It is estimated that up to one in five children/adolescents live with a parent with mental illness (Maybery, Reupert, Patrick, Goodyear, & Crase, 2009). Research has shown that children of parents with severe mental illness (SMI) are at elevated risk for internalizing problems, such as depression and anxiety, and externalizing problems, such as aggressive and rule-breaking behavior (Van Loon, Van De Ven, Van Doesum, Witteman, & Hosman, 2014). The risk of these children developing internalizing/externalizing problems is two to 13 times higher than the risk of children of parents without psychological problems (Dean et al., 2010; Harder et al., 2015).
Psychiatric stigma has been identified as a major barrier to adequate care among individuals with mental illness (Mak & Cheung, 2012). This stigma not only affects those with mental illness, but family members of the individual with mental illness also experience what has been called affiliate (or associative) stigma (Catthoor et al., 2015; Chang & Horrocks, 2006). It is widely acknowledged that negative attitudes and discrimination toward people with mental disorders are pervasive and socio-environmental factors (e.g., stigma), not the parental mental illness itself, present the greatest risk to children (Phillips, Pearson, Li, Xu, & Yang, 2002; Van Loon et al., 2015). Faulkner, Irving, Paglia-Boak, and Adlaf (2010) found that 67% of Canadian high school students reported they would feel ashamed if others knew that someone in their family was diagnosed with SMI. In addition, studies have found that peer relationships for children of parents with a mental illness would be likely to be abnormal, for they often have a lower peer group acceptance and are at higher risk of following a trajectory of deviant peer group affiliation, such as substance use and excessive use of the internet (Wong et al., 2009).
Research has also shown that family environment plays a significant role in shaping developmental outcomes among these high-risk individuals (Lau et al., 2018). A previous study manifested that parental mental illness is associated with low family cohesion, family conflict, and low family bonding (Van Loon et al., 2014). Family cohesion, which refers to the emotional bonding between members of a family, can be regarded as a protective mechanism, which plays an important role in protecting adolescents from harm associated with parental mental illness (Beardslee, Gladstone, & O'Connor, 2011). The quality of family relationships has been correlated with a variety of outcomes, such as emotional regulation, empathy, social competence, and self-reliance in adolescents (White, Shelton, & Elgar, 2014). Adolescence is an important developmental period, which is full of struggles that may contribute to the risk of onset of internalizing and externalizing problems (Wong et al., 2009). Adolescents of parents with SMI may encounter greater difficulties due to insufficient emotional support from their parents and stigma (Helsen, Vollebergh, & Meeus, 2000). Family cohesion might contribute to sensitivity about stigma issues. For example, low family cohesion would place individuals at greater risk for developing affiliate stigma, which could further exacerbate their psychological distress and maladaptation (Van Loon et al., 2014).
Previous studies (Xu, Rüsch, Huang, & Kösters, 2017; Yang, Thornicroft, Alvarado, Vega, & Link, 2014) revealed that in contrast to Western individuals, Chinese individuals endorse more social distance from people with mental illness. Affiliate stigma may be culturally salient among Chinese individuals given their beliefs toward mental illness and their values of face concern (Yang et al., 2013). Research found that Chinese individuals tended to emphasize biological roots of mental illness and might consider their ill relative as a disgrace to their family, which may further exacerbate their stigma (Mak & Cheung, 2012).
Although findings provide support for a relationship among family cohesion, affiliate stigma, and externalizing/internalizing problems, additional research is needed to explore whether family cohesion underlies the association between affiliate stigma and externalizing/internalizing problems. Therefore, the goal of the current study was to examine associations among affiliate stigma, family cohesion, and externalizing/internalizing problems, as well as the mediating role of family cohesion in the relationship between affiliate stigma and externalizing/internalizing problems in adolescents of parents with SMI in China.
A cross-sectional research design was used. After having received information about the aim of the study, participants were asked to sign an informed consent form. Anonymity was assured and it was made clear that participants could withdraw from the study at any time. A monetary reward (RMB 20 [Chinese currency]) was given to participants once their questionnaires were completed as a means of thanking them for their time and effort.
