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The family attitude scale: reliability

and validity of a new scale for
measuring the emotional climate of
families
David Kavanagh

Psychiatry Research

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 Psychiatry R esearch 70 Ž1997. 185]195

The family attitude scale: reliability and validity of a new

scale for measuring the emotional climate of families

David J. Kavanagh a,U , Paul O’Halloran b , Vijaya Manicavasagar c , Dianne

Clark d , Olga Piatkowska e , Chris Tennant f , Alan R osen g
a
Department of Psychiatry, Uni ®ersity of Queensland, Mental Health Centre, Royal Brisbane Hospital, Herston,
Queensland, 4064 Australia
b
Graduate School of Health and Medical Sciences, Uni ®ersity of Wollongong, Wollongong, NSW, 2522 Australia
c
Psychiatry Research and Teaching Unit, South Western Sydney Area Health Ser®ice, L i ®erpool, NSW,
2170 Australia
d
Department of Psychology, Uni ®ersity of Sydney, Sydney, NSW, 2006 Australia
e
Drug and Alcohol Ser®ices, Queenscliff Community Health Centre, Queenscliff, NSW, 2096 Australia
f
Department of Psychiatry, Uni ®ersity of Sydney, Royal North Shore Hospital, St. L eonards, NSW, 2065 Australia
g
Adult Mental Health Ser®ices, Royal North Shore Hospital and Area Health Ser®ice, St. L eonards, NSW,
2065 Australia

R eceived 30 May 1996; revised 7 February 1997; accepted 24 March 1997

Abstract

R esearch on outcomes from psychiatric disorders has highlighted the importance of expressed emotion ŽEE ., but
its cost-effective measurement remains a challenge. This article describes development of the Family Attitude Scale
ŽFAS., a 30-item instrument that can be completed by any informant. Its psychometric characteristics are reported in
parents of undergraduate students and in 70 families with a schizophrenic member. The total FAS had high internal
consistency in all samples, and reports of angry behaviour in FAS items showed acceptable inter-rater agreement.
The FAS was associated with the reported anger, anger expression and anxiety of respondents. Substantial
associations between the parents’ FAS and the anger and anger expression of students was also observed. Parents of
schizophrenic patients had higher FAS scores than parents of students, and the FAS was higher if disorder duration
was longer or patient functioning was poorer. Hostility, high criticism and low warmth on the Camberwell Family
Interview ŽCFI . were associated with a more negative FAS. The highest FAS in the family was a good predictor of a
highly critical environment on the CFI. The FAS is a reliable and valid indicator of relationship stress and expressed
anger that has wide applicability. Q 1997 Elsevier Science Ireland Ltd.

Keywords: Questionnaire; Assessment; Criticism; Expressed emotion

U
Corresponding author.

0165-1781r97r$17.00 Q 1997 Elsevier Science Ireland Ltd. All rights reserved.

