Does the Family APGAR Effectively Measure Family Functioning?
METHODS: Data were collected from 401 pediatricians and family physicians from the Pediatric Research in Office Settings network and the Ambulatory Sentinel Practice Network. The physicians enrolled 22,059 consecutive office visits by children aged 4 to 15 years. Parents completed a survey that included the Family APGAR and the Pediatric Symptom Checklist. Clinicians completed a survey that described child psychosocial problems, treatments initiated or continued, and specialty care referrals.
RESULTS: Family dysfunction on the index visit often differed from dysfunction at follow-up (k=0.24). Only 31% of the families with positive Family APGAR scores at baseline were positive at follow-up, and only 43% of those with positive scores at follow-up had a positive score at the initial visit. There were many disagreements between the Family APGAR and the clinician. The Family APGAR was negative for 73% of clinician-identified dysfunctional families, and clinicians did not identify dysfunction for 83% of Family APGAR–identified dysfunctions (k=0.06).
CONCLUSIONS: Our data do not support the use of the Family APGAR as a measure of family dysfunction in the primary care setting. Future research should clarify what it does measure.
A strong family orientation has been a cornerstone of family practice since its emergence in the late 1960s1-4 and is alo important in pediatrics.5 The development of family medicine as a dominant primary care specialty has occurred in parallel with the development of clinical applications of family systems theory.6-9 More recently the Institute of Medicine report on primary care in America10 has reaffirmed provision of care in the context of family and the community as a central component of primary care.
Integrating an effective family orientation into everyday practice has proved feasible and extant in family practice.11-13 Several approaches to examining and characterizing family function for research purposes have been proposed.14 These include a combination of analysis of communication, observation of interaction, and individual patient report. Many of these approaches are time consuming and not practical for use in large sample studies requiring a brief instrument. The ability to assess the family context, however, is critical to many primary care studies and particularly those that deal with behavior, mental health, and psychosocial problems.
The Family APGAR was introduced by Gabriel Smilkstein in 1978 to assess adult satisfaction with social support from the family.15 It draws its name from a 5-item measure of perceived family support in the domains of adaptation, partnership, growth, affection, and resolve. The statements focus on the emotional, communicative, and social interactive relationships between the respondent and his or her family, for example: “I find that my family accepts my wishes to take on new activities or make changes in my lifestyle.”
Several studies have examined the psychometric properties of the instrument. We focus on evidence about the validity of the instrument, as it has regularly been found to be internally consistent.16,17 Good and colleagues16 found that Family APGAR scores correlated highly (r=0.80) with scores on the Pless-Satterwhite Family Function Index18 in a small nonclinical sample (N=38). In a small sample of mental health outpatients (N=20), the same authors found that Family APGAR scores correlated (r=0.64) with therapists’ ratings of the degree of family distress. Foulke and coworkers19 administered the Family APGAR and the Family Adaptation and Cohesion Evaluation Scales20 (FACES II) to 140 families and found that the Family APGAR correlated with the FACES Cohesion scale (r=0.70) and with the Adaptability scale (r=0.59; Stephen Zyzanski, personal communication, June 2000). However, when Clover and colleagues21 administered the Family APGAR and the FACES II to 66 families they reported that there was no association between the 2 scales.
Smucker and coworkers22 found no association (k=-0.05) between the Family APGAR and physicians’ judgments about the presence of family dysfunction among 152 families. This lack of association, however, could have resulted from the physicians’ difficulties in recognizing family dysfunction, problems in the Family APGAR, or both. North and colleagues23 obtained ratings of the usefulness of family assessment tools from 299 family physicians. The Family APGAR was rated less useful than any other tool.
Smilkstein and coworkers17 found that adults in counseling perceived their families as more dysfunctional than adults in other samples. There was, however, no assessment of the family; thus the finding does not directly support the validity of the Family APGAR as a measure of family dysfunction. Smilkstein and colleagues also found that adopted children were more likely to perceive their families as dysfunctional than were biological children. This would not validate the Family APGAR as a measure of family dysfunction, because it seems unlikely that families who adopt are more dysfunctional than other families.
