@ The Association for Family Therapy 1995.

Published by Blackwell Publishers, 108 Cowley

Road, Oxford, OX4 lJF, UK and 238 Main Street, Cambridge, MA, USA.
Journal of Family Therapy ( 1995) 17: 299-3 I5
01 6 3 4 4 5

The Family Environment Scale: comparison with

the construct of Expressed Emotion

Panos Vostanis* a n d Judith NichollsT

The Family Environment Scale (FES) was completed by parents of 30

children with conduct disorders (CD), 30 children with emotional
disorders (ED), and 30 well-functioning controls. Parents were also
interviewed and rated for Expressed Emotion (EE), and mothers
completed the Child Behaviour Checklist (CBCL). Clinical families had
significantly lower ratings of Cohesion, Expressiveness, Intellectual-
Cultural and Active-Recreational Orientation. These differences were
not specific to either diagnostic group. Maternal Criticism was
associated with reported conflict in the C D group. The EE scales of
Criticism and Warmth (absence of warmth) were correlated with child
behaviour ratings in the C D group, in contrast with FES sub-scales.
Maternal scores of Cohesion were significantly associated with social
competence in the ED and the control group. Maternal ratings of
Conflict predicted dropping-out of treatment (CD group), and ratings of
Cohesion and Control had some value in predicting clinical outcome.
The implications for the future use of the Family Environment Scale and
other self-rated measures of family functioning are discussed.

Introduction
The role of parental attitudes in the development of child psycho-
pathology has been widely investigated. This has been done by either
studying the function of the whole family or by studying the
relationship between parental attitudes and aspects of child psycho-
logical development. The need for the assessment and measurement
of several aspects of family functioning led to the development of
research instruments based on reports by family members or on direct
observation (Jacob and Tennenbaum, 1988).Scales measuring family

* Senior Lecturer in Child and Adolescent Psychiatry, University of BirminKham,

- -
Queen Elizabeth Psychiatric Hospital, Mindelsohn Way, Edgbasion, Birmingham
B15 202. UK.
t Senior Registrar in Child and Adolescent Psychiatry, Oaklands Child and
Adolescent Unit, Birmingham, UK.
300 Panos Vostanis and Judith Nicholls
attitudes include disagreement (Pless and Satterwhite, 1973), affective
responsiveness and involvement (Epstein et al., 1983), and conflict
and overprotection (Kinston and Loader, 1986). The usefulness of
such scales has been investigated in both ‘normal’ (Barnhill. 1979:
Walsh, 1982) and dysfunctioGa1 families (Scoresby and Christensen;
1976).
The Family Environment Scale is a measure of family members’
perceptions of their family life, which has been extensively used in
different clinical samples (Jacob and Tennenbaum, 1988). This is one
of ten Social Climate Scales which have been developed by Moos and
his team (Moos, 1986). The scales assess a variety of ‘environments’
such as community settings (Family, Work, and Group Environment
Scale), educational environments (Classroom and University Resid-
ence Environment Scale), residential care and treatment settings
(Ward Atmosphere, Community-Oriented Programmes, and
Sheltered Care Environment Scale), and other institutions (Military
and Correctional Institutions Environment Scale).
Normative data have been collected from 1,125 ‘normal’ and 500
‘distressed’ families (Moos and Moos, 1986). Distressed families
perceived their family environments as lower in cohesion, express-
iveness, independence and intellectual/recreational orientation, and
higher in conflict. These differences were not accounted for by socio-
economic or cultural factors. However, educational and occupational
status within each sample were positively correlated with all the
above FES sub-scales - with the exception of conflict. The FES has
been applied in studies assessing psychopathology or evaluating
outcome in different clinical conditions (Jacob and Tennenbaum,
1988). Spiegel and Wissler (1983 and 1986), for example, found that
higher ratings of family expressiveness and cohesion predicted more
favourable clinical outcome and adjustment of adult hospitalized
patients. High family cohesion and active recreational orientation
have also been associated with better prognosis in alcoholism (Finney
et al., 1980).
The aim of this study was to test further the construct and
predictive validity of the Family Environment Scale by investigating
whether FES ratings distinguish between broad diagnostic groups of
child psychiatric disorders and whether FES ratings can predict
clinical outcome. As the validity of similar self-rated measures of
family functioning has been previously questioned (Roosa and Beals,
1990a and 1990b), the self-rated FES was compared with an
independently rated measure. The widely used construct of Expressed

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 The Family Enuironment Scale and EE 30 1
Emotion (Vaughn and Leff, 1976; Hibbs et al., 1993) was selected as a
representative comparison instrument, because its scales describe
similar family attitudes to the FES sub-scales.

