FAMILY MEDICINE

A medical specialty centered on the family as a

basic social unit. It is not only disease-oriented
but health-oriented which emphasizes on the
importance of disease prevention, health
maintenance and curative medicine.
FAMILY ASSESSMENT TOOLS

1. Family Genogram
2. Family APGAR
3. Family Circle Technique
4. SCREEM
5. Minuchin’s Family Map
6. Family Lifeline
7. Ecomap
8. Family Life Cycle
FAMILY GENOGRAM

• Uses:
• A quick overview of the interrelationships
between family members
• A way of looking at the medical and
psychosocial problems
• As a tool for understanding the
multigenerational family systems
HOW TO CONSTRUCT A FAMILY GENOGRAM
Make a family tree using the standard symbols
HOW TO CONSTRUCT A FAMILY GENOGRAM
Family Interaction Patterns
FAMILY GENOGRAM

Hypertension

Kidney stones

Bronchial asthma

Atopic Dermatitis

PTB
 FAMILY GENOGRAM
Each
generation is
identified by
a Roman
numeral.

Hypertension

Kidney stones

Bronchial asthma

Atopic Dermatitis

PTB
 FAMILY GENOGRAM
The first born of each
generation is farthest
to the left.

Hypertension

Kidney stones

Bronchial asthma

Atopic Dermatitis

PTB
FAMILY GENOGRAM

Connect spouses
in a horizontal
line. Males should
Hypertension
be on the left.
Connect children
Kidney stones
to them using a
Bronchial asthma
vertical line.
Atopic Dermatitis

PTB
 The family name is placed
FAMILY GENOGRAM above each major family unit.

Hypertension

Kidney stones

Bronchial asthma

Atopic Dermatitis

PTB
 Address of the family
FAMILY GENOGRAM should be placed below
the family name.

Hypertension

Kidney stones

Bronchial asthma

Atopic Dermatitis

PTB
 Date when the chart was
FAMILY GENOGRAM developed follows the
address so ages can be
adjusted over time.

Hypertension

Kidney stones

Bronchial asthma

Atopic Dermatitis

PTB
FAMILY GENOGRAM

Given names and

Hypertension
ages are placed
below each
Kidney stones
symbol.
Bronchial asthma

Atopic Dermatitis

PTB
FAMILY GENOGRAM

Hypertension Index patient is identified with an arrow.

Kidney stones

Bronchial asthma

Atopic Dermatitis

PTB
FAMILY GENOGRAM

Hypertension Persons living in the same

Kidney stones household are enclosed with a
Bronchial asthma heavy line.
Atopic Dermatitis

PTB
FAMILY GENOGRAM

Significant
Hypertension diseases can be
Kidney stones illustrated using
Bronchial asthma
symbols which
Atopic Dermatitis
appear in the
legend.
PTB
FAMILY APGAR
This is a 5-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.
Takes 10-15 minutes to answer.
Ideally, each member of the family should answer.
An estimate of the family satisfaction by the female head
of the household will provide an accurate assessment
of family functioning.
FAMILY APGAR

Limitations
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
 FAMILY 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 commnicating.
GROWTH
refers to both physical and emotional growth.
This measures the satisfaction of the available
freedom of change.
AFFECTION
is how emotions like love, anger and hatred
are shared between members. This measures
the members’ satisfaction with the intimacy
and emotional interaction that exist in the
family.
RESOLVE
refers to how time, space and money are
shared. This measures the member’s
satisfaction with the commitment made by
other members of the family.
Almost Some of Hardly
always the time ever
I am satisfied that I can turn to my
family for help when something is
troubling me
I am satisfied with the way my family
talks over things with me and shares
problems with me.
I am satisfied that my family accepts
and supports my wishes to take on new
activities and directions.
I am satisfied with the way my family
expresses affection and responds to my
emotions.
I am satisfied with the way my family
and I share time together.
FAMILY APGAR
Almost Some of Hardly
always the time ever
I am satisfied that I can turn to my family for 2 1 0
help when something is troubling me
I am satisfied with the way my family talks over 2 1 0
things with me and shares problems with me.
I am satisfied that my family accepts and 2 1 0
supports my wishes to take on new activities
and directions.
I am satisfied with the way my family expresses 2 1 0
affection and responds to my emotions.
I am satisfied with the way my family and I 2 1 0
share time together.