PI I S 0 1 6 5 - 1 7 8 1 Ž 9 7 . 0 0 0 3 3 - 4
186 D.J. Ka®anagh et al. r Psychiatry Research 70 (1997) 185] 195
1. Introduction
Over the last 30 years, a substantial number of
studies have examined the role of life events and
social environment on the course of schizophre-
nia ŽBebbington and Kuipers, 1992.. One indica-
tor of stressors within the living environment,
expressed emotion ŽEE ., has demonstrated a
strong association with the course of psychiatric
disorders ŽKavanagh, 1992.. High EE is usually
defined by the level of criticism, hostility or emo-
tional over-involvement ŽEOI . that is displayed by
one or more of the patient’s relatives on the
Camberwell Family Interview, CFI ŽVaughn and
Leff, 1976.. An increased risk of relapse is most
reliably demonstrated with criticism or hostility,
although high levels of emotional over-involve-
ment are also associated with poorer outcomes
ŽKavanagh, 1992..
The CFI has strong psychometric data support-
ing its use. After training in administration and
scoring, users can demonstrate high inter-rater
reliability ŽVaughn and Leff, 1976., and CFI rat-
ings correlate strongly with behavioural observa-
tions of family interactions ŽValone et al., 1983;
Miklowitz et al., 1984.. However, the CFI requires
4]5 hrperson to administer and score, and a
valid assessment of the home environment usually
requires the rating of at least two family members
ŽVaughn and Leff, 1976.. Access to training
courses also presents problems, especially for
practitioners outside the UK. A partial solution is
to develop a briefer interview method such as the
Five-Minute Speech Sample ŽFMSS. which is
rated on similar criteria to the CFI ŽMagana ˜ et
al., 1986.. The FMSS isa valid measure of EE,
although it misses some instances of high EE that
are identified by the CFI ŽMalla et al., 1991.. Like
the CFI, the FMSS requires that raters be trained
and monitored for reliability.
An alternative and potentially cost-effective
method of obtaining information on family
relationships is to use questionnaires. When this
study began, four main questionnaires had been
used in this area: the Parental Bonding Instru-
ment, PBI ŽParker et al., 1982.; the Level of
Expressed Emotion Scale, LEE ŽCole and Kazar-
ian, 1988.; the Patient R ejection Scale, PR S
ŽKreisman et al., 1979.; and the Family Environ-
ment Scale, FES ŽMoos and Moos, 1981.. While
all of them appeared conceptually linked to EE,
evidence on their association with the CFI was
weak Že.g. Parker et al., 1989..
There was a need to develop a questionnaire
that could be completed by either relatives or
patients, was sensitive to mild forms of criticism
or annoyance, and would show an association
with CFI variables. The current article describes
the development of the Family Attitude Scale
ŽFAS. which attempted to fill this need. The first
study used a sample of undergraduate students
and their parents to examine the psychometric
characteristics of the measure.
2. Study 1
2.1. Methods
2.1.1. Subjects
Two-hundred and twenty-eight undergraduate
psychology students Ž65 male, 163 female . took
part in the study for course credit. Students who
participated in the study invited their parents to
take part as well: 137 mothers and 119 fathers
agreed to take part. Data from the student and
both parents were obtained in 112 cases.
2.1.2. Family Attitude Scale (FAS)
Ten experienced clinicians reported common
statements and behaviours of family members in
relation to a relative with schizophrenia. Additio-
nal statements were derived from EE-related
concepts or were inspired by existing question-
naires. The resulting 80-item questionnaire was
administered to 42 mothers of schizophrenia
patients who were in contact with health services
in the Sydney metropolitan region or were mem-
bers of Schizophrenia Fellowship across Aus-
tralia. Thirty items with the highest item-re-
mainder correlations were selected for further
testing. This procedure meant that items origi-
nally expected to measure EOI were omitted,
since they neither loaded strongly on the overall
scale nor formed a coherent sub-scale. Man-
chester Ž1990. then administered the FAS to the
mothers of 82 undergraduate students. He found
 D.J. Ka®anagh et al. r Psychiatry Research 70 (1997) 185] 195
that the internal consistency of the 30-item scale
was very high Žalpha s 0.95..
The FAS is reproduced in Table 1. R espon-
dents reported how often each statement was true
at the moment, on a scale from ‘Every Day’ Ž4. to
‘Never’ Ž0.. Ten items were reverse scored. R e-
sponses were summed to give a score ranging
from 0 to 120, with higher scores indicating higher
levels of burden or criticism. The father’s FAS is
referred to below as the F-FAS, the mother’s as
the M-FAS. The students’ ratings of their be-
haviours and attitudes towards their fathers and
mothers are called the SFAS-F and SFAS-M,
respectively.
2.1.3. Other assessment measures
State and trait anxiety and anger were assessed
on the State-Trait Personality Inventory, STPI
ŽSpielberger et al., 1983., and the degree of anger
expression was assessed on the Anger Expression
scale, AX ŽSpielberger et al., 1985.. Students also
completed an Angry Behaviour Scale ŽABS., con-
sisting of four statements adapted from FAS items
that focused on anger expression Žitems 5, 8, 14
and 19 in Table 1.. These items consisted of:
‘Sherhe shouts at me’; ‘Sherhe loses hisrher
temper with me’; ‘Sherhe argues with me’; and
Table 1
The Family Attitude Scale
1. It is good to have him around a
2. He makes me feel drained
3. He ignores my advice
4. He is really hard to take
5. I shout at him
6. I wish he were not here
7. I feel that he is driving me crazy
8. I lose my temper with him
9. He is easy to get along with a
10. I am sick of having to look after him
11. He deliberately causes me problems
12. I enjoy being with him a,b
13. He is a real burden
14. I argue with him
15. I feel very close to him a
