The Assessment of Social
An Update
Myrna M. Weissman, PhD; Diane Sholomskas, MA; Karen John
\s=b\ Since a review of 15 social adjustment scales appeared six
years ago in the Archives, a number of new scales have been
developed and tested. Twelve new scales, three written self-
administered and nine interviewer-administered scales, are con-
sidered to be useful in clinical and epidemiologic research in
psychiatry. Future research in this area should include develop-
ment of scales for use with children, adolescents, and the
elderly; revision of scales to reflect changes in traditional roles,
especially among women; clarification of the concepts underly-
ing social functioning; and systematic explication and measure-
ment of these concepts.
(Arch Gen Psychiatry 1981;38:1250-1258)
Over thepast three decades there has been an unprece¬
dented interest in the community adjustment of
psychiatric patients that recently has expanded to include
medically ill patients. In psychiatry, interest in patients'
community adjustment has been a natural outgrowth of
the treatment trend from custodial to outpatient care. This
trend gained momentum in the United States with the
opening of community mental health centers in the 1960s
and further accelerated in the 1970s when it became
apparent that deinstitutionalized patients with chronic
disorders were having problems in the community.
The expansion of interest into the social world of the
patient required the addition of new measures of distur¬
bances, ones that were distinct from those that assess
abnormalities of thought or symptoms. Several scales were
developed for the assessment of social adjustment. The
first scales in psychiatry, which appeared in the 1950s and
1960s, were used to evaluate the posthospital adjustment of
schizophrenic patients discharged on regimens of the new
major tranquilizers or to assess psychotherapy outcome in
selected outpatient populations. In the 1970s, systematic
assessment of patients' social functioning became a part of
the evaluation of their initial state as well as of their
treatment outcome.
The first review of available social adjustment scales
appeared in 19751; it described 15 scales that met criteria of
reliability, validity, and utility. Social adjustment was
Accepted for publication July 7, 1981.
From the Departments of Psychiatry (Dr Weissman, Ms Sholomskas, and
Ms John) and Epidemiology (Dr Weissman), Yale University School of
Medicine, and the Depression Research Unit, Connecticut Mental Health
Center (Dr Weissman), New Haven, Conn.
Reprint requests to Yale University Depression Research Unit, Connect-
icut Mental Health Center, 904 Howard Ave, Suite 2A, New Haven, CT
06519 (Dr Weissman).
Downloaded from www.archgenpsychiatry.com at Columbia University, on April 14, 2010
Adjustment
defined and its components were outlined. Criteria for
evaluating scales with regard to content, methods for
obtaining information, sources of information, and psy¬
chometric properties were established. Other factors
involved in scale selection were described, such as time
period assessed, length of time to administer, scoring, and
training. Scales that were limited in scope, underdevel¬
oped, or developed for one particular study were not
included. The 15 scales in that review sufficiently met
selection criteria and included three early scales because of
their historical interest and because later scales were
derived from them.
Since 1975, a number of new social adjustment scales
have emerged. Some of these scales are adaptations of
preexisting scales for use with new patient populations,
some have been designed with medically ill patients in
mind, while others offer new approaches to the problem of
how "best" to assess social adjustment.
This review is intended to update the 1975 review of
social adjustment scales.1 Twelve scales that meet the
selection criteria outlined in the 1975 review are described
in detail, and a Table summarizing the characteristics of
the 12 new scales is presented. For the purposes of scale
selection, we suggest using the updated review in conjunc¬
tion with the 1975 review, since both include valuable
instruments and there is no repetition of scales.
In this review, the 12 scales are presented by method of
administration. The first three scales are written self-
administered reports, and the nine remaining scales
require in-person interviews either with the subject about
himself or with an informant.
WRITTEN SELF-ADMINISTERED REPORTS
KDS-15 Marital Questionnaire
The KDS-152*6 is an 80-item self-administered question¬
naire designed by Frank and Kupfer to assess marital
relationships. Each marital partner is asked to privately
complete the scale, which elicits both fixed-choice and
essay-type responses. Completion time is unspecified; how¬
ever, we estimate 30 to 60 minutes. Forms are to be
returned to the researcher-clinician without partners dis¬
cussing their responses.
The informant is asked to provide sociodemographic
information about himself or herself and each of his or her
parents and a developmental and psychosocial history that
focuses on the marital relationship of his or her parents.
The informant's current marital relationship is assessed
through questions about courtship patterns, attitudes of
extended family toward marriage, current living situation,
makeup of household (including children), expression of
affection, expression of disagreements between the couple,
as well satisfaction and dissatisfaction in these areas.
as
about the informant's specific sexual dysfunc¬
Questions
tions and those of his or her spouse are assessed for the
following two time spans: "most of marriage" and "only
recently." Items on parenting inquire about attitudes
toward children; factors contributing to the decision to
have children; attitudes toward child rearing, and effects
of children on the couple's relationship. Finally, work,
social activities, medical and psychiatric history, and opin¬
ions about sex-role division of responsibility in the house¬
hold are assessed. Attitudes toward divorce, changing
women's role, open marriages, etc, are elicited in essay
form, and the informant is asked to offer any additional
information that may provide insight into the marriage.
Individual items are scored. Reliability was tested using a
nonpatient population and was found to be good. The scale
discriminated between couples who were entering sexual therapy
and those who were not and between nonpatient and patient
groups on items dealing with satisfaction in a sexual relationship.
A study using the KDS-15 with 100 self-selected, nonpatient,
white, middle-class, educated married couples has been completed,
but concurrent validity has not been demonstrated. However,
clinicians find that when the KDS-15 is used for gathering
pretreatment information, it corresponds highly with information
gathered through an interview with the couple.
The KDS-15 appears to be quite suitable for use with both
patient and nonpatient populations. Whether it is applicable for
use with the less educated, who may have difficulty with the
essay-type questions, requires further testing.
The Social Adjustment Scale-Self-report (SAS-SR)
A written self-administered version of the Social Adjust¬
ment Scale (SAS), the SAS-SR713 by Weissman is compar¬
able with the SAS in that it contains 42 questions that
measure affective and instrumental performance in occu¬
pational role, social and leisure activities, relationship with
extended family, marital role, parental role, family unit,
and economic independence. The SAS-SR is completed in
15 to 20 minutes, ideally in the presence of a research
assistant who instructs about format, answers questions,
and checks for completeness of responses. The period
assessed is two weeks to facilitate recall and accurate
reporting of behavior. The form is precoded and is scored
on a five-point scale, from which role-area means and an
overall score and/or factorially derived dimensions can be
obtained. Higher scores indicate greater impairment.
Agreement between results from the SAS-SR and the SAS
interview was examined in 76 depressed outpatients receiving
pharmacological treatment and was found to be excellent. Agree¬
ment among the patient's self-report, the significant other's
self-report rating of the patient, and the interviewer's assessment
of the patient's condition was good.T When patients given the
diagnoses of primary affective disorders and their spouses were
asked to rate marital adjustment by means of the SAS-SR,
agreement between patients' ratings and spouses' ratings was
high."
The SAS-SR is sensitive to change in depressed patients; this
was demonstrated by comparing self-reported adjustment scores
before treatment, at the height of the illness, and after four weeks
of treatment. Improvement in the patient's social adjustment was
concomitant with clinical recovery." "
Edwards et al10 demonstrated high internal consistency (mean a
coefficient, r - .74) and test-retest stability across two time
periods (mean coefficient, r .80). The SAS-SR discriminates
=
between patient and nonpatient populations, with patient groups
yielding poorer adjustment scores.
Differences in marital adjustment as rated on the SAS-SR
appear to differentiate among diagnostic groups. Ruestow et al8
found that patients whose conditions were diagnosed as bipolar
Downloaded from www.archgenpsychiatry.com at Columbia University, on April 14, 2010
show better marital adjustment than patients whose conditions
were diagnosed as unipolar. Concurrent validity of the SAS-SR
has been demonstrated partially through discrimination of SAS-
SR scores between psychiatric populations and normal persons in
the community.
Norms are available for nonpatient community sample popula¬
tions, acutely ill and recovered depressed outpatients, schizophren¬
ics, alcoholics, and methadone-maintained opiate addicts.1113 It has
been suggested that the community norms be used as stable
criteria against which psychiatric populations may be compared.1"
The SAS-SR has been found useful in community health surveys of
the general population; in the evaluation of psychiatric outpatient
groups receiving psychotherapy and/or psychopharmacological
treatment; bipolar 1, ambulatory addicted, alcoholic, and schiz¬
ophrenic patients; heterogeneous samples of hospitalized psychiat¬
ric patients; and a college population. It currently is being used to
assess a wide range of nonpsychiatric patient and nonpatient
populations.
The scale has limitations for use with chronically ill
patients such as schizophrenics, with the elderly, and with
the young, since these patients may not be functioning in
many of the roles that are assessed (eg, current work,
marital, and parental roles).
The Self-assessment Guide
The Self-assessment Guide14'20 is a written, self-adminis¬
tered scale that was developed by Wilier and Biggin using
factors identified by long-term follow-up studies as asso¬
ciated with discharged patients' successful community
adjustment. Most of the items are based on factor-analytic
findings that differentiated patient and nonpatient social
functioning. Other items are based on the consensus of a
number of professionals in the mental health care field, or
relatives of patients, regarding what constitutes commun¬
ity adjustment.
The complete questionnaire contains 55 items that cover
the following seven areas: physical health, general affect,
interpersonal skills, personal relations, use of leisure time,
control of aggression, and support (employment). The
Self-assessment Guide is to be completed at admission and
at some specified time following discharge. It is designed
for evaluation of treatment outcome (and thus to be
responsive to changes in patients' behavior) and to predict
community tenure.
Studies of test-retest reliability and split-half comparison dem¬
onstrated that the Self-assessment Guide is a reliable measure¬
ment instrument. A comparison of patients and nonpatients
indicated that the scale differentiates between these two groups.
Although this comparison study was conducted on an earlier
version of the guide, the questions included in the final version do
not differ substantially from those in the earlier version.
As a measure of criterion-related validity, 25 patients completed
both the Self-assessment Guide and the Community Adjustment
Profile System Questionnaire. Both scales were intended to mea¬
sure similar factors of patients' levels of adjustment and were
highly correlated. Nonsignificant relationships between subscales
indicated the differences in emphasis placed on behavior or
adjustment categories by the two scales. Other tests of criterion-
related validity indicated that the guide very likely was measuring
what it was supposed to measure.
The Self-assessment Guide was designed to interface
with a goal-directed approach to treatment and the com¬
puter-assisted Goal Oriented Record. The purpose of the
guide at intake was to aid the treatment staff in determin¬
ing what problems the patient had prior to hospitalization
to establish treatment goals relevant to his community
adjustment. There is a computerized scoring system that
prints out a list of problems.
A brief, 13-item form of the Self-assessment Guide2" has
been developed for use in the follow-up of patients in
aftercare. Administration of the guide requires no special
 Social Adjustment Scales

