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ORIGINAL ARTICLE

Early‑onset bipolar disorder, stress, and coping responses of mothers:

A comparative study
M. Sam Paul, Dipanjan Bhattacharjee1,2, Roshan Vitthalrao Khanande1,2, Shamsul Haque Nizamie1,2
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Departments of
1
Psychiatric Social Work and 2Psychiatry, Central Institute of Psychiatry, Ranchi, Jharkhand, India

ABSTRACT

Background: Providing care and nurturance to a child with bipolar disorder (BPAD) is a challenging task for parents,
especially mothers. In Indian contexts, mothers are the primary caregivers of ailing children and they have to keep
intrafamily situation stable, which makes their role more stressful.
Objectives: The objective of the study was to assess maternal stress and coping in mothers of adolescents with
BPAD.
Materials and Methods: This study was a comparative one and carried out on sixty mothers of adolescents; of which
thirty were adolescents with BPAD, and the remaining thirty were the mothers of normal adolescents. The participants
were selected purposively as per the mothers’ age and education level, and the socioeconomic status of the families they
belong to. Sociodemographic and clinical data sheet, Parenting Stress Index/Short Form (PSI/SF), and Brief COPE were
applied on the mothers for data collection.
Results: Mothers’ of the BPAD adolescents reported higher scores in the both PSI/SF and Brief COPE.
Conclusion: Mothers of the adolescents with BPAD tend to perceive high level of stress and they also use maladaptive
coping more in dealing with stressful situations.

Key words: Bipolar disorder, early onset, mothers, stress and coping

INTRODUCTION child with bipolar disorder (BPAD) is a challenging job

Parenthood is an important phase of life containing
pride, pleasure, and challenges. Parenting is indeed a
challenging task by itself, and it becomes harder in the
case of children with health issues, especially chronic
and debilitating psychological problems. Caring of a
Address for correspondence: Dr. Dipanjan Bhattacharjee,
Department of Psychiatric Social Work, Central Institute of
Psychiatry, Kanke, Ranchi ‑ 834 006, Jharkhand, India.
E‑mail: dipanpsw@gmail.com
Submitted: 13‑Jul‑2020,  Revised: 30‑Aug‑2020,
Accepted: 23‑Oct‑2020,  Published: 14-Apr-2021
Access this article online
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Website:
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because of numerous illness‑related and nonillness related
factors – “securing appropriate treatment on long‑term
basis,” “ensuring adherence to the treatment,” “dealing
with the psychopathology of bipolar illness at home and in
community,” and most significantly “dealing with stigma,
prejudices, and stereotypes associated with the illness.”[1‑3]
Many of them have feelings such as “being cursed,” “sense of
shame and guilt,” and their “misfortune.”[3] They have to deal
with multiple problems such as illness, treatment, aftercare,
finances, immediate society, and community.[3,4] They are
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the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
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For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

How to cite this article: Paul MS, Bhattacharjee D,

DOI:
Khanande RV, Nizamie SH. Early-onset bipolar disorder,
stress, and coping responses of mothers: A comparative
10.4103/psychiatry.IndianJPsychiatry_865_20
study. Indian J Psychiatry 2021;63:152-61.

