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Global Assessment of Child Psychopathology
Global Assessment of Child Psychopathology HANS-CHRISTOPH STEINHAUSEN, M.D., PH.D. Abstract. The Children's Global Assessment Scale (CGAS) was analyzed wih regard to interrater reliability, discriminant validity, and clinical usefulness in two different studies. Whereinterrater reliability and discriminant validity were high, stability varied for different psychiatric diagnoses. In a clinical sample, sc~res we~e dependent on diagnoses, mental retardation, and socioeconomic status. A cutoff score of 70 clearly differentiated normal functioning from moresevere problemsin needof treatment. The scalesensibly reflected changedue to therapeutic interventions. J. Amer. Acad. Child Ado/. Psychiat., 1987, 26, 2:203-206. Key Words: global assessment, ratmg scale, psychopathology. The traditional approach to assessing psychopathology consists of describing symptoms or groups of symptoms in terms of their frequency and severity. From this approach stem the various rating scales and inventories permitting the calculation of a total score and additional subscores relating to symptoms, such as hyperactivity, emotional disorders, conduct disorders, and the like (e.g., Rutter et al., 1970; Conners, 1973; Achenbach, 1979). These strategies for assessing psychopathology provide detailed information and offer the advantage of a quantitative, possibly even standardized, definition of characteristic features. In contrast to this multidimensional approach to describing psychiatric disorders, a global method records the severity of a disorder in terms of a single measurement. Although this method means that much detailed information is necessarily lost, there are certain advantages. A global assessment of the severity of psychopathology condenses the total knowledge about the psychiatric and social disturbances of a patient into a single significant index. This kind of condensed measurement has become well established in psychotherapy research, particularly because it can reflect the effects of changes in treatment more closely than can separate dimensions of psychopathology. These global assessments naturally cannot replace the detailed description of symptoms, but their value lies in supplementing available information. Endicott et al. (1976) developed an instrument for measuring the global severity of psychiatric disorders in adults, which was then adapted by Shaffer et al. (1983) for use in children between 4 and 16 years of age. The Children's Global Assessment Scale (CGAS) runs from 0 to 100, with 0 indicating a child with the most severe disorder and 100 the most healthy child. Every 10th degree of the scale is provided with an anchor point that describes, in terms of function, the behavior of the child. Two studies were performed using a German translation of the CGAS by this investigator. In a first study, reliability and validity of this German version were tested. To some extent this study was a replication of the American study by Shaffer Received Sept. 2, 19H5: revised Jan. 6, 19H6: accepted Feb. 27. 19H6. Dr. Steinhausen is Professor ol' Child and Adolescent Psychiatry and Neurology at the Department' ofChild and Adolescent Psychiatry and Neurology. Free University o( Berlin, Platanenallee 23, D-1000 Berlin 19, West Germanv, where reprint requests should he sent. This article is based Oil papers presented at the VII Congress ofthe European Societv 0( Child and Adolescent Psychiatry, Lausanne, Switzerland, JU/i' i-H, 19HJ and the JIst Annual Meeting oi' the American Acade;ny ofChild Psychiatry, Toronto. October 9- I 4. 19H4. 0890-8567/87/2602-0203$02.00/0© 1987 by the American Acad-
emy of Child and Adolescent Psychiatry.
