A Parent–Child Relationship Scale Derived From the

Child and Adolescent Psychiatric Assessment (CAPA)

MARIANNE Z. WAMBOLDT, M.D., FREDERICK S. WAMBOLDT, M.D., LESLIE GAVIN, PH.D.,
AND SANDRA MCTAGGART, M.A.

ABSTRACT
Objective: To examine a measure of children’s perception of their relationships with parents. Method: The Child and
Adolescent Psychiatric Assessment (CAPA) was administered to 114 inpatients (aged 9–18 years) at a tertiary asthma
center from1991 to 1994. Ten items from the CAPA were developed as a separate scale, the Parent–Child Relationship
Scale (PCRS). Some subjects (82) were given family and child assessments. Results: The PCRS had good internal relia-
bility (Cronbach α = .72). Construct validity was demonstrated by correlations with child and parent report on the Family
Assessment Device (r = 0.46 and 0.35; p < .001) and high expressed emotion of the parent (t = 2.89; p < .01). Divergent
validity may be evidenced by the fact that the PCRS was not significantly related to high emotional over-involvement.
Predictive validity was shown by significant correlations with the total problem scores of parents’ (r = 0.28; p < .01) and chil-
dren’s (r = 0.41; p < .001) Achenbach reports, and prediction of CAPA psychiatric diagnosis (OR = 5.83; 95% CI
1.80–22.63). Conclusion: The PCRS can potentially be used to assess the child’s perspective of the parent–child relation-
ship for research or clinical purposes and deserves further study. J. Am. Acad. Child Adolesc. Psychiatry, 2001, 40(8):945–
953. Key Words: interview, parent–child relationship, expressed emotion.

As the number of children who survive chronic illness
increases, so does the number of medically ill children who
develop significant psychological sequelae from their ill-
ness (Pless and Nolan, 1991). Multiple hospitalizations,
effects on attachment, and traumatic medical procedures
have all been cited as risk factors for the development of
psychological problems (Wamboldt and Gavin, 1998).
Another salient variable in understanding the ill child’s
psychological outcome is the role of family processes in
preventing or enhancing the likelihood of psychopathol-
ogy in medically ill children (Wamboldt and Wamboldt,
2000b). How the family copes with a child’s medical ill-
ness may be most salient for how well the child copes. If
the family is able to metabolize the stress of the illness, they
Accepted February 27, 2001.
Drs. Marianne and Frederick Wamboldt are with the National Jewish
Medical and Research Center and the University of Colorado Health Sciences
Center, Denver. Dr. Gavin is with the Nemours Children’s Clinic, Orlando, FL.
Ms. McTaggart is with the Deveroux Cleo Wallace Center, Denver.
This investigation was supported by NIH grants M01-RR00051, K08-
MH01486, R03-MH48683, RO1-HL45157, and RO1-HL53391.
Reprint requests to Dr. M. Wamboldt, National Jewish Medical and Research
Center, 1400 Jackson Street, Denver, CO 80206; e-mail: wamboldtm@njc.org.
0890-8567/01/4008–0945䉷2001 by the American Academy of Child
and Adolescent Psychiatry.
may be more able to offer emotional support to the child,
thus alleviating some of the child’s potential distress.
Likewise, parents may be able to offer the disciplinary
structure needed for the child to continue in a normal tra-
jectory for psychological development without being
derailed by over-solicitous parenting. A major challenge
for families with a medically ill child is to be able to
acknowledge and deal with the negative feelings and
resentments about the illness without the negative affects
causing overt conflict with, or distancing from, the patient.
Of course, conflict, criticism, and withdrawal may exist
between parent and child for many reasons other than sup-
pressed emotions surrounding a medical illness. In the case
of preexisting parent–child difficulties, the stress of
chronic illness may exacerbate the underlying conflicts.
There are several threads of empirical evidence that
demonstrate the parent–child conflict as being associated
with the outcome of medical illnesses in children. In an
asthma study, Strunk et al. (1985) found that conflict
between the children and their parents, as rated through
chart notes, was a significant risk factor for death. Hauser
et al. (1990) have shown that an adolescent’s rating of
family conflict at the time of diabetes diagnosis is posi-
tively correlated with noncompliance 1 and 4 years later. In

