Soc Psychiat Epidemiol
DOI 10.1007/s00127-009-0022-8
ORIGINAL PAPER
A Spanish version of the Family Assessment Device
Sergio Barroilhet Æ Adrián Cano-Prous Æ
Salvador Cervera-Enguix Æ Maria João Forjaz Æ
Francisco Guillén-Grima
Received: 30 January 2007 / Accepted: 20 February 2009
Ó Springer-Verlag 2009
Abstract
Introduction This paper presents the results of a study on
the psychometric properties of an authorized Spanish ver-
sion of the McMaster Family Assessment Device, a self-
report measure of family functioning.
Materials and Methods The study sample comprised 60
psychiatric patients and their family member and 60 con-
trols, without mental health problems, and their family
member.
Results Compared to other studies, all subscales dis-
played adequate temporal stability and acceptable
reliability. While the instrument discriminated well
between the two groups of families on all subscales, the
results nevertheless indicated limitations in the inter-item
discriminant capacity of the ‘‘Roles’’ subscale. Factor-
analysis resulted in a three-factor model that does not
coincide with the established structure of this instrument.
Conclusion Proposals to improve and adapt questionnaire
are discussed with a view to make it applicable to cultures
S. Barroilhet (&)
Escuela de Psicologı́a, Universidad de los Andes,
Av. San Carlos de Apoquindo 2200, Santiago, Chile
e-mail: sbarroilhet@uandes.cl
A. Cano-Prous
S. Cervera-Enguix
Departamento de Psiquiatrı́a y Psicologı́a Médica,
Clı́nica Universidad de Navarra, Av. Pio XII, 36, 31008
Pamplona, Spain
M. J. Forjaz
Escuela Nacional de Sanidad, Centro de Salud Carlos III,
Madrid, Spain
F. Guillén-Grima
Unidad de Medicina Preventiva, Clı́nica Universidad de
Navarra, Av. Pio XII, 36, 31008 Pamplona, Spain
other than the one it was developed. Theoretical models
relating to psychosocial aspects such as family functioning,
albeit compatible in some areas, should be viewed with
caution in cultures different to that in which the model
originates.
Keywords Family functioning
Family measures

