, inconsistent discipline techniques, and use of corporal punishment) of patients with schizophrenia as perceived by themselves and their children and compare the same with healthy controls.
| Materials and Methods|| |
This cross-sectional study was conducted in a tertiary care public funded institute. All the participants were recruited after obtaining assent from the children and written informed consent of the parents. The study was approved by the ethics committee of the institute. The study sample was recruited by purposive sampling. This study aimed to evaluate the parenting, family quality of life and impact of parental schizophrenia on children in the form of abuse and maltreatment faced, perceived stress, coping, stigma experienced, and prodromal symptoms in children of patients with schizophrenia. In this paper, we present the data of parenting.
The study included 51 patients with schizophrenia along with their children and 51 healthy parents along with their children.
To be included in the study, the parents were required to be diagnosed with schizophrenia as per the Diagnostic and Statistical Manual of Mental Disorder-IV criteria, based on the Mini International Neuropsychiatric Interview-PLUS (MINI-PLUS), currently in remission at least for 6 months (as per Andreasen et al. criteria), having illness duration of more than 15 year and having at least 1 unmarried biological child in the age range of 15–20 years. Patients with the current/past history of any substance use disorder (other than tobacco), comorbid intellectual disability, organic brain syndrome, and major chronic physical illness. If the spouse was diagnosed with schizophrenia, bipolar affective disorder, obsessive compulsive disorder, major depressive disorder, recurrent depressive disorder, and substance dependence disorder (other than tobacco) were excluded.
The inclusion criteria for the children of patients with schizophrenia were aged 15–20 years, currently single and living with the parent with schizophrenia for at least 5 years. The presence of intellectual disability, organic brain syndrome, and a diagnosis of severe mental disorder (i.e., schizophrenia, bipolar affective disorder, obsessive–compulsive disorder, recurrent depressive disorder, and substance dependence disorder) led to exclusion of children.
Individuals in the control group (parents and children) were recruited by purposive sampling from those attending various outpatient services of the hospital and from the hospital staff. Both parents and children were screened for any psychopathology using MINI-screen and those found negative for any psychiatric disorder were included.
Patients with schizophrenia were evaluated on Positive and Negative Syndrome scale for Schizophrenia (PANSS) to rate the psychopathology and assess clinical remission in parents with schizophrenia. Modified MINI Screening instrument was used to screen the children for the presence of any psychiatric disorder.
Parenting was assessed using Alabama Parenting Questionnaire (APQ),, for both the groups. This is a 42-item self-report questionnaire, in which items assess five dimensions of parenting which are considered to be useful in understanding the etiology of externalizing problems in children. The scale has both parent and child form. The five-dimensions include positive involvement with children, positive parenting, poor monitoring and supervision, inconsistent discipline techniques, and use of corporal punishment. Each item is rated on a 5-point scale (never, almost never, sometimes, often, and always). The scale has acceptable reliability for various items (0.5–0.9) and internal consistency (0.68). It has good criterion validity in differentiating clinical and nonclinical groups., For this study, both child and parent forms were used to assess the perception of children about the parenting received from a parent with schizophrenia and also to assess the perception of own parenting by a parent with schizophrenia. Permission was obtained to use, translate and adapt the scale to Hindi. Hindi translation and adaptation were done by following the World Health Organization methodology.
For this study, parents in both the groups were approached by purposive sampling and those who fulfilled the selection criteria were recruited after obtaining written informed consent and assent. The assessments were carried out over one session.
Data were analyzed using (SPSS for Windows, Version 14.0. Chicago, SPSS Inc.). Categorical variables were described using frequency/percentage. Continuous variables are described using mean and standard deviation along with range. Comparisons were done using Chi-square test and t-test. The association of parenting and other variables was studied using Pearson's correlation coefficient and Spearman's correlation coefficient.
| Results|| |
The study included 51 patients with schizophrenia and their children and 51 healthy control parents and their children. The mean age of parents with schizophrenia was 45.23 years and two-third of them were educated beyond 10th. More than half of the parents with schizophrenia included in the study were male (56.9%), were employed (56.9%), and from nuclear families (52.9%). When the demographic profile of male and female patients was compared, significantly higher proportions of male patients were educated beyond 10th (Chi-square test value - 2.98; P = 0.004) and were employed (Chi-square test value - 5.25; P < 0.001). Comparison of demographic profile of patients with schizophrenia and healthy controls did not reveal any statistically significant difference on any of the demographic variables, except that higher proportions of parents in the healthy control group were employed [Table 1].