Method
Subjects
The design of the study has been described in detail elsewhere
(Vostanis et al., 1994). The sample consisted of parents of 30 children
with conduct disorder (CD) and 30 children with emotional disorder
(ED), who had been referred to a Child Psychiatry Service for the first
time (ICD-9 criteria, World Health Organization, 1978; at the time of
data collection, ICD-10 criteria had not been formally introduced -
WHO, 1992). Children with conduct disorders presented with
oppositional and aggressive behaviour; children with emotional
disorders presented with depressive and anxiety symptoms. A control
group consisting of parents of 30 well-functioning children matched
for sex and age was selected from two primary schools. Parents of
referred children were contacted after the first assessment and at nine
months. Controls were contacted once. Fifty-nine mothers (98.3%)
and 23 fathers (56.1% of fathers living with the child) of referred
children and all 30 mothers and 26 fathers (86.6%) of controls took
part. At nine months after the first assessment, 57 families were traced
(95%).
Demographic data are presented in Table 1. In summary, the three
groups did not differ significantly on sex or age of the child, and
paternal age. Controls were more likely to live with both parents (x2 =
15.7, p = 0.015). Children with CD were significantly more likely to
come from a lower socio-economic background (x2= 15.4, df= 2, p =
0.000) and to live with a younger mother (one-way analysis of
variance, df= 8 4 , f = 7.75, p = 0.000). These differences were taken
into account in the comparison of FES ratings between the three
groups (see below).

Measures
The Family Environment Scale (FES), The Family Environment Scale
has three forms: R (Real - people’s perceptions of family functioning,
which was used in this study), I (Ideal - people’s perceptions of the
family they would ideally like) and E (Expectations - what people

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302 Panos Vostanis and Judith Nicholls
TABLE 1 Description of the three groups

Conduct Emotional
disorders disorders Controls

Sample size (n) 30 30 30

Sex
Female 10 11 15
Male 20 19 15

Social class
Manual 25 11 13
Non-manual 5 19 17

Child age
Mean 8.7 9.4 8.8
SD 1.9 1.4 1.5
Min-Max 6-1 1 7-1 1 6-1 1

Parental status
Both biol. parents 15 16 24
Single parent 8 11 2
Biol. and stepparent 7 1 3
Foster/adoptive 0 2 1

Maternal age
Mean 34.0 39.4 37.9
Min-Max 23-45 3 1-46 3 1-46

Paternal age
Mean 37.6 41.8 40.4
Min-Max 23-59 30-55 30-52

expect a family climate to be like). It is intended to measure ten sub-

scales on three dimensions (Moos and Moos, 1976; Billings and
Moos, 1982; and see Table 2): Relationships (Cohesion, Express-
iveness, Conflict), Personal Growth (Independence, Achievement
Orientation, Intellectual-Cultural Orientation, Active-Recreational
Orientation, Moral-Religious Emphasis), and System Maintenance
(Organization, Control). Each informant is given a booklet with 90
statements describing different aspectslhabits of hislher family. He/
she is asked to mark with ‘X’whether each statement is True or False
on a separate answer sheet, and the total score is estimated for each
sub-scale (with a high score positive, and a maximum score of 9, for
each sub-scale).

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 The Family Environment Scale and EE 303
TABLE 2 Family Environment Scale: dimensions and subscales lfrom Moos and Moos, 1986)

A. Relationshq Dimensions
1. Cohesion: degree of commitment, help and support family members provide
for each other.
2. Expressiveness: extent to which family members are encouraged to act openly
and to express their feelings.
3 . ConJict: amount of openly expressed anger, aggression and conflict in the
family.

B. Personal Growth Dimensions

4. Independence: extent to which family members are assertive and self-
suficient, and make their own decisions.
5 . Achievement Orientation: extent to which activities (e.g. school or work) are
seen in a n achievement-oriented or competitive manner.
6. Intellectual-Cultural Orientation: interest in political, social, intellectual and
cultural activities.
7. Active-Recreational Orientation: participation in sociallrecreational activities.
8. Moral-Religious Emphasis: emphasis on ethicallreligious issues and values.

C. System Maintenance Dimensions

9. Organization: degree of clear organization and structure in planning family
activities and responsibilities.
10. Control: set rules and procedures used to run family life.

