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Negative expressed emotion best discriminates families with bipolar disorder children
Journal of Affective Disorders 148 (2013) 418–423
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Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Preliminary communication
Negative expressed emotion best discriminates families with bipolar disorder children Edmir G. Nader a, Ana Kleinman a, Bernardo Carrama~ o Gomes a, Claudia Bruscagin b, Bernardo dos Santos c, Mark Nicoletti d, Jair C. Soares d, Beny Lafer a, Sheila C. Caetano a,e,f,n a
Bipolar Research Program, Department and Institute of Psychiatry, University of Sa~ o Paulo Medical School, Sa~ o Paulo, Brazil ~ Paulo, Sao ~ Paulo, Brazil Post Graduation Program, Center for Family and Community, Pontifical Catholic University of Sao c Institute of Mathematics and Statistics, University of Sa~ o Paulo, Sa~ o Paulo, Brazil d Department of Psychiatry, University of Texas at Houston, Houston, TX, USA e ~ Paulo Medical School, Sao ~ Paulo, Brazil Laboratory of Psychiatric Neuroimaging, Department of Psychiatry, University of Sao f ~ Paulo, Sao ~ Paulo, Brazil Center for Interdisciplinary Research on Applied Neurosciences (NAPNA), University of Sao b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 October 2012 Accepted 6 November 2012 Available online 4 December 2012
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. & 2013 Elsevier B.V. All rights reserved.
Keywords: Bipolar disorder Family Children Adolescents Family characteristics Expressed emotion
1. Introduction A dysfunctional family environment has been associated with psychopathology in children and adolescents (Althoff et al., 2005). Specifically in children and adolescents with bipolar disorder (BD), the main family characteristics found were high expressed emotion (EE), conflict levels, maternal and paternal tension; and low maternal warmth and cohesion (Geller et al., 2002; Geller et al., 2008; Belardinelli et al., 2008; Chang et al., 2001; Romero et al., 2005; Coville et al., 2008; Miklowitz et al., 2009; Sullivan
n Corresponding author at: Bipolar Disorder Research Program, Rua Dr. Ovı´dio Pires de Campos, 785 Sa~ o Paulo, SP 05403-010, Brazil. Tel.: þ55 11 26617928; fax: þ 55 112 6617928. E-mail addresses: [email protected], [email protected] (S.C. Caetano).
0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2012.11.017
and Miklowitz, 2010). Furthermore, some of those features, such as high EE and low maternal warmth, were linked not only to the difficulties that such individuals have in interpersonal relationships but also to their relapse rates (Geller et al., 2002; Geller et al., 2008; Honig et al., 1995; Honig et al., 1997; Chang et al., 2003; Geller et al., 2000; Geller et al., 2004). Family characteristics in BD have been evaluated in research settings using various approaches and scales. The most used selfreport scales are: Adjective Checklist (ACL) (Friedmann and Goldstein, 1993), Family Environment scale (FES) (Moos and Moos, 2002), Family Adaptability and Cohesion Evaluation Scale—II (FACES—II) (Olson et al., 1982; Olson et al., 1991), Family Assessment Device (FAD) (Epstein et al., 1983), Family Attitude Scale (FAS) (Kavanagh et al., 1997) and Parent–Child Relationship Questionnaire (Furman and Giberson, 1995). Among direct interview scales, the most used are: Camberwell Family
E.G. Nader et al. / Journal of Affective Disorders 148 (2013) 418–423
Interview (CFI) (Vaughn and Leff, 1976), Five Minute Speech ˜ a et al., 1986) and Psychosocial Schedule Sample (FMSS) (Magan for School Age Children—Revised (PSS-R) (Puig-Antich et al., 1986). In spite of different formats, some of these scales measure similar constructs. For instance comparable results were found in families of patients with schizophrenia in EE measured by direct interviews, CFI and FMSS and a self-report scale, ACL (Friedmann and Goldstein, 1993). Evidence-based assessments are crucial; but empirically supported assessment instruments are not always feasible to be used in clinical settings, mainly because of training needs, costs and clinician and patient time-consuming evaluations (Ebesutani et al., 2012). In this sense, a self-report scale would be a more clinical friendly assessment. However, at this point, our evidencebased knowledge does not point to the best family feature or scale that could discriminate control from BD families. Our aim was to identify which are the best characteristics that discriminates control from BD families using three of the most used scales in the literature. The use of three different scales had the intention to make a comprehensive assessment of family features embodying the complexity of family appraisal. We evaluated communication through the Adjective Checklist selfreport scale (Friedmann and Goldstein, 1993), the family functioning using a self-report scale, Family Environment Scale (Moos and Moos, 2002), and a direct interview scale, the Psychosocial Schedule for School Age Children-Revised (Puig-Antich et al., 1986). We built then a classifier with the main characteristics found from each scale to assess the sensitivity and specificity of our results. For eventual translation to clinical use, since ACL is the more feasible scale to be used in a clinical setting, we built a classifier using only this scale to compare the ability of individual classification of both classifiers. Our hypotheses were that families with BD children would have higher EE, less cohesion, greater conflict, lower maternal warmth and higher parental tension, and these features would allow the construction of a valid classifier. ACL-based classifier would have worst sensibility and specificity than using the main characteristics found with the three scales to discriminate BD families from control families.
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Table 1 Sociodemographic and clinical variables in pediatric patients with bipolar disorder (BD) and healthy control families (CF). Variable
Age (years), mean 7 S.D. Gender, % female Ethnicity, n (%) White Black Mixed Asian IQ, mean 7 S.D. Socioeconomic class (scorea), n (%) A (Z 89) B (59–88) C (35–58) D (20–34) Age (years) at BD onset, mean 7 S.D. Psychosocial treatment, n (%) Individual psychotherapy Family psychotherapy Mood state(s), n (%) Hypomania þMania þ Mixed Depression Euthymia Young Mania Rating Scale score, mean 7S.D. Children’s Depression Rating Scale score, mean 7S.D. Clinical Global Impression Scale score, mean 7S.D. Children’s Global Assessment Scale, mean 7S.D. Comorbidities, n (%) Attention deficit hyperactivity disorder Oppositional defiant disorder Generalized anxiety disorder Simple þSocial phobia Panic þ Agoraphobia Separation anxiety disorder Post-traumatic stress disorder Obsessive-compulsive disorder Tourette syndrome Substance abuse
BD
CF
(n¼ 33)
(n¼ 29)
13.1 7 3.1 39.4
13.7 73.5 58.6
22 (66.7) 2 (6.1) 9 (27.3) 0 (0.0) 97.2 7 16.5
15 (51.7) 4 (13.8) 8 (27.6) 2 (6.9) 102.9 711.9 0.129nnn 0.781nn 2 (6.9) 17 (58.6) 10 (34.5) 0 (0.0)
3 (9.1) 18 (54.5) 10 (30.3) 2 (6.1) 12.2 7 3.2
P
0.427n 0.203nn 0.323nn
23 (69.7) 2 (6.1) 21 (63.6) 3 (9.1) 9 (27.3) 9.7 77.8 29.2 7 12.1 3.9 71.1 51.9 7 9.7
17 (51.5) 9 (27.3) 9 (27.3) 5 (15.2) 3 (9.1) 1 (3.0) 1 (3.0) 2 (6.1) 1 (3.0) 1 (3.0)
Note: BD—bipolar disorder.
