The Family Environment Scale: comparison with the construct of Expressed Emotion. Panos Vostanis* and Judith NichollsT

Transcription

1 @ The Association for Family Therapy Published by Blackwell Publishers, 108 Cowley Road, Oxford, OX4 ljf, UK and 238 Main Street, Cambridge, MA, USA. Journal of Family Therapy ( 1995) 17: I The Family Environment Scale: comparison with the construct of Expressed Emotion Panos Vostanis* and Judith NichollsT The Family Environment Scale (FES) was completed by parents of 30 children with conduct disorders (CD), 30 children with emotional disorders (ED), and 30 well-functioning controls. Parents were also interviewed and rated for Expressed Emotion (EE), and mothers completed the Child Behaviour Checklist (CBCL). Clinical families had significantly lower ratings of Cohesion, Expressiveness, Intellectual- Cultural and Active-Recreational Orientation. These differences were not specific to either diagnostic group. Maternal Criticism was associated with reported conflict in the CD group. The EE scales of Criticism and Warmth (absence of warmth) were correlated with child behaviour ratings in the CD group, in contrast with FES sub-scales. Maternal scores of Cohesion were significantly associated with social competence in the ED and the control group. Maternal ratings of Conflict predicted dropping-out of treatment (CD group), and ratings of Cohesion and Control had some value in predicting clinical outcome. The implications for the future use of the Family Environment Scale and other self-rated measures of family functioning are discussed. Introduction The role of parental attitudes in the development of child psychopathology has been widely investigated. This has been done by either studying the function of the whole family or by studying the relationship between parental attitudes and aspects of child psychological development. The need for the assessment and measurement of several aspects of family functioning led to the development of research instruments based on reports by family members or on direct observation (Jacob and Tennenbaum, 1988). Scales measuring family * Senior Lecturer in Child and Adolescent Psychiatry, University of BirminKham, - - Queen Elizabeth Psychiatric Hospital, Mindelsohn Way, Edgbasion, Birmingham B UK. t Senior Registrar in Child and Adolescent Psychiatry, Oaklands Child and Adolescent Unit, Birmingham, UK.

2 300 Panos Vostanis and Judith Nicholls attitudes include disagreement (Pless and Satterwhite, 1973), affective responsiveness and involvement (Epstein et al., 1983), and conflict and overprotection (Kinston and Loader, 1986). The usefulness of such scales has been investigated in both normal (Barnhill. 1979: Walsh, 1982) and dysfunctioga1 families (Scoresby and Christensen; 1976). The Family Environment Scale is a measure of family members perceptions of their family life, which has been extensively used in different clinical samples (Jacob and Tennenbaum, 1988). This is one of ten Social Climate Scales which have been developed by Moos and his team (Moos, 1986). The scales assess a variety of environments such as community settings (Family, Work, and Group Environment Scale), educational environments (Classroom and University Residence Environment Scale), residential care and treatment settings (Ward Atmosphere, Community-Oriented Programmes, and Sheltered Care Environment Scale), and other institutions (Military and Correctional Institutions Environment Scale). Normative data have been collected from 1,125 normal and 500 distressed families (Moos and Moos, 1986). Distressed families perceived their family environments as lower in cohesion, expressiveness, independence and intellectual/recreational orientation, and higher in conflict. These differences were not accounted for by socioeconomic or cultural factors. However, educational and occupational status within each sample were positively correlated with all the above FES sub-scales - with the exception of conflict. The FES has been applied in studies assessing psychopathology or evaluating outcome in different clinical conditions (Jacob and Tennenbaum, 1988). Spiegel and Wissler (1983 and 1986), for example, found that higher ratings of family expressiveness and cohesion predicted more favourable clinical outcome and adjustment of adult hospitalized patients. High family cohesion and active recreational orientation have also been associated with better prognosis in alcoholism (Finney et al., 1980). The aim of this study was to test further the construct and predictive validity of the Family Environment Scale by investigating whether FES ratings distinguish between broad diagnostic groups of child psychiatric disorders and whether FES ratings can predict clinical outcome. As the validity of similar self-rated measures of family functioning has been previously questioned (Roosa and Beals, 1990a and 1990b), the self-rated FES was compared with an independently rated measure. The widely used construct of The Association for Family Therapy

