Family environment in families with versus families without parental bipolar disorder: a preliminary comparison study

Examining the association of familial and social stress, trauma, and support on mood, anxiety, and behavioral symptoms and diagnoses in youth at risk for bipolar disorder and controls

INTRODUCTION

Youth with a family history of bipolar disorder (At-Risk) have a higher risk of developing psychiatric disorders and experiencing environmental stressors than youth without such family history (Control). We studied the differential associations of familial and environmental factors on developing psychiatric diagnoses and symptoms, in At-Risk and Control youth.

METHODS

At-Risk and Control youth (N = 466, ages 9-22) were systematically assessed for severity of symptoms, psychiatric diagnoses, and self-reported measures of stress and social support. We tested the association of family history and measures of stress or support with symptom severity and diagnoses.

RESULTS

At-Risk youth had higher symptom severity scores and were more frequently diagnosed with psychiatric disorders (all p values < 0.001). When predicting mood symptom severity, family history had an interaction effect with stressful life events (p < 0.001) and number of distinct traumatic events (p = 0.001). In multivariate models, At-Risk status predicted anxiety disorders (OR = 2.7, CI 1.3-5.4, p = 0.005) and anxiety severity (Coefficient = 0.4, CI 0.2-0.7, p < 0.001) but not mood or behavioral disorder diagnoses or severity.

LIMITATIONS

Measures of stress and social support were based on self-report. Not all participants had passed through the period of risk for developing the outcomes under study and the follow up period was variable. We could not fully study the differential impact of physical or sexual abuse due to low frequency of occurrence in controls.

CONCLUSION

At-Risk youth exhibit more severe mood symptoms compared to Controls when exposed to similar levels of stress or trauma. At-Risk youth are also more prone to develop anxiety which may be a precursor for bipolar disorder.

Family dysfunction, stressful life events, and mental health problems across development in the offspring of parents with an affective disorder

BACKGROUND

Offspring of parents with affective disorders (OAD) are at risk of developing a wide range of mental disorders. Deficits in the rearing environment and high levels of stress are well-known risk factors for negative outcomes in OAD. Building on prior research, we aim to examine the longitudinal relationships between family dysfunction, stressful life events, and mental health in OAD and control offspring of parents with no affective disorder. In the present study, we hypothesized that high levels of family dysfunction would be associated with more internalizing and externalizing problems across time in OAD than in controls, and that family dysfunction would mediate the relationship between stressful life events in adolescence and poor mental health in adulthood, particularly in OAD.

METHODS

As part of the TRacking Adolescents' Lives Survey (TRAILS), 2230 participants (51% female, Mage = 11.1 years, SD = 0.6, at baseline) and their parents completed measures across six time points, spanning 15 years. Mental health, family dysfunction, and stressful life events were assessed with the Youth and Adult Self-Report, Family Assessment Device, and an in-house measure, respectively.

RESULTS

Multi-group structured equation modeling revealed that family dysfunction was linked to internalizing and externalizing problems in OAD, but not controls, across time. Risk status did not moderate family dysfunction's mediation of the relationship between stressful life events and negative outcomes in adulthood.

CONCLUSIONS

OAD show high sensitivity to dysfunction in the rearing environment across childhood and adolescence, which supports the use of family based interventions to prevent the development of mental disorders in high-risk youth.

Family environment of youth with first episode Mania

BACKGROUND

The purpose is to compare youth- and caregiver-reported characteristics of family environment, within and between families with a child experiencing a first manic episode of bipolar disorder (BPD), and families without a child with BPD or familial history of psychiatric disorders (HF).

METHODS

Family environment of 61 families with a child with BPD and 44 HF were assessed with Family Environment Scale (FES). We compared FES subscale scores between families with BPD and HF, and caregiver- and youth-rated scores.

RESULTS

Families with BPD differed significantly from HF on 8/10 FES subscales scores. Youth differed significantly from their caregivers on 7/10 subscales. An interaction effect was observed such that youth with BPD reported lower cohesion and organization, and higher conflict than their caregivers; however, HF did not differ significantly on these domains.

CONCLUSIONS

Our results suggest that families with BPD have higher conflict and lower cohesion and organization compared to HF. Results also indicate differences between youth and caregiver perspectives in both groups, which may contribute to family discord. Interventions targeting areas of cohesion, organization, and conflict may be beneficial for youth with BPD and their families, specifically those that identify and bridge perceptual divides.

Cognitive, Family, and Quality-of-Life Characteristics of Youth with Depression Associated with Bipolar Disorder

Background: Depression associated with bipolar disorder (BD) is more common compared to mania. Cognitive, family, and quality-of-life (QOL) factors associated with pediatric bipolar depression are understudied. The goal of this study was to evaluate cognitive, family environmental, and QOL characteristics of youth with bipolar depression. Methods: Thirty-two youth (12-18 years of age) with BD type I currently depressed were recruited from inpatient and outpatient setting. Subjects were assessed using the Behavior Rating Inventory of Executive Function (BRIEF), the Family Environment Scale (FES), and the Child Health Questionnaire-Parental-Form 50 (CHQ-PF50). Results were compared with population norms and the relationship between these domains was calculated. Results: Youth with depression associated with BD did not show significant impairment in executive functions. They displayed impaired family environment in the domains of cohesion, independence, achievement orientation, and organization. Youth also displayed impairments in the psychosocial health domains compared with the population normative data. The CHQ-Psychosocial health significantly negatively correlated with the BRIEF-Global Executive Control score (r = -0.76, p < 0.0001). Conclusion: Depression in youth with BD is associated with impairments in family functioning and QOL. Impairments in psychosocial QOL are associated with cognitive functioning. Further intervention studies examining executive functioning and family environment as treatment targets are needed. ClinicalTrials.gov identifier:NCT00232414.

Bipolar Disorder, Religion, and Spirituality: A Scoping Review

Mental health clinicians frequently study the religion and spirituality (R/S) of their patients. There is, however, a paucity of empirical research concerning R/S of patients with bipolar disorder. This lack is exacerbated by the absence of an evaluation of how these studies relate to each other. Reviews to date concern almost exclusively quantitative studies; a review that synthesizes quantitative and qualitative research is needed. The aim of this paper is to provide a synthesis of empirical studies that is useful in clinical practice. Systematic searches for relevant journal articles in SCOPUS, PubMed, and PsycInfo found 14 quantitative and four qualitative studies. The research reveals that intrinsic religiosity and positive religious coping are the dimensions of R/S that have the most positive correlations with improvement of bipolar disorder symptoms as revealed by measures of clinical outcomes. Patients struggle with their religious experiences, and they wish that R/S would be taken into account by mental health professionals. The quantitative studies are not in conflict with the patient/person-centered focus of qualitative studies. This integration of quantitative data with a patient/person-centered focus shows how belief and illness affect each other. The tensions inherent in such an integration provide new insights for research and treatment. Unfortunately, the qualitative literature has not caught up with quantitative approaches in terms of diagnostic rigor.

