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The assessment of social adjustment: A review of techniques

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The Assessment of Social
A Review of Techniques
Myrna M. Weissman, PhD
Interest in the community adjustment of psychiatric patients has
led to the development of rating techniques for its evaluation. Selec-
tion of an appropriate scale for the task should include a review of its
item content, anchor points, coverage, method of obtaining informa-
tion, informant, psychometric properties, precision, cost, scoring,
and instructional material.
While no scale is without limitations, this report describes 15 cur-
rently available scales that meet many of the important criteria for
assessing social adjustment and are sufficiently developed to be use-
ful in evaluative research. This review also contains a list of pertinent
references to the scales and a guide to the literature on behavioral
rating scales.
Therepast has been an unprecedented interest over the
two decades in community and social adjust¬
ment of psychiatric patients. It is reflected in community
psychiatry training programs, studies of the posthospital
adjustment of psychiatric patients, epidemiologie commu¬
nity surveys, and, more recently, in prophylactic trials of
drugs and psychotherapy. A natural growth of the shift in
psychiatry from custodial care to therapy and prevention,
the trend gained momentum with the opening of the com¬
munity mental health centers in the 1960s and the in¬
crease in outpatient care. This trend has both mandated
and been a consequence of an increased awareness that
mental disorders occur in a social system and that the pa¬
tient's family life, friendships, and work patterns may
have an impact on treatment and course.
The expansion into the social world of the patient in¬
volved the addition of new measures of disturbance—that
of social adjustment—that were distinct from the abnor¬
malities of thoughts or symptoms. A number of scales
were developed for the assessment of social adjustment.
The first ones were used for evaluating the posthospital
adjustment of schizophrenic patients who had been dis¬
charged on a regimen of the new tranquilizers. Others
were developed primarily to assess psychotherapy out¬
come in selected outpatient populations.
In the last few years especially, evaluation of treat¬
ment effectiveness and utilization has become an impor¬
tant issue in mental health. In a parallel development,
there has been concern about refining study methods and
standardizing evaluative techniques. These interests are
reflected in the development of utilization review proce¬
dures in community mental health centers, and in the
establishment of a joint Food and Drug Administration-
American College of Neuropsychopharmacology (FDA-
Accepted for publication Sept 20, 1974.
From the Department of Psychiatry, Yale University School of Medicine,
and the Depression Research Unit, Connecticut Mental Health Center, New
Haven.
Read in part before the 11th annual meeting of the American College of
Neuropsychopharmacology, San Juan, Puerto Rico, Dec 5, 1974.
Reprint requests to the Depression Research Unit, Connecticut Mental
Health Center, 100 Park St, New Haven, CT 06511 (Dr. Weissman).
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Adjustment
ACNP) task force to develop guidelines for the evaluation
of psychotropic medications.
Given these interests, the trends for improvement of re¬
search techniques, and the availability of several social ad¬
justment scales, a review seems timely. This report will
describe current techniques for assessing social adjust¬
ment in adults and criteria for evaluating them. The core
of the report will be a description of 15 scales that meet
many of the important criteria. The content, adminis¬
tration, psychometric properties, feasibility, advantages,
limitations, and references for each scale will be described
briefly. References 1-12 list reports that can be used as a
guide to other behavioral rating
SOCIAL ADJUSTMENT
scales.
Definition and Components
Social adjustment, broadly defined, is the interplay be¬
tween the individual and the social environment. Specific
ways of behaving, referred to as roles, are commonly ac¬
cepted as and the individual is perceived in
appropriate
terms of the way his role performance conforms to the
norms of his referrant group.
The major roles any individual assumes are a function
of age and may be a function of psychopathology. Nor¬
mally, an adult will function in most of the following
roles: occupational; marital, as a spouse and parent; within
an extended family (parents, siblings, and close relatives);
and in the community. While there is overlap between
symptoms and social adjustment, they may also be rela¬
tively independent, eg, some persons can function reason¬
ably well although symptomatic, and others may function
poorly although asymptomatic. Symptoms are primarily a
reflection of internal psychological or physical states that
may have consequence in social relations. Social adjust¬
ment is a reflection of the patient's interactions with oth¬
ers, satisfactions and performance in roles, which are
more likely modified by previous personality, cultural,
and family expectation. There is debate about the inde¬
pendence of symptoms and social functioning. A resolu¬
tion requires that they be measured separately and as ac¬
curately as possible. In this way subgroups of patients in
whom the relationship may differ can be identified. These
different subgroups may require different therapeutic in¬
terventions.