152 © 2021 Indian Journal of Psychiatry | Published by Wolters Kluwer ‑ Medknow

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Paul, et  al.: Early onset bipolar disorder and coping with stress of mothers
often made to feel ashamed because of their children’s
illness. Therefore, they need to use several forms of coping
to deal with the challenges coming from different sources.[3‑6]
They have the feelings such as lack of respite, jitteriness,
sense of failure and loss, sense of hypersurveillances, loss
of self, asynchrony, and chronic fear.[6‑8] Early‑onset BPAD
is characterized by mixed mood states, rapid cycling, high
degree of elatedness and irritability, and frequent presence
of comorbidities. Early‑onset BPAD means BPAD occurring
before the age of 18 years or BPAD affecting children and
adolescents.[9‑11] The longitudinal course of early‑onset
BPAD is characterized by frequent changes in symptom
polarity with a fluctuating course.[9‑12]
Symptoms of early onset BPAD do not have substantial
similarity with adult BPAD.[9‑11,13,14] They have an ongoing,
generalized mood disturbance that combines symptoms of
both mania and depression. These symptoms can lead to
negative consequences such as “disruption of psychosocial
and family functioning,” “difficulty to interact with peers,”
“academic problems,” “poor relationship among siblings,”
and “poor parent–child relationships.”[8,12,15‑17]
Parents of adolescents with BPAD have been observed
to have higher likelihood of emotional distress or even
syndromal psychological problems, feeling of loss, tendency
to avoid social situation, poor marital relationship between
parents, and sense of resigning or leaving everything on
fate.[2‑4,17‑20] Families of adolescents with BPAD have the
higher likelihood of experiencing family crisis in the form
of family conflict, lack of cohesion, less adaptability with
problem situations, and expressed emotion.[18‑21] Some
past studies showed that mothers of these children and
adolescents tend to use several means of coping to deal with
their psychological distress, e.g., “seeking social support,”
“relying on general and specific beliefs,” “task‑oriented
coping,” and “emotion focused coping.”[21‑25]
Mothers were seen to be more affected by their children’s
problem than fathers. Emotion‑focused coping and active
avoidance coping were found to be predictor of parental
stress.[22‑24,26‑30] Seltzer et  al.[26] observed differences in
coping between the mothers of mentally ill and mentally
retarded individuals. Mothers of mentally ill individuals
used more emotion‑focused coping, which predicted
higher level of depression in mothers. Mothers of mentally
retarded individuals tended to be depressed due to their
child’s behavior problems. Coping acted as buffer against
stress for mothers of mentally retarded persons, while that
was not seen for mothers of mentally ill persons. Parenting
of adolescents with BPAD is a daunting task. Mothers have
often been entrusted with major responsibilities pertaining
to patient care and maintenance of family functioning, and
they tend to be crippled by overwhelming dual pressure
of patient care and family functioning.[22,26,30] Although in
Western World studies on mothers of adolescents with
Indian Journal of Psychiatry Volume 63, Issue 2, March-April 2021
BPAD have been done in the past, in India, they are very
sparse. The study was an attempt to study the perception
of stress and coping responses of the mothers of the
adolescents with BPAD.
MATERIALS AND METHODS
This study was conducted at the Central Institute of
Psychiatry (CIP), Ranchi, India. Current study was duly
approved by the Institutional Ethical Committee, and
informed consents were taken from each subjects selected
in the study appropriately. The contents of the Consent
Form were written in Hindi and English. This consent form
was given directly to literate mothers. The research team
had explained the informed consent form thoroughly in
simple language to the selected women. Signatures were
obtained from the literate mothers, whereas, thumb
impressions were taken from the illiterate women. Thumb
impression was taken in front of their relatives. The study
was a cross‑sectional hospital‑based comparative study
and the subjects were recruited purposively. The mothers
of normal adolescents were recruited from the pool of the
staffs of the CIP and two nearby areas belonging to the
Kanke Administrative Block of Ranchi district, Jharkhand
State. Those two areas are adjoining to this institute.
The current study was conducted on sixty mothers of
adolescents belonging to age range of 11–18 years. The
selected sixty mothers were further divided into study
and control Groups. The Study Group composed of thirty
mothers of adolescents with BPAD, whereas the control
group was made of thirty mothers of normal adolescents.
These two groups were matched as per the age of the
mothers, socioeconomic status, and mothers’ educational
status. The criteria of selection of study group were as
follows:
(a) Adolescents with the diagnosis of BPAD and the duration
of illness  ≥2  years;  (b) must have at least two episodes
of illness (mania or depression) in the past 2 years; (c) no
history of any other medical and/or psychiatric illness
and/or substance addiction and/or disability; and (d) mothers
actively involved in patient care for at least 2 year and living
in the same household with the adolescents. The GHQ‑12[31]
was applied on the mothers of normal adolescents (Control
Group) for ruling out psychological problems in them.
Mothers with score of ≤3 in GHQ‑12[31] were included in the
study. For data collection, following measures were used:
a. Sociodemographic and clinical data sheet – A data sheet
containing important socio‑demographic and clinical
parameters was developed for sociodemographic and
clinical profiling of the selected subjects of either group
b. The Parenting Stress Index/Short Form (PSI/SF)[32] – The
PSI/SF is the abridged form of original PSI. This measure
gives the Total Stress score from three sub‑scales:
Parental Distress, Parent‑Child Dysfunctional
Interaction, and Difficult Child
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Paul, et  al.: Early onset bipolar disorder and coping with stress of mothers
c. The Brief COPE Scale[33] – The Brief COPE is a 28‑item
multidimensional measure of strategies adopted for
coping with stressors. This is the abbreviated form
of larger 60‑item COPE Inventory.[34] The COPE is a
multidimensional inventory that comprises 15 scales
each composed of four items. The abbreviated
version, the Brief‑COPE[33] has 14 subscales composed
of two items each: (a) acceptance – suggesting
the acceptance of reality and preparing oneself;
(b) emotional Support – seeking emotional
support; (c) humor – trying to make fun on the
situation; (d) positive reframing – trying to see the
situation from a different perspective or searching
for something positive in it; (e) religion – seeking
comfort through religious or spiritual practices
and beliefs; (f) active coping – actively using of
strategies or plans to make the situation better;
(g) instrumental support – seeking help and advice
from other people; (h) planning – developing
specific strategy; (i) behavioral disengagement – not
attempting to cope; (j) denial – refusing to accept
the reality; (k) self‑distraction – involving in work
or other activities to get off problematic situation;
(l) self‑blaming – being self‑critical for the occurrence
of the problem or stressor; (m) substance Use – taking
the help of alcohol or other drugs to get off the feeling
of stress; (n) venting – expressing negative feelings.
Carver[27] categorized the strategies of acceptance,
emotional social support, humor, positive reframing,
and religion as Emotion Focused. On the other hand,
active coping, instrumental support, and planning
are considered as Problem‑Focused Strategies. Finally,
behavioral disengagement, denial, self‑distraction,
self‑blaming, substance use, and venting are
considered as Dysfunctional Coping Strategies
The data analysis was done by IBM SPSS®‑20 Windows
Version (IBM Inc, Armonk, New York 10504‑1722, United
States).
RESULTS
Table 1.1 shows the comparison between socio‑demographic
profiles of both the groups. There was no significant
difference between the mothers of adolescents with BPAD
and normal adolescents with regard to age, though the
children from control group were significantly younger than
study group. When other parameters of sociodemographic
Table 1.1: Comparison of sociodemographic profile between the study and control group (independent samples t‑test)
Variables
Study group (BPAD group) (n=30)
Adolescents’ age 15.37±1.38
Family size (number of members) 6.13±2.45
Mothers’ age 39.53±6.48
**Significant at <0.01 level. BPAD – Bipolar disorder; SD – Standard deviation
154
profile were compared [Table 1.2], the two groups were
comparable on most of the parameters; however, significant
differences were observed in religion, domicile, and family
history of mental illness. In terms of religion, majority of the
participants in study group followed Hinduism; however,
the number of participants was equal for Hinduism and
Christianity in the Control Group. With regard to family
history of mental illness, nearly half of the (n = 14)
participants in study group had the history of mental illness
in their respective families.
Mothers of the adolescents with BPAD had reported
significantly higher level of stress (scores of PSI/SF) [Table 2].
In all three areas of PSI/SF, i.e., “Parental Distress,”
“Parent–Child Dysfunctional Interaction,” and “Difficult
Child” as well as total score, mothers of the adolescents
with BPAD had reported significantly higher scores than
that of mothers of normal adolescents, suggesting higher
perception of stress among mothers of the adolescents
with BPAD. Significant differences were noted between
the mothers of the two groups of the adolescents in most
of the domains of the coping measuring instrument, i.e.,
Brief COPE [Table 3]. Barring two domains of Brief COPE,
“Substance use” and “Use of emotional support,” significant
differences were seen in remaining 12 domains of the
scale. It was noted that mothers of the normal adolescents
reported significantly higher scores in positively oriented
coping strategies such as active coping, use of instrumental
support, positive reframing, planning, humor and
acceptance. On the contrary, mothers of the adolescents
with BPAD scored significantly higher in maladaptive and
emotion focused coping mechanisms such as self‑blame,
turning to religion, venting of emotions, use of emotional
support, denial, and self‑distraction. The sociodemographic
parameter of “Family’s Income Status” has not been found
to have any significant implication on the coping strategies
adopted by the mothers of the adolescents with BPAD
[Table 4.1]. As per the income level, selected women were
divided into “Lower” and “Middle” Income families. Majority
of the selected women were from the lower income group
families (n = 25). The variable “family type” has been found
to have significant implication on two types of coping, i.e.,
“Religion” and “Self‑blame” [Table 4.2]. Mothers belonging
to nuclear families reported to use the religious activities
and self‑blaming significantly higher than that of mothers
of joint families. However, in other domains of Brief COPE
no significant differences were noted between these two
groups of families. The status of literacy of the study group
Group (n=60), mean±SD t (df=58) P
Normal control group (n=30)
13.63±2.31 3.53 <0.01**
5.27±1.34 1.70 0.094
36.97±6.66 1.52 0.135
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Paul, et  al.: Early onset bipolar disorder and coping with stress of mothers

