Parenting Characteristics of Families of Adolescents with Bipolar Disorder

Aim: The aim of the study was to examine the parenting characteristics of adolescents with bipolar disorder. Methods: Parenting style of 30 adolescents with bipolar disorder was assessed and compared with normal group of 30 adolescents. Multidimensional Parenting Scale was used for assessing parenting style. Results: There were significantly lower levels of love, encouragement, acceptance, progressivism, democratism and higher levels of hate, rejection, autocratism, discouragement, conservatism and dependency found among families’ of adolescents with bipolar disorder compared to the normal group. Conclusion: Results of the present study indicate that there may be such factors related with parenting style which may have a significant role in the onset and course of bipolar disorders in child and adolescent population. Early identification and targeted interventions in these areas might be required for prevention, management, rehabilitation and preventing relapses of children and adolescents with bipolar disorders.

family and parent child relations make healthy children and constitute overall public health.
Though the influence of friends gains importance in adolescence, parents still continue to exert their influence in shaping the behaviors and choices of teens. Parent child relationships, parenting style and family functioning have well-documented effects on adolescent health and development (Singh & Singh, 2001). Studies (O'Leavy et al, 1999;Arrindell et al, 1983) have emphasized the parent, child attachments as a powerful marker variable for later adjustment as well as emotional and behavioral development of the child.
There are well documented evidence which established different associations between parenting style and different mental and behavioral disorders. Maladaptive and affectionless parenting strategies may exaggerate the chances for developing phobic anxiety disorders (Arrindell et al, 1983) and depression (Bryce et al, 2007) among child adolescent population.
Low parental nurturing and aversive parental behavior during child rearing may both be associated with elevated risk for offspring personality disorders (Johnson et al, 2006). Parenting practices especially maternal discipline found to be predictive of externalizing behaviour Though there are limited evidences the, existing findings regarding the parenting characteristics in child and adolescent bipolar disorders are contradictory. Different studies were used different tools for assessing the parenting styles of children and adolescents with bipolar disorder make it difficult to reach a common conclusion. Though in different measurements a positive association between impaired quality of parenting and bipolar disorders found in some studies (Neeren et al, 2008;Davenport et al, 1979;Geller et al, 2000), a number of studies did not find any significant difference (Joyce, 1984;Parker, 1979;Perris et al, 1986;Cook et al, 1999).
The existing uncertainty and inconsistency regarding the study findings about the parenting characteristics of parents of child and adolescents with bipolar disorders requires more attention and comprehensive assessments. The present study was planned in this context with an aim of examining the parenting characteristics of families of adolescents with bipolar disorder.

Design, participants and setting
The present study was a cross sectional hospital based study conducted at the Child and Adolescent Psychiatric Unit of Central Institute of Psychiatry (CIP), Ranchi, India, within a time frame of 2008-2010. The present study included 60 adolescents between the age range of 13 to 18 years, among which 30 were adolescents with bipolar affective disorder and 30 were normal adolescents. A written conscent had been obtained from all the participants. The adolescents with bipolar disorder fulfilling the criteria for bipolar disorder, according to ICD-10 -DCR (WHO, 1993), staying with the parents at least for the last two years and their families were selected from the Child Psychiatric Unit of Central Institute of Psychiatry, Ranchi by using purposive sampling. The adolescents without bipolar disorder and their families were selected from a school in the nearby locality. The patients with comorbid mental illness, neurological disorders, chronic physical illness, physical disabilities and family history of mental illness among first degree relatives were excluded from the study and the same exclution criteria along with presence of any kind of mental illnesses had been applied to the normal group.

Measures
A socio-demographic and clinical data sheet was designed for the present study for recording socio-demographic and clinical variables like age of onset, duration of illness, family history and clinical characteristics. (Chauhan and Khokhar, 1985)  General Health Questionnaire (Goldberg & Hiller, 1979) was used in the study for screening normal participants and those scored 3 or more were excluded from the study.

Statistical analysis
The Statistical Package for Social Sciences (SPSS) 13.0 for windows was used for statistical analysis. Descriptive statistics were used for analyzing discrete and continuous variables. Chi square test was used for comparing categorical variables and student t-test for continuous variables. Table 1 shows the details of the socio demographic characteristics of the subjects. 66.7% of the patient group and 60% of normal group were males with an average age of 15.7 ± 1.17 years and 15.2 ± 1.21 years respectively. The average duration of illness was 3.05 ± 1.21 years.

