Elsevier

Journal of Affective Disorders

Volume 235, 1 August 2018, Pages 574-582
Journal of Affective Disorders

Research paper
Developmental evaluation of family functioning deficits in youths and young adults with childhood-onset bipolar disorder

https://doi.org/10.1016/j.jad.2018.04.078Get rights and content

Highlights

  • We examined family functioning in youths and adults with childhood-onset bipolar disorder (BD).

  • Family functioning was worse in participants with BD vs. healthy controls, regardless of demographics.

  • There was no influence for mood, global functioning, comorbidity, and most medications.

  • Removing those taking lithium showed a significant diagnosis-by-age interaction.

  • Youths with BD had worse family problem solving and communication relative to healthy controls.

Abstract

Background

Childhood-onset bipolar disorder (BD) is a serious condition that affects the patient and family. While research has documented familial dysfunction in individuals with BD, no studies have compared developmental differences in family functioning in youths with BD vs. adults with prospectively verified childhood-onset BD.

Methods

The Family Assessment Device (FAD) was used to examine family functioning in participants with childhood-onset BD (n = 116) vs. healthy controls (HCs) (n = 108), ages 7–30 years, using multivariate analysis of covariance and multiple linear regression.

Results

Participants with BD had significantly worse family functioning in all domains (problem solving, communication, roles, affective responsiveness, affective involvement, behavior control, general functioning) compared to HCs, regardless of age, IQ, and socioeconomic status. Post-hoc analyses suggested no influence for mood state, global functioning, comorbidity, and most medications, despite youths with BD presenting with greater severity in these areas than adults. Post-hoc tests eliminating participants taking lithium (n = 17) showed a significant diagnosis-by-age interaction: youths with BD had worse family problem solving and communication relative to HCs.

Limitations

Limitations include the cross-sectional design, clinical differences in youths vs. adults with BD, ambiguity in FAD instructions, participant-only report of family functioning, and lack of data on psychosocial treatments.

Conclusions

Familial dysfunction is common in childhood-onset BD and endures into adulthood. Early identification and treatment of both individual and family impairments is crucial. Further investigation into multi-level, family-based mechanisms underlying childhood-onset BD may clarify the role family factors play in the disorder, and offer avenues for the development of novel, family-focused therapeutic strategies.

Introduction

Childhood-onset bipolar disorder (BD) is a complex condition affecting 1–2% of youths (Van Meter et al., 2011). Compared to individuals with late adolescent- and adult-onset BD, youths with childhood-onset BD spend more time symptomatic with mixed depressive and manic presentations, rapid mood fluctuations, and subthreshold symptoms (Birmaher et al., 2009, Birmaher et al., 2014, Geller et al., 2008). These youths also have greater functional impairment (Perlis et al., 2009), poorer quality of life (Perlis et al., 2009), and higher risk for suicidality (Perlis et al., 2004). In addition, childhood-onset BD often persists into adulthood, leading to further impairment and negative outcomes (Axelson et al., 2011, Birmaher et al., 2009, Birmaher et al., 2014, Geller et al., 2008, Leverich et al., 2007). Given the enduring nature of this disorder, there is a critical need for studies to directly evaluate developmental effects by aggregating data from children, adolescents, and adults in order to examine the phenomenology and mechanisms of BD across the lifespan, and thereby enhance diagnosis and treatment efforts.

Family functioning is one such process relevant to BD and important to understand from a developmental perspective, as findings could indicate optimal family involvement in treatment and age-specific intervention targets. In addition to the patient, families of individuals with childhood-onset BD are quite impaired. Compared to healthy controls (HCs) and youths with other psychiatric conditions, families of youths with BD display high levels of conflict, control, aggression, quarreling, forceful punishment, tension, stress, and negative expressed emotion; and low levels of warmth, affection, intimacy, cohesion, expressiveness, organization, and positive expressed emotion (Belardinelli et al., 2008, Keenan-Miller et al., 2012, Nader et al., 2013, Perez Algorta et al., 2017, Schenkel et al., 2008). Family dysfunction also predicts worse course of BD in youths, including: 1) low maternal warmth (Geller et al., 2008); 2) chronic stress in family, romantic, and peer relationships (Kim et al., 2007, Siegel et al., 2015); 3) frequency and severity of stressful life events (Kim et al., 2007); 4) low levels of cohesion and adaptability (Sullivan et al., 2012); and 5) high levels of conflict (Sullivan et al., 2012). This relationship is also bidirectional, with patients’ symptoms/behaviors reciprocally influencing caregivers’ burden/distress (Reinares et al., 2016b). Thus, psychosocial evidence-based treatments (EBTs) for childhood-onset BD incorporate family-based strategies including psychoeducation, communication, problem solving, and affect regulation to address these impairments (Fristad and MacPherson, 2014).

Familial caregivers (e.g., parents, spouses, close relatives) of adults with BD display comparable dysfunction, including low levels of cohesion, expressiveness, and organization; and high levels of conflict (Miklowitz, 2011, Miklowitz and Johnson, 2009, Reinares et al., 2016a, Solomon et al., 2008, Weinstock et al., 2006). In addition, high expressed emotion (Kim and Miklowitz, 2004, Yan et al., 2004) and familial negative affective style (O'Connell et al., 1991) predict recurrence in adults with BD. However, no research has examined the persistence of family dysfunction into adulthood among individuals with childhood-onset BD. One study demonstrated that adults with retrospectively obtained childhood-onset BD experienced sustained psychosocial/functional impairment during prospective observation on a measure that assessed work, relationships (including family), recreation, and life satisfaction (Perlis et al., 2009). Though, family functioning in particular was not assessed in this study, and determination of childhood-onset BD diagnoses may have been influenced by retrospective recall bias (Leboyer et al., 2005). Importantly, no studies have directly compared family functioning in youths with BD vs. adults with prospectively verified childhood-onset BD (youth participants with BD followed into adulthood).