Psychological
KDS-15: A Marital Social Adjustment Scale- Self-assessment Adjustment
Questionnaire," Self-report,7" Guide,"-» Wilier to Illness Scale,2' "
Frank and Kupfer Weissman and Biggin Derogatis
Informant
Patient-subject X
Significant other
Method
Written, self-administered
Interview
Content
Occupational
Community-social
Marital
Parental
Extended family History
Economic
Physical environment
Physical health-illness
Legal matters
Utilization of health
facilities
Assessment of psy¬
chiatric symptoms Sexual dysfunction
Original use and pop¬
ulation studied
Original use Assess pretreat¬ Assess treatment outcome Assess treatment out¬ Assess adjustment to
ment marital ad¬ among depressed out¬ come mental illness
justment patients
Target population Couples entering Psychiatric outpatients, Discharged psychiatric Medically ill
therapy community residents patients, community
residents
Populations studied Patient and nonpa¬ Psychiatric outpatients, Discharged psychiatric Patients with Hodg-
tient couples community residents patients, community kin's disease and
residents lung cancer

Psychometric properties
Reliability Yes Yes Yes Yes
Validity Yes Yes Yes Partial
Sensitivity Yes Yes Yes No
Scoring system Yes Yes Yes Yes
Other characteristics
No. of items Approximately 80 42 55 45
Period assessed Varies Past 2 wk Past 3 mo Present