et al. (1983). The second study investigated the clinical utility of the CGAS, using a series of consecutive referrals to a child and adolescent psychiatric department. Method Data for both studies consisted of scores on the CGAS and clinical diagnoses recorded in accordance with the multiaxial scheme of classification (Rutter et al., 1975) in which psychiatric diagnoses are classified according to ICD-9. In the first study, a total of 10 case histories were rated by 14 clinicians who were members of a child and adolescent psychiatric university department. The first five case histories were each chosen at random and presented orally by a member of the team. The second set of another five case histories was presented in written form. They were taken from the English reliability study of Rutter et al. (1975). After 6 to 8 weeks, the five cases presented in written form were assessed again in order to test stability, this time exclusively in terms of CGAS scores. The second study was based on a consecutive series of patients (N = 428) admitted to the department. Mean age of the sample was 10.02 years (S.D. = 4.2). In the sample, 63% were boys and 37% were girls. In terms of socioeconomic status, (SES), 55 (6%) were of lower-class and 44 (4%) of middle-class origin. Again, CGAS scores and diagnoses were collected from different clinicians who rated their own cases. These clinicians had previously been enrolled in CGAS trainings. Independent of CGAS ratings, parents' responses to the child behavior questionnaire (Rutter et al., 1970) were available. In addition, a number of items were included in the analyses, i.e., SES and therapeutic measures. Results The first study dealt with interrater reliability, discriminant validity, and stability of CGAS scores. Findings with regard to interrater reliability and discriminant validity are shown in Table I, where means, standard deviations, and confidence intervals for 10 case histories and diagnoses are given. As shown in Table I, there is a high degree of agreement among raters. In 8 of the 10 case histories, the standard deviation is well under 10 scale points, and only in the third (infantile autism) and eighth case (anorexia nervosa) is it marginally above 10 scale points. The reliability for all assessors (N = 4), all of whom assessed all of the case histories, was also very high. The intraclass correlation coefficient was r = 0.93. Second, if one considers confidence intervals, there is some marked overlap of CGAS scores for certain diagnoses, i.e., mixed disturbance of conduct and emotions, adjustment reaction, enuresis, anorexia nervosa, and tics on the one hand,
STEINHAUSEN
204
TABLE I. Means, Standard Deviations, and Confidence Intervals (C1) or C(JAS Scoresfor Ten Cases -
----
---------
CGAS Scores Diagnosis
------
Mean
S.D.
CI
- - - - - - - - - - - - - - ----- -
Mixed disturbance of conduct and emotions Adjustment reaction Infantile autism Emotional disorder (neurosis) Enuresis Emotional disorder Schizophrenic psychosis Anorexia nervosa Mixed disturbance of conduct and emotions Tics
55.2
8.6
49.1-61.3
55.5 33.8 44.1
9.8 11.3 5.3
48.5-62.5 26.6-40.9 40.5-47.7
65.2 36.6 21.7 54.1 6\.1
9.4 7.0 9.4 1\.0 10.3
58.5-7\.9 32.5-40.6 15.7-27.6 47.8-60.5 54.2-68.0
57.3
7.6
52.7-6 \.9 -----
and infantile autism. schizophrenic psychosis. emotional disorders, and neuroses on the other hand. (In contrast to DSMIII. neuroses and emotional disorders specific to childhood and adolescence are included in ICD-9. Whereas neuroses include anxiety states. hysteria, phobic states, obsessive-compulsive disorders. neurotic depression. neurasthenia. depersonalization syndrome. and hypochondriasis, disturbances of emotions specific to childhood and adolescence include less well-differentiated emotional disorders characteristic of this developmental period.) Thus. the scale clearly differentiates between severely disabling conditions and more common diagnoses with minor problems. Third. among the less disabling conditions, no additional differentiation takes place (as one might expect, because the scale in theory should be independent of diagnoses). The findings with regard to reliability of diagnosis and stability of CGAS scores based on the retest undertaken after 6 to 8 weeks are shown in Table 2. Reliability of diagnosis was assessed only once. In only one case was there poor agreement with regard to diagnosis. Whereas the majority of clinicians diagnosed an emotional disorder specific to childhood and adolescence. a minority used the term neurosis. The overall stability of CGAS scores varied considerably and was rather poor for the case in which reliability of diagnosis was insufficient. An additional part of