FAMILY ASSESSMENT Family assessment is the collection of data about the composition of family and relationship among its

members. It is a continuous process of evaluating patterns of interaction between family members relevant to the child health issue. Though family assessment differs from family therapy it can and frequently is therapeutic. Involving family members in discussing family characteristics and activities often stimulates productive discussion and insight into family dynamics and relationship.

CALGARY FAMILY ASSESSMENT MODEL A theoretical foundation for assessing and intervening with families Wright and Leah in 2000 Drawn from systems, cybernetics, communication, change theory, postmodernism. Assumption : Individuals are the best understood within their larger context, which is usually the family. A circular/systemic perspective guides the practitioner to understand the reciprocity between family relationships and health status. Unlike linear perspective, which focuses on individual, the circular/systematic perspective emphasizes relationships and the reciprocal effects that individuals have on each other. A change in one family member affects all others. For instance, a childs diagnosis of chronic renal failure affects the family members. All form of communication is relevant. There is no such thing as not communicatingsilence is communication. Reality is subjective, not fixed or true, and cannot be imposed. Therefore each family members perspective is valid and legitimate and deserves to be heard. Negative labels such as dysfunctional family, noncompliant are observers perspective and is disrespectful of families and do not stimulate thought of how to help family to change. Practitioners are not change agents rather facilitators of change. By creating a context of collaboration and mutual trust with families , the knowledge, expertise, and strengths of both the practitioner and family are honoured and exemplified.

GENERAL GUIDELINES FOR FAMILY INTERVIEW Schedule the interview with the family at a time that is most convenient to all parties.

Include as many family members as possible. a) Engagement stage

Clearly state the purpose of the interview. Begin by asking each persons name and their relationship to client. Restate the purpose and objective of interview. Keep initial conversation general to put members at ease and to learn the big picture of the family and to establish comfort, mutual trust, cooperation. b) Assessment stage

Identify major concerns and reflect these back to the family to be certain that all parties get the same message. Identify the attempted solutions for the problem. Explore the goals family is seeking. c) Intervention stage d) Termination stage

Terminate the interview with summary of what was discussed and a plan for additional sessions if needed.

INDICATION FOR COMPREHENSIVE/DETAILED FAMILY ASSESSMENT 1) Children receiving comprehensive well child care 2) Children with stressful life events-chronic illness , disability, death of a family member. 3) Children requiring extensive home care 4) Children with developmental delays/congenital problems. 5) Children with suspected child abuse 6) Children with behavioural or physical problems that suggest family dysfunction as the etiology. ASSESSMENT OF FAMILY STRUCTURE Family structure refers to composition of family-who lives in the home and the social, cultural, religious and economic characteristics that influence a childs and familys overall health. Principle areas of concern:

1. Family composition 2. Home and community environment 3. Occupation and education of family members 4. Cultural and religious tradition

1) Family composition Primarily concerned with immediate members of the household

(name, age, relationship) Significant extended family support. e.g.:in case of single parent family,if grandparents are important support in child care then they have to be included. Sexual orientation-gay, lesbian, bisexual, heterosexual etc. Rank order of the child-first born/youngest. Previous marriages, death of spouse, divorce, separation. Genogram-family tree/family diagram. Uses symbol to diagrammatically record data about family structure. A genogram is a pictorial display of a person's family relationships and medical history. It goes beyond a traditional family tree by allowing the user to visualize hereditary patterns and psychological factors that punctuate relationships. It can be used to identify repetitive patterns of behavior and to recognize hereditary tendencies.

2) Home and community environment Type of dwelling/house Number of rooms/occupants Sleeping arrangements Number of floors ,accessibility of stairs, elevators

Adequacy of utilities Safety measures (fire escapes, smoke detectors, guardrails on windows) Environment hazards( poor sanitation, pollution, heavy street traffic Availability and location of health facilities, school, play areas Relationship with neighbours Recent crisis or change in home Childs reaction/adjustment to recent stressors

3) Occupation and education of family members Type of employment Work schedule Work satisfaction Exposure to environmental or industrial hazards Sources of income and adequacy Effect of illness on financial status Highest degree or education attained

4) Cultural and religious traditions Religious beliefs and practises Cultural and ethnic beliefs and practices Language spoken in home

POINTS TO REMEMBER: Information elicited in this part are most personal and confidential, include it towards end of the interview when rapport is established. Preferred method-interview technique.

DEVELOPMENTAL ASSESSMENT

Family development is unique path families create. It is shaped by both predictable and unpredictable events such as illness, death etc. Childs individual life cycle takes place within the family life cycle According to Carter and McGoldrick (1999) 2 of 6 stressful stages of family life cycle. 1. Families with young children Adjustment to marriage to make space for children. Joining in child rearing. Financial and household tasks. Realignment of relationship with extended family members to include parenting and grand parenting.

2. Families with adolescent Shift of parent child relationships to permit adolescents to move into or out of the system. Refocus on midlife, marital, and career issues. Beginning of shift towards joint caring for older generation. ASSESSMENT OF FAMILY FUNCTION Family function concerned with how family members behave towards one another and the quality of the relationship. The most important component in determining family health. Requires more skill on the part of the interviewer than does assessment of structure and is best approached after structure is assessed. Usual method for data collection is interview. In addition questionnaire and drawings can also be used for comprehensive assessment.

Methods 1. Family APGAR A brief screening questionnaire to reflect a family members satisfaction with the functional state of the family.

