Goal Attainment Scaling GAS As 1st and Most Popular Outcome Measure in Pediatric Therapy
Goal Attainment Scaling (GAS) in Pediatric Therapy
Goal Attainment Scaling GAS in Pediatric Therapy has in recent times become a benchmark technique used in assessing the functional goal attainment of children in pediatric therapy practice. Setting goal between clients and physiotherapists is a fundamental part of rehabilitation. Goal setting is “the formal process whereby a rehabilitation professional or a multidisciplinary team, together with the patient and/or their family, negotiate attainment goals in the management of the patient.” Goal setting is used in directing the rehabilitation intervention to a focused outcome.
Goal setting can also be shared in order to co-ordinate members of the multidisciplinary team and ensure they are working together towards a common set goal and that nothing important is left out in the service delivery. Goal setting is also used to ascertain the success of rehabilitation interventions. There is no consensus on a gold standard for a method of goal setting, but it is widely held that it is a priority for guiding rehabilitation interventions toward achievable and meaningful outcomes.
This work is aimed at assisting potential pediatric therapists to decide whether or not to use GAS and also to provide information about how to implement GAS with a minimum of bias.
Brief History of Goal Attainment Scaling GAS in Pediatric Therapy
GAS was first developed by Kiresuk & Sherman (1968) and used to evaluate mental health programs.
In 1979, GAS was considered the most popular outcome evaluation technique in the human sciences. GAS was initially used to measure the impact of intervention in the mental health field, with recent development and its efficiency, it has been adopted for use in other healthcare discipline. Currently GAS is widely used to evaluate health services, educational programs, and social services in many fields; rehabilitation, education, medicine, nursing, and social work.
There are two main reasons for measuring outcomes in the field of pediatric therapy:
- To evaluate outcomes for a specific child (to improve services to that child), and
- To determine the effectiveness of a service or program as a whole.
GAS can be used for both purposes–to document therapeutic change in individual children or to examine change in groups of children.
Many questions need to be considered when designing outcome evaluation studies for children receiving occupational, physical, or speech-language therapy, either in the community or in a health care centre. One of the fundamental questions is whether to use a standardized or individualized measurement approach–or both.
Individualized methods indicate whether single individuals have achieved the goals of intervention. These methods also provide clear goals and priorities for intervention, ensure the ongoing relevance of the child’s goals, and reflect a client-centered perspective to service delivery.
One of the most widely-used individualized approaches is goal attainment scaling GAS, which provides an individualized, criterion referenced measure of change.
Use of Goal Attainment Scaling GAS in Pediatric Therapy Services
GAS has been used in several studies of the effects of pediatric therapy services for children with developmental, physical, and communication needs (e.g., Brown, Effgen, & Palisano, 1998; Ekström, Johansson, Granat, & Carlberg, 2005; King et al., 1998; King, McDougall, Tucker et al., 1999; Palisano, Haley, & Brown, 1992; Palisano, 1993; Steenbeek, Meester-Delver, Becher, & Lankhorst, 2005; Stephens & Haley, 1991)
Brown et al. (1998)
- Examined the effects of physical therapy intervention on attaining gross motor goals in 24 individuals aged 3 to 30 years with severely limited physical and cognitive abilities.
- GAS was used to measure change in gross motor ability after 18 weeks of twice-weekly therapy intervention.
- 3 goals were set for each participant, with one goal randomly selected as a control goal.
- Participants’ improvement on goals was assessed during therapy, recess and at home.
- GAS indicated that participants demonstrated improvement during therapy, which did not consistently transfer to the recess and home settings.
- Participants showed greater improvement on treatment goals than on control goals during therapy, but there were no differences between treatment and control goals during recess and at home.
Ekström et al. (2005)
- Evaluated functional training for children with cerebral palsy using GAS.
- The intervention was carried out in the context of natural settings.
- 14 children aged 6 months to 6 years participated in the 5-month intervention.
- 77% of goals were attained King et al. (1998).
- One objective of this feasibility study was to examine the utility of GAS for evaluating therapy services provided to children with special needs in the regular school setting.
