Because clinicians and researchers are often expected to evaluate and link children's problems to diagnostic categories to facilitate clinical care, a secondary purpose of the present study is to examine the relationship between temperament and DSM-oriented diagnostic categories. Moreover, given research evidence of sex differences in temperament and behavior Olino et al. The Emory University Institutional Review Board approved this study, and the mothers provided written informed consent.
The ECBQ was used to assess temperament according to maternal report. This parent-report measure consists of items evaluating 18 domains of temperament in children between the ages of 18 and 36 months. Parents are asked to rate the frequency of temperament-related domains observed over the previous 2 weeks on a scale from 1 never to 7 always. Factor analysis revealed a three factor structure of the ECBQ: The parent-report CBCL for ages 1.
The CBCL scales contained in the measure are: Distributions were examined and indicated that the data were not normally distributed. The Mann—Whitney U test was performed to test for sex differences in temperament and behavior between girls and boys. Given the preliminary nature of the study and that a specific set of hypothesized associations was examined, an adjustment for multiple comparisons was deemed highly conservative and was not conducted. A total of 38 mother—toddler dyads were approached, and 30 were eligible for study participation. One offspring was included from each mother.
The sample consisted of 16 boys and 14 girls, with mean age Temperament scores, as determined by the three broad factors of the ECBQ measure, ranged from a score of 1. The mean scores were 2. Consistent with the hypotheses, the broad temperament dimension Negative Affectivity and the individual ECBQ scales Sadness and Shyness were positively associated with Internalizing Problems, whereas Sociability was negatively associated with Internalizing Problems.
There were no other significant sex differences.
This is the first systematic investigation of temperament and behavior and concurrent associations between these two domains in toddlers of mothers with BD, a population at high familial risk for psychopathology. The major findings are consistent with the hypotheses and with the limited number of studies focused on temperament in OBD.
The correlational analyses confirmed concurrent relationships between temperament and behavior. The results are in line with prior research in children indicating concurrent and longitudinal associations between high levels of Negative Affectivity and high levels of internalizing problems, and between low levels of Effortful Control and high levels of externalizing problems Eisenberg et al.
This, combined with the finding of seven cases of CBCL scores in the borderline range and two in the clinical range, might suggest that young OBD with these temperament traits might be at increased risk for development of behavioral problems over time and should be monitored closely. This has critical implications for clinical practice with OBD. How can the present findings combined with research on temperament-based interventions benefit clinicians, OBD, and parents with BD more effectively parent youth to prevent the development of clinically significant psychiatric symptoms?
Research indicates that child temperament interacts with parenting practices. Children with difficult temperament have worse externalizing symptoms in response to negative discipline and have fewer externalizing symptoms and aggression in response to positive parenting Van Zeijl et al. Moreover, research evidence of a bidirectional relationship between child temperament and parenting in toddlerhood Braungart-Rieker et al.
Such findings can be used by clinicians to assist parents with BD to identify their parenting patterns with OBD high in negative emotionality, and teach temperament-based strategies to break the negative cycle between parent and child. Also, McClowry and colleagues outline helpful guidelines for the development and adaptation of temperament-based interventions examined through the lens of self-regulation, which could be beneficial for clinical practice with OBD.
From a developmental perspective, the present findings of concurrent significant associations between specific ECBQ scales in the broad temperament dimension Negative Affectivity and Effortful Control with internalizing and externalizing problems, respectively, appear to be a downward extension of research in pediatric BD. The results provide novel evidence for the role of negative affect and impaired attentional resources in a high-risk population of toddlers of mothers with BD.
Specifically, pediatric BD studies have shown that emotionally demanding environments, in particular those characterized by frustration Rich et al. Attentional performance in children with BD was impaired only in the setting of negative emotions Rich et al. The current study is the first report in the literature to provide evidence for the importance of negative affect and attentional deficits at a much earlier developmental stage in toddlers at risk for development of mood disorders and other comorbid conditions.
The present findings suggest that early in development, OBD already demonstrate subtle temperament trait markers e. This indicates that perhaps difficult temperament characteristics early in development may serve as global indicators of risk across a spectrum of internalizing and externalizing problems.
