# Changes in emotional dysregulation profile among offspring of parents with bipolar disorder: a family-based intervention pilot study

Erica Fongaro, Florence Pupier, Marie-Christine Picot, Nathalie Franc, Marion Soler, Emilie Olié, Virginie Maurice, Diane Purper-Ouakil, Hala Kerbage

<figure><img src="image_1.png" /></figure>

## ► To cite this version:

Erica Fongaro, Florence Pupier, Marie-Christine Picot, Nathalie Franc, Marion Soler, et al. Changes in emotional dysregulation profile among offspring of parents with bipolar disorder: a family-based intervention pilot study. International Journal of Bipolar Disorders, 2025, 13 (1), pp.31. 10.1186/s40345-025-00398-3. doi:10.1186/s40345-025-00398-3

HAL Id: hal-05349405

https://hal.science/hal-05349405v1

Submitted on 5 Nov 2025

HAL is a multi-disciplinary open access archive for the deposit and dissemination of scientific research documents, whether they are published or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

<figure><img src="image_2.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
BRIEF REPORT

Open Access

<figure><img src="image_3.png" /></figure>

Check for
updates

# Changes in emotional dysregulation profile among offspring of parents with bipolar disorder: a family-based intervention pilot study

Erica Fongaro¹,<fnref n="2" />*, Florence Pupier¹, Marie-Christine Picot<fnref n="3" />, Nathalie Franc¹, Marion Soler<fnref n="3" />, Emilie Olié<fnref n="4" />,<fnref n="5" />, Virginie Maurice¹, Diane Purper-Ouakil¹,<fnref n="2" /> and Hala Kerbage¹,<fnref n="2" />

**Abstract** Offspring of parents with bipolar disorder (OBD) are at increased risk for mood and behavioral disorders, with emotional dysregulation being an early marker. This pilot study aimed to evaluate the effect of a family-focused intervention on emotional dysregulation in OBD, hypothesizing a significant reduction in CBCL Emotional Dysregulation Profile scores over 12 months. Twenty-five OBD aged 6–16 years participated in a four-session psychoeducational program. Significant reductions were observed in CBCL emotional dysregulation scores suggesting that a brief family-focused program may reduce dysregulation and improve functioning in OBD.

**Trial registration number** Clinicaltrials.gov. ID NCT03299140. Registered on the 17th September, 2017.

**Keywords** Bipolar disorder, Offspring, CBCL, Emotional dysregulation, Family-focused treatment

## Introduction

Bipolar disorder (BD) is a chronic mood disorder with early onset and high heritability (70–80%) [1], affecting 1–2% of adults [2]. Parents with BD often exhibit mood instability and impaired caregiving, contributing to disrupted parent–child relationships [3–5]. Their offspring

(OBD) are at significantly elevated risk for mood, anxiety, behavioural, and attentional disorders [5].

Emotional dysregulation—a transdiagnostic marker of severe psychopathology—is common in OBD and may precede formal diagnosis [6]. The Child Behavior Checklist Emotional Dysregulation Profiles (CBCL-EDP), reflecting attention, aggression, and anxiety/depression, is a validated early indicator of emotional and behavioral instability [7].

Despite well-documented vulnerability, preventive interventions for asymptomatic but high-risk youth remain scarce [8]. Most programs target early symptomatic children, leaving many at familial risk unsupported [9]. Recent trials highlight the promise of family-based preventive interventions [10]. Family-Focused Treatment (FFT) is one such program shown to reduce conflict and improve emotion regulation in at-risk youth [11].

