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Revista de cercetare [i interven]ie social\
ISSN: 1583-3410 (print), ISSN: 1584-5397 (electronic)
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RISK FACTORS AND RESILIENCE IN THE OFFSPRING
OF PSYCHOTIC PARENTS
Laura NUSSBAUM, Alexandru OGODESCU, Lavinia HOGEA,
Liliana NUSSBAUM, Irina ZETU
Revista de cercetare [i interven]ie social\, 2017, vol. 56, pp. 114-122
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REVISTA DE CERCETARE SI INTERVENTIE SOCIALA
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REVISTA DE CERCETARE {I INTERVEN}IE SOCIAL| - VOLUMUL 56/2017
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Risk Factors and Resilience in the
Offspring of Psychotic Parents
Laura NUSSBAUM1, Alexandru OGODESCU2, Lavinia HOGEA3,
Liliana NUSSBAUM4, Irina ZETU5
Abstract
We approach an integrated research-action model of the interactions between the
psychosis of the parent, parenting, family relations, the child’s development, risk and
resilience factors. The research objectives are: identifying the resilience factors, the
research of the interaction between the risk and resilience mechanisms, predicting or not
the development of psychopathology in children of psychotic parents, the dynamic eva-
luation of the resilience. The longitudinal study was conducted in the period 2003-2013 on
a group of 75 children with a schizophrenic parent and 70 children with a parent with
bipolar disorder. We applied the scales: CBCL, Vth Axis ICD 10, PANSS and CD-RISC
(Connor-Davidson Resilience Scale). Through PANSS for the psychotic parents, we corre-
lated the scores for specific items with those obtained by the children through CD-RISC.
Through MANOVA and the Pearson test we correlated the dependent variables with the
predictive influence factors. The high PANSS scores for specific items were correlated
negatively with the resilience scores of the children with psychotic parents. The maximum
frequency of positive codifications on the Vth Axis, found for: rejection behavior from one
parent (76, 4%), family disharmony (73, 52%), distorted family communication (70, 58%),
was significantly correlated (p<0.001) with low scores of the child’s resilience for personal
competency, negative effects tolerance, safe interpersonal relations, high performance.
The social, family support and social connectedness proved to be relevant variables.
Resilience can be modified and improved through targeted interventions, so that the
understanding of the resilience process and of the concurrent factors is needed.
Keywords Abstract Teaser: resilience, research-action, parenting,
1
University of Medicine and Pharmacy “Victor Babes”, Department of Neurosciences, Child and
Adolescent Psychiatry Discipline, Timisoara, ROMANIA. E-mail: nussbaumlaura@yahoo.
com
2
University of Medicine and Pharmacy “Victor Babes”, Department of Pediatric Dentistry,
Timisoara, ROMANIA. E-mail: ogodescu@yahoo.com
3
University of Medicine and Pharmacy “V. Babes”, Department of Neurosciences, Psychology
Discipline, Timisoara, ROMANIA. E-mail: laviniahogea@yahoo.com (corresponding author)
4
Mental Health Department for Children and Adolescents, Timisoara, ROMANIA. E-mail: laura_
nussbaum@yahoo.com.au
5
University of Medicine and Pharmacy “Grigore T. Popa”, Department of Orthodontics and
Dentofacial Orthopaedics, Iasi, ROMANIA. E-mail: nicoleta.zetu@gmail.com
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REALITIES IN A KALEIDOSCOPE
Introduction
Research in the frame of developmental psychopathology, which is focused on
children, exposed to high-risk family environments, identified children having
parents with severe psychopathology, who develop maladjustment or sympto-
matology or who adapted well despite the challenges posed to their adjustment
(Cohen, 2007; Ionescu, 2013; Luthar, 2006). Children of parents with schizo-
phrenia/affective disorders who avoided a psychopathologic outcome through
developing a healthy pattern are considered to be more resilient (Rutter, 1990;
Cicchetti & Garmezy, 1993; Cohen, 2007). The “high risk” design of choosing
children, offspring of psychotic parents who developed and who didn’t express
psychopathology, encourages the examination of gene-environment, risk and
protective factors interactions (Bartels & Hudziak, 2007; Hjemdal, 2007). De-
velopmental psychopathology and well-being are a function of the interplay of
bio-psychosocial risks and resilience factors in children and their supportive
environments (Carrey & Ungar, 2007). Previous research showed the multi-
plicative effects of cumulative and interactive risks on child adjustments and on
the expression of psychopathology (Rutter, 2003). Recent studies converge on the
idea that high risk children may acquire cognitive vulnerability by receiving
direct inferential feed-back from significant others or as result of negative paren-
ting practice (Pastor et al., 2015). Prevention interventions should target at-risk
populations because the goal is to prevent a high risk person from developing
psychopathology (Nussbaum, 2000).
