A review of potential cognitive and environmental risk markers in children of bipolar parents

Parental bipolar disorder, family environment, and offspring psychiatric disorders: A systematic review

BACKGROUND

Our objective was to systematically review non-experimental studies of parental bipolar disorder (BD), current family environment, and offspring psychiatric disorders to identify characteristics of family environment associated with parental BD and risk for offspring psychiatric disorders.

METHODS

CINAHL, Embase, PsycINFO, and PubMed were searched using MeSH terms to identify studies on offspring of BD parents published through September 2017. We followed PRISMA guidelines and used the Risk of Bias Assessment Tool for Nonrandomized Studies (RoBANS). We calculated prevalence ratios and 95% confidence intervals to compare offspring psychiatric disorders within and across studies.

RESULTS

Of 10,454 unique documents retrieved, we included 13 studies. The most consistent finding was lower parent-reported cohesion in families with a BD parent versus no parental psychiatric disorders. Family environment did not differ between BD parents and parents with other disorders. Offspring of BD parents had higher prevalence of psychiatric disorders than offspring of parents without psychiatric disorders but did not differ from offspring of parents with other disorders. Families with a BD child had higher conflict than families without a BD child.

LIMITATIONS

Comparisons between studies were qualitative. A single reviewer conducted screening, data extraction, and bias assessment.

CONCLUSIONS

Family environment in families with a BD parent is heterogeneous. The pattern of findings across studies also suggests that family problems may be associated with parental psychiatric illness generally rather than parental BD in particular. Few studies included offspring-reported measures. Given the association of family conflict with offspring mood disorders, further study is merited on children's perceptions of the family environment in the BD high-risk context.

Differences in coping strategies in adult patients with bipolar disorder and their first-degree relatives in comparison to healthy controls

INTRODUCTION

The objective of this study was to compare patients with bipolar disorder (BD), their first-degree relatives and a group of healthy controls in terms of use of adaptive and maladaptive coping strategies, exploring differences between specific types of strategies and their correlations with clinical variables.

METHODS

This was a cross-sectional study enrolling 36 euthymic patients with BD, 39 of their first-degree relatives and 44 controls. Coping strategies were assessed using the Brief COPE scale.

RESULTS

Significant differences were detected in the use of adaptive and maladaptive strategies by patients, their first-degree relatives and controls. Patients used adaptive strategies less often than the patients' relatives (p<0.001) and controls (p = 0.003). There was no significant difference between first-degree relatives and controls (p=0.707). In contrast, patients (p<0.001) and their relatives (p=0.004) both exhibited higher scores for maladaptive coping than controls. There was no significant difference regarding the use of maladaptive strategies between patients and their relatives (p=0.517).

CONCLUSIONS

First-degree relatives were at an intermediate level between patients with BD and controls regarding the use of coping skills. This finding supports the development of psychosocial interventions to encourage use of adaptive strategies rather than maladaptive strategies in this population.

Intellectual Functioning in Offspring of Parents with Bipolar Disorder: A Review of the Literature

Impaired intellectual functioning is an important risk factor for the emergence of severe mental illness. Unlike many other forms of mental disorder however, the association between bipolar disorder and intellectual deficits is unclear. In this narrative review, we examine the current evidence on intellectual functioning in children and adolescents at risk for developing bipolar disorder. The results are based on 18 independent, peer-reviewed publications from 1980 to 2017 that met criteria for this study. The findings yielded no consistent evidence of lower or higher intellectual quotient (IQ) in offspring of parents diagnosed with bipolar disorder. Some tentative evidence was found for lower performance IQ in offspring of bipolar parents as compared to controls. It is recommended that future research examine variability in intellectual functioning and potential moderators. These findings demonstrate the need to examine how intellectual functioning unfolds across development given the potential role of IQ as a marker of vulnerability or resilience in youth at high risk for affective disorders.

Does perfectionism in bipolar disorder pedigrees mediate associations between anxiety/stress and mood symptoms?