3 The Family Enuironment Scale and EE 30 1 Emotion (Vaughn and Leff, 1976; Hibbs et al., 1993) was selected as a representative comparison instrument, because its scales describe similar family attitudes to the FES sub-scales. Method Subjects The design of the study has been described in detail elsewhere (Vostanis et al., 1994). The sample consisted of parents of 30 children with conduct disorder (CD) and 30 children with emotional disorder (ED), who had been referred to a Child Psychiatry Service for the first time (ICD-9 criteria, World Health Organization, 1978; at the time of data collection, ICD-10 criteria had not been formally introduced - WHO, 1992). Children with conduct disorders presented with oppositional and aggressive behaviour; children with emotional disorders presented with depressive and anxiety symptoms. A control group consisting of parents of 30 well-functioning children matched for sex and age was selected from two primary schools. Parents of referred children were contacted after the first assessment and at nine months. Controls were contacted once. Fifty-nine mothers (98.3%) and 23 fathers (56.1% of fathers living with the child) of referred children and all 30 mothers and 26 fathers (86.6%) of controls took part. At nine months after the first assessment, 57 families were traced (95%). Demographic data are presented in Table 1. In summary, the three groups did not differ significantly on sex or age of the child, and paternal age. Controls were more likely to live with both parents (x2 = 15.7, p = 0.015). Children with CD were significantly more likely to come from a lower socio-economic background (x2 = 15.4, df= 2, p = ) and to live with a younger mother (one-way analysis of variance, df= 84,f= 7.75, p = ). These differences were taken into account in the comparison of FES ratings between the three groups (see below). Measures The Family Environment Scale (FES), The Family Environment Scale has three forms: R (Real - people s perceptions of family functioning, which was used in this study), I (Ideal - people s perceptions of the family they would ideally like) and E (Expectations - what people

4 302 Panos Vostanis and Judith Nicholls TABLE 1 Description of the three groups Conduct Emotional disorders disorders Controls Sample size (n) Sex Female Male Social class Manual Non-manual Child age Mean SD Min-Max Parental status Both biol. parents Single parent Biol. and stepparent Fos ter/adoptive Maternal age Mean Min-Max Paternal age Mean Min-Max expect a family climate to be like). It is intended to measure ten subscales on three dimensions (Moos and Moos, 1976; Billings and Moos, 1982; and see Table 2): Relationships (Cohesion, Expressiveness, Conflict), Personal Growth (Independence, Achievement Orientation, Intellectual-Cultural Orientation, Active-Recreational Orientation, Moral-Religious Emphasis), and System Maintenance (Organization, Control). Each informant is given a booklet with 90 statements describing different aspectslhabits of hislher family. He/ she is asked to mark with X whether each statement is True or False on a separate answer sheet, and the total score is estimated for each sub-scale (with a high score positive, and a maximum score of 9, for each sub-scale).

5 The Family Environment Scale and EE 303 TABLE 2 Family Environment Scale: dimensions and subscales lfrom Moos and Moos, 1986) A. Relationshq Dimensions 1. Cohesion: degree of commitment, help and support family members provide for each other. 2. Expressiveness: extent to which family members are encouraged to act openly and to express their feelings. 3. ConJict: amount of openly expressed anger, aggression and conflict in the family. B. Personal Growth Dimensions Independence: extent to which family members are assertive and selfsuficient, and make their own decisions. Achievement Orientation: extent to which activities (e.g. school or work) are seen in an achievement-oriented or competitive manner. Intellectual-Cultural Orientation: interest in political, social, intellectual and cultural activities. Active-Recreational Orientation: participation in sociallrecreational activities. Moral-Religious Emphasis: emphasis on ethicallreligious issues and values. C. System Maintenance Dimensions 9. Organization: degree of clear organization and structure in planning family activities and responsibilities. 10. Control: set rules and procedures used to run family life. The FES sub-scales have been found to have good internal consistency and test-retest reliability Uacon and Tennenbaum, 1988; Moos, 1990). The FES sub-scales (e.g. Cohesion and Conflict) have been found to describe similar concepts to those measured by other family assessment instruments (Holahan and Moos, 1983; Bloom, 1985), which supported their construct validity (Moos and Moos, 1986). Moos ( 1990) asked nine independent raters to assign 45 FES items to one of five sub-scales. The finding that at least six of the raters (67%) categorized correctly 39 of the 45 items provided evidence, according to the authors, for the good content and face validity of the FES items and sub-scales. In this study, the FES was completed by both parents, if they were available, at the first assessment. The Camberwell Family Interview (Expressed Emotion ratings). This was originally developed by Brown and Rutter (1966) and was later abbreviated and modified into its present form by Vaughn and Leff (1976). The CFI is a semi-structured interview with a family member or carer that collects information on family life and parental attitudes