2. Methods 2.1. Participants We evaluated 33 pediatric patients with DSM-IV-diagnosed BD (mean age7standard deviation: 13.1 73.1 years old): 16 with BD type I (BD I); 1 with BD type II (BD II); and 16 with BD not otherwise specified (BP-NOS). All of the patients were enrolled in the Bipolar Disorder Program at the Institute of Psychiatry of the University of Sa~ o Paulo Medical School, in Sa~ o Paulo, Brazil. Patients were diagnosed with BP-NOS if they presented episodes that were clearly manic or hypomanic yet lacked the necessary duration to meet the criteria for a diagnosis of BD I or BD II (Birmaher et al., 2006). Twenty-nine healthy control families of children or adolescents with no personal or family history of psychiatric illness (mean age of the offspring: 13.773.5 years old) were recruited via advertisements within the local community. Patients and controls were eligible only if intelligence quotient (IQ) Z70. The only exclusion criterion was having a disease that affected the central nervous system. Demographic and clinical characteristics of the sample are presented in Table 1. The study was approved by the Research Ethics Committee of the University of Sa~ o Paulo. The parents or legal guardians of all subjects gave written informed consent.
a Brazilian Association of Market Research Institutes Demographic and Socioeconomic Class Scale (Jannuzzi and Baeninger, 1996). n Mann–Whitney Test. nn Fisher’s exact test. nnn T-test.
2.2. Data collection To identify current and lifetime psychiatric disorders, we employed the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime version. Parents or legal guardians were interviewed separately from the subjects, who were then interviewed about themselves (Kaufman et al., 1997). Socioeconomic status was determined with the Brazilian Association of Market Research Institutes Demographic and Socioeconomic Class Scale (Jannuzzi and Baeninger, 1996). We determined IQs with the Wechsler Abbreviated Scale of Intelligence (Wechsler, 1999). In the BD group, we also used the Children’s Global Assessment Scale to evaluate global severity based on psychiatric symptoms and functional impairment (Shaffer et al., 1983), as well as the Clinical Global Impression Scale (Guy, 1976) to evaluate the clinical severity of the disorder. To assess the severity of depression and mania, we applied the Children’s Depression Rating Scale Revised (Poznanski et al.,
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1985) and the Young Mania Rating Scale (Young et al., 1978), respectively. 2.3. Family instruments The Adjective Checklist (ACL) devised by Friedmann and Goldstein (1993) is a list of 20 adjectives (10 positive and 10 negative) designed to assess the level of criticism and emotional over-involvement in a parent–child relationship. The items are presented twice, first to assess the behavior of the informant (parent or guardian) toward the subject (child or adolescent) and a second time to assess the behavior of the subject toward the informant. This scale is widely accepted as an EE measure (McCarty et al., 2004). The Family Environment Scale (FES), devised by Moos and Moos (2002) is a 90-item, self-report scale that characterizes the social and environmental aspects of families by evaluating the perception of the individual of the current family environment (Moos and Moos, 2002; Moos and Moos, 2009). The 90 items are grouped into 10 subscales, within three dimensions: Relationship, which comprises the subscales of cohesion, expressiveness, and conflict; Personal Growth, comprising the subscales of independence, achievement orientation, intellectual-cultural orientation, active-recreational orientation, and moral-religious emphasis; and System Maintenance, comprising the subscales of organization and control (Moos and Moos, 2002; Romero et al., 2005). The Psychosocial Schedule for School-Age Children-Revised (PSS-R) (Puig-Antich et al., 1986) elicits data regarding demographics, life events, social functioning, and family functioning. Parent and child are interviewed separately to obtain individual and global ratings regarding the functioning of the child. The PSSR also evaluates overall family organization and marital functioning (Geller et al., 2000; Puig-Antich et al., 1986).
The normality of continuous data was verified by the Kolmogorov–Smirnov test. The Mann–Whitney test was used in order to compare ages between groups. We used a t-test to compare the BD and non-BD groups’ mean IQ. Analysis of covariance models were adjusted to assess differences between the two groups in terms of the EE variables (positive and negative EE) and the FES dimensions. To compare the two groups in terms of the PSS-R ratings, we used a logistic regression model and Fisher’s exact test. A Fisher’s linear discriminant analysis was used to build a classifier with the three scales characteristics that were statistically significant when comparing BD families and control families, and the ACL-based classifier. We applied Bonferroni and false discovery rate corrections. The level of significance was set at 5%.
3. Results 3.1. Sociodemographic and clinical characteristics There were no statistically significant differences between the BD group and the healthy control group in terms of age, gender, ethnicity, IQ, pubertal status, and socioeconomic status of the parents. The sociodemographic characteristics are described in Table 1. 3.2. Family assessments
2.4. Data analysis
3.2.1. The adjective checklist (ACL) The Adjective Checklist results are shown in Table 2. In comparison with the families in the healthy control group, those in the BD group presented lower positive EE, by the offspring toward the parents (F¼51.57, Po0.001) and by the parent(s) toward the offspring (F¼18.38, Po0.001); and higher negative EE by the offspring toward the parents (F¼ 98.27, Po0.001) and by the parent(s) toward the offspring (F¼31.72, Po0.001).
All statistical analyses were performed with the Statistical Package for the Social Sciences, version 14.0 (SPSS Inc., Chicago, IL, USA). Fisher’s exact test was used in order to analyze categorical variables (gender, socioeconomic status, and pubertal development).