Completion time 30-60 min 15-20 min 20 min 20-30 min

training, but it is preferable to have someone with the
patient to answer questions asked by the patient and to
ensure completion. At follow-up, better results were
obtained with the supervised questionnaires; however,
adequate results were also obtained by mail, and slightly
less than adequate results were obtained by telephone.
INTERVIEWS
Psychological Adjustment to Illness Scale (PAIS)
The PAIS21-'1 was developed by Derogatis specifically to
measure a person's adjustment to a medical illness. It is a
semistructured interview that is administered to the
patient or significant other by a trained interviewer. The
scale consists of 45 questions that assess performance in
the following seven areas: (1) the patient's adjustment to
the illness, expectations about treatment and the treating
clinicians, and information about his or her medical disor¬
der; (2) the effect the medical illness has had on the
patient's employment; actual time lost; and amount of
change that has resulted from the illness in job perform¬
ance, vocational goals, work expectations, satisfactions,
and interpersonal relationships; (3) the patient's function¬
ing within the "domestic environment," the disruption and
difficulties as a result of the illness, the quality of the
patient's relationship and communication with other
household members, and the family's adaptation to the
patient's illness, are measured; the impact of the illness on
financial resources, increase in dependency, and actual
physical disability all are included in this area; (4) "sexual
behavior and satisfaction"; (5) the impact of the medical
illness on "extended family relationships"; the quality of
relationships, communication, dependency, and interest in
interaction with the extended family are measured; (6) the
impairment or disruption in the patient's "social environ¬
ment"; interest and participation in leisure activities take
into account the degree of physical impairment; and (7) the
impact of the illness on the person's "psychological func¬
tioning"; the presence of anxiety, depression, and negative
body image are used as indexes of the psychological impact
of the illness.
Ratings are made on a four-point scale that is skewed
toward documenting the impairment, with a higher rating
indicating greater impairment. The questions, which take
from 20 to 30 minutes, are operationalized so that persons
from various educational backgrounds can be interviewed
reliably.

Downloaded from www.archgenpsychiatry.com at Columbia University, on April 14, 2010

 different medical illnesses is needed, and Derogatis (writ¬
ten communication, Dec 8, 1980) reports that work in the
latter area, as well as foreign-language translations and a
Denver Community Standardized Interview
Mental Health to Assess Social written self-administered version, currently are under¬
"
Questionnaire,"" Maladjustment,"' way.
Ciarlo and Davis Clare and Cairns
X The Denver Community Mental Health Questionnaire
(DCMHQ)
The DCMHQ-'4-21' is a 79-item, semistructured interview
designed by Ciarlo and Davis for use by trained nonprofes-
sionals to assess the personal and social functioning of
patients in mental health centers from ages 18 through 65
years. It consists of concrete, simple questions and can be
administered without regard to diagnosis or ethnic or
educational background. Psychological distress and satis¬
faction with health care service received, as well as social
behavior, are assessed. The dimensions rated include psy¬
chological distress, interpersonal isolation from family and
friends, home and work productivity, public system de¬
pendency, alcohol and drug abuse and their negative
consequences, client satisfaction with the services, inter¬
personal aggression with friends, legal difficulties, and the
frequency of use of hard and soft drugs.
The scale's internal consistency, ability to detect changes in
patient's before and after treatment, and ability to discriminate
between groups of patients have been demonstrated. Interrater
Pretreatment evaluation Assessment of social reliability was found to be satisfactory.
and treatment out- maladjustment Validity has been demonstrated by the following: empirical
come independence of the subscales, which are supposed to represent
Psychiatric inpatients General medical pa- separate psychological constructs; significant differences between
and outpatients tients, normal com¬ criterion groups (clients vs community samples); relationships
munity residents between the client's self-report and the independent report of a
Normal community resi- General medical pa- significant other; and low but significant positive correlations
dents andpsychiatric tients between clinicians' ratings and DCMHQ scores.21
patients Norms by sex are based on three separate community samples
(N 212) taken over a period of six years (1972 to 1977). Only one
=

Yes Yes scale (work productivity) showed a significant community change

Yes Partial over the period studied.
Yes No
The authors do not recommend using the scale in a
Yes Yes written self-administered form. A mail-out version was
79 41
found to be feasible, but it produced a lower response rate
Last 24 hr to last 30
and a loss of lower socioeconomic cases. A training pro¬
Not specified
days gram for interviewers and a scoring system have been
45 min 1 hr developed. The scale is estimated to take about 45 minutes
to complete. The DCMHQ is being used currently in
centers other than those in Denver, but published results
Interrater reliability was reported on 37 patient interviews are not yet available.
that raters corated (r .83 on total score). The reliability coeffi¬
=

cients ranged from r2 .82 to rs .33 on subtests. The reliability

= =
coefficients for the "extended family relationships" subtest were
not significant, and the author stated that the items in this area
would be defined further to improve reliability. L. Derogatis, PhD
(unpublished manuscript, 1981) recently has completed a factor-
analytic study that has confirmed empirically the dimensional
structure of the PAIS and demonstrated high discriminative
sensitivity for most scales between samples of males screened
positive and negative for lung cancer. The first formal norm,
which was based on 120 patients with lung cancer, also has been
established for the PAIS.
Construct and criterion validity have been partially established
for the PAIS. In another validity study, the subjects were 37
children who carried a diagnosis of Hodgkin's disease for two
years and 38 parents of children with a diagnosis of Hodgkin's
disease, yielding a total sample of 75. The "vocational environ¬
ment" and "extended family relationships" sections were found to
not support construct and criterion validity. The PAIS correlated
well with patient self-assessment scales (eg, Symptom Checklist 90
and Beck Depression Inventory).
The PAIS is a promising scale. It has problems with
reliability and validity in the area of extended family. Data
on the applicability of the PAIS with patients having
Standardized Interview to Assess Social Maladjustment
This scale'"'" wasdeveloped by Clare and Cairns with
the explicit goal of operationalizing and standardizing
criteria against which social maladjustment can be mea¬
sured. The authors' additional goals were that the scale be
easy to administer and score and be generally applicable
for use in medical and community settings.
Social relationships (marital, familial, leisure, and occu¬
pational) and money management are assessed. The
unique aspect of this scale is that three measured general
categories are relevant to and cut across all of the domains.
They are "material conditions," "social management," and
"satisfaction"; independent assessment ratings are deter¬
mined for each of these categories.
In their attempt to establish objective criteria by which
social adjustment and satisfaction could be measured, the
authors standardized ways of measuring material condi¬
tions. The importance of these criteria is that to realistical¬
ly assess a person's social functioning and satisfaction, a
yardstick of basic requirements for living needs to be
established. This approach minimizes the impact of subjec-

