Impact of early onset bipolar disorder on family functioning: Adolescents' perceptions of family dynamics, communication, and problems
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Journal of Affective Disorders 66 (2001) 25–37
www.elsevier.com / locate / jad
Research report
Impact of early onset bipolar disorder on family functioning:
Adolescents’ perceptions of family dynamics, communication, and
problems
a,b ,
Heather A. Robertson *, Stan P. Kutcher a , Diane Bird a,c , Linda Grasswick d
a
Department of Psychiatry, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Abbie Lane Building, Ste. 4083,
5909 Jubilee Road, Halifax, N.S., Canada
b
IWK-Grace Health Centre, Department of Psychiatry, Halifax, N.S., Canada
c
Dalhousie University, Department of Pharmacology, Halifax, N.S., Canada
d
Royal Ottawa Hospital, Forensic Unit, Ottawa, ON, Canada
Received 19 January 2000; accepted 25 July 2000
Abstract
Objective: This research investigated the impact of adolescent onset bipolar illness on perceived family functioning in
stabilized bipolar I (B) and unipolar (U) probands, and normal controls (C). Method: Sample N 5 119: 44 bipolar 1(17 M,
27 F), 30 unipolar (9 M, 21 F), and 45 controls (19 M, 26 F). Mean ages: 19.9, 18.5 and 18.2 years, respectively.
Instruments: Family Adaptability and Cohesion Scale (FACES II), Parent–Adolescent Communication Scales (PACS),
Social Adjustment Inventory for Children and Adolescents (SAICA). Results: There were no significant group or sex
differences between controls and mood disordered youth – assessed intermorbidly – in ratings of relationship with either
parent. Bipolars acknowledged significantly more minor conflicts with parents than either unipolars or controls. Ratings by
mood disordered subjects were significantly less positive in terms of shared activities and communication with siblings.
Mood disordered youth and controls were not differentiated on the basis of family adaptability, and all family cohesion
scores were within population norms. No significant group differences were observed in communication with parents.
Limitations: This self-report study was conducted intermorbidly, does not include objective measures of family functioning,
nor does it assess the effect of psychiatric illness in other family members on family functioning. Conclusions: Assessed
intermorbidly, bipolar adolescents’ perceptions of family dynamics do not seem to diverge significantly from controls.
Further research is needed to investigate the impact of adolescent bipolar illness on family life during acute phases of the
illness, as well as the effect on family functioning of psychiatric disorders in other family members. 2001 Elsevier
Science B.V. All rights reserved.
Keywords: Bipolar I; Unipolar; Youth; Perceived family functioning
*Corresponding author. Tel.: 1 1-902-473-1693; fax: 1 1-902-473-4596.
E-mail address: robertsh@is.dal.ca (H.A. Robertson).
0165-0327 / 01 / $ – see front matter 2001 Elsevier Science B.V. All rights reserved.
PII: S0165-0327( 00 )00281-026 H. A. Robertson et al. / Journal of Affective Disorders 66 (2001) 25 – 37
1. Background of empirical data supporting its efficacy, family
therapy is used extensively in the treatment of child
Bipolar illness is a chronic disorder characterized and adolescent psychiatric disorders, in part, because
by a relapsing and remitting course. It has been of the premise that behavior in youth is strongly
suggested that 30–40% of bipolar adults experience determined by family factors (Sargent, 1997). De-
the initial manic episode during adolescence spite lack of empirical evidence, family therapy has
(Loranger and Levine, 1978). However, that figure been recommended for use in mood disordered
may underestimate substantially the incidence of adolescents (Diamond and Siqueland, 1995; Sargent,
adolescent-onset bipolar illness if the initial major 1997) as well as those who are bipolar (Weber et al.,
depressive episode is used as the marker for illness 1988; Scott, 1995; Miklowitz, 1996).
