Comparison of family functioning in families of depressed patients and nonclinical control families in China using the Family Assessment Device and the Family Adaptability and Cohesion Evaluation Scales II
Department of Psychiatry, West China Hospital, Sichuan University, Chengdu, China
Department of Social Work and Social Administration, University of Hong Kong, Hong Kong, Department of Psychiatry, West China Hospital, Sichuan University, Chengdu, China
Department of Psychiatry, West China Hospital, Sichuan University, Chengdu, China
Department of Psychiatry, West China Hospital, Sichuan University, Chengdu, China
Department of Psychiatry, West China Hospital, Sichuan University, Chengdu, China
The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USAGabor Keitner, MD
The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
Background: Family functioning influences the course and long-term outcome for patients with depression. It is important to understand the family functioning of depressed patients from the viewpoint both of patients and their family members. The objective of this study was to explore the association between family functioning and depression in a sample of Chinese families, using the Family Assessment Device (FAD) and the Family Adaptability and Cohesion Evaluation Scales II (FACES II).
Method: This study was conducted in a sample of 61 depressed patients and their family members and 61 nonclinical controls in mainland China. It compared the perception of depressed patients and their family members and evaluated agreement between family members.
Results: Results indicate that in mainland China, functioning among families with a depressed family member is poorer than that of control families. Depressed patients reported less satisfaction than did their family members. There were significant differences on 4 of the 7 FAD scales among depressed patients and their family members, whereas no discrepancies were found on the FACES II. For the FAD, low agreement between patients and family members was found on all scales except behavioral control. Moderate agreement appeared on all dimensions of FACES II except for ideal cohesion and dissatisfaction with cohesion for the families of depressed patients.
Conclusions: Depression is associated with impaired family functioning in families in mainland China. When applying the FAD and FACES II to samples of Chinese families, clinicians should be aware that the FAD may be more sensitive to detecting problems in some areas than the FACES II.
Keywords: family functioning, depression, Family Assessment Device, Family Adaptability and Cohesion Evaluation Scales II
ANNALS OF CLINICAL PSYCHIATRY 2014;26(1):47-56
Depression is one of the most common mental disorders worldwide and often is a chronic illness that recurs over many years.1 Depression creates a heavy burden both for patients and their family members. Research has found that depressed patients endorse more physical, psychological, and social problems than do healthy control subjects.2,3 Benazon et al4 found that individuals living with a depressed spouse reported more depressed mood than the general population and experienced specific burdens, such as missing work, problems with neighbors, and financial stress.
Many studies have explored differences between families with a depressed member and those without, ie, nonclinical families. Evidence indicates that families with depressed family members experience significant impairment in family functioning.5-8 Even after the remission of an acute exacerbation of major depression, family functioning does not immediately return to normal.9 Family functioning also plays an important role in recovery from depression. For example, Keitner et al10 have suggested that unhealthy family functioning is associated with a slower rate of recovery from a depressive episode. Goodyer et al11 found that healthy family functioning increased the chances of early recovery for the depressed individual. In summary, family functioning influences the course and long-term outcome of depression.12
It is important to understand the family functioning of depressed patients from the viewpoint of patients and their family members. Previous research has suggested that depressed patients perceive family functioning differently than their family members do. For example, Keitner et al13 found that suicidal depressed patients viewed their family functioning more negatively than did their family members. Tamplin et al14 reported that adolescents with depression perceived family functioning more negatively than did their parents. A possible reason for the discrepancy may be that depressed patients’ assessment of family functioning is distorted by their negative mood.15 There are important clinical implications of understanding family functioning in families with a depressed family member because it may predict patients’ clinical outcomes.16 Family interventions have the potential to improve the prognosis of depressed patients and to ameliorate quality of life for patients and their family members.17,18
Most previous studies on family functioning of depressed patients were conducted in Western cultures and used the Family Assessment Device (FAD). The FAD has demonstrated consistently solid psychometric data in Western countries.19 Although the validity and reliability of the Chinese FAD has been demonstrated,20 researchers in mainland China also commonly use the Chinese version of the Family Adaptability and Cohesion Evaluation Scales II (FACES II), which has demonstrated validity in Chinese populations.21 The results of previous studies using the FACES II found deficits in family cohesion and adaptability in Chinese patients with depression.22,23
The FAD and the FACES II originated from different theories of family functioning and therefore measure different facets of family life. To compare the characteristics of family functioning among Chinese families (defined as parents and their children) with a depressed family member, it may be important to use both the FAD and the FACES II. The present study is the first of its kind to employ the FAD and the FACES II to investigate family functioning in families with a depressed family member in a mainland Chinese sample. It also compares patient ratings to family member ratings.
