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I’m Not Being Critical, You’re Just Too Sensitive: Pediatric Bipolar Disorder and Families

Abstract

The present study examines the relationship between Perceived Criticism (PC) and Sensitivity to Criticism (SC) in youth with Bipolar Spectrum Disorder (BPSD), their symptomatic experiences, and family functioning. We hypothesized that findings for youth would be consistent with findings for adults indicating that PC and SC would be associated with a worse clinical presentation, and that associations between family criticism and sensitivity and youth symptoms would be stronger for youth with BPSD than with other clinical diagnoses. We examined 828 youths ages 4–18 years (M = 10.9, SD = 3.4) and their caregivers from diverse ethnic and socioeconomic backgrounds using the Longitudinal Expert evaluation of All Data (LEAD) diagnoses (Spitzer, Comprehensive Psychiatry, 24, 399-411 1983), the parent-reported General Behavior Inventory (Youngstrom et al., Psychological Assessment, 13, 267–276 2001), The Perceived Criticism Scale (Hooley and Teasdale, Journal of Abnormal Psychology, 98, 229–235 1989), and the Family Assessment Device (Epstein et al., Journal of Marital and Family Therapy, 9, 171–180 1983). We found significant positive association between parent reports of youth criticalness and more severe manic and depression symptoms, greater mood lability, higher suicidality, and worse overall functioning. Youth with BPSD were significantly more critical and had higher SC than youth without BPSD. Interactions between BPSD and family criticalness and sensitivity were found in their links with youth symptoms. Negative associations between criticism and sensitivity and youth global family functioning were significant only for youth with BPSD. The positive association between criticism and youth mood lability was significant only for youth with BPSD. Our findings suggest that family factors and interactional patterns impact and are influenced by functioning in youth with BPSD and that family-based treatments should be considered routinely with these youth.

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References

  1. Algorta, G. P., Youngstrom, E. A., Frazier, T. W., Freeman, A. J., Youngstrom, J. K., & Findling, R. L. (2011). Suicidality in pediatric bipolar disorder: predictor or outcome of family processes and mixed mood presentation? Bipolar Disorders, 13(1), 76–86.

    Article  Google Scholar 

  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington: Author.

    Book  Google Scholar 

  3. Axelson, D. A., Birmaher, B. J., Brent, D., Wassick, S., Hoover, C., Bridge, J., & Ryan, N. (2003). A preliminary study of the kiddie schedule for affective disorders and schizophrenia for school-age children mania rating scale for children and adolescents. Journal of Child and Adolescent Psychopharmacology, 13, 463–470.

    Article  Google Scholar 

  4. Bergink, V., Larsen, J. T., Hillegers, M. H. J., Dahl, S. K., Stevens, H., Mortensen, P. B., Petersen, L., & Munk-Olsen, T. (2016). Childhood adverse life events and parental psychopathology as risk factors for bipolar disorder. Translational Psychiatry, 6, e929. https://doi.org/10.1038/tp.2016.201.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Byles, J., Byrne, C., Boyle, M. H., & Offord, D. R. (1988). Ontario child health study: reliability and validity of the general functioning subscale of the McMaster family assessment device. Family Process, 27, 97–104.

    Article  Google Scholar 

  6. Cooke, R. G., Young, L. T., Mohri, L., Blake, P. I., & Joffe, R. T. (1999). Family-of-origin characteristics in bipolar disorder: a controlled study. Canadian Journal of Psychiatry, 44, 379–381.

    Article  Google Scholar 

  7. Cox, M., & Paley, B. (1997). Families as systems. Annual Review of Psychology, 48, 243–267.

    Article  Google Scholar 

  8. Cuellar, A., Johnson, S., & Ruggero, C. (2009). Affective reactivity in response to criticism in remitted bipolar disorder. Journal of Clinical Psychology, 65, 925–941.

    Article  Google Scholar 

  9. Cutting, L. P., Aakre, J. M., & Docherty, N. M. (2006). Schizophrenic patients’ perceptions of stress, expressed emotion, and sensitivity to criticism. Schizophrenia Bulletin, 32(4), 743–750.