Recruitment and Data Collection
A convenience sample was recruited from two community mental health centers. The current study included adolescents ages 11 to 16 who had a parent(s) with SMI. Adolescents ages 17 and 18 were not included because of their busy school schedule. Recruitment of participants was conducted by the lead author (C.C.) who visited the community health center twice per week for 8 weeks and contacted all suitable patients through staff members in the community mental health centers. Parental mental illness was defined based on documentation of the community health center (with diagnosis certifications from physicians in formal mental health institutions). Inclusion criteria were: (a) adolescents having a parent(s) with a diagnosis of SMI (e.g., schizophrenia, mood disorder [including bipolar disorder, mania, and depression]) who maintained medication therapy, were clinically stable, and not aggressive or hostile; (b) sufficient cognitive capacity and able to communicate; and (c) provided informed consent. Families with a child with significant developmental delay, severe chronic illness, or both were excluded.
Families who met inclusion criteria were contacted by the researcher via telephone. The study purpose and procedures were explained, and permission was requested for adolescents' participation. Consent forms along with questionnaires were delivered during a home visit. One hundred sixty-four eligible adolescents agreed to take part in the study. Adolescents completed the questionnaires at their home independently and all returned the questionnaires. No participant had two parents with mental illness, and no adolescents were from the same family, due to China's “one-child policy.”
Demographic Variables. Demographic variables including parental employment status (one/two parent[s]) employed vs. both parents unemployed), adolescent living situation (living or not living with both biological parents), adolescents' and parents' age and gender, and household income were completed by adolescents. Demographic data on parental age, parental years of education, marital status, type of parental mental illness, and chronicity of the disorder were gathered from the documentation of the community health center.
Family Cohesion. The 14-item family cohesion subscale of the Family Adaptability and Cohesion Evaluation Scale (FACES) was used to evaluate family cohesion (Fei et al.,1991; Olson,1986). Adolescents rated items such as “Family members support each other in difficult times” on a 5-point Likert scale ranging from 1 (almost never) to 5 (almost always). Total scores ranged from 14 to 70, with higher scores indicating better family cohesion. Internal consistency for this instrument was α = 0.85 in Fei et al. (1991) and α = 0.82 in the current study.
Affiliate Stigma. Affiliate stigma was measured using the 22-item Affiliate Stigma Scale, which includes three domains: cognitive (seven items), affect (seven items), and behavior (eight items) (Mak & Cheung, 2008). Adolescents rated each item on a 4-point Likert scale, ranging from 1 (strongly disagree) to 4 (strongly agree), with higher scores indicating a greater level of affiliate stigma. The psychometric properties of the Affiliate Stigma Scale have been supported, including excellent internal consistency (α = 0.85 to 0.94), person separation reliability (coefficient = 0.88 to 0.99), predictive validity, and concurrent validity. In the current study, Cronbach's alpha was 0.87.
Adolescent Internalizing and Externalizing Problems. Adolescent internalizing and externalizing problems were assessed with the Chinese version of the Youth Self Report-2010 (YSR; Wang et al., 2013), which measures problems adolescents experienced in the previous 6 months. Adolescents rated the items on a 3-point scale, where 0 = not true, 1 = somewhat or sometimes true, and 2 = very true or often true. The YSR comprises 112 problem items and eight subscales: (1) withdrawn, (2) somatic complaints, (3) anxious/depressed, (4) delinquent behavior, (5) aggressive behavior, (6) social problems, (7) thought problems, and (8) attention problems. These eight subscales can be used to compute an internalizing score, an externalizing score, and a total problem score. Among these dimensions, (1), (2), and (3) make up the internalizing factor, whereas (4) and (5) constitute the externalizing factor. In the current study, the internalizing score and externalizing score of each adolescent were used. The Chinese version of the YSR has been established to have high reliability and validity (Song, Wang, Zheng, Chen, & Wang, 2010). In the current study, Cronbach's alphas for the internalizing and externalizing scales were 0.84 and 0.88, respectively.
