Journal of Psychosomatic Research 93 (2017) 110117

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Journal of Psychosomatic Research

Measuring family functioning in families with parental cancer: Reliability

and validity of the German adaptation of the Family Assessment
Device (FAD)
Volker Beierlein, M.Sc. a,, Johanna Christine Bultmann, M.Sc. a, Birgit Mller, Ph.D. b, Kai von Klitzing, M.D. c,
Hans-Henning Flechtner, M.D. d, Franz Resch, M.D. e, Wolfgang Herzog, M.D. f, Elmar Brhler, Ph.D. g,j,
Daniel Fhrer, M.Sc. h, Georg Romer, M.D. b,i, Uwe Koch, M.D., Ph.D. a, Corinna Bergelt, Ph.D. a
a
Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Germany
b
Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital Muenster, Germany
c
Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Leipzig University Hospital, Germany
d
Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatic Medicine, Otto-von-Guericke-University, Magdeburg, Germany
e
Department of Child and Adolescent Psychiatry; Heidelberg University Hospital, Germany
f
Department of General Internal Medicine and Psychosomatics, Heidelberg University, Germany
g
Department of Medical Psychology and Medical Sociology, Leipzig University Hospital, Germany
h
Department of Child and Adolescent Psychiatry, Psychosomatic s and Psychotherapy, Charit University Medicine Berlin, Germany
i
Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany
j
Clinic and Policlinic for Psychosomatic Medicine and Psychotherapy, University Medical Center Mainz, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The concept of family functioning is gaining importance in psycho-oncology research and health care
Received 31 October 2016 services. The Family Assessment Device (FAD) is a well-established measure of family functioning. Psychometric
Accepted 18 November 2016 properties inherent in the German 51-item adaptation of the FAD are examined in different samples of families
with parental cancer.
Keywords: Methods: Acceptance, reliability, and validity of FAD scales are analysed in samples from different study settings
Cancer
(N = 1701 cancer patients, N = 261 partners, N = 158 dependent adolescent children 11 to 18 years old).
Family functioning
Family Assessment Device
Results: Missing items in the FAD scales (acceptance) are rare for adults (b 1.1%) and adolescent children (b 4.4%).
Psychometric properties In samples of adults and older adolescents (15 to 18 years), all FAD scales except for the Roles scale are signicant-
Parents ly reliable (0.75 Cronbach's 0.88). The scales correlate highly (0.46 Pearson's r 0.59) with the criterion
Adolescents satisfaction with family life (convergent validity), and have smaller correlations (0.16 r 0.49) with measures
of emotional distress and subjective well-being (divergent validity). In most FAD scales, adults seeking family
counselling report worse family functioning (0.24 Cohen's d 0.59) than adults in other samples with parental
cancer (discriminative validity).
Conclusion: Overall, the German 51-item adaptation of the FAD reveals good acceptance, reliability, and validity
for cancer patients and their relatives. Particularly the scale General Functioning shows excellent psychometric
properties. The FAD is suitable in the assessment of families with parental cancer for adults and adolescents
older than 11 years.
2016 Elsevier Inc. All rights reserved.

1. Introduction

Corresponding author at: University Medical Center Hamburg-Eppendorf,

Department of Medical Psychology, Martinistr. 52, 20246 Hamburg, Germany.
E-mail addresses: v.beierlein@uke.de (V. Beierlein), johanna.bultmann@web.de
(J.C. Bultmann), birgit.moeller@ukmuenster.de (B. Mller),
Kai.vonKlitzing@medizin.uni-leipzig.de (K. von Klitzing),
hans-henning.echtner@med.ovgu.de (H.-H. Flechtner),
Franz.Resch@med.uni-heidelberg.de (F. Resch), wolfgang.herzog@med.uni-heidelberg.de
(W. Herzog), elmar.braehler@medizin.uni-leipzig.de (E. Brhler),
Daniel.Fuehrer@charite.de (D. Fhrer), Georg.Romer@ukmuenster.de (G. Romer),
koch@uke.de (U. Koch), bergelt@uke.de (C. Bergelt).
Today, cancer patients are not the only focus of public health care
and psycho-oncology research, and now their whole family system is
considered by health care providers and researchers in this eld to be
very important. The Family Assessment Device (FAD) [1,2] is a well-
established measure to assess family functioning based on the theoret-
ical concept of the McMaster Model of Family Functioning (MMFF) [3,4].
Grounded on many years of clinical experience, the MMFF was devel-
oped with the goal to provide a treatment program for family therapists,

