Mental Health Professionals View on the Need for Early Intervention for Offspring of Individual With Schizophrenia in India

Schizophrenia is a debilitating mental illness not only for the individual but also for the family, especially the children. There is a definitive likelihood of the vulnerability being transmitted to the child. As a result of the parents illness there may also be disruptions in the family dynamics and in home environment. However, many children have been found to show resiliency. The aim of this particular study was to explore the need for intervention in children who’s either parent were being treated for schizophrenia. Using qualitative Interpretative Phenomenological Approach (IPA) mental health professionals from all over India were interviewed with the help of validated interview guide. To understand their lived in experience of these professionals the audio recorded interviews were transcribed and analysed for exploring the themes using thematic analysis. Significant themes found indicated that early interventions were crucial for the wellbeing of the child, specifically in the Indian scenario.

Studies indicate 20 percent of the Indian population suffering from one or the other form of mental health disorder that requires psychiatric intervention (Math &Srinivasaraju, 2010)such as cognitive retraining (Thara&Anuradha,2007).However the impact of mental health issues such as stigma is pervasive (Shah &Beinecke, 2009) resulting in less number of people approaching for any interventions (Somers, 2006).
Major psychiatric problems such as schizophrenia are a debilitating mental illness not only for the individual but also for the family, especially for the children (Schiffman, LaBrie, Carter, Cannon, Schulsinger, Parnas,& Mednick, 2002).Family is a primary social group that ensures survival and shapes the personality and adaptability of the children (Masten&Gewirtz, 2006).A nurturing and secure family environment is of paramount importance in the growth of the children (Davis, Lee, Horan, Clarke, McGee, Green, &Marder, 2013).Poor family environment plays a role in later depression, attitude towards suicide and loneliness (Segrin, Nevarez, Arroyo, & Harwood, 2012).
Being afflicted with a mental illness may affect parenting to a large extent (Somers, 2006).Research has indicated that growing up with a parent suffering from mental illness can influence the child's development in a range of ways (Herbert, Manjula, & Philip, 2013).Family history of psychopathology and disturbed familial functioning play contributory roles in later development of psychopathology in the offspring ( (Shah, Kamat, Sawant, &Dhavale, 2003).
To cope with the challenges, there is a need for increasing the resiliency (Fergusson &Horwood, 2003).Resiliency bridges the experiences of inner and outer world.With the right kind of social support and family dynamics as also timely intervention, the child can grow up to be a healthy functioning individual.This further highlights the need for intervention with such a population.On the other hand, if issues are not out rightly present, the timely intervention can help prevent any issues from arising.

Methods
The aim of the present study is tounderstand the experiences of the mental health professionals (MHPs) from all over India on the need for interventions for offspring of individuals with schizophrenia.
The study adopts a qualitative research design.The qualitative research methodology employs techniques such as interviews, case studies and narratives etc that are often unavailable in the quantitative research paradigm, thus enabling the exploration of the reasons and mechanisms behind aspects of the human psyche and behaviour.
The current study adopted an interpretative phenomenological approach that explores personal experiences.The most frequently used mode of carrying out this approach is through in-depth interviews that allow the investigator to completely explore in detail, the participant's world.

data Collection Process
Phase I-The first step in the process of data collection began with the development of interview schedules.The interview schedules were developed in the format of an in depth interview guide and a semi structured questionnaire, use of which depended on the convenience of the MHPs.
For the development of the interview schedules, extensive review of literature was conducted.Following this, interview questions were identified, from that the interview guide was formulated and validated by an expert panel.The panel consisted of two clinical psychologists; both are experts in qualitative research, a psychiatrist and a psychiatric social worker.
Phase II-43 participants -Clinical psychologists (18), psychiatrists (20) and psychiatric social workers (5) were selected through linear snowball sampling.They were screened for minimum of five years of working experience with individuals suffering from Schizophrenia.MHPS who have had any history of mental health issues and substance abuse were excluded using General Health Questionnaire ( GHQ 12 )and a screening tool.
Phase III-Data collection began with obtaining consent from the participants.They were briefed about the study after getting the informed consent signed by the participants then theinterview began.In depth interviews were conducted with some of the MHPs while semi structured questionnaires were administered to those MHPs who did not have sufficient time for an in depth interview.The in depth interviews were audio recorded.
Phase IV-Once the in depth interviews were completed and the semi structured questionnaires filled, audio recordings were transcribed verbatim.Memo questions were prepared based on the interviews for further elaboration and the participants were contacted regarding the same.Response of the participants were obtained and added to the transcripts.Member check was also carried out by the researcher.Phase V-Once data collection and subsequent memo questions were completed, the data collected was validated by an expert panel.The panel assessed the quality of the questions asked and also the length of the interviews and the comprehensiveness of the memo questions.Audio recordings and transcripts were also analyzed.
Phase VI-Once the transcription was completed, the process of data analysis began.Thematic analysis was used to analyze the data.This primarily involved drawing significant, common and recurring themes from the dataset.Thematic analysis seeks an overall pattern, common themes and also principles that provide theoretical explanations to phenomenon.It is more of an approach to analyzing data rather than a technique.Analysis was done by two independent coders.While one was manual in nature, the other was done through NVIVO.The results were drawn from both the analysis, keeping a common ground in between.The inter rater reliability was checked between the coders and the Kappa value was found to be 80 percent which is a high value indicates that the reliability between the coders was good.
The study was conducted from 2014 till 2016.The researcher is based out of the city of Bengaluru, India However the data was collected from the sample from all over India.

