FAMILY ASSESSMENT TOOLS DEPARTMENT OF PUBLIC HEALTH PREVENTIVE

FAMILY ASSESSMENT TOOLS DEPARTMENT OF PUBLIC HEALTH & PREVENTIVE MEDICINE FACULTY OF MEDICINE, UNIVERSITAS PADJADJARAN 2013

LEARNING OBJECTIVES • Describe the advantages for assessing family (C 2) • Define the family genogram, family map, family APGAR and its function (C 2)

WHY DO WE NEED TOOLS TO ASSESS THE FAMILY? • assess family functioning • assess family dynamic • assess coping mechanisms of the family • assess resources • assess family structure

Why do we Need tools to Assess the family? • to have a picture of the multigenerational patterns of behavior or illnesses. • to assess the normal crisis or common illness to be encountered in each stage of development. • to provide anticipatory care and guidance.

An understanding of the family in terms of the struggles to be functional will enable FP to make correct diagnosis and intervention

FAMILY DYNAMICS • An interactions and relationships among the individual members of a family • Reflects and influence the physical, mental and spiritual health of the individuals in a family.

FAMILY DYNAMICS • An understanding of the dynamics helps the attending family physician to diagnose the disease and dis-ease in the patient sitting in his consultation room and to recognize the factors that may help or retard the recovery of this patient.

FAMILY ASSESSMENT TOOLS Anatomy • Genogram Development Function • Family life cycle • APGAR • Family Map • Lifeline • SCREEM Impact • BATHE

GENOGRAM Is a biopsychosocial family tree. It records the family in its life cycle, family illnesses and relationship A genogram is a versatile clinical tool that can help FP integrate a patient’s family information into the medical problem-solving process for better patient care

• A genogram supplements the problem list giving FP an overview of the main problems affecting the family over 3 or more generations • A genogram can be drawn in skeletal form during one of the first few visits, ideally the first visit and then it can elaborated during subsequent visits as more is known about the family

GENOGRAM COMPONENTS Symbols Standardized Symbols used in Family Genograms male female d date of divorce D Date of death abortion or miscarriage Sex not specified Deceased/death A Adopted female b date of birth m date of marriage Induced abortion Pregnancy-child in utero Dizygotic twins Monozygotic Twins

STANDARDIZED SYMBOLS USED IN FAMILY GENOGRAMS Symbols of diseases or situation Obesity ♥ ♥ Allergy xxx Alcoholism Asthma Hypertension Heart disease Stroke Depression War Casualty

COMMONLY USED ABBREVIATIONS ALC Alcoholic GI GI tract disease ALL Allergy HT Hypertension MI Myocard Infarction ARTH Arthritis CAD Coronary Artery Disease CVA Cerebrovascular Accident CA DEP Cancer DM Diabetes mellitus Depression MVP Mitral Valve Prolapse PUD Peptic Ulcer Disease SLE Systemic Lupus Erythematosis TB Tuberculosis

STANDARDIZED SYMBOLS USED IN FAMILY GENOGRAMS 1989 Close relationship married and year Family living together 1990 1992 Separation and year Divorce and year 1989 Unmarried relationship Conflictual relationship Distance relationship 1989 1992

Bakri, as of 8 April 2010 1. Symbols 2. Three or more generations 3. The name of family 4. A listing of the first born of each family to the left, with siblings listed sequentially to the right 5. The names of all family member 1969 I II III Ardi, 68 1970 Nia, 64

6. Age or year of birth of all family members 7. Any deaths, incl. age of death and cause 8. Dates of marriages and divorces 9. Significant diseases or problems of family members 10. Indication of members living together in the same household 11. A key depicting all symbols used 12. Symbols selected for simplicity and maximum visibility

FAMILY INFORMATION IS USED IN 3 TYPE SITUATIONS: 1. Evaluating somatic complaint by testing biopsychosocial hypotheses 2. Assessing a patient’s risk for biomedical and mental disorders 3. Planning management by considering how family factors may facilitate or complicate it

USES OF THE GENOGRAM (CROUCH AND DAVIS, 1987) • Allowing the family physician and other health professional to review quickly the family situation • Building rapport by using the first names of family members, knowing who is living in the home • Identifying at a glance significant risk factors : Hypertension, DM, Ca, Obesity etc • Recognizing the need for screening in patients who at high risk • Promoting lifestyle changes and health education (healthy living) • Demonstrating that family relationship are a concern of the family physician and important to the health of each family member

Relationship of the members This is a self-drawing by an 8 year old girl who participated in a support group for children affected by domestic violence sponsored by Cedar Valley Friends of the Family. One cannot escape sensing this child's unhappiness; the frown she drew on her little face clearly sets the mood. However, the up-sidedown rainbow is perhaps the most significant message. . . Generally, we think of rainbows as a happy reminder of hope for the future. In this simple drawing, the little girl innocently, but quite vividly

FAMILY MAP Genogram : 24 January 2008 Ani Sugeng myoma 84 AMI 43 60 Utomo Sri 58 DM CA Colon/Renal 54 FAM Arti Putro Lung Ca 1959 48 44 Tyio Tuti 84 44 Nina Sam 46 20 16 Aria Imam

APGAR • This is a five-item questionnaire designed to elicit the patient’s perception of the current state of his family relationships, and serves as a rapid screening instrument for family dysfunction.

APGAR • Adaptation is the capability of the family to utilize and share inherent resources • Partnership is sharing of decision making. This measures the satisfaction attained in solving problems by communicating. • Growth refers to both and emotional growth. This measures the satisfaction of the availability freedom of change

APGAR • Affection is how emotions like love, anger and hatred are shared between members. This measures the members’ satisfaction with intimacy and emotional interaction that exist in the family. • Resolve refers to how time, space and money are shared. This measures the members’ satisfaction with the commitment made by other members of the family.

• 8 -10 point (Highly functional family) • 4 -7 point (Moderately dysfunctional family) • 0 -3 point (Severely dysfunctional family)

BATHE TECHNIQUES (STUART AND LIEBERMAN’S) • 15 minutes method of primary care counseling • It helps draw out the quiet patient and provides a structure of when to move on in a talkative patient B = Background A = Affect T = Troubling H = Handling E = Empathy

• B = Background : assessing what’s the background situation (areas of psychological problems) • “How are things at home? ” At work? • What’s different in your life between now and before? • A = Affect = the patient’s affect (about common areas generating strong feelings) • “How do you feel about your home life? ” • “How do you feel about your work/school? ”

• T = Troubling: the problem that is most troubling for the patient • “What most worries you about your life? ” • “How stressed are you by this problem? ” • “What do you think this problem means to you? ” • H = Handling: the manner in which the patient has been handling the problem, problems are often mishandled life difficulties • “How are you handling the problems in your life? ” • “What have you tried to solve the difficulty? ” • “How much support are you getting at home/work? ” • “Who gives you support for dealing with problems? ”

• E = Empathy : respons that conveys empathy, express understanding of the patient’s distress • “I can understand that you would feel angry” • “That must have been difficult” • “This is a tough situation to be in”

THANK YOU… 1. Rakel RE. The Family Genogram. In Rakel RE. Textbook of Family Practice. Sixth Edition. WB Saunders Co. Philadelphia. 2002. pp 19 – 30. 2. Lee Gan, Azwar. A, Wonodirekso. Family Medicine Practice. Singapore, 2004. section 3 chapter 3 pp 5862