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WAMBOLDT ET AL.
addition, adolescent paper/pencil reports of family func-
tioning are related to adolescents’ adherence to medical
treatments (Bender et al., 1998). These self-report family
measures do not differentiate between overall family func-
tioning and more specific parent–child relationships.
One methodology used to assess parent–patient rela-
tionship is to have the parent speak about their child in an
unstructured setting, then to systematically code the con-
tent and process of their language. Using these measures of
expressed emotion (EE), investigators found that parents
of an asthmatic child were more likely to acknowledge
having a negative relationship with their child and to
express more direct criticism of their child than were par-
ents of non-ill children (Hermanns et al., 1989; Schobinger
et al., 1992). Moreover, criticism was positively correlated
with severity of asthma. High ratings of parental criticism
are associated with treatment nonadherence and worse
outcome in adolescents with asthma (Wamboldt et al.,
1995). High EE is also correlated with nonadherence and
poorer outcome in children with diabetes (Koenigsberg
et al., 1993; Stevenson et al., 1991). Thus, both self-report
measures and observational measures indicate that an
underlying attitude of conflict or criticism in the parent–
patient relationship is associated with noncompliance and
poorer medical outcome. Although there are no studies
that directly address whether conflict is also associated with
poorer psychological outcome in medically ill children,
there have been several studies that show that high EE is
associated with more behavioral problems in non-ill chil-
dren (Asarnow et al., 1993; Vostanis et al., 1994). It is likely
that EE may also predict for poorer psychological outcome
in medically ill children.
The EE measure relies on parent input only, and
although it has been compared to other direct ratings of
parent–child interactions, it is controversial as to what
aspects of family relationships the EE measure taps
(Wamboldt et al., 2000a). It is thought that EE occurs in
response to a state of the patient and to a state of the par-
ent giving the report (Hibbs et al., 1993; Schreiber et al.,
1995). It would be helpful to understand the mechanism
whereby this marker of family trouble leads to worse out-
come. To do so, it would be helpful to have a method of
understanding children’s view of their relationship with
their parents. Unfortunately, family researchers continue
to be challenged in measuring family relationships from
the child’s perspective. The original interview used to
assess EE, the Camberwell Family Interview (CFI), is too
long and uses questions that are unsuitable for children. A
946
more recent method of assessing EE, the Five Minute
Speech Sample technique (FMSS) (Magana, 1993), re-
quires an individual to speak freely and uninterrupted for
5 minutes about the target person. Children may have dif-
ficulty with the ambiguity of this task. Indeed, one group
(Marshall et al., 1990) tried to use a 3-minute speech sam-
ple of children to rate EE toward their parent and found
that most children could not speak longer than 90 sec-
onds during the task. Another group (Hodes et al., 1999)
has attempted to assess EE by means of a “whole family
interview” that lasts approximately 1 hour. Ratings from
this interview correlated moderately with the CFI sub-
scale scores (r = 0.25–0.67). However, their technique did
not yield a rating of the child’s attitude toward the par-
ents. Thus, the current interview techniques for assessing
EE in parents do not seem applicable to children.
In an effort to find an interview measure of children’s
perception of their relationships with their parents, a subset
of questions was taken from the Child and Adolescent Psy-
chiatric Assessment (CAPA) (Angold et al., 1995b; Angold
and Rutter, 1990). The content of the scale is discussed, as
well as the relationship of the scale score with other mea-
sures of family functioning, with child emotional and
behavioral problems, and with psychiatric diagnoses.
METHOD
Subjects
The subjects, 114 inpatients at a tertiary asthma center during the
years 1991 to 1994, were part of two research projects, both approved
by the National Jewish Medical and Research Center’s Internal Review
Board. The first project was designed to assess the psychometric prop-
erties of the CAPA in a medically ill population. The second project
involved the CAPA as part of a more extensive study of family influ-
ences on asthma treatment and outcome. The mean age of subjects was
13.6 (range 9–18) years. There were 56 girls and 58 boys. A total of 66
subjects (58%) were currently living with both biological parents, 25
(22%) were living with one biological parent, and 23 (20%) were living
in two-adult households (biological parent and step or adopted parent
[14], two adoptive parents [2], a parent and live-in partner [4], or
grandparents [3]). The children came from the following ethnic back-
grounds: 76% white, 13% African American, 6% Hispanic, 2% Native
American, and 3% mixed race. Socioeconomic backgrounds included
all five Hollingshead classes (Hollingshead, 1975): I, 14%; II, 38%; III,
31%; IV, 10%; and V, 7%.
The subjects were referred to the National Jewish Medical Center for
asthma that had failed to respond to outpatient treatment, steroid side
effects, repeated ER visits or hospitalizations for asthma, and/or loss of
more than 30 days of school. Many of the children had severe asthma:
