Perceived parenting styles and bonding among adolescents with mental illness: Okasha Institute of Psychiatry experience

Background Worldwide, at least 10% of adolescents have a documented mental illness, which is a leading source of morbidity, mortality, and functional impairment. Among individuals aged between 10 and 24 years, psychiatric disorders account for 45% of all years lived with disability. Parenting discipline styles are fundamental in shaping adolescents’ emotional integrity, cognitive capabilities, and behavioral patterns. To compare parenting styles and parental bonding dimensions in adolescents with different psychiatric disorders versus a group of healthy adolescents matched for age and sex. Patients and methods A case–control study conducted at Okasha Institute of Psychiatry, Ain Shams University Hospitals, involved 50 participants of adolescents diagnosed with variable psychiatric disorders and 50 matched healthy controls. Results Authoritarian parenting style was evident in mentally ill adolescents, while authoritative parenting style was prevalent in healthy controls. In terms of parental bonding, mentally ill adolescents experienced a low level of care and a high level of overprotection from both parents. Conclusion The results of the study demonstrated that parenting styles may serve as predictors and predisposing factors for psychiatric disorders in adolescents. Adolescents with psychiatric disorders perceived both parents as more authoritarian, less authoritative. They also received a low level of care and a high level of overprotection from both parents.


Introduction
Although parental history of mental illness is one of the most influential risk factors for subsequent development of mental illness in offspring, parenting has a critical role in the etiology [14].
Parenting has been linked to long-term negative effects on an offspring's mental health [6].The development of a child's personality, social interactions, and close relationships with significant others are impacted by varying parenting approaches.Baumrind states that parents who are authoritative are typically interested in their children's activities and attentive to their needs.Authoritarian parents, on the other hand, monitor their children's behavior through a strict and unbending set of rules.Lacking authority over their children, permissive parents seldom discipline them and rarely make many requests [5].According to earlier research, parenting styles that are accepting and warm are consistently associated with positive outcomes in their offspring, while rejection and hostility are associated with negative consequences.
Adolescents who lack parental warmth and experience high levels of rejection and overprotection exhibit a wide range of aggressive and delinquent behaviors.Furthermore, among adolescents, the perception of parental rejection had a strong correlation with hostility, delinquency, and poor mental health outcomes [1].
The degree of care and protection provided by parents is a major factor in fostering a strong bond with their offspring.Elevated levels of protection or insufficient care can subsequently heighten susceptibility to mental health disorders [15].
Low parental care throughout adolescence and excessive parental control are associated with the development of a wide array of mental disorders, such as eating disorders in adulthood, anxiety disorders, depression [19], substance misuse or dependency, and suicide [20].

Aim of the work
This study is a case-control study, which compasses 50 patients and 50 matched healthy controls of the same age, sex, and education which took place between November 2022 and September 2023 to compare different parenting styles and parental bonding dimensions in adolescents with various psychiatric disorders versus a group of healthy adolescents matched for age and sex.

Study population Group 1
Included adolescents recruited from adolescents' outpatient psychiatry clinics, at the Okasha Institute of Psychiatry located in Cairo, Egypt, who sought help for various symptoms related to psychiatric disorders.

Inclusion criteria
Egyptians, age range: 11-18, gender: both sexes, residing with both parents who are not suffering from a major mental disorder.

Exclusion criteria
Patients whose parents were absent due to travel, divorce, or death; patients with co-morbid intellectual disability; patients suffering from acute mental disorders such as acute mania and psychosis; patients who refuse participation; and illiterate patients.

Group 2
Matched healthy adolescents whose parents are employees working in Okasha Psychiatry Institute, Ain Shams University, matched for age and gender, not diagnosed with major psychiatric disorder and residing with both parents.

