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. Author manuscript; available in PMC: 2022 Mar 1.
Published in final edited form as: J Psychopathol Behav Assess. 2020 Nov 3;43(1):84–94. doi: 10.1007/s10862-020-09848-x

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

Tina D Du Rocher Schudlich 1, Chase Ochrach 2, Eric A Youngstrom 3, Jennifer K Youngstrom 4, Robert L Findling 5
PMCID: PMC8011526  NIHMSID: NIHMS1643786  PMID: 33814696

Abstract

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

Keywords: Bipolar disorder, family, children and adolescents, perceived criticism, sensitivity to criticism

Bipolar Spectrum Disorders (BPSD) encompass bipolar I (lifetime history of at least one manic or mixed episode), bipolar II (history of at least one hypomanic and one major depressive episode), cyclothymic disorder (at least a year with no more than two months symptom free, marked with hypomanic and depressive symptoms that do not reach threshold for mania or major depression), and bipolar Not Otherwise Specified, which could fail to meet full criteria based on duration or symptom count (American Psychiatric Association, 2013). Certain family factors can increase risk for BPSD. These can reflect genetic factors (Smoller & Finn, 2003), environmental risk factors, or more proximal interpersonal interactions (Mesman et al., 2016). Adverse early-life events, including family disruption and parental psychopathology, have both been linked to increased risk for BPSD development in adults (Bergink et al., 2016). Family systems theory posits that the family system achieves homeostasis through interdependence, circular patterns of behavior and communication, and stable features (Minuchin, 1985). Both normative and disordered functioning in youth are considered shared experiences which impact and are influenced by all members of the system (Cox & Paley, 1997). Family risk factors are thus paramount to understanding individual youth functioning. For example, parental depression and BPSD related to poor family functioning and greater family conflict, which associated with child-onset BPSD (Du Rocher Schudlich, Youngstrom, Calabrese, & Findling, 2008). Further, history of suicide attempts and more frequent hospitalizations associate with low family cohesion and low parental care, respectively, in adults with BPSD and their families (Cooke, Young, Mohri, Blake, & Joffe, 1999). Thus, family relationships may increase risk for the development and severity of BPSD.

Expressed Emotion

Expressed emotion (EE) is a construct representing the extent of critical, hostile, and/or emotionally over-involved attitudes expressed by a family member about a psychiatric patient in the patient’s absence (Hooley & Hoffman, 1999). This hostility and overinvolvement is also expected to permeate interactions between family members and the patient. Research on adults shows that stressful interpersonal interactions, including high expressed negative emotion, may be related to the onset of mood disorders (Hooley & Hiller, 2001), as well as poorer treatment response (STEP-BD) and faster relapse (Perlis et al., 2004). Several studies have linked high EE emotions in relatives with depressive and manic episodic relapse in adults with BPSD (Miklowitz, 2007; Yan, Hammen, Cohen, Daley, & Henry, 2004). Additional studies of adults suggest manic symptoms, depressive symptoms and hospital admissions may be more likely when families are high in EE compared to when families are low in EE (Miklowitz, Goldstein, Nuechterlein, Snyder, & Mintz, 1988).

Less is known about the relationship between EE and BPSD in youth populations. Parents of youth with BPSD who had high EE reported lower family cohesion and lower family adaptability compared to parents with low EE (Miklowitz et al., 2009). In a sample of both youths and adults with BPSD and their families, high EE was associated with negative affective style and higher rates of relapse (Reinares et. al, 2016). Overall, evidence suggests that EE could be linked with the course and symptoms of BPSD, starting in youth.

Perceived Criticism

Perceived criticism (PC) is a dimension of EE that measures the amount of criticism and overprotectiveness an individual perceives from a family member’s behaviors (Masland & Hooley, 2015). PC differs from the broader construct of EE in that it only measures criticism, whereas EE in general includes hostility, emotional overinvolvement, overprotectiveness, and rejection in addition to criticalness (Hooley, 2007). Adults with bipolar disorder responded with higher levels of negative affect and lower levels of vigor compared to controls when criticized by strangers (Cuellar, Johnson, & Ruggero, 2009).

