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Volume 25 |
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Number 6 |
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Published by : PROFESSIONAL MEDICAL PUBLICATIONS |
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Volume 25 |
October - December 2009 (Part-II) |
Number 6 |
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Psychological problems in children of parents with mental illness:
A comparative study from Lahore, Pakistan
Nazish Imran1, Ahsan Sattar2,
Naeem Amjad3, Muhammad Riaz Bhatti4
ABSTRACT
Objective: Mental illness in parents and its link with adverse outcomes for children has been well reported in western literature, but there is a paucity of published studies from Pakistan on this issue. The aim of our study was to determine the prevalence of psychological problems in children of parents having mental illness and to compare it with children of parents without any diagnosed psychiatric problems in urban area of a developing country.
Methodology: A case control study was conducted from January to April 2008 in Lahore. Following informed consent, cases were recruited through interviewing psychiatric patients. Controls were children of parents with no diagnosed psychiatric illness and were recruited through a school. A structured questionnaire for demographic information, and Strengths and Difficulties Questionnaire (SDQ) were filled in by parents.
Results: Seventy- six parents were recruited to get a sample of 200 children. (100 cases, 100 controls). The mean age of children was 9.7 years and 111(55.5%) were boys. Children of parents with psychiatric problems had almost two times higher rate of mental health problems compared to controls (55% versus 28%; P value <0.001). Emotional difficulties (P=0.028) and conduct problems (P=0.025) were found to be statistically significant. Boys were more likely to be hyperactive and have conduct and social difficulties. Girls had higher rates of emotional problems.
Conclusion: Children of parents with mental illness are at much higher risk of childhood psychiatric problems. Risk was higher for males than females. Majority of parents had not sought any help for their children difficulties.
KEY WORDS: Child mental health, Parental mental illness, Pakistan, risk factors.
Pak J Med Sci October - December 2009 (Part-II) Vol. 25 No. 6 895-900
How to cite this article:
Imran N, Sattar A, Amjad N, Bhatti MR. Psychological problems in children of parents with mental illness: A comparative study from Lahore, Pakistan. Pak J Med Sci 2009;25(6):895-900.
1. Dr. Nazish Imran.
MBBS, MRCPsych (London)
Assistant Professor
2. Ahsan Sattar.
MSc (Psychology)
3. Dr Naeem Amjad.
Post graduate Trainee.
4. Dr Muhammad Riaz Bhatti.
Professor,
MBBS; FRCPsych; MRCPsych, DPM (London)
1-4. Department of Child & Family Psychiatry.
King Edward Medical University/
Mayo Hospital,
Lahore - Pakistan.
Correspondence:
Dr. Nazish Imran,
MBBS, MRCPsych (London)
Assistant Professor,
Department of Child & Family Psychiatry,
King Edward Medical University/ Mayo Hospital,
Lahore - Pakistan.
E-mail: nazishimran@hotmail.com
* Received for Publication: August 20, 2009
* Revision Received: October 29th 2009
* Revision Accepted: October 31st 2009
INTRODUCTION
Pakistan has a population of 172 million with 65.3 million children under the age of 14 years.
1 Lack of mental health services for this huge young population poses a significant problem as there is very little systematic research into the prevalence of childhood psychopathology and associated risk factors. Child and Adolescent mental health is influenced directly and indirectly by numerous factors including genetic factors, developmental status, physical health, educational abilities as well as social factors. Among the social factors, family structure and functioning, quality of parental relationship and parental mental illness have been implicated in the genesis and maintenance of childhood psychiatric problems.2 Mental illness in parents and its link with adverse outcomes for children has been well reported in western literature.3-5 Meltzer et al demonstrated that children of parents who screened positive on GHQ-12 were three times more likely to have mental disorder than those whose parents have sub threshold scores.6 These children have been recognized as target population for prevention and early intervention of mental health problems, which is of paramount importance as there is significant evidence that childhood problems can lead to adult mental illness and criminality.7 Although the evidence for association between parental mental illness and psychological problems in children is compelling, there is a paucity of published studies from Pakistan on this issue. We therefore aimed to determine prevalence of psychological problems in children of parents having mental illness and to compare it with children of parents without any diagnosed psychiatric problems.METHODOLOGY
This was a case control study conducted from January to April 2008 in Lahore city of Pakistan. Institutional Review Board of King Edward Medical University/Mayo Hospital approved the study. Cases were recruited through interviewing psychiatric patients in a tertiary care Hospital (both outpatients and inpatients), who were parents of dependent children up to 16 years of age, not acutely unstable psychiatrically and gave informed consent to participate in the study. Controls were identified as children of parents with no diagnosed psychiatric illness and were recruited through a private school in the same locality. Research team informed these parents about the study and sought written informed consent by means of a letter sent by school administration. Those parents, who agreed to participate, were then requested to fill in the questionnaire. Illiterate parents were assisted by the research team in filling the questionnaire. No incentives were provided in order to avoid any bias.
