Description
consider the following case vignette:
Annie is a 13-year-old Asian American girl; the youngest child in a family of four older siblings. Her parents are both high school teachers and came to United States from India to attend college and stayed to raise a family together. They travel as a family to India several weeks of every year to be with extended family. Annie understands some phrases in the dialect spoken by her extended family, but she and her sisters consistently speak to their parents in English. When Annie was 5 years old, she was hospitalized for three weeks for a serious illness. Since that time, she has been in good health, but has struggled with her fears and anxiety.
Annie is extremely shy and avoids situations in which she needs to interact with new people or large groups. She worries about making mistakes in her schoolwork and becomes extremely anxious when taking tests. Sometimes, she becomes so nervous that her heart races; she begins to tremble and has difficulty breathing. Annie is also afraid of the dark and does not want to be alone in her room at night. She often requires the presence of one of her parents or older sisters until she falls asleep. As her oldest three sisters have left home to pursue their education and careers, the family is finding Annie’s need for reassurance more burdensome.
Instructions
Download Unit 3 Assignment Template. Use it to complete your assignment.
Part I: Examining Three Models of Psychopathology
Review each of the three models of abnormality—biological, psychological, and sociocultural—and apply key principles from each model to frame what is happening to Annie and her family.
Analyze how each model explains the factors leading to Annie’s presenting behaviors.
Part II: Assessment Instruments to Aid in Diagnosis
Formulate a culturally sensitive assessment strategy using a combination of at least two measures listed below (and linked in Resources) to assist with the assessment of Annie and her family. Describe how the assessments will be administered and interpreted using scholarly sources to support the strategy.
DSM-5: Assessment Measures:
Parent/Guardian-Rated DSM-5 Level 1 Cross Cutting Symptom Measure.
DSM-5: Cultural Formulation:
Cultural Formulation Interview.
Hamilton and Carr’s “Systematic Review of Self?Report Family Assessment Measures.”
Part III: Systemic Perspective for Diagnosis
With an assessment strategy established:
Analyze how the DSM and ICD may augment guidance for working with families from a systemic perspective.
Describe the Z code or codes that apply, noting the limitations and risks of using these codes for Annie and her family.
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[Unit and Assignment Title]
[Learner Name]
[COURSE NUMBER – NAME]
[Date]
[Professor Name]
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Unit and Assignment Title
Start writing your introduction here (1-2 paragraphs). An effective introduction prepares
the reader by identifying the purpose of the paper and providing the organization of the paper.
Please double-space and remember to indent all paragraphs throughout your paper. Aim to keep
your writing objective using 3rd person. Review paper guidelines on page requirements and
number of sources required. Unless citing a classic work, aim to cite research articles and texts
published within the past 5 years. Please use headings throughout your paper that are consistent
with the paper’s scoring guide to ensure you are adequately addressing all required areas.
When you finish writing your paper, re-read it to check for errors and make sure your
ideas flow well. A helpful tip is to read your paper aloud to yourself. Please submit your papers
to turnitin to avoid plagiarism and improve the originality in your writing. Also, remember as a
Capella learner you have FREE access through iGuide to personal tutoring services with
Smarthinking.com.
Part 1: Examining Models of Psychopathology
In this section, you will apply the three models (biological, psychological, and
sociocultural) to the case of Annie provided in the assignment instructions. To meet the first
Distinguished criterion, “Applies key principles from theoretical models of psychopathology
to describe and identify psychological disorders and uses specific examples to support the
description” apply each model to explain what is happening for Annie and her family. Note that
each model includes at least one central idea that you will need to address. This can be
accomplished in 2 or 3 well contructed paragraphs or roughly one page.
Now that the key principals of each model have been established, describe how each
model explains what contributed to Annie and her family’s presenting situation. To meet the
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Distinguished criteria, “Analyzes current perspectives about the etiology of psychological
disorders based on theoretical models and uses specific examples to support the analysis”
present a rationale for how well these models account for the etiology of Annie’s fears and how
the family has adapted. Cite sources beyond your text to develop your analysis. This can also be
accomplished in about one page.
Part 2: Assessment Instruments to Aid in Diagnosis
This section will require that you explore the assessments linked in the instructions and
develop an assessment strategy utilizing two instruments that takes Annie and her family’s
culture into consideration before you begin writing. The Distinguised criterion reads, “Identifies
culturally relevant strategies for administering and interpreting assessment and test results
providing specific examples to support the explanation”. Notice that the assessment strategy
is the focus and includes both administering and providing results of the assessments. Carefully
consider your assessment options so your strategy is clear and will fit within the framework of
how you will practice within your specialization. MFCT learners should include one of the
assessments reviewed in the article. MHC learners may opt to focus on the assessmenets
provided in the DSM. Address how they would be utlized with support from the literature.
Optional articles in the course syllabus can be located by entering the title of the article in the
search tool Summon found on the main page of the Capella Library.
Once the strategy is established, examine how culture will be taken into account when
formulating the diagnosis. The specific diagnosis for Annie is not needed. Address the
Distinguished criteria, “ Analyzes the impact of culture upon the application of diagnostic
systems drawing from the professional literature to support the analysis”. What information
included in the case is relevant to consider? What is cultural information is not provided that will
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be important to explore with the family before a diagnosis is determined? This will require
support from peer reviewed articles. You are encouraged to locate articles through the Capella
Library. This section of your paper will likely require one and a half to two pages.
Part 3: Systemic Perspectives for Diagnosis
This third section addresses the fifth criteria of the scoring guide, “Analyzes models of
assessment perspective from a systems perspective with support from scholarly sources”.
Annie is presenting for treatment with her family and they have a shared problem. Consider how
well the DSM and ICD codes can adequately capture what will be the focus of treatment from a
systems perspective working with Annie and her family. Note that you need to identify the
specific V and Z codes that apply including the limitations and risks of using these codes as part
of your analysis. Establishing a position will require support from peer reviewed articles. You
are encouraged to locate articles through the Capella Library or the Optional Readings included
in your course syllabus. This section of your paper will likely require one page.