As with EE, there is less research on the correlations between PC and youths compared to adult populations. Research on the effects of each EE and PC on youths with BPSD suggests family factors may be related to expressed symptoms. In a sample of adolescents from a residential treatment facility, perceived caregiver criticism correlated with various forms of psychopathology and emotion dysregulation (Whalen, Malkin, Freeman, Young, & Gratz, 2015). Both adolescents and adults with bipolar disorder who experienced symptomatic relapse received harsher criticisms from relatives compared to controls (Rosenfarb et al., 2001). In another sample of adolescents and adults, patients who reported greater distress in response to perceived criticism from relatives experienced more severe manic symptoms at follow-up compared to patients who were less distressed by the criticism (Miklowitz, Wisniewski, Miyahara, Otto, & Sachs, 2005). Thus, PC has been associated with the expression of manic and depressive symptoms and the ways adults and youths with BPSD relate to their family members.

A related dimension of EE is sensitivity to criticism (SC), which is understood as the extent to which an individual perceives a situation as a criticism and how hurt they feel in response to such criticism (Cutting, Aakre, & Docherty, 2006; Hooley & Teasdale, 1989). An additional consideration regarding the potential relationship between PC and SC and youth symptoms is based on the tendency for individuals with BPSD to experience greater mood lability as well as the documented relationship between higher distress in response to criticism and more severe manic symptoms in individuals with BPSD (American Psychological Association, 2013; Hantouche et al., 1998; Miklowitz et al., 2005). Presumably, higher irritability at baseline may lead to stronger reactions to perceived criticism from family members, particularly for youth with higher sensitivity to this criticism. Furthermore, the adult literature suggests PC and SC may relate to worse functioning in cases of BPSD compared to other diagnoses (Miklowitz et al., 2005; Yan et al., 2004). These aforementioned findings from the adult literature support the possibility that PC and SC will yield similar effects in youth.

Moreover, previous research suggests youth with BPSD report significantly lower quality of life scores compared to youth with other medical and psychiatric diagnoses (Freeman, Youngstrom, Michalak, Siegel, Meyers, & Findling, 2009). Youth with BPSD also tend to experience more mood lability compared to youth with unipolar depression and high rates of suicidality, both of which are associated with poor family functioning (Algorta, Youngstrom, Frazier, Freeman, Youngstrom, & Findling, 2011). These findings suggest that criticism and SC may be more closely associated with functioning for youth with BPSD compared to youth with other psychiatric diagnoses.

Historically, PC has been examined in patients as a global construct considering family criticism of patients and patients’ sensitivity, rather than broken down into its component elements: perception of criticism expressed by close others, and the sensitivity the patient experiences in response to that criticism (Hooley, 2007). Our study, with its focus on greater specificity of the various PC elements, will elucidate which aspects of this construct may be most detrimental to individual and family functioning and may be helpful to pinpoint specific directions for clinical intervention. To our knowledge, no studies to date have examined the specific components of PC discretely, and thus our analysis is exploratory.

Current Study

Although research extensively explores EE and PC for adult populations, less is known about these constructs in families of children and adolescents with BPSD. We extended the traditional definition of PC to include the additional dimensions of youth criticism of caregivers and caregiver sensitivity because we hypothesize that youth criticalness may contribute to more pervasive family dynamics of criticism and rejection. This extension allows for a fuller consideration of the associations between youth BPSD and family dynamics, especially youth contributions to problematic family interactions. The reciprocal criticism and hostility may cause distress for the youth which may impact specific symptoms and general functioning. Furthermore, we used parent-report data only for this study to attempt to understand caregivers’ and youths’ use of and response to criticism from the perspective of the caregiver.

In the present study, our first aim was to determine if PC and SC related to early-onset BPSD and higher severity of symptoms consistent with findings from adult data. We were curious about the relationship between PC and BPSD in particular as it has been minimally explored in both youth and adults, yet the literature supports a connection between EE (of which PC is a dimension) and BPSD (Miklowitz, 2007; Yan et al., 2004). Further, much of the existing literature conceptualizes BPSD within a diathesis-stress model, suggesting interpersonal stress in the form of PC may be related to depressive or manic episodic relapse (Renshaw, 2008). Specifically, we hypothesized that higher levels of PC and SC would be associated with a worse clinical picture (i.e., more severe mood symptoms, worse global functioning, and higher suicidality) for youth. Our second aim was to examine the extent to which PC and SC were associated with this more severe symptomatic profile specifically within cases having BPSD compared to cases without BPSD (consistent with the adult literature), to determine if the association was unique to BPSD. Based on previous findings that youth with BPSD may experience more severe symptoms and worse family functioning (Algorta et al., 2011; Freeman et al., 2009), we hypothesized that criticism and SC would be significantly associated with BPSD more strongly than other clinical diagnoses, such as Depression, Anxiety, and ADHD.