The objectives of this study were: 1) to explore differences in family functioning between families with a depressed adult and nonclinical families in a mainland Chinese population; 2) to investigate whether depressed patients and their family members perceive family functioning differently; and 3) to compare the characteristics of family functioning using the FAD and FACES II in a mainland Chinese sample.
The sample was composed of 61 depressed Chinese patients who met DSM-IV criteria for major depressive disorder and their family members, and 61 nonclinical comparison individuals and their family members. The participants were inpatients from the Mental Health Center, West China Hospital of Sichuan University, China. If patients with major depressive disorder were living with ≥1 family members ≥50 hours per week, they were invited to participate in this study along with 1 family member. If patients lived with >1 family member, 1 family member (eg, parent, spouse) was chosen to participate in the study using the method of simple random sampling. The nonclinical sample was recruited from a community near the Sichuan University in Chengdu (all were volunteers who had seen our advertisement posted on a bulletin board for nearly 4 months). To match with the number of subjects in the depressed group, 2 family members were recruited from each family, and their relationship had to match a family relationship in the depressed patients’ group. As in the patient sample, nonclinical subjects also needed to live together ≥50 hours each week. Exclusion criteria for all participants included comorbid mental disorders; neurologic disorders; severe physical problems that might make the patients unable to complete the questionnaires, eg, amputation; and active substance abuse or dependence within the 3 months prior to the study. Nonclinical subjects did not have a history of any psychiatric disorder. The study was approved by the institutional review board of West China Hospital. Informed consent was obtained from all participants before the study.
The demographic questionnaire items included sex, age, role in the family, marital status, employment, and number of years of education. Patients with major depressive disorder were diagnosed by the attending psychiatrists using DSM-IV criteria. The diagnosis was confirmed according to DSM-IV criteria by the study psychiatrist (MJ.S.T.).
The Family Assessment Device (FAD)24 was developed to measure perceptions of family functioning based on the McMaster Model of Family Functioning.25 The FAD is a 60-item self-report questionnaire with each question answered on a 4-point scale (1 represents strongly agree, and 4 represents strongly disagree). It measures the 6 dimensions of the McMaster Model of Family Functioning and provides an additional measure of overall family functioning. The first dimension is problem solving (PS), which refers to the family’s ability to solve problems. Communication (CM) is the second dimension, which refers to whether communication in the family is clear and direct or vague and indirect. The third dimension is roles (RL), which addresses the issue of how roles and responsibilities are allocated among family members. The fourth dimension is affective responsiveness (AR), which refers to family members’ ability to respond to a range of situations with appropriate quality and amount of emotion. The fifth dimension, affective involvement (AI), refers to how family members experience interest in and involvement with each other. Behavioral control (BC), the sixth dimension, assesses whether the family has norms or standards governing individual behavior and responses to emergency situations. The additional dimension, general functioning (GF), assesses the overall health/pathology of the family. On all dimensions, higher scores represent less satisfaction with family functioning.
Cutoff values for each scale have been established to distinguish between healthy and unhealthy functioning.26 Family intervention may be recommended if family mean scores exceed the established cutoffs on ≥4 of the 7 scales or if the family’s mean GF score is in the unhealthy range (>2.0).27 The Chinese version of FAD used in this study was validated by Shek et al.28 In that study, the internal consistency (as measured by Cronbach α) of the 6 dimensions varied widely (PS, α=0.68; CM, α=0.66; RL, α=0.68; AR, α=0.57; AI, α=0.67; and BC; α=0.55; as well as GF, α=0.85) and test-retest reliability was acceptable (intraclass correlation coefficient [ICC]=0.56 to 0.85).29 Similarly, the internal consistency of all dimensions from our sample presented in this study also varied widely: PS, α=0.69; CM, α=0.76; RL, α=0.71; AR, α=0.68; AI, α=0.86; BC, α=0.56; and GF, α=0.89. The internal consistency of the BC scale was poor in both samples and, therefore, should be interpreted cautiously.