Psychometric properties
Introduction
The study of the influence of psychosocial variables on
diseases, both medical and psychiatric, has grown impor-
tance in recent years. Among these variables, family
dynamics assumes prominence as a factor of great interest
[41]. Simple instruments to assess families with problems
can be very useful in clinical psychiatric activity and other
medical specialties [40], since family functioning has been
related to the course and prognosis of many psychiatric and
medical illnesses [2, 8, 20, 35, 39, 43, 46, 50, 72].
The development of family functioning scales has
sought to cover this area of interest. These instruments
have had to be adapted for application in different cultures,
which in Spain has given rise to validated Spanish versions
of instruments such as the Family Apgar [9, 95] or FACES
III [83, 87]. However, subsequent studies have reported on
the limitations of these instruments. The former has
showed some limitations in its sensitivity with Spanish
samples [66]. The latter is based on a model under revision
which has led the authors to make substantial changes to
the instrument and recently create FACES IV [37, 84], with
no validated Spanish versions to date. Therefore, better
alternatives are needed to assess the functioning of families
in Spain.
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The Family Assessment Device (FAD) is a 60-item self-
report questionnaire, developed to assess the six dimen-
sions of the McMaster Model of Family Functioning
(MMFF). It has been translated and adapted to assess
functioning of families in Canada [13], Hungary [52], Italy
[89], Netherlands [106], Greece [26], Turkey [56], Pales-
tine [5], Israel [4], Lebanon [49], Japan [90], China [93],
and Australia [91]. Recently, Walrath et al. [105] and
Aarons et al. [1] have explored some of the psychometrical
properties of a Spanish version for US Hispanics [1, 105].
The English version of this instrument was developed by
Epstein et al. [32], and has been used to assess family
functioning in non-clinical families [48, 99] and families
with various medical [48] and psychiatric disorders [38, 48,
58], as well as psychosocial problems [57, 82, 101]. A
number of studies have used this instrument in mental
health. Family functioning in samples of patients with
depression has been compared to that of healthy controls
[51, 53, 55, 74–76, 100]. It has also been used to study
samples of patients with eating disorders [15, 23, 81, 110],
schizophrenia [27, 89], self-harm and suicidal behavior
[44, 67, 96], addictions [71, 80], bipolar disorder [28, 102],
OCD [25, 34], ADHD [29], and social phobia [61]. Simi-
larly, the FAD has been used to investigate the family
functioning of families of patients with traumatic brain
injury [42, 65, 94], cancer [30, 62, 92], HIV [77], chronic
neurologic diseases [11, 17, 19, 26, 59], diabetes [60],
asthma [10], and obesity [18], among other medical
illnesses. Particularly interesting is its use in recently
reported family cohort studies to determine the contribu-
tion of family functioning to pathogenesis of mental
disorders [97].
This questionnaire has a low correlation with social
desirability, and a moderate correlation with other self-
administered family functioning instruments, being capable
of differentiating significantly between families which have
been clinically assessed as functional and dysfunctional [54,
103]. The FAD’s cut-off points for distinguishing dys-
functional from functional families have adequate
sensitivity and specificity, and in general the reliability of
its subscales is acceptable [73]. The questionnaire has
shown appropriate temporal stability for all seven subscales
(range 0.66–0.76). Kabacoff et al. [48] have confirmed the
factor structure of the 60-item version hypothesized for the
model by comparing families of psychiatric patients, fam-
ilies of patients with medical pathology, and families of
healthy subjects [48].
This study sought to explore the validity and reliability of
an authorized Spanish version of the FAD in a psychiatric
and medical sample, targeting the questionnaire’s internal
reliability, temporal stability, and discriminant validity. For
clarity purposes, we will use the term ‘‘Spanish families’’
when referring to families from Spain, and we will use
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Soc Psychiat Epidemiol
‘‘Hispanic families’’ when speaking about Spanish-speaking
families from other cultures outside Spain.
Methods
Participants
The group of cases covered by the study comprised 60
families of psychiatric patients diagnosed with dysthymic
disorder (pure dysthymia or dysthymia plus a major
depressive episode), as defined by ICD-10 (F 34.1) [109]
and consulting at the outpatient psychiatric clinic at a
University Hospital in Pamplona (Spain), and a cohabi-
tating adult relative. The control group included 60
families of medical patients, made up of subjects who
consulted a physician due to an acute medical condition,
plus their respective relative. The groups were classified
according to sociodemographic variables by the Hollings-
head scale [45], and controls were matched with the
psychiatric patients for the following variables: sex, age,
marital status, and family role (father, mother, son, etc.).
Subjects with clinical diagnosis of other major psychiatric
disorders (other than major depression) and personality
disorders were excluded. The General Health Question-
naire (GHQ-28) was used to detect subjects with
psychopathology among the control group and among the
relatives of psychiatric patients. When probable cases were
detected (GHQ-28 [ 5 pts), subjects were additionally
evaluated with the Spanish version [64] of the AMDP
system [7] and excluded when psychiatric symptoms were
found. Those with equal or less than 5 pts in the GHQ-28
were not explored further and were included in the study.
A further sample of 26 healthy subjects was individually
included for the test–retest reliability analysis. These sub-
jects were recruited from hospital employees who were
currently living with at least one family member. The heal-
thy status of this latter sample was determined clinically by a
general practitioner in a short, semi-structured interview that
asked about any history of psychiatric or serious medical
illness in the past; any history of physical or emotional
problems in the last month, and about the existence of
current treatment for medical or mental health problems.
Procedure
Stage I: Adaptation
The translation of the original English-language version
was done in accordance with standard protocols used for
intercultural adaptation of psychology questionnaires [12,
33, 107]. The translation and adaptation process consisted
of forward translation from English into Spanish by two
Soc Psychiat Epidemiol
independent translators, reconciliation of forward transla-
tion, and then back translation into English by a bilingual
expert. Translators converged into one translated version,
based on resolution of discrepancies between translators in
Spain and FAD’s authors at the Family Research Program
of Brown Medical School. The pilot test of the final version
was conducted on a sample of 64 psychiatric patients and
their relatives. These 64 families attended a family therapy
clinic and were an independent sample that completed the
first Spanish version, after the translation and adaptation
process. They also completed a form in which they were
asked if they understood the items in the questionnaire and
if they found any problems or had any suggestions. These
patients did not participate further in the study. After this
pilot test, some minor changes were discussed with the
FAD’s authors, and then they were incorporated to the final
version. These changes involved phrase sequencing and
conflicts between textual translation and meaning
translation.
The questionnaire was administered at the end of each
evaluation and was individually completed by each family
member.
Stage II: Validation
Participants were recruited during a 12-month period. In all
cases, participants completed the questionnaire in the
presence of a member of the research team. Queries and
doubts were dealt with, as required. In addition, the
researcher completed a form with sociodemographic and
clinical data.
Instruments
The FAD is made up of seven subscales designed to
measure the MMFF’s six dimensions of family function-
ing, namely: ‘‘Problem Solving’’ (PS), which reflects the
family’s skill in solving its problems and the steps taken to
achieve this; ‘‘Communication’’ (CM), which refers to the
effectiveness, scope, clarity, and direction of the informa-
tion exchanged; ‘‘Roles’’ (RL), which assesses the extent to
which families have established patterns of behavior for
handling family tasks; ‘‘Affective Responsiveness’’ (AR),
which assesses family members’ skill in responding with
the appropriate emotions; ‘‘Affective Involvement’’ (AI),
which refers to the quality of the interest, concern, and
involvement that family members show to one another; and
‘‘Behavioral Control’’ (BC), which describes the expected
standards and limits for behavior. This questionnaire also
includes a ‘‘General Functioning’’ (GF) subscale.
The FAD is designed to be completed by every family
member over the age of 12 years. The items consist of
general statements about families. The respondent has to
decide how well statement represents his own family, using
one of four alternatives offered, i.e., strongly agree, agree,
disagree, or strongly disagree. These alternatives are scored
from 1 to 4, such that the lower the score, the better the
family functioning. To arrive at the overall mean family
score, the individual values obtained by each family
member in each subscale are averaged [48].
The GHQ-28 is a 28-item self-report questionnaire
designed as a screening device. A two-stage process was
undertaken in which results on the GHQ-28 determined if
formal psychiatric interview to establish a psychiatric
diagnosis was needed. Consequently, it was used as a
measure of ‘‘psychiatric caseness’’ [6]. It assesses four
dimensions of psychiatric symptoms: somatic symptoms,
anxiety/insomnia, social dysfunction, and depression. The
reliability (Cronbach’s Alpha) of the GHQ-28 paper-and-
pencil Spanish version is 0.90 [104], and the threshold
score of 5/6 suggests a probable psychiatric case with a
sensibility of 82% and specificity of 84% [63]. As well, this
questionnaire showed a good internal consistency among
the control group and among the relatives of psychiatric
patients in our sample (Cronbach’s Alpha = 0.86).
Data analysis
To assess the internal consistency of the scale, we mea-
sured the reliability of each of the FAD subscales using the
Cronbach’s alpha reliability coefficient [22]. Its temporal
stability was evaluated by the reliability test–retest coeffi-
cient. For both analyses, we replicated the methodology of
the FAD authors [73] by considering 1 week between the
test and its repetition.
To explore inter-item discriminant validity, we com-
pared the two groups of observations classified by their
extreme scores on the total scale, usually the highest and
lowest quartiles. Items that failed to display significant
differences between the two extreme groups were deemed
unsatisfactory. This means that, for these items, families
that scored high and those that scored low on the particular
subscale tend to answer in the same manner [68].
To clarify the FAD’s factor structure, we conducted a
factor analysis considering all psychiatric and medical
subjects, as well as their relatives. For analytical purposes,
previous psychometric studies on the FAD were taken as
reference [32, 48, 89]. In view of the FAD’s method of
construction [32, 48] and its dimensional structure [48, 89],
construct validity was studied according to the alpha
method [69] with Promax (non-orthogonal) rotation, in
order to find the simplest underlying factor structure,
assuming that the items, rather than being independent
from one another, were instead interrelated. This analysis
was performed considering the complete sample of sub-
jects. Inline with other authors, the 12 items of the GF
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 Soc Psychiat Epidemiol

