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http://bjp.rcpsych.org/ on November 27, 2012
Published by The Royal College of Psychiatrists
B R I T I S H J O U R N A L O F P S YC H I AT RY ( 2 0 0 3 ) , 1 8 2 ( s u p p l . 4 4 ) , s 3 2 ^ s 3 5
None.
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METHOD
The intention of the investigation was to
replicate as nearly as possible the assessment of clinical data in ordinary practice.
The approach used was the measure of
agreement between raters who scored case
vignettes. An example of a case vignette is
shown in the Appendix. To determine
whether levels of agreement were robust a
Selection of vignettes
Case vignettes were selected from the caseload of 12 senior psychiatrists to represent
the heterogeneous psychopathology in
people with learning disability. This process
ensured that there was a representative
selection of case material that was heterogeneous in nature but which correctly
reflected current practice and documentation in the catchment area. The psychiatrists were asked to include a summary of
the presenting problem, history findings
and course and treatmentresponse information, although the last of these was
optional.
Scoring procedure
The vignettes were assessed independently
and simultaneously by 19 professionals in
a first phase (Table 1) and 25 in a second
phase (Table 2). In the first phase, all participants received written course material
and 2 hours common introduction to scoring the Modified GAF scale. In the second
U S E OF T H E G LO B A L A S S E S S M E N T OF F UN C T I ON S C A L E IN L E A R NIN
NI N G D I S A B I L I T Y
T
Table
able 1 First-phase interrater reliability of modified Global Assessment of Function (GAF ) (worst/current scores)1
Variable
Overall level of
agreement (n
(n19)
19)
0.63 (good)
0.26 (poor)
0.35 (poor)
0.36 (poor)
0.49 (fair)
12.5
18.1
15.7
75
63.6
68.4
47.2
2.2
N/A
Table 2
Second-phase interrater reliability of original Global Assessment of Function (GAF ) (worst scores)1
Variable
(n12)
12)
(n13)
13)
(n25)
25)
0.54 (fair)
0.15 (poor)
0.28 (poor)
25
15.4
Psychiatrists, %
66.6
46.2
5.1
N/A
0.77 (11)
3.42 (3.4)
N/A
20
56
1. Distribution of scores and reliability for GAF ratings at worst level of function in 38 cases rated by 25 raters.
RESULTS
The results are shown in Tables 1 and 2 for
the two phases of the study. There was a
Table 3
(a) We obtained an overall intraclass reliability coefficient (R1) among all the raters in a given data-set,
using the BigRi program (Cicchetti & Showalter, 1988).
(b) We obtained a separate RI for each rater with every other rater.
(c) Applying the clinical or practical criteria of Cicchetti & Sparrow (1981), we classified each of the
Analysis of data
All data were analysed for interrater reliability using the intraclass correlation coefficient (Bartko, 1966). This is appropriate for
the assessment of continuous data and
allowance is made for chance association
in calculating agreement. Using a computer
program BigRi (Cicchetti & Showalter,
1988), both overall levels of agreement
and rater bias were assessed for the raters.
We also applied a new reliability statistic
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OL I V E R E T A L
DISCUSSION
The findings demonstrate the positive and
negative aspects of the GAF. The ease with
which it can be applied to the wide range of
patients with learning disability on the
basis of clinical vignettes alone, some of
which are vague and not particularly conducive to quantitative assessment, shows
the versatility of the instrument. The staff
involved had a wide range of professional
expertise, and no difficulties were experienced in understanding the instrument
despite only minimum training. However,
the level of agreement was relatively low
for both current and worst-case scenarios.
It is clear from the large range of scores
that there is considerable difficulty in
rating global function across the domains
of personality, intellectual level and
symptomatology of mental state disorder.
There was considerable rater bias in the
assessments of GAF scores, with a wide
variation between mean scores for each
rater. The variation was associated with
poorer agreement. The fact that there was
concordance between reliable and unreliable raters suggests that the achieving of
good and poor reliability is not a chance
event and is probably accounted for by
different perceptions of the GAF scale in
its current form.
The findings are similar to those of
Loevdahl & Friis (1996), who estimated
the level of GAF agreement with 104 raters
from 6 therapeutic centres in their assessment of 5 clinical case vignettes. Systematic
differences between centres were up to 6
points, and the authors concluded that
GAF reliability was unsatisfactory in routine clinical settings. However, Rey et al
(1995), using well-trained raters, reported
interrater reliability ranging from 0.83 to
0.87 for the GAF of general psychiatric
patients in a clinical setting. The reliability
and the validity of the GAF was also tested
by Jones et al (1995) with psychiatric
patients, and their trained raters had an
interrater reliability score of 0.72 for the
GAF in total.
Several methods could improve agreement in learning disability. These include:
(a) splitting the scale into clinical and
social function sections (Tyrer et al,
al,
1998);
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APPENDIX
Sample case vignette
C is a 35-year-old, single African ^ Caribbean man
institutionalised since the age of 4 years.
Problems include:
(a) unprovoked, unpredictable, opportunistic aggression against others, several of these incidents
resulting in grievous bodily harm;
(b) property destruction;
(c) sexual attacks on vulnerable persons of both
genders;
(d) self-injurious behaviour including biting, slapping,
poking causing tissue damage;
(e) sexual over-arousal and masturbation;
(f)
(f ) antisocial behaviour, inclusive of faecal smearing,
screaming, overactivity;
(g) poor sleep pattern.
