Global Assessment of Relational Functioning Scale (GARF): II. Reliability and Validity in a Sample of Families of Bipolar Patients

The companion article by the Group for the Advancement of Psychiatry (GAP) Committee on the Family (see p. 155, this issue) describes the development of the Global Assessment of Relational Functioning (GARF) scale. The present study evaluated the reliability and concurrent validity of a manualized version of the GARF in recently episodic bipolar patients (N = 73 ) participating with family members in laboratory interaction tasks. The GARF was applied with high reliability by raters with little clinical experience. GARF ratings discriminated between families rated high and low in expressed emotion, with families rated as high in emotional overinvolvement showing the lowest relational functioning scores. GARF scores also correlated with affective negativity scores derived from the interactional task-based affective style and coping style coding systems. However, relational ratings were independent of levels of concurrent symptoms or illness chronicity among individual patients. GARF ratings may inform the treatment plans for patients with psychiatric disorders, but the optimal methods of data collection and rater training must be determined.     

Validity of the Global Assessment of Relational Functioning (GARF) When Used By Community-Based Therapists

Construct validity of the Global Assessment of Relational Functioning (GARF) was assessed using a health services research approach, a mode of study that captures the naturalistic practice of health service providers. A sample of 395 couple/family cases with GARF scores assigned pre- and post-therapy by 222 community-based marriage and family therapists yielded these results: 1) pretreatment GARF scores were negatively correlated with severity of client problems; 2) GARF change scores were positively correlated with client reported changes in functioning; 3) GARF change scores were positively correlated with therapist-reported client change; 4) GARF change scores were positively correlated with client satisfaction; 5) pretreatment GARF scores were negatively correlated with number of therapy sessions; and 6) pretreatment GARF scores and client diagnoses showed no relationship. Given these results the GARF appears to have construct validity in community settings, and is a promising brief assessment tool for relational functioning.     

Don't Take Out This Appendix! Generalizability of the Global Assessment of Relational Functioning Scale

This study investigated the generalizability of the Global Assessment of Relational Functioning (GARF) Scale. Found in an appendix of the Diagnostic and Statistical Manual of Mental Disorders under "Criteria Sets for Axes Provided for Future Study," the GARF Scale provides a global rating of a relational unit (family or couple). Thirty-two raters assigned GARF ratings to five relational units. Generalizability analyses indicate extremely high dependability of GARF scores across raters. Higher generalizability coefficients were found for raters who had formal education in family systems theory. Overall, these results are an encouraging step towards adopting the GARF for widespread use.     

Concurrent validity of the Global Assessment of Functioning Scale for clients with schizophrenia

Although the Global Assessment of Functioning (GAF) scale is a widely utilized instrument, little data on construct validity is available about its use with clients having schizophrenia. This study compared point-specific GAF scores with concurrent ratings of symptomatology and social and occupational impairments using the Functional Assessment Rating Scale (Ward & Dow, 1994). A linear multiple regression analysis of empirical data from investigations of clients' global functioning showed that increased work and school-related problems, danger to others, and psychotic symptoms predicted lower GAF scores. In general, GAF scores seem to reflect the construct of global psychological, social, and occupational functioning that the scale was designed to measure.     

Construct validity of the Global Assessment of Functioning Scale for clients with anxiety disorder

The Global Assessment of Functioning Scale is a widely used although poorly researched measurement of overall mental health or illness. This study investigated construct validity for clients with anxiety disorder. Analysis suggests that current suicidality was the most significant predictor of ratings. Current homicidality, work/school problems, and inability to care for oneself were not significantly correlated with scale ratings.     