Evaluating Social Adjustment Scales
Criteria for
In choosing a social adjustment instrument, there are
certain criteria that an investigator should consider, while
recognizing that no scale will fulfill all of them. These cri¬
teria are as follows:
Content.—The content of an instrument should be eval¬
uated in terms of the areas assessed and the anchor points
for making the assessments. The areas assessed should be
extensive and have broad coverage. To evaluate what this
coverage might be, the components of social adjustment
Should be considered. Social adjustment is not unitary or
a In-Person Interview.—The
a global concept. The concept includes functioning in dif¬
ferent roles. Within each role, functions can be further
subdivided into instrumental and affective tasks, or be¬
havior and attitudes in roles. Certain behaviors may not
be role-dependent and may be common to all roles, such as
involvement, reticence in relationships, satisfaction,
and hostility with others. A rating instrument that as¬
sesses many of these discrete components of social adjust¬
ment offers more precision and may have greater utility in
classifying or in differentiating treatment effects.
Discretely defined rather than global anchor points for
making these assessments further contribute to pre-
ciseness. Global response ratings disclose only a few facets
of the complex changes that can occur in patients and are
less desirable. Operationalizing both the discrete compo¬
nents of the behaviors assessed and the anchor points is
inherently difficult, due to the value judgments implicit in
their definitions and the questions then raised about what
should be defined as normal. A number of scales have dealt
with these issues by measuring adjustment in terms of
amount of dysfunction, or by using broad dimensions of
behavior and global ratings.
Method of Obtaining Information.—There are a number
of options in the method and source of information. De¬
pending on cost, intent, and feasibility, each has its ad¬
vantages and limitations.
Self-Report Inventories.—Self-report inventories contain
a list of straightforward items that the informant is asked
to rate in order to describe himself or the patient, in the
case of relative ratings. The response points are usually
global (eg, "not at all" to "extremely"). Such inventories
have the advantage of economy, as a skilled interviewer
and a training program are not required. A research as¬
sistant may remain with the informant during the rating
in order to assure completeness. Illiterate informants re¬
quire that the assistant read the inventory. The removal
of interviewer bias and cost are important advantages of
this method.
It has disadvantages with psychotic and delusional pa¬
tients who tend to underreport their impairments,13 or
with patients too disturbed to complete the task, under¬
stand the intent of the questions, or who desire to falsify
their response.14
Mail Questionnaires and Telephone Interviews.—The mail
questionnaire is the least expensive method because it
does not require staff time to administer. However, as Ho-
garty15 points out, reliability is questionable, completeness
often inadequate, and sensitive material cannot be elic¬
ited. Illiteracy, position preference, and underresponse to
emotionally laden material also limit its use.16 Telephone
interviews present similar problems and advantages with
the exception that interview completeness and response
rate are easier to control by telephone.
Mail and telephone interviews have definite value in
large-scale follow-up evaluations, in which brief and ob¬
jective assessments are useful, when the patient refuses
an in-person interview, or where geographic mobility
makes interviewing impractical. Relatively straight¬
forward factual information can be obtained that would
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otherwise be lost.
in-person interview is the
most costly method, requiring the most skilled staff. The
actual degree of skill varies with the nature of the assess¬
ment. Structured interviews with precoded descriptive
items require the least trained interviewer. Unstructured
interviews or global items, which necessitate clinical judg¬
ments, require the most training and experience. The
semistructured interviews lie somewhere between. In a
semistructured interview, lead questions are provided and
the interviewer asks additional questions to elicit infor¬
mation necessary to make the final rating. Training is re¬
quired to insure that the interviewer asks sufficiently ap¬
propriate questions so that reliable informant response
can be obtained.
The disadvantages of this method are the cost, inter¬
viewer preparation and training, and the potential inter¬
viewer bias. The advantage is that the most complete in¬
formation can be obtained, since the patient's own
responses as well as an evaluation of these responses can
be rated. The interviewer may be able to calm the dis¬
turbed patient who might otherwise be unable to partici¬
pate, can detect the tendency to underreport or falsify,
and can make efforts to have the subject give accurate in¬
formation.14
Given the initial cost and time investment of most re¬
search studies, the in-person interview method is prefer¬
able for completeness. However, there is much to be said
for the self-report inventory or use of both methods to¬
gether, and neither method compensates for a poorly de¬
signed or inadequately tested questionnaire.