Table 1.2: Comparison of sociodemographic profile between the study and control group (Chi‑square test/Fisher’s
exact test)
Variables Group (n=60) χ2/Fisher’s df P
Study group (mothers of Normal control group (mothers exact test#
BPAD adolescents), n (%) of normal adolescents), n (%)
Sex of children
Male 17 (57) 20 (67) 0.635 1 0.42
Female 13 (43) 10 (33)
Religion
Hindu 27 (90) 14 (47) 15.39# ‑ <0.01**
Islam 2 (7) 2 (6)
Christian 1 (3) 14 (47)
Educational status of children
Illiterate 1 (3) 1 (3) 0.305# ‑ 0.89
Primary 11 (37) 9 (30)
≥Secondary 18 (60) 20 (67)
Domicile
Rural 24 (80) 16 (53) 4.80 1 0.028*
Urban 6 (20) 14 (47)
Marital status
Unmarried 27 (90) 30 (100) 3.16# ‑ 0.237
Married 3 (10) 0 (0)
Fathers’ occupation
Farmer 17 (57) 17 (57) 0.867# ‑ 0.699
Private 11 (37) 9 (30)
Service 2 (6) 4 (13)
Socioeconomic status
Lower 25 (83) 20 (67) 2.22 1 0.136
Middle 5 (17) 10 (33)
Family type
Nuclear 20 (67) 22 (73) 0.317 1 0.573
Joint 10 (33) 8 (27)
Family history of mental illness
No 16 (53) 30 (100) 18.26# ‑ <0.01**
Yes 14 (47) 0 (0)
FDR history of mental illness
No 25 (83) 30 (100) 5.45# ‑ 0.052
Yes 5 (17) 0 (0)
Present marital status of mothers
Married 26 (87) 30 (100) 4.28# ‑ 0.112
Widowed 4 (13) 0 (0)
Mothers’ education
Illiterate 16 (53) 9 (30) 3.36 1 0.067
Literate 14 (47) 21 (70)
Mothers’ occupation
House wife 28 (93) 29 (97) 0.351# ‑ 1.00
Employed 2 (7) 1 (3)
**Significant at <0.01 level, *Significant at <0.05 level, #Fisher’s exact test. FDR – First degree relative; BPAD – Bipolar disorder

