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Using tests of Life style and Social behaviour to assess the Global functioning of individuals.
Education, 113(4), 579-585.

Cassel R.N., and Costello, B.R. (1993).

The concept of "global functioning" derives directly from the work of the American Psychiatric Association (APA)in trying to build accountability in our health care program. It is presently contained in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) (1987). The Global Functioning Assessment Scale contained in that manual, as shown in Figure 1 below, is the legal basis for dispensing public monies for health care services in the United States today.

Global Functioning Scale

The DSM-III-R global functioning scale is used by the health care provider to assess a patient's global functioning when health care is begun, and then again each period when payment is requested for such services. Effective health care is expected to increase the global functioning of patients involved. The implication, of course, is that where global functioning is not improved, such health care is not effective. To insure accountability in the use of public monies, periodic peer reviews are prescribed by law to insure that proper intervention strategies are being employed (Cassel, 199 lb).

90 percent - good functioning in social, school, and work.
80 percent - slight impairment in social, school or work.
70 percent - mild symptoms: generally functioning well.
60 percent - moderate symptoms: difficulty in functioning.
50 percent - serious symptoms: serious functioning impairment.
40 percent - impairment in reality testing with major dysfunctioning in one of above areas.
30 percent - behaviour influenced by delusions with an inability to function in all three areas above.
20 percent - danger of hurting self or others, and with lack of communication ability.
10 percent - serious suicidal act with plans for death.

Revolution in Health Care

The health care revolution began near the end of the 19^th century when contagious diseases no longer were a major concern. It has now undergone the following stages or changes in terms of the nature of intervention strategies (Boatwright, 1992; and Holmes, 1992):

1. Contagious Disease - now controlled by antibiotics and vaccines, and by improved approaches to health care.
2. Chronic Illness - Type-A personality and the new at-risk science linking life style and child-like behaviour to coronary heart disease (Cigarettes, alcohol, obesity, exercise, drugs, negative diet, etc.) (Cassel, 1988).
3. Holistic Medicine - a healthy body necessary for a healthy mind, and where a change in one is accompanied by a corresponding change in the other. Guided imagery and subliminal stimulus typical as intervention strategies (Cassel, 1986).
4. Wellness and Fitness - wellness is more than absence of disease, and must include "zest" for living, and where harmony in one’s neural functioning is essential. It is here where the global functioning and health status are considered to be related (Cassel, 1987; and Cowen, 1991).

Figure 1
Global Functioning Test (GFT)
(Confidential Record)
LIFE SPACE AREAS

Global Functioning Areas

SOCIAL MATURITY AREAS: CHILD LIKE AREAS:

1 -COPING SKILLS 3-SYMPATHY 5-DEFENSIVE 7-HEALTH

2-CONFORMITY 4-LOCUS OF CONTROL 6-REGRESSION 8-DEPRESSION

TOTAL-MATTOT TOTAL-CHITOT

The GFT is based on a new approach to assessment where both potential (maturity) and deficit (child-like) behaviour are included in the same test. Each one of the eight part scores is so weighted that a maximum score is always 100. Therefore, one is able to assess strengths and weaknesses based on such scores, i.e., if score is 50, for example, it represents only half of the 100 that is possible. The profile, on the other hand, compares an individual with a norm group. Here scores front 40 to 60 represent average individuals, where percentage of global functioning ranges from 16 to 94 percent. Scores above 60 are in top 16 percent in relation to norm group. Scores below 40 represent the bottom 16 percent in relation to norm group.

New Goals for Health Care

Beginning with the "Chronic Illness" stage there has been a shift in the goals for health care provider. In the Chronic Illness stage, for the first time, responsibility for health care shifted from the health care provider to the patient. It was clear, of course, that the at-risk patient because of cigarettes, alcohol, drugs, lack of exercise, overweight and nutrition, teenage pregnancies, suicide, etc. must take charge of own health care if positive change is expected. Here for the first time the patient is given alternatives of strategies to be employed by the health care provider, with a careful explanation of hazards and likely consequences of those suggested. The election of the particular strategy to be employed is by the patient; as opposed to the health care provider under traditional medicine. The new goal for all health care has become the increase of the global functioning of patients involved (Cassel, 1954; and 1985a & b).

Wellness and Global Functioning

Under the DSM-III-R prescription, which today serves as the legal basis for public payment of health care, wellness as a measure of health status and global functioning are considered to be the same. Much more important the theatre of life in relation to global functioning and wellness has been expanded from the work place (where disability alone reigned) to include school and social. Social, of course, includes the family, and community interactions as well. Industry has boasted for years that 80 percent of what is involved for promotion in the work place is how one gets along with people, and not competency in one's job skills (Cowen, 1991; and National Wellness Association, 1992).