Scores range from 0 to 62 and 0 to 64 for internalizing and externalizing problems, respectively. The problem behavior scales have been normed according to age and gender categories. The clinical threshold of a normalized T-score of 69/63 or higher was used to measure clinically significant internalizing/externalizing behavioral problems.
Ethical approval was granted by the Academic Research Committee of the authors' institution. The investigation conforms with the principles outlined in the Declaration of Helsinki, and written informed consent was obtained from participants prior to the start of the study.
Descriptive statistics and correlations were calculated using SPSS version 14. Means and standard deviations of the main variables were calculated. Pearson's correlation coefficients among the main variables were calculated. Baron and Kenny's (1986) method was adopted to test whether the mediator factor (family cohesion) affected the associations between affiliate stigma scores and internalizing and externalizing problems. Adolescents' gender was controlled in the analyses. Finally, to determine the statistical significance of mediation effects, Sobel tests were calculated. Significance was set at the 0.05 level, and all tests of significance were two-tailed.
Parents' ages ranged from 35 to 51 (mean = 39.56 years, SD = 4.91 years) with a mean illness duration of 12.1 years. Parents' years of education ranged from 6 to 15 (mean = 6.56 years, SD = 4.45 years). Mean age of adolescents (N = 164) was 12.23 years (SD = 5.64 years), and 80 were male (48.8%) and 84 were female (51.2%). Regarding employment status, 52.4% of parents were both employed (n = 86) and 5.5% of both parents were unemployed (n = 9). Chronicity of parental mental illness was predominantly >10 years (n = 121, 73.8%). Parental mental illnesses in the current sample were schizophrenia (65%) and mood disorders (35%). The majority of participants' monthly household income was between 1,000 and 3,000 yuan (n = 94, 57.3%), followed by >3,000 yuan (n = 48, 29.3%), and <1,000 yuan (n = 22, 13.4%). Of adolescents, 148 (90.2%) lived with both parents and 16 (9.8%) did not live with their parents; no adolescent lived with one parent (Table 1). All adolescents who did not live with their parents lived with their grandparents (this information was provided by staff members in the community mental health centers).
Sociodemographic Data of the Sample (N = 164)
Demographics and Study Variables
In the total sample, 10.9% (n = 18) of adolescents were above the borderline clinical range on the externalizing behavioral problems scale and 14% (n = 23) of adolescents were above the borderline clinical range on the internalizing behavioral problems scale. This proportion is much higher compared to previous research in the Netherlands (Van Loon et al., 2014), which reported that adolescents with a parent with mental illness scored in the borderline clinical range for externalizing (10.9% vs. 1.6%; t = 2.671, p = 0.001) and internalizing (14% vs. 3.2%; t = 3.412, p = 0.001) problems.
Differences in the study variables regarding demographics were analyzed by a breakdown of the sample by adolescent age and gender, adolescent living situation, parental employment status, household income, parental educational level, marital status, type of parental mental illness, and chronicity of the disorder. Apart from adolescent gender, no significant differences emerged regarding the demographic variables for any of the study variables. The analysis of variance between two gender groups revealed one significant difference in the externalizing/internalizing problems: male adolescents reported more externalizing problems than female adolescents (t = 4.501, p < 0.05), and female adolescents reported more internalizing problems than male adolescents (t = −3.433, p < 0.05).
Relationship Among Variables
Correlations among all variables (i.e., family cohesion, affiliate stigma, and adolescent externalizing/internalizing problems) were explored. A significant relationship was found between adolescent externalizing/internalizing problems and family cohesion (r = −0.462, p < 0.01; r = −0.534, p < 0.001, respectively) and affiliate stigma (r = 0.512, p < 0.01; r = 0.656, p < 0.01, respectively), and a negative significant relationship between family cohesion and affiliate stigma (r = −0.432, p < 0.01) (Table 2).
