[Mental Illness 2019; 11:7884] [page 9]

Life in Family Buildings as aunique environment in TurkeySeheryeli Yılmaz,1 Osman Sabuncuoglu21Bakırköy Mazhar Osman MentalHealth and Neurological DiseasesEducation and Research Hospital,Istanbul; 2Department of Child andAdolescent Psychiatry, MarmaraUniversity Medical School, Istanbul,Turkey

AbstractFamily building (FB) is a building

where residents of different flats are closerelatives. Being quite common in metropo-litan areas, these unique psychosocial envi-ronments remain underexamined. We aimedto research into the interactions within thefamily and psychosocial features of FBs.One hundred and one children living in FBsand FB-experiences of their parents wereassessed by semi-structured interviewsusing K-SADS-PL. Mothers scored theirsatisfaction from FB-lifestyle in the scale of0-100. The sample consisted of 35 girls and66 boys. Mean age was 108±37.4 months.ADHD and anxiety disorders were the com-mon diagnoses. Eighty-two families livedwith paternal relatives. Number of relative-neighbors in the building changed between2-10. Forty-one mothers scored ≤50 fortheir satisfaction; 58% believed FBs affec-ted their children’s symptoms negatively.Examining the perceived advantages anddisadvantages of FBs, ‘extreme criticism’and ‘social support’ were the decisive itemsto predict mothers’ satisfaction levels.Having both positive and negative effects,FB-lifestyle seem to complicate interperso-nal relations within the family. This studyhas revealed some preliminary findings, butfurther studies are required in the field.

IntroductionBringing two continents together,

Turkey has a great multiplicity of cultures.People living in urbanized areas haveEuropean life styles; whereas in the suburbsof big cities and rural parts of the country,people live more traditional and conservati-ve lives.1 The social diversity reflects onhousing as traditional houses and apartmentbuildings.2 After the industrial revolutionthere was a sudden and mass migration ofpoverty-stricken farmers into the cities. Theexodus from the countryside caused manyproblems. The most outstanding one was on

housing. Migrants built shanties on publicland.3 Primitive FBs were formed, as theshanty owners built second and third floorsto accomodate comings of migrated relati-ves and newlyweds. Later on instead oftheir shanties, constructers started to buildFBs for these families. FBs today are jerry-built buildings with several floors andapartment units where relatives live in sepe-rate apartments. The apartments are usuallyowned and occupied within the family, thespare apartments are either empty or forrent. Formed over 50 years time and stillexisting, the notion of FBs has become aphenomenon. Childhood family environ-ments have a crucial role in mental andphysical health development.4 Thus thisunique environment needs to be acknowled-ged further. In this study we aimed to rese-arch into the life in FBs; in terms of child-rens’s psychopathology, psychosocial featu-res and interactions within the family.

Materials and Methods

SubjectsThe study was conducted among pati-

ents who were admitted to Child andAdolescent Psychiatry Outpatient Clinic inMarmara University Hospital. 101 familiesthat live in FBs volunteered to take part.There was no exclusion criteria.

Data collection toolsSociodemographic information questi-

onnaire. The form was conducted by theresearch team. Information about the child’sage, sex, developmental milestones, medi-cal and psychiatric history, family historyfor psychiatric disorders; and parent’s com-plaints and comments about living in FBswere gathered.

The schedule for affective disorders andschizophrenia for school-age children–pre-sent and lifetime (K-SADS-PL) (Turkishversion). K-SADS-PL is one of the mostcommonly used standardized semi structu-red diagnostic interviews in child and ado-lescent psychiatry. It is used to evaluate thepsychopathology of children. It was develo-ped by Kaufman et al.5 Turkish validationof the inventory was conducted by Gokleret al.6

Other conditions like developmentaldelay, mental retardation, learning disor-ders, autism spectrum disorders were diag-nosed by the appropriate tests and clinicalexamination.

EthicsThe study was approved by the

Marmara University Medical SchoolClinical Studies Ethics Committee on 04April 2014 and informed consent was obtai-ned from all parents.

Statistical analysisThe statistical analyses were performed

using SPSS 23; P<0.05 is considered as sta-tistically significant.

ResultsThere were 35 girls (34.7%) and 66

boys (65.3%) in the sample. The age rangewas from 1.4 years to 17.7 years and themean age was 108±37.4 months. 20% offamilies defined their income as ‘poor’;45% as ‘moderate’ and 35% as ‘sufficient’.