<figure><img src="image_4.png" /></figure>

Springer

<footnote>*Correspondence:
Erica.Fongaro@chu-montpellier.fr
¹Centre Hospitalier Universitaire de Montpellier, Saint Eloi Hospital,
Montpellier, Hérault, France</footnote>

<footnote n="2">²CESP INSERM U 1018 UVSQ Psychiatry Development and Trajectories,
Villejuif, France</footnote>

<footnote n="3">³Clinical & Epidemiological Research Unit, CHU, Montpellier, Montpellier,
France</footnote>

<footnote n="4">⁴Department of Emergency Psychiatry and Acute Care, Lapeyronie
Hospital, CHU Montpellier, Montpellier, France</footnote>

<footnote n="5">⁵IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France</footnote>
Drawing on FFT principles, we developed a brief family-based intervention within a Child and Adolescent Mental Health Service (CAMHS) in France. This pilot study evaluated its impact on emotional dysregulation in OBD, hypothesizing a significant reduction in CBCL emotional dysregulation profile scores over 12 months.

## Materials and methods

### Study design and participant recruitment

This monocentric observational pilot study recruited OBD aged 6–16 years and at least one parent with BD from the Bipolar Expert Center (CHU Montpellier) and community referrals over a 24-month period (2014–2016). Of the 49 families initially contacted, 42 met inclusion criteria, and 25 enrolled and completed the intervention, representing an attrition rate of 40.5%. Inclusion required informed consent and parental clinical stability based on their clinician’s judgement. Offspring psychiatric symptoms were not required for inclusion; all children of parents with bipolar disorder aged 6–16 years were eligible, regardless of clinical status. This approach allowed both symptomatic and asymptomatic youth at familial risk to participate, reflecting the program’s preventive aims. Among symptomatic participants, many had chronic or recurrent conditions such as ADHD or

anxiety disorders, but illness duration was not a selection criterion. Exclusion criteria were a current mood episode, ASD, intellectual disability, or any condition hindering group participation, in either parent or child. This study was approved by the ethics committee “COMITE DE PROTECTION DES PERSONNES SUD-MEDITARRA-NEE I” (IRB ID: 2014-A00204-43). All participants provided written informed consent prior to their inclusion.

## Intervention

The intervention consisted of a family-based program adapted from Miklowitz’s FFT, a cognitive-behavioral approach combining psychoeducation, communication enhancement, and problem-solving training originally developed for early-onset BD. Our adaptation focused on families where only the parent had BD, aiming to strengthen offspring coping skills, family communication, and early responses to emotional dysregulation. Four 3-hour sessions were delivered at the St Eloi CAMHS over six months, approximately every six weeks, by experienced clinicians trained in family and cognitive-behavioral therapy Sessions were intentionally spaced to allow families time to practice skills at home between sessions. Two parallel groups ran simultaneously:

Parents’ group: one session on psychoeducation about BD symptoms, aetiology, heritability, and offspring vulnerability; two sessions on educational strategies for reducing familial conflict, establishing stable routines (e.g., sleep hygiene), and managing emotional dysregulation using behavioural strategies (e.g., time-out, “special time” routines inspired by Barkley’s program); and one session on communication skills for labelling emotions, encouraging positive behaviours, and fostering family cohesion.

Offspring group: one session on psychoeducation about parental BD with open discussion; one session on emotion regulation strategies (e.g., anger management techniques); one session on communication skills (e.g., active listening, assertiveness); and one session on problem-solving and stress management.

Unlike standard FFT protocols involving 12–21 conjoint sessions, our adaptation used four sessions combining separate parent and youth groups with brief joint activities and structured homework assignments. This format allowed age-appropriate psychoeducation and skills training while reducing attendance barriers common in routine care. Parents and youth practiced communication and problem-solving techniques together at home using guided exercises, ensuring that key FFT components were retained despite fewer in-person conjoint sessions. Table 1 summarizes the content of each session.