Background

Bipolar disorder (BD) and the anxiety disorders are highly comorbid. The present study sought to examine perfectionism and goal attainment values as potential mechanisms of known associations between anxiety, stress and BD symptomatology. Measures of perfectionism and goal attainment values were administered to 269 members of BD pedigrees, alongside measures of anxiety and stress, and BD mood symptoms. Regression analyses were used to determine whether perfectionism and goal attainment values were related to depressive and (hypo)manic symptoms; planned mediation models were then used to test the potential for perfectionism to mediate associations between anxiety/stress and BD symptoms.

Results

Self-oriented perfectionism was associated with chronic depressive symptoms; socially-prescribed perfectionism was associated with chronic (hypo)manic symptoms. Self-oriented perfectionism mediated relationships between anxiety/stress and chronic depressive symptoms even after controlling for chronic hypomanic symptoms. Similarly, socially-prescribed perfectionism mediated associations between anxiety/stress and chronic hypomanic symptoms after controlling for chronic depressive symptoms. Goal attainment beliefs were not uniquely associated with chronic depressive or (hypo)manic symptoms.

Conclusions

Cognitive styles of perfectionism may explain the co-occurrence of anxiety and stress symptoms and BD symptoms. Psychological interventions for anxiety and stress symptoms in BD might therefore address perfectionism in attempt to reduce depression and (hypo)manic symptoms in addition to appropriate pharmacotherapy.

Electronic supplementary material

The online version of this article (doi:10.1186/s40345-017-0102-8) contains supplementary material, which is available to authorized users.

Quality of life in youth with bipolar disorder and unaffected offspring of parents with bipolar disorder

BACKGROUND

There have been few studies investigating quality of life (QoL) in pediatric bipolar disorder (BD) patients and none comparing it with that observed in unaffected offspring of parents with BD and healthy controls.

METHODS

The self-report Youth Quality of Life Instrument-Research version (YQoL-R) was administered in 26 pediatric BD patients, 17 unaffected offspring of parents with BD, and 24 individuals with no history of DSM-IV Axis I psychiatric disorders. All diagnoses were determined through interviews based on the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version.

RESULTS

There were statistical differences among the groups for all YQoL-R domains. Pairwise comparisons showed that perceived QoL was significantly worse in the BD group than in the unaffected offspring and healthy subjects, a difference that persisted even when only euthymic subjects were analyzed. There were no significant differences between the unaffected offspring and healthy subjects for any YQoL-R domain.

LIMITATIONS

Our sample was small. There was no QoL report from subjects parents nor data about family environment or BD parents' mood state.

CONCLUSIONS

There is a need for studies to investigate in greater detail the relationship between QoL and psychological resilience, particularly in the unaffected offspring of parents with BD.

Neuropsychological characteristics of child and adolescent offspring of patients with bipolar disorder

BACKGROUND

Bipolar disorder (BD) is a severe mental disorder with a strong genetic component. The assessment of child and adolescent offspring of patients diagnosed with BD (BDoff) provides an opportunity to investigate vulnerability factors and the first abnormalities associated with the disorder. Previous literature in child and adolescent BDoff is scarce and controversial. However, some studies concur in identifying significant impairment in executive functions, memory and attention. The present study aims to compare global neuropsychological characteristics of child and adolescent offspring of patients with bipolar disorder with a group of offspring of parentswith no history of psychotic disorder, and to assess the influence of psychopathology on neuropsychological performance.

METHODS

This research was part of The Bipolar and Schizophrenia Young Offspring Study (BASYS). A group of BDoff (N= 90) and a group of offspring of parents with no history of psychotic disorder (CC) (N = 107) were assessed with a complete neuropsychological battery. Intellectual quotient, working memory, processing speed, verbal memory and learning, visual memory, attention and executive functions were included in the cognitive assessment.