- 16 children receiving an average of 13 therapy sessions over 4 to 5 months had 1 to 3 functional goals set in one of 3 target areas: communication, productivity, or mobility.
- Findings showed that all children made improvements on their goals.
- Study concluded GAS was a responsive measure of children’s functional change in the 3 target areas and was appropriate for evaluating therapy outcomes in the school setting.
King, McDougall, Tucker et al. (1999)
- One objective of this program evaluation study was to use Goal Attainment Scaling GAS to measure the extent to which children with special needs achieved their individual, functional goals in the school setting.
- 50 children received an average of 17 therapy sessions throughout the school year.
- Each child worked toward 1 to 2 goals set in one of the following target areas: communication, productivity, or mobility.
- Findings showed that 98% of the children made improvement on their functional goals after receiving intervention, and maintained that improvement 5 to 6 months later.
Palisano et al. (1992)
- Tested sensitivity of GAS to measure change and involved 65 infants 3 to 30 months old with motor delays as measured by the Peabody Developmental Motor Scale (PDMS).
- Therapists set 2 motor goals per infant prior to a 6 month intervention period.
- Findings showed that the infants scored higher than expected at the end of intervention.
- Study results support the validity of GAS as a responsive measure of motor change in infants with motor delays.
- Study examined the validity and responsiveness of GAS; GAS was compared to the PDMS.
- 2 goals were set for 2 consecutive 3 month periods for 21 infants with motor delay.
- Study results support the content validity and the responsiveness of GAS, and provide evidence that GAS and the PDMS measure different aspects of motor development.
Steenbeek et al. (2005)
- Evaluated the effect of botulinum toxin type A treatment for children with cerebral palsy using Goal Attainment Scaling GAS.
- 11 children participated in the study.
- Goals were recorded weekly for 14 weeks.
- 9 of 11 children showed significant improvement on their goals Stephens & Haley (1991).
- Study investigated the validity and sensitivity to change of the PDMS and GAS.
- 54 children 0 to 3 years old and enrolled in early intervention programs were included.
- 1 to 2 goals were set for each child prior to a 6 month therapy period.
- PDMS and GAS correlations were low (Stevens and Haley suggest that GAS should not be highly correlated with developmental tests that apply the same standard to everyone).
- Study concluded that GAS can be used to complement the results of standardized motor assessment (if using GAS alone, interpret with caution).
Description of Goal Attainment Scaling GAS in Pediatric Therapy
GAS is an individualized, criterion-referenced measure of change. It involves:
- Defining a unique set of goals for each child,
- Specifying a range of possible outcomes for each goal (on a scale recommended to contain five levels, from -2 to +2), and
- Using the scale to evaluate the child’s functional change after a specified intervention period.
Goal Attainment Scaling GAS is a 5-Point Rating Scale.
A score of,
-2 represents the child’s baseline level before intervention, Much less than expected.
-1 represents improvement that is less than the expected level of attainment after intervention.
0 represents the expected level of attainment after intervention.
+1 represent greater than expected outcome and
+2 represent levels of attainment that exceed expectations but represent outcomes that the child is thought to be capable of achieving under favorable conditions.
Merits of Goal Attainment Scaling GAS
- GAS is criterion-referenced, rather than norm-referenced, making it responsive to minimal clinically significant changes.
- Useful for measuring individual goals.
- Useful for evaluating functional goals.
- Goals can be written for all levels of functional difficulty identified by the International Classification of Functioning, Disability, and Health (World Health Organization, 2001) (i.e., impairment, activity limitation, participation restriction).
- Promotes cooperative goal setting.
- Reflects a client-centred perspective to service delivery.
- Yields a numeric score for analysing group performance Potential Benefits.
- Improved conceptualization and delivery of intervention.
- Improved clarity of therapy objectives for therapists and clients.
- Realistic client and therapist expectations of therapy.
- Increased client satisfaction.
- Increased motivation of the client toward improvement, provided by the very existence of the goals.
Potential Limitations of Goal Attainment Scaling GAS
- Reliability ± The reliability of a therapist’s judgment of the impact of intervention.
