Does the Family APGAR Effectively Measure Family Functioning?

Less than a third of the families who screened positive at time 1 on the Family APGAR also screened positive at follow-up. By the design of our study, only families in which the clinician had recognized a psychosocial problem at time 1 were followed up. It is plausible that the prevalence of family dysfunction among such families is higher than the general population. If so, it implies that in the general population, the rate of positive time-2 Family APGAR scores given positive time-1 scores would be even lower. The pattern of strong internal consistency and weak temporal stability suggests that the Family APGAR tracks a labile characteristic of families. By itself the transience of positive Family APGAR scores does not imply that it is an invalid measure of dysfunction. It is possible that family dysfunction can be serious but transient. Given what the Family APGAR actually measures, however, this interpretation is hard to support. A positive Family APGAR score is a report by a single individual that the family does not adequately communicate with, emotionally support, adapt to, or problem-solve with him or her. Is one such report evidence of serious family dysfunction, or does normal family functioning include occasional transient disturbances of the relations between a family and one of its members? We incline to the latter view.

Also, the Family APGAR was not associated with clinician reports of family dysfunction. Disagreement between clinicians and the Family APGAR does not necessarily imply that the Family APGAR is wrong. It is likely that clinicians have difficulty recognizing family dysfunction, as would be suggested by the literature showing that clinicians often fail to recognize psychiatric disorder.^32,33 In the latter case, however, it has been found that primary care clinicians’ judgments about the presence of psychiatric disorders fail to agree with well-validated psychiatric instruments. Given the scarcity of previous evidence about the validity of the Family APGAR, we do not believe that the lack of agreement between the clinicians and the Family APGAR implies that the clinicians were in error. All we can say is that there is little agreement between the instrument and clinician-identified family dysfunction.

Limitations

Our data have important limitations for examining the ability of the Family APGAR to provide a measure of family function. In our study, the Family APGAR was reported by a single adult in the family. We do not have data from other adults in the family or the index child in the study. Also, we do not have a gold standard criterion assessment of family dysfunction. Our study focused on psychosocial problems in the index child, and thus we did not document a complete picture of the psychosocial problems of the family. Finally, entry into the study was through a child’s visit; this was not a systematic sample of families visiting primary care offices. Therefore, our study oversampled families of children who were presenting for a medical or psychosocial problem.

Future Research

The Family APGAR appears to have utility in family practice research, but researchers should carefully consider how they are using it. Further research could provide a more complete explanation of the association between distress as measured by the Family APGAR and psychosocial problems in children. Our speculation is that because the Family APGAR assesses an adult’s perceptions of family support, low scores may measure parental distress, which will sometimes reflect parental depression. The detrimental effects of parental depression on children are well established. This suggests that the Family APGAR may be an important variable to investigate as a determinant of care-seeking behavior, parent and physician treatment decisions, and as a marker for problems in one or more children. It might be more efficient, however, to screen for parental depression.

Conclusions

Although originally introduced as an assessment of adult satisfaction with family support, the Family APGAR has developed a research following as a measure of family functioning. We present data from a large community-based study of behavioral problems in children that raise questions about the Family APGAR as a measure of family dysfunction. Viewed in the light of the scarcity of previous evidence on the validity of the Family APGAR, we do not believe it should be used as a measure of family functioning. However, because the Family APGAR is associated with child psychosocial problems, it remains of interest for clinical research. One of the goals of future research should be to clarify what the Family APGAR does measure.

We note, however, that the fundamental problems we have discussed may not be in the Family APGAR but rather in the lack of clarity about the meaning of family dysfunction.¹³ What is the justification for using a measure of social support as a measure of family dysfunction? Many other issues arise in discussion of dysfunctional families, such as parental drug use, the lack of a stable family residence, neglectful child rearing, and the occurrence of domestic violence. The Family APGAR was never intended to measure these issues. A prerequisite for future research must be a clarification of what it means to label a family as dysfunctional.