Conclusion
Please provide a conclusion that summarizes the main ideas of your paper.
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References
Gladding, S. T., & Newsome, D. W. (2010). Clinical mental health counseling in community and
agency settings (3rd ed.). Upper Saddle River, NJ: Merrill.
NOTE: Consult your APA manual for proper examples on citing and referencing APA style. The
Capella Writing Center also has helpful tutorials.
Systematic Review of Self-Report Family
Assessment Measures
ELENA HAMILTON*
ALAN CARR*,†
To read this article in Chinese, please see the article’s Supporting Information on Wiley Online
Library (wileyonlinelibrary.com/journal/famp).
A systematic review of self-report family assessment measures was conducted with reference to their psychometric properties, clinical utility and theoretical underpinnings. Eight
instruments were reviewed: The McMaster Family Assessment Device (FAD); Circumplex
Model Family Adaptability and Cohesion Evaluation Scales (FACES); Beavers Systems
Model Self-Report Family Inventory (SFI); Family Assessment Measure III (FAM III);
Family Environment Scale (FES); Family Relations Scale (FRS); and Systemic Therapy
Inventory of Change (STIC); and the Systemic Clinical Outcome Routine Evaluation
(SCORE). Results indicated that five family assessment measures are suitable for clinical
use (FAD, FACES-IV, SFI, FAM III, SCORE), two are not (FES, FRS), and one is a new
system currently under-going validation (STIC).
Keywords: Family assessment; Family therapy research; Systematic review
Fam Proc 55:16–30, 2016
INTRODUCTION
T
here is an increased focus on conducting routine evaluations to monitor mental health
service outcomes in order to demonstrate service effectiveness. Within the field of couple and family therapy, it is therefore important for therapists to be familiar with psychometrically robust assessment instruments for monitoring the outcome of systemic therapy
(Carr, 2012; Lebow, 2014). Self-report scales, observational rating scales, and clinical
interviews are the principal types of family assessment instruments. Self-report family
assessment instruments aim to evaluate the way in which families function to solve tasks
associated with progression through the family life cycle. Typically, these tools contain
items relevant to domains such as family communication and problem solving, family emotional cohesion, family rules, roles and routines, and so forth. A large number of self-report
family assessment instruments have been developed.
The aim of this review was to systematically examine self-report measures to identify
their psychometric properties and clinical utility in the context of their intended use, and
to identify measures suitable for monitoring outcomes.
Self-report measures were selected for review if (1) their primary purpose was to assess
family functioning and (2) they had been identified in recent authoritative reviews as
being the most widely used in couple and family therapy research (i.e., Lebow & Stroud,
2012; Sanderson et al., 2009). Using these inclusion criteria, eight self-report measures
were selected for review. Of the eight measures selected, seven were developed in North
*School of Psychology, University College Dublin, Dublin, Ireland.
†
Clanwilliam Institute, Dublin, Ireland.
Correspondence concerning this article should be addressed to Dr. Elena Hamilton, School of Psychology, Newman Building, University College Dublin, Belfield, Dublin 4, Ireland. E-mail: Elena.hamilton@
ucdconnect.ie.
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Family Process, Vol. 55, No. 1, 2016 © 2015 Family Process Institute
doi: 10.1111/famp.12200
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HAMILTON & CARR
America and one is a new instrument recently developed in the United Kingdom and
Ireland. The eight instruments are
•
•
•
•
•
•
•
•
The McMaster Family Assessment Device (FAD)
The Circumplex Model Family Adaptability and Cohesion Evaluation Scales (FACES)
The Beavers Systems Model Self-Report Family Inventory (SFI)
The Family Assessment Measure III (FAM III)
The Family Environment Scale (FES)
The Family Relations Scale (FRS)
The Systemic Therapy Inventory of Change (STIC)
The Systemic Clinical Outcome Routine Evaluation (SCORE).
SYSTEMATIC REVIEW SEARCH METHOD
A series of systematic reviews was conducted to identify studies relevant to each instrument. An electronic search of the PsycINFO database was carried out using search terms
relevant to each instrument. A manual search of relevant referenced material was also
conducted. No date restrictions were imposed in order to obtain a full range of studies.
Studies were selected for inclusion if they empirically assessed the factor structure, reliability, validity, responsiveness, clinical utility, or other psychometric properties of the
instrument. Studies were excluded if (1) they were not published in a peer-reviewed journal; (2) they did not assess the psychometric properties of the relevant instrument; (3) full
text articles were not available, unless sufficient information was cited in reputable
sources. Studies that dealt with translated and culturally adapted versions of the measures were also excluded from the review.
This review sought to examine key psychometric properties of each measure selected,
such as: internal reliability; test re-test reliability; construct validity; criterion validity in
terms of capacity to significantly differentiate between clinical and nonclinical cases; factor structure; and responsiveness in terms of capacity to reliably detect change in functioning over time. To deal with potential variation between reporting of psychometric
properties across studies, a series of tables were constructed which present a summary of
results relating to key findings of each study, for each measure. Where provided, statistics
were reported. As a general guideline, correlation effect sizes were rated using the following rule of thumb: r above 0.8 = strong correlation, r between 0.8 and 0.2 = moderate correlation, and r below 0.2 = weak correlation. Cronbach’s alpha coefficients used to
establish internal consistency reliability were rated using the following scale: a above
0.9 = excellent reliability; a 0.9 – 0.8 = good reliability; a 0.8 – 0.7 acceptable reliability; a
0.7 – 0.5 = less than acceptable reliability; and a less than 0.5 = unacceptable reliability.
