Senior Professor of Psychiatry, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.
The role of the family
The role of the family in the causation and maintenance of mental illness and its recovery process is complex. The family plays a significant role in the development of a person’s personality. The nature of the relationships has an effect on the individual’s ability to cope in adversity and adapt to stressful situations.
Families are different from country to country as well as within a community. Traditionally families in Eastern countries are regarded as extended; whereas Western families are regarded as nuclear. Typical extended families however are rarely encountered in countries like Sri Lanka at present. Sri Lankan families are neither typical nuclear nor extended. In other words, families continue to evolve even in developing countries.
A positive aspect of our families is that the members within the family still have close ties with each other and also with other relatives and friends. In childhood, adverse family environment can give rise to problems in their developmental stages. It is known that the characteristics of the families, social relationships and the child’s development are intricately linked as the family acts as a powerful mediating factor in determining coping strategies of their members in various problematic situations including problems with health (Wilkinson, 1998). Erikson’s original work attempted to show a link between the personality development and socialization by describing various stages (eight stages) of life.
Relevance of attachment
The importance of Bowlby’s and Ainswoth’s theories, ideas and work with regard to the early attachment in the process of psychological development of children and subsequent mental health has been discussed (Bretherton, 1992). Even though there are criticisms about Bowlby’s theories and the maternal deprivation hypothesis, there is a relevance in explaining psychological problems such as persistent anxiety and angry behaviour encountered in children following separation from caring/attachment figures. It also explains the experience of loss giving rise to symptoms of depression and sadness.
On the other hand, ethological and animal studies as for example Harlow’s research with monkeys, demonstrated profound effects on social functioning with a lack of contact with parents or peers in the early period of rearing (Harlow, 1963, Harlow, 1958)
An important issue that needs to be addressed in the Sri Lankan context is the psychological sequel of children of Middle-East employees. These children go through a multitude of adversities in life such as exposure to violence, all sorts of abuse and neglect, financial difficulties, malnutrition and problems with education. Separation from the primary caring/attachment figure results in problems in development of a secure attachment among many such children.
A study done in North Colombo Teaching Hospital, Sri Lanka, demonstrated that behavioural symptoms were more often encountered in children hospitalized for paediatric problems whose parents were employed in the Middle-East than in the controls. Alcohol and substance misuse among the remaining parent is more than in the controls.
Research reveals that the children in step families have an increased tendency to have problems in social relationships and health and also internalizing and externalizing behaviours. There is a need for more research in order to fill the gaps in systematic research on step families as there is an increasing number of children undergoing major changes in their families. This will help clarify who is vulnerable to the experiences associated with life in step families and to ascertain deleterious and protective experiences (Dunn, 1995). A study suggested that although the children exposed to living in a step family had an increased risk of adverse psychosocial outcomes, the increased risk seemed to be related to compounding social, contextual and individual factors antecedent to the environment/formation of the step family (Nicholson et al., 1999) .
An association between institutional rearing and a considerable psychiatric morbidity among children has been shown and removing young children from institutions and placing them in “foster” families significantly reduced internalizing disorders and the girls were significantly more responsive than boys (Zeanah et al., 2009) .
Genetic and environment influence
Multifactorial causation of the childhood disorders and the importance of paying attention to gene-environment correlations and interactions have been discussed (Rutter, 1999).
One needs to understand the additive nature of these adversities when dealing with children who are exposed to traumatic events. In addition to paying attention to the genetic basis, understanding salient social environments especially early adversities in the offspring and caregiver relationships is important in understanding the causation of psychiatric symptoms (Wamboldt and Reiss, 2006).
Influence of maternal mental health on the offspring
It is also evident that ante-natal maternal mood can give rise to lasting effects on the psychological development of the child. An association of ante-natal stress and anxiety of mothers and emotional and behavioural problems in offspring has been demonstrated (Glover and O'Connor, 2002). There is evidence that there may be altered levels of cortisol with maltreatment such as neglect, abuse and witnessing abuse and other adversities. A recent study has shown that cumulative maltreatments in childhood were associated with flattened morning cortisol secretion in mid-adult life and supported the notion that the down-regulation of HPA axis in response to childhood maltreatment leading to flattened cortisol diurnal rhythm which may have implications for subsequent health outcomes (Power et al., 2012) .
It has also been demonstrated that there is a higher risk of developing offspring psychopathology when children were exposed to both ante-natal depression and childhood maltreatment (Pawlby et al., 2011) .
It is noteworthy that the biological as well as psychosocial risk factors affect the developing brain and adversely influence the development of children. Inadequate cognitive stimulation, stunting, iodine deficiency and iron –deficiency anaemia are some factors. There is also evidence for other risk factors such as intrauterine growth retardation, lead exposure, malaria, HIV infection, maternal depression, institutionalization and exposure to societal violence can compromise the development of children. Protective mechanisms are associated with more maternal education, less maternal depression, good quality child rearing environment, better child nutritional status and ability to make use of available intervention services (Walker et al., 2011).
Parent’s psychopathology/maladaptive parenting and offspring’s mental health
Children of mentally ill parents had an increased rate of persistent emotional and behavioural disturbance which tended to involve conduct disorders. The psychiatric risk to children was greater when the parents had personality disorders associated with high levels of hostile behavior. Boys showing temperamental risk factors were most vulnerable to the effects associated with parental mental disorder (Rutter and Quinton, 1984). Another more recent study involving 22 countries around the globe demonstrated parent psychopathology as a robust non-specific predictor of offspring disorder. This has implication in prevention programmes to improve the functioning of parents as well as to improve intergenerational transmission of mental disorders (McLaughlin et al., 2012) .