<table><caption>**Table 1** Overview of the family-focused program for emotional dysregulation in OBD: content themes and activities</caption><thead><tr><td>Session</td><td>Parents' group content</td><td>Offspring group content</td><td>Format &amp; activities</td></tr></thead><tbody><tr><td>Session 1</td><td>Psychoeducation: symptoms, etiology, heritability of BD, offspring vulnerability</td><td>Psychoeducation about parental BD, open discussion on questions/concerns</td><td>Interactive presentations, Q&amp;A, group discussions</td></tr><tr><td>Session 2</td><td>Educational strategies: reducing familial conflict, establishing routines (e.g., sleep hygiene), understanding emotional dysregulation, prevention strategies</td><td>Emotion regulation strategies: identifying emotions, anger management tools</td><td>Role-playing, small-group exercises, skills practice</td></tr><tr><td>Session 3</td><td>Communication skills: labeling emotions, praising positive behaviors, family communication strategies</td><td>Communication skills: active listening, assertiveness training, expressing emotions safely</td><td>Communication games, modeling by facilitators, family-based exercises</td></tr><tr><td>Session 4</td><td>Problem-solving approaches: stress management, early detection of relapse, collaborative problem-solving</td><td>Problem-solving and coping strategies: stress management, confidence-building</td><td>Joint activities with parents and youth, guided problem-solving practice, goal-setting exercises</td></tr></tbody></table>
## Measures

Participants were assessed at baseline (T0), 6 months (T1), and 12 months (T2) using a standardized battery of validated instruments. Emotional and behavioral problems were evaluated primarily using the CBCL 4–18 [12, 13], with the EDP score, serving as the main outcome measure. The CBCL-EDP were calculated as the summed T-scores of the Anxious/Depressed, Attention Problems, and Aggressive Behavior subscales. The Kidzie-Schedule for Affective Disorders and Schizophrenia

<table><caption>**Table 2** Description of OBD clinical and demographic characteristics</caption><thead><tr><th>Variable</th><th>Category</th><th>N=25</th></tr></thead><tbody><tr><td rowspan="2">Gender</td><td>Girls</td><td>14 (56.0%)</td></tr><tr><td>Boys</td><td>11 (44.0%)</td></tr><tr><td>Age (years)</td><td>Mean (±DS)</td><td>10.87<br>(2.34)</td></tr><tr><td rowspan="2">School level</td><td>Elementary and middle school</td><td>14 (56.0%)</td></tr><tr><td>High School</td><td>11 (44.0%)</td></tr><tr><td>Parental authority</td><td>Both parents</td><td>19 (76.0%)</td></tr><tr><td>Living with both bio-parents</td><td>Both biological parents (married or shared care)</td><td>22</td></tr><tr><td rowspan="3">Current treatment</td><td>Bipolar parent only</td><td>3</td></tr><tr><td>Medication</td><td>7 (28.0%)</td></tr><tr><td>Day unit hospitalization</td><td>3 (12.0%)</td></tr><tr><td rowspan="2">CGAS (T0)</td><td>Mean (±DS)</td><td>62.92<br>(16.48)</td></tr><tr><td>≥ Cut-off = 70</td><td>10 (40.0%)</td></tr><tr><td rowspan="2">CBCL (T0)</td><td>&lt; Cut-off = 70</td><td>15 (60.0%)</td></tr><tr><td>No Emotional Dysregulation</td><td>8 (32.0%)</td></tr><tr><td rowspan="5">KSADS</td><td>Deficient Emotional<br>Self-Regulation</td><td>10 (40.0%)</td></tr><tr><td>Dysregulation Profile</td><td>7 (28.0%)</td></tr><tr><td>ADHD</td><td>16 (64.0%)</td></tr><tr><td>Oppositional Defiant Disorder</td><td>6 (24.0%)</td></tr><tr><td>Separation Anxiety Disorder</td><td>9 (36.0%)</td></tr><tr><td rowspan="5">ADHD</td><td>Major Depressive Disorder</td><td>8 (32.0%)</td></tr><tr><td>Generalized Anxiety Disorder</td><td>8 (32.0%)</td></tr><tr><td>Sleeping disorder</td><td>6 (24.0%)</td></tr><tr><td>Mania</td><td>2 (8.0%)</td></tr><tr><td>Post-Traumatic Stress Disorder</td><td>4 (16.0%)</td></tr></tbody></table>

