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Early-onset bipolar disorder: A family treatment perspective

Published online by Cambridge University Press:  25 October 2006

DAVID J. MIKLOWITZ ,
ADRINE BIUCKIANS  and
JEFFREY A. RICHARDS
DAVID J. MIKLOWITZ
Affiliation:
University of Colorado, Boulder
ADRINE BIUCKIANS
Affiliation:
University of Colorado, Boulder
JEFFREY A. RICHARDS
Affiliation:
University of Colorado, Boulder
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Abstract

Mood disorder symptoms and their associated functional impairments are hypothesized to come about as the result of the conjoint, interactive influences of genetic, biological, and psychological vulnerabilities, family distress, and life stress at different points of development. We discuss a developmental psychopathology model that delineates pathways to high family conflict and mood exacerbation among early-onset bipolar patients. New data from a treatment development study indicate that adolescent bipolar patients in high expressed emotion families have more symptomatic courses of illness over 2 years than adolescents in low expressed emotion families. Chronic and episodic stressors are also correlated with lack of mood improvement while adolescents are in treatment. Family-focused treatment (FFT) given in conjunction with pharmacotherapy appears to ameliorate the course of bipolar disorder in adults. This treatment has recently been modified to address the developmental presentation of bipolar disorder among adolescents. We present data from an open trial of FFT and pharmacotherapy (N = 20) indicating that bipolar adolescents stabilize in mania, depression, and parent-rated problem behaviors over 2 years. Future research should focus on clarifying the developmental pathways to early-onset bipolar disorder and the role of protective factors and preventative psychosocial interventions in delaying the first onset of the disorder.This research was supported by National Institute of Mental Health Grants MH43931, MH62555, and MH073871; a Distinguished Investigator Award from the National Alliance for Research on Schizophrenia and Depression; and a grant from the Robert Sutherland Foundation.

Type
Research Article
Information
Development and Psychopathology , Volume 18 , Issue 4 , December 2006 , pp. 1247 - 1265
Copyright
© 2006 Cambridge University Press

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References

REFERENCES

Achenbach, T. M., Edelbrock, C., & Howell, C. T. (1987). Empirically based assessment of the behavioral/emotional problems of 2- and 3-year-old children. Journal of Abnormal Child Psychology, 15, 629–650.Google Scholar
Akiskal, H. S. (1996). The prevalent clinical spectrum of bipolar disorders: Beyond DSM-IV. Journal of Clinical Psychopharmacology, 16(Suppl. 1), 4–14.Google Scholar
Altorfer, A., Kasermann, M. L., & Hirsbrunner, H. (1998). Arousal and communication: 1. The relationship between nonverbal, behavioral, and psychophysiological indices of the stress response. Journal of Psychophysiology, 12, 40–59.Google Scholar
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Asarnow, J. R., Goldstein, M. J., Tompson, M., & Guthrie, D. (1993). One-year outcomes of depressive disorders in child psychiatric in-patients: Evaluation of the prognostic power of a brief measure of expressed emotion. Journal of Child Psychology and Psychiatry, 34, 129–137.Google Scholar
Axelson, D., Birmaher, B., Brent, D., Wassick, S., Hoover, C., Bridge, J., et al. (2003). A preliminary study of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children Mania Rating Scale for children and adolescents. Journal of Child and Adolescent Psychopharmacology, 13, 463–470.Google Scholar
Bellivier, F., Golmard, J. L., Henry, C., Leboyer, M., & Schurhoff, F. (2001). Admixture analysis of age at onset in bipolar I affective disorder. Archives of General Psychiatry, 58, 510–512.Google Scholar
