**4.2 Social skills**

Research identifies a negative influence of parental schizophrenia on HR offspring, arising deficits in social skills in the domains of social competence, reduced smiling, affective flattening, assertion, empathy, cooperation, positive involvement, physical anhedonia, self-esteem, self-confidence, social adjustment and employment situation. This emphasises upon the debilitating negative impacts of parental schizophrenia on the psychosocial well-being of offspring.

## **4.3 Internalising and externalising behavioural problems**

Furthermore, it was found there to be a greater prevalence of internalising and externalising behavioural problems amongst HR offspring in which the incidence was greater for the HR group than the HC group [60]. HR offspring were also found to have *fewer positive emotions*, *greater negative emotions and reduced quality of life*, all of which differed from the HC group in mean scores [7]. This highlights upon the behavioural issues experienced for HR offspring further indicating a negative impact on the psychosocial well-being of HR offspring.

The findings of this review build upon the idea that parental schizophrenia influences the development of psychiatric disorders amongst HR offspring [7, 8, 10–15, 17–19, 35, 43–45, 62] which have also identified the development of psychiatric conditions amongst HR offspring. Moreover, the stated findings also build upon the idea that parental schizophrenia arises social deficits amongst HR offspring as also detailed in previous literature [7, 12, 23–28]. Overall there is a negative impact of parental schizophrenia on the psychosocial well-being of offspring as displayed across all studies. This signifies a genetic propensity being passed from the parent with schizophrenia to the offspring.

There were several interesting findings unrelated to the psychosocial well-being of HR offspring. Firstly, it was found that the prevalence for psychiatric disorders in HR offspring was higher for males than females, arising questions into potential gender characteristics, such as different coping mechanisms resulting in differed psychosocial distresses [58, 65]. The predominance of males in some studies and females in other studies may aid in differentiating the impacts of gender on the psychosocial well-being of HR offspring. Moreover, social functioning amongst HR Japanese offspring was not significantly impacted, which suggest cultural differences amongst HR offspring regarding psychosocial well-being [55]. Overall, studies included in this review cover a broad range of cultures, allowing the conclusions of this review to be generalised to many cultures, whilst building upon previous literature and highlighting upon the cumulative incidences across cultures [13–15]. Future research may look into examining western and non-western cultures to make comparisons along with the investigation of gender differences.

In addition, an anomalous finding arose, in which eight HR offspring had excellent social skills and nine HR offspring displayed below average scores, none of which were within the average on measures of social skills [61]. This suggests that offspring within this study had extreme scores on each end but may have been due to the relatively small sample size. Interestingly, it was also found that poor physical anhedonia and positive involvement were present in those aged 17 years and below, whereas those aged above 17 years displayed lower cooperation levels [63]. This highlights differences in age, in which future studies could address by comparing different age groups. Findings presented strengthen the diathesis-stress explanation. In addition, this may indicate possible ideas for intervention strategies targeted for different age groups. Therefore, these particular results can inform clinicians and therapists of the psychosocial impacts parental schizophrenia has on different age groups.

Moreover, another study found [7] lower levels of family functioning and a greater perception of losses in resources and lowered resource gains. This suggests that there are negative impacts of parental schizophrenia unrelated to the psychosocial outcomes as the environmental stressors involved in this study were lowered levels of family functioning. These environmental stressors regarding family functioning could have been maltreatment, neglect or an unidentified stressor. This finding could identify as a confounding factor, as these outcomes may have resulted in the lowered quality of life and greater negative emotions. Therefore, it may be difficult to examine a causal relation between parental schizophrenia and the impact this has on the psychosocial well-being of HR offspring. Future research may consider investigating these aspects to distinguish the extent to which this impacts HR offspring. It was also found that those within the HR group had higher scores on measures of quality of life than the ME and FE group [56]. This suggests that there are confounding factors influencing the findings in an opposite direction. Highlighting upon the existence of possible confounding factors, there was a greater prevalence of psychiatric disorders amongst HR offspring in disturbed familial environments [66]. This implies that the environmental factors surrounding HR offspring may play an important role in the development of negative impacts on the psychosocial well-being of HR offspring.