6 304 Panos Vostanis and Judith Nicholls about the identified individual during the previous three months. Expressed Emotion consists of two frequency scales, Critical and Positive Comments, and three global, Warmth, Emotional Over- Involvement (both scales 0-5) and Hostility (scale 0-3). Previously defined criteria (Vaughn and Leff, 1976) were used. The construct of EE has been found to be reliable if used by trained raters (Parker et al., 1988). Its concurrent validity has been tested against several interactional measures (Kuipers, 1979), and its predictive validity has been supported by its ability to predict relapse in schizophrenia and other psychiatric disorders (Hooley, 1985; Kuipers, 1987). The interviewer (PV) had been trained in the use of the CFI and in rating EE. In this study, audiotapes were scored for EE by an independent rater ('JN). The rater was trained by rating the same CFI materials. In addition, a pilot study was undertaken on the reliability of EE ratings in a separate sample of referred and nonreferred children. The interviewer and the rater independently scored interviews with 18 parents, and their inter-rater reliability was supported (Spearman rank correlation coefficient of at least 0.80 for each EE scale). In this study, parents were interviewed jointly, as it has been found that reliable ratings of Expressed Emotion can be made when two parents are present (Szmukler et al., 1987; Berkowitz, 1987). All interviews were audiotape-recorded. Expressed Emotion was independently rated for each parent. The rater was blind to the group status of the subjects. The Child Behaviour Checklist (CBCL). This is a widely used questionnaire measuring child behaviour and child social competence (Achenbach and Edelbrock, 1983). Behavioural items are classified into Externalizing and Internalizing symptoms. The CBCL has been standardized in large clinical and non-referred samples (Barkley, 1988). It has been found to be highly reliable (Achenbach and Edelbrock, 1983) and its construct validity has been supported by high correlation with other behaviour rating scales (Fombonne, 1989) and clinical interview schedules (Verhulst and Van der Ende, 1991). The CBCL was completed by mothers at the first assessment and at nine months, as it has been found to be a valid measure of child psychopathology (McConaughy et al., 1992). In addition to the CBCL, three other outcome data were rated from the clinical case notes at nine 1995 The Association for Family Therupr

7 The Family Enuironment Scale and EE clinical change of the child at the last outpatient contact: worse/no change, slight/some improvement, much improvement/recovery; 0 presence of child psychiatric disorder at the last clinical contact: psychiatrically normal or trivial/minor abnormalities, definite disorder with a degree of handicap; and 0 clinical status at nine months: still in attendance/surveillance, discharged, lapsed. Results (a) Comparison of FES ratings between the clinical and the control group Comparison of maternal ratings. Mothers of non-referred children (n = 29) rated their family environments significantly higher than mothers of children with psychiatric disorders (n = 50) on Cohesion (Mann- Whitney test, z = 2.20, p = 0.03), Expressiveness (z = 3.20, p = O.OOl), Intellectual-Cultural Orientation (2 = 3.39, p = ) and Active-Recreational Orientation (z = 2.38, p = 0.02), and lower on Moral-Religious Emphasis (z = 2.31, p = 0.02). Comparison of paternal ratings. Significant differences were detected in the same FES scales as rated by fathers of non-referred (n = 22) and referred children (n = 19). Fathers of controls rated the scales of Cohesion (Mann-Whitney test, z = 2.17,p = 0.03), Expressiveness (z = 2.60, p = 0.009), Intellectual-Cultural Orientation (z = 3.48, p = ) and Active-Recreational Orientation higher (z = 1.99, p = 0.046), and the scale of Moral-Religious Emphasis lower (z = 2.65, p = 0.008). Comparison of mothers and fathers FES ratings. Within the clinical group, the associations between maternal and paternal ratings were tested by Pearson correlation test. A high degree of agreement was found between parents on all FES scales, with the exception of Independence (n = 16; Table 3). Similarly, parents of controls were found to agree significantly on all FES scales, with the exception of Independence and Control (n = 22; Table 3). (6) FES ratings in the CD and ED groups Maternal FES ratings (Table 4). The three groups (CD: n = 23, ED: n = 27 and controls: n = 29) were significantly distinguished by four FES scales (K-Wallis test), i.e. Expressiveness (x2 = 11.3, p = 1995 The Association for Family Therapy