Note. Items are rated 4 Ževery day., 3 Žmost days., 2 Žsome days., 1 Žvery rarely., 0 Žnever ..
a
R everse scored.
b
Item 12 was derived from the Patient R ejection Scale ŽKreisman et al., 1979..
187
‘Sherhe says nasty or sarcastic things to me’. The
frequency of these events was reported using the
same scale as the FAS. The ABS enabled us to
validate the parents’ FAS reports of angry out-
bursts.
The students also reported arguments at home
over the last month that involved them and each
parent, estimating argument frequency and the
seriousness and duration of the most serious inci-
dent. The overall question was: ‘Every household
has some arguments from time to time. During
the last month, were there any arguments at
home, or any unpleasant comments, or times when
anyone raised hisrher voice?’. They separately
rated the frequency of events involving them and
each parent as ‘not at all’ Žcoded 0., ‘once or
twice’ Ž1.5., ‘three or four times’ Ž3.5. or ‘more
than four times’ Ž5.. They rated the most serious
incident with their mother and father as ‘very
minor’ Žcoded 1., ‘minor’ Ž2., ‘moderate’ Ž3., ‘seri-
ous’ Ž4. or ‘very serious’ Ž5.. They also stated how
long the most serious incident lasted, from ‘- 5
min’ Žcoded as 0.05 h ., through ‘5]30 min’ Ž0.30.,
‘30]60 min’ Ž0.75., ‘1]2 h’ Ž1.5., to ‘) 2 h’ Ž3..
Students reported demographic data in a bio-
graphical questionnaire. They also stated whether
they were currently living at home and, for each
16. I can cope with him a
17. Living with him is too much for me
18. He is infuriating
19. I find myself saying nasty or sarcastic things to him
20. He appreciates what I do for him a
21. I feel that he is becoming easier to live with a
22. I wish he would leave me alone
23. He takes me for granted
24. He can control himself a
25. He is hard to get close to
26. I feel that he is becoming harder to live with
27. I feel very frustrated with him
28. He makes a lot of sense a
29. I feel disappointed with him
30. He tries to get along with me a
188 D.J. Ka®anagh et al. r Psychiatry Research 70 (1997) 185] 195
day of the week, they estimated how many hours
they were in the same room as each parent.
2.1.4. Procedure
Students completed the biographical question-
naire, argument reports, FAS and ABS on each
parent, followed by the STPI and AX. Parents
completed an FAS about their relationship with
the student, followed by the STPI and AX.
2.1.5. Statistics
R eports of significance on all correlations and
t-tests are one-tailed.
2.2. Results
2.2.1. Sample characteristics
The students had a mean age of 19.5 years
Žrange s 17]45., and 98% had never been mar-
ried. Eighty-one percent had been born in Aus-
tralia, and 86% had English as their first lan-
guage. Eighty-three percent were living with one
or both of their parents. The mean weekly con-
tact with their mothers was 20.9 h ŽS.D.s 11.4 h;
range s 0]40 h ., and their average contact with
fathers was 16.3 h ŽS.D.s 11.2 h; range s 0]40 h ..
Fathers had an average of 13.1 years of formal
education ŽS.D.s 4.1. and mothers had 12.5 years
ŽS.D.s 3.5.. Only 10 students Ž4.4% . had ob-
tained treatment for a psychological problem in
the past. Average scores on the STPI and AX
scales are displayed in Table 2. They closely ap-
proximated the mean scores in normative sam-
ples.
The 212 students in contact with their mothers
had an average of 2.0 arguments with them in the
previous month ŽS.D.s 1.4.. The 196 in contact
Table 2
Mean scores in Study 1
Students Mothers
Mean ŽS.D..
STPI
State anxiety 18.0 Ž5.5. 16.7 Ž5.5.
Trait anxiety 21.1 Ž5.7. 18.6 Ž4.9.
State anger 12.1 Ž3.5. 12.2 Ž3.7.
Trait anger 21.3 Ž5.2. 18.7 Ž4.8.
Anger expression ŽAX. 10.8 Ž8.4. 5.1 Ž8.4.
with fathers averaged 1.5 arguments over the
month ŽS.D.s 1.5.. The most serious arguments
with their parents were rated ‘moderate’ on aver-
age Žwith mothers: mean s 2.1, S.D.s 1.0; with
fathers: mean s 1.9, S.D.s 1.1.. Arguments lasted
an average of less than 20 min, but there was a
high degree of variability Žmothers: mean s 19.6
min, S.D.s 35.6; fathers: mean s 17.2 min,
S.D.s 31.8..
Female students reported higher trait anxiety
than men Ž F1,226 s 14.38, P - 0.001. and lower
levels of anger expression Ž F1,226 s 6.22, P - 0.05..
Student women were also in greater contact with
their mothers Ž F1,222 s 3.88, P - 0.05..
2.2.2. Internal consistency and normati ®e data on
the FAS
The FAS had very high internal consistency in
all subgroups ŽM-FAS, g alpha s 0.95; F-FAS, g
alpha s 0.96; SFAS-M, g alpha s 0.97; SFAS-F, g
alpha s 0.95.. Additivity was acceptable in each
case. The results strongly supported the use of
the FAS as a single scale. Normative data are
displayed in Table 3.
2.2.3. Cultural differences
Cultural differences were evident on several
measures involving fathers. The F-FAS was less
negative if the students’ first language was En-
glish ŽEnglish, mean s 24.6; non-English, mean s
39.0; F1,117 s 10.44, P - 0.005.. These fathers were
also in less contact with the students Ž F1,222 s 8.74,
P - 0.01., but after control for contact, the effect
of language on the F-FAS remained significant
Ž F1,115 s 12.85, P - 0.001.. When English was the
first language of students, fathers also reported
less anger Žstate: F1,118 s 27.46, P - 0.001; trait:
F1,118 s 12.01, P - 0.01., lower levels of anger ex-
pression Ž F1,118 s 9.50, P - 0.01. and less anxiety
Žstate: F1,118 s 9.62, P - 0.01; trait: F1,118 s 3.91,
P - 0.05.. Effects of language on the students
Fathers FAS were not observed, but the SFAS-F was
lower if students were born in Australia Žmean s
35.3 vs. 42.3; F1,213 s 4.41, P - 0.05..
17.0 Ž5.7.
Cultural differences were much less marked in
18.1 Ž5.0. mothers, but when they did emerge, they were in
13.0 Ž4.9. the same direction as in fathers. The M-FAS
19.3 Ž5.5. effect for language fell short of the 0.05 signifi-
7.0 Ž9.2. cance level ŽEnglish, mean s 25.1; non-English,
 D.J. Ka®anagh et al. r Psychiatry Research 70 (1997) 185] 195 189