http://dx.doi.org/10.1016/j.jpsychores.2016.11.007
0022-3999/ 2016 Elsevier Inc. All rights reserved.
 V. Beierlein et al. / Journal of Psychosomatic Research 93 (2017) 110117 111

and a theoretical framework for research. The MMFF emphasizes the in-
terrelatedness of the family members and the family system, and repre-
sents six dimensions of family functioning that are considered of high
relevance in clinical practice, namely Problem Solving, Communication,
Roles, Affective Responsiveness, Affective Involvement, and Behaviour
Control (for a brief description of the dimensions, see Table 1). As a
screening and research tool, the FAD operationalises and measures
transactional patterns of the family system within the dimensions of
the MMFF and one additional subscale, General Functioning, which as-
sesses the overall functioning of a family system. The current original
English version of the FAD [2] consists of 60 statements that refer to
healthy and unhealthy behaviours in the family as a whole. Respon-
dents are asked to evaluate their agreement to these statements on a
4-point Likert scale (strongly agree, agree, disagree, strongly
disagree). Subscale scores are calculated as the means of their corre-
sponding items, with no more than 50% of missing items in a scale,
and range from 1 (healthy family functioning) to 4 (unhealthy family
functioning).
The FAD was translated for assessment in numerous countries and
cultures (e.g., Italy [5]; China [6,7]; Armenians in Lebanon [8]; Turkey
[9]) and is used in a variety of subjects in the context of mental health
(e.g., [1013]), and in the context of somatic diseases (e.g., [1417]).
In regard to cancer diseases, family functioning was assessed by the
FAD in families with childhood cancer (e.g., [1821]) and parental can-
cer (e.g., [2225]). In Germany the FAD was employed in studies regard-
ing social phobia [2629], parental chronic somatic illness [30], and
parental cancer (e.g., [3134]), but yet no information concerning the
translation of the FAD into the German language and analysis of its psy-
chometric properties have been published until today.
The reliability and validity of the FAD has been proven in many stud-
ies for clinical and non-clinical populations [1,2,3537], but until now,
not much is known about whether the FAD is also a reliable and valid
measure for cancer patients and their family members. Some studies
on families with a cancer patient reported scale reliabilities as a prereq-
uisite for further analysis [19,2124,38,39]. Only one study on cancer
patients focused on psychometric properties (General Functioning scale
only) [40]. The results of the reliability analysis in these studies were
satisfactory for most scales, but in all studies including the complete
set of subscales, reliability of at least one scale was below the common
standard of r 0.70 [41], specically for the scales Roles, Behaviour Con-
trol, and Problem Solving.
In the context of the German multicentre research project, Psycho-
social Support for Children of Parents with Cancer (German:
Verbundprojekt Kinder krebskranker Eltern; VKKE) [42], funded by
the German Cancer Aid from 2009 to 2012, a revised translation and
adapted version of the FAD was developed to assess family functioning
in cancer patients, their partners and adolescent children. Because there
is still a lack of comprehensive studies on the psychometric properties
of the FAD for the cancer patient population, the present study aims to
analyse the reliability and validity of this revised German translation
and adaptation of the FAD for families with a parental cancer patient,
based on the data from the VKKE project.
2. Material and methods
2.1. Samples
In the VKKE project, three separate populations of families with a
parent suffering from cancer participated in the following studies:
Sample 1 in this data set consists of families with a parental cancer
patient which received a manualised family-centred counselling
aimed at supporting families in several aspects of coping with the illness
in the family system. Families were included in the counselling services
provided by the university hospitals of Hamburg, Berlin, Leipzig, Mag-
deburg and Heidelberg. The analysed data of this sample were collected
between August 2009 and August 2011. Sample 2 comprises families
with a parental cancer patient who was not seeking family counselling
at the end of acute medical care. These families were mainly recruited
in the eastern part of Germany. Data collection from this sample was
conducted between October 2009 and March 2011. Finally, Sample 3
consists of cancer patients who participated in an epidemiological sur-
vey, which included mid- to long-term cancer survivors in two northern
federal states of Germany, Hamburg and Schleswig-Holstein. The cancer
registries of the two federal states submitted patient data. The surveys
were administered from October to November 2010 in Hamburg, and
from June to September 2011 in Schleswig-Holstein.
For Samples 1 and 2, all patients, their partners and their adolescent
children aged 11 to 18 years were included in the study, when they gave
signed and informed consent, sufciently completed questionnaires,
and basic socio-demographic and medical data (e.g., information
about age, sex and tumour diagnosis) were available. Additionally, for
Sample 3 the following inclusion criteria applied: age of the patient
was between 25 and 55 years old to maximise the probability of
reaching patients with children; and the most recent report of cancer in-
cidence had been submitted to the cancer registries within the past 12
to 60 months. Patients who were diagnosed by tumour sites with a
bad prognosis (e.g., lung cancer) were excluded to minimise the risk
of inconveniencing severely ill respondents with an unexpected
questionnaire.
All studies in the VKKE project were approved by the ethics commit-
tees of the participating federal states. A similar core questionnaire was
assessed in all studies and contained psychosocial demographics, med-
ical data, and standardised measures of well-being, emotional distress,
and coping. The FAD was used to assess family functioning as one pri-
mary outcome. The questionnaire was completed by patients, spouses
and their adolescent children (N 11 years) in Samples 1 & 2 and by pa-
tients only in Sample 3. The data from all the projects were merged
into a cross-sectional data set containing multiple perspectives from
parents and children.
2.2. Translation and adaptation of the FAD
At rst, the English original version of the FAD was translated into
the German language for the previous European research project, Chil-
dren of Somatically Ill Parents (COSIP) [30], in a forward-backward-