Table 2: Comparison of stress between study group and control group (independent samples t‑test)
Variables Group (n=60), mean±SD t P
Study group (mothers of BPAD adolescents) (n=30) Normal control group (mothers of normal adolescents) (n=30) (df=58)
PD 41.80±7.43 35.23±9.35 3.01 <0.04**
PDCI 42.17±7.07 31.47±6.76 5.99 <0.01**
DC 41.70±6.92 31.53±8.58 5.05 <0.01**
Total score 125.67±19.83 98.23±21.76 5.11 <0.01**
**Significant at <0.01 level. BPAD – Bipolar disorder; SD – Standard deviation; PD – Parental distress; PDCI – Parent‑Child Dysfunctional Interaction; DC – Difficult
child

mothers has not been found to affect coping significantly mothers. However, factor like “family history of mental
as seen as per scores on all the domains of the Brief COPE, illness” has not been found to have significant implication
except the domain of “venting” [Table 4.3]. In this domain, on the coping styles of the mothers’ of the adolescents with
literate mothers scored significantly higher than illiterate BPAD [Table 4.4].

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Paul, et  al.: Early onset bipolar disorder and coping with stress of mothers

Table 3: Comparison of coping strategies of mothers of the adolescents with bipolar disorder and normal
adolescents (independent samples t‑test)
Variables (domains of the brief Group (n=60), mean±SD t (df=58) P
COPE) Study group (mothers of Normal control group (mothers
BPAD adolescents) (n=30) of normal adolescents) (n=30)
Emotion focused coping
Acceptance 3.06±1.14 4.90±1.12 −6.262 <0.001***
Use of emotional social support 5.20±1.12 4.73±1.04 1.661 0.102
Humor 2.33±0.75 4.86±1.52 −8.146 <0.001***
Positive reframing 3.33±1.21 5.93±1.08 −8.766 <0.001***
Religion 5.13±1.45 2.50±0.86 8.527 <0.001***
Total score of the domain 21.40±6.54 26.30±5.59 −3.116 <0.03**
Problem focused coping
Active coping 3.76±1.27 6.26±1.04 −8.284 <0.001***
Use of instrumental support 4.33±1.42 5.36±1.24 −2.994 <0.04**
Planning 3.30±1.26 5.73±1.25 −7.476 <0.001***
Total score of the domain 17.30±4.67 21.80±4.39 −3.839 <0.001***
Dysfunctional coping
Behavioral disengagement 4.16±1.11 2.26±0.44 8.644 <0.001***
Denial 4.46±1.07 2.10±0.30 11.608 <0.001***
Self‑distraction 6.23±0.97 2.43±0.72 17.146 <0.001***
Substance use 2.56±0.81 2.23±0.50 1.902 0.062
Venting 4.96±0.99 2.23±0.56 13.022 <0.001***
Self‑blame 5.86±1.65 2.13±0.50 11.810 <0.001***
Total score of the domain 18.16±4.16 18.20±2.63 −0.037 0.971
**Significant at <0.01 level; ***Significant at <0.001 level. BPAD – Bipolar disorder; SD – Standard deviation