The FES sub-scales have been found to have good internal

consistency and test-retest reliability Uacon and Tennenbaum, 1988;
Moos, 1990). The FES sub-scales (e.g. Cohesion and Conflict) have
been found to describe similar concepts to those measured by other
family assessment instruments (Holahan and Moos, 1983; Bloom,
1985), which supported their construct validity (Moos and Moos,
1986). Moos ( 1990) asked nine independent raters to assign 45 FES
items to one of five sub-scales. The finding that at least six of the
raters (67%) categorized correctly 39 of the 45 items provided
evidence, according to the authors, for the good content and face
validity of the FES items and sub-scales. In this study, the FES was
completed by both parents, if they were available, at the first
assessment.

The Camberwell Family Interview (Expressed Emotion ratings). This was

originally developed by Brown and Rutter (1966) and was later
abbreviated and modified into its present form by Vaughn and Leff
(1976). The CFI is a semi-structured interview with a family member
or carer that collects information on family life and parental attitudes

@ 1995 The Association for Family Therapy

304 Panos Vostanis and Judith Nicholls
about the identified individual during the previous three months.
Expressed Emotion consists of two frequency scales, Critical and
Positive Comments, and three global, Warmth, Emotional Over-
Involvement (both scales 0-5) and Hostility (scale 0-3). Previously
defined criteria (Vaughn and Leff, 1976) were used.
The construct of EE has been found to be reliable if used by trained
raters (Parker et al., 1988). Its concurrent validity has been tested
against several interactional measures (Kuipers, 1979), and its
predictive validity has been supported by its ability to predict relapse
in schizophrenia and other psychiatric disorders (Hooley, 1985;
Kuipers, 1987). The interviewer (PV) had been trained in the use of
the CFI and in rating EE. In this study, audiotapes were scored for
EE by an independent rater ('JN). The rater was trained by rating the
same CFI materials. In addition, a pilot study was undertaken on the
reliability of EE ratings in a separate sample of referred and non-
referred children. The interviewer and the rater independently scored
interviews with 18 parents, and their inter-rater reliability was
supported (Spearman rank correlation coefficient of at least 0.80 for
each EE scale). I n this study, parents were interviewed jointly, as it
has been found that reliable ratings of Expressed Emotion can be
made when two parents are present (Szmukler et al., 1987; Berkowitz,
1987). All interviews were audiotape-recorded. Expressed Emotion
was independently rated for each parent. The rater was blind to the
group status of the subjects.

The Child Behaviour Checklist (CBCL). This is a widely used question-

naire measuring child behaviour and child social competence
(Achenbach and Edelbrock, 1983). Behavioural items are classified
into Externalizing and Internalizing symptoms. The CBCL has been
standardized in large clinical and non-referred samples (Barkley,
1988). It has been found to be highly reliable (Achenbach and
Edelbrock, 1983) and its construct validity has been supported by
high correlation with other behaviour rating scales (Fombonne, 1989)
and clinical interview schedules (Verhulst and Van der Ende, 1991).
The CBCL was completed by mothers at the first assessment and at
nine months, as it has been found to be a valid measure of child
psychopathology (McConaughy et al., 1992). In addition to the
CBCL, three other outcome data were rated from the clinical case
notes at nine months:

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 The Family Enuironment Scale and EE 305
0 clinical change of the child at the last outpatient contact: worse/no
change, slight/some improvement, much improvement/recovery;
0 presence of child psychiatric disorder at the last clinical contact:
psychiatrically normal or trivial/minor abnormalities, definite
disorder with a degree of handicap; and
0 clinical status at nine months: still in attendance/surveillance,
discharged, lapsed.

Results
(a) Comparison of F E S ratings between the clinical and the control group
Comparison of maternal ratings. Mothers of non-referred children (n =
29) rated their family environments significantly higher than mothers
of children with psychiatric disorders (n = 50) on Cohesion (Mann-
Whitney test, z = 2.20, p = 0.03), Expressiveness ( z = 3.20, p =
O.OOl), Intellectual-Cultural Orientation (2 = 3.39, p = 0.000) and
Active-Recreational Orientation ( z = 2.38, p = 0.02), and lower on
Moral-Religious Emphasis ( z = 2.31, p = 0.02).

Comparison of paternal ratings. Significant differences were detected in

the same FES scales as rated by fathers of non-referred (n = 22) and
referred children (n = 19). Fathers of controls rated the scales of
Cohesion (Mann-Whitney test, z = 2.17,p = 0.03), Expressiveness ( z
= 2.60, p = 0.009), Intellectual-Cultural Orientation ( z = 3.48, p =
0.000) and Active-Recreational Orientation higher ( z = 1.99, p =
0.046), and the scale of Moral-Religious Emphasis lower ( z = 2.65, p
= 0.008).