Informant
Information about the patient's social adjustment gen¬
erally is obtained by one of three sources: the patient, a
significant other, or clinical records.
The Patient as Informant—The patient is the most direct
and available source of information in outpatient studies.
Nonpsychotic outpatients, especially depressives, can be
reasonably reliable informants. The use of other infor¬
mants may be unfeasible in studies in which the patient
has never been hospitalized, since the family may not be
involved.17 The disadvantage of this method is that only
the bias of the patient is rated. Whether this is more or
less valid than the bias of other informants is an open
question, and additional work is needed in comparing data
from patient and significant other informants.
Significant Others as Informants.—In this method a per¬
son knowledgeable about the patient, usually a close rela¬
tive, is asked to rate the patient's adjustment. It is an im¬
portant source of information in studies of schizophrenics
discharged from the hospital, because these patients tend
to underreport and misrepresent impairments. In addi¬
tion, the families of schizophrenics are usually involved
during the treatment course and are more apt to be avail¬
able.
The disadvantages are that a patient must have a rela¬
tive or close friend who is willing to cooperate. Problems
in the choice of relative and agreement between relatives
have been well reviewed by Hogarty15 and by Clausen.18
Records.—The use of records for information is the least
 Table 1.—Detailed Characteristics of 15 Scales Assessing Social Adjustment
Instruments
Normative Social Inef¬ Mandel Social Personal Ad¬ Katz Personality
Social Adjust¬ fectiveness Adjustment Adjustment justment and Adjustment Social Net-
Characteristics ment Scale Scale Scale Inventory Role Skills Scale work Scale
Content
Occupational
Community
Marital Family Family Family
Parental
Extended family
Economic
Instrumental (I), affective (A) I, A I, A
Items—defined (D), global (G)
Ratings—D, G
Number of items 27 15 37 33 118 205 17
Number of ratings 4
Time period assessed Varies Varies Past 3 mos Past mo 3 weeks Present
Method
Self-report
Mail questionnaire Optional
In-person interview
Structured
Semistructured
Unstructured
Informant
Patient
Significant other Optical
Records
Psychometric Properties
Reliability No Yes No Yes Yest Yes Yes
Validity Yes Yes No No Yest Yes Yes
Sensitivity No Yes No No Yes Yes Yes
Scoring system No Yes Yes Yes Yes Yes Yes
Other
Completion time 1 hr 1 hr 25-45 min.
Forms—precoded (P), uncoded (U) U
Training manual No Yes Yes Yes Yes Yes No
(Continuedon page 360)
expensive or reliable method. Unless records are specifi¬ a few minutes and is comprehensive is unattainable. As
cally set up for research purposes, they tend to be variable Spitzer and Endicott note, a comprehensive evaluation re¬
and incomplete. quires about an hour. A more lengthy one results in inter¬
A combination of information sources is the most ex¬ viewer and subject fatigue and annoyance.
pensive and variable. If uniform sources of information Scoring.—A well-developed, quantitative scoring system
are not available on all patients, then comparisons be¬ and precoded score sheets are important in processing and
tween patients are difficult to make. analyzing data.
Psychometric Properties.—An instrument should possess Training.—Results may differ between research teams
demonstrated reliability, validity, norms, and sensitivity because of divergent interpretation of the rating instru¬
to change. The various kinds of reliability and validity ments. A developed training program and instructional
have been well described.18 Spitzer and Endicott14 have material are highly desirable.
made an excellent point in discussing validity. As they
SCALES
note, the investigator should have evidence for concurrent
validity of the instrument as a measure of the dimension There are innumerable scales that include assessments
in which he is interested. of social functioning. Many of them are limited in scope,
Other Factors Contributing to a Scale's Value undeveloped, or developed for one particular study. These
have not been included.
Time Period Assessed.—The time period under assess¬ Of the scales reviewed, 15 sufficiently met the criteria to
ment should be explicitly stated. This insures preciseness be potentially useful. Among these are several of the
and enables the investigator to differentiate long-stand¬ earliest scales developed during the 1950s. These have
ing patterns of adjustment from short-term effects that been included for their historical interest, since many of
may be treatment-related. It reduces confusion for the in¬ the later scales were derived from them. Each scale will be
formant and helps to focus the questions. described briefly, according to the criteria previously set
Length of Time to Administer.—An assessment that takes forth. Table 1 describes the 15 scales by these criteria.