onset (Kutcher et al., 1998; Robertson et al., 1998a, The relationship between family functioning and
submitted). Management of bipolar illness in adoles- mood disorders has been the focus of limited re-
cents may be more challenging than adults because search. Miller et al. (1986) assessed families of adult
of the complexity of developmental issues, which patients diagnosed with major depression, schizo-
involve an interplay of cognitive, personality, psy- phrenia, alcoholism, adjustment disorder, and bipolar
chosexual, social and biological factors. Research disorder, as well as a group of matched non-psychi-
evidence indicates that the onset of bipolar disorder atric controls, using the Family Assessment Device
in adolescence may be associated with disrupted (FAD). The families of depressed patients demon-
development across multiple spheres of function strated significantly more difficulties compared to the
(Strober and Carlson, 1982; Strober et al., 1989; control group on each of the FAD scales (problem
Fristad et al., 1992; Kutcher, 1993; Carlson et al., solving, communication, roles, affective responsive-
1994; Carlson, 1996; Papatheodorou and Kutcher, ness, affective involvement, behavior control, and
1996; Bird et al., 1998a,b; Robertson et al., 1998a– general functioning), while bipolar and schizophre-
c). nic families did not differ significantly from controls.
Compared to adult onset bipolar disorder, the Chang et al. (1999) demonstrated that families in
onset of bipolar illness in youth may be associated which one or both parents had bipolar disorder
with a more severe illness (Carlson et al., 1994; reported more conflict, less organization, and less
Kutcher, 1994), poorer recovery from both manic cohesion compared to controls, as measured by the
and depressive episodes (Strober, 1994), and high Family Environment Scale (FES) (Chang et al.,
rates of relapse despite optimized psychosocial and 1999). These features of family interaction were
psychopharmacologic interventions (Papatheodorou associated with the presence of psychopathology in
and Kutcher, 1996). Pharmacological treatment is a children although not bipolar illness specifically.
mainstay in the management of bipolar illness re- In studies of youth, Puig-Antich et al. (1993)
gardless of age (Kusumakar et al., 1997), and evaluated family relationships in a group of de-
psychosocial interventions, including psychoeduca- pressed adolescents using the Psychosocial Schedule
tion, have been proposed as an adjunct to medication for School-Aged Children (PSS), finding that adoles-
in the treatment of bipolar illness (Scott, 1995; cents had significant problems in their relationships
Quackenbush et al., 1996; Kusumakar et al., 1997; with parents and siblings, relative to controls.
Parikh et al., 1997; Kutcher et al., submitted). Kashani et al. (1995) reported that poor family
Involvement of the family in the management of a cohesion, not adaptability, distinguished depressed
patient’s psychiatric illness has been proposed to be from non-depressed children. Stierlin et al. (1986),
an important part of the treatment plan, for both using a study design confounded by interviewer bias,
adults and adolescents (Sargent, 1997; Miklowitz observed 22 families which contained a young adult
and Goldstein, 1990). However, there is little empiri- bipolar and 11 families with a young adult diagnosed
cal evidence to support the use of family therapy, with schizoaffective disorder. They concluded that
behavioral family management therapy, or group bipolar families displayed ‘restrictive complemen-
therapy in bipolar adults or adolescents (Parikh et al., tarity’ (a rigid attitudinal pattern in which the parents
1997; Robertson et al., 1997). Regardless of the lack hold extreme and opposite views towards the pa-H. A. Robertson et al. / Journal of Affective Disorders 66 (2001) 25 – 37 27
tient), ‘coalitions’ (in which family members were sion / exclusion criteria specified an entry Beck De-
pressured to take sides), and ‘rigidly held beliefs’ pression Inventory score of , 13, and no mood-
(for example that certain emotions can be ‘willed’). related hospitalizations in the 5 months preceding
To date, however, insufficient research evidence is evaluation. All probands were being followed as
available to characterize family functioning in bipo- outpatients. Mean length of illness, calculated from
lar youth, or to determine if there are specific the first reported mood episode to the time of
patterns of family difficulties which may differentiate participation in this study, was 4.3 years for bipolars
the families of bipolar teens from those of either and 3.6 years for unipolars. Normal controls were
normal controls or other adolescent onset mood similarly assessed and did not meet any current or
disorders. Specifically, how does bipolar illness past DSM IV psychiatric diagnosis. These were
affect teenagers’ relationships with parents and sib- recruited through study advertisements posted in
lings? What is the subjective impact of adolescent high schools, colleges, and community centres. In-
bipolar illness on family functioning, and under what formation on current living status / situation and
circumstances may family therapy be reasonably family history of mental illness was obtained through
recommended? This information is necessary for adolescents’ reports.