The mean age of children was 18.9 years. Males outnumbered females and more than three-fourth (78.4%) were educated beyond 10th standard and were students at the time of assessment [Table 1]. When the children of both the groups were compared, no significant difference was noted on the demographic variables.
Clinical profile of parents with schizophrenia
The mean age of onset of schizophrenia for the study group was 22.5 (standard deviation [SD] - 4.7) years and mean duration of illness at the time of assessment was 22.5 (SD 5.5) years). All the patients were receiving single antipsychotic medication at the time of assessment, with olanzapine being the most common medication, followed by clozapine. Slightly less than half (47.1%) of the patients were admitted at least once to the hospital for schizophrenia, with mean number of admission in lifetime being 0.92 (SD - 1.1). Only one-fifth (19.6%) of them had received electroconvulsive therapy (ECT) in their lifetime and slightly less than half (47.1%) had a history of surreptitious use of antipsychotic medications. One-fourth (23.5%) of the patients exhibited suicidal behavior in their lifetime. In terms of clinical course about two-third (68.6%) of patients had episodic course with residual symptoms. Physical comorbidity was present in one-sixth (17.6%) of patients, with hypertension being the most common physical comorbidity.
When male and female patients were compared, it was seen that compared to males, females had earlier onset of illness, higher proportion of them were admitted to hospital for schizophrenia in their lifetime and lower proportion of them had a history of surreptitious use of medications. In terms of psychopathology, mean score for negative symptom subscale was more than the positive symptom subscale, with mean total PANSS score of 41.8 (SD - 12.6). On comparison, no significant difference emerged between male and female patients [Table 2].
When assessed on APQ, as per parents with schizophrenia mean weighted scores (calculated by dividing the mean score for the domain by the number of items included in the particular domain) were highest for the domain of positive involvement, and this was followed by positive parenting, inconsistent discipline, poor monitoring/supervision and was least for corporal punishment [Table 3]. On children version of APQ as rated by children of patients with schizophrenia, scores were highest for the domain of positive involvement, and this was followed by positive parenting, corporal punishment, inconsistent discipline, and least for poor monitoring/supervision [Table 3]. When the perception of parenting was compared between male and female parents, no statistically significant difference was noted between the groups. Similarly, when male and female children were compared no statistically significant difference was noted between the groups.
When the perception of parenting of patients with schizophrenia and the healthy controls was compared, significant difference was noted in 4 out of the 5 domains of parenting. Similarly, when the perception of parenting as per the children of patients with schizophrenia and children in the healthy controls was compared, significant difference was noted in 4 out of the 5 domains of parenting [Table 3].
Correlates of perception of parenting as per patients with schizophrenia with sociodemographic and clinical variables of patients with schizophrenia
There was no significant correlation between any of the domains of parenting and age of the patients. Higher age of onset was associated with positive parenting. None of the other parenting domains had any association with age of onset [Table 4].
|Table 4: Correlation of perception of parenting as per parents with demographic and clinical profile of parents|
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Parents who were more educated more often indulged in corporal punishment domain (t-test value: 2.17; P = 0.034). Parents with schizophrenia from lower socioeconomic status (t-test value: 2.28; P = 0.027) and urban locality (t-test value: 2.59; P = 0.013) had more positive involvement compared to those from higher socioeconomic status and rural locality, respectively. Patients with schizophrenia from urban locality reported higher positive parenting compared to those from rural locality (t-test value: 2.85; P = 0.006). Similarly, patients with schizophrenia who were admitted at least once for their illness reported higher positive involvement (t-test value: 2.11; P = 0.04) and higher positive parenting (t-test value: 2.14; P = 0.037). Higher numbers of lifetime episodes of illness were associated with significantly lower corporal punishment (t-test value: 2.1; P = 0.043).
Lower level of positive symptoms, negative symptoms, and total PANSS score were associated with higher corporal punishment [Table 4].
The age of children did not correlate significantly with any of the domains of parenting, as assessed by parents with schizophrenia. When the children who were students and those who were employed were compared, the mean scores were significantly higher for the domain of corporal punishment for children who were employed (t-test value: −2.26; P = 0.028). Gender and education of children did not have any significant association with any of the parenting domain as reported by the parents.
Correlation of perception of parenting as per the children with their sociodemographic profile and clinical profile of parents with schizophrenia
No statistically significant difference was seen between perception of parenting as reported by the children age and gender of the parent, level of education of the parent, occupation of the parent, socioeconomic status, locality, surreptitious use of antipsychotics in the lifetime and longitudinal course in lifetime.