the first study involved considering whether or not the length of clinical experience or the professional group had a significant impact on CGAS score. In the latter case the assessments of child psychiatrists and psychologists were compared. There were no systematic differences in the assessment for either factor (clinical experience or professional group). The second study. based on clinical cases consecutively admitted to the department, addressed the impact of diagnoses, intelligence. and SES on CGAS scores. Furthermore. an attempt was made to validate a cutoff score of 70 differentiating between "normalcy" and "pathology" and to analyze whether or not the scale reflects therapeutic changes during inpatient treatment. CGAS scores significantly differentiated between psychiatric diagnoses (I-' = 23.3. dl» 5; 404, [J = 0.00 I). Post hoc tests
by the SCHEFFE procedure, however. revealed that only neuroses and conduct disorder had significantly different scores from the rest of diagnoses (i.e., enuresis, adjustment reactions. emotional disorder. and the hyperkinetic syndrome (see Figure 1). In addition, mentally retarded children (IQ < 70) received significantly lower scores than all other children of low (IQ = 70-85), average (IQ = 85-115), or high (IQ > 115) intelligence. Socioeconomic status was another important variable because lower-class children had significantly lower CGAS scores than middle-class children (mean = 54.2, S.D. = 14.3, versus mean = 59.8, S.D. = 13.8, I-' = 6.03, df= 1;404, [J = 0.015). There were no significant interactions among diagnosis. intelligence, and socioeconomic status. In addition, there was a modest but significant correlation (r = -0.20. [J = 0.00 I) between CGAS rating and total score of the child behavior questionnaire. It was hypothesized that a cutoff point of 70 on the CGAS might help to differentiate the ranges of normalcy and pathology. In order to validate this criterion, diagnoses and treatment measures were analyzed in relation to the cutoff score. Findings are shown in Table 3. As shown, a diagnosis of neurosis or conduct disorder is almost never correlated with scores above 70, whereas in the case of enuresis, adjustment reactions. emotional disorder, and the hyperkinetic syndrome approximately a quarter of the sample scores were above 70. With regard to treatment measures one may conclude that inpatient treatment and medication are almost never indicated with children scoring above 70. These children rarely need any kind of treatment. Finally, sensitivity of the scale with regard to therapeutic changes during inpatient treatment was tested by comparing TABLE 2. Reliability ofDiagnosis and Stability Crw(1icients of (,GAS Scores tor Five Written Case Histories
-----
No. of Assessors
Diagnosis Mixed disturbance of conduct and emotions Adjustment reaction Infantile autism Emotional disturbance (neurosis) Enuresis
8 9 10 10 9
Reliability (%)01'
Diagnosis
p
fI _._--_._-
0.59
0.06
90 IO{) 54.55
0.49 0.66 0.22
0.09 0.02 NS
100
0.85
0.002
90
~~~~
~~
RNctlon~
Condutl ~ ..~~
l~j·1/1
IN"?91
IN-I\f
IN·o81
AlIJu.,tml:nl
Stability of CGAS
----_._--
(mQtIOrltil
~tHr\ IN·loWl
H'I'lerklnt'tll
~ndr_Olnr IN.lOl
"co
FI(;.
I. ('GAS scores for different psychiatric diagnoses.
205
GLOBAL ASSESSMENT OF PSYCHOPATHOLOGY
scores at admission and discharge in a series of 10 consecutive cases. These were the first 10 patients who had been discharged from the ward after ('GAS rating had been introduced for evaluation of therapeutic change. Findings are shown in Table 4. The whole sample had significantly higher scores at discharge than at admission (Wilcoxon test: P = 0.0 I). Some cases. however. showed rather poor improvement. Discussion The aim of the first study was to determine the test criteria of a new instrument. Interrater reliability of the method was satisfactory. Stability of the ratings within an interval of 6 to 8 weeks, however. was much better for either severe disorders (e.g., infantile autism) or monosymptomatic disorders (e.g., enuresis) than for complex or less severe disorders (e.g.. mixed disturbance of conduct and emotions or adjustment reaction). When clinicians failed to agree with regard to diagnosis, as was the case with regard to neurosis and emotional disorder, stability of the ('GAS score was also insufficient. This finding relates to one of the major problems in using the CGAS in
TABLE 3. Relationship ofMain Diagnoses and Treatment Measures to a Cut-offPoint 0(70 on the CGAS CGAS Score
71-100
0-70
Treatment measures Inpatient treatment Medication Indication for treatment
73 153 25
100 73.3 72.7 98.6 90.5 78.1
16 7
34 15 349
97.1 100.0 86.4
0 55
22
22 8
%
N
N
