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TOOLS IN FAMILY TOOLS IN FAMILY ASSESSMENTASSESSMENT
Patient coming in to the clinic with Patient coming in to the clinic with health problem health problem cannot be fully cannot be fully understoodunderstood if only the pathophysiology if only the pathophysiology of medical problem is consideredof medical problem is considered
Family relationship + family social Family relationship + family social system + family cultural system = system + family cultural system = better evaluation & better health carebetter evaluation & better health care
Family systems Family systems approach toapproach to common common clinicalclinical situation can facilitate a new situation can facilitate a new levellevel of understanding of patient’s of understanding of patient’s problemproblem
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.36
Steps in Incorporating Steps in Incorporating Family Systems Approach Family Systems Approach
into Clinical Practiceinto Clinical Practice STEP 1STEP 1
RECOGNIZE FAMILY RECOGNIZE FAMILY STRUCTURESTRUCTURE
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.36
RECOGNIZING FAMILY RECOGNIZING FAMILY STRUCTURESTRUCTURE
know individuals in the familyknow individuals in the family
names, place of residence, specific names, place of residence, specific roles in the family, stage of family in roles in the family, stage of family in family life cycle, significant dates in family life cycle, significant dates in the familythe family
complete a family genogramcomplete a family genogram
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.36
FAMILY GENOGRAMFAMILY GENOGRAM
Very excellent tool in learning about family Very excellent tool in learning about family structurestructure
Records names and roles of each member Records names and roles of each member of the familyof the family
Separates extended family into several Separates extended family into several householdhousehold
Documents medical problems of each Documents medical problems of each member of the familymember of the family
Documents significant dates in the family Documents significant dates in the family historyhistory
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.36
FAMILY GENOGRAMFAMILY GENOGRAM
Graphic representation of following Graphic representation of following components of a family:components of a family:
1. Family Tree1. Family Tree
2. Functional Chart2. Functional Chart
3. Family illness/History3. Family illness/History
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.36
malemale deathdeath
femalefemale index patientindex patient
spontaneous abortionspontaneous abortion marital discord & GFmarital discord & GF
pregnancypregnancy adoptedadopted
cause of deathcause of death marriage and yearmarriage and year
separation & yearseparation & year not marriednot married
conflictual relationshipconflictual relationship distant relationshipdistant relationship
close relationshipclose relationship overly closeoverly close
dominant relationshipdominant relationship marital discordmarital discord
A
2005
1968
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.46
FAMILY TREEFAMILY TREE Must contain 3 or more generations, each
identified by a Roman numeral 1st born of each generation is farthest to
left, with siblings following to right in order of birth
Family name placed above each major family unit
Given names and ages are placed below each symbol
One member of family is of greater medical significance because of an illness (index patient, identified with an arrow)
Date is indicated when chart was developed so ages would be adjusted over time
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.36
FUNCTIONAL CHARTFUNCTIONAL CHART
Gives a more Gives a more dynamic imagedynamic image of family of family Allows one to judge totality of family Allows one to judge totality of family
unit (strengths & weaknesses, ability to unit (strengths & weaknesses, ability to withstand future stressful situations)withstand future stressful situations)
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.36
FAMILY FAMILY ILLNESS/HISTORYILLNESS/HISTORY
Denotes presence of inherited Denotes presence of inherited diseases or familial tendencies diseases or familial tendencies indicating potential problems in the indicating potential problems in the familyfamily
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.36
Ben,43 1942
Maria,78
2003
Salvador,63
2000
Vicenta,52
1996
COLANSE PIEDRA
Berto 48
Celso 46
Erdul,44
Jojo 41
Monch 37
Pepe 35
Gil 32
Samuel 29
Evelyn,49
Erlyn, 23 Mayet, 22 Nina,19
I
II
III
cancer
allergy
cardiac pathology
asthma
Colanse-Piedra Colanse-Piedra FamilyFamily
June 28,2008June 28,2008
↑
Cris, 25 Bert,20 Don, 27
STEP 2STEP 2
UNDERSTANDING NORMAL UNDERSTANDING NORMAL FAMILY FUNCTIONFAMILY FUNCTION
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.37
Basic Family FunctionsBasic Family Functions
Provide support to each otherProvide support to each other
Establish autonomy & independence for Establish autonomy & independence for each personeach person
Create rules governing conduct of family & Create rules governing conduct of family & of individuals within the familyof individuals within the family
Adapt to change in environmentAdapt to change in environment
Communicate with each otherCommunicate with each other
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.37
STEP 3STEP 3
LEARNLEARN TO ASSESS TO ASSESS FAMILYFAMILY STRUCSTRUCTURE AND FUTURE AND FUNCTIONNCTION
IN IN CLINICAL PRACCLINICAL PRACTICETICE
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.39
FAMILY ASSESSMENT FAMILY ASSESSMENT INSTRUMENTSINSTRUMENTS
1.1. Family GenogramFamily Genogram
2.2. Family CircleFamily Circle
3.3. Family MapFamily Map
4.4. Family APGAR by SmilksteinFamily APGAR by Smilkstein
5.5. Clinical Biography and Life EventsClinical Biography and Life Events
6.6. SCREEMSCREEM
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.39
Family Circle
A graphic method
for disclosing dynamics of family interaction using circles.
