Introduction
In the study of the effects environmental factors have on the development of adolescent psychopathology, one line of research that has received prominent attention has been the study of expressed emotion. Expressed emotion (or: EE) is literally a measure of the emotions expressed by a significant family member or spouse to an individual suffering from a psychopathological disorder and is used as a predictor of relapse following hospitalization [
1]. This line of research, started by George Brown in the 1950s, was first used to better understand why certain persons relapsed back into schizophrenia when living with a significant relative or spouse after hospitalization and why others did not relapse (e.g., Brown, 1985) [
1]. It was found that certain aspects of the emotional climate at home seemingly augment the patient’s symptoms, leading to relapse.
Initially, EE data were collected by interviewing the important family member with the Camberwell Family Interview (CFI) [
2] as to his/her interaction with the patient. Scoring of the CFI EE interview focuses on three domains in which negative interpersonal interactions can occur in the household environment between the mother and the adolescent. Specifically, these domains are the mother’s emotional over-involvement, hostility, and criticism to the adolescent. In previous cross-sectional studies based on the CFI interview of EE, high maternal EE has been found to be associated with high levels of adolescent internalizing [
3,
4] and externalizing symptoms [
5,
6]. This has led EE researchers to take the stance that mothers that express a great amount of EE on any or all of these three domains (which is commonly referred to in the literature as high EE) enhances an adolescent’s symptom development; an EE effects model [
7]. More importantly, many of the present-day EE therapeutic interventions are based on the assumption that maternal EE enhances adolescent symptom development [
2]. However, studies on the direction of effects between psychopathology and EE are not necessarily consistent, and therefore the question arises whether the parental EE effects model is correct.
Indeed, a number of recent adolescent–parent EE studies have explicitly challenged the assumed direction of effects [
8‐
10]. These studies have found both bidirectional and child effects models in addition to maternal effects models as well. While earlier EE studies only interviewed of the provider of the EE, these recent adolescent–mother EE studies have used an EE questionnaire as opposed to an interview. Hence both the recipient and provider of the EE provided answers about the family EE climate. The findings of these recent EE studies have challenged the findings of previous EE studies that only examined unidirectional maternal effects. This use of EE questionnaires, which are quickly administrated and scored, as opposed to EE interviews (e.g., the CFI interview takes approximately 2 h to conduct and approximately 3 h to code), has allowed for prospective, longitudinal studies addressing effects of EE (as opposed to the traditional retrospective, cross-sectional studies of EE interviews based on the CFI).
One of the most used EE questionnaires that have been employed in recent adolescent–mother EE studies is the level of expressed emotion questionnaire (LEE) [
11‐
13]. This questionnaire, much like the original CFI EE interview, focuses on the perspective of the person being asked about the family EE climate. Specifically, the 38-item version of the LEE questionnaire comprised four EE dimension scales. These four scales are criticism, which is related to the CFI EE domain of criticism, intrusiveness, which is related to the CFI EE domain of over-involvement, irritation, which is related to the CFI EE domain of hostility, and lack of emotional support, which purports to measure a general emotional negativity common in the EE household environment. Importantly, while in the original EE CFI interview studies it was the mother who was interviewed about the EE household environment, now both the mother and the adolescent can be asked with the LEE questionnaire.
However, most recent longitudinal EE studies have focused on just one person’s perspective, either that of the mother or that of the adolescent. For example, a longitudinal study by Hale et al. [
14] of the mothers’ EE suggests that it is the course of the internalizing and externalizing symptoms of adolescents from the general community that affects maternal EE, and not the mothers’ perceived EE influencing the course of the adolescents’ symptoms. This study of Hale et al. [
14] did not include the adolescent’s perceived EE.
