Early-onset bipolar disorder, stress, and coping responses of mothers: A comparative study

Abstract

Background:

Providing care and nurturance to a child with bipolar disorder (BPAD) is a challenging task for parents, especially mothers. In Indian contexts, mothers are the primary caregivers of ailing children and they have to keep intrafamily situation stable, which makes their role more stressful.

Objectives:

The objective of the study was to assess maternal stress and coping in mothers of adolescents with BPAD.

Materials and Methods:

This study was a comparative one and carried out on sixty mothers of adolescents; of which thirty were adolescents with BPAD, and the remaining thirty were the mothers of normal adolescents. The participants were selected purposively as per the mothers' age and education level, and the socioeconomic status of the families they belong to. Sociodemographic and clinical data sheet, Parenting Stress Index/Short Form (PSI/SF), and Brief COPE were applied on the mothers for data collection.

Results:

Mothers' of the BPAD adolescents reported higher scores in the both PSI/SF and Brief COPE.

Conclusion:

Mothers of the adolescents with BPAD tend to perceive high level of stress and they also use maladaptive coping more in dealing with stressful situations.

INTRODUCTION

Parenthood is an important phase of life containing pride, pleasure, and challenges. Parenting is indeed a challenging task by itself, and it becomes harder in the case of children with health issues, especially chronic and debilitating psychological problems. Caring of a child with bipolar disorder (BPAD) is a challenging job because of numerous illness-related and nonillness related factors – “securing appropriate treatment on long-term basis,” “ensuring adherence to the treatment,” “dealing with the psychopathology of bipolar illness at home and in community,” and most significantly “dealing with stigma, prejudices, and stereotypes associated with the illness.”[1,2,3] Many of them have feelings such as “being cursed,” “sense of shame and guilt,” and their “misfortune.”[3] They have to deal with multiple problems such as illness, treatment, aftercare, finances, immediate society, and community.[3,4] They are often made to feel ashamed because of their children's illness. Therefore, they need to use several forms of coping to deal with the challenges coming from different sources.[3,4,5,6] They have the feelings such as lack of respite, jitteriness, sense of failure and loss, sense of hypersurveillances, loss of self, asynchrony, and chronic fear.[6,7,8] Early-onset BPAD is characterized by mixed mood states, rapid cycling, high degree of elatedness and irritability, and frequent presence of comorbidities. Early-onset BPAD means BPAD occurring before the age of 18 years or BPAD affecting children and adolescents.[9,10,11] The longitudinal course of early-onset BPAD is characterized by frequent changes in symptom polarity with a fluctuating course.[9,10,11,12]

Symptoms of early onset BPAD do not have substantial similarity with adult BPAD.[9,10,11,13,14] They have an ongoing, generalized mood disturbance that combines symptoms of both mania and depression. These symptoms can lead to negative consequences such as “disruption of psychosocial and family functioning,” “difficulty to interact with peers,” “academic problems,” “poor relationship among siblings,” and “poor parent–child relationships.”[8,12,15,16,17]

Parents of adolescents with BPAD have been observed to have higher likelihood of emotional distress or even syndromal psychological problems, feeling of loss, tendency to avoid social situation, poor marital relationship between parents, and sense of resigning or leaving everything on fate.[2,3,4,17,18,19,20] Families of adolescents with BPAD have the higher likelihood of experiencing family crisis in the form of family conflict, lack of cohesion, less adaptability with problem situations, and expressed emotion.[18,19,20,21] Some past studies showed that mothers of these children and adolescents tend to use several means of coping to deal with their psychological distress, e.g., “seeking social support,” “relying on general and specific beliefs,” “task-oriented coping,” and “emotion focused coping.”[21,22,23,24,25]

Mothers were seen to be more affected by their children's problem than fathers. Emotion-focused coping and active avoidance coping were found to be predictor of parental stress.[22,23,24,26,27,28,29,30] Seltzer et al.[26] observed differences in coping between the mothers of mentally ill and mentally retarded individuals. Mothers of mentally ill individuals used more emotion-focused coping, which predicted higher level of depression in mothers. Mothers of mentally retarded individuals tended to be depressed due to their child's behavior problems. Coping acted as buffer against stress for mothers of mentally retarded persons, while that was not seen for mothers of mentally ill persons. Parenting of adolescents with BPAD is a daunting task. Mothers have often been entrusted with major responsibilities pertaining to patient care and maintenance of family functioning, and they tend to be crippled by overwhelming dual pressure of patient care and family functioning.[22,26,30] Although in Western World studies on mothers of adolescents with BPAD have been done in the past, in India, they are very sparse. The study was an attempt to study the perception of stress and coping responses of the mothers of the adolescents with BPAD.

