The Evaluation of Family Functioning by the Family Assessment Device: A Systematic Review of Studies in Adult Clinical Populations

• Author: Gabor I. Keitner,Laura Staccini,Silvana Grandi,Elena Tomba
• Date: 01 March 2015
• Published date: 01 March 2015
• DOI: http://doi.org/10.1111/famp.12098

The Evaluation of Family Functioning by the Family

Assessment Device: A Systematic Review of

Studies in Adult Clinical Populations

LAURA STACCINI

*

ELENA TOMBA

*

SILVANA GRANDI

*

GABOR I. KEITNER

†

A large body of research, documenting the impact of a family’s functioning on health

outcomes, highlights the importance of introducing the evaluation of patients’ family

dynamics into clinical judgment. The Family Assessment Device (FAD) is a self-report

questionnaire designed to assess specific dimensions of family functioning. This qualita tive

systematic review, which follows PRISMA guidelines, aimed to identify the FAD’s

clinimetric properties and to report the incremental utility of its inclusion in clinical set-

tings. A thorough literature search was performed, using both computerized and manual

searches, yielding a total of 148 studies that were included in this review. The FAD has

been extensively used in a variety of research contexts. In the majority of studies it was

able to discriminate between clinical populations and controls and among groups of

patients with different illnesses. The FAD also showed good test–retest and concurrent

reliability, and modest sensitivity to change after treatment. FAD-dysfunctional family

functioning was related to several patient clinical outcomes, including lower recovery rates

and adherence to treatment, longer recovery time, poorer quality of life, and increased risk

of relapse and drop-out. The present review demonstrates that the FAD is a suitable

instrument for the evaluation of family functioning both in clinical and research settings.

Keywords: Medical Illness; Psychiatric Disorders; Family Functioning; Assessment;

Clinimetrics

Fam Proc 54:94–115, 2015

Dramatic changes have recently characterized health care systems. The need to reduc e

the cost of care, the tendency to promote early discharge of patients, and the shift of

health conditions toward ageing and chronicity have led to an increasing demand on

patients’ family members, who have become largely responsible for the management of

long-term care and treatment of the ill person (Langhorne & Duncan, 2001). There is a

large body of research documenting the effects of the illness on family functioning and the

impact of family functioning on illness recovery across many medical disciplines (Mar tire,

Schulz, Helgeson, Small, & Saghafi, 2010). Moreover, interest in family therapy has

increased, as outlined by numerous studies on family based interventions (Hartmann,

Bazner, Wild, Eisler, & Herzog, 2010; Martire et al., 2010). However, the specific aspects

*

Laboratory of Psychosomatics and Clinimetrics, Department of Psychology, University of Bologna, Bologna

Italy.

†

Department of Psychiatry and Human Behavior, Brown University, Providence, RI.

Correspondence concerning this article should be address to Laura Staccini, Department of Psychology,

University of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy. E-mail: laura.staccini2@unibo.it.

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Family Process, Vol. 54, No. 1, 2015 ©2014 Family Process Institute

doi: 10.1111/famp.12098

of family functioning and processes that are most implicated in the positive management

and favorable outcomes of specific disorders remain less clearly understood (Pritchett

et al., 2011). As a result, there is a growing need for methods and robust instruments with

good clinimetrics properties for family assessment. The term “clinimetrics” (Feinstein,

1987) is concerned with the quality of clinical measurements. Some important features

that determine the sensibility of an index are its discrimination properties (sensitivity/

responsiveness; Fava, Tomba, & Sonino, 2012; Feinstein, 1987) and its incremental valid-

ity, which refers to the exclusive contribution in predictive power associated with a partic-

ular assessment procedure during the clinical decision process (Sechrest, 1963). The

clinimetric perspective supports clinicians evaluating a broad global rating of clinical

phenomena by including the evaluation of psychosocial variables (Tomba & Bech, 2012).

According to these considerations, patients’ family functioning should be also included in

the clinical judgment. The term “family functioning” refers to the ability of the family to

work together as a unit to satisfy the basic needs of its members (Ryan & Keitner, 2009).

This concept originates from a family system perspective which assumes that the patient

and family members are part of a complex integrated system. Family functioning may be

irrevocably changed by the sudden occurrence of an illness in a previously healthy family.

The McMaster Model of Family Functioning (MMFF; Bishop, Epstein, & Levin, 1978;

Ryan, Epstein, Keitner, Miller, & Bishop, 2005) recognizes six characteristics of family

relationships which have been found to be relevant in the clinical context: Problem Solv-

ing, Communication, Roles, Affective Responsiveness, Affective Involvement, and Behav-

ior Control (see Table S1). The MMFF fulfils several important criteria supporting its

suitability in clinical work and in research: (a) it is grounded on a solid multidimensional

theory of family functioning, able to give a comprehensive profile of the family including

areas of strengths and weaknesses; (b) it offers well-validated objective and subjective

measures which provide a systematic assessment of patterns of family functioning across

its theoretical multiple domains; (c) it presents a manualized family therapy, specifically

structured for the treatment and restoration of the dimensions (the Problem Centered

Systems Therapy of the Family-PCSTF; Archambault, Evans, Mansfield, & Keitner,

2014).

Among the empirical measurements of the constructs developed by the Authors of

MMFF (Ryan et al., 2005), the Family Assessment Device (FAD; Epstein & Bishop, 1983;

Miller, Epstein, Bishop, & Keitner, 1985; Mansfield, Keitner, & Dealy, 2015) is a self-

report questionnaire that can be administered on a large scale in a cost-efficient manner,

is relatively brief and easy to administer, and offers a global measure of family function-

ing. The FAD has been translated into 25 languages and has been widely used by

researchers (Miller, Ryan, Keitner, Bishop, & Epstein, 2000a). However, a systematic

review of the studies that used the FAD in clinical settings has not been undertaken.

Given the importance of introducing the evaluation of patients’ family dynamics into

clinical judgment, we provided a qualitative systematic review, using the guid elines of the

preferred reporting items for systematic reviews and meta-analyses (PRISMA; Moher

et al., 2009), aimed to identify the clinimetric properties of the FAD and to report the

incremental utility of its inclusion in clinical settings, in terms of its relationships with

clinical outcomes. The implications for both research and treatment planning purposes

will be discussed.

DESCRIPTION OF THE FAMILY ASSESSMENT DEVICE (FAD)

The Family Assessment Device is a self-report scale designed to measure family

members’ perceptions of family functioning. It is a multidimensional measure composed

of six subscales assessing the dimensions of the McMaster Model (Problem Solving,

Fam. Proc., Vol. 54, March, 2015

STACCINI, TOMBA, GRANDI, & KEITNER

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