An important first step toward a longitudinal study that did include both the mother’s and the adolescent’s perspectives of the mother’s EE, in one and the same study, found a bidirectional effect between adolescent depression and generalized anxiety disorder symptom dimensions and perceived maternal EE criticism [
10]. This study also found stronger child effects (that of the adolescent internalizing symptom dimensions predicting perceived maternal EE criticism) than maternal effects. However, this study only focused on perceived maternal EE criticism and did not include either the other perceived EE factors (such as lack of emotional support, intrusiveness, and irritation) or adolescent externalizing symptom dimensions. So while this aforementioned study is an important first step, in order to understand if high EE household environments help create or enhance psychopathological symptomatology in adolescents (as is contented by previous EE CFI interview studies) or if the reverse is the case, measures of both adolescent and mother perceived EE need to be included in a longitudinal model addressing adolescent internalizing and externalizing symptom dimensions.
To tackle this omission in the EE literature, the goal of the present 6-year, longitudinal study is to include both the parent’s and the adolescent’s perspectives of all the parent’s EE components in order to disentangle the effects various parental EE components have on the adolescent’s internalizing and externalizing symptom development and vice versa. In order to accomplish this goal, data were used from the ongoing, longitudinal study of Research on Adolescent Development and Relationships (or: RADAR). The RADAR study collected LEE data from both adolescents and their mothers. While the longitudinal LEE study of mothers by Hale et al. [
14] used this same database after 3 years of data collection, the present 6-year longitudinal study now also includes both the adolescent and mother responses on all LEE scales after 6 years of data collection so that in one and the same statistical model the effects of EE of both respondents can be compared to one another. By including the responses of both the receiver of EE (the adolescent) and the provider of EE (the mother) in the same model, the relative effects of EE on adolescent’s internalizing and externalizing symptom development can be better understood.
Discussion
This 6-year, longitudinal study found that both internalizing and externalizing symptoms predicted the adolescent’s perception of maternal expressed emotion over time. Furthermore, both internalizing and externalizing symptom dimensions predicted the mother’s perception of her own EE criticism toward her adolescent over time. It should be noted that this is the first longitudinal study that included both the adolescent’s and the mother’s perceptions of the different facets of the EE household environment when studying the effects EE and adolescent psychopathological symptoms have on one another. In a nutshell, this study demonstrated that adolescent psychopathological symptom dimensions are predictive of an adolescent’s perceptions of the EE household environment and the mother’s perception of her own EE criticism.
Presently, in EE theory, it is commonly held that high EE household environments help enhance adolescent psychopathological distress (an EE effect model). This view is based on Hooley’s central hypothesis [
24,
25] that high EE in relatives (such as mothers) reflects their underlying beliefs that the patient (such as adolescents) could do more to control their psychopathological symptoms if the adolescent desired to do so and that the failure to control their psychopathological symptoms is due to a unique intrapersonal factor of the patient (for example, a personal habit). This is also known in psychotherapies that focus on high EE household environments as “blaming the patient.” According to a highly cited review of the literature on relative EE and patient psychopathological symptoms, the authors state that all of the published investigations in their literature review of adults and children confirmed this hypothesis [
26]. However, the authors do note that a limitation is that most of the studies that they included in their review are cross-sectional and they only employ correlational analyses.
Importantly, in this 6-year longitudinal study of maternal EE and adolescent psychopathological symptoms, it was demonstrated that a psychopathological effect model (the adolescent’s psychopathological symptoms) is a better explanation of the association between parent/adolescent EE and adolescent psychopathological symptom dimensions (in other words, adolescent symptoms enhancing EE) than an EE effect model. These findings seem to contradict the commonly held view that high EE household environments help enhance adolescent psychopathological distress.
This point leads back to considerations about family treatments of adolescent internalizing and externalizing symptom dimensions. Most family treatments that employ the EE concept focus on an EE effects model [the EE provider (i.e., the mother) affecting the EE receiver (i.e., the child)] [
27]. A psychopathological effects model, in which the child’s psychopathological symptoms elicit EE from the mother, has received much less attention in therapies designed to reduce EE. It is quite conceivable that both a psychopathological effects model (as has been found in this study) as well as an EE effect model (as has been found in previous studies such as Hale et al. [
9,
18]) help explain the relationship between maternal EE and the course of adolescent internalizing and externalizing symptoms. Specifically, in Cognitive Therapy, a major focus of the therapy is on the beliefs a person holds as to his or her interactions with others. This “belief” is literally the person’s perception of the interactions he or she has with others. Hence it is possible that psychotherapies that use the EE concept could be refined to incorporate these divergent perceptions on the part of the mother as well as the part of the adolescent.
