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The Questionnaire of Family Functioning: A Preliminary Validation of a
Standardized Instrument to Evaluate Psychoeducational Family Treatments
Article in Community Mental Health Journal · January 2008
DOI: 10.1007/s10597-007-9093-8 · Source: PubMed
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Community Mental Health Journal, Vol. 43, No. 6, December 2007 (Ó 2007)
DOI: 10.1007/s10597-007-9093-8
The Questionnaire of Family
Functioning: A Preliminary
Validation of a Standardized
Instrument to Evaluate
Psychoeducational Family Treatments
Rita Roncone, M.D.
Monica Mazza, Ph.D.
Donatella Ussorio, M.D.
Rocco Pollice, M.D.
Ian R.H. Falloon, M.D.
Pierluigi Morosini, M.D.
Massimo Casacchia, M.D.
ABSTRACT: The aim of the study was to develop and preliminarily validate a selfcompleted questionnaire that could help in the assessment of families before and
during psycho-educational interventions. The questionnaire was developed according
to the cognitive-behavioural psycho-educational model. From an initial 38-item version
of the questionnaire, a final shorter 24-item version was derived. The validation study
of the final version was conducted on relatives of schizophrenic and schizoaffective
patients: 31 for the test–retest reliability study and 92 for the confirmation of the
subscales and convergent validity study vs. SF-36 and the questionnaire on Family
Problems, PF. The final questionnaire showed good psychometric properties. The threeR. Roncone, M. Mazza, D. Ussorio, R. Pollice, I.R.H. Fallon, and M. Casacchia are affiliated with
the Department of Experimental Medicine-Psychiatry, University of LÕAquila, Italy.
I.R.H. Fallon, now deceased, was affiliated with the Department of Psychiatry, University of
Auckland, New Zealand.
P. Morosini is affiliated with the National Health Institute, National Center for Epidemiology,
Surveillance, and Health Promotion, Italy.
Address correspondence to Rita Roncone, M.D. Department of Experimental MedicinePsychiatry, University of LÕAquila, Via Vetoio, Coppito2, I-67100, LÕAquila, Italy; e-mail:
rita.roncone@cc.univaq.it.
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Ó 2007 Springer Science+Business Media, LLC
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Community Mental Health Journal
core dimensions of Problem-Solving, Communication Skills, and Personal Goals were
clearly outlined in the items correlation analysis. The association with family burden
and health-related quality of life was as expected. The FF provides a promising
assessment of the family functioning pattern that is the object of psychoeducational
family interventions. Further studies are needed to confirm the validity of the
instrument, that could be helpful both in planning and in monitoring psychoeducational interventions and in mental health promotion projects.
KEY WORDS: family functioning; questionnaire; validation; psychoeducation; problem solving.
INTRODUCTION
The Psycho-educational Cognitive-behavioural Approach
The psycho-educational cognitive-behavioural approach was first
evaluated by Falloon (Falloon et al., 1982) and has been the object of
many controlled studies, with different names and variants (Anderson
& Hinojosa, 1984; Brooker et al., 1994; Glynn et al., 1992; Hahlweg,
Revensdorf, & Schindler, 1984; Hahlweg, Durr, & Müller, 1995; Held,
1995; Kavanagh et al., 1993; Kuipers, Birchwood, & McCreadie, 2002
Lancashire et al., 1997; Linszen, Dingemans, & Van der Does, 1996;
McFarlane et al., 1995; Miklowitz et al., 2000; Randolph et al., 1994;
Schooler et al., 1997; Tarrier, Barrowclough, Porceddu, & Fitzpatrick,
1994; Telles et al., 1995; Zastowny, Lehman, Cole, & Kane, 1992). The
availability of treatment manuals in many languages has facilitated its
implementation (Falloon, Held, Roncone, Coverdale, & Laidlaw, 1998;
Lancashire et al., 1997).
