Content of measures

Behavioural measures may include a wide range of clinically relevant content. Symptoms are most commonly elicited during clinical interviews, and their assessment is covered in CÜaMeLiJOJ..,. However, self-completed questionnaires or checklists may also supplement clinical interviews, and specific behavioural problems may be assessed by observer-completed ratings or checklists. Woo et al.(9) describe an interesting approach to symptomatic assessment, in which videotaped interactions between patients (who met research diagnostic criteria for schizophrenia, including both high and low 'expressed emotion' families) and a family member were coded for the presence of subclinical signs of pathology.

Rating scales typically cover both general social and functional behaviour. While most such measures cover a relatively limited number of functional areas, and are often designed for use with a specific subclient group, some measures are designed for wider use. An example is the Functional Performance Record, (19 comprising 600 items, that may be used not only with people with long-standing psychiatric disabilities, but also with people with enduring physical disabilities and with learning disabilities. There are 27 content topics with a number of specific questions attached to each, which enables very detailed goal-planning.

Behavioural measures have a special use in the assessment of disturbed or bizarre behaviour, where the patient commonly has little insight or knowledge of the nature or degree of their disturbance, and where the continuation of this behaviour poses either a major ongoing management problem or a barrier to their placement in the community. An example of such a measure is the Aberrant Behavior Checklist/11 This is a 58-item behavioural rating scale completed by an informant, with the content covering five subscales: irritability, agitation, and crying; social withdrawal and lethargy; stereotyped behaviour; hyperactivity and non-compliance; inappropriate speech.

The Katz Adjustment Scales(12) are widely used self-rated questionnaires covering the pattern of everyday work and occupation, with separate scales for completion by the identified patient and the relative. The patient's scale has 134 items, covering symptoms, social adjustment, expected social activities, and performance and satisfaction with those activities (together with the discomfort experienced by the symptoms). The relative's scale comprises 205 items covering the same domains, but it only assesses the presence of symptoms and not their discomfort.

The subjective quality of life enjoyed by patients is of increasing concern, and because it is a multidimensional concept (covering physical, economic, aesthetic factors, etc.) it is often used loosely. The American Quality-of-Life scale proposed by Lehman (1.3) has been widely used in psychiatric studies, but British studies are increasingly using the Lancashire Scale. (1.4)

Most measures simply describe the current functioning of the patient, without offering a framework for translating the obtained scores into clinical priorities for treatment. The 'needs assessment' approach takes account of the views of the patient and carer as to the relative importance of different aspects of the assessment, and also takes into account the extent to which needs have been met, or remain unmet. Marshall et al.(1..5) derived the Cardinal Needs Schedule to measure the needs for psychiatric and social care among patients with severe psychiatric disorders. They rated 15 areas of psychiatric and social functioning (such as drug side-effects and the patient's ability to handle their own money) while considering three criteria: co-operation—the patients desire to be helped; carer stress; and severity. The 15 areas of functioning they identify (see Bo.x.2) are a useful summary of the main areas most relevant to the rehabilitation and continuing care of severely mentally ill adults.

Box 2

Areas of functioning covered by the Cardinal Needs Schedule

Psychotic symptoms

Physical illness

Transport and amenities

Underactivity

Neurotic symptoms

Education

Side-effects

Socially embarrassing

Occupation

Dangerous or obstructive

Domestic skills

Communication

Organic symptoms

Money and own affairs

Hygiene and dressing

In many areas of psychiatric practice the use of multiple measures, including some behavioural measures, may be helpful. Rutter, (1..6) in reviewing changes in child psychiatry, pays particular attention to the importance of sound measurement by contrasting standardized interviews and checklists, and points out that multiple measures involving different informants, which are repeated over time, are necessary to reduce error and minimize rater bias. Research studies may use complex multiple measures, but these are unlikely to be achievable in clinical practice. For example, Deale et a/.,(lZ> in evaluating the outcome of a treatment trial for chronic fatigue, used ten outcome measures, namely: three functional impairment measures; two fatigue measures; two psychological distress questionnaires or inventories; and three other variables, including a global self-rating and a self-written statement of illness attributions. In clinical practice, multiple measures should be selected so that each measure is the most relevant for each category of behaviour, with care taken to consider the overall assessment load on any one individual in the light of their other clinical commitments, not forgetting the time taken to analyse the resulting data.

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