Psychopathology in children aged 10–17 of bipolar parents: Psychopathology rate and correlates of the severity of the psychopathology

Journal of Affective Elsevier

167

Disorders, 16 (1989) 167-179

JAD 00609

Psychopathology in children aged lo-17 of bipolar parents: psychopathology rate and correlates of the severity of the psychopathology Maria Grigoroiu-Serbhescu, Dan Christodorescu, Irina Jipescu, Adriana Totoescu, Elvira Marinescu and Viorica Ardelean Institute

ofNeurology and Psychiatry, SOS. Berceni, 10, Bucharest, Romania (Received 28 May 1987) (Revision received 20 July 1988) (Accepted 10 August 1988)

Summary Seventy-two proband children aged lo-17 of bipolar parents, matched with 72 control children of normal parents, were investigated using DSM-III diagnostic criteria and multiple sources of information. The psychopathology rate in children (61% in probands versus 25% in controls) was related to the impact of psychic disorders on the children’s adaptive functioning. The effect of several variables describing the psychiatric status of both parents and familial environment on the severity of psychopathology in children was analysed. Disordered and non-disordered probands were compared with respect to illness characteristics of their parents, familial environment, personality traits, and IQ by means of canonical discriminant analysis.

Key words: Bipolar

parents;

DSM-III

criteria;

Severity

Introduction The involvement of genetic factors in the aggregation of bipolar illness is evidenced by twin studies (Bertelsen et al., 1977; Torgersen, 1986) and adoption studies (Mendlewicz and Rainer, 1977; von Knorring et al., 1983). Offspring studies

Address for correspondence: Dr. M. Grigoroiu-Serb&nescu, Institute of Neurology and Psychiatry, SOS. Berceni, 10, Bucharest, Romania, O.P. 61, C.P. 6180, R-75622. 0165-0327/89/$03.50

0 1989 Elsevier Science Publishers

of psychopathology;

Children

reflect the interaction of genotypic and environmental influences. In recent years several studies on the psychopathology in children of bipolar parents were published (McKnew et al., 1979; Cytryn et al., 1982; Decina et al., 1983; Gershon et al., 1985; Kashani et al., 1985). The evidence of a high rate of psychopathology and especially of depression in these children has been connected with the genetic hypothesis of continuous vulnerability (Gershon et al., 1983) or of a more or less specific predisposition to temperamental instability (Akiskal, 1985a).

B.V. (Biomedical

Division)

168

But usually studies concerned with offspring of bipolar parents did not consider the severity of the psychopathology found in children through its impact on the adaptive functioning of children (except the studies by McKnew et al. (1979) and Gershon et al. (1985), in which severity of depression was rated). Generally, small samples of children of bipolar parents were directly investigated (9-31 subjects in a large age range, 5-16) by the above-mentioned authors and the clinical interview was the only source of information, except Decina et al.‘s study (1983) in which psychological assessment was also performed. In a review of the literature on children of affectively ill parents Cytryn et al. (1986) emphasised the need for further studies which should compare larger samples of children of affectively ill parents and normal parents since ‘the use of normal controls and controls with other psychiatric and non-psychiatric pathology is rare’ (p. 171) while Beardslee (1986) considered the study of adaptation ‘a necessary complement to the study of diagnosis’ (p. 190). The aims of the present study were: (a) to evaluate the rate of psychopathology in children of bipolar parents (i) considering the impact of the severity of psychopathology on their adaptive functioning, (ii) investigating a larger sample of proband children strictly matched to an equal number of control children with normal parents, and (iii) using direct investigation of children and parental couples and multiple sources of information; (b) to examine the effect of some variables related to parental illness and familial environment on the severity of psychopathology found in children; and (c) to compare disordered and nondisordered children of bipolar parents with respect to individual resources (personality traits and IQ) and variables describing familial psychopathology and environment. Method (I) Subjects Proband (P) parents were 47 patients hospitalised in the Gh. Marinescu hospital who met DSM-III criteria for bipolar (BP) I illness. There were 28 females and 19 males in the age range

31-54. The mean duration of their illness was 12.20 years with a SD of 7.88 years (range 2-32). Mean number of hospitalisations was 8.89 (SD = 5.44) in females and 8.39 (SD = 3.87) in males. In the female parents the mean number of depressive episodes was 9.56 (SD = 4.68, range 2-23) and the average number of manic and mixed episodes was 5.70 (SD = 4.56, range 2-20). In the male parents the mean number of depressive episodes was 6.22 (SD = 4.32, range 2-20) and the mean number of manic and mixed episodes was 6.06 (SD = 3.98, range 3-16). Age at onset of the illness ranged between 15 and 42 years (x = 29.80, SD = 7.30). The 47 BP parents had 72 children in the age range 10-17. Spouses of the bipolar parents: 37 spouses were available for direct investigation, while 10 spouses could not be investigated either because of separation from the BP parent or refusal to discuss with the research staff. The age range of the spouses was 29-56 years (x = 42.00, SD = 4.25). Control (C) parents. The way in which C parents were recruited was motivated by the following reasons: (i) the intention to reduce the risk of including false normals; (ii) the experience of a previously conducted national epidemiological study (Christodorescu et al., 1984) in which we noted a widespread tendency to dissimulate psychic disorders in the general population contacted on the initiative of psychiatry investigators. In order to benefit from an independent source of validation of the decision of normality made by the researchers on the basis of a clinical interview about C parents we recruited them in collaboration with the staff and social services of four institutions: two big enterprises, a school, and a hospital. These institutions were chosen in order to ensure professional and cultural similarity between P and C families. (The staff and social services can provide valid information about the behaviour of the employees and keep evidence of their hospitalisations and sick leaves.) The C parents initially had to meet the following conditions: having a profession in the same field and with the same educational level as one of the BP parents; having at least one child of the same sex and age or 1 year older than one of the children of the matched BP parent; having worked in that institution for at least 3 years to be known.