furthering our understanding of the onset and course
of this illness and for the design and delivery of 2.2. Instruments
therapeutic interventions designed to optimize out-
come. As part of a comprehensive assessment of func-
The present study was designed to investigate the tioning, all subjects completed a variety of self-
perceptions of mood-disordered youth, both unipolar report questionnaires pertaining to family life and
and bipolar, with respect to their relationships with symptom measurement and were interviewed using a
each parent and with their siblings. This is seen as a semistructured measure of adaptive social function-
first step in identifying specific areas of functional ing. A current symptom profile was obtained using
problems within the families of bipolar teenagers The Symptom Checklist-58 (Derogatis et al., 1974;
which can then inform the development of treatment Kutcher, 1997).
programs for this population. Family functioning was assessed using the Parent–
Adolescent Communication Scales (PACS; Barnes
and Olson, 1992) which are standardized 20-item
2. Method Likert format self-report scales, assessing openness,
selectivity, strengths, weaknesses, and problematic
2.1. Subjects issues in the adolescent–mother and adolescent–
father dyads, and the Family Adaptability and Cohe-
The sample was comprised of 44 youth with sion Evaluation Scale (FACES II; Olson and Tiesel,
bipolar I disorder (17M:27F, mean age 5 19.9 years, 1992) which is a 30-item Likert format self-report
S.D. 5 2.9 years), 30 unipolar youth (9M:21F, mean instrument measuring dimensions of adaptability
age 5 18.5 years, S.D. 5 2.8 years), and 45 normal (discipline, negotiation, roles, leadership) and cohe-
controls (19M:26F, mean age 5 18.2 years, S.D. 5 sion (family boundaries, emotional bonding, time
1.6 years). Clinical probands were recruited from spent together). Normative data for this instrument is
specialized mood disorders clinics in academic cen- based on a stratified random sample of families
tres. Bipolar and unipolar probands all met DSM IV across the USA from each stage of the family life
criteria (APA, 1994) for Bipolar I Disorder or cycle (from young childless couples at Stage 1
Unipolar Major Depressive Disorder, respectively, through to retirees at Stage 7). Additionally, the
determined by clinical interview and the Kiddie home life subsection of the Social Adjustment
Schedule for Affective Disorders and Schizophrenia Inventory for Children and Adolescents (SAICA;
(Chambers et al., 1985). All were judged medically Biederman et al., 1993; John et al., 1987) was used
and psychiatrically stable at time of assessment, as to evaluate themes of shared activities, responsibility,
established by their treating clinician. Study inclu- affection, and communication within families.28 H. A. Robertson et al. / Journal of Affective Disorders 66 (2001) 25 – 37
2.3. Analysis defined as any psychiatric problem in a first degree
relative, for which professional assistance was
Between-group mean scores were compared for sought, and / or for which a formal diagnosis was
the Symptom Checklist-58 (factor subscale scores), received. These reports reflect a variety of clinical –
the PACS (‘Problems’ and ‘Openness’ Subscales, and subclinical – range symptoms in first-degree
Total Scale Scores), SAICA (‘Home Life’ Subscale) relatives, across a variety of comorbid or non-over-
and FACES II (‘Adaptability’ and ‘Cohesion’ Sub- lapping conditions (including depression, anxiety,
scales). The effects of group and sex were assessed OCD, substance abuse, etc.) These data are summa-
using Analysis of Variance (ANOVA) and significant rized in Table 1.
omnibus F ratios were further assessed using joint Analysis of bipolar illness course revealed first
univariate 0.9500 Bonferroni confidence intervals onset to be depression in 74% of the sample.