Downloaded from www.archgenpsychiatry.com at Columbia University, on April 14, 2010

 Social Adjustments Scales (cont)
Social Behavior
Interview Schedule for Assessment
Personal Resources Social Role Adjustment Social Interaction,"™ Schedule,""
Inventory," Instrument,"" Henderson and Platt, Weyman,
Clayton Cohler et al Duncan-Jones and Hirsch
Informant
Patient-subject X
Significant other
Method
Written, self-administered
Interview
Content
Occupational Homemaker
Community-social Xs
Marital Household
Parental
Extended family
Economic
Physical environment
Physical health-illness
Legal matters
Utilization of health
facilities
Assessment of psy¬
chiatric symptoms
Original use and popula¬
tions studied
Original use Pretreatment as¬ Measure women's ad¬ Longitudinal epidem¬ Measure impact
sessment of so¬ justment to adult iologica! study of illness on
cial support sys¬ roles significant
tem others
Target population Psychiatric inpa- Normal community resi¬ Nonpsychotic neurotic Discharged
tients dents, psychiatrically persons, community psychiatric or
ill mothers residents medical pa¬
tients
Populations studied Depressed outpa¬ Normal community Normal community Discharged
tients women residents, nonpsy¬ psychiatric
chotic neurotic per¬ and medical
sons patients
Psychometric properties
Reliability No Yest Yes Yes
Validity No Yest Partial Yes
Sensitivity No Yes No Yes
Scoring system Yes Yes Yes
Other characteristics
No. of items 41 200 52 239
Period assessed Last 6 or 12 mo Present Present Past 1 mo, past
3 mo
Completion time 20 min 1-2 hr 1 hr 45 min-154 hr
"The instrument refers to these factors as a support system.
tThese properties are for the earlier version only.

tive report, and the person's subjective report may be
compared with the objective criteria.
The category of social management and the assessment
of functioning is extricated less easily from subjective
report. However, the authors explicitly define social func¬
tioning in terms of leisure time and social and familial
relationships. The satisfaction category takes into account
the person's subjective report and measures the degree of
satisfaction reported.
The semistructured interview is administered in about
one hour by a trained interviewer. Forty-one ratings are
made on a four-point scale that indicates the degree of
maladjustment. The schedule is easy to score and may be
analyzed by component analysis. A manual contains a
detailed glossary, sample probes, and suggestions for
handling problems.30
Interrater reliability was demonstrated by several methods. The
overall percent of agreement between raters was measured with
respect to how frequently the raters agreed or disagreed on the
presence or absence of maladjustment. There were lower percent¬
ages of agreement among raters when indicating the presence
rather than absence of maladjustment, but general agreement
was good. Weighted values were high for eight interrater
reliabilities. For three of the 17 items analyzed, a significant
difference among raters was reported (household care, leisure
opportunities, and number of leisure activities).
Partial validity has been established. The scale has been used in
a number of studies of psychosocial morbidity in the community
and in general practice in the United States, the United Kingdom,
and Europe.3236
Personal Resources Inventory (PRI)
This scale was developed by Clayton37 to assess the
resources or social supports available to a person during his
or her "most well" period of functioning in a defined
one-year period. The PRI is composed of 41 items adminis¬
tered in a structured interview with the patient on admis-

Downloaded from www.archgenpsychiatry.com at Columbia University, on April 14, 2010

 Despite the fact that reliability and validity studies are
not yet complete, this new scale is very promising because
it provides a means for collecting data on another dimen¬
SocialAdjustment sion of a person's social environment. It may prove useful
Scale-li,"·*5 Levels of Function for comparing differences in the resources available to
Schooler, Hogarty, Scale,"·" various patient and nonpatient populations. A computer¬
and Weissman Strauss andCarpenter ized scoring system is being developed, but a precoded data
X
summary sheet is now available (P. Clayton, MD, written
communications, 1977, 1980).
Social Role Adjustment Instrument (SRAI)
The SRAI31'" was developed by Cohler et al because they
could find no instrument that was suited to measure the
conflict women experience in adapting to adult roles.39
Designed for a study of women's adjustment to mother¬
Household hood, this scale assesses how successfully a woman has
adjusted to her major adult roles. It provides separate
measures of the degree of contact maintained with others
in a specific role and her adaptation to that role.
The instrument consists of 25 nine-point scales and
approximately 200 items that are administered in a semi-
structured one- to two-hour interview. A high score indi¬
cates satisfactory performance. The present form of the
Time hospitalized SRAI is a modification and revision of an earlier instru¬
ment developed by Shader et al.4"
A woman is asked to rate her performance as a home-
maker, friend, wife, mother, and daughter. For each role,
Assess adjustment Predict patient outcome separate ratings are made on the frequency of contact with
of schizo¬ the other or others involved with the particular role
phrenics relationship, the degree of conflict experienced with
Schizophrenic in- Psychiatric inpatients regard to that role, the depth of investment or involvement
patients and out¬ with the other or others, and overall adaptation to that
patients role.
For three of the specified roles, additional scales are
Schizophrenic in- Schizophrenic and non- scored and are included in determining overall ratings of
patients and out- schizophrenic patients adjustment. For the role of wife, a separate rating is
patients
completed on the degree of sexual satisfaction experienced
in marriage. For the maternal role, a separate rating is
Yes Yes made on the degree of satisfaction that a woman derives
Partial Yes from motherhood. For the role of daughter, a separate
No Yes rating is made on the extent to which a woman can achieve
Yes Yes appropriate and flexible autonomy from her own par¬
ents.
52 For a woman's performance as a housewife, a rating is
Past 2 mo Past mo-4-1 yr made on the extent to which she can carry out the
associated tasks of cooking, cleaning, managing the house¬
1 hr 15-30 min
hold budget, and supervising the children's activities when
her husband is not present; a rating also is made on her
degree of involvement in a hobby or other form of recrea¬
tion. As a result of these more specific data, four summary
sion to a psychiatric treatment facility. A manual with
adjustment scales are rated, including global social affilia¬
tion, overall investment in interpersonal relationships,
specific probes, anchor points, and a predefined rating overall inner discomfort, and overall psychiatric distur¬
system for the items is available. Specific guidelines for bance.
defining the 12-month period to be assessed also are Shader et al·" reported excellent interrater reliability correla¬
provided in the manual and are those delineated in the tions. Test-retest interviews conducted 18 months apart with a
Research Diagnostic Criteria.3" Overall and specific ratings
are obtained for the following potential sources of social
nonpatient sample showed stability over time in ratings, suggest¬
ing that the interviewer was able to code these interviews in a
support: current marriage, dating relationships, family, reliable manner.
friends, neighbors, job or work role, financial resources, A principle-component analysis was performed on all 25 scales
social contact, living situation (safety and physical based on the correlation matrix for the combined ratings. Four
aspects), and other resources (eg, religion, organizations, factors emerged from this analysis. These were capacity for
recreation, and pets). affiliation, emotional investment in marriage, mature intergener-
The interviewer asks the patient to make specific and ational ties, and conflict regarding parenthood.
global assessments of the social supports available prior to The SRAI is appropriate for, and has been shown to
the onset of the current illness. A trained research assis¬ discriminate between, patient and nonpatient populations.
tant can administer the scale, since interviewer assess¬ Its focus is limited to the traditional roles of women, but it
ments of the patients are not required, and the interviewer provides a thorough evaluation of a woman's adjustment to
is instructed to score "what the patient says." those roles.

