Journal of Family Psychology 1998, Vol. 12, No.

2, 220-233

Copyright 1998 by the American Psychological Association, Inc. 0893-3200/98/$3.00

A Partial Test of the Psychosomatic Family Model: Marital Interaction Patterns in Asthma and Nonasthma Families
S u z a n n e N o r t h e y , W i l l i a m A. Griffin, a n d S o n i a K r a i n z Arizona State University The psychosomatic family model (PFM) implicates marital quality in childhood asthma chronicity and exacerbation. The PFM posits that the child's symptomatology varies in relation to parent interaction patterns characterized by conflict avoidance and brief intradyadic engagement. This investigation of 40 families sought to determine if marital dyads show differential conditional likelihoods for these behavioral characterizations as a function of having an asthmatic or nonasthmatic child. Using observational data collected in the home, a series of logit models examined the likelihood of extended dyadic engagement, disagreement, and child solicitation. As predicted, nonasthma couples were more likely to disagree and had longer intradyadic engagements, whereas asthma family couples were more solicitous. Contrary to expectation, marital quality was not a significantpredictor of child solicitation in the asthma family couples. al., 1993; Ramsey, 1989; Rosser, 1981). Consequently, couples with a chronically ill child are more likely to divorce than are couples without an ill child (Jessop & Stein, 1989). Moreover, as parents spend a disproportionate amount of their time caring for the diagnosed youth, siblings may become jealous, angry, and less cooperative (Lobato, 1990; Moody, McCormick, & Williams, 1990: Perrin et al., 1993). With chronic illness, the entire family suffers. Asthma is the most prevalent chronic childhood disease. It currently affects about 4.8 million (7%) children under 18 years of age (Adams & Marano, 1995), and the disease appears to be increasing. Annual hospitalization rate for children less than 24 years old rose by 28% from 1980 to 1993, with children under 5 years old being most affected ("Air Pollution," 1996). There has also been a concomitant rise in asthma-related deaths among children under 14 Suzanne Northey, William A. Griffin, and Sonia years old, from 1.7 to 3.2 per million population Krainz, Department of Family Resources and Human ("Air Pollution," 1996). Development,Arizona State University. Allergenic, infectious, familial, socioecoCorrespondence concerning this article should be nomic, environmental, and psychosocial factors addressed to William A. Griffin, Marital Interaction Lab, Department of Family Resources and Human have been linked to asthma morbidity (Etzel, Development, YI-IE 2502, Arizona State University, 1995). Although each factor, either singularly or Tempe, Arizona 85287-2502. Electronic mail may be synergistically, contributes to the disease, the sent to William.Griffin@asu.edu. familial contribution is especially important. 220 Up to 20% of preschool children in the United States develop a chronic illness (Canny & Levinson, 1994). Medical expenses may be 6 times higher for a chronically ill child compared with a healthy child, representing up to 10% of the annual income for some families (Canny & Levinson, 1994; Lobato, 1990; Thompson, 1985). However, the financial cost is often secondary to the psychological effect that childhood chronic illness has on other family members (Penin, Shayne, & Bloom, 1993). Diagnosis of a child's chronic illness elicits varied reactions from parents, ranging from anger and resentment to guilt and depression (Penin et al., 1993; Travis, 1976). Marital relationships are sometimes strained because of uncertainty about disease prognosis, increased financial responsibilities, reduced leisure time, and fatigue (Kazak & Nachinan, 1991; Perrin et

A PARTIALTEST OF THE PSYCHOSOMATICFAMILYMODEL The preponderance of a child's time is spent at home with his or her family, and studies have concluded that negative family interactions adversely affect the asthmatic child (Block, Jennings, Harvey, & Simpson, 1964; Long et al. 1958; Minuchin et al., 1975). Although family behavior and asthma exacerbation have been linked, the specific mechanisms associated with the linkage have not been identified. A few speculative theoretical models have been forwarded, the most prominent being the psychosomatic family model (Minuchin et al., 1975). Psychosomatic Family Model Minuchin et al.'s (1975) psychosomatic family model (PFM) proposes three necessary conditions for the development of psychosomatic illness in children. First, the child possesses physiological vulnerability to a chronic illness. Second, the family engages in four specific dysfunctional interaction patterns: (a) enmeshment or overinvolvement among family members, (b) overprotectiveness or excessive concern for each other's well being, (c) rigidity or redundant interaction patterns that stifle change, and (d) lack of conflict resolution or failure to resolve problems by avoiding or detouring conflict. Third, parents recruit the ill child into potentially contentious marital discussions. Such triangulation occurs at the expense of the child's well-being because child recruitmerit purportedly results in increased symptom manifestation (Byng-Hall, 1980; Minuchin et al., 1975; Onnis, Tortolani, & Cancrini, 1986; Wood et al., 1989). Minuchin et al. (1975) concluded that the rigid, overprotective, and enmeshed interactional patterns characterizing psychosomatic families reflect a low threshold for conflict. The various strategies proposed in the PFM (e.g., triangulation) are parental attempts to avoid conflict; spouses in these families behave in ways that reduce the likelihood of contentious intradyadic engagement. Parents, in effect, maneuver to avoid conflict. This model unequivocally implicates marital dyad interactions in tlae child's asthma chronicity and exacerbation. The PFM posits that a child's symptomatology varies in relation to the parent's conflict level. This assumed relationship between marital interaction style and expressed symptomatology is so strongly en-