Validation of the Norwegian version of the Social Functioning Scale (SFS) for schizophrenia and bipolar disorder

Hellvin, T., Sundet, K.,Vaskinn, A., Simonsen, C.,Ueland, T., Andreassen, O.A. & Melle, I. (2010). Validation of the Norwegian version of the Social Functioning Scale (SFS) for schizophrenia and bipolar disorder. Scandinavian Journal of Psychology 51, 525–533. Studies of social functioning in severe mental disorders are disadvantaged by the multitude of different assessment instruments in use. The present study aims to establish reliability and validity of the Norwegian version of the Social Functioning Scale (SFS) and to examine social functioning in bipolar disorder (BD) compared to schizophrenia (SZ) and healthy controls (HC). SFS, a 76 item questionnaire divided into seven subscales measuring various aspects of daily life functioning, was administered to samples diagnosed with BD (n = 100) or SZ (n = 100) and to HC (n = 100), recruited from the ongoing Tematic Organized Psychosis (TOP) study. Reliability analyses prove adequate psychometric properties both for the composite full scale score (α: 0.81) as well as for the seven subscale scores (α: 0.60–0.88). Principal component analysis of the subscales confirms a one‐component structure, explaining 59% of the variance. Although significantly correlated with the Global Assessment of Functioning, our results indicate that the SFS measures different aspects of social functioning, is less influenced by demographic and clinical characteristics, but differentiates at the same time significantly BD from SZ. Thus, SFS adds valuable information as a supplement to standard clinician‐rated assessment tools of social functioning, suited both for research and clinical work.     

The interplay among temperament,neuropsychological abilities,and global functioning in young hyperactive/inattentive children

Cognition and emotion have been shown to interact and influence psychological functioning. However, to date these interactions have only been examined cross‐sectionally among inattentive and/or hyperactive/impulsive children. This study investigated the moderating effects of neuropsychological functioning at age 3–4 years on the relation between negative emotionality at age 3–4 years and global functioning 1 year later, at age 4–5 years. Hyperactive/inattentive (H/I; n = 114) preschoolers entered the study (BL: baseline) and were seen again 1 year later (F1). Children's BL scores on a neuropsychological test (NEPSY) and their temperament as rated by parents (Child Behavior Questionnaire) and teachers (Temperament Assessment Battery for Children‐Revised) were obtained, as were clinicians’ ratings of their global functioning (Children's Global Assessment Scale) at F1. Hierarchical linear regression analyses revealed that BL temperament variables accounted for significant variance in F1 Global Functioning. Significant interactions indicated that higher Verbal Executive abilities were associated with better child functioning when parent‐rated Effortful Control was high, but not when Effortful Control was low. Additionally, high levels of Nonverbal Executive skills were associated with higher child global functioning when both parent‐ and teacher‐rated negative affect was low, but not when negative affect was high.     

Family Functioning Assessment in a Community Sample of African American Caregivers and Children

Racial/ethnic minority youth receive approximately half of the mental health services of their non-minority peers. Improved methods for identifying African American families in need of behavioral health services are necessary. The Family Assessment Device and General Functioning subscale have been found to be reliable and able to detect family functioning impairment in a generalized sample, but less is known about the reliability and validity of the assessment with an African American community sample. Data from 53 African American caregiver-child (ages 7–13) dyads was collected including family demographics and the Family Assessment Device General Functioning (FAD_GF) scale. Confirmatory factor analysis was conducted to determine the minimal number of FAD_GF items (12 vs. 6 items) that were valid and reliable. The 12-item FAD_GF and the 6-item scale had acceptable psychometric properties, and the 6-item measure demonstrated improved model fit over the 12-item scale and identified more clinically impaired families (6-item: 28% vs. 12-item: 23%). The 6-item measure of family functioning was more sensitive 12-item FAD_GF. This brief measure may prove useful for identifying and assessing African American families.

