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University of Dublin, Trinity College, Faculty of Health Sciences, School of Nursing and Midwifery, 24 D’Olier Street, Dublin 2, e-mail: macgrec{at}tcd.ie
Child and Family Centre, St Mary’s Hospital, Dublin Road, Drogheda
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) were developed as a routine measure of outcomes in child and adolescent psychiatry. In a preliminary study we administered subscale 12 of HoNOSCA (Family Life and Relationships) to 20 families and compared the results with two well-established measures of family functioning and a measure of abnormal psychosocial situations associated with psychopathology.
RESULTS
Strong correlations were found between HoNOSCA sub-scale 12 and both self-assessed and clinician-assessed measures of family functioning. However, there was little relationship between HoNOSCA (12) and a measure of abnormal psychosocial situations.
CLINICAL IMPLICATIONS
HoNOSCA (12) appears to provide a quick and valid assessment of overall family dysfunction and can be used in a time-efficient manner as a means to assess where further more comprehensive family assessment or family therapy may be required.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The validity and reliability of some sub-scales is clearly in question. It is not clear from the literature exactly what aspects of family functioning and experience the sub-scale of Family Life and Relationships actually measures or against what gold standards this subscale has been correlated - if at all.
The aim of this study was to investigate the concurrent validity of the Family Life and Relationships sub-scale of HoNOSCA by comparing it with two well-established measures of family functioning and a measure of psychosocial functioning that has a strong family emphasis.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Twenty families agreed to participate in the study. Clinicians seeing the families rated them using HoNOSCA and Axis V of ICD-10 (Associated Abnormal Psychosocial Situations). Each family member completed a Demographic Family Information Sheet, a Child Behavior Checklist (CBCL), and the Family Assessment Device (FAD). Trained family therapists then interviewed the families using the McMasters Structured Interview of Family Functioning (McSIFF, Bishop et al, 1980). This interview provided information that enabled the family to be rated on the McMasters Clinical Rating Scale (MCRS).
Measures
Health of the Nation Scales for Children and Adolescents (HoNOSCA)
This is a clinician-rated scale consisting of 13 items plus two option
scales. The Trainer’s Guide for sub-scale 12 (Problems with
Family Life and Relationships) instructs clinicians to use this item to refer
to relationships with parents and siblings in the family home (or foster or
residential home). In addition:
parental personality problems, mental illnesses and marital difficulties should only be rated here if they have an effect on the child, though this will usually be the case. Problems associated with physical, emotional or sexual abuse should be included but this scale is not intended to address abusive or neglectful features alone. Difficulties arising from over involvement and overprotection should also be included, as well as difficulties arising from family re-organisation as a result of relocation or bereavement (Gowers et al, 1997).
In summary, this scale is purported to measure a hybrid of family functioning indices (relationships, overinvolvement, etc.) and life events (abuse, bereavement, etc.).
McMasters Structured Interview of Family Functioning
This structured interview (Bishop et
al, 1980) was developed so that researchers and clinicians
could conduct valid and reliable family interviews. The interview addresses
six areas of family functioning: roles, behavioural controls, problem-solving,
communication, affective responsiveness and affective involvement. The
dimensions of the McSIFF are based on the McMasters model of family
functioning.
McMasters Clinical Rating Scale
This is a seven-item scale that rates each of the six dimensions of the
McMasters model. It also gives an overall health/pathology rating. It was
designed for use either by a rater who observes an in-depth family interview
or by a researcher or clinician who carries out a structured interview (i.e.
the McSIFF). The scale measures family functioning across a continuum from
very dysfunctional to superior functioning on a seven-point Likert scale.
Concurrent validity with the Family Assessment Device (FAD) has been
demonstrated (Fristad, 1989),
as has discriminant validity, interrater reliability and test-retest
reliability over a 3-month period (Keitner
et al, 1992).
Family Assessment Device
The FAD is a paper-and-pencil questionnaire, which can be filled out by all
family members over the age of 12. It yields seven scales: the six domains of
family functioning (identified in the McMaster Model) and a General Family
Functioning Scale that assesses the overall health/pathology of the family.
Epstein & Bishop (1981)
suggest that the FAD is both a reliable and valid instrument.
Child Behavior Checklist
The CBCL is a well-recognised inventory of emotional and behavioural
problems designed for children aged 4–18 years of age. It is considered
to be both a valid and reliable instrument and has been standardised
(Achenbach, 1991).