The Family Adaptability and Cohesion Evaluation Scales II (FACES II)30 was designed to evaluate family cohesion and adaptability, concepts based on the Circumplex Model of Family Functioning. The FACES II is a 30-item self-report questionnaire with each question answered on a 5-point scale (0 represents almost never, and 4 represents almost always). Levels of dissatisfaction with family functioning are measured as follows: participants answer all 30 items twice. The first time, they rate their perception of actual conditions in the family, and the second time they rate their ideal family condition. The difference between perceptions of actual and ideal conditions yields a discrepancy score, which measures participants’ dissatisfaction with family functioning.31 Cohesion is defined as the degree of emotional bonding between family members, and adaptability refers to the ability of the family system to change in response to situational and developmental stress. The Chinese version of FACES II used in this study was translated by Phillips,21 and its psychometric properties were found to be satisfactory and appropriate for use in China.32 In the Phillips study, the internal consistency of all of the scales was as follows: perceived cohesion, α=0.85; ideal cohesion, α=0.76; perceived adaptability, α=0.73; and ideal adaptability, α=0.68. The test-retest reliability was acceptable (ICC=0.54 to 0.91). Similarly, the internal consistency of all scales from our sample was satisfactory (perceived cohesion, α=0.84; ideal cohesion, α=0.81; perceived adaptability, α=0.71; and ideal adaptability, α=0.72).
Descriptive statistics were computed for all variables. Differences between categorical variables were analyzed with chi-square tests. Independent t tests were used to compare the mean scores of FAD and FACES II between depressive families and control families. Paired t tests were used to compare family functioning scores of patients and their family members. Pearson’s product moment correlation was used to explore the relationship between family members. ICCs also were used to assess the level of agreement between family members. Low agreement corresponds to ICC=0 to 0.3; moderate agreement to ICC=0.3 to 0.7; and high agreement to ICC=0.7 to 1.0. All statistical analyses were carried out using SPSS, version 11.0 (SPSS Inc.), with the level of significance set at P < .05 (2-tailed test).
The demographic data on the subjects are summarized in TABLE 1. The depressed subjects and control subjects were not significantly different in age or sex composition. All subjects were age >18. There were no significant differences between the 2 groups on the distribution of family role, marital status, or education. Employment status between the 2 groups was significantly different. There were more unemployed participants in the depressive group. Given that all of the depressed participants were receiving inpatient treatment, many patients and their family members who took care of them might have resigned their jobs.
Family functioning between depressive families and control families
TABLE 2 compares family functioning between depressed families and control families. Families with depressed patients reported dysfunction in all dimensions of FAD except problem solving. Family means for control families were in the healthy range on all dimensions except behavioral control. Mean scores on all FAD scales were significantly higher in depressed families than in control families, indicating worse functioning. With regard to FACES II scales, depressed families perceived significantly less cohesion and adaptability than did control families and also endorsed more dissatisfaction on these 2 dimensions than did the control group. However, the 2 groups rated ideal conditions on cohesion and adaptability similarly.
FAD and FACES II family means, standard deviations, and comparisons between depressed and control families
||McMaster cutoff score
||Depressed (n=61), mean (SD)
||Control (n=61), mean (SD)
Proportion of unhealthy family functioning
TABLE 3 shows the proportion of healthy/unhealthy family functioning on the 7 dimensions of FAD for the depressed and control groups as determined by “healthy/unhealthy” clinical cutoff scores on each of the FAD scales (the McMaster cutoffs are shown in TABLE 2).26 Chi-square tests were used to assess differences in frequency in the number of depressed and control families in the unhealthy range on FAD scales. Significantly more depressed families were in the unhealthy range than control families on all dimensions except problem solving and roles. Additionally, all depressed families scored in the unhealthy range on behavioral control, as did most control families. When using the criterion of ≥4 scales exceeding the cutoffs to define whether the families need intervention,27 significantly more depressed families reached the criterion (78.7%) than did control families (44.3%) (χ2=15.263; df=1; P < .001). When using the family’s mean general functioning score (>2.0) to define unhealthy functioning, the depressed families had a significantly higher unhealthy proportion (77.0%) than control families (57.4%).