Correlations Between Variables (N = 164)
Mediator Effects of Cohesion on the Associations Between Affiliate Stigma and Externalizing/Internalizing Problems
To examine the effect of the potential mediating role of family cohesion on internalizing/externalizing problems, Baron and Kenny's (1986) approach was followed and three regression models were estimated: (a) regressing the mediator on the independent variable; (b) regressing the dependent variables on the independent variables; and (c) regressing the dependent variables on the independent variable and mediator. These three steps in regression analysis were followed to assess the outcome measures (Table 3).
Three Step Regression Analysis Testing the Mediation Effects of Family Cohesion
According to Baron and Kenny (1986), a full mediation role will occur when the relationship is eliminated and a partial mediation role will occur when the relationship is decreased significantly. As seen in Figure 1, the correlation between affiliate stigma and externalizing problems decreased from β = 0.415 to β = 0.278 when family cohesion was controlled. The Sobel test revealed that this difference was significant (Z = −4.97, p < 0.001). These results indicate that family cohesion partially mediated the relationship between affiliate stigma and externalizing problems. Similarly, the correlation between affiliate stigma and internalizing problems was eliminated (from β = 0.383 to β = −0.042) when family cohesion was controlled (Figure 2). The Sobel test revealed that this difference was significant (Z = −5.18, p < 0.001). This result indicates that family cohesion fully mediated the relationship between affiliate stigma and internalizing problems.
Mediation role of family cohesion in the relationship between affiliate stigma and externalizing problems.
Mediation role of family cohesion in the relationship between affiliate stigma and internalizing problems.
To examine the possibility that gender may moderate the mediating effect of family cohesion between affiliate stigma and externalizing/internalizing problems, two path models were fitted separately for males and females. The result revealed that paths were equivalent for males and females and did not lead to a significant decrease in model fit, suggesting that gender did not moderate the mediation effect of family cohesion between affiliate stigma and externalizing/internalizing problems.
Ample research has already revealed that children of parents with SMI are at high risk of developing emotional and behavioral problems compared to the general population (Harder et al., 2015; Van Santvoort, Hosman, Van Doesum, & Janssens, 2014). In the current sample, significantly higher proportions were found in the borderline clinical range on externalizing/internalizing behavior (10.9%/14%) compared to previous research in other countries (Van Loon et al., 2014). Although the current authors have no exact data from normative Chinese adolescents, studies in low-income families and divorced single parent families indicated that children in disadvantaged situations are at increased risk of developing mental health problems compared to the general Chinese population (Ding & Song, 2018; Li, Zou, Jin, & Ke, 2008). Children of parents with SMI might be at more disadvantaged situation than children from low-income families and divorced single parent families (Yu & Cai, 2017). Therefore, it is important to understand how parental mental illness influences the development of problems in their children, and specific attention should be paid to these families.
Consistent with previous studies (Harshaw, 2015), the current study supports the notion that males tend to have externalized problems, whereas females typically exhibit internalized problems, which highlights the importance of considering child characteristics in relation to their psychosocial development. In addition, the current study revealed significant relationships among family cohesion, affiliate stigma, and adolescent externalizing/internalizing problems. Previous research indicated that the affiliate stigma experienced by children of parents with mental illness may lead to negative outcomes such as problem behaviors (Harder et al., 2015; Rasic, Hajek, Alda, & Uher, 2013), relationship disturbances, poor psychological well-being, and decreased quality of life (Huang, Li, & Shu, 2016; Koschade & Lynd-Stevenson, 2011). For example, research has found that relatives of individuals with a mental illness have reported difficulties in having friends come to their home and maintaining and developing relationships with others (Ostman & Kjellin, 2002). Furthermore, young people have trouble disclosing that they have a parent with mental illness to teachers and friends at school, thus creating a level of isolation for themselves (Van Loon et al., 2015).
Affiliate stigma is a process that is pervasive and evident cross-culturally (Catthoor et al., 2015), and may be culturally salient among Chinese individuals given their beliefs toward mental illness and their values of face concern (Mak & Cheung, 2008). Thus, stigma-coping strategies should be incorporated in early mental health services to facilitate identification and provision of interventions to this population, especially adolescents in those families (Grové, Reupert, & Maybery, 2016). The first step might be to develop strategies to publicly promote positive and healthy attitudes toward mental illness. By increasing education and awareness of mental illness in the community, the level of stigma and discrimination experienced by people with a mental illness and their family could be dramatically reduced (Hargreaves, Bond, O'Brien, Forer, & Davies, 2008).