     

Predicting Response to Intensive Multimodal Inpatient Treatment: A Comparison of Single- and Multiple-Class Growth Modeling Approaches

In a modest body of research, personality functioning assessed via performance-based instruments has been found to validly predict treatment outcome and, to some extent, differential response to treatment. However, state-of-the-science longitudinal and mixture modeling techniques, which are common in many areas of clinical psychology, have rarely been used. In this article, we compare multilevel growth curve modeling (MLM) and latent class growth modeling (LCGM) approaches with the same data set to illustrate the different research questions that can be addressed by each method. Global Assessment of Functioning (GAF) scores collected at 6 points during the course of a long-term multimodal inpatient treatment of 58 severely and persistently mentally ill adults were used to model the trajectory of treatment outcome. Pretreatment Rorschach-based markers of personality functioning and other markers of psychiatric severity were examined as covariates in each modeling approach. The results of both modeling approaches generally indicated that more psychologically impaired clients responded less favorably to treatment. The LCGM approach revealed 2 unique trajectories of improvement (a persistently low group and a higher starting, improving group). Personality functioning and baseline psychiatric variables significantly predicted group membership and the rate of change within the groups. A side-by-side examination of these 2 methods was found to be useful in predicting differential treatment response with personality functioning variables.     

Reliability and Validity of a Short Version of the General Functioning Subscale of the McMaster Family Assessment Device

The General Functioning 12‐item subscale (GF12) of The McMaster Family Assessment Device (FAD) has been validated as a single index measure to assess family functioning. This study reports on the reliability and validity of using only the six positive items from the General Functioning subscale (GF6+). Existing data from two Western Australian studies, the Raine Study (RS) and the Western Australian Child Health Survey (WACHS), was used to analyze the psychometric properties of the GF6+ subscale. The results demonstrated that the GF6+ subscale had virtually equivalent psychometric properties and was able to identify almost all of the same families who had healthy or unhealthy levels of functioning as the full GF12 subscale. In consideration of the constraints faced by large‐scale population‐based surveys, the findings of this study support the use of a GF6+ subscale from the FAD, as a quick and effective tool to assess the overall functioning of families.     

The Family Assessment Device: An Update

The current study set out to describe family functioning scores of a contemporary community sample, using the Family Assessment Device (FAD), and to compare this to a currently help‐seeking sample. The community sample consisted of 151 families who completed the FAD. The help‐seeking sample consisted of 46 families who completed the FAD at their first family therapy appointment as part of their standard care at an outpatient family therapy clinic at an urban hospital. Findings suggest that FAD means from the contemporary community sample indicate satisfaction with family functioning, while FAD scores from the help‐seeking sample indicate dissatisfaction with family functioning. In addition, the General Functioning scale of the FAD continues to correlate highly with all other FAD scales, except Behavior Control. The cut‐off scores for the FAD indicating satisfaction or dissatisfaction by family members with their family functioning continue to be relevant and the FAD continues to be a useful tool to assess family functioning in both clinical and research contexts.     

Parental bonding and personality disorder: the mediating role of alexithymia

This study explored whether alexithymic features mediate the effect of perceived adverse parenting during childhood on being diagnosed with a PD in adulthood. Two hundred sixty-five psychiatric outpatients were evaluated with the Toronto Alexithymia Scale (TAS-20), the Parental Bonding Instrument (PBI), the Structured Interview for DSM-IV Personality, the Structured Clinical Interview for DSM-IV Axis I Disorders, the Clinical Global Impression scale, and the Global Assessment of Functioning scale. The statistical model for mediation proposed by Baron and Kenny (1986) was employed to detect whether the TAS scores account for the relation between PBI scores and a PD diagnosis. The results indicated that although altered parental bonding (and specifically, excessive maternal protection) may enhance the risk of PD, its effect is completely mediated by the alexithymic feature Difficulty Describing Feelings to Others (DDF), after controlling for gender, age, educational level, type, severity and age of onset of Axis I disorders. Therefore, this study suggests that the presence of DDF accounts for the effect of maternal overprotection as a risk factor for PD.     