Table 1
Dimensions of the McMaster Model of Family Functioning and subscales of the Family Assessment Device: Scale names, and brief descriptions.

FAD scale name # Items Description of scale

Problem solving 6 Dealing with problems of any type in the family, including the processes of problem identication, actions necessary
to solve the problem and evaluation of success
Communication 9 Communicating in a clear and direct manner within the family
Roles 11 Clear and reasonable roles and accountability of family members
Affective responsiveness 6 Capability of expressing a full range of emotions in the family, appropriate in quality and quantity
Affective involvement 7 Empathic involvement in particular activities and interests of individual family members
Behaviour controla 9 Flexible behaviour control related to dangerous situations, expressing psycho-biological needs, and interpersonal socialising
General functioning 12 Overall functioning of the family system
a
The scale of Behaviour Control was excluded from the present study; see text.
112 V. Beierlein et al. / Journal of Psychosomatic Research 93 (2017) 110117
translation process [43]. For the recent German VKKE project, this rst
translation of the FAD was revised, in which ambiguous items were
newly translated using the same forward-backward-translation meth-
od. During a project meeting to review the core questionnaire of the
VKKE multicentre research project, it became apparent that some
items of the subscale Behaviour Control could not sufciently be adapted
for today's German culture. For example, the items we have no clear
expectations about toilet habits and we have rules about hitting peo-
ple do not have appropriate equivalents in the German language and
culture nowadays. After intensive discussion, all principle investigators
of the VKKE project (child psychiatry and psycho-oncology experts) de-
cided to remove the subscale Behaviour Control from the survey prior
data collection, primarily for ethical reasons to reduce respondent bur-
den in the highly strained families. This decision was also supported
by our ndings of low scale reliability in the former European COSIP
study (parents: r = 0.57; adolescents: r = 0.37); also there were nd-
ings of low reliability for this subscale reported in the literature by other
studies [5,7,8]. There have been no further adaptations to the resulting
51-item German version of the FAD (the German questionnaire and
scoring instructions are available as Online Supplementary Material).
2.3. Additional measures
In previous studies the association of FAD subscales with other mea-
sures of family functioning along with measures of emotional distress
and subjective well-being have been examined to assess the validity
of the FAD [e.g., 7,23,37,39]. Similarly, to evaluate the associations of
the FAD subscales in our study with these constructs, following mea-
sures of the VKKE core questionnaire have been included into the
analyses:
2.3.1. Satisfaction with family life/FLZM
The Questions on Life SatisfactionModules (German: FLZM) [44] is an
instrument to assess general life satisfaction and health-related quality
of life, separated into two modules containing eight dimensions each.
In the present study, only the module General Life Satisfaction was ex-
clusively administered to study participants in Sample 3 (cancer survi-
vors). For further analyses, only item 5 of that module, Satisfaction
with Family Life, will be regarded.
2.3.2. HADS
The Hospital Anxiety and Depression Scale [4547] is a commonly
used and well validated instrument to assess anxiety (HADS-A) and de-
pression (HADS-D) in populations with physical illness or symptoms.
Both subscales consist of seven items each. For all samples in this
study, the HADS was administered to adults only.
2.3.3. SF-8
The Short-Form Health Survey SF-8 [48,49] is used to measure sub-
jective health-related quality of life (HRQoL) with eight single-item
scales, each representing an important domain of subjective well-
being. Scores for two higher-order domains of physical and mental
well-being (Physical Component Summary PCS; Mental Component
Summary MCS) can be calculated. PCS and MCS were chosen to evaluate
associations with FAD subscales. The SF-8 was administered in all sam-
ples only to adults.
2.3.4. Kidscreen10 quality of life index
The Kidscreen [50] was developed to assess subjective health and
well-being in children and adolescents aged between 8 and 18 years.