18% had a respiratory arrest, 11% had asthma-related seizures, 32% had
blacked out as a result of their asthma, and 53% were dependent on oral
steroids. As part of the procedure on the inpatient unit, all patients were
seen individually, with their families, and in group therapy by a psycho-
social team. At the end of the hospital stay, the primary clinician gave
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the child appropriate DSM-III-R diagnoses, using all available infor-
mation. The clinicians on the inpatient unit were blind to assessments
done as part of this study.
Procedure
Subjects and their parent (or parents) assented or consented to
participate. The child CAPA interviewers (trained research assistants)
were blind to all other measurements. A subset of 82 subjects and
their parents also completed questionnaires and participated in two
videotaped family tasks, including the FMSS.
Measures
Clinical Diagnoses. After all of the study information was obtained,
the clinical discharge summaries were coded for Axis I and II diag-
noses. “Any Family Relationship Diagnosis” was coded if either V61.2
(parent–child problem) or V61.8 (other specified family circum-
stances) were present.
Child and Adolescent Psychiatric Assessment. The CAPA (version 2.0)
(Angold et al., 1995b; Angold and Rutter, 1990) is an interviewer-based
diagnostic interview with versions for use with children 8 to 18 years old
and/or their parents, which has been adapted for assessments in both
clinical and epidemiological research. In this study, only children were
interviewed. A series of diagnostic algorithms written in SAS provide
diagnoses according to the DSM-III, DSM-III-R, DSM-IV and ICD-10
systems, plus a range of symptom scores that include the frequency and
symptom duration requirements mentioned in DSM-III-R (Angold
et al., 1995b). The interview has yielded good test-retest reliability for
the DSM-III-R diagnoses of major depression, dysthymia, overanxious
disorder, and substance abuse/dependence: κ values range from 0.74 to
1.0 (Angold and Costello, 1995a). The κ values for conduct disorder
and oppositional disorder are acceptable at 0.61 and 0.58, respectively.
The κ values for the posttraumatic stress disorder screen symptoms were
0.40 to 0.79, and reliability of posttraumatic stress disorder symptoms
in those who passed the screen was excellent (intraclass correlation coef-
ficient [ICC] = 0.94–0.99) (Costello et al., 1998).
In this sample, 10 CAPAs were randomly selected to test interrater
reliability. Two coders rated audiotapes of the CAPA interview. The κ
values for diagnoses ranged from 0.78 (overanxious disorder) to 1.0 (all
others). For purposes of this paper, “Any CAPA diagnosis” included
major depression, dysthymic disorder, separation anxiety, simple pho-
bia, panic disorder, generalized anxiety disorder, overanxious disorder,
agoraphobia, avoidant anxiety disorder, posttraumatic stress disorder,
oppositional defiant disorder, or conduct disorder.
Parent–Child Relationship Scale. The Parent–Child Relationship
Scale (PCRS) is based on responses given by the child to a series of ques-
tions regarding their relationships with their parents, which makes up
one of the first sections of the CAPA interview. Although the current
CAPA version is 4.2, the items included in the PCRS have not been
changed from the earlier version. This section of the interview takes 10
to 20 minutes to administer. The subject is asked to identify their pri-
mary adult caregivers as per the CAPA criteria (Angold and Costello,
2000). The primary female caregiver is labeled “parent 1” by conven-
tion. The second parental adult in the household is labeled “parent 2.”
The child is then asked to discuss various aspects of their relationship
with each parent figure, including the amount and quality of time spent
with that person, the type of discipline and supervision given by that
parent, the ability to confide in them, etc. The child is asked specific
probes by the interviewer and additional probes to elicit enough details
so that the interviewer can rate the child per the CAPA criteria (Angold
and Costello, 2000). Twelve items were initially selected on the basis of
face validity. SPSS was used to calculate Cronbach α, and two items
were observed to significantly lower the scale’s internal consistency
(Parental Over-Involvement and Parental Smoking). After deletion of
these two items, the 10 remaining items had a Cronbach α of .72.
Interrater reliability for the PCRS was excellent (ICC = 0.97). For anal-
yses in this study, a score of 1 SD above the mean, or 9, was considered
the clinical “cutoff.” The items are listed in Table 1, and scoring criteria
are shown in the Appendix.
Family Assessment Device. The Family Assessment Device (FAD)
(Epstein et al., 1983; Miller et al., 1985) is a 60-item self-report measure
of family functioning that is empirically derived from the McMaster
Model of Family Functioning. The FAD shows good reliability
(Cronbach α ranging from .71 to .92; 1-week test-retest correlations
from 0.66 to 0.76). Impressive validity has been seen in numerous
studies, including samples with chronic medical illness (Bishop et al.,
1986) and a large epidemiological study (Byles et al., 1988). Items are
rated on a 0- to 4-point scale. Scores >2 indicate families with potential
clinical psychopathology.
Five Minute Speech Sample. The FMSS is a brief measure of family
EE, specifically the dimensions of criticism and emotional over-
involvement. In this procedure, parents are asked individually to