Multidimensional and intergenerational impact of Severe Mental Disorders

BACKGROUND

Severe Mental Disorders (SMDs) affect multiple generations although this is poorly studied. The aim of this study was to investigate the intergenerational and multidimensional impacts of SMD in rural Ethiopia.

METHODS

This comparative study was nested within an existing population-based cohort study. We collected data from a total 5762 family members of 532 households (266 households with at least one family member with SMD and 266 sex and age matched mentally well controls from the neighborhood) in 2019. The main outcomes were multidimensional poverty, mortality, food insecurity, and family satisfaction.

FINDINGS

Multidimensional poverty Index was higher in the households of persons with SMD (74·44%) than the comparison households (38·35%). School attendance was lower in children of people with SMD (63·28%) than children of the comparisons (78·08%). The median years of schooling was also lower among children of people with SMD than the controls. This lower attendance was also true among siblings of people with SMD (35·52%) than the comparisons (49·33%). Over the course of 20 years, family members who have a person with SMD in their household had 23% increased risk of death compared to family members who did not have a person with SMD in their household. Severe food insecurity was also higher in the SMD households (20·68%) than the comparison (13·53%) while family satisfaction was lower.

INTERPRETATION

Families of people with SMD experience pervasive multidimensional and intergenerational impacts. Interventions should consider the broader family social and healthcare needs of the broader family.

Family Functioning in Families Affected by Parental Mental Illness: Parent, Child, and Clinician Ratings

Family functioning is often impaired in families with a parent with mental illness and is linked to child mental health. This study aims to gain a better understanding of family functioning in affected families by comparing ratings among family members and by analyzing associations with clinician-rated family functioning. The cross-sectional sample comprised 210 families with ratings of 207 patients, 139 partners, and 100 children. Parents with a mental illness as well as their partners and children completed the German version of the Family Assessment Measure (FAM). Clinician ratings were obtained by the Global Assessment of Relational Functioning Scale (GARF). We conducted several mixed models to compare ratings of family functioning while accounting for family cluster. Family dysfunction was consistently elevated compared to a normative sample. On several domains, parents with a mental illness perceived family functioning to be worse compared to their partners and children. Partners and children did not differ in their perceptions of family functioning. Ratings of family members were moderately associated with clinician ratings. We discuss the importance of multi-informant assessment of family functioning and the implementation of family-based interventions for families with a parent with mental illness.

Emotion socialization in mothers with mood disorders: Affective modeling and recollected responses to childhood emotion

Growing evidence suggests that emotion socialization may be disrupted by maternal depression. However, little is known about emotion-related parenting by mothers with bipolar disorder or whether affective modeling in early childhood is linked to young adults' recollections of emotion socialization practices. The current study investigates emotion socialization by mothers with histories of major depression, bipolar disorder, or no mood disorder. Affective modeling was coded from parent-child interactions in early childhood and maternal responses to negative emotions were recollected by young adult offspring (n = 131, 59.5% female, M age = 22.16, SD = 2.58). Multilevel models revealed that maternal bipolar disorder was associated with more neglecting, punishing, and magnifying responses to children's emotions, whereas maternal major depression was associated with more magnifying responses; links between maternal diagnosis and magnifying responses were robust to covariates. Young adult recollections of maternal responses to emotion were predicted by affective modeling in early childhood, providing preliminary validity evidence for the Emotions as a Child Scale. Findings provide novel evidence that major depression and bipolar disorder are associated with altered emotion socialization and that maternal affective modeling in early childhood prospectively predicts young adults' recollections of emotion socialization in families with and without mood disorder.

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.

Resilience and insight in euthymic patients with bipolar disorder

BACKGROUND

The relationship between resilience and insight may be of potential importance for coping with stress in bipolar disorder (BD). The aim of this study was to investigate if there was a relation between insight and resilience in euthymic patients with BD and also to analyze the associations between resilience, impulsivity, aggression, alcohol use and affective temperament.

METHODS

142 patients with BD type I in remission period were involved. Resilience Scale for Adults-Turkish version, Schedule for Assessment of Insight, Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire, Barratt Impulsiveness Scale, Buss-Perry Aggression Questionnaire, Michigan Alcoholism Screening Test were used.

RESULTS

Total insight scores were negatively correlated with the scores of perception of future. As distinct from other subscales of resilience, family cohesion had independent significant associations with insight in relabelling of psychotic experiences and attention impulsivity. There was no relationship between total insight and total resilience scores. Resilience scores were negatively correlated with number of depressive episodes and number of suicide attempts. Degree of aggression, degree of impulsivity, scores of depressive and hyperthymic temperament significantly predicted resilience.

LIMITATIONS

Recruitment of patients from a tertiary centre limits the generalizability of the findings.

CONCLUSIONS

Better insight was related to negative perception of the future and did not have significant associations with total resilience. Number of depressive episodes, number of past suicide attempts correlated with resilience, emphasizing the importance of interventions to increase resilience in BD.

Multidimensional impact of severe mental illness on family members: systematic review

OBJECTIVE

The impact of severe mental illnesses (SMIs) is not limited to the person with the illness but extends to their family members and the community where the patient comes from. In this review, we systematically analyse the available evidence of impacts of SMI on family members, including parents, grandparents, siblings, spouses and children.

DATA SOURCES

PubMed, PsycINFO, Embase and Global Index Medicus were searched from the inception of each database up to 9 November 2019. We also did manual searches of grey literature.

ELIGIBILITY CRITERIA

We included studies that assessed the impacts of SMI on any family member. We excluded studies in admitted clinics and acute wards to rule out the acute effect of hospitalisation.

DATA EXTRACTION

Two reviewers extracted data independently using the Cochrane handbook guideline for systematic reviews and agreed on the final inclusion of identified studies.

RISK OF BIAS

The quality of the included studies was assessed using effective public health practice project quality assessment tool for quantitative studies.The review protocol was registered in the PROSPERO database.

RESULTS

We screened a total of 12 107 duplicate free articles and included 39 articles in the review. The multidimensional impact of SMI included physical health problems (sleeplessness, headache and extreme tiredness.), psychological difficulties (depression and other psychological problems) and socioeconomic drift (less likely to marry and higher divorce rate and greater food insecurity). Impacts on children included higher mortality, poor school performance and nutritional problems. However, the quality of one in five studies was considered weak.