APGAR stands for acronym- adaptation, partnership, growth, affection, resolve. Can be completed in 5 min. Suitable for families with different culture and lifestyle Can be done by children of age 10yrs or older. Separate forms for friends and fellow workers as they form the significant sources of support. The response to 5 question are scored as 2-almost always 1-some of the time 0-hardly ever

A score of 7-10; high functional family.4 to6 moderately functional and 0to3-a severely dysfunctional. A low score in any item-signals family dysfunction. Not recommended for individuals from enmeshed or psychosomatic environment. Patients with asthma, atopic dermatitis, or irritable bowel syndrome may report falsely high scores. Relevant question How many family members aided each other in time of need?

Definition Adaptation use of intrafamilial and extrafamilial resources for problem solving when family equilibrium is stressed during a crisis.

Partnership sharing of decision making and nurturing responsibilities by family members.

In what way have family members received help or assistance from friends and community agencies?

Growth physical and emotional maturation and self fulfilment that is achieved by family members through mutual guidance and support.

How have family members changed during the past years? How has this change been accepted by family members? In what way family members aided each

other in growing or developing independent lifestyle?

Affection-caring and loving relationship that exists among family members.

How have members of your family responded to emotional expressions such as affection, love, sorrow, or anger?

Resolve commitment to devote time to other members of the family for physical and emotional nurturing. It also usually involves decision to share wealth and space.

How do members of your family share time, space and money?

2. Feetham family functioning survey Provides information about family members perception of relationships that contribute to or are affected by family functioning. Recommended primarily as a research instrument, but can also be used in clinical setting. The survey consists of 25 ratings of family functioning (-household task, childcare, sexual and marital relationship, interaction with family, friends,; communityinvolvement, and sources of emotional support.) and two open ended questionnaire. Each question rated on a 7-point scale. Takes less than 10min. Can be used with single parent and two parent family EG:

The amount of time you spend with your spouse? a) How much is there now? b) How much should be there? c) How important is this to me? 3. Kinetic family drawing Involves asking family members to draw their family doing something.

 Offer only general suggestions during encouraging to avoid giving themes. Appropriate for child>4yrs. Focus of KFD-not only family unit but also interaction and activity of each family members. Drawing gives persons perspective of family dynamics and his place in family matrix. Evaluating KFD o o Note omissions of family members. If omitted ask child if everyone is included. Ask child to explain what each member is doing. Encourage to tell as much as possible. Note for signs of physical intimacy or distance. Note placement of people in the drawing; top or bottom. Note facial expression; happy, sad, angry. Note grouping of members.

o o o o

4. Conjoint family drawing Valuable tool in uncovering family dynamics and relationship. Can be used as a learning experience to help well families learn about them. Give family a large sheet of white paper and varied colour pencil/crayon and ask to draw pictures without exchanging pencils. Assess for o o o o o Who initiates drawing? Who uses most or least space? Does anyone infringe on others space? Does someone take lead in organising? Who copies anothers theme?

5. For home assessment of child a) HOME-home observation for management of environment b) Home screening questionnaire.(HSQ)

Some questions require direct observation while some can be answered by parents. For thorough assessment by observing childs development and family interaction at the richest environment-home.

Functional assessment areas Family interaction and roles Refers to ways family members relate to each other. Chief concern-amount of intimacy and closeness among the members, especially spouses. Roles refer to behaviours of people as they assume different status or position. Observe for:

* * *

family members response to each other ( cordial, hostile, cool etc). obvious roles of leadership vs. submission. Support and attention shown to various members. Assessment questions

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What activities do the family perform together? Whom do family members talk to when something is bothering them? What are the members household chores? How easy or difficult is it for family to change or accept new

responsibilities for household task? Power, decision making and problem solving Refers to individual members control over others in the family. Manifested through family decision making and problem solving. Chief concern- clarity of boundaries of power between parents and children. Can assess by giving hypothetical problems.eg; child failing in school. How family will handle this? Assessment questions

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Who usually makes the decision in the family? If one parent makes decision can the child appeal to the other parent to change it? What input do children have in making decisions or discussing rules? Who makes and enforces rules? What happens when a rule is broken?

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Communication Concerned with clarity and directness of communication. Experts in child behaviour management encourage parents to say what you mean and mean what you say , so that child receive clear, direct communication including non verbal. Observe for: * * * * Who speaks to whom? If one person speaks for another or interprets. If member appears disinterested when certain individual speak. If there is agreement between verbal and non verbal messages.

Assessment questions * * * How often do family members wait until others are finished talking? Do parents tend to talk down to children? Do parents or older siblings tend to lecture and preach?

Expression of feelings and individuality Concerned .with personal space and freedom to grow with limits and structure needed for guidance. Observing patterns of communication offers clues to how freely feelings are expressed. Assessment questions * Is it ok for family members to get happy or sad?

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Who gets angry most? What do they do? If someone is upset, how do other family members try to comfort that person? Who comforts specific family members? What is the familys response when someone wants to try out a new job or a new sport?

As per Calgary family assessment model functional assessment has two major division-: 1. Instrumental functioning Includes activities of daily living 2. Expressive functioning Emotional communication Verbal communication Nonverbal communication Circular communication-reciprocal positive and negative communication between individuals Problem solving Roles Influence Beliefs Alliance and coalitions CONCLUSION Working with families is essential in paediatric health care. Most illnesses have a component related to the family-genetic/environmental/social.Children cannot be viewed in isolation from their families, and thus family assessment is a imperative component of paediatric health care.

BIBLIOGRAPHY 1. Fox J A. primary health care of infants, children and adolescents.Mosby:2nd ed. St.Louis.2002.p-10-19.

2. Wong D L, Hockenberry M L. Nursing care of infants and children. Mosby:7th ed.Philadelphia.2003.P-64-81,160-164. 3. Wright L M, Leahey M. Nurses and families. F A Davis co: 4th ed. Philadelphia. 2005.