Procedure
After being informed of the study's goal and methodology, adolescents who sought medical advice for a variety of reasons and symptoms associated with psychiatric problems were encouraged to participate in the research.
Participants were subsequently required to fill out a short, predesigned sheet including personal data and sociodemographic data, parental bonding instrument (PBI), parental authority questionnaire, and the Arabic version of the K-SADS-PL (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version).
Healthy matched controls were offered KSADS to exclude psychiatric disorders, as well as parental bonding instrument and parental authority questionnaire (PAQ).
Stanford-Binet Intelligence Scale was used to exclude adolescents with below-average intelligence quotient (IQ).Also, to rule out possible psychiatric disorders, General Health Questionnaire was used as a screening tool for parents.A score of 7 or higher was excluded from the study.

Operational definitions
Parental bonding can be described as an attachment between the child and the parent.
According to Bowlby [7], attachment could be secure or insecure.
Secure attachment is defined as parents who are always sensitive and consistent in responding to child's need.
Insecure attachment is defined as parents who often neglect or reject the child's need for attention.
According to Parker et al. [18], attachment can be measured through the childhood and adolescence recollections of adult individuals of two parental behaviors: care and overprotection.
Parental care is defined as affection, understanding, and warmth in opposition to rejection and indifference.
Parental overprotection is defined as control, infantilization, intrusion, and encouragement of dependency in contrast to the promotion of autonomy.

Tools
The Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version (K-SADS-PL): It is a semi-structured interview for the age group between 6 and 18 years of age [13], it is used to assess current and lifetime history of psychiatric disorders, according to DSM-V criteria.The Arabic version of the K-SADS-PL used in this study was translated and validated by Moussa et al. [16] at Cairo University.
General Health Questionnaire (GHQ-28): is self-report screening tool, consisting of 28 questions to find out whether a person's current mental state differs from his/ her original state.GHQ consists of 4 subscales: somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression [12].Arabic version by Okasha [17] was used to exclude parents with possible psychiatric disorder in the current study.
The parental bonding instrument (PBI) [18]: measures adolescents' perceptions of parent attitudes and behaviors indicative of parent-adolescent bonding.The instrument has 25 items that yield two subscales created by Parker as follows: "care" (12 items) and "overprotection" (13 items).Responses were Likert-type rated that ranged from 0 (very unlike) to 3 (very like).Total scores range from 0 to 36 and 0 to 39, respectively.Adolescents conveyed their overall experiences with their parents from age 6 until the time of interview.Adolescents' perceptions of parent care and overprotection were assessed independently for each biological parent.Higher scores indicate greater degrees of these two attributes.Arabic translated and validated version was used [2].
Parental authority questionnaire [4]: was used to measure permissive, authoritarian, and authoritative parental authority prototypes.It consists of 30 items per parent; each of these scores is derived from the phenomenological appraisals of the parents' authority by their son or daughter.Arabic translated and validated version by Dwairy [10] was used.

Statistical analysis
Version 27 of the Statistical Package for Social Science (IBM SPSS) was used to enter, code, and amend the data.When the quantitative data were determined to be non-parametric, they were given as the median and interquartile range (IQR), and when they were parametric, as the mean, standard deviations, and ranges.Numbers and percentages were used to display the qualitative characteristics.
ROC curve was drawn to determine the discriminating ability of different PA and PB scores.An AUC of more than 0.7 was considered high.
Bivariate correlation was performed between continuous variables of interest and a p value of less than 0.05 was considered significant.The p value was considered significant as the following: p value > 0.05: nonsignificant (NS), p value < 0.05: significant (S), p value < 0.01: highly significant (HS).

Ethical considerations
This study was approved from the ethical committee at the Faculty of Medicine, Ain Shams University, with reference number FMASU MS 137/2023.Informed written consent was obtained from the guardians of each participant.Participants had the right to participate or withdraw from the study at any time.