Main diagnoses Neurosis Enuresis Adjustment reaction Conduct disorder Emotional disorder Hyperkinetic syndrome
0
0
8
26.7 27.3 1.4 9.5 21.9
3 1
I
2.9 0 13.6
clinical practice. Although the scale primarily emphasizes functioning, some of the anchor points are not free from diagnostic information. For instance, "suicidal preoccupations and ruminations. school refusal and other forms of anxiety. obsessive rituals. major conversion symptoms." and so forth, are provided to illustrate "moderate degree of interference in functioning in most social areas or severe impairment of functioning in one area" (CGAS score 50-41). This information, rather than psychosocial functioning, may. at least in some cases, primarily influence the rating on the CGAS. Besides the aspect of reliability, validity of the scale was also confirmed. In terms of discriminant validity, the CGAS does ditTerentiate among cases with ditTerent degrees of severity. Because there are no other scales like the CGAS that address the same issues, additional studies of concurrent validity are difficult to perform. This study found only a small but significant overlap with number of symptoms as reported by parents. Thus. one has to conclude that level offunctioning is not entirely independent of symptom load. On the other hand, these two aspects of psychiatric disorder are not equivalent, but rather supplementary. Similar findings were obtained by ShatTer et al. (1983) in their study in which CGAS and another parent questionnaire had a moderate correlation. Some additional evidence of the validity of the instrument was supplemented by the fact that there appeared to be no bias ensuing from clinicians with ditTering levels of experience and types of training in medicine and psychology. The clear description of anchor points and the simple theoretical framework emphasizing psychosocial functioning obviously reduces any potential bias in diagnosticians with varying clinical background. Taken together, all this evidence fulfills essential criteria for judging the soundness of a psychological tool of measurement, the result being that it will be possible to use the scale in future research projects. The second study primarily tested the clinical utility of the ('GAS by using it in a consecutive series of in- and outpatients of a child and adolescent psychiatric department. Again, there was much evidence that the scale had sufficient discriminant
TABLE 4. CGAS Scores/or {/Series ofInpatients at Admission and Discharge .... _._--- -- . __ .__ ..--------------
-
-
-----------------~
CGAS Score at Age
Sex
SES"
Psychiatric Diagnoses
M
2 3
17 15 13
F F
MC MC LC
4
10
F
LC
5
14
F
LC
6 7 8 9 10
17 15 17 17 18
M
MC MC MC MC MC
Neurotic depression, transvestitism Anorexia nervosa Mixed disturbance of conduct and emotions Mixed disturbance of conduct and emotions, hyperkinetic syndrome Conversion reaction, mixed disturbance of conduct and emotions Schizophrenic psychosis Anorexia nervosa Neurotic depression Anorexia nervosa Schizophrenic psychosis
Case I
F
M F
M
" SES, socioeconomic status; MC, middle class; LC, lower class.
----------
Admission
Diseharge
40 45 42
50 50 52
41
52
45
56
50 35 35 35 20
50 60 55 70 65
-- - - - - - - - - - - - - - - - - - - -
206
STEINHAUSEN
validity. Diagnostic differentiation might have been even better if a sufficient number of patients with severe disorders (e.g.. psychoses) had been available. Certainly, the seale also reflects the fact that mental retardation, but not the different levels of normal intelligence, is an important determinant of psychosocial functioning. Here one might have expected that learning disability (IQ 70-85) might also be associated with impaired functioning as reflected by the CGAS . Socioeconomic status is also an important factor influencing ('GAS scores. Whether this reflects true differences dependent on different socialization processes or a bias by middle-class oriented clinicians cannot be determined from the present study. The proposal to use a cutoff score of 70 on the ('GAS in order to separate normal functioning from pathological cases was clearly substantiated by the analyses . All clinical cases with more severe disorders (i.e.. neuroses and conduct disorders) had scores below 70. and even in the less severe cases (e.g.. emotional disorders, and so forth) the vast majority of subjects had scores below this criterion. Additional validation of this cutoff seore came from the fact that important treatment variables were significantly correlated with the criterion. Medicat ion and inpatient treatment were consistently associated with ('GAS seores below 70, and treatment was indicated only in a small minority of children with scores above the cutoff criterion.