Table 3
FAS norms from Studies 1 and 2

n Mean ŽS.D.. R ange 10th percentile 50th percentile 90th percentile

Study 1
M-FAS 137 25.9 Ž16.0. 3]72 9 22 53
F-FAS 119 26.3 Ž16.2. 0]120 9 24 43
SFAS-M 226 34.2 Ž20.5. 1]98 10 30.5 64
SFAS-F 216 36.4 Ž19.0. 0]95 14 34 63

Study 2
M-FAS 58 36.8 Ž17.9. 5]76 14 36 59
F-FAS 51 39.9 Ž17.6. 9]81 14 44 60
O-FAS 27 37.6 Ž19.2. 4]74 10 39 61
Highest FAS 69 45.1 Ž17.4. 12]81 19 50 66

mean s 33.7; F1,135 s 3.48, P s 0.06.. Mothers
were in less contact with students in English-
speaking homes Ž F1,221 s 5.56, P - 0.05., but con-
tact had little effect on M-FAS scores Ž F1,131 s
1.03, NS.. Mothers reported less state anger if the
student’s first language was English Ž F1,136 s 5.46,
P - 0.05.. No cultural differences for either par-
ent were observed in the frequency, seriousness
or duration of arguments.
2.2.4. Relationship of the FAS with respondents’
anxiety, anger and anger expression
Table 4 reports the relationship between the
FAS and measures of mood and anger expression
that were provided by the same respondent. The
strongest relationships were between the FAS
and AX, but significant correlations were also
obtained with STPI anger and anxiety. The asso-
ciations were most pronounced for the F-FAS
and for the student ratings of arguments in the
home.
2.2.5. Inter-rater agreement on FAS beha®ioural
items
A test of inter-rater agreement was provided by
a comparison of the ABS and the FAS behaviou-
ral items Žitems 5, 8, 14 and 19.. Mothers and
students correlated 0.57, P - 0.0011, on the fre-
quency of angry behaviour by mothers, and fa-
thers and students correlated 0.42, P - 0.001, in
their ratings of paternal behaviour.
2.2.6. Relationships of students’ argument reports
with parents’ FAS
The association of FAS scores with arguments
between the parent and student provides one
index of FAS utility. Parental reports of angry
behaviour on the four relevant FAS items ac-
counted for about 12% of the variance in argu-
ment frequency Žmothers: r s 0.35, P - 0.001; fa-
thers: r s 0.36, P - 0.001.. Among the 15 stu-
dents who did not have English as their first
language, the association between angry be-
haviour on the FAS and argument frequency ap-
peared particularly strong Žmothers: r s 0.62, P -
0.05; fathers: r s 0.53, P - 0.05..
Correlations between the total FAS and stu-
dent reports of arguments were expected to be
weaker, because the content of the FAS is not
restricted to overt conflict. The M-FAS and F-FAS
were significantly associated with all of the argu-
ment variables, but in the total sample the FAS
accounted for only 2]12% of the variance
Žfrequency: M-FAS 0.23, P - 0.01; F-FAS 0.18,
P - 0.05; seriousness: M-FAS 0.21, P - 0.01; F-
FAS 0.16, P - 0.05; duration: M-FAS 0.34, P -
0.001; F-FAS 0.18, P - 0.05..
2.2.7. Reciprocity of FAS ratings
If parents were critical or angry with the stu-
dent, the student was significantly more likely to
express similar attitudes toward the parent ŽM-
190 D.J. Ka®anagh et al. r Psychiatry Research 70 (1997) 185] 195

Table 4
Correlates of the FAS and SFAS with other measures from the same respondent in Study 1

Parental ratings Student ratings

M-FAS F-FAS SFAS-M SFAS-F

STPI
State anxiety 0.35UUUU 0.43UUUU 0.23UUUU 0.29UUUU
Trait anxiety 0.29UUUU 0.34UUUU 0.37UUUU 0.32UUUU
State anger 0.26UUUU 0.48UUUU 0.24UUUU 0.29UUUU
Trait anger 0.24UUU 0.44UUUU 0.27UUUU 0.34UUUU
AX Žanger expression . 0.35UUUU 0.49UUUU 0.40UUUU 0.39UUUU

R eports of arguments
Frequency 0.39UUUU 0.39UUUU
Seriousness of worst argument 0.49UUUU 0.41UUUU
Duration 0.42UUUU 0.31UUUU

Note. One-tailed significance.