Method

Procedures

The institutional review boards of all institutions involved in the project reviewed and approved the procedures. Participants were recruited through either a community mental health center where all families were invited to participate in the study at intake or an enriched sample drawn from a university research center where families were referred by a study coordinator based on the family’s interest in a mood disorders assessment. More than two thirds of the sample consisted of families presenting to the Midwest urban community mental health center where they were seeking treatment for their child. All guardians provided written consent and youths provided written assent prior to completing study procedures. Families were included if they could complete the assessments in English and youth were not diagnosed with a pervasive developmental disorder. The present paper is a secondary analysis of a subset of the variables.

Participants

Participants were 828 youths who ranged in age from 4 years 11 months to 18 years 0 months (M=10.9, SD=3.4). Approximately 60% were male; 69% were African American, 22% Caucasian, 2% Hispanic, and 6% other racial/ethnic minorities or biracial groups. The median family annual income was $12,500, with a range from $5,000 or less, up to $150,000-$200,000. Parents had on average a high school graduate education. The sample included 153 participants (18.5%) who met criteria for bipolar spectrum disorders, 229 (27.7%) for unipolar depression, 364 (44%) for disruptive behavior disorders, 59 (7.1%) for other diagnoses, such as various anxiety and adjustment disorders, and 15 (1.8%) did not meet criteria for a diagnosis. Parent income and education did not vary as a function of child bipolar status. Table 1 presents means and standard deviations for key variables as a function of bipolar status.

Table 1.

Means and Standard Deviations for the Full Sample

Youth with Bipolar n = 153 Youth without Bipolar n = 675
M (SD) M (SD)
Parent Reports
 Caregiver Critical of Youth 5.47 (2.43) 5.46 (2.73)
 Youth Critical of Caregiver 5.98 (2.83)a 5.26 (2.91)b
 Youth Sensitive to Criticism 7.32 (2.64)a 6.42 (2.95)b
 Caregiver Sensitive to Criticism 4.70 (2.76)a 4.41 (2.83)b
 Family Assessment Device 2.08 (.46) 1.99 (.43)
Depression z Score .76 (.85)a −.17 (.80)b
Mania z score 1.24 (.78)a −.28 (.56)b
KSADS Mood Lability 3.04 (1.35)a 1.51 (.90)b
GFES 65.61 (13.03)a 68.46 (11.28)b
CGAS current 47.70 (6.53)a 53.69 (8.56)b
Suicidality .74 (.69)a .46 (.62)b
Number of Diagnoses 4.39 (1.78)a 3.57 (1.67)b
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Note.

Columns with differing superscripts (a, b) are significantly different from one another based on two-tailed, independent samples t-tests, p < .05.

KSADS = Kiddie Schedule for Affective Disorders and Schizophrenia; GFES = Global Family Environment Scale; CGAS = Child Global Assessment Scale.

Criterion Diagnoses

Longitudinal Expert Evaluation of All Data (LEAD) Diagnoses.

(Spitzer, 1983). Highly trained raters completed the Kiddie Schedule of Affective Disorders and Schizophrenia-Present and Lifetime version (Kaufman et al., 1997), augmented with the depression and mania modules of the Washington University version (Geller et al., 2001). Clinicians administered the interview to parents and youth sequentially. Data collection varied across participants, with some being able to finish in one visit, whereas others with more complex histories, took two visits. Even young children were directly interviewed for at least an hour, providing an opportunity to observe the child and form direct impressions of mental status, activity level, and rule out possible developmental disability. Credibility of parent report based on clinician judgment was also assessed, with 0 (Poor), 1 (Fair) and 2 (Good). Mean credibility was 1.53 (SD =.59). Inter-rater reliability exceeded kappa=0.85 among all raters. Further details regarding these procedures are available in earlier publications (see Youngstrom, Meyers, Demeter, et al., 2005). Interviewers made global ratings of youth functioning from a low of 1 to a high of 100 using the Children’s Global Assessment Scale (CGAS; Shaffer et al. 1983) and a global rating of the family environment (GFES; Rey et al. 1997) using a 1 to 90 scale; high scores indicate better functioning. The GFES considers how stable, secure, and nurturing the child’s family environment is, as well as factors such as discipline, supervision, and parental discord.

Measures

General Behavior Inventory (GBI; Depue et al., 1981).

The General Behavior Inventory is a self-report instrument that contains 73 questions rating depressive, hypomanic, and mixed mood symptoms on a scale of 0–3 (Danielson et al., 2003). The GBI has been adapted for parent report (PGBI) as well (Youngstrom et al., 2001). Primary caregivers completed the parent version for youth 5–17 years of age. The hypomanic/biphasic and depression scales have excellent reliability and validity, all αs > 0.90 in the present sample.