RESULTS

BDoff showed significantly worse performance in processing speed and immediate recall of visual memory relative to CC. When the presence of any lifetime psychopathology was analysed, the results showed that belonging to the BDoff group was the main explicative factor for the scores obtained in both processing speed and visual memory immediate recall, regardless of the presence of psychopathology.

CONCLUSIONS

These findings suggest that processing speed and visualmemory should be taken into consideration in future research on vulnerability markers of BD.

An exploratory randomised controlled trial of a web-based integrated bipolar parenting intervention (IBPI) for bipolar parents of young children (aged 3-10)

BACKGROUND

Communication, impulse control and motivation can all be affected by Bipolar Disorder (BD) making consistent parenting more difficult than for parents without mental health problems. Children of parents with BD (CPB) are at significantly increased risk of a range of mental health issues including Attention Deficit Hyperactivity Disorder (ADHD), anxiety, depression, substance use, and sleep disorders. Furthermore, CPB are also at elevated risk for BD compared to the general population. This paper describes the rationale and protocol for a pilot randomised controlled trial (RCT) designed to assess the feasibility and acceptability of a new online intervention providing interactive psychoeducational information and parenting support for parents with BD.

METHODS AND DESIGN

This article describes a single-blind randomised controlled trial comparing an Integrated Bipolar Parenting Intervention (IBPI) in addition to treatment as usual (TAU) with TAU alone. Participants will be recruited from across the UK from mental health services and through self-referral. The primary outcome of the study is the feasibility and acceptability of IBPI as indicated by recruitment to target, use of the intervention site, and retention to follow-up. Parents with BD allocated to the IBPI condition will have access to the intervention for 16 weeks. Effect size estimates will be obtained with respect to child behaviour, parenting skills and measures of parental mental health using measures taken at baseline (0), and at 16, 24, 36, and 48 weeks post randomization.

DISCUSSION

This is the first randomised controlled trial of an integrated bipolar disorder parenting intervention. The benefits and challenges of delivering this online intervention, and evaluation using online RCT methodology are discussed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN75279027 Registered 12 August 2013.

Early signs of anomalous neural functional connectivity in healthy offspring of parents with bipolar disorder

OBJECTIVES

Bipolar disorder (BD) has been associated with dysfunctional brain connectivity and with family chaos. It is not known whether aberrant connectivity occurs before illness onset, representing vulnerability for developing BD amidst family chaos. We used resting-state functional magnetic resonance imaging (fMRI) to examine neural network dysfunction in healthy offspring living with parents with BD and healthy comparison youth.

METHODS

Using two complementary methodologies [data-driven independent component analysis (ICA) and hypothesis-driven region-of-interest (ROI)-based intrinsic connectivity], we examined resting-state fMRI data in 8-17-year-old healthy offspring of a parent with BD (n = 24; high risk) and age-matched healthy youth without any personal or family psychopathology (n = 25; low risk).

RESULTS

ICA revealed that, relative to low-risk youth, high-risk youth showed increased connectivity in the ventrolateral prefrontal cortex (VLPFC) subregion of the left executive control network (ECN), which includes frontoparietal regions important for emotion regulation. ROI-based analyses revealed that high-risk versus low-risk youth had decreased connectivities between the left amygdala and pregenual cingulate, between the subgenual cingulate and supplementary motor cortex, and between the left VLPFC and left caudate. High-risk youth showed stronger connections in the VLPFC with age and higher functioning, which may be neuroprotective, and weaker connections between the left VLPFC and caudate with more family chaos, suggesting an environmental influence on frontostriatal connectivity.

CONCLUSIONS

Healthy offspring of parents with BD show atypical patterns of prefrontal and subcortical intrinsic connectivity that may be early markers of resilience to or vulnerability for developing BD. Longitudinal studies are needed to determine whether these patterns predict outcomes.