Comparison of mothers’ and fathers’ F E S ratings. Within the clinical group,

the associations between maternal and paternal ratings were tested by
Pearson correlation test. A high degree of agreement was found
between parents on all FES scales, with the exception of Independ-
ence (n = 16; Table 3). Similarly, parents of controls were found to
agree significantly on all FES scales, with the exception of Independ-
ence and Control (n = 22; Table 3).

(6) F E S ratings in the CD and ED groups

Maternal F E S ratings (Table 4). The three groups (CD: n = 23, ED: n = 27
and controls: n = 29) were significantly distinguished by four FES
scales (K-Wallis test), i.e. Expressiveness (x2 = 11.3, p = 0.003),

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306 Panos Vostanis and Judith Nicholls
TABLE 3 Association between maternal and paternal FES ratings (Pearson correlation
coef$cient)

Clinical group: Controls:

Mothers-fathers Mothers-fathers
(.*I (r*)
FES scale (n = 16) P** (n = 22) P**

Cohesion 0.71 0.0002 0.87 0.000

Expressiveness 0.80 0.000 0.52 0.0 12
Conflict 0.82 0.000 0.51 0.016

Independence 0.26 0.33 0.33 0.13

Achievement Orientation 0.66 0.005 0.62 0.002
Intell-Cultural Orientation 0.60 0.014 0.77 0.000
Active-Recreat. Orientation 0.94 0.000 0.85 0.000
Moral-Religious Emphasis 0.73 0.001 0.84 0.000

Organization 0.84 0.000 0.60 0.003

Control 0.88 0.000 0.23 0.30

*r: Pearson correlation coefficient

**p: level of statistical significance

Intellectual-Cultural Orientation (X' = 13.3, p = O.OOl), Active-

Recreational Orientation (x2
= 6.3, p = 0.04), and Moral-Religious
Emphasis (x2
= 9.7, p = 0.008).
The differences in maternal ratings of Expressiveness and Intel-
lectual-Cultural Orientation were accounted for by high scores in the
controls. The differences in the ratings of Active-Recreational
Orientation were mainly accounted for by low scores in the CD group,
and in maternal ratings of Moral-Religous Emphasis by high scores in
the ED group. When demographic variables were controlled for,
Expressiveness and Intellectual-Cultural Orientation still distin-
guished between the three groups. In contrast, differences in maternal
ratings of Active-Recreational Orientation were mediated by social
class (stepwise multiple regression, jl = 0.90, p = 0.08), and
differences in ratings of Moral-Religious Emphasis by social class @ =
0.99, p = 0.35) and parental status (no variable was entered in this
equation).

Paternal FES ratings. Three of these scales as rated by fathers also

distinguished between the three groups (CD, ED and controls), i.e.
Expressiveness (K-Wallis test: x2
= 6.8, p = 0.032 - high score in

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 The Family Environment Scale and EE 307
TABLE 4 Maternal FES ratings (Kruskal- Wallis Analysis of Variance)

Conduct Emotional
disorders disorders
FES scale (n = 23) (n = 27) (n = 29) x2 P

Cohesion 36.4 35.3 47.2 4.8 0.09

Expressiveness 37.4 30.7 50.7 11.3 0.003
Conflict 40.5 39.7 39.9 0.01 0.99

Independence 38.4 34.7 46.1 3.7 0.16

Achievement Orientation 40.4 41.7 38.1 0.4 0.83
Intell-Cultural Orientation 28.6 37.4 51.4 13.3 0.001
Active-Recreat. Orientation 32.5 37.8 48.0 6.3 0.04
Moral-Religious Emphasis 37.2 50.6 32.3 9.7 0.008

Organization 42.4 35.3 42.6 1.7 0.42

Control 43.1 43.7 34.1 3.1 0.20

controls), Intellectual-Cultural Orientation (x2

= 12.5, p = 0.001 -
high scores in controls), and Moral-Religious Emphasis = 7.2,p = (x2
0.027 - low scores in controls). The FES ratings were similar for the
two clinical groups. Differences in paternal ratings of Expressiveness
and Intellectual-Cultural Orientation were not affected by demo-
graphic variables, but ratings of Moral-Religious Emphasis ceased to
distinguish between the three groups when they were controlled for
paternal age. I t must be stressed, however, that these differences were
based on small numbers of participating fathers (CD: n = 11, ED: n
= 8, and controls: n = 22).