subscale were excluded from the analysis [89], seeing as
this is a dimension developed to be correlated with the
other subscales and assumed to be multifactorial [32, 48].
The descriptive analysis consisted of a frequency anal-
ysis for qualitative variables (sex, residence, marital status,
educational level, occupation, SES), and means and stan-
dard deviation for quantitative variables (age, FAD total
scale and subscale scores). In the bivariate analysis, we
included comparisons between patients with dysthymia and
medical controls, and between their respective relatives.
Chi-square or Fisher’s exact test were used to compare
nominal (sex, marital status) or ordinal categorical (edu-
cational level, occupation, SES) variables. For comparison
of means between two groups, we used the t-test in cases
where the distribution was normal, and non-parametric
tests with non-normal distributions. Correlations with their
statistical significance were estimated using Pearson’s
correlation coefficient, or Spearman’s rho coefficient in the
case of non-normal univariate distributions.
Results
The characteristics of the sample are presented in Table 1.
In general, no significant differences were observed
between groups, except for the fact that relatives of cases

Table 1 Demographic and social characteristics of each group of subjects

Psychiatric Medical P Relatives of Relatives of P
sample sample psychiatric sample medical sample
(n = 60) (%) (n = 60) (%) (n = 60) (%) (n = 60) (%)

Sex 0.847
Male 23.3 23.3 66.7 65.0
Female 76.7 76.7 33.3 35.0
Age in years 0.854 0.025
Mean (SD) 52.0 (11.2) 51.2 (12.1) 52.6 (15.3) 45.5 (17.1)
Range 22–70 19–72 20–83 15–78
Residence 0.540
Urban 70.0 75.0
Rural 30.0 25.0
Marital Status 0.390 0.1491
Married 81.7 88.3 80.0 70.0
Single 13.3 8.3 15.0 28.3
Widowed 1.7 3.3 1.7 1.7
Cohabiting 3.3 0 3.3 0
Educational level 0.141 0.195
Grade school (incomplete) 20.0 11.7 10.0 6.7
Grade school (complete) 31.7 26.7 38.3 23.3
Junior high 30.0 50.0 41.7 51.7
Higher education 18.3 11.7 10.0 18.3
Occupation 0.266 0.035
Unemployed 13.3 5.0 23.3 10.0
Housewife 38.3 30.0 11.7 11.7
Student 3.3 3.3 1.7 16.7
Employee 36.7 46.7 40.0 41.7
Businessman 3.3 11.7 16.7 10.0
Professional 5.0 3.3 6.7 10.0
SESa 0.811
SES 1: low 5.0 8.3
SES 2: middle-low 18.3 13.3
SES 3: middle 26.7 21.7
SES 4: middle-high 25.0 30.0
SES 5: high 25.0 26.7
a
Hollingshead Scale, SES socioeconomic status

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Soc Psychiat Epidemiol
were on average 7 years older than relatives of controls;
and more students and fewer unemployed members were to
be found among the latter. According to CIE-10 criteria,
51% of the patients with dysthymia also had a superim-
posed major depressive episode.
Table 2 lists each individual item in Spanish, broken
down by subscale. At the end of the recruitment phase, 240
valid questionnaires were obtained, corresponding to two
members (patient/control and one relative) from each of the
120 families (60 for the psychiatric group, and 60 for the
control group). Table 3 compares the resulting Cronbach’s
alphas with those reported by other studies [1, 32, 48, 89,
93]. In the total sample, internal consistency for the 60
scale items was high (Cronbach’s alpha = 0.94), which
suggests that, in general, all items contributed to measuring
this common construct of family functioning. However,
elimination of items 5, 10, 24 and 54 led to an appreciable
improvement in the coefficient alpha for their respective
subscales.
The temporal stability of all subscales proved adequate,
though special mention should be made for the high cor-
relation between test–retest means in CM and GF
(Table 4). A high correlation was observed among sub-
scales with a range between 0.45 (between AI and AR) and
0.81 (between CM and GF).
Perceptions of family functioning may vary among
different members of a given family; thus we analyzed the
correlation between patients/controls and their respective
relatives finding a low but positive correlation for every
FAD subscale. Correlations ranged from 0.21 for PS
(P = 0.019) to 0.45 for CM (P \ 0.001). When analyzed
separately, patients with dysthymia and their respective
relatives also showed a positive correlation for PS, CM,
AR, AI, and GF subscales, ranging from 0.26 for PS
(P = 0.047) to 0.50 for AR (P \ 0.001). However, RL and
BC subscales showed no correlation between patients and
their own relatives (r = 0.25, P = 0.057; and r = 0.13,
P = 0.312, respectively).
Regarding the inter-item discriminant validity analysis,
comparison of items between extreme groups of patients
and controls, and between extreme groups of relatives of
patients and controls, failed to yield non-discriminant items
in either group with respect to the final scores, with the
exception of item 10 (P = 0.072). Nevertheless, when the
final score for each subscale between subjects (patients or
controls) and relatives was averaged, thereby obtaining the
family mean functioning score for this subscale, and the
items in the highest and lowest quartiles compared, items 5,
24, 4, 10, 40, and 45 did prove non-discriminant
(P [ 0.10), with the last four belonging to the RL subscale.
Significant differences were observed between the families
of psychiatric patients and control families in the final
scores of all FAD scales (Table 5). The conclusion to be
drawn from this comparison is that families of psychiatric
patients are more dysfunctional than are control families in
all dimensions of family functioning. When the theoretical
cut-off point [73] for classifying families as functional or
dysfunctional in the different dimensions was taken into
account, the number of dysfunctional dimensions explained
68.5% of the variability of the General Functioning scale
score (P \ 0.001) in the linear regression.
The factor analysis yielded three factors around which
all the items were grouped, and which proved capable of
accounting for 31.3% of the variance. The factor configu-
ration matrix is shown in Table 6. Factor 1 accounted for
23.31% of the variance and included items 49, 50, 9, 22,
28, 3, 57, 19, 38, and 2. This factor (ten items) could be
named ‘‘Emotional response’’, and included items that refer
to: problem solving from the emotional point of view
(mainly items 50 and 38); emotional communication of
both positive (items 28 and 49) and negative emotions
(items 3 and 57); and the degree of difficulty in expressing
such emotions (items 22, 9, and 19). Factor 2 accounted for
4.30% of the variance and included items 55, 20, 48, 29,
60, 7, 59, 30, and 58. This factor (nine items) could be
named ‘‘Problem Solving’’, and included items that refer
to: the solution of specific problems identified (item 7, 20,
55, and 58); problem-solving strategy (item 60); the type of
communication required for this purpose (items 29 and 59);
and expected behaviors (items 30 and 48). Factor 3
accounted for 3.69% of the variance and included items 8,
45, 37, 42, 33, 35, 34, 25, 13, 14, 39, and 47. This factor
(12 items) could be named ‘‘Emotional involvement’’, and
included items that refer to major emotional involvement
with others insofar as this serves the personal interests of
individuals (items 13, 25, 33, 37, and 42), as well as other
items that refer to aspects that influence such involvement
(items 14, 35, and 39). The remaining items (8, 34, 45 and
47) seem conceptually different, yet if a conceptual asso-
ciation were to be forced upon the factor, items 45 and 47
could then be seen as the effects of the degree of emotional
involvement (since they are influenced by ‘‘how much the
others matter to me’’), and items 8 and 34 could be linked
to emotional manifestation of an underlying personal
problem that might be projected into the family setting and
be connected with the concept of egocentrism.
Discussion
The cultural context within which the family is embedded
helps to determine family values and expected behavior
[70]. Functional requirements of social life are not uniform
across cultural settings [47]. Hence, family functioning
patterns seem to be diverse in different cultures, and may
be based on the functionality of different dimensions [31,
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Table 2 Spanish version items and corresponding FAD subscales