To explore associations of adolescents' HRQoL with family functioning,
the Kidscreen 10-item self-report Global Index Score was assessed.
The Kidscreen was administered to adolescents 11 to 18 years old in
the Samples 1 & 2.
2.4. Statistical analyses
To account for possible biased effects in all analyses by the depen-
dent data of adolescent children whose siblings also participated in
the study, one child per family was chosen using a random sampling
procedure. The analysed sample sizes for patients are N = 147 (Sample
1), N = 161 (Sample 2), and N = 1393 (Sample 3). Partners contributed
to the samples with N = 147 (Sample 1) and N = 114 (Sample 2). Sam-
ple sizes for adolescents are N = 83 (Sample 1) and N = 75 (Sample 2).
Samples are analysed for differences in socio-demographic characteris-
tics and in medical data (ANOVA; 2).
As an indicator of comprehensibility and clarity of the translated FAD
items, missing data in single items and the full completion per subscale
are examined. Well-phrased items should correspond to a low rate of
missing values, i.e. a high acceptance of the scale. Percentages of single
missing items and fully completed scales are calculated for adults and
adolescents.
Reliability of the FAD is estimated as internal consistency
(Cronbach's ). Reliability coefcients are reported for all FAD subscales,
and also for the whole instrument by analysing all items as a single scale
according to former studies on the FAD (e.g., [7,8,51,52]). Because reli-
ability coefcients are dependent on variations due to random variables,
following Fan & Thompson [53], all coefcients were tested against a hy-
pothesized population reliability of H0: r = 0.70 at a signicance level
of p b 0.05. The value of 0.70 to test reliability coefcients was chosen as
an accepted standard of minimum reliability [41]. Complementary ex-
tended reliability analyses to examine internal consistency in more ho-
mogeneous subgroups and to assess consistency of the FAD subscales at
the item level were performed, and are available as Online Supplemen-
tary Material.
As it is hypothesized that the item Satisfaction with Family Life of the
FLZM is closely related to the construct of family functioning, convergent
validity of the FAD is evaluated by correlations of the FAD subscales with
this item that was responded by patients in Sample 3. To assess diver-
gent validity, FAD subscale correlations with anxiety and depression
(HADS), physical and mental HRQoL (SF-8 PCS; SF-8 MCS) (adults in
Samples 13), and with the Kidscreen10 Global Quality of Life Index
(adolescents in Samples 1 & 2) are examined. Although these measures
are known to be associated with family functioning to a certain degree,
they can be referred to as divergent measures as they represent differ-
ent constructs. Thus, it is expected that the item Satisfaction with Family
Life has a stronger correlation with FAD scales than the divergent mea-
sures, as satisfaction with family life and family functioning are evident-
ly more closely related. All correlations are calculated as Pearson's r.
Discriminative validity (i.e., known-groups validity) of the FAD is
assessed by statistically signicant differences in subscale scores be-
tween the different study settings. It is hypothesized that family mem-
bers who were seeking family counselling (Sample 1) report worse
family functioning than do family members who did not seek counsel-
ling at the end of the acute medical care (Sample 2), and worse func-
tioning compared with mid- to long-term cancer survivors (Sample
3). To account for differences in socio-demographic and medical charac-
teristics between the samples, differences in adjusted means of subscale
scores between samples are tested by analysis of covariance (ANCOVA).
Post-hoc pairwise comparisons of samples are conducted by t-tests
using Bonferroni correction of condence intervals. The adjusted
standardised mean differences of the pairwise tests are reported as
Cohen's d separately for patients, partners and adolescents.
3. Results
3.1. Sample characteristics
Regarding socio-demographic and medical characteristics, we found
statistically signicant differences between samples for age, frequency
distribution of tumour sites, months since diagnoses, education level
 V. Beierlein et al. / Journal of Psychosomatic Research 93 (2017) 110117 113

Table 2
Sample characteristics: socio-demographic and medical variables in Sample 1 (family counselling), Sample 2 (no counselling), and Sample 3 (cancer survivors).