(c) Relationship between maternal EE and FES ratings. Because of the

small numer of fathers who completed the FES and were also rated for
EE, this analysis was restricted to maternal ratings. The pairs of EE-
FES scales that measure similar concepts were compared, i.e. Critical
Comments-Conflict, Warmth-Cohesion, Positive Comments-
Expressiveness, and Emotional Over-Involvement-Control. The
Pearson coefficient of correlation was estimated for each pair within
each of the three groups (Table 5). In the CD group (n = 2 3 ) , the only
scales that were significantly correlated were ratings of maternal
criticism and mothers’ ratings of family conflict. In the ED (n = 27)
and the control group (n = 28), none of the four pairs of EE-FES
scales was found to be significantly correlated.

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308 Panos Vostanis and Judith Nicholls
TABLE 5 Relationship between maternal EE and FES ratings (Pearson coefficient of
correlation)

Children with conduct disorders (n = 23)

Critical Comments-Conflict R = 0.51 (p < 0.01)
Warm th-Cohesion R = 0.30 (NS)
Positive Comments-Expressiveness R = 0.16 (NS)
EOI-Con trol R = -0.03 (NS)
Children with emotional disorders (n = 21)
Critical Comments-Conflict R = -0.04 (NS)
Warmth-Cohesion R = -0.01 (NS)
Positive Comments-Expressiveness R = 0.29 (NS)
EOI-Control R = -0.06 (NS)

Non-referred children (n = 28)

Critical Comments-Conflict R = 0.35 (NS)
Warm th-Cohesion R = -0.11 (NS)
Positive Comments-Expressiveness R = -0.22 (NS)
EOI-Con trol R = 0.32 (NS)

This lack of significant associations indicates that mothers’

perceptions of their family environment are not consistent with
observational measures of their attitudes towards their children. In
order to investigate the relationship between self-reported and
independent ratings further, it was important to know which of the
two constructs was more strongly associated with child behaviour
ratings within the CD and ED groups.

(d) Which of the two constructs (maternal EE, FES) was more strongly
associated with CBCL ratings?
Within each of the three groups, one FES sub-scale and the
corresponding EE scale were entered as independent .variables in a
stepwise multiple regression, with one of the CBCL scores (external-
izing, internalizing or social competence) as the dependent variable.
In the C D group, lack of maternal warmth was significantly
associated with the level of externalizing symptoms (13 = -0.60, p =
0.003), in contrast with maternal ratings of cohesion (13 = 0.02, p =
0.92). Similarly, critical comments were significantly associated with
externalizing symptoms (13 = 0.56, p = 0.007), but this was not true
for ratings of conflict (13 = 0.12, p = 0.57).

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 The Family Enuironment Scale and EE 309
I n the ED group, the reverse pattern was established in that ratings
of cohesion predicted levels of social competence f$ = 0.45, p =
0.026), which was not true for maternal warmth @ = 0.04, p = 0.81).
In the control families, criticism predicted both externalizing f$ =
0.63, p = 0.0002) and internalizing symptoms @ = 0.45, p = 0.013),
and impaired social competence p = -0.43, p = 0.022), but no
significant association was found for ratings of conflict. Maternal
cohesion and warmth were negatively correlated with externalizing
symptoms (cohesion: j3 = -0.52, p = 0.006; warmth: j3 = -0.43, p =
0.0006). I n addition, cohesion predicted social competence (13 = 0.41,
p = 0.03).

(e) Outcome data and testing the predictive validity of F E S scales

Different types of treatmendmanagement were employed: in 11 CD
(37%) and nine ED families (30%) family work/family therapy,
including the use of behavioural techniques, was used. The rest were
offered advice (seven CD and seven ED), educational or social
services provision (six CD), individual psychotherapy (psycho-
dynamic or cognitive-behavioural: two C D and eight ED), inpatient
admission (four ED), medication (one ED), or no treatment after the
initial assessment (four CD and one ED).
At the time of follow-up, 16 CD (54%) and five ED families (1 7%)
had lapsed from treatment (x2
= 9.07, d f = 2, p = 0.011). Fourteen
children with CD (47%) had not changed or were symptomatically
x2
worse, in contrast with two children with ED (7% - = 13.25, a'f=
2 , p = 0.001). Eighteen children with CD (60%) and nine children
with ED (30%) still fulfilled criteria for a psychiatric disorder with
some degree of handicap (x2
= 5.45, df= 1, p = 0.02 - described in
Vostanis and Nicholls, forthcoming).
In order to test the predictive validity, the FES Relationships scales
were entered together with the corresponding EE scale as the
independent variables in a stepwise multiple regression analysis, with
changes in CBCL scores at nine months (symptoms or social
competence) or clinical outcome at the last contact, with the clinician
as the dependent variable. In the CD group, ratings of maternal
conflict predicted dropping-out of treatment f$ = 0.51, p = 0.012).
Although lack of maternal warmth at the time of the first assessment
was found to predict presence of psychiatric disorder at the last
clinical contact (13 = -0.45, p = 0.03), this was not established for
ratings of maternal cohesion f$ = -0.21, p = 0.29). Maternal