3.2.2. The FES Table 2 also shows the FES findings. In comparison with the control group, the BD group presented less cohesion (F¼10.99, P¼0.002), less organization (F¼9.37, P¼0.003), greater conflict
Table 2 Expressed emotion and family environment scale scores in families with children or adolescents with bipolar disorder (BD) and healthy control families (CF). Instrument/Variable
BD
CF
F
p
E.S.
(n¼33)
(n¼29)
Mean7 S.D.
Mean7 S.D.
49.58 7 12.41 48.94 7 10.22 61.21 7 9.70 34.73 7 9.00
71.72 7 10.14 22.62 7 10.26 72.17 7 8.73 21.38 7 7.88
51.57 98.27 18.38 31.72
o 0.001 o 0.001 o 0.001 o 0.001
0.475 0.633 0.244 0.358
47.61 7 13.80 50.18 7 11.29 55.36 7 11.82 41.61 7 12.49 49.73 7 10.25 45.21 7 13.59 47.09 7 11.84 59.36 7 8.89 54.36 7 9.65 57.12 7 6.43
57.48 7 7.15 51.31 7 10.45 42.34 7 9.69 44.45 7 10.68 52.59 7 6.98 52.03 7 11.03 50.76 7 11.83 61.52 7 7.94 61.14 7 6.59 49.62 7 8.14
10.99 0.05 14.66 1.45 3.01 3.59 1.38 2.72 9.37 13.02
0.002 0.826 o 0.001 0.233 0.089 0.063 0.246 0.105 0.003 0.001
0.172 0.001 0.217 0.027 0.054 0.063 0.025 0.049 0.150 0.197
Adjective Check list scoresn Positive EE by offspring toward parent Negative EE by offspring toward parent Positive EE by parent toward offspring Negative EE by parent toward offspring Family Environment Scale subscale scoresnn Cohesion Expressiveness Conflict Independence Achievement orientation Intellectual-cultural orientation Active-recreational orientation Moral-religious emphasis Organization Control
Note: BD: bipolar disorder; CF: control families; EE: expressed emotion; S.D.: standard deviation; F: test statistic (degrees of freedom ¼ 53); E.S.: effect size. n
With Bonferroni correction for multiple analyses: p o0.013. With Bonferroni correction for multiple analyses: po 0.005.
nn
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421
Table 3 Characteristics of the relations between parents and their children or adolescents with bipolar disorder (BD) and control families (CF), according to the Psychosocial Schedule for School-Age Children-Revised. BD (n¼33)
CF (n¼ 29)
%
%
Comparison Wald
p-Value
OR (BD)
Bonferroni correction threshold
Non - intact family
60.6
20.7
6.999
0.008
5.55
0.050
Mother–child Relations Frequent activities Usually confides Consistent limits Frequent hostility Presence of corporal punishment Low maternal warmth High maternal tensionn
– 62.5 50.0 40.6 81.3 46.9 84.4 100.0
– 86.2 75.9 82.8 17.2 24.1 55.2 58.6
– 4.152 6.558 12.174 16.921 1.600 3.831 –
– 0.042 0.010 o0.001 o0.001 0.206 0.050 o0.001
– 0.24 0.17 0.05 41.22 2.38 3.83 –
0.007 – – – – – – –
Father–child Relations Frequent activities Usually confides Consistent limits Frequent hostility Presence of corporal punishment Low paternal warmth High paternal tension
– 36.7 36.7 50.0 43.3 20.0 86.7 96.7
– 65.4 61.5 73.1 11.5 15.4 65.4 57.7
– 6.109 7.006 3.858 5.371 0.050 3.979 8.551
– 0.013 0.008 0.049 0.020 0.823 0.046 0.003
– 0.18 0.12 0.25 7.00 1.20 4.83 51.43
0.007 – – – – – –
Wald: test statistics, degrees of freedom: 1, OR: odds ratio. We used the Bonferroni method to correct for multiple comparisons. The corrected probability values in each domain were the following: 7 Comparisons and p r 0.007 corrected for mother–child relationship, 7 Comparisons and p r 0.007 corrected for father–child relationship. n
Fisher Exact Test.
(F¼14.66, Po0.001), and greater control (F¼13.02, P¼0.001). We found no differences between the BD and non-BD families regarding the FES subscales for expressiveness, independence, achievement orientation, intellectual-cultural orientation, activerecreational orientation, and moral-religious emphasis. 3.2.3. The PSS-R The PSS-R results showed that, in comparison with the healthy control families, the BD families presented higher maternal tension (Po0.001), higher paternal tension (Wald¼ 8.551, P¼0.003), and a higher rate of non-intact family status (Wald¼6.999, P¼0.008). These, together with other variables and statistics, are presented in Table 3. 3.3. Linear discriminant analysis 3.3.1. The 3 scale-based classifier We first built a classifier based on all statistical significant measures found in the three scales applied: lower positive EE and higher negative EE, by the offspring toward the parents and by the parent(s) toward the offspring; less cohesion, organization, greater conflict and control; and greater maternal and paternal tension, higher rate of non-intact family. The cross-validated classification accuracy was 87.3%, with a sensitivity of 93.1% and a specificity of 80.8%. In the discriminative pattern, negative EE by the offspring toward the mother or father ranked first (0.798), followed by positive EE by the offspring toward the mother or father ( 0.599), negative EE by the mother or father toward the offspring (0.449), maternal tension (0.381), positive EE by the mother or father toward the offspring ( 0.362), greater conflict (0.353), paternal tension (0.326), higher rate of non-intact family (0.316), less organization ( 0.281), greater control (0.276), less cohesion ( 0.271). 3.3.2. ACL-based classifier We then built the ACL-based classifier and found, in the crossvalidated classification, an accuracy of 87.1%, a sensitivity of
93.9% and a specificity of 79.3%. In the discriminative pattern, negative EE by the offspring toward the mother or father ranked first (0.908), followed by positive EE by the offspring toward the mother or father ( 0.686), negative EE by the mother or father toward the offspring (0.555), and positive EE by the mother or father toward the offspring ( 0.418).