TABLE 1
Mean Scores on the Parent–Child Relationship Scale Items
Parent 1 (n = 111) Parent 2 (n = 91)
Mean (SD) Mean (SD)

1. Positive Activities With Parents 0.31 (0.80) 0.36 (0.88)

2. Parent–Child Communication 0.97 (0.21) 1.42** (1.42)
3. Inadequate Supervision 0.43 (0.86) 0.45 (0.90)
4. Harsh Discipline 0.19 (0.61) 0.20 (0.60)
5. Selective Negative View 0.17 (0.59) 0.26 (0.73)
6. Involvement of Child in Arguments 0.50 (0.93) 0.59 (0.99)
7. Withdrawal 0.47*** (0.97) 0.19 (0.61)
8. Discord 0.42*** (0.90) 0.23 (0.67)
9. Arguments With Parent 1.15 (1.36) 1.09 (1.36)
10. Arguments With Parent Involving Physical Violence 0.07 (0.38) 0.04 (0.03)
Parent–child relationship score 4.42 (4.56) 4.68 (4.75)

Note: Probability values for t tests between groups: ** p < 0.01; *** p < 0.001.

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WAMBOLDT ET AL.
state their thoughts and feelings about their adolescent for 5 minutes.
The audiotape of these comments is transcribed, then coded accord-
ing to the most recent method of Magana-Amato (Magana, 1993).
Consistent with prior work with the EE construct, the FMSS pro-
vides categorical classification of the speaker as high or low on the
dimensions of criticism and emotional over-involvement, as well as
overall EE. The FMSS is a brief, cost-effective alternative to the
benchmark CFI that provides highly accurate, albeit slightly under-
estimated, ratings of EE (Wamboldt et al., 2000a). In the present
study, the primary coder of the FMSS was blind to all other data.
Twenty five percent of the tapes were chosen at random and recoded
by a second coder to establish reliability. Complete agreement was
found for criticism (κ = 1.0).
Child Behavior Checklist. The Child Behavior Checklist (CBCL)
(Achenbach, 1991a) provides a parent report of the adolescent’s func-
tioning across multiple domains. This widely used measure has been
well standardized and has excellent reliability (test-retest correlation =
0.93, interparent correlation = 0.76, Cronbach α = .96).
Teacher’s Report Form. The Teacher’s Report Form (TRF) (Achenbach
and Edelbrock, 1986) is a teacher-rated complement to the CBCL
that assesses psychosocial adjustment in the school setting. All chil-
dren admitted to the National Jewish Medical Center were enrolled in
a branch of the Denver Public School System on the hospital’s cam-
pus. Ratings were obtained from their teacher during the last week of
hospital stay. The TRF appears as robust as the CBCL (test-retest cor-
relation = 0.92, interteacher correlation = 0.60, Cronbach α = .97)
(Achenbach and Edelbrock, 1986).
Youth Self-Report. The Youth Self-Report (YSR) (Achenbach,
1991b) is an adolescent-rated complement to the CBCL. Psychometric
properties of the YSR are also excellent (test-retest correlation = 0.79;
Cronbach α= .95) (Achenbach, 1991b).
For analyses in this study, a clinical cutoff of 65 on the total prob-
lem score was used for the YSR, TRF, and CBCL.
Data Analysis
The mean PCRS and standard deviations for parent 1 and parent
2 were compared by means of t tests. The remaining analyses were
performed with the mean PCRS score for those subjects with two
PCRS ratings and the single PCRS score for those subjects with one
rating. Spearman correlations were performed between the PCRS
and the FAD, CBCL, YSR, and TRF. For categorical variables, t tests
were done on PCRS scores between groups. Nominal logistic regres-
sions were then performed to examine which variables predicted
presence of CAPA or clinical diagnoses. All analyses were done with
JMP-SAS on a Macintosh G3.
TABLE 2
Spearman Correlations Between PCRS and Self-Report Measures (n = 84)
Variable PCRS Parent FAD Child FAD
PCRS 1.00
ParentFAD 0.35*** 1.00
ChildFAD 0.46*** 0.52***
CBCTOT 0.28** 0.34***
TRFTOT 0.18† 0.00 –0.06
YSRTOT 0.41*** 0.20†
Note: PCRS = Parent–Child Relationship Scale; FAD = Family Assessment Device; CBCTOT = Child Behavior Checklist,
total problem score; TRFTOT = Teacher’s Report Form, total problem score; YSRTOT = Youth Self-Report, total problem score.
† p < .10; * p < .05; ** p < .01; *** p < .001.
948
RESULTS
PCRS Items
Table 1 lists the mean item scores for parent 1 and par-
ent 2. The possible range of scores on the PCRS is 0 to
30, with high scores indicating more difficulty. The dis-
tribution was skewed, with the median score being 3.0.
Sociodemographic Variables and PCRS
PCRS scores were not different across child age, child
gender, child ethnicity, parent age, parent gender, and
two- versus one-parent households. The PCRS was sig-
nificantly lower (i.e., less problematic) for biological or
adoptive mothers than for stepmothers, live-in female
partners of the father, or grandmothers (4.5 versus 16.0;
p < .0001). The father’s PCRS score was also signifi-
cantly lower if there was a biological or adoptive mother
in the home, as opposed to a stepmother, live-in female
partner, or grandparent (5.0 versus 16.0; p < .001). The
PCRS was not related to severity of the child’s asthma as
assessed by steroid dose on admission, number of
adverse asthma events, or hospitalizations.
Relationship to Self-Report Measures