RESULTS
Due to space constraints and the large number of tables in this article, all of the tables
are presented in the Supporting Information. Forty-eight empirical validation studies
were identified for inclusion in this review: 11 of these assessed the FAD; 3 FACES; 6 SFI;
7 FAM III; 13 FES; 1 FRS; 2 STIC; and 5 assessed the SCORE, which are detailed in this
section and also presented in Table S1.
The McMaster Family Assessment Device
The McMaster Model of Family Functioning was developed by Epstein, Baldwin, and
Bishop (1983). The model outlines structural and organizational properties of the family
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FAMILY PROCESS
unit and identifies transactional patterns between family members that are associated
with healthy and unhealthy families. The McMaster Model identifies 6 dimensions of family life which are associated with dysfunctional family patterns and are the focus of therapeutic interventions: problem solving, communication, role functioning, affective
responsiveness, affective involvement, and behavior control (Miller, Ryan, Keitner,
Bishop, & Epstein, 2000). Problem solving is the family’s ability to effectively resolve a
problem without causing disruption to family functioning. Communication is defined as
the family’s approach to information exchange, in particular verbal communication. Role
functioning is characterized by the patterns of behavior undertaken by individual family
members. Affective responsiveness refers to the ability of the family to respond with
appropriate emotions and feelings to a range of stimuli. Affective involvement is described
as the family’s capacity and the degree to which it values each individual member. Behavior control is defined as the family’s approach to managing its members’ behavior in 3
areas: physically dangerous situations, meeting psychobiological needs, and interpersonal
socializing behaviors.
Three assessment instruments have been developed based on the McMaster Model: the
self-report Family Assessment Device (FAD; Epstein et al., 1983), the clinician-directed
McMaster Structured Interview of Family Functioning (McSIFF), and the clinician-rated
McMaster Clinical Rating Scales (MCRS; Epstein, Baldwin, & Bishop, 1982; Miller, Kabacoff, Bishop, Epstein, & Keitner, 1994). The FAD was selected for review because it is a
self-report measure.
According to Epstein et al. (1983), the FAD was designed for use as a screening instrument to identify problem areas of family functioning. It was created based on the model’s
assumption that family functioning is related more to transactional and systemic factors
than to individual family members’ characteristics. The FAD was therefore developed to
collect information on the dimensions of the family system which are deemed clinically relevant by the model.
The FAD is the most widely used measure of family assessment, according to an extensive review of instruments used to assess couple and family therapies compiled by Sanderson et al. (2009). It contains 60 items and responses are given on 4-point Likert scales:
“strongly agree,” “agree,” “disagree,” and “strongly disagree” and is designed for completion by family members 12 years and older (Miller et al., 2000). The measure yields a general functioning score and a score for each of the six key domains of the model. Each of the
7 scales contain 6 – 12 items. Scores range from healthy to unhealthy on a 4-point scale.
The FAD has been assessed for use with children below 12 years and was found to have
good concurrent construct validity with mother’s reports on three different measures of
family functioning but low reliability for younger children (Bihun, Wamboldt, Gavin, &
Wamboldt, 2002).
Eleven studies were identified through the systematic review for inclusion. Nine studies assessed general psychometric properties of the 60-item version of the FAD, and two
assessed the 12- and 6-item versions of the General Functioning scale of the FAD.
From Table S2 it may been seen that several studies report that the FAD demonstrates
good to excellent reliability as assessed by Cronbach’s alpha coefficients. Overall, reliability for the general functioning scale is higher than that of the other six domains (Bihun
et al., 2002; Epstein et al., 1983; Kabacoff, Miller, Bishop, Epstein, & Keitner, 1990). Adequate test–retest reliability has been established (Miller, Epstein, Bishop, & Keitner,
1985). The FAD has demonstrated construct validity in terms of moderate correlations
with other self-report measures of family functioning and low correlations with social
desirability sets (Miller et al., 1985), and low to moderate correlations with clinician-rated
measures of family functioning (Barney & Max, 2005; Miller et al., 1994). The FAD has
also been shown to significantly differentiate between clinical and nonclinical cases, which
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supports its criterion validity (Akister & Stevenson-Hinde, 1991; Epstein et al., 1983;
Mansfield, Keitner, & Dealy, 2015; Miller et al., 1985; Sawyer, Sarris, Baghurst, Cross, &
Kalucy, 1988). Additionally, the 12-item general functioning scale (Mansfield et al., 2015)
and a briefer 6-item version of this scale (Boterhoven De Haan, Hafekost, Lawrence, Sawyer, & Zubrick, 2015) have been shown to significantly differentiate between clinical and
nonclinical cases, which supports criterion validity, and have demonstrated construct
validity in terms of correlations with existing measures of family functioning. Kabacoff
et al. (1990) conducted factor analyses on the six domains of the FAD, excluding the 12
items contained in the general functioning scale, which were assessed separately. These
analyses were carried out on data from 887 families including nonclinical, psychiatric, and
medical cases and support the six domain model of the FAD. However, Ridenour, Daley,
and Reich (1990, 2000) examined the factor structure of the 60-item version of the FAD
using data from 503 cases collected by Epstein et al. (1983) and found that the six domains
assessed by the FAD are not distinctive and contain overlapping factors.
In summary, a systematic review of literature identified eleven validation studies,
which provided evidence to support the FAD as a reliable and valid family assessment
measure. Strengths of the FAD include its demonstration of internal reliability, test–retest reliability, construct validity, and criterion validity in terms of its ability to differentiate between clinical and nonclinical cases. The main limitation of the FAD relates to the
continued controversy over its factorial validity.