4. Discussion Our families of children and adolescents with BD, when compared with the families of healthy children and adolescents, presented lower positive EE and higher negative EE, by the offspring toward the parents and by the parent(s) toward the offspring; less cohesion, organization, greater conflict and control; lower rate of intact family, greater maternal and paternal tension. Our findings of higher negative EE levels are consistent with previous studies (Coville et al., 2008; Miklowitz et al., 2009; Sullivan and Miklowitz, 2010; Fristad, 2006; Fristad et al., 2003; Fristad et al., 1998a; Fristad et al., 1998b). The EE assessment can encompass a broad range of systemic dysfunctions within the family, such as poor communication and impaired problem solving (Miklowitz et al., 2009). Classically, a high level of negative EE is associated with a high level of criticism of BD patients by their families (Friedmann and Goldstein, 1993). The high frequency and intensity of negative adjectives used by the parents to refer to their child is also considered a proxy of their behavior towards their offspring as reported in direct observations of more negative and antagonistic interactions of the parents to their child (McCarty et al., 2004; Chambless et al., 1999). Another possible explanation regards the psychopathology of BD per se. Given that BD is characterized by extremes (mania and depression), instability, and impulsivity (Miklowitz et al., 2009), there could be a demand for greater intensity and frequency in the use of negative adjectives (Geller et al., 2000). Parents may be likely to use these adjectives to highlight and then try to inhibit the child’s inappropriate behavior. However, constant repetition of these adjectives could induce children to
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identify themselves with negative images, which could then influence their behavior (Miklowitz et al., 2009). In the present study, the FES scale showed that the BD family group, in comparison with the healthy family group, presented less cohesion (the degree of commitment and support family members provide to one another); greater conflict (the amount of openly expressed anger and conflict), greater control (how much the established rules are used to run the family life) and less organization (the degree of importance given to clear organization in planning family activities and dividing responsibilities). Lower levels of cohesion and higher levels of conflict have been previously reported in the families of BD parents (Chang et al., 2001; Romero et al., 2005) as well as BD children and adolescents (Belardinelli et al., 2008). Taken together, these findings of lack of family support and conflicts in parent/child relationships may indicate a bidirectional association, with the behavior of one influencing that of the other. One could also argue that impaired patient perception of the emotional state of their relatives might lead the former to respond in ways that are not appropriate to the context (Fristad et al., 2009). In this sense, the abnormal pattern of emotion recognition in BD children and adolescents (Hoertnagl et al., 2011) could be related to these family features. Higher levels of control, as observed in our BD family group, could represent an attempt to minimize the damage caused by the symptoms of BD. A need to establish rules designed to control the affected family members, for instance, to avoid excessive involvement in pleasant activities with high potential of negative consequences. Our families with BD youth also presented lower levels of organization, which are consistent with Chang et al. (2001). Excessive levels of control could also be related with the need to overcome difficulties in organization. We found in the PSS-R that there was higher maternal and paternal tension in the families of children and adolescents with BD than in the families of healthy children and adolescents. These data are consistent with those reported in the study conducted by Geller et al., 2000. One should expect that children with BD require parenting skills that are far beyond regular skills, such as imposing limits on impulsive and aggressive behavior. The greater demand for attention and support from a child or adolescent with BD can make it harder to provide the necessary care. Consequently, parents might feel impotent on a personal or relationship level, which can generate feelings of hostility and irritability (Geller et al., 2000). The resulting increase in tension and avoidance can ultimately lead to a reduction in parental warmth. Regarding the classifiers results, the offspring’s EE toward the mother, reported by the parents, was the family characteristic that best discriminated BD family from healthy control families. This finding was obtained not only by the 3 scale-based classifier, but also by the ACL-based classifier. Indeed, both classifiers presented high accuracy. Since the discriminative pattern in the 3 scale-based classifier showed three of the EE measures ranking first (negative EE by the offspring toward the parents, positive EE by the offspring toward the parents, negative EE by the parents toward the offspring) it was expected that the ACL-based classifier would also have high sensibility and specificity. The ACL-based classifier demonstrated high accuracy of this self-report scale to discriminate BD families from healthy control families. This result identified an evidence-based assessment feasible to be used in clinical settings. In fact, the high level of negative EE has been associated with high rates of relapse (Honig et al., 1995; Honig et al., 1997) and psychotherapy interventions have been demonstrated as effective (Fristad, 2006; Fristad et al., 2003; Fristad et al., 1998a; Fristad et al., 1998b). In addition, it can be supposed that this index of family poor communication may be extended to the parent–child–doctor interaction as a difficulty
to come to a consensus on which problems should be target on treatment (Hawley and Weisz, 2003). Family interaction should be evaluated as one of the treatment decisions in clinical practice. The limitations of our study are the small sample size and the cross-sectional design, which prevented us from establishing causality or prognoses. An important strength of our study is that we were able to replicate in Brazil previous findings regarding the family characteristics of children and adolescents with BD. Cultural differences are known to play an important role in family studies, as observed by Vianna et al. (2007) that reported higher levels of cohesion and organization and lower levels of conflict in Brazilian families compared to USA normative data. Our data may suggest that the abnormal dynamics and communication in the families of children and adolescents with BD can be generalized to Western societies. This is the first study to simultaneously evaluate communication and family functioning in families of children and adolescents with BD in order to identify the best discriminant characteristics of such families. EE was the best discriminant feature between BD and control families. The high sensitivity and specificity of the ACL-based classifier highlight a feasible scale to be used in clinical settings improving not only the assessment of those patients but also refining possible treatment proposals. In family psychotherapy, strategies to improve communication among all family members can be implemented. A psychoeducational approach that could address the high levels of EE, such as teaching the families how to separate the symptoms from the personality characteristics of the BD offspring is essential. Psychoeducational interventions that include the families of BD children and adolescents have been associated with better outcome (Fristad, 2006; Fristad et al., 2003; Fristad et al., 1998a; Fristad et al., 1998b; Miklowitz and Johnson, 2009). There is a need for further studies assessing the impairment and prognosis associated with the patterns of communication in such families, as well as for the establishment of specific treatment approaches.
Role of funding source Disclosure: Ana Kleinman has received scholarship from CNPq. Dr Lafer has received research support from CNPq and FAPESP, and has been a speaker for AstraZeneca. Dr. Caetano had received scholarships from FAPESP and CNPq.
Conflict of interest The authors have no financial or potential conflict of interest to disclose with respect to the subject matter of this paper.
Acknowledgments This research was supported in part by the Fundac- a~ o de Amparo a Pesquisa de Sa~ o Paulo, Brazil (FAPESP); the Conselho Nacional de Desenvolvimento Cientifico e Tecnolo´gico, Brazil (CNPq); the National Alliance for Research on Schizophrenia and Depression (NARSAD), Young Investigator; the American Psychiatric Association/AstraZeneca Young Minds in Psychiatry International Awards and the L’Ore´al, ABC and Unesco - Para Mulheres na Ciˆencia, L’Ore´al, ABC e Unesco, Brazil.