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.39
FAMILY CIRCLEFAMILY CIRCLE
M OMMY
PAPA
MELVIN
NINABATZ
NANANG
JULIUS
MAYET
Taken from the “Daffodil” case presentation
FAMILY MAPFAMILY MAP
Developed by Salvador Minuchin Developed by Salvador Minuchin (Psychiatrist-Family therapist)(Psychiatrist-Family therapist)
Facilitates communication of Facilitates communication of information about a family system to information about a family system to colleagues so that they can be colleagues so that they can be understoodunderstood
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.50
functional relationshipfunctional relationship
dysfunctiondysfunction
over-involved relationship with plenty of over-involved relationship with plenty of intrusionintrusion
rigid boundary where rules are clear but non-rigid boundary where rules are clear but non-negotiablenegotiable
clear boundary but negotiableclear boundary but negotiable
boundary that is diffuse or unclearboundary that is diffuse or unclear
presence of coalition or alliance between these presence of coalition or alliance between these peoplepeople
escape from the systemescape from the system
third person is triangulated by conflict between third person is triangulated by conflict between the the other 2other 2
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.50
Taken from the “Daffodil” case presentation
FAMILY APGARFAMILY APGAR
Rapid screening test instrument for Rapid screening test instrument for family dysfunctionfamily dysfunction
Has adequate reliability and validity Has adequate reliability and validity to measure individual’s level of to measure individual’s level of satisfaction about family satisfaction about family relationshipsrelationships
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.40
FAMILY APGARFAMILY APGAR
AA ADAPTATIONADAPTATION PP PARTNERSHIPPARTNERSHIP GG GROWTHGROWTH AA AFFECTIONAFFECTION RR RESOLVERESOLVE
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.40
ADAPTATIONADAPTATION Capability of family to utilize & share inherent Capability of family to utilize & share inherent
resources (intra/extra-familial)resources (intra/extra-familial)
PARTNERSHIPPARTNERSHIP Sharing of decision-making; measures satisfaction Sharing of decision-making; measures satisfaction
attained in solving problems by communicatingattained in solving problems by communicating
GROWTHGROWTH Physical & emotional growth; measures satisfaction of Physical & emotional growth; measures satisfaction of
available freedom to changeavailable freedom to change
AFFECTIONAFFECTION How love, anger, hatred are shared between How love, anger, hatred are shared between
members; measures members’ satisfaction with members; measures members’ satisfaction with intimacy & emotional interaction existing in the familyintimacy & emotional interaction existing in the family
RESOLVERESOLVE How time, money, space are shared; measures How time, money, space are shared; measures
members satisfaction with commitment by other members satisfaction with commitment by other members of familymembers of familyPineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.40
When is Family APGAR When is Family APGAR needed?needed?