Downloaded from www.archgenpsychiatry.com at Columbia University, on April 14, 2010

 Interview Schedule for Social Interaction
(ISSI)
The ISSI4750 was developed by Henderson and Duncan-
Jones to assess the "current state of a person's social
relationships,"47 and, within that system, to measure the
availability of and the person's perceived adequacy of
social supports. It is intended to provide a descriptive
representation of social relationships and the basis for the
development of a "causal model of interrelationships."47
The authors hypothesize a model that assumes that suppor¬
tive social relationships act as a buffer in times of stress
and, perhaps, offset the development of psychiatric ill¬
ness.
The conceptual structure of the ISSI is based on Weiss's
theoretical model in which social relationships are defined
by the following six dimensions: attachment, social inte¬
gration, taking responsibility for another, reassurance of
worth, reliable alliance, and obtaining guidance.
The ISSI consists of 52 items in a semistructured
interview that takes approximately one hour to administer.
A precoded interview, an interview guide manual in which
each of the 52 items is operationalized, and directions for
data analysis are available.
Designed for use in a longitudinal epidemiological study of
nonpsychotic or neurotic disorders, the ISSI was administered to a
random sample of 756 adults in Canberra, Australia. Data from
the first wave of the study were analyzed; they supported the
construct validity and reliability of the scale. A detailed descrip¬
tion of the data analysis and the development of ISSI items can be
obtained.
Correlation matrices were calculated, and 24 variables that
measure availability of social supports and 29 variables that
measure adequacy of social supports were isolated. The authors
state that the ISSI items correspond well to Weiss's structural
model. The reliability of the 52 items was tested on a subsample of
282 persons. Reliability coefficients for the items that measure
availability of social supports ranged from .43 for reliable alliance
to .73 for social integration. Coefficients for adequacy of social
supports ranged from .31 for reliable alliance to .80 for social
integration. Test-retest reliability was measured over a four-
month interval, and reliability was stable over time.
The ISSI is potentially suitable for use with various adult
populations, including normal persons, psychiatrically ill
persons, and the elderly, but this has not yet been demon¬
strated. Its well-developed approach to the assessment of
social relationships makes it ideal for studies that focus on
this aspect of social functioning.
The Social Behavior Assessment Schedule (SBAS)
The SBAS5152 was designed by Platt et al to evaluate
both the objective changes due to the patient's mental or
physical illness and the subjective distress experienced by
the family due to these changes. The informant is a
significant other, and guidelines for choosing the appro¬
priate informant (eg, face-to-face contact, lives in the same
household, a hierarchy of relatives) have been delineated
by the authors. To quantify the impact of the illness, the
patient's disturbed behavior, his or her limited social
performance, and the adverse effects of the patient's
behavior on the household are included, as well as items
that measure the distress to the informant arising from
these factors.
The interview is administered by a trained interviewer.
The interview consists of 239 defined and global items
administered in a semistructured format that takes about
60 to 90 minutes to complete. The interview consists of six
sections, five of which cover the past month; section 5
assesses the past three months. Rated in the sections are
(1) background information collected about the patient's
illness, his or her behavior, and its effect on the family in
view of the patient's recent social history; (2) the patient's
Downloaded from www.archgenpsychiatry.com at Columbia University, on April 14, 2010
behavior, which is rated in terms of onset, severity, and
distress experienced by the informant as a result of the
patient's behavior; (3) the patient's social performance,
health, and employment history; (4) the objective conse¬
quence of the patient's behavior on the informant and the
household, as well as the "reported distress" or the emo¬
tional consequence of each symptom, and the date of onset
of the adverse effects; (5) serious concomitant life events
experienced by the informant or by his or her household;
and (6) support systems available to the informant, which
are assessed in terms of help from friends, relatives, and
social services, and housing situation. The interview man¬
ual defines the anchor points to be rated.
Partial validity has been established. Several studies have been
designed to measure the scale's validity. One hundred twenty-
seven significant others were interviewed at the time of the
patient's hospitalization and after 16 weeks. The relationship
between the patients' symptomatic behavior and the extent of the
informants' distress was examined. In this analysis, the severity
of the illness was held constant, and the authors reported that
there was a divergence in the relationship between severity of the
objective symptoms and the extent of the informant's distress.'1
The data suggested that informants have "different attitudes
toward different problems" and lend validity to the concept that
subjective and objective aspects of "burden" should be considered
separately.
Interrater reliability was established by four raters on nine
SBAS interviews (in-person and taped). The raters were of diverse
professional backgrounds. Agreement between pairs of raters for
the total score of the six sections of the SBAS was .92 to .99 for
intraclass correlations and .87 to .98 for Kendall's W coefficient.
High correlations were found for objective ratings of behavior (eg,
social performance, .98); equally good agreement was shown for
items rating reported distress on the same items (eg, social
performance, .93). The item analysis showed good reliability
among raters; however, there was greater variability in agree¬
ment. The SBAS was compared with other instruments that assess
social behavior and symptoms (eg, the Present State Examination,
the Current and Past Psychopathology Scale, and the Structured
and Scaled Interview to Assess Maladjustment) and showed