Finally, the usefulness of the ('GAS was also documented in a small series of inpatients for whom ratings had been obtained at admission and discharge. It was shown that CGAS scores indeed reflected change due to treatment. The pattern varied individually, reflecting the fact that different patients suffering from the same disorder (e.g.. anorexia nervosa or schizophrenic psychosis) responded d ifferently to treatment. Therefore, one may conclude that the ('GAS. besides serving in a wide variety of evaluation studies, should be specificall y used in treatment and outcome stud ies. References Achenbach, T. M. (1979). The child behavior profile: an empirically based system for assessing ch ildren 's behavioral problem and competencies. 1111. J. Mcnt. II/Ih .. 7:22-24. Co n ners. C. K. (1973). Rating scales for use in drug studies with ch ildren . Psychopharm. Bull.. Special issue. pp. 24-42. End icou . L , Spitzer. R. L.. Fleiss. J. L. & Cohen. J. (1976). The global assessment scale. A procedure for measuring overall severity of psychiatric disturbance. Arch. Gen. Psvchiatr. , 33:766-771 . Rutter. M.. Tizard, 1.. Wh itmore. K. (1970). Education, Health and Beha viour. London: Longman. - -. Shaffer , D. & Sturgc, C. (197 5), ,., XI/ide 10 a multi-axial classification schem e fo r psychiatric disorders in childhood and adolescence. Unpublished manuscript. Department of Child and Ado lescent Psychiatry, Institute of Psychiatry. London . Shaffer, D.. Gould. M. S.. Brasic, J. et al. (1983). A children's global assessment scale (CGAS). Arch. Gen. Psychiat.. 40: 1228-1231.
emy of Child and Adolescent Psychiatry.
et al. (1983). The second study investigated the clinical utility of the CGAS, using a series of consecutive referrals to a child and adolescent psychiatric department. Method Data for both studies consisted of scores on the CGAS and clinical diagnoses recorded in accordance with the multiaxial scheme of classification (Rutter et al., 1975) in which psychiatric diagnoses are classified according to ICD-9. In the first study, a total of 10 case histories were rated by 14 clinicians who were members of a child and adolescent psychiatric university department. The first five case histories were each chosen at random and presented orally by a member of the team. The second set of another five case histories was presented in written form. They were taken from the English reliability study of Rutter et al. (1975). After 6 to 8 weeks, the five cases presented in written form were assessed again in order to test stability, this time exclusively in terms of CGAS scores. The second study was based on a consecutive series of patients (N = 428) admitted to the department. Mean age of the sample was 10.02 years (S.D. = 4.2). In the sample, 63% were boys and 37% were girls. In terms of socioeconomic status, (SES), 55 (6%) were of lower-class and 44 (4%) of middle-class origin. Again, CGAS scores and diagnoses were collected from different clinicians who rated their own cases. These clinicians had previously been enrolled in CGAS trainings. Independent of CGAS ratings, parents' responses to the child behavior questionnaire (Rutter et al., 1970) were available. In addition, a number of items were included in the analyses, i.e., SES and therapeutic measures. Results The first study dealt with interrater reliability, discriminant validity, and stability of CGAS scores. Findings with regard to interrater reliability and discriminant validity are shown in Table I, where means, standard deviations, and confidence intervals for 10 case histories and diagnoses are given. As shown in Table I, there is a high degree of agreement among raters. In 8 of the 10 case histories, the standard deviation is well under 10 scale points, and only in the third (infantile autism) and eighth case (anorexia nervosa) is it marginally above 10 scale points. The reliability for all assessors (N = 4), all of whom assessed all of the case histories, was also very high. The intraclass correlation coefficient was r = 0.93. Second, if one considers confidence intervals, there is some marked overlap of CGAS scores for certain diagnoses, i.e., mixed disturbance of conduct and emotions, adjustment reaction, enuresis, anorexia nervosa, and tics on the one hand,
STEINHAUSEN
204
TABLE I. Means, Standard Deviations, and Confidence Intervals (C1) or C(JAS Scoresfor Ten Cases -
----
---------
CGAS Scores Diagnosis
------
Mean
S.D.
