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.
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:
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.
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)
Ekström et al. (2005)
King, McDougall, Tucker et al. (1999)
Palisano et al. (1992)
Steenbeek et al. (2005)
GAS is an individualized, criterion-referenced measure of change. It involves:
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.
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).
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.
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.
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.
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.
Good number of organizational conditions are needed to be in place for the successful implementation of a program evaluation study using GAS.
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.
There are a number of potential limitations in using Goal Attainment Scaling GAS in a program evaluation study:
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.
|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.|
Name of Participant: ……………………………………………………………………………..
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)|
|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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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.
Brown, D. A., Effgen, S. K., & Palisano, R. J. (1998). Performance following abilityfocused physical therapy intervention in individuals with severely limited physical and cognitive abilities. Physical Therapy, 78, 934-947.
Cardillo, J.E, & Smith A. (1994). Psychometric issues. In T. Kiresuk, A. Smith, & J.
Cardillo (Eds.), Goal attainment scaling: Applications, theory, and measurement (pp. 173-212). Hillsdale, NJ: Lawrence Erlbaum Associates.
Cytrynbaum, S., Ginath, Y., Birdwell, J., & Brandt, L. (1979). Goal attainment scaling: A critical review. Evaluation Quarterly, 3, 5-40.
King, G., Tucker, M., Alambets, P., Gritzan, J., McDougall, J., Ogilvie, A., Husted, K., O’Grady, S., Malloy-Miller, T., & Brine, M. (1998). The evaluation of functional, school-based therapy services for children with special needs: A feasibility study. Physical and Occupational Therapy in Pediatrics, 18, 1-27.
King, G., McDougall, J., Tucker, M., Gritzan, J., Malloy-Miller, T., Alambets, P., Gregory, K., Thomas, K., & Cunning, D. (1999). An evaluation of functional, school-based therapy services for children with special needs. Physical and Occupational Therapy in Pediatrics, 19, 5-29.
King, G., McDougall, J., Palisano, R. J., Gritzan, J., Tucker, M. (1999). Goal attainment scaling: Its use in evaluating pediatric therapy programs. Physical and Occupational Therapy in Pediatrics, 19, 30-52.
Kiresuk, T. J., & Sherman, R. E. (1968). Goal attainment scaling: A general method for evaluating comprehensive community mental health programs. Community Mental Health Journal, 4, 443-453.
Kiresuk, T. J., Smith, A., & Cardillo, J. E. (1994). Goal attainment scaling: Applications, theory, and measurement. Hillsdale, NJ: Lawrence Erlbaum Associates.
Palisano, R. J., Haley, S. M., & Brown, D. A. (1992). Goal attainment scaling as a measure of change in infants with motor delays. Physical Therapy, 72, 432-437.
Palisano, R. J. (1993). Validity of goal attainment scaling with infants with motor delays. Physical Therapy, 73, 651-658.
Steenbeek, D., Meester-Delver, A., Becher, J., & lankhorst, G. (2005). The effect of botulinum toxin type A treatment of the lower extremity on the level of functional abilities in children with cerebral palsy: evaluation with goal attainment scaling. Clinical Rehabilitation, 19, 274-282.
Stephens, T. E., & Haley, S.M. (1991). Comparison of two methods for determining change in motorically handicapped children. Physical and Occupational Therapy in Pediatrics, 11, 1-17.
Stollee, P., Zaza, C., Pedlar, A., & Myers, A. M. (1999) Clinical experience with goal attainment scaling in geriatric care. Journal of Aging and Health, 11, 96-124.
World Health Organization. (2001) ICF. International Classification of Functioning, Disability and Health. Geneva: World Health Organization.
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