Gaf tool

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According to scoring instructions for GAF, when the current level of functioning is scored, the lowest score for the last week should be used; the lowest level of functioning is chosen because of its clinical relevance [ 51 ]. Rating GAF may mean choosing the lowest score for other specified time periods, for example the lowest level in the past month or for the worst week during the month prior to interview [ 3 , 37 , 39 , 63 , 69 ].

However, assigning the lowest GAF score is not without problems. It may give a wrong impression of both the overall mental situation and the present status [ 42 ]; the highest level of functioning should not be disregarded [ 12 , 31 , 39 , 57 , 70 ] as it may predict outcome [ 71 ]. For example, the highest level of functioning for at least a few months during the last year may be very predictive of outcome [ 19 , 52 ] and indicate the potential level of functioning [ 60 ].

Also, it has been reported that the highest level of functioning during the past year can be highly correlated with current level [ 19 ]. If the patient is not well described by either the highest or the lowest GAF for the last week, a solution may be to use more scores; for example, scores such as highest and lowest for the last year, the highest and lowest the patient has ever had, or scores for when the patient is symptomatic and asymptomatic.

Rating of average functioning has also been proposed [ 29 , 50 ], for example, the average level of functioning during the previous 3 weeks [ 5 , 57 ]. If such scores describe the patient well, they can be added. Internationally, both the single-scale and dual-scale GAF are in use.

For the single-scale GAF, according to the manual for DSM-IV-TR [ 12 ] only one value should be recorded, namely, 'whichever is the worse' of the symptom and functioning values [ 5 , 12 , 21 , 22 ]. It is assumed that the GAF-S and GAF-F are comparable scales [ 16 , 27 ], so recording only the most severe of the GAF-S and GAF-F scores is in accordance with the general principle of using the most severe condition as the overall score [ 16 ]; however, the difference between the two scales is disregarded so it is not clear which factor of symptoms and functioning is being measured [ 52 ].

An alternative could be to record the average of symptoms and functioning levels [ 72 ], but this raises the question of whether or not symptoms and functioning have equal weight, and the importance of any weighting effect [ 73 ].

Although the values on each scale may be close [ 29 ], symptoms and functioning are different aspects of patient condition and they do not necessarily vary together [ 23 ], so in some countries a dual-scale GAF is used where both GAF-S and GAF-F are recorded [ 13 ].

In the clinical setting, comments can be added to a GAF score on why a particular score was chosen, which may be important when others take over treatment. It may also have an educational effect, add meaning to the scores, and improve inter-rater reliability [ 42 ]. However, it would be helpful if guidelines included a norm for the choice of score with more detailed information about which score to record; this is not an easy task, as mental illness is a multifaceted and complex problem.

Deciding the criteria for such a norm is problematic. It is difficult to find empirical research aimed at finding the right GAF value lowest, highest, or average , or combination of GAF values, to record for different applications. The potential applications for GAF scoring are wide ranging and include different diagnostic categories, the chronic and acutely ill, treatment decisions, prediction or measurement of outcome, choice of level of care, and measurement of case mix.

Little is known about which score gives the best inter-rater reliability and validity, and it is not known whether separate GAF-S and GAF-F, or the lower of the two scores is best for treatment decisions and measurement of outcome, or how much weight should be given to GAF-S versus GAF-F for such applications.

Scoring within the point intervals is open to subjective judgment and finer distinctions readily become somewhat random.

In practice, clinicians tend to score around the decile or mid-decile divisions of the scale [ 42 ]. Patients who are scored in the same point interval should be relatively homogenous in functioning, but functioning is a construct with many facets and when information for a more accurate score is lacking, intermediate scores in the deciles are chosen [ 63 , 74 ].

It is possible that more detailed verbal instructions would result in more accurate scores. An alternative to having more anchor points is to use categorical scales for scoring within the point intervals, in which case the anchor points with key words and examples of symptoms and functioning items should be graded [ 13 , 75 ].

Both symptoms and functioning can be graded in different ways [ 76 ]. A categorical scale requires a decision about the number of categories; such scales often have five categories, for example: very marked, marked, neither marked nor weak, weak, or very weak. Numbers of categories other than five can also be considered [ 61 , 77 ]. More experienced raters may be able to make finer distinctions and score correctly with more categories, but scoring in the clinic is often carried out by people with different educational backgrounds [ 15 , 16 , 19 — 21 , 29 ].

An alternative procedure for scoring within point intervals is found in the 'modified GAF' [ 24 ], which uses the number of criteria met: for example, for the interval , when one criterion is met the score should be and when two criteria are met it should be In the history of GAF, systematic work to improve scoring within point intervals is limited and it is not known how to best score within point intervals. This also applies to the use of categorical scales for scoring, which requires considerations concerning the nature and number of categories.

There can be a vast difference between the mental states of different patients. However, a dual-scale GAF scoring uses two straight lines that is, a multidimensional phenomenon is scored in a two-dimensional way , which may not reflect this complexity.