QUESTIONNAIRE
Demographic data: The questionnaire comprised of an initial section on demographic information which elicited details like parents age, gender, education, employment status, number of children, type of housing, change of accommodation and their psychiatric diagnosis (if applicable).Parents recorded the age and gender of each child under 18 years old. Parents were asked if they had sought any help for their children in the past and any perceived barriers for seeking help were also assessed.
Strengths and Difficulties Questionnaire: Children were screened for behavioural and psychological problems by using a universally validated screening tool, Extended Strengths and Difficulties Questionnaire (SDQ).
8,9 SDQ can be completed by parents or teachers for children and adolescents of 3-16 years of age. . We used its Urdu version, which has been validated to assess psychopathology in children in Pakistan.10,11 SDQ measures 25 attributes, which are grouped in subscales of five items each, generating scores for conduct, hyperactivity, emotional, peer problems and prosocial behaviour. All scales excluding the last are added to generate a total difficulties score (0-40). Total difficulties and categories scores can be coded in normal, borderline and abnormal categories. Besides common areas of emotional and behavioural difficulties, SDQ also inquires whether the informant thinks that the child has a problem in these areas and if so, asks about resultant distress and social impairment. Data was analyzed by using SPSS 10.00 version. Descriptive statistics were computed for the socio demographic characteristics of children and parents. The frequency distribution for the normal, borderline and abnormal categories on total SDQ and subsets score were computed. The two groups scores were compared using chi-square. P value <0.05 was considered as significant.RESULTS
Seventy- six parents were recruited to get a sample of 200 children between the ages of 4-16 years (100 children as cases and 100 children as controls). The parents age range was 25-58 (mean 38.8 years, s.d=7.53). There were 26 men and 50 women. Forty parents (52.6%) had less than eight years of formal education and forty five parents lived in joint family setup. Thirty (39.5%) were unemployed while forty five parents (72.4%) had monthly income of less than 10,000 Pakistani rupees.
Thirty three parents reported psychiatric illness: Schizophrenia five, Depression 13, Anxiety three, Bipolar Affective disorder two, Postpartum Psychosis one, Obsessive Compulsive Disorder one, and Drug Dependence one. Four patients reported multiple diagnoses and in three the diagnosis was unclear.
PREVALENCE OF CHILDREN WITH MENTAL HEALTH PROBLEMS
Data was collected for 200 children between the ages of 4-16 years. The mean age was 9.7 years (s.d=3.8) and one hundred eleven (55.5%) were boys. Total SDQ and subscale categories scores for both cases and controls are presented in Table-I. Children of parents with psychiatric problems in our study had almost two times higher rate of mental health problems compared to controls(55% versus 28%). Table-II
presents the results of chi-square analysis between the two groups. Children of parents with Psychiatric illness were more likely to have higher rate of total mental health difficulties (P value .000) in particular, emotional difficulties (P=.028) and conduct problems (P=.025).Gender differences were also observed in SDQ subscale scores, among the children who scored in the clinical range, (Table-III). Boys were more likely to be hyperactive and have conduct and social difficulties. Girls had higher rates of emotional problems.
Difficulty, Impact and Burden: Parents reported that 85 children (42.5%) had difficulties in mental health: 56 had minor difficulties, 23 definite and 6 severe. Most difficulties had been present for more than a year in 53 (63.1%) children. These difficulties interfered in friendships (26.5%), classroom learning (27%), home life (37%), and leisure activities (19.5%).
Help Seeking and barriers to Treatment: Only nine of the 76 parents had sought help for their children behaviour problems in the past. Common reasons cited by parents for not seeking help included feeling that it was not needed(19.4%), that they should be able to handle problems alone(55.7%), didn’t knew where to go for help(26.8%), didn’t think anyone can help(10.3%), fear of what others would think(14.4%) and fear of what treatment will be given to the child(10.3%).
