outcome predictors in a longitudinal study of high-risk boys
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638 Journal of Clinical Psychology, July 1994, Vol. 50, No. 4
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OUTCOME PREDICTORS IN A LONGITUDINAL STUDY OF HIGH-RISK BOYS
DEBORAH F. GREENWALD AND DAVID W . HARDER
Northeastern University Tufts University
This study of high risk investigated a 3-year follow-up sample of boys in the University of Rochester Child and Family Study of intact families in which at least one parent had been hospitalized for a psychiatric disorder. These families and their sons were studied in order to identify predictive factors for child outcome. Best-functioning (n = 17) and worst-functioning (n = 13) groups of boys (from a total N = 94) were differentiated success- fully by time 1 parent and family interaction predictors. These variables in- cluded several measures of parent deviant communication and balanced/ warm family interaction, chronicity and level of parent pathology, and socioeconomic class. Parent diagnosis was not associated significantly with outcome.
This study was part of the University of Rochester Child and Family Study (URCAFS; Wynne, 1984; Wynne, Cole, & Perkins, 1987), a longitudinal investigation of multiple aspects of child and parent functioning and family interaction in a cohort of intact Caucasian families selected because at least one parent had been hospitalized for psychiatric disorder. These families were studied in order to assess factors likely to create and/or signify deveIopmental risks for psychological disorder in the offspring. In addition, the URCAFS project has focused upon those features of parents, families,
This research was supported by NIMH Program Project Grant MH-22836, Lyman C. Wynne, Principal Investigator. In addition to the authors, other investigators on the teams collaborating in this study were Manhal Al-Khayyal, Alfred Baldwin, Clara Baldwin, Robert E. Cole, Jeri Doane, Lawrence Fisher, Frederic Jones, James E. Jones, Ronald F. Kokes, Stephen Munson, Patricia Perkins, Lyman C. Wynne, and Pamela Yu.
Outcome Predictors in High-risk Boys 639
and childrens functioning that were expected to predict competent behavior in children over time, behavior that probably would provide some protection against the risk factors. Logistical limitations forced a restriction of the studys focus to male offspring only.
The project variables included measures of the index (patient) parents diagnosis, level of both parents social and employment functioning, family interaction and communication, and, for 3-year outcome, childrens functioning in a variety of situa- tions.
Parental diagnosis, disease chronicity, and level of social and occupational func- tioning were hypothesized to have an impact on child functioning, either through genetic or environmental pathways, or both (Harder & Greenwald, 1992). Communication and other aspects of interaction in families also were hypothesized to have broad effects on the development of child competence and adaptation (Greenwald, 199Ob). Clear com- munication was expected to help children develop cognitive competencies, such as ac- curate reality-testing and the ability to focus attention and to integrate new informa- tion. The boys social and emotional functioning presumably would be affected in similar ways because the children in families with clear communication would be likely to feel more confident about how they need to behave in order to meet parental expectations (Greenwald, 199Ob). This is hypothesized to facilitate well-regulated behavior and pro- mote low anxiety. Similarly, positive family affective environment also would be expected to show associations with competent child behaviors. Conversely, unclear or deviant parental communication and/or a negatively toned family environment were expected to be associated with greater risks during child development (Doane, West, Goldstein, Rodnick, & Jones, 1981).
Previous URCAFS research with the entire sample (Greenwald, 199Ob; Harder & Greenwald, 1992) has found evidence for the predictive usefulness of several parent and family interaction variables for longitudinal assessments of child functioning. While the assessed aspects of outcome for the high-risk sons did not include diagnosis or explicit measures of psychopathology, because the subjects were still in the early years of their risk histories, the boys were assessed in five different ways to reflect greater or lesser degrees of adaptive or maladaptive behavior. As previously predicted, the absence of deviant communication, the presence of balanced and warm family interaction, general functioning level of the ex-patient parent (an average of 3.9 years after most recent psychiatric hospitalization), diagnosis, chronicity of disease, and social class all were associated significantly with child (interim) 3-year outcome.
While prior URCAFS research included all those child subjects for whom data were available (N = 94), the current study focused on a subset of the larger sample, those offspring who demonstrated either the most clearly adaptive or most clearly maladap- tive functioning at the 3-year follow-up point. The purpose of the present study was to identify the pattern of parent and family measures that differentiates these distinctly competent and maladaptive boys within the larger sample. The larger sample of 94 followed-up boys functioned at a level comparable to their peers in both the school setting (mean teacher and peer ratings of URCAFS boys were not significantly lower than class averages) and in overall social-emotional competence (as indicated by an URCAFS sample IQ mean of 1 11.9). Therefore, a smaller group was selected in order to identify and assess those boys whose functioning was distinctly below average because these individuals would be expected to be most likely to develop symptomatology in the future. Conversely, those whose functioning was clearly above average would be predicted to be most likely to show robust coping skills and resistance to future psychopathology. Those variables that most clearly differentiated these two groups might well prove, in the long run (after further replications), to be the best indicators of true risk.
640 Journal of Clinical Psychology, JUI) 1994, Vol. 50, No. 4
Subjects and Procedure The subjects in this study were the male offspring of intact families in which one
parent had been hospitalized previously for functional psychiatric disorder with a catchment area of upstate New York. Parent patients with brain damage, IQs lower than 80, or severe substance abuse (Wynne et al., 1987) were excluded. The sons of these patients, 4,7, or 10 years old at the beginning of the study, were assessed initially and at follow-up 3 years later (plus or minus 4 months). These boys were largely from middle-class families, Hollingshead (1957) two-factor index classes I1 through IV, with a mean of class 111. The subject pool consisted of 94 boys for whom sufficient data were available from the follow-up cohort of the original sample of 145 (Harder & Green- wald, 1992).
Parent DSM-III-R (American Psychiatric Association, 1987) diagnoses were made by a consensus of two diagnostic teams, which consisted of experienced psychiatrists and clinical psychologists, who worked from semi-structured interviews (Greenwald, 1990a; Harder & Greenwald, 1992; World Health Organization, 1973). These diagnoses ranged from schizophrenia to nonpsychotic depression to personality disorders. For pur- poses of the analyses these were collapsed into schizophrenic spectrum/non-spectrum and affective disordednon-disorder dichotomies (Wynne, 1987). Two other promising parent variables for predicting offspring outcome were the chronicity of the parent disorder and the index parent Global Assessment Scale (Endicott, Spitzer, Fleiss, & Cohen, 1976).
Family interaction variables included communication deviance measures of father and of mother (Loveland, Wynne, & Singer, 1963; Wynne, 1987) extracted from a Family Consensus Rorschach procedure (Cole et al., 1984), a composite parent communication index (Jones et al., 1984), and measures of the combined activity/balance/warmth in the family interaction assessed in two different settings, the Family Consensus Rorschach and the Family Free Play (Cole et al., 1984). Communication deviance is a measure of lack of shared focus and lack of clarity in communication; parental communication deviance has been found to correlate with schizophrenia spectrum disorders in offspring (Doane et al., 1981; Goldstein, Rodnick, Jones, McPherson, & West, 1978). The com- posite parent communication index was a combined measure of communic