Frequency table depicting number of families in the healthy and unhealthy range on the FAD
|Unhealthy range, n (%)
||Healthy range, n (%)
||Unhealthy range, n (%)
||Healthy range, n (%)
FAD and FACES II scores between patients and family members
Depressed patients scored significantly higher on problem solving, communication, affective responsiveness, and behavioral control than did their family members, whereas there were no significant differences in the control group (TABLE 4). These results suggest that the depressed patients perceived family functioning more negatively than did their family members. There were no significant differences between family members on either perceived or ideal conditions on the FACES II. Similarly, there were no differences between family members on dissatisfaction scores on the FACES II.
FAD and FACES II means, standard deviations, comparisons, and agreement between patients and their family members in depressed and control families
||Patient (n=61), mean (SD)
||Family member (n=61), mean (SD)
||Patient and family ICC
||Control (n=61), mean (SD)
||Family member (n=61), mean (SD)
||Control and family ICC
Correlation/agreement between family members on the FAD and FACES II
TABLE 4 shows the correlations between family members on the FAD and FACES II scales for the 2 groups. The relationship between family scores on all scales was stronger for control families than for depressed families. There was no significant correlation between the depressed patients and their family members for any of the FAD dimensions except behavioral control, but there were significant positive correlations for all dimensions of the FACES II except ideal cohesion and its dissatisfaction.
TABLE 4 also shows agreement between family members on the 2 measures. Agreement on the FAD between depressed patients and their family members was low on all scales except behavioral control, on which agreement was in the moderate range. Agreement between family members on the FACES II among depressed families was moderate, except for ideal ratings of cohesion. For the controls and their family members, the agreement of all the dimensions on the FAD or FACES II was moderate to high.
This is the first study to use the FAD and FACES II family assessment measures to assess family functioning of depressed patients in a Chinese sample. The results of this study indicated that families with depressed patients endorsed less satisfaction with family functioning than did nonclinical families, and that depressed patients perceived family functioning less favorably than did their family members on the FAD but not the FACES II.
The results of this study replicate previous research findings that the families of depressed patients experience higher levels of dysfunction compared with nondepressed families. This was true regardless of the measurement tool used. Depressed patients, for their part, tended to perceive family functioning, as measured by the FAD, as being worse than their family members did. The FAD appears to be more sensitive to detecting discrepancies between patient and family member perceptions of functioning than does FACES II.
In the present study, depressed families reported significantly worse family functioning on all FAD scales than did nonclinical families. Previous research has found that families with a depressed member had higher mean scores than nonclinical families on all FAD scales.33,34 Furthermore, when using health/pathology cutoff scores for the FAD, Keitner et al found that depressed families evidenced a higher rate of unhealthy family functioning on the dimensions of problem solving, communication, affective involvement, and general functioning.9 The present study had similar findings, with a higher proportion of unhealthy ratings on communication, affective responsiveness, affective involvement, behavioral control, and general functioning.
The results of the present study also suggest that specific areas of impaired family functioning might vary by culture. In the Chinese culture, patients with depression might not attach a great deal of value to expressing their emotions, and may therefore score in the unhealthy range on affective responsiveness. Similarly, depressed patients and their families seem to be less satisfied with norms or standards governing individual behavior, which could explain the elevated behavioral control scores. However, problem solving for the depressed families did not differ significantly from that of the control families, which was alien to the results in the Western countries. The possible reasons may include: 1) families with a depressed family member might still solve routine matters, although with reduced efficiency, and 2) adverse effect of depression might focus mainly on affection and expression.
When using the family’s mean general functioning score (>2.0) to define unhealthy functioning, the depressed families had a significantly higher unhealthy proportion (77.0%) than control families (57.4%). When using another criterion of Akister’s approach (≥4 scales of FAD exceeding the cutoffs),27 the results of the present study showed that significantly more (78.7%) depressed families than control families (44.3%) were unhealthy enough to warrant clinical intervention. In the study by Tamplin et al, the corresponding percentages were 56% and 29%, respectively.33 The present study confirms that the dimensions of communication, affective responsiveness, affective involvement, behavioral control, and general functioning are strongly impacted by depression.