Assessment of affect integration: validation of the affect consciousness construct

Affect integration, or the capacity to utilize the motivational and signal properties of affect for personal adjustment, is assumed to be an important aspect of psychological health and functioning. Affect integration has been operationalized through the affect consciousness (AC) construct as degrees of awareness, tolerance, nonverbal expression, and conceptual expression of nine discrete affects. A semistructured Affect Consciousness Interview (ACI) and separate Affect Consciousness Scales (ACSs) have been developed to specifically assess these aspects of affect integration. This study explored the construct validity of AC in a Norwegian clinical sample including estimates of reliability and assessment of structure by factor analyses. External validity issues were addressed by examining the relationships between scores on the ACSs and self-rated symptom- and interpersonal problem measures as well as independent, observer-based ratings of personality disorder criteria and the Global Assessment of Functioning (GAF) scale from the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994).     

Family Assessment Measure (FAM) and Process Model of Family Functioning

This paper provides an overview of twenty years' work in the development of the Family Assessment Measure (FAM), based on the Process Model of Family Functioning. The Process Model describes a conceptual framework for conducting family assessments according to seven key dimensions: task accomplishment, role performance, communication, affective expression, involvement, control, values and norms. The FAM provides measures of these dimensions at three levels: whole family system (general scale, fifty items), various dyadic relationships (dyadic scale, forty-two items) and individual functioning (self-rating scale, forty-two items). In addition, the general scale includes social desirability and defensiveness response style measures. Brief FAMs (fourteen items) are available for each scale as well. The measurement properties of FAM have been evaluated in a variety of clinical and non-clinical settings. Reliability estimates are very good in most contexts. FAM's validity has been supported using a number of techniques. Overall, the weight of the evidence is that FAM's effectively and efficiently assess family functioning and provide strong explanatory and predictive utility. This empirical evidence reinforces experiences of clinicians, indicating that FAM provides a rich source of information on family functioning.     

Large variations of global functioning over five years in treated patients with personality traits and disorders

The aim of this study was to examine the long-term course of global functioning in patients with personality disorders (PD) and investigate predictors of variation. The Global Assessment of Functioning (GAF) was repeated over five years in 352 patients with PDs of varying severity, all treated in psychotherapeutic day hospitals. Growth models were used for statistical analysis. Large variations in the long-term course of global functioning were evident in this clinical sample. At five-year follow-up, 46% reached a GAF-score above 60 with a mean GAF-score of 71. Their linear change-rate over the five years was estimated to be 4.4 GAF points per year. The average five-year GAF-score for the remaining subgroup (54%) was 50 and their linear yearly change-rate was 0.8 GAF points. Greater relief of symptom distress and interpersonal problems was typical of patients with functional improvement. The number of avoidant PD criteria was associated with slower functional change.     

Susceptibility to retroactive interference: The effect of context as a function of age and cognition

Previous studies have shown that contextual cues improve memory performance and reduce interference in younger adults. However, it is not clear whether middle-aged and older adults can also benefit from contextual cues, or if this ability diminishes with ageing and cognitive decline. In order to test this question, we tested 69 middle-aged adults (aged 30–50 years) and 65 older adults (aged 65–85). Participants completed a retroactive interference paradigm with or without contextual cues. Cognitive functioning of older adults was assessed using the Montreal Cognitive Assessment, which is a sensitive and highly validated tool to detect cognitive decline in older age. The results showed that while middle-aged adults were able to benefit from context to improve recognition and reduce interference, older adults were not able to benefit from it. However, when we compared older adults with lower (<26) and higher (≥26) scores on the Montreal Cognitive Assessment, we found that older adults with high cognitive functioning could benefit from context advantage at retrieval to improve recognition compared to those with lower cognitive functioning. Yet, similar to older adults with lower cognitive functioning, they could not benefit from context advantage at encoding and hence were still susceptible to interference.     