The current results also underscore the protective effect of family cohesion against future adolescent psychosocial adaption problems. Family cohesion reflects the emotional bond that family members have with one another and has been defined as the level of support, affection, acceptance, and connectedness within the family (Reeb et al., 2015). Similar to previous studies (Coker & Borders, 2001; Nash, McQueen, & Bray, 2005), the significant relationship between family cohesion and affiliate stigma indicates that adolescents are less likely to experience mental illness–related stigma when they feel supported and connected within their family. The current study provided preliminary support for the importance of specific family psychosocial processes in understanding the adaptation of children of parents with SMI.
The current results also showed that affiliate stigma has a direct and indirect relationship with internalizing/externalizing problems and family cohesion mediated the relationship between affiliate stigma and internalizing/externalizing problems. In other words, adolescents living in a cohesive family are less likely to experience stigma associated with their parents' mental illness and less likely to develop internalizing and externalizing problems. Whereas family cohesion only partially mediated the relationship between affiliate stigma and externalizing problems, it fully mediated the relationship between affiliate stigma and adolescent internalizing problems. One possible explanation for the difference of the effect in relation to stigma and internalizing/externalizing problems may be the gender differences in problem behaviors in the current sample. As previous literature revealed, internalizing symptoms were reported more frequently by girls than boys, and externalizing symptoms were reported more by boys than girls (Anyan, Bizumic, & Hjemdal, 2018; Tambelli, Laghi, Odorisio, & Notari, 2012). Another possible explanation for the difference may be that internalizing problems are more strongly influenced by family psychosocial processes. Previous study results have indicated that of various psychosocial determinants, family social support was the strongest predictor of internalizing problems for adolescents whose parents had a chronic illness (Sieh, Oort, Visser-Meily, & Meijer, 2014); Similarly, Pace and Zappulla (2013) found that parental support was negatively related to internalizing behaviors; however, there was lack of a significant association between parental support and externalizing problems. Longitudinal analyses showed that active coping, parental monitoring, and self-disclosure were protective against developing internalizing problems 2 years later but found no protective factors for externalizing problems (Van Loon et al., 2015). These findings point to the importance of family cohesion in understanding adolescents' affiliate stigma and adaption problems.
During this transitional period, adolescents spend large amounts of time in the school environment. However, children living in families affected by mental illness are often socially and emotionally isolated in school (Hayman, 2009). Given that face concern is a culturally salient construct on social representations that may exacerbate the experience of affiliate stigma and dampen the well-being among Chinese individuals (Mak & Cheung, 2008), the family support system may play a more important role in such adverse circumstances. The results of the current study are in accordance with research that showed family cohesion might be an important factor that protects these at-risk adolescents against developing negative outcomes later (Reeb et al., 2015).
The two support mechanisms of family and friends change throughout the adolescent period and these intrapersonal factors may interact with each other. For example, parental and peer support have consistently been found to be inversely related to internalizing behaviors such as anxiety and depression (Vazsonyi & Belliston, 2006). However, longitudinal research has shown that peer support was protective against depressive symptoms among adolescents with high parental support but may act as a risk factor for adolescents with low parental support (Young, Berenson, Cohen, & Garcia, 2005). Thus, the mechanism of parental and peer support on adolescents' development needs further exploration.