average to good reliability.
The SBAS is an impressive scale. The interview manual
and guidelines provide excellent examples of operationaliz-
ing and defining ratings. Further work on the scale's
validity and sensitivity are forthcoming.52 The initial data
showed that the scale discriminates objective from subjec¬
tive burden and accurately measures the impact of physical
or psychiatric illness on a patient's household.
Social Adjustment Scaie-ll (SAS-II)
The SAS-II interview53-5'· is an adaptation of the SAS
interview by Schooler, Hogarty, and Weissman and was
designed specifically for use with schizophrenic popula¬
tions. It contains 52 questions that are administered in a
semistructured interview by a trained rater; it takes about
one hour to complete. Five global judgments are made by
the rater at the completion of the interview, and all
interviewer's ratings are made on the basis of a "commu¬
nity norm" for social functioning. The informant for the
SAS-II is either the patient or a significant other, and
there are corresponding versions of the interview manual
available.
Work role, relationship with a "principal household
member," conjugal and nonconjugal sexual adjustment,
romantic involvement, parental role, extended family rela¬
tionships, social leisure activities, and personal well-being
are assessed. As with the SAS, both instrumental and
affective questions are rated for each area of social
adjustment. However, the SAS-II reflects the special living
situations of the chronically mentally ill, who tend to live in
a protected environment within the household of a relative,
within their own marital relationship, or within a small
group as a single person. However, the scale is not limited
in use to the chronically mentally ill. The SAS-II facilitates
assessment of a person's social functioning in a wider
variety of situations (eg, the category, "principal household
member" covers the informant's relationship with a house¬
hold member with whom he or she has the most contact).
Furthermore, the SAS-II assesses conjugal and nonconju-
gal sexual functioning and the person's personal well-
being, degree of satisfaction with life, ability to care for
himself or herself, and loneliness.
The interview manual and score sheet are precoded, and the
scale can be summed in eight role areas as well as in ten
statistically derived factors. Total scores, means, SDs, and factor
item loadings are available on a sample of approximately 200
hospitalized schizophrenics.
Fifty-six ambulatory schizophrenic patients and their signifi¬
cant others provided data for a reliability study, and overall
agreement between informants was excellent (Spearman's rank
correlation coefficient, .98).54 Interrater reliability and validity
studies for the SAS-II have not been reported. However, the scale
recently was found to differentiate depressed schizophrenic outpa¬
tients from nondepressed schizophrenic outpatients.''5
Levels of Function Scale
This four-item scale5660 was developed by Strauss and
Carpenter to assess functioning and to measure outcome in
hospitalized psychiatric patients. It is one of the few scales
designed for use with hospitalized populations and was
used in the International Pilot Study of Schizophrenia to
evaluate functioning prior to hospitalization, throughout
the initial hospitalization, and over a two-year follow-up
period.
Social relations (frequency of contact), employment (per¬
cent of time employed), symptoms (severity in the last
month), and time hospitalized are evaluated. The following
two time periods are assessed: (1) the past year for three
areas of functioning (social, employment, and time hospi¬
talized) and (2) the past month for symptoms. The scale is
administered in a semistructured interview with the
patient, and ratings are made on a five-point scale. All
ratings are defined operationally, and a "total outcome"
score is derived by summing scores obtained on the indi¬
vidual items. Although ratings have anchor points, the
interviewer rates the patient through comparison with the
"concept of normal" for the patient's peer group, therefore
leaving the final assessment to the interviewer's general
conception of "normal." All items are precoded. The length
of time to administer the scale is not specified, but it
probably would be 15 to 30 minutes, depending on the
amount of probing needed to make judgments. It would
appear that a skilled interviewer is necessary for adminis¬
tering this form.
The authors reported good concurrent interrater reliability on
all four items. Test-retest reliability is reported between a two-
year and five-year follow-up of the same population.
The predictive validity of the scale was demonstrated by
comparing it with several other criteria. The four outcome areas of
the scale were assessed in 85 subjects assigned a DSM-II diagnosis
of schizophrenia. The results indicated that when individual
predictors, such as length of previous hospitalization, are com¬
pared with the outcome item scores, correlations ranged from
r =
.30 with duration of hospitalization to r =
.54 with social
relations and r .61 with total outcome. The authors stress that,
=
for accurate prediction of outcome for schizophrenic patients,
assessments of the four major areas of functioning are needed.'"
Although they found that there were interactions among areas
and levels of function (most significantly between poor social
relations and unemployment), the four areas of functioning also
operate as independent factors and appear to be continuous over
time (eg, the patient's diagnosis contributed to the prediction of
Downloaded from www.archgenpsychiatry.com at Columbia University, on April 14, 2010
outcome). However, the least reliable predictor of outcome was
length of hospitalization.
Most recently, the Levels of Function Scale was used in a
prospective and follow-up study of first-admission patients
with functional psychotic disorders. Social relations and
employment functioning in the year prior to hospitaliza¬
tion were shown to be the best predictors of outcome for
schizophrenics as well as for other groups. As a result of
this new finding, Strauss and Carpenter51' suggest that the
concept of social impairment may be useful in predicting
outcome in all psychiatric disorders.
COMMENT
There currently at least 27 published scales that
are
various aspects of social functioning and that
measure