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 Table 1.—Detailed Characteristics of 15 Scales Assessing Social Adjustment (Continued)
instruments
Social Current & Structured &
Community Social Dysfunction Psychiatric Psychiatric Past Psycho- Scaled Inter- Social
Adaptation Disability Rating Status Evaluation pathology view to Assess Adjustment
Schedule Scale Scale Schedule Form Scales Maladjustment Scale
Content
Occupational
Community
Marital
Parental
Extended family
Economic
Instrumental (I), af¬
fective (A) I, A I, A I, A Not differentiated I, A I, A
Items—defined (D),
global (G)
Ratings—D, G Usually D
Number of items 217 49 21 321 27 171 60 48
Number of ratings Varies 11
Time period assessed Present Present Today or Past week Past week Past mo; age Past mo Past 2
past week &mo &mo 12yron mo
Method
Self-report
Mail questionnaire
In-person interview Optional Optional
Structured
Semistructured
Unstructured
Informant
Patient
Significant other
Records
Psychometric Properties
Reliability Yes Yes Yes Yes Yes Yes Yes Yes
Validity Yes Yes Yes Yes Yes Yes Yes Yes
Sensitivity Yes Yes Yes Yes Yes Yes Yes Yes
Scoring system Yes Yes Yes Yes Yes Yes Yes Yes
Other
Completion time 30-60 min 45-90 min 30-45 min 30-50 min 30-50 min 1-2 hr 1 hr 45-60 min
Forms—precoded (P),
uncoded (U)
Training manual Yes Yes Yes Yes Yes Yes Yes Yes
* Informant includes patient and two observers.
t Available on earlier version only.

Early Scales unstructured, in-person interviews, one with the patient

1. Normative Social Adjustment Scale.202-—This scale
sesses employment, economics, family life (marital, paren¬
tal, and extended), and community. Twenty-seven items
are rated on a 5-point scale with defined response points.
Information is collected by an hour-long semistructured
interview with the patient. The time period assessed
varies from four weeks to one year. Reliability, scoring,
sensitivity, and norms are not reported, and validity data
are limited. One of the earliest scales, it has broad cov¬
erage of the major role areas and includes instrumental
and affective role assessments.
2. Social Ineffectiveness Scale.-3 2ß—This scale assesses
the patient's ineffectiveness in important relationships in¬
cluding own and marital family, occupational and social
associations, and with the interviewer. Fifteen defined
categories are rated on a 5-point global scale by a psychia¬
trist and a concealed rater. The psychiatrist conducts two
and one with a relative. A total of four ratings are ob¬
as¬ tained from the two interviews and a final rating com¬
bines the judgment of all four ratings. The time period is
unspecified. Interrater reliability is acceptable and valid¬
ity, as sensitivity to change under different treatments, is
presented. There is a scoring system and instructional ma¬
terial is available. This scale is important because it laid
the groundwork for the development of later scales. The
authors do not recommend its use currently because of the
cumbersome interview method and the reliance on clinical
impressions for ratings (B. Lieberman, PhD, and M. Par-
loff, PhD, written communication, 1972).
3. Mandel Social Adjustment Rating Scale.27 :,°—This scale
assesses the extent to which a person adapts to societal
norms in the areas of occupation (as a worker, student,
and retired person); family life (including marital, paren¬
tal, and extended); economic situations; and health, re¬
ligious, residence, and community adjustment. Thirty-

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seven operationally defined items are rated on a 5-point
scale with discretely defined response points. Information
is collected from the subject in an unstructured interview.
The time period assessed is unspecified on most items and
varies from weekly to monthly on others. Data on reliabil¬
ity, validity, norms, and sensitivity to treatment are not
published. There is a scoring system and manual.
This scale has excellent coverage of the major roles and
includes a section for retired persons, so that it is useful
for the elderly. It is comprehensive, covers both instru¬
mental and affective performance, and has well-defined
response points. The unstructured interview method and
variable time periods assessed may present problems in
interrater reliability.
The Significant Other as Informant
The significant other as informant has been comprehen¬
sively reviewed in reports by Fiske and Hogarty, from a
monograph prepared by Waskow and Parloff.12 The mate¬
rial on Katz has been derived from that report.