The Perceived Criticism Scale (PCS; Hooley & Teasdale, 1989).

Caregivers completed the PCS, which contains two dimensions: criticism and sensitivity to criticism. Caregivers rated how critical they are of the target youth and how critical the target youth is of them. Additionally, caregivers rate how upset they get when criticized by youth and how upset youth get when criticized by them. The four-item questionnaire is administered with 10-point Likert scoring; higher scores reflect greater criticism and sensitivity. The PCS has good reliability and validity.

Family Assessment Device (FAD; Epstein et al., 1983).

Adding to the clinical picture for youth, the FAD is a parent report questionnaire measuring family functioning and transaction patterns that can distinguish healthy from unhealthy families (Epstein et al., 1983). A 27-item short form of the FAD shows good reliability and validity for young children and adolescents (Byles et al., 1988). The primary caregiver rated each statement based on how well it described their own family, using a four-point Likert-type scale, ranging from a 1 (Strongly Agree) to 4 (Strongly Disagree). Ten of the items are reverse keyed, so that higher total scores (after reversal of items that are keyed negatively) mean less adaptive family functioning. In the present sample, α=0.91 for the total score.

Mood Ratings.

Present analyses used severity scores from the KSADS Mania Rating Scale (KMRS) and KSADS Depression Rating Scale (KDRS; Axelson et al., 2003), which provide more complete coverage of the DSM-IV symptom criteria and are more developmentally appropriate than older mood rating scales. The KSADS captured information about affective lability and mood changes within the same day (Item #13 on the KSADS Mania Rating Scale), suicidal ideation and behavior. The KMRS and KDRS were rated for all comers enrolled in the project. In most protocols the KSADS uses gating questions and skip outs for the depression and mania modules; but for this project there were no skip outs for the mood modules, and all participants got asked about all symptoms. In the present sample, α=.86 for the depressive and.93 for the manic score.

Data Analysis Plan

For the purpose of analyses, we created two composite variables: one for depression symptoms and one for manic symptoms. The composites z-scored and combined the KSADS and GBI scales; this expanded the content coverage (particularly because the GBI includes symptoms and behaviors in addition to the DSM symptoms covered by the KSADS) and also halved the number of dependent variables, reducing risk of false positive results. Correlations for the KSADS and GBI were r = .58, p <.001 and r = .43, p <.001 for the depression and mania scales, respectively.

To assess Aim 1, we conducted multiple regressions with all predictors entered simultaneously, assessing associations between PC, SC and youth symptoms. Because of the similar pattern of correlations across both the BPSD and non-BPSD samples, we ran regressions on the full sample. We also inspected the Variance Inflation Factors (VIF), to determine if multicollinearity was an issue.

To assess Aim 2, we conducted two-tailed, independent samples t-tests comparing PC, SC and clinical presentations for youth with and without BPSD. We also conducted multiple linear regressions (all predictors entered simultaneously) utilizing Hayes’s macro (Hayes, 2018), examining whether associations between youth clinical presentation and criticalness and sensitivity varied as a function of youth bipolar status. To reduce the number of analyses and the potential for type I errors, parent report of parent and youth criticism and parent and youth SC variables were each averaged (rather than considered separately, to create a single PC variable and single SC variable), centered and then multiplied by bipolar status to create the interaction terms. We followed up significant interactions with simple slopes analyses.

Results

Preliminary Analyses, Assumptions, and Missing Data

We used SPSS v27 to analyze our data. After determining that data were missing completely at random, we used list-wise deletion procedures for missing data. Because of the large age range of participants, we examined whether the average scores on any of the clinical outcomes were associated with child age and gender independent of family criticism or SC. For group comparisons of age effects, age was divided into ten years and younger versus eleven years and older. Numerous significant associations were found between several clinical outcomes and child age and gender. In all cases, older children demonstrated a worse clinical picture or functioning than younger children, with two exceptions: scores on the GFES and CGAS. Additionally, females demonstrated a worse clinical picture than males, and parents reported higher levels of SC in themselves and their daughters than when they had sons.

We also examined whether outcomes varied as function of race or income. White youth had higher scores on suicidality and the depression composite than African American youth, and Hispanic and White youth had higher scores on the mania composite and mood lability than African American youth. As a result, remaining regression analyses added child age, gender, and race as covariates.