CONCLUSIONS

Our review indicated a high level of multidimensional impact across multiple generations. The serious nature of the impact calls for interventions to address the multidimensional and multigenerational impact of SMI, particularly in low/middle-income countries. Given the relatively high number of studies rated methodologically weak, more robust studies are indicated.

PROSPERO REGISTRATION NUMBER

CRD42018064123.

Patterns and predictors of family environment among adolescents at high and low risk for familial bipolar disorder

Children's perceptions are important to understanding family environment in the bipolar disorder (BD) high-risk context. Our objectives were to empirically derive patterns of offspring-perceived family environment, and to test the association of family environment with maternal or paternal BD accounting for offspring BD and demographic characteristics. Participants aged 12-21 years (266 offspring of a parent with BD, 175 offspring of a parent with no psychiatric history) were recruited in the US and Australia. We modeled family environment using latent profile analysis based on offspring reports on the Conflict Behavior Questionnaire, Family Adaptability and Cohesion Evaluation Scales, and Home Environment Interview for Children. Parent diagnoses were based on the Diagnostic Interview for Genetic Studies and offspring diagnoses were based on the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. Latent class regression was used to test associations of diagnosis and family environment. Two-thirds of all offspring perceived well-functioning family environment, characterized by nurturance, flexibility, and low conflict. Two 'conflict classes' perceived family environments low in flexibility and cohesion, with substantial separation based on high conflict with the father (High Paternal Conflict), or very high conflict and rigidity and low warmth with the mother (High Maternal Conflict). Maternal BD was associated with offspring perceiving High Maternal Conflict (OR 2.8, p = 0.025). Clinical care and psychosocial supports for mothers with BD should address family functioning, with attention to offspring perceptions of their wellbeing. More research is needed on the effect of paternal BD on offspring and family dynamics.

Family functioning in youth at-risk for serious mental illness

BACKGROUND

There is evidence that family functioning can be impaired in families of individuals with schizophrenia, first-episode psychosis, bipolar disorder, and recurrent depression, which are considered to be serious mental illnesses (SMI). Poor family functioning is one of the predictors of the course of SMI. However, it is unclear if poor family functioning is a result of illness, or conversely if poor family leads to higher risk of illness. Nonetheless, family functioning may be impaired even before the onset of illness, and little is known about earlier stages of risk and the importance of the family environment for youth at-risk for SMI.

OBJECTIVE

The present study aimed to examine differences in family functioning in a sample of youth at-risk of SMI across different clinical stages compared to healthy controls (HCs).

METHODS

Family functioning was evaluated with the Family Adaptability and Cohesion Evaluation Scales-IV (FACES-IV) for 41 non-help seeking youth with risk factors for SMI (Stage 0), 52 help-seeking youth with early mood and anxiety symptoms and distress (Stage 1a), 108 youth with an attenuated psychiatric syndrome (Stage 1b), and 42 HCs.

RESULTS

Results from multivariate linear regression analyses showed that participants in Stage 1a and Stage 1b significantly differ from participants in Stage 0 and HCs on most of the family functioning scales. However, these results were statistically but not clinically significant as the percentile values for each group fell within the same clinical ranges. The only clinical difference was that participants in stages 1a and 1b were somewhat less satisfied with their family compared to healthy controls and stage 0 participants.

CONCLUSIONS

An examination of group mean values demonstrated no difference in family functioning between the different groups with all groups in the healthy functioning range. However, family satisfaction is lower in youth at-risk for SMI who present with early signs of mood, anxiety or subthreshold psychotic symptoms than other participants. Early family psychoeducational interventions could be beneficial to improve family functioning.

Prevalence of psychopathology in bipolar high-risk offspring and siblings: a meta-analysis

This meta-analysis aimed to update existing data on the comparison of prevalence rates of psychopathology primarily among offspring with at least one parent with bipolar disorder (BD) and offspring of parents without psychiatric illness. Seventeen studies were derived from a systematic search of PsychInfo, Medline, Scopus and Embase. Inclusion criteria were use of a control offspring group, standardized diagnostic procedures and reporting of clear frequency data. Risk of psychopathology was estimated by aggregating frequency data from selected studies. Compared to control offspring, high-risk BD offspring are nine times more likely to have a bipolar-type disorder, almost two and a half times more likely to develop a non-BD affective disorder and over two times more likely to develop at least one anxiety disorder. High-risk offspring also showed a significant increased risk of other non-mood psychopathology such as attention deficit hyperactivity disorder (ADHD), any type of behavioral disorder and substance use disorder (SUDs). Risk of developing a broad range of affective and non-affective psychopathology is significantly higher in high-risk BD offspring. Identifying clinical presentations of this genetically high-risk cohort is important in establishing appropriate preventative treatment.

The association between social skills deficits and family history of mood disorder in bipolar I disorder

Objective:

To compare social skills and related executive functions among bipolar disorder (BD) patients with a family history of mood disorders (FHMD), BD patients with no FHMD and healthy control (HCs).

Methods:

We evaluated 20 euthymic patients with FHMD, 17 euthymic patients without FHMD, and 31 HCs using the Social Skills Inventory (SSI) and a neuropsychological battery evaluating executive function, inhibitory control, verbal fluency and estimated intelligence.

Results:

Both BD groups had lower SSI scores than controls. Scores for one subfactor of the social skills questionnaire, conversational skills and social performance, were significantly lower among patients with FHMD than among patients without FHMD (p = 0.019). Both groups of BD patients exhibited significant deficits in initiation/inhibition, but only BD patients with FHMD had deficits in verbal fluency, both compared to HC. There were no associations between social skills questionnaire scores and measures of cognitive function.

Conclusion:

Euthymic BD patients have lower social skills and executive function performance than HC. The presence of FHMD among BD patients is specifically associated with deficits in conversational and social performance skills, in addition to deficits in verbal fluency. Both characteristics might be associated with a common genetically determined pathophysiological substrate.

Family environment and psychopathology in offspring of parents with bipolar disorder

BACKGROUND

The aim of this study was to examine the relationship between family environment (cohesion and parental bonding), high-risk status, and psychopathology (internalizing and externalizing problems) among offspring of parents with bipolar disorder (BD), from the perspective of both offspring and their parents. We further tested if family environment mediated the relationship between bipolar risk status and internalizing and externalizing problems.

METHOD

High-risk (n = 90) BD offspring and control (n = 56) offspring aged 12-21 years old, and their parents, completed questionnaires on family cohesion and offspring internalizing and externalizing problems. Offspring also completed a parental bonding questionnaire. Group differences were examined, followed by multi-level mediation analysis with maximum likelihood and robust standard errors.