– Present and Lifetime Version (Kiddie-SADS-PL) [14] was used to establish DSM-based psychiatric diagnoses and conducted with both the child and at least one parent. Dimensional ratings of emotional and behavioural adjustment were obtained via the Strengths and Difficulties Questionnaire (SDQ) [15] and was completed by parents and by youth aged ≥ 11 years (self-report version). Functional impairment was assessed using the Children’s Global Assessment Scale (CGAS) [16]. Mood symptoms were evaluated using the Children’s Depression Rating Scale – Revised (CDRS-R) [17] for depressive symptoms. Attention and hyperactivity were assessed with the ADHD Rating Scale IV (ADHD-RS-IV) [18]. The Wechsler Abbreviated Scale of Intelligence (WASI) was administered at baseline (T0) by trained clinicians to assess youths’ general intellectual functioning [19]. All other measures were administered at T0, T1, and T2, except for the ADHD-RS-IV, which was administered only at T0 and T2.

## Statistical analyses

CBCL-EDP changes and other outcome measures were evaluated using paired t-tests or Wilcoxon signed-rank tests. Correlations used Spearman ρ and Pearson r. Analyses were conducted in SAS v9; significance was p < .05.

## Results

### Participants and clinical characteristics

The clinical and demographic characteristics are presented in Table 2 for children and Table 3 for parents. Of the 49 families contacted, 42 met eligibility criteria, and 25 enrolled in the study, corresponding to a participation rate of 59.5%. The attrition rate of 40.5% reflects eligible families who declined participation prior to enrolment. All 25 enrolled families completed the full program (i.e., all four sessions), and no families dropped out once the intervention had begun. 84.0% of participants met criteria for at least one psychiatric diagnosis based on the KSADS-PL, 43.0% met criteria for more than one diagnosis, and 16.0% did not meet criteria for any psychiatric diagnosis. At baseline, 60% of youth scored below 70 on the CGAS, reflecting significant functional impairment. Regarding emotional dysregulation, 40% were in the Deficient Emotional Self-Regulation (DESR) range and 28% met criteria for the Dysregulation Profile (DP ≥ 210) (Table 2).

### Primary and secondary outcomes

CBCL-EDP did not differ significantly from T0 (M = 191.76) to T1 (M = 182.9), t(44) = 1.12, *p* = .27. and significantly declined from T0 to T2 (M = 176.88; mean difference = −14.88; t(24) = −4.48; *p* < .001). (Fig. 1). This change was unrelated to gender, age, education, parental BD type or prior treatment and family structure. There

<footnote n="1">1) In the French school system, élémentaire (ages 6–10) and collège (ages 11–14) were combined as “Elementary/Middle school” to facilitate comparison with international terminology. High school refers to lycée (ages 15–18)</footnote>

<footnote n="2">2) “Parental authority” refers to legal custody and medical decision-making rights whereas “Living with both biological parents” refers to the child’s primary residence</footnote>

<footnote n="3">3) Treatment categories are not mutually exclusive; some youth received more than one type of intervention. Psychiatric/psychological care includes outpatient psychiatric or psychological treatment, whereas psychoeducation refers to structured, group- or family-based educational programs about mental health conditions and coping strategies</footnote>

<footnote n="4">4) DESR (Deficient Emotional Self-Regulation) and DP (Dysregulation Profile) are based on the summed T-scores of the Attention Problems, Aggressive Behavior, and Anxious/Depressed subscales. DESR = 180–210; DP ≥ 210</footnote>

<footnote n="5">5) For the KSADS-PL, Percentages indicate the proportion of participants meeting DSM-IV criteria for each diagnosis based on the KSADS-PL. Categories are not mutually exclusive</footnote>
<table><caption>**Table 3** Description of BD parents' clinical and demographic characteristics</caption><thead><tr><th>Variable</th><th>Category</th><th>n (%) N=25</th></tr></thead><tbody><tr><td rowspan="2">Gender</td><td>Women</td><td>15 (60.0%)</td></tr><tr><td>Men</td><td>10 (40.0%)</td></tr><tr><td>Age (years)</td><td>Mean</td><td>43.16 (±5.34)</td></tr><tr><td>BD Type I</td><td></td><td>14 (56.0%)</td></tr><tr><td>BD Type II</td><td></td><td>6 (24.0%)</td></tr><tr><td>BD Type III</td><td></td><td>2 (8.0%)</td></tr><tr><td>BD Not Specified</td><td></td><td>3 (12.0%)</td></tr><tr><td rowspan="3">Current Treatment</td><td>Medication (mood stabilizer)</td><td>7 (28.0%)</td></tr><tr><td>No mood stabilizer</td><td>7 (28.0%)</td></tr><tr><td>Current inpatient hospitalization</td><td>3 (12.0%)</td></tr></tbody></table>

