Overall, mild to moderate levels of psychosocial impairment were evident in work (includes academics) and interpersonal (includes family and friends) domains of functioning in our sample of BP youth. On average, BP youth endorsed good recreational functioning but reported moderate dissatisfaction with their overall level of functioning.
Multivariate analysis indicated that overall functional impairment among BP youth is greatest among adolescents (regardless of whether illness onset was in childhood or adolescence), those currently in a mood episode, with current psychotic symptoms, and current CD. Poorer interpersonal functioning was most strongly associated with current psychosis, CD and ODD, whereas poorer work functioning was predicted by older age, current mood episode, and greater manic severity. Impairment in recreational functioning was greatest among adolescents with late onset, those in a current mood episode, and those with greater depressive severity. Finally, dissatisfaction with functioning was most highly associated with adolescence (regardless of age of onset), current mood episode, greater depressive severity, and CD.
The level of functional impairment on the semi-structured A-LIFE scale in this sample is similar to that reported among adolescents with body dysmorphic disorder (Phillips et al. 2006
). As compared with two other recent studies of functioning in BP youth, our findings indicate less functional impairment--this may be explained by two methodological differences: the type of assessment instruments used and the definition of psychosocial functioning employed. Rucklidge (2006)
reported on intra-individual domains of functioning (e.g., self-esteem) using self-report methodology, whereas Esposito-Smythers et al. (2006)
examined family functioning (e.g., conflict) via self- and parent-report.
Like Biederman et al. (2005)
, we found that BP adolescents, regardless of age of onset, reported greater functional impairment across domains than BP children. Given that psychosocial demands increase throughout development, older youth may find their illness symptoms render them less capable of meeting the mounting psychosocial challenges.
It is noteworthy that mild to moderate impairment was evident in work, interpersonal, and satisfaction domains, whereas recreational functioning remained good even while in-episode. This finding is similar to that reported by Rademacher et al. (2007)
in which acutely manic/mixed adolescents exhibited impairment when compared with national norms in all domains of psychosocial functioning with the exception of “social limitations.” Our clinical experience indicates that many BP youth engage in recreational activities that remain feasible during symptomatic periods (e.g., playing computer games). It is also possible that hypomanic symptoms “buffer” against the negative impact of the illness on functioning, and even serve to enhance functioning in certain domains.
Results indicate that current psychosis is a strong predictor of impairment across functional domains in pediatric BP. Given findings from Birmaher et al. (2006)
from the first 263 COBY subjects in which lifetime psychosis predicted more time with mood symptoms over follow-up, psychosis may serve as a marker for greater illness duration and severity, thereby influencing psychosocial functioning.
Functioning did not differ between BP subtypes (I, II, NOS) in the present sample of youth. These findings converge with Judd's (2007)
findings in adults and suggest that BP spectrum illnesses confer similar risk for disability and impairment. Similar to findings from other samples of depressed (Seeley 2002
) and BP youth (Biederman et al. 1997
), we found that comorbid CD was associated with particularly poor outcomes.
In support of our hypothesis, we found BP youth in an affective episode were more impaired than those in partial remission/recovery in every functional domain examined and were less satisfied with their functioning. Similar to findings among BP adults, we found that BP youth in-episode, as compared with those in partial recovery/remission, experienced greater functional impairment in every psychosocial domain examined. Yet, functional impairment remained evident, albeit to a lesser degree, between illness episodes. Our findings converge with those of previous studies indicating significant impairment across domains among youth with BP during episodes of illness (Wilens et al. 2003
;Geller et al. 2000
;Lewinsohn et al. 1995
) as well as during periods of syndromic and symptomatic recovery (DelBello et al. 2007
;Goldstein et al. 2006
). Furthermore, similar to findings by Judd and colleagues (2005)
among BP adults using the LIFE, our data indicate functioning in BP youth is more highly impaired during depressive episodes versus manic/mixed/cycling episodes. Depressive symptoms appear to have a particularly deleterious impact on recreational functioning and satisfaction with functioning among BP youth, whereas manic symptoms appear to most strongly impede work functioning in this population.
The converging evidence thus supports the notion that youth with BP experience significant functional impairment both during and between mood episodes. However, the direction of causality remains to be established. It is possible that functional impairments predate illness onset. Alternatively, a third variable may account for the relationship—for example, compromised cognitive functioning. Functional impairment may emerge as a result of episodes of illness or be attributable to subsyndromal symptomatology between episodes. Per Hammen's (1991)
stress generation model, episodes of illness may lead to increases in social stress and subsequent deterioration in functioning. Youth with BP may fall behind their healthy peers in terms of psychosocial development during episodes of illness and are not able to fully recover from the delay when the episode remits. Finally, Post's kindling model (Post and Weiss 1995
) may not only explain course and severity of illness, but also psychosocial functioning. This argument may be particularly compelling given the critical period for brain development throughout childhood and adolescence (Dahl 2004
The limitations of the present study include the reliance on patient and parent retrospective report of functioning. Additionally, self- and parent-perceptions of the subjects' functioning may be differentially impacted by developmental differences—i.e., younger children may have less insight into their impairment, while their parents may have lower expectations regarding psychosocial functioning.
COBY is largely a clinical sample, and thus may not be representative of pediatric BP patients who have not sought treatment. However, results from Lewinsohn's (1995)
epidemiological sample indicate similar functional impairment among BP youth. Additionally, although findings from adult studies support a relationship between cognitive deficits and functional impairment during periods of remission in BP (Martinez-Aran et al. 2004
), cognitive functioning was not formally assessed at intake.
Pediatric BP is associated with significant psychosocial impairment, particularly during the adolescent years and among those with greater illness severity and comorbid DBD. The present findings highlight the importance of future work on the development of treatments focused on improving psychosocial functioning in pediatric BP, particularly in the areas of family and peer interactions. Interventions for BP youth should seek to not only reduce symptoms and prevent relapse, but also promote normalization of psychosocial functioning.
Forthcoming prospective data from COBY will further inform our understanding of the temporal relationship between mood symptoms, episodes of illness, comorbidities, and functioning among BP youth. Given that critical building blocks of successful psychosocial development are established throughout childhood and adolescence, further study of the impact of the illness on psychosocial development is imperative in order to decrease the deleterious impact early episodes may have on subsequent functioning.