Results
This case-control study encompassed 100 participants at the adolescent psychiatry clinics at Okasha Institute of Psychiatry, Ain Shams University Hospital, which provide service twice per week on Sunday and Tuesday, each serving an average of 10-15 adolescents.They were categorized into 2 groups: group 1 adolescents recruited from adolescents' psychiatry clinic, those who sought help for various symptoms related to psychiatric disorders.The control group participants (group 2) were selected from adolescents' offspring of employees working in the institute.
Their age group ranged from 11 to 18 years old, with a mean age of 14.64 ± 2.24.
There was no statistically significant difference between cases and controls except for the year of education, as shown in Table 1.

Diagnosis according to K-SADS-PL
The study group consisted of 50 adolescents with different psychiatric disorders as shown in Fig. 1.

Perceived parenting styles
The parental authority questionnaire showed a highly significant difference between both groups, as adolescents with psychiatric disorders perceived both parents as more authoritarian, less authoritative with a p value < 0.001 compared to healthy controls (group 2).
Also, adolescents with psychiatric disorders perceived their mothers as less permissive with a p value < 0.001 compared to the control group.
No significant difference between the two groups regarding father's permissive parenting style with p value 0.082 as shown in Table 2 and Fig. 2.
Interestingly, PAQ mother authoritarian score of value (32.5) was able to discriminate between cases and control groups with specificity 98% and sensitivity of 86% as shown in the ROC curve illustrated in Fig. 3 with an AUC of 0.988.

Perceived parental bonding
The parental bonding instrument's results showed highly significant difference between cases and controls where adolescents with psychiatric disorders received lower level of care and higher level of overprotection by both parents than controls as shown in Table 3 and Fig. 4.
Interestingly, mother and father overprotection scores were able to discriminate between cases and controls as shown in the ROC curve illustrated in Fig. 5 with an AUC of 0.991 and 0.999, respectively.A cut off value of father overprotection score of 20.5 showed 94% sensitivity and 98% specificity, while a cut off value of mother overprotection of 20.5 showed 96% sensitivity and 96% specificity as shown in Fig. 5.
Significant negative correlation (r = − 0.387) was evident between PBI care mother and father scores in the control group that was lacking in the cases group as shown in Table 4. Again, a significant positive correlation (r = 0.299) was evident in the control group between father care score and mother overprotection scores that was lacking in the cases group as shown in Table 4.
Adolescents with MDD and ADHD perceived their parents as more authoritarian, less authoritative and less permissive.They also received low levels of care and high levels of overprotection from both parents.
Meanwhile, adolescents with GAD, OCD, anorexia nervosa, and conduct disorders perceived their parents as more authoritarian, less authoritative.They also received low levels of care and high levels of overprotection from both parents as demonstrated in Table 5.

Discussion
A crucial time for laying the groundwork for long-term mental health is adolescence.Many studies have investigated the impact of parenting in the development of psychopathology, while few have focused on the perception of their adolescent offspring themselves.The current study focuses on the perceived parental interactions from the adolescents' point of view in terms of authority and bonding and their impact on the development of adolescent psychopathology in a sample of an Egyptian population suffering from various mental disorders in comparison to healthy matched controls.

Impact of parenting styles on the mental health of adolescents
According to the results of the current study, adolescents who suffer from mental disorders perceived their parents as more authoritarian.The explanation is that adolescents internalize their parents' attitudes, leading to increased self-judgment and aggression toward others.This occurs when authoritarian parents place a greater emphasis on obedience, discipline, and control, and punish their offspring harshly.
Conversely, Dwairy et al. [9] who conducted a study in eight Arab societies on adolescents found that authoritarian parenting was barely associated with higher psychological disorders.Their findings show that authoritarian parenting alone is not associated with negative outcomes although authoritarian parenting combined with permissiveness leads to negative outcomes in terms of connectedness and psychological disorders.Additionally, adolescents with psychiatric disorders perceived their parents as less authoritative.This finding was in line with Uji et al. [23] who found that authoritative maternal and paternal parenting was beneficial to children's later mental health.This is explained by the balance between two aspects of authoritative parenting: communicating with the child in a way that respects their autonomy, and second using parental authority over them when needed.As a result, a state that encourages both self-control and emotional expression is created.
Regarding permissive parenting style, the present study showed that adolescents with psychiatric disorders perceived their mothers as less permissive.
This could be attributed to the fact that permissive parents are warm, welcoming, and loving, which can have benefits for adolescents, including higher levels of social connection and building relationships.
They are also less controlling over their adolescents, which helps the adolescents express their autonomy and examine their problem-solving skills, that results in better self-confidence.
This was not in line with a previous Indian study conducted by [22] which stated that adolescents with permissive parenting styles have poor mental health when compared with authoritative and authoritarian parenting styles.
Meanwhile, [24] in a British study concluded that permissive parenting style leads to poor mental health, but its effect was comparatively lower than authoritarian parenting style.