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trenched in the psychotherapy literature that many, if not most, treatment programs involving illnesses thought to have a psychosomatic component address parent interaction patterns (see, e.g., Schlundt & Johnson, 1990; Vandereycken, Kog, & Vanderlinden, 1989; Woodside & Shekter-Wolfson, 1991). Although the PFM proposes to explain family etiology and maintenance factors associated with childhood psychosomatic illness, the model and Minuchin et al.'s (1975, Minuchin, Rosman, & Baker, 1978) investigations contain numerous flaws. For example, Minuchin and colleagues used small samples with a constricted range of illness severity and no control group (Coyne & Anderson, 1988). A greater problem was Minuchin et al.'s (1975) failure to define behaviorally the PFM constructs. Inadequate and nonspecific definitions stifled the use of observational coding, a methodology necessary to confirm the proposed behavioral patterns (Coyne & Anderson, 1988; Kog, Vertommen, & Vandereycken, 1987; Vuchinich, Emery, & Cassidy, 1988). Without behavioral evidence for the proposed patterns, Minuchin and his colleagues could not verify empirically that psychological factors exacerbated, prolonged, or were even associated with childhoodchronicillness (Coyne & Ando'son, 1988). In response to these methodological shortcomings, several investigators attempted to replicate the initial findings on the PFM (see, e.g., Burbeck, 1979; Kog et al., 1987; Onnis et al., 1986; Wood et al., 1989). Although evidence for some of the PFIVI's constructs was found, these studies were hampered by some of the same methodological flaws, including small sample size (Onnis et al., 1986), omission of a control group (Kog et al., 1987; Wood et al., 1989), inclusion of only severely ill participants (Onnis et al., 1986), and especially relevant, inad= equately defined constructs (Kog et al., 1987; Wood et al., 1989). Although generally flawed, the studies did produce one consistent finding: Conflict and conflict avoidance in chronic illness families occurred consistently with the PFM. For example, Kog et al. (1987) found that among the variables examined, only conflict correlated with interaction, outcome, and self-report measures. And Wood et al. (1989) found that during arguments, marital partners triangulated the chronically ill child into disputes. Wood et al.

222

NORTHEY, GRIFFIN, AND KRAINZ male child without asthma. Participant families responded to flyers posted at medical facilities housing pediatricians, allergists, and respiratory specialists and to ads placed in community-based newspapers. Each family consisted of 2 parents and a 6--lI-year-old asthmatic or nonasthmatic male child with at least one other sibling. Boys with asthma met the following criteria: (a) physician-diagnosed asthma with symptoms present for a minimum of 1 year and (b) parental verification of the child's current asthma condition. Parents in both conditions were told that the goal of the study was to examine family interaction patterns during the evening meal. All families received $25 for their participation in the study. Demographic information about family size, ages, sex, race, religion, parent's education and occupation, date of marriage, and history of psychotherapy was obtained from each family. No significant differences were found across groups on any of the demographic variables, 1 except for wife's age (see Table 1). Of the 40 families, 88% were Caucasian, 8% were Mexican American, and 4% were African American.

(1989) also reported that parental recruitment increased disease symptomatology. Together these findings suggest that marital conflictresolution strategies are relevant and quantifiable in this population (Kog et al., 1987). As such, lack of conflict resolution by the marital dyed forms the cornerstone of the PFM model and, accordingly, should discriminate between asthma and nonasthnm families. The PFM delineates at least five testable hypotheses about the expected marital dyad behavior sequences in families with a chronically ill child in which the illness is thought to have a psychosomatic component. First, nonasthma family couples, being more willing to have extended dyadic interactions, are more likely to both (Hypothesis 1) agree and (Hypothesis 2) disagree with their spouse during a conversation; either response, especially the "agree," sets the stage for extended dialogue. Hypotheses 3 through 5 also address the proposed avoidance of extended marital dialogue. Hypothesis 3 states that nonasthma family couples, being willing to maintain dyadic engagement, are more likely to have contiguous d y a d i c "agrees." In Hypothesis 4, asthma families, being quick to reduce or avoid conflict, are more likely to produce the unique sequence of marital dyad "disagree" followed by "child divert." This hypothesis is consistent with Minuchin et al.'s (1975) statement that children are more likely to intrude into the marital conversation as the likelihood of conflict increases or, to use their term, conflict "cues" the child. Finally, Hypothesis 5 states that to avoid extended engagement, asthma family couples are more likely to leave the dyadic arena and engage a child. This tests the notion that asthma family couples are more likely to recruit their children into the marital domain. These hypotheses test only a portion of the PFM; each focuses on specific behavioral sequences associated with marital dyads. If the PFM is correct, couple behavior should differ as a function of having an asthmatic or nonasthmatie child in the home. Method

Instruments Asthma inventory. We developed an asthma inventory that contained questions about age at diagnosis, symptom severity, frequency of attacks, asthma triggers, prescribed medications, and history of hospitalization. Marital Adjustment Test (MAT). The MAT (Locke & Wallace, 1959) is a valid and reliable measure of marital satisfaction that distinguishes distressed from nondistressed couples (Crane, Allgood, Larson, & Griffin, 1990). This 15-item Likert-type instrument was included because of the posited theoretical relationship between marital quality, family relationships, and psychosomatic illnesses (Minuchin et al., 1975). Scores range from 2 to 158 for each spouse,
1 A t test indicated that families in the asthma group reported using mental health services significantly more frequently than did the nonasthma group, t(38) = -2.49, p < .05. Seven families in the asthma group received mental health services compared with only 1 family in the control group. A review of the reasons given for going to therapy showed no consistent pattern within the asthma group. A test of homogeneity was done to determine whether contingency table matrices of the coded behaviors differed between those asthma families that had been to therapy and those that had not. Following the procedure outlined in Gottman and Roy (1990), a likelihood ratio chi-square indicated that the two groups were not significantly different, LR X2(172, N = 20) = 22.23, p > .05, suggesting that it was appropriate to pool the asthma families.

Participants
Forty families from a large southwestern city participated in the study: 20 families containing a male child with asthma and 20 families containing a

A PARTIAL TEST OF THE PSYCHOSOMATIC FAMILY MODEL Table 1

223

Group Means for Demographic Data

Nunasthma group
(n = 2 0 )

Asthma group (n = 20)

Measure and group Education (years) Husbands Wives Hollingshead socioeconomic status score Age (years) Husbands Wives Marital length (years) Family size Children Boys Girls Child age (years) Boys Target male Girls *p < .05.

