Family tools complete

Family Assessment Tools for Family Medicine Physician. Techniques use for assessment of a patient.

1. FAMILY ASSESSMENT TOOLS Tabaranza, Brigitte Ulrike MD

2. 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.

3. Family Practice The medical specialty that provides a continuing and comprehensive health care for the individual and the family. ( Rakel , 1998, 2011) To heal a patient, one has to understand his/her inner world – the values he/she lives by; his thoughts, feelings, and fears, and his/her perception of the illness and its effects on his life. ( McWhinney , 1997). The management of illness requires a consideration of personal and religious beliefs; social, economic or cultural problems; personal feelings and expectations; and the patient’s family. (There is a recognition of the effects of these factors on the patient’s illness).

4. Relationship between families and their physician is a powerful vehicle for influencing patients about issues regarding health and illness Thus a good family assessment is needed in order to promote a working alliance

5. FAMILY ASSESSMENT TOOLS Designed for family physicians to have a systematic way of understanding the family and to aid them in evaluating the impact of illness on a person and on his/her role in the family.

6. 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

7. Step 2 Understand the normal family function

8. 5 Basic Family Functions Provide support to each other Establish autonomy and independence for each person in the system Create rules that govern the conduct of the family and its members Adapt to change in the environment Communicate with each other

9. 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.

10. Dysfunctional Family Defined as a family with chronic inability to respond to the needs or to cope with changes and stresses in the environment

11. 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.

12. Family Assessment Tools ANATOMY Genogram DEVELOPMENT Family Life Cycle FUNCTION APGAR Family Map Lifeline SCREEM

13. Different Family Assessment Tools Family Genogram Family Map Family APGAR SCREEM SCREEM Family Resource Survey (SCREEM-Res) Family Lifeline Family Life Cycle Ecomap

14. FAMILY GENOGRAM Can be used to gather data about an individual, couple or family, especially on inheritance patterns, family illnesses, family members, family structures and emotional processes over time. It is a compulsory part of the patient’s chart because it provides: A way to visually overlay biomedical and psychosocial information. Quick overview of the family members and relationship. A study tool for gaining a comprehensive understanding of mutigenerational family systems ( pineda , 1999).

15. Family Genogram 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

16. Family Genogram 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

17. 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

18. 3. Family Illness/History This indicates the presence of heredofamilial diseases in which potential problems in the family can arise.

19. FAMILY GENOGRAM The names and ages of all family members The exact dates of births, marriage, separation, divorce, death and other significant life events. Information covering 3 or more generations Family Illness The firstborn of each family to the left with other siblings sequentially to the right. Indication of which members live together in the same household. The names of 2 families with the address of the index family The informant/s Significant Dates and date the Genogram was generated

20. Sample Genogram

21. Sample Genogram with Interaction Pattern Between People

22. Family Map A tool designed to reflect family relationships and interaction patterns. This application is use for the communication of information about the family system and its dynamics in order to address psychosocial issues. It also provides a schematic description on whom to ask for assistance in making decisions for the patient.

23. Tools That Explores Family Processes ENMESHMENT – one has to explore whether family members seldom act independently or get over involved with each other. DISENGAGEMENT – one has to explore whether family members are isolated from each other or have little emotional response from each other.

24. Tools That Explores Family Processes TRIANGULATION – one has to explore whether the family member talks directly to each other about personal matters. COALITION – one has to explore whether one member of the family is siding with another member.

25. Samples Family Map Mother Father Patient (Identified)

26. APGAR It is a tool that qualitatively measures family functioning. It is a 10 to15-minute paper and pencil technique that elicits the patient’s perception and level of satisfaction on the current state of her family member’s relationships ( Smilkstein , 1978) This is a 5 item questionnaire designed to elicit the patient’s perception of the current state of his family relationships and which serve as a rapid screening instrument for family dysfunction.

27. APGAR DESCRIPTION A Adaptation The capability of the family to utilize and share inherent resources. P Partnership Measures the satisfaction attained in solving problems by communication. G Growth Refers to the freedom of change both physical and emotional growth. A Affection It is the intimacy and emotional interaction in the family. R Resolve The member’s satisfaction with the commitment made by other members of the family.