Assessment of Affect Integration: Validation of the Affect Consciousness Construct

Affect integration, or the capacity to utilize the motivational and signal properties of affect for personal adjustment, is assumed to be an important aspect of psychological health and functioning. Affect integration has been operationalized through the affect consciousness (AC) construct as degrees of awareness, tolerance, nonverbal expression, and conceptual expression of nine discrete affects. A semistructured Affect Consciousness Interview (ACI) and separate Affect Consciousness Scales (ACSs) have been developed to specifically assess these aspects of affect integration. This study explored the construct validity of AC in a Norwegian clinical sample including estimates of reliability and assessment of structure by factor analyses. External validity issues were addressed by examining the relationships between scores on the ACSs and self-rated symptom- and interpersonal problem measures as well as independent, observer-based ratings of personality disorder criteria and the Global Assessment of Functioning (GAF) scale from the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM–IV]; American Psychiatric Association, 1994).     

Contact sports, moral functioning and planned behaviour theory

The goal was to test the psychometric properties of the Moral Functioning Scale in a Greek athletic context, and to investigate any possible relation between moral functioning and planned behaviour. The sample comprised 384 athletes, 103 from the sport of football (soccer), 97 from basketball, and 184 from water polo. To measure moral functioning the researchers used a scale developed by Gibbons, Ebbeck, and Weiss. Planned Behaviour was assessed with a questionnaire based on Planned Behaviour Theory. Hierarchical regression analysis indicated strong association for Attitudes, Intention, Role Identity, and Perceived Behavioural Control with the four dilemmas of the moral functioning scale. The moral reasoning measure is a promising tool for measuring athletes' moral dilemmas in Greece.     

Transition to young adulthood: A prospective study

In this paper, the authors report on the transition to young adulthood (18-25) in the highest functioning 18 individuals in our cohort (GAF 90) from a prospective longitudinal study of 76 lives followed from birth. These 18 individuals provide as clear a view as possible into the inner lives of people least distorted by psychopathology. This gives us a more crystalline photograph of psychic structure: the precipitant of family, society and psyche itself. Using a standard DSM IV criterion, Global Assessment Functioning (GAF), provides phenomenological homogeneity, but leaves us with heterogeneity of inner life. The 18 individuals had relatively rare drug or alcohol use and less sexual partners. Vocational functioning exceeded intimacy. Four had tumultuous pathways into adulthood. Nine were crossover cases, coming from sub-optimal mothering, with significant variation in gender distribution and intrapsychic structure. The paper discusses factors facilitating and inhibiting development and the nature of memories.     

Validation of a 28‐item version of the Systemic Clinical Outcome and Routine Evaluation in an Irish context: the SCORE‐28

This article describes the development, in an Irish context, of a three‐factor, twenty‐eight‐item version of the Systemic Clinical Outcome and Routine Evaluation (SCORE) questionnaire for assessing progress in family therapy. The forty‐ item version of the SCORE was administered to over 700 Irish participants including non‐clinical adolescents and young adults, families attending family therapy, and parents of young people with physical and intellectual disabilities and cystic fibrosis. For validation purposes, data were also collected using brief measures of family and personal adjustment. A twenty‐eight‐item version of the SCORE (the SCORE‐28) containing three factor scales that assess family strengths, difficulties and communication was identified through exploratory principal components analysis. Confirmatory factor analysis showed that the factor structure of the SCORE‐28 was stable. The SCORE‐28 and its three factor scales were shown to have excellent internal consistency reliability, satisfactory test‐retest reliability and construct validity. The SCORE‐28 scales correlated highly with the General Functioning Scale of the Family Assessment Device, and moderately with the Global Assessment of Relational Functioning Scale, the Kansas Marital and Parenting Satisfaction Scales, the Satisfaction with Life Scale, the Mental Health Inventory – 5, and the total problems scale of the Strengths and Difficulties Questionnaire. Correlational analyses also showed that the SCORE‐28 scales were not strongly associated with demographic characteristics or social desirability response set. The SCORE‐28 may routinely be administered to literate family members aged over 12 years before and after family therapy to evaluate therapy outcome.