(post-hoc mean comparisons). Two sided alpha Breakdown by sex showed this pattern for depression
levels of P , 0.05 were used to determine statistical preceding mania was more predominant in females
significance. Relationship between the two subscale than males (Pearson r 5 3.59, Chi square by Fisher
measures of the FACES II was further tested by Exact Test P 5 0.07; 84.6% depression at mean age
regression analysis and correlational measures. Pro- of 14.6 years vs. 15.4% mania at mean age of 15.0
portional rates of family history of (any) psychiatric years). For males the percentages were more evenly
illness were calculated for each study group. Family distributed (58.8% depression as first onset at mean
history was examined as a possible covariate in the age of 16 years vs. 41.2% mania at mean age of 16.8
determination of significant between-groups differ- years). Bipolar females reported earlier onset than
ences in family functioning, using regression tech- males for both types of episode (F 5 4.86, P 5
niques. 0.034* for mania onset; F 5 6.4, 5 0.01** for de-
pression onset). For unipolar youth, mean age of
onset was similar for both sexes (males at mean age
3. Results of 14.2 years and females at mean age of 14.5 years).
Age of depression onset was earlier for unipolar than
Among bipolar youths, 21 / 44 reported a first bipolar probands (F 5 4.1, P 5 0.048*).
degree relative with some form of mental illness, At assessment, none of the patients or controls met
compared to 20 / 30 unipolar youth reporting, and diagnostic criteria for a current episode of depres-
5 / 45 of the controls. Presence of family history was sion, mania or hypomania, both bipolar (B) and
Table 1
Adolescent report of psychiatric history in first degree relatives
Youth Family Depression Bipolar Anxiety / OCD Alcoholism Substance Other a . 1 Dx b
Member Panic abuse
Bipolar Mother 9 3 4 – – – 1 4
Father 6 3 2 1 1 – – 2
Sibling 1 – 2 – – – 2 1
Unipolar Mother 11 – 2 1 1 1 1 2
Father 8 – 1 – 4 2 – 3
Sibling 3 – 1 – – 1 2 1
Control Mother – – – – 1 – – –
Father – – – – 2 – – –
Sibling 3 – 1 – 1 1 1 1
a
Adolescents cannot specify the psychiatric condition for which professional help sought by relative.
b
Dx 5 Number in given row receiving (past / present) treatment of more than one psychiatric disorder (not necessarily overlapping /
comorbid).H. A. Robertson et al. / Journal of Affective Disorders 66 (2001) 25 – 37 29
unipolar (U) adolescents presented as symptomatic, quality of communication. The majority of 44 bipo-
as measured by the Symptom Checklist-58. Based on lar respondents were living at home with parents
a comparison of factor subscale scores, probands (80%) and a minority were in other arrangements
(B,U) were more likely than controls (C) to report (7% in group home, 9% living alone, and 4% with
being slightly bothered by symptoms relating to: friend / or partner). Eighty two percent of unipolar
depression (F 5 11.8, P , 0.001; B, U . C), inter- youth were living at home with parents, 10% with
personal sensitivity (F 5 6.67, P 5 0.002; B, U . C) friends, and the remaining either lived alone or other
and anxiety (F 5 10.38, P , 0.001; B . U . C). relatives (4% each, respectively). All study controls
Groups were not differentiated on the basis of were currently living in the nuclear family context.
somatic or obsessive–compulsive symptomatology Analysis revealed no statistically significant differ-
(Fig. 1). No significant main effects of sex or ences between mood-disordered youth and controls
group 3 sex interactions were observed on any SCL- with respect to global ratings of: relationship with
58 factor subscale (Fig. 1). Beck Depression Inven- Mother (P . 0.05) or relationship with Father (P 5
tory (BDI) scores obtained at time of assessment 0.05, ns Bonferroni), all groups reporting moderate
were consistent with the finding of ongoing subclini- to very active relationships with parents (Fig. 2). In
cal depressive symptomatology for clinical probands. terms of reported problems with parents (i.e., refusal
Bipolar and unipolar youth did not differ statistically to honor restrictions or do chores, irresponsibility
from each other on this index, but their mean scores around the house, damage to family property),
were significantly elevated relative to normal con- bipolar youth acknowledged more problems than
trols (F 5 8.78, P , 0.001; B,U . C). In addition, a either unipolars or controls (F 5 5.84, P 5 0.004,
significant main effect of sex was observed on the B . U . C), but for all groups these difficulties were
BDI (F 5 5.03, P 5 0.027, F . M), but the group 3 minor in nature and infrequent (Fig. 3). For global
sex interaction did not reach statistical significance. ratings of relationship with siblings, mood disor-
Assessment of current home behavior (SAICA) dered youth (B and U) were significantly less
required subjects to evaluate their relationships with positive than controls (F 5 5.22, P 5 0.007, B, U ,
each parent – and with siblings – in terms of shared C) in terms of shared activities, friendliness, and
activities, the amount of affection demonstrated, and overall communication (Fig. 2). Clinical groups were
Fig. 1. Current symptom profile.30 H. A. Robertson et al. / Journal of Affective Disorders 66 (2001) 25 – 37
Fig. 2. Current home behaviour.