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310 Panos Vostanis and Judith Nicholls
cohesion was, however, predictive of clinical improvement 0 = 0.38, p
= 0.049), and ratings of maternal control predicted poor clinical
outcome in the E D group 0 = -0.39, p = 0.04).
Finally, the power of FES scales to predict Expressed Emotion at
nine months was tested. Initial scores of corresponding FES and EE
scales were entered as independent variables in a stepwise multiple
regression, with levels of the EE scale at nine months as the dependent
variable. Maternal ratings of control were significantly associated
with levels of emotional over-involvement at nine months in the ED
group (J’ = 0.45, p = 0.02).

Discussion
Measures of family functioning are used for both clinical and research
purposes. Such measures may be used to describe patterns of family
life and pathology, as potential predictors of outcome, or as outcome
measures themselves. Self-completed questionnaires such as the
Family Environment Scale are easier to administer than observational
and/or independently rated instruments that require training. They
are also less expensive and time-consuming. However, their validity
needs to be tested in cross-sectional and longitudinal studies. This
was the aim of this paper.
Several scales of the FES were found to distinguish between the two
groups of referred families and the control group of ‘normal’ families.
This was consistent for mothers and fathers. Not surprisingly, the
FES scales indicate better family functioning in the control families,
i.e. higher levels of expressiveness/communication, cohesion and
emphasis on social activities. O n the other hand, no difference was
detected on self-ratings of conflict. This was contrary to clinical
impression, as one would expect higher levels of conflict in families of
children with psychiatric disorders. Scoresby and Christensen ( 1976)
had previously found higher expressiveness, cohesion and organiza-
tion, and lower conflict in non-clinical than clinical families. They
interpreted the findings as indicative of more complementary and
symmetrical interaction in the clinical families and more parallel
interaction in the non-clinical families.
Parents in both groups had a high degree of agreement on most
FES scales. Mothers and fathers had similar perceptions of their
family relationships (which include cohesion, conflict and express-
iveness). Of course this does not imply the lack of conflict in clinical
families - the association merely indicates that spouses were aware of

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 The Family Environment Scale and EE 31 1
similar patterns of family functioning. A consistent finding was the
lack of agreement in clinical and control families on the role of
independence within their family. Whether this factor has a causal
role in maladaptive relationships needs to be explored further.
FES scores were not significantly different between parents of
children with conduct and emotional disorders. The only exception
was the sub-scale of active-recreational orientation, which was
particularly low for mothers of children with conduct disorders.
McGee et al. (1984) found that children with aggression or hyper-
activity had reports of poor family relationships as detected by the
FES (global ratings), compared with children without these charac-
teristics. This question needs to be re-addressed in future studies with
more homogenous clinical/family characteristics.
The association between maternal criticism and self-reported
conflict in the group of children with conduct disorders was consistent
with Hibbs et al. (1993). They found an association between family
conflict and high levels of Expressed Emotion, which was mainly
determined by the number of critical comments. Criticism is the
strongest predictor of child psychopathology in non-clinical and
clinical samples (Hibbs et al., 1991; Vostanis and Nicholls, 1992;
Vostanis, 1994). In this study, the independently rated measure of
Expressed Emotion (particularly the scales of Critical Comments and
Warmth) was found to be more strongly associated with child
behaviour ratings than the parent-rated Family Environment Scale.
Although the two widely used instruments have not been developed to
measure the same dimensions, they do describe similar aspects of
family functioning. One would therefore expect to find an association
between some of their scales. This has not been confirmed. The lack of
association could be explained in two ways.
(a) By raising questions about the validity of the FES (and
particularly the scale of Conflict, Expressiveness and Control)
and of other self-completed measures of family functioning.
Questions about the validity of certain sub-scales of the FES have
already been raised by Roosa and Beak (1990a and 1990b).
(b) Even if family conflict is present and rated by an independent
assessor, it is not perceived as such by the family. This hypothesis
may apply specifically to parents of children with conduct
disorders and may have implications for family therapy tech-
niques. Families, for example, may be facilitated to acknowledge
underlying conflict and to develop better coping strategies.

