Hong Kong Journal of Psychiatry (1997)  7 (1), 39-45


Savita Malhotra & Rajinder P. Kaur

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It is a comparative study of temperament and psychopathology in children born to mentally sick parents. 200 children one each of 80 psychotic parents (40 schizophrenic and 40 affective disorder) 80 neurotic parents ( 40 schizophrenic and 40 affective disorder) 80 neurotic parents ( on ICD 10 criteria) and 40 healthy parents were studied for differences in temperament and psychopathology. Children as well as parents were matched for age, sex (equal numbers of ill fathers and ill mothers were taken i.e. 40 each) and care was taken to include families only with one parents as ill and the other was healthy. Children of psychotic as well as neurotic parents differed in temperament from those of healthy parents in being less sociable, (withdrawing & unadaptable) with negative emotions ; low activity and intensity of emotional reactions; low distractibility as well as low rhythmicity using Malhotra’s Temperament Schedule which is an Indian adaptaton of Chess & Thomas’s Parent Temperament Questionnaire. Similarly these children showed higher score on psychopathology as compared to normals on Childhood Psychopathology Measurement schedule, an Indian adaption of CBCL. Parental illness parameters like duration of illness, length of exposure of child to parental illness and child’s age at first exposure to parental illness did not contribute to differences in their temperament or psychopathology. This study highlights the possibility of temperament as being the behavioural marker of risk for psychiatric disorder and significant meditational variable between the predisposition and clinical disorder in children of mentally sick parents.

Keywords: temperament, high-risk children, parental mental illness


The children of parents with chronic or recurrent mental disorder have substantially increased risk of psychiatric illness in them. This risk is not entirely due to the genetic influences involved but also due to the fact that chronic or recurrent mental disorder is associated with abnormal parental behaviour, family discord, maladaptive communication and impaired parent-child interaction. Mental disorder in the parent could be a kind of stress on the child. Children under these circumstances may exhibit a range of problems from minor variations in temperament and adjustment to manifest psychiatric disorder (Canino et al 1990; Orvaschel 1990; Garmezy & Masten 1994).

Children born to mothers with psychiatric illness before pregnancy are more likely to have negative mood and low rhythmicity (Wolkind & De-Salis, 1982); negative mood, easy frustration, emotional instability and unhappiness (Worland et al 1984), which are the adverse temperamental traits predictive of behaviour disorder in later childhood.

In the New York high-risk project (Erlenmeyer - Kimling et al 1991) offspring of schizophrenic, affectively ill, and psychiatrically normal parents were followed up till the average age of 27 years and it was reported that later psychopathology in them was the outcome of the direct effect of having a schizophrenic parent. Anderson and Hammen(l 993) reported significantly poorer psychosocial functioning in children of unipolar depressed mothers as compared to those of bipolar or medically ill mothers.

Research in the area of temperament of children born to mentally ill parents is sparse. After the earliest work of Graham, et al (1973) not many researchers have examined the variations of temperament among children born to mentally ill parents and its possible sources.

Temperament is an ancient psychobiological concept and is being applied to research on human development in recent years. Although there are many definitions of temperament but the general definition accepts that it consists of biologically rooted individual differences in behaviour tendencies that are present early in life are relatively stable across various kinds of situation and over the course of time (Bates, 1987; Goldsmith et al., 1987; Kohnstamn, 1986).

Temperament is largely innate and it influences the environment of the child in a reciprocal two-way relationship (Thomas et al 1968; Chess & Thomas 1991). Thus, the child's own temperament influences parental behaviour towards him/her which in turn may influence his temperament and also determine how the child adjusts to the environment. Theoretically it can be postulated that factors which can alter parental behaviour and interaction with the child e.g. parental mental illness, could affect the child's temperament or his/her overall adjustment or psychopathology. If temperament could be shown to vary as a function of parenting variables, it would indicate that the environmental contribution is as significant as the genetic contribution to variance in temperament. This field of research would also elucidate the important link between inherent vulnerability and its maximization by the environment.


This study aimed at examining the temperament and psycho-pathology in children born to mentally ill parents and to study the interrelationships between the nature of mental illness and the temperament.


It is a comparative study of children born to psychotic and neurotic parents comparing them with those of normal parents on temperament and psychopathology.

The sample comprised of 200 children each born to parents, divided in three groups of 80 psychotic parents (40 schizophrenic and 40 affectively ill), 80 neurotic parents and 40 normal parents. Equal member (40 each) of psychotic and neurotic mothers and fathers were included.