Biederman, J., Mick, E., Faraone, S. V., Spencer, T., Wilens, T. E., & Wozniak, J. (2003). Current concepts in the validity, diagnosis and treatment of paediatric bipolar disorder. International Journal of Neuropsychopharmacology, 6, 293–300.Google Scholar
Brent, D. A., Perper, J. A., Goldstein, C. E., Kolko, D. J., Allan, M. J., Allman, C. J., et al. (1988). Risk factors for adolescent suicide: A comparison of adolescent suicide victims with suicidal inpatients. Archives of General Psychiatry, 45, 581–588.Google Scholar
Brown, J. V., Bakeman, R., Celano, M. P., Demi, A. S., Kobrynski, L., & Wilson, S. R. (2002). Home-based asthma education of young low-income children and their families. Journal of Pediatric Psychology, 27, 677–688.Google Scholar
Butzlaff, R. L., & Hooley, J. M. (1998). Expressed emotion and psychiatric relapse: A meta-analysis. Archives of General Psychiatry, 55, 547–552.Google Scholar
Cannon, M., Jones, P., Gilvarry, C., Rifkin, L., McKenzie, K., Foerster, A., et al. (1997). Premorbid social functioning in schizophrenia and bipolar disorder: Similarities and differences. American Journal of Psychiatry, 154, 1544–1550.Google Scholar
Carter, T. D., Mundo, E., Parikh, S. V., & Kennedy, J. L. (2003). Early age at onset as a risk factor for poor outcome of bipolar disorder. Journal of Psychiatric Research, 37, 297–303.Google Scholar
Caspi, A., Moffitt, T. E., Morgan, J., Rutter, M., Taylor, A., Arseneault, L., et al. (2004). Maternal expressed emotion predicts children's antisocial behavior problems: Using monozygotic-twin differences to identify environmental effects on behavioral development. Developmental Psychology, 40, 149–161.Google Scholar
Chambers, W. J., Puig-Antich, J., Hirsch, M., Paez, P., Ambrosini, P. J., Tabrizi, M. A., et al. (1985). The assessment of affective disorders in children and adolescents by semi-structured interview: Test–retest reliability. Archives of General Psychiatry, 42, 696–702.Google Scholar
Chen, Y. W., & Dilsaver, S. C. (1996). Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other Axis I disorders. Biological Psychiatry, 39, 896–899.Google Scholar
Cicchetti, D., & Hinshaw, S.P. (2002). Editorial: Prevention and intervention science: Contributions to developmental theory. Development and Psychopathology, 14, 667–671.Google Scholar
Cicchetti, D., & Rogosch, F. A. (1996). Equifinality and multifinality in developmental psychopathology. Development and Psychopathology, 1996, 597–600.Google Scholar
Cicchetti, D., & Rogosch, F. A. (2002). A developmental psychopathology perspective on adolescence. Journal of Consulting and Clinical Psychology, 70, 6–20.Google Scholar
Cicchetti, D., & Schneider-Rosen, K. (1986). An organizational approach to childhood depression. In M. Rutter, C. Izard, & P. Read (Eds.), Depression in young people: Clinical and developmental perspectives (pp. 71–134). New York: Guilford Press.
Cicchetti, D., & Toth, S. L. (1995). Developmental psychopathology and disorders of affect. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Vol. 2. Risk, disorder, and adaptation (pp. 369–420). New York: Wiley.
Cohen, A. N., Hammen, C., Henry, R. M., & Daley, S. E. (2004). Effects of stress and social support on recurrence in bipolar disorder. Journal of Affective Disorders, 82, 143–147.Google Scholar
Cornblatt, B., Obuchowski, M., Roberts, S., Pollack, S., & Erlenmeyer-Kimling, L. (1999). Cognitive and behavioral precursors of schizophrenia. Development and Psychopathology, 11, 487–508.Google Scholar
Cornblatt, B. A., Green, M. F., & Walker, E. F. (1999). Schizophrenia: Etiology and neurocognition. In T. Millon, P. H. Blaney, & R. D. Davis (Eds.), Oxford textbook of psychopathology (pp. 277–310). New York: Oxford University Press.