Fig. 3. Current problems at home with parents and siblings.
more likely than controls to report difficulties with youth (bipolar and unipolar) were significantly more
their siblings (F 5 3.11, P 5 0.05, B, U . C), al- likely than controls to describe their families as less
though these were typically minor and involved cohesive / less connected as measured by the Cohe-
avoidance and detachment as opposed to directly sion Subscale (F 5 5.49, P 5 0.005, B, U , C). The
conflictual behaviors (Fig. 3). No significant effects three groups were not differentiated on the basis of
of sex or group 3 sex interactions were observed on their subjective reports of family adaptability (P .
any of the SAICA indices. 0.05). Importantly, all FACES II ratings (for both
Self-report ratings of family cohesion and adapt- cohesion and adaptability) approximated US national
ability (FACES II) identified that mood-disordered norms. No significant sex differences or sex byH. A. Robertson et al. / Journal of Affective Disorders 66 (2001) 25 – 37 31
Fig. 4. FACES II: Family adaptability and cohesion.
group interactions were found of any of the above analysis, observed differences between groups on the
indices of the FACES II (See Fig. 4). cohesion index did not covary significantly as a
A measure of ‘family health’ (the linear relation- function of reported family history of psychiatric
ship between cohesion and adaptability measures; illness. Clinical status was a significant predictor of
Olson et al., 1992) showed that for each group, mean mean cohesion score (F 5 4.13, P 5 0.02; C . B, U)
scores were in the normative range and these two but family history in and of itself did not emerge as a
dimensions of family functioning were significantly significant covariate (t 5 2 1.46, P 5 0.15) for this
correlated (for bipolars, Pearson correlation coeffi- study population.
cient r 5 0.8, F 5 74.2, P , 0.0001; for unipolars, Youth ratings of communication with mother and
Pearson r 5 0.79, F 5 46.6, P , 0.0001; for controls, communication with father (PACS), did not reveal
Pearson r 5 0.64, F 5 38.7, P , 0.0001; for full any significant group or sex differences, or sex 3
sample, Pearson r 5 0.77, F 5 169.7, P , 0.0001). group interactions (by ANOVA, all P . 0.10) All
As the FACES II cohesion subscale was the only scale scores were well within US population norms
index of family functioning on which our study for this instrument (Fig. 5).
groups significantly diverged, we examined whether
the presence of any family psychiatric history acted
as a significant covariate in the determination of 4. Discussion
between-groups differences in cohesion ratings.
Among the bipolar youths 48% reported a first The results of this study show that – intermorbidly
degree relative with some form of mental illness, – our cohort of stabilized youth with bipolar I
compared to 67% of unipolar youths and 11% of the disorder do not report significantly problematic
controls (Pearson Chi-square 5 25.8, P , 0.0001). family difficulties, relative to unipolar or normal
This points to an association between clinical status control comparators. Indeed, taken overall, the multi-
and reporting of family history of psychiatric illness, ple measures of family functioning assessed in this
with both patient groups reporting higher rates than study suggest that from the perspective of the
controls (See Table 1). However, in a regression adolescent, there are no substantial differences in32 H. A. Robertson et al. / Journal of Affective Disorders 66 (2001) 25 – 37
Fig. 5. Parent adolescent communication – relationship with mother / father.