169

No other data about the C parents were available to the researchers at the moment when the clinical investigation of these parents and of their spouses was completed. In this way 78 intact and separated volunteer parental couples were selected. After performing psychiatric investigation of the C parents according to the procedure described below, researchers’ decision of normality was confronted with the information provided by the staff and social services about the primarily contacted parent. Consequently nine parental couples were removed because of discord between the two sources of information (alcoholism was usually hidden at our interview) and eight couples were removed because of clear psychiatric diagnoses made in at least one of the parents in each couple by the researchers on the basis of the interview (anxious disorders, somatisation disorder). Finally 61 parental couples were considered normal and they had 72 children. Age range in the C parents was 30-56 (x = 42.12, SD = 7.61). None of the C parents acknowledged a family history of psychiatric disorder. Comparison between the P and C parental couples with respect to socio-cultural and marital status shown in Table 1 indicates no significant difference between the two samples. Proband (P) children were represented by the 72 children of the 47 BP parents. There were 38 girls and 34 boys in the age range lo-17 (57 = 12.92,

TABLE

1

SOCIO-CULTURAL AND MARITAL POLAR AND NORMAL PARENTS Bipolar Socio-cultural status a 1 0 2 2 (4.25%) 3 22 (46.80%) 4 10 (21.27%) 5 13 (27.66%) Marital status married 35 (74.46%) divorced 7 (14.89%) remarried 5 (10.63%)

STATUS

IN

Control

X2

0 3 22 16 20

0.84 df=2 NS

(4.91%) (36.06%) (26.23%) (32.78%)

49 (80.32%) 5 (8.19%) 7 (11.47%)

’ The socio-cultural status takes into account occupational and income level of both parents; the highest level and 1 the lowest.

BI-

1.29 df = 2 NS educational, 5 designates

SD = 2.32). Thirty-four children were in the age group lo-12 and 38 in the age group 13-17. Control (C) children were 72 offspring of the 61 C parental couples. The age range of the C children was lo-17 (x = 13.08, SD = 2.21). Every C child was strictly matched for sex and socio-cultural level of his/her family with a P child. Age matching was also strict in 65 cases (90.27%). In seven cases (9.73%) the controls were 1 year older than their P pairs. There were 38 girls and 34 boys; 34 children were in the age group lo-12 and 38 children in the age group 13-17. (2) Investigation procedures Diagnostic procedure of bipolar parents. A clinical interview based on DSM-III criteria for BP illness was addressed to patients who received a hospital diagnosis of manic-depressive disorder from an adult research psychiatrist. The patients were interviewed shortly before their discharge from the hospital at a time when their mood was relatively normal. After the interview the psychiatrist reviewed the hospital records of the present and past illness episodes and did the final diagnosis in consensual discussion with the hospital psychiatrist who referred the patient. The severity of the BP illness was rated on a scale as the sum of scores assigned for five criteria: number of hospitalised episodes, number of nonhospitalised episodes, mean duration of the episodes in weeks, annual frequency of the episodes, occupational efficiency over the intervals between illness episodes. An information record on psychiatric disorders in the patients’ first-degree relatives and in the first-degree relatives of their spouses as well as a parental attitudes and familial atmosphere scale were administered to the patients. Parental attitudes were described by five items: affection toward children, adequacy of sanctions and rewards, interest in the material conditions of the child’s life, interest in the child’s school activity, degree of independence allowed the child. High scores indicated positive attitudes. The familial atmosphere was assessed on three items: reciprocal affection and respect of the parents for each other, moral interest of the parents in children (providing moral help, affection, security), absence/presence of conflicts and tensions among family members and

170

the way of solving them (peaceful vs. verbally or/and physically aggressive). Diagnostic procedure of the spouses of bipolar parents and of control parents. Two clinical adult psychologists conducted a clinical interview using a symptom list and DSM-III criteria for disorders on axes I and II with 37 spouses of the BP parents and 106 C parents when visiting their homes. Additionally, an information record on psychiatric history in these parents’ first-degree relatives and the parental attitudes and familial atmosphere scale were administered. For 10 spouses of the BP parents and 16 spouses of the C parents, who were either separated from the contacted parent or refused to discuss with the researchers, information was indirectly collected from the available parent and his/her relatives. The final diagnosis was a consensual diagnosis established by an adult psychiatrist not participating in the investigation of these subjects and their direct interviewer. All adult assessors were not involved at all in any type of child assessment. Diagnoses made in spouses of BP parents were: normal 34 (72.34’%), alcohol abuse eight (17.02%), dysthymic disorder two (4.25%), generalised anxiety disorder one (2.12%), histrionic personality one (2.12%), schizoaffective psychosis one (2.12%). Diagnostic procedure of the children. (a) Clinical assessment. The K-SADS-E interview (PuigAntich et al., 1981) supplemented by us with an interview concerned with other DSM-III child and adolescent diagnoses (avoidant, schizoid, identity, dysthymic and oppositional disorder, developmental disorders, psychic disorders with physical manifestations) was administered separately to the child and to one of the parents (usually to the mother) by two clinical child psychologists blind to the psychopathological status of the parents. BP parents interviewed about their children could not distort the information too much, because all of them were interviewed after discharge from the hospital when normalisation of their mood was evident. Moreover, the opinion of the other parent and sometimes the opinion of other close relatives, as well as teachers’ opinions about the general functioning of the children, were recorded. (b) The psychological investigation was conducted by two psychologists blind to all informa-