Combined with the abovementioned findings regarding frustration in pediatric BD, it is possible that frustration might be a trait-related vulnerability marker and one of multiple risk factors in unaffected OBD. This might suggest that shy, inhibited, and anxious OBD may be at increased risk for the development of behavioral problems. This is in line with the notion of anxiety as an early predictor of later psychopathology in OBD Simeonova et al. Also, it is important to note that in the study sample of 30 toddlers, there were 7 cases with CBCL scores in the borderline range Scales: Although this finding should be interpreted with caution, because of its descriptive nature, it provides some evidence for the emergence of very early behavioral problems is OBD.
Given that this is the first study to examine temperament and behavior in toddlers of mother with BD, direct comparison with previous studies is not possible. The overall findings, nevertheless, are consistent with the limited number of studies of temperament in OBD, which support the relationship between temperament and symptoms of mania, depression, and overall psychopathology. Also, a retrospective study of early childhood temperament in infancy and toddlerhood in children with BD found that several characteristics of difficult temperament emotional intensity, negative mood, irregular rhythms in toddlerhood, experiencing distress during separation in infancy were associated with current symptoms of mania and depression West et al.
The findings are consistent with results from a study with a normal sample of 1. Also, studies utilizing the CBCL with toddlers from the general population Kott and Verhulst and with autism spectrum disorder Hartley and Sikora show that girls have more sleep problems than boys. It is possible that the finding of a sex difference in sleep problems reflects a normative trend. On the other hand, given that sleep dysregulation is a core feature of mood psychopathology in pediatric and adult populations, it is also possible that this is an early indicator of emerging difficulties.
Given the small sample size, however, the results should be viewed as exploratory and interpreted with caution. Although the study of temperament in child offspring of parents with BD is a small literature at present, the current findings are in line with investigations reporting results from different age groups. What emerges is a unique picture of the developmental trajectory of temperament traits of OBD characterized by global impairments in flexibility, frustration tolerance, inhibitory control, soothability, ability to follow daily rhythm patterns, and negative affectivity.
This literature underscores the importance of investigating temperament longitudinally and across developmental stages. Some limitations need to be considered in interpreting the study findings.
Criticism has been voiced about the current approach, because of a contamination problem caused by item-content overlap in the assessment of temperament and behavior. Studies have reported, however, that even after removal of the threat to validity presented by overlap in measures, there continue to be significant, interpretable relationships between temperament and behavior Lengua et al. Also, because of the small number of toddlers studied, it was not possible to examine potential differences in temperament and behavior between OBD subgroups based on maternal diagnosis BD I vs.
Furthermore, the toddler assessments were completed by an affected mother with BD. Research has cautioned that mothers' evaluations of their children's behavior is influenced by their own mental state, therefore raising questions about the validity of child behavior reports by mothers who are currently emotionally distressed Najman et al. Conversely, evidence suggests that maternal symptoms e. They provide useful information on current child functioning Rice et al.
The maternal mood state during the evaluation of the toddlers, however, was not addressed, which is a limitation of this study. Also, given the preliminary nature of this investigation and that a specific set of hypothesized associations was examined, an adjustment for multiple comparisons was deemed highly conservative and was not conducted.
Cause-effect association or observation bias? I had this overwhelming feeling that had I failed him and lost the opportunity to redeem our relationship. There are no published studies examining associations between temperament and behavior during toddlerhood in OBD. A P value of 0. Because clinicians and researchers are often expected to evaluate and link children's problems to diagnostic categories to facilitate clinical care, a secondary purpose of the present study is to examine the relationship between temperament and DSM-oriented diagnostic categories. Given the small sample size, however, the results should be viewed as exploratory and interpreted with caution.
This needs to be kept in mind when interpreting the study findings. In addition, the lack of comparison group of offspring of parents without psychopathology or a psychiatric control group is a limitation. In the summer he wore winter clothes, complaining he was cold. The inside labels on his shirt and seams on his socks sent him into fits of rage. Over the next three and a half years, we saw five psychiatrists, each offering a different diagnosis.
Finally, after being treated with an anti-depressant, he experienced a full-blown manic episode and was ultimately diagnosed with early-onset bipolar disorder. In addition to dealing with my son's diagnosis, I found very little support for my family or myself. I began talking with other moms at the playground, explaining why my son was different and what his aberrant behaviors meant. We talked openly and honestly about it and encouraged him to do so as well. In the early years, our openness came back to haunt us.