Personality, coping, risky behavior, and mental disorders in the offspring of parents with bipolar disorder: a comprehensive psychosocial assessment

OBJECTIVES

It has been proposed that the offspring of parents with bipolar disorder (OBD), through genetic mechanisms and early family interactions, develop a heightened sensitivity to stress, maladaptive coping, and dysregulated behavior, which ultimately increases the risk for affective disorders. The current study tested certain predictions of this model by assessing different psychosocial and health-related outcomes in the OBD, including personality, coping style, smoking, suicidality, high-risk sexual behaviors, criminality, and mental health.

METHOD

The sample was composed of 74 OBD and 75 control offspring, who were between 14 and 27 years of age (mean: 19.38±3.56). Participants underwent a diagnostic interview and a structured interview to assess high-risk behavior and other maladaptive outcomes, and they completed the Revised NEO Personality Inventory and Coping in Stressful Situations questionnaire.

RESULTS

The rates of affective (31.1%) and non-affective (56.8%) disorders were elevated in the OBD compared to controls (9.5% and 32.4%). Relative to controls, OBD endorsed fewer task-oriented and more distraction coping strategies [Wilk׳s λ=.83, F(1, 136) =6.92, p<.01], and were more likely to report engaging in high-risk sexual behavior (OR=2.37; Wald=4.13, 1 df, p<05). Importantly, OBD reported elevated high-risk sexual behavior relative to controls, irrespective of affective disorder diagnosis.

CONCLUSION

The results highlight a potential risk profile for the OBD, consisting of ineffective coping strategies and risky sexual behavior and are discussed in the context of current knowledge of stress and coping in this population.

LIMITATIONS

The present findings were based on cross-sectional data and relied on offspring self-report. It would be useful to corroborate these findings with biobehavioural and longitudinal measures.

Family environment of bipolar families: a UK study

BACKGROUND

Aspects of family environment (FE) such as family support, organisational structure and levels of conflict can increase risk of Bipolar Disorder (BD) in offspring of BD parents.

METHODS

The family environment of 16 BD and 23 healthy control (HC) families was assessed using the Family Environment Scale (FES). Canonical Correspondence Analysis (CCA) was used to determine the degree of variation in scores on the FES dimensions within each family and a Generalised Linear Modelling (GLM) approach was used to investigate the extent to which scores on the different FES dimensions differed between families.

RESULTS

On the FES, BD families experienced an environment with higher levels of conflict and lower levels of expressiveness, organisation, intellectual-cultural orientation and active-recreational orientation than healthy control families. Differences in FES scores were driven by presence of parental BD and total number of children in the family. However, socio-economic status (SES) was not found to have an effect in this study.

LIMITATIONS

As an American instrument the FES may not have been sensitive enough to the cultural context of a UK sample. The relatively small sample size used may have limited the statistical power of the study.

CONCLUSIONS

Greater numbers of children have the same effect on levels of conflict as the presence of BD, while SES does not appear to be as important a factor in FE as previously thought. Our results suggest that family based interventions focusing on psychoeducation and improved communication within these families may address issues of conflict, organisation and expressiveness.

Dysfunctional family environment in affected versus unaffected offspring of parents with bipolar disorder

OBJECTIVE

Children of parents with bipolar disorder (BD) are at heightened risk for developing mood and other psychiatric disorders. We proposed to evaluate the environment of families with at least one parent with BD type I (BDF) with affected offspring (aBDF) and unaffected offspring (uBDF) compared with control families without a history of DSM-IV Axis I disorder (CF).

METHOD

We used the Family Environment Scale (FES) to evaluate 47 BDF (aBDF + uBDF) and 30 CF. Parents were assessed through the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Diagnosis of the offspring was determined through the Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Version (K-SADS-PL) interview.

RESULTS

There were statistically significant differences between aBDF, uBDF and CF in cohesion (p = 0.003), intellectual-cultural orientation (p = 0.01), active-recreational orientation (p = 0.007), conflict (p = 0.001), control (p = 0.01), moral-religious emphasis (p = 0.01) and organization (p = 0.001). The aBDF showed higher levels of control (p = 0.02) when compared to the uBDF.