Compared to children from nuclear family, those belonging to extended/joint family reported significantly higher positive involvement (t-test value: −2.14; P = 0.037). Compared to the children, whose parents with schizophrenia were never admitted to an inpatient facility for schizophrenia, children, whose parents were admitted at least once reported significantly higher positive parenting (t-test value: −2.5; P = 0.016) and lower corporal punishment (t-test value: 2.38; P = 0.021). Compared to children, whose parents had never received ECT, children of parents, who had ever had received ECT reported significantly higher positive parenting (t-test value: −2.20; P = 0.032). Compared to children whose parents did not have any suicidal behavior in the lifetime, children of parents with suicidal behavior in the lifetime reported significantly higher positive parenting (t-test value: −2.57; P = 0.013). PANSS scores of parents did not have any significant correlation with perception of parenting by children.
Correlation of perception of parenting as per the parents with perception of parenting by the children
There was significant correlation between the 2 (positive involvement and positive parenting) out of the 5 parenting domains of parenting as reported by parent and the children [Table 5].
|Table 5: Correlation of perception of parenting as per parents with perception of parents as per children (Pearson's correlation coefficient)|
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| Discussion|| |
The present study included patients with schizophrenia who were currently in remission for at least 6 months and were suffering from schizophrenia for at least 15 years. Clinical remission and long duration of illness were considered as inclusion criteria. This was done to overcome the impact of the current relapse or fluctuating psychopathology on the perception of parenting of both, patients as well as their children. Similarly, long duration of illness was considered as an inclusion criteria to have a long term of perspective of parenting deficits. Further, this ensured that the adolescents who were evaluated for their perception of parenting too would have experienced certain deficits, if present to report the same. Most of the previous studies, which have studied parenting, have been limited to female parents. In contrast, the present study involved inclusion of both male and female parents. This was done considering the fact that in Indian society, marriages are often intact over the long run and father also play an important role in parenting in the context of India. Accordingly, it can be said that, parenting as assessed in the present study, reflects the long-term impact, rather than the impact of the current psychopathology and short-term perspective.
In terms of offsprings, the study was limited to children, who were adolescents or young adults, who were currently single. This was done to include the subjects who were possibly more dependent on their parents, both for emotional and materialistic need. Further, this also involved inclusion of cognitively matured individuals who could possibly report the parenting deficits they have faced in their life. Lack of definite psychopathology in the offsprings ensured that, the perception of parenting reported by them was not influenced by their own psychopathology. Previous studies evaluating the perception of parenting by children, have not reported much about their mental state.
The sociodemographic profile of the patients included in this study broadly resembles the profile of patients included in some of the earlier studies from India,,, and abroad., The sociodemographic profile is also similar to previous studies from our center which has evaluated various psychosocial aspects of patients with schizophrenia.,,,,,, The mean age of onset of 22.5 years in our sample is commensurate with the global literature and the previous studies from India, and this center., The mean duration of illness in this study was longer than some of the previous studies, reflecting the inclusion of patients with long standing schizophrenia. The mean total PANSS score of 40.5, is also similar to some of the previous studies from this center, which have evaluated patients of schizophrenia in clinical remission. Having patients with clinical remission, ensured that a homogeneous group of patients were included in the study and this minimized the effect of active psychopathology on reporting of parenting.
Previous studies which have evaluated the mothers with schizophrenia have shown that the mothers are more remote, silent, verbally and behaviorally intrusive, self-absorbed, flaccid, insensitive and unresponsive, and less demanding. Other studies suggest that parents with schizophrenia have difficulties in forming attachments with their children and nurturing them appropriately and indulge in permissive, neglectful, and authoritarian parenting styles. There is also some evidence to suggest that parental schizophrenia is associated with chaotic and ambivalent communication, severe impairments in ability of parenting, disorganized, and disrupted parenting. Findings of the present study too reflect similar features. In the present study, as per both parents and children in the healthy control group, the parenting skills of patients with schizophrenia and their children, were lower than the healthy controls.
The positive parenting domain in the present study evaluated parental virtues such as praise, reward, and showing affection. Similarly, the positive involvement indicates involvement of parents in various aspects of child's life, such as education, sports, and family activities. Lower positive parenting and positive involvement among patients with schizophrenia reflect the deficits in showing affection and poor nurturance. Poor monitoring domain assesses the supervisory role the parent play in disciplining the child. Inconsistency in disciplining their children among patients with schizophrenia may be understood in the light of the residual psychopathology. The presence of these deficits in patients with schizophrenia reflects their poor involvement in child care.