Treatment categories are not mutually exclusive; parents may have received more than one type of treatment. Current hospitalization refers to parents who were still formally hospitalized at baseline but were clinically stable and in the final phase of their inpatient stay, thus meeting inclusion criteria. None were in the acute phase at study entry. Medication (mood stabilizer) refers to parents prescribed at least one mood stabilizer; no mood stabilizer refers to those receiving only other psychotropic classes (e.g., antidepressants, antipsychotics)

were non-significant improvements across the total score of other outcome measures from T0 to T1 (CBCL-Total Score: t(44) = 1.45, *p* =.15; CBCL Externalizing: t(44) = 0.99, *p* =.32; CBCL Internalizing: t(44) = 1.46, *p* =.15;

<table><caption>**Table 4** Group comparisons between participants with and without a psychiatric diagnosis and the CBCL-EDP score changes</caption><thead><tr><th>Baseline measure (KSADS)</th><th>With</th><th>Without</th><th>p-value</th></tr></thead><tbody><tr><td>ADHD</td><td>-7.50 (±9.24)</td><td>-19.80 (±18.78)</td><td>0.04*</td></tr><tr><td>Anxiety Disorders</td><td>-7.22 (±9.23)</td><td>-19.19 (±18.45)</td><td>0.08</td></tr><tr><td>Oppositional Defiant Disorder</td><td>-15.42 (±17.80)</td><td>-10.20 (±12.52)</td><td>0.55</td></tr><tr><td>Sleep Disorders</td><td>-15.39 (±15.90)</td><td>-19.17 (±14.05)</td><td>0.48</td></tr><tr><td>Depression</td><td>-16.36 (±15.17)</td><td>-4.00 (±26.23)</td><td>0.23</td></tr></tbody></table>

CDRS-R: Mann-Whitney U = 231.5, *p* =.89; SDQ: t(42) = 0.25, *p* =.80; CGAS: t(44) = 1.45, *p* =.15). The CBCL-Total Score Score significantly improved from T0 to T2 (CBCL-Total Score: t(48) = 2.00, *p* =.05). There were no significant improvements across the other outcomes (CBCL Externalizing: t(48) = 1.85, *p* =.07; CBCL Internalizing: t(48) = 1.92, *p* =.06; CDRS-R: Mann-Whitney U = 233, *p* =.37; SDQ: t(46) = 1.32, *p* =.19; CGAS: t(44) = 1.45, *p* =.15; ADHD-RS-IV: t(45) = 1.04, *p* =.30) (Fig. 1). Group comparisons were conducted between participants with and without a psychiatric diagnosis to evaluate differences in CBCL-EDP score changes (Table 4).

<figure><img src="image_5.png" /><figcaption>**Fig. 1** Measures mean scores at baseline, 6 months and 12 months</figcaption></figure>
Discussion

This pilot study assessed the effects of a brief family-
based intervention targeting emotion dysregulation in
OBD. The sample had high psychiatric vulnerability—
predominantly ADHD, anxiety, and depression—exceed-
ing epidemiological rates [20], possibly reflecting
selection bias, as families seeking support for mental
health problems may have been more inclined to partici-
pate. CBCL-EDP scores were elevated at baseline, align-
ing with previous findings on symptom complexity in
at-risk youth [21–25].