The psycho-educational cognitive-behavioural approach usually
includes the following strategies: individual evaluation of each member
of the family; assessment of the problem solving capacity of the family
as a whole; education regarding the nature of the disorder and its
biomedical and psychosocial treatment; identification of early warning
signs; improvement of communication skills (see later); structured
problem solving (see later); personal and family objective setting; social
skills and vocational training; and evidence-based psychological
strategies for specific problems, such as anxiety syndromes.
Family Assessment Instruments
The measurement of family relationships in families of people affected
by mental illness has been one of the most interesting issues for the last
40 years.
The stressors in the vulnerability-stress model include those of the
Expressed Emotion, EE construct (Brown, Birley, & Wing, 1972), such as
Rita Roncone, M.D., et al.
593
criticism, hostility, and emotional over-involvement (Brown & Rutter,
1966; Vaughn & Leff, 1976). High EE in families of schizophrenics has
been found to predict recurrence of florid symptoms (Brown et al., 1972).
A number of instruments aim at assessing Expressed Emotion and
family atmosphere, for instance, the well-known Camberwell Family
Interview (CFI); a short-version of the CFI, the Five Minute Speech
Sample, FMSS (Gottschalk & Gleser, 1969; Magana et al., 1986); the
Affective Style, AS (Doane, West, Goldstein, Rodnick, & Jones, 1981;
Doane, Falloon, Goldstein, & Mintz, 1985), which is based on direct
observation of families engaged in solving a problem; the Kategoriensystem fur Partnerschftliche Interaktion, KPI (Hahlweg et al., 1990);
the Carer Stress Interview (Falloon, Graham-Hole, & Woodroffe, 1993;
Falloon, Magliano, Graham-Hole, & Woodroffe, 1996; Falloon, Roncone,
Held, Coverdale, & Laidlaw, 2002), which investigates caregiversÕ
stress, attitudes towards the future and physical and mental health;
and the Cardinal Needs for Carers that was used by Barrowclough
et al. (1999) in a controlled trial of systematic psychosocial interventions based on an assessment of needs.
Among the self-completed questionnaires are:
the questionnaire of Family Problems, FP (Morosini, Roncone,
Veltro, Palomba, & Casacchia, 1991) which was developed with the
aim of assessing both Expressed Emotion and family burden of
care. A factorial analysis of the FP identified four factors. The first
was associated with ‘‘Objective and subjective burden’’, the others
with ‘‘critical attitudes’’, ‘‘emotional over-involvement’’ and ‘‘social
support and received help’’. A short version includes only the items
pertaining to the subjective and objective burden of care (Schene,
Tessler, & Gamache, 1994);
the Family Environment Scale, FES (Moos & Moos, 1981; Spiegel
& Wissler 1986), a self-rating 90-item true–false measure that
assesses dimensions of family functioning in the areas of interpersonal relationships, personal growth and basic organizational
structure of the family. The family atmosphere is evaluated along
the following ten dimensions: (1) cohesion, (2) expressiveness, (3)
conflict, (4) independence, (5) achievement orientation, (6) intellectual orientation, (7) active-recreational orientation, (8) moralreligious orientation, (9) organization and (10) control.
the Dyadic Adjustment Scale (Spanier, 1979), a 32-item questionnaire designed to measure relational adjustment and satisfaction
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in intimate couples. The scale measures dyadic adjustment for the
following four components: (1) degree of consensus, (2) cohesion, (3)
general relational satisfaction and (4) affective expression.
In the psycho-educational cognitive-behavioural approach the focus is
not on family atmosphere or attitudes, or on caregivers burden but on the
skills that family members should possess in order to help each other better.
An instrument that assesses the relevant domains is the Family
Assessment Device (Epstein, Baldwin, & Bishop, 1983; Keitner et al.,
1995; Miller, Epstein, Bishop, & Keitner, 1985; Roncone et al., 1998). The
FAD has 60 items and includes seven scales regarding: (1) ProblemSolving; (2) Communication; (3) Roles; (4) Affective Responsiveness; (5)
Affective Involvement; (6) Behaviour Control; (7) General Functioning.