In our sample (n=101), attention defici-ency hyperactivity disorder (ADHD) wasfound to be the most common diagnosis(n=75, 74%); followed by anxiety disordersand intellectual disability (Table 1). One ofthe most common symptoms wasenuresis/encopresis (14%). All participantswere living in FBs, the mean duration was10.7±5.6 years (range: 1-29 years). Only6% was living in a rental, owned by a stran-ger. Eighty-two families out of 101 livedwith paternal relatives (81.2%) and 28

Mental Illness 2019; volume 11:7884

Correspondence: Seheryeli Yilmaz, MedicalPark Gebze Hospital, Department of Childand Adolescent Psychiatry, Kavak cad. No:5Gebze, Kocaeli, Turkey.Tel: +90.262.6757575 - Fax: +90.262.6757515.E-mail: seheryeli11@msn.com

Key words: Child psychiatry, public health,family building, mental health, satisfaction.

Contributions: the authors contributed equally.

Conflict of interest: the authors declare nopotential conflict of interest.

Funding: none.

Received for publication: 25 Septmber 2018.Accepted for publication: 19 November 2018.

This work is licensed under a CreativeCommons Attribution-NonCommercial 4.0International License (CC BY-NC 4.0).

©Copyright S. Yılmaz and O. Sabuncuoglu, 2019Licensee PAGEPress, ItalyMental Illness 2019; 11:7884doi:10.4081/mi.2019.7884

children’s parents had a consanguineousmarriage. The decision of living in FBs wasmostly made passively (65%), due to mar-riage or by the patriaches. In only 14% offamilies, both partners planned and wantedto live in a FB aimfully. 10% declared thatthey were living in FBs because of econo-mical obligations. The number of relative-occupied flats in the FB changed from twoto ten. ‘Familial density’ of FBs was calcu-lated by dividing the number of relative-occupied flats by the total number of flats inthe building. The mean value for familialdensity (dfam) in our sample was 0.7±0.3(min. 0.06, max 1). When asked about thefrequency of meeting with neighbor-relati-ves, 74% of families declared they meteveryday and 33% reported they spent allday together. Although they live in separateapartments, 12% of families eat all theirmeals and 8% eat at least 3 to 5 days a weektogether with the relatives.

Sixty parents (59%) believed living inFB was interrelated to their children’ssymptoms; and over 80% of them declaredthat they thought living in FB affected theirchildren negatively. Sixty-six children hadalready been patients of our outpatient clinicwhen the study started. Only 7 of thosefamilies (11%) had received interventions(inquiry, information, advice, monitoring)targeting difficulties due to FBs. Three ofthese families were able to implement thelimit setting suggestions into life; and theyall reported positive outcome.

Mothers were asked to score theirsatisfaction from living in FBs, in the scaleof 0 to 100. The mean satisfaction score(SSFB) was 59.1±33.8. Median score was 70;41 mothers scored 50 points or less and 27%of mothers scored over 80 points. Whenasked about their preferences on housing;54% declared they would like to live in abuilding without family-members.

The mothers mentioned someadvantages and disadvantages for their lifein FBs. In means of perceived advantages;

85% felt more secure; 82% got help inchildcare, 65% got social and 31% gotfinancial support. As disadvantages, familiescomplained about limit setting difficulties(69%), extreme criticism and gossiping(54%), privacy issues (31%) and ‘notmaking decisions without consulting toelderly’ (18%). Correlations between FB-related data (SSFB and dfam) and theperceived advantages, disadvantages andsociodemographic data are summarized inTable 2. No significant correlation was foundbetween SSFB and dfam. SSFB wassignificantly and highly correlated toadvantages of feeling secure, having socialsupport, getting help in childcare anddisadvantages of experiencing extremecriticism and having privacy issues(P<0.001). Hierarchical Multiple Regressionwas used to assess the ability of theseadvantages and disadvantages to predictlevels of satisfaction (SSFB), after controllingfor the influence of children’s age. Totalvariance explained by the model as a wholewas 55.5%, F (6,93) = 19.34, P<0.001.Children’s age was explaining 4.6% of thevariance in SSFB, as the advantages anddisadvantages explained an additional 51%.In the final model, only having socialsupport and experiencing extreme criticismwere found statistically significant. Havinga higher beta value (β=-0.39; P<0.001)extreme criticism is the most decisiveelement on SSFB (Table 3).