tion about children and parents. The following assessments were performed: (i) personality traits (anxiety, tolerance to frustration, egocentrism, emotional stability, depressive reactivity, emotional sensitivity and involvement, introversion, perfectionism) as measured by two inventories developed by us - an adult personality inventory (Serbtiescu-Grigoroiu, 1981) modified for adolescents aged 12-17 and a personality inventory for children aged lo-11 (SerbSinescu-Grigoroiu, 1987) (personality inventories were answered by both the child and one of the parents about the child); (ii) intelligence level (Raven PM 38 test and Longeot-Piaget scale for formal thinking); (iii) attention functioning in short-term activities (coding test of WISC-R and WAIS-R) and in long-term activities (about 1.5 h) (criteria valid for attention assessment were introduced as parallel parameters in the evaluation of the Raven and Longeot-Piaget scales without modifying the tests). (c) School functioning was investigated by means of a standard record with 36 items covering eight variables: school performance, adjustment to school discipline, motivation for school work, emotional reactivity in school. situations, social relationship difficulties, attention deficit during courses, hyperkinesis, dissocial and antisocial behaviour. The information was supplied by teachers. The items of the school record were not intended to form a scale and they were considered separately in connection with those diagnostic criteria for which school behaviour was more relevant than the child’s behaviour in other situations and with the criteria involved by the rating scale of the severity of the child’s psychopathology. (d) Final diagnosis of the children. All sources of information about children were finally reviewed by two investigations - one psychiatrist who did not participate in any kind of investigation, totally blind to the status of children and parents, and the clinical psychologist who interviewed the children, blind to the psychopathological status of their parents. Preference rules worked for conflicting information in the diagnostic process. For ADDH and ADD preference was given to teachers’ reports and psychological assessments. For conduct disorders teachers’ and parents’ reports were given priority. For mood and anxious disorders as well

171

as for all intemalising disorders children’s reports were given first weight followed by parents’ reports. For personality disorders psychological investigation (inventories) ranked first among the other sources of information. The final diagnosis was consensual, but when diagnostic opinions were divergent the final decision belonged to the blind psychiatrist. Multiple DSM-III diagnoses were made in children with a child having up to three diagnoses. Personality disorder diagnosis was used for subjects aged 15-17 who for years had manifested traits qualifying for a certain personality diagnosis. For diagnosing hyperthymic personality Schneider’s criteria as modified by Akiskal(1985b) were used in interpreting the multiple sources of information, this type of personality disorder not being described by DSM-III criteria. Severity of psychopathology in children was rated on a three-item scale first developed for the purposes of the present study (Serb%nescuGrigoroiu, 1988). The scale was designed to measure a continuum ranging from normality to incapacitating psychopathology. The item impor-

TABLE

tance provided by stepwise multiple regression was the following: number of impaired areas of psychosocial functioning of the child and duration of the modifications of the child’s behaviour (areas considered: family, peers, school, community, physical well-being); decrease of school performance below the expected level according to IQ due to the psychic disorder; subjective distress caused by the psychic disorder either to the child or to the family leading to a call for medical help (consultation, medication, hospitalisation, institutionalisation). Each item was scaled on four degrees of impairment (no impairment, mild, moderate, severe); each degree was described behaviourally. The total severity score ranged between 0 and 21 with the following categories: normal (O-4), mild (5-10) moderate (ll-16), severe (17-21). Inter-rater reliability of the scale calculated on a sample of 35 children seen in clinical practice by three raters was 0.91. (3) Statistical methods t and x2 tests were used

for comparing

2

STRUCTURE

OF THE PSYCHOPATHOLOGY

Diagnosis

Non-bipolar depressive disorders Bipolar disorder Suicide attempt Anorexia nervosa Anxious disorders

Total proband sample

IN PROBAND Total control sample

8% (6)

1% (1)

AND CONTROL

Proband girls

1% 1% 1% 12%

(ROUNDED

PERCENTAGES)

Proband boys

Control boys

3% (1)

0%

0%

0% 0% 0%

0% 0% 0%

0% 0% 0%

5% (2)

9% (3)

3% (1)

3% (1)

29% (10)

P -c0.05 0% 0% 0%

(1) (1) (1) (9)

Control girls

16% (6)

P < 0.05

CHILDREN

4% (3)

3% 3% 3% 16%

(1) (1) (1) (6)

7% (5)

13% (5)

P c.0.05 ADDH

21% (15)

P < 0.001 Conduct disorders Oppositional disorder Personality disorders Identity disorder Disorders with physical manifestations Mental retardation N

the

11%

(8)

7% (5) 0%

3% (2) 12% (9)

3% (2)

3% (1)

0%

3% (1) 21% (8)

0%

P -c0.05

21%

(7)

15% (5)

5% (2)

3% (1) 3% (1)