However, the assessed family functioning features are more or less different from those specifically targeted in family behavioural psychoeducational treatment, for example, the ‘‘communication’’ scale of the
FAD is related to ‘‘the exchange of information among family members in
a direct and clear way’’ and not to the specific communication skills, that
are a part of the psycho-educational treatment, i.e. expression of pleasant
and unpleasant feelings about specific behaviour and active listening.
STUDY AIM
The main aim of this study was the development and validation of a
self-report instrument to ascertain the core aspects of family interpersonal functioning that are addressed in family psycho-educational
interventions in order to assist the therapists both in the initial
assessment and in the progress and outcome assessment. The
increasing dissemination of this approach seemed to justify the development of a specific questionnaire, that could be used routinely in
clinical practice as well as in research, to facilitate its uniform and
rigorous implementation and validation.
METHODS
Initial Development of the Family Functioning Questionnaire (FF)
As already mentioned, the theoretical model underlying the development of the FF was
cognitive-behavioural family treatment (Falloon et al., 1982; Falloon, Boyd, & McGill,
1984; Falloon et al., 1993; Falloon, 2001).
Rita Roncone, M.D., et al.
595
A 60 item list of questions related to three fundamental domains of family interventions (problem solving, communication skills, personal goal setting) were derived
from the literature and the authorsÕ personal experience.
Problem solving items concerning the six steps of structured problem-solving:
identify the problem or the objective, list possible alternative solutions, discuss the
positive and the negative aspects of each proposal, choose the best (or better, a satisfying and realistic solution), plan the solution, check and review the implementation
and planning.
The basic communication skills items concerned the expression of positive and
negative feelings, the making of requests and active listening (probing questions, brief
summary of what has been understood).
The personal goals items enquired into the capability of each family member to
identify personal everyday goals (not linked to patient care). It may be useful to comment that some caregivers, especially mothers, find it very difficult to express goals
that are different from ‘‘the improvement of my relative’’ or ‘‘spending more time with
him/her’’. These statements are considered typical of emotionally over-involved attitudes.
Two of the authors conducted a focus-group on the preliminary version with 12
relatives of schizophrenic patients attending an out-patient service.
The items that were judged both clear and relevant were kept and sometimes
reworded.
The resulting questionnaire had 38 items. The items were rated on a 4-point scale
from 0 to 3 (‘‘always’’, ‘‘often’’, ‘‘sometimes’’, ‘‘never’’), with 0 corresponding to lack of
skill or negative attitude.
The 38 item-version of the FF was administered to a sample of 127 relatives of non
selected psychiatric users of the Day-Hospital of the Psychiatric Department of the
University.
The questionnaire was re-administered to a smaller sub-sample, the first 48 subjects, after one week in a test–retest reliability study.
On the basis of these studies, other items were discarded or reworded. The resulting
shorter 24-item version of the questionnaire was administered to 92 caregivers of
psychiatric patients suffering from schizophrenia or schizoaffective disorder according
to DSM-IV criteria. These made up about 65% of all relatives (n = 140) who were
included in a multi-centred efficacy trial that compared individual and multifamily
psycho-educational treatment. Of the 92 caregivers, 50 belonged to the single-family
and 42 to the multifamily intervention.
The questionnaire was administered to 31 of these relatives twice, one week apart.
Convergent Validity
The instruments that were used to assess convergent validity were the Short Form 36
(SF-36) Health Status Questionnaire (Ware & Sherbourne, 1992) and the short version
of the Questionnaire of Family Problems, FP (Morosini et al., 1991, see introduction).
They were administered together with the 24-item version of the FF.
The Short Form 36 (SF-36) Health Status Questionnaire (Italian version by Apolone
& Mosconi, 1998) is a well-known international instrument that purports to measure
health-related quality of life. It includes eight domains: physical functioning, PF, Role
Functioning–Physical, RP, Bodily Pain, BP, General Health, GH, Vitality, VT, Social
Functioning, SF, Role Functioning–Emotional, RE, Mental Health, MH, and perceived
health change in the past year.