Our findings demonstrate a significant reduction in CBCL-EDP scores from baseline to 12 months, supporting the potential of brief family-based programs to reduce emotional dysregulation in high-risk youth. Those clinical benefits are consistent with previous FFT research [11, 26]. Interestingly, no significant changes were observed at 6 months, which may indicate that the benefits of psychoeducation and skills practice require time to consolidate before being reflected in measurable symptom change. This pattern is consistent with interventions where sustained improvement emerges only after repeated practice and integration into family routines [27–29] While we did not collect additional indicators such as per-session attendance rates or structured satisfaction measures, the absence of dropout and sustained engagement across all sessions suggest that the intervention was feasible in a real-world CAMHS setting.

Youth with ADHD showed the greatest reductions in emotion dysregulation, which may reflect the strong overlap between ADHD-related attentional and behavioural regulation difficulties and dysregulation processes. The structured psychoeducational content, emphasis on routines, and parent–child communication strategies included in the program may have been particularly effective for this subgroup [30]. Notably, improvements were observed for emotional dysregulation even though other outcome measures, such as mood symptoms or global functioning, did not show significant change. This suggests that dysregulation may be a more proximal and sensitive marker of intervention effects, potentially preceding broader improvements in mood or overall functioning. Targeting dysregulation may therefore represent an important early intervention strategy, especially in at-risk populations where symptoms are heterogeneous and not yet syndromic.

The small sample size, non-epidemiological design, lack of control group, and significant attrition, typical in similar studies [31], limit definitive conclusions. Additionally, parent-reported psychopathology may introduce bias through symptom overreporting [32]. Multi-informant assessments would enhance reliability. Moreover, the absence of measurement on participant acceptability/sat isfaction and parental practices, should be systematically

assessed in future studies. Given BD's strong heritability
[21] and elevated psychopathology risk in OBD ([5, 33]–
[34]), prioritizing early detection and preventive family-
based interventions is essential [35]. Our study supports
the feasibility and potential benefits of such family-based
approaches in CAMHS, though larger controlled trials
are necessary. Future research should focus on their role
in disorder prevention, improving global functioning,
and clarifying genetic-environmental interactions.

Acknowledgements

We thank all the participants for their time and cooperation.

Author contributions

FP, NF and DPO conceptualised the study. FP and VM recruited and collected the data. MS, MCP and EF conducted statistical analyses. EF wrote the manuscript. HK, EO and DPO critically revised the manuscript. All authors reviewed and approved the final submission.

Funding

This work was funded by the CHU of Montpellier (AOI 2013).

Data availability

The anonymised dataset is available from the corresponding author.

Declarations

Ethics approval and consent to participate

This study was approved by the ethics committee "COMITE DE PROTECTION DES PERSONNES SUD-MEDITARRANEE I" (IRB ID: 2014-A00204-43). All participants provided written informed consent prior to their inclusion. The research was conducted in accordance with the ethical standards of the institutional and national research committee and with the Declaration of Helsinki.

Competing interests

The authors declare no competing interests.

Received: 16 July 2025 / Accepted: 9 October 2025

Published online: 03 November 2025

References

1. Smoller JW, Finn CT. Family, twin, and adoption studies of bipolar disorder. Am J Med Genet C. 2003;123 C(1):48–58. https://doi.org/10.1002/ajmgc.20013.

2. Vieta E, Berk M, Schulze TG, Carvalho AF, Suppes T, Calabrese JR, et al. Bipolar disorders. Nat Rev Dis Primers. 2018;4:18008. https://doi.org/10.1038/nrdp.2018.8.

3. Morris AS, Silk JS, Steinberg L, Myers SS, Robinson LR. The role of the family context in the development of emotion regulation. Soc Dev. 2007;16(2):361–88. https://doi.org/10.1111/j.1467-9507.2007.00389.x.

4. Hodgins S, Faucher B, Zarac A, Ellenbogen M. Children of parents with bipolar disorder. A population at high risk for major affective disorders. Child Adolesc Psychiatr Clin N Am. 2002;11(3):533–53. https://doi.org/10.1016/s1056-4993(02)00002-0. ix.

