Offspring of Patients with Affective Disorders: IILEON CYTRYN, M.D., DONALD H. McKNEW, JR., M.D., JOHN J. BARTKO, PH.D.,

MARTINE LAMOUR, M.D., AND JOELLE HAMOVITT, M.S.W.

Nineteen children, aged 5 to 15, of 13 manic-depressive parents and 21 children aged 5 to15 of 13 normal parents were evaluated for affective disorder using blind ratings andinterviewers and employing both the Weinberg Criteria and the DSM·III. Significantlymore index families had depressed children than normal families as measured by Weinbergand DSM-III Criteria. The presence of depression in the children did not correlate with I:geor sex and no manic or psychotic children were seen.

Journal of the American Academy of Child Psychiatry, 21, 4:389-391, 1982.

In a previous open study (McKnew et al., 1979) 30children (aged 5 to 15) of 16 parents hospitalized witha major effective disorder were assessed for the pres·ence of affective illness in two structured interviews,at 4-month intervals, on the basis of the WeinbergCriteria (Weinberg et al., 1973). Of the 30 children, 9were depressed on both interviews and 16 were de­pressed on one interview. There was no significantcorrelation between the presence of depression andthe age or sex of the children. None of the childrenwas manic or psychotic.

The present study was undertaken in order to vali­date the above preliminary findings by the use of blindinterviewers and raters, as well as the inclusion of acontrol group.

Methods

We studied two groups of children, ages 5 to 15:A. Nineteen children of 13 consecutive patients hos­

pitalized in the National Institute of MentalHealth with the diagnosis of Major AffectiveDisorder. (Mean age 11, 10 boys, 9 girls, Holl­ingshead-Redlich Scale-2.7.)

B. Twenty-one control children of 13 parents whowere free of major physical or mental illness.(Mean age 11.1, 13 boys, 8 girls, Hollingshead­Redlich Scale-2.1).

Drs. Cytryn and McKnew are staff psychiatrists in the Unit onChildhood Mental Illness of the Biological Psychiatry Branch,and the Laboratory of Developmental Psychology, N.I.M.H. Theyare also with the George Washington University School of Medi­cine, where Dr. Cytryn is CliniccLl Professor and Dr. McKnew isClinical Associate Professor, Department of Psychiatry and Be­havioral Sciences and Child Health and Development. Dr. Bartkois a mathematical statistician, Division of Biometry and Epide­miology, N.I.M.H. Dr. Lamour and Ms. Hamovit are with the Uniton Childhood Mental Illness, N.I.M.H.

Dr. Lamour is supported by a fellowship from the "Foundationpour la recherche medicale francaise."

Reprints may be requested from Dr. Cytryn, National Institute ofMental Health, Building 10, Room 2N21O, Bethesda, MD 20205.

0002-7138/82/2104-0389 $02.00/0 © 1982 by the American Acad­emy of Child Psychiatry.

All the children were white, save for one black childin each group, and all were the biological offspring ofthe parents. The control group was matched with theindex group on the following parameters: (a) age,within a 2-year span; (b) sex; and (c) socioeconomicstatus according to the Hollingshead-Redlich Scale,within a one-point span.

All the parents in both groups were assessed by theLife Schedule of Affective Disorders and Schizophre­nia (L-SADS) and diagnosed using the Research Di­agnostic Criteria (RDC) as modified by Gershon(Leckman et al., 1977; Spitzer et al., 1977). All childrenwhose IQ was below 90 or who had a chronic physicalillness were excluded. The matching of the children,the screening and interviewing of the parents, as wellas the random scheduling of the children for inter­views, were done by an independent colleague in orderto maintain the blindness.

All the children were interviewed by a member ofour team who was blind as to the purpose of the studyand who had no knowledge of the origin of any givenchild. The two interviews at 4-month intervals werestructured according to a previously developed formatwhich elicits all types of childhood psychopathology.The interviews lasted approximately 45 minutes. Atthe end of each interview, the children were ratedindependently by the child interviewer on the follow­ing rating scales: (a) the Children's Psychiatric RatingScale (CPRS) of the ECDEU, and (b) the Children'sAffective Rating Scale (CARS). The interviews wereobserved through a one-way mirror by two other teammembers who rated the child on the same scales. Thenature of the structured interview, as well as theinterrater reliability on the CARS and CPRS has beenreported elsewhere (McKnew et al., 1979).

