SCORE PROJECT

1. SCORE PROJECT Dr Julia Bland (Project Chair) Consultant Psychiatrist in Psychotherapy, Maudsley Hospital, London Prof. Peter Stratton, Leeds University Dr Emma Janes, Maudsley Hospital, London Dr Anne Ward, Maudsley Hospital, London Ms Judith Lask, Institute of Psychiatry, London

2. BACKGROUND Reviewed literature on the most widely used & researched self report measures (SRMs) of family function: lack of consensus re what to use. Intention to develop a SRM for use in FT which has been inspired by and designed to compliment CORE Gulf between efficacy & effectiveness research and a pressing need for an instrument that will facilitate and improve upon the clinical measurement of family functioning and be an acceptable means of providing outcome data

3. PURPOSE & SCOPE of OUTCOME RESEARCH IN FT Stakeholders include: Families themselves Clinicians and service developers Teachers and trainers Managers & policy makers Referrers The general public

4. Practitioner Research networks An efficient means of gathering �practice based evidence�. Meets the needs of both Evidence-Based Practice and Practice-Based Evidence due to the involvement of multiple institutions and centres with academic support. Collaborating clinicians (usually linked with one or more academic departments) collect and share data from their every day practice with the potential to generate large, clinically representative datasets.

5. APPLYING SRMs to FAMILIES: PROBLEMS: DEVELOPMENTAL ISSUES NORMATIVE ISSUES CULTURAL ISSUES MULTIPLE INFORMANTS & VARIABLE PERCEPTIONS: HOW TO SCORE IT? SOCIAL DESIRABILITY

6. REVIEW OF SRMs of FAMILY FUNCTIONING: Family-Concept Q Sort, Van der Veen 1965 Beavers Timberlawn Family Evaluation Scales (BTFES) Lewis et al 1976 The Family APGAR, Smilkstein, 1978 Family Adaptability and Cohesion Evaluation Scales (FACES), Olson et al 1979, 1985 .

7. REVIEW OF SRMs of FAMILY FUNCTIONING CONTd: The Inventory of Family Feelings, Lowman, 1980 Family Environment Scale (FES), Moos & Moos 1982 Family Assessment Device (FAD), Epstein at al, 1983 Family Functioning Scales (FFS), Bloom 1985 The Family Strengths Questionnaire, Olson 1985 Family Assessment Measure (FAM III), Skinner, 1987

8. Child-rated measures of family relations The Personal data form (Emery & O�Leary, 1982) Children�s Perception of Interparental Conflict Scale (Grych & Fincham, 1990) The Child�s View (Margolin, 2000)

9. Additional measures of family functioning Observer-Rated Scales: Home Observation for Measurement of the Environment (HOME)

10. Expressed Emotion Research: CFI (Vaughn & Leff, 1976) Oulu Family Rating Scale (OPAS, Teinari et al, 1994) Family Attitude Scale (Kavanagh et al, 1997) Family Questionnaire (Wiedemann et al 2002) Family Questionnaire (Quinn et al, 2003)

11. Goal Attainment Scaling & Satisfaction research Historical exclusion of clients views from outcome research� GAS (Kiresuck & Sherman, 1968) Adapted for FT research by Woodward et al, 1978

12. Gaps in the literature: Developments in FT theory & Practice Paucity of items relating to family member�s appraisals of change and levels of satisfaction/dissatisfaction with their service. The group then generated questions that were felt to address these particular issues.

13. Consultation stage Formal and informal expert consultation Service user consultation Lay consultation, including deliberate sampling of people from diverse ethnic backgrounds

14. Statistical advice The team sought statistical advice from a statistician at the Institute of Psychiatry Importance of phased piloting of SCORE to ensure psychometric validity. The first section of SCORE provides quantitative data on family functioning. Five hypothesized domains of family functioning are measured in this section: (1) Atmosphere/ Mood, (2) Conflict, (3) Expressiveness/ Communication, (4) Rules/ roles and (5) Functionality/ adaptability.

15. The SCORE40 The current version of SCORE has 8 items that are conceptually linked to each domain (i.e. 40 items, plus 5 questions inviting free response for qualitative analysis). Piloting this version will enable us to perform a factor analysis of completed items following stage one piloting and to ascertain the internal consistency of SCORE, as well as the domain structure (if there is one) of the measure. This process will enable redundant or erroneous items to be removed from the questionnaire.

16. Capture of idiosyncratic (qualitative) data The latter 5 items in SCORE ask the respondent to: describe their family; identify what they feel they main problem is for the family and rate how bad it is; say what change they would most hope for; whether they feel FT is the right approach and how they felt about filling out the Q. Wording of final items is adapted for use post therapy and enables family members to rate how useful/otherwise they found FT for their difficulties. Qualitative data from the first pilot will be analysed and should help inform the development of the measure

17. Ethical Approval Ethical approval was granted in January 2006 for multi-site piloting of SCORE. Each pilot site needs to register with COREC to initiate application. Close attention to confidentiality, patient information, informed consent, data storage & custodianship. Database of interested parties

18. Timing of Pilot Phases Stage 1: Piloting of questionnaire at multiple sites. Commenced March 2006 Stage 2: Statistical analysis of data and questionnaire refinement- hopefully by end 2008 Stage 3: Extended piloting of refined questionnaire at multiple sites. Likely to be at least 18m away Stage 4: Psychometric analysis and validation studies

19. Progress so far Piloting ongoing at 4 sites: Maudsley (adult), Barnet Enfield and Harringay Trust (adult), Tavistock (CAMHS), Nottingham (LD service). So far, data has been collected on 61 families 5 further sites (mainly CAMHS) have been a favourable opinion and are due to commence pilots soon

20. Common Difficulties Confusion, anxiety (and frustration!) re the process of gaining ethical & R&D approval Missing data: especially demographic data Not recording instances where Q is not given out: need for a consecutive sample Difficulty of using SCORE with interpreters Different versions of SCORE!

21. Comments: �it seemed to take ages at first but we soon were able to speed it up� �people with reading difficulties found it difficult� �It generated an interesting discussion about how each member defined their family and how their answers might be different according to who was included�

22. Suggestions of research uses of SCORE Generating an evidence base appropriate to relational therapies Examining effects of therapy with: Different lengths Different client groups Different approaches Collaboration across countries A national data-base Practitioner Networks of researchers Exploring cultural differences between families �����.

23. Suggestions of therapy uses of SCORE Pre-therapy information Discussing the items that are significant for clients Indicating major areas of change, and of no change, between sessions A context for discussions of usefulness Using the items to alert family members to disregarded aspects Checking for difference between therapist and client perceptions

24. Interested in Piloting the SCORE at your place of work? Contact details: Dr Emma Janes, SpR Psychiatry, Maudsley Hospital, Denmark Hill, London SE5 8AZ. Tel:07879632399 Emma.Janes@slam.nhs.uk