CONCLUSIONS

Families with a BD parent presented more dysfunctional interactions among members. Moreover, the presence of BD or other psychiatric disorders in the offspring of parents with BD is associated with higher levels of control. These results highlight the relevance of psychosocial interventions to improve resilience and family interactions.

Life events in bipolar patients: a comparative study with siblings and healthy controls

BACKGROUND

While many studies have focused on life events in depressive disorders, data regarding them in bipolar disorder are scant. The aim of this work was to explore the characteristics of life events in bipolar patients.

METHODS

Sixty bipolar patients have been included in our study. The evaluation focused on the sociodemographic and clinical characteristics with a standardized measurement of life events using Paykel's interview. The results were compared with those of siblings and healthy controls groups. The three groups were matched for age and sex.

RESULTS

Compared to the controls, bipolar patients and their siblings had a higher global score of life events and more events in the fields of work, socio-family events and health. Bipolar patients reported more desirable events compared with their siblings and controls. The siblings reported higher scores of uncontrollable and undesirable events than patients and controls, and a higher score of controllable events than patients.

LIMITATIONS

The Paykel's interview has no validated Tunisian version, which could be a methodological bias in the assessment of life events. Moreover, the assessment of the life events was made during the euthymic phase of the bipolar disorder; however, there was no standardized measure of mood symptoms, to confirm this euthymia.

CONCLUSION

Our findings could help in the identification of the etiopathogeny of bipolar disorder and would contribute to improve the understanding and management of these patients focusing on the psychosocial aspect which is often overlooked.

A Pilot Web Based Positive Parenting Intervention to Help Bipolar Parents to Improve Perceived Parenting Skills and Child Outcomes

Background: Children of bipolar parents are at elevated risk for psychiatric disorders including bipolar disorder. Helping bipolar parents to optimize parenting skills may improve their children's mental health outcomes. Clear evidence exists for benefits of behavioural parenting programmes, including those for depressed mothers. However, no studies have explored web-based self-directed parenting interventions for bipolar parents. Aims: The aim of this research was to conduct a pilot study of a web-based parenting intervention based on the Triple P-Positive Parenting Programme. Method: Thirty-nine self-diagnosed bipolar parents were randomly allocated to the web-based intervention or a waiting list control condition. Parents reported on their index child (entry criterion age 4–10 years old). Perceived parenting behaviour and child behaviour problems (internalizing and externalizing) were assessed at inception and 10 weeks later (at course completion). Fifteen participants (4 control group and 11 intervention group) did not provide follow-up data. Results: Levels of child behaviour problems (parent rated; Strengths and Difficulties Questionnaire) were above clinical thresholds at baseline, and problematic perceived parenting (self-rated; Parenting Scale) was at similar levels to those in previous studies of children with clinically significant emotional and behavioural problems. Parents in the intervention group reported improvements in child behaviour problems and problematic perceived parenting compared to controls. Conclusions: A web-based positive parenting intervention may have benefits for bipolar parents and their children. Initial results support improvement in child behaviour and perceived parenting. A more definitive study addressing the limitations of the current work is now called for.

[Guideline on bipolar disorders and the importance of trialogue: chances and risks]

The term trialogue means the best possible equally contributing cooperation between affected patients and therapists as well as the self-evident inclusion of relatives. This is true for therapy, antistigma efforts by the planning of care, in associations such as the German Society for Bipolar Disorders and by assimilation of guidelines. Trialogue has a history and in its current version many levels and a hopeful vision of characteristics of understanding and treatment. This idea is presented here and relationships with characteristics of understanding and therapy of bipolar disorders will be made. Finally the recommendations of guidelines on trialogue will be presented and essential headings will be discussed under the aspect of trialogue: where and how are basic ideas and core demands of associations of affected persons and relatives considered? How is the process of trialogue to be assessed for the assimilation of guidelines? What are the chances and risks for the implementation? How can trialogue support the implementation?