Finally, we assessed whether parent credibility was associated with parent reports of PC and SC. All correlations were insignificant, with the exception of parent SC, which was negatively correlated with credibility (r = −.09, p < .05), such that greater parent SC was linked with lower credibility.

Aim 1: Determine if PC and SC Showed Relationships to BPSD Consistent with Findings from Adult Data

Correlations among variables are presented Table 2. Parent reports of parent and youth criticalness and sensitivity to criticism were all correlated positively with each other. Parent report of youth SC was associated with worse youth symptoms and family functioning across the board. Parent report of youth PC and parent SC were both associated with worse family functioning and worse youth symptoms, except for the GFES. Parent report of parent PC was associated with worse family functioning and suicidality.

Table 2.

Intercorrelations

Variable 1 2 3 4 5 6 7 8 9 10 11 12 13 14
1. Caregiver Critical of Youth ---
2. Youth Critical of Caregiver .66*** ---
3. Youth Sensitive to Criticism .31*** .33*** ---
4. Caregiver Sensitive to Criticism .38*** .42*** .42*** ---
5. Composite Average Sensitivity Variable .41*** .45*** .84*** .85*** ---
6. Composite Average Critical Variable .90*** .92*** .35*** .44*** .47*** ---
7. Family Assessment Device .11** .18*** .27*** .16*** .25*** .16*** ---
8. Mania z score .04 .18*** .12** .20*** .19*** .12** .09** ---
9. Depression z Score .03 .21*** .17*** .27*** .26*** .13*** .22*** .65*** ---
10. KSADS Mood Lability .01 .12** .07* .12** .12** .07 .07 .62*** .42*** ---
11. GFES .03 −.05 −.07* −.00 −.04 −.01 −.17*** −.14*** −.17*** −.01 ---
12. CGAS current .01 .09** −.10** −.10** −.10** −.05 −.15*** .37*** −.39*** −.28*** .23*** ---
13. Suicidality .10** .21*** .20*** .23*** .23*** .17*** .26*** .23*** .44*** .19*** −.14*** −.23*** ---
14. Number of Diagnoses .05 .09** .13*** .10** .10** .08* .06 .30*** .34*** .19** −.18*** −.33*** .21*** ---
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Note. KSADS = Kiddie Schedule of Affective Disorders and Schizophrenia, GFES = General Family Environment Scale, CGAS = Child Global Assessment Scale. N= 812.

*

p < .05.

**

p < .01.

***

p < .001, two-tailed.

Regression results are presented in Table 3. Notably, multicollinearity did not appear to be an issue in these regressions given the acceptable VIF values (ranging from 1.02 – 1.91). In both the manic and depression symptoms models, parent reports of youth criticalness and youth SC were both associated with higher manic and depressive symptoms, whereas caregiver criticalness was associated with less of both types of symptoms. A similar pattern emerged for mood lability, except that it was not significantly related to parent reports of youth SC. For the GFES, caregiver criticalness was associated higher GFES scores. For the CGAS, higher caregiver criticalness was associated with higher overall scores, whereas parent reports of youth criticalness were associated with lower scores. For suicidality, parent reports of youth criticalness and youth SC, and caregiver SC were associated with higher suicidality. For number of diagnoses, caregiver SC was related to a higher number of child diagnoses. Effect sizes for the full models were large, and small to medium for the individual predictors.

Table 3.

Regression Analysis Predicting Youths’ Symptoms from Family Criticism and Sensitivity in the Full Sample

Model Youth Critical of Caregiver Caregiver Critical of Youth Youth Sensitive to Criticism Caregiver Sensitive to Criticism
Youth Bipolar Symptoms/Measures (DVs) R2 f2 Part f2 Part f2 Part f2 Part f2
Depression z score (n=781) .32 36.17*** .11*** .12 −.11*** .12 .12*** .14 .03 .03
Mania z score (n=783) .53 87.53*** .09** .10 −.09*** .10 .10*** .11 .05 .05
KSADS Mood Lability (n=747) .31 32.43*** .06* .06 −.08** .09 .05 .05 .02 .02
GFES (n=784) .06 4.73*** −.03 .03 .08* .09 .05 .05 −.07* .08
CGAS Current (n=791) .11 9.90*** −.06 .06 .09** .10 −.03 .03 −.07* .08
Suicidality (n=790) .19 17.66*** .06 .06 −.03 .03 .08* .08 .06 .06
Number of Diagnoses (n=806) .06 5.11*** .02 .02 −.02 .02 .03 .03 .11** .12
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Note. Analyses controlled for child age, gender, and race but results are not presented for the sake of brevity. GFES = General Family Environment Scale, CGAS = Child Global Assessment Scale.