M
15.00 13.80 72.95 38.15 36.25* 14.30 5.40 2.25 1.15 9,10 8.70 6.70

SD

SD
2.18 2.12 27.00 5.06 4.19 6.50 0.67 1.85 0.72 2.39 1.90 3.34

2.84 15.50 1.70 14.00 23.60 74.80 5.12 35.15 4.24 33.15 5.76 11.30 1.39 1.11 0.98 2.92 1.30 5.54 4.85 1.85 1.00 7.62 8.10 4.00

with scores less than 101 indicating marital distress. Initial reliability coefficients for the MAT range from .73 to .90 (Locke & Wallace, 1959). Internal consistency is .83 (Cross & Sharpley, 1981, cited in L'Abate & Bagarozzi, 1993). For this sample, Cronbach's alpha showed minimally adequate internal consistency; alpha was .69 across the entire sample, .69 for the asthma group, and .69 for the control group. A series of t tests assessing group comparability found no significant mean differences within group across gender, across group within gender, across group couple scores, but the number of distressed spouses differed by group (see below). Mean scores for both groups indicated nondistressed marital relationships (see Table 2). A Pearson product-moment correlation coefficient for both groups indicated moderate and significant intracouple agreement on the quality of the marital relationship, nonasthma: r(20) = .65,p < .01; asthma: r(20) = .68,p < .01. A Pearson product-moment correlation coefficient between couple MAT score and the total number of events that each family contributed to the entire data set was not significant, r(40) = -.23, p = . 15. Although couple MAT scores were not significantly different between the two groups, asthmagroup couples were, on average, less satisfied with their marriages than were control-group couples (see Table 2). Nine spouses (45%) in the asthma group reported being maritally dissatisfied, whereas only 3

(15%) were similarly dissatisfied in the control group. This difference was statistically significant, X2(1, N = 40) = 4.28, p < .05. This suggests that an averaged couple score (i.e., couple MAT) loses some important information about the differences between the two groups. Given the putative relationship between marital quality and psychosomatic illnesses, this distinction is critical because only one distressed spouse is needed to substantially alter dyadic interaction sequences (Buger & Jacobson, 1979; Gottman, 1994). To account for the possible influence of one distressed spouse on marital interaction, the individual MAT score was used to create a dichotomized score of couple marital quality.2 Couples were assigned a score of 0 if either partner scored in the distressed range of the MAT, otherwise the couple received a score of 1. This dichotomized score formed the marital satisfaction proxy used as a covariate in the data-analytic models. To account for other factors that might influence marital interaction, we had each spouse complete a series of self-report instruments that assessed depression, social conventionalization, social status, and parent perception of target child behavior. Depression scale. Numerous studies have found that depressive behavior in a spouse can substantially alter couple interaction (Hooley, 1992). The 21-item Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) was used to assess depression. This commonly used insmunent has acceptable psychometric properties (Beck, Steer, & Garbin, 1988). Across groups, no significant differences were found; all respondents scored in the low range for depression. Conventionalization Scale. The Edmonds Conventionalization Scale measures the propensity for spouses to give socially desirable responses about their marriage (Edmonds, 1967). The Edmonds Marital Conventionalization scale is often used in conjunction with marital satisfaction measures to assess a respondent's propensity to provide socially

2 It could be argued that reducing the interval level MAT score to a nominal level indicator loses information; but this is true only in the general statistical sense. The argument is irrelevant for the identification of unique (i.e., distressed) individuals. As Filsinger (1983) noted, there is no universally accepted method for determining marital distress. Appropriate assessment of the marital state depends on the questions asked of the data. Specifically, is it more important to know about the couple or the individuals within the couple? For these data, the averaged couple score is not a good predictor of specific spousal behavior whereas the individual score is (see Snyder, 1983; Weiss, 1981).

224 Table 2

NORTHEY, GRIFFIN, AND KRAINZ

Mean Scores for Husband and Wife Self-Report Instruments

Nonasthmagroup Husband Measure MAT BDI Edmonds Wife Couple Husband Asthmagroup Wife Couple

SD

M
113.85 7.05 10.10

SD
19.90 7.27 7.67

SD

SD

SD

SD

117.65 20.72 5.25 4.54 14.00 9.92

115.75 20.15 6.15 4.40 12.05 8.05

107.50 21.68 7.65 6.37 11.50 6.78

110.15 23.48 6.70 7.43 14.15 7.83

108.82 22.35 7.17 6.08 12.82 6.76

Note.

MAT = Marital Adjustment Test; BDI = Beck Depression Inventory; Edmonds = Edmonds Marital Conventionalization Scale.

desirable responses to questions about marital quality or satisfaction (i.e., false positive). Asthma and nonasthma group scores indicated average conventionalization, with no differences between groups (see Table 2). Measure of socioeconomic status. A Hollingshead score was calculated for each couple to assess socioeconomic status. The Hollingshead Index of Social Position uses both an occupational and educational scale to determine a person's social status (Hollingshead, 1971; Hollingshead & Redlich, 1958). A series of t tests comparing husband, wife, and couple status scores across groups found no significant differences (see Table 2). Child Behavior Checklist. It is possible that parents with a chronically ill child might perceive their child's behavior differently from parents of children without a chronic illness. To account for this, we had both parents in this study complete the parent self-report Child Behavior Checklist (CBCL; Achenbach, 1978; Achenbach & Edelbrock, 1978, 1979, 1981) designed to assess 6-11-year-old boys' behavior problems during the previous 6 months. The CBCL is a standardized measure of children's behavior problems and competencies of children between the ages of 4 and 16. Achenbach (1978) reported good test-retest reliability for mothers, .95 for behavior problems, and .99 for social competence. Composite scores were obtained for three separate types of child psychopathology: depression, anxiety, and conduct disorder (Gersten, Beals, West, & Sandler, 1987). For this sample, Cronbach's alphas showed high internal consistency; alpha was .94 across the subgroups, .94 for the asthma group, and .94 for the nonasthma group. A series of t tests indicated no significant differences for child anxiety, conduct disorder, and depression within group across reporter and between group same reporter.