The answer to the problem is not necessarily to have more scales covering different aspects of, for example functioning, as this would require a more complex scoring process [ 13 ]. However, if guidelines for rating are not good enough, the value of an assessment instrument is reduced. It does seem appropriate to consider development of guidelines for different conditions.

Panels of experts aided by empirical data could develop norms with ranges of relevant GAF values. The comprehensibility of anchor points with key words and examples for different diagnostic group should be considered and it would be helpful to include examples of patients scored and not scored in each decile [ 13 , 77 ].

The reliability of scores is not necessarily the same for all diagnostic groups. To ensure assignment of the correct GAF value, advice could be given on how to obtain good information for each patient for example which psychiatric interview to use.

For some diagnostic groups, this can mean collecting more information than for others. Guidelines should have information on how to take different comorbid conditions into consideration. If different GAF values are expected for different ages and sexes, this should be noted in the guidelines, but there is little information available about this. Different norms of functioning can represent different baselines against which the patient is evaluated, so, for example, instruments should be adapted to assessing older patients, to include scoring of dementia and happiness at the end of life [ 9 ].

Guidelines could also be different for different situations, for example for admission to inpatient departments and for community studies [ 13 ].

GAF should score impairment due to mental condition, but the effect of somatic and mental impairment can be interrelated and it can be difficult to distinguish between them [ 14 ]. The GAF rating should not be influenced by considerations on prognosis, previous diagnosis, presumed nature of the underlying disorder, or whether or not the patient is receiving medication or some other form of help [ 5 , 12 , 50 , 51 ].

There is limited empirical information concerning the suitability of existing guidelines for different conditions, different groups of patients and patients with several other characteristics.

The effect of adapting guidelines to these variations is not known. Having different guidelines for symptoms and functioning has been little explored. GAF has been translated into many languages, but languages encode meaning in different ways. Instruments should be adapted to different cultures and languages [ 6 , 7 , 40 , 73 , 78 ]. People from different cultures can answer in different ways when questions are asked, for a number of reasons [ 73 , 79 ], and this can have consequences for GAF values.

It is important to understand illness explanations and help-seeking behaviours [ 80 ] within the patients' cultural framework and patients should be evaluated against what is 'normal' in their own culture. Cultural factors can be important for attitudes to disorder [ 81 — 83 ], and the use of GAF in multiethnic societies presents challenges to assessment [ 9 ]. Language differences may also present problems; a patient may be clearly psychotic when interviewed in their own language, but not when interviewed in a foreign language [ 83 ].

When translated into other languages, the guidelines for rating GAF, interviews for rating GAF, and GAF itself for example anchor points with key words and examples can be influenced. Translation of assessment instruments can involve translation, back translation, review and modification and guidelines are available for translating tests and assessment instruments [ 9 , 84 ].

Little is known about the importance of translation and culture for GAF guidelines. The safety of international comparisons should be questioned. Meta-analyses based on data from countries with different languages and cultures may be influenced by these differences. We are a long way from having a comprehensive set of heuristic guidelines that could support the assessor in executing the scoring process [ 85 ], but progress in the study of the assessment process is anticipated [ 9 ].

Guidelines should be based on both theory, and empirical knowledge [ 85 ] about how each guideline works in practice. Development of new guidelines for GAF would be facilitated by first reviewing the literature about guidelines for psychological assessment, and extracting relevant points [ 6 , 7 ]. New empirical research could then be performed, for example by performing qualitative studies of the actual process of scoring, to search for items that are relevant for guidelines, while bearing in mind that if the scoring process is made too complex, errors are more likely to be introduced [ 76 ].

The existence of international guidelines would provide support to the implementation and use of the guidelines in different countries. Guidelines should reflect consensus on practice [ 7 ] and a draft of new guidelines for GAF should therefore be circulated widely to provide ample opportunity for comments [ 56 ]. A GAF scale with new guidelines should also be tested out for reliability and validity for different diagnoses, with different scorers, across different sites and with different patient populations.

To study the effects of varying guidelines, knowledge of 'true' values would be useful and mean scores from expert panels can work as reference norms [ 29 ].

When designing a norm for the scoring process, it is important to consider which process can best achieve the aims. It is essential to first define the purpose of a scoring system. For example, a system that is mainly intended for clinical use should be viewed by clinicians as sensible and easy to use. However, having a short version of the guidelines for the clinic and more detailed guidelines for research could result in scores that are not directly comparable; evidence-based treatment is, by definition, based on research and this could pose a problem for its implementation.

The requirement for guidelines to be short and concise makes it necessary to decide which information should be given in the guidelines and which in the manual. Computerisation of assessment may well be the future. Assigning scores could begin with a visible GAF scale on the screen, where placing the cursor at different places along the scale reveals different windows with information about the criteria for scoring; clicking the mouse in one of these windows could make even more detailed information available in another window.