UUU
P - 0.01.
UUUU
P - 0.001.

FASrSFAS-M: r s 0.49, P - 0.001; F-FASr the students’ state anger, and the F-FAS was
SFAS-F: r s 0.43, P - 0.001.. However the stu- strongest for trait anger and state anxiety. After
dents had more negative attitudes towards their the entry of the FAS, no other variable retained
parents than their parents expressed towards them significance. The M-FAS was also the most pow-
ŽTable 3; mothers: F1,361 s 16.40, P - 0.001; fa- erful predictor of the students’ anger expression,
thers: F1,333 s 24.00, P - 0.001.. but maternal AX continued to predict the stu-
dents’ scores Žchange in r 2 s 0.050, F1,109 s 6.17,
2.2.8. Prediction of students’ anxiety, anger and anger P - 0.05.. Gender was the strongest predictor of
expression from parents’ FAS trait anxiety, and its entry eliminated the predic-
The utility of the FAS was likely to be en- tive effects of any other variable.
hanced if parental ratings on it were related to A more rigorous test involved forcing the entry
levels of anger or anxiety that are reported by of all variables other than the FAS, and then
adult children, since these provided an analogue examining whether the M-FAS and F-FAS jointly
to higher levels of symptomatology. Pearson cor-
relations of the M-FAS and F-FAS with the stu-
Table 5
dents’ STPI and AX scores are displayed in Table Prediction of the students’ STPI and AX from the parents’
5. All of the correlations were in the direction of FAS in Study 1
more negative FAS scores being related to higher
levels of anger, anger expression and anxiety in Student ratings M-FAS F-FAS
the students. Anxiety appeared less strongly pre- STPI
dicted than anger, and the FAS prediction of State anxiety 0.19UU 0.24UUU
anger expression was only significant for mothers. Trait anxiety 0.19UU 0.13U
We examined predictions of the students’ scores State anger 0.32UUUU 0.26UUU
further through multiple regressions in which we Trait anger 0.25UUU 0.33UUUU
AX Žanger expression . 0.32UUUU 0.15U
compared the predictive contribution from the
FAS with predictions from: Ža . the students’ gen- Note. One-tailed significance.
U
der and language of origin; and Žb . the parents’ P - 0.10.
UU
P - 0.05.
relevant STPI or AX score. In stepwise regres- UUU
P - 0.01.
sions, the M-FAS was the strongest predictor of UUUU
P - 0.001.
 D.J. Ka®anagh et al. r Psychiatry Research 70 (1997) 185] 195
added to the prediction. In the case of state
anger, the two FAS measures still added 8.6% to
the predicted variance Ž F2,105 s 5.31, P - 0.05..
They added 6.9% to the prediction of trait anger
Ž F2,105 s 4.34, P - 0.05., and in the prediction of
anger expression they contributed an additional
4.2% Ž F2,105 s 2.65, P - 0.10.. No significant con-
tribution to the prediction of state anxiety was
offered by the FAS after control for other vari-
ables.
2.3. Discussion
The FAS displayed extremely high internal
consistency across all samples and demonstrated
a high level of validity. Levels of agreement
between students and parents on the frequency of
angry behaviour were acceptable, and ratings of
angry behaviour significantly correlated with the
frequency of arguments in the previous month.
Substantial reciprocity of attitudes and behaviour
was shown by the FAS measures from students
and their parents.
A parental FAS accounted for 10]11% of the
variation in students’ AX, state and trait anger,
and state anxiety, and these predictions were
stronger than ones from parental mood or demo-
graphic variables. In the prediction of anger and
AX, a significant effect from the parents’ FAS
remained even after gender, language of origin
and the parent’s anger or AX were forced to
enter the equation. The FAS therefore offered a
substantial and unique contribution to the predic-
tion of the students’ anger and anger expression.
While these results did not necessarily imply a
causal relationship between the FAS and the stu-
dents’ anger, they were consistent with such an
effect.
Some unexpected differences were observed
between the subgroup of students who did not
have English as their first language and the En-
glish speakers. Further research should test
whether a tendency towards more negative scores
in the non-English subgroup can be replicated. If
it is a true result, the determinants and effects of
it should be examined.
Collectively, the data from Study 1 suggested
that the FAS was a reliable measure of dissatis-
191
faction, anger and anxiety in relation to a specific
person. The next step in its development was to
apply the scale during an acute exacerbation of
schizophrenia so that the applicability of the FAS
to families with a schizophrenic member could be
examined. We aimed to test the association of the
FAS with the Camberwell Family Interview and
examine correlations with patient characteristics.
3. Study 2
3.1. Method
3.1.1. Subjects
Patients and their families were recruited for a
controlled trial of family intervention vs. individ-
ual treatment ŽKavanagh et al., 1997.. All patients
were experiencing an exacerbation of schizophre-
nia or schizo-affective disorder as defined by
DSM-III-R ŽAmerican Psychiatric Association,
1987. and were aged between 16 and 65. Potential
subjects were excluded if they had a primary
diagnosis of drug or alcohol abuse or dependency