Table 4.1: Comparative description between the coping strategies of the mothers of adolescents with bipolar disorder
as per selected sociodemographic parameters (socioeconomic status of the family) (independent samples t‑test)
(bipolar disorder group)
Variables (domains of the brief Group (n=30), mean±SD t (df=28) P
COPE) Mothers belonging to lower Mothers belonging to middle
income families (n=25) income families (n=5)
Emotion focused coping
Acceptance 3.12±1.16 2.80±1.09 0.565 0.577
Use of emotional social support 5.20±1.19 5.20±0.83 0.000 1.000
Humor 2.32±0.74 2.40±0.89 −0.212 0.834
Positive reframing 3.20±1.15 4.00±1.41 −1.366 0.183
Religion 5.28±1.40 4.40±1.67 1.246 0.223
Total score of the domain 16.84±4.49 19.60±5.41 −1.448 0.159
Problem focused coping
Active coping 3.76±1.33 3.80±1.09 −0.063 0.950
Use of instrumental support 4.24±1.36 4.80±1.78 −0.799 0.431
Planning 3.28±1.27 3.40±1.34 −0.191 0.850
Total score of the domain 20.64±6.36 25.20±6.76 −1.214 0.235
Dysfunctional coping
Behavioral disengagement 4.20±1.22 4.00±0.00 0.360 0.722
Denial 4.48±1.12 4.40±0.89 0.149 0.882
Self‑distraction 6.28±0.93 6.00±1.22 0.582 0.565
Substance use 2.60±0.81 2.40±0.89 0.493 0.626
Venting 5.08±0.99 4.40±0.89 1.412 0.169
Self‑blame 6.00±1.52 5.20±2.28 0.986 0.333
Total score of the domain 17.92±4.48 19.40±1.81 −0.718 0.478
SD – Standard deviation

The regression analysis was done to assess the confounding DISCUSSION

factors such as “family history of mental illness,” “religion,”
“lower level of education of mothers,” and “rural locality”
in the study group (BPAD) and their roles in influencing the
findings of the study. However, those factors had not been
found to have significant implications on the coping styles
employed by the mothers [Table 5].
The current study was an attempt to examine the stress
and coping of the mothers of the adolescents with BPAD.
BPAD impacts skill development in children leading to
family situation becoming fussy and unsteady. In the
present study, mothers of the adolescents with BPAD were

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Paul, et  al.: Early onset bipolar disorder and coping with stress of mothers

Table 4.2: Comparative description between the coping strategies of the mothers of adolescents with bipolar disorder
as per selected sociodemographic parameters (type of the family) (independent samples t‑test) (bipolar disorder group)
Variables (domains of the brief Group (n=30), mean±SD t (df=28) P
COPE) Mothers belonging to Mothers belonging to
nuclear families (n=20) Indian joint families (n=10)
Emotion focused coping
Acceptance 2.90±1.02 3.40±1.34 −1.135 0.266
Use of emotional social support 5.20±1.00 5.20±1.39 0.000 1.000
Humor 2.40±0.82 2.20±0.63 0.675 0.505
Positive reframing 3.30±1.17 3.40±1.34 −0.209 0.836
Religion 5.50±1.27 4.40±1.57 2.057 0.049*
Total score of the domain 20.75±6.61 22.70±6.54 −0.763 0.452
Problem focused coping
Active coping 3.90±1.25 3.50±1.35 0.803 0.429
Use of instrumental support 4.55±1.50 3.90±1.19 1.188 0.245
Planning 3.30±1.34 3.30±1.15 0.000 1.000
Total score of the domain 16.70±4.58 18.50±4.85 −0.994 0.329
Dysfunctional coping
Behavioral disengagement 4.30±1.21 3.90±0.87 0.922 0.364
Denial 4.65±1.08 4.10±0.99 1.340 0.191
Self‑distraction 6.35±0.98 6.00±0.94 0.928 0.361
Substance use 2.60±0.82 2.50±0.84 0.311 0.758
Venting 5.00±1.02 4.90±0.99 0.254 0.801
Self‑blame 5.40±1.60 6.80±1.39 −2.347 0.026*
Total score of the domain 18.20±4.37 18.10±3.95 0.061 0.952
*Significant at <0.05 level. SD – Standard deviation