The use of electronic patient records represents a possibility for new quality assurance methods. Some diagnoses are not combinable with high GAF scores; if such a diagnosis has been given, a warning could pop up on the screen if a GAF score that is too high is given.

A reminder may come up if the psychiatric record is completed for a new patient without having entered a GAF score. When a GAF score has not been given for an outpatient for the last 3 months, a reminder could pop up on the screen. Computer-based scoring of GAF can give high correlation with scoring based on clinical impression [ 88 ], but difficulties with computer-assisted assessment suggest a number of guidelines for users [ 41 ].

The International Test Commission has developed guidelines on computer-based and internet-delivered testing [ 89 — 94 ], but these guidelines were not developed with GAF in mind. Work with a scoring instrument is not complete without testing or pilot study [ 82 , 95 ]. Alterations to the scoring process are not necessarily always improvements, and a pilot study is needed to reveal any additional changes that are necessary.

Literature reviews can play a role in development of guidelines [ 96 ]. The present study can be defined as a systematic review [ 48 , 49 ]. Several important criteria for review articles are satisfied, such as defining the problem, informing the reader of the status of current research, identifying gaps and suggesting the next step [ 97 ].

An encompassing hand search of literature was done because it was considered that some relevant publications were likely not to be included in computerised databases. A combination of searching reference lists and reading publications has been considered the most thorough way of hand searching [ 98 ].

PubMed includes more than psychology-related journals [ 99 ], but as the search showed few publications to deal specifically with guidelines for rating GAF, the search was continued in other databases. The citation tracking in Google Scholar is not completely reliable when it comes to listing the most frequently cited first, but screening of the first 1, results represents a thorough Google Scholar search.

In step i , a stage was reached where new perspectives could not be identified by reading more publications; the situation is described by the term 'saturation' from qualitative research. It is not considered likely that publications that could have changed the results were missed as a result of the search process. The design and conduct of the present study protected against bias [ 47 , 48 ].

The literature review identified the state of knowledge for GAF guidelines and a review of this type can be valuable in work to develop better guidelines. In the history of GAF, limited focus has been given to development of guidelines and currently available guidelines are short. In the clinic, the primary goal of the assessment process is to contribute to the solution of a person's problems [ ]. A generic and global scoring system, such as GAF, that covers the range from positive mental health to severe psychopathology has advantages for clinical practice for example, routine quality assessment of treatment, supplementing scales that give more detail [ 75 ], research for example, comparison of treatment outcome across diagnoses , and policy and management planning for example, allocation of resources, measurement of case mix in psychiatric organisations.

For GAF to have such a broad range of applications, it must be good enough for the purpose. It is important not to simply dismiss GAF because of problems concerning either the instrument itself [ 13 ] or guidelines; existing scales can be dismissed too lightly [ 72 ]. A scoring system must be robust enough to allow for scorer bias and more random errors of measurement.

If GAF is not good enough, a given change in GAF value would not necessarily reflect a corresponding change in severity. Subjectivity in scoring should be kept to a minimum; some scorers can be unwilling to give a low score because of the negative labelling of clients [ 22 ] and clinicians who do most of their work with one patient category may use their experience as a norm.

Improved consistency of scoring can be achieved locally by delivering courses in rating GAF [ 22 ], but the risk of variation between different local standards will remain. Improved guidelines have the potential to reduce such bias. The aim of better guidelines is to make scores more reliable, to improve comparability of scores for example across organisations and from different studies , to make combination of scores in meta-analysis safer, help in assigning more accurate scores choosing better between individual points in the point ranges , to provide more accurate information for the choice of intervention and evaluation of treatment results, and to be of help in the education and training of assessors.

However, it is not a matter of course that new guidelines will give much better GAF scores. The clinical situation is not just about having a perfect scoring system; it is equally important to earn the respect and trust of the patient [ 70 ]. New guidelines should not be destructive for the clinician-patient relationship.

They should also be adaptable and tolerate changes in clinical practices; information for scoring should be easy to obtain; and the scoring process should not be too time consuming.

Evidence-based medicine has shown that examples of successful implementation of guidelines exist, but also that implementation is not always successful [ ].

It is important that once new guidelines for GAF have been developed, they are implemented effectively. The present review has focused on guidelines for rating GAF, but other factors can also play a part in the choice of GAF value. Factors that have not been treated include: 1 characteristics of the patient interview and the importance of collecting information from different sources; 2 characteristics of the rater, i.

The guidelines that are currently available for rating GAF are not the result of a sophisticated development, but guidelines are important for reliable assessments.

There are few published studies dealing specifically with guidelines for rating GAF. This study presents a number of points that are relevant for new guidelines and show a significant potential for development.

International panels of experts have a role to play, and a manual for GAF can be developed. Computerisation of the scoring process can offer advantages for rating. In light of the current situation, care should be exercised when comparing outcomes across facilities and also with international comparison, and meta-analyses.