have been reasonably well developed and tested. Included
are the 12 scales reviewed here and 15 scales reported
previously.1 Although we have reviewed only one,22 there
are other scales that have been developed exclusively for
use with nonpsychiatric, medically ill patients that might
be appropriate for use with psychiatric populations.61 In
particular, there has been interest in studying the social
adjustment of patients after posttraumatic coma62 63 as
well as patients treated for a variety of other diseases (eg,
cancer, arthritis, psoriasis).
While the scales reviewed here represent a range of
approaches to the measurement of social adjustment, there
are still at least two major limitations in the available
methodology. These limitations are both practical and
conceptual. On a practical level, the scales have been tested
on, and are applicable to, only adult populations. There is a
lack of scales designed specifically for children, adoles¬
cents, or the elderly. Moreover, many of the scales cannot
be adapted to reflect changes in traditional roles, especially
among women.
On the conceptual level, the scales often include overlap¬
ping and unspecified concepts. At least five conceptual
areas underlying social functioning can be identified and
are measured with varying emphasis, depending on the
scale. These areas are social supports, social attachments,
social competence, social status, and social role perform¬
ance. Since dysfunctioning in each of these areas may have
considerably different implications for intervention, a
fruitful task for future development would be the explica¬
tion and measurement of them. An additional impetus for
the clarification of these conceptual areas is that impair¬
ment in social functioning has emerged as an integral part
of the DSM-III diagnosis. Specificity in diagnostic criteria,
which has been a major achievement of the DSM-III,
suggests that social functioning ultimately be approached
in the same manner.
Despite the availability of a number of scales, the
assessment of social adjustment has not been highly
developed. In the 1975 review and in this update we have
described scales that met certain criteria for utility and
development, and we have pointed out their strengths and
limitations. We have deliberately avoided a comparative
review of existing scales to avoid premature closure in a
field that has just begun to emerge.
Work on this review was supported in part by the Yale Mental Health
Clinical Research Center, New Haven, Conn, grant MH 30929.
References
1. Weissman MM: The assessment of social adjustment: A review of
techniques. Arch Gen Psychiatry 1975;32:357-365.
2. Frank E, Anderson C, Rubinstein D: Frequency of sexual dysfunction
in 'normal' couples. N Engl J Med 1978;299:111-115.
3. Frank E, Anderson C, Curtis E: Frequency of sexual dysfunction in
'normal' couples. Read before the meeting of the Eastern Association for
Sex Therapy, New York, March, 1977.
4. Frank E, Anderson C, Kupfer DJ: Profiles of couples seeking sex
therapy and marital therapy. Am J Psychiatry 1976;133:559-562.
5. Frank E, Kupfer DJ: In every marriage there are two marriages. J Sex
Marital Ther 1976;2:137-143.
6. Frank E, Kupfer DJ: The KDS-15: A Marital Questionnaire. Pitts-
burgh, Western Psychiatric Institute and Clinic, University of Pittsburgh,
1974.
7. Weissman MM, Bothwell S: The assessment of social adjustment by
patient self-report. Arch Gen Psychiatry 1976;33:1111-1115.
8. Ruestow P, Dunner D, Bleecker B, et al: Marital adjustment in primary
affective disorder. Compr Psychiatry 1978;19:565-571.
9. Dunner DL, Gerard IJ, Fieve RR: Social adjustment in primary
affective disorder. Read before the Sixth World Congress of Psychiatry,
Honolulu, Aug 28-Sept 3, 1977.
10. Edwards DW, Yarvis RM, Mueller DP, et al: Test-taking and the
stability of adjustment scales: Can we assess patient deterioration? Evalu-
ation Q 1978;2:275-292.
11. Weissman MM, Prusoff BA, Thompson WD: Social adjustment by
self-report in a community sample and in psychiatric outpatients. J Nerv
Ment Dis 1978;166:317-326.
12. Pottenger M, McKernon J, Patrie LE, et al: The frequency and
persistence of depressive symptoms in the alcohol abuser. J Nerv Ment Dis
1978;166:562-570.
13. Newberry P, Weissman MM, Myers JK: Working wives and house-
wives: Do they differ in mental status and social adjustment? Am J
Orthopsychiatry 1979;49:282-291.
14. Williams RA, Walker RG: Schizophrenics at time of discharge:
Prognostic value of clinical condition. Arch Gen Psychiatry 1961;4:87-90.
15. Willer B, Howard P: Development of a computer assisted progress
record for psychiatry, in Garwick G (ed): Goal Attainment Review: Volume
1. Minneapolis, Program Evaluation Resource Center, 1974, chap 6.
16. Willer B, Biggin P: Self-assessment Guide: Rationale, Development,
and Evaluation. Toronto, Lakeshore Psychiatric Hospital, 1974.
17. Willer B: Individualized patient programming: An experiment in the
use of evaluation and feedback for hospital psychiatry. Evaluation Q
1977;1:587-608.
18. Willer B, Biggin P: Comparison of rehospitalized and non-hospitalized
psychiatric patients on community adjustment: Self-assessment Guide.
Psychiatry 1976;39:239-244.
19. Willer B, Miller G: On the validity of goal attainment scaling as an
outcome measure in mental health. Am J Public Health 1976;66:1197-1198.
20. Willer B, Miller GA: A brief scale for predicting rehospitalization of
former psychiatric patients. Can Psychiatr Assoc J 1977;22:77-81.
21. Derogatis LR: Scoring and Procedures Manual for PAIS. Baltimore,
Clinical Psychometric Research, 1976.
22. Derogatis LR: PAIS S.R. Self Report. Baltimore, Clinical Psychomet-
ric Research, 1978.
23. Morrow GR, Chiarello RJ, Derogatis LR: A new scale for assessing
patients' psychosocial adjustment to medical illness. Psychol Med 1978;8:605-
610.
24. Ciarlo JA, Reihman J: The Denver Community Mental Health
Questionnaire: Development of a multi-dimensional program evaluation
instrument, in Coursey R, Spector G, Murrell S, et al (eds): Program
Evaluation for Mental Health: Methods, Strategies, and Participants. New
York, Grune & Stratton Inc, 1977, pp 131-167.
25. Ciarlo JA, Reihman J: The Denver Community Mental Health Ques-
tionnaire: Development of a Multi-dimensional Program Evaluation
Instrument. Denver, Mental Health Systems Evaluation Project, Northwest
Denver Mental Health Center and the University of Denver, 1975.