4. Social Adjustment Inventory Method.3135—The pa¬
tient's adaptation in social and family relations, work,
self-care practices, and antisocial behavior is assessed. A
mail questionnaire, 33 global items are rated on a 6-point
defined scale by a significant other. A home visit is made
to nonresponders. There are separate forms for women
and men. The method was developed for measuring the
impact of a veteran's hospital treatment program on the
adaptation of patients returned to the community and has
been used primarily with this population. Instrumental
performance in community and work roles is assessed. In¬
formation is obtained on the patient's prehospital adjust¬
ment during the past two years, which serves as a base
line, and on posthospital adjustment in the past three
months. Data are available on reliability, but not on valid¬
ity. The method for collecting available information was
tested by examining the enrollment of patients, recruit¬
ment of informants, and transmission of information, and
was considered efficient by these criteria. There is a scor¬
ing system but the form is not precoded. Considerable in¬
formation is available on the recruitment of informants,
timing of assessments, and patterns of informant cooper¬
ation.
5. Personal Adjustment and Role Skills (PARS III).36 39-
Symptoms and adjustment in household management,
parenthood, employment, social participation, and use of
alcohol and drugs are assessed. This is the third revision of
a scale designed to measure community behavior and ad¬
justment of former adult psychiatric patients. All three
versions were developed on veteran's hospital psychiatric
patients. The PARS III consists of a 120-item form for
men and a 115-item form for women. A self-report inven¬
tory, it is completed by the patient's relative and has been
designed for use as a mail questionnaire. Ratings are
made on a 5-point global scale. The time period assessed is
"the last month." Reliability and validity has been estab¬
lished on an earlier version of the scale, which was shorter
and was not administered as a mail questionnaire.
A scoring system, results of factor analysis, and an in¬
strumental manual are available. The form is precoded.
Norms are being prepared for state hospital patients,
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using the earlier scale. This earlier version has been used
to evaluate the effectiveness of a veteran's hospital psy¬
chiatric program and the PARS III has been used with
outpatients attending a community mental health center
and receiving counseling.
The precoded mail questionnaire form is economical.
The earlier versions have undergone more development
than this later version. Coverage of role performance is
limited to instrumental performance and management
skills. Community and occupational adjustment are well-
assessed and a substantial portion of the scale deals with
symptoms. The authors note some problem with missing
data and response rate with the mail questionnaire.
6. The Katz Adjustment Scale-Relative's Form (KASR).4045
—Symptomatic behavior and life-situation adjustment of
patients in the community are assessed. A self-report in¬
ventory, 205 items are rated on a 4-point global scale by a
close family member who has recently interacted with the
patient. Items are clearly stated and require only a sixth
grade reading level. Twenty-five to 45 minutes are re¬
quired for completion. A three-week time period is as¬
sessed.
The scale contains the following five sections: a 127-item
rating of symptoms and social behavior; a 16-item rating
of performance at socially expected tasks; a 16-item rat¬
ing of the relative's expectation for the performance of
these tasks; a 23-item rating of free time activities; and a
23-item rating of the relative's satisfaction with perform¬
ance of free time activities. This scale has been widely
used over the past decade in a variety of settings, and
with heterogeneous diagnostic and nonpatient popula¬
tions. There are considerable data available on reliability,
validity, sensitivity, and norms, as well as instructional
material and a color movie film for training purposes.
This scale is excellent as an assessment of the patient's
instrumental performance in the family and recreational
participation. Marital, parental, and extended family rela¬
tions have less coverage and may require supplementa¬
tion. Relative cooperation is reported to be good. The ex¬
tensive development and use of this scale makes it an
attractive relative informant inventory.
The Patient as Informant
7. Personality and Social Network Adjustment Scale.46-48—
Broad areas of the patient's adjustment in society, work,
associational and family groups, and within himself are
assessed. A self-report inventory, 17 globally defined
items are rated on a 5-point global scale by the patient.
The form has been used as a mail questionnaire. Earlier
work using a mail questionnaire with a relative informant
proved unfeasible due to insufficient relative cooperation.
Moderate repeat reliability data and evidence for validity
are presented. The scale has been used primarily to eval¬
uate the treatment effects of a therapeutic community or
with hospitalized psychiatric patients. The time period as¬
sessed is "at present." The scale is simple and quick to
complete and requires no training. There is a scoring sys¬
tem. The form is not precoded.
