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 patients family to evaluate his problem.

Family Systems Medicine

The primary goal of Family Systems Medicine is to view the patients 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 familys 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 Family
as of April 11, 2010 Project 4, Quezon City

1943

1947

Constantino, 64 2006

Mila Fatima 47 1994

1967

1964 1968 1970

1965

1982

2007

Thess 42

Nel 45

May 39

Jojo 44

1973

1971

Peng 27

Ruptured aneurysm Heart failure Hypertension Bronchial Asthma

Chok 36

2005

Tere 38

Ja 4

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
Dex

Mama Pesh

Mama chuchi Rihanne Me

Arra

Ja Chok

Kuya Nel

Erin

Ate Tere

Family APGAR
This is a 5-question assessment tool used for rapid assessment of family function and dysfunction. It measures an individuals 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 extrafamilial 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 patients behavior makes you suspect a psychosocial problem possibly due to family dysfunction.

FAMILY APGAR QUESTIONNAIRE PART I

Helps define the degree of the patients satisfaction or dissatisfaction with family function

Part I
Almost always (2) Some of the time (1) Hardly ever (0)

A P G A R

I am satisfied that I can turn to my family for help when something is troubling me. I am satisfied with the way my family talks about things with me and shares problems with me. I am satisfied that my family accepts and supports my wishes to take on new activities or directions. I am satisfied with the way my family expresses affection and responds to my emotions such as anger, sorrow, and love. I am satisfied with the way my family and I share time together.

Filipino Family APGAR Part I

Palagi( 2) Paminsa nminsan (1) Halos hindi (0) A Akoy nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema. Akoy nasisiyahan sa paraang nakikipagtalakayan sa akin ang aking pamilya tungkol sa aking problema. Akoy nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais na gawin patungo sa mga bagong landas para sa aking ikauunlad. Akoy nasisiyahan sa paraang ipinadadama ng aking pamilya ang kanilang pagmamahal at nauunawaan ang aking damdamin katulad ng galit, lungkot, at pag-ibig. Akoy nasisiyahan na ang aking pamilya at ako ay nagkakaroon ng panahon sa isat-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

How do you get along? Well Fairly Poor

Part II
If you dont live with your family, list down the persons you turn to for help
Name Relationship Age Sex

How do you get along?

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

Pathology
-Isolated from extra-familial -Problem of over commitment

Cultural
-cultural pride and satisfaction can be identified Religious - Offers satisfying spiritual experiences as well as contacts with an extra-familial support group

- Ethnic and cultural inferiority

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

-handicapped to comprehend

- Not utilizing health care facilities/resources

DRAFT
Draw a Family Test This is a simple, practical, and costeffective tool for assessing family functions that can be administered individually or ingroup 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 nonnegotiable

 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!