Tools in Family Assessment

JI Veridiano,Ofelia S.

Introduction

• Every patient is a member of a family

• A physician must always keep in mind that the way a patient reacts to an illness will depend a lot on his family

• It will depend on the family physician as to up to what level he will involve a patient’s family to evaluate his problem.

Family Systems Medicine

• The primary goal of Family Systems Medicine is to view the patient’s problem in multiple context

Family Systems in Clinical Practice

• The family physician must be able to understand first the basic concepts of family structure and function.

Step 1

• Recognize the Family Structure

• Know the individual members of the family

• A systematic way of obtaining and recording this information is through the use of a Family Genogram

Family Genogram

1. Family Tree• Must consist of 3 or more generations

with each generation identified by Roman numerals

• The first born of each generation is farthest to the left with the following siblings going to the right according to order of birth

• Family name is placed above each major family unit

• Names and ages written below the symbol

• Index patient is identified with an arrow

• Date must be indicated when it was made to be able to adjust the ages over time

2. Functional Chart

• It gives a more dynamic image of the family especially the relationship of each member to other members. This allows one to judge the family’s totality as a unit, its strengths and weaknesses, and its adaptability in future stressful situations

3. Family Illness/History

• This indicates the presence of heredofamilial diseases in which potential problems in the family can arise.

Step 2

• Understand the normal family function

5 Basic Family Functions

1. Provide support to each other

2. Establish autonomy and independence for each person in the system

3. Create rules that govern the conduct of the family and its members

4. Adapt to change in the environment

5. Communicate with each other

Functional Family

• Defined as a family wherein a balance between these functions is achieved. Imbalances may result from over or under emphasis of these functions.

Dysfunctional Family

• Defined as a family with chronic inability to respond to the needs or to cope with changes and stresses in the environment

Step 3

• Learn to assess Family Structure and Function in Clinical Practice

• Family assessment tools have been made to aid the family physician in assessing the family structure and function in clinical practice.

Family Assessment Tools

• Family Genogram• Family Circle• Family APGAR• FACES (Family Adaptability and Cohesion

Evaluation Scale)• FES (Family Environmental Scale)• Clinical Biography and Life Events• SCREEM• DRAFT (Draw A Family Test)• Family Mapping

Family Genogram

• A graphic representation of a family tree that displays detailed data about the relationships among individuals in a family

• Allows the user to analyze hereditary patterns and psychological factors that punctuate these relationships

Family Genogram

• Quickly identify and understand various patterns in the patient's family history which may have had an influence on the patient's current state of mind

• Maps out relationships and traits that may otherwise be missed on a pedigree chart

Family Genogram

• An excellent tool to learn about the family structure but has limited role in assessing the family functions. It contains the following informations:

• Names, gender, date of birth, date of death, and roles of each family member

• Divisions of an extended family into several households• Medical problems and chronic illnesses of each family

member• Significant dates in the family history• Nature of the family relationships

Veridiano Familyas of April 11, 2010

Project 4, Quezon City

1943 1947

Constantino, 64 2006 ■ Mila Fatima 47 1994 ∆

∆ Ruptured aneurysm■ Heart failure♥ Hypertension♦ Bronchial Asthma

Thess 42 ♥ Nel 45 May 39 ♦ Jojo 44 ♥ 1973 1971 Peng 27 ♥

1967 1964 1968 1970 1965 1982

Chok 36 ♦ 2005 Tere 38

Ja 4 ♦

2007

Family Circle

• Family circles are often used on individuals and in some small groups.

• Instructions are given to the patient to look at the circle as if it is his family and then draw small circles to represent the patient and those people who are important to him.

• Difficulty of interpretation and standardization poses as a disadvantage.

Family Circle

Me

Mama Pesh Mama chuchi

Chok

Ja Kuya Nel

Dex

Arra

Erin Ate Tere

Rihanne

Family APGAR

• This is a 5-question assessment tool used for rapid assessment of family function and dysfunction.

• It measures an individual’s level of satisfaction about family relationships.

Family APGAR

• Adaptation- the ability of a family to use and share inherent resources which can be either intra- or extra-familial

• Partnership- the sharing of decision making which measures the satisfaction of solving problems through communicating

• Growth- pertains to both physical and emotional aspects and measures the satisfaction of the freedom to change

• Affection- emotions that are shared with and between family members which measures the satisfaction with the intimacy and emotional interaction that exist in the family

• Resolve- refers to how time, money, and space are shared; this measures the satisfaction with the commitment made by members of the family

Family APGAR

There are 4 basic situations wherein the Family APGAR is needed:

• When the family is directly involved in caring for the patient.

• When treating a new patient in order to get information to serve as general view of family function

• When treating a patient whose family is in crisis.• When a patient’s behavior makes you suspect a

psychosocial problem possibly due to family dysfunction.

FAMILY APGAR QUESTIONNAIRE PART I

• Helps define the degree of the patient’s satisfaction or dissatisfaction with family function

Part I

Almost always (2)

Some of the time

(1)

Hardly ever

(0)

A I am satisfied that I can turn to my family for help when something is troubling me.