Item Subscale

1. Es difı́cil planear actividades en la familia porque no nos entendemos bien GF

2. Resolvemos casi todos los problemas cotidianos del hogar PS
3. Cuando alguien está molesto, los demás saben por qué CM
4. Cuando se le pide a uno que haga algo, es necesario comprobar que lo haya hecho RL
5. Si alguien tiene problemas, los demás se involucran demasiado AI
6. En tiempos de crisis podemos contar con el apoyo de los demás GF
7. No sabemos qué hacer cuando surge una emergencia BC
8. A veces se nos acaban las cosas que necesitamos RL
9. Somos reacios a demostrar el afecto que sentimos los unos por los otros AR
10. Nos aseguramos de que los miembros de la familia cumplen con sus responsabilidades familiares RL
11. No podemos hablar entre nosotros de la tristeza que sentimos GF
12. Normalmente actuamos según las decisiones que hemos tomado respecto a los problemas que surgen PS
13. Los demás se interesan por ti solamente cuando es importante para ellos AI
14. No se puede saber cómo se siente una persona según lo que dice CM
15. Las tareas de la familia no están lo suficientemente repartidas RL
16. Cada uno es aceptado por lo que es GF
17. Es fácil no hacer lo que se debe y salir impune BC
18. La gente dice las cosas abiertamente, sin rodeos CM
19. Algunos de nosotros no somos muy emotivos en nuestras respuestas AR
20. Sabemos lo que hay que hacer en caso de una emergencia BC
21. Evitamos hablar de nuestros temores y preocupaciones GF
22. Nos es difı́cil hablar entre nosotros de sentimientos de afecto CM
23. Nos cuesta trabajo realizar nuestros pagos RL
24. Después de tratar de resolver un problema, por lo general nuestra familia discute si la solución fue buena o no PS
25. Somos demasiado egocéntricos AI
26. Podemos expresar nuestros sentimientos los unos hacia los otros GF
27. No tenemos claro qué se espera en cuanto al aseo personal BC
28. No mostramos el amor que sentimos los unos por los otros AR
29. Hablamos con las personas de nuestra familia directamente, sin intermediarios CM
30. Cada uno de nosotros tiene unos deberes y responsabilidades especı́ficos RL
31. Hay muchos malos sentimientos en la familia GF
32. Sabemos qué está bien o mal en cuanto a pegar a los demás BC
33. Solamente nos interesamos por los demás cuando se trata de algo que nos interesa personalmente AI
34. Tenemos poco tiempo para dedicar a intereses personales RL
35. Muchas veces no decimos lo que queremos decir CM
36. Sentimos que somos aceptados por lo que somos GF
37. Mostramos interés por los otros cuando nos es ventajoso personalmente AI
38. Resolvemos casi todos los problemas emocionales que surgen PS
39. El afecto es secundario con relación a otras cosas en nuestra familia AR
40. Hablamos sobre quién ha de hacer las tareas de la familia RL
41. El tomar decisiones es un problema para nuestra familia GF
42. En nuestra familia los unos se interesan por los otros sólo cuando les es ventajoso AI
43. Somos francos los unos con los otros CM
44. No nos comportamos según lo establecido BC
45. Si se le pide a alguien que haga algo, hay que recordárselo RL
46. Somos capaces de decidir cómo resolver los problemas GF
47. Si no hacemos lo que debemos, no sabemos qué puede pasar BC
48. En nuestra familia cualquier cosa se permite BC

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Table 2 continued
Item Subscale

49. Expresamos afecto AR

50. Nos enfrentamos a los problemas relacionados con nuestros sentimientos PS
51. No nos llevamos bien GF
52. No nos hablamos cuando estamos enfadados CM
53. Por lo general estamos descontentos con las tareas de la casa que se nos han dado RL
54. Aunque tenemos buenas intenciones, nos entrometemos demasiado en la vida de los demás AI
55. Sabemos qué está bien o mal con respecto a las situaciones peligrosas BC
56. Nos hablamos en confianza GF
57. Lloramos abiertamente AR
58. No tenemos acceso a un medio de transporte adecuado RL
59. Cuando no nos gusta lo que alguien ha hecho, se lo decimos CM
60. Tratamos de pensar en diferentes maneras de resolver problemas PS
PS problem solving, CM communication, RL roles, AR affective responsiveness, AI affective involvement, BC behavioral control, GF general
functioning

