Global Assessments of Functioning "GAF" Scores in Social Security Disability Mental Health
I am going to start this discussion in this blog entry by breaking down Social Security Administration Administrative Memorandum AM-13066 REV Effective Date 10/14/2014 that (1) gives a brief explanation of what the GAF is (2) discusses why GAF Scores are problematic in the disability determination process (3) tells Social Security Administrative Law Judges what factors to consider when using and giving any weight to GAF Scores and (4) tells how Administrative Law Judges are NOT to us GAF scores in the disability determination process.
The following is the breakdown or the original AM paraphrased and reorganized for better reading.
About GAF Scores
GAF Scores are scores based on a scale given by individuals working in the mental health field to individuals receiving mental health services. The individual may be a doctor, a physicians assistant, a licensed therapist or other mental health professional. The score is that mental health professionals subjective opinion. It is meant to measure the severity of an individual's symptoms and their level of healthy or normal psychological, social, and occupational functioning. If an individuals score is not the same for their severity and their level of functioning, the final score defaults to the lower of the two.
Every ten years or so the American Psychiatric Association (APA) publishes something called the Diagnostic and Statistical Manual or Mental Disorders or the "DSM" which provides common language and standard criteria for the classification of mental disorders. The DSM-IV included for the first time the GAF scale and scores. The more recent DSM-5 removed the GAF Scale completely and recommends using something called the WHODAS created by the World Health Organization as it being a much more scientifically valid rating instrument. Some of the many reasons for its removal are stated by Social Security.
Little Value of GAF Scores and their Scientific Validity
The main reason Social Security says the GAF scale is "problematic" when using it in disability determinations is the lack of standardization in how rater use the scale and determine the scores.
The Main Reason the GAF is Problematic is that There is No Standardization in How Raters Use the Scale and Determine Scores
(1) Instructions in the DSM IV are Unclear
(2) Scores are Very General
(3) Training and Experience Levels Among Raters Greatly Vary
(4) Raters Rarely Note whether the Score Reflects Function, Symptoms or Both
(5) Raters Rate Patients Against the Distinctive Population They Have Known (not the general population)
(6) Low Consistency Among Raters in How They Use the Scale and Determine Scores at any Point in - Time for Any Given Individual
(7) The More Raters Giving Scores Over Time to an Individual the Less Reliable the Scores
(8) Great Difficulty Exists in Being Able to Validly Compare GAF Ratings Assigned by Different Raters or Even by the Same Rater at Substantially Different Points in Time
(9) There is No Way to Evaluate Whether any Given Rater at any Point in Time has Correctly Used the (10) Scale and Arrived at the Correct Score.
(11) Relevant Supporting Details for the Score by the Rater is Often Lacking
(12) Individual Scores of Individuals Cannot be Compared in Functioning (i.e. a 60 Score Does Not Mean that Someone is Doing 10% Better than Someone with a 50 Score)
(13) These Rating Problems Alone or in Combination Can Lead to Improper Assessment of Impairment Severity
(14) Judges Cannot Draw Reliable Inferences from Differences in GAF Ratings Assigned by Different Raters or from a Single GAF Rating
(15) GAF Ratings are not Designed to Predict Outcome
(16) GAF Ratings are of Limited Value for Assessing Prognosis or Treatment Outcome
Factors Judges Must Consider in Determining How Much Weight to Give GAF Scores
Judges must consider the following main factors and sub factors when deciding how much weight, if any, to give GAF scores.
1. The Rater
Are They an "Acceptable Medical Source" or Are They "Not an Acceptable Medical Source?"
Are They a Specialist? If so, What Is Their Expertise?
How Many Times Had They Seen the Claimant Face to Face?
Over How Long a Period of Time Had They Been Seeing the Claimant?
How Many Raters Have There Been Over Time?
2. The Ratings
How Many Ratings Are There?
Are the Ratings Generally Consistent Over Time?
Does the Rater Clearly Explain the Reason(s) Behind the Ratings?
Does the Rater Clearly Explain the Time Period to Which the Ratings Apply?
Was the Rating Given Using a GAF Rating Instrument such as the Daily Living Activities Functional Assessment (DLA-20)?
3. Other Evidence
How Consistent Is/Are the Score(s) with other Evidence?
Is the GAF Well Supported by Other Evidence in the File?
Is There Any Contradicting Evidence?
Basic Framework Rules for the Judges
If GAF Scores are to be used in any findings of Impairment Severity or Mental Limitations including any Disability Determination or Decision, THERE MUST BE Other Evidence that Supports the Scores.
GAF Scores may NOT be used in support of meeting some or all of any Listing, including the Intellectual Functioning IQ requirements and the B Criteria of the Mental Disorders Listing.
GAF Scores may NOT be used in the conducting a Mental Residual Functional Capacity Assessment.
After reading and rereading what is only a four page memorandum I have more questions than conclusions. I'll continue this in my next entry.