DISCUSSION
This survey was carried out with the objective to screen the psychological health of children of parents with mental illness and compare it with that of community sample. Our study found prevalence of 28% in the community sample. Previous studies done in Pakistan have documented community prevalence of psychological problems in children to be between 9.3% to 34%.
12,13 Robert et al reviewed 52 epidemiological studies of child and adolescent mental health disorders and found significant variation in prevalence rates between 1% to 50% with a mean prevalence rates of 15.8%.14 This wide variation may be because of differences in age groups studied, sampling criteria and screening instruments used. In comparison to the community sample, the prevalence of mental health difficulties in our sample of children of parents with mental illness, according to SDQ score is two times higher. This supports the existing finding that Mental illness in parents puts children at a much higher risk of mental health difficulties. In the absence of similar studies from Pakistan, we compared our results with studies done in western world. .Vicki Cowling et al found 2.5 times higher prevalence of mental health problems in their sample of children whose parents had mental illness and Meltzer et al found an even higher risk of more than three times compared to community sample.6,15 Evidence is stronger for association of maternal mental health disorders with increase risk for emotional and behavioral problems in children as well as severe impairment in their functioning and development.16,17 Infants of depressed mothers have been found to be more withdrawn, have more difficult temperaments and less securely attached to their mothers.18 Relationship with peers and adults also appears to be affected in toddlers and preschool children of mothers with mental health difficulties.19Multiple factors can explain the association between psychiatric disorder in parents and mental health problems in their children. Children of parents with mental illness are exposed to considerable genetic risk.
20 Presence of mental illness in one or both parents can also adversely affect their ability to fulfill the challenging responsibilities and cope with demands of parenting thus putting children at risk for psychological problems, neglect and abuse.21 In addition stress of parenting can itself precipitate or exacerbate mental illness particularly if the child has chronic physical health issues, disability, or emotional and behaviour problems. Dover et al found that around one third of parents of children who are referred to a child and adolescent mental health services will themselves have a psychiatric disorder.22We used SDQ which is a universal valuable screening tool and has been found to be easy, inexpensive and effective in detecting children mental health problems in developing world.
23 It has been compared with the Child Behaviour Checklist (CBCL) and the Rutter Questionnaire.8 It’s Urdu version used in our study has also been validated and is able to distinguish psychological problems between study groups.11 However as SDQ was not followed by diagnostic interview, we may have found much higher rates of psychopathology than the actual prevalence. Male gender has been consistently reported in the past literature as a predictor of psychopathology.13 We also found males to be at much higher risk of psychological problems like conduct problems, hyperactivity disorder, peer problems and antisocial difficulties. It was interesting to note that although 50% of patients reported significant family burden due to children difficulties, but only a few had sought any help mainly due to perception to be expected to deal with these problems themselves. Also there was lack of awareness as to who to ask for help. This highlights that professionals need to be more vigilant in assessing any difficulties; families may be facing and help them to cope in a better way.Limitations of the study: Our study has various limitations. The sample size was small and recruited from only one hospital in Lahore city therefore results may not be generalizable. The researcher helped illiterate parents to fill in the questionnaire and it may have resulted in bias. We used Parent filled SDQ only to assess child psychopathology. Information from multiple sources would have been more reliable. Also screening tools lead to reporting of higher rates of psychological problems if not followed by a diagnostic interview. SDQ is also less sensitive in assessing phobias and anxiety in children which may have been missed in our sample.
24CONCLUSION
Children of Parents with mental illness are at much higher risk of childhood Psychiatric problems. Consistent with previous studies, risk was higher for males than females. In the absence of dedicated Child and adolescent mental health services in Pakistan, all professionals dealing with children needs to be aware of high prevalence of childhood Psychiatric difficulties and associated distress and burden to families. Assessment of the child at the time of parental referral can be one way to identify child emotional and behavioural problems, which may help in early intervention and appropriate referrals. Further research in child mental health is urgently needed in Pakistan to determine the actual need and planning for Child Psychiatry services.
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19. Cicchetti D, Rogosch FA, Toth SL. Maternal depressive disorder and contextual risk; Contributions to the development of attachment insecurity and behavior problems in toddlerhood. Development and psychopathology 1998;10:283-300.
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