With respect to the limitations of this study, it should be noted that EE was only measured with the LEE and that the CFI interview was not used. In an overview of the measures of EE, it has been discussed whether questionnaire-based measures of EE measure EE in the same way as the CFI interview does, while also raising the point that clinically useful and accessible EE alternatives for the CFI interview are needed [
28]. Therefore, it is not possible to judge if the LEE findings of this study would be similar to the CFI interview measured EE and future studies are recommended to address this issue. However, as previously stated, the LEE has good psychometric properties and an advantage that the LEE holds over the CFI is that the LEE can be quickly administrated and scored, as opposed to the CFI (which takes several hours to conduct and code) thereby better allowing for prospective, longitudinal studies addressing effects of EE.
Secondly, with respect to the LEE, the results of this study are limited by only studying maternal EE and not collecting paternal EE data as well. We would suggest that future research should also collect the fathers’ EE scores since previous research has shown that there is a unique interplay between an adolescent’s internalizing symptoms and his/her father’s behaviors which is not necessarily the same as the mother’s behaviors [
29].
Finally, it should also be noted that the correlations between the mothers’ and the adolescents’ rated LEE scores were significant, but low (see Table
1). As noted by Bögels and Van Melic [
30], low correlations between child and parent ratings of parental behaviors commonly occur in such studies and they suggest that a reason for this occurrence might be personal biases associated with the child’s perspective and the mother’s own perspective. While direct observation of behaviors might help solve this perspective problem, these same authors also suggest that an advantage that questionnaires have over home observations is that questionnaires are less intrusive and the respondent’s “answers are based on home observations and infinite samples of behavior across infinite situations and tasks” (p. 1585) [
30].
Additionally, this study focused only on self-reports of internalizing and externalizing symptoms from adolescents from the general community. This should not be confused with a clinical diagnosis of a psychiatric disorder. A structured clinical interview could have been used to help determine the strength of the relationship between the adolescents’ self-reports of internalizing and externalizing symptoms and an actual diagnosis of these related disorders. Moreover, these adolescents came from the general community, whereas many previous studies of EE and adolescent internalizing and externalizing symptoms came from clinical populations. However, it has also been suggested that prospective longitudinal community studies of psychopathological symptom dimensions may help circumvent the problem of referral bias that frequently occurs in the clinical setting and may better characterize the course of developmental psychopathological symptoms [
31]. Nevertheless, future studies in the clinical setting should be conducted to replicate these findings.
It could also be asked if self-reports by 13 year olds (the first wave of this study) could be considered accurate. The questionnaires that were used for the internalizing (RADS) and externalizing (YSR) symptom dimensions have shown good psychometric properties in various studies for children of 13 years of age or younger (RADS: e.g., [
32]; YSR: e.g., [
33]). However, there has been much less study of age groups with EE questionnaires such as the LEE. Previous studies have found the psychometric properties of the LEE with adolescents of 13 years or older to be good [
9,
18]. Still, there have been much less studies with the LEE with adolescents as there has been with the RADS and the YSR. Hence, future studies with the LEE in adolescent populations may further address this current issue.
In conclusion, the results of this longitudinal EE study that followed adolescents from 13 to 18 years of age found that both internalizing and externalizing symptom dimensions predicted the adolescent’s perception of maternal EE as well as the mother’s own rated EE criticism over time. As was previously noted, in EE theory, it is commonly held that high EE household environments help enhance adolescent psychopathological distress (an EE effect model). However, this study found a psychopathological effect model contradicting the commonly held view that high EE household environments help enhance adolescent psychopathological distress. The findings of this study should give both researchers and therapists a reason to reevaluate only using the EE effects model assumption in future EE studies.