Table 3 Comparative reliability of the Family Assessment Device

Author Sample FAD Subscales Total scale
n PS CM RL AR AI BC GF

Epstein et al. [32] Community sample 294 0.74 0.75 0.72 0.83 0.78 0.72 0.92
Kabacoff et al. [48] Non-clinical sample 627 0.74 0.70 0.57 0.73 0.76 0.70 0.83
Psychiatric sample 1,138 0.80 0.70 0.69 0.73 0.78 0.73 0.84
Medical sample 298 0.80 0.76 0.69 0.75 0.70 0.71 0.86
Wenniger et al. [106] Community sample 233 0.73 0.79 0.66 0.81 0.70 0.70 0.89
Roncone et al. [89] Non-clinical sample 110 0.77 0.72 0.56 0.72 0.59 0.53 0.79
Psychiatric sample 80 0.78 0.45 0.52 0.52 0.60 0.35 0.77
Medical sample 71 0.71 0.46 0.33 0.54 0.39 0.20 0.69
Total sample 261 0.76 0.56 0.49 0.6 0.55 0.36 0.76 0.88
Shek [93] Clinical mixed sample 281 0.73 0.65 0.64 0.67 0.52 0.52 0.93
Non-clinical sample 451 0.70 0.62 0.57 0.56 0.60 0.56 0.92
Total sample 732 0.72 0.64 0.61 0.61 0.57 0.55 0.92
Walrath et al. [105] Hispanic psychiatric sample 0.76
Aarons et al. [1] Hispanic psychiatric sample 323 0.72 0.68 0.59 0.68 0.67 0.75 0.82 0.93
Caucasian psychiatric sample 1,302 0.74 0.74 0.73 0.77 0.76 0.75 0.87 0.94
Present study Psychiatric sample 60 0.63a 0.67 0.68b 0.75 0.82c 0.64 0.84 0.93d
a b c
Medical sample 60 0.69 0.76 0.51 0.75 0.80 0.78 0.85 0.93d
a b c
Total sample 120 0.69 0.75 0.65 0.78 0.82 0.73 0.86 0.94d
PS problem solving, CM communication, RL roles, AR affective responsiveness, AI affective involvement, BC behavioral control, GF general
functioning
a
Item 24 excluded, as it reduced Cronbach’s alpha to 0.58 (total sample)
b
Item 10 excluded, as it reduced Cronbach’s alpha to 0.62 (total sample)
c
Items 5 and 54 excluded, as they reduced Cronbach’s alpha to 0.70 (total sample)
d
No items excluded

78]. Multidimensional approaches are the most helpful to functioning. Among multidimensional measures of family
evaluate families in different cultures since they consider functioning, the FAD has special sociocultural properties
several perspectives to analyze family dynamics, allowing that make it suitable for transcultural research in psycho-
a greater capacity to capture a wider spectrum of social domains. This is especially relevant for research in

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Table 4 Means, standard deviations, and test-retest correlation In general, the lower the participants’ educational level
coefficients of the Family Assessment Device (FAD): results from 26 and the higher their age, the greater the difficulty
non-clinical subjects
encountered when answering the FAD. The main difficul-
FAD Subscales Test Retest Correlation r ties were problems comprehending some concepts and
Mean SD Mean SD terms (e.g., ‘‘egocentric’’), problems in answering items
worded in the negative (e.g., ‘‘not showing our love for one
Problem solving 1.71 0.35 1.71 0.33 0.85* another’’), or problems in complying with the instructions
Communication 1.68 0.41 1.67 0.36 0.91* (e.g., some argue that answer choices had to be wrong
Roles 1.79 0.37 1.83 0.31 0.86* because in their family they ‘‘always or almost always
Affective responsiveness 1.82 0.49 1.79 0.44 0.86* agree with each other’’). Consequently, although partici-
Affective involvement 1.49 0.32 1.50 0.33 0.77* pants were instructed that the FAD ‘‘can be filled out by all
Behavioral control 1.61 0.38 1.55 0.32 0.83* family members over the age of twelve’’ with no upper age
General functioning 1.43 0.33 1.41 0.35 0.91* limit, the relatively high mean age of our sample could be a
* P \ 0.001 limitation for achieving better psychometric results.
With respect to reliability, some items displayed limi-
Hispanic cultures, considering that the FAD has two spe- tations when it came to measuring family functioning,
cific subscales that evaluate emotional dynamics. In fact, in proved inaccurate, or were highly susceptible to being
Hispanic families emotional dynamics within the family influenced by other factors, and were therefore excluded to
seem to be more weighted and valued by family members optimize the reliability of certain subscales. Two of these
as keys of family functioning, compared to other cultures items (5 and 54) referred to the same phenomenon, namely,
[31, 85]. ‘‘if someone has problems, the others tend to become
We conducted an analysis of the psychometric charac- overinvolved’’, and ‘‘although we have good intentions, we
teristics of a Spanish version of the FAD. The popularity of interfere too much in the lives of the others’’. Low reli-
this questionnaire as a family functioning assessment ability of these items could be due to the fact that in many
instrument is confirmed by the large number of associated Spanish families, affective relationships tend to be close, so
studies in English-speaking countries, but its validity has that involving oneself closely with other family members
still to be verified in other cultures. While the results of our may well be regarded by some as normal and, in certain
study are hopeful, we nonetheless feel that this Spanish circumstances, as even desirable. This aspect may be
version of the FAD can still be improved upon. Even so, shared with other Hispanic communities outside Spain.
consideration should be given to the limitations of our According to McGoldrick et al. [70], Hispanic groups
study which reside in a small sample size, the lack of ‘‘share a deep sense of family commitment, obligation and
convergent validation and confirmatory factor analysis; and responsibility. Family ties are strong and relationships are
in that no formal interview criteria were used to confirm the intense. Keeping the family together is emphasized to the
psychiatric diagnosis. point that dependence on and sacrifice for the group is
We considered it acceptable to include families of often encouraged’’ [31, pp. 554]. With respect to item 10,
patients with acute medical pathology as ‘‘non-clinical ‘‘we ensure that family members fulfill their family
families’’ after ruling out the presence of psychopathology. responsibilities’’, the answer is imprecise because super-
This takes into account the results obtained in Kabacoff vision of compliance with responsibilities can be
et al.’s study [48], in which no significant differences were influenced by other factors, such as the stage of the family
observed between such ‘‘medical’’ families and ‘‘non- life cycle: in families with young children, supervision is to
clinical’’ families without medical pathology [48]. be expected, whereas in later stages a lack of supervision

