Table 2 PIR-GAS manual excerpts on reliability aspects and authors’ comments

#1 “A skilled clinician [who conducts a diagnostic evaluation and formulates an intervention plan] can use the concepts and measures in Axis II to formulate and focus interventions.” (p. 41f)

The qualification of raters does not focus on explicit skills, e.g., specific training, or years of professional experience with children. It remains unclear whether any member of a multi-professional team (including several professional disciplines, such as child and adolescent psychiatrists, nurses, and pedagogical staff) with various levels of clinical experience can provide an equivalent rating quality. Additionally, there is a scientific demand for independent diagnostic information, e.g., by third-party raters.

#2 “In assessing the parent-infant relationship, the clinician should consider multiple aspects of the family dynamic (overall functioning level, level of distress and adaptive flexibility in both the child and the parent; level of conflict and resolution between the child and the parent; effect of quality of the relationship on the child’s developmental progress.” (p. 41f)

The manual describes several global issues, or potential psychometric subdimensions of the PIR-GAS, such as functioning or distress, that are related to family dynamics. It appears that these subdimensions play different roles across the range of relationship quality. The manual does not name distinct observable criteria for these potentially different aspects and does not specify how to document them. Individual child and parental distress, for example, should be separated from the stress that arises from relationship problems. Furthermore, there is no guideline regarding how to weigh and integrate contradictory information.

#3 “The clinician typically completes the scale after multiple clinical evaluations for a referred problem.” (p. 42)

To reliably apply the PIR-GAS, the user needs to know how long, how often, in how many and in what type of situations (alone or with the mother, siblings, or others) the child and primary caregiver should be observed. What is an acceptable minimum to yield reliable ratings? It would be interesting to know whether and how a typical PIR-GAS-observation-situation could be defined.

#4 “Diagnoses of relationship disturbances or disorders are made not only on the basis of observed behavior but also on the basis of the parent’s subjective experience of the child as expressed during a clinical interview and the subjective experience of the child, as expressed in a play interview, for example.” (p. 42)

The authors recommend a clinical integration of data from different sources and an assessment using different methods, including observations performed by a clinician, the usage of retrospective and current information about the mother-child interaction reported by the mother during a clinical interview, and observation of the child by a skilled clinician in a play interview. Again, documentation and weighting of single observations and their integration are not described. Furthermore, the inclusion of all available information into a final PIR-GAS rating, as recommended in the manual, renders the validation of a PIR-GAS rating difficult, as there are no external criteria left.