RESULTS
Majority of the respondents were from Hindu religion (86.7% & 70%) with an education of below matriculation level. Most of the respondents were students from rural, low socio-economic families without any family history of psychiatric illness.  Note: BPAD-M: bipolar affective disorder, last episode manic BPAD-DEP: bipolar affective disorder, last episode depressive Table 2 shows details of the results of Multidimensional Parenting Scale. Majority of the families in both groups fall under normal range according to the cutoff scores, but there was a significant difference found in the score ranges between the two groups in many of the sub domains. In positive domains prominent differences found in the in the areas of love (p<.001), encouragement (p<.01), acceptance, progressivism and democretism (p<.05). In the negative domains a p <.001level of significant difference found in the areas of rejection, conservatism and dependency and p<.01level significant levels of differences were found in the areas of hate, discouragement and autocratism. indicates deviant parenting and in negative domains a higher score than 60 indicates deviant parenting on the basis of cutoff scores.
As the Table 2 shows in both of the positive and negative domains, the mean score of both groups was coming under normal functioning on the basis of cutoff scores. But one cannot ignore the fact that there is a big difference between the score ranges of both group. The differences between score range has been suggesting a definite lacking of parental love, encouragement, acceptance, progressivism and democratize for the clinical group in the positive domains. It is clearly indicating that the children with bipolar disorder lacking love and encouragement in significantly greater levels compared to the normal group. It is also evident from Table 2 that the parents of bipolar patients has shown higher levels of hate, rejection, autocratism, discouragement, conservatism and dependency compared to the normal group.
Previous studies also investigated about the relationship of perating and Bipolar disorders in different aspects by using different tools and malfunctioning in multiple domains has beed observed. Lower levels of acceptance, warmth, higher levels of negative psychological control and greater levels of emotional maltreatment from both parents of children with bipolar disorders and greater levels of physical maltreatment by mothers found in an earlier study by Neeren et al (2008). Adverse life events in the forms of maltreatment especially from divorced or separated parents are found to be more common among pediatric Bipolar patients in another study (Marchand et al, 2005). Repetitive maladaptive patterns of avoidance of affect, unrealistic standards of conformity and displaced parental low self-esteem were found among children with bipolar disorders by Davenport et al (1979) in structured interviews. A significantly greater

Parenting Characteristics of Families of Adolescents with Bipolar Disorder
© The International Journal of Indian Psychology | 173 impairment on maternal-child warmth, maternal-child and paternal-child tension found among

7-16-year-old patients with bipolar disorders than compared with Attention Deficit
Hyperactivity Disorder and normal community controls by Geller et al (2000). Interestingly the only maternal side found to be impaired in the study by Rosenfarb et al (1994), in which bipolar patients reported less maternal affection and attachment with mothers than normal control, but did not differ from controls on paternal affection and attachment.
Though some studies found no significant difference of parental characteristics of bipolar children and a control group (Joyce, 1984;Parker, 1979;Perris et al, 1986;and Cook et al, 1999) many The small sample size of the present study may reduce the generalization of the study findings. It is lacking the representation of all subcategories of bipolar affective disorder, as most of the respondents in the patient group were diagnosed with bipolar affective disorder manic type. The majority of the participants were male in the present study and most of the respondents belonged to low socioeconomic status from rural areas. Due to limited sample frame and lack of time, the socio-demographic variables was not uniform in all areas of the clinical group and normal group. There may be a relationship between the number of episodes, relapses and the study variables, which were not addressed in the present study.

CONCLUSION
Parent child attachments and parenting style has been widely discussed in significance with various psychiatric disorders. But the relationships between early onset bipolar disorders and parenting style have never been studied adequately. Although the results are contradictory, most of the studies show the importance of parenting style with respect to the early onset bipolar disorders. The results of the present study indicate that there may be such factors related with parenting style which may have a significant role in the onset and course of bipolar disorders in child and adolescent population. Early identification and targeted interventions in these areas might be required for prevention, management, rehabilitation and preventing relapses of bipolar disorders among children and adolescents.

Conflict of interest
Nil