Does the Family APGAR Effectively Measure Family Functioning?

This procedure produced a sample of 22,059 children seen in office visits. Among those visits 774 (3.5%) with missing data on 1 or more of the 5 APGAR items were excluded, resulting in a final study sample of 21,285 visits.

Procedures

Procedures and consent forms for the CBS were approved by institutional review boards affiliated with PROS, ASPN, and the University of Pittsburgh. Study procedures have been described in detail elsewhere³² Consenting parents (or the accompanying primary caregiver) filled out a parent questionnaire while waiting to see the clinician. The questionnaire included demographic data, the Family APGAR, and the Pediatric Symptom Checklist (a psychosocial screening instrument). The clinician did not see the completed Family APGAR, Pediatric Symptom Checklist, or other parent questionnaire data.

After seeing a patient the clinician completed a survey about the encounter, documenting whether a new, ongoing, or recurrent psychosocial problem was present, including an explicit statement of family dysfunction. Finally, the survey also included a checklist of a series of psychosocial problems that the clinician might have recognized in the child (clinicians could and often did check more than one problem).

Procedures for Follow-up

A random sample of children with clinician-identified psychosocial problems was identified for follow-up. African American children were oversampled for follow-up to obtain a sufficient sample. A total of 1970 children were included in the follow-up, and 1354 (69%) were successfully followed up. For this analysis, we used the 1146 patients with complete APGAR data for whom the adult respondent was the same at enrollment and follow-up.

Results

Table 1 shows the associations between the Family APGAR scores and several demographic variables. The strongest predictor of a low Family APGAR score was when the child’s parents were either not married or were separated. Table 2 presents the results for individual items of the Family APGAR.

Internal Consistency

We examined the intercorrelation of the Family APGAR items to determine whether the scale measured a single dimension of family functioning. The correlations of items with the total score ranged from r=0.63 to 0.71. Coefficient a, a summary measure of the intercorrelation of items, equaled 0.85, and deletion of any item from the scale reduced the a. This is a respectable level of internal consistency, suggesting that the Family APGAR items can all be viewed as measures of a single underlying dimension.

Stability of Family APGAR Over Time

Table 3 compares response on the Family APGAR on the initial and follow-up visits. There was a slight but statistically significant difference between the frequency of positive scores (Ž5, indicating family dysfunction) with families appearing more dysfunctional at the follow-up (McNemar’s test: (c2[1]=29.02; P <.001).

If the Family APGAR measures a stable characteristic of family functioning, a family’s dysfunctional status at the index visit should usually agree with its status at the 6-month follow-up. However, only 31% of families appearing dysfunctional during the initial visit still seemed so during the follow-up, and only 43% of those appearing dysfunctional during the follow-up appeared so during the initial visit. The k statistic, a chance-corrected measure of the agreement between the time 1 and time 2 scales, was only 0.24.

Clinician Assessment of Psychosocial Problem and the Family APGAR

Table 4 presents the concordance between a positive score on the Family APGAR and clinicians’ identification of family dysfunction. This Table includes the subset of children for which clinicians recognized a psychosocial problem, because this is the group for which a clinician would be likely to use the Family APGAR. There were high rates of disagreement between clinicians and the scale concerning positive cases. The Family APGAR was negative for 73% of clinician-identified dysfunctional families, and clinicians did not identify dysfunction for 83% of APGAR-identified dysfunctions. Although there was a significant positive association between the Family APGAR and clinician identifications (c2[1]) =19.12; P <.002), the k agreement statistic was only 0.06.

Discussion

Our study adds important new information on the performance of the Family APGAR as a measure of family support and dysfunction. Our results confirm some of the previous work that found that the Family APGAR is an internally consistent measure. Nevertheless, it is unclear exactly what it measures. The Family APGAR did not remain stable across assessments that averaged 6 months apart. On the one hand, it is correlated with both parental reports of symptoms and physician treatment decisions. Previously we reported²⁷ an association of Family APGAR with behavioral problems in children as assessed by both physicians’ reports and scores on the Pediatric Symptom Checklist.²² Also, positive Family APGARs were more frequent among single or separated parents. This could reflect a higher level of dysfunction among such families, but it is equally consistent with the premise that the Family APGAR is a measure of family support.