This scale is brief and economical. However, the data
obtained may be limited in complexity. Role coverage is
limited and there is no specific assessment of marital or
 Table 2.—Comparison of Three Adjustment Scales*
Current & Past
Psychiatric Status Psychiatric Evaluation Psychopathology
Schedule (PSS) Form (PEF) Scales (CAPPS)
Coverage Symptoms & impairment in daily Same as PSS plus characteristics Similar to PEF plus history relevant
routine, leisure time, alcohol & of present illness & major reason to severity, prognosis, & diag¬
drug use & role functioning as for admission nosis
wage earner, housekeeper, stu¬
dent, mate, & parent
Items 321 discrete descriptions of be¬ 27 broad dimensions of behavior 171 global items with guiding defi¬
havior rated on dichotomous with guiding definitions on 6- nitions rated on 6-point scale
scale point scale
Time period Past week & past mo for role func¬ Same as PSS Past mo & age 12 yr to past mo
assessed tioning, alcohol, & drug use
Source of informa¬ Patient informant Multiple sources (patient, family, Same as PEF
tion & case records)
Method Structured interview Interview guide optional Same as PEF
Time to complete 30-40 min 30-50 min with interview guide 1-2 hr with interview guide
Instrument 21-page step-down booklet & score 9-page step-down booklet & score 13-page protocol with 26-page in¬
sheets sheets terview schedule
Administration Training guides available; requires Training guides available; requires Training guides available; same as
less clinical experience for ad¬ more clinical experience for ad¬ PEF
ministration ministration
Data processing Computer programs available for Same as PSS Same as PSS
scoring_
* R. L. Spitzer and J. Endicott, unpublished data, 1972.

parental role. Individual assessments and response points
are global. It is currently being used as an outcome assess¬
ment in psychotherapy.
8. Community Adaptation Schedule (CAS).4"-52—This scale
assesses behavior, affect, and cognition in work, family
(marital and parental), and social: larger commercial and
professional communities. It is a 217-item self-report in¬
ventory, completed by the patient and rated on a 6-point
scale, which includes measures of intensity, attitude, and
frequency. The time period assessed is "at the present
time." Data on reliability, validity, internal consistency,
and instructional material are available. The scale takes
30 to 60 minutes to complete and requires sixth grade level
reading ability. Norms for various patient and nonpatient
groups are published in a manual. A scoring system and
templates are available.
The most definitive application of the scale has been
in multitreatment studies of aftercare, including psy¬
chotherapy. The scale has broad coverage of roles and in¬
cludes both instrumental and affective performance.
Items included present a mixture of lifelong character-
iological behavior and measures of current behavior dur¬
ing the past year, making it potentially less sensitive for
evaluative research.
9. The Social Disability Scale.53-55—This scale assesses
the patient's physical and behavioral impairments, social
modifiers, qualifications and performances demanded
from others, and the tolerance limits of the social system.
Forty-nine areas are assessed, including 37 areas of physi¬
cal and seven areas of behavioral impairments, and five
areas of social modification. The number of response
points vary and are well-defined. Information is collected
by semistructured interview with the patient, lasting 45
to 90 minutes, and conducted by a trained professional or
paraprofessional. Data on reliability, validity, sensitivity
to change, a scoring system, and instructional material for
training are available. The time period assessed is "now."
Items are precoded and designed for computer analysis.
This scale is designed for the assessment of social dis¬
ability in chronic patients in order to plan rehabilitation
programs. As such, it includes excellent coverage of physi¬
cal disability, psychopathology, occupational and recrea¬
tional limitations, and environmental modifiers of per¬
formance. Role performance covers a small portion of the
scale. Marital and parental roles are absent, as are affec¬
tive tasks.
It has been used with medical patients, for which it is
well-designed. It is less suitable in psychiatric studies be¬
cause of its emphasis on physical impairments.
10. Social Dysfunction Rating Scale (SDRS).56-eo-Subjéc¬
rive and objective performance in the self, interpersonal,
and performance systems are assessed. Twenty items are
rated on a 6-point ordered-rating scale. A semistructured
interview conducted by a trained professional social
worker with the patient, and taking 30 to 45 minutes, is
used. The rater is required to make judgment of the pa¬
tient's performance in relation to the patient's peer group
and the general population. The time period assessed is
"today" or "the past week." Reliability and validity data,
a scoring system, results of factor analysis, a manual, and
instructional material are available.