Cancer patients Partners of cancer patientsa Adolescent children of cancer

patientsb

Sample 1 Sample 2 Sample 3 p Sample 1 Sample 2 p Sample 1 Sample 2 p

N 147 161 1393 147 114 83 75

Age (M/SD) 43.7 (6.7) 40.1 (5.9) 47.5 (5.9) b0.001c 42.6 (6.7) 40.7 (7.2) 0.029c 13.8 (2.2) 14.3 (2.2) 0.180c
Female (%) 72.8 79.5 73.5 0.244d 46.3 27.2 0.002d 55.4 46.7 0.272d
Tumour sites (%) b0.001d b0.001d b0.001d
Mamma 35.4 62.1 53.4 23.1 54.4 26.5 65.3
Prostate/Testicular 1.4 2.5 9.7 1.4 3.5 2.7
Haematological 9.5 4.3 7.8 9.5 6.1 9.6 2.7
Skin 4.8 1.9 7.5 4.1 0.9 6.0 1.3
Colorectal 6.8 6.5 8.2 8.4
Gynaecological 10.2 10.6 6.2 6.1 12.3 9.6 10.7
Head & neck 2.7 6.8 2.5 2.7 8.8 1.2 8.0
Stomach 4.8 4.3 8.8 4.4 8.4 5.3
Others 24.6 7.5 6.4 36.0 9.7 30.1 4.0
Months since diagnosis (M/SD) 26.2 (37.1) 16.2 (28.4) 44.1 (23.4) b0.001c 26.7 (34.2) 16.4 (28.6) 0.010c 30.8 (44.1) 18.3 (33.7) 0.050c
Highest education in family (%) b0.001d 0.015d 0.060d
9 years 6.8 2.5 20.3 4.8 2.7 7.5 4.4
1012 years 39.0 63.9 47.4 40.4 58.4 43.8 63.2
N12 years 54.1 33.5 32.3 54.8 38.9 48.8 32.4
Family income (%) b0.001d 0.052d 0.056d
b2000 Eur 28.9 42.8 20.2 24.8 34.8 30.4 44.1
20003000 Eur 26.1 28.3 29.7 28.4 33.0 27.8 32.4
3000 Eur 45.1 28.9 50.1 46.8 32.1 41.8 23.5

Bold values indicate signicance at p b 0.05

a
Medical variables are related to the cancer patient in the family of the partner.
b
Medical variables are related to the parent with cancer in the family of the adolescent child (1118 years).
c
ANOVA.
d
2.

within the family, and family income (Table 2). Patients in Sample 1
(seeking counselling) were diagnosed with a broader range of tumour
sites and more often have the highest family education level. Patients
in Sample 2 (no counselling) are the youngest, were most often diag-
nosed with breast cancer, have the shortest time since diagnosis, and
more often have a low family income. Patients in Sample 3 (cancer sur-
vivors) are oldest, have the longest time after their rst diagnosis, have
the lowest family education level, and have highest family income. In all
3 samples, the percentage of female patients is above 72% (no signicant
difference). In Samples 1 and 2, the percentage of partners of cancer pa-
tients in the sample is less, but with similar ndings for all other charac-
teristics as reported by the patients. For adolescents in Samples 1 and 2,
the sick parent's socio-demographic family characteristics and medical
variables tend to differ as described above for patients and partners,
but there is no statistical signicance. The ages and percentages of fe-
male participants are comparable between samples.
3.2. Acceptance of FAD translated items
signicantly higher statistically than the required minimum (r N 0.70,
p b 0.05), and range from r = 0.75 to r = 0.87 (Roles: r = 0.66)
(Table 3). With regard to adolescents aged 15 to 18 years (Sample 1
and 2 combined), similar results are found (0.79 r 0.88, p b 0.05;
Roles: r = 0.53), with even slightly higher coefcients than for adults
in the subscales Problem Solving, Affective Involvement, and General Func-
tioning. Lower reliability coefcients are found in the subgroup of ado-
lescents aged from 11 to 14 years, ranging from r = 0.71 to r = 0.82
(Roles: r = 0.52), and with statistically signicant coefcients only in
the subscales Communication (r = 0.78) and General Functioning
(r = 0.82). Finally, regarding the results of the extended reliability
analyses (Online Supplementary Material), stability of high reliability
coefcients across more homogenous subgroups is evident in the sub-
scales Affective Responsiveness (0.73 r 0.85), Affective Involvement,
Affective Involvement (0.74 r 0.82), General Functioning
(0.82 r 0.88), and the whole FAD 51-item scale (0.92 r 0.95).
In terms of consistency of FAD subscales at the item level, all items,