    Article  Google Scholar 

  10. Danielson, C. K., Youngstrom, E. A., Findling, R. L., & Calabrese, J. R. (2003). Discriminative validity of the general behavior inventory using youth report. Journal of Abnormal Child Psychology, 31, 29–39.

    Article  Google Scholar 

  11. Depue, R. A., Slater, J. F., Wolfstetter-Kausch, H., Klein, D., Goplerud, E., & Farr, D. (1981). A behavioral paradigm for identifying persons at risk for bipolar depressive disorder. Journal of Abnormal Psychology, 90, 381–437.

    Article  Google Scholar 

  12. Du Rocher Schudlich, T. D., Youngstrom, E. A., Calabrese, J., & Findling, R. (2008). The role of family functioning in bipolar disorder in families. Journal of Abnormal Child Psychology, 36, 849–863.

    Article  Google Scholar 

  13. Epstein, N. B., Baldwin, L. M., & Bishop, D. S. (1983). The McMaster family assessment device. Journal of Marital and Family Therapy, 9, 171–180.

    Article  Google Scholar 

  14. Freeman, A. J., Youngstrom, E. A., Michalak, E., Siegel, R., Meyers, O. I., & Findling, R. L. (2009). Quality of life in pediatric bipolar disorder. Pediatrics, 123(3), e446–e452.

    Article  Google Scholar 

  15. Fristad, M. A., & Macpherson, H. A. (2014). Evidence-based psychosocial treatments for child and adolescent bipolar spectrum disorders. Journal of Clinical Child and Adolescent Psychology, 43, 339–355. https://doi.org/10.1080/15374416.2013.822309.

    Article  PubMed  Google Scholar 

  16. Geller, B., Zimerman, B., Williams, M., Bolhofner, K., Craney, J. L., DelBello, M. P., & Soutullo, C. (2001). Reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 450–455.

    Article  Google Scholar 

  17. Hantouche, E. G., Akiskal, H. S., Lancrenon, S., Allilaire, J. F., Sechter, D., Azorin, J. M., et al. (1998). Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multi-site study (EPIDEP). Journal of Affective Disorders, 50(2–3), 163–173.

    Article  Google Scholar 

  18. Hayes, A. F. (2018). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach (2nd ed.). New York: The Guilford Press.

    Google Scholar 

  19. Hooley, J. M. (2007). Expressed emotion and relapse of psychopathology. Annual Review of Clinical Psychology, 3, 329–352. https://doi.org/10.1146/annurev.clinpsy.2.022305.095236.

    Article  PubMed  Google Scholar 

  20. Hooley, J. M., & Hiller, J. B. (2001). Family relationships and major mental disorder: Risk factors and preventive strategies. In B. R. Sarason & S. Duck (Eds.), Personal relationships: Implications for clinical and community psychology (pp. 61–87). New York: Wiley.

    Google Scholar 

  21. Hooley, J. M., & Hoffman, P. D. (1999). Expressed emotion and clinical outcome in borderline personality disorder. The American Journal of Psychiatry, 156, 1557–1562. https://doi.org/10.1176/ajp.156.10.1557.

    Article  PubMed  Google Scholar 

  22. Hooley, J. M., & Teasdale, J. D. (1989). Predictors of relapse in unipolar depressives: expressed emotion, marital distress, and perceived criticism. Journal of Abnormal Psychology, 98, 229–235.

    Article  Google Scholar 

  23. Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., & Ryan, N. (1997). Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. Journal of the American Academy of Child &Adolescent Psychiatry, 36, 980–988. https://doi.org/10.1097/00004583-199707000-00021.

    Article  Google Scholar 

  24. Masland, S., & Hooley, J. (2015). Perceived criticism: a research update for clinical practitioners. Clinical Psychology: Science and Practice, 22, 211–222. https://doi.org/10.1111/cpsp.12110.

