Theory of mind, empathy and alexithymia in children of mothers with bipolar I disorder: A family‐contextual perspective

BACKGROUND: Bipolar I disorder (BD-I) is associated with persistent social-cognitive and emotional impairments; however, little is known about affective theory of mind (ToM), empathy, alexithymia and perceived family functioning in the children of mothers with BD-I. METHODS: In this case-control study, 80 mothers (40 BD-I, 40 healthy controls; HC) and their children (12-18 years; 40 children of BD-I mothers and 40 children of HC mothers) were assessed. Maternal diagnoses and euthymic status were confirmed using DSM-5-based clinical interviews and standardized mood rating scales. Children completed self-report and performance-based measures assessing affective ToM, empathy, alexithymia, psychiatric symptoms and perceived family functioning, while mothers were assessed for affective ToM. Sensitivity analyses adjusted for child symptoms, alongside exploratory moderation and mediation analyses. RESULTS: Mothers with BD-I and their children showed lower affective ToM than HC. In unadjusted analyses, children of mothers with BD-I also showed lower emotional empathy, greater difficulty identifying feelings and poorer perceived family functioning. After adjustment for child symptom burden, affective ToM and emotional empathy remained significant, whereas alexithymia-related differences were attenuated and family-functioning differences persisted only in selected domains. Secondary exploratory analyses indicated that family integrity was related to variation in selected outcomes, while mediation findings were limited. CONCLUSIONS: Children of mothers with BD-I appear to show a selective affective-social vulnerability profile, particularly lower affective ToM and reduced emotional empathy; assessment of selected affective-social domains may therefore help guide early preventive support for high-risk youth. Exploratory mediation findings should be interpreted cautiously and require replication in longitudinal, multi-informant studies.