Davies, P. T., & Cicchetti, D. (2004). Toward an integration of family systems and developmental psychopathology approaches. Development and Psychopathology, 16, 477–481.Google Scholar
Ellicott, A., Hammen, C., Gitlin, M., Brown, G., & Jamison, K. (1990). Life events and the course of bipolar disorder. American Journal of Psychiatry, 147, 1194–1198.Google Scholar
Engel, G. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136.Google Scholar
Field, T. (1989). Maternal depression effects on infant interaction and attachment behavior. In D. Cicchetti (Ed.), Rochester symposium on developmental psychopathology: Vol. 1. The emergence of a discipline (pp. 139–163). Hillsdale, NJ: Erlbaum.
Frank, E., Kupfer, D. J., Thase, M. E., Mallinger, A. G., Swartz, H. A., Fagiolini, A. M., et al. (2005). Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Archives of General Psychiatry, 62, 996–1004.Google Scholar
Fristad, M. A., Gavazzi, S. M., & Mackinaw-Koons, B. (2003). Family psychoeducation: An adjunctive intervention for children with bipolar disorder. Biological Psychiatry, 53, 1000–1009.Google Scholar
Geller, B., Craney, J. L., Bolhofner, K., Nickelsburg, M. J., Williams, M., & Zimerman, B. (2002). Two-year prospective follow-up of children with a prepubertal and early adolescent bipolar disorder phenotype. American Journal of Psychiatry, 159, 927–933.Google Scholar
Geller, B., Tillman, R., Craney, J. L., & Bolhofner, K. (2004). Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype. Archives of General Psychiatry, 61, 459–467.Google Scholar
Goldstein, T. R., Miklowitz, D. J., & Richards, J. A. (2002). The relationship between expressed emotion attitudes and individual psychopathology among relatives of bipolar patients. Family Process, 41, 647–659.Google Scholar
Gordon, B. (1981). Child temperament and adult behavior: An exploration of “goodness of fit.” Child Psychiatry and Human Development, 11, 167–178.Google Scholar
Greene, R. W., & Ablon, J. S. (2006). Treating explosive kids: The collaborative problem-solving approach. New York: Guilford Press.
Gueorguieva, R., & Krystal, J. H. (2004). Move over ANOVA: Progress in analyzing repeated-measures data and its reflection in papers published in the Archives of General Psychiatry. Archives of General Psychiatry, 61, 310–317.Google Scholar
Hammen, C., Brennan, P. A., & Shih, J. H. (2004). Family discord and stress predictors of depression and other disorders in adolescent children of depressed and nondepressed women. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 994–1002.Google Scholar
Hammen, C., Ellicott, A., Gitlin, M., & Jamison, K. R. (1989). Sociotropy/autonomy and vulnerability to specific life events in patients with unipolar depression and bipolar disorders. Journal of Abnormal Psychology, 98, 154–160.Google Scholar
Hampson, S. E., Skinner, T. C., Hart, J., Storey, L., Gage, H., Foxcroft, D., et al. (2001). Effects of educational and psychosocial interventions for adolescents with diabetes mellitus: A systematic review. Health Technology and Assessment, 5, 1–79.Google Scholar
Henin, A., Biederman, J., Mick, E., Sachs, G. S., Hirshfeld-Becker, D. R., Siegel, R. S., et al. (2005). Psychopathology in the offspring of parents with bipolar disorder: A controlled study. Biological Psychiatry, 58, 554–561.Google Scholar
Hinshaw, S. P., & Cicchetti, D. (2000). Stigma and mental disorder: Conceptions of illness, public attitudes, personal disclosure, and social policy. Development and Psychopathology, 12, 555–598.Google Scholar
Hooley, J. M., Gruber, S. A., Scott, L. A., Hiller, J. B., & Yurgelun-Todd, D. A. (2005). Activation in dorsolateral prefrontal cortex in response to maternal criticism and praise in recovered depressed and healthy control participants. Biological Psychiatry, 57, 809–812.Google Scholar
Howe, G. W., Reiss, D., & Yuh, J. (2002). Can prevention trials test theories of etiology? Development and Psychopathology, 14, 673–694.Google Scholar
Howe, M. E., Saxena, K., & Chang, K. (2006). Factors influencing age at onset in a pediatric cohort with familial bipolar disorder. Manuscript submitted for publication.
Hudson, J. L., Kendall, P. C., Coles, M. E., Robin, J. A., & Webb, A. (2002). The other side of the coin: Using intervention research in child anxiety disorders to inform developmental psychopathology. Development and Psychopathology, 14, 819–841.Google Scholar
Johnson, S. L., & Miller, I. (1997). Negative life events and time to recovery from episodes of bipolar disorder. Journal of Abnormal Psychology, 106, 449–457.Google Scholar
Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., et al. (1997). Schedule for affective disorders and schizophrenia for school-age children—Present and lifetime version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 980–988.Google Scholar
Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey replication. Archives of General Psychiatry, 62, 593–602.Google Scholar
Kim, E. Y., & Miklowitz, D. J. (2004). Expressed emotion as a predictor of outcome among bipolar patients undergoing family therapy. Journal of Affective Disorders, 82, 343–352.Google Scholar
Kim, E. Y., Miklowitz, D. J., Biuckians, A., & Mullen, K. (in press). Life stress and the course of early-onset bipolar disorder. Journal of Affective Disorders.
Kowatch, R. A., Sethuraman, G., Hume, J. H., Kromelis, M., & Weinberg, W. A. (2003). Combination pharmacotherapy in children and adolescents with bipolar disorder. Biological Psychiatry, 53, 978–984.Google Scholar
Leverich, G. S., McElroy, S. L., Suppes, T., Keck, P. E. J., Denicoff, K. D., Nolen, W. A., et al. (2002). Early physical and sexual abuse associated with an adverse course of bipolar illness. Biological Psychiatry, 51, 288–297.Google Scholar
Lewinsohn, P. M., Seeley, J. R., Buckley, M. E., & Klein, D. N. (2002). Bipolar disorder in adolescence and young adulthood. Child and Adolescent Psychiatric Clinics of North America, 11, 461–475.Google Scholar
Malkoff-Schwartz, S., Frank, E., Anderson, B., Sherrill, J. T., Siegel, L., Patterson, D., et al. (1998). Stressful life events and social rhythm disruption in the onset of manic and depressive bipolar episodes: A preliminary investigation. Archives of General Psychiatry, 55, 702–707.Google Scholar
Marchand, W. R., Wirth, L., & Simon, C. (2005). Adverse life events and pediatric bipolar disorder in a community mental health setting. Community Mental Health Journal, 41, 67–75.Google Scholar
Masten, A. S., & Coatsworth, J. D. (1998). The development of competence in favorable and unfavorable environments: Lessons from research on successful children. American Psychologist, 53, 205–220.Google Scholar
McClellan, J. (2005). Commentary: Treatment guidelines for child and adolescent bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 236–239.Google Scholar
Meyer, S. E., Carlson, G. A., Wiggs, E. A., Ronsaville, D. S., Martinez, P. E., Klimes-Dougan, B., et al. (2006). A prospective high-risk study of the association among maternal negativity, apparent frontal lobe dysfunction, and the development of bipolar disorder. Development and Psychopathology, 18, 573–589.Google Scholar
Miklowitz, D. J. (2004). The role of family systems in severe and recurrent psychiatric disorders: A developmental psychopathology view. Development and Psychopathology, 16, 667–688.Google Scholar
Miklowitz, D. J., George, E. L., Axelson, D. A., Kim, E. Y., Birmaher, B., Schneck, C., et al. (2004). Family-focused treatment for adolescents with bipolar disorder. Journal of Affective Disorders, 82(Suppl. 1), 113–128.Google Scholar
Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, T. L., & Suddath, R. L. (2003). A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry, 60, 904–912.Google Scholar
Miklowitz, D. J., & Goldstein, M. J. (1997). Bipolar disorder: A family-focused treatment approach. New York: Guilford Press.