For adults (patients and partners in all samples combined), the fre-
quencies of a missing response per item range from 0.2% to 1.1%, and Table 3
for adolescents (Samples 1 & 2 combined) from 0% to 4.4% (see Online Reliability: coefcients of internal consistency (Cronbach's ) of FAD subscales and the en-
tire FAD 51-items scale in joint samples of adults (cancer patients and their partners), and
Supplementary Material, Table S1). Regarding the completeness of re-
their adolescent children (11 to 14 years, and 15 to 18 years).
sponses within each subscale, 95.9% to 97.3% of the adults completed a
scale without any missing item. For adolescents, their completeness of Reliability (Cronbach's ) Adults Adolescents
responses within scales range from 89.2% to 95.6%. No remarkable dif- Role Sample 1, 2 & 3 Sample 1 & 2 Sample 1 & 2
ferences in missing items between age groups of adolescents are 1114 years 1518 years
found. When missing items were replaced by the mean score of all n 1962 86 72
other items in that scale (if b50% of missing items per scale), 99.6% to Problem solving 0.75 0.71 0.82
99.9% of all adult scale scores and 99.4% to 100% of all adolescent scale Communication 0.81 0.78 0.79
Roles 0.66 0.52 0.53
scores could be calculated in this study.
Affective responsiveness 0.84 0.73 0.84
Affective involvement 0.79 0.77 0.83
3.3. Analyses of reliability General functioning 0.87 0.82 0.88
FAD 51-item scale 0.95 0.92 0.95
In the combined samples of all adults (patients and partners), the re- Statistically signicant internal consistencies (Cronbach's N 0.70; p b 0.05) are printed in
liability coefcients (Cronbach's ) of all subscales, except Roles, are bold. Sample 1: family counselling; Sample 2: no counselling; Sample 3: cancer survivors.
114 V. Beierlein et al. / Journal of Psychosomatic Research 93 (2017) 110117

except one item from the subscale Roles, show satisfactory consistency
with their corresponding subscale scores, with item-scale correlations
ranging from ritmin = 0.29 to ritmax = 0.74 (Online Supplementary
Material).
3.4. Convergent and divergent validity analyses
All FAD subscales correlate to a higher degree with Satisfaction with
Family Life (FLZM: r = 0.46 to r = 0.59) in the sample of cancer
survivors compared with measures of emotional distress (anxiety
(HADS-A): r = 0.22 to r = 0.38; depression (HADS-D): r = 0.32 to
r = 0.44) and physical/mental HRQoL (SF-8 PCS: r = 0.16 to
r = 0.25; SF-8 MCS: r = 0.27 to r = 0.41) in the combined sam-
ples of all adults. Positive correlations indicate higher emotional distress
associated with worse family functioning, whereas negative correla-
tions indicate an association of higher satisfaction with family life/sub-
jective well-being with higher family functioning. The strength of
associations is highest for all measures in the General Functioning scale
(except for Roles in SF-8 PCS). Emotional distress and mental well-
being have higher correlations with FAD scales than does physical
well-being. For adolescents, correlations of FAD scales with global
HRQoL (Kidscreen10: r = 0.38 to r = 0.49) are higher than corre-
lations with HRQoL for adults (Table 4).
4. Discussion
4.1. Samples characteristics
As expected, socio-demographic data and medical characteristics
(e.g., age, sex, time since diagnosis) vary broadly between the samples
because of different study/sampling contexts. In the counselling group
(Sample 1) compared to the other samples, the frequencies of tumour
diagnosis are of a greater variety, indicating that patients with a more
rare diagnosis in this age group and their partners are seeking family
counselling. The higher family education level in the counselling
group may reect more difcult access to counselling services for less
educated families.
4.2. Acceptance of the FAD
Rare missing items in the German FAD demonstrate excellent accep-
tance of the measure for adult cancer patients and their partners. Fre-
quencies of missing values in FAD items for adolescents vary more but
are small enough to show satisfactory properties of comprehensibility
and clarity of item/scale contents for younger and older adolescent
study participants.
4.3. Reliability analyses