**175**

*The Impacts of Parental Schizophrenia on the Psychosocial Well-Being of Offspring:…*

Environmental factors are important to identify, as these alone can result in negative outcomes such as the incidence of psychiatric conditions amongst HR offspring. This is because the offspring may experience an upbringing whereby the environment is distorted, thus elevating the risk for negative impacts on the psychosocial well-being of offspring. Across all findings, the effect sizes and mean differences between the HR groups and control groups were not 100%, suggesting other factors influencing the onset of negative psychosocial distress and difficulties. Also, there were not vast differences between the HR group and control groups regarding the effect sizes and mean differences, for example, it was found there to be mean incidence of 39.15 for externalising/internalising behavioural issues amongst HR offspring, in comparison to a 31.53 mean incidence for the HC group [60]. This supports the idea that the environmental factors play a role in the negative impacts, further strengthening the idea of a diathesis-stress explanation. The direction of the findings may have been due to the participant size across studies. Most studies included had a relatively large sample size [56–59, 62, 63, 65, 66]. However, some studies had a relatively small sample size. The small sample size amongst these particular studies may have resulted in the effect size and mean incidence scores/ratings produced and thus reducing the statistical power and generalisability of these findings. Therefore, future reviews may aim to include studies consisting of a relatively larger sample, similar to each other and the control groups,

There were many confounding factors which were not mentioned or described such as environmental factors, including maltreatment, child abuse, marital conflict and other stressful life events as detailed in previous literature [12, 34, 44–49, 51]. This may imply that poor psychosocial functioning may not be due to having a parent with schizophrenia but rather the surrounding environment of the offspring. Previous literature identifies a link to the negative impacts on the psychosocial wellbeing of HR offspring which may suggest and support the diathesis-stress model of the development of these outcomes. This model suggests that environmental factors increase the risk of developing psychological difficulties, particularly amongst HR offspring as they have a genetic vulnerability as mentioned in previous literature [36–42] in which an environmental stressor occurs which triggers a negative outcome (i.e. the onset of a psychiatric condition or symptom), also stated in previous literature [43, 44]. To summarise, findings cannot establish which factor causes the outcome; therefore, future research must aim to address this by incorporating the

Moreover, findings revealed there to be a positive correlation between the duration of parental schizophrenia on the self-esteem of HR offspring [64] which suggests that the longer the parent was diagnosed with schizophrenia, the greater the self-esteem scores within the HR group (mean duration of parental illness = 11.67 years). This is a confounding result, as it implies that parental schizophrenia in the long-term had an almost reversal effect on scores of levels of self-esteem. This may have been due to the HR offspring being able to adjust and adapt to their parent's mental illness over time, which also further suggests confounding factors involved in this outcome. All other studies included did not sufficiently state the duration of parental illness or age of offspring at which parent diagnosis occurred. This is an important aspect for future studies to address.

Furthermore, it was also found that HR offspring had lower self-esteem in earlyonset offspring, in comparison to later onset offspring in which self-esteem scores were higher (mean age of onset = 10.6 years) [64]. This indicates that the younger the offspring is when their parent is diagnosed, the worse the impact this has on

*DOI: http://dx.doi.org/10.5772/intechopen.91658*

**4.4 Confounding factors**

to prevent biased findings.

measures for environmental factors.

*The Impacts of Parental Schizophrenia on the Psychosocial Well-Being of Offspring:… DOI: http://dx.doi.org/10.5772/intechopen.91658*

#### **4.4 Confounding factors**

*Quality of Life - Biopsychosocial Perspectives*

The findings of this review build upon the idea that parental schizophrenia influences the development of psychiatric disorders amongst HR offspring [7, 8, 10–15, 17–19, 35, 43–45, 62] which have also identified the development of psychiatric conditions amongst HR offspring. Moreover, the stated findings also build upon the idea that parental schizophrenia arises social deficits amongst HR offspring as also detailed in previous literature [7, 12, 23–28]. Overall there is a negative impact of parental schizophrenia on the psychosocial well-being of offspring as displayed across all studies. This signifies a genetic propensity being