5. Lau P, Hawes DJ, Hunt C, Frankland A, Roberts G, Wright A, et al. Family environment and psychopathology in offspring of parents with bipolar disorder. J Affect Disord. 2018;226:12–20. https://doi.org/10.1016/j.jad.2017.09.010.

6. Bianchi V, Brambilla P, Garzitto M, Colombo P, Fornasari L, Bellina M, et al. Latent classes of emotional and behavioural problems in epidemiological and referred samples and their relations to DSM-IV diagnoses. Eur Child Adolesc Psychiatry. 2017;26(5):549–57. https://doi.org/10.1007/s00787-016-0918-2.

7. Masi G, Muratori P, Manfredi A, Pisano S, Milone A. Child behaviour checklist emotional dysregulation profiles in youth with disruptive behaviour
disorders: clinical correlates and treatment implications. Psychiatry Res.
2015;225(1-2):191-6. Epub 2014 Nov 20. PMID: 25480545.

8. Zalpuri I, Singh MK. Treatment of psychiatric symptoms among offspring of parents with bipolar disorder. Curr Treat Options Psychiatry. 2017;4(4):341-56. https://doi.org/10.1007/s40501-017-0126-9.

9. Vallarino M, Henry C, Etain B, Gehue LJ, Macneil C, Scott EM, et al. An evidence map of psychosocial interventions for the earliest stages of bipolar disorder. Lancet Psychiatry. 2015;2(6):548-63. https://doi.org/10.1016/S221 5-0366(15)00156-X.

10. Müller AD, Gjøde ICT, Thams N, Ingversen S, Moszkowicz M, Jepsen JRM, et al. Family-based preventive intervention for children of parents with severe mental illness: a randomized clinical trial. JCPP Adv. 2024;4(3):e12216. https:// doi.org/10.1002/jcv2.12216.

11. Miklowitz DJ, Axelson DA, Birmaher B, George EL, Taylor DO, Schneck CD, et al. Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. Arch Gen Psychiatry. 2008;65(9):1053-61. https://doi. org/10.1001/archpsyc.65.9.1053.

12. Achenbach TM. Manual for the child behavior Checklist/4-18 and 1991 profile. Burlington, VT: University of Vermont, Department of Psychiatry; 1991.

13. Achenbach TM, Rescorla LA. Manual for the ASEBA School-Age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families; 2001.

14. Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., ... Ryan, N. (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(7), 980-988. doi:10.1097/00004583-199707000-00021

15. Goodman R. The strengths and difficulties questionnaire: a research note. J Child Psychol Psychiatry. 1997;38(5):581-6. https://doi.org/10.1111/j.1469-761 0.1997.tb01545.x.

16. Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, Aluwahlia S. A children's global assessment scale (CGAS). Arch Gen Psychiatry. 1983;40(11):1228-31. https://doi.org/10.1001/archpsyc.1983.01790100074010.

17. Poznanski EO, Mokros HB. Children's depression rating Scale, revised (CDRS-R). Los Angeles: Western Psychological Services; 1996.

18. DuPaul GJ, Power TJ, Anastopoulos AD, Reid R. ADHD rating Scale-IV: Checklists, norms, and clinical interpretation. New York: Guilford Press; 1998.

19. Wechsler D. Wechsler abbreviated scale of intelligence. San Antonio, TX: The Psychological Corporation; 1999.

20. Birmaher B, Axelson D, Monk K, Kalas C, Goldstein B, Hickey MB, et al. Lifetime psychiatric disorders in school-aged offspring of parents with bipolar disorder: the Pittsburgh bipolar offspring study. Arch Gen Psychiatry. 2009;66(3):287-96. https://doi.org/10.1001/archgenpsychiatry.2008.546.

21. Mesman E, Nolen WA, Reichart CG, Wals M, Hillegers MHJ. The dutch bipolar offspring study: 12-year follow-up. Am J Psychiatry. 2013;170(5):542-9. https://doi.org/10.1176/appi.ajp.2012.12030401.

22. Faraone SV, Tsuang MT. Heterogeneity and the genetics of bipolar disorder. Am J Med Genet C. 2003;123 C(1):1-9. https://doi.org/10.1002/ajmg.c.20017.

