Major depressive disorder in a Kenyan youth sample: relationship with parenting behavior and parental psychiatric disorders

Studies on mental health problems during child and youth development phases indicate that families of children diagnosed with a depressive disorder tend to be dysfunctional [1‐7]. The dysfunctions include unhealthy quality of marital interactions, presence of psychiatric disorders among parents, and maladaptive parental behaviors. These dysfunctions have been shown to be mediating factors for children to develop psychiatric disorders [8‐15]. It has also been shown that in this type of family setting, there exists a high rate of parent-to-parent or parent-to-child conflicts that make members highly vulnerable to develop a psychiatric disorder [1‐15]. Previous studies in this area also show that youths brought up in these homes where one psychiatric disorder occurs often have one or more co-morbid psychiatric disorders [16‐21]. This effect seems to be stronger when both parents suffer from any psychiatric disorder [8‐15]. Compared to depressed youths of non-depressed parents, youths with a family history of depression have been found to suffer more severe and chronic forms of depression, more relapses, psychiatric co-morbidity, impaired psychosocial functioning, and suicidal behavior [21‐23].

World Health Organization (WHO)-based studies indicate that the prevalence of psychiatric disorders previously seen in adult life has increased enormously among children and youths in the past few years [24‐27]. Four percent of 12- to 17-year olds and 9% of 18- to 24-year olds have been shown to suffer from major depressive disorder (MDD) [26, 27]. These WHO studies also indicate that depression is the most prevalent disorder worldwide with wide reaching consequences in youths [24‐26]. Further, it has been shown that some forms of parenting styles are associated with child abuse. A study by Khasakhala et al. [28] found that there were statistical differences (p < 0.05) between perceived paternal permissive parenting behavior and emotional and physical neglect of the youths, perceived paternal authoritarian parenting behavior and emotional and physical abuse of the youths, while perceived uninvolved parenting behavior was found to be associated with both emotional and physical neglect of the youths. In the study, mothers who had authoritarian parenting style emotionally and physically abused their youths, while those who were uninvolved, emotionally and physically neglected their youths [28]. Uninvolved parents give negative attention to the behaviors and activities their youths display; this is the opposite of approval, and therefore, this behavior does not protect the youth from developing psychiatric disorders. Studies also indicate that untreated MDD in youths is associated with later development of anxiety disorders, bipolar mood disorders, and substance abuse disorders [18‐20]. It has also been shown that youths with co-morbid depression come from dysfunctional families and have severe substance abuse disorders [8, 10]. Depression has been shown to be associated with youth suicidal behavior which is a major problem in many countries, as it is the third leading cause of death in young people [11].

In Kenya, the prevalence of depression among youths attending general health facilities and those in secondary schools has been found to be high [8, 10]. The prevalence of clinically depressive symptoms in Kenya is 43.7% among youths in public schools in Nairobi province, while the prevalence of those attending general health facilities is 41.3% [29, 30]. Khasakhala et al. [28] found that more than a quarter of youths in high school suffer from MDD which has a relationship with aspects of perceived maladaptive parenting behavior. Parental psychopathology has also been shown to be associated with maladaptive parenting behavior. Thus, these family dysfunctions are characterized with poor communication, poor problem solving, and the presence of hostile criticism in the family [31‐35]. Therefore, a parent with mental disorder has poor interactive skills perceived as a maladaptive parental behavior by children; this is a mediator for children to develop psychopathology, in particular MDD [31‐35]. The nature of this association is of considerable interest to mental health workers and scientists alike, in part because it may be possible to reduce the odds that children will develop psychiatric disorders if parents are helped to modify their parental behavior or access psychiatric treatment in case the parent has a psychiatric disorder.

There is need therefore to document the negative and important roles that parents/caregivers play not only to help their children successfully transit into teenage/adulthood but also because this transition should have a healthy relationship void of psychopathology. The primary question addressed in this paper is whether the presence of parental psychiatric morbidity and perceived maladaptive parental behavior serve as useful indicators of associating MDD in youth age 13 to 25 years. The main aim of this paper was to assess the relationship between parents, psychiatric disorders and maladaptive parental behaviors and youths MDD. The hypothesis of the study was that parents with a psychiatric disorder face challenges in bonding with their children as they exhibit maladaptive parenting behavior, a mediator for their offspring's to develop psychiatric disorders. This study was designed to address the magnitude of the burden of disease related to psychiatric disorders in a family setting in Kenya, which remain unrecognized and undertreated. Studies carried out in developed countries indicate that parental psychopathology is associated with maladaptive parenting behavior [13, 15, 36‐38], and maladaptive parenting behavior is associated with an increased likelihood of youths developing mood disorders [3‐6].

A total of 250 youths were recruited, but only 245 were included in the final analysis. Five youths declined to allow their parents to participate as they were (sexually) abused in a family setting.