Renne & Creer, 1985; Vuchinich, 1987). Reactivity studies have shown that the presence of audiovisual equipment during dinner has minimal effect on typical family interaction behaviors (Christensen & Hazzard, 1983; Haynes, Follingstad, & Sullivan, 1979). Data from a pilot study indicated that dinnertime conversations often produced an insufficient number of the needed codeable statements (see Coding Conflict Avoidance below), so a 10-rain postdinner family task was added to increase the opportunity for intradyadic dialogue. For the task, family members were asked to discuss with each other the content of a recent family dispute, how it started, who was involved, and its outcome. This additional task provided sufficient data for statistical analyses) A total of 1,584 events were available for data analysis. The research team arrived at the home before 3 A test of stationarity was done to determine similarity of probability structure across the dinner and task observation periods (Caiffin & Gottman, 1990). Following the procedure outlined in Gottman and Roy (1990), a likelihood ratio chi-square indicated that the two periods were significantly different from their combined probability structure, LR X2 (30, N = 40) = 51.14,p < .05, suggesting that the interactions generated over the two periods differed from each other. As noted by Gottman and Roy (1990), significance on this test is due, in large part, to the number of observations, not the number of participants, and as such, investigators should be cautious about using a liberal alpha level (e.g., p -.05) too rigidly when making data-analytic decisions. Although it was possible to analyze the interactions separately, sparse cell counts in the separated contingency tables would weaken parameter estimates in the data-analytic model. More important, it was thought that by combining the observation periods, a more generalizable statement could be made about the interactions of the families across activities. Given the data-analytic and interpretation advantages, the data were combined into a composite dataset with 1,584 events.

Procedure and Data Collection Task

The ritualistic nature of the evening meal provides a natural setting for gathering observational data (e.g.,

A PARTIAL TEST OF THE PSYCHOSOMATIC FAMILY MODEL dinnertime to set up a tripod-mounted video recorder. R was placed 6 to 8 feet from the dining table and positioned to include all family members. To facilitate acclamation to the recording process, the research team spent 10--15 min with the family describing the study or answering questions in very general terms. After the family seemed comfortable, they were given the set of instructions for completing the after-dinner task. Parents were then taught how to turn off the video recorder. When the family was seated and dinner was about to begin, the investigators made final camera adjustments, began recording, and left the home. After the family completed the dinner and task and a parent stopped the camera, the spouses separated and each opened an envelope containing the selfreport instruments. They were explicitly told to complete the forms separately and not to discuss the forms or the answers with their spouses. To avoid contamination, we ensured that all questionnaires that might provoke or influence interactions were completed after the videotaped interactions. After 1.5 hr the research team returned to pick up the equipment and self-report data. Dinners averaged 25.13 min in length and tasks averaged 16.52 min, providing an average of approximately 42.00 rain of videotaped interaction per family. A series of t tests (dr = 38) indicated no significant group differences for rate of events (number of events/time on task), mean time on task, and mean number of events.

225

Coding Conflict Avoidance

Previous investigators attempting to assess marital conflict avoidance strategies within the framework of this model tended to use gross level descriptions (e.g., recruit, triangulate) clearly unsuited for behavioral microanalysis. Descriptions of the strategies tended to be poorly defined and too general and inferential to code refiably. To code the proposed processes, we broke the putative patterns into component parts: agrees, disagrees, child solicitation, and child diversion. Minuchin et aL (1975) clearly suggested that the behavioral phenomenon characterizing psychosomatic families is sequentially based, both at the micro and macro levels. Throughout their seminal article, they used terms such as transactional patterns, family

processes that trigger.., symptoms, reinforcement for symptoms, conflict avoidance patterns, transactional sequences, enact maladaptive sequences, set off a chain of alliances, and cue family members.
These terms clearly imply sequence, contingency, and conditional probability. An analysis of the rate of these behaviors, generally in the form of unconditional probabilities, but would have failed to capture the behavioral interdependence assumed in this

theory. Thus, we had to develop a coding structure and data-analytic strategy that would capture the nuances discussed by Minuchin et al. (1975). To compare asthma versus nonasthma families, we used a cross-classification scheme that entailed finding conceptually relevant triggering events and then assessed subsequent behaviors for two consecutive talk turns (Bakeman & Gottman, 1986). Similar three talk-turn sequences have been found to capture sufficiently the important prohabilistic features of negative family conflict (Vuchinich, 1984). A parent-generated declarative statement was designated as the trigger event (e.g., "You should get a job that pays more money"); this provided an opportunity to observe another family member's immediate response to the position statement. It was defined as a three-word or greater statement that reflects a parent's position (i.e., stand, opinion) and is directed to the other spouse while holding the conversational floor. The position statement provided an opportunity for marital agreement, disagreement, or child involvement. By using this format, it was possible to assess a spouse's willingness to stay engaged during a potentially contentious discussion or, conversely, to go outside the marital dyad to recruit other family members into the conversation. Coding two talk turns following the declarative statement (referred to as To) captured the next speaker (child or spouse; referred to as T1) and the subsequent speaker's response (referred to as T2). The Family Interaction Tactics (FIT) coding system was developed to record these short behavior sequences (Griffin, Krainz, & Northey, 1994; see the Appendix for brief code descriptions; the complete manual can be obtained from William A. Griffin). Possible spousal response codes included agree, disagree, topic shift-by-parent, and topic shift-to-child.Possible child codes included child divert, child talk-toparent, and child talk-to-child. Child response patterns are not reported in the current study. Behaviors not fitting these categories were coded as "other." Only 7% and 9% of the codes were classified as "other" for the TI speaker code and the subsequent T2 speaker response, respectively, All family interactions were gleaned initially for relevant codeable units (i.e., statements directed toward the spouse). Using 15% of the codeable units per family, we generated an interrater refiability with an acceptable kappa of .93 for the selected units. After obtaining initial reliability, coded video segments were again reviewed, all declarative statements within the codeable units were retained, and nondeclarative statements were discarded. An acceptable kappa of .81 was obtained for 15% of the selected statements. Following each declarative statement (To), the next two talk turns were classified according to the coding