As can be seen in Table 2, the PCRS correlates well
with both child and parent report of family dysfunction,
as measured by the overall FAD score. It is also moderately
correlated with the CBCL, YSR, and TRF total problem
scores.
Table 3 depicts the PCRS scores of children from
high or low EE groups. As can be seen, the PCRS scores
are significantly higher in subjects for whom the parents
were rated as being high on the critical subdimension of
the FMSS (n = 16), as well as high overall EE (n = 38),
but do not differ significantly among families rated high
or low on emotional over-involvement.
CBCTOT TRFTOT YSRTOT
1.00
0.27** 1.00
0.18† 1.00
0.41*** 0.51*** 0.24* 1.00
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TABLE 3 TABLE 4
Relationship of the Parent–Child Relationship Scale (PCRS) Prevalence of DSM-III-R Diagnoses as Reported by
and Five Minute Speech Sample (FMSS) Variables the CAPA and by Clinician
High Low CAPA Clinician
PCRS PCRS Diagnoses Diagnoses
FMSS Scale Mean (SD) n Mean (SD) n t Test (n = 114) (n = 114)
DSM-III-R Disorders n % n %
EE 6.13 (5.1) 38 3.7 (3.7) 76 2.89**
EOI 5.6 (4.2) 26 4.8 (4.5) 56 0.77 Any anxiety disorder 34 29.8 30 26.3
Criticism 7.5 (1.1) 16 4.5 (0.5) 66 2.51** Overanxious disorder 23 20.2 16 14.0
OCD 0 0 1 0.9
Note: EE = expressed emotion; EOI = emotional overinvolvement. Separation anxiety 14 12.3 6 5.3
** p < .01. Simple phobia 7 6.1 1 0.9
Agoraphobia 3 2.6 0 0
Presence of Psychiatric Disorders in the Sample Panic disorder 2 1.8 0 0
Avoidant disorder 1 0.9 2 1.7
This is a unique sample, consisting of children with PTSD 2 1.7 7 6.1
asthma referred to a tertiary care center. As such, it is likely Any depressive disorder 9 7.9 22 19.3
to have higher rates of psychiatric comorbidity than one Dysthymia 5 4.4 9 7.9
Major depression 6 5.3 13 11.4
would expect in an outpatient sample of youths with Any externalizing disorder 7 6.1 11 9.6
asthma. Table 4 shows the CAPA diagnoses given, as com- Conduct disorder 5 4.4 7 6.1
pared with the clinical diagnoses assigned on the inpatient Oppositional disorder 2 1.8 5 4.4
“Relationship” diagnoses NA NA 56 49.1
unit, which were blind to any study information. Almost No. of Axis I diagnoses
40% of subjects met DSM-III-R criteria for some Axis I 0 68 59.6 65 57.0
disorder; 20% to 25% had at least two disorders. 1 18 15.8 28 24.6
There was fairly poor agreement between the CAPA 2 13 11.4 17 14.9
≥3 15 13.1 4 3.5
and clinical diagnoses: the κ coefficients were 0.27 for any
externalizing disorder, 0.46 for any anxiety disorder, and Note: CAPA = Child and Adolescent Psychiatric Assessment;
0.49 for any depressive disorder. This poor agreement is OCD = obsessive-compulsive disorder; PTSD = posttraumatic stress
disorder; NA = not applicable.
not surprising, given that the CAPA was only administered
to the child, whereas the clinical diagnosis also took into
account the parent report and observation of the child. to screen for psychological problems, it was expected that
Nonetheless, this low agreement has been typical of other the CBCL, TRF, and YSR would be associated with hav-
studies that compared structured interviews to clinician ing a psychiatric diagnosis. Thus, all variables were tested
assessments. Welner et al. (1987) found agreement be- by means of bivariate nominal logistic regressions with
tween the Diagnostic Interview for Children and Adoles- both the CAPA diagnoses and clinical diagnoses; the
cents and the clinician’s chart diagnoses to range between results are shown in Table 5. It is surprising that the
0.18 and 0.52. Weinstein et al. (1989) also found low κ paper/pencil measures filled out by the parent (i.e., the
values between the Diagnostic Interview Schedule for
CBCL and the FAD) did not differentiate those children
Children and clinician diagnoses, ranging from 0.03 to
with a psychiatric diagnosis. The odds ratio (OR) for the
0.17. As discussed by Angold and Costello (1995a), the
CBCL was high (2.49); perhaps the fact that it did not
CAPA has stringently operationalized the DSM criteria for
frequency and intensity of symptoms and may in fact reach significance was due to power limitations. The TRF
underestimate the number of some actual diagnoses. In and YSR did differentiate the presence of a CAPA diagno-
support of this idea, the number of diagnoses by clinicians sis (OR = 4.82 and 4.34, respectively). Neither the teen
exceeded the number yielded by the CAPA for overall dis- nor parent FAD significantly differentiated those with a
orders, depressive disorders, and externalizing disorders. CAPA or clinical Axis I diagnosis, although the teen FAD
did predict for a clinical relationship diagnosis (OR =
Utility for Prediction of Child Psychiatric Diagnosis 3.59). The PCRS differentiated between those subjects
One of the questions of this study was whether any of who met criteria for any CAPA diagnosis (OR = 5.83) or
the family measures used would be predictive of psychiat- for any clinical relationship diagnosis (OR = 4.48) and
ric diagnoses. Because the Achenbach scales are often used almost met statistical significance in predicting a clinical