Table 5 Discriminant validity

FAD subscales Psychiatric sample Non-clinical sample Z
of the Family Assessment
Device Mean SD Mean SD

Problem solving 2.09 0.28 1.87 0.23 -4.49*

Communication 2.16 0.32 1.84 0.30 -5.02*
Roles 2.24 0.28 2.04 0.22 -3.853*
Affective responsiveness 2.26 0.47 1.84 0.34 -5.012*
Affective involvement 2.03 0.37 1.78 0.25 -4.167*
Behavioral control 1.94 0.27 1.65 0.29 -4.972*
General functioning 1.97 0.37 1.63 0.29 -4.915*
* P \ 0.001

123
Soc Psychiat Epidemiol

Table 6 Factor loadings for FAD obtained using exploratory factor analysis with alpha method of extraction and Promax rotation
Items FAD Factor
scale
Emotional Problem Emotional
response solving implication

49 Expressing tenderness AR 0.76

50 Confronting problems involving feelings PS 0.65
9 Reluctant to show affection AR 0.64
22 Difficulties talking about tender feelings CM 0.58
28 Not showing our love for each other AR 0.57
3 Knowing why someone is upset CM 0.55
57 Crying openly AR 0.45
19 Some of us don’t respond emotionally AR 0.44
38 Resolving most emotional upsets PS 0.44
2 Resolving most everyday problems PS 0.41
55 Rules about dangerous situations BC 0.59
20 Knowledge of what to do in an emergency BC 0.58
48 Anything goes in our family BC 0.57
29 Talking directly to people in our family CM 0.54
60 Thinking of different ways to solve problems PS 0.54
7 Not knowing what to do in an emergency BC 0.50
59 Telling when we don’t like what someone has done CM 0.48
30 Each of us has particular duties and responsibilities RL 0.45
58 Not having reasonable means of transport RL 0.43
8 Sometimes running out of things that we need RL 0.59
45 If people are asked to do something, they need reminding RL 0.56
37 Showing interest in each other when getting something out of it AI 0.50
personally
42 Family showing interest in each other only when they can get AI 0.50
something out of it
33 Getting involved with each other only when we can get something AI 0.45
out of it personally
35 Often don’t saying what we mean CM 0.45
34 Little time to explore personal interests RL 0.44
25 Being too self-centered AI 0.44
13 Paying interest to others when something is important to them AI 0.42
14 Can’t tell how a person is feeling from what they are saying CM 0.41
39 Tenderness takes second place to other things in our family AR 0.40
47 If the rules are broken, we don’t know what to expect BC 0.40
PS problem solving, CM communication, RL roles, AR affective responsiveness, AI affective involvement, BC behavioral control, GF general
functioning

might be desirable. This item could also be influenced by
asymmetry in the distribution of tasks and chores in many
Spanish families, since responsibilities mainly lie with
parents, and the mother in particular. In such a case, the
functional solution would be for neither spouse to have any
need to ensure that the other met his/her responsibilities.
With respect to item 24, ‘‘after solving a problem, our
family generally discusses whether or not the solution was
a good one’’, its inconsistency with its subscale could be
explained by a flaw in translation connected with the
double meaning of the Spanish word for ‘‘discuss’’, i.e.,
‘‘discutir’’, which can mean ‘‘to talk about’’ and ‘‘to
argue’’.
Once these items had been eliminated, the reliability of
the subscales proved adequate compared to other studies
[32, 48, 89]. The AR and AI reliability was even better than
most of the previous studies, and GF showed a slightly
lower reliability than the original study. The PS subscale,
however, registered a comparatively lower reliability. One
possible explanation for this may be that the latent construct
did not work well for families from Spain compared to
Anglo-American families, as other authors have suggested