MATERIALS AND METHODS

This study was conducted at the Central Institute of Psychiatry (CIP), Ranchi, India. Current study was duly approved by the Institutional Ethical Committee, and informed consents were taken from each subjects selected in the study appropriately. The contents of the Consent Form were written in Hindi and English. This consent form was given directly to literate mothers. The research team had explained the informed consent form thoroughly in simple language to the selected women. Signatures were obtained from the literate mothers, whereas, thumb impressions were taken from the illiterate women. Thumb impression was taken in front of their relatives. The study was a cross-sectional hospital-based comparative study and the subjects were recruited purposively. The mothers of normal adolescents were recruited from the pool of the staffs of the CIP and two nearby areas belonging to the Kanke Administrative Block of Ranchi district, Jharkhand State. Those two areas are adjoining to this institute. The current study was conducted on sixty mothers of adolescents belonging to age range of 11–18 years. The selected sixty mothers were further divided into study and control Groups. The Study Group composed of thirty mothers of adolescents with BPAD, whereas the control group was made of thirty mothers of normal adolescents. These two groups were matched as per the age of the mothers, socioeconomic status, and mothers' educational status. The criteria of selection of study group were as follows:

(a) Adolescents with the diagnosis of BPAD and the duration of illness ≥2 years; (b) must have at least two episodes of illness (mania or depression) in the past 2 years; (c) no history of any other medical and/or psychiatric illness and/or substance addiction and/or disability; and (d) mothers actively involved in patient care for at least 2 year and living in the same household with the adolescents. The GHQ-12[31] was applied on the mothers of normal adolescents (Control Group) for ruling out psychological problems in them. Mothers with score of ≤3 in GHQ-12[31] were included in the study. For data collection, following measures were used:

1. Sociodemographic and clinical data sheet – A data sheet containing important socio-demographic and clinical parameters was developed for sociodemographic and clinical profiling of the selected subjects of either group

2. The Parenting Stress Index/Short Form (PSI/SF)[32] – The PSI/SF is the abridged form of original PSI. This measure gives the Total Stress score from three sub-scales: Parental Distress, Parent-Child Dysfunctional Interaction, and Difficult Child

3. The Brief COPE Scale[33] – The Brief COPE is a 28-item multidimensional measure of strategies adopted for coping with stressors. This is the abbreviated form of larger 60-item COPE Inventory.[34] The COPE is a multidimensional inventory that comprises 15 scales each composed of four items. The abbreviated version, the Brief-COPE[33] has 14 subscales composed of two items each: (a) acceptance – suggesting the acceptance of reality and preparing oneself; (b) emotional Support – seeking emotional support; (c) humor – trying to make fun on the situation; (d) positive reframing – trying to see the situation from a different perspective or searching for something positive in it; (e) religion – seeking comfort through religious or spiritual practices and beliefs; (f) active coping – actively using of strategies or plans to make the situation better; (g) instrumental support – seeking help and advice from other people; (h) planning – developing specific strategy; (i) behavioral disengagement – not attempting to cope; (j) denial – refusing to accept the reality; (k) self-distraction – involving in work or other activities to get off problematic situation; (l) self-blaming – being self-critical for the occurrence of the problem or stressor; (m) substance Use – taking the help of alcohol or other drugs to get off the feeling of stress; (n) venting – expressing negative feelings. Carver[27] categorized the strategies of acceptance, emotional social support, humor, positive reframing, and religion as Emotion Focused. On the other hand, active coping, instrumental support, and planning are considered as Problem-Focused Strategies. Finally, behavioral disengagement, denial, self-distraction, self-blaming, substance use, and venting are considered as Dysfunctional Coping Strategies

The data analysis was done by IBM SPSS®-20 Windows Version (IBM Inc, Armonk, New York 10504-1722, United States).