The scale is currently being used in studies involving
schizophrenic, alcoholic, and drug-addicted patients, and
has been used with older subjects. It is brief and well-
suited to aged populations for whom major role function¬
ing may be absent. Marital, parental, or extended family
role functioning are not covered individually. Recreational
and occupational roles are covered under the performance
system. The self and interpersonal items include symptom
assessments. Response points are global and the questions
require a skilled interviewer.
11. Psychiatric Status Schedule (PSS):
12. Psychiatric Evaluation Form (PEF):
13. Current and Past Psychopathology Scales (CAPPS).61"70

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—These three scales will be discussed together, since they
were developed by the same research group and overlap in
conceptualization and item content. See Table 2 for a com¬
parison of their content and administration.
The PSS assesses symptoms and impairments in daily
routine, leisure time, alcohol and drug use, and role func¬
tioning as wage earner, housekeeper, student, mate, and
parent. Three hundred twenty-one discrete descriptions of
behavior are rated on a dichotomous scale. Information is
collected from the patient during a structured interview
administered by a trained research assistant, taking 30 to
50 minutes to complete. The time period assessed is the
last week, except for items dealing with role functioning,
and alcohol and drug use, for which the last month is as¬
sessed. A 21-page booklet includes the interview guide,
and score sheets are used. Computer programs and train¬
ing guides are available. Data on reliability, validity, and
results of factor analysis are available. The instrument is
sensitive to clinical changes and has been widely used in a
variety of settings and diagnostic groups.
The PEF includes assessments of the same symptoms,
impairments, and role functioning as the PSS. However,
the areas are assessed as broad dimensions of behavior
rather than as individually defined components. Defini¬
tions of the dimensions are included to assist the rater.
Twenty-seven items are rated on a 6-point global scale,
ranging from "none" to "extreme." The time period as¬
sessed is the same as the PSS. Information is usually lim¬
ited to that obtained during a structured interview with
the patient, although other sources, such as informants or
case records, can be used. An optional interview guide is
provided; however, the interview can be altered. The in¬
terview takes 30 to 50 minutes. The flexible source of
information and optional interview methods require a
skilled rater with a range of clinical experience, as com¬
pared with the PSS. A nine-page step-down booklet and
precoded score sheet, training guide, and computer pro¬
gram are available. As with the PSS, extensive reliability
and validity data are available. Factor scores have been
calculated and the form currently is being widely used.
Both the PSS and the PEF take the occupational, mate,
and parent role scales and derive a summary index of role
functioning that has been found reliable and useful. This
index permits a comparison of individuals who perform
different roles.
The CAPPS is similar to the PEF in item content and
coverage and includes additional historical items relèvent
to severity, prognosis, and diagnosis. It was developed as
a basis for a computerized diagnosis, including dimensions
of disturbance. One hundred seventy-one broadly defined
items with guiding definitions are rated on a 6-point glo¬
bal scale. The time period assessed is the past month for
the current scales, and age 12 years to the last month for
the past scales. As in the PEF, the information is usually
limited to that obtained during a structured interview of
the patient, but other sources may be used. Similar to the
PEF, there is an optional interview guide. The interview
takes one to two hours if the guide is used. A clinically ex¬
perienced rater, as with the PEF, is required. A 13-page
protocol with a 26-page interview schedule, precoded score
sheets, computer program, a training manual, and data on
Downloaded from www.archgenpsychiatry.com at Columbia University, on May 24, 2010
reliability and validity are available.
.As a social adjustment assessment, per se, the scales
have minor limitations. The role areas comprise only a
portion of the scale. The PSS does assess discrete aspects
of role performance and includes both instrumental and
affective functioning within roles. However, the PEF and
CAPPS do not differentiate instrumental and affective
performance.
These three scales commendable. The work is de¬
are
tailed, highly developed, and widely used. Each scale com¬
bines in one instrument measures of psychopathology and
social adjustment. The choice of one over the other de¬
pends on the time available and amount of precision re¬
quired. The PSS is more precise, structured, and reliable.
The PEF generally takes less time to administer, but is
suitable for experienced clinicians. It might be used in
situations in which the information is already available
because the rater knows the patient or has extensive
records. The CAPPS has the unique feature of providing
historical information.
14. Structured and Scaled Interview to Assess Malad¬
justment (SSIAM).71-74—This scale assesses subjective dis¬
tress, deviant behavior, and friction with others in five
roles: work (worker, housewife, or student), social, family,
marital, and sex. Objective behavior in a given social con¬
text and subjective reactions in that context are included.