123

[1, 105]. For Spanish families, the PS scale may have a
multidimensional structure. This is evidenced in the facto-
rial analysis results with PS items loading on different
factors. However, these considerations are only hypotheses,
and will have to be tested in future studies with larger and
more representative samples.
Two other studies, Walrath et al. [105] and Aarons et al.
[1], had explored psychometric properties of Spanish ver-
sions of the FAD in Hispanic families [1, 105]. Both
studied Hispanic families who participated in the evalua-
tion process of the Comprehensive Community Mental
Health Services for Children and Their Families program
[CMHS]) in the US [16]. Compared to Aarons et al. [1]
results, and considering only our psychiatric sub-sample,
we obtained a lower internal consistency for PS and BC
subscales and higher for all the other subscales. Also, we
found a higher internal consistency for the GF subscale
compared to Walrath et al. [105] results. These differences
could be explained by the dissimilar characteristics of the
samples. In fact, Walrath et al. [105] and Aarons et al. [1]
considered families in an earlier stage of the vital family
cycle, and in which the index patient was an adolescent
child (approximately 13 years of age on average), while the
present study considered older families where most of the
index subjects were older adults (approximately 50 years
of age on average). As said earlier for BC, it seems inter-
esting to reflect on the hypothesis that some dimensions of
the MMFF could be ‘‘age sensitive’’.
Nevertheless, there are also some limitations in Aarons
et al. [1] and Walrath et al. [105] that have to be consid-
ered. First, both studies examined a sample of Hispanic
families living in the US. While living in a non-Hispanic
country, these Hispanic families may have been on dif-
ferent stages of an acculturation process. None of these
studies controlled for this variable. Second, as Aarons et al.
[1] specify in their discussion that because of sample size
considerations, they did not break down the Hispanic
American group into Spanish speaking (24.5%) versus
English speaking (75.2%). These groups completed a
Spanish version and an English version, respectively. They
allude to Connelly et al. [21] warning that combining
results across language groups may obscure important
differences [21]. In turn, Walrath et al. [105] considered
participants who completed the Spanish-translated FAD,
but only report results for GF subscale. Conversely, the
present study is the first done with the 60-item Spanish
version of the FAD, in Spanish speaking Hispanics families
living in a Spanish speaking country.
A high level of test–retest correlation was registered by
all subscales except AI, which showed moderate correla-
tion. This demonstrates the instrument’s adequate temporal
stability. However, it has to be taken into account that, as in
the studies by Miller et al. [73] and Roncone et al. [89], the
123
Soc Psychiat Epidemiol
sample of subjects considered for this measurement was
different than the study sample. This sample was composed
of healthy hospital employees because patients that atten-
ded our hospital came from all over Spain, and it was
difficult to make them participate in a two-time measure
with 1 week of difference. Consequently, the results are
not necessarily comparable and have to be considered
independently.
To determine family functioning score, we averaged
individual scores following the conventional procedure to
reach a family score as done by FAD authors [38, 48, 74,
75]. When analyzed independently, the scores of index
subjects (patients and controls) and their respective rela-
tives for each FAD subscale showed a positive correlation,
although low for PS and RL, and moderately low for AI
and BC subscales. Nevertheless, perceptions of family
functioning may vary among different members of a given
family [32]. For PS and RL, another possible explanation
could be their comparatively lower reliability in our study.
Although moderate, psychiatric patients and their relatives
did show a positive correlation for their subscales scores,
except for RL and BC subscales. Besides the low reliability
explanation, some authors have suggested that differences
in perception of family functioning in psychiatric patients
could reflect patient psychopathology [58] or interpersonal
intra-familiar factors [24]. The possibility that the psychi-
atric illness (in this case the current dysthymic disorder
and/or the superimposed major depressive episode), could
affect FAD subscales scores correlations between patients
and their relatives, has to be considered. In fact, Koyama
et al. [58] found that the perceptions of family functioning
were not significantly correlated between patients with
schizophrenia and their family members [58]. However, in
the same study patients with affective disorders showed a
positive correlation between family members for all sub-
scales, and previously Miller et al. [75] reported high
correlations between patients with depression and their
families [75]. With respect to interpersonal intra-familiar
factors, and specifically for the BC dimension, some
authors have found evidence suggesting that behavioral
control could be a more subjective experience [108], and
consequently some divergence between family members
could be expected.
Although the results using family members’ average
subscale scores are not necessarily considered representa-
tive of the overall family functioning (especially in absence
of clinical rating scales or other clinical family assessment
methods), all FAD subscales managed to discriminate
between families of psychiatric patients and families of
medical patients. Even though we were unable to obtain
cut-off points due to the absence of a family functioning
gold standard, in the clinical families group five subscales
registered a mean score of over 2. The FAD creators affirm
Soc Psychiat Epidemiol
that, since the categories of the answers to each item range
from 1 to 4, a subscale mean of less than 2.0 indicates that
a greater number of items have been directed in a func-
tional direction, just as a value of more than 2.0 suggests
difficulties in this area of functioning. Therefore, from a
theoretical point of view, 2.0 would be the ideal cut-off
point for each subscale [73]. Although the original authors,
employing other clinical measures (clinical interviews and
other questionnaires) in the clinical validation of the FAD,
found cut-off points other than 2.0 which afforded greater
sensitivity and specificity for each subscale [32], a family
cannot be classified as qualitatively dysfunctional in this
dimension with a value lower than 2.0: it can only be
classified as relatively more dysfunctional from a quanti-
tative standpoint. This is an aspect not previously covered
in the literature addressing this instrument.
In the inter-item discriminant validity analysis, items 4,
40, and 45 displayed a low discriminant power between
low scoring and high scoring families, in terms of family
functioning averages for this subscale. These items were
not discarded because views on aspects of family func-
tioning may vary among different members of a given
family. Even so, such items would have to be considered as
to interpret the results of the RL subscale to which they
belong. Lastly, items 5, 10, and 24 also proved non-dis-
criminant, though these had already been questioned in the
reliability analysis.
For the purposes of the factor analysis we did not con-
sider separately the psychiatric and non-psychiatric
samples nor patients and family members’ samples because
of the small sample size. For the extraction of factors, the
alpha method was used. This method of factor analysis was
designed for situations where it is more appropriate to think
of objects as being randomly sampled from a population of
items. According to McDermeit et al. [69], ‘‘when the
objects being factored are items from an inventory that is
assumed to have one or more scales, then the model for the
alpha method is consistent with the classical true score
model in test theory’’ (p. 1) [70].
Although the extraction and rotation method chosen
might be assumed to be the most suitable for the analysis
from a theoretical point of view, there are no references
that these methods had been previously used by other
authors. The factor analysis resulted in a three-factor model
which did not coincide with the structure hypothesized for
the instrument. This, we knew a priori, would have been
difficult to demonstrate in view of the lack of independence
of the subscales, as was shown by the correlation analysis,
and has been pointed out by FAD’s creators [32, 48], and
endorsed by other authors studying FAD versions in dif-
ferent languages [88, 89, 93] including Spanish [1]. The
three factors initially identified accounted for a small per-
centage of the variance (31.3%), comparable with other
family assessment instruments [36], and inline with Shek
[93] findings on the Chinese FAD [93], but lower than
other FAD studies [1, 48, 89]. This could be due to the
extraction method: not only it is different to that used by
other authors, but, on not taking advantage of random
variability to increase the variance explained by the factors
and considering the factors as intercorrelated, it also fur-
nishes a more realistic result. However, the FAD subscales
were not developed by means of a factor analysis method.
The FAD is a questionnaire constructed a priori with fac-
tors purpose-designed to measure the MMFF dimensions.
Although 92% of the items in the English version loaded
on the hypothesized factors, 8% did not do so, and many
items also loaded highly on factors other than those
hypothesized.
We renamed two of the factors extracted in order to
highlight the differences in the dimensions encountered in
our Spanish versus the Anglo-American sample. In our
study, the first factor (Emotional Response) corresponds to
the heaviest and most homogeneous factor. Broadly
speaking, it coincides with the AR dimension of the
MMFF, but it also includes other implicit aspects that can
also be present in other dimensions, such as communica-
tion and emotional problem-solving skills. The second
factor (Problem solving), somewhat more heterogeneous,
assesses the family’s degree of competence when it comes
to solving problems adequately inline with the cognitive-
behavioral model (proposed by the MMFF authors) at the
respective pre-established stages, but it introduces the
aspect of ‘‘communication’’, which is deemed essential for
achievement of this goal in the interpersonal context of the
family. Lastly, the third factor includes items that address
elements of the Affective Involvement dimension of the
MMFF, and refers to emotional involvement conditional
upon individual interests as opposed to disinterested emo-
tional involvement. We agree with Roncone et al. [89] in
that this concept is more closely aligned with the concept
of egocentrism, and that this negative aspect of emotional
involvement might correspond to a new dimension [89].
Without prejudice to the above, the remaining items that
load, to an acceptable level, on this factor are distantly
connected to this concept.
Nevertheless it must also be considered, as Aarons et al.
[1] stated, that ‘‘the factor structure of the FAD varies
across cultures, possibly because cultural norms regarding
family functioning vary by racial/ethnic background’’
(p. 559).
Dealing in depth with cultural differences in family
functioning dimensions, there are some differences that
warrant mention. In the case of the RL dimension, it seems
that in many Anglo-American families, members are
expected to cooperate on an equal basis in performing
chores and sharing responsibilities [98], as suggested by
123