Objectives
Our aims were: the quantification of the resilience mechanisms in high risk
children; to assess how multiple risk factors during different developmental
periods work together and express psychopathology or provide the offspring of a
psychotic parent, the opportunity to be resilient; the identification of protective
factors in the subgroups that were less prone to develop psychopathology despite
exposure to risk; the evaluation of resilience in different timepoints in order to
assess the efficacy of targeted interventions. We also targeted the prospective
identification of children with a high probability to develop a mental illness in
order to prevent through improving the resilience mechanisms or to apply a proper
intervention.
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Methodology
Our prospective research was performed in the University Hospital of Psychiatry
for Children and Adolescents, Timisoara, in the period from 2003-2013, on high
risk children, with ages between 10-19 years, who were offspring of psychotic
parents:75 children with a parent suffering of schizophrenia and 70 children of
parents with bipolar disorder (Nussbaum, 2000). We identified help-seeking fa-
milies, with one psychotic parent, having children, who needed care in our clinic
in that period (Lazarescu & Ienciu, 2012). We signed the informed consent with
the parents and the assent to participate with the children. From the 75 high risk
children, being offspring of parents with schizophrenia, 55 developed psycho-
pathology and 20 were without. From the 70 high risk children of parents with
bipolar disorder: 40 children were with psychopathology and 30 without. The
children without psychopathology in both groups, were siblings of those who
developed psychopatholgy, living in the same environment.
We applied the standardized research instruments: PANSS-Positive and Ne-
gative Syndrome Scale was applied on the psychotic parents; CBCL and the Fifth
Axis ICD 10 were applied on all the parents in the study groups; CD-RISC-
Connor-Davidson Resilience Scale on the two groups of children; CD-RISC
consists of 25-items that measure the ability to cope with stress and adversity. It
was designed to quantify self-reports of resilience and to measure response to
treatment in a clinical population. Each item is rated on a 5-point scale (0-4),
higher scores reflecting greater resilience. The items reflect several aspects of
resilience that include: a sense of personal competence, tolerance of negative
affect, positive acceptance of change, trust in one’s instincts, sense of social
support, spiritual faith, and an action-oriented approach to problem solving (Connor
& Davidson, 2003; Ionescu, 2013). Through PANSS, we evaluated the positive,
negative and general symptoms of the psychotic parents and we correlated the
scores for specific items with those obtained by the children through CD-RISC
for the resilience. Through the CBCL, we evaluated some symptomatic categories
referring to behavioral and social competence problems of the children, perceived
by their parents. Through the Fifth Axis we evaluated the abnormal psycho-social
conditions. The categories included in this axis, have been chosen, knowing the
fact that they can represent significant risk factors (Nussbaum, 2000). We applied
the scales in different timepoints in order to evaluate and quantify the efficacy of
proper interventions through the resilience scores.
We used: descriptive statistics-average, standard deviation, absolute and re-
lative frequencies, parametric statistical tests-simple ANOVA and simple factorial
ANOVA; the Pearson correlation test to check for the presence of statistically
significant correlations between the CD-RISC-CBCL results, the CD-RISC-Fifth
Axis results and the PANSS-CD-RISC results; We applied the qui square analysis
to evaluate if the variation of the resilience scores from CD-RISC, was statistically
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REALITIES IN A KALEIDOSCOPE
significant in different timepoints. We had the support of SPSS and MedCalc
statistics. We evaluated the differences between the children with and without
psychopathology in both groups concerning their own mechanisms of resilience
or their risk factors.