RESULTS

Table 1.1 shows the comparison between socio-demographic profiles of both the groups. There was no significant difference between the mothers of adolescents with BPAD and normal adolescents with regard to age, though the children from control group were significantly younger than study group. When other parameters of sociodemographic profile were compared [Table 1.2], the two groups were comparable on most of the parameters; however, significant differences were observed in religion, domicile, and family history of mental illness. In terms of religion, majority of the participants in study group followed Hinduism; however, the number of participants was equal for Hinduism and Christianity in the Control Group. With regard to family history of mental illness, nearly half of the (n = 14) participants in study group had the history of mental illness in their respective families.

Table 1.1.

Comparison of sociodemographic profile between the study and control group (independent samples t-test)

Variables	Group (n=60), mean±SD		t (df=58)	P
	Study group (BPAD group) (n=30)	Normal control group (n=30)
Adolescents’ age	15.37±1.38	13.63±2.31	3.53	<0.01**
Family size (number of members)	6.13±2.45	5.27±1.34	1.70	0.094
Mothers’ age	39.53±6.48	36.97±6.66	1.52	0.135

**Significant at <0.01 level. BPAD – Bipolar disorder; SD – Standard deviation

Table 1.2.

Comparison of sociodemographic profile between the study and control group (Chi-square test/Fisher’s exact test)

Variables	Group (n=60)		χ2/Fisher’s exact test#	df	P
	Study group (mothers of BPAD adolescents), n (%)	Normal control group (mothers of normal adolescents), n (%)
Sex of children
Male	17 (57)	20 (67)	0.635	1	0.42
Female	13 (43)	10 (33)
Religion
Hindu	27 (90)	14 (47)	15.39#	-	<0.01**
Islam	2 (7)	2 (6)
Christian	1 (3)	14 (47)
Educational status of children
Illiterate	1 (3)	1 (3)	0.305#	-	0.89
Primary	11 (37)	9 (30)
≥Secondary	18 (60)	20 (67)
Domicile
Rural	24 (80)	16 (53)	4.80	1	0.028*
Urban	6 (20)	14 (47)
Marital status
Unmarried	27 (90)	30 (100)	3.16#	-	0.237
Married	3 (10)	0 (0)
Fathers’ occupation
Farmer	17 (57)	17 (57)	0.867#	-	0.699
Private	11 (37)	9 (30)
Service	2 (6)	4 (13)
Socioeconomic status
Lower	25 (83)	20 (67)	2.22	1	0.136
Middle	5 (17)	10 (33)
Family type
Nuclear	20 (67)	22 (73)	0.317	1	0.573
Joint	10 (33)	8 (27)
Family history of mental illness
No	16 (53)	30 (100)	18.26#	-	<0.01**
Yes	14 (47)	0 (0)
FDR history of mental illness
No	25 (83)	30 (100)	5.45#	-	0.052
Yes	5 (17)	0 (0)
Present marital status of mothers
Married	26 (87)	30 (100)	4.28#	-	0.112
Widowed	4 (13)	0 (0)
Mothers’ education
Illiterate	16 (53)	9 (30)	3.36	1	0.067
Literate	14 (47)	21 (70)
Mothers’ occupation
House wife	28 (93)	29 (97)	0.351#	-	1.00
Employed	2 (7)	1 (3)

**Significant at <0.01 level, *Significant at <0.05 level, ^#Fisher’s exact test. FDR – First degree relative; BPAD – Bipolar disorder