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Contents lists available at SciVerse ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Preliminary communication
Negative expressed emotion best discriminates families with bipolar disorder children Edmir G. Nader a, Ana Kleinman a, Bernardo Carrama~ o Gomes a, Claudia Bruscagin b, Bernardo dos Santos c, Mark Nicoletti d, Jair C. Soares d, Beny Lafer a, Sheila C. Caetano a,e,f,n a
Bipolar Research Program, Department and Institute of Psychiatry, University of Sa~ o Paulo Medical School, Sa~ o Paulo, Brazil ~ Paulo, Sao ~ Paulo, Brazil Post Graduation Program, Center for Family and Community, Pontifical Catholic University of Sao c Institute of Mathematics and Statistics, University of Sa~ o Paulo, Sa~ o Paulo, Brazil d Department of Psychiatry, University of Texas at Houston, Houston, TX, USA e ~ Paulo Medical School, Sao ~ Paulo, Brazil Laboratory of Psychiatric Neuroimaging, Department of Psychiatry, University of Sao f ~ Paulo, Sao ~ Paulo, Brazil Center for Interdisciplinary Research on Applied Neurosciences (NAPNA), University of Sao b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 October 2012 Accepted 6 November 2012 Available online 4 December 2012
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. & 2013 Elsevier B.V. All rights reserved.
Keywords: Bipolar disorder Family Children Adolescents Family characteristics Expressed emotion
1. Introduction A dysfunctional family environment has been associated with psychopathology in children and adolescents (Althoff et al., 2005). Specifically in children and adolescents with bipolar disorder (BD), the main family characteristics found were high expressed emotion (EE), conflict levels, maternal and paternal tension; and low maternal warmth and cohesion (Geller et al., 2002; Geller et al., 2008; Belardinelli et al., 2008; Chang et al., 2001; Romero et al., 2005; Coville et al., 2008; Miklowitz et al., 2009; Sullivan
n Corresponding author at: Bipolar Disorder Research Program, Rua Dr. Ovı´dio Pires de Campos, 785 Sa~ o Paulo, SP 05403-010, Brazil. Tel.: þ55 11 26617928; fax: þ 55 112 6617928. E-mail addresses: [email protected], [email protected] (S.C. Caetano).
0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2012.11.017
and Miklowitz, 2010). Furthermore, some of those features, such as high EE and low maternal warmth, were linked not only to the difficulties that such individuals have in interpersonal relationships but also to their relapse rates (Geller et al., 2002; Geller et al., 2008; Honig et al., 1995; Honig et al., 1997; Chang et al., 2003; Geller et al., 2000; Geller et al., 2004). Family characteristics in BD have been evaluated in research settings using various approaches and scales. The most used selfreport scales are: Adjective Checklist (ACL) (Friedmann and Goldstein, 1993), Family Environment scale (FES) (Moos and Moos, 2002), Family Adaptability and Cohesion Evaluation Scale—II (FACES—II) (Olson et al., 1982; Olson et al., 1991), Family Assessment Device (FAD) (Epstein et al., 1983), Family Attitude Scale (FAS) (Kavanagh et al., 1997) and Parent–Child Relationship Questionnaire (Furman and Giberson, 1995). Among direct interview scales, the most used are: Camberwell Family
E.G. Nader et al. / Journal of Affective Disorders 148 (2013) 418–423
Interview (CFI) (Vaughn and Leff, 1976), Five Minute Speech ˜ a et al., 1986) and Psychosocial Schedule Sample (FMSS) (Magan for School Age Children—Revised (PSS-R) (Puig-Antich et al., 1986). In spite of different formats, some of these scales measure similar constructs. For instance comparable results were found in families of patients with schizophrenia in EE measured by direct interviews, CFI and FMSS and a self-report scale, ACL (Friedmann and Goldstein, 1993). Evidence-based assessments are crucial; but empirically supported assessment instruments are not always feasible to be used in clinical settings, mainly because of training needs, costs and clinician and patient time-consuming evaluations (Ebesutani et al., 2012). In this sense, a self-report scale would be a more clinical friendly assessment. However, at this point, our evidencebased knowledge does not point to the best family feature or scale that could discriminate control from BD families. Our aim was to identify which are the best characteristics that discriminates control from BD families using three of the most used scales in the literature. The use of three different scales had the intention to make a comprehensive assessment of family features embodying the complexity of family appraisal. We evaluated communication through the Adjective Checklist selfreport scale (Friedmann and Goldstein, 1993), the family functioning using a self-report scale, Family Environment Scale (Moos and Moos, 2002), and a direct interview scale, the Psychosocial Schedule for School Age Children-Revised (Puig-Antich et al., 1986). We built then a classifier with the main characteristics found from each scale to assess the sensitivity and specificity of our results. For eventual translation to clinical use, since ACL is the more feasible scale to be used in a clinical setting, we built a classifier using only this scale to compare the ability of individual classification of both classifiers. Our hypotheses were that families with BD children would have higher EE, less cohesion, greater conflict, lower maternal warmth and higher parental tension, and these features would allow the construction of a valid classifier. ACL-based classifier would have worst sensibility and specificity than using the main characteristics found with the three scales to discriminate BD families from control families.
419
Table 1 Sociodemographic and clinical variables in pediatric patients with bipolar disorder (BD) and healthy control families (CF). Variable
Age (years), mean 7 S.D. Gender, % female Ethnicity, n (%) White Black Mixed Asian IQ, mean 7 S.D. Socioeconomic class (scorea), n (%) A (Z 89) B (59–88) C (35–58) D (20–34) Age (years) at BD onset, mean 7 S.D. Psychosocial treatment, n (%) Individual psychotherapy Family psychotherapy Mood state(s), n (%) Hypomania þMania þ Mixed Depression Euthymia Young Mania Rating Scale score, mean 7S.D. Children’s Depression Rating Scale score, mean 7S.D. Clinical Global Impression Scale score, mean 7S.D. Children’s Global Assessment Scale, mean 7S.D. Comorbidities, n (%) Attention deficit hyperactivity disorder Oppositional defiant disorder Generalized anxiety disorder Simple þSocial phobia Panic þ Agoraphobia Separation anxiety disorder Post-traumatic stress disorder Obsessive-compulsive disorder Tourette syndrome Substance abuse
BD
CF
(n¼ 33)
(n¼ 29)
13.1 7 3.1 39.4
13.7 73.5 58.6
22 (66.7) 2 (6.1) 9 (27.3) 0 (0.0) 97.2 7 16.5
15 (51.7) 4 (13.8) 8 (27.6) 2 (6.9) 102.9 711.9 0.129nnn 0.781nn 2 (6.9) 17 (58.6) 10 (34.5) 0 (0.0)
3 (9.1) 18 (54.5) 10 (30.3) 2 (6.1) 12.2 7 3.2
P
0.427n 0.203nn 0.323nn
23 (69.7) 2 (6.1) 21 (63.6) 3 (9.1) 9 (27.3) 9.7 77.8 29.2 7 12.1 3.9 71.1 51.9 7 9.7
17 (51.5) 9 (27.3) 9 (27.3) 5 (15.2) 3 (9.1) 1 (3.0) 1 (3.0) 2 (6.1) 1 (3.0) 1 (3.0)
Note: BD—bipolar disorder.