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312 Panos Vostanis and Judith NichollJ
In contrast with previous studies with adult patients and their
families, the Family Environment Scale was not found overall to
predict clinical outcome. High ratings of conflict by mothers of
children with conduct disorders predict dropping-out of treatment,
which may be a mediating factor leading to poor outcome. A similar
association has been established between parental criticism, dropping-
out of treatment and continuing symptoms in adolescents with eating
disorders (Szmukler et al., 1985; Le Grange et al., 1992). Generating
conclusions on the predictive value of the FES from this study is
limited because of the different types of treatment used by the
clinicians. A previous study showed that Expressed Emotion is a
potentially useful measure of change in family therapy (Vostanis et al.,
1992). I t would be interesting to replicate this finding by also
administering the FES during family therapy, and to include FES
ratings by both parents and children (the latter was not possible in
this study, as all children were between 6 and 11 years of age).

Conclusion
The use of the Family Environment Scale, which was used as a
representative self-completed measure of family life, revealed some
interesting patterns within the clinical and the control group, and
some differences between the two groups, particularly in the
communication and expression of feelings. The lack of diagnostic
specificity was not surprising but one would expect higher levels of
self-reported conflict in the referred families. With the exception of the
association between self-rated conflict and independently rated
criticism in the CD group, neither the construct nor the predictive
validity of the FES as a whole or of the Relationships dimension were
supported. Although the findings obviously require replication in
different samples, self-reported measures of family functioning should
be used with caution by clinicians. They should preferably be used to
complement clinical assessment, observational instruments of family
functioning and outcome measures of symptomatic change.

Acknowledgement
We are grateful to all families who participated in the study. We
would also like to thank all consultant child psychiatrists at the
Heathlands Unit for their help. The study was partly funded by the
Queen Elizabeth Psychiatric Hospital Research Fund.

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 The Family Environment Scale and EE 313

References
Achenback, T. M. and Edelbrock, C. (1983) Manual for the Child Behavior Checklist and
Revised Child Behavior Profile. Burlington: University of Vermont Publishers.
Barkley, R. (1988) Child behavior ratings and checklists. In: M. Rutter, A. H. Tuma
and I. S. Lann (eds) Assessment and Diagnosis in Child Psychopathology. London: Fulton
Publishers, pp. 113-155.
Barnhill, L. (1979) Healthy family systems. The Family Coordinator, 94-100.
Berkowitz, R. (1978) Rating expressed emotion from initial family therapy sessions.
Journal of Family Therapy, 9: 27-37.
Billings, A. and Moos, R. (1982) Family environments and adaptation: a clinically
applicable typology. American Journal of Family Therapy, 10: 26-38.
Bloom, B. ( 1985) A factor-analysis of self-report measures of family-functioning.
Family Process, 24: 225-239.
Brown, G. and Rutter, M. (1966) The Measurement of family activities and
relationships. Human Relations, 19: 241-263.
Epstein, N., Baldwin, L. and Bishop, D. (1983) The McMaster Family Assessment
Device. Journal of Marital and Family Therapy, 9: 171-180.
Finney, J., Moos, R. and Mewborn, R. (1980) Posttreatment experiences and
treatment outcome of alcoholic patients six months and two years after hospitaliza-
tion. Journal of Consulting and Clinical Psychology, 48: 17-29.
Fombonne, E. (1989) The Child Behavior Checklist and the Rutter Parental
Questionnaire. Psychological Medicine, 19: 777-785.
Hibbs, E., Hamburger, S., Kruesi, M. and Lenane, M. (1993) Factors affecting
expressed emotion in parents of ill and normal children. American Journal of
Orthopsychiatry, 63: 103-1 12.
Hibbs, E., Hamburger, S., Lenane, M., Rappoport, J., Kruesi, M., Keysor, C. and
Goldstein, M. (1991) Determinants of expressed emotion in families of disturbed
and normal children. Journal of Child Psychology and Psychiatry, 32: 757-770.
Holahan, C. and Moos, R. (1986) The quality of social support: measures of family
and work relationships. British,Journal of Clinical Psychology, 22: 157-162.
Hooley, J. (1985) Expressed emotion: a review of the critical literature. Clinical
Psychology Review, 5 : 119-139.
Jacob, T. and Tennenbaum, D. (1988) Family assessment methods. In: M. Rutter,
A. H. Tuma and I. S. Lann (eds) Assessment and Diagnosis in Child Psychopathology,
London: Fulton Publishers, pp. 196-231.
Kinston, W. and Loader, P. (1986) Preliminary psychometric evaluation of a
standardized clinical family interview. Journal of Family Therapy, 8: 35 1-369.
Kuipers, L. (1970) Expressed emotion: a review. British Journal of Social and Clinical
PsychoLou, 18: 237-243.
Kuipers, L (1987) Research in expressed emotion. Social Psychiatry, 22: 216-220.
Le Grange, D., Eisler, I., Dare, C. and Hodes, M. (1992) Family criticism and
self-starvation: a study of expressed emotion. Journal of Family Therapy, 14: 177-192.
McConaughy, S., Stanger, C. and Achenbach, T. (1992) Three-year course of
behavioral/emotional problems in a national sample of 4- to 16-year-olds:
I. Agreement among informants. Journal of the American Academy of Child and
Adolescent Psychiatry, 31: 932-940.
McGee, R., Williams, S. and Silva, P. (1984) Background characteristics of