28. 4 Basic Situations where the Family APGAR is needed When the family will be directly involved in caring for the patient. When treating a new patient in order to get info 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.

29. Family APGAR is also valuable in the following conditions or situations: Symptoms that manifest themselves as psychosomatic disorders. Difficult patients Marital or sexual difficulties Multiple presentations by multiple family members Drug or alcohol abuse Evidence of sexual and physical abuse on wife or a child Multiple presentations of a family member –”The thick file syndrome”

30. Family APGAR Part I Questionnaire

31. Filipino Family APGAR Part I Palagi (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.

32. 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

33. Family APGAR Part II Questionnaire Who Lives in your home? How do you get along? Name Relationship Age Sex Well Fairly Poor If you don’t live with your family, list the persons to whom you turn to for help. How do you get along? Name Relationship Age Sex Well Fairly Poor

34. APGAR Scoring

35. Limitations of the Tool The data obtained is restricted to what the patient is willing to disclose about himself/herself and his family. The tool measures the patient’s satisfaction with his family’s functioning but not the family functioning itself (Lisordra-krings,1995)

36. SCREEM It is an acronym that represents family resources and is a tool where the family physician helps the family members identify and assess their resources to meet a crisis. If there is a lack of resources, it can also serve as a kind of pathology in certain situations. Relationships of health behavior, practices and utilization of health services and barriers to patient care.

37. SCREEM It is commonly used when the need for care is long or lasts a lifetime such as in the case of chronically-ill, terminally-ill, and hospice care patients. It can also be used to assess resources of difficult and non-compliant patients.

38. SCREEM

39. SCREEM Family Resource Survey (SCREEM-RES) It is a 12 item self-administered family resources questionnaire in Filipino based on SCREEM. It is a appropriate in assessing the family’s capacity to participate in the provision of health care or to cope with crisis ( Corales & Medina, 2011). The format of the tool is user-friendly and therefore, apt for a doctor in a busy Family Practice.

40. SCREEM Family Resource Survey (SCREEM-RES) Family caregivers are asked to choose one of the following rsponses : Strongly disagree Disagree Agree Strongly Agree The interpretation of SCREEM-RES is similar to the Family APGAR where the sum of the scores is interpreted (Medina et al. 2011) : 0-6 = means the family has severely inadequate family resources. 7-12 = moderately inadequate family resources . 13-18 = adequate family resources

41. SCREEM-RES Questionnaire

42. SCREEM-RES Questionnaire

43. Family Lifeline It is a tool that summarizes the history of the family, particularly the individual or the family’s significant experiences over a period of time in a chronologically-sequenced manner, and includes how the family has coped with these stressful life events. The interpretation is based on the most significant event that probably affected the health of each member or influenced the health-seeking behavior or perception on health of the individual or the family.

44. Family Lifeline Is used to show the family’s significant events over a period of time in a chronological sequence It includes normative and non normative crisis It is sometimes placed side by side with the illness history It helps process how flexible a family is when dealing with these changes

45. Family Lifeline Sample

46. Family Life Cycle This is a description of the family dynamics through clearly defined stages of development. It provides a predictable and chronological sequence of events in the family’s life, which can be related to clinical events and to the health maintenance of family members.