2. Methods 2.1. Participants We evaluated 33 pediatric patients with DSM-IV-diagnosed BD (mean age7standard deviation: 13.1 73.1 years old): 16 with BD type I (BD I); 1 with BD type II (BD II); and 16 with BD not otherwise specified (BP-NOS). All of the patients were enrolled in the Bipolar Disorder Program at the Institute of Psychiatry of the University of Sa~ o Paulo Medical School, in Sa~ o Paulo, Brazil. Patients were diagnosed with BP-NOS if they presented episodes that were clearly manic or hypomanic yet lacked the necessary duration to meet the criteria for a diagnosis of BD I or BD II (Birmaher et al., 2006). Twenty-nine healthy control families of children or adolescents with no personal or family history of psychiatric illness (mean age of the offspring: 13.773.5 years old) were recruited via advertisements within the local community. Patients and controls were eligible only if intelligence quotient (IQ) Z70. The only exclusion criterion was having a disease that affected the central nervous system. Demographic and clinical characteristics of the sample are presented in Table 1. The study was approved by the Research Ethics Committee of the University of Sa~ o Paulo. The parents or legal guardians of all subjects gave written informed consent.
a Brazilian Association of Market Research Institutes Demographic and Socioeconomic Class Scale (Jannuzzi and Baeninger, 1996). n Mann–Whitney Test. nn Fisher’s exact test. nnn T-test.
2.2. Data collection To identify current and lifetime psychiatric disorders, we employed the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime version. Parents or legal guardians were interviewed separately from the subjects, who were then interviewed about themselves (Kaufman et al., 1997). Socioeconomic status was determined with the Brazilian Association of Market Research Institutes Demographic and Socioeconomic Class Scale (Jannuzzi and Baeninger, 1996). We determined IQs with the Wechsler Abbreviated Scale of Intelligence (Wechsler, 1999). In the BD group, we also used the Children’s Global Assessment Scale to evaluate global severity based on psychiatric symptoms and functional impairment (Shaffer et al., 1983), as well as the Clinical Global Impression Scale (Guy, 1976) to evaluate the clinical severity of the disorder. To assess the severity of depression and mania, we applied the Children’s Depression Rating Scale Revised (Poznanski et al.,
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E.G. Nader et al. / Journal of Affective Disorders 148 (2013) 418–423
1985) and the Young Mania Rating Scale (Young et al., 1978), respectively. 2.3. Family instruments The Adjective Checklist (ACL) devised by Friedmann and Goldstein (1993) is a list of 20 adjectives (10 positive and 10 negative) designed to assess the level of criticism and emotional over-involvement in a parent–child relationship. The items are presented twice, first to assess the behavior of the informant (parent or guardian) toward the subject (child or adolescent) and a second time to assess the behavior of the subject toward the informant. This scale is widely accepted as an EE measure (McCarty et al., 2004). The Family Environment Scale (FES), devised by Moos and Moos (2002) is a 90-item, self-report scale that characterizes the social and environmental aspects of families by evaluating the perception of the individual of the current family environment (Moos and Moos, 2002; Moos and Moos, 2009). The 90 items are grouped into 10 subscales, within three dimensions: Relationship, which comprises the subscales of cohesion, expressiveness, and conflict; Personal Growth, comprising the subscales of independence, achievement orientation, intellectual-cultural orientation, active-recreational orientation, and moral-religious emphasis; and System Maintenance, comprising the subscales of organization and control (Moos and Moos, 2002; Romero et al., 2005). The Psychosocial Schedule for School-Age Children-Revised (PSS-R) (Puig-Antich et al., 1986) elicits data regarding demographics, life events, social functioning, and family functioning. Parent and child are interviewed separately to obtain individual and global ratings regarding the functioning of the child. The PSSR also evaluates overall family organization and marital functioning (Geller et al., 2000; Puig-Antich et al., 1986).
The normality of continuous data was verified by the Kolmogorov–Smirnov test. The Mann–Whitney test was used in order to compare ages between groups. We used a t-test to compare the BD and non-BD groups’ mean IQ. Analysis of covariance models were adjusted to assess differences between the two groups in terms of the EE variables (positive and negative EE) and the FES dimensions. To compare the two groups in terms of the PSS-R ratings, we used a logistic regression model and Fisher’s exact test. A Fisher’s linear discriminant analysis was used to build a classifier with the three scales characteristics that were statistically significant when comparing BD families and control families, and the ACL-based classifier. We applied Bonferroni and false discovery rate corrections. The level of significance was set at 5%.
3. Results 3.1. Sociodemographic and clinical characteristics There were no statistically significant differences between the BD group and the healthy control group in terms of age, gender, ethnicity, IQ, pubertal status, and socioeconomic status of the parents. The sociodemographic characteristics are described in Table 1. 3.2. Family assessments
2.4. Data analysis
3.2.1. The adjective checklist (ACL) The Adjective Checklist results are shown in Table 2. In comparison with the families in the healthy control group, those in the BD group presented lower positive EE, by the offspring toward the parents (F¼51.57, Po0.001) and by the parent(s) toward the offspring (F¼18.38, Po0.001); and higher negative EE by the offspring toward the parents (F¼ 98.27, Po0.001) and by the parent(s) toward the offspring (F¼31.72, Po0.001).
All statistical analyses were performed with the Statistical Package for the Social Sciences, version 14.0 (SPSS Inc., Chicago, IL, USA). Fisher’s exact test was used in order to analyze categorical variables (gender, socioeconomic status, and pubertal development).