ICD-10 Axis V
The psychosocial axis (Axis V) of the World Health Organization
(1996) Multi-Axial
Classification of Child and Adolescent Psychiatric Disorders lists nine
abnormal psychosocial situations associated with psychopathology: abnormal
intrafamilial relationships; mental disorder, deviance or handicap in the
child’s primary support group; inadequate or distorted intrafamilial
communication; abnormal qualities of upbringing; abnormal immediate
environment; acute life events; societal stressors; chronic interpersonal
stress associated with school/work; and stressful events/situations resulting
from the child’s disorder. A semi-structured interview, the Interview
Schedule for Children, has been developed as a companion to Axis V - however,
its administration takes about 60 min (Van
Goor-Lambo et al, 1990). We developed a simple tick-box
sheet in line with the methodologies for application of the Axis V scheme
proposed by Van Goor-Lambo et al
(1990), to be filled in by
clinicians who had already fully assessed the family. Coding was performed
strictly in terms of whether the child’s situation fulfilled the
guidelines for the category, irrespective of whether such psychosocial
circumstances are thought to be causal of psychiatric disorder. Codings from
the research criteria of ICD-10, Axis V were employed: a score of 2 indicated
the situation definitely applied during the specified period (see below) and
was of a type and severity that definitely met the diagnostic guidelines of
the Axis V glossary; a score of 1 indicated that the situation definitely
applied during the specified time period, was of a type that fulfilled the
category guidelines, but was of a severity that fell short of the specified
criteria in spite of being judged abnormal and potentially significant; a
score of zero indicated that the psychosocial situation with respect to the
future was broadly within the normal range (including minor abnormalities of
little clinical significance). No scores were given when criteria could not
have applied to the child given their particular circumstances or where
insufficient information was available to make the coding. The coding time
frame was based on the child’s lifetime, on the basis of evidence that
the situation or life event had played a role in causative processes.
We also generated a total score of adversity by summing all scores across the nine sub-scales.
Data analysis
The data were analysed using the Statistical Package for the Social
Sciences (SPSS) version 10, for Windows. Non-parametric correlation
coefficients between the variables were computed using Spearman’s
rho.
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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HoNOSCA and Axis V
Significant correlations were found between HoNOSCA (12) and the Axis V
sub-scales Inadequate or distorted intrafamilial communication (r=0.498,
P<0.05) and Societal pressure (r=0.482, P<0.05). There
were no other correlations between HoNOSCA and any of the other sub-scales of
Axis V or of the total score for Axis V
(Table 1).
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HoNOSCA and MCRS
There were significant correlations between HoNOSCA (12) and all the MCRS
sub-scales besides affective responsiveness: problem-solving
(r=-0.534, P<0.05); roles (r=-0.471,
P<0.05); affective involvement (r=-0.559,
P<0.05); communication (r=-0.530, P<0.05);
behavioural controls (r=-0.643, P<0.01); and general
functioning (r=-0.509, P<0.05)
(Table 2). The negative scores
between the MCRS and HoNOSCA relate to how the MCRS scores: lower scores in
the MCRS indicate that the family have more marked difficulties whereas higher
scores indicate overall healthy family functioning.
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HoNOSCA and FAD
The HoNOSCA (12) was significantly correlated with the mean family scores
for the following FAD sub-scales: general functioning (r=0.553,
P<0.05); affective responsiveness (r=0.468,
P<0.05); roles (r=0.666, P<0.01); and
communication (r=0.619, P<0.01)
(Table 3). HoNOSCA (12) was
also significantly correlated with mothers’ scores for the following FAD
sub-scales: communication (r=0.646, P<0.01); roles
(r=0.620, P<0.01); affective responsiveness
(r=0.564, P<0.01); affective involvement
(r=0.456, P<0.05); and general functioning
(r=0.617, P<0.01)
(Table 4).
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The results indicate that HoNOSCA (12) correlates well with the FAD completed by the families and the MCRS completed by the researchers. There was little, if any, relationship between HoNOSCA (12) and Axis V. In other words, when applying HoNOSCA (12) to families, it appears that we are principally measuring aspects of family functioning in line with the McMasters’ theoretical model and not the life events and family psychosocial adversities that it alludes to in its definition. The interpretation of this finding is difficult and we believe this is because of a lack of clarity in the definition of the HoNOSCA (12) sub-scale itself. The description of HoNOSCA (12) in the Trainer’s Guide indicates that it spans both family functioning and life events; however, it is clear that in coding, some life events (parental mental illness) should be subordinated to the former and considered only for their effect upon the child. The Trainer’s Guide is ambiguous regarding rating abuse: ‘it should be included but this scale is not intended to address abusive or neglectful factors alone’ (Gowers et al, 1997). In the separate Glossary for HoNOSCA Score Sheet it is clearly indicated that sexual and/or physical abuse can be included on its own as a life event (Gowers et al, 1998). In other words, it assumes that its occurrence within the family coexists with relationship problems.