Table 4.3: Comparative description between the coping strategies of the mothers of adolescents with bipolar disorder
as per selected sociodemographic parameters (literacy level of mothers) (independent samples t‑test) (bipolar disorder
group)
Variables (domains of the brief Group (n=30), mean±SD t (df=28) P
COPE) Illiterate mothers (n=16) Literate mothers (n=14)
Emotion focused coping
Acceptance 3.37±1.20 2.71±0.99 1.624 0.116
Use of emotional social support 5.25±1.23 5.14±1.02 0.256 0.800
Humor 2.25±0.68 2.42±0.85 −0.637 0.529
Positive reframing 3.00±1.03 3.71±1.32 −1.657 0.109
Religion 5.25±1.23 5.00±1.70 0.463 0.647
Total score of the domain 20.81±7.04 22.07±6.12 −0.519 0.608
Problem focused coping
Active coping 3.81±1.42 3.71±1.13 0.206 0.838
Use of instrumental support 4.18±1.55 4.50±1.28 −0.594 0.558
Planning 3.37±1.20 3.21±1.36 0.342 0.735
Total score of the domain 16.68±4.57 18.00±4.86 −0.761 0.453
Dysfunctional coping
Behavioral disengagement 3.93±1.23 4.42±0.93 −1.211 0.236
Denial 4.50±1.03 4.42±1.15 0.179 0.860
Self‑distraction 6.37±0.88 6.07±1.07 0.850 0.403
Substance use 2.62±0.80 2.50±0.85 0.412 0.684
Venting 4.62±0.95 5.35±0.92 −2.119 0.043*
Self‑blame 5.87±1.36 5.85±1.99 0.029 0.977
Total score of the domain 16.87±4.78 19.64±2.81 −1.893 0.069
*Significant at <0.05 level. SD – Standard deviation

compared with the mothers of normal adolescents on
stress and coping. The current study was conducted on
sixty mothers, of which thirty mothers of adolescents with
BPAD and thirty mothers of normal children. Majority
of the earlier studies were done on parents and among
them only few studies were done with mothers of children
having psychosis or children with disability.[7,8,21‑23,25,29,30,35,36]
Majority of studies done on psychosis were done in the
context of schizophrenia.[37‑42] The current study especially
looks into the parenting stress of mothers of adolescents
with BPAD. Maximum emphasis had been given in
previous studies on the coping mechanisms of parents
of children having developmental disabilities,[22,30,35,43‑46]
but studies on parents of children having psychosis were

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Paul, et  al.: Early onset bipolar disorder and coping with stress of mothers

Table 4.4: Comparative description between the coping strategies of the mothers of adolescents with bipolar disorder
as per selected sociodemographic parameters (family history of mental illness) (independent samples t‑test) (bipolar
disorder group)
Variables (domains of the Brief Group (n=30), mean±SD t P
COPE) Family history of mental illness absent (n=14) Family history of mental illness present (n=16) (df=28)

Emotion focused coping

Acceptance 3.12±1.25 3.00±1.03 0.294 0.771
Use of emotional social support 5.12±0.88 5.28±1.38 −0.384 0.704
Humor 2.37±0.80 2.28±0.72 0.317 0.754
Positive reframing 3.37±1.20 3.28±1.26 0.198 0.845
Religion 5.25±1.43 5.00±1.51 0.463 0.647
Total score of the domain 20.43±6.76 22.50±6.35 −0.857 0.399
Problem focused coping
Active coping 3.68±1.19 3.85±1.40 −0.357 0.724
Use of instrumental support 4.50±1.41 4.14±1.46 0.680 0.502
Planning 3.12±1.25 3.50±1.28 −0.806 0.427
Total score of the domain 16.25±3.67 18.50±5.50 −1.332 0.194
Dysfunctional coping
Behavioral disengagement 4.06±1.28 4.28±0.91 −0.539 0.594
Denial 4.37±0.71 4.57±1.39 −0.493 0.626
Self‑distraction 6.12±1.14 6.35±0.74 −0.646 0.523
Substance use 2.56±0.81 2.57±0.85 −0.029 0.977
Venting 4.87±1.02 5.07±0.99 −0.530 0.600
Self‑blame 5.62±1.50 6.14±1.83 −0.851 0.402
Total score of the domain 17.25±4.76 19.21±3.21 −1.303 0.203
SD – Standard deviation