Mothers of the adolescents with BPAD had reported significantly higher level of stress (scores of PSI/SF) [Table 2]. In all three areas of PSI/SF, i.e., “Parental Distress,” “Parent–Child Dysfunctional Interaction,” and “Difficult Child” as well as total score, mothers of the adolescents with BPAD had reported significantly higher scores than that of mothers of normal adolescents, suggesting higher perception of stress among mothers of the adolescents with BPAD. Significant differences were noted between the mothers of the two groups of the adolescents in most of the domains of the coping measuring instrument, i.e., Brief COPE [Table 3]. Barring two domains of Brief COPE, “Substance use” and “Use of emotional support,” significant differences were seen in remaining 12 domains of the scale. It was noted that mothers of the normal adolescents reported significantly higher scores in positively oriented coping strategies such as active coping, use of instrumental support, positive reframing, planning, humor and acceptance. On the contrary, mothers of the adolescents with BPAD scored significantly higher in maladaptive and emotion focused coping mechanisms such as self-blame, turning to religion, venting of emotions, use of emotional support, denial, and self-distraction. The sociodemographic parameter of “Family's Income Status” has not been found to have any significant implication on the coping strategies adopted by the mothers of the adolescents with BPAD [Table 4.1]. As per the income level, selected women were divided into “Lower” and “Middle” Income families. Majority of the selected women were from the lower income group families (n = 25). The variable “family type” has been found to have significant implication on two types of coping, i.e., “Religion” and “Self-blame” [Table 4.2]. Mothers belonging to nuclear families reported to use the religious activities and self-blaming significantly higher than that of mothers of joint families. However, in other domains of Brief COPE no significant differences were noted between these two groups of families. The status of literacy of the study group mothers has not been found to affect coping significantly as seen as per scores on all the domains of the Brief COPE, except the domain of “venting” [Table 4.3]. In this domain, literate mothers scored significantly higher than illiterate mothers. However, factor like “family history of mental illness” has not been found to have significant implication on the coping styles of the mothers' of the adolescents with BPAD [Table 4.4].

Table 2.

Comparison of stress between study group and control group (independent samples t-test)

Variables	Group (n=60), mean±SD		t (df=58)	P
	Study group (mothers of BPAD adolescents) (n=30)	Normal control group (mothers of normal adolescents) (n=30)
PD	41.80±7.43	35.23±9.35	3.01	<0.04**
PDCI	42.17±7.07	31.47±6.76	5.99	<0.01**
DC	41.70±6.92	31.53±8.58	5.05	<0.01**
Total score	125.67±19.83	98.23±21.76	5.11	<0.01**

**Significant at <0.01 level. BPAD – Bipolar disorder; SD – Standard deviation; PD – Parental distress; PDCI – Parent-Child Dysfunctional Interaction; DC – Difficult child

Table 3.

Comparison of coping strategies of mothers of the adolescents with bipolar disorder and normal adolescents (independent samples t-test)

Variables (domains of the brief COPE)	Group (n=60), mean±SD		t (df=58)	P
	Study group (mothers of BPAD adolescents) (n=30)	Normal control group (mothers of normal adolescents) (n=30)
Emotion focused coping
Acceptance	3.06±1.14	4.90±1.12	−6.262	<0.001***
Use of emotional social support	5.20±1.12	4.73±1.04	1.661	0.102
Humor	2.33±0.75	4.86±1.52	−8.146	<0.001***
Positive reframing	3.33±1.21	5.93±1.08	−8.766	<0.001***
Religion	5.13±1.45	2.50±0.86	8.527	<0.001***
Total score of the domain	21.40±6.54	26.30±5.59	−3.116	<0.03**
Problem focused coping
Active coping	3.76±1.27	6.26±1.04	−8.284	<0.001***
Use of instrumental support	4.33±1.42	5.36±1.24	−2.994	<0.04**
Planning	3.30±1.26	5.73±1.25	−7.476	<0.001***
Total score of the domain	17.30±4.67	21.80±4.39	−3.839	<0.001***
Dysfunctional coping
Behavioral disengagement	4.16±1.11	2.26±0.44	8.644	<0.001***
Denial	4.46±1.07	2.10±0.30	11.608	<0.001***
Self-distraction	6.23±0.97	2.43±0.72	17.146	<0.001***
Substance use	2.56±0.81	2.23±0.50	1.902	0.062
Venting	4.96±0.99	2.23±0.56	13.022	<0.001***
Self-blame	5.86±1.65	2.13±0.50	11.810	<0.001***
Total score of the domain	18.16±4.16	18.20±2.63	−0.037	0.971

**Significant at <0.01 level; ***Significant at <0.001 level. BPAD – Bipolar disorder; SD – Standard deviation

Table 4.1.