8 306 Panos Vostanis and Judith Nicholls TABLE 3 Association between maternal and paternal FES ratings (Pearson correlation coef$cient) FES scale Cohesion Expressiveness Conflict Clinical group: Controls: Mothers-fathers Mothers-fathers (.*I (r*) (n = 16) P** (n = 22) P** Independence Achievement Orientation Intell-Cultural Orientation Active-Recreat. Orientation Moral-Religious Emphasis Organization Control *r: Pearson correlation coefficient **p: level of statistical significance Intellectual-Cultural Orientation (X' = 13.3, p = O.OOl), Active- Recreational Orientation (x2 = 6.3, p = 0.04), and Moral-Religious Emphasis (x2 = 9.7, p = 0.008). The differences in maternal ratings of Expressiveness and Intellectual-Cultural Orientation were accounted for by high scores in the controls. The differences in the ratings of Active-Recreational Orientation were mainly accounted for by low scores in the CD group, and in maternal ratings of Moral-Religous Emphasis by high scores in the ED group. When demographic variables were controlled for, Expressiveness and Intellectual-Cultural Orientation still distinguished between the three groups. In contrast, differences in maternal ratings of Active-Recreational Orientation were mediated by social class (stepwise multiple regression, jl = 0.90, p = 0.08), and differences in ratings of Moral-Religious Emphasis by social = 0.99, p = 0.35) and parental status (no variable was entered in this equation). Paternal FES ratings. Three of these scales as rated by fathers also distinguished between the three groups (CD, ED and controls), i.e. Expressiveness (K-Wallis test: x2 = 6.8, p = high score in

9 The Family Environment Scale and EE 307 TABLE 4 Maternal FES ratings (Kruskal- Wallis Analysis of Variance) FES scale Conduct disorders Emotional disorders (n = 23) (n = 27) (n = 29) x2 P Cohesion Expressiveness Conflict Independence Achievement Orientation Intell-Cultural Orientation Active-Recreat. Orientation Moral-Religious Emphasis Organization Control controls), Intellectual-Cultural Orientation (x2 = 12.5, p = high scores in controls), and Moral-Religious Emphasis (x2 = 7.2,p = low scores in controls). The FES ratings were similar for the two clinical groups. Differences in paternal ratings of Expressiveness and Intellectual-Cultural Orientation were not affected by demographic variables, but ratings of Moral-Religious Emphasis ceased to distinguish between the three groups when they were controlled for paternal age. It must be stressed, however, that these differences were based on small numbers of participating fathers (CD: n = 11, ED: n = 8, and controls: n = 22). (c) Relationship between maternal EE and FES ratings. Because of the small numer of fathers who completed the FES and were also rated for EE, this analysis was restricted to maternal ratings. The pairs of EE- FES scales that measure similar concepts were compared, i.e. Critical Comments-Conflict, Warmth-Cohesion, Positive Comments- Expressiveness, and Emotional Over-Involvement-Control. The Pearson coefficient of correlation was estimated for each pair within each of the three groups (Table 5). In the CD group (n = 23), the only scales that were significantly correlated were ratings of maternal criticism and mothers ratings of family conflict. In the ED (n = 27) and the control group (n = 28), none of the four pairs of EE-FES scales was found to be significantly 1995 The Association for Family Therajy

10 308 Panos Vostanis and Judith Nicholls TABLE 5 Relationship between maternal EE and FES ratings (Pearson coefficient of correlation) Children with conduct disorders (n = 23) Critical Comments-Conflict Warm th-cohesion Positive Comments-Expressiveness EOI-Con trol Children with emotional disorders (n = 21) Critical Comments-Conflict Warmth-Cohesion Positive Comments-Expressiveness EOI-Control Non-referred children (n = 28) Critical Comments-Conflict Warm th-cohesion Positive Comments-Expressiveness EOI-Con trol R = 0.51 (p < 0.01) R = 0.30 (NS) R = 0.16 (NS) R = (NS) R = (NS) R = (NS) R = 0.29 (NS) R = (NS) R = 0.35 (NS) R = (NS) R = (NS) R = 0.32 (NS) This lack of significant associations indicates that mothers perceptions of their family environment are not consistent with observational measures of their attitudes towards their children. In order to investigate the relationship between self-reported and independent ratings further, it was important to know which of the two constructs was more strongly associated with child behaviour ratings within the CD and ED groups. (d) Which of the two constructs (maternal EE, FES) was more strongly associated with CBCL ratings? Within each of the three groups, one FES sub-scale and the corresponding EE scale were entered as independent.variables in a stepwise multiple regression, with one of the CBCL scores (externalizing, internalizing or social competence) as the dependent variable. In the CD group, lack of maternal warmth was significantly associated with the level of externalizing symptoms (13 = -0.60, p = 0.003), in contrast with maternal ratings of cohesion (13 = 0.02, p = 0.92). Similarly, critical comments were significantly associated with externalizing symptoms (13 = 0.56, p = 0.007), but this was not true for ratings of conflict (13 = 0.12, p = 0.57).