3.2.2. The FES Table 2 also shows the FES findings. In comparison with the control group, the BD group presented less cohesion (F¼10.99, P¼0.002), less organization (F¼9.37, P¼0.003), greater conflict
Table 2 Expressed emotion and family environment scale scores in families with children or adolescents with bipolar disorder (BD) and healthy control families (CF). Instrument/Variable
BD
CF
F
p
E.S.
(n¼33)
(n¼29)
Mean7 S.D.
Mean7 S.D.
49.58 7 12.41 48.94 7 10.22 61.21 7 9.70 34.73 7 9.00
71.72 7 10.14 22.62 7 10.26 72.17 7 8.73 21.38 7 7.88
51.57 98.27 18.38 31.72
o 0.001 o 0.001 o 0.001 o 0.001
0.475 0.633 0.244 0.358
47.61 7 13.80 50.18 7 11.29 55.36 7 11.82 41.61 7 12.49 49.73 7 10.25 45.21 7 13.59 47.09 7 11.84 59.36 7 8.89 54.36 7 9.65 57.12 7 6.43
57.48 7 7.15 51.31 7 10.45 42.34 7 9.69 44.45 7 10.68 52.59 7 6.98 52.03 7 11.03 50.76 7 11.83 61.52 7 7.94 61.14 7 6.59 49.62 7 8.14
10.99 0.05 14.66 1.45 3.01 3.59 1.38 2.72 9.37 13.02
0.002 0.826 o 0.001 0.233 0.089 0.063 0.246 0.105 0.003 0.001
0.172 0.001 0.217 0.027 0.054 0.063 0.025 0.049 0.150 0.197
Adjective Check list scoresn Positive EE by offspring toward parent Negative EE by offspring toward parent Positive EE by parent toward offspring Negative EE by parent toward offspring Family Environment Scale subscale scoresnn Cohesion Expressiveness Conflict Independence Achievement orientation Intellectual-cultural orientation Active-recreational orientation Moral-religious emphasis Organization Control
Note: BD: bipolar disorder; CF: control families; EE: expressed emotion; S.D.: standard deviation; F: test statistic (degrees of freedom ¼ 53); E.S.: effect size. n
With Bonferroni correction for multiple analyses: p o0.013. With Bonferroni correction for multiple analyses: po 0.005.
nn
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421
Table 3 Characteristics of the relations between parents and their children or adolescents with bipolar disorder (BD) and control families (CF), according to the Psychosocial Schedule for School-Age Children-Revised. BD (n¼33)
CF (n¼ 29)
%
%
Comparison Wald
p-Value
OR (BD)
Bonferroni correction threshold
Non - intact family
60.6
20.7
6.999
0.008
5.55
0.050
Mother–child Relations Frequent activities Usually confides Consistent limits Frequent hostility Presence of corporal punishment Low maternal warmth High maternal tensionn
– 62.5 50.0 40.6 81.3 46.9 84.4 100.0
– 86.2 75.9 82.8 17.2 24.1 55.2 58.6
– 4.152 6.558 12.174 16.921 1.600 3.831 –
– 0.042 0.010 o0.001 o0.001 0.206 0.050 o0.001
– 0.24 0.17 0.05 41.22 2.38 3.83 –
0.007 – – – – – – –
Father–child Relations Frequent activities Usually confides Consistent limits Frequent hostility Presence of corporal punishment Low paternal warmth High paternal tension
– 36.7 36.7 50.0 43.3 20.0 86.7 96.7
– 65.4 61.5 73.1 11.5 15.4 65.4 57.7
– 6.109 7.006 3.858 5.371 0.050 3.979 8.551
– 0.013 0.008 0.049 0.020 0.823 0.046 0.003
– 0.18 0.12 0.25 7.00 1.20 4.83 51.43
0.007 – – – – – –
Wald: test statistics, degrees of freedom: 1, OR: odds ratio. We used the Bonferroni method to correct for multiple comparisons. The corrected probability values in each domain were the following: 7 Comparisons and p r 0.007 corrected for mother–child relationship, 7 Comparisons and p r 0.007 corrected for father–child relationship. n
Fisher Exact Test.
(F¼14.66, Po0.001), and greater control (F¼13.02, P¼0.001). We found no differences between the BD and non-BD families regarding the FES subscales for expressiveness, independence, achievement orientation, intellectual-cultural orientation, activerecreational orientation, and moral-religious emphasis. 3.2.3. The PSS-R The PSS-R results showed that, in comparison with the healthy control families, the BD families presented higher maternal tension (Po0.001), higher paternal tension (Wald¼ 8.551, P¼0.003), and a higher rate of non-intact family status (Wald¼6.999, P¼0.008). These, together with other variables and statistics, are presented in Table 3. 3.3. Linear discriminant analysis 3.3.1. The 3 scale-based classifier We first built a classifier based on all statistical significant measures found in the three scales applied: lower positive EE and higher negative EE, by the offspring toward the parents and by the parent(s) toward the offspring; less cohesion, organization, greater conflict and control; and greater maternal and paternal tension, higher rate of non-intact family. The cross-validated classification accuracy was 87.3%, with a sensitivity of 93.1% and a specificity of 80.8%. In the discriminative pattern, negative EE by the offspring toward the mother or father ranked first (0.798), followed by positive EE by the offspring toward the mother or father ( 0.599), negative EE by the mother or father toward the offspring (0.449), maternal tension (0.381), positive EE by the mother or father toward the offspring ( 0.362), greater conflict (0.353), paternal tension (0.326), higher rate of non-intact family (0.316), less organization ( 0.281), greater control (0.276), less cohesion ( 0.271). 3.3.2. ACL-based classifier We then built the ACL-based classifier and found, in the crossvalidated classification, an accuracy of 87.1%, a sensitivity of
93.9% and a specificity of 79.3%. In the discriminative pattern, negative EE by the offspring toward the mother or father ranked first (0.908), followed by positive EE by the offspring toward the mother or father ( 0.686), negative EE by the mother or father toward the offspring (0.555), and positive EE by the mother or father toward the offspring ( 0.418).