23. Diler RS, Uguz S, Seydaoglu G, Erol N, Avci A. Differentiating bipolar disorder in Turkish prepubertal children with attention-deficit hyperactivity disorder. Bipolar Disord. 2007;9(3):243-51. https://doi.org/10.1111/j.1399-5618.2007.000 347.x.

24. Carlson GA, Finch SJ, Fochtmann LJ, Ye Q, Wang Q, Naz B, et al. Antidepressant-associated switches from depression to mania in severe bipolar disorder. Bipolar Disord. 2007;9(8):851-9. https://doi.org/10.1111/j.1399-5618.2007.0004 24.x.

25. Duffy A. Does bipolar disorder exist in children? A selected review. Can J Psychiatry. 2007;52(7):409-17. https://doi.org/10.1177/070674370705200702.

26. Miklowitz DJ, Chang KD, Taylor DO, George EL, Singh MK, Schneck CD, et al. Early psychosocial intervention for youth at risk for bipolar I or II disorder: a one-year treatment development trial. Bipolar Disord. 2011;13(1):67-75. https://doi.org/10.1111/j.1399-5618.2011.00890.x.

27. Müller AD, Gjøde ICT, Thams N, Ingversen S, Moszkowicz M, Jepsen JRM, et al. Family-based preventive intervention for children of parents with severe mental illness: a randomized clinical trial. JCPP Adv. 2024;4(3):e12216. https://doi.org/10.1002/jcv2.12216.

28. Cohen F, Schünke J, Vogel C, Anders Y. (2020). Longitudinal Effects of the Fam-
ily Support Program Chancenreich. Frontiers / PMC.

29. Jugovac S, O'Kearney R, Hawes DJ, Pasalich DS. Attachment- and emotion-
focused parenting interventions for child and adolescent externalizing
and internalizing behaviors: a meta-analysis. Clin Child Fam Psychol Rev.
2022;25(4):754-73. https://doi.org/10.1007/s10567-022-00401-8.

30. Miklowitz DJ, Schneck CD, Singh MK, Taylor DO, George EL, Cosgrove VE, et al. Early intervention for symptomatic youth at risk for bipolar disorder: a randomized trial of family-focused therapy. J Am Acad Child Adolesc Psychiatry. 2013;52(2):121-31. https://doi.org/10.1016/j.jaac.2012.10.007.

31. Chacko A, Wymbs BT, Chimiklis A, Wymbs FA, Pelham WE. Evaluating a comprehensive strategy to improve engagement to group-based behavioral parent training for high-risk families of children with ADHD. J Abnorm Child Psychol. 2012;40(8):1351-62. https://doi.org/10.1007/s10802-012-9666-z.

32. Wals M, Hillegers MH, Reichart CG, Ormel J, Nolen WA, Verhulst FC. Prevalence of psychopathology in children of a bipolar parent. J Am Acad Child Adolesc Psychiatry. 2001;40(9):1094-102. https://doi.org/10.1097/00004583-20010900 0-00019.

33. Maoz H, Goldstein T, Goldstein BI, Axelson DA, Fan J, Hickey MB, Monk K, Sakolsky D, Diler RS, Brent D, Kupfer DJ, Birmaher B. The effects of parental mood on reports of their children's psychopathology. J Am Acad Child Ado- lesc Psychiatry. 2014;53(10):1111-e11225. https://doi.org/10.1016/j.jaac.2014. 07.005.

34. Diler RS, Birmaher B, Axelson D, Obreja M, Monk K, Hickey MB, et al. Dimensional psychopathology in offspring of parents with bipolar disorder. Bipolar Disord. 2011;13(7-8):670-8. https://doi.org/10.1111/j.1399-5618.2011.00966.x.

35. Miklowitz DJ, Alatiq Y, Geddes JR, Goodwin GM, Williams JMG. Thought suppression in patients with bipolar disorder. J Abnorm Psychol. 2010;119(2):355-65. https://doi.org/10.1037/a0018613.

**Publisher’s note**

Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.