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A Psychometric Evaluation of Two Measures of Expressed Emotion in Caregivers of Children with Mood Disorders

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A Psychometric Evaluation of Two Measures of Expressed Emotion in Caregivers of Children with Mood Disorders A PSYCHOMETRIC EVALUATION OF TWO MEASURES OF EXPRESSED EMOTION IN CAREGIVERS OF CHILDREN WITH MOOD DISORDERS DISSERTATION Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University By Nicole Klaus, M.A. * * * * * The Ohio State University 2006 Dissertation Committee: Dr. Mary A. Fristad, Advisor Approved by Dr. Michael Vasey Dr. Steven J. Beck ____________________________________ Graduate Advisor in Psychology ABSTRACT Expressed emotion (EE) refers to criticism, hostility, and emotional overinvolvement (EOI) displayed by family members toward a patient. EE has been associated with higher rates of relapse and poor outcome in adults with a range of psychiatric disorders. In children, caregiver EE is related to presence and course of multiple disorders. EE measures developed for adult populations have been used in studies of children. However, questions have arisen regarding their appropriateness in such applications. The present study examined reliability, stability, and validity of two measures of EE, the Five Minute Speech Sample (FMSS) and Expressed Emotion Adjective Checklist (EEAC), in caregivers of children with mood disorders. During the FMSS, a relative is asked to speak freely about the patient. Audiotaped speech samples are later coded by qualified raters. The EEAC is a self-report measure listing adjectives that are rated according to their frequency of expression by the patient and relative toward each other. Both EE measures were completed by 180 mothers and 106 fathers of children with mood disorders as part of a study examining efficacy of family psychoeducational treatments. Data were also collected on constructs theoretically related and unrelated to EE including reports of the child’s behavior, mood, and anxiety symptoms. A subset of parents completed EE measures again six and twelve months later. ii FMSS interrater reliability was lower in this sample than in previous studies. Stability was greater at one-year than at six-month follow-up, perhaps reflecting seasonal variations in child mood symptoms. Little evidence was found for validity of the EOI scale. Criticism was concurrently related to child, but not parent, variables. Mothers’ criticism predicted child mood and anxiety symptoms one year later. EEAC scores remained stable over time. Child subscale scores were most strongly related to other child variables. Parent subscale scores were more strongly related to parent variables. Mothers’ EEAC scores predicted child mood symptoms and fathers’ EEAC scores predicted child behavior problems one year later. Further, mothers’ EEAC scores moderated the effects of psychoeducational treatment. The EEAC appears to be an inexpensive and convenient measure of EE, with validity comparable to or exceeding the FMSS. iii ACKNOWLEDGMENTS I wish to express my deepest appreciation to my advisor, Dr. Mary Fristad, for the intellectual support and guidance which made this dissertation possible. Her influences in shaping my clinical and research skills will remain with me for a lifetime. I would also like to thank my committee members who provided valuable suggestions and feedback. I would like to think the families who participated in this research study. Their willingness to open their lives for this research has contributed directly to this study and has provided me with unique and rewarding clinical experiences and inspiration. I am grateful to the dedicated research staff of the MFPG project who have been a pleasure to work with. I also appreciate the efforts of many undergraduate research assistants who devoted considerable time to transcribing speech samples and preparing data for entry. I have benefited greatly from the support and encouragement of family and friends throughout the preparation of this dissertation. My husband, Martin Klaus, has given me unconditional love and support, and this is dedicated to him. I also wish to thank Tena and Rod Wasinger, Crystal Wasinger, Cory Wasinger, Ruth Dysart, and Amanda Howard for their words of encouragement and comic relief over the past year. Finally, these data were collected with financial support from a grant awarded to Dr. Fristad from the National Institute of Mental Health. iv VITA June 26, 1978…………………………….. Born- Ransom, Kansas 2000……………………………………… B.A., Psychology and Human Development, University of Kansas 2004……………………………………… M.A., Psychology The Ohio State University 2000-2005…………………………….......Graduate Teaching and Research Associate, The Ohio State University 2005-2006………………………………..Pre-doctoral Psychology Intern West Virginia University School of Medicine PUBLICATIONS Klaus, N. & Fristad. M. A. (2005). Family psychoeducation: An adjunctive intervention for children with bipolar disorder. Directions in Psychiatry, 25, 217-229. FIELDS OF STUDY Major Field: Psychology v TABLE OF CONTENTS Page Abstract…………………………………………………………………………….......... ii Acknowledgments………………………………………………………………………. iv Vita………………………………………………………………………………………. v List of Tables………………………………………………………………………..........ix List of Figures………………………………………………………………………….... xi Chapters: 1. Introduction………………………………………………………………………. 