The FAD 51-item scale has excellent reliability in combined samples

3.5. Discriminative validity
The results of ANCOVA show that there are statistically signicant
differences of FAD subscale scores (adjusted for age, sex, time since di-
agnoses, highest education level in the family, and family income) be-
tween the different study settings (counselling, no counselling, cancer
survivors) in several dimensions of family functioning in the subgroups
of patients and partners (Table 5). Patients in the counselling setting
(Sample 1) report worse family functioning than patients in the non-
counselling sample (Sample 2) in all FAD scales except for Affective Re-
sponsiveness, with standardised mean differences ranging from d =
0.29 to d = 0.59. Similarly, patients who seek counselling (Sample 1)
and cancer survivors (Sample 3) differ signicantly on all FAD scales, ex-
cept for Communication and Affective Responsiveness, with worse func-
tioning in patients who seek counselling (d = 0.24 to d = 0.39). For
cancer patients without counselling (Sample 2) and cancer survivors
(Sample 3), only the FAD scales Problem Solving (d = 0.33) and
Roles (d = 0.22) differ signicantly, with cancer survivors perceiving
worse functioning in these dimensions. Furthermore, partners in the
family counselling context perceive worse family functioning than
non-counselled partners for all scales except Communication (d = 0.30
to d = 0.48). No signicant differences are found for adolescents be-
tween the samples in all scales.
and in all adult and adolescent subsamples, with r N 0.90, which ac-
counts for high inter-correlations between all items (and scales) and
the length of the test. Because of the high reliability, a total score of all
FAD items may be precise enough for diagnostic purposes on an individ-
ual level for adults and adolescents ages 11 years and older. The usabil-
ity of a FAD total score for diagnostic procedures in the clinical practice
should be addressed in future studies. Also, the General Functioning scale
shows statistically signicant high reliability (r N 0.80) for adults and
adolescents (1118 years). Even though almost all other FAD subscales
reveal good to excellent internal consistency in the combined heteroge-
neous samples, reliability may be limited in more homogenous popula-
tions with specic characteristics (see Online Supplementary Material),
or in populations of adolescents aged younger than 15 years. Thus, we
suggest that future studies routinely examine reliability coefcients
for each scale in each subsample and incorporate their magnitude into
the interpretation of test results.
The Roles scale has poor reliability (r b 0.70) in all combined sam-
ples and subsamples, and our ndings are in agreement with the results
from several studies (e.g., [2,5,7]). Possible reasons for the low internal
consistency of this scale may be an ambiguous understanding of some
item content by the respondents (see Online Supplementary Material),
or that item content describes facets of rather a multidimensional sub-
scale. Furthermore, as the original FAD has been developed in the

Table 4
Convergent & divergent validity: correlations of FAD scales with measures of emotional distress (HADS), health-related quality of life (SF-8, KidScreen10), and satisfaction with family life
(FLZM, item 5).

Patients & partners Patients Adolescents

Sample 1, 2 & 3 Sample 3 Sample 1 & 2

Correlations (Pearson's r) HADS-A HADS-D SF-8 PCS SF-8 MCS FLZM item 5 Kidscreen10 self-report

n 1932 1928 1887 1887 976 156

Problem solving 0.24 0.34 0.16 0.30 0.48 0.42
Communication 0.31 0.37 0.19 0.33 0.52 0.42
Roles 0.35 0.36 0.25 0.35 0.46 0.47
Affective responsiveness 0.22 0.32 0.17 0.27 0.47 0.38
Affective involvement 0.33 0.34 0.18 0.31 0.46 0.44
General functioning 0.38 0.44 0.19 0.41 0.59 0.49