When the perception of parenting as per parent and children was assessed, there was significant correlation between only 2 domains, i.e., positive involvement and positive parenting. The lack of significant correlation for the other 3–5 domains possibly reflects the difference in the expectations of the children and the perceived role played by the parents. This finding possibly suggests that the evaluation of parenting should not be limited to assessment of only parents or children only. Accordingly, it can be concluded that the present study suggests that there are parenting deficits in parents with schizophrenia. Hence, clinicians dealing with patients of schizophrenia must evaluate their parenting skills and impart training to parents to improve the parenting outcomes. Further, the children should be assessed from time to time for their perception of parenting skills of the ill parent and when required they must be provided psychological support to deal with the parenting deficits to minimize the negative impact of poor parenting.
Correlates of perception of parenting as per the patients with schizophrenia
In general, sociodemographic variables did not have any association with perception of parenting. Significantly higher score on the domain of positive involvement was reported by patients of schizophrenia from lower socioeconomic status and urban locality. In terms of clinical correlates higher age at onset had significant positive correlation with a positive parenting domain which reflects that due to later onset of illness possibly the parenting was not affected too much. In addition, significantly higher score on the domain of positive parenting was reported by patients of schizophrenia who were admitted at least once for their illness. Higher number of lifetime episodes of illness was associated with significantly lower score on the domain of corporal punishment. As there are no previous studies evaluating these associations, it is difficult to draw any conclusion about this association. The association of higher number of lifetime episodes with lower corporal punishment could be a reflection of indifference of the parents or may be a reflection of good parenting in patients with episodic illness.
When the association of perception of parenting as per the patients with schizophrenia and psychopathology was evaluated, less severe psychopathology was associated with higher perception of corporal punishment domain of parenting. In general, available data suggest that a higher psychopathology is associated with a higher level of punishment of children. Findings of the present study are contrary to the findings in the literature. However, it is important to understand that, in the present study psychopathology was cross-sectionally assessed, whereas the parenting had more longitudinal perspective. Accordingly, it can be said that this association may be a spurious association or may be a reflection of guilt of the parents, who are currently in remission, who may be negatively evaluating all their behavior toward their children.
In terms of correlation of perception of parenting as perceived by children and demographic variables of children and parents, higher age of children was associated with lower perception of positive parenting and higher perception of corporal punishment. None of the other demographic variables emerged to have any association with parenting. The current level of psychopathology in parents also did not have any association with perception of parenting as per the children.
As there are no previous studies in this regard, it is not possible to draw any conclusion about the various associations seen in the present study. Future studies must attempt to replicate these findings.
Findings of the present study must be interpreted in the light of its limitations. The study was limited to a single center. The study included patients in remission attending the outpatient services of a general hospital psychiatric unit. Accordingly, the findings of this study may not be generalized to those living in the community and not experiencing symptomatic remission. Patients had long duration of illness, hence, the findings may not be generalized to those experiencing first episode of psychosis. The study was limited to adolescent and adult children. It is quite possible that the younger children could have different perspective of parenting. The study sample was also relatively small and the patients were evaluated only once. This study did not evaluate the parenting skills of the healthy parent. It is quite possible that many of the deficits of a parent with schizophrenia were overcome by the healthy parent and resultantly, the children did not experience significant negative consequences of having one parent with schizophrenia. Similarly, the study did not evaluate the parenting provided to children of patient by significant others (i.e., grandparents and uncle/aunts). It is quite possible that these family members compensated for the parental parenting deficits and resultant negative consequences on the offsprings. Future studies should try to overcome the limitations of this study by studying larger sample size, drawn from community samples, by focusing on patients in different phases of illness and studying the same sample longitudinally. Inclusion of children in the different age groups will also provide more useful information.
| Conclusion|| |
The present study suggests that parenting skills of patients with schizophrenia are lower than the parents in the healthy controls. There was no significant difference in the perception of parenting between male and female parents with schizophrenia. Perception of parenting is in general not affected by the demographic and clinical details of the patients with schizophrenia. Higher severity of residual positive and negative symptoms in patients with schizophrenia is associated with lower corporal punishment. There is significant correlation of parenting as assessed by patients with schizophrenia themselves and their children, for the domains of positive involvement and positive parenting domains. Considering the parenting deficits in patients with schizophrenia, there is a need to develop intervention programs to improve the parenting skills of patients with schizophrenia.
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Conflicts of interest
There are no conflicts of interest.
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Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]