ethical considerations
The interviews were conducted only after the informed consent had been collected from the participants.Participants were informed that their participation in the study was voluntary and that they had the right to withdraw from the study at any point of time.Participants were ensured of anonymity.Participants were ensured that the data collected would be kept confidential and would only be used for research purposes.After data collection, participants were debriefed through member check for their inputs.

Results and disCussions
The experience of the MHPs on the need for interventions for offspring of individuals with schizophrenia was explored and the results are elaborated in six global themes namely family environment, preventive measures, academic performance, behavioural issues, social cognition, coping and resilience.

the family environment
For the family members, accepting the mental illness of a loved one can be a complicated process results in emotional turmoil to process all the ambivalent emotions, anger, embarrassment and guilt leads to burn out (Chien, Chan, & Morrissey, 2007;Stanley &Shwetha, 2006).Studies on family environment points out that there is increased risk for these children to develop schizophreniaand difficulty in cognitive domain and social domains (Schiffman, LaBrie, Carter, Cannon, Schulsinger, Parnas,&Mednick, 2002).
'Yes him/her spouse has a problem but concentrating and caring for him/her, and not giving importance to the child will crop up another problem at home'(P11, personal communication).
'There will be lot of other issues also existing since like taking care of the others, the spouse…then neglect, maybe the neglect of the children would be there'(P16, personal communication).
'there is no structure to their life; nobody is like, getting them ready to go to school and stuff like that….Because children have not been looked after, they haven't been taken care of.I mean, you'd get like I said…language is very limited'(P35, personal communication).
The above verbatim of MHPs shows that there is disturbances in the family environment resulting in poor structure, neglect and lack of communications resulted in imbalanced emotion maladaptive behaviour among family members.Studies by Chien, Chan and Morrissey (2007) conclude that this disruption in the family environment may result in poor academic performance and poor adjustment to emotional issues.

helps in improving the Cognitive Functioning
This global theme captures the neuro cognitive deficits that were either reported by the parents/teachers or displayed by the children.Neuro cognition includes the domains of attention, concentration, problem solving, memory, executive functions, processing skills and learning skills.Some children may show a dip in their academic performance or a lack of interest in studying which then adversely affects their marks (Niemi, Suvisaari, Tuulio-Henriksson, &Lönnqvist, 2003); Keshavan, Shrivastava, &Gangadhar, 2010).
'Have followed up these children, and early intervention which helped them a lot, they were able to get good marks and perform well in their life'(P2, personal communication, 2014).
'See some children umm…basically when they lack stimulation, when they lack parental care and support, obviously affects their scholastic performance, (P42, personal communication 2016).
The personal communication quoted here implies that some children of parents with schizophrenia do manifest academic difficulties and intervention provided was helpful.

Reduces Behavioural problems
This global theme referred to issues in behaviour such as truancy, aggression, rebelliousness, oppositional features, and conduct problems.These behaviour patterns may be found collectively or they may manifest individually.The participants were of the view that because of such behaviours, the parent child relationship was affected.Studies have also shown that children can inherit the genetic vulnerability, predisposing them to develop certain behavioural issues ( 'Behaviour problems like stubbornness and defiance… problems'(P3, personal communication).

More of adamancy is seen, irritability, aggressiveness'(P4 and P5, P7 personal communication). ' D i s i n h i b i t i o n … b e h a v i o u r a l problems'(P18, personal communication).
'Social backwardness…shyness, inappropriate behaviour in play, dressing and self care'(P19, P34 personal communication).
'In my understanding the deficits seen in these children would be…socio-behavioural skill deficits…deficits in these areas are likely to lead to lower adjustment in several areas'(P13, personal communication).

social cognition
Social cognition in this context refers to the child's ability to understand social norms, process them and respond to them appropriately.Social cognition is essential if one is to live harmoniously in society.With a well developed social cognition, an individual will be able to understand different social cues and learn to respond to these cues according to the social norms available.When there are deficits in this paradigm, the children may be sidelined by their peers thus isolating them.The subsequent isolation only worsens the situation for such children as the availability of social support declines.In a study conducted by Montrose, Gur, Gur, Sweeney and Keshavan(2010),the social adjustment of children born to parents with schizophrenia was studied.The investigation revealed that the children faced issues in social situations and social adjustment due to their misjudgement of others' reactions, expressions and behaviour in a social environment.
Poor social skills here refer to the child's inability to mingle with other children as also the inability to conform to social norms.Issues in social behaviour, according to some of the participants could also be aggravated by cognitive distortions.Poor socialization could because of excessive shyness, difficulty making friends due to lack of trust or being unable to understand social cues.