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TABLE 5
Odds Ratios for Predictors of Psychiatric Diagnosis
Any CAPA Diagnosis Any Axis I Clinical Diagnosis Family Relationship Diagnosis
OR 95% CI OR 95% CI OR 95% CI

CBCL 2.49 0.93–6.97 1.89 0.71–5.23 0.78 0.29–2.08

TRF 4.82 1.03–34.49 1.91 0.44–9.87 0.97 0.21–4.40
YSR 4.34 1.15–21.16 1.38 0.38–5.19 1.90 0.53–7.81
PCRS 5.83 1.80–22.63 2.94 0.94–10.17 4.48 1.31–20.70
FMSS.EE 2.21 0.99–4.99 3.32 1.49–7.61 1.23 0.56–2.71
FMSS.Crit 3.85 1.24–13.46 1.54 0.51–4.79 1.88 0.62–6.09
FMSS.EOI 0.48 0.17–1.25 2.30 0.90–6.11 1.00 0.39–2.55
Teen FAD 1.42 0.58–3.57 1.58 0.65–3.94 3.59 1.43–9.50
Parent FAD 0.99 0.41–2.42 1.14 0.47–2.75 2.02 0.83–5.01

Note: CAPA = Child and Adolescent Psychiatric Assessment; CBCL = Child Behavior Checklist; TRF = Teacher’s Report
Form; YSR = Youth Self-Report; PCRS = Parent–Child Relationship Scale; FMSS.EE = Five Minute Speech Sample, expressed
emotion; FMSS.Crit = Five Minute Speech Sample, criticism; FMSS.EOI = Five Minute Speech Sample, emotional over-
involvement; FAD = Family Assessment Device; OR = odds ratio; CI = confidence interval.