Comparative description between the coping strategies of the mothers of adolescents with bipolar disorder as per selected sociodemographic parameters (socioeconomic status of the family) (independent samples t-test) (bipolar disorder group)

Variables (domains of the brief COPE)	Group (n=30), mean±SD		t (df=28)	P
	Mothers belonging to lower income families (n=25)	Mothers belonging to middle income families (n=5)
Emotion focused coping
Acceptance	3.12±1.16	2.80±1.09	0.565	0.577
Use of emotional social support	5.20±1.19	5.20±0.83	0.000	1.000
Humor	2.32±0.74	2.40±0.89	−0.212	0.834
Positive reframing	3.20±1.15	4.00±1.41	−1.366	0.183
Religion	5.28±1.40	4.40±1.67	1.246	0.223
Total score of the domain	16.84±4.49	19.60±5.41	−1.448	0.159
Problem focused coping
Active coping	3.76±1.33	3.80±1.09	−0.063	0.950
Use of instrumental support	4.24±1.36	4.80±1.78	−0.799	0.431
Planning	3.28±1.27	3.40±1.34	−0.191	0.850
Total score of the domain	20.64±6.36	25.20±6.76	−1.214	0.235
Dysfunctional coping
Behavioral disengagement	4.20±1.22	4.00±0.00	0.360	0.722
Denial	4.48±1.12	4.40±0.89	0.149	0.882
Self-distraction	6.28±0.93	6.00±1.22	0.582	0.565
Substance use	2.60±0.81	2.40±0.89	0.493	0.626
Venting	5.08±0.99	4.40±0.89	1.412	0.169
Self-blame	6.00±1.52	5.20±2.28	0.986	0.333
Total score of the domain	17.92±4.48	19.40±1.81	−0.718	0.478

SD – Standard deviation

Table 4.2.

Comparative description between the coping strategies of the mothers of adolescents with bipolar disorder as per selected sociodemographic parameters (type of the family) (independent samples t-test) (bipolar disorder group)

Variables (domains of the brief COPE)	Group (n=30), mean±SD		t (df=28)	P
	Mothers belonging to nuclear families (n=20)	Mothers belonging to Indian joint families (n=10)
Emotion focused coping
Acceptance	2.90±1.02	3.40±1.34	−1.135	0.266
Use of emotional social support	5.20±1.00	5.20±1.39	0.000	1.000
Humor	2.40±0.82	2.20±0.63	0.675	0.505
Positive reframing	3.30±1.17	3.40±1.34	−0.209	0.836
Religion	5.50±1.27	4.40±1.57	2.057	0.049*
Total score of the domain	20.75±6.61	22.70±6.54	−0.763	0.452
Problem focused coping
Active coping	3.90±1.25	3.50±1.35	0.803	0.429
Use of instrumental support	4.55±1.50	3.90±1.19	1.188	0.245
Planning	3.30±1.34	3.30±1.15	0.000	1.000
Total score of the domain	16.70±4.58	18.50±4.85	−0.994	0.329
Dysfunctional coping
Behavioral disengagement	4.30±1.21	3.90±0.87	0.922	0.364
Denial	4.65±1.08	4.10±0.99	1.340	0.191
Self-distraction	6.35±0.98	6.00±0.94	0.928	0.361
Substance use	2.60±0.82	2.50±0.84	0.311	0.758
Venting	5.00±1.02	4.90±0.99	0.254	0.801
Self-blame	5.40±1.60	6.80±1.39	−2.347	0.026*
Total score of the domain	18.20±4.37	18.10±3.95	0.061	0.952

*Significant at <0.05 level. SD – Standard deviation

Table 4.3.

Comparative description between the coping strategies of the mothers of adolescents with bipolar disorder as per selected sociodemographic parameters (literacy level of mothers) (independent samples t-test) (bipolar disorder group)