- Validity ± Whether the GAS procedure is measuring what purports to measure (GAS has been criticized as being a way for therapists to set easy goals that are not clinically relevant)
How to Improve Reliability of Goal Attainment Scaling GAS
- Involve experienced therapists (at least one year of experience in program).
- Provide comprehensive training in GAS to therapists.
- Ensure goals are well-written.
- Use independent raters (i.e., raters who do not have a personal investment in outcome score) and provide training to raters
How to Improve Validity of Goal Attainment Scaling GAS
- Kiresuk et al. (1994) strongly urge that GAS be supplemented with measures that provide more defensible estimates of post-treatment status (i.e., standardized measures) to provide a comprehensive assessment of outcome.
- Employ randomly selected control goals (after Brown et al., 1998).
Guidelines for Using Goal Attainment Scaling GAS
Number of Goals to Set:
- Available resources, including time, will influence the number of goals set for a client within a certain intervention period.
- For psychometric reasons, Kiresuk et al. (1994) recommend setting at least three goals per client.
- For practical reasons, studies have set 1 or 2 goals per client (King et al., 1998; King, McDougall, Tucker et al., 1999; Palisano, Haley, & Brown, 1992; Palisano, 1993; Stephens & Haley, 1991).
Determining Who Sets Goals:
- According to strict research methodology (Cytrynbaum et al., 1979), the therapist who sets the goals should not be the same therapist who provides the treatment, as they have a vested interest in the client achieving the goals.
- In actual clinical practice it is most realistic and cost-effective for the treating therapist to be involved in goal setting (Lewis, Spencer, Haas, & DiVittis, 1987; Kiresuk et al., 1994).
For example, in the King, McDougall, Tucker et al. (1999) study, it did not make sense from a clinical standpoint for one therapist to set the goals in conjunction with the teacher, parent, and child, and then have a different therapist provide treatment who had not established rapport with these individuals (such a procedure would be disruptive to the therapist/client relationship and would not be an accurate representation of the way school-based therapy services are provided).
Minimizing Bias in Goal Setting
- Use collaborative goal setting, involving several individuals; this helps to ensure that the goals are clinically meaningful and relevant and not just easy goals that therapists set on their own and can be sure of attaining (Clark & Caudrey, 1986; Stollee et al., 1999).
As an example, in King, McDougall, Tucker et al. (1999), each child’s treating therapist, parents, teacher, and when appropriate, the child him/herself, determined the child’s baseline assessment level (-2) and the expected level of attainment at the end of intervention (0), then, the treating therapist and a research assistant determined the –1, +1, and +2 levels.
- Involve “GAS” therapists (not involved in treatment) and a research assistant (or a person well-trained in GAS) in goal review.
In King, McDougall, Tucker et al. (1999), the research assistant and the “GAS” therapists of the same discipline as the child’s treating therapist reviewed the GAS scales and made suggestions for improvement.
- Use a standardized procedure with set criteria [see GAS Checklist, APPENDIX B, used by King, McDougall, Tucker et al. (1999)].
Criteria for Writing Goals in Goal Attainment Scaling GAS Format
Six Basic Requirements:
- Time Frame.
As a whole, the scale should meet the following criteria:
- Aim for clinically equal intervals between all scale levels e.g. The jump from +1 to +2 should not require a much larger change in attainment than the jump from -2 to -1.
- Amount of change between levels needs to be clinically relevant.
- Improvement should be measured using only one variable of change (as long as the goal remains meaningful), keeping other variables constant. e.g. -2 The child walks 100m with platform walker in 8 minutes with two hands on walker to assist with steering.
the above goal includes three variables: distance, time, and level of assistance.
Decide on one variable by which to measure change in performance, say time, and hold other variables constant e.g. 0 The child walks 100m with platform walker in 6 minutes with two hands on walker to assist with steering.
- Specify a time period for achievement of a goal. Intervention should take place over a set time period, such as 4 to 5 months or a given number of therapy sessions.
Each level on the scale should meet the following criteria:
- All rating scale levels should be phrased in the present tense e.g. The child can……
- All scale levels should be achievable or realistically possible.
- All scale levels should be written as clearly as possible, in concrete behavioural terms.