*

p < .05.

**

p < .01.

***

p < .001, two-tailed.

Aim 2: Examine Whether PC and SC Were Associated with a Worse Clinical Presentation for Youth with BPSD

As seen in the t-tests in Table 1, youth with BPSD demonstrated lower functioning in terms of both symptoms and family environment than youth without BPSD. Youth with BPSD were both more critical and sensitive than youth without BPSD, t (813) = −2.77, p = .006 and t (813) = −3.45, p = .001, respectively. Youth with BPSD had worse FAD and GFES scores than youth without BPSD, t (817) = −2.24, p = .026 and t (802) = 8.08, p = .001, respectively.

As can be seen in Table 4, there were numerous main effects for both average sensitivity and average criticism predicting worse youth symptoms and family functioning. Effect sizes for full models were small to large. Main effects were qualified by four significant interactions: bipolar status interacted with average criticism to predict GFES and mood lability, whereas bipolar status interacted with average sensitivity to predict GFES and number of diagnoses. These interactions were probed by testing the simple slopes defining the relationship between bipolar status at levels of sensitivity and criticism 1 SD below the mean, the mean, and 1 SD above the mean. The negative associations between criticism (B = −1.18, SE = 0.40, p < .01) and sensitivity (B = −1.03, SE = 0.45, p < .05) and youth global family functioning were significant only for youth with bipolar disorder (Figures 1a and 2a, respectively). The positive association between criticism (B = .09, SE = 0.03, p < .05) and youth mood lability was significant only for youth with bipolar disorder. Finally, the positive association between sensitivity (B = .10, SE = 0.03, p < .001) and youth number of diagnoses was significant only for youth without bipolar disorder. However, examination of zero-order correlations between sensitivity and youth number of diagnoses revealed positive associations, indicating likely suppressor effects in the regressions.

Table 4.

Regression Analysis Predicting Youths’ Symptoms from Family Criticism in the Full Sample

Depression Z Score (n=781) Mania Z Score (n=783) KSADS Mood Lability (n=747) GFES (n=784)
Predictor β 95% CI β 95% CI β 95% CI β 95% CI
Critical .02 .00 .05 .02* .00 .04 .01 −.02 .04 .26 −.09 .60
Bipolar Status .80*** .45 1.15 1.32 1.05 1.60 1.03*** .58 1.49 4.90 −.33 10.12
Critical X Bipolar .01 −.05 .06 .03 −.01 .08 .07* .01 .15 −1.43*** −2.28 −.59
F = 51.49***, R2 = .28, f2 = .39 F = 132.05***, R2 = .50, f2 = 1 F = 52.08***, R2 = .29, f2= .41 F = 6.25***, R2 = .05, f2 = .05
Sensitivity .06*** .03 .08 .05*** .03 .07 .03 −.00 .07 .05 −.33 .42
Bipolar Status .96*** .57 1.35 1.75*** 1.44 2.05 1.51*** .99 2.02 3.35 −2.62 9.32
Sensitivity X Bipolar −.02 −.08 .04 −.04 −.09 .00 −.01 −.09 .08 −1.08*** −2.02 −.13
F = 55.50***, R2 = .30, f2 = .43 F = 137.04***, R2 = .51, f2 = 1.04 F = 50.95***, R2 = .29, f2 = .41 F = 5.34***, R2 = .04, f2= .04
Suicidality (n=790) Number of Diagnoses (n=806) CGAS Current (n=791)
β 95% CI β 95% CI β 95% CI
Critical .03*** .01 .04 .05 −.00 .10 −.03 −.28 .21
Bipolar Status .01 −.25 .28 .95 *** .18 1.71 −5.04* −8.76 −1.31
Critical X Bipolar .03 −.01 .08 −.02 −.15 .10 −.22 −.83 .38
F = 26.84***, R2 = .17, f2 = .20 F = 6.05***, R2 = .04, f2 = .04 F = 14.20***, R2 = .10, f2= .11
Sensitivity .04*** .02 .06 .10*** .05 .17 −.32* −.56 −.05
Bipolar Status .12 −.17 .42 1.64 .78 2.49 −6.45** −10.63 −2.27
Sensitivity X Bipolar .01 −.04 .06 −.14* −.28 −.08 .04 −.62 .70
F = 27.97***, R2 = .18, f2 = .22 F = 7.81***, R2 = .06, f2= .06 F = 15.12***, R2 = .10, f2= .11
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Note. Analyses controlled for child age, gender, and race but results are not presented for the sake of brevity. GFES = General Family Environment Scale, CGAS = Child Global Assessment.