Parenting and the emotional and behavioural adjustment of young children in families with a parent with bipolar disorder

BACKGROUND

Children of parents with bipolar disorder are at increased risk of disturbance.

AIMS

This study examined relationships between parental mood, parenting, household organization and child emotional and behavioural adjustment in families with a parent with bipolar disorder to determine areas of specific need for parenting support.

METHOD

48 parents were recruited through advertisements via self-help organizations. The study was conducted online. Parental mood and activity was assessed by self-report questionnaires (CES-D, ISS, MDQ and SRM); parenting was assessed using the Parenting Scale (PS). The SDQ was used to assess the parent's view of their child's emotional and behavioural difficulties. The Confusion, Hubbub and Order Scale (CHAOS) assessed household organization.

RESULTS

Parents reported high levels of difficulties across all measures and scores were above clinical cut-offs on most scales. Children were reported as showing high levels of disturbance on the SDQ, including all sub-scales. Parenting and depression scores were significantly positively correlated, as were depression, parenting and CHAOS score. Regression analyses indicated that CHAOS was the strongest predictor of Total Difficulties and Emotional Symptoms on the SDQ.

CONCLUSIONS

Families are likely to benefit from interventions tailored to meet their parenting needs.

Brief report: a family risk study exploring bipolar spectrum problems and cognitive biases in adolescent children of bipolar parents

Children of parents with bipolar disorder are at increased risk of bipolar spectrum diagnoses. This cross-sectional study explores cognitive factors in the prediction of vulnerability to bipolar disorder. Adolescents at high-risk (with a parent with bipolar disorder; n = 23) and age and gender matched adolescents (n = 24) were recruited. Parent and adolescent diagnoses were evaluated (SCID and SADS-L). Adolescents completed self-report measures assessing attributional style (ASQ), appraisal of hypomania-relevant experiences (HIQ), and hypomanic personality/temperament (HPS). Despite limitations in the power of the study, significantly more adolescents at high-risk for disorder received bipolar spectrum diagnoses. Groups did not differ in attributional style, hypomanic temperament or appraisals of hypomania-relevant experiences. A trend in ASQ results and general implications are discussed. The current study suggests that familial risk of bipolar disorder is not inevitably associated with cognitive biases in adolescence.

Bipolar disorder in young people: Description, assessment and evidence-based treatment

OBJECTIVE

The literature on bipolar in children and adolescents was reviewed to provide an update for clinicians.

REVIEW PROCESS

Literature of particular relevance to evidence-based practice was selected for critical review.

OUTCOMES

An up-to-date overview of clinical features, epidemiology, prognosis, aetiology, assessment and intervention was provided.

CONCLUSIONS

Bipolar disorder in children and adolescence is a relatively common, multifactorially determined and recurring problem which persists into adulthood. Psychometrically robust screening questionnaires and structured interviews facilitate reliable assessment. Multimodal chronic care programmes involving medication (notably lithium) and family-oriented psychotherapy are currently the treatment of choice.

Longitudinal Predictors of Bipolar Spectrum Disorders: A Behavioral Approach System (BAS) Perspective

We review longitudinal predictors, primarily psychosocial, of the onset, course, and expression of bipolar spectrum disorders. We organize our review along a proximal - distal continuum, discussing the most proximal (i.e., prodromes) predictors of bipolar episodes first, then recent environmental (i.e., life events) predictors of bipolar symptoms and episodes next, followed by more distal psychological (i.e., cognitive styles) predictors, and ending with the most distal temperament (i.e., Behavioral Approach System sensitivity) predictors. We then present a theoretical model, the Behavioral Approach System (BAS) dysregulation model, for understanding and integrating the role of these predictors of bipolar spectrum disorders. Finally, we consider the implications of the reviewed longitudinal predictors for future research and psychosocial treatments of bipolar disorders.