DiscussionTwo thirds of our sample was male, and

this is compatible with the literature on thecharacteristics of children and adolescentsadmitted in child psychiatry outpatientunits.7 ADHD and anxiety disorders beingthe most common diagnoses in our studywas also supported by the literature.8,9

In addition to screening for

Article

Table 1. Frequency of children’s diagnosesin the sample (n=101).

Diagnosis Frequency %

ADHD 75 74.3Anxiety Disorder 23 22.8

Intellectual Disability 14 13.9Autism Spectrum Disoerder 8 7.9

Language Disorder 6 5.9Depression Disorder 5 5

ODD 2 2Learning Disorder 2 2

Psychotic Disorders 2 2Conduct Disorder 1 1

Tic Disorder 1 1ADHD = Attention Deficiency Hyperactivity Disorder. ODD =Oppositional Defiant Disorder.

Table 2. Summary of the correlationsbetween FB-related data (SSFB and dfam)and sociodemographic features.

Sociodemographic features SSFB dfam

Children's age -0.21* -0.37**Duration of FB life -0.003 0.01

Consanguineous marriage -0.08 0.06Birth weight -0.02 0.02

Perinatal complications 0.15 -0.02Milestones Speaking 0.14 -0.06 Walking -0.07 0.15 Toilet training -0.01 -0.03

Perceived advantages of FB Security 0.47** 0.08 Financial 0.25* 0.01 Social Support 0.60** 0.03 Childcare 0.46** 0.12Perceived disadvantages of FB Limit setting difficulties -0.09 0.17 Consulting to elderly -0.21* 0.05 Criticism -0.60** 0.06 No privacy -0.35** 0.02FB = Family building. SSFB = Satisfaction scores of mothers from liv-ing in a FB. dfam = familial density. *P<0.05. **P<0.01.

Table 3. Hierarchical multiple regression analyses predicting the mothers’ self-reported satisfaction scores from living in a family build-ing (SSFB) (n=100).

B SE B β 95% CI R2 F DR2 DF

Model 1 0.05 4.69* Constant 79.95** 10.18 [59.76, 100.15] Children's age (m) -0.19* 0.09 -0.21* [-0.37, -0.02] Model 2 0.56 19.34** 0.51 21.30** Constant 46.40** 11.81 [22.94, 69.85] Children's age (m) -0.03 0.07 -0.03 [-.16, .11] Adv. - Security 10.97 9.03 0.12 [-6.97, 28.91] Adv.- Social support 17.91** 6.56 0.25** [4.88, 30.93] Adv. - Childcare 13.86 8.22 0.16 [-2.47, 30.18] Disadv.- Criticism -26.07** 5.31 -0.39** [-36.62, -15.52] Disadv.- No privacy -8.42 5.46 -0.12 [-19.27, 2.43] CI = confidence interval. B is for unstandardized coefficients. β is for standardized coefficients. SE B = standard error for B. (m) = months. Adv. = advantage. Disadv. = disadvantage. *P<0.05. **P<0.01.

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psychopathology; we also gatheredsignificant amount of sociological data aboutlife in FBs. More than three quarters offamilies were living with father’s relatives;and many of them reported that theywouldn’t choose to live in a FB if they hadsuch an option. Patriarchal dominance mayexplain these mechanisms of decisionmaking on housing. Although patriarchalstructure has changed form eventually, it isstill very common in Turkish society; and it’sthe dominant culture in rural areas. The lackof free will when choosing their homeenvironment can be interpreted asinadequate family independence andinsufficient individuality of parents. Thatindicates the presence of a public healthproblem, as well.

Living in a FB, is like living in a buil-ding and a traditional house at the sametime. For better or for worse, it is differentfrom living in the same neighbourhood withyour relatives. In literature, family is knownas a protective factor for psychiatric disor-ders.10,11 However during our practice werealized that life in FBs can sometimes becomplicated for our patients and theirparents. Besides feeling more secure andgetting more family support in social, finan-cial, childcare areas; they experience moregossiping, privacy issues and child-rearingdifficulties. “My mother-in-law enters whe-never she likes, even without knocking,even in the middle of the night.” says one ofthe mothers in our study. That was becausein their building, keys were hanging outsidethe doors of flats. Another mom was com-plaining about upbringing difficulties shewas facing, as “When I say no to my son, heruns upstairs to grandma and grandpa’s; andthey grumble to me about how I must dowhatever their little prince wants”. Manyparents complain in outpatient clinic thatthey can’t set limits to their relatives aboutapplying our suggestions or can’t decide ontheir child’s treatment plan because theirpatriaches think the child doesn’t need themedication.