0% 0%

3% (1)

0%

0%

5% (2) 0%

6% (2) 6% (2)

6% (2) 3% (1)

P < 0.05

0%

1% (1)

8% (6) 3% (2)

6% (4) 1% (1)

72

12% (4)

P -T0.05

72

0% 11% (4) 0% 38

38

34

34

172

frequency of different disorders and overall rates of psychopathology in P and C samples, as well as in a nationwide sample. Simultaneous and stepwise multiple regressions and one-way analysis of variance were used for identifying variables with significant effect on the severity of the psychopathology in children. Canonical discriminant analysis for classificatory and descriptive purposes was used when comparing disordered and non-disordered P groups of children with respect to individual and familial characteristics that best discriminate between them. Results (I) Structure of the psychopathologv in proband and control children Table 2 displays the structure of the point prevalence of the disorders found in P and C children. Comparison between P and C samples indicates significant differences for: depressive disorders of the non-bipolar type (unipolar major depression, minor depression, dysthymic disorder), anxious disorders (overanxious disorder, phobic disorder, avoidant disorder, adjustment reaction with anxious mood, unspecified non-depressed emotional disorder, simple phobias), ADDH and personality disorders (hyperthymic, histrionic, avoidant, schizotypal). Comparison by sex between P and C offspring shows significant differences for depressive disorders (non-bipolar type) and personality disorders in girls and for ADDH in boys. (2) Overall rates of psychopathology Table 3 shows the point prevalence of psychopathology without taking into account the degree of impairment caused by the disorder to the child’s adaptive functioning in P and C samples, as well as in a group of 6019 children aged lo-16 extracted from a sample of 15 300 subjects aged 1-16 investigated in an epidemiological national study using DSM-III criteria and four sources of information about the child (Christodorescu et al., 1984). (Though both current and past symptoms were recorded, past symptoms seemed sometimes

TABLE

3

OVERALL RATES OF BAND AND CONTROL CENTAGES) Sample

Total proband sample (n = 72) Total control sample (n=72) National study (n = 6019)

PSYCHOPATHOLOGY IN CHILDREN (ROUNDED

No diagnosis

l-3 diagnoses

39%

61%

(28) 75%

(44) 25% 1

PROPER-

x2

P < 0.001

(54) 83% (5032) Variation of psychopathology rate among different counties: 12%21%

Proband girls (n = 38) Control girls (n = 38) Girls in national study (n = 3086) Proband boys (n=34) Control boys (n=34) Boys in national study (n = 2933)

37%

63%

(14) 76%

(24) 24%

(29) 86% (2665)

(9) 14% (421)

P i 0.001

NS i

41%

59%

(14) 73%

(20) 37% i

(25) 81% (2367)

(9) 19%

P < 0.01

NS

(566)

to be doubtful to allow reliable diagnoses and reliable figures of lifetime prevalence.) The comparison between the total P and C samples, as well as the comparison made by sex, indicates a clear prevalence of psychopathology in P offspring, while the rates in the C samples do not differ significantly from the rates in the national sample. Table 4 presents the overall rates of psychopathology as a function of the severity of the psychopathology in an empirical classification based on categories determined by row scores of severity of the psychopathology, as well as in a dichotomous classification based on canonical discriminant analysis with linear classification function in which predictors were the three criteria involved in the definition of the severity of the psychopathology. Empirically we have combined the group of normal P offspring with the P group with mild

173 TABLE 4 SEVERITY OF PSYCHOPATHOLOGY IN PROBAND DISCRIMINANT ANALYTIC CLASSIFICATION Sample

AND CONTROL

CHILDREN.

EMPIRICAL

AND CANONICAL

Empirical classification Normal

Total proband sample

28 (39%)

Total control sample

54 (75%)

X2 Disordered Mild

Moderate

10 (14%)

22 (30%)

38 (53%)

Severe 12 (17%) 34 (47%) P < 0.001

6 (8%) 60 (83%)

9 (13%)

3 (4%) 12 (17%)

Canonical discriminant analytic classification

Total proband sample Total control sample

Non-disordered

Disordered

32 (44%)

40 (56%)) P < 0.001

58 (81%)

14 (19%) i

Figures in parentheses are rounded percentages.

psychopathology overlooking the minor psychosocial impairment associated with the disorders included in this category. This results in the reduction of the psychopathology rates both in P (from 61% to 47%) and in C (from 25% to 17%) samples. Classification based on canonical discriminant analysis, where posterior probabilities of group membership decided the inclusion in one of the groups, was less permissive than the empirical classification; the psychopathology rate decreased by only 5% in both the P and C samples. But the differences between the two samples still remained highly significant, when comparing both total and sex-divided samples. (3) Relationship between the sex and age structure of the psychopathology in proband children and the sex of the bipolar parent As shown in Table 5 we tried to relate the psychopathology structure and psychopathology rates in offspring of BP parents to the sex and age group of the child and to the sex of the BP parent. (Psychopathology rates presented in this Table must be regarded with caution because dividing the total sample according to three simultaneous

criteria (age and sex of the child and sex of the BP parent) results in small size groups.) In Table 5 the assignment of children to the disordered groups was based on the classificatory canonical discriminant linear function which considered 40 children as disordered versus 44 considered disordered by the empirical classification. Each child was counted once in the diagnostic category that most contributed to his/her psychopathology score regardless of the number of diagnoses made in the child. The psychopathology rates do not differ either as a function of the sex of the child or the sex of the ill parent. The psychopathology rates are close to 50% in all age groups, except the boys in the age group 10-12, who display a higher rate, but this may occur by chance. As to the structure of psychopathology the prevalence of the depressive and anxious disorders in girls and the prevalence of ADDH and conduct disorders in boys whatever the sex of the ill parent is evident. The frequency (and severity of the types) of depression tends to increase with age (four non-bipolar depression cases including major depression and dysthymia and one case of BP