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NORTHEY, GRIFFIN, AND KRAINZ

scheme. A kappa of .83 was attained for T1 codes, and a kappa of .88 was attained for 1"2codes.4 Only 5% (n = 72) of all codes were a disagreechild divert combination. To ensure an adequate parameter estimation of the data-analytic models, it was decided that a minimum of 5% (n ~ 80) was necessary before analyses could be done; therefore, this hypothesis was not tested (Hosmer & Lemeshow, 1989; Wickens, 1989).

Data Analysis
All analyses were confirmatory: Each hypothesized sequence of family behavior was tested in the direction implied by the theory. Because we coded only specific behavioral sequences, sequential analysis of all sequences was unnecessary. Instead, the likelihood score of the specified three-turn sequence became the family score, allowing the use of more traditional inferential statistics. Each directional hypothesis was tested using a logit model with the dependent variable being the family's estimated likelihood to engage in the specified behavioral pattern associated with each hypothesis. Here the dependent variable was discrete categorical converted to a proportion of occurrence for each code (e.g., "agree" at TO per family. Shifting the dependent variable from a discrete choice response (0/I) to a proportion is referred to as grouping the data (see Greene, 1997). For these data, each hypothesis was a statement specifying the likelihood of an outcome (i.e., code sequence); the outcome either occurred (1) or d/d not occur (0) for each coded event, thus forming a dichotomous dependent variable. As events occur, they generate a probability of occurrence in the form of odds (i.e., occur/not occur). Although interpretable, odds lack several mathematical qualities desirable in a dependent variable. To obtain the desired properties, odds are transformed by taking theirnatural log (base e; Aldrich & Nelson, 1984; Griffin& Gottman, 1990). By taking the natural log of the odds, this log-odds estimate has the desirable property of having a range of _+oo (Wickens, 1989). In logit modeling, this log-odds or logit is regressed on the specified covariates in the linear model (DcMaris, 1992; Liao, 1994).5 For each model, the influence of each independent variable on the log-odds (of occurrence) for the dependent variable is reflectedin the predictor variable's estimated regression coefficient, holding the influence of the other predictors constant. Each regression coefficient ([3) associated with each independent variable reflects the estimated change in the log-odds of the dependent variable, thus larger [3s reflect greater influence (Liao, 1994). Each model generates a z test statistic for each independent variable; this test statistic reflects the influence of the

4 The coding of these data took approximately 1 year; 10 undergraduate coders began the project, and 6 remained until its completion. One particularly good student became the criterion coder. Among coder checks done by the criterion coder, 15% were reviewed for reliability by the investigators (Cohen's kappa = .86). Training occurred in the following three stages: (a) memorization of the codes; (b) group coding with code definition clarification; and (c) reliability obtained for T] then T2 codes. The investigators initially conducted the code definition training, individual and group practice, and review sessions; the criterion coder subsequently handled these duties. Coders initially practiced with interaction segments from the pilot study tapes. After successfully identifying behaviors that matched the codes, each coder practiced with tapes from both the asthma and control groups. Investigators logged practice tape IDs and coder IDs to ensure that the coder would not eventually code his or her practice tape. Before coding the Tl data, each coder reached a minimum kappa of .70 on the practice tapes; there was a similar requirement before beginning the 1"2 coding. Coders averaged 125-150 hr of training before coding T1 codes. Reliability was maintained throughout the study by coding 15% of each tape. If a tape failed to meet the necessary Cohen's kappa of .70, it was recoded until the coder assigned to the family was able to obtain the requisite level. Across 40 families, 1,584 events were coded using the coding scheme. At T~, the codes occurred in the following frequencies and percentages (%): agree, 573(36); disagree, 203(13); other, 110(07); topic shift by parent, 29(02); topic shift to child, 159(10); and child divert; 510(32). At 1"2,the frequencies (%) were agree, 354(22); disagree, 138(09); other, 152(09); topic shift by parent, 39(02); topic shift to child, 289(18); and child divert, 612(39). 5 It is the natural log of the odds that is regressed on the independent variable. Specifically, where p equals the probability of an event,

[ P~ I

is called the logit or logistic transformation. The basic formula for the logit regression with a categorical variable is log~

(_-g,) = p + k~,

where p (mu) represents an overall average of the logit, and k (lambda) represents the effect of being classified in level i of condition (in these data). Some

A PARTIAL TEST OF THE PSYCHOSOMATIC FAMILY MODEL independent variable on the log-odds of the dependent variable. For the logit model, a value ->1.96 is significant (p < .05). To interpret the estimated influence of the independent variable, [3 is exponentiated (take the antilogarithra where the base is e; Liao, 1994). To exponentiate simply means to raise the value of e (natural log; ~ 2.718) to the number, or in these analyses, e(fl). This exponeutiated regression coefficient yields the estimated change in the odds of occurrence (or odds shift) of the dependent variable (DeMafis, 1992). Hence, for this study, the logit model provides an estimate of the direction and magnitude of change in the likelihood for the specified behavior sequences. These data were analyzed with the microcomputer-based statistical software program LIMDEP (Greene, 1990). Logit modeling is done in a series of steps. For these analyses, a simple constant-only model was initially constructed, and each subsequent model added an additional covariate (Hosmer & Lemeshow, 1989; Knoke & Burke, 1980). Being confirmatory, the initial data-analytic model used only one variable, condition. Yet, because of the predicted influence of marital satisfaction (MS) on family interaction, MS was always added to any model that produced a significant condition effect; the model was then re-fit to the data. In effect, each hypothesis was tested using a series of models, each built on the other sequentially. Depending on model construction, the possible independent variables were condition, MS, and a Condition MS interaction term.

