Environmental Factors

Even if the familial transmission of bipolar disorder has been well established, the concordance rate between identical twins does not approach 100%, suggesting a combined role of genetic predisposition and environmental factors [67]. A bipolar parent with recurrent episodes is often dysfunctional, neglectful or absent, and this chronic or recurrent situation can influence the child's development [35,36]. Negative family interactions, including higher expressed emotions, have been proved to be predictive of relapse in bipolar adolescents and adults [68], but studies considering the family environment in the presence of a bipolar parent, and its effect on offspring, are rare. Conrad and Hammen [69] evaluated the offspring of bipolar mothers and found that a better outcome was associated with social competence and a healthy father. Marital discord, parental divorce, a second parent with psychopathology, and chronicity of illness were predictors of psychopathology in children of bipolar parents [6,13,16,70]. Inoff-Germain et al. [70] found that mothers with bipolar disorder had more negative reactions towards their children than mothers with unipolar depression and healthy mothers, supporting the hypothesis that parenting may be a critical element for the psychopathological outcome. Furthermore, socioeconomic status was found to be related to the presence of psycho-pathology in the offspring [16,18].

Chang et al. [35] have specifically explored family environment in families with one bipolar parent, assessed by the Family Environment Scale (FES) [71]. Data show, according to parents' ratings, lower scores on the cohesion and organization scales, and higher scores on the conflict scale, compared to population means. Scores did not differ between families with one or two affected parents, as well as between bipolar offspring with or without an axis I DSM-IV diagnosis. This finding suggests the lack of a specific relationship between negative family environment and the development of psychopathology in the offspring.

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