Parents whispered about him at t-ball games, no one invited him to birthday parties, sleepovers or play dates. The children on the playground called him names like psycho, looney head and mental case. The boys taunted him and told him to go back to the mental hospital even though he'd actually never been at one.
Each day when I picked him up from school, he would shuffle over to the car with his head hanging down, telling me of yet another example of the bullying he had endured. Even though the bipolar families had more comorbid diagnoses, there was a similar distribution of diagnoses among the study groups, with a few exceptions. Pregancy and newborn diagnoses were less common in bipolar families; such families have been noted for individuals with bipolar disorder in previous research. Adding to the hypothesis that the effect of bipolar disorder extends beyond the individual with the diagnosis are the findings that children with the diagnosis had the lowest per-member costs.
This increase in cost appears to be driven by the use of health care resources by parents. The health care costs of parents, particularly mothers, with bipolar children are substantially affected, more so than those of the spouses of individuals with bipolar disorder, possibly because of the psychological stress associated with caring for a child with a disability.
Most informal caregivers of children are mothers, 20 thereby augmenting this effect. The high costs incurred by these families make them ideally suited for case management, which can reduce the level of mania symptoms. As with all research, some limitations may need to be considered. Although our analysis used a unique and rich data set, analyses based on insurance claims data are limited by several factors, including:. Potential selection biases also exist; it is possible that bipolar disorder might be underreported in claims data as a result of social stigma, practice differences between primary care physicians and specialists, and other factors.
We should also consider a factor that might have limited the generalizability of the results. The study sample might have represented a high-functioning population of individuals with bipolar disorder.
Excluding families with other serious mental health diagnoses from the control group might have led to overestimating incremental costs. It has been reported that approximately one-third of patients diagnosed with unipolar depression also fit the diagnostic criteria for bipolar spectrum disorder. An additional limitation might be the lack of cost data for some services provided under capitated health plans. Our approach was to exclude these services, which could have resulted in an underestimation of total costs. Bipolar families appear to have unmet needs based on their higher utilization of health care resources, including prescriptions.
More research is needed to determine whether effective drug and behavioral health treatment of bipolar patients can alleviate the burden on family members, thereby decreasing their health care utilization, or whether the effect persists. Future research should also focus on methods to address these unmet needs, such as family counseling and family-based disease management.
Our findings support the evidence that bipolar disorder has a significant financial impact on family members in addition to the individual with the diagnosis. Families containing a member with bipolar disorder incur far greater direct medical costs than families without a serious mental illness. Caring for or living with these individuals is associated with secondary medical consequences. Further research is needed to elucidate the factors that affect the health of and the health care costs for caregivers and family members of individuals with bipolar disorder as well as the impact of therapy for these families.
Research for this study was funded by AstraZeneca. At the time of the study, Dr. Chatterton was a paid consultant to AstraZeneca, and Dr. Rajagopalan were employees at AstraZeneca. Ke is an employee of AstraZeneca, and Dr. Lazarus is an employee and stockholder at AstraZeneca. National Center for Biotechnology Information , U. Journal List P T v. Author information Article notes Copyright and License information Disclaimer. Accepted Nov This article has been cited by other articles in PMC.
Open in a separate window. Cost per Family No. Although our analysis used a unique and rich data set, analyses based on insurance claims data are limited by several factors, including: American Psychiatric Association; Costs of bipolar disorder. The lifetime cost of bipolar disorder in the U.
An estimate for new cases in Pharmacoeconomics 19 5 Part 1: The economic burden of affective disorders.
The Emergence of a Bipolar Disorder: A Mother's Perspective by Maureen Murdock informs the reader about the early signs of bipolar disorder in an adolescent. Bipolar Disorder: A Mother's Perspective. Putting baby locks on the kitchen cabinets to protect my toddler was one thing, but locking away the steak knives from.
Health economics and cost implications of anxiety and other mental health disorders in the United States. Wyatt RJ, Henter I.
An economic evaluation of manic-depressive illness, Depressive disorders in spouses of mentally ill patients. Family functioning and parent general health in families of adolescents with major depressive disorder. The health and well-being of black mothers who care for their adult children with schizophrenia. Predictors of burden and infectious illness in schizophrenia caregivers. Gallagher SK, Mechanic D. Living with the mentally ill: