TOOLS FOR FAMILY ASSESSMENT
JI Veridiano, Ofelia S.
Family Medicine and Community Health
Fatima University Medical Center
April 2010
Introduction
Every patient that we encounter is a member of a family and a physician
must always keep in mind that the way a patient reacts to an illness will depend a
lot on his family. Several investigators have hypothesized that in treating a
patient, one must treat also the family as a unit to yield a more certain diagnosis,
a better medical outcome, and even prevent diseases. With this, it will depend on
the family physician as to up to what level he will involve a patient’s family to
evaluate his problem.
Overview of Family Systems Medicine
As a family physician, one must always view a patient’s problem in multiple
context meaning that one does not only consider the pathophysiology of a certain
disease but should also consider and evaluate family relationships, family social
and cultural systems to provide better health care. This is the primary goal of
Family Systems Medicine which will lead to a better understanding of a patient’s
condition.
Incorporating a Family Systems Approach into Clinical Practice
To be able to incorporate a family systems approach into clinical practice,
the family physician must be able to understand first the basic concepts of family
structure and function.
This is a three-step process which is as follows:
Step 1- RECOGNIZE THE FAMILY STRUCTURE
In order to understand the family, one must first know the individual
members of it. The following information must be obtained: names of each family
member, place of residence, specific roles in the family, stage of the family in the
family life cycle, and significant dates in the family.
A systematic way of obtaining and recording this information is through the
use of a Family Genogram which is a scheme or a graphic representation of both
the genetic pedigree of a family and key psychosocial and interactional data using
standardized symbols.
a. 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
b. 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
c. 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
The 5 basic family functions are:
1. Provide support to each other
- Can be in the form of physical, emotional, social, or financial
- There is a sense of belongingness when family members do things
together as one
2. Establish autonomy and independence for each person in the system to
enhance personal growth of individuals within the family
- Each individual has defined roles to play within and outside the
family
- The essence of autonomy is to be able to maintain the integrity of
each individual
3. Create rules that govern the conduct of the family and of individuals
within it
- Deals with interaction patterns, authority, and decision-making
- These are mostly unwritten rules of behaviors that becomes
apparent when an outsider visits the family
4. Adapt to change in the environment
- Essential in order to progress from one stage of the family life
cycle to another
- There are two types of changes: First order and Second order
- The first order change involves adaptation to environmental
changes that requires minimal change in the family structure
- The second order change involves fundamental changes in the
family structure
5. Communicate with each other
- Mostly verbal, non-verbal, and implied messages
FUNCTIONAL FAMILY- is 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
It has been the standard medical practice to meet the family as a unit in
instances when a patient is rushed to the emergency room with a life-threatening
condition, a patient with a chronic illness, and even death of a family member.
Oftentimes the family physician is unprepared to assemble family
members for assessment. Thus, family assessment tools have been made to aid
the family physician in assessing the family structure and function in clinical
practice.
Family Assessment Instruments
1.
2.
3.
4.
5.
6.
7.
8.
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 GENOGRAM
A family genogram is a graphic representation of a family tree that displays
detailed data about the relationships among individuals in a family. It goes
beyond the traditional family tree by allowing the user to analyze hereditary
patterns and psychological factors that punctuate these relationships.
Genograms allow a therapist and his patient to 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. It also maps out relationships and
traits that may otherwise be missed on a pedigree chart.
The family genogram is an excellent tool to learn about the family structure but
has limited role in assessing the family functions. It contains the following
informations:
1. Names, gender, date of birth, date of death, and roles of each family
member
2. Divisions of an extended family into several households
3. Medical problems and chronic illnesses of each family member
4. Significant dates in the family history
5. Subtle information about the family
6. Nature of the family relationships
Genograms can vary significantly because there is no limitation as to what type of
data can be included.
FAMILY CIRCLE
Family circles are often used on individuals and in some small groups. A
large circle is drawn by the family physician on a piece of paper who then gives
instructions 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.