*

p < .05.

**

p < .01.

***

p < .001, two-tailed.

Figures 1a. and 1b.

Figures 1a. and 1b.

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Bipolar Status as a Moderator of Associations Between Criticism and Global Family Environment and Mood Lability

Figures 2a. and 2b.

Figures 2a. and 2b.

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Bipolar Status as a Moderator of Associations Between Sensitivity and Global Family Environment and Number of Diagnoses

Discussion

Addressing gaps in research on associations between pediatric BPSD and expressed emotion, the current study utilized a strong, multiple assessment procedure for BPSD and mood symptomatology in an ethnically diverse sample of youth to examine youth and caregiver criticalness and sensitivity to criticalness, and their associations with comorbidity, symptom severity, suicidality, general functioning, and family functioning in youth with BPSD. In using parent reports only for this study, we assessed how SC and expression of criticism on the part of both youths and caregivers were perceived by caregivers in our sample. The large sample afforded a good amount of statistical power, so small effect sizes could be significant. Therefore, we reported effect sizes (such as part correlations) to help gauge the potential practical significance of findings.

Our findings supported a significant positive association between parent reports of youth criticalness and more severe manic and depression symptoms, greater mood lability, higher suicidality, and worse overall functioning. These findings appear to be the first suggesting that communication styles in youth with BPSD—especially criticism—may directly relate to the youths’ own functioning. Youth who experience mood lability may be more likely to criticize others. This may be related to misunderstandings between youth experiencing mood lability and the caregivers who cannot fully make sense of these symptoms.

Additionally, youth who were more sensitive to receiving criticism from their caregivers experienced more severe depressive and manic symptoms and significantly higher suicidality. This is consistent with previous findings which found adults with bipolar disorder responded to criticism with more negative affect compared to controls (Cuellar, et al. 2009). Previous findings similarly found low family cohesion, low parental care, and overprotection to correlate with a history of suicide attempts in adults with BPSD (Cooke et al., 1999).

These findings align with family systems theory (Cox & Paley, 1997; Minuchin, 1985) which supports the idea that BPSD is not solely a disorder of the individual child but has repercussions for the entire family unit. In light of this theory, one possibility is that more severe youth symptoms may elicit higher levels of criticism from caregivers, which then leads to increased worsening of symptoms in youth, resulting in a cyclical pattern. Higher symptom severity may lead the youth to be more vulnerable to impacts of environmental insults, including worse family environment, through which worse functioning may develop. An additional consideration is the high heritability of emotional dysregulation (Morris, Silk, Steinberg, Myers, & Robinson, 2007). If both the youth and the caregiver are emotionally dysregulated, the caregiver may struggle with managing the youth’s symptoms leading to inappropriate responses to youth which may in turn worsen symptoms.

Our findings partially supported our second aim exploring whether associations between family criticism and sensitivity and youth symptoms would be stronger for youth with BPSD than with other clinical diagnoses. Youth with BPSD had overall worse functioning in most domains assessed compared to youth without BPSD, including higher mean scores in caregiver report of their own PC and SC. Additionally, interactions between BPSD and family criticalness and sensitivity were found in their links with youth symptoms. Negative associations between criticism and sensitivity and youth global family functioning were significant only for youth with BPSD. The positive association between criticism and youth mood lability was significant only for youth with BPSD. This may be explained by the previously documented tendency for youth with BPSD to report more mood lability, lower quality of life scores, and worse family functioning compared to youth with other diagnoses (Algorta et al., 2011; Freeman et al., 2009). Although there were a few significant interactions between bipolar status and family criticism and sensitivity, in most cases there were no significant differences based on bipolar status, therefore associations with youth outcomes were not unique to youth with BPSD. This was contrary to our expectation that positive associations between caregiver and youth PC and SC would be more pronounced in youth with BPSD due to the tendency of these youth to be especially high in irritability, which may predispose them to more intense interpersonal reactions (Wozniak et al., 2005). Although inconsistent with our hypotheses, our findings are consistent with previous research demonstrating that EE (of which PC is a dimension) may be observed in families with a range of serious mental illness diagnoses (Hooley, 2007). This suggests, consistent with family systems, a reciprocal relationship where youth with mental illness may create an environment in which youth are both more critical and sensitive to criticism and their criticism and SC may be met with more in kind from their caregiver. Alternatively, more severe mental health symptoms in youth may be especially challenging for caregivers to manage and, as a result, this challenge may elicit criticism from caregivers.