The current study has important practical implications. Children of parents with mental illness experience affiliate stigma, which could influence their emotional and behavioral development. Education about mental illness will help reconstruct perceptions of the illness and reduce affiliate stigma. More importantly, interventions that focus specifically on parents and entire families that include individual psychoeducational meetings, psychoeducational family interventions, parent training, and mother–child interventions would help support and inform parents to improve parenting skills and the quality of the parent–child interaction (Van Doesum & Hosman, 2009). Although such preventive interventions have proven to be effective, they have only reached a marginal proportion of children and their families (Van Loon et al., 2014). Parents with SMI have generally been neglected by mental health policymakers and providers (Schrank, Moran, Borghi, & Priebe, 2015). Although psychiatric care structures are continuously developing in China, family still plays a primary and important role in the caring of psychiatric patients, and the social support systems for these families are not sufficient. Given the risks and challenges for parents with SMI and their children, the need for effective interventions aimed at families to support parents with SMI in their parenting role and enhance family cohesion is crucial.
The current study has some limitations that should be considered. First, the authors used a series of hierarchical linear modeling analyses based on the approach developed by Baron and Kenny (1986). This causal step approach may have limits for comprehensively explaining the mediating role with assumed causal relationships among the variables (Lee & Salman, 2018). Future studies that use structural equation modeling analysis should be more helpful. Second, all the obtained information was collected by self-report measures; therefore, the accuracy of individual reporters cannot be assured. Third, other factors (e.g., peer relationships) may play significant roles in the relationship between affiliate stigma and adolescent psychosocial adaption. Future studies that examine the effects of multiple mediators on the relationships among variables could help clarify the nature of the relationships and provide beneficial evidence to health care practitioners. Furthermore, all data were collected at a single point in time to focus specifically on the issues of the co-occurrence of experienced stigma and family cohesion and problem behaviors. Future longitudinal research could focus on the interactive and differential effects of individual, family, and peer factors on the psychosocial adaption of adolescents living with a parent with mental illness and investigate the paths that affiliate stigma, family cohesion, and adjustment undertake during development.
Findings from the current study revealed that adolescents living with a parent with SMI could experience affiliate stigma, which may lead to negative outcomes such as elevated risk of developing internalizing and/or externalizing problems. Family cohesion might be an important factor that protects these at-risk adolescents against developing negative outcomes. Given the risks and challenges for parents with mental illness and their children, the need for effective interventions to support these families is crucial. Taking into account the current findings, when designing preventive interventions, mental health nurses should establish family environment, such as family cohesion, as a distinct target within existing interventions that may be beneficial for these high-risk children.
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Sociodemographic Data of the Sample (N = 164)
| Male||80 (48.8)|
| Female||84 (51.2)|
|Parental employment status|
| Both parents employed||86 (52.4)|
| One parent employed||69 (42.1)|
| Both parents unemployeda||9 (5.5)|
|Chronicity of parental SMI|
| >10 years||121 (73.8)|
| 5 to 10 years||31 (18.9)|
| <5 years||12 (7.3)|
|Type of parental SMI|
| Schizophrenia||107 (65.2)|
| Mood disorder||57 (34.8)|
|Household income (monthly/yuan)|
| >3,000||48 (29.3)|
| 1,000 to 3,000||94 (57.3)|
| <1,000||22 (13.4)|
|Adolescent lives with parents|
| Yes||148 (90.2)|
| No||16 (9.8)|
|Parental marital status|
| Married||148 (90.2)|
| Single||8 (4.9)|
| Other||8 (4.9)|
Correlations Between Variables (N = 164)
|1. Family cohesion||1|
|2. Affiliate stigma||−0.432***|
|3. Externalizing problems||−0.462**||0.512**|
|4. Internalizing problems||−0.534***||0.656***||0.415***|
Three Step Regression Analysis Testing the Mediation Effects of Family Cohesion
|Step||Dependent Variable||Cumulative R2||ΔR2||Predictor||Final β||t Test|
|1||Externalizing problems||0.084||0.084||Adolescent gender||−0.131||−3.846**|
|Internalizing problems||0.087||0.087||Adolescent gender||−0.231||−6.846**|
|2||Family cohesion||0.345||0.345||Affiliate stigma||−0.769||9.325***|
|3||Externalizing problems||0.084||0.084||Adolescent gender||−0.131||−3.846**|
|Internalizing problems||0.087||0.087||Adolescent gender||−0.131||−3.846**|