All scores were converted onto a scale of 0 to 100, where 100 indicates best health or
absence of burden.
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These instruments were selected for the convergent validity study because it was
considered possible that problem solving, and communication skills, together with the
capability of defining personal goals, would be negatively associated with high burden
of care and poor quality of life, especially poor emotional functioning. More relevant
instruments for measuring the same constructs were not available or could not be
considered as reference tools (i.e. the possible differences could not be attributed to the
inferiority of the new instrument).
Statistical Analyses
Data analysis was performed with SPSS for Windows version 12.
Intra-class correlation coefficients were calculated to estimate test–retest reliability.
CronbachÕs alpha analysis was used to explore the internal consistency of the whole
instrument and of the three selected domains or subscales (problem solving, communication skills, personal objectives). Internal consistency was also estimated through
the correlation matrix of individual items with the average of the three subscales.
To analyse convergent validity (with SF-36 and the questionnaire on Family Problems—PF), PearsonÕs correlation coefficients were calculated.
A preliminary factor analysis of the first version had been performed on the first
sample of 127 caregivers.
RESULTS
First Version. Test–retest and Construct Validity
In the test–retest reliability study of the pre-final version of the questionnaire intra-class correlations were at least 0.75 for 32% of the
items, between 0.74 and 0.50 for 47% and lower than 0.50 for 21%.
The internal consistency, as measured with CronbachÕs alpha, was
good for the total score of the scale (CronbachÕs alpha = 0.75), and the
three subscales, Problem Solving (alpha = 0.84), Communication Skills
(alpha = 0.76), Personal Goals (alpha = 0.75).
In a preliminary factor analysis, items that were not clearly associated with one of the three aforementioned domains, or only weakly
associated with the personal goals one (for instance ‘‘My family members respect me’’), were deleted.
The items of the Problem Solving and Communication Skills subscales were also reduced. For example, the original item 13 (‘‘When we
discuss a family problem we choose the solution that we can most
readily put into practice, not the perfect solution’’) and item 24 (‘‘In our
family nobody helps other family members to remember the tasks we
have decided to carry out’’) had high loading on both subscales and
were therefore removed.
Among the retained items, those with an intra-class correlation
lower than 0.7 were reworded.
Rita Roncone, M.D., et al.
597
The retained items are reported in Table 1, while the items removed
after the first validation study are listed in Appendix 1.
Final Version
As already mentioned, a total of 92 relatives took part to the final 24
item version validation study. Mean age was 52.1 ± 15.6 years, mean
education 9.1 ± 4 years, 56% were females, 8.5% were married; 38.1%
employed. Most caregivers were relatives (66% parents, 26% brothers
or sisters, 4% spouses, 1% sons or daughters, 3% other relatives).
The mean time to complete the 24-item questionnaire was about
12 minutes.
Test–retest and Construct Validity
The intra-class correlation was found to be higher than 0.75 for 42%,
between 0.74 and 0.60 for 46% and lower than 0.60 for 3% (12%) of the
items. The latter items were reworded.
Internal consistency, as measured by CronbachÕs alpha, was good for
the full scale (CronbachÕs alpha value = 0.84), and the three subscales:
the eight items Problem Solving (PS), with alpha value = 0.83; the
eight items Communication (C), alpha value = 0.71; the eight items
Personal Goal (PG), alpha value = 0.66.
The correlations of individual items with the summary score of their
subscale was good (Table 1): from 0.73 to 0.57 for the PS, from 0.71 to
0.43 for the CS and from 0.68 to 0.40 for the PS. The correlations with
the relevant subscale summary score were always higher than those
with the other two summary scores.
Problem Solving and Communication subscales were strongly correlated with each other (0.72), while the correlations between Problem
Solving and Personal Goals (0.51) and Communication and Personal
Goals (0.46) were lower.
Convergent Validity
It was of collateral interest that in SF-36 the relatives of the psychiatric
patients included in our study showed worse scores than the normal
Italian population (Apolone & Mosconi, 1998) in the subscales of
Physical Functioning (t-test: t = 2.722, p = 0.007), Bodily Pain
(t = 1.901, p = 0.057), Vitality (t = 2.440, p = 0.015), Mental Health
(t = 2.243, p = 0.025).
