Positive functioning: does it add validity to maladaptive functioning items?

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Abstract

Examines whether indicators of positive functioning add validity to a previously validated maladaptive functioning index (VFI; [Evaluation Progm Plann. 21(1998) 263]). Twenty-nine face valid positive functioning items were selected from data on a clinical sample of 393 children between the ages of 12 and 17. Thirteen items were found to significantly predict either psychopathology, change in psychopathology, alternate methods of measuring functioning, and/or service utilization. Stepwise and hierarchical regressions were used to determine the relationship between the VFI and positive functioning and the aforementioned criteria. The positive functioning items were found to be mildly negatively correlated with the VFI but the VFI had superior criterion based and incremental validity. Further research and measurement development will be needed before it is recommended that program evaluators use positive functioning as an outcome of services.

Introduction

In clinical training and the children's mental health services literature, the assessment of positive functioning has often been considered a fundamental aspect of conducting a comprehensive assessment (Lewis, 1991, Parker and Zuckerman, 1990). This approach considers that the goal of mental health services is not just to decrease psychopathology but also to promote positive, adaptive behavior and healthy psychological status (Heflinger, 1992, Kazdin, 1993). Evaluators need information about positive functioning in order to determine if it should be included as an outcome measure of service effectiveness.

We conceptualize the construct functioning as existing on a continuum from maladaptive functioning to adaptive functioning to positive functioning. Maladaptive functioning is defined as impairment; an individual's actions that show inability to deal with the stresses and events of everyday life according to what is acceptable to society (Summerfelt & Bickman, 1994). Adaptive functioning is defined as behavior effective in meeting the typical personal and social demands and expectations as defined within one's environment (Harrison, 1989, Summerfelt and Bickman, 1994). Positive functioning is defined as the exceeding of normative social role expectations such that these behaviors are viewed not just as the absence of impairment but also as the presence of strengths (Kazdin, 1993, Reilly, 1996). Positive functioning goes beyond adaptive behavior. It is superior functioning. It is demonstrating developmental assets, thriving in various settings, being developmentally advanced or better adjusted, better than average, compared to ones peers. Scales and Leffert (1999) found that most adolescents have less than half of their list of ‘developmental assets’.

Functioning is conceptualized in the literature as incorporating several dimensions: community functioning, family functioning, school/occupational functioning, peer functioning, and personal functioning (e.g. Hodges et al., 1992, Summerfelt and Bickman, 1994). This includes having numerous age appropriate friends, above average school performance, making positive contributions to the community such as through volunteer work, etc.

The importance of studying positive functioning in the field of child and adolescent mental health is emphasized throughout Stroul's (Stroul (1996)) book about systems of care in children's mental health services. Several chapters stress the importance of noting competencies and skills. In fact, Lourie, Katz-Leavy, and Stroul (1996) and Epstein, Sharma, McKelvey, and Frankenberry (1996) emphasize that a strengths-based orientation should drive assessment and be a key factor in the development of an individualized service plan. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires a section for noting patient strengths in treatment plans (Lehnhoff, 1993). A strengths based orientation is believed to help protect patient rights as decision-makers move from a ‘placement’ orientation to a ‘planning’ orientation (Lourie et al., 1996). Treatment and community resources and settings can then be matched to the interests and strengths of the child. However, if program evaluators do not have tools to measure positive functioning, how can they determine if a program is providing a strengths-based approach?

It has been suggested that the identification of a patient's strengths provides clinicians with the material upon which to construct a treatment plan (Lehnhoff, 1993). Those with more positive functioning may have strengths that can be built on resulting in more improvement in less time, a shorter course of treatment. Kazdin (1995) adds that neglecting the assessment of positive functioning may place limits on what treatment can accomplish. Conoley, Padula, Payton, and Daniels (1994) found that building on client strengths was related to implementation of treatment recommendations by clients. In addition, Steenbarger (1994) noted that several studies have found that client interpersonal functioning mediates duration and outcome of treatment. Strohmer, Pellerin, and Davidson (1995) found that clinicians made more favorable judgments of clients when they noted positive client information. Positive functioning may also imply better coping abilities. Those with better coping abilities may have less need for external supports and thus require less restrictive and less costly care. Sholle-Martin and Alessi (1988) found that children hospitalized for psychiatric disturbances have significantly lower levels of adaptive functioning than a normal standardization sample. This difference could be more pronounced for children with different levels of positive functioning.