RESULTS

Both offspring and parents in the high-risk group reported higher levels of internalizing and externalizing problems than controls. According to offspring reports, high-risk status, lower maternal and paternal care in parental bonding, was independently associated with internalizing problems. Lower maternal care alone predicted externalizing problems. Family environment did not mediate the relationship between bipolar risk status, and offspring problems.

LIMITATIONS

Due to rates of missing data from parent reports of offspring psychopathology, mediation analysis was completed using offspring reports.

CONCLUSIONS

The offspring-report data presented indicate that low parental warmth and connection were associated with internalizing and externalizing problems as an independent risk factor, in addition to bipolar risk status. The parent-child relationship therefore warrants attention as a potential target for prevention strategies with such families.

What can we learn from offspring studies in bipolar disorder?

We offer a contemporary review of studies of the offspring of parents with bipolar disorder and explore the clinical characteristics of these populations. We discuss how different methodological approaches may influence study findings and may explain some of the heterogeneity in the results reported. We also highlight some of the environmental risk factors that may increase the likelihood of transition from an ‘at-risk’ or high-risk state to bipolar disorder. Last, we briefly discuss the implications of study findings for early intervention strategies and comment on such issues as genetic counselling and primary and early secondary prevention programmes.

Parenting practices in middle childhood mediate the relation between growing up with a parent having bipolar disorder and offspring psychopathology from childhood into early adulthood

The offspring of parents with bipolar disorder (OBD) are at high risk for developing mental disorders. In addition to genetic factors, environmental risk is purported to be associated with these negative outcomes. However, few studies have examined this relation. Using concurrent and longitudinal data, we examined if support, structure, and control provided by parents in middle childhood mediated the relation between having a parent with or without bipolar disorder, and offspring mental health. The sample included 145 offspring (77 OBD, 68 controls) aged 4 to 14 years and their parents. Parent and teacher ratings of child behavior were collected, and diagnostic assessments were conducted in offspring 12 years later (n = 101). Bootstrapping analyses showed that low levels of structure mediated the relation between having a parent with bipolar disorder and elevated internalizing and externalizing difficulties during middle childhood. For the longitudinal outcomes, parental control emerged as the strongest mediator of the relation between parents’ bipolar disorder and offspring psychopathology. Suboptimal childrearing may have different immediate and enduring consequences on mental health outcomes in the OBD. Parental structure has robust effects on emotional and behavioral problems in middle childhood, while levels of control promote psychological adjustment in the OBD as they mature.

Integrated transcriptome and methylome analysis in youth at high risk for bipolar disorder: a preliminary analysis

First-degree relatives of patients with bipolar disorder (BD), particularly their offspring, have a higher risk of developing BD and other mental illnesses than the general population. However, the biological mechanisms underlying this increased risk are still unknown, particularly because most of the studies so far have been conducted in chronically ill adults and not in unaffected youth at high risk. In this preliminary study we analyzed genome-wide expression and methylation levels in peripheral blood mononuclear cells from children and adolescents from three matched groups: BD patients, unaffected offspring of bipolar parents (high risk) and controls (low risk). By integrating gene expression and DNA methylation and comparing the lists of differentially expressed genes and differentially methylated probes between groups, we were able to identify 43 risk genes that discriminate patients and high-risk youth from controls. Pathway analysis showed an enrichment of the glucocorticoid receptor (GR) pathway with the genes MED1, HSPA1L, GTF2A1 and TAF15, which might underlie the previously reported role of stress response in the risk for BD in vulnerable populations. Cell-based assays indicate a GR hyporesponsiveness in cells from adult BD patients compared to controls and suggest that these GR-related genes can be modulated by DNA methylation, which poses the theoretical possibility of manipulating their expression as a means to counteract the familial risk presented by those subjects. Although preliminary, our results suggest the utility of peripheral measures in the identification of biomarkers of risk in high-risk populations and further emphasize the potential role of stress and DNA methylation in the risk for BD in youth.

Incidence, characteristics and course of narrow phenotype paediatric bipolar I disorder in the British Isles

OBJECTIVE

To estimate the surveillance incidence of first-time diagnosis of narrow phenotype bipolar I disorder (NPBDI) in young people under 16 years by consultants in child and adolescent psychiatry (CCAP) in the British Isles and describe symptoms, comorbidity, associated factors, management strategies and clinical outcomes at 1-year follow-up.

METHOD

Active prospective surveillance epidemiology was utilised to ask 730 CCAP to report cases of NPBDI using the child and adolescent psychiatry surveillance system.

RESULTS

Of the 151 cases of NPBDI reported, 33 (age range 10-15.11 years) met the DSM-IV analytical case definition with 60% having had previously undiagnosed mood episodes. The minimum 12-month incidence of NPBDI in the British Isles was 0.59/100 000 (95% CI 0.41-0.84). Irritability was reported in 72% cases and comorbid conditions in 51.5% cases with 48.5% cases requiring admission to hospital. Relapses occurred in 56.67% cases during the 1-year follow-up.

CONCLUSIONS

These rates suggest that the first-time diagnosis of NPBDI in young people <16 years of age by CCAP in the British Isles is infrequent; however, the rates of relapse and admission to hospital warrant close monitoring.

Family functioning in bipolar disorder: Characteristics, congruity between patients and relatives, and clinical correlates

Functional improvement has become one of the aims of the treatment of bipolar disorder. However, scant attention has been given to family functioning, even though it has a role in the illness outcome and is affected by the disorder. The aims of this study were to compare family functioning reported by euthymic patients with bipolar disorder and healthy controls; explore the level of congruence in the perception of family environment between patients with bipolar disorder and their relatives; and analyse the relationship between clinical variables and family functioning. The sample comprised 82 adult euthymic subjects with bipolar disorder, 82 family caregivers of these patients and 47 healthy controls. Participants completed the Family Environment Scale. Results showed moderate correlations and a mean pattern almost identical between relatives' and patients' reported scores in family functioning subscales. There were significant differences between patients and controls, favourable for the latter, in the subscales cohesion (p<0.005), expressiveness (p=0.002), conflict (p=0.038), intellectual-cultural orientation (p=0.001), active-recreational orientation (p<0.005), and a non-significant trend in organization (p=0.064). Significant associations were found between family environment and clinical variables of severity. These findings contribute to increasing the understanding of family functioning in bipolar disorder and highlight the importance of family work.

Early parent-child relationships and risk of mood disorder in a Canadian sample of offspring of a parent with bipolar disorder: findings from a 16-year prospective cohort study

AIM

Exposure to parental bipolar disorder (BD) early in life may increase the risk of developing a mood disorder. However, the impact of early parent-child relationships when a parent is affected and how this impacts an offspring's risk remains unclear. The primary objective of this study was to determine the association between parent-child relationships and risk of mood disorder in offspring of parents with BD and, secondly, to determine the interaction of temperament and life stress on this association.