or had dementia, neoplasm, brain injury, or any
other major disorder. Apart from psychiatric
admissions, the patients were living with their
parental or spousal family or stayed with them on
most weekends over the previous 3 months.
Patients and their families had to be fluent in
English to take part in the study.
3.1.2. Measures
Semi-structured interviews with patients and
their families provided data on the patients’ age,
ethnic origin, first language and educational level,
as well as the education of parents. Weekly con-
tact time with each family member was assessed
using questions about each person’s daily activi-
ties, and the highest contact time in the family
was used as the index of family contact hours.
History of the disorder was established using
combined information from patients and rela-
tives, and from the patients’ files.
The Expanded Brief Psychiatric R ating Scale,
EBPR S ŽLukoff et al., 1986., was used to assess
symptom levels of patients. In addition a self-re-
port measure of the psychiatric symptoms of both
patients and other family members was obtained
192 D.J. Ka®anagh et al. r Psychiatry Research 70 (1997) 185] 195
using the 28-item General Health Questionnaire,
GHQ-28 ŽGoldberg and Hiller, 1978.. An indica-
tion of the patient’s functional status was given by
assessments on the Life Skills Profile, LSP ŽR osen
et al., 1989., by family members and the patient’s
case manager.
The FAS was given to all family members who
took part in the study. A patient ]report version
ŽSFAS. was not used. In keeping with the termi-
nology of Study 1, the FAS from non-parental
relatives was referred to as the O-FAS. Expressed
emotion was assessed by the Camberwell Family
Interview, CFI ŽVaughn and Leff, 1976., and
scored by accredited raters ŽDC, DK and VM ..
Cutoffs for high EE were six or more critical
comments ŽC ., three or more on emotional over-
involvement ŽEOI . or the presence of hostility
ŽH .. Patients completed the Parental Bonding
Instrument, PBI ŽParker et al., 1982., in which
they retrospectively reported on each parent’s
behaviours and attitudes during the first 16 years
of their life. Scores on PBI Care and Protection
were obtained on both parents.
3.1.3. Procedure
Patients and adult family members who had a
significant degree of contact with each other were
asked to participate in the study. After written
consent was obtained, patients were assessed on
the BPR S and GHQ. Within 2 weeks, participat-
ing family members completed the CFI, FAS,
GHQ and LSP. Therapists were asked to com-
plete the LSP.
3.1.4. Statistics
R eports of significance on all correlations and
t-tests are one-tailed.
3.2. Results
3.2.1. Sample characteristics
Seventy patients participated in the study Ž46
men and 24 women.. FAS scores were available
from 69 families Ž58 mothers, 51 fathers and 27
others, comprising six spouses, 17 siblings and
four other relatives and friends.. R esults from
non-parental relatives are reported as a single
group because of the small numbers in each of
the subgroups. Patients had a median age of 27
years Žrange s 19]49., and 93% had English as
their first language. They had an average of 11.3
years of education, which was comparable with
that of their parents Žmothers: mean s 10.4, fa-
thers: mean s 11.5 years.. Median disorder
chronicity was 35 months Žrange s 1 month ]23
years., with a median of three psychiatric admis-
sions.
CFI ratings were available from 69 families,
with at least two family members being rated in
50 cases Ž72% .. Forty families Ž58% . met criteria
for high EE Ž25r60 mothers, 22r52 fathers, 4r20
others.. Nine of the high-EE environments had
two assessed members scoring high in EE, and
one had three members with high EE scores. Of
the low-EE environments, 68.9% had at least two
members assessed on the CFI. In four of the
remaining nine low-EE families, the one person
assessed was the spouse, and another three were
in one-parent households. Median contact time
between the patients and one or more family
members was 21 hrweek, and 20% had contact
time of 35 h or above.
3.2.2. FAS internal consistency and normati ®e data
Coefficient alpha values were 0.95 for mothers,
0.94 for fathers and 0.96 for other relatives. Cor-
rected item-total correlations exceeded 0.25 for
all items. The scores of parents in Study 2 were
significantly more negative than for parents in
Study 1 ŽTable 3; mothers: F1,193 s 17.60, P -
0.001; fathers: F1,168 s 23.88, P - 0.001..
3.2.3. Relationship of the FAS to the CFI and PBI
The FAS showed little association with PBI
subscales, but it was significantly correlated with
high criticism and hostility, and low warmth on
the CFI ŽTable 6.. In fact, the M-FAS accounted
for 44% of the variance in the CFI criticism that
was expressed by mothers. No significant correla-
tions with EOI were observed. The small group of
18 other relatives provided similar correlations to
those provided by parents ŽO-FAS with criticism:
r s 0.40, P - 0.10; hostility: r s 0.48, P - 0.05;
EOI: r s y0.08, NS, warmth: r s y0.41, P -
0.05..
Another way to examine the relationship
between the CFI and FAS was to examine the
FAS scores of parents who were rated high vs.
 D.J. Ka®anagh et al. r Psychiatry Research 70 (1997) 185] 195 193