Based on these ratings, their observations, and anyother available information from parents and/orschool, the above-mentioned investigators who wereblind as to the origin of each patient, diagnosed thechild by consensus as depressed if he met the Wein­berg Criteria (Weinberg et al., 1973).

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390 CYTRYN ET AL.

When the DSM-III criteria became available in finalform, our recorded structured interviews and ratingsallowed us to rediagnose the children, using thosecriteria. Thus, each child received two diagnoses,Weinberg and DSM-III. A child was diagnosed asdepressed if he or she met the DSM-III Criteria forMajor Depressive Disorder or Dysthymic Disorder.Our diagnostic assessment of the children, focused ontheir present status and recent past. Lifetime diag­noses were not made since no appropriate instrumentswere available at the time of the study.

The 40 children in our study come from 26 families.Since the hypothesis in this study is that child andadult depressions aggregate in families and this hy­pothesis has received considerable support from otherstudies (Puig-Antich, 1980), we decided to make thefamily the unit of analysis as children in the samefamily will share the same risk to develop the disorder.

The statistics used were the Fisher Exact Test andthe l test (Siegel, 1956).

Results

Of the 13 index families, 11 had one or more childrenwho were depressed on at least one interview as mea­sured by the Weinberg criteria while two families hadno children who satisfied the Weinberg criteria on anyinterview. In contrast, of the 13 control group families,10 had children who were all Weinberg negative and3 families had children who satisfied the WeinbergCriteria. This difference is statistically significant l= 7.58 (p = 0.01).

Using the DSM-III criteria, the following resultswere obtained. In the index group, 9 families had atleast one depressed child, while 4 families had none.In the control group 3 families had at least one de­pressed child, while 10 had none. This difference isagain statistically significant l = 3.87 (p = 0.05). Inthe index group, 3 families had children with MajorDepressive Disorder while 1 control family had a childwith such a disorder. The remaining children withaffective illness in both groups had Dysthymic Disor­der. In addition to affective disorders, the DSM-IIIdiagnoses of Overanxious Disorder were made in thechildren of 2 proband families and in one of the controlfamilies. Another index family had a child with aSimple Phobia. No child had manic or psychotic symp­toms.

According to RDC criteria, two spouses of the indexparents had Depressive Personality, three spouses hadminor Depression, one had General Anxiety and onehad a Phobic Reaction. Six spouses were free of psy­chopathology. A comparison of the offspring of fami­lies with two affectively ill parents did not show thatthe former are at any greater risk for having an affec-

tive illness. There was also no significant correlationbetween the diagnosis of the index parent (Bipolar,Unipolar, and Schizo-Affective) or the age or sex ofthe child and the frequency of an affective illness inthe children.

However, we found that the frequency of affectivedisorders in the children was significantly higher if thechild and the index parent were of opposite sex (FisherExact p = 0.03).

Discussion

The high incidence of depressive disorders in theoffspring of affectively ill parents which we reportedin our first open study has been confirmed by thiscontrolled study using the offspring of normal parents.Similarly confirmed were the findings of no correlationof depressive diagnosis in the children with age andsex, as well as the absence of mania and psychosis.

The Weinberg Criteria were used for two reasons.(1) At the beginning of this study, the DSM-III Cri­teria were only in a formative stage and the use ofRDC in children had not yet been published. (2) Ourfirst offspring study (McKnew et al., 1979) used theWeinberg Criteria and it seemed essential to use thesame standards as a basis for comparison. The dis­crepancy in this study between the Weinberg Criteriaand the DSM-III Criteria in the proband group hasalso been noted by several authors (Apter et al., 1981;Carlson and Cantwell, 1980). Both groups found thatthe Weinberg Criteria are often overinclusive andsometimes underinclusive, as compared with DSM-IIICriteria. In addition, it should be noted that Carlsonet al. were comparing Weinberg Criteria only to MajorDepressive Disorder while Apter et al. and we includedDysthymic Disorders as well.

The high incidence of depression in the children ofthe index group can be due to many factors such as:(1) the hardship of having a parent with any chronicillness which requires hospitalization (Rutter, 1966),(2) genetic vulnerability, and (3) the impact of livingwith a mentally ill parent.

The curious finding of a significantly increased in­cidence of affective illness in the opposite sex offspringof a manic depressive proband cannot be generalizedbecause of our small sample. However, the potentialsignificance of this finding warrants further investiga­tion.

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