Miklowitz, D. J., Goldstein, M. J., Doane, J. A., Nuechterlein, K. H., Strachan, A. M., Snyder, K. S., et al. (1989). Is expressed emotion an index of a transactional process? I. Parents' affective style. Family Process, 28, 153–167.Google Scholar
Miklowitz, D. J., Goldstein, M. J., & Nuechterlein, K. H. (1995). Verbal interactions in the families of schizophrenic and bipolar affective patients. Journal of Abnormal Psychology, 104, 268–276.Google Scholar
Miklowitz, D. J., Goldstein, M. J., Nuechterlein, K. H., Snyder, K. S., & Mintz, J. (1988). Family factors and the course of bipolar affective disorder. Archives of General Psychiatry, 45, 225–231.Google Scholar
Miklowitz, D. J., & Johnson, S. L. (2006). The psychopathology and treatment of bipolar disorder. Annual Review of Clinical Psychology, 2, 199–235.Google Scholar
Miklowitz, D. J., Richards, J. A., George, E. L., Suddath, R. L., Frank, E., Powell, K., et al. (2003). Integrated family and individual therapy for bipolar disorder: Results of a treatment development study. Journal of Clinical Psychiatry, 64, 182–191.Google Scholar
Miklowitz, D. J., Simoneau, T. L., George, E. L., Richards, J. A., Kalbag, A., Sachs-Ericsson, N., et al. (2000). Family-focused treatment of bipolar disorder: 1-year effects of a psychoeducational program in conjunction with pharmacotherapy. Biological Psychiatry, 48, 582–592.Google Scholar
Mossay, C., De Buck, C., Filosof, D., & Parise, L. (2003). Chronic respiratory pathology in the child: Overview of 10 years of multidisciplinary management in a pediatric medical center. Allergy and Immunology (French), 35, 241–246.Google Scholar
Murray, C. J. L., & Lopez, A. D. (1996). The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Boston: Harvard University Press.
Murray, R. M., Sham, P., Van Os, J., Zanelli, J., Cannon, M., & McDonald, C. (2004). A developmental model for similarities and dissimilarities between schizophrenia and bipolar disorder. Schizophrenia Research, 71, 405–416.Google Scholar
O'Connell, R. A., Mayo, J. A., Flatow, L., Cuthbertson, B., & O'Brien, B. E. (1991). Outcome of bipolar disorder on long-term treatment with lithium. British Journal of Psychiatry, 159, 129–132.Google Scholar
Panton, J., & Barley, E. A. (2000). Family therapy for asthma in children. Cochrane Database Systematic Reviews, 2, CD000089.Google Scholar
Pavuluri, M. N., Birmaher, B., & Naylor, M. W. (2005). Pediatric bipolar disorder: A review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 846–871.Google Scholar
Perlick, D. A., Hohenstein, J. M., Clarkin, J. F., Kaczynski, R., & Rosenheck, R. A. (2005). Use of mental health and primary care services by caregivers of patients with bipolar disorder: A preliminary study. Bipolar Disorders, 7, 126–135.Google Scholar
Perlick, D. A., Miklowitz, D. J., Link, B. G., Struening, R., Kaczynski, R., Gonzalez, J., et al. (2006). Perceived stigma, depressive symptoms, and coping strategies among caregivers of patients with bipolar disorder. Manuscript submitted for publication.