Raters' global assessments and a general prognostic mea¬
surement are made. Sixty items are rated on an 11-point
scale with anchoring definitions for five of the 11 points.
Information is collected during a structured interview
with the patient, conducted by a trained professional with
clinical experience, taking about 30 minutes to administer.
Specific instructions for the structuring of the interview
are printed on the interview schedule. The time period as¬
sessed varies, but "the past month" is the most usual. Reli¬
ability, validity, scoring, results of factor analysis, and in¬
structional material are available. The current form is not
precoded. The scale has been used in an outpatient psycho¬
therapy study.
This is one of the few structured social adjustment in¬
terviews. The interview structuring, anchoring defini¬
tions, and guiding explanations reduce ambiguity and
provide precision. The items are well thought out, and op-
erationalize aspects of behavior in a detailed fashion. The
coverage is broad and areas are tapped that are partic¬
ularly relevant to outpatient populations. The specificity
of maladjustment into five fields, and further into three
areas, allows examination of different aspects of function¬
ing.
The scale was designed as an outcome measure for psy¬
chotherapy and, as such, the quantitative or instrumental
aspects of behavior have less coverage and may require
supplementation. These limitations are minor and this
scale has much to recommend it.
15. The Social Adjustment Scale (SAS).75-79-Instrumen-
tal and affective performance in work (worker, housewife,
or student), social and leisure activities, relationships with
extended family, marriage (as a parent), economic inde¬
pendence, and rater global evaluations are assessed. Each
role area includes assessments of performance at tasks,
interpersonal relations, friction, and satisfaction in roles.
The scale is modified from the SSIAM previously de¬
scribed. The core of items has been revised and anchor
points for scoring have been changed. However, many of
the items are directly comparable.
Forty-eight operationally defined items are rated on a
5-point scale. Information is obtained through a semi-
structured interview with the patient, taking 45 to 60
minutes and conducted by a trained bachelor's degree-
level rater. Initial questions are specified on the interview
format. A two-month period is assessed. Data on reliabil¬
ity, validity, sensitivity, scoring, results of factor analysis,
instructional material, and a manual are available. The
scoring sheet is precoded.
The scale was designed for a prophylactic trial of anti¬
depressants and psychotherapy in outpatient women. It
has been used with nonpsychiatric populations and suicide
attempters, and is currently being used with methadone-
maintained patients. A self-report version is being tested.
Coverage is broad, both in roles and in instrumental and
affective performance. The scale has not been used with a
variety of psychiatric diagnoses and its use with male pa¬
tients is not available yet, so that its value in a range of
circumstances has not been tested.
COMMENT
Fifteen social adjustment scales, which met certain cri¬
teria, have been described. Others that are quite promis¬
ing are under development. For example, J. R. Witten-
born, PhD, Rutgers University, New Brunswick, NJ, will
soon be reporting results of a new social adjustment scale
he developed and used to investigate the status of de¬
pressed patients after treatment. Cohler et al8" have re¬
cently reported results of role adjustment in mothers hos¬
pitalized for psychiatric illnesses, using a measure of
social relationships, the Social Role Performance Instru¬
ment (SRPI) that was developed by their group. More new
techniques can be expected as interest in this area grows.
Of the 15 scales reported here, three have been presented
for their historical import rather than their current use,
leaving the researcher with 12 scales from which to make
a selection. This selection for a particular study can be
narrowed down further after decisions are made about in¬
formant, source of information, cost, and content. No deci¬
sion will be without compromise. Although there is consid¬
erable room for scale development, and none of the scales
presented will stand as the final instrument, there is also a
strong need for standardization of methods between stud¬
ies. A compromise should be reached between the toler¬
ance of those evaluated, the creative instincts of those
evaluating, and the need for standardization. It might be
best to include intact a standard and widely used scale
and to supplement with innovations. In this way the art of
assessments will not atrophy but information based on
comparative data from a number of studies can accumu¬
late.
This investigation was supported in part by contract FDA 73-9 to the
American College of Neuropsychopharmacology.
J. R. Wittenborn, PhD, was principal investigator and Gerald L. Kler¬
man, MD, was chairman for the committee on the evaluation of anti¬
depressants. Elmer Gardner, MD, and Barrett Scoville, MD, of the FDA
supported this study and allowed the publishing of this report.
Downloaded from www.archgenpsychiatry.com at Columbia University, on May 24, 2010
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