Impact of parental bonding on mental health of adolescents
Our study showed that adolescents with different psychiatric disorders received low level of parental care and high level of parental overprotection that was in line with Cimino et al. [8], who showed that there is an exceedingly critical contrast between two groups with respect to maternal care: higher within the control group, whereas maternal overprotection: higher within the cases group.One possible explanation is that adolescents who experience inadequate parental care may develop poor emotional control, psychological inflexibility, low selfesteem, poor coping skills, and poor problem-solving abilities, which in turn may render them susceptible to a range of psychopathologies.
Overprotective parenting styles can result in extreme dependency in adolescents and poor coping skills.Conversely, adolescents may rebel against their parents' expectations.If they feel too smothered, they may learn to lie or manipulate their parents.

Dynamic roles of both parents
Interestingly, the present study showed significant negative correlation between PBI care mother and father scores in the control group that was lacking in the cases group; this explains that in healthy adolescents, the presence of at least one caring parent could provide warmth and protection from mental illness.A lack of care would result in different psychopathologies.Also, a significant positive correlation was evident between father care scores and mother overprotection scores that was lacking in the cases group, given that mother overprotection could result in deleterious mental consequences [3].The current study denoted that one parent care such as father care could omit these maladaptive protection consequences and protect the offspring, whereas a lack of this dynamicity could result in mental illnesses.

Conclusion
A wide spectrum of mental health problems among adolescents are linked to pathogenic parents who exhibit high levels of control, overprotection, and low levels of care; on the other hand, parents who exhibit high levels of care appear to be protective against mental disorders in adolescents.

Limitations
Given the critical role that parenting plays in determining the mental health and wellbeing of offspring, this study is, to our knowledge, one of the few in the Middle East to address how parental interactions from the perspective of the adolescent could affect mental health outcomes.However, the study lacks a significant number per each group of different mental disorders, which makes it difficult to draw appropriate conclusions about parental authority and bonding patterns on their own.

Fig. 3
Fig. 3 ROC curve illustrating the discriminating ability of mother's authoritarian PAQ score between cases and controls (AUC = 0.988)

Fig. 4 Fig. 5
Fig. 4 Mother and father PBI overprotection mean score in cases versus controls

Table 1
Sociodemographic characteristics of study participants in cases and control groups Different psychiatric diagnoses of the studied participants in group 1. MDD major depressive disorder, GAD generalized anxiety disorder, OCD obsessive compulsive disorder, ADHD attention-deficit/hyperactivity disorder

Table 2
Average PAQ scores of study participants in cases and control groups Fig. 2 Average father and mother authoritarian PAQ score in cases versus controls

Table 3
Average PBI scores of study participants in cases and control groups

Table 4
Correlation between mother and father PBI care score and mother PBI overprotection score and father PBI care score in cases versus controls

Table 5
PAQ and PBI mother and father average score in different diagnoses groups of cases MDD major depressive disorder, GAD generalized anxiety disorder, OCD obsessive compulsive disorder, ADHD attention-deficit/hyperactivity disorder