Our main findings indicate that Kenyan youths with MDD seeking mental health treatment services are more likely to have mothers with MDD and are more likely to perceive their mothers as exhibiting a rejecting parenting behavior. This finding is similar to previous studies which have shown that the presence of psychiatric disorders among parents, which is associated with maladaptive parental behaviors, is a mediating factor for children to develop psychiatric disorders [8‐15]. Focusing first on the intergenerational associations of MDD, our findings are comparable to studies that use the ‘top-down’ approach which consistently shows that children of depressed parents have a substantially increased risk to experience not only depressive disorders but also other DSM-IV disorders [1, 2, 4‐11]. These results are also comparable to ‘bottom-up’ studies that examine clinically referred depressed children and adolescents, which showed increased rates of depression and other forms of psychopathology in parents [19‐23]. Although perceived parenting behavior models play different roles for different youth psychosocial outcomes, overall, our results support the attachment theory which highlights the importance of specific perceived parenting behavior, the attachment between a child and their parents. Our findings are consistent with the notion that parental depression has a negative impact on the emotional and behavioral functioning of offspring. This is because parental depression leads to family disruption and marital discord which has a negative impact to the mental well-being of children.

Our study found that youths with MDD also were more likely to have other co-existing DSM-IV axis I disorders (substance abuse, any anxiety, and conduct disorder), suggesting that co-morbid psychiatric disorders also need attention during treatment. The perceived rejecting maternal behavior as shown in this study is a negative factor inducing severe psychological distress; therefore, a child with depressive disorder tries to escape from internalizing their feelings (depression) by acting out (externalizing them) and, in the process, starts abusing alcohol/substances. This is a similar finding by Rankin et al. [48]. This raises the possibility that parental behavior may be a risk factor in the development of multiple psychiatric disorders in the same child.

The result in this study indicate that multiple independent variables associated with MDD in youth include the following: rejecting maternal parenting behavior, maternal MDD, and other co-morbid psychiatric disorders among youths. Rejecting maternal parenting behavior and depressive disorder in a parent are associated with greater odds for children to develop MDD. Rejecting behavior plays an important role in the development of psychiatric disorders in children, and this had an association with parents' psychiatric disorders. This finding may explain the dysfunctional family nature in this study population. Parental psychopathology, in particular depressive disorder in mothers, could have a paring to genetic predisposition which in turn is associated with greater odds for children to develop depressive disorder. This explains how disconnected this family setting functions. There is increased conflict in this type of family setting. The perceived maternal rejecting parenting behavior obstructs the interaction between mother and her children. The rejecting parenting behavior in such a family setting is perceived by children to be a poor emotional expression, ‘I have no interest in you’ and therefore disconnects the child from the mother, creating a barrier for the child to explore and form connecting bonds with his/her parent(s). This barrier results into insecure attachment which was described earlier by Bowlby [49‐51]. This unconnectedness between the child and parent leads to confusion, conflict, and frustration in the growing child, a precursor for a child to develop psychopathology which presents as either an internalizing (depression/anxiety) or externalizing disorder (alcohol abuse/conduct).

As indicted by the results of this study, a high proportion of youth who perceived that their mother had rejecting parenting behavior had higher odds of developing depression and abusing alcohol/substance (multiple substances). This finding is comparable to prior family studies in patient samples [31‐34], which revealed that parental psychopathology is associated with maladaptive parental behavior and, in turn, is associated with increased odds of psychopathology among their children. This demonstrates that children who perceive their mothers to have rejecting parental behavior are more likely to develop MDD than children of parents with other parental behavior.

Previous studies [31‐34] suggest potential explanations for how parental characteristics may contribute to MDD in their children. Rejecting maternal behavior may restrict the child's development of autonomy that leads to competence which allows the developing child to explore their environment. Perceived parenting rejection by mothers may lead to a dysfunctional parent–child bond, which may result in difficulties for the child to explore the environment, leading to a helplessness experience. In addition, rejection may keep the child from engaging in social situations, thereby restricting the opportunities to learn social skills and therefore remain inferior. These findings are of interest, in particular, if the onset of mental disorders among youth can be prevented as suggested by Bowlby [49‐51], whereby parents can be assisted to modify their child-rearing practices.

More importantly, from these results, rejecting maternal parenting behavior may play a role in the development of psychopathology in children whether or not a mother has psychopathology. This is more so because rejecting maternal parenting behavior is relatively more common in our society [45]; therefore, it may be important to educate the public about these abnormal parenting styles that are associated with an increased risk of offspring to develop psychopathology. This data is consistent with previous research findings which have indicated that parental psychopathology is associated with maladaptive parental behavior [11, 29‐32] which is also associated with increased risk of the children to develop psychopathology. Perceived rejecting maternal parental behavior was the only independent variable, where higher scores on the rejecting-ineffective parenting scale were associated with higher odds of MDD among the youth. Perceived rejecting maternal parenting behavior therefore influences family life, and parental psychopathology is linked to poor child-rearing practices. This social life around the growing child defines important tasks that the growing person needs to achieve.

These results provide vital insights into the intergenerational effects on child mental health. The study adds to the existing body of research on the role of parenting behavior and parental psychiatric disorders and their associations with youth MDD. Our main findings indicate that perceived rejecting maternal parenting behavior and maternal MDD are associated with youth MDD.