ACKNOWLEDGEMENTS
We thank Parkside Health NHS Trust
Trust for their funding and support of the Parkside Learning Disability
Research Initiative (PLDRI) and Helen Bond, Senior
Library Assistant, Hertfordshire Partnership NHS
Trust,
Trust, for her invaluable assistance throughout the
project. We also appreciate the work of Donald
Showalter, Senior Computer Programmer, VA
Northeast Program Evaluation Center,West Haven,
CT, USA, who wrote the reliability assessment
computer programs used in this investigation. The
Parkside Learning Disability Research Initiative
(PLDRI) Group involves seven NHS trusts and
health authorities. Parkside Health NHS Trust:
Trust: Mary
Antony, Michael Attwood, Alina Bakala, Angela
Brady, Yang Chang, Cathy Claydon, Fred Cowperthwaite, Kofi Krafona, Zenobia Nadirshaw, Nihal
Ranasinghe, Vijaya Sharma and Heather Shaw;
Barnet Healthcare NHS Trust:
Trust: Shridhar Mahadeshwar; Brent and Harrow Health Authority:
Authority: Nandha
Balan; Harrow and Hillingdon NHS Trust:
Trust: Adrienne
Regan and Iqbal Singh; Hertfordshire Partnership
NHS Trust:
Trust: Marius Cooray, Nimal Marker, George
Matthew, Jack Piachaud, Renuga Rasaratnam, Poppy
Sebaratnam and
Shyamala Thalayasingham;
Hounslow and Spelthorne NHS Trust:
Trust: Stephanie De
Silva, Venkat Murthy and Manga Sabaratnam;
Leicestershire and Rutland Healthcare NHS Trust:
Trust: Regi
Alexander.
History
C comes from a close-knit but disorganised, large
family. Very little is known about his natural father
who left home when C was an infant. Early history
is sparse, except that his mother had a prolonged
labour. He was described as slow and difficult from
childhood. Speech was limited to the odd word and
noises. At the long-stay institution he continued to
be disruptive and aggressive towards other people.
From the age of 12 he was sexually active and
needed constant supervision in the mixed childrens
ward to prevent attacks on both male and female
children. He was admitted to a community childrens
unit for people with severe learning disability
(National Health Service) and subsequently to an
assessment ^ treatment facility where he has
remained in view of his complex needs. Intensive
work within the unit has resulted in considerable
improvement of his activities of daily living and
communication.
Findings
On examination,
examination,C
C is a well-built man who is likely to
be intimidating to strangers or, alternatively, overfriendly. He has no dysmorphic features. He has
limited eye contact and is able to communicate his
basic needs using single words or very short sentences in conjunction with Makaton signs. Attention
span is limited. He likes repetitive movements and
flicking as well as ritualistic tapping and slapping.
Likes playing with his bodily fluids. Does not like
changes in routine, repeats the same words and
sounds. He enjoys music, especially rhythms with a
strong beat. Periodically he becomes persistently
U S E OF T H E G LO B A L A S S E S S M E N T OF F UN C T I ON S C A L E IN L E A R NIN
NI N G D I S A B I L I T Y
CLINICAL IMPLICATIONS
Ratings of global function using the Global Assessment of Function (GAF ) scale in
learning disability are not reliable for ordinary clinical practice.
&
Reliability is better for current function than for a description of worst lifetime
function.
&
&
Course
Management has particular emphasis on social-skills
training. The behaviour problems have responded in
a limited way as a result of the specialist input, structure and discipline, within the unit. Nevertheless,
he continues to need intensive supervision at all
times and has been detained under Section 3 of the
Mental Health Act since 1990, following a serious
physical attack on a fellow resident. The cyclicity of
his hyperactivity inclusive of escalation of behaviour
problems and sleep disorder has been much
reduced by the current regimen of medication.
LIMITATIONS
&
Ratings of global function were compared using the case vignette method only.
&
Most of the raters were not familiar with the GAF scale before the study.
The quality of the case vignettes was variable and, even though this reflected
ordinary clinical practice, it could have influenced levels of agreement.
&
REFERENCES
American Psychiatric Association (1987) Diagnostic
PATRICIA OLIVER, PhD, Faculty of Medicine, Imperial College, Paterson Centre, London, UK; SHERVA
COORAY, FRCPsych, Parkside Health NHS Trust,
Trust, Kingsbury Community Unit, Brent, London, UK; PETER
TYRER, FRCPsych, DOMENIC CICCHETTI, PhD, Department of Psychological Medicine, Imperial College,
London, UK
Correspondence: Sherva Cooray, Consultant Psychiatrist, Parkside Health NHS Trust,
Trust, Kingsbury Community
Unit, Honeypot Lane, London NW9 9QY, UK
, Rosenheck, R., Showalter, D., et al (1999) Interrater reliability levels of multiple clinical examiners in the
evaluation of a schizophrenic patient.Quality of life: level
of functioning and neuropsychological symptomatology.
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13, 157^170.
Endicott, J., Spitzer, R. L., Fleiss, J. L., et al (1976)
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