Limitations

The primary limitation in this study was use of parent reports only, rather than both parent and youth reports. Our methods for diagnosis of the youth and their symptoms were well-formulated and we utilized an ethnically and socioeconomically diverse sample for this study. However, in assessing youth and caregiver SC and criticalness we were limited by only the caregivers’ perspectives. The results of youth and caregiver SC and criticalness, as well as the impact of that SC and criticalness on functioning, may look different if we assess youth reports. Parents may be over- or underreporting their own SC and criticalness, and over-reporting the SC and criticalness of their children. However, parent-report has benefits in that previous research found that clinicians judged caregivers as more credible on average than youths, though this dropped sharply with adolescents (Youngstrom et al., 2011). Other factors associated with higher parent credibility included better functioning families and more educated caregivers; caregiver credibility was unrelated to caregiver mood symptoms or being the mother (Youngstrom et al., 2011).

A further limitation is that we did not assess for precipitants or consequences of criticism in families. Because we did not use observational experience sampling, we could only use parent reports of criticism and SC. Future research should utilize experience sampling to observe potential triggers in the family that may precede criticism or that may prime youth or parents to be more sensitive to criticism. This research should also explore how the family members respond to criticism to assess the interactional patterns between youth and caregivers.

Clinical Implications

A key contribution of the present paper is to underscore that BPSD is associated with greater interpersonal criticism and SC than seen in families also seeking outpatient services for youth. Our findings suggest that family factors interact with symptoms and general functioning for youth with BPSD. For youth with BPSD, it is possible that understanding the family environment and utilizing family-based interventions may be especially important. Our research suggests that family interactional styles—including the expression of, sensitivity to and perception of criticism—associate with symptom severity, suicidality and mood lability in youth with BPSD. Some conflict is normative in families of adolescents, as children have been found to increase their risky, sensation-seeking behaviors and experience still-developing self-regulation in adolescence (Steinberg et al., 2016). Targeting the youth’s SC and own criticalness toward his or her family may be especially pertinent for treatment, considering associations with mood lability and global family environment. Involving the family in treatment, providing psychoeducation about the development of symptoms in BPSD, communication skill building, emotion-regulation skills, and relapse prevention are all seen as successful interventions for youth with BPSD (Fristad & Macpherson, 2014). Children with BPSD do not experience their symptoms in a vacuum; their functioning is part of a reciprocal interaction between themselves and their family. Based on this research, clinicians should be aware that the entire family is influenced by BPSD, and treatment should consider how to change disruptive patterns.

Acknowledgments

This research was supported in part by NIH R01 MH066647 (PI: E. Youngstrom). Conflict of Interest: Dr. Du Rocher Schudlich, Ms. Chase Ochrach, Dr. Eric Youngstrom, and Dr. Jennifer Younstrom all declare that they have no conflicts of interest. Dr. Findling receives or has received research support, acted as a consultant and/or has received honoraria from Acadia, Adamas, Aevi, Akili, Alcobra, Alkermes, Allergan, Amerex, American Academy of Child & Adolescent Psychiatry, American Psychiatric Press, Arbor, Axsome, Daiichi-Sankyo, Gedeon Richter, Genentech, KemPharm, Luminopia, Lundbeck, MedAvante-ProPhase, Merck, NIH, Neurim, Noven, Nuvelution, Otsuka, PCORI, PaxMedica,Pfizer, Physicians Postgraduate Press, Q BioMed, Receptor Life Sciences, Roche, Sage, Signant Health, Sunovion, Supernus Pharmaceuticals, Syneos, Syneurx, Takeda, Teva, Tris, TouchPoint, and Validus.

Funding: This study was funded by NIH (grant number R01 MH066647).

Footnotes

Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.

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

Contributor Information

Tina D. Du Rocher Schudlich, Department of Psychology, 516 High Street, MS 9172, Western Washington University, Bellingham, WA 98225-9172, USA.

Chase Ochrach, Department of Psychology, 516 High Street, MS 9172, Western Washington University, Bellingham, WA 98225-9172, USA.

Eric A. Youngstrom, Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, CB #3270 Davie Hall, Chapel Hill, NC 27599-3270, USA

Jennifer K. Youngstrom, Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Davie Hall, Chapel Hill, NC 27599, USA

Robert L. Findling, Psychiatry and Behavioral Sciences, Johns Hopkins University, 1800 Orleans St., The Charlotte R. Bloomberg Children’s Center Building, Baltimore, MD 21287, USA

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