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A Tool for Medical Providers to Evaluate Family Functioning

Posted By Catherine Van Fossen, Keeley J. Pratt, Robert Murray, Joey Skelton, Thursday, November 1, 2018


Family functioning is one way to measure how a family meets its physical and psychological needs; in other words, it quantifies the family’s emotional environment1,2. Family functioning has been found to be associated with chronic physical and mental illness in children3–6; however, family functioning is not consistently measured in clinical health care settings or large scale studies investigating child wellness. While there are multiple measures available to assess family functioning, we sought to identify a measure that enabled individuals to report their own functioning and did not require lengthy assessment or responses.7


The purpose of this study was to pilot a brief measure of family functioning in pediatric primary care. We administered the General Functioning Subscale of the Family Assessment Device1,8, which consisted of 12 items to 400 families from two different pediatric primary care sites in Columbus, Ohio. One of the challenges we face as researchers and practitioners is to identify tools that will accurately and consistently measure a phenomenon of interest. In addition, we are also interested in measures that can accomplish these tasks without creating fatigue in our patients and participants. Patients are often inundated with assessment at appointments, increasing the likelihood of incomplete or inaccurate answers. Through piloting the General Functioning Subscale, we hoped to identify a brief measure, capable of assessing family functioning, or the overall family emotional climate, in pediatric settings. Further, we sought to understand the rate of families presenting to pediatric primary care with clinically significant levels of impairment in their family functioning. 


To qualify for our study, participants needed to read and write in English, be patients at a pediatric primary care office, and have at least one child between the ages of 2-18. In addition to the General Functioning Subscale of the Family Assessment Device, participants completed a brief demographic questionnaire, which assessed caregiver age, race/ethnicity education, employment, marital status, and child age, race/ethnicity, education, health insurance, and health diagnosis, as well as family income and the number of people living in the household. Most caregivers in our sample were female (77.7%) with a mean age of 38.18 years (SD = 7.96; range = 21-69 years). The majority of caregivers identified as Caucasian (81.5%), followed by African American (13.7%), Asian (1.0%), Biracial or Multiracial (1.3%), and Other (2.5%); however, a small number of participants identified as Hispanic (3.3%). Children were on average approximately 8 years old (SD=4.53; range=2-18 years), with a near even split of male and female child participants (53.6%). Children in this sample were insured with private health insurance (72.8%), and the majority of families reported an income above $50,000 per year.


In order to evaluate the psychometric properties of the General Functioning Subscale of the Family Assessment Device, we evaluated its reliability and convergent validity. Reliability, when measured through internal consistency is a measure of whether each person answers the 12 items in a similar or predictable fashion. This measure was found to have high reliability (α = .90). The second thing we evaluated was the convergent validity of the questionnaire. In this study, we were specifically investigating whether all 12 items could fit together as one construct: family functioning. The model fit was χ2(54) = 56.44, P = .38, with root mean square error of approximation = .01 and comparative fit index =.99, which indicates good model fit, and a single factor of family functioning. After establishing that the General Functioning Subscale of the Family Assessment Device was acceptable for use in pediatric settings, we explored the rate of families who scored above the clinical cut-off for impaired family functioning. This means that families were indicating impairment at the same level of families who were presenting for family therapy. Approximately 13% of families seeking pediatric care had clinically significant impaired family functioning, or problematic family dynamics.


The General Functioning Subscale of the Family Assessment Device offers a promising way to quantify family dynamics in pediatric care settings. The brief questionnaire (12 items) can be administered to families and scored with minimal training. Physicians seeking to provide comprehensive care to families can utilize this tool to make data driven decisions about referrals to behavioral health providers. Finally, the rate of impaired family functioning practice in pediatric primary care emphasizes the need for high quality integrated care for children and their families. 