Research and Global Functioning

There has been an abundance of recent research findings that clearly indicate that one's life style, social development, and need fulfilment are critical areas related to his/ her own global functioning. In this research the role of the health care provider has changed to be that of being a quasi-tutor, and the patient assumes full responsibility for own health care. The world of the patient becomes more focused, and where perceptions of the patient serve as the basis for selecting intervention strategies

Framingham Studies

Beginning in the late 1940s, the studies at Framingham, Massachusetts introduced Type-A Personality, and the "at-risk" science was born. In the study of 20 tribes in Africa there was no evidence of coronary heart disease (CHD), but when such members migrated to the Western culture, they too showed evidence of CHD. The life style of individuals played a critical role in the wellness of people, and the individual must take charge of own health care (Castelli, 1986; Cassel, 1985b).

San Francisco Study

The first study ever reported to learn the nature of the syndrome underlying deviant behaviour of mostly white youngsters was the San Francisco Study by Block and Block. Children at age 4 were first studied and evaluated, and then periodically in a systematic manner follow-up assessments were made during the next 14 years through age 18. The syndrome discovered to be present early in life, during adolescent years, before drugs and deviant behaviour was described as being child like in nature (Shedler and Block, 1990):

1. Not dependable or responsive.
2. Not productive or able to get things done.
3. Guileful and deceitful (denial and distrustful).
4. Unable to delay gratification.
5. Rebellious and nonconforming (antisocial).
6. Pushed and stretched limits continuously.
7. Self-indulgent (not socially at ease).
8. Low aspirations (absence of life goals).
9. Expressed hostile feelings directly.
10. Felt cheated and victimised by life.

AASA Study of At-Risk Students

The American Association of School Administrators (AASA) (1991) in a nation-wide study has determined that the underlying problem in our schools is with the health and wellness of students. Their initial studies sought to find the causes related to the at-risk students where the focus was on alcohol, cigarettes, drugs, eating disorders and nutrition, suicide, obesity, teenage pregnancies, etc. On the basis of in-depth studies of the at-risk problem the AASA in their booklet "Healthy kids for the year 2000: An action plan for schools" (1991) recommended a comprehensive health education program for each school:

1. Co-ordinated by a professional health educator.
2. Teacher training in health education.
3. Health screening tests.
4. Staff development incorporating health strategies.
5. Building an awareness of health needs.
6. Health education advisory committees.
7. Necessary research and evaluation components.

Global Functioning Assessment Program (GFAP)

A Global Functioning Assessment Program (GFAP) was developed at the Cassel Research Centres based on each of the above referenced research findings. The GFAP has now been validated in numerous situations both at the college and high school levels. It is comprised of three different psychological assessment instruments and is now available from one of the Cassel Centres (Chula Vista, California; Mornington, Australia, and Adelaide, Australia):

Life Style

The Life Style Analysis Test (LFSTYLE) was designed based largely on the findings of the Framingham studies (Cassel, 1990a; and Gilley and Uhlig, 1985). It is an assessment instrument as described by Matarazzo (1990) because it has one part that depicts the positive life style, and a second depicting negative life style. Each of the two parts has four part scores comprised of 25 true/ false items. Each item correctly answered is weighted 4 points; so that the maximum part score for each part is always 100. The part scores are selected to provide meaningful information for better understanding the world of the individual:

Part I - Positive Life Style:

Total Score - APOSIV

Part II - Negative Life Style:
5. Loneliness (LON).
6. Anxiety (ANX).
7. Health Concerns (NEG).
8. Depression (DEP)

Total Score - ANEGIN

Social Development (BALANCE)

The Independence Versus Regression Test (BALANCE) was developed based largely on the findings of the San Francisco study (Cassel, 1991a). The first part measures maturity and is comprised of 4 part scores each with 25 true/false items. The second part measures child-like behaviour and has the same number of items in each part score. Each item correctly answered is weighted 4 points; so that the maximum score for each part score is always 100.

Part I - Maturity:
1. Coping Skills (COP).
2. Conforming (CON).
3. Sympathy (SYM).
4. Locus of Control (LOC).

Total - INDTOT.

Part II - Child-Like:
5. Rationalisation (RAT).
6. Regression (REG).
7. Repression (REP).
8. Escape (ESC).

Total - REGTOT.

Need Gratification

From the early work of Henry A. Murray at Harvard we have the notion that all human behaviour is designed by the individual for purposes of gratifying needs that are present, conscious or unconscious in nature. Maslow (1954) advanced this theory described by Murray by suggesting that needs exist on a hierarchical scale; so that needs lower on the scale deal with necessities for life); while needs higher on the scale deal with affiliation, safety, belonging, self-actualisation, and curiosity. In order for an individual to become involved in education (curiosity), for example under Maslow, it is essential that all needs lower on the scale must be reasonably well met. Much later at Stanford Festinger (1957) described the theory of "dissonance" where need presence is accompanied by feelings of discomfort. Based on this theory The Need Gratification Test (NEEDS) was designed to assess need presence in 12 different areas of life (Cassel, 1984; 1990b):

1. Home & Family.
2. Religion and Inner Development.
3. Affiliation & Social.
4. Security & Law.
5. School & Education.
6. Romance & Psycho-sexual.
7. Sports & Risk Taking.
8. Health & Safety.
9. Travel & Relaxation.
10. Aesthetic & Beauty.
11. Money & Productivity.
12. Survival & Pollution.