MMFF authors. Indeed, when defining RL dimension, they
proposed to assess ‘‘whether tasks are clearly an equitably
assigned to family members’’ [32]. Although in a cultural
transition [3], many Spanish families, however, may still
hold the traditional patriarchal model of tasks and chores
assignment, in which the mothers/wives traditionally per-
form or are responsible for most of the household chores
[14]. McGoldrick et al. [70] characterization of Hispanic
families matches with this view. These are families in
which ‘‘the woman’s main responsibilities are to care for
the home and to keep the family together, meanwhile the
husband is not expected to perform household tasks or to
help child rearing’’ [31, p. 554]. Muñoz [79] confirm this
perspective in Spain adding that ‘‘the reality is that the man
helps the woman but does not share tasks and chores at
home’’ [79, p. 143]. The low reliability of RL subscale in
Aarons et al. [1] study also supports this hypothesis.
It should be pointed out that the higher the mean age of
subjects, the greater the likelihood of this traditional view
of roles being held [86]. This should be considered when
assessing older families with RL scale. Consequently, this
subscale might be less applicable to our sample in the light
of the high mean age of psychiatric patients and paired
medical controls. In contrast, the AR and CM dimensions
did not show these limitations and appear to display a
greater congruence between the two cultures.
In addition to their comparative high reliability, the
GF, CM, and AR subscales are those whose results, in our
opinion, possess greatest clinical validity in the explora-
tion of family functioning in our sample. This assertion is
based on the higher level of correlation among family
members, and in the high loading of CM and AR items
under the factors that accounted for most of the variance
of the factorial solution. Specifically with respect to the
General Functioning subscale, we observed that it corre-
lated moderately with the remaining subscales, but that its
most outstanding feature was the fact that its score proved
proportional to the number of dysfunctional dimensions,
thus supporting the assumption that the higher the number
of dysfunctional dimensions, the higher the degree of
family dysfunction, which lies at the core of the MMFF.
This assumption has a number of implications. In the first
place, families may register difficulties in some specific
dimension but this does not automatically make them
dysfunctional. Indeed, there is the possibility that dys-
function in one dimension may be offset by excellent
functioning in another. The number of dysfunctional
dimensions, rather than the intensity of dysfunction in
some specific dimensions, can be assumed to have greater
impact on the level of General Functioning, though it is to
be expected that a more intense dysfunction in any one
dimension would raise the likelihood of others being
affected. This conceptualization highlights the importance
123
Soc Psychiat Epidemiol
of multidimensional assessment. In the second place,
multidimensional assessment adds specificity to the
diagnosis of family dysfunction, which is reflected in the
General Functioning subscale. This is desirable for an
instrument that measures psychosocial aspects which, by
definition, are not specific and whose intercultural varia-
tion is regarded as being wide. Indeed, its appropriate
psychometric properties in different studies and cultures,
and the fact that its items seem to measure aspects of the
six MMFF dimensions, have led some authors to use the
GF scale as a scale apart and even propose that it could
be used as a measure of family functioning for the
detection of family dysfunction in large-scale studies, or
in cases where the remaining subscale values are non-
significant [13, 88].
Future studies should include an assessment of concur-
rent validity with simultaneous measures as external
validators, as well as predictive validity using longitudinal
examination of family functioning in both clinical and non-
clinical samples.
Conclusions
Family functioning in both non-clinical and clinical fami-
lies has been little studied in the Spanish population due to
the lack of valid instruments for measuring it. One alter-
native to overcome this is to translate and validate
instruments which have been created in other cultures and
have proved their usefulness in the field of clinical medi-
cine and research. The FAD is a widely used and validated
instrument. One advantage of the FAD, as compared to
other instruments that measure family functioning, is that it
focuses on family functioning from a multidimensional
stance.
We presented the results on the first adaptation of the
FAD to be used in Spain. Despite being preliminary, the
results of our study highlight the difficulties entailed in
performing this task, and emphasize the fact that theoreti-
cal models relating to psychosocial aspects such as family
functioning, albeit compatible in some areas, should be
viewed with caution in cultures different to that in which
the model originates. Our study suggests that Spanish
families may assess their functioning on the basis of some,
but not all, of the dimensions proposed by the MMFF. In
Spanish families, aspects linked to the emotional dynamics
and communication may possibly be those most clearly
associated with family functioning, but this has to be
studied further. This study has identified some strengths
and limitations of the FAD which will be considered in a
future study as part of an overall attempt to obtain a version
that, culturally speaking, is better adapted to the reality of
Spanish families.
Soc Psychiat Epidemiol
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