CI
- - - - - - - - - - - - - - ----- -
Mixed disturbance of conduct and emotions Adjustment reaction Infantile autism Emotional disorder (neurosis) Enuresis Emotional disorder Schizophrenic psychosis Anorexia nervosa Mixed disturbance of conduct and emotions Tics
55.2
8.6
49.1-61.3
55.5 33.8 44.1
9.8 11.3 5.3
48.5-62.5 26.6-40.9 40.5-47.7
65.2 36.6 21.7 54.1 6\.1
9.4 7.0 9.4 1\.0 10.3
58.5-7\.9 32.5-40.6 15.7-27.6 47.8-60.5 54.2-68.0
57.3
7.6
52.7-6 \.9 -----
and infantile autism. schizophrenic psychosis. emotional disorders, and neuroses on the other hand. (In contrast to DSMIII. neuroses and emotional disorders specific to childhood and adolescence are included in ICD-9. Whereas neuroses include anxiety states. hysteria, phobic states, obsessive-compulsive disorders. neurotic depression. neurasthenia. depersonalization syndrome. and hypochondriasis, disturbances of emotions specific to childhood and adolescence include less well-differentiated emotional disorders characteristic of this developmental period.) Thus. the scale clearly differentiates between severely disabling conditions and more common diagnoses with minor problems. Third. among the less disabling conditions, no additional differentiation takes place (as one might expect, because the scale in theory should be independent of diagnoses). The findings with regard to reliability of diagnosis and stability of CGAS scores based on the retest undertaken after 6 to 8 weeks are shown in Table 2. Reliability of diagnosis was assessed only once. In only one case was there poor agreement with regard to diagnosis. Whereas the majority of clinicians diagnosed an emotional disorder specific to childhood and adolescence. a minority used the term neurosis. The overall stability of CGAS scores varied considerably and was rather poor for the case in which reliability of diagnosis was insufficient. An additional part of the first study involved considering whether or not the length of clinical experience or the professional group had a significant impact on CGAS score. In the latter case the assessments of child psychiatrists and psychologists were compared. There were no systematic differences in the assessment for either factor (clinical experience or professional group). The second study. based on clinical cases consecutively admitted to the department, addressed the impact of diagnoses, intelligence. and SES on CGAS scores. Furthermore. an attempt was made to validate a cutoff score of 70 differentiating between "normalcy" and "pathology" and to analyze whether or not the scale reflects therapeutic changes during inpatient treatment. CGAS scores significantly differentiated between psychiatric diagnoses (I-' = 23.3. dl» 5; 404, [J = 0.00 I). Post hoc tests
by the SCHEFFE procedure, however. revealed that only neuroses and conduct disorder had significantly different scores from the rest of diagnoses (i.e., enuresis, adjustment reactions. emotional disorder. and the hyperkinetic syndrome (see Figure 1). In addition, mentally retarded children (IQ < 70) received significantly lower scores than all other children of low (IQ = 70-85), average (IQ = 85-115), or high (IQ > 115) intelligence. Socioeconomic status was another important variable because lower-class children had significantly lower CGAS scores than middle-class children (mean = 54.2, S.D. = 14.3, versus mean = 59.8, S.D. = 13.8, I-' = 6.03, df= 1;404, [J = 0.015). There were no significant interactions among diagnosis. intelligence, and socioeconomic status. In addition, there was a modest but significant correlation (r = -0.20. [J = 0.00 I) between CGAS rating and total score of the child behavior questionnaire. It was hypothesized that a cutoff point of 70 on the CGAS might help to differentiate the ranges of normalcy and pathology. In order to validate this criterion, diagnoses and treatment measures were analyzed in relation to the cutoff score. Findings are shown in Table 3. As shown, a diagnosis of neurosis or conduct disorder is almost never correlated with scores above 70, whereas in the case of enuresis, adjustment reactions. emotional disorder, and the hyperkinetic syndrome approximately a quarter of the sample scores were above 70. With regard to treatment measures one may conclude that inpatient treatment and medication are almost never indicated with children scoring above 70. These children rarely need any kind of treatment. Finally, sensitivity of the scale with regard to therapeutic changes during inpatient treatment was tested by comparing TABLE 2. Reliability ofDiagnosis and Stability Crw(1icients of (,GAS Scores tor Five Written Case Histories
-----
No. of Assessors
Diagnosis Mixed disturbance of conduct and emotions Adjustment reaction Infantile autism Emotional disturbance (neurosis) Enuresis
8 9 10 10 9
Reliability (%)01'
Diagnosis
p
fI _._--_._-
0.59
0.06
90 IO{) 54.55
0.49 0.66 0.22
0.09 0.02 NS
100
0.85
0.002
90
~~~~
~~
RNctlon~
Condutl ~ ..~~
l~j·1/1
IN"?91
IN-I\f
IN·o81
AlIJu.,tml:nl
Stability of CGAS
----_._--
(mQtIOrltil
~tHr\ IN·loWl
H'I'lerklnt'tll
~ndr_Olnr IN.lOl
"co
FI(;.