4. Discussion Our families of children and adolescents with BD, when compared with the families of healthy children and adolescents, presented lower positive EE and higher negative EE, by the offspring toward the parents and by the parent(s) toward the offspring; less cohesion, organization, greater conflict and control; lower rate of intact family, greater maternal and paternal tension. Our findings of higher negative EE levels are consistent with previous studies (Coville et al., 2008; Miklowitz et al., 2009; Sullivan and Miklowitz, 2010; Fristad, 2006; Fristad et al., 2003; Fristad et al., 1998a; Fristad et al., 1998b). The EE assessment can encompass a broad range of systemic dysfunctions within the family, such as poor communication and impaired problem solving (Miklowitz et al., 2009). Classically, a high level of negative EE is associated with a high level of criticism of BD patients by their families (Friedmann and Goldstein, 1993). The high frequency and intensity of negative adjectives used by the parents to refer to their child is also considered a proxy of their behavior towards their offspring as reported in direct observations of more negative and antagonistic interactions of the parents to their child (McCarty et al., 2004; Chambless et al., 1999). Another possible explanation regards the psychopathology of BD per se. Given that BD is characterized by extremes (mania and depression), instability, and impulsivity (Miklowitz et al., 2009), there could be a demand for greater intensity and frequency in the use of negative adjectives (Geller et al., 2000). Parents may be likely to use these adjectives to highlight and then try to inhibit the child’s inappropriate behavior. However, constant repetition of these adjectives could induce children to
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identify themselves with negative images, which could then influence their behavior (Miklowitz et al., 2009). In the present study, the FES scale showed that the BD family group, in comparison with the healthy family group, presented less cohesion (the degree of commitment and support family members provide to one another); greater conflict (the amount of openly expressed anger and conflict), greater control (how much the established rules are used to run the family life) and less organization (the degree of importance given to clear organization in planning family activities and dividing responsibilities). Lower levels of cohesion and higher levels of conflict have been previously reported in the families of BD parents (Chang et al., 2001; Romero et al., 2005) as well as BD children and adolescents (Belardinelli et al., 2008). Taken together, these findings of lack of family support and conflicts in parent/child relationships may indicate a bidirectional association, with the behavior of one influencing that of the other. One could also argue that impaired patient perception of the emotional state of their relatives might lead the former to respond in ways that are not appropriate to the context (Fristad et al., 2009). In this sense, the abnormal pattern of emotion recognition in BD children and adolescents (Hoertnagl et al., 2011) could be related to these family features. Higher levels of control, as observed in our BD family group, could represent an attempt to minimize the damage caused by the symptoms of BD. A need to establish rules designed to control the affected family members, for instance, to avoid excessive involvement in pleasant activities with high potential of negative consequences. Our families with BD youth also presented lower levels of organization, which are consistent with Chang et al. (2001). Excessive levels of control could also be related with the need to overcome difficulties in organization. We found in the PSS-R that there was higher maternal and paternal tension in the families of children and adolescents with BD than in the families of healthy children and adolescents. These data are consistent with those reported in the study conducted by Geller et al., 2000. One should expect that children with BD require parenting skills that are far beyond regular skills, such as imposing limits on impulsive and aggressive behavior. The greater demand for attention and support from a child or adolescent with BD can make it harder to provide the necessary care. Consequently, parents might feel impotent on a personal or relationship level, which can generate feelings of hostility and irritability (Geller et al., 2000). The resulting increase in tension and avoidance can ultimately lead to a reduction in parental warmth. Regarding the classifiers results, the offspring’s EE toward the mother, reported by the parents, was the family characteristic that best discriminated BD family from healthy control families. This finding was obtained not only by the 3 scale-based classifier, but also by the ACL-based classifier. Indeed, both classifiers presented high accuracy. Since the discriminative pattern in the 3 scale-based classifier showed three of the EE measures ranking first (negative EE by the offspring toward the parents, positive EE by the offspring toward the parents, negative EE by the parents toward the offspring) it was expected that the ACL-based classifier would also have high sensibility and specificity. The ACL-based classifier demonstrated high accuracy of this self-report scale to discriminate BD families from healthy control families. This result identified an evidence-based assessment feasible to be used in clinical settings. In fact, the high level of negative EE has been associated with high rates of relapse (Honig et al., 1995; Honig et al., 1997) and psychotherapy interventions have been demonstrated as effective (Fristad, 2006; Fristad et al., 2003; Fristad et al., 1998a; Fristad et al., 1998b). In addition, it can be supposed that this index of family poor communication may be extended to the parent–child–doctor interaction as a difficulty
to come to a consensus on which problems should be target on treatment (Hawley and Weisz, 2003). Family interaction should be evaluated as one of the treatment decisions in clinical practice. The limitations of our study are the small sample size and the cross-sectional design, which prevented us from establishing causality or prognoses. An important strength of our study is that we were able to replicate in Brazil previous findings regarding the family characteristics of children and adolescents with BD. Cultural differences are known to play an important role in family studies, as observed by Vianna et al. (2007) that reported higher levels of cohesion and organization and lower levels of conflict in Brazilian families compared to USA normative data. Our data may suggest that the abnormal dynamics and communication in the families of children and adolescents with BD can be generalized to Western societies. This is the first study to simultaneously evaluate communication and family functioning in families of children and adolescents with BD in order to identify the best discriminant characteristics of such families. EE was the best discriminant feature between BD and control families. The high sensitivity and specificity of the ACL-based classifier highlight a feasible scale to be used in clinical settings improving not only the assessment of those patients but also refining possible treatment proposals. In family psychotherapy, strategies to improve communication among all family members can be implemented. A psychoeducational approach that could address the high levels of EE, such as teaching the families how to separate the symptoms from the personality characteristics of the BD offspring is essential. Psychoeducational interventions that include the families of BD children and adolescents have been associated with better outcome (Fristad, 2006; Fristad et al., 2003; Fristad et al., 1998a; Fristad et al., 1998b; Miklowitz and Johnson, 2009). There is a need for further studies assessing the impairment and prognosis associated with the patterns of communication in such families, as well as for the establishment of specific treatment approaches.
Role of funding source Disclosure: Ana Kleinman has received scholarship from CNPq. Dr Lafer has received research support from CNPq and FAPESP, and has been a speaker for AstraZeneca. Dr. Caetano had received scholarships from FAPESP and CNPq.
Conflict of interest The authors have no financial or potential conflict of interest to disclose with respect to the subject matter of this paper.
Acknowledgments This research was supported in part by the Fundac- a~ o de Amparo a Pesquisa de Sa~ o Paulo, Brazil (FAPESP); the Conselho Nacional de Desenvolvimento Cientifico e Tecnolo´gico, Brazil (CNPq); the National Alliance for Research on Schizophrenia and Depression (NARSAD), Young Investigator; the American Psychiatric Association/AstraZeneca Young Minds in Psychiatry International Awards and the L’Ore´al, ABC and Unesco - Para Mulheres na Ciˆencia, L’Ore´al, ABC e Unesco, Brazil.
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