11 The Family Enuironment Scale and EE 309 In the ED group, the reverse pattern was established in that ratings of cohesion predicted levels of social competence f$ = 0.45, p = 0.026), which was not true for maternal = 0.04, p = 0.81). In the control families, criticism predicted both externalizing f$ = 0.63, p = 2) and internalizing = 0.45, p = 0.013), and impaired social competence p = -0.43, p = 0.022), but no significant association was found for ratings of conflict. Maternal cohesion and warmth were negatively correlated with externalizing symptoms (cohesion: j3 = -0.52, p = 0.006; warmth: j3 = -0.43, p = 6). In addition, cohesion predicted social competence (13 = 0.41, p = 0.03). (e) Outcome data and testing the predictive validity of FES scales Different types of treatmendmanagement were employed: in 11 CD (37%) and nine ED families (30%) family work/family therapy, including the use of behavioural techniques, was used. The rest were offered advice (seven CD and seven ED), educational or social services provision (six CD), individual psychotherapy (psychodynamic or cognitive-behavioural: two CD and eight ED), inpatient admission (four ED), medication (one ED), or no treatment after the initial assessment (four CD and one ED). At the time of follow-up, 16 CD (54%) and five ED families (1 7%) had lapsed from treatment (x2 = 9.07, df= 2, p = 0.011). Fourteen children with CD (47%) had not changed or were symptomatically worse, in contrast with two children with ED (7% - x2 = 13.25, a'f= 2,p= 0.001). Eighteen children with CD (60%) and nine children with ED (30%) still fulfilled criteria for a psychiatric disorder with some degree of handicap (x2 = 5.45, df= 1, p = described in Vostanis and Nicholls, forthcoming). In order to test the predictive validity, the FES Relationships scales were entered together with the corresponding EE scale as the independent variables in a stepwise multiple regression analysis, with changes in CBCL scores at nine months (symptoms or social competence) or clinical outcome at the last contact, with the clinician as the dependent variable. In the CD group, ratings of maternal conflict predicted dropping-out of treatment f$ = 0.51, p = 0.012). Although lack of maternal warmth at the time of the first assessment was found to predict presence of psychiatric disorder at the last clinical contact (13 = -0.45, p = 0.03), this was not established for ratings of maternal cohesion f$ = -0.21, p = 0.29) The Associationfor Family Therapy

12 310 Panos Vostanis and Judith Nicholls cohesion was, however, predictive of clinical improvement 0 = 0.38, p = 0.049), and ratings of maternal control predicted poor clinical outcome in the ED group 0 = -0.39, p = 0.04). Finally, the power of FES scales to predict Expressed Emotion at nine months was tested. Initial scores of corresponding FES and EE scales were entered as independent variables in a stepwise multiple regression, with levels of the EE scale at nine months as the dependent variable. Maternal ratings of control were significantly associated with levels of emotional over-involvement at nine months in the ED group ( J = 0.45, p = 0.02). Discussion Measures of family functioning are used for both clinical and research purposes. Such measures may be used to describe patterns of family life and pathology, as potential predictors of outcome, or as outcome measures themselves. Self-completed questionnaires such as the Family Environment Scale are easier to administer than observational and/or independently rated instruments that require training. They are also less expensive and time-consuming. However, their validity needs to be tested in cross-sectional and longitudinal studies. This was the aim of this paper. Several scales of the FES were found to distinguish between the two groups of referred families and the control group of normal families. This was consistent for mothers and fathers. Not surprisingly, the FES scales indicate better family functioning in the control families, i.e. higher levels of expressiveness/communication, cohesion and emphasis on social activities. On the other hand, no difference was detected on self-ratings of conflict. This was contrary to clinical impression, as one would expect higher levels of conflict in families of children with psychiatric disorders. Scoresby and Christensen ( 1976) had previously found higher expressiveness, cohesion and organization, and lower conflict in non-clinical than clinical families. They interpreted the findings as indicative of more complementary and symmetrical interaction in the clinical families and more parallel interaction in the non-clinical families. Parents in both groups had a high degree of agreement on most FES scales. Mothers and fathers had similar perceptions of their family relationships (which include cohesion, conflict and expressiveness). Of course this does not imply the lack of conflict in clinical families - the association merely indicates that spouses were aware of