The circles can be small or large depending on the person’s significance or
importance to the patient.
An advantage of this tool is that the physician can leave the patient to
accomplish this and see other patients. But because this is subjective, difficulty of
interpretation and standardization poses as a disadvantage.
Dex
Mama Pesh
Mama
chuchi
Arra
Rihanne
Me
Ja
Kuya Nel
Chok
Erin
FAMILY APGAR
Ate Tere
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. As this is only a 5-item questionnaire, it requires little time to
complete.
APGAR stands for:
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
There are 4 basic situations wherein the Family APGAR is needed:
1. When the family is directly involved in caring for the patient.
2. When treating a new patient in order to get information to serve as general
view of family function
3. When treating a patient whose family is in crisis.
4. When a patient’s behavior makes you suspect a psychosocial problem
possibly due to family dysfunction.
FAMILY APGAR QUESTIONNAIRE PART I
Part I- Helps define the degree of the patient’s satisfaction or dissatisfaction with
family function
Almost Some
always
of
(2)
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 QUESTIONNAIRE PART I
Sagutin ang mga sumusunod ayon sa relasyon ninyong mag-anak
Palagi
(2)
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
Paminsanminsan
(1)
Halos
hindi
(0)
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
FAMILY APGAR QUESTIONNAIRE PART II
Who lives in your home?
Name
Relationship
How do you get along?
Age
Sex
If you don’t live with your own family,
list the persons to whom you turn to
for help
Name
Relationship
Age
Sex
Sino-sino ang nakatira sa inyong tahanan?
Well
Fairly
Poor
How do you get along?
Well
Fairly
Poor
Paano ang inyong relasyon?
Pangalan
Relasyon
Edad Kasarian
Kung hindi ka nakakahingi ng tulong sa iyong
sariling pamilya, kani-kanino ka humihingi
ng tulong?
Pangalan
Relasyon
Edad Kasarian
Mabuti
Hindi
gaanong
mabuti
Hindi
mabuti
Paano ang inyong relasyon?
Mabuti
Hindi
Hindi
gaanong mabuti
mabuti
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
It is believed that an individual’s personal experiences with issues regarding
health and sickness are connected with his personal life; therefore a family
physician must be able to understand and see the connection why certain
individuals get sick more often than others and correlate it with the patient’s life
story. This is why 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
Screem is 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.
Resource
Social
Pathology
- Social interaction is evident
among family members
- Well-balanced lines of
communication with extrafamilial social groups such
as friends, sports, clubs,
and other community
groups
- Isolated from extrafamilial groups
- Problem of overcommitment
- Cultural pride and
satisfaction can be
identified especially in
distinct ethnic groups
- Ethnic/cultural
inferiority
- Offers satisfying spiritual
experiences as well as
contacts with extra-familial
support group
- Rigid dogma and
rituals
- 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
- Education of family
members is adequate to
allow members to solve or
comprehend most of the
- Handicapped to
comprehend
Cultural
Religious
Economic
Educational
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
- Not utilizing health
care
facilities/resources
DRAFT (Draw a Family Test) by R. Cruz MD and A. Pineda MD
This is a simple, practical, and cost-effective tool for assessing family
functions that can be administered individually or in-group test. It is a projective
technique that does not only provide clues on personalities of family members
but also serves as a diagnostic device. In this test, members of the family are
given the opportunity to express oneself and consequently reveal innate
difficulties within the family system.
The family is seated around a table and each member is given a blank paper
and pencil. They will be then instructed to draw their family and its members and
their whole bodies. These drawing would be then analyzed by a Clinical
Psychologist based on Draw-A-Person test and Kinetic Family Drawing.
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:
a. Composition- family members currently living in the household, if
they are kin or non-kin, and their ages
b. Social History- social background of each member regarding
education, income, occupation, marital status, ethnicity, and
culture
c. 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
a. Health history
b. 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.
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 overinvolved 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