- All scale levels should specify an observable behaviour.
Rating Goals After Intervention
- Each person’s performance is observed either naturalistically (in the classroom, hallway, etc.) or on a specific assigned task, depending on the nature of the goal.
- For goals whose attainment cannot be observed under naturally occurring circumstances, the therapist interacts with the client and requests performance of the goal. The therapist orients the child to perform the goal. If prompting is required, the therapist starts with the expected (0)level of the scale and prompts performance up or down, depending on the client’s success.
- The number of trials each client will be given when attempting his/her goal should be established.
- Brown et al. (1998) allowed up to 3 trials per goal (for children with severely limited physical and cognitive abilities).
- Consider the view of the person being rated (i.e., the person may be motivated to perform well for the visiting rater or may act out inappropriately).
- In order to reduce “hype” regarding the rater’s visit, inform the client in advance of the visit and assure the client that regular performance is what is called for.
- The rater should be unobtrusive (maintain a low profile).
Demonstrating the Reliability of the GAS Rating Procedure
It is recommended that GAS scores be examined for inter-rater reliability to establish absence of bias.
Inter-rater reliability is determined by correlating the ratings of the original “ GAS” therapists” with a second “GAS” therapist on random sub-sample of goals [King, McDougall, Tucker et al. (1999) correlated the ratings of 30% of study goals].
The two “GAS” therapists should rate the goals on the same occasion (independently), or one of the raters could observe the therapy session and the other rater observe a video tape of the session.
DECIDING WHETHER OR NOT TO USE GOAL ATTAINMENT SCALING GAS IN PEDIATRIC THERAPY EVALUATION PROGRAMS
Good number of organizational conditions are needed to be in place for the successful implementation of a program evaluation study using GAS.
- A motivated team whose members are committed to the evaluation and who share a common drive toward improvement of therapy services,
- Adequate orientation and training of therapists,
- The availability of people to coach therapists in the proper application of GAS, so that both technical and practical issues are addressed in an integrated fashion, and
- Sufficient resources allocated to do the
A primary strength of GAS is its ability to measure change in performance, whereas most standardized measures are discriminative tools designed to measure post-intervention status (based on norms for children without special needs) and have not been validated as responsive to clinically significant change. Clinical significance refers to the magnitude of an effect in real world terms.
GAS is criterion-referenced, rather than norm-referenced, making it potentially responsive to small changes that are perceived by children, families, and teachers as important for daily function.
GAS may be particularly useful for children with low cognitive functioning, since standardized measures may not be sensitive to the small but meaningful changes targeted for these individuals.
Relatively few standardized measures address functional outcomes that are appropriate for children with special needs within a context such as school (e.g., children’s ability to walk from the bus to the school classroom).
Standardized assessments of function often are designed to measure a broad range of abilities. Some of these areas may not reflect therapy goals and not be relevant to particular children. Pediatric studies provide a fair amount of evidence that GAS and parallel standardized measures provide scores that are only moderately correlated with one another. For formal program evaluation purposes, Goal Attainment Scaling (GAS) and standardized measures use are both recommended.
In addition to the ability to measure change in the performance of individual children, GAS has other advantages: clinical utility, relevance, client involvement, and acceptability. GAS is ideally suited to collaborative goal setting between a therapist, child, parent, and other professionals (such as teachers). Its collaborative use reflects a client- or family-centered approach to service delivery.
Other potential advantages of Goal Attainment Scaling GAS include:
- Improved clarity of therapy objectives for both therapists and clients,
- Improved conceptualization and delivery of the intervention,
- More realistic client and therapist expectations of therapy,
- Increased client satisfaction, and
- Increased motivation of the client toward improvement, provided by the very existence of goals.
PHYSICAL THERAPY IN PEDIATRICS
There are a number of potential limitations in using Goal Attainment Scaling GAS in a program evaluation study:
- Biases in goal scaling and rating can occur,
- Training and standardized implementation procedures are required, which are time-consuming (when therapists are unfamiliar with GAS), and
- GAS can interfere with day-to-day practice because, when conducting a program evaluation, therapists should not modify a goal in the course of the intervention.