P I am satisfied with the way my family talks about things with me and shares problems with me.

G I am satisfied that my family accepts and supports my wishes to take on new activities or directions.

A I am satisfied with the way my family expresses affection and responds to my emotions such as anger, sorrow, and love.

R I am satisfied with the way my family and I share time together.

Filipino Family APGAR Part IPalagi(2)

Paminsan-

minsan (1)

Halos hindi

(0)

A Ako’y nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema.

P Ako’y nasisiyahan sa paraang nakikipagtalakayan sa akin ang aking pamilya tungkol sa aking problema.

G Ako’y nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais na gawin patungo sa mga bagong landas para sa aking ikauunlad.

A Ako’y nasisiyahan sa paraang ipinadadama ng aking pamilya ang kanilang pagmamahal at nauunawaan ang aking damdamin katulad ng galit, lungkot, at pag-ibig.

R Ako’y nasisiyahan na ang aking pamilya at ako ay nagkakaroon ng panahon sa isa’t-isa.

Family APGAR Part II

• Delineates relationships with other members, identifies persons who can give assistance to the patient, and indicates conflicts not revealed in part I

Part II

• Who lives in your home?

Name Relationship Age Sex

Well Fairly Poor

How do you get along?

Part II

• If you don’t live with your family, list down the persons you turn to for help

• How do you get along?

Name Relationship Age Sex

Well Fairly Poor

Family APGAR

• Scoring:

• 8-10 points = highly functional family

• 4-7 points = moderately dysfunctional family

• 0-3 points = severely dysfunctional family

FACES

• Family Adaptability and Cohesion Evaluation Scale

• This is an assessment tool based on the Olson’s circumflex model of family function. The patient rates his family on a 30-item questionnaire on a 1-5 scale which measures the adaptability and cohesion of a family.

FES

• Family Environment Scale

• This is a tool developed by Moos which is a 90-item questionnaire used as a research tool to compare health care results with family variables.

Clinical Biographies and Life Chart

• Clinical biographies and life charts make valuable tools because it has the capacity to put side by side significant life and clinical events with their dates of occurrences and make a connection between these facts.

SCREEM

• An important tool to assess a family’s capacity to participate in the provision of health care or to cope with crisis. It makes use of 6 factors which can be considered as resource or as pathology.

SCREEM

Resource Pathology

Social-social interaction is evident among family members-Family members have well-balanced lines of communication with extra-familial social groups

-Isolated from extra-familial-Problem of over commitment

Cultural-cultural pride and satisfaction can be identified

- Ethnic and cultural inferiority

Religious

- Offers satisfying spiritual experiences as well as contacts with an extra-familial support group

- Rigid dogma/rituals

SCREEM

Economic

- Economic stability is sufficient to provide both reasonable satisfaction with financial status and an ability to meet economic demands of normative life events

-Economic deficiency-Inappropriate economic plan

Educational

- Education of members is adequate to allow members to solve or comprehend most problems that arise within the format of the lifestyle established by the family

-handicapped to comprehend

Medical

- Medical health care is available through channels that are easily established and have previously been experienced in a satisfactory manner

- Not utilizing health care facilities/resources

DRAFT

• Draw a Family Test • This is a simple, practical, and cost-

effective tool for assessing family functions that can be administered individually or in-group test.

• Members of the family are given the opportunity to express oneself and consequently reveal innate difficulties within the family system.

DRAFT

• DRAFT has been found to be useful and revealing because of the following reasons:

1.Evasive and guarded patients are more likely to reveal their underlying traits because subjects are more intellectually aware of what they may reveal through verbal communication.

2.The unconscious label which represents adultered basic needs can be expressed through drawing.

3.Drawings are the first to show incipient psychopathology and the last to lose the signs of illness after patient recovery.

Family Assessment Model

I. Family Identification by its:• Composition- family members currently living

in the household, if they are kin or non-kin, and their ages

• Social History- social background of each member regarding education, income, occupation, marital status, ethnicity, and culture

• Community and Neighborhood- the general tone of the neighborhood, its resources and their availability, the affluence or meagerness of the area, and the character of its residents

II. Individual and Family Data

• Health history

• Family dynamics- dysfunction is often reflected in the health status of the family

Family Mapping

• This assessment tool was developed by a psychiatrist-family therapist Salvador Minuchin to facilitate the communication of information about a family system to colleagues through the use of symbols.

Family Mapping

• A double line between two people indicates a functional relationship

• A single line with a break in the middle indicates dysfunction

• Three parallel lines between two people denotes an over-involved relationship where there is plenty of intrusion.

• A solid line perpendicular to the relationship line symbolizes a rigid boundary where the rules are but non-negotiable

• A broken line perpendicular to the relationship lines symbolizes a boundary that is clear but negotiable

• A dotted line perpendicular to the relationship line signifies a boundary that is diffuse or unclear.

• A bracket encompassing several people signifies the presence of a coalition or alliance between these people

[ ]

• An arrow pointing away from the system signifies escape from the system

• An open ended arrow with its open end embracing two individuals and the pointed end pointing to a third signifies that the third person is being triangulated by the conflict between the other two

Thank You!