Table 5: Regression analysis between coping styles and independent variables (family type, mothers’ literacy level,
religion and family history of mental illness)
Model Unstandardized Standardized t P F R R2 ΔR2
coefficients coefficients
B SE β
Constant 14.90 2.56 ‑ 5.81 0.001** 0.98 0.185 0.034 0.000
Problem focused coping and family type 1.80 1.81 0.185 0.99 0.329
Constant 15.37 2.67 ‑ 5.75 0.001** 0.58 0.142 0.020 −0.015
Problem focused coping and mothers’ literacy 1.31 1.72 0.142 0.76 0.453
Constant 18.58 2.45 ‑ 7.58 0.001** 0.31 0.105 0.011 −0.024
Problem focused coping and religion −1.13 2.02 −0.105 −0.56 0.580
Constant 14.00 2.61 ‑ 5.35 0.001** 1.77 0.244 0.060 0.026
Problem focused coping and family history of mental illness 2.25 1.68 0.244 1.33 0.194
Constant 15.25 2.71 ‑ 5.61 0.001** 0.63 0.149 0.022 −0.013
Problem focused coping and place of residence 1.70 2.14 0.149 0.79 0.433
Constant 18.80 3.61 ‑ 5.20 0.001** 0.58 0.143 0.020 −0.015
Emotion focused coping and family type 1.95 2.55 0.143 0.76 0.452
Constant 19.55 3.76 ‑ 5.20 0.001** 0.26 0.098 0.010 −0.026
Emotion focused coping and mothers’ literacy 1.25 2.42 0.098 0.51 0.608
constant 22.97 3.43 ‑ 6.68 0.001** 0.24 0.092 0.008 −0.027
Emotion focused coping and religion −1.39 2.83 −0.092 −0.49 0.628
Constant 18.37 3.72 ‑ 4.92 0.001** 0.73 0.160 0.026 −0.009
Emotion focused coping and family history of mental illness 2.06 2.40 0.160 0.58 0.399
Constant 18.30 2.32 ‑ 7.84 0.001** 0.04 0.011 0.000 −0.036
Dysfunctional coping and family type −0.10 1.64 −0.011 −0.06 0.952
Constant 14.10 2.26 ‑ 6.22 0.001** 3.58 0.337 0.113 0.082
Dysfunctional coping and mothers’ literacy 2.76 1.46 0.337 1.89 0.069
Constant 17.47 2.19 ‑ 7.96 0.001** 0.11 0.63 0.004 −0.032
Dysfunctional coping and religion 0.61 1.81 0.063 0.33 0.739
Constant 15.28 2.33 ‑ 6.54 0.001** 1.69 0.239 0.057 0.023
Dysfunctional coping and family history of mental illness 1.96 1.50 0.239 1.30 0.203
**Significant at <0.01 level. SE – Standard error

concerned with the burden of care[29,37‑41] instead of coping fillip by assessing the mothers’ coping responses against
mechanisms. The present study has tried to emerge as a the stress of early‑onset BPAD in their children. In most