intrafamily relationships amongst these groups. Our special school programs (39% of bipolars, 7% of
findings suggest that clinical lore about the family unipolars), guidance counselling (89% bipolars, 97%
impact of bipolar illness must be modified by unipolars), a variety of individual ‘supportive’ psy-
considerations relating to the phase of this disorder. chotherapies (77% bipolars, 87% unipolars), and
Family functioning assessed when youths are first group therapy (70% bipolars, 30% unipolars). How-
diagnosed and / or are in the acute state may be ever, neither clinical group reported having been
different than that found in a stabilized cohort (such involved in any systematic, structured, or dynamic
as ours) assessed interepisode, a number of years family therapies over the course of the illness or
post-illness onset. These results indicate that the currently (Robertson et al., 1998b; Kutcher et al.,
clinical lore may overestimate the degree of family submitted). Therefore it would seem unlikely that
dysfunction in stable bipolar teens and fails to these encouraging results vis-a-vis perceived family
adequately address aspects of illness course as this functioning could be attributed to beneficial effects
pertains to family functioning. of extensive family therapy.
One potential confound in these findings could be Other authors have highlighted the utility of
the result of family therapy conducted in the patient adjunctive psychoeducational approaches in this
cohort. It could be considered that if the bipolar population in order to promote more positive out-
probands had undergone family therapy, the results comes for mood disordered youth, particularly in
would be due to treatment effects. However, exami- terms of promoting resilience (coping skills) and
nation of treatment history for our probands revealed adherence to pharmacologic and psychosocial treat-
little or no evidence of family therapy. Indeed, ments, (Parikh et al., 1997). The specialized mood
probands reported only limited direct parental in- disorder clinics from which our sample was recruited
volvement in their treatment (for example their have a strong psychoeducational component avail-
occasional presence at their child’s clinic appoint- able to both young patients and family members, as
ments). As part of an overall treatment strategy, part of the illness management model. The majority
many study probands had also received various short of bipolar and unipolar youth in the current study
term psychosocial interventions to deal with specific described psychoeducation – about the illness, medi-
problems – often associated with academic function cations, and lifestyle management – as very helpful,
and planning or peer relationships. These included in terms of contributing positively to clinical out-H. A. Robertson et al. / Journal of Affective Disorders 66 (2001) 25 – 37 33 come and current well-being (95% of bipolars and picture, suggesting that for this sample, adolescent 85% of unipolars) (Robertson et al., 1998b; Kutcher mood disorder in and of itself does not seem to have et al., submitted). Psychoeducational strategies a consistently and significantly negative impact on would entail discussion and dissemination to patients sharing, affection, support, and communication in the and family of printed information relating to under- adolescent–parent dyad. There is evidence to suggest standing the illness, medications (dosage, mode of that relationships with siblings may be compromised action, possible side-effects, and interactions), for youngsters with bipolar or major depressive lifestyle modifications, daily rhythms, recognizing illness. These problems apparently persist despite prodromal symptoms, knowing when to seek help, effective management of the illness, and may be etc. To the extent that family systems may be altered complicated by subsyndromal symptomatology or in beneficial ways as a function of psychoeducation, other unknown factors not evaluated in the present (i.e., to promote adherence, reduce family stressors, study. and increase coping skills) then – as an active component of family interventions – these strategies should be encouraged over family therapies based on 5. Limitations of the current study purely theoretical foundations and or extrapolated from adult populations or other forms of psychiatric Studies utilizing self-report measures are open to disorder. bias. The youth may be under reporting or mini- Findings of this study have shown that mood- mizing difficulties they may have in communication disordered youth and their never psychiatrically ill with their siblings and parents. Miller et al. (1986) peers were not differentiated on (i) quality of noted that their manic subjects (an adult inpatient communication with parents (openness and problem population) tended to minimize family dysfunction resolution), (ii) perceptions of family adaptability on the FAD relative to reports by other family (responsiveness to situational and developmental members. Their findings are similar to ours, in that changes), and (iii) overall satisfaction with their dysfunctions in the families of bipolar patients were relationship to either parent (affection and shared not pervasive or severe enough to distinguish them activities). The tendency toward lower cohesion from controls. These authors also argue that ob- scores (measured as a global index) in clinical served impairments in family functioning may stem probands may be indicative of some minor difficul- from disruptions related to hospitalization of a family ties they experience which relate to connectedness or member and the stress of an acute episode and as closeness with other family members. Subscale items such should not be extrapolated to family functioning assess emotional bonding (i.e., ‘Family members feel after remission, when these illness-related stressors very close to each other’), coalitions (i.e., ‘Members would be expected to be less acute. It is possible that pair up rather that do things as a total family’), our assessments – based on a stabilized outpatient family boundaries (i.e., ‘It is easier to discuss population – might have been less encouraging if problems with people outside the family.’), time obtained during acute episodes. Yet it would remain (i.e., ‘Family members like to spend their free time to be established if this was a reflection of over- together’), space (i.e., ‘Our family gathers together reporting of dysfunction or an accurate appraisal of a in the same room’), decision-making (i.e., ‘Members difficult family situation. consult other family members on their decisions’), It could be argued that perception of family friends (i.e., ‘Members know each other’s best functioning by mood disordered probands was direct- friends’), and interests / recreation (i.e., ‘We have ly influenced by their stage of illness, as has been difficulty thinking of things to do as a family’). noted in depression (Keitner and Miller, 1990), and However, observed differences between probands that their perception changed with the emergence of and study controls on this index were not representa- symptoms, as has been shown in depression in tive of clinical range problems or behavior outside of adolescents (Marton and Maharaj, 1993). A potential normative expectations for this age group. confound could therefore be the mental state of the Taken as a whole, our findings present a favorable subject at the time of assessment. In the present
34 H. A. Robertson et al. / Journal of Affective Disorders 66 (2001) 25 – 37 study, no proband met criteria for a current mood of family functioning, the role of diagnostic status episode, but the clinical sample reported significantly and symptom severity, and the effect of these on more mild psychiatric symptoms than did controls. reporting of family dysfunction. This might be of use The effect of these subsyndromal symptoms would, in identifying some specific areas of focus for the however, be expected to negatively impact on the development of psychoeducational strategies and clinical subjects’ self report. That is, both unipolar behavioral interventions which target areas of proven and bipolar teens would be expected to ‘over-report’ difficulty for mood disordered youth, including per- difficulties and this would be expected to produce haps family cohesiveness and sibling relationships. greater discrepancies in observations. That such discrepancies were not observed in the present study (lack of statistically significant differences between 6. Clinical relevance ratings by clinical probands and controls on the majority of indices) suggests that subsyndromal This study has attempted to elucidate the percep- symptoms may not have a uniformly distorting tion of mood-disordered youth about their family influence on perceived family functioning. If any- communication style and interactional pattern with thing, these findings highlight the need for a more parents and siblings. Although the results are derived finely-tuned analysis of the relationship between from self-report and semi-structured interview, this current symptomatology and self-report indices, gen- population of unipolar and bipolar youth did sig- erally. Other research reporting potential negative nificantly not differ from the control group with biases on the part of depressed patients may reflect respect to their communication with parents, their differences in the severity of underlying symptoms satisfaction with the relationship with their parents, for those study samples, as compared to ours. or their perception of family adaptability. While Mental illness occurring in a family member, parental reports of the same variables would be an particularly a mother, has been shown to influence important tool in the overall assessment of the family functioning (Tamplin et al., 1998). In the family, these results appear to moderate previous present study we obtained – through the adolescents’ observations of bipolar families (Miklowitz et al., retrospective self-report only – a report of any 1988; Miklowitz and Goldstein, 1990; Wuerker, family history of mental illness (in first-degree 1996) with respect to negative affective style and relatives). As stated previously, approximately half criticism. In the adult literature, family interaction of the bipolar sample reported a first degree relative patterns and communication style (for example high with some form of mental illness, compared to two ‘expressed emotion’, negative affective style, inade- thirds of unipolar youths, and about 10% of controls. quate communication skills, ineffective coping stra- Due to the limited nature of our sample – data on tegies) have been shown to affect relapse rates in