In addition, strengths may buffer against psychopathology. Positive functioning may make a child resilient to the stressors and risk factors that can contribute to psychopathology (Jessor, 1992). Resilient children may get relief from stressful environments through creative interests, hobbies, extra-curricular activities, friendships, or school (Bland et al., 1994, Cohler et al., 1995, Werner, 1995). Thus, positive behaviors may be part of the process of resilient children bouncing back from adversity through their individual and interpersonal competencies (Bland et al., 1994, Dyer and McGuinness, 1996). Positive experiences such as social success, taking up positions of responsibility, and success in academics, sports, music, or craftwork may help in the acquiring or reinforcing of one's sense of self-worth, self-esteem, and the sense that one can escape high risk environments and control what happens to oneself (Bland et al., 1994, Dyer and McGuinness, 1996, Rutter, 1990). This would then help protect against psychopathology. Positive behaviors also may involve a child such that he/she does not have time for problem behavior and/or positive behaviors may promote orientations and social networks incompatible with problem behavior (Jessor, Van den Bos, Vanderryn, Costa, & Turbin, 1995). Numerous studies have found negative relationships between positive behaviors and problem behaviors or delinquency (e.g. Jessor, 1992, Jessor et al., 1995, Kazdin, 1989, Kolvin et al., 1988, McGee and Williams, 1991, Reilly, 1996, Scales and Leffert, 1999, Stouthamer-Loeber et al., 1993). On the other hand, several studies have either not found or only found a mild inverse association between positive and negative behaviors suggesting that positive behaviors are independent of and may not affect/protect against problem behaviors (e.g. Kazdin, 1993, Luthar and Zigler, 1992, Resnicow et al., 1995). Besides the fact that these findings are somewhat conflictual, they are also problematic in that all of these studies measured positive functioning with only a few variables or by taking the inverse wording of a maladaptive functioning item. A better positive functioning measure could assist prevention researchers in identifying which children will most likely succeed in a prevention program and which children need the most assistance in a prevention program. This measure could even provide program developers with ideas for areas of strengths based intervention (especially if evaluators find that children who succeed in programs have certain strengths that children who do not succeed lack). Thus, there seems to be sufficient justification to include a strengths-based functioning measure in evaluations of mental health services.

A brief review of the approaches used to measure functioning in children demonstrates the fact that most measures of level of functioning focus on maladaptive functioning and neglect the importance of positive functioning (Bickman et al., 1998, Summerfelt and Bickman, 1994). Several researchers have stated that positive behaviors and positive functioning have not been adequately addressed in mental health services research due to the focus on problem behaviors, deficits, and disease models (Epstein et al., 1996, Hoagwood, 1996, Reilly, 1996, Resnicow et al., 1995). Kazdin (1995) hypothesizes that researchers neglect the assessment of positive functioning due to the commonly held view that reduction of symptoms invariably leads to increases in prosocial functioning. If this relationship does not exist, then treatment outcome research may be neglecting an important outcome variable (Kazdin, 1993). Focusing on problems may give a distorted negative view of a program. In fact, Scales and Leffert (1999) suggest that evaluations of programs focusing on prevention of youth problems have frequently been unable to document long-term effects. They suggest that by measuring positives (which tend to be more stable than symptomatology), program evaluators may be able to see long-term impact, i.e. ‘program success’ with youths. Unfortunately, when researchers have chosen to look at any positive functioning items, they have used very few items. Researchers have used as few as one positive functioning item and only as many as six (e.g. Donovan et al., 1988, Jessor et al., 1995, Resnicow et al., 1995).

In the present study, data from the Fort Bragg Program Evaluation Project (FBEP), a major evaluation of an innovative mental health service delivery system for children (FBEP; Bickman, Guthrie, Foster, Lambert, Summerfelt, Breda, & Heflinger, 1995), was used to temporarily construct a brief positive functioning index. Unlike prior research on positive functioning, the following study attempted to take a broader look at positive functioning by including as many positive functioning items across several domains of functioning as were located in the FBEP data set. Unlike the aforementioned studies, studying positive functioning was the central purpose of this secondary data analysis. In addition, a primary goal of this study was to compare positive functioning to a measure of maladaptive functioning with established criterion validity, the Vanderbilt Functioning Instrument (VFI). The VFI consists of items such as contact with police, parent–child fights, and attempted suicide (refer to Bickman et al. (1998) for full list of items). This comparison was done to demonstrate that measuring positive functioning is as important as measuring maladaptive functioning. Standard psychometric tests of scale construction were not conducted as this study was an attempt to examine more positive functioning items than have been used in prior research and not an attempt to develop a measure for others to use. In addition, the positive functioning items were not contained within a single positive functioning measure.

Section snippets

Choice of items

In this study, 29 face valid positive functioning items were selected from baseline data consisting of between 2500 and 3000 variables collected as part of the Fort Bragg Evaluation project. Items were drawn from both parent and child reports at baseline. These items were selected from several instruments used in the evaluation project—the Child Background Form (Vanderbilt; developed for Fort Bragg evaluation project), the Youth Self Report (YSR), the Child Behavior Checklist (CBCL, Achenbach,

Results

In the present study, data from the FBEP was used to select items for a brief positive functioning index, the PFI. Results will be presented as two studies in four steps. Study I, item selection, used a randomly selected derivation sample for the following steps: (a) selected face valid positive functioning areas; (b) selected items with the best criterion related validity. Study II, validation, used a cross-validation sample to study the validity of the index: (c) compared the concurrent

Discussion

In response to the practice of researchers and evaluators to neglect the measurement of positive functioning when measuring level of functioning in children's mental health research, numerous positive functioning items were examined in the present study. From a list of 29 positive functioning items, 13 positive functioning items with the best validities were selected (more items than have been used in any prior research on positive functioning). These positive functioning items were then

Acknowledgements

This research was funded by the US Army Health Services Command (DA-DA10-89-C-0013) as a subcontract from the North Carolina Department of Human Resources/Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, and a grant to Dr Leonard Bickman (RO1MH-46136) from the National Institute of Mental Health.

The authors wish to thank Dr Tom Summerfelt and Dr Warren Lambert for their considerable assistance.

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