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Paul, et  al.: Early onset bipolar disorder and coping with stress of mothers
cases, mothers have to take the greater responsibility
in patient care and they are expected to keep a balance
between patient care and steadying the family functions.
Therefore, their task is tougher than any other persons
in the relationship systems of the patients.[2,4,18,22] In the
present study, the sample size was 60; of which 30 were
mothers of adolescents with BPAD and the remaining 30
were mothers of normal children.
The sample size of this study is comparable to previously
done studies on similar population with children having
disabilities and psychosis;[22,42] although some studies have
had a much larger sample size than the present study.[29,47]
However, the adoption of stringent selection criteria for
subjects gave this study the adequate robustness which is
evident through the comparability between the study and
normal control group [Tables 1.1 and 1.2].
However, in this study, significant difference between the
study and control groups was seen in family history of mental
illness. In bipolar group, majority of the selected children
have one or more members with significant psychiatric
disorder (n = 16 [53%]). This finding of present study has
been found to be in assonance with the studies done in
to explore the genetic loading of BPAD. Findings of those
studies indicate the morbid risk of BPAD in first‑degree
relatives of bipolar probands ranges between 3% and 8%.
The risk of illness in the first‑degree relatives of patients
with BPAD is increased nearly 10 times over the normal
community, and the rate of prevalence is enumerated to
be 5%–10% in siblings and 10% in dizygotic twins and >50%
in monozygotic twins.[48‑52] In the current study, parenting
stress was assessed using PSI/SF.[33] The PSI/SF provided
a total stress score from three scales: parental Distress,
Parent–Child Dysfunctional Interaction, and Difficult Child.
Mothers of adolescents with BPAD scored significantly
higher than the mothers of normal adolescents in all
three domains as well as total scores of the PSI/SF.[33] The
Brief COPE[34] scale was applied on the mothers of either
adolescent for assessing their coping strategies. In the
current study, mothers of normal adolescents reported
higher scores on Problem‑Focused Strategies (Active Coping,
Use of Instrumental Support, and Planning) [Table 3];
whereas, mixed results were seen in Emotion Focused
Coping (Acceptance, Use of Emotional Support, Humor,
Positive Reframing, and Religion). No significant difference
was seen in Use of Emotional Support; significantly higher
use of Acceptance, Humor, and Positive Reframing was
reported by the mothers of normal adolescents’. Mothers
of the adolescents with BPAD had reported significantly
higher use of “Religion” to cope with the stress. In
Dysfunctional Coping Strategies (Behavioural Disengagement,
Denial, Self‑Distraction, Self‑Blame, Substance Use and
Venting), significant difference was seen between these
two groups of mothers. However, no significant difference
was seen between them in “Substance” domain. In all other
Indian Journal of Psychiatry Volume 63, Issue 2, March-April 2021
strategies of this particular form of coping, mothers of the
adolescents with BPAD had reported significantly higher
scores. In early‑onset BPAD, parents have the feeling of
loss, sadness, distress, and apprehensiveness like any other
chronic and debilitating health problems, including mental
illness.[2‑8,13,53] In the families of the patients’ with early onset
BPAD, problems such as expressed emotions, burden of
care, and disruption in family functions are observed. Those
problems were also found to be similar like families with
other forms of chronic mental and behavioral problems, for
example, schizophrenia, Autism, Autism Spectrum Disorder
and mental retardation.[13,19‑25,36] Early‑onset BPAD is a
complex and heterogeneous psychiatric disorder, and it has
some distinctive difference with adult onset BPAD.[14] Many
a time, children and adolescents with BD have psychiatric
co‑morbidities like ADHD, ODD, Conduct Disorder, and
anxiety disorders.[9,13,14] In the current study, variable like
“socio‑economic status of family” (Lower Income Family and
Middle Income Family) did not have significant implication
on the coping strategies of the mothers of the adolescents
with BPAD [Table 4.1]. However, “type of family” has
been observed to have some implications on the usage of
specific coping strategies of these mothers. Mothers living
in the nuclear families reported significantly higher use of
“religion” than mothers of joint families. However, mothers
of the joint families had reported significantly higher use
of “self‑blame” [Table 4.2]. In nuclear families, scope for
interactions with larger family system or extended family
unit and getting support from many people simultaneously
is much lesser. Mothers have to depend on their
husbands (fathers of the adolescents) for seeking emotional
support and comfort. In many cases, husbands do not
get adequate time to spend with their wives. This reason
might have influenced the mothers to rely on religion to
stave off their stress. Mothers belonging to Indian form
of joint family system reported significantly higher use of
“self‑blame” to cope with the stressor, i.e., illness of their
children. Indian joint family system has some limitations,
e.g., “less privacy,” “ambiguity in decision‑making process,”
“problem in parenting,” and occurrences of discontents
and disagreements in relation to several aspects of family
functions, childcare and parenting. Sometimes, women are
not given adequate importance by the elders and family
is strictly driven by age‑old traditionalistic views which
condone the women’s role in major family issues and tasks.
Because of those reasons, women of this family system
often have the feeling of deprivation. In the current study,
this might have influenced the mothers to use self‑blaming,
because they might have the feeling of not being supported
by others.[54‑56] The Regression Analysis was carried out on
the Study Group (BPAD Group) to assess the influence of
confounding variables like “family history of mental illness,”
“religion,” “lower level of education among mothers,” and
“predominance of subjects from rural locality” and those
were significantly higher in the study group, which might
have influence the findings. However, the regression
159
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Paul, et  al.: Early onset bipolar disorder and coping with stress of mothers
analysis [Table 5] suggested that, those factors did not
have overall significant influence on the coping styles of the
mothers of the adolescents with BPAD.
However, this study has some significant limitations in
the forms of “significant difference between the BPAD
and normal adolescents in their mean age,” “small sample
size,” “not including important variables such as burden of
caregiving, spousal support, marital relationship between
parents, and perceived social support of mothers.” Those
variables might have important implications on the
perception of stress, selection, and usage of specific coping
strategies from the side of mothers.
CONCLUSION
Mothers of the adolescents with BPAD tend to perceive high
level of stress and they also have significantly higher level
of dysfunctional relationship with their children. Mother of
these children tend to use maladaptive coping more while
dealing with stressful situations.
Acknowledgment
Authors of the current study would like to express their
sincere thanks and gratitude to the Administration of the
institute where this study was carried out for extending
cooperation and support.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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