174 TABLE

5

STRUCTURE THE CHILD

OF THE PSYCHOPATHOLOGY IN PROBAND AND THE SEX OF THE BIPOLAR PARENT Bipolar

Female children

Male children

Figures

(n = 38)

(n = 34)

in parentheses

are rounded

CHILDREN

father (n = 19)

AS A FUNCTION

Bipolar

mother

OF THE SEX AND AGE OF

(n = 28)

Age 10-12: n = 8 Disordered: 4 (50%) - Depressive disorders: 2 (25%) (minor depression: 2) - Anxious disorders: 2 (25%)

Age 10-12: n = 12 Disordered: 6 (50%) - Depressive disorders: 0 - Anxious disorders: 3 (25%) - Conduct disorders: 1 (8%) - ADDH: 2 (16%)

Age 13-17: n = 9 Disordered: 5 (55%) - Depressive disorders: 4 (44%) (unipolar major depression: 1, dysthymia: 2, minor depression: 1) - Personality disorders: 1 (11%) (histrionic)

Age 13-17: n = 9 Disordered: 5 (55%) - Depressive disorders: 1 (11%) (bipolar major depression: 1) - Anxious disorders: 1 (11%) - Personality disorders: 3 (33%) (histrionic, hyperthymic, avoidant)

Age 10-12: n = 7 Disordered: 5 (71%) - Depressive disorders: 0 - Anxious disorders: 1 (14%) - ADDH: 4 (57%)

Age 10-12: n = 7 Disordered: 6 (85%) - Depressive disorders: 0 - Anxious disorders: 1 (14%) - ADDH: 3 (43%) - Conduct disorders: 2 (28%)

Age 13-17: n = 5 Disordered: 3 (60%) - Depressive disorders: 0 - Anxious disorders: 1 (20%) - Conduct disorders: 1 (20%) - Mental retardation: 1 (20%)

Age 13-17: n = 15 Disordered: 6 (40%) _ Depressive disorders: 0 - Anxious disorders: 0 - Conduct disorders: 4 (27%) - ADDH: 1(6%) - Personality disorder: 1 (6)

percentages.

depression in the age. group 13-17 versus two cases of minor depression in the age group 10-12). Anxious disorders seem to be more frequent than depressive disorders in the younger age group 10-12. (4) Correlates of the severity of the psychopathoIogV in children A first group of multiple regressions performed on the P group considered the severity of the psychopathology in children as criterion and the following variables as predictors: severity of the illness of the BP parent, psychopathological status of the non-BP parent, number of manic and mixed episodes and number of depressive episodes of the BP parent, age of the BP parent at the onset of the illness, parental attitudes of both parents (com-

bined score), number of years spent by the child with the BP parent. Because the results of the regressions did not vary with the number of predictors introduced stepwise (at least five, at most seven), Table 6 shows a regression in which all the above-mentioned predictors were introduced. As indicated by significance levels of the weighting coefficients the severity of the psychopathology in children is significantly correlated with the severity of the illness of the BP parent, the presence of the psychopathology in the non-BP parent, number of manic and mixed episodes of the BP parent and age of the BP parent at the onset of the illness. Number of depressive episodes of the BP parent and number of years spent together with the BP parent did not prove to be significant. The same lack of significance is valid

175 TABLE 6 STEPWISE MULTIPLE TORS AND SEVERITY

REGRESSION WITH PARENTAL ILLNESS AND ENVIRONMENTAL OF THE CHILD’S PSYCHOPATHOLOGY AS CRITERION

VARIABLES

AS PREDIC-

Predictor

t for weighting coefficients

R

Severity of the illness of the bipolar parent Psychopathological status of the non-bipolar parent Number of manic and mixed episodes of bipolar parent Age of the bipolar parent at the onset of the illness Number of depressive episodes of the bipolar parent Parental attitudes Number of years spent with the bipolar parent

- 2.94

0.578 F = 5.29 df-7with64 P c 0.01 n = 72

for parental attitudes. In regressions where the variable ‘severity of the BP illness’ was not introduced, parental attitudes appeared to be linked to the severity of the psychopathology in children. One-way analysis of variance was applied to study the relationship between the severity of the psychopathology in children and the following variables: the type of familial psychopathology in first-degree relatives of the BP parent, sex of the BP parent, familial atmosphere, socio-cultural level of the family. Type of familial psychopathology in first-degree relatives of the BP parent determined four groups of P children: group I, 31 children whose BP parents had no psychopathology in their first-degree relatives; group II, 18 children whose BP parents had first-degree relatives with an affective disorder; group III, eight children whose BP parents had first-degree relatives with non-affective diagnoses; group IV, 15 children whose BP parents had first-degree relatives with unspecified psychiatric diagnoses. The F test (F = 4.75, df = 3 with 68, P < 0.01) indicated a significant link between the severity of the psychopathology in children and the presence of psychopathology in the first-degree relatives of the BP parent, but there was no significant difference in the severity of the psychopathology among the three groups of children with familial psychopathology according to the type of psychopathology. The sex of the BP parent had no significant effect on the severity of the psychopathology in children (F = 0.094, df = 1 with 70).