13 The Family Environment Scale and EE 31 1 similar patterns of family functioning. A consistent finding was the lack of agreement in clinical and control families on the role of independence within their family. Whether this factor has a causal role in maladaptive relationships needs to be explored further. FES scores were not significantly different between parents of children with conduct and emotional disorders. The only exception was the sub-scale of active-recreational orientation, which was particularly low for mothers of children with conduct disorders. McGee et al. (1984) found that children with aggression or hyperactivity had reports of poor family relationships as detected by the FES (global ratings), compared with children without these characteristics. This question needs to be re-addressed in future studies with more homogenous clinical/family characteristics. The association between maternal criticism and self-reported conflict in the group of children with conduct disorders was consistent with Hibbs et al. (1993). They found an association between family conflict and high levels of Expressed Emotion, which was mainly determined by the number of critical comments. Criticism is the strongest predictor of child psychopathology in non-clinical and clinical samples (Hibbs et al., 1991; Vostanis and Nicholls, 1992; Vostanis, 1994). In this study, the independently rated measure of Expressed Emotion (particularly the scales of Critical Comments and Warmth) was found to be more strongly associated with child behaviour ratings than the parent-rated Family Environment Scale. Although the two widely used instruments have not been developed to measure the same dimensions, they do describe similar aspects of family functioning. One would therefore expect to find an association between some of their scales. This has not been confirmed. The lack of association could be explained in two ways. (a) By raising questions about the validity of the FES (and particularly the scale of Conflict, Expressiveness and Control) and of other self-completed measures of family functioning. Questions about the validity of certain sub-scales of the FES have already been raised by Roosa and Beak (1990a and 1990b). (b) Even if family conflict is present and rated by an independent assessor, it is not perceived as such by the family. This hypothesis may apply specifically to parents of children with conduct disorders and may have implications for family therapy techniques. Families, for example, may be facilitated to acknowledge underlying conflict and to develop better coping strategies The Association for Family Therapy

14 312 Panos Vostanis and Judith NichollJ In contrast with previous studies with adult patients and their families, the Family Environment Scale was not found overall to predict clinical outcome. High ratings of conflict by mothers of children with conduct disorders predict dropping-out of treatment, which may be a mediating factor leading to poor outcome. A similar association has been established between parental criticism, droppingout of treatment and continuing symptoms in adolescents with eating disorders (Szmukler et al., 1985; Le Grange et al., 1992). Generating conclusions on the predictive value of the FES from this study is limited because of the different types of treatment used by the clinicians. A previous study showed that Expressed Emotion is a potentially useful measure of change in family therapy (Vostanis et al., 1992). It would be interesting to replicate this finding by also administering the FES during family therapy, and to include FES ratings by both parents and children (the latter was not possible in this study, as all children were between 6 and 11 years of age). Conclusion The use of the Family Environment Scale, which was used as a representative self-completed measure of family life, revealed some interesting patterns within the clinical and the control group, and some differences between the two groups, particularly in the communication and expression of feelings. The lack of diagnostic specificity was not surprising but one would expect higher levels of self-reported conflict in the referred families. With the exception of the association between self-rated conflict and independently rated criticism in the CD group, neither the construct nor the predictive validity of the FES as a whole or of the Relationships dimension were supported. Although the findings obviously require replication in different samples, self-reported measures of family functioning should be used with caution by clinicians. They should preferably be used to complement clinical assessment, observational instruments of family functioning and outcome measures of symptomatic change. Acknowledgement We are grateful to all families who participated in the study. We would also like to thank all consultant child psychiatrists at the Heathlands Unit for their help. The study was partly funded by the Queen Elizabeth Psychiatric Hospital Research Fund The Association for Family Therapy

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