Results
The most frequent diagnostic categories of the offspring with psychopathology
are illustrated in Figure 1- HR SZ- high risk children with schizophrenic parents
and HR BPD-high risk children of parents with bipolar disorder:
11
10
9
8
7
6
5
4
3
2
1
0
s
rs rs H Ds rs Ti co meer s OCdDers der so bia ietyiety d ers
de d e AD er r de r d r r x x r
di so r di sor i sord d iso sy nddisor diso disoial phn and an di so
al ddu ct rettetion nt anic S oc ratioal ize tin g
ni ng uage n e r a
r g io n u a tm P pa e E
Lea Lan p os it Co Tol imin jus S e G en
Op E Ad
HR SZof the
Figure 1. Diagnoses HR high
BPD risk
Total diagnose s of HR children
children
Concerning the diagnoses of the high risk children we found the lowest CD-
RISC scores of resilience for the offspring with generalized anxiety disorders,
OCD-Obsessive-compulsive disorder and ADHD, as a marker of low self-efficacy
and low self-esteem.
The CD-RISC, CBCL, DSM IV Fifth Axis, PANSS scores and the
Correlations Analysis
Through the CD-RISC application, we noticed in both groups of children who
developed psychopathology, low resilience scores in the main domains, coded
through the key factors: strong sense of self-efficacy, tenacity, emotional and
cognitive control under pressure, adaptability, control and meaning. The lowest
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resilience scores were registered for the children of parents with schizophrenia
with one exception concerning the domain-aspects of persistence/tenacity, where
the offspring of depressive parents had the lowest resilience score. The mean total
CD-RISC score for the high risk children who developed psychopathology was
45.5 (standard deviation-sd=8.7) for the offspring of schizophrenic parents and
52.8 (sd =9.4) for the offspring of bipolar parents (Connor & Davidson, 2003).
Figure 2 illustrates the mean scores in CD-RISC on the 5 domains coded through
the 25 items of the scale for: HRPBPD-high risk children of parents with bipolar
disorder, HRPSZ-high risk children of parents with schizophrenia, T2HRPBPD-
timepoint2 scores - children of parents with bipolar disorder, T2HRPSZ-time-
point2 scores - high risk children of parents with schizophrenia and for the
offspring, who didn’t develop any psychopathology.
Tenacity /self efficacy
8 HRPBPD
6
HRPSZ
4
Meaning Strengthening through stress
2 T2 HRPBPD
0
T2 HRPSZ
HR children
without
Control Adaptability psychopathology
Figure 2. Mean scores in CD-RISC on the 5 domains in timepoint 1 and 2
We evaluated the CD-RISC scores of the high risk children with psycho-
pathology for timepoint1 and after applying proper intervention strategies in
timepoint2. We noticed higher mean total resilience scores (improved from 45.5
to 58.2 for the offspring of schizophrenic parents and from 52.8 to 69.7 for
HRPBPD) and on the 5 key domains, reflecting greater resilience in both studied
groups after the individualized interventions. We noticed that the children without
psychopathology in both groups had generally higher mean scores for resilience
in CD-RISC, as well as concerning the 5 key factors: tenacity/self-efficacy,
strengthening through stress, adaptability, control and meaning. Their mean total
resilience scores in timepoint1 were 70.6 for HRPSZ and 74.3 for HRPBPD
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REALITIES IN A KALEIDOSCOPE
(sd=10.4) and their highest mean scores found were for tenacity/self-efficacy. In
their case, targeted intervention has not been applied and in timepoint2 we found
for HRPSZ-25% and for HRPBPD-30% developed psychopathology and their
mean total resilience scores were 57.3.-HRPSZ and 60.1-HRPBPD.