2.71 2.44 2.02 0.64 0.58 0.71

P P P P

i c < <

0.01 0.01 0.02 0.05

NS NS NS

Familial atmosphere assessed according to the three criteria mentioned in the Method section was briefly characterised as: peaceful, tensioned without manifest conflicts, conflicting with verbal violence, conflicting with verbal and physical violence. The effect of the familial atmosphere on the severity of the psychopathology in children was significant (F = 4.54, df = 3 with 140, P < 0.01) due to the important contribution of the extreme groups to the variance. The general effect of the socio-cultural level of the family on the severity of the psychopathology in children was supported by an F-value of 5.22, df = 2 with 141, P < 0.01. The lower socio-cultural levels (1 and 2 in our five-class stratification) were associated with more severe psychopathology in children, while the severity of the psychopathology did not significantly vary among the mean and high levels. (5) Comparison between disordered and non-disordered proband offspring (canonical discriminant analysis) Comparison according to variables describing the psychopathological status of the parents and familial environment. For this comparison the classification of P offspring into disordered (n = 40) and non-disordered (n = 32) provided by canonical

discriminant analysis was used because it had the advantage of taking into account the intra-familial correlation of the severity of the psychopathology classifying into the same group both members of four sibling pairs that were assigned to different

176

groups in the row score classification. Siblings included in different groups could affect the discriminant function by having parents with the same characteristics. Since none of the statistics used in canonical discriminant analysis to select and order the contribution of different variables to the group separation is free of criticism (Huberty, 1984) we used three statistics at the same time (within-structure coefficients, standardized weights, and F to remove values) and we interpreted that contribution pattern which was supported by at least two statistics. At this point we summarise the results of several stepwise canonical discriminant analyses in which combinations of five variables describing both the psychopathological status of the parents and familial environment were used. The non-disordered P group differed significantly from the disordered group in all combinations (F varied between 4.05 and 4.52, df = 5 with 66, P -c 0.01; canonical correlations for the first linear canonical function varied between 0.50 and 0.53, P < 0.001). The best discriminants between the two groups were (P levels are given for structure coefficients and F to remove): severity of the illness of BP parent (P < O.OOl), number of manic and mixed episodes of the BP parent (P -c O.Ol), presence of the psychopathology in the non-BP parent (P -e

TABLE

0.05) and age of the BP parent at the onset of the illness (P < 0.05). The number of depressive episodes of the BP parent, parental attitudes, and number of years spent with the BP parent did not significantly contribute to the differentiation of the groups. Canonical discriminant analysis using personality variables and IQ as discriminants. A second type of descriptive stepwise canonical discriminant analysis used as discriminants between the disordered and the non-disordered P groups personality variables (anxiety (A), emotional stability (S), tolerance to frustration (TF), depressive reactivity (D), introversion (I), egocentrism (E), emotional sensitivity and involvement (R), perfectionism (P)) and IQ as individual resources. Two versions of canonical discriminant analysis were performed considering the two types of classification of P offspring into disordered and nondisordered. Since the results were very similar, Table 7 presents the canonical discriminant analysis based on the row score classification (28 children with no diagnosis and 44 children with any diagnosis). The difference between the two groups was significant (F= 5.31, df = 9 with 62, P < 0.01, canonical correlation = 0.59, P < 0.001). Agreement between the patterns of contribution of the personality variables to the separation of the two

7

COMPARISON BETWEEN DISORDERED NANT ANALYSIS WITH PERSONALITY

AND NON-DISORDERED PROBAND TRAITS AND IQ AS VARIABLES)

OFFSPRING

(CANONICAL

Variable

Standardised weights

Structure coefficients

PC

z,a

Xb2

t

A S TF D I E R P

0.662 - 0.308 0.747 0.274 0.069 - 0.074 -0.244 - 0.241 - 0.109

0.264 - 0.717 0.782 0.216 - 0.017 0.496 - 0.249 - 0.454 - 0.193

< 0.05 i 0.001 < 0.001 NS NS < 0.01 = 0.05 < 0.01 NS

7.92 17.84 7.08 3.92 11.60 9.44 14.76 6.52 95.84

9.78 11.90 12.02 5.61 11.50 12.52 13.21 4.09 92.45

P < 0.05

IQ

F = 5.31, df = 9 with 62, P < 0.01 a w,, mean value for the non-disordered proband group. b x,, mean value for the disordered proband group. ’ P refers to the significance of structure coefficients.