227

readers may be more familiar with the analogous model having an interval level variable,

og, ~I----~/} = a + ~3X;

[ Pi l

this is usually referred to as the logistic model or logistic regression (Agresti & Finlay, 1986; DeMaris, 1992; see Greene, 1997, for a detailed description of these models). For the current analyses, each event-likelihood score for a given family received a weighting based on the number of events used to estimate the likelihood. More formally, the logit is regressed on the independent variables X with weights,
w i = [n~,(1 -- pi] tr2,

where n is the number of occurrences used to calollate, the odds. Weighting is necessary ito account for the variation in occurrences across families. Failing to account for this variation ignores inherent heteroskedasticity and underestimates the efficiency of the estimate of the regression coefficient ([3;Greene, 1995, p. 415).

Models for each of the five hypotheses were tested in the same order. First, Model 1, containing the constant and condition, was tested against a model containing only the constant; if estimated model log-likelihoods were significantly different, as indicated by a significant likelihood ratio chi-square, Model 1 was used to interpret relevant parameter estimates. Next, if condition was significant in Model 1, then Model 2 containing both condition and MS, the proxy for marital distress, was run. Finally, if condition and MS were both significant in Model 2, Model 3 containing condition, MS, and a Condition x MS interaction term was run. The final model for each tested hypothesis was selected according to its fit to the data as assessed by a likelihood ratio chi-square. Best fit was determined bythe amount of decrease in the log-likelibood estimate of one model compared with the previous model, which contained fewer covariates. If the additional parameter (covariate) did not improve the fit to the data, modeling stopped, and the previous model was considered the best fit (DeMaris, 1992; Hosmer & Lemeshow, 1989). The value of the likelihood ratio chi-square is twice the absolute difference in the log likelihoods of the compared models, with degrees of freedom equal to the difference in the number of variables between models. Data for covariates condition and MS were coded either 0 or 1. For condition, asthma families were coded 1 and nonasthma families were coded O. For the variable MS (representing marital quality), families without a distressed spouse were coded 1, and families with at least one distressed spouse were coded O. Variable coding determined the direction, thus interpretation, of results. For example, a positive regression coefficient ([3) for condition implied that the respective code was endorsed more in the asthma group, whereas a negative [3 indicated that it occurred more in the nonasthma group. Interpretation was similar for MS. In general, the data-analytic strategy for this study was simple: (a) Code complex behavioral sequences thought to discriminate asthma versus nonasthraa families; CO) use logit analysis to model the odds associated with the conditional likelihoods generated by the proposed sequences; and (c) if a significant difference is found by condition, add MS to determine if it is influencing the observed difference. Constructed as such, all modeling ceases when nonsignificance is found. From this data-analytic method three sources of information about the variable's influence are available to the investigator: (a) the regression coefficient (described above); Co) the shift in odds by variable level, a ratio of this shift provides the "odds ratio"; and (c) the predicted probability of the hypothesized behavioral sequence. Predicted probability of the

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Table 3

NORTHEY, GRIFFIN, AND KRAINZ

Logit Analysis Results for PFM Marital Dyad Interaction Hypothesis

Model variable and variable level Condition Nonasthma Asthma Marital satisfaction Distress Nondistress Nonasthma, nondistress Nonasthma, distress Asthma, nondistress Asthma, distress ~ -.462 -.562 za -2.918
1.58

Odds shift

Predicted probability

Greater disagrees, nonasthma

0.63 -3.546
1.75

0.57 .19 .41 .08 .22

Creater agree-agree, nonasthma Condition Nonasthma Asthma -.415 -2.682 1.51 0.66 Greater child recruit, asthma Condition Nonasthrna Asthma .657 3.863 0.52 1.93 .04 .13 .21 .10

Note. Hypothesis 1 (greater agrees, nonasthrna) is not included because of

nonsignlficance. PFM = psychosomatic family model (Minuchin et al., 1975). ap < .025 for condition; p < .05 for marital satisfaction. sequence is given by: Odds/(l + odds), where the estimated odds are calculated by e~+ea; here e is the antilog, a is the intercept, 13 is the estimated regression coefficient, and x indicates variable level (I or 0; see footnote 5). A hand calculator is sufficient to estimate the predicted probabilities from the data-analysis printout. One-tailed tests were conducted for condition in each of the four models. To minimize Type I error rate, we used the Bonferronl method to generate an appropriate alpha level for each test, with an overall experimentwide alpha of .05. Thus, with four planned tests, .05/4 = .0125, with .0125 x 2 (for one-tailed) = p < .025, as the alpha required to obtain significance for condition. A conservative alpha of .025 increases contidence that any significant difference between groups reflects a true difference in interaction patterns, as predicted by the theory. Such a conservative approach is endorsed when doing confirnmtory analyses (Wang, 1993; Wiekens, 1989). Alpha for MS and for Condition MS remained at the commonly acceptedp < .05. Results The first hypothesis tested was that controlgroup couples were more likely to agree with each other following a position statement. No model substantially improved the fit to the data beyond the constant-only model. Hypothesis 2 was that nonasthma-group spouses would be more likely to disagree with each other following a position statement. The best fittingmodel for this hypothesis was one that contained condition and MS, L R X2(1,N = 40) = 12.40,p < .05;adding a Condition M S interaction term did not improve the fit to the data. The main effect of condition was in the expected direction, z = - 2 . 9 1 8 , p < .025. The exponentiated regression coefficient for condition (e -.~sls = .63) indicated that being in the asthma group multiplied the odds of this code sequence by .63 (reduces the likelihood), whereas being in the control group increased the odds by 1.58 (1L63). And the likelihood of producing a disagree code was 2.52 (1.58/.63) times higher for the control group than for the asthma group (see Table 3). Within this same model the main effect of MS was also significant in the expected direction, z = -3.546, p < .05. The exponentiated regression