Variables (domains of the brief COPE)	Group (n=30), mean±SD		t (df=28)	P
	Illiterate mothers (n=16)	Literate mothers (n=14)
Emotion focused coping
Acceptance	3.37±1.20	2.71±0.99	1.624	0.116
Use of emotional social support	5.25±1.23	5.14±1.02	0.256	0.800
Humor	2.25±0.68	2.42±0.85	−0.637	0.529
Positive reframing	3.00±1.03	3.71±1.32	−1.657	0.109
Religion	5.25±1.23	5.00±1.70	0.463	0.647
Total score of the domain	20.81±7.04	22.07±6.12	−0.519	0.608
Problem focused coping
Active coping	3.81±1.42	3.71±1.13	0.206	0.838
Use of instrumental support	4.18±1.55	4.50±1.28	−0.594	0.558
Planning	3.37±1.20	3.21±1.36	0.342	0.735
Total score of the domain	16.68±4.57	18.00±4.86	−0.761	0.453
Dysfunctional coping
Behavioral disengagement	3.93±1.23	4.42±0.93	−1.211	0.236
Denial	4.50±1.03	4.42±1.15	0.179	0.860
Self-distraction	6.37±0.88	6.07±1.07	0.850	0.403
Substance use	2.62±0.80	2.50±0.85	0.412	0.684
Venting	4.62±0.95	5.35±0.92	−2.119	0.043*
Self-blame	5.87±1.36	5.85±1.99	0.029	0.977
Total score of the domain	16.87±4.78	19.64±2.81	−1.893	0.069

*Significant at <0.05 level. SD – Standard deviation

Table 4.4.

Comparative description between the coping strategies of the mothers of adolescents with bipolar disorder as per selected sociodemographic parameters (family history of mental illness) (independent samples t-test) (bipolar disorder group)

Variables (domains of the Brief COPE)	Group (n=30), mean±SD		t (df=28)	P
	Family history of mental illness absent (n=14)	Family history of mental illness present (n=16)
Emotion focused coping
Acceptance	3.12±1.25	3.00±1.03	0.294	0.771
Use of emotional social support	5.12±0.88	5.28±1.38	−0.384	0.704
Humor	2.37±0.80	2.28±0.72	0.317	0.754
Positive reframing	3.37±1.20	3.28±1.26	0.198	0.845
Religion	5.25±1.43	5.00±1.51	0.463	0.647
Total score of the domain	20.43±6.76	22.50±6.35	−0.857	0.399
Problem focused coping
Active coping	3.68±1.19	3.85±1.40	−0.357	0.724
Use of instrumental support	4.50±1.41	4.14±1.46	0.680	0.502
Planning	3.12±1.25	3.50±1.28	−0.806	0.427
Total score of the domain	16.25±3.67	18.50±5.50	−1.332	0.194
Dysfunctional coping
Behavioral disengagement	4.06±1.28	4.28±0.91	−0.539	0.594
Denial	4.37±0.71	4.57±1.39	−0.493	0.626
Self-distraction	6.12±1.14	6.35±0.74	−0.646	0.523
Substance use	2.56±0.81	2.57±0.85	−0.029	0.977
Venting	4.87±1.02	5.07±0.99	−0.530	0.600
Self-blame	5.62±1.50	6.14±1.83	−0.851	0.402
Total score of the domain	17.25±4.76	19.21±3.21	−1.303	0.203

SD – Standard deviation

The regression analysis was done to assess the confounding factors such as “family history of mental illness,” “religion,” “lower level of education of mothers,” and “rural locality” in the study group (BPAD) and their roles in influencing the findings of the study. However, those factors had not been found to have significant implications on the coping styles employed by the mothers [Table 5].

Table 5.

Regression analysis between coping styles and independent variables (family type, mothers’ literacy level, religion and family history of mental illness)