Table 6 of low-criticism homes Ž g x 2 s 6.84, d.f.s 1, P -

Correlations between the FAS and other measures in Study 2
0.01..
M-FAS F-FAS
3.2.4. Relationship of the FAS with other measures
Parental CFI The father’s FAS was significantly associated
Criticism 0.66UUUU 0.38UUU
with the GHQ, as were the scores of the 25
Hostility 0.39UUU 0.31UU
Emotional over-involvement 0.10 0.05 non-parental relatives Ž r s 0.56, P - 0.01.. GHQ
Warmth y0.42UUUU y0.36UUU Anxiety was associated with high FAS in all groups
ŽM-FAS: r s 0.28, P - 0.05; F-FAS: r s 0.27, P -
PBI 0.05; O-FAS: r s 0.54, P - 0.01.. Somatic symp-
Care y0.22UU y0.22U toms were related to high FAS for fathers Ž r s
Protection 0.03 0.24U
0.28, P - 0.05. and other relatives Ž r s 0.64, P -
Parents’ total GHQ 0.16 0.30UU
Disorder chronicity 0.30UU 0.34UUU 0.001.. The FAS was not affected by the educa-
Patient age 0.22UU 0.15 tion of the respondent.
Patients’ BPR S Both the M-FAS and F-FAS showed significant
Psychosis 0.09 0.23U relationships with disorder chronicity and with
Total 0.18U 0.29UU
poorer patient functioning as rated by the respon-
Patients’ total GHQ 0.06 0.20U
LSP on patient dent ŽTable 6.. Lower LSP ratings by therapists
By therapist y0.11 y0.48UUU were also associated with more negative FAS
By relative y0.68UUUU y0.63UUUU ratings for fathers, but not for mothers. Only
Note. Uncorrected probabilities.
weak correlations were obtained with the patients’
U
P - 0.10. symptom levels, although symptoms were stabilis-
UU
P - 0.05. ing by the time that patients were assessed.
UUU
P - 0.01.
UUUU
P - 0.001.
3.3. Discussion