diagnosis (OR = 2.94). The FMSS EE construct was the
only variable to predict clinical Axis I diagnosis.
Utility for Predicting Medical Outcome
A subset of the participants participated in a follow-
up study. Mean conflict was correlated with Medication
Adherence (r = –0.19, p < .13) and was not correlated
with either Quality of Life or Behavioral Adherence at
24-month followup.
DISCUSSION
We propose that the PCRS could be used to measure
the child’s perception of difficulty in the parent–child
relationship. The PCRS was derived from the CAPA, an
interviewer-based diagnostic interview for 8- to 18-year-
old children. The CAPA criteria are well spelled out in
the CAPA glossary, and lay interviewers can be trained
to reach acceptable interrater reliabilities (Angold and
Costello, 2000).
Validity Issues
The PCRS items are a combination of empirical ques-
tions (e.g., how often does the child have a 5-minute con-
versation with the parent) and perception questions (e.g.,
does the child perceive that they are more negatively
treated than their siblings). Thus, the scale seems to have
face validity regarding the child’s perception of their rela-
tionship with a parent. The internal reliability and inter-
rater reliability were good. Construct validity was indicated
by the fact that the scale showed good correlation with
both parent and child self-report of family functioning on
the FAD, as well as clinical diagnoses of parent–child rela-
tionship problems. The scale was also significantly related
to an observer’s rating of the parent’s relationship style with
the child on the basis of the EE construct: PCRS scores
were significantly higher for those parents who were rated
as high on the criticism subscale of the FMSS scoring.
Finally, the PCRS scores discriminated biological or adop-
tive parents from other types of parent figures in a way that
would have been expected from other literature on this
topic. Divergent validity may be evidenced by the fact that
the PCRS was not significantly related to high emotional
over-involvement. Because the original CAPA item about
parental overprotection was deleted from the PCRS to
improve internal consistency, it is not surprising that the
resultant PCRS does not relate to observed emotional
over-involvement.
What of clinical utility? Although the PCRS, TRF,
YSR, and High Criticism on the FMSS all were signifi-
cant predictors of whether or not the child received a psy-
chiatric diagnosis from the CAPA, the PCRS had the
highest OR (5.83). Neither the child- nor parent-reported
FAD were predictive, despite the fact that each was highly
correlated with the PCRS. Part of the reason for this may
be that the PCRS deals specifically with parental behav-
iors toward the child, which may be the most salient
aspect of family function for the child’s emotional health,
whereas the FAD assesses more general family function-
ing. There is also the potential of interviewer bias. Because
the PCRS was part of the CAPA interview, the inter-
viewer could not be blind to the rest of the CAPA and
would know about psychiatric symptoms. However, the