Post, R. M. (1992). Transduction of psychosocial stress into the neurobiology of recurrent affective disorder. American Journal of Psychiatry, 149, 999–1010.Google Scholar
Priebe, S., Wildgrube, C., & Muller-Oerlinghausen, B. (1989). Lithium prophylaxis and expressed emotion. British Journal of Psychiatry, 154, 396–399.Google Scholar
Radke-Yarrow, M., Nottelmann, E., Belmont, B., & Welsh, J. D. (1993). Affective interactions of depressed and nondepressed mothers and their children. Journal of Abnormal Child Psychology, 21, 683–695.Google Scholar
Radke-Yarrow, M., Nottelmann, E., Martinez, P., Fox, M. B., & Belmont, B. (1992). Young children of affectively ill parents: A longitudinal study of psychosocial development. Journal of the American Academy of Child & Adolescent Psychiatry, 31, 68–77.Google Scholar
Rea, M. M., Tompson, M., Miklowitz, D. J., Goldstein, M. J., Hwang, S., & Mintz, J. (2003). Family focused treatment vs. individual treatment for bipolar disorder: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 71, 482–492.Google Scholar
Rogosch, F.A., Cicchetti, D., & Toth, S.L. (2004). Expressed emotion in multiple subsystems of the families of toddlers with depressed mothers. Development and Psychopathology, 16, 689–709.Google Scholar
Rosenfarb, I. S., Goldstein, M. J., Mintz, J., & Nuechterlein, K. H. (1995). Expressed emotion and subclinical psychopathology observable within the transactions between schizophrenic patients and their family members. Journal of Abnormal Psychology, 104, 259–267.Google Scholar
Satin, W., La Greca, A. M., Zigo, M. A., & Skyler, J. S. (1989). Diabetes in adolescence: Effects of multifamily group intervention and parent simulation of diabetes. Journal of Pediatric Psychology, 14, 259–275.Google Scholar
Simoneau, T. L., Miklowitz, D. J., Richards, J. A., Saleem, R., & George, E. L. (1999). Bipolar disorder and family communication: Effects of a psychoeducational treatment program. Journal of Abnormal Psychology, 108, 588–597.Google Scholar
Simoneau, T. L., Miklowitz, D. J., & Saleem, R. (1998). Expressed emotion and interactional patterns in the families of bipolar patients. Journal of Abnormal Psychology, 107, 497–507.Google Scholar
Strachan, A. M., Feingold, D., Goldstein, M. J., Miklowitz, D. J., & Nuechterlein, K. H. (1989). Is expressed emotion an index of a transactional process? II. Patient's coping style. Family Process, 28, 169–181.Google Scholar
Sturgeon, D., Turpin, G., Kuipers, L., Berkowitz, R., & Leff, J. (1984). Psychophysiological responses of schizophrenic patients to high and low expressed emotion relatives: A follow-up study. British Journal of Psychiatry, 145, 62–69.Google Scholar
Tarrier, N., Barrowclough, C., Porceddu, K., & Watts, S. (1988). The assessment of psychophysiological reactivity to the expressed emotion of the relatives of schizophrenic patients. British Journal of Psychiatry, 152, 618–624.Google Scholar
Tarrier, N., Vaughn, C., Lader, M. H., & Leff, J. P. (1979). Bodily reactions to people and events in schizophrenics. Archives of General Psychiatry, 36, 311–315.Google Scholar
Vaughn, C. E., & Leff, J. P. (1976). The influence of family and social factors on the course of psychiatric illness: A comparison of schizophrenia and depressed neurotic patients. British Journal of Psychiatry, 129, 125–137.Google Scholar
Wendel, J. S., Miklowitz, D. J., Richards, J. A., & George, E. L. (2000). Expressed emotion and attributions in the relatives of bipolar patients: An analysis of problem-solving interactions. Journal of Abnormal Psychology, 109, 792–796.Google Scholar
Wynne, L. C., Shields, C. G., & Sirkin, M. I. (1992). Illness, family theory, and family therapy: I. Conceptual issues. Family Process, 31, 3–18.Google Scholar
Wysocki, T., Greco, P., Harris, M. A., Bubb, J., & White, N. H. (2001). Behavior therapy for families of adolescents with diabetes: Maintenance of treatment effects. Diabetes Care, 24, 441–446.Google Scholar
Yan, L. J., Hammen, C., Cohen, A. N., Daley, S. E., & Henry, R. M. (2004). Expressed emotion versus relationship quality variables in the prediction of recurrence in bipolar patients. Journal of Affective Disorders, 83, 199–206.Google Scholar
Zahn-Waxler, C., Iannotti, R., Cummings, E. M., & Denham, S. (1990). Antecedents of problem behaviors in children of depressed mothers. Development and Psychopathology, 2, 271–291.Google Scholar
Zahn-Waxler, C., Mayfield, A., Radke-Yarrow, M., McKnew, D. H., Cytryn, L., & Davenport, Y. B. (1988). A follow-up investigation of offspring of parents with bipolar disorder. American Journal of Psychiatry, 145, 506–509.Google Scholar