    Article  Google Scholar 

  25. Mesman, E., Birmaher, B. B., Goldstein, B. I., Goldstein, T., Derks, E. M., Vleeschouwer, M., et al. (2016). Categorical and dimensional psychopathology in Dutch and US offspring of parents with bipolar disorder: a preliminary cross-national comparison. Journal of Affective Disorders, 205, 95–102. https://doi.org/10.1016/j.jad.2016.06.011.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Miklowitz, D. (2007). The role of the family in the course and treatment of bipolar disorder. Current Directions in Psychological Science, 16, 192–196.

    Article  Google Scholar 

  27. Miklowitz, D. J., Goldstein, M. J., Nuechterlein, K. H., Snyder, K. S., & Mintz, J. (1988). Family factors and the course of bipolar affective disorder. Archives of General Psychiatry, 45, 225–231. https://doi.org/10.1001/archpsyc.1988.01800270033004.

    Article  PubMed  Google Scholar 

  28. Miklowitz, D., Wisniewski, S., Miyahara, S., Otto, M., & Sachs, G. (2005). Perceived criticism from family members as a predictor of the course of bipolar disorder. Psychiatry Research, 136, 101–111. https://doi.org/10.1016/j.psychres.2005.04.005.

    Article  PubMed  Google Scholar 

  29. Miklowitz, D., Axelson, D., George, E., Taylor, D., Schneck, C., Sullivan, A., Dickinson, L., & Birmaher, B. (2009). Expressed emotion moderates the effects of family-focused treatment for bipolar adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 643–651. https://doi.org/10.1097/CHI.0b013e3181a0ab9d.

    Article  PubMed  Google Scholar 

  30. Minuchin, P. (1985). Families and individual development: provocations from the field of family therapy. Child Development, 56(2), 289–302.

    Article  Google Scholar 

  31. Morris, A. S., Silk, J. S., Steinberg, L., Myers, S. S., & Robinson, L. R. (2007). The role of family context in the development of emotion regulation. Social Development, 16, 361–388.

    Article  Google Scholar 

  32. Perlis, R., Miyahara, S., Marangell, L., Wisniewski, S., Ostacher, M., DelBello, M., Bowden, C., Sachs, G., & Nierenberg, A. (2004). Long-term implications of early onset in bipolar disorder. Biological Psychiatry, 55, 875–881.

    Article  Google Scholar 

  33. Reinares, M., Bonnin, C. M., Hidalgo-Massei, D., Sanchez-Moreno, J., Colom, F., & Vieta, E. (2016). The role of family interventions in bipolar disorder: a systematic review. Clinical Psychology Review, 43, 47–57. https://doi.org/10.1016/j.cpr.2015.11.010.

    Article  PubMed  Google Scholar 

  34. Renshaw, K. (2008). The predictive, convergent, and discriminant validity of perceived criticism: a review. Clinical Psychology Review, 28, 521–534.

    Article  Google Scholar 

  35. Rey, J. M., Singh, M., Hung, S. F., Dossetor, D. R., Newman, L., Plapp, J. M., & Bird, K. D. (1997). A global scale of measure the quality of the family environment. Archives of General Psychiatry, 54, 817–822.

    Article  Google Scholar 

  36. Rosenfarb, I., Miklowitz, D., Goldstein, M., Harmon, L., Nuechterlein, K., & Rea, M. (2001). Family transactions and relapse in bipolar disorder. Family Process, 40, 5–14. https://doi.org/10.1111/j.1545-5300.2001.4010100005.x.

    Article  PubMed  Google Scholar 

  37. Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H., & Aluwahlia, S. (1983). A children’s global assessment scale (CGAS). Archives of General Psychiatry, 40, 1228–1231. https://doi.org/10.1001/archpsyc.1983.01790100074010.

    Article  PubMed  Google Scholar 

  38. Smoller, J. W., & Finn, C. T. (2003). Family, twin, and adoption studies of bipolar disorder. American Journal of Medical Genetics, Part C, 123C, 48–58. https://doi.org/10.1002/ajmg.c.20013.