METHODS

Two hundred and thirty-three offspring completed annual clinical assessments following Kiddie Schedule for Affective Disorders (KSADS) format interviews as part of an ongoing Canadian prospective cohort study conducted from 1996 to 2013. Offspring completed measures of early adversity, life stress and temperament. Clinical data from the affected parents were prospectively collected over the first decade of their offspring's life using SADS format interviews.

RESULTS

Higher perceived neglect from mother and offspring emotionality were significantly associated with the hazard of mood disorder (hazard ratio (HR): 1.1, 95% confidence interval (CI): 1.0-1.2 and HR: 1.7, 95% CI: 1.0-3.1, respectively). Duration of exposure to parental BD significantly interacted with offspring emotionality to predict mood disorder (P = 0.01). Further, perceived neglect from mother was associated with offspring high emotionality (P = 0.02).

CONCLUSIONS

Neglect from mother is a significant early predictor of mood disorder in offspring at familial risk for BD and may increase emotional sensitivity. Psychosocial support and interventions for high-risk families could be beneficial in reducing early adversity, maternal neglect and the risk of subsequent mood disorders in offspring.

Linking family cohesion and flexibility with expressed emotion, family burden and psychological distress in caregivers of patients with psychosis: A path analytic model

The present study aimed to evaluate a path analytic model accounting for caregivers' psychological distress that takes into account perceived family cohesion and flexibility, expressed emotion and caregiver's burden associated with the presence of mental illness in the family. 50 first-episode and 50 chronic patients diagnosed with schizophrenia or bipolar disorder (most recent episode manic severe with psychotic features) recruited from the Inpatient Psychiatric Unit of the University Hospital of Heraklion, Crete, Greece, and their family caregivers participated in the study. Family functioning was assessed in terms of cohesion and flexibility (FACES-IV), expressed emotion (FQ), family burden (FBS) and caregivers' psychological distress (GHQ-28). Structural equation modelling was used to evaluate the direct and indirect effects of family dynamics on caregivers' psychological distress. The results showed that neither family cohesion nor family flexibility exerted significant direct effects on caregivers' psychological distress. Instead, the effect of flexibility was mediated by caregivers' criticism and family burden indicating an indirect effect on caregivers' psychological distress. These results apply equally to caregivers of first episode and chronic patients. Family interventions aiming to improve dysfunctional family interactions by promoting awareness of family dynamics could reduce the burden and improve the emotional well-being of family caregivers.

Stress and cortisol in disaster evacuees: an exploratory study on associations with social protective factors

Though cumulative emotional and physical effects of disasters may diminish evacuees' short and long-term mental and physical health, social factors may buffer such consequences. We approached survivors of the October 2007 San Diego, California firestorms. We gathered data during the evacuation and 3 months afterward. Questionnaires measured social support as well as PTSD, depression, and anxiety symptoms. Saliva samples were used to assess the stress hormone, cortisol. Analyses, adjusting for age, gender, and socioeconomic status, showed PTSD symptoms were associated with flattening of the diurnal cortisol rhythm during evacuation. Secondary analyses showed those reporting a family emphasis on moral and religious values had lower psychological distress. Though anxiety symptoms had significantly decreased in the overall sample at follow-up, blunted cortisol rhythms persisted among those individuals with continued high anxiety. Results highlight a possible psychological, and perhaps a physiological, benefit of social and existential factors in disaster situations. Future work should explore the role of psychosocial factors and stress physiology in the development of long-term health concerns among individuals exposed to disaster.

Correlates of Adolescent-reported and Parent-reported Family Conflict Among Canadian Adolescents With Bipolar Disorder

BACKGROUND

Family conflict exacerbates the course of bipolar disorder (BP) among adults. However, few studies have examined family conflict among adolescents with BP, and fewer have looked at adolescent-reported and parent-reported family conflict separately.

METHODS

Subjects were 89 adolescents, aged 13 to 19 years, with a diagnosis of BP on the basis of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (KSADS-PL). Subjects were divided into high-conflict and low-conflict groups using a median split on the Conflict Behavior Questionnaire (child report and parent report). The χ(2) analyses and independent samples t tests were performed for univariate analyses. Multivariable logistic regression analyses were performed on variables with P<0.2.

RESULTS

Parent-reported and adolescent-reported Conflict Behavior Questionnaire scores were significantly correlated (r=0.50, P<0.001). High parent-reported family conflict was positively associated with recent manic symptoms, externalizing comorbidities, and dimensional scores reflecting emotional dysregulation. High adolescent-reported family conflict was positively associated with recent manic symptoms and emotional dysregulation, and negatively associated with socioeconomic status and lifetime psychiatric hospitalization. Bipolar subtype was significantly associated with high versus low family conflict.

LIMITATIONS

The limitations of this study included being a cross-sectional study, use of a medium-sized sample, and lack of a control group.

CONCLUSIONS

Despite substantial agreement between adolescents and parents regarding the amount of family conflict, there were meaningful differences in the factors associated with adolescent-reported and parent-reported conflict. These findings demonstrate the importance of ascertaining family conflict from adolescents as well as from parents. Moreover, these findings can potentially inform family therapy, which is known to be effective for adolescents with BP.

Interaction between BDNF rs6265 Met allele and low family cohesion is associated with smaller left hippocampal volume in pediatric bipolar disorder

BACKGROUND

Genetic and environmental factors are implicated in the onset and evolution of pediatric bipolar disorder, and may be associated to structural brain abnormalities. The aim of our study was to assess the impact of the interaction between the Brain-Derived Neurotrophic Factor (BDNF) rs6265 polymorphism and family functioning on hippocampal volumes of children and adolescents with bipolar disorder, and typically-developing controls.

METHODS

We evaluated the family functioning cohesion subscale using the Family Environment Scale-Revised, genotyped the BDNF rs6265 polymorphism, and performed structural brain imaging in 29 children and adolescents with bipolar disorder, and 22 healthy controls.

RESULTS

We did not find significant differences between patients with BD or controls in left or right hippocampus volume (p=0.44, and p=0.71, respectively). However, we detected a significant interaction between low scores on the cohesion subscale and the presence of the Met allele at BNDF on left hippocampal volume of patients with bipolar disorder (F=3.4, p=0.043). None of the factors independently (BDNF Val66Met, cohesion scores) was significantly associated with hippocampal volume differences.

LIMITATIONS

small sample size, cross-sectional study.

CONCLUSIONS

These results may lead to a better understanding of the impact of the interaction between genes and environment factors on brain structures associated to bipolar disorder and its manifestations.