  1. Child's age between 5-14 years.
  2. Only one parent should be suffering from mental illness (the other parent should be healthy as determined by a clinical interview with the subject and the spouse.
  3. Both parents should be living together along with the child (this is the usual living situation in India).
  4. Psychotic illness in parent included schizophrenia and affective illness in equal numbers. Neurotic illness included all categories of neurotic disorders, as per ICD-10 criteria.
  5. Duration of illness should be at least six months.
  6. Normal parents should have scored lower than the cutoff for psychiatric disorder on PGI Health Questionnaire N2 (Verma 1978). This scale is an adaptations of CMI (Cornell Medical Index) assessing neurotism in a given population, using culturally relevant items and norms. There are 60 items (50 for neuroticism and 10 for lie score) in simple This scale has been used extensively in India as a quick screening test for discrimination between neurotic and normal population. Mentally ill parents were recruited from the outpatient service of the Department of Psychiatry at the Postgraduate Institute of Medical Education & Research, Chandigarh. All those fulfilling the inclusion criteria were assessed clinically in detail by a qualified psychiatrist. The diagnosis on ICD-10 was made which was confirmed by the senior consultant (SM).


Age, sex and education of both the parents; and illness details like duration of illness, length of exposure of child to parental illness, clinical diagnosis of ill parent, age at which the child was first exposed to parental illness was recorded in each case.

Normal parents were recruited from the paediatrics Outpatients department of the same institute where they brought their children for minor and brief physical ailments. They were assessed clinically to rule out major psychiatry disorder and screened on the PGI Health Questionnaire N2. Those scoring below the cut off point for neurotic disorder and meeting other inclusion criteria were taken in the study.

The healthy parent was interviewed for data on child's temperament and psychopathology.


Temperament was assessed on Temperament Measurement Schedule (TMS) which is an Indian adaptation of Chess & Thomas's Parent Temperament Questionnaire (Malhotra & Malhotra 1988). It is a bilingual scale (English & Hindi), measuring nine temperament variables described by Thomas & Chess (1968) through 5 items each, enquiring about the behaviour of the child in routine life situations relevant to our population. These nine temperament variables were subjected to factor analysis, since some of these were correlated, which yielded 5 temperament factors namely, Sociability (comprises of approach, withdrawal, adaptability and threshold of responsiveness); Emotionality (includes quality of mood and persistence); Energy (includes activity and intensity of response); Distractibility & Rhythmicity. Each item is rated on a five point scale with point 3 serving as the mid-point for intensity and frequency of the concerned behaviour. Scores on the 5 items included in each of the nine temperament variables are averaged and then summed to arrive at the respective factor scores. Reliability of assessment both inter-rater and (0.82 to 0.96) as well as test-retest (0.83 to 0.94) and validity has been high as reported in Malhotra & Malhotra (1988); & Malhotra et al (1986).

TMS differs from the original Parent Interview Schedule of Thomas. Chess and Birch (1968) in that it is based on situations that are applicable to Indian setting; the language has been changed to keep the functional equivalence of the terms; and that it finally derives five factors from the nine variables measured.

Psychopathology was assessed using the Childhood Psychopathology Measurement Schedule (CPMS) which is an Indian adaptation of Achenbach's Child Behaviour Checklist (Malhotra et al 1988). CPMS again is a bilingual interview schedule (English & Hindi) measuring 75 behavioral problem items in yes-no responses rated as 1 & 0. Items which were not applicable in Indian setting in CBCL were excluded. These 75 items were subjected to factor analysis to arrive at syndromes. 8 CPMS factors emerged namely: 1. Low intelligence with behavior problems 2. Conduct disorders 3. Anxiety 4.Depression 5. Psychotic symptoms 6. Special symptoms 7. Physical illness with emotional problems and 8. Somatisation. Scores on the constituent items are summed to arrive at factor scores which showed high degree of concurrent validity and reliability (Malhotra et al 1988). CPMS can be used as a screening instrument with the cut off score of 10 and above indicating psychiatric disorder with 87% specificity and 82% sensitivity ; as a tool to measure the severity of disorder (indicated by overall score) and also the factor scores showing specific types of psychopathology. Norms are provided for the general population (Malhotra et al 1988).

CPMS differs from the CBCL in that it includes only the Behaviour Problem Scale and excludes the social competence scale of CBCL; some of the items which did not apply or could not be translated, like behaves like opposite sex, bragging or boasting, were deleted; scoring was on two points Yes (1) or no (0) instead of three points 0, 1,2. in CBCL; and the norms for Indian population were used for comparison; CPMS has 75 items instead of 118 in Behaviour problem scale of CBCL. Thus the scales which have been used are well standardized on Indian population and have satisfactory reliability and validity and norms for local population. Care was taken to include equal number of I I psychotic mothers and fathers (40 each) and neurotic mothers and fathers (40 each).

Temperament scores in the three groups were compared using one way ANOVA. Pearson's product moment correlation were computed for temperament and parental illness variables. Stepwise regression was done to see the contribution of parental illness variables to child's temperament and psychopathology. Effect on child's temperament of whether the mother or the father was ill, was analysed using a two-way ANOVA.