Model	Unstandardized coefficients B	Standardized coefficients		t	P	F	R	R2	ΔR2
		SE	β
Constant	14.90	2.56	-	5.81	0.001**	0.98	0.185	0.034	0.000
Problem focused coping and family type	1.80	1.81	0.185	0.99	0.329
Constant	15.37	2.67	-	5.75	0.001**	0.58	0.142	0.020	−0.015
Problem focused coping and mothers’ literacy	1.31	1.72	0.142	0.76	0.453
Constant	18.58	2.45	-	7.58	0.001**	0.31	0.105	0.011	−0.024
Problem focused coping and religion	−1.13	2.02	−0.105	−0.56	0.580
Constant	14.00	2.61	-	5.35	0.001**	1.77	0.244	0.060	0.026
Problem focused coping and family history of mental illness	2.25	1.68	0.244	1.33	0.194
Constant	15.25	2.71	-	5.61	0.001**	0.63	0.149	0.022	−0.013
Problem focused coping and place of residence	1.70	2.14	0.149	0.79	0.433
Constant	18.80	3.61	-	5.20	0.001**	0.58	0.143	0.020	−0.015
Emotion focused coping and family type	1.95	2.55	0.143	0.76	0.452
Constant	19.55	3.76	-	5.20	0.001**	0.26	0.098	0.010	−0.026
Emotion focused coping and mothers’ literacy	1.25	2.42	0.098	0.51	0.608
constant	22.97	3.43	-	6.68	0.001**	0.24	0.092	0.008	−0.027
Emotion focused coping and religion	−1.39	2.83	−0.092	−0.49	0.628
Constant	18.37	3.72	-	4.92	0.001**	0.73	0.160	0.026	−0.009
Emotion focused coping and family history of mental illness	2.06	2.40	0.160	0.58	0.399
Constant	18.30	2.32	-	7.84	0.001**	0.04	0.011	0.000	−0.036
Dysfunctional coping and family type	−0.10	1.64	−0.011	−0.06	0.952
Constant	14.10	2.26	-	6.22	0.001**	3.58	0.337	0.113	0.082
Dysfunctional coping and mothers’ literacy	2.76	1.46	0.337	1.89	0.069
Constant	17.47	2.19	-	7.96	0.001**	0.11	0.63	0.004	−0.032
Dysfunctional coping and religion	0.61	1.81	0.063	0.33	0.739
Constant	15.28	2.33	-	6.54	0.001**	1.69	0.239	0.057	0.023
Dysfunctional coping and family history of mental illness	1.96	1.50	0.239	1.30	0.203

**Significant at <0.01 level. SE – Standard error

DISCUSSION

The current study was an attempt to examine the stress and coping of the mothers of the adolescents with BPAD. BPAD impacts skill development in children leading to family situation becoming fussy and unsteady. In the present study, mothers of the adolescents with BPAD were compared with the mothers of normal adolescents on stress and coping. The current study was conducted on sixty mothers, of which thirty mothers of adolescents with BPAD and thirty mothers of normal children. Majority of the earlier studies were done on parents and among them only few studies were done with mothers of children having psychosis or children with disability.[7,8,21,22,23,25,29,30,35,36] Majority of studies done on psychosis were done in the context of schizophrenia.[37,38,39,40,41,42] The current study especially looks into the parenting stress of mothers of adolescents with BPAD. Maximum emphasis had been given in previous studies on the coping mechanisms of parents of children having developmental disabilities,[22,30,35,43,44,45,46] but studies on parents of children having psychosis were concerned with the burden of care[29,37,38,39,40,41] instead of coping mechanisms. The present study has tried to emerge as a fillip by assessing the mothers' coping responses against the stress of early-onset BPAD in their children. In most cases, mothers have to take the greater responsibility in patient care and they are expected to keep a balance between patient care and steadying the family functions. Therefore, their task is tougher than any other persons in the relationship systems of the patients.[2,4,18,22] In the present study, the sample size was 60; of which 30 were mothers of adolescents with BPAD and the remaining 30 were mothers of normal children.

The sample size of this study is comparable to previously done studies on similar population with children having disabilities and psychosis;[22,42] although some studies have had a much larger sample size than the present study.[29,47] However, the adoption of stringent selection criteria for subjects gave this study the adequate robustness which is evident through the comparability between the study and normal control group [Tables 1.1 and 1.2].