DISCRIMI-

P < 0.001 P < 0.001 NS NS

P i 0.01 NS

P = 0.01 NS

171

groups yielded by structure coefficients and standardised weights is high. Only the importance of D and E variables is different in the two patterns and for a final decision the t test for the difference between the mean scores was considered. According to the structure coefficient pattern the most important difference between disordered and non-disordered P offspring is made by emotional stability, tolerance to frustration, egocentrism and perfectionism, anxiety and emotional sensitivity and involvement. A cluster analysis of personality traits of P children as compared with C children aimed at looking for personality structures or traits specific to P children was described elsewhere (Serbanescu-Grigoroiu et al., 1988). Discussion The overall rate of psychopathology of 61% found in our sample of children of BP parents is close to figures reported by other studies which used DSM-III diagnostic criteria (Decina et al., 1983; Gershon et al., 1985; Kashani et al., 1985). This rate decreased when the severity of psychopathology was evaluated as a function of the impairment caused by the psychiatric disorder to the psychosocial functioning of the child; the decrease was more important in an empirical combination of the non-disordered P group with the mild psychopathology P group (from 61% to 47%) but less important (from 61% to 55%) when a sophisticated method of classification of P children into disordered and non-disordered such as canonical discriminant analysis was used. The male or female sex of the BP parent was not associated with significantly different psychopathology rates in either male or female offspring. Compared to previous studies, the rate of nonbipolar depressive disorders in our P sample was lower (8.33%) as against 30% depression in the study by M&new et al. (1979), 63% depressive disorders in the study by Cytryn et al. (1982), 48% depressive disorders in the study by Gershon et al. (1985). As regards the major depression it reached also low figures (1.39% unipolar depression, 1.39% bipolar depression and 2.77% unipolar and bipolar depression in the P sample and 0% in the C

sample), while Cytryn et al. (1982) indicated 16% major depression in 19 children of BP parents and 4.76% in 29 C children. Gershon et al. (1985) found 10% major depression in P children (three of 29) and 14% in 37 C children using DSM-III criteria. Our depression figures both in P and C samples could be explained by: the larger size of the samples, the computation of point prevalence instead of lifetime prevalence, cultural factors expressed in the attitude of perceiving and reporting internalising symptoms in the children. These symptoms are paid less attention and they are reported when they markedly hamper the child’s functioning for a longer period. The depressive disorders figure found in our C sample (1.39%) is compatible with figures found in epidemiological studies both on the Romanian population and on other populations, e.g., the study by Rutter (1986) in the Isle of Wight. In our national study (Christodorescu et al., 1984) depressive disorders diagnosed according to DSM-III criteria reached 0.68% in the age group lo-11 (1935 children) and 0.79% in the age group 12-16 (4084 children). Rutter (1986) found 0.15% depressive disorders at age 10 in a sample of 2000 children and 0.45% ‘pure depressive disorders’ or 1.75% ‘mixed affective disorders’ in the same sample 4 years later. The distinction between the clinical and subclinical level of depression deserves special attention. Treating this issue elsewhere (SerbanescuGrigoroiu et al., 1988) we found that depressive reactivity as a personality trait (subclinical level) is more widespread than depressive disorders both in P and C children (22% vs. 15%). In the present study we have differentiated the two levels of depression. Analysing the relationship between depression in children and their age group it emerged that generally, the frequency of depression and also the frequency of more severe types of depression such as major depression increased with increasing age. That was valid for girls, who are more often affected by depression than boys. A striking similarity was found between our study and Rice et al.‘s study (1987) as to the rate of BP illness in offspring (1.39% in our study and 1.5%/1.6% in Rice et al. study which included offspring of different ages).

178

The severity of psychopathology in children is undoubtedly a function of multiple factors. We tried to analyse some factors related to the mental status of the parental couple, familial psychopathology and familial environment. We also considered the number of years spent by the child with the BP parent. When considering all these factors in their joint action modelled statistically by multiple regression we found that the environmental factors studied by us lost their significance for the severity of psychopathology in children though familial atmosphere proved to have a significant effect on the severity of psychopathology in the combined sample of P and C children when it was analysed separately in one-way analysis of variance. But the extremely violent and insecure atmosphere which most contributed to the variance was also dependent on the mental status of the parents. Our findings are in line with the data reported by Parker (1979) and Joyce (1984) in adult studies which have shown that poor parental bonding is of little ‘aetiological relevance in bipolar disorder’. Analysis of personal resources as expressed by personality traits differentiated the disordered P offspring from the non-disordered ones in that non-disordered subjects appeared more stable and involved emotionally, more perfectionistic, less egocentric and anxious. These personality traits are the support for good social adjustment and achievement and they are strikingly similar to traits described in retrospective assessments of the premorbid personality of adult BP patients (Akiskal et al., 1983). On the contrary, the group of P children displaying psychopathology at an early age was characterised by a set of traits that could be integrated in a more general factor called instability (emotional instability, intolerance to frustration, shallowness in school work and other activities and interpersonal relationships, more prone to anxiety). This supports the theory of Akiskal (1985a) about ‘ temperamental instability’ as a vulnerability factor for affective disorders. A long-term follow-up of our samples could relate the above-mentioned results concerning personality traits in offspring of BP parents to an older hypothesis of Cadoret et al. (1971) according to which an association would exist between premorbid personality traits and early or late onset of the affective illness.

Acknowledgements The authors are grateful to Drs. Rodica NSstase, Anca Sirbulescu, Corneliu Constantinescu and Elena Gherman for their help in performing the present work. They are also indebted to Mr. Stelian Popa for mathematical assistance.

