Mood disorder symptoms and their associated functional impairments are hypothesized to come about as the result of the conjoint, interactive influences of genetic, biological, and psychological vulnerabilities, family distress, and life stress at different points of development. We discuss a developmental psychopathology model that delineates pathways to high family conflict and mood exacerbation among early-onset bipolar patients. New data from a treatment development study indicate that adolescent bipolar patients in high expressed emotion families have more symptomatic courses of illness over 2 years than adolescents in low expressed emotion families. Chronic and episodic stressors are also correlated with lack of mood improvement while adolescents are in treatment. Family-focused treatment (FFT) given in conjunction with pharmacotherapy appears to ameliorate the course of bipolar disorder in adults. This treatment has recently been modified to address the developmental presentation of bipolar disorder among adolescents. We present data from an open trial of FFT and pharmacotherapy (N = 20) indicating that bipolar adolescents stabilize in mania, depression, and parent-rated problem behaviors over 2 years. Future research should focus on clarifying the developmental pathways to early-onset bipolar disorder and the role of protective factors and preventative psychosocial interventions in delaying the first onset of the disorder.
"Specifically, these treatments posited that these behaviors had detrimental effects on children with bipolar disorder and may encourage negative reactions in children (e.g., temper tantrums, self-destructive behavior). These negative reactions, in turn, exacerbated further high emotion expression behaviors [149, 150]. Thus, many of the psychotherapeutic interventions available sought to address dysfunctional communication styles within families that might exacerbate the presence of bipolar symptoms and to teach families about the management of bipolar disorder via psychoeducation  in either individual or group settings . "
[Show abstract][Hide abstract] ABSTRACT: Although bipolar disorder historically was thought to only occur rarely in children and adolescents, there has been a significant increase in children and adolescents who are receiving this diagnosis more recently (Carlson, 2005). Nonetheless, the applicability of the current bipolar disorder diagnostic criteria for children, particularly preschool children, remains unclear, even though much work has been focused on this area. As a result, more work needs to be done to further the understanding of bipolar symptoms in children. It is hoped that this paper can assist psychologists and other health service providers in gleaning a snapshot of the literature in this area so that they can gain an understanding of the diagnostic criteria and other behaviors that may be relevant and be informed about potential approaches for assessment and treatment with children who meet bipolar disorder criteria. First, the history of bipolar symptoms and current diagnostic criteria will be discussed. Next, assessment strategies that may prove helpful for identifying bipolar disorder will be discussed. Then, treatments that may have relevance to children and their families will be discussed. Finally, conclusions regarding work with children who may have a bipolar disorder diagnosis will be offered.
"In a controlled study on parenting style and family environment, parental communication style was more negative and less expressive, but only currently depressed children perceived family conflict and not asymptomatic offspring or controls (Vance et al., 2008). The studies of Miklowitz et al. (2003, 2004, 2006) found expressed emotions, assessed by measurements of criticism, rejection, hostility, and emotional over-involvement , to be common in families of BD and associated with increased risk of BD at adolescence. Bipolar disorder can impact maternal care by interfering with parenting, but may also affect family planning, gestation, delivery, and breastfeeding. "
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: Bipolar disorder (BD) is a highly incapacitating disease typically associated with high rates of familial dysfunction. Despite recent literature suggesting that maternal care is an important environmental factor in the development of behavioral disorders, it is unclear how much maternal care is dysfunctional in BD subjects. OBJECTIVE: The objective of this study was to characterize maternal care in DSM-IV/SCID diagnosed BD type I subjects compared to healthy controls with (PD) and without (NPD) other psychiatric diagnoses. MATERIALS AND METHODS: Thirty-four BD mothers and 106 controls underwent an interview about family planning and maternal care, obstetrical complications, and mother-child interactions. K-SADS-PL questions about violence exposure were used to ascertain domestic violence and physical/sexual abuse. RESULTS: BD mothers were less likely to have stable unions (45.5%; p<0.01) or to live with the biological father of their children (33.3%; p<0.01), but had higher educational level and higher rates of social security use/retirement. They also had fewer children and used less contraceptive methods than controls. Children of BD women had higher rates of neonatal anoxia, and reported more physical abuse (16.1%; p=0.02) than offspring of NPD mothers. Due to BD mothers' symptoms, 33.3% of offspring suffered physical and/or psychological abuse. LIMITATIONS: Post hoc analysis, and the use of questions as a surrogate of symptoms as opposed to validated instruments. CONCLUSION: This is one of few reports confirming that maternal care given by BD women is dysfunctional. BD psychopathology can lead to poor maternal care and both should be considered important environmental risk factors in BD, suggesting that BD psychoeducation should include maternal care orientation.
"Miklowitz presented data from several adult studies , including one that compared the effectiveness of each of FFT, IRST, CBT and psychoeducation in nearly 300 adults with BP . He also discussed four studies in adolescents [8,80-82], one study of children and adolescents , and two studies in children . In each, the study population was assigned to either psychosocial treatment(s) or a form of community or collaborative care. "
[Show abstract][Hide abstract] ABSTRACT: This commentary grows out of an interdisciplinary workshop focused on controversies surrounding the diagnosis and treatment of bipolar disorder (BP) in children. Although debate about the occurrence and frequency of BP in children is more than 50 years old, it increased in the mid 1990s when researchers adapted the DSM account of bipolar symptoms to diagnose children. We offer a brief history of the debate from the mid 90s through the present, ending with current efforts to distinguish between a small number of children whose behaviors closely fit DSM criteria for BP, and a significantly larger number of children who have been receiving a BP diagnosis but whose behaviors do not closely fit those criteria. We agree with one emerging approach, which gives part or all of that larger number of children a new diagnosis called Severe Mood Dysregulation or Temper Dysregulation Disorder with Dysphoria.
Three major concerns arose about interpreting the DSM criteria more loosely in children than in adults. If clinicians offer a treatment for disorder A, but the patient has disorder B, treatment may be compromised. Because DSM's diagnostic labels are meant to facilitate research, when they are applied inconsistently, such research is compromised. And because BP has a strong genetic component, the label can distract attention from the family or social context.
Once a BP diagnosis is made, concerns remain regarding the primary, pharmacological mode of treatment: data supporting the efficacy of the often complex regimens are weak and side effects can be significant. However, more than is widely appreciated, data do support the efficacy of the psychosocial treatments that should accompany pharmacotherapy. Physicians, educators, and families should adopt a multimodal approach, which focuses as much on the child's context as on her body. If physicians are to fulfill their ethical obligation to facilitate truly informed consent, they must be forthcoming with families about the relevant uncertainties and complexities.
Child and Adolescent Psychiatry and Mental Health 03/2010; 4(1):9. DOI:10.1186/1753-2000-4-9
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