One may think, facing these difficulties;if they weren’t happy, they would move out.Though this may not be the true-life. In tra-ditional culture, moving out would meanbetraying and disobeying the patriach; andfor the father of our patient, it’d also meannot being a good enough son to his parents.In some of the families, it may even becomea financial burden if the patriarch holds thecontrol of the family business.

According to our results, FBs have agreat range in number of apartments theycontain. And while some FBs are in all-relative structure, some host outsiderneighbors along with the family. To managethese diversities in analyses, we came up

with the term, familial density (dfam). Due toour clinical experience, we expected thatdfam would be significantly correlated withSSFB and sociodemographic variables,though it wasn’t. Apart from our limitedsample size, we may argue that FB life stylehas influence on parents independent fromthe number of relative-neighbors.

In the study, one third of families spendall day together with at least one of theirneighbor-relatives and only go to theirseperate apartment at night for sleep. Forchildren, this may mean closeness anddiversity in relationships, as well as anenmeshed family setting.

In accordance with our preconceptions,an important finding in the present study wasthat many families showed low-satisfactionfor living in a FB. Turkish StatisticalInstitute’s (TUIK) Life Satisfaction Researchin 2013 was conducted among 196203people all around Turkey. According to theresults; out of 6360 women living inIstanbul, 78.5% declared their satisfactionabout their residential housing as eithersatisfied or very satisfied.12 Our SSFB resultsof 27% scoring 80 or more as satistactionlevel was indeed very different. Our samplewas mothers of a clinical population, all gotmarried once, living in a FB; whereas TUIKstudy was community based, the participantswere over 18 but not all of them weremarried nor gave birth and they weren’tasked about living in a FB. Although theseresults should not be interpreted as the resultof a FB life-style only, the differencebetween satisfaction scores are remarkable.

The regression analyses point out that‘experiencing extreme criticism’ becomesdecisive when predicting satisfaction scores.They also relate high satisfaction to havingsocial support in FB. Starting from this pointof view we may come to a conclusion thatpsychological stress seems to identifysatisfaction rather than concrete stress likeeconomical dependence, childcare help etc.Parents’ belief that their children’s symptomswere interrelated to living in the FB andmostly in a negative way was anotherimportant finding, showing that this issueshould always be handled properly inclinical practice regardless of their diagnosis.The environment FBs provide may alter theway the parents perceive their children’sbehavioral symptoms. On the other hand,symptom presentation of certain disorders(i.e. ADHD) may be more complicated inFBs due to limit setting difficulties.Although limit setting and behavioralinterventions had high efficiency in FBresidents, in outpatient visits counsellingabout the difficulties in FBs was quite rare.This may be explained by insufficientliterature work on the topic, limited time for

assessment or frequent change of rotatingdoctors. In clinical evaluation andmanagement, approaching FB as anenvironmental variable and asking thefamily members about their life andsatisfaction from it, may help to increase thequality of mental health service for bothchildren and their families.

LimitationsSome limitations exist in the present

study. As it was conducted using a clinicalsample, it should be kept in mind that manypeople who didn’t or couldn’t come to theoutpatient clinic were not assessed. As ourhospital is located in a suburban county ofIstanbul, most of our data came from thatlocation. Standardization for age, diagnosis,duration of therapy among patients was notestablished. Although we did someregression analyses to predict satisfaction,the sample size was not big enough for factoranalyses of advantages and disadvantages.

ConclusionsAs a unique sociocultural environment

in Turkey, it was important to have a betterunderstanding on the FBs, and their impacton children and families. Our study showedthat the phenomenon of FBs arose years agoand still lives on because it corresponds tosome requirements in life, like socialsupport, feeling secure, help in childcare.But the study also pointed to mothers’ lowsatisfaction scores in association withextreme criticism. Mothers’ relating theiroffsprings’ symptoms to FBs was also ofnotice. The present study introduces arelatively new dimention of Turkish cultureto the researchers worldwide. The supportiveenvironment families offer for couples andchildren, seem to change in FBs due to thedynamics of interpersonal relations. Moreclinical research is definitely needed in thisunderexplored field; as well asepidemiological and community basedstudies to discover the psychologicalinfluence of FBs. In the future, after morestudies in the field we may identify the FBlife as a unique enviromental factor thataffects mental health in children and parents.

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