There are two reasons for this:
First, the study intervention period may not be sufficiently long for change to be expected on a new or modified goal.
Secondly, therapists may elect to change goals they discover that they cannot meet, which undermines the utility of GAS.
The major drawback to GAS is the possibility of bias in the use of the tool, which can affect its validity. Unintentional bias can occur in goal scaling (so goals are overly easy to attain) or in goal rating (showing children make improvements that are not in fact real).
Reliability and validity can be improved, however, by comprehensive training of raters, adequate definitions of the levels of goal attainment, and the use of multiple raters.
A collaborative goal setting model (a common feature of a multidisciplinary, family-centered approach to service delivery) helps to ensure that goal levels are meaningful and ratings are valid because both are based on a consensus involving several individuals who are knowledgeable about the child and invested in ensuring that
the child makes real gains.
Thus, collaborative goal setting helps to ensure that therapy goals are meaningful to the child and family and not simply easy goals that therapists set on their own and can be sure of attaining, which is a criticism raised by many.
From observations noted in Kings et al., 1999 work in respect to differences between the rehabilitation disciplines with respect to the ease of writing appropriate functional goals.
The GAS scaling format appears easiest to apply for speech therapy goals and harder to apply for physical therapy and occupational therapy goals. As well, in King et al., speech-language pathologists found it easier to set goals that could be integrated into the child’s function in the school setting. Speculations are that the established hierarchy of the development of speech sounds may assist speech-language pathologists in setting goals in the area of articulation.
Physical and occupational therapists needed to give more thought to the process of writing the various goal attainment levels. For instance, physical therapists in the work found it hard to set equal intervals between goal levels for goals targeting unique mobility difficulties and found it hard to establish relevant goal levels for high functioning children.
Appendix A – Common Errors in Writing GAS Scales
|Overly Generalized Goals||If the expected level (i.e., 0 level) of a scale is written in very general terms (e.g., “the client walks a greater distance in a set period with assistance”), it will be difficult or impossible to create the remaining scale points||The expected level of a scale should be written as clearly as possible (e.g., “the client walks with platform walker 100 metres in six minutes with two hands on walker to assist with steering”).|
|Overly Technical Goals||A goal setter may use terms specific to his/her profession in creating a scale that the goal rater is not familiar with.||Write goals in common terms, especially if the rater and goal setter differ in professional backgrounds.|
|Multiple Variables of Change||A scale may include two or more variables of change. This could be problematic if the scale is written so that improvement is expected to occur simultaneously on these variables.||Decide on one variable by which to measure change and hold others constant. If, in doing so, the goal does not remain clinically meaningful, two (or more) variables could change within in a single scale, provided that improvement is not expected to occur simultaneously on these variables.|
|Unequal Scale Intervals||A scale may be created where the amount of clinical change is greater between, say, the +1 and +2 levels than the amount of change between the -2 and -1 levels.||Aim for clinically equal intervals between all levels of the scale.
|Clinically Irrelevant or Unrealistic Scale Levels||A scale may be created where one or more of the levels represents an amount of change that would not be clinically relevant (i.e., amount of change is too small to matter) or amount of change is unrealistic for the client (i.e., amount of change is too great).||The amount of change between all scale levels needs to be clinically relevant and all levels should be achievable for the client.
|Using Different Tenses (i.e., Past, Present, Future) When Writing Scale Levels||A GAS scale may be written with the -2 level written in one tense and all other levels in another tense, which could be confusing and bias the goal rater.||All scale levels should be phrased in the present tense, in order for evaluation to make sense at different time points (i.e., “the client can …”).
|Redundant or Incomplete Scale Levels||A scale may be written where a client could be scored on two levels at the same time (e.g., the +1 level has walking distances specified between “40 and 50 metres” and the +2 level specifies distances between “50 and 60 metres”. If a client walks exactly 50 metres, both the +1 and the +2 level would be correct. On the other hand, a gap could be present in the scale where a client could not be scored on any level (e.g., the +1 specifies walking distances between “40 and 50 metres” and the +2 specifies distance between “60 and 70 metres”; if a client walks 55 metres, neither +1 nor +2 is correct).||Be careful not to create scale levels that are redundant or incomplete. Careful wording (e.g., +1 would be “more than 40 metres and up to 50 metres” and +2 would be “more than 50 metres and up to 60 metres” or specific instructions to the rater (e.g., if a client obtains a midway point between two levels, score the client at the lower level) will be of benefit.