26. Ciarlo JA, Davis C: Outcomes for adult clients, in Davidoff I,
Guttentag M, Offutt J (eds): Evaluating Community Mental Health
Services: Principles and Practice, publication No. (ADM) 77-465. US Dept of
Health, Education, and Welfare, 1977, pp 369-392.
27. Reihman J. Ciarlo JA, Hargreaves W: A method for obtaining
follow-up outcome data, in Hargreaves W, Attkisson C, Siegel L, et al (eds):
Resource Materials for Community Mental Health Program Evaluation: IV.
Evaluating the Effectiveness of Services. San Francisco, National Institute
of Mental Health, 1974, pp 132-135.
28. Ciarlo JA: Monitoring and analysis of mental health program outcome
data. Evaluation 1977;4:109-114.
29. Butters E, Lobb J, Ciarlo JA: The Denver Community Mental Health
Questionnaire: Replication of the psychometric analysis and addition of the
Home Productivity Scale. Read before the Rocky Mountain Psychological
Association convention, Denver, 1978.
30. Clare AW, Cairns VE: Design development and use of a standardized
interview to assess social maladjustment and dysfunction in community
studies. Psychol Med 1978;8:589-604.
31. Clare AW, Cairns VE: A Manual for Use in Conjunction With the
General Practice Research Unit's Standardized Social Interview Schedule.
London, Institute of Psychiatry, 1979.
32. Cooper B, Harwin BG, Depla C, et al: Mental health care in the
community: An evaluative study. Psychol Med 1975;5:372-380.
33. Hesbacher PT, Rickels K, Goldberg D: Social factors and neurotic
Downloaded from www.archgenpsychiatry.com at Columbia University, on April 14, 2010
symptoms in family practice. Am J Public Health 1975;65:148-155.
34. Huxley P, Goldberg D: Social versus clinical prediction in minor
psychiatric disorders. Psychol Med 1975;5:96-100.
35. Kedward HB, Sylph JA: Social correlates of chronic neurotic disorder.
Soc Psychiatry 1974;9:91-98.
36. Sylph JA, Kedward HB, Eastwood MR: Chronic neurotic patients in
general practice. J R Coll Gen Pract 1969;17:162-170.
37. Clayton P, Hirschfeld R: Personal Resources Inventory (PRI). St
Louis, Washington University School of Medicine, 1977.
38. Spitzer RL, Endicott J, Robins E: Research Diagnostic Criteria (RDC)
for a Selected Group of Functional Disorders, ed 3. New York, New York
State Psychiatric Institute, 1978.
39. Cohler B, Woolsey S, Weiss J, et al: Child rearing attitudes among
mothers volunteering and revolunteering for a psychological study. Psychol
Rep 1968;23:603-612.
40. Shader R, Kellam S, Durrell J: Social field events during the first
week of hospitalization as predictors of treatment outcome for psychotic
patients. J Nerv Ment Dis 1967;145:142-153.
41. Cohler B, Weiss J, Grunebaum H: Child care attitudes and emotional
disturbance among mothers of young children. Genet Psychol Monogr
1970;82:3-47.
42. Grunebaum H, Weiss J, Gallant D, et al: Mentally ill mothers in the
hospital and at home, in Abroms G, Greenfield N (eds): The New Hospital
Psychiatry. New York, Academic Press Inc, 1971, pp 159-174.
B, Grunebaum H, Weiss J, et al: The child care attitudes of two
43. Cohler
generations of mothers. Merrill Palmer Q 1971;17:3-17.
44. Cohler B: Character, mental illness, and mothering, in Grunebaum H,
Weiss J, Cohler B, et al (eds): Mentally Ill Mothers and Their Children.
Chicago, University of Chicago Press, 1975, pp 231-309.
45. Cohler B, Grunebaum H, Weiss J, et al: Social relations, stress, and
psychiatric hospitalization among mothers of young children. Soc Psychia-
try 1974;9:7-12.
46. Cohler B, Grunebaum H, Weiss J, et al: Social role performance and
psychopathology among recently hospitalized mothers. J Nerv Ment Dis
1974;159:81-90.
47. Henderson S, Byrne DG, Duncan-Jones P, et al: Social relationships,
adversity and neurosis: A study of associations in a general population
sample. Br J Psychiatry 1980;136:574-583.
48. Henderson S, Duncan-Jones P, Byrne DG, et al: Measuring social
relationships: The Interview Schedule for Social Interaction. Psychol Med
1980;10:1-12.
49. Henderson S: Social relationships, adversity and neurosis: An analysis
of prospective observation. Br J Psychiatry 1981;138:391-399.
50. Duncan-Jones P, Henderson S: Interview Schedule for Social Interac-
tion (ISSI), 10th ed. Canberra, Australia, Social Psychiatry Research Unit,
Australian National University, 1978.
51. Platt S, Weyman A, Hirsch S, et al: The Social Behavior Assessment
Schedule (SBAS): Rationale, contents, scoring and reliability of a new
interview schedule. Soc Psychiatry 1980;15:43-55.
52. Platt SD, Hirsch SR, Knights AC: Effects of brief hospitalization on
psychiatric patients' behaviour and social functioning. Acta Psychiatr
Scand 1981;63:117-128.
53. Schooler N, Hogarty G, Weissman MM: Social Adjustment Scale II
(SAS II), in Hargreaves WA, Attkisson CC, Sorenson JE (eds): Resource
Materials for Community Mental Health Program Evaluators, publication
No. (ADM) 79-328. US Dept of Health, Education, and Welfare, 1979, pp
290-330.
54. Glazer W, Aaronson HS, Prusoff BA, et al: Assessment of social
adjustment in chronic ambulatory schizophrenics. J Nerv Ment Dis
1980;168:493-497.
55. Glazer W, Prusoff B, John k, et al: Depression and social adjustment
among chronic schizophrenic outpatients. J Nerv Ment Dis, to be pub-
lished.
56. Strauss JS, Carpenter WT Jr: The prediction of outcome in schizo-
phrenia: I. Characteristics of outcome. Arch Gen Psychiatry 1972;27:739-
746.
57. Strauss JS, Carpenter WT Jr: Characteristic symptoms and outcome
in schizophrenia. Arch Gen Psychiatry 1974;30:429-434.
58. Strauss JS, Carpenter WT Jr: The prediction of outcome in schizo-
phrenia: II. Relationships between predictor and outcome variables: A
report from the WHO International Pilot Study of Schizophrenia. Arch Gen
Psychiatry 1974;31:37-42.
59. Strauss JS, Carpenter WT Jr: Prediction of outcome in schizophrenia:
III. Five-year outcome and its predictors. Arch Gen Psychiatry 1977;34:159-
163.
60. Strauss JS, Kokes RF, Ritzier BA, et al: Is social competence a valid
axis for DSM III? Read before the American Psychiatric Association
meeting, Chicago, May 14-19, 1979.
61. Jennett B, Bond M: Assessment of outcome after severe brain
damage. Lancet 1975;1:480-484.
62. Oddy M, Humphrey M, Uttley D: Subjective impairment and social
recovery after closed head injury. J Neurol Neurosurg Psychiatry
1978;41:611-616.
63. Jennett B, Teasdale G, Knill-Jones R: Predicting outcome from severe
head injury. J R Coll Physicians Lond 1975;9:231-237.