1. In the family we collaborate together to find the best way to
solve our problems.
4. When a decision has been made
about what to do about a family
problem, we all lend a hand to
carry it out.
7. When we have dealt with a
problem in the family we usually discuss what we have done
and whether it helped.
10. I find it helpful to tell what I
think about a problem in my
family because they seem to
take account of my opinion.
13. If we have a family problem we
all meet together to discuss it.
16. When we have a problem in our
family we plan together what to
do about it.
Items
.610
.485
.517
.340
.556
.317
.660
.641
.569
.729
.687
Communication
.713
Problem-solving
.182
.125
.403
.105
.334
.189
Personal
Goals
Correlation Coefficients of the Items of 24-item Family Functioning Questionnaire with the
Three Identified Subscales
TABLE 1
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Community Mental Health Journal
19. When we have a problem in the
family I can suggest solutions
without worrying about being
criticised.
22. In our home it is difficult to decide how to solve a problem because we never agree about
anything.
2. I can talk with my family about
the things that make me unhappy.
5. If I am unhappy with the
behaviour of someone in my
family I tell them and suggest
some ways that we can get along better.
8. If someone in the family does
something kind for me, I thank
them.
11. When someone in my family
does or says something I like, I
tell them openly that I am
pleased.
14. When I am angry with someone
in the family I tend not to speak
to him/her.
.340
.322
.578
.479
.629
.609
.473
.590
.625
.421
.141
.442
.271
.262
.314
.049
.293
.226
.061
.231
.380
Rita Roncone, M.D., et al.
599
17. If one of my family members does
something kind for me I almost never
thank then because I do not think it is
really necessary.
20.When I need my family to help me with
something I ask them kindly and do not
make demands or orders.
23.When I say to a family member that
they have done something that I do not
approve of, I tell them in a polite way so
that not to offend them personally.
3. I have little time for my own hobbies
and interests, because I spend most of
my free time in caring for my family.
6. Despite many problems I have to deal
to deal with in my family, I always find
a little time for myself.
9. It is important that everyone in the
family has time for themselves.
Items
.707
.593
.432
.111
.098
.172
.342
.228
.199
.180
.231
Communication
.463
Problem-solving
TABLE 1 (continued)
.592
.677
.407
.007
.226
.217
Personal
Goals
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Community Mental Health Journal
.226
.001
.112
.151
.150
.273
.025
.111
.182
.111
Answer scale: ‘‘always’’, ‘‘often’’, ‘‘sometimes’’, ‘‘never’’. Scores of items 22, 14, 17, 3, 18, have been inverted.
12. I succeed to in doing what I
promise myself to do.
15. I manage to do some things
alone, without my family.
18. I have to deal with so many
difficulties in my family that I
have almost completely given
up my interests.
21. I meet friends outside my
family.
24. I can easily find interests that
keep me busy.
.442
.536
.400
.403
.445
Rita Roncone, M.D., et al.
601
*p < 0.05, **p < 0.01, ***p < 0.001.
Questionnaire Family Problems, FP
Objective burden
Subjective burden
SF-36
Physical Functioning, PF
Role Functioning–Physical, RP
Bodily Pain, BP
General Health, GH
Vitality, VT
Social Functioning, SF
Role Functioning–Emotional, RE
Mental Health, MH
)0.12
)0.25*
0.29*
0.13
0.26*
0.24*
0.41***
0.18
0.24*
0.29**
ProblemSolving
)0.16
)0.26*
0.05
)0.11
0.00
0.05
0.25*
0.00
)0.01
0.12
Communication
Skills
)0.26**
)0.13
0.14
0.02
)0.22
0.04
0.07
0.06
0.05
0.28**
Personal
Goals
Family Functioning questionnaire, FF
)0.26*
)0.27*
0.23
0.03
0.13
0.17
0.31**
0.18
0.15
0.32**
FF Total
score
PearsonÕs Correlation Coefficients of Health-related Quality of Life (SF-36), Burden of Care
(FP) and the Subscales of FF in the Relative of Schizophrenic Patients. N = 92
TABLE 2
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Community Mental Health Journal
Rita Roncone, M.D., et al.
