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 HOLTZMAN, W. H. (1950). Validation studies of the Rorschach test: Impulsiveness in the superior adult. IKEGAM~, T. (1979). Cognitive style in children: The relation between reflection-impulsivity and Rorschach KATZ, J. M. (1971). OM, P. (1985). The psychological assessment of impulsivity: A review. Journal of Psychoeducational Asses- OSTROV, E., OFFER, D., MAROHN, R. C., & ROSENWEIN, T. (1972). The impulsivity index: Its application RAPAPORT, D., GILL. M. M., SCHAFER, R., & HOLT, R. R. (1%8). Diagnostic psychological testing (rev. SEIDEL, W. T., & JOSCHKO, M. (1991). Assessment of attention in children. Clinical Neuropsychologist, 5 , WAALKES, M., & PANTLE, M. (1992). Is the new Rorschach Depression Index a better measure of depression Journal of Clinical Psychology, 6, 348-351. scores. Psychologia, 22, 207-221. Reflection-impulsivity and color-form sorting. Child Development, 42, 745-754. ment, 3 , 141-156. to juvenile delinquency. Journal of Youth and Adolescence, I , 179-196. ed.). New York: International Universities Press. 53-66. for adolescents? Upublished manuscript. 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 METHOD 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 communication deviance and healthy (i.e., clear) communication (Al-Khayyal, 1980) for both parents across all situations in which these variables were assessed. Activity/balance/warmth in family interaction is a measure that reflects a high level of balanced and warm interaction among family members and has been found to correlate with child school competence (Baldwin, Baldwin, & Cole, 1982; Cole et al., 1984). In the Family Consensus Rorschach procedure, the entire family as a unit is administered the Rorschach test and asked to come to agree- ment on percepts. The Family Free Play procedure involved a half-hour session in which the two parents and the index boy were instructed to play as they would at home. Five child variables were used in classifying the outcome of the subjects (Green- wald, 1990a): (1) and (2) ratings of the child in relation to his classmates functioning made by his teacher and by other children in his class (for each of these, the index child was not identified) (Fisher, 1980; Fisher, Schwartzman, Harder, & Kokes, 1984); and clinician ratings of the child based (3) on parent reports (the Rochester Adaptive Behavior Inventory (RABI; Jones, 1977); and (4) on parent and child interviews, together with psychological assessment data (the COPE variable; Munson, Baldwin, Yu, Baldwin, & Greenwald, 1984); and (5) WISC IQ, seen as a measure of the childs social/emotional competence as well as of cognitive functioning (Greenwald, 1989). Boys were considered to show highly adaptive (or, conversely, highly maladaptive) functioning, for the pur- poses of this study, if they scored high (or low) relative to the rest of the sample on three of the five variables. The teacher and peer score cut-offs were one standard deviation Outcome Predictors in High-risk Boys 64 1 above and below the mean (50 on a T scale). High and low RABI scores were defined as the highest and lowest three scale points on a 9-point scale; high and low COPE scores were the two higher and two lower points of a 4-point range. The IQ score cut-offs were one-half standard deviation above and below the sample mean (1 11.9) of a somewhat restricted range of scores. This process resulted in a high-functioning group of 17 boys and a low-functioning group of 13 boys, with 64 boys excluded because they fell in the mid-range. Despite the small numbers in each group, this process was felt to be justified because the boys identified were clearly more adaptive or maladaptive than the average child in the sample. RESULTS AND DISCUSSION Students t-tests were performed on each of the potential predictor variables, using the outcome groups as the independent variable. Table 1 shows that, as expected, most of the potential predictors included in the study significantly differentiated the highest- functioning from the lowest-functioning URCAFS boys despite the low numbers in the groups. The most successful differentiations (at p < .004) were achieved by activity/balance/ warmth obtained from the Family Consensus Rorschach procedure (t = 3.24) and by the amount of communication deviance (CD) shown by the mother during the same Family Consensus Rorschach (t = - 3.19). The next most successful differentiators were family communication deviance level (t = 2.98; p < .007) and socioeconomic class (t = -2.93; p < .007). The family CD measure included the Consensus Rorschach variables of mother and father CD, each of which singly differentiated the study groups at the .05 level of significance, CD indices from individually administered father and mother projective tests, and measures of healthy communication for each parent. Socioeconomic status long has been associated with more severe psychological difficulties, particularly schizophrenia (e.g., Harder et al., 1990), although the mechanism of impact - genetic and/or environmental - is unknown (Dohrenwend & Dohrenwend, 1 969). Other predictors that successfully differentiated the two groups in this study were activity/balance/warmth from the Free Play Procedure (t = 2.17; p < .05); index parent global assessment score (t = 2.25; p < .05), based on symptomatology level as well as social and occupational functioning; and chronicity of disorder (t = 2.25, p < .05). Perhaps most surprising was the failure of schizophrenic spectrum diagnosis to differentiate the groups. The affective diagnosis variable also failed to separate the groups. Table 1 SigniJicant Parent and Family Interaction Predictors of Adaptive (n = 17) and Maladaptive (n = 13) Outcome Estimated effect size r t P (n = 30) Socioeconomic class Family Free Play Activity/Balance/Warmth Rorschach Activity/Balance/Warmth Mothers Communication Deviance (CD) Fathers CD Family CD Chronicity Patient Global Assessment Scale - 2.93 2.17 3.24 -3.19 -2.15 2.98 2.25 -2.31 .007 .037 .004 .004 .039 .007 .027 .031 - .48 .38 .56 - .52 - .38 .55 - .40 .39 Positive rs indicate association with adaptive outcome. 642 Journal of Clinical Psychology, July 1994, Vol. 50, No. 4 Some evidence, including previous URCAFS work (e.g., Harder & Greenwald, 1992), has strongly suggested an especially heightened risk of disorder in the offspring of schizophrenics. Yet among these best-functioning and lowest-functioning boys the non- diagnostic variables, which reflect the chronicity of the difficulties in the index parent and problematic interaction patterns in the family, are the factors that appear to have the more important significance. A near-significant result appeared for the interaction of schizophrenic spectrum and chronicity, but it appeared to be only the result of the chronicity effects. It may be that the relative weakness of parent schizophrenia spectrum diagnosis, with its implied genetic contribution to the functioning of the offspring, and the heightened importance of family and communication variables, may reflect the fact that the schizo- phrenic patient parents in this sample were comparatively high-functioning. That is, the sample of patients in this study included, by definition, only those who were able to marry and parent, thus excluding the most severely disturbed chronic and unremitting schizophrenics, for whom genetic factors have been theorized to be more prominent. Tentative predictor effect sizes, in terms of percentage differences in outcome group membership (Rosnow & Rosenthal, 1989), also are presented in Table 1. The magnitude of predictor associations is, of course, subject to future replications because the present group sizes are very small. REFERENCES AL-KHAWAL, M. (1980). Healthy parental communication as a predictor of child competence in families with a schizophrenic andpsychiatrically disturbed non-schizophrenic parent. Doctoral dissertation, Univer- sity of Rochester. AMERICAN PSYCHIATRIC ASSOCIATION (1987). Diagnostic and statistical manual of mental disorders (3rd ed. rev.). Washington: Author. BALDWIN, A. L., BALDWIN, C. P., &COLE, R. E. (1982). 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