Total Score - NEETOT (Sum of 12 part scores).

The Global Functioning Assessment Test (GFT)
From the research using The Life Style Analysis Test (LYSTYLE), and The Independence Versus Regression Test (BALANCE) The Global Functioning Assessment Test (GFT) was constructed. It is comprised of two separate parts MATURITY and IMMATURITY with four separate part scores in each (Cassel, 1993):

Part I-MATURITY
1. Coping skills (COP)
2. Conformity (CON)
3. Sympathy (SYM)
4. Locus of Control (LOC)

Total Score-MATTOT

Part II -IMMATURITY:
5. Excuses (DEF)
6. Pouting (REG)
7. Health (NEG)
8. Depression (DEP)

Total Score-IMATOT

Strengths and Weaknesses

Each one of the part scores is comprised of 25 true/false items, and is intended to resemble a standardised interview. The maximum score for each part is 100; so if a person receives a score of 50, it is only half of what it could be. By comparing the Part scores one is able to determine strengths and weakness in relation to the functions as measured by the test.

Normed Profile

The normed profile is displayed in Figure 1 on page 580. It is based on normed data for corresponding individuals which using a McCally T-Score ranging from 20 to 80,with a mean of 50, and a standard deviation of 10. Average scores are from 40 to 60 and contain 68 percent of norm group. Scored above 60 are above average, and those below 40 are below average. There are presently two different norms: (1) Youth, and (2) Adult. In addition each of the norms is provided separately for: 1. Male, 2. Female, and 3. General (both sexes).

Global Functioning

Scores from MATURITY and IMMATURITY are combined statistically to form the Global Functioning index and normed profile on the far right of Figure 1, page 580. Effective change in health care must deal with the central core of the individual involved. It must focus squarely on the strengths and weaknesses as perceived by that person, and which are shown in the GFT profile. Not from the perspective of the health care provider.

References

Boatwright, M.A. (1992). Use of GPA attributes in guidance to foster global functioning of college students. Chula Vista, California: Project Innovation.

Cassel, R.N. (1954). Psychological aspects of happiness. Peabody Journal of education, 50(1), 73-82.

Cassel, R.N. (1984). Need gratification and brain dominance: Nucleus for transpersonal psychology and biofeedback. Psychology, 21(2), 48-54.

Cassel, R.N. 1985a). Fostering wellness through positive emotions. College Student Journal, 19(2), 202-206.

Cassel, R.N. (1985b). Critical risk factors associated with Type-A Proneness. Education, 105(3), 337-339.

Cassel, R.N. (1986). Forging an ego-ideal as an extension of one’s ego-status. Psychology, 21(1), 3035.

Cassel, R.N. (1987). Use of select nutrients to foster wellness. Psychology, 24(3), 24-29.

Cassel, R.N. (1988). Defensive living as the basis for fitness. Journal of Instructional Psychology, 15(2), 51-56.

Cassel, R.N. (1990). The life style analysis test(LFSTYLE). Chesterfield, Missouri: Psychologists & Educators.

Cassel, R.N. (1990). The need gratification test (7VEEDS). Chesterfield, Missouri: Psychologists & Educators.

Cassel,R.N.(1991a). The independence versus regression test (BAL4NCE). Chesterfield, Missouri: psychologist & Educators.

Cassel, R.N. (1991b). School dropout odyssey: A tragic health crisis. Chesterfield, Missouri: Psychologists &

Educators.
Cassel, R.M. (1993). Cutting Edge: ‘Re Global Functioning Test (GFT). National FORUM of Educational Administration and Supervision Journal. 10(3) f -69.
Castelli, W.P., et.al.(1986). Incidence of coronary heart disease and lippoprotein cholesterol levels. Journal of American Medical Association, 256(20), 2835-2838.
Cowen, E.L. (1991). In pursuit of wellness. American Psychologist, 46(4), 404-408.
Diagnostic statistical manual of mental disorders, Third Edition - Revised (DSM-III-R) (1 98 7). Washington, D.C.: American Psychiatric Association.
Festinger, L. (1957). A theory of cognitive dissonance. Stanford, California: Stanford University Press

LIFE STYLE AND SOCIAL BEHAVIOR
Gilley, W.F., and Uhlig, G.E.(1985). Validation of Cassel Type-A Assessment Profile. Psychology, 22(2),4-10.
Healthy kids for the year 2000: An action plan for schools. (1991). Arlington, Virginia: American Association of School Administrators.
Holmes, R.M. (1992). Wellness attributes related to the GPA of college students. Education Monograph No.1. Chula Vista, California: Project Innovation.
Maslow, A.H. (1954). Motivation and personality. New York: Harper and Brothers.
Matarazzo, J.D. (1990). Psychological assessment versus psychological testing. American Psychologist, 45(9), 999-1017.
National Wellness Association (1992), 1319 Freemont Street, South Hall, University of Wisconsin, Stevens Point, Wisconsin.
Shedler, B.S., and Block, J. (1990). Adolescent drug use and psychological health: A longitudinal study.
American Psychologist, 45(5), 612-630.