1.        Epstein NB, Baldwin LM, Bishop DS. THE McMASTER FAMILY ASSESSMENT DEVICE * Previous First Next. J Marital Fam Ther. 1983;9(2):171-180. doi:10.1111/j.1752-0606.1983.tb01497.x

2.        Miller IW, Ryan CE, Keitner GI, Bishop DS, Epstein NB. The McMaster Approach to Families: theory, assessment, treatment and research. J Fam Ther. 2000;22(2):168-189. doi:10.1111/1467-6427.00145

3.        Ferro MA, Boyle MH. The Impact of Chronic Physical Illness, Maternal Depressive Symptoms, Family Functioning, and Self-esteem on Symptoms of Anxiety and Depression in Children. J Abnorm Child Psychol. 2015;43(1):177-187. doi:10.1007/s10802-014-9893-6

4.        Halliday JA, Palma CL, Mellor D, Green J, Renzaho AMN. The relationship between family functioning and child and adolescent overweight and obesity: A systematic review. Int J Obes. 2014. doi:10.1038/ijo.2013.213

5.        Georgiades K, Boyle MH, Jenkins JM, Sanford M, Lipman E. A Multilevel Analysis of Whole Family Functioning Using the McMaster Family Assessment Device. J Fam Psychol. 2008;22(3):344-354. doi:10.1037/0893-3200.22.3.344

6.        Herzer M, Ph D, Godiwala N, et al. Family functioning in the context od pediatric chronic conditions. J Dev Behav Pediatr. 2010;31(1):1-14. doi:10.1097/DBP.0b013e3181c7226b.Family

7.        Hamilton E, Carr A. Systematic Review of Self-Report Family Assessment Measures. Fam Process. 2016;55(1):16-30. doi:10.1111/famp.12200

8.        Byles J, Byrne C, BOYLE MH, Offord DR. Ontario Child Health Study: Reliability and validity of the General Functioning Scale of the McMaster Family Assessment Device. Fam Process. 1988;30(1):97-104. doi:10.1111/j.1545-5300.1988.00097.x


Catherine Van Fossen, M.S. is a doctoral student at the Ohio State University (OSU) in Human Development and Family Science and the Couple and Family Therapy Specialization in the Department of Human Sciences. Catherine has trained in both school and hospital settings to provide family therapy to diverse families. Catherine was awarded the American Association of Marriage and Family Therapy Minority Fellowship in 2016 and 2017. Catherine’s area of research is family based behavioral care interventions in pediatric primary care, with a focus on minority and underserved populations. 


Keeley J. Pratt, Ph.D. is an Associate Professor in Human Development and Family Science and the Couple and Family Therapy Specialization in the Department of Human Sciences and in the Department of Surgery at OSU. She completed her doctorate in Medical Family Therapy at East Carolina University, and a post-doctoral research fellowship at Research Triangle Institute International in an Obesity Signature Program. Dr. Pratt is an Associate Editor for Families, Systems, and Health. Her area of research is family-based pediatric and adult weight management and culturally tailoring weight management for racial/ethnic minority and underserved/insured families.


Robert Murray, MD attended Indiana University School of Medicine and did his residency training in pediatrics at DeVos Children’s Hospital, Spectrum Health, in Grand Rapids, Michigan. He was a professor in the Department of Pediatrics of the OSU School of Medicine and Nationwide Children’s Hospital He was the Director of the Borden Center for Nutrition and Wellness and served as the past President of the Ohio Chapter of the Academy of Pediatrics. 


Joey Skelton, MD received his BS from Furman University, and MD from the University of Tennessee, Memphis College of Medicine. He did his training in Pediatrics at the Children’s Hospital of Wisconsin and the Medical College of Wisconsin, and completed a Masters in Health Sciences Research at Wake Forest University. He is an Associate Professor of Pediatrics at Wake Forest School of Medicine, and is Director of Brenner FIT, an interdisciplinary pediatric weight management program at Brenner Children’s Hospital. His area of research is family-based pediatric weight management and attrition from treatment. 

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