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PCRS was also one of the best predictors of a clinical
diagnosis, with an OR of 2.94. The fact that it did not
reach statistical significance may be a power issue. Overall,
a higher PCRS was associated with a greater likelihood of
concurrent CAPA or clinical diagnosis.
Limitations
In future studies, the PCRS should be tested as a stand-
alone interview, and the PCRS and CAPA should be
administered by different interviewers. The PCRS should
be tested in other samples, including psychiatric as well as
normative samples, to see if the relationships hold up. The
CAPA was also only administered to the adolescent, not
the parent, and there is typically a discrepancy between
child and parent report of child psychopathology. For
example, in an epidemiological sample of over 1,400 ado-
lescents, the correlation among child, mother, and father
ratings (from the CAPA as well as Achenbach scales)
ranged from 0.1 to 0.3 overall (Hewitt et al., 1997). The
results from this study indicate that higher scores on the
PCRS were associated with medically ill children who also
met criteria for a DSM-III-R diagnosis. Whether the
PCRS will present the same relationship to psychiatric
disorders in non-medically ill children remains to be estab-
lished. One would suspect, for example, that older chil-
dren would have higher PCRS scores than younger
children. The fact that this was not found in this sample
may be due to the nature of the chronic illness, which may
keep these adolescents at home and more dependent on
parents. Moreover, the majority of this sample was white.
The PCRS should be tested in larger minority populations
before its utility can be generalized to those samples.
Clinical Implications
Assessing the child’s perception of their relationship
with their parents may be a salient marker for which med-
ically ill youths are also suffering with significant psycho-
logical symptoms. Although this information may not
come as a surprise to family-oriented clinicians, this report
substantiates the idea that paying attention to patients’
perceptions of their family relationships is clinically rel-
evant. These data lend support to the notion of eliciting
and scoring information about the child’s parental rela-
tionships as a way of screening for medically ill children
who already have significant psychological problems that
could be amenable to treatment. Whether a higher PCRS
will also predict which medically ill children may go on to
develop psychiatric disorders remains to be tested in
J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 8 , AU G U S T 2 0 0 1
THE PARENT–CHILD RELATIONSHIP SCALE
future studies. An interview that is conversational in
nature, and not too overtly psychologically oriented, may
be more user friendly to medically ill children than the
more traditional symptom surveys, and may provide
more useful information in a shorter period of time as
well. Further research should test whether the PCRS (as a
stand-alone interview) would make a useful screen for
children with a variety of medical illnesses.
Why are parent–child relationships particularly salient
for medically ill children? Chronic illness stresses both
child and parents. For parents with a genetic predisposi-
tion to depression, the stress may lead to more criticism in
the parents, which would then lead to more psychological
symptoms in the children. A family approach to children
with medical illness, especially targeting those children
with a family history of affective and/or anxiety disorders,
may be most efficacious in preventing the stress of illness
from precipitating psychological problems as well.
APPENDIX: ITEM RATINGS OF THE PARENT–CHILD
RELATIONSHIP SCALE (PCRS)
1. Positive Activities With Parents: Rate the quality of
the time spent with parent in any activity in which
both parent and child are actively involved.
0 = All or most (at least 75%) shared activities said to
be a source of enjoyment to child
2 = At least some (24%–75%) shared activities are a
source of tension, worry, or disinterest to the child
3 = Most (at least 75%), or all shared activities are a
source of tension, worry, or disinterest to the child
2. Parent–Child Communication: Frequency of conver-
sations between child and parent, regardless of who ini-
tiates the conversations, and regardless of whether child
or parent enjoys the conversations. An exchange must
last more than 5 minutes, not involve shouting or
aggression, and not be explicitly focused on disciplinary
matters or criticism to be regarded as a conversation.
0 = Conversations at least daily
1 = Conversations four to six times per week
2 = Conversations one to three times per week
3 = Conversations less than weekly
4 = Conversations less than monthly
3. Inadequate Supervision: Parents failure to provide
sufficient supervision as shown by frequent lack of
knowledge of the child’s whereabouts, and/or fails to
maintain effective control or disciplinary strategies,
and/or is not concerned or does not attempt to inter-
vene when the child’s behavior is deviant or defiant.
951
WAMBOLDT ET AL.
0 = Appropriate supervision/control for age and cir-
cumstances
2 = Whereabouts of child not known at least once
per week, or parent unable to exercise effective
control at least once per week
3 = Whereabouts of child unknown at least five times
per week, or parent usually (50% of time) unable
to exercise effective control
4. Harsh Discipline: Parent uses a harsh, restrictive, or
physical disciplinary style, leading to punishments
that are more severe than would usually be thought
appropriate.
0 = Appropriate discipline
2 = A disciplinary style that is more severe than most
parents would use, but delivered in a basically
nurturant setting
3 = Severe discipline, delivered coldly, or frequently
in anger, unaccompanied by a generally nurtu-
rant atmosphere
5. Selective Negative View: The child is regarded more
negatively by the parent than the other children in
the family.
0 = Child treated in same way as rest of children
2 = Child treated differently from other children in a
negative manner, at least sometimes
3 = Child is regarded as being markedly different
from other children in family, and subjected to
markedly different rules or restrictions
6. Involvement of Child in Arguments: The child is
involved in parental arguments, either by directly tak-
ing part, protesting to parents during the argument,
becoming withdrawn, or by attempts being made by
one or both parents to use the child as an ally in the
argument.
0 = Child not involved in parental arguments
2 = Child is upset by arguments at least sometimes, as
manifested by protesting about them to parents,
crying, or becoming withdrawn
3 = Attempts are made by one or both parents to
actively involve the child in at least some arguments.
Child may refuse to respond to these demands
Parental Incapacity: A change in the child’s ability to
maintain a relationship with the parent that is rel-
atively harmonious and capable of containing positive
and nurturant communication. The incapacity may
involve withdrawal (refusal or inability to be involved
with or talk to parent) and/or discord (aggression,
arguments, fights, or disruptive behavior).
952
7. Withdrawal
0 = No incapacity
2 = Partial incapacity
3 = Severe incapacity
8. Discord
0 = No incapacity
2 = Partial incapacity
3 = Severe incapacity
9. Arguments With Parent: Disagreements, lasting
more than 10 minutes, that result in a dispute
involving raised voices, shouting, verbal abuse,
physical aggression, or fights.
0 = no arguments in past 3 months
2 = one to four arguments in past 3 months
3 = five or more arguments in past 3 months
10. Arguments With Parent Involving Physical
Violence.
0 = no
2 = yes
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