|Baseline Level is Set at Inappropriate Level||A scale may be written with -2 as the baseline when a client has a progressive, chronic condition. This scale would not capture any deterioration in condition.||When no deterioration is expected in client’s performance, -2 can be defensibly used as the client’s baseline. When evaluating the performance of clients with progressive conditions who may deteriorate in function over time, it would make sense to set the baseline at -1, leaving room for deterioration over the intervention period.
|Blank Scale Levels||It may be difficult to write the more extreme levels of a scale, tempting the goal setter to leave these levels blank. If a client happens to achieve an upper or lower extreme, it would be impossible to rate the client’s performance.||Be careful to set goals where it is possible to complete all scale levels.|
Appendix B – Goal Attainment Scaling Checklist
Name of Participant: ……………………………………………………………………………..
- Therapy Goal: Expected Outcome (i.e., a score of 0)
As a whole, the scale must meet the following criteria:
|Criteria||Criterion Met||Criterion Not Met||Comments|
|Amount of change between levels is clinically important|
|There are approximately equal intervals between levels|
|There is a set time period for goal achievement|
|Scale reflects a single variable of change (or, if not feasible, each level reflects a single variable of change)|
Each level on the scale must meet the following criteria:
|Criteria||Criterion Met||Criterion Not Met||Comments|
|Be written in concrete behavioral terms|
|Specify an observable behavior|
|Be written in the present tense|
|Be achievable or realistically possible|
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Appendix C – Examples of Goals Written in GAS Format
Example 1 of GAS Scale for Physical Therapy
Therapy Discipline: Physical
Therapy Target Area: Movement Functions
Sub-category: Control of Voluntary Movement Functions
Functional Level: Impairment
Time Line: 5 months
Goal Attainment Rating Scale:
-2 The client is able to lift his head and right arm when attempting to roll from supine to prone over his left side.
-1 The client is able to roll half way from supine to prone over his left side (and attain left-side lying).
0 The client is able to roll from supine to prone over his left side.
+1 The client is able to roll from supine to prone and half way back to supine over his left side (and attain left-side lying).
+2 The client is able to roll from supine to prone and back to supine over his left side.
Example 2 of GAS Scale for Physical Therapy
Therapy Discipline: Physical Therapy
Target Area: Mobility
Sub-category: Moving Around Using Equipment
Functional Level: Activity Limitation
Time Line: 5 months
Goal Attainment Rating Scale:
-2 The client walks with walker from library to classroom in 6 minutes, with supervision and verbal cueing.
-1 The client walks with walker from library to classroom within 4 to 5 minutes, with supervision and verbal cueing.
0 The client walks with walker from library to classroom in 3 minutes or less, with supervision and verbal cueing.
+1 The client walks with walker from library to classroom in 3 minutes or less, with supervision and no verbal cueing.
+2 The client walks with walker from library to classroom in 3 minutes or less independently (no supervision and no verbal cueing.
Note: if client walks a distance that falls between scale levels (e.g., 5.5 minutes), the client will be rated at the lower scale level.
Inferring from this work therapists should make informed decisions about whether or not to use Goal Attainment Scaling (GAS) in Pediatric Therapy, based on an understanding of the questions they need to ask and the requirements for using GAS appropriately and effectively in pediatric therapy practices.
Goal Attainment Scaling (GAS) has been criticized due to its potential for bias when implemented without thought and care. A more hopeful or let’s say a balanced perspective have been provided in this work. GAS can be implemented appropriately when guidelines and standard procedures are used.
Under these conditions, it is well worth the effort to use GAS to evaluate pediatric therapy practice. Service providers, parents, and children themselves benefit from the knowledge provided by goal attainment scaling, pediatric therapists are therefore encouraged to adopt the use of Goal Attainment Scaling (GAS) in pediatric therapy practice.
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