Through the CBCL, we found in both offspring groups, who developed psycho-
pathology lower median total competencies scores, high, clinically significant
externalizing scores, the high risk children of schizophrenic parents being most
affected. These values in high risk children prove the fact that a high percentage
of children with psychotic parents show a dysfunctional social functioning. High
risk children in both groups, showed high scores for depression, hyperactivity and
aggressiveness. The siblings who didn’t develop psychopathology had higher
median total competencies scores and their CBCL externalizing and internalizing
scores were in non-clinical range. They were very close to the healthy parent,
finding a meaning even in the disturbed family system. Therefore the availability
of a stable attachment person was crucial. Their age was higher than the age of
their siblings with psychopathology, when their parents developed psychosis. We
found high statistically significant correlations (Spearman’s p =0.012) between
the CBCL externalizing, total, competencies scores of the children in both groups
and the resilience scores on CD-RISC. Figure 3 represents, through the dispersion
diagram, the negative correlation between the Externalizing scores of the children
in both high risk groups through CBCL and the resilience scores through the CD-
RISC. So that, high Externalizing scores of the high risk children predicted low
CD-RISC resilience scores.
In the cases of children without psychopathology from both high risk groups,
the more the child exhibited overall competence and skills through the CBCL, the
less likely it was that the child showed externalizing behavior problems and his
scores for resilience in CD-RISC were higher. The Pearson correlations between
the high PANSS scores of the parents and low resilience scores were statistically
significant, especially in the case of psychotic mothers and concerning the ne-
gative symptoms of the schizophrenic mother and the resilience scores of the
offspring (p<0,001).
The maximum frequency of positive codifications on the Fifth Axis in both
study groups of high risk children of schizophrenic and bipolar parents, was
significantly correlated (p<0.001) with low scores of the child’s resilience for
personal competency, negative effects tolerance, safe interpersonal relations,
adaptability. We found through the Pearson correlations between CD-RISC - Fifth
Axis, high negative correlations, meaning that higher scores for the abnormal
family relations and distorted communication predicted low resilience scores.
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Externalization
Resilience scores
Figure 3. The Negative Correlation between Externalization (CBCL) and Resilience
scores (CD-RISC)
Discussions
The fact that the resilience of the high risk children improved in time after
targeted interventions, gives hope that the outcome and the onset of psycho-
pathology can be influenced. Our research-action model of systemic, family-
centered evaluation and intervention, proved to be a successful way to enhance
the empowerment, the positive aspects of individual and family functioning even
under high risk conditions. Through the whole research, the needs of the parents
as well as of the children were approached concomitantly creating an interface
between the mental health services for children with those of the adult services
(Nussbaum, 2000; Lazarescu & Ienciu, 2012). Our study of resilience, including
children with and without psychopathology, assessing genetic and environmental
factors, is likely to lead to improvements in the ability to design effective inter-
ventions (Bartels & Hudziak, 2007). The vulnerable child has some characteristics,
which put him in a risk position. If proper intervention strategies are applied, the
vulnerability can be balanced through protective factors. So, that we have to work
on the rehabilitation of the child and of the parental capacities. Through the
resources and quantification of resilience, we achieved new perspectives of imple-
menting a complex and individualized model of interventional strategies.
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Conclusions
Resilience is modifiable and can improve after targeted interventions. The
presence of seemingly healthy adaptation of high risk children at one deve-
lopmental stage may change in time, positive adaptation never being permanent,
so they need early intervention and support, too. The quantification of resilience
remained a significant predictor of outcome, proving to be a target for early
detection and prevention of psychopathology.
Concerning, the risk/protective factors, non-shared environmental influences
are important for age-specific behavioral problems, in our case the age of the
sibling at the onset of the parent’s psychosis was crucial. The abnormal psycho-
social conditions for the children are higher in the families with a schizophrenic
parent, especially the mother, this fact becoming a burden for the psychological
development and the prognosis.
Acknowledgements
These authors contributed equally to this work and thus share first authorship.
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