Children in the three groups of psychotic (COP), neurotic (CON) and healthy parents (COH), did not differ in age and sex (Table 1). However, significantly more children of psychotic parents were in lower classes in school as compared to the other two groups.

Mean duration of exposure of the child to parental illness was more in psychotic group; and the age of the child at which he/she was first exposed to parental illness was lower in psychotic group.

Parent's age and education compared for the 'ill' and the 'well parent groups did not differ (Table 2).Spouses of the ill parent were all administered PGI Health Questionnaire - N2 to exclude the possibility of psychiatric disorder in order to minimize the variation in genetic loading and to obtain reliable information.

Duration of illness in psychotic parents was higher (man 5.84 ±5.34 years) as compared to that in neurotic parents (mean 2.53 ± 2.02) (t=5.17, p<0.01). Mean age at which parent developed illness was not different in psychotic (32.33± 7.35) and neurotic (34.05 ± 6.91) subgroups.


Scores on five temperament factors in children in three groups were significantly different (Table 3). All the scores were significantly lower in psychotic and neurotic groups as compared to normal group. Temperament scores did not have significant correlation with the length of exposure of the child to parental illness and to the age at which the child was first exposed to parental illness (Table 4) except for one on rhythmicity.

In the psychotic group, children of schizophrenic parent or affective disorder parent did not differ on temperament scores (Table 5). Similarly the effect of whether it is the mother or the father who is ill on child temperament was examined through a two-way analysis of variance for both psychotic and neurotic groups. F value was 2.148, p not significant, indicating no difference.



On CPMS, children of psychotic parents obtained a mean score of 10.79 (SD=9.22); in those of neurotic parents it was mean=10.56(SD=9.94) and in healthy parents group it was mean=2.88 (SD=2.92), (F=l2.92, P<.01) indicating a greater amount of psychopathology in children of sick parents. (The cut-off point for psychiatric disorder on CPMS is > 10). Child's CPMS score and duration of illness of parents or of the age at which the child was first exposed to parental illness had no correlation. Stepwise regression was done taking the temperament and psychopathology as the dependent variables and clinical variables relating to parental illness i.e. the nature of illness whether psychotic or neurotic; duration of illness; duration of exposure of the child to parental illness; and age of the child at the time of onset of parent's illness as the independent variables. Variance attributable to these independent variables was highly insignificant both in temperament (R .246, R2 0.061) and in psychopathology (R 0.195, R2 0.038).


In this study, it was attempted to examine systematically whether children born to mentally sick parents differed in temperament from those born to parents without psychiatric disorder; and if they did, did this variation relate to the parental disorder parameters. Samples of both parents (sick and well) in the groups of psychotic, neurotic and normals were comparable in age, sex, education respectively. Similarly, children did not differ in age and sex in the three groups except for educational level which was lower in children of psychotic parents despite their parents having an educational level comparable to other groups.

Most significant finding in this study had been the difference in temperament of children between the three groups. Children of psychotic as well as neurotic parents showed low sociability i.e. were withdrawing and less adaptable; lower emotionality (persistently negative mood); lower energy i.e. less activity and less intensity of emotions; low distractibility and less regular biological rhythms.

This pattern of temperament did not differ between the psychotic and neurotic groups and it fitted with the "difficult child" constellation described by Thomas and Chess (1977) except for the variables of energy (high activity and high intensity) and distractibility which did not cluster in their difficult child description. This is not surprising because "difficultness" as a concept takes into account the environmental and socio-cultural factors in an interactive perspective where each is modified by the other (Devries 1989 PP 81-85). Thus, what is considered as a 'difficult child' in the US may not be so in India. Moreover, it is also possible that what constitutes a temperament risk for future clinical disorder may be different in India as compared to that in the Western countries. It has been pointed out that there is no universal pattern temperament risk factors and that there may be specificity of relationship between temperament traits and certain psychiatric disorders (Malhotra 1989, Maziade 1990). Support for such a hypothesis comes from our earlier studies in which high activity and intensity were seen in children with conduct disorders (Malhotra 1988); in children of alcoholics (Sharma et al 1995) and in children of addicts (Malhotra et al 1993).

Since high activity and intensity were seen in children with conduct disorder which is a clinical disorder and also in those who are at greater risk for conduct disorder such as the children of alcoholics, there seems to be some continuity from risk to disorder in terms of these temperament variables involved. Tarter et al (1990) have described high activity as the temperament factor associated with higher risk for alcoholism among children and sugg-ested that lack of behavioural self-regulation in hyperactive children may be a central feature of alcoholism vulnerability.