A PARTIALTEST OF THE PSYCHOSOMATIC FAMILYMODEL coefficient for MS ( e "'5616 ---- .57) indicated that being in the nondistressed group multiples the odds of this code sequence by .57, and being distressed increases the odds by 1.75 (11.57). This indicated that distressed couples were 3.08 (1.75/.57) times more likely than the nondistressed to disagree. In addition, the effect of condition and MS on the likelihood of "disagree" can be illustrated by examining the predicted probabilities for each level of condition across both levels of MS. The predicted probability of a disagree code for distressed marital dyads in the nonasthma group was .41, compared with .19 among nondistressed nonasthma family couples. In comparison, marital dyads in the asthma group with comparable levels of distress were about half as likely to disagree; distressed couples had a predicted probability of .22 and nondistressed couples had a predicted probability of .08 (see Table 3). These predicted probabilities show that (a) distressed couples, irrespective of condition, have a higher likelihood of a disagree code than did nondistressed couples, and Co) asthma families had a lower likelihood of a disagree code than did controls irrespective of MS. Hypothesis 3 examined whether nonasthma family couples had a higher likelihood of contiguous agree codes. Condition, as the single covafiate in model, was significant, z -- -2.682, p ~ .025. No other model improved the fit to the data. The exponentiated coefficient for condition (e".4146= .66) indicated that being in the asthma group multiples the odds of this code sequence by .66 and increases the odds by 1.51 (1/.66) for the control group. The likelihood of producing an agree-agree code was 2.29 (1.51/.66) times higher for the nonasthma group than for the asthma group (see Table 3). Hypothesis 4, probably the most fundamental hypothesis of the PFM, implies that asthma family couples will seek interaction with their children more than will nonasthma family couples. Condition, as the single covariate in Model 1, was significant, z = 3.863, p < .025. No other model improved the fit to the data. Exponentiating the regression coefficient for condition (e.6-sss = 1.93) indicated that being in the asthma group increased the odds of this code sequence by 1.93, and being in the control group decreased the odds by .518 (1/1.93). The

229

likelihood of engaging a child initially following a declarative statement was 3.72 (1.93/.518) times higher in the asthma families than for the nonasthma family group. Discussion The PFM is premised on the notion that couples in families with an asthmatic child are maritally distressed, want to avoid conflict, and have a need to recruit children into conversations for the purpose of detouring the marital dyad. Do the results of this study support this contention? The answer is equivocal. As predicted in the model, nonasthma couples evinced greater proclivity toward intradyadic behaviors (agree-agree and disagree codes), and asthma family couples were more likely to solicit a child. Supporting the model was the finding that nonasthma couples were more willing to maintain intradyadic extended "agrees." Also, nonasthma-group couples were much more likely to overtly disagree. Across both groups, and consistent with the marital interaction literature, increased disagreement was related to marital dissatisfaction (Weiss & Heyman, 1990). Yet, compared with spouses in the nonasthma group, distressed asthma family couples were about half as likely to refute their partner's statements, providing indirect evidence that these illness families limited potential conflictual intradyadic dialogue. Instead of intradyadic engagement, these results suggest that asthma-group couples solicRed children. Using predicted probabilities generated by the best fitting model, we were able to estimate that child solicitation, analogous to Minuchin et ai.'s (1975) "child recruitmerit," was about 3.72 times more likely in asthma family couples than in control families (see Table 3). On average, 1 out of every 7 to 8 times a declarative statement was uttered by an asthma-group parent, a child was solicited; this occurred only 1 out of every 25 times in nonasthma families. Yet, although the data appeared to support the PFM, there were several features of these results that were inconsistent with the model. For example, although Minuchin and colleagues (Minuchin et al., 1975) inferred that marital distress was the primary motivation for adopting strategies to detour conflict, marital satisfaction was not a significant predictor of child solicitation. Moreover, subsequent analyses of these

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NORTHEY, GRIFFIN, AND KRAINZ data suggest that such patterns are more indicative of dysfunctional families rather than functional families. As such, avocation of this exclusion pattern should be tempered until additional studies can determine the value of parent solicitation and child involvement. Although these data simultaneously support and, in some respects, refute Minuchin et al.'s (1975) view of the dynamics in these type of families, there are several methodological features needed in future studies to better interpret the behavior of families in which chronic illness exists. Other than the larger sample size that would allow more complex statistical modeling, future studies must include a nonasthnmtic chronic illness group (e.g., ulcerative colitis, juvenile diabetes). Inclusion of such a group(s) would allow comparisons across ill and non-ill families, making it possible to assess whether interactional differences can be found among groups and whether any unique features are associated with a specific illness or with illness in general. Moreover, to test the PFM, all conditions should have a substantial proportion of maritally distressed dyads. For example, additional distressed couples in the current study, we think, would have provided a higher base rate of contiguous "disagrees," an interactional sequence we were unable to test. Having a large sample with an adequate distribution of marital satisfaction scores is pivotal to interpreting the likelihood and sequencing of the predicted patterns. References Achenbach, T. (1978). The child behavior profile: I. Boys aged 6-11. Journal of Consulting and Clinical Psychology, 46, 478-488. Achenbach, T., & Edelbrock, C. (1978). The classification of child psychopathology: A review and analysis of empirical efforts. Psychological Bulletin, 85, 1275-1301. Achenbach, T., & Edelbrock, C. (1979). The child behavior profile: II. Boys aged 12-16 and girls aged 6-11 and 12-16. Journal of Consulting and Clinical Psychology, 47, 223-233. Acbenbach, T., & Edelbrock, C. (1981). Behavioral problems and competencies reported by parents of normal and disturbed children aged 4 through 16. Monographs of Social Research in Child Development, 46, 188. Adams, P., & Marano, M. 0995). Current estimates from the National Health Interview survey. ~tal