Candidate Risks Indicators for Bipolar Disorder: Early Intervention Opportunities in High-Risk Youth

BACKGROUND

Psychiatric illnesses like bipolar disorder are increasingly understood to be neurodevelopmental disorders with clinical, psychological, and biological indicators recognizable long before the emergence of the full-blown syndromes.

METHODS

This paper is a selective review of findings from studies of high-risk children of affected parents that inform the knowledge of illness risk and development markers of bipolar disorder. We specifically focus on candidate clinical, biological, and psychological risk indicators that could serve as targets for future early intervention and prevention studies.

RESULTS

There is convergent evidence from prospective studies that bipolar disorder typically debuts as depressive episodes after puberty. In some high-risk children, sleep and anxiety disorders precede mood disorders by several years and reflect an increased vulnerability. An association between early exposure to adversity (eg, exposure to parental illness, neglect from mother) and increased risk of psychopathology may be mediated through increased stress reactivity evident at both behavioral and biological levels. Inter-related psychological processes including reward sensitivity, unstable self-esteem, rumination, and positive self-appraisal are risk factors for mood disorders. Disturbances in circadian rhythm and immune dysfunction are associated with mood disorders and may be vulnerability markers influenced by these other risk factors.

CONCLUSIONS

There is accruing evidence of a number of measurable and potentially modifiable markers of vulnerability and developing illness in youth at familial risk for bipolar disorder. Longitudinal studies of multiple biological and psychological risk processes in high-risk offspring, both individually and together, will improve our understanding of illness onset and lead to the development of specific early interventions.

Interparental violence and maternal mood disorders as predictors of adolescent physical aggression within the family

Although a wealth of research has examined the effects of parental mood disorders on offspring maladjustment, studies have not identified whether elevated interparental violence (IPV) may be an exacerbating influence in this pathway. This study examined levels of physical IPV perpetration and victimization in mothers with unipolar depression or Bipolar Disorder (BD) and the processes by which maternal physical IPV moderated adolescents' physical aggression in families with maternal mood disorders. Mothers with lifetime mood disorders were predicted to have elevated IPV compared to well mothers, and maternal IPV was expected to moderate the association between lifetime mood disorders and adolescent aggression. Participants included 61 intact families with maternal depression (n = 24), BD (n = 13), or well mothers (n = 24) and two siblings (ages 10 to 18 years). Using the Conflict Tactics Scale, mothers reported on IPV perpetration and victimization, and adolescents reported on physical aggression. Mothers with BD reported significantly higher IPV perpetration, but not victimization, than depressed or well mothers. An interaction between maternal BD and IPV perpetration was a significant predictor of adolescent aggression. Main effects of maternal IPV victimization and interaction effects of maternal depression and either type of IPV on adolescent aggression were not significant. Adolescents of mothers who have BD and perpetrate IPV may be particularly vulnerable to being aggressive. Prevention and policy efforts to deter transmission of aggression in high-risk families should target families with maternal BD and intervene at the level of conflict resolution within the family. Aggr. Behav. 41:253-266, 2015. © 2014 Wiley Periodicals, Inc.

Preliminary study of anxiety symptoms, family dysfunction, and the brain-derived neurotrophic factor (BDNF) Val66Met genotype in offspring of parents with bipolar disorder

Several genetic and environmental factors place youth offspring of parents with bipolar disorder (BD) at high risk for developing mood and anxiety disorders. Recent studies suggest that anxiety symptoms, even at subclinical levels, have been associated with an increased risk for developing BD. The brain-derived neurotrophic factor (BDNF) gene has been implicated in the pathophysiology of both BD and anxiety disorders. We aimed to explore whether anxiety in BD offspring was associated with the BDNF Val66Met polymorphism. 64 BD offspring (mean age: 13.73 (S.D. 3.45) M = 30, F = 34) and 51 HC (mean age: 13.68 (S.D. 2.68) M = 23, F = 28) were compared on presence of the met allele and on scores from the Multidimensional Anxiety Scale for Children (MASC). To assess family function, we used the Family Adaptability and Cohesion Evaluation Scales (FACES-IV). The Baron & Kenny method was the statistical approach used to examine the moderating effects between variables. BD offspring showed higher levels of overall anxiety than did the HC group. BD offspring with the val/val genotype showed higher levels of anxiety than BD offspring with other genotypes. No significant levels of anxiety or its association with BDNF genotype were found in the HC group. BD offspring group showed significantly more family dysfunction when compared with the HC group and the family dysfunction moderated the association between the BDNF genotype and anxiety symptoms. This study demonstrated the potential interplay of three factors: BD offspring, anxiety symptoms and family dysfunction.

Bipolar disorder and parental psychopathology

PURPOSE

Few population-based studies have examined the association between parental psychopathology and bipolar disorder (BPD) in offspring. One limitation is lack of control for potential confounding by indicators of parental socio-economic status or maternal smoking during pregnancy. Furthermore, none of them included analyses restricted to parental diagnoses received prior to the birth of the offspring. Associations could not be affected by child-related factors affecting the parent in such analyses. This study explores associations between those parental psychiatric disorders diagnosed at any point of time as well as those diagnosed before offspring birth, and BPD in offspring.

METHODS

In this nested case-control study, we identified 1,861 cases, age up to 25 years, 3,643 matched controls, and their parents from Finnish national registers. The associations were examined using conditional logistic regression, calculating odds ratios (OR) and adjusting for region of birth, parental age and education and mother's smoking during pregnancy.

RESULTS

Anytime diagnosed parental disorders associating with BPD in offspring (95% confidence interval) were BPD [OR (maternal) 5.2 (2.52-10.62); OR (paternal) 8.1 (3.77-17.26)], schizophrenia and related psychoses [OR (maternal) 3.1 (1.69-5.84); OR (paternal) 4.5 (1.97-10.27)], other affective disorders [OR (maternal) 3.0 (2.08-4.21); OR (paternal) 3.0 (1.97-4.47)] and maternal anxiety disorders OR 2.6 (1.08-6.42). Statistically significant associations were also found for parental schizophrenia and related psychoses, and other affective disorders, diagnosed before offspring birth.

CONCLUSIONS

BPD is associated with many parental psychiatric disorders, particularly BPD and schizophrenia and related psychoses. The associations must be partially due to child-independent factors. Covariate adjustments had only a minor impact on the associations.

