Does the Global Assessment of Functioning Assess Functioning? (Research)

Adaptive functioning/impairment is an important mental health outcome domain that is conceptually distinct from symptom severity. The Global Assessment of Functioning (GAF; American Psychiatric Association, 1994) is the most commonly used measure of adaptive functioning/impairment in mental health settings. We suspect that GAF scores may be influenced by factors other than functional impairment. In this study, three raters classified, with high reliability, the reasons given by eight clinicians for 80 GAF ratings. As expected, GAF ratings were strongly influenced by factors other than adaptive functioning/impairment, like symptom severity. The GAF is not a good measure of adaptive functioning, yet important decisions affecting clinicians and clients are made on the basis of GAF scores. Better measures of adaptive functioning are needed. ********** The assessment of adaptive functioning and impairment is frequently underemphasized or overlooked altogether in mental health treatment outcome studies. Instead, most studies focus on changes in symptom severity (Krupnick, 1999; Mintz, Mintz, Arruda, & Hwang, 1992). This is unfortunate for several reasons. First, recognizing changes in adaptive functioning--the ability to lead an independent and productive life--is important if we are to understand mental health treatment from a biopsychosocial perspective rather than from the narrower biomedical model (Engel, 1977, 1980; Schwartz, 1982). The assessment of adaptive functioning allows us to look at skills and strengths that are developed through counseling in addition to abnormalities and deficits that are corrected. Second, changes in adaptive functioning and symptom severity may not always occur together. We might expect psychosocial interventions that emphasize coping, resiliency, and rehabilitation to have greater effects on adaptive functioning than psychotherapies and pharmacotherapies that target only symptoms. Failing to measure general functioning may underestimate the impact of these psychosocial interventions (Krupnick, 1999). In addition, the lukewarm response of many clinicians to controlled clinical trials may, in part, be due to their recognition that most efficacy studies leave this important aspect of clients' experiencing unmeasured (Addis, Wade, & Hatgis, 1999; Goldfried, 1999; Seligman, 1995). Finally, an exclusive focus on symptom change severely limits the ability to compare treatments and their cost effectiveness across diagnostic groups (e.g., how many hours of insomnia are equal to a delusion?). Adaptive functioning/impairment is a metric that can be applied more easily across groups of clients. There is little consensus about the meaning of adaptive functioning or its flip-side, impairment (Brekke, 1992; Phelan, Wykes, Goldman, 1994). For clarity's sake, when discussing adaptive functioning, functional abilities or impairments, we will refer to a domain that includes work functioning and productivity, the ability to actively participate in social relationships and to manage appropriate social roles, and the ability to care for one's daily physical needs (e.g., grooming, feeding, managing money). This use of functional impairment represents a very different outcome domain than symptom severity. Symptoms typically refer to how well parts of a person are working. Examples of symptoms include mood states (e.g., depression, anxiety, euphoria), other internal states (e.g., low self-esteem), physical abnormalities (e.g., insomnia, poor appetite, psychmotor agitation), and cognitive difficulties (e.g., aphasia, distractibility, obsessions). Functional impairment and adaptive functioning focus on what individuals can do, the quality of their daily activity, and their need for assistance. Adaptive functioning emphasizes the integrated behavior of whole people. Examples of functional difficulties include poor school performance, relationship difficulties, trouble with the law, neglected parental responsibilities, the inability to work, and deficits in grooming. …