    Article  Google Scholar 

  39. Spitzer, R. L. (1983). Psychiatric diagnosis: are clinicians still necessary? Comprehensive Psychiatry, 24, 399–411.

    Article  Google Scholar 

  40. Steinberg, L., Icenogle, G., Shulman, E. P., Breiner, K., Chein, J., Bacchini, D., et al. (2016). Around the world, adolescence is a time of heightened sensation seeking and immature self-regulation. Developmental Science, 21. https://doi.org/10.1111/desc.12532.

  41. Whalen, D., Malkin, M., Freeman, M., Young, J., & Gratz, K. (2015). Brief report: Borderline personality symptoms and perceived caregiver criticism in adolescents. Journal of Adolescence, 41, 157–161. https://doi.org/10.1016/j.adolescence.2015.03.009.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Wozniak, J., Biederman, J., Kwon, A., Mick, E., Faraone, S., Orlovsky, K., et al. (2005). How cardinal are cardinal symptoms in pediatric bipolar disorder? An examination of clinical correlates. Biological Psychiatry, 58(7), 583–588.

    Article  Google Scholar 

  43. Yan, L., Hammen, C., Cohen, A., Daley, S., & Henry, R. (2004). Expressed emotion versus relationship quality variables in the prediction of recurrence in bipolar patients. Journal of Affective Disorders, 83, 199–206.

    Article  Google Scholar 

  44. Youngstrom, E. A., Findling, R. L., Danielson, C. K., & Calabrese, J. R. (2001). Discriminative validity of parent report of hypomanic and depressive symptoms on the general behavior inventory. Psychological Assessment, 13, 267–276. https://doi.org/10.1037/1040-3590.13.2.267.

    Article  PubMed  Google Scholar 

  45. Youngstrom, E. A., Meyers, O., Demeter, C., Youngstrom, J., Morello, L., Piiparinen, R., Feeny, N., Calabrese, J. R., & Findling, R. L. (2005). Comparing diagnostic checklists for pediatric bipolar disorder in academic and community mental health settings. Bipolar Disorders, 7, 507–517. https://doi.org/10.1111/j.1399-5618.2005.00269.x.

    Article  PubMed  Google Scholar 

  46. Youngstrom, E. A., Youngstrom, J. K., Freeman, A. J., De Los Reyes, A., Feeny, N. C., & Findling, R. L. (2011). Informants are not all equal: predictors and correlates of clinician judgments about caregiver and youth credibility. Journal of Child and Adolescent Psychopharmacology, 21, 407–415. https://doi.org/10.1089/cap.2011.0032.

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

This research was supported in part by NIH R01 MH066647 (PI: E. Youngstrom).

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Correspondence to Tina D. Du Rocher Schudlich.

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Dr. Du Rocher Schudlich, Ms. Chase Ochrach, Dr. Eric Youngstrom, and Dr. Jennifer Younstrom all declare that they have no conflicts of interest. Dr. Findling receives or has received research support, acted as a consultant and/or has received honoraria from Acadia, Adamas, Aevi, Akili, Alcobra, Alkermes, Allergan, Amerex, American Academy of Child & Adolescent Psychiatry, American Psychiatric Press, Arbor, Axsome, Daiichi-Sankyo, Gedeon Richter, Genentech, KemPharm, Luminopia, Lundbeck, MedAvante-ProPhase,Merck, NIH, Neurim, Noven, Nuvelution, Otsuka, PCORI, PaxMedica,Pfizer, Physicians Postgraduate Press, Q BioMed, Receptor Life Sciences, Roche, Sage, Signant Health, Sunovion, Supernus Pharmaceuticals, Syneos, Syneurx, Takeda, Teva, Tris, TouchPoint,and Validus.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. This article does not contain any studies with animals performed by any of the authors.

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Du Rocher Schudlich, T.D., Ochrach, C., Youngstrom, E.A. et al. I’m Not Being Critical, You’re Just Too Sensitive: Pediatric Bipolar Disorder and Families. J Psychopathol Behav Assess 43, 84–94 (2021). https://doi.org/10.1007/s10862-020-09848-x

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Keywords

  • Bipolar disorder
  • Family
  • Children and adolescents
  • Perceived criticism
  • Sensitivity to criticism