Circumplex Model Family Adaptability and Cohesion Evaluation Scales
The Circumplex Model of Marital and Family Systems is centered on three dimensions
of family functioning: family cohesion, flexibility, and communication (Olson & Gorall,
2003). Family cohesion refers to the emotional bonds family members have towards each
other and is appraised by degrees of low (disengaged) to high (enmeshed) separateness
versus togetherness. Family flexibility refers to a family’s ability to adapt leaderships,
roles, and rules in response to events or stress and is assessed on a scale of low (rigid) to
high (chaotic) levels of stability versus change. Balanced levels of cohesion and flexibility
are related to good family functioning whereas unbalanced levels (extremes of high or low
levels) are related to problematic family functioning. Family communication is considered
to be a facilitating dimension which impacts family cohesion and flexibility.
Several couple and family assessment instruments have been developed based on the
Circumplex Model. Four key family assessment instruments are included in the Family
Inventories Package (FIP; Olson, 2011; www.facesiv.com): the self-report Family Adaptability and Cohesion Evaluation Scales (FACES-IV; Olson, 2011) and its two ancillary
measures, the Family Communication Scale (FCS) and the Family Satisfaction Scale
(FSS), as well as the clinician-rated Clinical Rating Scale (CRS; Olson, 1990). FACES-IV
was selected for review because it is the principal self-report measure of family functioning of the model.
The FACES tool was designed to assess family functioning based on the Cirumplex
Model and examines the three dimensions of the model: family cohesion, flexibility, and
communication. According to Olson (2000), the model and its assessment instruments
were specifically developed for clinical assessment, treatment planning, and research on
outcome effectiveness of marital and family therapies. Sanderson et al. (2009) report that
the FACES measure is the third most frequently used measure of family functioning in
couple and family therapy outcome research. The FACES tool has been revised on three
occasions and is now its fourth edition, FACES-IV (Olson, 2011).
Family Adaptability and Cohesion Evaluation Scales-IV contains 42 items with 5-point
response formats, which assess family functioning on the two main dimensions of the
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FAMILY PROCESS
Circumplex Model, cohesion and adaptability, across six scales. Two scales assess the two
balanced constructs of the model, cohesion and flexibility. Higher scores on the balanced
scales are associated with better family functioning. Four scales assess the four unbalanced constructs of the model, disengaged and enmeshed (cohesion), and rigid and chaotic
(flexibility). Higher scores on the unbalanced scales are associated with problematic family functioning. Along with the balanced and unbalanced total scores, FACES-IV yields a
Circumplex total ratio figure, which provides a summary of a family’s balanced and unbalanced characteristics in a single score, which is recommended for use in research (Olson,
2011). A 24-item version of FACES-IV has also been developed (Tiesel & Olson, 2007; as
cited by Franklin, Streeter, & Springer, 2001) and is comprised of four unbalanced scales:
enmeshed; disengaged; chaotic; and rigid. However, this version is not included in the
FIP.
Three studies were identified through the systematic review for inclusion. Two studies
assessed general psychometric properties of the 42-item version of FACES-IV, and one
study dealt with the 24-item version.
From Table S3, it may be seen that for the 42-item version internal reliabilities ranged
from good (Olson, 2011) to acceptable (Marsac & Alderfer, 2011) for all scales except the
enmeshed scale, which was found to have less than acceptable levels of internal reliability.
Internal reliabilities for the 24-item version were found to be acceptable for all scales
except the rigid scale, which was found to have less than acceptable levels of internal reliability (Franklin et al., 2001). The FACES-IV 42-item version has demonstrated construct
validity in terms of strong correlations with other measures of family functioning on all
scales, with the exception of the enmeshed and rigid scales, which displayed small correlations with other measures (Olson, 2011). Additionally, Olson (2011) reports negative correlations with unbalanced scales and positive correlations with balanced scales. However,
Marsac and Alderfer (2011) report no correlations between the enmeshed and rigid scales
and other measures of family functioning and parenting. The FACES-IV 42-item version
has shown criterion validity in terms of its capacity to accurately identify problematic families in a proportion of cases (Marsac & Alderfer, 2011; Olson, 2011). Additionally, Olson
(2011) and Franklin et al. (2001) demonstrated an acceptable fit to the model using factor
analyses for both the 42- and 24-item versions.
In summary, a systematic review of literature identified three validation studies which
provided evidence to support the 42- and 24-item versions of FACES-IV as a reliable and
valid family assessment measure. Strengths of the FACES-IV include its demonstration of
internal reliability, construct validity, and criterion validity in terms of its ability to differentiate between clinical and nonclinical cases and a stable factor structure. The main limitation of the FACES-IV measure is the relatively limited number of empirical validation
studies to corroborate these findings.
Beavers Systems Model Self-Report Family Inventory
The Beavers Systems Model of family functioning is centered on two constructs, family
competence and family style, and provides a cross-sectional perspective of family functioning (Beavers & Hampson, 2000). Family competence is concerned with the structure and
adaptive flexibility of the family system. High levels of competency are associated with the
capacity to adapt the structure of the system to effectively deal with stressful situations.
Family style is conceptualized as a family’s method of interaction, ranging from centripetal to centrifugal. Centripetal families perceive most satisfaction as coming from
within the family, whereas centrifugal families believe most satisfaction comes from outside the family system. Movement from centripetal to centrifugal styles throughout the
family life cycle is facilitated by high competence and is associated with better family
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functioning. The model identifies nine types of family functioning based on the combination of the competence and style dimensions, ranging from optimal functioning families to
severely dysfunctional families.
Three family assessment instruments have been developed based on the Beavers Systems Model: the Beavers Self-Report Family Inventory (SFI; Beavers & Hampson, 1990),
the Beavers Interactional Competence Scale (BISC; Beavers & Hampson, 2000) and the
Beavers Interactional Style Scale (BIS; Beavers & Hampson, 2000). The BISC and BIS are
observational clinician-rated measures. The SFI was selected for review because it is a
self-report measure.
The SFI, and the two clinician-rated measures, the BISC and BIS, were developed to
classify a family’s profile of functioning based on the Beavers Systems Model (Beavers &
Hampson, 2000).