Keeping in mind the interactionist concept of temperament environment interrelationships (Chess & Thomas 1986. 1991;) Bell & Chapman 1986; Houts, Shutty & Emery 1985) and that the temperament despite being a heritable trait could be modified by the environment (Goldsmith 1989), it was attempted to analyse the amount of variance in temperament attributable to the parental illness variables like the nature, duration and severity of mental illness; age at which the child was first exposed to illness; duration of exposure and which parent was ill. However, no contribution could be found.

Influence of parental mental illness on the Child's mental health could be mediated through genetic influences as well as through such environmental factor that are likely to be arising from parental illness like faulty communication, neglect and abuse, parental discord, poor interaction and poor interpersonal relations. These psychological and social difficulties are likely to be more severe when the illness is more severe and disruptive as for example in psychotic disorder vs a neurotic illness, or when it is more prolonged. Effect on the child if it is primarily mediated through environmental factors, should be more when the child is faced at a very young age with parental illness or when the primary care given i.e. mother is sick rather than the father. In this study, the results showed that temperament of children had no relationship to the duration of illness of the parent; or to the child's age at first exposure to parental illness; to nature of illness whether schizophrenia, affective disorder or neurosis; or whether the father was ill or the mother was ill. The main effect on temperament was from being born to a psychotic or a neurotic parent.

Although there is general evidence available in favour of higher psychopathology rates in children of mentally disordered parents but the extent to which these are due to genetic or biological influences, or due to negative psychosocial and psychological factors that tend to coexist with parental mental disorder like poverty, unemployment marital discord and negative rearing practices is not clear. Although it is reported that children born to a schizophrenic patient have approx. 8-10 times higher risk of developing schizophrenia during their lifetime than in general population (Gottesman & Shields 1982), severity of parental illness and associated psychosocial disadvantage is a strong predictor of problem behavior among offspring (Sameroff & Seifer 1990; Goldstein & Tuma 1987). During childhood risk associated with parental schizophrenia is similar to the risks associated with other severe mental disorders in parents and has a more general cast (Garmezy and Masten 1994). Characteristics of the child and the environmental consequences of the parents illness play a greater role in the transmission of psycho-pathology in families particularly depression, schizophrenia and alcoholism than the genetic factors (Silverman 1989).Sameroff (1974) worked with four groups of 26 mothers, each having a diagnosis of schizophrenia, neurotic depression, personality disorder; or no disorder and found that prenatal maternal anxiety and severity of mental illness in the mother contributed to difficult temperament. Our finding did not support this or in other words exposure to parental illness did not add to the variance in children's temperament or in psychopathology. Although environm-ental consequences of parental illness were not examined in the present study, the findings indicate that child's temperament would be an important determinant of maladjustment or psychopathology in children born to mentally sick parents.

Most studies on children with chronic stress of physical illness or handicap have focused on family functioning as a potential mediator of psychological adaptation (Varni 1983; Varni et al 1988; Johnson 1985) and very few empirical investigations have considered child's temperament (Wallander et al 1989, Malhotra and Malhotra 1990.Temperament has been construed as an important factor determining the vulnerability to psychopathological disorders operating through mechanisms like increased susceptibility to negative environmental influences; goodness of fit between temperament and environment effect of children's characteristics on parents and others; temperamental influences on the range and choice of experiences; and temperamental contribution to personality development (Rutter 1989).

In the present study children of both the psychotic as well as neurotic groups of parents had psychopathology scores which were just above the cut-off point for clinical disorder, indicating maladjustment. Low educational attainment of children of psychotic parents was another index of maladjustment (Table 1) in the present study. Since children of mentally sick parents are more likely to have psychiatric disorder (Rutter 1984, Sameroff and Seifer 1990), difficult or adverse temperamental traits may be the behavioural markers or the mediational variables between the predisposition and the manifest disorder.

Thus it may be possible to conclude that temperament could serve as a behavioural marker of risk for psychiatric disorder in children of mentally sick parents. Clinical implications of these findings are significant genetic predisposition may manifest itself in temperamental variation in children which is no less significant than the environmental consequences of parental mental disorder determining the psychological adjustment of the children of mentally ill parents.

Since temperament can be identified at an early age, children at risk for disorder later on could be identified early enough for possible primary prevention.


This study was done with research grant from the Postgraduate Institute of Medical Education & Research, Chandigarh, INDIA.


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*Savita Malhotra MD, PhD Additional Professor of Psychiatry, Department of Psychiatry, Postgraduate Institute of Medical Education & Research at Chandigarh. India
Rajinder P Kaur MA, PhD, Social Scientist, Department of Psychiatry, Postgraduate Institute of Medical Education & Research at Chandigarh. India

*Correspondence; Dr. Savita Malhotra, Additional Professor, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh - 160 012, INDIA.

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