There were several interesting findings unrelated to the psychosocial well-being of HR offspring. Firstly, it was found that the prevalence for psychiatric disorders in HR offspring was higher for males than females, arising questions into potential gender characteristics, such as different coping mechanisms resulting in differed psychosocial distresses [58, 65]. The predominance of males in some studies and females in other studies may aid in differentiating the impacts of gender on the psychosocial well-being of HR offspring. Moreover, social functioning amongst HR Japanese offspring was not significantly impacted, which suggest cultural differences amongst HR offspring regarding psychosocial well-being [55]. Overall, studies included in this review cover a broad range of cultures, allowing the conclusions of this review to be generalised to many cultures, whilst building upon previous literature and highlighting upon the cumulative incidences across cultures [13–15]. Future research may look into examining western and non-western cultures to

passed from the parent with schizophrenia to the offspring.

make comparisons along with the investigation of gender differences.

psychosocial impacts parental schizophrenia has on different age groups.

perception of losses in resources and lowered resource gains. This suggests that there are negative impacts of parental schizophrenia unrelated to the psychosocial outcomes as the environmental stressors involved in this study were lowered levels of family functioning. These environmental stressors regarding family functioning could have been maltreatment, neglect or an unidentified stressor. This finding could identify as a confounding factor, as these outcomes may have resulted in the lowered quality of life and greater negative emotions. Therefore, it may be difficult to examine a causal relation between parental schizophrenia and the impact this has on the psychosocial well-being of HR offspring. Future research may consider investigating these aspects to distinguish the extent to which this impacts HR offspring. It was also found that those within the HR group had higher scores on measures of quality of life than the ME and FE group [56]. This suggests that there are confounding factors influencing the findings in an opposite direction. Highlighting upon the existence of possible confounding factors, there was a greater prevalence of psychiatric disorders amongst HR offspring in disturbed familial environments [66]. This implies that the environmental factors surrounding HR offspring may play an important role in the development of negative impacts on the psychosocial well-being of HR offspring.

In addition, an anomalous finding arose, in which eight HR offspring had excellent social skills and nine HR offspring displayed below average scores, none of which were within the average on measures of social skills [61]. This suggests that offspring within this study had extreme scores on each end but may have been due to the relatively small sample size. Interestingly, it was also found that poor physical anhedonia and positive involvement were present in those aged 17 years and below, whereas those aged above 17 years displayed lower cooperation levels [63]. This highlights differences in age, in which future studies could address by comparing different age groups. Findings presented strengthen the diathesis-stress explanation. In addition, this may indicate possible ideas for intervention strategies targeted for different age groups. Therefore, these particular results can inform clinicians and therapists of the

Moreover, another study found [7] lower levels of family functioning and a greater

**174**

Environmental factors are important to identify, as these alone can result in negative outcomes such as the incidence of psychiatric conditions amongst HR offspring. This is because the offspring may experience an upbringing whereby the environment is distorted, thus elevating the risk for negative impacts on the psychosocial well-being of offspring. Across all findings, the effect sizes and mean differences between the HR groups and control groups were not 100%, suggesting other factors influencing the onset of negative psychosocial distress and difficulties. Also, there were not vast differences between the HR group and control groups regarding the effect sizes and mean differences, for example, it was found there to be mean incidence of 39.15 for externalising/internalising behavioural issues amongst HR offspring, in comparison to a 31.53 mean incidence for the HC group [60]. This supports the idea that the environmental factors play a role in the negative impacts, further strengthening the idea of a diathesis-stress explanation.

The direction of the findings may have been due to the participant size across studies. Most studies included had a relatively large sample size [56–59, 62, 63, 65, 66]. However, some studies had a relatively small sample size. The small sample size amongst these particular studies may have resulted in the effect size and mean incidence scores/ratings produced and thus reducing the statistical power and generalisability of these findings. Therefore, future reviews may aim to include studies consisting of a relatively larger sample, similar to each other and the control groups, to prevent biased findings.

