Does the Family APGAR Effectively Measure Family Functioning?
A few studies have examined whether low Family APGAR ratings (which mean higher perceived family dysfunction) predict other clinical phenomena,12,22,24-27 with mixed results. However, an association between a patient’s report on the Family APGAR and later mental health service use does not directly bear on whether the instrument is a valid measure of family dysfunction. Therefore, the evidence of whether the Family APGAR is a valid measure of family dysfunction is mixed.
We used the Family APGAR as a measure of family dysfunction in a large study of psychosocial problems in children. Our study accomplished 3 goals that had not been achieved in previous research. First, we examined the internal consistency of the Family APGAR in a very large sample of office-based visits (N=21,285). In an internally consistent survey the items essentially measure one thing. Researchers who use the Family APGAR to compare families on the basis of functionality are assuming that there is a single dimension of family characteristics that is tapped by the survey.
Second, we used a large sample of repeat office visits (N=1146) to examine whether positive (dysfunctional) Family APGAR scores are stable over 6 months. When health service workers speak of dysfunctional families they often mean those that are persistently dysfunctional. Similarly, clinicians often adopt a watch and wait strategy for dealing with an initial report of psychosocial problems.28 If a positive score on the Family APGAR signals persistent dysfunction, then a positive score at the index visit should usually be matched by a positive score at follow-up.
Third, in a large sample of office visits (N=4050) we examined whether an adult family member’s report of problems on the family APGAR matched the clinician’s independent judgments of whether there were family problems. Although there are many reasons to expect disagreements between a valid survey measure of family dysfunction and clinicians’ judgments, a very weak level of agreement would raise questions about whether the Family APGAR measured dysfunctionality.
Methods
Study Sites
The Child Behavior Study (CBS) was conducted in several large primary care research networks in North America. The Ambulatory Sentinel Practice Network (ASPN), a family practice research network, included 141 practices in 41 states and 6 Canadian provinces and was composed of approximately 680 clinicians. Eightyfive percent of the ASPN clinicians were family physicians, 7% were nurse practitioners, and 8% were physician assistants. Additional family physician participants came from the Wisconsin Research Network and the Minnesota Academy of Family Physicians Research Network, which had characteristics similar to ASPN. The primary care practice–based Pediatric Research in Office Settings (PROS) network included more than 1500 clinicians from more than 480 pediatric practices in all 50 states and the Commonwealth of Puerto Rico. Eightynine percent of the PROS clinicians were pediatricians, 10% were nurse practitioners, and 1% were physician assistants. Of the 206 practices participating in the CBS, 30% were urban, 38% were suburban, and 32% were rural.
All clinicians participating in the CBS were included for our analysis (401 clinicians in 44 states, the Commonwealth of Puerto Rico, and 4 Canadian provinces). The clinicians included 267 pediatricians, 134 family practitioners, and 29 nurse clinicians. Previous research from both ASPN and PROS confirmed the comparability of patients, clinicians, and practices in primary care network studies with those identified in national samples.29,30 In addition, we compared participating pediatric clinicians with a random sample of pediatricians from the American Academy of Pediatrics31 on demographic factors and practice characteristics. We found few differences between participating clinicians and other clinicians.
Patient Sample
Each participating clinician enrolled a consecutive sample of approximately 55 children aged 4 to 15 years presenting for nonemergent care with a parent or primary caretaker. We enrolled each child only once and excluded children seen for procedures only. Some eligible children were not recruited, primarily because of parental refusal (63% of eligible but not participating children) and occasionally because the opportunity was either overlooked by the office staff (25%) or because the family dropped out of the study (12%). We compared participating children with those who were eligible but not participating on the basis of age and sex, and found no differences. In addition, we examined whether clinician or practice characteristics might affect patient participation, including clinician discipline, geographic region, practice population size, percentage of managed care patients, and clinician attitudes toward mental health treatment. Only those clinicians located in the South and West seemed to include a higher percentage of their eligible participants (94% to 89% for each); none of the other measured sources of selection bias were statistically significant.