Family functioning in families of first-episode psychosis patients as compared to chronic mentally ill patients and healthy controls

The present study aimed to investigate possible differences in family environment among patients experiencing their First Episode of Psychosis (FEP), chronic patients and controls. Family cohesion and flexibility (FACES-IV) and psychological distress (GHQ-28) were evaluated in families of 50 FEP and 50 chronic patients, as well as 50 controls, whereas expressed emotion (FQ) and family burden (FBS) were assessed in families of FEP and chronic patients. Multivariable linear regression analysis, adjusted for confounders, indicated impaired cohesion and flexibility for families of FEP patients compared to controls, and lower scores for families of chronic patients compared to those of FEP patients. Caregivers of chronic patients scored significantly higher in criticism, and reported higher burden and psychological distress than those of FEP patients. Our findings suggest that unbalanced levels of cohesion and flexibility, high criticism and burden appeared to be the outcome of psychosis and not risk factors triggering the onset of the illness. Furthermore, emotional over-involvement both in terms of positive (i.e. concern) and negative behaviors (i.e. overprotection) is prevalent in Greek families. Psychoeducational interventions from the early stages of the illness should be considered to promote caregivers' awareness regarding the patients' illness, which in turn, may ameliorate dysfunctional family interactions.

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.

Parenting with bipolar disorder: coping with risk of mood disorders to children

Children of individuals with bipolar disorder (BPD) have increased risk for mood disorders and other adverse psychosocial outcomes due to genetic and environmental risk. Though parents with BPD are aware of increased risk to children, little is known about efforts undertaken in response or their perceived utility. Among parents who self-report with BPD, this study identifies key variables associated with parental coping with children's risk of mood disorders; and explores the relationship between monitoring children's moods and perceived coping efficacy. In this U.S. study, active parental coping with, and cognitive distancing from, child's risk were measured using novel scales. Parents (n = 266) who self-identified as having BPD completed a web-based survey. They had at least one unaffected child. Most participants endorsed monitoring their children's moods. Monitoring was associated with increased perceived control over the child's well-being (p < 0.005), but not feeling less worried. Active parental coping with risk to children was positively associated with active coping with own illness (β = 0.25, p = 0.001), family history (β = 0.24, p = 0.001), and self-report of current depression (β = 0.16, p = 0.037), explaining 13.8% of the variance (F = 8.81, p < 0.001). Cognitive distancing from the child's risk was positively associated with confidence in diagnosis (β = 0.25, p = 0.001), and negatively associated with self-report of current mania (β = -0.19, p = 0.007), perceiving BPD as genetic (β = -0.26, p < 0.001) and having more children (β = -0.20, p = 0.004); explaining 16.2% of the variance (F = 8.63, p < 0.001). Parents' adaptation to their own BPD was modestly correlated with active coping with child's risk (r = 0.15, p < 0.05) but not with cognitive distancing. The findings support the importance of understanding causal attributions and the value of genetic education and counseling for parents with BPD. Further research is necessary to elucidate the psychological benefits of active coping versus cognitive distancing from child's risk, and explore additional variables that predict parental coping with children's risk of mood disorders.

Negative expressed emotion best discriminates families with bipolar disorder children

BACKGROUND

Children and adolescents with bipolar disorder (BD) live in family environments with high levels of expressed emotion (EE), conflict, and tension; as well as low maternal warmth and cohesion. These family characteristics have been evaluated in research settings using different scales. Nonetheless, empirically supported assessment instruments are not always feasible to be used in clinical settings. Our aim was to identify the best characteristics that discriminate BD families from control by building a classifier with the main characteristics found from different scales. We also built a classifier based on the adjective check-list scale (ACL) because this scale would be the most feasible one to be used in clinical setting.

METHODS

We evaluated 33 families of pediatric BD patients and 29 control families. Two self-report scales, ACL and the Family Environment Scale (FES), and a direct interview scale, the Psychosocial Schedule for School Age Children-Revised (PSS-R), were administered.

RESULTS

BD families presented lower positive EE and higher negative EE, less cohesion, organization, greater conflict and control; lower rate of intact family, higher maternal and paternal tension compared to control families. Both classifiers demonstrated high accuracy. The offspring's EE toward the mother was the family characteristic that best discriminated BD from control families.

LIMITATIONS

Small sample size and cross-sectional design.

CONCLUSIONS

Families of BD children presented altered communication and functioning. The high accuracy of the ACL-based classifier highlights a feasible scale to be used in clinical settings. Further studies assessing prognosis associated with the patterns of communication in such families are needed.

Family functioning and the course of adolescent bipolar disorder

The symptoms of bipolar disorder affect and are affected by the functioning of family environments. Little is known, however, about the stability of family functioning among youth with bipolar disorder as they cycle in and out of mood episodes. This study examined family functioning and its relationship to symptoms of adolescent bipolar disorder, using longitudinal measures of family cohesion, adaptability, and conflict. Parent- and adolescent-reported symptom and family functioning data were collected from 58 families of adolescents with bipolar disorder (mean age =14.48±1.60; 33 female, 25 male) who participated in a 2-year randomized trial of family-focused treatment for adolescents (FFT-A). Cohesion and adaptability scores did not significantly change over the course of the study. Parent-reported conflict prior to psychosocial treatment moderated the treatment responses of families, such that high-conflict families participating in FFT-A demonstrated greater reductions in conflict over time than low-conflict families. Moreover, adolescent mania symptoms improved more rapidly in low-conflict than in high-conflict families. For all respondents, cohesion, adaptability, and conflict were longitudinally correlated with adolescents' depression scores. Finally, decreases in parent-reported conflict also predicted decreases in adolescents' manic symptoms over the 2-year study. Findings suggest that family cohesion, adaptability, and conflict may be useful predictors of the course of adolescent mood symptoms. Family conflict may be an important target for family intervention in early onset bipolar disorder.

What differentiates children visiting outpatient mental health services with bipolar spectrum disorder from children with other psychiatric diagnoses?

OBJECTIVES

To determine the contribution of parent-reported manic symptoms, family history, stressful life events, and family environment in predicting diagnosis of bipolar spectrum disorders (BPSD) in youth presenting to an outpatient psychiatric clinic.

METHODS

A total of 707 6- to 12-year-old children [621 with elevated symptoms of mania (ESM+) based on screening via the Parent General Behavior Inventory 10-item Mania Scale (PGBI-10M) and 86 without ESM (ESM-)] received a comprehensive assessment.

RESULTS

Of the 629 with complete data, 24% (n = 148) had BPSD. Compared to those without BPSD (n = 481), children with BPSD: were older (Cohen's d = 0.44) and more likely to be female (Cohen's d = 0.26); had higher parent-endorsed manic symptom scores at screening (Cohen's d = 0.36) and baseline (Cohen's d = 0.76), more biological parents with a history of manic symptoms (Cohen's d = 0.48), and greater parenting stress (Cohen's d = 0.19). Discriminating variables, in order, were: baseline PGBI-10M scores, biological parent history of mania, parenting stress, and screening PGBI-10M scores. Absence of all these factors reduced risk of BPSD from 24% to 2%.