There were many confounding factors which were not mentioned or described such as environmental factors, including maltreatment, child abuse, marital conflict and other stressful life events as detailed in previous literature [12, 34, 44–49, 51]. This may imply that poor psychosocial functioning may not be due to having a parent with schizophrenia but rather the surrounding environment of the offspring. Previous literature identifies a link to the negative impacts on the psychosocial wellbeing of HR offspring which may suggest and support the diathesis-stress model of the development of these outcomes. This model suggests that environmental factors increase the risk of developing psychological difficulties, particularly amongst HR offspring as they have a genetic vulnerability as mentioned in previous literature [36–42] in which an environmental stressor occurs which triggers a negative outcome (i.e. the onset of a psychiatric condition or symptom), also stated in previous literature [43, 44]. To summarise, findings cannot establish which factor causes the outcome; therefore, future research must aim to address this by incorporating the measures for environmental factors.

Moreover, findings revealed there to be a positive correlation between the duration of parental schizophrenia on the self-esteem of HR offspring [64] which suggests that the longer the parent was diagnosed with schizophrenia, the greater the self-esteem scores within the HR group (mean duration of parental illness = 11.67 years). This is a confounding result, as it implies that parental schizophrenia in the long-term had an almost reversal effect on scores of levels of self-esteem. This may have been due to the HR offspring being able to adjust and adapt to their parent's mental illness over time, which also further suggests confounding factors involved in this outcome. All other studies included did not sufficiently state the duration of parental illness or age of offspring at which parent diagnosis occurred. This is an important aspect for future studies to address.

Furthermore, it was also found that HR offspring had lower self-esteem in earlyonset offspring, in comparison to later onset offspring in which self-esteem scores were higher (mean age of onset = 10.6 years) [64]. This indicates that the younger the offspring is when their parent is diagnosed, the worse the impact this has on

HR offspring's self-esteem levels. This further indicates that age has an impact on the vulnerability of HR offspring, in which developmental literature can address in future research, by conducting more longitudinal studies to map the trajectory of this vulnerability and make comparisons between different age groups (i.e. less than 10 years old and greater than 10 years old). Moreover, parental physical illness was incorporated by eliminating HR offspring of those that were suffering from chronic physical illnesses [64], to minimise the effect of this stressor. This is because this may cause greater significant stress on the HR offspring, which may impact the psychological difficulties the HR offspring may encounter. Therefore, to minimise bias amongst the findings, these particular HR offspring were excluded from the study.

Considering living arrangements amongst HR offspring, the HR perspective was explored amongst those adopted offspring living away from the biological parent suffering from schizophrenia [66]. Findings revealed that HR offspring still displayed a greater prevalence of psychopathology in comparison to the HC group. This finding highlights upon a predominant genetic vulnerability amongst HR offspring, despite being reared away from their biological parent with schizophrenia. This builds upon previous literature [36–42] highlighting upon the idea that brain abnormalities are genetically transmitted to HR offspring, thus supporting a diathesis-stress explanation.

#### **4.5 Clinical implications**

The findings build upon the idea that parental schizophrenia negatively impacts the psychosocial well-being of HR offspring regarding the following aspects: the prevalence of emotional and behavioural symptoms, internalising and externalising behaviours, psychiatric conditions, lowered quality of life, poorer self-concept, social adjustment, social functioning and employment situation. The greatest impact across studies in this review was the impairments in social functioning, which can be interpreted using the diathesis-stress explanation. The genetic vulnerabilities appeared to have been transmitted from parent to offspring, whereby environmental factors and stressors surrounding these individuals triggered an onset of these impairments. This review provides a more current set of findings with the inclusion of social impacts as well as psychological impacts, in comparison to the previous systematic review based solely upon the development of psychiatric conditions of HR offspring [11].

The current findings can aid public health authorities in raising awareness for this HR population by means of prioritising education in mental health, mass media and by increasing public funding. Revelations can also encourage early visits to mental health centres for screenings and evaluations to prevent and provide support [12]. It can also inform clinicians about targeted intervention strategies for HR offspring, such as taking into consideration the developmental differences in the onset of psychosocial distress. All these aspects can either prevent the later emergence of psychosocial difficulties or reduce experienced.