However, in this study, significant difference between the study and control groups was seen in family history of mental illness. In bipolar group, majority of the selected children have one or more members with significant psychiatric disorder (n = 16 [53%]). This finding of present study has been found to be in assonance with the studies done in to explore the genetic loading of BPAD. Findings of those studies indicate the morbid risk of BPAD in first-degree relatives of bipolar probands ranges between 3% and 8%. The risk of illness in the first-degree relatives of patients with BPAD is increased nearly 10 times over the normal community, and the rate of prevalence is enumerated to be 5%–10% in siblings and 10% in dizygotic twins and >50% in monozygotic twins.[48,49,50,51,52] In the current study, parenting stress was assessed using PSI/SF.[33] The PSI/SF provided a total stress score from three scales: parental Distress, Parent–Child Dysfunctional Interaction, and Difficult Child. Mothers of adolescents with BPAD scored significantly higher than the mothers of normal adolescents in all three domains as well as total scores of the PSI/SF.[33] The Brief COPE[34] scale was applied on the mothers of either adolescent for assessing their coping strategies. In the current study, mothers of normal adolescents reported higher scores on Problem-Focused Strategies (Active Coping, Use of Instrumental Support, and Planning) [Table 3]; whereas, mixed results were seen in Emotion Focused Coping (Acceptance, Use of Emotional Support, Humor, Positive Reframing, and Religion). No significant difference was seen in Use of Emotional Support; significantly higher use of Acceptance, Humor, and Positive Reframing was reported by the mothers of normal adolescents'. Mothers of the adolescents with BPAD had reported significantly higher use of “Religion” to cope with the stress. In Dysfunctional Coping Strategies (Behavioural Disengagement, Denial, Self-Distraction, Self-Blame, Substance Use and Venting), significant difference was seen between these two groups of mothers. However, no significant difference was seen between them in “Substance” domain. In all other strategies of this particular form of coping, mothers of the adolescents with BPAD had reported significantly higher scores. In early-onset BPAD, parents have the feeling of loss, sadness, distress, and apprehensiveness like any other chronic and debilitating health problems, including mental illness.[2,3,4,5,6,7,8,13,53] In the families of the patients' with early onset BPAD, problems such as expressed emotions, burden of care, and disruption in family functions are observed. Those problems were also found to be similar like families with other forms of chronic mental and behavioral problems, for example, schizophrenia, Autism, Autism Spectrum Disorder and mental retardation.[13,19,20,21,22,23,24,25,36] Early-onset BPAD is a complex and heterogeneous psychiatric disorder, and it has some distinctive difference with adult onset BPAD.[14] Many a time, children and adolescents with BD have psychiatric co-morbidities like ADHD, ODD, Conduct Disorder, and anxiety disorders.[9,13,14] In the current study, variable like “socio-economic status of family” (Lower Income Family and Middle Income Family) did not have significant implication on the coping strategies of the mothers of the adolescents with BPAD [Table 4.1]. However, “type of family” has been observed to have some implications on the usage of specific coping strategies of these mothers. Mothers living in the nuclear families reported significantly higher use of “religion” than mothers of joint families. However, mothers of the joint families had reported significantly higher use of “self-blame” [Table 4.2]. In nuclear families, scope for interactions with larger family system or extended family unit and getting support from many people simultaneously is much lesser. Mothers have to depend on their husbands (fathers of the adolescents) for seeking emotional support and comfort. In many cases, husbands do not get adequate time to spend with their wives. This reason might have influenced the mothers to rely on religion to stave off their stress. Mothers belonging to Indian form of joint family system reported significantly higher use of “self-blame” to cope with the stressor, i.e., illness of their children. Indian joint family system has some limitations, e.g., “less privacy,” “ambiguity in decision-making process,” “problem in parenting,” and occurrences of discontents and disagreements in relation to several aspects of family functions, childcare and parenting. Sometimes, women are not given adequate importance by the elders and family is strictly driven by age-old traditionalistic views which condone the women's role in major family issues and tasks. Because of those reasons, women of this family system often have the feeling of deprivation. In the current study, this might have influenced the mothers to use self-blaming, because they might have the feeling of not being supported by others.[54,55,56] The Regression Analysis was carried out on the Study Group (BPAD Group) to assess the influence of confounding variables like “family history of mental illness,” “religion,” “lower level of education among mothers,” and “predominance of subjects from rural locality” and those were significantly higher in the study group, which might have influence the findings. However, the regression analysis [Table 5] suggested that, those factors did not have overall significant influence on the coping styles of the mothers of the adolescents with BPAD.

However, this study has some significant limitations in the forms of “significant difference between the BPAD and normal adolescents in their mean age,” “small sample size,” “not including important variables such as burden of caregiving, spousal support, marital relationship between parents, and perceived social support of mothers.” Those variables might have important implications on the perception of stress, selection, and usage of specific coping strategies from the side of mothers.

CONCLUSION

Mothers of the adolescents with BPAD tend to perceive high level of stress and they also have significantly higher level of dysfunctional relationship with their children. Mother of these children tend to use maladaptive coping more while dealing with stressful situations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.