The SFI (Beavers & Hampson, 2000) is comprised of 36 items, which are answered on a
3-point Likert scale. The SFI yields scores on five domains of family functioning, which
are central to the Beavers Systems Model: health/competence; conflict; cohesion; leadership; and emotional expressiveness.
Six studies were identified through the systematic review for inclusion. All six studies
dealt with general psychometric properties of the SFI.
From Table S4, it may been seen that Hampson, Beavers, and Hulgus (1989) report
good internal reliability on SFI scales as assessed by Cronbach’s alpha values. Good test–
retest reliabilities were established by Hampson et al. (1989); however, Hampson, Beavers, and Hulgus (1990) observed less than adequate test–retest reliabilities for conflict,
cohesion, and leadership scales. The SFI has demonstrated construct validity in terms of
overall moderate correlations with other self-report and clinician-rated measures of family
functioning (Beavers & Hampson, 1990; Hampson, Hulgus, & Beavers, 1991; Hampson
et al., 1989). The SFI has also shown criterion validity in terms of its capacity to significantly distinguish between heterogeneous clinical cases (Beavers & Hampson, 1990). Beavers and Hampson (2000) report a five-factor model structure based on the domains of
family functioning, which are central to the Beavers Systems Model. However, Hampson
et al. (1989, p. 126) report a six-factor model structure. Both studies do not report the
methods used to establish these factor structures. Goodrich, Selig, and Trahan (2012) conducted exploratory factor analyses and revealed that a two-factor model provided the best
fit, in which the first factor represents positive facets of family functioning and the second
represents negative aspects.
In summary, a systematic review of literature identified six validation studies which
provide evidence to support the SFI as a reliable and valid family assessment measure.
Strengths of the SFI include its demonstration of internal reliability and criterion validity
in terms of its ability to differentiate between clinical and nonclinical cases. The main limitation of the SFI measure is the discrepancy between findings relating to test–retest reliability and factor structure.
Family Assessment Measure III
The Process Model of family functioning is a theoretical framework for conducting family assessments and understanding family systems. The model integrates different
approaches to family assessment, therapy, and research and, unlike the McMaster, Circumplex, and Beavers Systems models, it is not a paradigm of family therapy (Steinhauer,
Santa-Barbara, & Skinner, 1984). The model is comprised of seven main concepts related
to family functioning: task accomplishment, role performance, communication, affective
expression, involvement, control, values, and norms (Skinner, Steinhauer, & Sitarenios,
2000). Task accomplishment is described as the central goal of the family system and
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FAMILY PROCESS
includes four operations : (1) task or problem identification; (2) exploration of alternative
solutions; (3) implementation of selected approach; and (4) evaluation of outcome. Task
accomplishment is mediated by the auxiliary concepts of the model. Skinner et al. (2000)
also explain that the Process Model recognizes that a range of factors can impact family
functioning, such as individual intra-psychological and total family system processes.
One self-report family assessment instrument has been developed based on the Process
Model of family functioning, the Family Assessment Measure (FAM III; Skinner et al.,
2000), which was selected for systematic review.
Skinner et al. (2000) report that the FAM III was created for use as an assessment
measure in clinical and community practice, a measure of therapy outcomes, and also for
use in research on family processes.
The FAM III was designed to assess family functioning based on the concepts of the
model and is comprised of three distinct scales: the general scale, the dyadic relationships
scale, and the self-rating scale. The general scale assesses the family from a systems level
and contains 50 items and nine subscales. The general scale yields a total score for family
functioning, seven scores for each of the concepts of the model, and an additional two
scores, which measure social desirability and defensiveness response styles. The dyadic
relationships scale examines the relationship between two individuals in the family and is
comprised of 42 items and seven subscales. The dyadic relationship scale produces a total
score for family functioning and seven scores for each of the model concepts. The self-rating scale evaluates an individual family member’s perception of his/her own functioning
within the system and contains 42 items and seven subscales. The self-rating scale provides a total score and seven subscale scores. In addition, there are briefer, 14-item versions of the FAM scales (general, dyadic relationships, and self-rating), which each yield
an overall score of family functioning. Items on all scales are scored on 4-point Likert
scales ranging from “strongly agree” to “strongly disagree” (Jacob, 1995). According to
Skinner et al. (2000), the FAM has been designed for use with family members
10–12 years and older. Sanderson et al. (2009) report that the FAM is the fourth most
commonly used family assessment instrument in a review of couple and family therapy
outcome studies.
Seven studies were identified through the systematic review for inclusion. Five studies
dealt with general psychometric properties of the 50-item general scale, one study
employed the 42-item self-rating scale, and one study examined all three FAM scales.
From Table S5 it can be seen that internal reliabilities as assessed by Cronbach’s alpha
coefficients were excellent for the three FAM scales: general, dyadic relationships, and
self-rating scales (Skinner, Steinhauer, & Santa-Barbara, 1995). Internal reliabilities ranged from acceptable to unacceptable for the seven subscales of the general scale (Gondoli
& Jacob, 1993; Jacob, 1995). Jacob (1995) reports less than adequate test–retest reliability
for the general scale and its subscales. The general scale has demonstrated construct
validity in terms of strong correlations (Bloom, 1985) and moderate correlations with other
self-report measures of family functioning (Bloomquist & Harris, 1984; Jacob, 1995). The
general scale and self-rating scales have shown criterion validity in terms of their capacity
to significantly distinguish between problem cases and nonproblem cases (Forman, 1988;
Skinner, Steinhauer, & Sitarenios, 1983). Skinner et al. (2000) outline a seven-factor
model for each of the FAM scales; however, they do not report the methods of analysis
used to establish this. Gondoli and Jacob (1993) examined the factor structure of the 50item general scale and report a good fit for a one-factor model of family functioning, which
does not offer support for the original seven-factor model outlined by Skinner et al. (2000).