' A s o b s e r v e d b y m e p o o r l y, poor socialization'(P11, P12, P 6 personal communication).
'There may be socialisation difficulties' (P20, personal communication).
The above verbatim gets the support of the study by Niemi, Suvisaari, Tuulio-Henriksson and Lönnqvist (2003)which reveals that deficits in social skills among these children.Similarly study on the social adjustment of children born to parents with schizophrenia was studied (Montrose, Gur, Gur, Sweeney &Keshavan, 2010).The investigation revealed that the children faced issues in social situations and social adjustment due to their misjudgement of others' reactions, expressions and behaviour in a social environment.In a study by Spinelli (1995) high risk children displayed deficits on measures of social intelligence, causing them difficulties in their interpersonal relationships and with their peer groups.
Helps in coping and enhancing resilience.As these children are genetically vulnerable to develop schizophrenia (Shah, Kamat, Sawant, &Dhavale, 2003; Nishida, Sasaki, Harada, Fukuda, Masui, Nishimura, & Okazaki, 2009) when intervention is provided early on, it not only helps the child in terms of working through the difficulties but also prepares them for the challenges they might face in the future and how they can effectively handle stress.Thus, children will be in a better position to cope with stressors, becoming resilient to adversities.
'Remedial interventions as well as those that focus on strengthening skills is likely to equip them to handle stress that might come from demands as they grow older'(P13, personal communication, 2014).
Because the more early you detect a problem and the more quickly you go to a specialist, the more early the intervention… it has long-lasting and everlasting effects'(P16, personal communication, 2015).
According to this participant, remedial interventions as well as skills training can help the offspring of individual with schizophrenia to deal with different kinds of stressors.As children grow older, the nature and intensity of stressors also change and they have to be prepared to deal with various kinds of challenges including preventing them from adapting the ill parent's behaviour and help the cope with the illness of the parent (McFarlane, Dixon, Lukens, & Lucksted, 2003;Masten&Gewirtz, 2006), enhancing the resilient nature acting as a buffer for the child later (Kersey &Malley, 2005).Employing a host of adaptive, coping techniques over time will help the child overcome challenges and work through them in a positive manner (Chatterjee, Leese, Koschorke, McCrone, Naik, John, &Thara, 2011) Preventive measures Since schizophrenia has a genetic basis (Sawa&Kamiya, 2003), there is a possibility that the vulnerability may be transmitted to the child now has a predisposition Therefore, such issues need to be addressed then and there (Keefe & Harvey, 2012).
Many of the MHPs were of the view that early intervention could help in identifying the possible issues that the children might be facing and if these are identified at the right time, then an escalation can be prevented (Diwadkar, Montrose, Dworakowski, Sweeney, & Keshavan, 2006).
'I would feel that the first thing is to identify, because many of these disorders as I have read, will not develop if you intervene at the right time; and the first thing in intervention is to identify if there is a problem and not all high risk children will develop schizophrenia; and not all these children have problems in the cognition or behaviour.So I feel that there should be some way of identification.So after identification you could, ah you know, intervene based on the problems that you find.'(P1, personal communication, 2014).
'The problems with children will be that as age varies, these sorts of changes in the presentation, all these we will have to look at.'(P6,personal communication, 2014).
'Most beneficial effect would be in terms of preventing psychopathology in adulthood.Parents need to be watchful for any signs and Seek professional help to address these problems so that any later psychopathology could be prevented'(P12, P40, personal communication, 2014).
However the following verbatim gives two different approaches to handle the issue.While the participant does not talk favouring any, the two approaches are definitely thought provoking.
'There are two groups of people, one group believes that we have to attack it aggressively, others saywait andwatch'(P24, personal communication, 2014).

ConClusion
Results of the present study indicated that children of parents with schizophrenia did demonstrate neurocognitive deficits such as deficits in attention, concentration, memory, executive functions, problem solving and the social-cognition paradigm as also behavioral deficits such as temper tantrums, demanding behavior, bizarre behavior and so on.
Thus, there is an imminent need for intervention.If issues are present, then interventions can be designed to address them.If issues are not present, then the intervention takes the shape of a remedial approach, providing the needed support and guidance for the child to be resilient and cope with the challenges.A resilient child will be in a better position to form social relations and engage in quality interactions thus ensuring a stable source of support for the child who in turn can contribute toward making the well-adjusted and functioning.Required resources should be mobilized such that intervention can be provided but as also made accessible to all the children.Childhood is the time for exploring and no one child ought to be deprived of this (though it happens more often than not).Society in general and MHPs specifically have a social responsibility to ensure that the necessary care is provided to these children so that they also have a chance to live life just as the others.aCknowledgeMent This research paper is the product of the major research project titled" Need, Challenges And Interventions In Children Whose Parents Are Diagnosed With Schizophrenia" funded by CHRIST (Deemed to be University), Bengaluru,India.The author wished to acknowledge Ms. Parvathy, Ms.Shruthi Santhanam, Ms. Harshita Narendra, and Mr. Samuel Rukshshan for working in this project as research assistants.