References Akiskal, H.S. (1985a) Interaction of biologic and psychologic factors in the origin of depressive disorders. Acta Psychiatr. Stand. Suppl. 319, 131-139. Akiskal, H.S. (1985b) Affective disorders in referred children and younger siblings of manic-depressives. Arch. Gen. Psychiatry 42, 996-1003. Akiskal, H.S., Hirschfeld, M.A. and Yerevanian, B.I. (1983) The relationship of personality to affective disorders. Arch. Gen. Psychiatry 40, 801-810. American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. American Psychiatric Association, Washington DC. Beardslee, W.R. (1986) The need for the study of adaptation in the children of parents with affective disorders. In: M. Rutter, C.E. Izard and P.B. Read @Is.), Depression in Young People. Developmental and Clinical Perspectives. Guilford Press, New York, NY, pp. 189-204. Bertelsen, A., Harvald, B. and Hauge, M. (1977) Danish twin study of manic-depressive disorders, Br. J. Psychiatry 130, 330-351. Cadoret, R.J., Baker, M. and Dorzab, J. (1971) Depressive disease: personality factors in patients and their relatives. Biol. Psychiatry 3, 85-93. Christodorescu, D., Serb%nescu-Gtigoroiu, M., Cantili, L., Nedelcu, H. and Jost, L. (1984) Frequency of the psychic and neuropsychic disorders in children and adolescents from 1 to 16 years of age in Romania. Unpublished manuscript. Cytryn, L., McKnew, D.H., Bartko, J.J., Lamour, M. and Hamovit, J. (1982) Offspring of patients with affective disorders, Part 2. J. Am. Acad. Child Psychiatry 21, 389-391. Cytryn, L., M&new, D.H., Zahn-Waxier, C. and Gershon, E.S. (1986) Developmental issues in risk research: the offspring of affectively ill parents. In: M. Rutter, C.E. Izard and P.B. Read (Eds.), Depression in Young People. Developmental and Clinical Perspectives. Guilford Press, New York, NY, pp. 163-187. Decina, P., Kestenbaum, C.J., Farber, S., Kron, L., Gargan, M., Sackeim, H.A. and Fieve, R.R. (1983) Clinical and psychological assessment of children of bipolar probands. Am. J. Psychiatry 140, 548-553. Gershon, E.S., Numberger, J.J., Nadi, N.S., Berrettini, W.H. and Goldin, L.R. (1983) Current status of genetic research in affective disorders. In: J. Angst (Ed.), The Origins of

I79 Depression: Current Concepts and Approaches. Springer, Berlin, pp. 187-204. Gershon, E.S., M&new, D.H., Cytryn, L., Hamovit, J., Schreiber, J., Hibbs, E. and Pellegrini, D. (1985) Diagnoses in school-age children of bipolar affective disorders patients and normal controls. J. Affect. Disord. 8, 283-291. Huberty, C.J. (1984) Issues in the use and interpretation of discriminant analysis. Psychol. Bull. 95, 156-171. Joyce, P.R. (1984) Parental bonding in bipolar affective disorder. J. Affect. Disord. 7, 319-324. Kashani, J.H., Burk, P.J., Horvitz, B. and Reid, J.C. (1985) Differential effect of subtypes of parental major affective disorder on children. Psychiatr. Res. 15, 195-204. Von Knorring, A.L., Cloninger, R., Bohman, M. and Sigvardson, S. (1983) An adoption study of depressive disorders and substance abuse. Arch. Gen. Psychiatry 40, 943-950. Longeot, F. (1974) Les Tests Operatoires Collectifs. I.N.O.P., Paris. M&new, D.H., Cytryn, L., Efron, A.M., Gershon, E.S. and Bunney, W.E. (1979) Offspring of patients with affective disorders. Br. J. Psychiatry 134, 148-152. Mendlewicz, J. and Rainer, J.D. (1977) Adoption study supporting genetic transmission in manic-depressive illness. Nature 268, 327-329. Parker, G. (1979) Parental characteristics in relation to depressive disorders. Br. J. Psychiatry 134, 138-147. Puig-Antich, J., Orvaschel, H., Tabrizi, M.A. and Chambers, W.J. (1981) Schedule for affective disorders and schizophrenia for school-age children - Epidemiologic Version,

K-SADS-E, 3rd Working Draft. Department of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY. Rice, J., Reich, T., Andreasen, N.C., Endicott, J., Van Eerdewegh, M., Fishman, R., Hirschfeld, R.M.A. and Klerman, G.L. (1987) The familial transmission of bipolar illness. Arch. Gen. Psychiatry 44, 441-447. Rutter, M. (1986) The developmental psychopathology of depression: issues and perspectives. In: M. Rutter, C.E. Izard and P.B. Read (Eds.), Depression in Young People. Developmental and Clinical Perspectives. Guilford Press, New York, NY, pp. 3-30. Schneider, K. (1950) Die psychopatischen Persiinlichkeiten. Franz Deutike, Vienna. Serb?inescu-Grigoroiu, M. (1981) Personality inventory for psychopathologic use. Neural. Psychiatry (Rom. J. Med.) 19, 53-65. Serbanescu-Grigoroiu, M. (1987) A brief inventory for assessing personality traits and disorders in children aged 8-11. Neurol. Psychiatry (Rom. J. Med.) 25, 41-56. Serbtiescu-Grigoroiu, M. (1988) A rating scale for the severity of psychopathology in children. Neurol. Psychiatry (Rom. J. Med.) (in press). Serbanescu-Grigoroiu, M., Christodorescu, D., Totoescu, A., Marinescu, E. and Ardelean, V. (1988) Depressive disorders and depressive personality traits in offspring aged lo-17 of bipolar I and normal parents. J. Youth Adolesc. (in press). Torgersen, S. (1986) Genetic factors in moderately severe and mild affective disorders. Arch. Gen. Psychiatry 43, 222-226.