I. ('GAS scores for different psychiatric diagnoses.
205
GLOBAL ASSESSMENT OF PSYCHOPATHOLOGY
scores at admission and discharge in a series of 10 consecutive cases. These were the first 10 patients who had been discharged from the ward after ('GAS rating had been introduced for evaluation of therapeutic change. Findings are shown in Table 4. The whole sample had significantly higher scores at discharge than at admission (Wilcoxon test: P = 0.0 I). Some cases. however. showed rather poor improvement. Discussion The aim of the first study was to determine the test criteria of a new instrument. Interrater reliability of the method was satisfactory. Stability of the ratings within an interval of 6 to 8 weeks, however. was much better for either severe disorders (e.g., infantile autism) or monosymptomatic disorders (e.g., enuresis) than for complex or less severe disorders (e.g.. mixed disturbance of conduct and emotions or adjustment reaction). When clinicians failed to agree with regard to diagnosis, as was the case with regard to neurosis and emotional disorder, stability of the ('GAS score was also insufficient. This finding relates to one of the major problems in using the CGAS in
TABLE 3. Relationship ofMain Diagnoses and Treatment Measures to a Cut-offPoint 0(70 on the CGAS CGAS Score
71-100
0-70
Treatment measures Inpatient treatment Medication Indication for treatment
73 153 25
100 73.3 72.7 98.6 90.5 78.1
16 7
34 15 349
97.1 100.0 86.4
0 55
22
22 8
%
N
N
Main diagnoses Neurosis Enuresis Adjustment reaction Conduct disorder Emotional disorder Hyperkinetic syndrome
0
0
8
26.7 27.3 1.4 9.5 21.9
3 1
I
2.9 0 13.6
clinical practice. Although the scale primarily emphasizes functioning, some of the anchor points are not free from diagnostic information. For instance, "suicidal preoccupations and ruminations. school refusal and other forms of anxiety. obsessive rituals. major conversion symptoms." and so forth, are provided to illustrate "moderate degree of interference in functioning in most social areas or severe impairment of functioning in one area" (CGAS score 50-41). This information, rather than psychosocial functioning, may. at least in some cases, primarily influence the rating on the CGAS. Besides the aspect of reliability, validity of the scale was also confirmed. In terms of discriminant validity, the CGAS does ditTerentiate among cases with ditTerent degrees of severity. Because there are no other scales like the CGAS that address the same issues, additional studies of concurrent validity are difficult to perform. This study found only a small but significant overlap with number of symptoms as reported by parents. Thus. one has to conclude that level offunctioning is not entirely independent of symptom load. On the other hand, these two aspects of psychiatric disorder are not equivalent, but rather supplementary. Similar findings were obtained by ShatTer et al. (1983) in their study in which CGAS and another parent questionnaire had a moderate correlation. Some additional evidence of the validity of the instrument was supplemented by the fact that there appeared to be no bias ensuing from clinicians with ditTering levels of experience and types of training in medicine and psychology. The clear description of anchor points and the simple theoretical framework emphasizing psychosocial functioning obviously reduces any potential bias in diagnosticians with varying clinical background. Taken together, all this evidence fulfills essential criteria for judging the soundness of a psychological tool of measurement, the result being that it will be possible to use the scale in future research projects. The second study primarily tested the clinical utility of the ('GAS by using it in a consecutive series of in- and outpatients of a child and adolescent psychiatric department. Again, there was much evidence that the scale had sufficient discriminant
TABLE 4. CGAS Scores/or {/Series ofInpatients at Admission and Discharge .... _._--- -- . __ .__ ..--------------
-
-
-----------------~
CGAS Score at Age
Sex
SES"
Psychiatric Diagnoses
M
2 3
17 15 13
F F
MC MC LC
4
10
F
LC
5
14
F
LC
6 7 8 9 10
17 15 17 17 18
M
MC MC MC MC MC
Neurotic depression, transvestitism Anorexia nervosa Mixed disturbance of conduct and emotions Mixed disturbance of conduct and emotions, hyperkinetic syndrome Conversion reaction, mixed disturbance of conduct and emotions Schizophrenic psychosis Anorexia nervosa Neurotic depression Anorexia nervosa Schizophrenic psychosis
Case I
F
M F
M
" SES, socioeconomic status; MC, middle class; LC, lower class.