47. Family Life Cycle STAGES TASKS TO BE ACHIEVED HEALTH IMPLICATIONS Leaving Home (Unattached Adult) Establishing personal independence. Beginning emotional separation from parents. Episodic medical problems -STDs -Unwanted pregnancy Newly Married Couple -Establishing an intimate relationship with spouse. -Developing further the emotional separation from parents. -Early pregnancy -STDs -Infertility -Gynecologic problem Learning To Live Together -Dividing the various marital roles in an equitable way. -Establishing a new, more independent relationship with family -Early pregnancy -STDs -Infertility -Gynecologic problem Family with Young Children -Opening the family to include a new member. -Dividing the parenting roles. -Accidents and p oisoning -Mental Retardation -Behavioral Problems Family with Adolescent I ncreasing the flexibility of the family boundaries to allow the adolescent(s) to move in and out of the family system. -Drug and other substance abuse -STDs and gynecological problems -Skin diseases -Circumcision -Menstrual problems Launching Family -Accepting the multitude of exits from and entries into the family system. -Adjusting to the ending of parenting roles. -Pre/Postmenopausal Syndromes -Degenerative Diseases -Malignancies Retirement -Adjusting to the ending of the wage-earning roles. -Developing new relationships with children, grandchildren and each other. -Degenerative diseases -Chronic Illnesses -Malignancies -Gynecologic/Urologic Problems Old Age -Dealing with lessening abilities and greater dependence on others. -Dealing with losses of friends, family members and, eventually, each other. -Degenerative diseases -Chronic Illnesses -Malignancies -Gynecologic/Urologic Problems

48. Family Life Cycle

49. ECOMAP It is a pictorial representation of a family’s connections to persons and/or systems in their environment. It’s purpose is to support classification of family needs and decision making about potential interventions, and it is to create shared awareness of the family’s significant connections and the constructive influences those connections may be having.

50. ECOMAP It can illustrate 3 separate dimensions for each connections: IMPACT of the connection QUALITY of the connection STRENGTH of the connection

51. ECOMAP is Necessary & Valuable because it: Enables a structured, consistent process for gathering specific, valuable information related to the current state of a family or individual being assessed. Supports the engagement of the family in a dialogue. Identifies and illustrates strengths that can built upon and weaknesses that can be addressed. Summarizes complex data and information into a visual, easy to see and understand format to support understanding and planning. Illustrates the nature of connectedness and the impact of interactions in pre-defined “domain” areas. Provides a consistent base of information to inform and support intervention decisions. Allows objective evaluation of progress. Helps support integration of the concept of family assessment as an ongoing process. Reduces narrative in other parts of the family assessment process. Integrates the values and concepts in a practical way.

52. Rules in Drawing the Ecomap At the center of the ecomap , a simplified view of the target family members in the household should be depicted, using Genogram symbols and conventions. The intent is for each individual in the household to be addressed. There are some domains that will, for some families, apply at the household level, or for all individuals in the family. Each individual can be “brought out of the center” into its own circle and then domains that need to be addressed for the individual can be. If a family or an individual is so complex that the ecomap becomes messy, you can illustrate any individual or household on its own.

53. Rules in Drawing the Ecomap Illustrate the existence of a connection and the strength of it. Illustrate the impact of a connection, place an arrow on the end of the line indicating whether resources and energy are flowing to a person or away from a person. If a connection is stressful, illustrate with a jagged line superimposed on the connection line. Brief summary comments may be written inside the domain circles. Domains should be identified on the ecomap .

54. Sample Ecomap

55. Other Family Assessment Tools Draft (Draw a Family Test) The Family Circle

56. 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.

57. DRAFT Foundto 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.

58. Draw a Family Test It tells a lot about the patient’s feelings, relationships they have with people around, self-esteem and intellectual problems. a very informative method of getting to know the patient especially when working with kids.

59. Family Circle A brief, graphic method for disclosing, gathering and discussing family dynamics as discussed by one or more family members Are often used in individuals but they can be applied to small groups Through this tool one can assess openness, boundaries, support, function, triangulation and interdependence in the family Difficulty of interpretation and standardization poses as a disadvantage.

60. Family Circle Me Mama Pesh Mama chuchi Chok Ja Kuya Nel Dex Arra Erin Ate Tere Rihanne

61. Levels of Family Involvement Lastly, it is essential for family physician to know how far they can go in assessing family dynamics and their relation to health care. Doherty et al. (1999) created a model of the five levels of involvement with families.

62. Five Levels of Family Involvement Level I: Minimal emphasis on the family in the delivery of health care Level II: Ongoing medical information and advise. Level III: Feelings and support. Level IV: Assessment of family dysfunction and provision of intervention. Level V: Family Therapy.

63. Thank You