All correlations (Pearson's r) are statistically signicant (p b 0.001). Sample 1: family counselling; Sample 2: no counselling; Sample 3: cancer survivors. HADS: Hospital Anxiety and De-
pression Scale; HADS-A: anxiety subscale; HADS-D: depression subscale. SF-8: Short-Form Health Survey; SF-8 PCS: Physical Component Summary; SF-8 MCS: Mental Component Sum-
mary. FLZM: Questions on Life SatisfactionModules; Item5: satisfaction with family life. Kidscreen 10: self-reported 10-item Global Index Scale.
 V. Beierlein et al. / Journal of Psychosomatic Research 93 (2017) 110117
Table 5
Discriminative validity: adjusted mean scores, standard deviations, and standardised mean differences (Cohen's d) between Sample 1 (family counselling), Sample 2 (no counselling), and
Sample 3 (cancer survivors).
United States during the 1980s, the meaning of the concept of Roles in-
side families may have changed over time, or the concept may not be di-
rectly transferrable from the American culture to a culture outside the
US. Therefore, future studies should examine cultural appropriateness
and timeliness in more detail, not only for the subscale Roles, but also
for the other scales, in particular the scale Behaviour Control, which
needed to be excluded from this study for the aforementioned reasons.
4.4. Convergent and divergent validity
The pattern of correlations between the subscales of the FAD and
measures of satisfaction with family life (FLZM), health-related quality
of life (SF-8; Kidscreen-10 Index) and emotional distress (HADS)
found in this study are in line with ndings in previous studies [7,23,
35,3739], and support evidence for construct validity. The magnitudes
of the associations between the FAD and Satisfaction with Family Life
are higher (convergent validity) than the associations with the other
measures (divergent validity). The low correlations between the FAD
scales and the Physical Component Score of the SF-8 indicate that family
functioning in families with parental cancer has only a weak association
with the physical burden of the parents. However, emotional distress in
parents or decreased overall well-being of their children is noticeably
high associated with a more dysfunctional family system, hence indicat-
ing the FAD to be a sensitive measure in populations with parental
cancer.
4.5. Discriminative validity
As it was expected, cancer patients and their partners seeking family
counselling (Sample 1) report noticeably worse family functioning in at
least four of the FAD scales than do cancer patients and partners without
counselling (Sample 2) or cancer survivors (Sample 3). There are no dif-
ferences in the perceived family functioning of adolescents between the
counselling setting (Sample 1) and the non-counselling sample (Sample
2). From a psychometric point of view, the FAD shows discriminative
validity in populations with adults, but not in populations of adoles-
cents. A possible qualitative interpretation of this result may be that
children in the adolescent age may have a focus on coping with the sit-
uation of parental cancer outside the family system [54].
5. Limitations
An important limitation of the presented study is the elimination of
the subscale Behaviour Control prior data collection. Although there
were good reasons to do so, namely, potentially culturally inappropriate
item content that may produce respondent burden and poor reliability
115
of this subscale found in previous studies of the translated FAD, the
comparability of the German translation with the original FAD or
other translations is restricted to the remaining subscales Problem Solv-
ing, Communication, Roles, Affective Responsiveness, Affective Involvement,
and General Functioning. Due to the naturalistic design of the study of
the VKKE project it was not possible to analyse the FAD in a control
group of healthy participants, and no information on drop-out could
be gathered systematically for non-responder analysis. Strengths of
the study are rstly the presentation of psychometric characteristics of
the FAD based on relatively large sample sizes of participants from dif-
ferent study settings in the context of parental cancer, what may ease
the planning to use the FAD in future studies. Secondly, this study ex-
tends the formerly very scarce information whether the FAD is psycho-
metrically sound also in populations of adolescents aged 11 to 14 years.
6. Conclusion
The rst analysis of acceptance, reliability and validity of the German
adoption of the FAD for different groups of cancer patients, their part-
ners and dependent children show good psychometric properties for
the instrument in various study settings. Especially the General Func-
tioning scale can be used reliably for adults and adolescents 11 years
old and older. As the German adaptation of the FAD proved to be reliable
and valid in very different populations of families with parental cancer,
it can be considered to play an important role in the assessment of fam-
ily functioning in future studies.
Role of the funding source
The sponsors had no involvement in the study.
Conict of interest
The authors have no competing interests to report.
Grant information/Acknowledgements
This study is part of the German multi-site research project, Psycho-
social Services for Children of Parents with Cancer, supported by the
German Cancer Aid (Deutsche Krebshilfe, grant # 108303). In this
multi-site project, the following institutions and Principal Investigators
are collaborating:
- Dept. of Child and Adolescent Psychiatry and Psychotherapy, Ham-
burg-Eppendorf University Medical Center (Prof. Georg Romer);
- Institute of Medical Psychology, Hamburg-Eppendorf University
Medical Center (Prof. Uwe-Koch-Gromus);
116 V. Beierlein et al. / Journal of Psychosomatic Research 93 (2017) 110117
- Dept. of Child and Adolescent Psychiatry, Psychosomatics & Psycho-
therapy, Charit University Medical Center, Berlin (Prof. Ulrike
Lehmkuhl)
- Dept. of Child and Adolescent Psychiatry, Psychotherapy & Psychoso-
matics, University Medical Center, Leipzig (Prof. Kai v. Klitzing);
- Institute of Medical Psychology and Medical Sociology, University
Medical Center, Leipzig (Prof. Elmar Brhler);
- Dept. of Psychosomatic and General Clinical Medicine; University
Medical Center, Heidelberg (Prof. Wolfgang Herzog);
- Dept. of Child and Adolescent Psychiatry, University Medical Center,
Heidelberg (Prof. Franz Resch);
- Dept. of Child and Adolescent Psychiatry, Psychotherapy and Psycho-
somatics, Otto-von-Guericke University, Magdeburg (Prof. Hans-
Henning Flechtner).
Appendix A. Supplementary material
Supplementary material to this article can be found online at http://
dx.doi.org/10.1016/j.jpsychores.2016.11.007.
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