----------
Admission
Diseharge
40 45 42
50 50 52
41
52
45
56
50 35 35 35 20
50 60 55 70 65
-- - - - - - - - - - - - - - - - - - - -
206
STEINHAUSEN
validity. Diagnostic differentiation might have been even better if a sufficient number of patients with severe disorders (e.g.. psychoses) had been available. Certainly, the seale also reflects the fact that mental retardation, but not the different levels of normal intelligence, is an important determinant of psychosocial functioning. Here one might have expected that learning disability (IQ 70-85) might also be associated with impaired functioning as reflected by the CGAS . Socioeconomic status is also an important factor influencing ('GAS scores. Whether this reflects true differences dependent on different socialization processes or a bias by middle-class oriented clinicians cannot be determined from the present study. The proposal to use a cutoff score of 70 on the ('GAS in order to separate normal functioning from pathological cases was clearly substantiated by the analyses . All clinical cases with more severe disorders (i.e.. neuroses and conduct disorders) had scores below 70. and even in the less severe cases (e.g.. emotional disorders, and so forth) the vast majority of subjects had scores below this criterion. Additional validation of this cutoff seore came from the fact that important treatment variables were significantly correlated with the criterion. Medicat ion and inpatient treatment were consistently associated with ('GAS seores below 70, and treatment was indicated only in a small minority of children with scores above the cutoff criterion.
Finally, the usefulness of the ('GAS was also documented in a small series of inpatients for whom ratings had been obtained at admission and discharge. It was shown that CGAS scores indeed reflected change due to treatment. The pattern varied individually, reflecting the fact that different patients suffering from the same disorder (e.g.. anorexia nervosa or schizophrenic psychosis) responded d ifferently to treatment. Therefore, one may conclude that the ('GAS. besides serving in a wide variety of evaluation studies, should be specificall y used in treatment and outcome stud ies. References Achenbach, T. M. (1979). The child behavior profile: an empirically based system for assessing ch ildren 's behavioral problem and competencies. 1111. J. Mcnt. II/Ih .. 7:22-24. Co n ners. C. K. (1973). Rating scales for use in drug studies with ch ildren . Psychopharm. Bull.. Special issue. pp. 24-42. End icou . L , Spitzer. R. L.. Fleiss. J. L. & Cohen. J. (1976). The global assessment scale. A procedure for measuring overall severity of psychiatric disturbance. Arch. Gen. Psvchiatr. , 33:766-771 . Rutter. M.. Tizard, 1.. Wh itmore. K. (1970). Education, Health and Beha viour. London: Longman. - -. Shaffer , D. & Sturgc, C. (197 5), ,., XI/ide 10 a multi-axial classification schem e fo r psychiatric disorders in childhood and adolescence. Unpublished manuscript. Department of Child and Ado lescent Psychiatry, Institute of Psychiatry. London . Shaffer, D.. Gould. M. S.. Brasic, J. et al. (1983). A children's global assessment scale (CGAS). Arch. Gen. Psychiat.. 40: 1228-1231.