If our clinical raters have interpreted HoNOSCA (12) as requiring discrimination between life events as cold historical facts (to be excluded) and life events according to how they impact upon the child and their relationships within the family, then the lack of correlation between HoNOSCA (12) and Axis V indicates of course a correct use of HoNOSCA according to the Trainer’s Guide but not the Glossary.
There might be other explanations for this finding. Axis V is a broad multi-axial framework, which looks at the family’s psychosocial situation over a life span (or a specified time frame) whereas HoNOSCA measures the child’s symptomatology over a 2-week period.
Also, the lack of a correlation between HoNOSCA and Axis V might be in part a result of the poor reliability of the psychosocial axis when tested in day-to-day practice (Willemse et al, 2003). It might also be owing to different professional groups’ ability within child psychiatry to work with criterion-based classifications. Applying Axis V reliably and validly requires a complex understanding of diagnostic classification; something medical staff clearly have more experience of. This is in contrast to the HoNOSCA which can be used reliably by members of a multidisciplinary team. Further training may be required, especially for ICD-10 Axis V so that all members of the multidisciplinary team are completing assessments in a consistent manner.
There are recognised limitations of this research. The sample size of 20 families is small. Also, there was a time delay between the families’ first appointment with their clinician and the family interview with the researchers. The family may have already changed their individual and family behaviours following the first encounter with the services.
The HoNOSCA promotes a multidisciplinary approach to care and encourages team members to practise from an outcome perspective. HoNOSCA (12) appears to provide a quick and valid assessment of overall family dysfunction, one that corresponds to the theoretical model of McMasters. It can be used in a time-efficient manner as a means to assess whether further more comprehensive family assessment or family therapy is required. Finally, this small study indicates that some revision of the definition of the scale in the Trainer’s Guide and the practical use of it in the Glossary is required to bring both into closer harmony.
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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BISHOP, D., EPSTEIN, N., KEITNER, G., et al (1980) The McMasters Structured Interview for Family Functioning. Providence, RI: Brown University Family Research Program.
EPSTEIN, N. B. & BISHOP, D. S. (1981) Problem centered systems therapy of the family. Journal of Marital and Family Therapy, 7, 23 -31.
FRISTAD, M. (1989) A comparison of the McMasters and circumplex family assessment instruments. Journal of Marital and Family Therapy, 15, 259 -269.[CrossRef]
GOWERS, S. G., HARRINGTON, R., WHITTON, A., et al (1997) HoNOSCA: Health of the Nation Outcome Scales, Child and Adolescent Mental Health. Trainer’s Guide. Liverpool & London: University of Liverpool & Royal College of Psychiatrists.
GOWERS, S. G., HARRINGTON, R., WHITTON, A., et al (1998) HoNOSCA: Health of the Nation Outcome Scales, Child and Adolescent Mental Health. Glossary for HoNOSCA Score Sheet. Liverpool & London: University of Liverpool & Royal College of Psychiatrists.
GOWERS, S. G., HARRINGTON, R. C., WHITTON, A., et al
(1999) Brief scale for measuring the outcomes of emotional and
behavioural disorders in children. Health of the Nation Outcome Scales for
Children and Adolescents (HoNOSCA). British Journal of
Psychiatry, 174, 413
-416.
KEITNER, G., RYAN, C. & MILLER, I. (1992) Recovery
and major depression: factors associated with 12 month outcome.
American Journal of Psychiatry,
149, 93-99.
VAN GOOR-LAMBO, G., ORLEY, J., POUSTKA, F., et al (1990) Classification of abnormal psychosocial situations: preliminary report of a revision of a WHO scheme. Journal of Child Psychology and Psychiatry, 31, 229 -241.
WILLEMSE, G., VAN YPEREN, T. & RISPENS, J. (2003) Reliability of the ICD-10 classification of adverse familial and environmental factors. Journal of Child Psychology and Psychiatry, 44, 202 -213.
WING, J. K., BEEVOR, A. S. & CURTIS, R. H. (1996) Health of the Nation Outcome Scales (HoNOS). Research and development. British Journal of Psychiatry, 172, 11-18.
WORLD HEALTH ORGANIZATION (1996) Multiaxial Classification of Child and Adolescent Psychiatric Disorders: the ICD–10 Classification of Mentaland Behavioural Disorders in Children and Adolescents. Cambridge: Cambridge University Press.
YATES, P., GARRALDA, M. E. & HIGGINSON, I. (1999)
Paddington Complexity Scale and Health of the Nation Outcome Scales for
Children and Adolescents (HoNOSCA). British Journal of
Psychiatry, 174, 417
-423.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