In summary, a systematic review of literature identified seven validation studies which
provide evidence to support the FAM III as a reliable and valid family assessment measure. Strengths of the FAM III include its demonstration of internal reliability; however,
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only one study examined all three scales that comprise the FAM III. The general scale
demonstrated construct validity and criterion validity in terms of its capacity to distinguish between clinical and nonclinical cases. The main limitation of the FAM III measure
is its general scales’ demonstration of moderate to weak internal reliabilities, less than
adequate test–retest reliabilities, and unstable factor structure. Additionally, the FAM III
is reportedly designed for use to measure outcomes in therapy; however, no empirical validation studies were identified in this review that examine the responsiveness to change in
the FAM III.
Family Environment Scale
The Family Environment Scale (FES; Moos, 1979) was developed using a social systems
ecological model and is not based on a particular theory of family functioning. The FES
was designed to assess the social and environmental characteristics of the family. The
FES was the second most used family assessment measure in a review of couple and family therapy outcome studies (Sanderson et al., 2009). The FES is comprised of 90 items,
which are answered on a dichotomous scale of true or false. The FES provides three perspectives of family member’s accounts of their family environment: real (how it is), ideal
(how it would be in an ideal situation), and expected (how it is likely to be in future situations). The FES has been designed for use with children 11 years and older. Moos and
Moos (2009; as cited on www.mindgarden.com) describe the measure in terms of three
dimensions of family environment: family relationship, personal growth, and system
maintenance, and it contains ten subscales. The first dimension, family relationship, is
concerned with the level of commitment and support between family members, the direct
expression of feelings, and the amount of anger and conflict displayed within the family.
These concepts are assessed via the Family Relationship Index dimension of the FES,
which contains three subscales to evaluate cohesion, expressiveness, and conflict. The second dimension, personal growth, deals with concepts such as individual member’s self-sufficiency, intellectual, political and cultural interests, and ethical and moral values. The
Personal Growth dimension of the FES addresses these subjects on five subscales: independence, achievement orientation, intellectual-cultural orientation, active-recreational
orientation, and moral-religious emphasis. The third dimension, systems maintenance,
oversees the organization and structure of the family system. The Systems Maintenance
subscale of the FES assesses these issues on two subscales, organization and control.
Greene and Plank (1994) describe a short-form version of the FES, which is comprised
of 40 items and answered on a 4-point Likert scale ranging from “strongly agree” to
“strongly disagree.” However, Greene and Plank (1994) report less than adequate reliability and found that the factor structure did not fit the original model.
According to Moos and Moos (2009), the FES can be used in a variety of ways, including
family assessment and formulation, assessing different perspectives on family functioning, and as a tool to monitor changes in family functions and program evaluation.
Thirteen studies were identified through the systematic review for inclusion. All 13
studies dealt with general psychometric properties of the FES, and most reported using
the “real” version.
From Table S6, it may been seen that internal consistency reliability was reported to be
less than adequate in most studies (Bloom, 1985; Boyd, Gullone, Needleman, & Burt,
1997; Chipuer & Villegas, 2001; Horton & Retzlaff, 1991; Loveland-Cherry, Youngblut, &
Leidy, 1989; Moos, 1979; Sanford, Bingham, & Zucker, 1999). Vostanis and Nicholls
(1995) determined that five FES scales showed criterion validity in terms of their capacity
to significantly distinguish between clinical and nonclinical cases. Several studies provide
evidence that challenges the three dimension and ten scale factor structure of the FES
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FAMILY PROCESS
(Boake & Salmon, 1983; Chipuer & Villegas, 2001; Fowler, 1981, 1982; Sanford et al.,
1999), and suggest alternative factor configurations. Oliver, May, and Handal (1988)
established a three-factor model in a normative sample, and Kronenberger and Thompson
(1990) observed a three-factor model in a sample of families with chronically ill children.
However, both Oliver et al. (1988) and Kronenberger and Thompson (1990) describe the
conceptualization of these factors differently from Moos and Moos’ (2009) framework.
In summary, a systematic review of literature identified thirteen validation studies,
which do not provide evidence to support the FES as a reliable and valid family assessment instrument. The studies outlined above indicate that the FES demonstrated less
than adequate internal reliability and an unstable factor structure and that five of the ten
subscales demonstrated criterion validity in terms of their capacity to distinguish between
clinical and nonclinical cases.
Family Relations Scale
The Family Relations Scale (FRS) was developed by Tolan, Gorman-Smith, Huesmann, and Zelli (1997) to address the need for a measure to examine the influence of
family characteristics on psychopathology and anti-social behavior in adolescents living
in urban areas. Gorman-Smith, Tolan, Zelli, and Huesmann (1996) report that the FRS
was designed to assess families, based on their proposed theory of family characteristics
and mediating effects on youth psychopathology. According to Gorman-Smith et al.
(1996), the FRS, and the theory of family functioning and youth pathology on which it
is based, was developed to address the need for a model to assess the link between family characteristics and risk. Gorman-Smith et al. (1996) propose that two distinct characteristics of family life, parenting practices and family processes, are risk factors for
youth antisocial behavior. Parenting practices are described in relation to the methods
of socialization and control of the child, which encompass behaviors such as discipline,
supervision, and monitoring of the child. Family processes are defined in terms of the
characteristics of the family unit and include factors such as beliefs and values, emotional warmth and support among family members, organization, and communication.
The FRS (Tolan et al., 1997) contains 92 items and responses are given on a 5-point
Likert scale of agreement. The measure is comprised of six scales, which assess three
higher order dimensions of cohesion, structure, and beliefs. The six scales are: cohesion;
beliefs about the family; deviant beliefs; organization; support; and communication.