Mean scores on the behavioral control dimension of the FAD, even for the control families, were in the unhealthy range, consistent with the Wang study,29 which ascribed the elevated behavioral control scores in the control group to Chinese cultural factors that downplay individual standards of behavior. They suggested that Chinese families emphasize external authority and conformity to rules, and pay less attention to developing and enforcing internal rules of conduct for their family members. When encountering items of behavioral control in FAD, such as “Without obeying to the rules, the family member still could have no penalty,”24 they might answer it with difficulty because there had been no rule about penalties in their families. Another possibility, however, is that the authority of elders in Chinese culture makes it difficult for other family members to express their own thoughts, feelings, or opinions. They had to obey their parents’ orders, and this phenomenon made them view their family functioning on the behavioral control dimension negatively. Besides, the intensive control and deference to elders’ authority might lead to incomplete communication among family members and cause family members’ discontentment on the dimension of behavioral control. This also could explain the moderate agreement on this dimension among both depressed and control families.
There may be another plausible reason accounting for the elevated scores. Some of the behavioral control items are related to reactions to emergencies, and Chinese culture generally does not emphasize how to deal with emergencies. Elevated scores in behavioral control, therefore, might not indicate unhealthy functioning in the Chinese culture. Interpretations of behavioral control scores should be made cautiously also because of the low internal consistency of the behavioral control scale in both this sample and the Shek sample.28
FACES II results from the present study suggested that depressed families experience worse family functioning on the dimensions of perceived cohesion and adaptability than do nonclinical families. Both Western and Chinese samples have demonstrated that families with depressed patients report low cohesion and adaptability on the FACES II.31,35
As with many previous studies,14,33,36 the results of the present study indicate that the depressed patients endorsed less satisfaction than their family members on the following dimensions: problem solving, communication, affective responsiveness, and behavioral control. One explanation could be that depressive symptoms may influence perceptions of family functioning negatively.37,38 Alternatively, the behavior and attitudes of the depressed person might create an environment in which the person is rejected by his or her significant others, and this might cause that person’s poor feelings about family functioning.39
The results of this study also indicate that there was no significant correlation between patients and their family members on any of the FAD dimensions except behavioral control. Agreement on all the FAD scales for depressed families also was low except for behavioral control, whereas the agreement for control families was relatively high. This finding contradicts other studies in Western samples. Tamplin et al14 reported that there were significant correlations between parents and their depressed adolescents on mean scores of 4 out of 7 FAD scales (ie, roles, affective responsiveness, behavioral control, and general functioning), and agreement in control families was less than that of depressed families.33 The reason for this disparity could be that the depressed subjects in the Tamplin study were adolescents, whereas the subjects in this study were adults. The adolescents might have different perceptions of the family and use different criteria to define family competence. In addition, the authors of the present study suggest that depressed patients’ family members may be reluctant to communicate openly for fear of “triggering” the patient’s potential distress. Moreover, patients were prone to blocking their inner world, and their communication with family members may have decreased as a consequence. Nevertheless, effective communication is a critical ingredient for healthy family functioning.25
Limitations of this study include the relatively small sample size—only 61 families of patients with depression and 61 families of controls were recruited for this study. Secondly, the tools for investigating the family functioning, FAD and FACES II, were entirely subjective. Future studies should use objective assessments of family functioning.
FAD and FACES II scores from the present study suggest that families with a depressed family member experience less satisfaction with family functioning than do control families. Both measurement instruments may be helpful in assessing families in mainland China. Importantly, the results of this study showed that the FACES II scores between patients and their family members were not significantly different, and that patient and family scores were significantly correlated. It is possible that the FACES II cannot differentiate between patient and family perceptions, whereas the FAD can. When comparing perceptions of family functioning between patients and their family members, the FAD is more sensitive than the FACES II. However, the FACES II may be more straightforward and objective than the FAD in Chinese samples. Both measurement tools have utility for assessing Chinese families, and using both rather than either alone is likely to yield a more comprehensive understanding of family functioning. Given that decreases in depressive mood were associated with perceived family support,40 families may benefit from interventions aimed at increasing family support in depressed families.41,42
ACKNOWLEDGEMENTS: We thank all participants who made this research possible.
DISCLOSURE: The authors report no financial relationships with any company whose products were mentioned in this article or with manufacturers of competing products.
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CORRESPONDENCE: Yi Huang, MD Department of Psychiatry West China Hospital Sichuan University Chengdu, China 610041 E-MAIL: firstname.lastname@example.org
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