Another recent study on association between maladaptive parenting and child self-control over time, has demonstrated that parenting and child self-control affect each other emphasizing the potential of early intervention targeting both parents and children at the same time (Cecil et al., 2012) .
Domestic violence and mental health
Intimate partner violence as domestic violence is still not identified early in south Asia. Victims suffer silently. A study in India on mental health correlates in women has shown a strong association between domestic spousal violence and poor mental health and emphasized the need for proper interventions (Kumar et al., 2005) . An US study has shown that childhood physical abuse as well as witnessing of maternal battering are common among children who subsequently had poor mental health in a follow up study. An emotionally abusive environment accentuates the decrements in mental health scores (Edwards et al., 2003) .
A Sri Lankan study related to domestic violence has shown that even though the women were undergoing victimization the majority continued with the marriage. This may be due to a variety of reasons including financial constraints to lead an independent life and societal stigma. (Kuruppuarachchi and Wijeratne, 2005). However the children who witness violence can have long term psychological problems.
Childhood adversities and adult mental health
Childhood adversities, environment and the mental health in childhood and early adolescent periods are very important determinants of subsequent psychological health in adulthood. It has been consistently demonstrated that childhood adversities such as separation, violence, alcoholic parents, mentally disturbed parents and poor parenting can give rise to mental health problems in later life.
There is evidence that multiple forms of childhood maltreatment such as sexual abuse, physical abuse and witnessing of maternal violence can adversely influence subsequent mental health as an adult in a dose responsive manner as the number of abusive experiences increased (Edwards et al., 2003) .
Recent and longstanding adversities tend to increase the risk of development of emotional distress and emotional disturbances during school age too.
A WHO World mental health survey on childhood adversities and adult psychopathology has shown that childhood adversities are highly prevalent and interrelated and can give rise to a wide range of disorders such as conduct disorders, ADHD, oppositional defiant disorder, adulthood depression, anxiety disorders, PTSD and substance misuse. It has also been demonstrated that adversities associated with factors leading to poor adaptation of family functioning such as parental mental illness, child abuse and neglect were the most powerful predictors of disorders. This study also revealed the sub additive nature of multiple childhood adversities associated with poor family functioning which has implications for intervention programmes (Kessler et al., 2010) .
Association between childhood behaviour problems and subsequent criminal tendency has been studied in the West. Follow up studies have shown that disruptive behaviour in childhood has powerful long-term consequence leading to antisocial behaviour in adulthood. Environmental, family, school and child risk factors including poor parenting have been linked to development of conduct disorders and also negative juvenile and adulthood outcomes such as high school dropout and truancy rates, anti-social behaviour, criminal behaviour, unemployment, family disruption, intergenerational transmission of conduct problems to children, psychiatric disorders and drug and alcohol misuse. The importance of identifying the risk factors and preventive interventions to reduce the risk and to promote the protective factors has been emphasized (Bywater, 2012).
There is a considerable increase in victimizing experiences during childhood even among patients with psychosis. Adverse childhood experiences are significant risk factors for most mental health problems including psychosis (Read and Bentall, 2012).
There are vulnerability factors as well as protective factors. The end result depends on the balance between these factors. A simple example is that a sexually abused child living in an environment with other adversities will have more psychological problems as an adult, compared to a child who has been abused but subsequently has had a caring environment.
Suicide and deliberate self-harm among children and adolescents is another area of concern. Suicide is the third leading cause of death among adolescents. Childhood adversities are risk factors for the onset and persistence of suicidal behavior. Intrusive and aggressive adversities particularly are powerful predictors (Bruffaerts et al., 2010) . A study conducted in the North Colombo Teaching Hospital in Sri Lanka also demonstrated that there is a significant association between separation from parents in childhood and subsequent suicidal attempts in adulthood in otherwise normal adults (Kuruppuarachchi and Williams, 2003).
Most of the work with regard to suicide has been done in relation to the risk factors and to a lesser degree on protective factors (Bertolote, 2004). It is important to pay attention to the role of protective factors such as problem solving capacity, seeking help, good relationships with the family and close associates (Wasserman et al., 2008).
Good parent-child relationship facilitates the development of positive experiences within the family and provides the child with social skills and emotional security that helps them to cope in a resilient way. There is a strong association between the quality of the parent child relationship and the child outcomes (Scott, 2010).
Individual happiness is associated with a stable family upbringing in addition to the other factors such as employment, good health, stable financial situation, personal freedom and values (Kelly, 2011).
Our traditional protective factors
In Sri Lanka, “Daham Pasal” education is a unique phenomenon where the children are exposed to listening to various “Jathaka” and other similar religious stories in temples on Sundays. This can help to improve the moral development, tolerance and subsequent “stable and positive” personality development. We might be able to make use of these available resources in shaping personalities of people. Great works such as “Bhagavad-Gita and Panchatantra” written in India (now translated to many languages) may also be very important in this context.
Even though emotional warmth and caring attitudes are beneficial, high expressed emotions, criticisms and intrusiveness in the environment adversely affect the outcome of many mental illnesses including schizophrenia and affective disorders.
Conclusions and future directions
It is time to recognise the importance of preserving “psychosocially healthy families”, and maintaining family networks and integrity to prevent behavioural and emotional problems in childhood and subsequent psychopathology in adulthood. It is essential to identify the vulnerable families and deal with them effectively to minimize the burden on society. More cross-culturally relevant, methodologically sound research work is needed to understand the complex gene-environment interaction in the causation of psychopathology.
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