Unfortunately, research is often artificially bifurcated by regulatory requirements or investigator expertise/training in pediatrics or adults, and few datasets have prospectively established childhood-onset BD (Birmaher et al., 2009, Geller et al., 2008). These limitations make it challenging to evaluate developmental differences in mechanisms and processes implicated in childhood-onset BD. In addition, no studies have specifically examined the developmental progression of familial dysfunction in this condition, despite its relevance to onset and course of the disorder (Geller et al., 2008, Kim et al., 2007, Reinares et al., 2016b, Siegel et al., 2015). Importantly, parent and family variables also influence psychosocial treatment outcomes in childhood-onset BD, serving as both moderators (Miklowitz et al., 2009, Sullivan et al., 2012, Weinstein et al., 2015) and mediators (MacPherson et al., 2016, Mendenhall et al., 2009). Thus, enhanced understanding of family processes in childhood-onset BD is crucial from both a phenomenological and intervention perspective.

To address gaps in the literature and better conceptualize familial dysfunction across development, the current study examined family functioning in youths with BD, adults with prospectively verified childhood-onset BD, and youth and adult HCs. Adults with BD were followed since childhood via their participation in the Brown University site of the Course and Outcome of Bipolar Youth (COBY) study to ensure that retrospective recall bias did not impact BD diagnoses (Birmaher et al., 2009, Leboyer et al., 2005). Hypotheses were based on research documenting a more severe course of illness and functional impairment in youths vs. adults with BD (Birmaher et al., 2009, Geller et al., 2008, Perlis et al., 2009, Perlis et al., 2004). In addition, youths likely had less time to seek treatment and develop strategies for managing symptoms/stressors than adults with childhood-onset BD, given longer duration of illness in the latter, potentially contributing to exacerbated family dysfunction at younger ages. Thus, it was hypothesized that: 1) youths and young adults with childhood-onset BD would demonstrate impaired family functioning compared to HCs; and 2) youths with BD would display worse family functioning compared to adults with childhood-onset BD.

Section snippets

Participants and procedures

Participants were enrolled in one of two studies approved by the Institutional Review Boards of Bradley Hospital and Brown University. Written informed parental consent and child assent were obtained for youths; written informed consent was obtained for adults. Subsequently, parents, youths, and adults completed assessments and measures cross-sectionally. The sample included 116 individuals with childhood-onset BD (70 youths, 46 adults) and 108 HCs (46 youths, 62 adults).

Inclusion criteria for

Demographics

There were no differences between participants with BD vs. HCs for sex and race (Tables 1 and 2). Collapsing across ages, participants with BD were younger and had lower FSIQ than HCs; there was no difference in Hollingshead-categorized SES (Table 1). When examining demographics across diagnostic groups by age groups, youths with BD had significantly lower FSIQ and SES than youth HCs; there was no difference in age (Table 2). Adults with BD were significantly younger and had significantly lower

Discussion

To our knowledge, this is the first study to take a developmental approach to investigate family functioning in youths and young adults with prospectively verified childhood-onset BD. Results indicated that participants with BD had significantly worse family functioning in all domains (problem solving, communication, roles, affective responsiveness, affective involvement, behavior control, general functioning) compared to HCs, even when controlling for SES and FSIQ. The hypothesized

Author's contributions

Heather A. MacPherson and Daniel P. Dickstein conceptualized the current study. Heather A. MacPherson conducted all statistical analyses, led the literature search, and wrote the first draft of the manuscript, as well as reformulated each following draft.

Amanda L. Ruggieri and Rachel E. Christensen constructed and organized the database file for these analyses and assisted with data cleaning.

Amanda L. Ruggieri, Rachel E. Christensen, Elana Schettini, Kerri L. Kim, and Sarah A. Thomas assisted

Funding

This study was supported by Emma Pendleton Bradley Hospital and the National Institute of Mental Health grants K22MH074945 and R01MH087513 (Principal Investigator Daniel P. Dickstein).Young adult participants with bipolar disorder were recruited from Brown University’s site of the Course and Outcome in Bipolar Youth (COBY) study (R01MH059929). The funders had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to

Acknowledgments

We gratefully acknowledge and thank the youths, young adults, and their families for their time and effort participating in these studies, without which this research would not be possible.

Conflicts of Interest

None.

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      For example, families of adolescents with or at risk for depression present with high levels of conflict, anger, criticism, harsh parenting, and hostility; low levels of cohesion, support, and warmth; and problematic parenting styles, practices, and communication (Beardslee et al., 1998; Bodner et al., 2018; Garber, 2006; Milevsky et al., 2007; Sander and McCarty, 2005; Sheeber et al., 2007; Van Loon et al., 2014). Families of youth with bipolar disorders also display high levels of conflict, control, aggression, quarreling, forceful punishment, tension, stress, and negative expressed emotion; low levels of warmth, affection, intimacy, cohesion, adaptability, expressiveness, organization, and positive expressed emotion; and impaired functioning overall (Belardinelli et al., 2008; Keenan-Miller et al., 2012; MacPherson et al., 2018; Nader et al., 2013; Perez Algorta et al., 2018; Schenkel et al., 2008; Sullivan et al., 2012). Although no strong and consistent risk factors for long term prediction of suicidality have emerged (Franklin et al., 2017), some research suggests that poor family functioning (e.g., impaired family problem solving, family conflict, and low levels of parental support) confers exacerbated short term risk for suicidal ideation (SI) and behavior in adolescence (King and Merchant, 2008; Wagner et al., 2003).

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