data found that children in asthma families were 3 times more likely to respond to the parent's solicitation. Asthma parents successfully engaged their children 1 out of every 14 times, this occurred only 1 out of every 50 times for nonasthma-group parents (Krainz, Cniffin, & Northey, 1997). Although the propensity of asthma families to avoid disagreement was found, Minuchin et al.'s (1975) rationale for its occurrence was not. Marital distress, in general, did not predict extradyadic behavior. If child solicitation was not intended to buffer marital discord, what is the function of recruiting children into marital discussions? Other investigators have suggested that families with a chronically ill child attempt to minimize stress in the home in hopes of preventing or reducing illness exacerbation (e.g., Perrin et al., 1993). Support for this contention in these data might be evident where both distressed and nondistressed asthma couples minimiTe disagreeing in front of the children. This interpretation of parental interaction is consistent with Coyne and Anderson's (1989) conclusion that Minuchin et al. (1975, 1978) misunderstood the utility of unique marital behavioral patterns in these families. Rather than being dysfunctional, the marital behaviors were actually parental maneuvers to decrease stress. Coyne and Anderson (1989) suggested that parents attempt to reduce stress by limiting spousal disagreements and by including children in family discussions. The empirical data of this study support these theoretical speculations. In addition, parents interacting in this manner may be simply fostering good family dynamics. For example, because a chronically ill child often requires additional caregiving and receives differential attention, siblings may feel neglected, or at least secondary to the ill child. It is possible that in these families, parental solicitousness is less reflective of marital conflict and more indicative of compensatory attempts to involve all the children in family interactions and activities. Again, these data cannot address directly this issue, but results are consistent with the interpretation. Moreover, such results would suggest that family-based interventions premised on the PFM might be misguided. A principle component of this model is to strengthen the parental dyad by excluding the children during routine conversations. These

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Health Statistics, 10(193). Washington, DC: National Center for Health Statistics. Agresti, A., & Finlay, B. (1986). Statistical methods for the social sciences. (2nd ed.). San Francisco: Macmillan. Air Pollution and Respiratory Health Branch, Centers for Disease Control. (1996). Asthma mortality and hospitalization among children and young adults--United States, 1980-1993. Morbidity and Mortality Weekly Report, 45, 350-353. Aldrich, J. H., & Nelson, F. D. (1984). Linear probability, log#, and probit models (Sage university paper series on quantitative applications in the social ~iences, 07-045). Beverly Hills, CA: Sage. Bakeman, R., & Gottman, J. (1986). Observing interactions: An introduction to sequential analysis. New York: Cambridge University Press. Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8, 77-100. Beck, A. T., Ward, C., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Block, J., Jennings, P., Harvey, E., & Simpson, E. (1964). Interaction between allergic potential and psychopathology in childhood asthma. Psychosomatic Medicine, 16, 307-320. Buger, A. L., & Jacobson, N. S. (1979). The relationship between sex role characteristics, couple satisfaction, and problem-solving skills. American Journal of Family Therapy, 7, 52-61. Burbeck, T. W. (1979). An empirical investigation of the psychosomatic family model, Journal of Psychosomatic Research, 23, 327-337. Byng-Hall, J. (1980). Symptom bearer as distance regulator. Family Process, 19, 355-365. Canny, G., & Levinson, H. (1994). Asthma. In G. Laughlin and H. Eigen (Eds.), Respiratory disease in children: Diagnosis and management (pp. 223-261). Baltimore: Williams & Wilkins. Christensen, A., & Hazzard, A. (1983). Reactive effects during naturalistic observation of families. Behavioral Assessment, 5, 349-362. Coyne, J. C., & Anderson, B . J. (1988). The psychosomatic family reconsidered: Diabetes in context. Journal of Marital and Family Therapy, 14, 113-123. Coyne, J. C., & Anderson, B. J. (1989). The psychosomatic family reconsidered II: Recalling a defective model and looking ahead. Journal of Marital and Family Therapy, 15, 139-148. Crane, R., Allgood, S., Larson, J., & Griffin, W. (1990), Assessing marital quality with distressed and nondistressed couples: A comparison and equivalency table for three frequently used measures. Journal of Marriage and the Family, 52, 87-93.

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A PARTIAL TEST OF THE PSYCHOSOMATIC FAMILY MODEL Appendix Code Descriptions (Excluding "Other" Code) Code Agree Disagree Topic shift-by-parent General description P1 makes a position statement toward P2, and P2's verbal or nonverbal response indicates that the two parties are in agreement on the issue. Code as a disagree when P1 makes a position statement to P2, and P2 negates, nullifies, or opposes P l ' s statement. P1 makes a position statement toward P2, and P2 responds by initialing a new topic. Must determine if topic is consistent across speakers by assessing the main point or issue being conveyed. P1 speaks to P2, and P2 turns to Child 1, 2, 3 (C1, C2, C3, etc.) and initiates a new topic or discussion; P2 goes outside the marital dyad and changes topic through engaging in conversation with child. PI makes a position statement to P'2 and a child (CI, C2, C3, etc.) initiates a new discussion or topic before P2 is able to respond. Also included are loud noises, exclamations ("Wow! .... Oh!"), screams, or any blatantly distracting behaviors. Parent(s) may attend to the behavior by commenting on it, by turning their head in the child's direction, or by ceasing discussion with the spouse. If this occurs at '1"2 code as either: Child Talk-Parent (CT-P), when diversion is directed toward a parent or parents, or Child TalkChild (CT-C), when diversion is directed toward a sibling or siblings.

233

Topic shift-to-child

Child divert

Note.

P1 = Parent 1; P2 = Parent 2; C1 = Child 1.1"2 = speaker response.

Received March 6, 1997 Revision received N o v e m b e r 3, 1997 Accepted N o v e m b e r 19, 1997