1 Development of EE concept.…………………………………………….. 1 Adult studies of EE………….…………………………………………… 4 Schizophrenia…………………………………………………..... 5 Mood disorders………………………………………………...… 6 Eating disorders………………………………………………….. 8 Anxiety disorders………………………………………………… 9 Borderline personality disorder……………………………….… 11 Alcoholism…………………………………………………….... 11 Diabetes……………………………………………………….… 11 Summary………………………………………………………... 12 EE in children………………………………………………...………… 12 Association of EE with child psychopathology………….……... 14 Longitudinal studies…………………………………….………. 16 Contribution of parent characteristics to EE status…….……….. 19 Summary……………………………………………….……….. 20 Theoretical models and treatment implications……………………….... 20 Measurement issues in child research…………………………………... 22 Psychometrics of the FMSS…………………………………………….. 24 Interrater reliability...…………………………………………… 26 Concurrent validity…………………………………………...… 27 Predictive validity………………………………………………. 28 Test-retest reliability……………………………………………. 28 Convergent validity…………………………………………….. 29 Factor structure…………………………………………………. 32 Psychometrics of the EEAC……………………………………………. 33 Concurrent validity……………………………………………... 33 Internal consistency…………………………………………….. 34 vi Convergent validity…………………………………………….. 35 Parent-child concordance………………………………………. 36 Purpose of present study and hypotheses………………………………. 36 Concurrent validity…………………………………………...… 38 Test-retest reliability…………………………………………… 38 Convergent validity…………………………………………….. 39 Discriminant validity…………………………………………… 39 Predictive validity………………………………………………. 39 2. Methods…………………………………………………………………………. 41 Participants and procedure……………………………………………… 41 Measures………………………………………………………………... 43 Demographics………………………………………………..…. 43 Five Minute Speech Sample (FMSS)…………………………... 44 Expressed Emotion Adjective Checklist (EEAC)………………. 44 Children’s Interview for Psychiatric Syndromes, Child and Parent versions (ChIPS and P-ChIPS)………………….. 44 Children’s Depression Rating Scale, Revised (CDRS-R)…….... 45 Mania Rating Scale………………………………...…………… 45 Mood Severity Index (MSI)…………………………………….. 46 Kaufman Brief Intelligence Test (K-BIT)…………………….... 46 Home and Community Social Behavior Scales (HCSBS)……… 46 Treatment Beliefs Questionnaire- Parent Version (TBQ-P)….… 47 Social Support Scale for Children (SSS)……………………….. 47 Teacher Report Form (TRF)……………………………………. 48 3. Results…………………………………………………………………………... 49 Descriptive statistics……………………………………………………. 50 EEAC…………………………………………………………… 50 FMSS…………………………………………………………… 51 FMSS interrater reliability……………………………………………… 51 Concurrent validity……………………………………………………... 52 Categorical data………………………………………………… 52 Continuous data……………………………………………….... 52 Test-retest reliability……………………………………………………. 54 EEAC…………………………………………………………… 54 FMSS………………………………………………………….... 55 Convergent validity……………………………………………………... 56 vii EEAC…………………………………………………………… 56 FMSS…………………………………………………………… 56 Discriminant validity…………………………………………………… 57 EEAC………………………………………………………….... 59 FMSS…………………………………………………………….60 Predictive validity………………………………………………………..61 Predictions of symptoms one year later………………………….61 Treatment-related changes in EE predicting mood improvement……………………………………………. 64 Additional analyses…………………………………………………..…. 65 4. Discussion………………………………………………………………………. 67 FMSS………………………………………………………………….... 67 Reliability………………………………………………………. 67 Stability…………………………………………………………. 68 Validity…………………………………………………………. 69 Summary and conclusions……………………………………… 75 EEAC………………………………………………………………….…77 Internal consistency…………………………………………….. 77 Stability………………………………………………………..... 77 Validity…………………………………………………………. 77 Relationship to FMSS…………………………………………... 80 Summary and conclusions…………………………………….... 81 Limitations and directions for future research.…………………………. 83 References………………………………………………………………………………. 84 Appendices A: Tables………………………………………………………………………... 96 B: Figures…………………………………………………………………..….. 123 C: Questionnaires……………………………………………………………….126 viii LIST OF TABLES Table Page 1 EEAC Descriptives …………….………………………………………………. 97 2 FMSS Descriptives ...……………………………………………………...…… 98 3 FMSS CRIT Predictions of EEAC Scores …………... ……………………….. 99 4 EEAC Means by FMSS CRIT Status ………………………………………… 100 5 Correlations between EEAC and FMSS Continuous Scales…………………...101 6 EEAC Test-retest Reliability………………………………………………….. 102 7 FMSS Continuous Scales Test-retest
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