CONCLUSIONS

  History of parental manic symptoms remains a robust predictor of BPSD in youth seeking outpatient care, even after accounting for parent report of manic symptoms in the child at screening. However, the risk factors identified as associated with BPSD, together had limited value in accurately identifying individual participants with BPSD, highlighting the need for careful clinical assessment.

Personality of parents with bipolar disorder and interpersonal functioning among their offspring: a prospective 10-year study

A comparison of offspring of parents with bipolar disorder (OBD) and offspring of parents with no mental disorder (ONMD) showed that parents' neuroticism was associated with internalizing and externalizing problems among their children. The present study examined whether parents' neuroticism predicted poor interpersonal functioning among offspring 10 years later and whether the problems observed in middle childhood mediated the association between parents' neuroticism and offspring functioning. When offspring were in middle childhood, parents completed the revised NEO Personality Inventory and rated the child's behavior on the Child Behavior Checklist. Ten years later, 65 OBD and 59 ONMD completed interviews assessing mental disorders and interpersonal and noninterpersonal functioning. High neuroticism and low agreeableness in parents predicted poor interpersonal functioning in their offspring in late adolescence-early adulthood. The offspring's externalizing and internalizing problems in middle childhood partially mediated the association between parents' personality and offspring interpersonal functioning. Moreover, the association between parents' neuroticism and offspring internalizing problems was stronger among the OBD than the ONMD. Overall, the results suggested an intergenerational transmission of risk whereby high neuroticism and low agreeableness in parents were associated with behavioral problems among offspring in middle childhood that, in turn, predicted poor interpersonal functioning 10 years later.

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.

Psychosocial functioning in offspring of parents with bipolar disorder

BACKGROUND

Offspring of parents with bipolar disorder are at increased risk for a range of psychopathology, including bipolar disorder. It is not clear if they also have impairments in their psychosocial functioning.

METHODS

We compared the psychosocial functioning of three groups of children enrolled in the Pittsburgh Bipolar Offspring Study (BIOS): offspring of probands with bipolar disorder (n=388), offspring of probands with other types of psychopathology (n=132), and offspring of healthy probands (n=118). Psychosocial functioning was assessed at study intake using the schedule of the Adolescent Longitudinal Interval Follow-Up Evaluation (A-LIFE), the Child Behavior Check List (CBCL) and the Children's Global Assessment Scale (CGAS).

RESULTS

Offspring of probands with bipolar disorder exhibited impairments in various aspects of psychosocial functioning. On all measures, they had worse functioning in comparison with offspring of healthy probands. Offspring of probands with bipolar disorder generally exhibited more impairment than offspring of probands with nonbipolar psychopathology. After adjusting for proband parent functioning and the child's Axis I psychopathology, functioning of offspring of probands with bipolar disorder was similar to that of offspring of healthy probands.

LIMITATIONS

Data are cross-sectional and therefore do not allow for causal conclusions about the association between parental psychopathology, child psychopathology and offspring psychosocial functioning.

CONCLUSIONS

Offspring of parents with bipolar disorder exhibit impairments in psychosocial functioning which appear largely attributable to proband parent functional impairment and the child's own psychopathology. As such, interventions to improve parental functioning, as well as early interventions to treat the child's psychopathology may help reduce the risk for long-term functional impairment in offspring.

Can positive family factors be protective against the development of psychosis?

Genetic and environmental factors are both involved in the aetiology of psychotic disorders. The aim of this study was to assess if positive and negative environmental factors, together with psychotic family antecedents, are associated with the recent development of psychosis. We also investigated the interactions between family history of psychosis and positive and negative family environment. The sample comprised 110 children and adolescents, who had suffered a first psychotic episode and 98 healthy controls. All subjects were interviewed about their socioeconomic status, family history of psychosis and family environment (Family Environment Scale, FES). Early onset psychosis was significantly associated with a family history of psychosis. Family environment was perceived as more negative and less positive among patients than among controls. A negative family environment increased the risk of psychosis independently of the family history of psychosis. However, there was a significant protective effect of a positive family environment for persons with a family history of psychosis. This effect was not seen in subjects without a family history of psychosis. Therefore, our results support the importance of considering both family history of psychosis and family environment in the early stages of psychosis.

Twelve-month follow-up of family communication and psychopathology in children and adolescents with a first psychotic episode (CAFEPS study)

We analyzed the potential influence of family relationships and history of psychiatric disorders on the presentation and course of early psychotic disorders. We recruited 110 subjects aged 9-17 years with a first psychotic episode and 98 matched healthy controls, and followed them for 1 year. Data were collected through clinical interviews and the Parent-Adolescent Communication Inventory. A family history of psychosis-related disorders was more common in patients' families, with a five-fold higher risk for psychoses related disorders than families of healthy controls. If we consider psychoses related disorder in first-degree relatives, the risk is even higher, rising to 15-fold. The families of patients with a first psychotic episode score themselves worse in communication than the families of healthy controls. More problems in communication at baseline correlated with a higher degree of psychopathology and a lower clinical improvement after 12 months of follow-up.

Risk for suicidal ideation among the offspring of bipolar parents: results from the Bipolar Offspring Study (BIOS)

The objective of the study was to examine rates and identify risk factors for suicidal ideation among offspring of parents with bipolar disorder. Subjects included 388 offspring of parents with bipolar disorder and 250 offspring of matched community controls enrolled in the Pittsburgh Bipolar Offspring Study (BIOS). Offspring of bipolar probands displayed greater rates of lifetime suicidal ideation than offspring of controls (33% versus 20%). Factors most strongly associated with lifetime suicidal ideation in offspring of bipolar parents included offspring mood disorder, hostility, recent sexual abuse, and family conflict. Offspring of parents with bipolar disorder are at elevated risk for suicidal ideation as compared with offspring of controls. Suicide risk assessment in this population should attend to specific risk factors identified.

Preferential association between childhood emotional abuse and bipolar disorder

Childhood trauma has been suggested to be involved in the susceptibility to bipolar disorder. However, case-control studies are lacking, and the preferential implication and the dose-effect of different trauma subtypes remain poorly investigated. Two hundred six bipolar patients and 94 controls completed the Childhood Trauma Questionnaire (CTQ; Bernstein et al., 1994). The CTQ total score was higher for bipolar patients than for controls. The presence of multiple trauma was significantly more frequent in bipolar patients than in controls (63% vs. 33%). Multiple logistic regression suggested that only emotional abuse was associated with bipolar disorder with a suggestive dose-effect. Clinical practice should include systematic assessment of childhood trauma among bipolar patients with a particular focus on emotional abuse.