One study was identified through a systematic review. Tolan et al. (1997) described the
development and validation of the FRS in a sample of boys from schools in disadvantaged
urban areas (N = 287). Tolan et al. (1997) report internal consistency reliability between
.54 and .87, most of which were less than acceptable (> .70).
In summary, the results of the systematic review yielded limited empirical research
into the validation of the FRS. Therefore, there was insufficient evidence to support the
FRS as a valid and reliable family assessment instrument.
Systemic Therapy Inventory of Change
The Systemic Therapy Inventory of Change (STIC; Pinsof, Goldsmith, & Latta, 2012) is
the first online multi-systemic and multi-dimensional client feedback system. The STIC
was specifically designed to track change in family and couple therapy, and to bring a multi-systemic perspective to the study of change in individual therapy (Pinsof et al., 2009).
Technological feedback systems, such as the STIC, have the potential to address the
research-practice gap and enhance assessment practices (Sexton, Patterson, & Datchi,
2012).
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The STIC is based on the Integrative Problem Centered Meta Frameworks (IPCM;
Pinsof, Breunlin, Russell, & Lebow, 2011; Breunlin, Pinsof, Russell, & Lebow, 2011),
which provides a multi-systemic perspective for family, couple, and individual therapy.
The IPCM has been developed to address the need for an integrative psychotherapeutic
perspective based on four main issues that currently affect psychotherapeutic practice
today (Breunlin et al., 2011). The integrative perspective approach of the IPCM aims to:
(1) synthesize the plethora of empirically validated treatments and knowledge available to
psychotherapists; (2) address the need to move beyond the treatment of individuals
towards a multi-systemic approach based on the growing body of evidence to support this
method; (3) address cultural factors in practice and research; and (4) bridge the gap
between research and practice by using real-time data in clinical practice.
The IPCM is founded on four components employed across systemic and individual psychotherapies: hypothesizing, planning, conversing, and feedback.
The STIC assesses and monitors client progress and therapeutic alliance over the
course of therapy, and feeds this information to therapists and other stakeholders on
demand (Pinsof et al., 2012). The STIC system is comprised of two self-report assessments, the STIC INITIAL and the STIC INTERSESSION. The STIC INITIAL is completed by family members before the first therapy session and contains a demographic
questionnaire and six system scales: Individual Problems and Strengths (IPS); Family of
Origin (FOO); Relationship with Partner (RWP); Family/Household (FH); Child Problems
and Strengths (CPS); and Relationship with Child (RWC). Responses on each scale are
given on 5-point Likert scales, which assess the frequency of each item and range from
“not at all” to “all the time”. The STIC INTERSESSION is completed within 24 hours of
the next therapy session and contains brief versions of the six scales of the STIC INITIAL
and an additional three scales to assess therapeutic alliance, which are administered
based on the type of therapy a client is receiving: Individual Therapy Alliance Scale
(ITAS-r), Couple Therapy Alliance Scale (CTAS-r), and Family Therapy Alliance Scale
(FTAS-r). Responses on each of the therapeutic alliance scales are given on 7-point Likert
scales of agreement.
Two studies were identified through a systematic review. In both studies, clients
attending a family and child therapy service were recruited and participation varied for
each of the STIC scales. Pinsof et al. (2015) also collected data from a nonclinical sample.
Pinsof et al. (2009) describe the development and validation of the STIC INITIAL scales.
Pinsof et al. (2009) established the factor structure of each of the five scales of the STIC
INITIAL using exploratory and confirmatory factor analyses. Three of the scales contained nine factors and two of the scales comprised eight. Internal reliabilities for each of
the scales and their subscales ranged from adequate to good. Pinsof et al. (2009) report
that four of the five scales demonstrated strong correlations with other established measures of assessment, which indicated strong construct validity. Pinsof et al. (2015)
assessed both the STIC INITIAL and INTERSESSION scales. This study supported the
factor structure of the STIC scales, reliabilities, test–retest reliability, and criterion validity in terms of the STIC’s capacity to differentiate between clinical and nonclinical cases,
and established clinical cut-off scores.
In summary, the results of the systematic review yielded two empirical research studies
into the validation of the STIC system, which provided evidence to support the STIC as a
reliable and valid family assessment measure. Strengths of the STIC include its demonstration of internal reliability, test–retest reliability, construct validity, and criterion
validity in terms of its ability to differentiate between clinical and nonclinical cases. The
main limitation of the STIC relates to the absence of evidence to support its responsiveness to change over time. However, Pinsof et al. (2009) report that the STIC system is currently under-going further large-scale validation studies.
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FAMILY PROCESS
Systemic Clinical Outcome and Routine Evaluation
The Systemic Clinical Outcome and Routine Evaluation (SCORE; Stratton, Bland,
Janes, & Lask, 2010) is a self-report family assessment instrument designed for use by
family members 12 years and older. The SCORE was developed to address the need for a
family assessment measure for routine use in clinical settings to assess client and service
outcomes in the United Kingdom and Ireland. The construction of the SCORE was based
on that of the Clinical Outcomes and Routine Evaluation (CORE). The CORE is a selfreport measure of intra-individual psychological distress which is not focused on a brand
of therapy or diagnosis and was designed through a process of practitioner collaboration
and consultation (Barkham et al., 1998; Evans et al., 2000). The CORE is focused on individual pathology and therefore not sensitive to the constructs addressed by systemic family therapies. The SCORE is not an adapted systemic version of the CORE, but a new
assessment measure modeled on the same development processes as the SCORE (Stratton, McGovern, Wetherell, & Farrington, 2006).
The development of the SCORE was based on a review of current theory and existing
family assessment measures (Janes, 2005), clinical experience, expert collaboration, and
consultation with practitioners in the field of family therapy through practice research
networks (PRNs) via the Association for Family Therapy and Systemic Practice (AFT)
email list. The SCORE has been revised from a 40-item version to briefer 28-item and 15item versions through a series of empirical studies and an extensive appraisal process
involving a qualitative review with expert practitioners (Stratton & Hanks, 2008; Stratton
et al., 2006, 2010). A child version of the SCORE has also been developed and is described
by Jewell, Carr, Stratton, Lask, and Eisler (2013).