603
As for the FP (Family Problems) instrument, the scores showed a
higher objective than subjective burden (mean 38.55, with 16.5 standard deviation, and mean 23.2, with 12.2 standard deviation).
Table 2 shows the correlations between the FF subscales and total
scores and the SF-36 and FP scales scores.
Subscales. Positive correlations of Problem Solving subscale were
marked with the Vitality and Mental Health SF-36 subscales and were
statistically significant, but weak with Physical Health and Emotional
Functioning SF-36 subscales. The FF Personal Goals factor appeared
weakly associated with the SF-36 Mental Health subscale and the FF
Communication skills subscale with the SF-36 Vitality subscale.
The FF Personal goals scale was negatively associated with the
Objective burden of care, while Problem-solving and Communication
skills were negatively associated with Subjective burden.
Total Score. The total FF scores showed a positive association with
the SF-36 subscales Vitality and Mental Health and a weaker negative
association with both PF Objective and Subjective burden of care.
DISCUSSION
It should be emphasised that the Family Functioning questionnaire or
FF investigates positive qualities of family functioning and not negative features, such as hostility, conflict, overprotection or intrusiveness.
It was developed to measure communication and problem-solving skills
of family members and their ability to identify and achieve personal
goals.
The fact that our sample of schizophrenic patientsÕ family membersÕ
health-related quality of life was lower than in the normal population
was expected, and supports the integrity of the study.
This preliminary validation study shows that the FF has good
psychometric properties.
The test–retest reliability study gave satisfying results, the time of
completion was low and the correlation pattern of the items of our
selected dimensions was well related to those expected.
We anticipated that family functioning could be related to high
burden of care and poor health-related quality of life. In fact, family
skills, as measured by the FF, were associated positively with quality of
life and negatively with family burden.
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Community Mental Health Journal
On the whole, the Family Functioning Questionnaire seems a
promising instrument to assess the communication and problem-solving skills of family members and their ability to identify and achieve
personal goals.
Family psycho-educational treatments are not easy to implement,
because they are not compatible with the theoretical training of many
clinicians, are more complex to organise than standard medication and
individual psychotherapy, and the positive outcomes take a rather long
time (Casacchia & Roncone, 1999; McFarlane, McNary, Dixon, Hornby,
& Cimett, 2001). The availability of an easy and quick instrument to
detect specific areas of need and to monitor family progress during the
interventions may add a small contribution to their desirable dissemination.
However, a number of limitations of the study have to be considered.
The limited number of subjects included in the final version validation
study did not allow a proper factorial analysis to be performed.
A confirmatory factor analysis is being planned. The modified version of
the three items that showed the lowest test–retest reliability have been
approved by a focus group but not yet validated in a new sample.
Instrument responsiveness or sensitivity to change has not been
investigated with a follow-up study.
Further studies are therefore desirable in order to confirm our
results and affirm the validity of this instrument.
APPENDIX 1. ITEMS THAT WERE REMOVED AFTER THE FIRST
VALIDATION STUDY
When we discuss a family problem we choose the solution that we
can most readily put into practice, not the perfect one.
I cannot understand how my family members are feeling because
they do not talk about their problems in the family.
I ask lots of questions so that I can better understand what my
family members are thinking about or are saying.
I usually agree with my family members.
I do not like my family members.
We laugh about things together in our family.
If things are not going well in my family, I find others to talk to
about it.
Rita Roncone, M.D., et al.
605
I think that our family situation will improve.
I am happy with the efforts my family members are making to
improve the situation.
My family members respect me.
My family members help me out when I need it.
I feel ashamed to talk to others about my family situation.
In our family we do things together, also when we are away from
home.
I do not get on with my family members.
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