family psychiatric history – it is not possible to draw schizophrenia (Brown et al., 1972; Vaughn et al., straightforward conclusions about the relationship 1984), depression (Hooley et al., 1986; Okasha et al., between family history and current family func- 1994), and bipolar disorder (Miklowitz et al., 1988). tioning as described by these adolescents. However, However, arguments for the necessity of family it is encouraging that their recent perceptions of therapy in bipolar disorder have not been well family dynamics remain largely positive and in line supported, and the research evidence which does with population norms, despite the existence of a exist supports a psychoeducational model of family family psychiatric history. Furthermore, we found intervention. Psychoeducation has been shown to be that family psychiatric history did not act as a an important intervention in the management of significant covariate in the determination of between- mood disorders, including bipolar illness in adults groups differences in cohesion ratings (FACES II). and adolescents (Glick et al., 1985, 1994; Parikh et However, further research is necessary to sys- al., 1997). Information about symptoms, etiology, tematically evaluate the effect of psychiatric illness course of the illness, and treatment provided to the (past / current) in family members of young psychiat- patient and family improves treatment compliance in ric patients, the impact of this on particular aspects bipolar illness (Miklowitz, 1996) and depression
H. A. Robertson et al. / Journal of Affective Disorders 66 (2001) 25 – 37 35
(Kusumakar and Kennedy, 1996). Psychoeducation these disorders. Thus, treatment programs employing
has also been combined effectively with other psy- family therapies in these clinical groups on an ‘a
chotherapeutic approaches to family intervention priori’ or theoretical foundation may not be indi-
(Spurkland and Vandvik, 1989), and group therapy cated. Alternatively, evaluation and monitoring of
(Shakir et al., 1979; Volkmar et al., 1981). sibling relationship, psychoeducation, and assistance
As Miklowitz and Goldstein (1990) point out, the with concrete and specific problems as they arise,
involvement of families in psychosocial interventions may be of benefit.
is not always necessary, and the mechanisms that In conclusion, further research is needed to dif-
mediate efficacy (or lack thereof) have not been ferentiate those problems and underlying dynamics
carefully delineated. For example, reports of reduced which may be unique to families with bipolar
relapse rates following family interventions may be members, from those issues which may be generic to
directly mediated by changes in intra-familial stress the early onset mood-disorders (bipolar and unipolar)
or other family dynamic, or be indirectly mediated as a group. Decisions concerning the validity of
by changes in patient education, awareness and self-report ratings of family functioning and the
compliance, or variation in other illness characteris- necessity for family-based interventions must be
tics and comorbid conditions. Thus while family informed by evidence, which for the bipolar adoles-
therapy has been recommended for bipolar illness, cent cohort is to date very limited. This information
there have been few systematic investigations of will hopefully contribute to the development of
specific areas of family functioning needing to be optimal psychosocial treatment approaches, and will
targeted in therapy. It has been suggested that family help to elucidate the specific aspects of family
therapy improves the patient’s social support net- interventions which reportedly contribute to favor-
work and the emotional environment which in turn able outcomes in bipolar and unipolar youth and
may mitigate precipitants of the illness that arise their families.
from family conflict (Zaretsky and Segal, 1994 /
1995). Psychodynamic formulations often have as
their premise the assumption that families of bipolar Acknowledgements
and unipolar youth tend to be dysfunctional in their
communication patterns, that they are problematic in The authors gratefully acknowledge the support of
a way that families with ‘normal’ teens are not, and The Canadian Psychiatric Research Foundation, The
are therefore in need of special interventions de- Queen Elizabeth II Health Sciences Centre, The
signed to modify or ‘restore’ intrafamily relation- Halifax Stanley Centre for the Study of Bipolar
ships. Some support, albeit weak, for this assumption Disorder, and the Nova Scotia Department of Health
exists for unipolar depression in youth, from our Designated Mental Health Research Fund. The au-
finding of a consistent, but nonsignificant, trend thors also thank the treatment staff of the Adolescent
toward lower scores for unipolar youth on various Unit, Sunnybrook Health Sciences Centre, University
indices but not for the bipolar youth. As seen of Toronto and the treatment staff of the Mood
through the eyes of the adolescents, the families of Disorders Clinic, IWK-Grace Health Centre, Halifax,
bipolar youth are not dysfunctional, according to the Nova Scotia. Thanks also to Ms. Christine Himmel-
self-report and interview indices employed in the man for research assistance.
present study.
While psychosocial variables may play an im-
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