Each item on the SCORE is presented as a statement about family life. Responses to all
SCORE items are given on 6-point Likert scales ranging from 1 = “that describes my family extremely well”, to 6 = “not at all”. Negatively phrased items are reverse scored and
higher scores are indicative of poor family functioning. The SCORE yields a total family
problem score and three subscale scores: family strengths, family difficulties, and family
communication. The SCORE also contains an open-ended question about the main problem within the family, and respondents rate the severity and impact of this problem on 10point scales.
The SCORE was developed for routine administration in clinical settings to assess family functioning and monitor client outcomes.
Five studies were identified through the systematic review for inclusion. Four studies
assessed general psychometric properties of the 15-item version, three studies assessed
the 28-item version and one assessed the 40-item version.
From Table S7, it may be seen that several studies report that all versions of the
SCORE and its subscales demonstrate adequate to excellent reliability as assessed by
Cronbach’s alpha coefficients (Cahill, O’Reilly, Carr, Dooley, & Stratton, 2010; Fay et al.,
2013; Hamilton, Carr, Cahill, Cassells, & Hartnett, 2015; Stratton et al., 2010). Good test–
retest reliability has been established for the 15- and 28-item versions (Fay et al., 2013;
Hamilton et al., 2015). The 15- and 28-item versions of the SCORE have demonstrated
construct validity in terms of moderate correlations with other self-report measures of
family functioning, low correlations with social desirability sets, and low to moderate correlations with clinician-rated measures of family functioning (Cahill et al., 2010; Fay
et al., 2013; Hamilton et al., 2015). The SCORE 15- and 28-item versions have also been
shown to significantly differentiate between clinical and nonclinical cases, which supports
their criterion validity (Hamilton et al., 2015). A stable factor structure has been established (Cahill et al., 2010; Fay et al., 2013; Hamilton et al., 2015; Stratton et al., 2010).
Additionally, the SCORE 15- and 28-item versions have been shown to demonstrate
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responsiveness in terms of clinical change and reliable change as assessed by the reliable
change index (RCI, Jacobson & Truax, 1991; Hamilton et al., 2015; Stratton et al., 2014).
Hamilton et al. (2015) report that a web-based system for administrating and scoring the
SCORE 15- and 28-item versions is available.
In summary, a systematic review of literature identified five validation studies which
provide evidence to support the 15- and 28-item versions of the SCORE as a reliable and
valid family assessment measure. Strengths of the 15- and 28-item versions include their
demonstration of internal reliability, test–retest reliability, construct validity, criterion
validity in terms of its ability to differentiate between clinical and nonclinical cases, a
stable factor structure, and responsiveness to change in family functioning over time. The
main limitation of the SCORE measure is the need for ongoing investigation of the responsiveness to change over time of the 15- and 28-item versions of the SCORE and replication
across various therapeutic settings.
CONCLUSION
The current series of systematic reviews conducted to identify empirical validation
studies of seven self-report family assessment measures revealed that five family
assessment measures are suitable for clinical use (FAD, FACES-IV, SFI, FAM III,
SCORE), two are not (FES, FRS), and one is a new system currently under-going validation (STIC).
However, the results also highlight several issues regarding the appropriateness of
four of the five assessment measures that were found to be suitable for clinical use
(FAD, FACES-IV, SFI, FAM III). First, these scales were created decades ago, with the
exception of the revised FACES measure, FACES-IV. For example, of the 28 studies
identified for these four measures only six were conducted in the last 10 years. Secondly,
each measure has been designed for use within the framework of their respective theoretical models of family functioning. Therefore, these findings may not represent current
theoretical, therapeutic, or clinical practices. For example, older measures and validation
studies may not reflect the current movement within the field of psychotherapy towards
an integrative approach which has been documented by Breunlin et al. (2011) and Pinsof
et al. (2011). However, there is no evidence to suggest that these measures are not currently useful within their intended theoretical models. Thirdly, each of these measures
contain large numbers of items, ranging from 36- to 60-item scales, which are too cumbersome for routine administration in clinical settings. Finally, no studies were identified
which explicitly examined the responsiveness of these measures to changes in family
functioning over time. Further research is needed to establish the responsiveness to
change over time of the measures developed to track client outcomes FACES-IV, FAM
III, and FES.
The SCORE and STIC stand out as new and particularly useful scales for routine use in
clinical practice. The briefer 15- and 28-item versions of the SCORE have demonstrated
good psychometric properties, take a short amount of time to administer, and have demonstrated responsiveness to change in family functioning over time. The STIC is a more elaborate and comprehensive recently developed instrument, which shows considerable
promise as a family assessment instrument and as a system for providing routine feedback
to therapists on therapeutic progress.
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SUPPORTING INFORMATION
Additional Supporting Information may be found in the online version of this article:
Table S1. Comparison of psychometric properties, clinical utility, and theoretical
underpinnings of the eight self-report family assessment measures.
Table S2. The McMaster Family Assessment Device (FAD) summary of empirical validation studies included in review.
Table S3. The Circumplex Model Family Adaptability and Cohesion Evaluation Scale
IV (FACES-IV) summary of empirical validation studies included in review.
Table S4. The Beavers Systems Model Self-Report Family Inventory (SFI) summary of
empirical validation studies included in review.
Table S5. The Process Model of Family Functioning Family Assessment Measure III
(FAM III) summary of empirical validation studies included in review.
Table S6. Family Environment Scale (FES) summary of empirical validation studies
included in review.
Table S7. Systemic Clinical Outcome and Routine Evaluation (SCORE) summary of
empirical validation studies included in review.
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