1.1. When family is directly involved in When family is directly involved in caring for the patientcaring for the patient
2.2. When treating a new patient in When treating a new patient in order to serve as general view of order to serve as general view of family functionfamily function
3.3. When treating a patient whose When treating a patient whose family is in crisisfamily is in crisis
4.4. When patient’s behavior makes you When patient’s behavior makes you suspect a psychosocial problem suspect a psychosocial problem possible due to family dysfunctionpossible due to family dysfunction
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.40
ALMOST ALMOST ALWAYSALWAYS
Score = Score = 22
SOME OF SOME OF THE THE TIMETIME
Score = Score = 11
HARDLY HARDLY EVEREVER
Score = Score = 00
AA I am satisfied that I can I am satisfied that I can turn my family for help turn my family for help when something is when something is troubling metroubling me
PP I am satisfied with the way I am satisfied with the way my family talks on things my family talks on things with me & shares with me & shares problems with meproblems with me
GG I am satisfied that my I am satisfied that my family accepts & supports family accepts & supports my wishes to take on new my wishes to take on new activities or directionactivities or direction
AA I am satisfied with the way I am satisfied with the way my family expresses my family expresses affection & responds to affection & responds to my emotion such as my emotion such as anger, sorrow & loveanger, sorrow & love
RR I am satisfied with the way I am satisfied with the way my family and I share time my family and I share time togethertogether
Parameters
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.41
SCORING:SCORING:
8 – 108 – 10 HIGHLY FUNCTIONALHIGHLY FUNCTIONAL
4 – 74 – 7 MODERATELY DYSFUNCTIONALMODERATELY DYSFUNCTIONAL
0 – 30 – 3 SEVERELY DYSFUNCTIONALSEVERELY DYSFUNCTIONAL
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.41
CLINICAL CLINICAL BIOGRAPHY &BIOGRAPHY & LLIFE IFE EVENTSEVENTS
Valuable tools which can facilitate Valuable tools which can facilitate analysis of connectionanalysis of connection
Individual’s experiences with health Individual’s experiences with health and sickness are connected with his and sickness are connected with his personal lifepersonal life
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.48
Example (taken from “Daffodil” case Example (taken from “Daffodil” case presentation)presentation)
1982 - Childhood years 1982 - Childhood years 1983 - Sibling Rivalry1983 - Sibling Rivalry1990 - “ First love”1990 - “ First love”
- Financial Difficulties- Financial Difficulties1992 - Sexually Violated1992 - Sexually Violated19971997 - Met Bobby - Met Bobby Common-law relationshipCommon-law relationship1999 - 21999 - 2ndnd pregnancy pregnancy2000 - 32000 - 3rdrd pregnancy pregnancy - Resignation of Bobby- Resignation of Bobby2001 - “Guest Relations Officer”2001 - “Guest Relations Officer”
2002 - “New boyfriend” 2002 - “New boyfriend” 4 4thth pregnancy pregnancy
2004 - 52004 - 5thth pregnancy pregnancy - Reconciliation with Bobby- Reconciliation with Bobby
2005 - Financial problems2005 - Financial problems
2006 - Vaginal bleeding2006 - Vaginal bleeding - Hospitalized - Hospitalized Cervical Cancer Cervical Cancer
SCREEMSCREEM Important as to assess family’s Important as to assess family’s
capacity to participate in provision capacity to participate in provision of health care and its capacity to of health care and its capacity to cope with crisis cope with crisis
Pineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.48
SCREEMSCREEMRESOURCERESOURCE
SSOCIALOCIAL
Social interaction is evident among family members. Social interaction is evident among family members. Family members have well-balanced lines of Family members have well-balanced lines of
communication with extra-familial social groups.communication with extra-familial social groups.
CCULTURALULTURAL
Cultural pride or satisfaction can be identified, Cultural pride or satisfaction can be identified, especially in distinct ethnic groups.especially in distinct ethnic groups.
RRELIGIOUSELIGIOUS
Religion offers satisfying spiritual experiences as Religion offers satisfying spiritual experiences as well as contacts with an extra-familial support well as contacts with an extra-familial support
group.group.
EECONOMICCONOMIC
Economic stability is sufficient to provide both Economic stability is sufficient to provide both reasonable satisfaction with financial status and an reasonable satisfaction with financial status and an ability to meet economic demands of normative life ability to meet economic demands of normative life
events.events.
EEDUCATIONDUCATION
ALAL
Education of family members is adequate to allow Education of family members is adequate to allow members to solve or comprehend most of the members to solve or comprehend most of the
problems that arise within the format of the life style problems that arise within the format of the life style established by the familyestablished by the family
MMEDICALEDICAL
Health care is available through channels that are Health care is available through channels that are easily established and have previously been easily established and have previously been
experienced in a satisfactory mannerexperienced in a satisfactory mannerPineda, Alejandro Jr.. Proceedings of the Orientation Course in Family Medicine.p.48