low in EE. There was a tendency for parents to
have higher FAS scores if they were rated as high
EE Žmothers: mean s 34.4 vs. 42.3, t52 s 1.64, P
s 0.0531; fathers: mean s 36.9 vs. 45.5, t 47 s 1.66,
P s 0.052.. These relationships were constrained
by the lack of relationship between the FAS and
EOI. If a binary EE judgment were simply based
on CFI criticism or hostility, high EE was associ-
ated with a higher FAS score for both parents
Žmothers: mean s 34.4 vs. 49.6, t52 s 2.70, P -
0.01; fathers: 37.1 vs. 48.1, t 47 s 1.99, P - 0.05..
An environment is usually rated as high EE if
the CFI of just one family member is in the high
range. The closest analogy with FAS scores would
be to take the highest-rating questionnaire. Norms
for this score are shown in Table 3. We compared
high- and low-EE environments on the measure,
and the effect was short of the one-tailed 0.05
significance level Ž t67 s 1.34, P - 0.10.1. However
when EE was determined only by CFI Criticism,
the effect was t67 s 3.23, P s 0.001. A cutoff of
) 50 on the highest FAS score correctly identi-
fied 71% of high-criticism environments and 62%
Study 2 replicated the observation of high in-
ternal consistency for the FAS. The level of con-
sistency suggested that the number of items in the
scale might be further reduced, and research on
shortened versions of the scale will continue. FAS
scores were substantially higher than in the stu-
dent sample, presumably reflecting the substan-
tially greater challenges posed by offspring with
schizophrenia.
The importance of these coping challenges was
also demonstrated by the significant correlations
of the FAS with chronicity and poorer patient
functioning. These results may have reflected a
jaundiced view being taken by critical relatives
when estimating the patients’ capabilities, but this
explanation appeared unlikely in the case of
chronicity. The duration of disorder was es-
tablished from all available sources, offering little
opportunity for parental bias to influence the
results ŽMintz et al., 1989.. The link between the
FAS and LSP ratings parallelled previous obser-
vations that LSP disability and perceived burden
correlated significantly. Perhaps the parents’ FAS
194 D.J. Ka®anagh et al. r Psychiatry Research 70 (1997) 185] 195
is providing an index of burden or stress that is
produced by more severe or long-standing patient
deficits. Alternatively, the result may reflect ef-
fects of criticism on patient functioning and dis-
order outcomes that have occurred in the past
ŽHogarty et al., 1988..
Study 2 replicated associations of the FAS with
emotional distress of the rater, as reflected in
correlations between the FAS and the GHQ-
anxiety score of the rater. The links appeared
especially strong in the non-parental relatives.
Heightened FAS scores in that group may be
especially likely to reflect generalised distress.
The primary test of validity for the FAS in
Study 2 was its correlation with the CFI. Higher
FAS ratings were significantly correlated with high
criticism and hostility, and with low warmth, espe-
cially for mothers. Their CFI criticism andFAS
had 44% shared variance. This suggested that the
FAS Žor a revised form of it . has the potential to
detect high EE in situations where EE is primar-
ily determined by hostility or criticism. The lack
of significant relationships between the FAS and
EOI highlighted the heterogeneity of the EE
concept itself. In our study, as in previous work
ŽParker et al., 1989., CFI criticism and hostility
were highly correlated Ž r s 0.72, P - 0.001 for
mothers and r s- 0.63, P - 0.001 for fathers.,
but EOI showed inconsistent associations with
both criticism Ž r s 0.13, NS for mothers; r s 0.28,
P - 0.05 for fathers. and hostility Ž r s 0.27, P -
0.05 for mothers; r s y0.04, NS for fathers.. EE
is best seen as a loose aggregation of several
family attitudes and behaviours that may have
separate contributions to the increase in relapse
risk ŽKavanagh, 1992.. The strength of the FAS is
that it offers a very internally consistent measure
that is most closely related to the hostilityrcriti-
cism aspect of EE determination.
In sharp contrast to the correlations with the
CFI, there were only very weak associations
between the FAS and PBI. This is not considered
a significant problem for the FAS, since previous
research with the PBI has suggested that it is
probably measuring a different set of constructs
than the CFI ŽParker et al., 1989.. In order to
check on this interpretation, we looked at associa-
tions between the CFI and PBI in the present
sample. Maternal care, the only variable to have
significant correlations with the FAS, was also the
only PBI variable to have a significant relation-
ship to CFI criticism Ž r s y0.32, P - 0.01. or
hostility Ž r s y0.28, P - 0.05.. Paternal care was
only associated with the fathers’ EOI Ž r s 0.26,
P - 0.05. and warmth Ž r s 0.38, P - 0.05., while
PBI protection did not significantly correlate with
any CFI variables. Since the PBI was collected
during a positive symptom exacerbation, the re-
sults may also reflect problems with the PBI
reports by patients while positive symptoms are
elevated. These problems are not shared by the
relatives’ reports on the CFI or FAS. However,
the SFAS might also be subject to distortions
during an acute episode of schizophrenia. In or-
der to test this possibility, a longitudinal study is
required with repeated measures of the FAS,
SFAS and independent assessments of conflict.
After Study 2 had begun, we located a ques-
tionnaire measure developed by Docherty et al.
Ž1990. that also attempted to measure EE-related
variables. In a small sample examined by Docherty
et al. Ž1990., the 70-item criticism scale correlated
0.66 with CFI criticism, just as did the FAS with
maternal CFI criticism. Unlike our study, in
Docherty et al. Ž1990., the researchers included
multiple relatives of the same patient as if they
were additional independent observations. This
approach was likely to inflate their correlations.
The FAS is shorter than the Docherty et al.
questionnaire, but the latter incorporates a mea-
sure of EOI. In order to evaluate the relative
utility of the FAS and the two questionnaires,
both measures should be used in a study that
attempts to predict relapse.
The FAS is emerging as a reliable, brief mea-
sure of anger, burden or ‘stress’within a relation-
ship. It can be given to anyone in the family, is
brief, focused and requires no training to admin-
ister. Further research will determine the predic-
tive utility of the scale in relation to psychotic
symptoms.
Acknowledgements
This research was supported by a R esearch and
Development Grant from the Commonwealth
 D.J. Ka®anagh et al. r Psychiatry Research 70 (1997) 185] 195
Department of Health and Community Services.
An earlier report on Study 2 was submitted by
Paul O’Halloran in partial fulfilment of require-
ments for the Master in Clinical Psychology, Mac-
quarie University.
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