@ 1995 The Association for Family Therapy

314 Panos Vostanis and Judith Nicholls
aggressive, hyperactive, and aggressive-hyperactive boys. Journal of the American
Academy of Child Psychiatry, 23: 280-284.
Moos, R. (1986) The Social Climate Scales. Palo Alto, CA: Consulting Psychologists
Press.
Moos, R. (1990) Conceptual and empirical approaches to developing family-based
assessment procedures: resolving the case of the Family Environment Scale. Family
Process, 29: 199-208.
Moos, R. and Moos, B. (1976) A typology of family social environments. Family
Process, 15: 357-371.
Moos, R. and Moos, B. (1986) Family Environment Scale - Manual (2nd ed). Palo Alto,
CA: Consulting Psychologists Press.
Parker, G., Johnston, P. and Hayward, L. (1988) Parental expressed emotion as a
predictor of schizophrenic relapse. Archives of General Psychiatry, 45: 806-8 13.
Pless, I. and Satterwhite, B. (1973) A measure of family functioning and its
application. Social Sciences and Medicine, 7: 613-621.
Roosa, M. W. and Beals, J. (1990a) Measurement issues in family assessment: the
case of the Family Environment Scale. Family Process, 29: 191-198.
Roosa, M. W. and Beals, J. (1990b) A final comment on the case of the Family
Environment Scale. Family Process, 29: 209-21 1.
Scoresby, A. L. and Christensen, B. (1976) Differences in interaction and environ-
mental conditions of clinic and non-clinic families: implications for counselors.
Journal of‘Marriage and Family Counseling, 63-7 1.
Spiegel, D. and Wissler, T. (1983) Perceptions of family environment among
psychiatric patients and their wives. Family Process, 22: 539-549.
Spiegel, D. and Wissler, T. (1986) Family environment as a predictor of psychiatric
rehospitalization. American Journal of Psychiatv, 143: 56-60.
Szmukler, G., Berkowitz, R., Eisler, I., LefY, J. and Dare, C. (1987) Expressed
emotion in individual and family settings. British Journal ofPsychiatry, 151: 174-1 78.
Szmuklv, G., Eisler, I., Russell, G. and Dare, C. (1985) Anorexia nervosa, parental
‘expressed emotion’ and dropping out of treatment. British Journal ofPsychiatry, 147:
265-27 1.
Vaughn, C. and Leff, J, (1976) The measurement ofexpressed emotion in the families
of schizophrenic patients. British Journal of Social and Clinical Psychology, 15: 157-165.
Verhulst, F. and Van der Ende, J. (1991) Assessment of child psychopathology:
relationships between different methods, different informants and clinical judgment
of severity. Acta Psychiatrica Scandinavia, 84: 155-1 59.
Vostanis, P. (1994) The role of parental expressed emotion in conduct and emotional
disorders of childhood. Unpublished MD thesis, University of Birmingham.
Vostanis, P., Burnham, J. and Harris, Q. (1992) Changes of expressed emotion in
systemic family therapy. Journal of Family Therapy, 14: 15-28.
Vostanis, P. and Nicholls, J. (1992) Expressed emotion in parents of non-referred
children aged 6 to 11 years from two school populations. Child: Care, Health and
Development, 18: 249-257.
Vostanis, P. and Nicholls, J. (forthcoming) Nine-month changes in maternal
expressed emotion in conduct and emotional disorders of childhood. Journal of Child
Psychology and Psychiatry.
Vostanis, P., Nicholls, J. and Harrington, R. (1994) Maternal expressed emotion in
conduct and emotional disorders of childhood. Journal of Child Psychology and
Psychiatry, 35: 365-376.

@ 1995 The Association for Family Therapy

 The Family Environment Scale and EE 315
Walsh, F. (ed.) (1982) Normal Family Processes. New York: Guilford.
World Health Organization ( 1978) International Classification of Diseases, 9th Revision.
Geneva: World Health Organization.
World Health Organization ( 1992) International Classajication of Diseases, 10th Revision.
Geneva: World Health Organization.

@ 1995 The Association for Family Therapy