8-10 points – Highly functional family

4-7 points – Moderately dysfunctional family
0-3 points – Severely dysfunctional family
FAMILY APGAR
Palagi Paminsan- Hinding-
minsan hindi
Ako's naisisyahan dahil nakakaasa ako ng tulong
mula sa aking pamilya sa oras ng pangangailangan
Ako'y nasisiyahan sa paraang nakikipagtalakayan sa
akin ang aking pamilya tungkol sa aking mga
problema
Ako'y nasisiyahan at ang aking pamilya ay
tinatanggap at sinusuportahan ang aking mga nais
gawin patungo sa mga bagong landas para sa aking
ikauunlad.
Ako'y nasisiyahan sa paraang ipinadadama ng aking
pamilya ang kanilang pagmamahal at pag-unawa sa
aking damdamin katulad ng galit, lungkot, at pag-ibig.
Ako'y nasisiyahan na ang aking pamilya at ako ay
nagkakaroon ng panahon sa isa't isa.
 FAMILY APGAR PART II
Who lives in your home? How do you get along?
Sino-sino ang nakatira sa inyong tahanan? Paano ang inyong relasyon?
Name and
Fairly
Relationship Age Sex Well Poor
Hindi Gaanong
Pangalan at Edad Kasarian Mabuti Hindi Mabuti
Mabuti
Relasyon
If you don't live with your family, list the person to
whom you turn to for help? How do you get along?
Kung hindi ka nakakahingi ng tulong sa iyong Paano ang inyong relasyon?
sariling pamilya, kani-kanino ka humihingi ng
tulong?
Name and
Relationship Age Sex Well Fairly Poor
Pangalan at Edad Kasarian Mabuti Hindi Gaanong Hindi Mabuti
Relasyon Mabuti
FAMILY CIRCLE
A brief, graphic method for disclosing, gathering and
discussing family dynamics as discussed by one or more
family members.
The family physician draws a large circle on a piece of paper
and instructs the patient as follows:
This circle stands for your family as it is now.
Draw in some smaller circles to represent yourself and all
the people important to you – Family and others.
People can be inside, outside, touching, or far apart. They
can be large or small depending on their significance or
influence.
FAMILY CIRCLE
Advantages:
The physician can see another patient while the other patient is
busy completing the family circle technique.
Actual assessment of the family occurs when the patient explains
the diagram he or she has made.
One can assess the openness, boundaries, support, function,
triangulation and inner dependence in the family.
Disadvantages:
Difficulty in standardizing and interpreting
FAMILY CIRCLE
Exploratory questions:
1. What if you remove a significant member of the circle?
2. Who do you run to for support?
3. How would you like things to be different?
4. Who is missing? Why?
5. Why are they inside or outside the circle?
6. What is the communication pattern?
7. Who is in the power position?
8. What does the distance mean?
9. Who are grouped together?
10. What is the fluidity within the circle?
SCREEM
Important in the assessment of the family as to its capacity to
participate in provision of health care or to cope with crisis.
SCREEM is an acronym that stands for several factors considered as
a resource and as a pathology.
Social
Cultural
Religion
Economic stability
Education
Medical health care
SCREEM
RESOURCES PATHOLOGY
SOCIAL
 Social interaction is evident among
family members. Family members have The family is socially isolated from extra-
well-balanced lines of communication with familial groups.
extra-familial social groups such as
friends, sports groups, clubs and other
community organizations.
CULTURAL
 Cultural pride or satisfaction can be The family has feelings of cultural-ethnic
identified, especially in distinct ethnic inferiority or shame.
groups.

RELIGIOUS
 Religion offers satisfying spiritual Dogma and rituals are so rigid that they
experiences as well as contacts with an limit the family's problem-solving capacity.
extra-familial support group.
SCREEM
RESOURCES PATHOLOGY
ECONOMIC
Economic stability is sufficient to Financial problems make it difficult for
provide both a reasonable satisfaction the family to meet monetary demands
with financial status and an ability to of crisis or illness.
meet the economic demands of normal
life events and illness.
EDUCATIONAL
 Education of the family members is Handicaps limit the ability of family
adequate to allow members to solve or members to comprehend the problem
comprehend most of the problems that or recommend solutions.
arise within the format of the lifestyle
established by the family.

MEDICAL A family has not established lines of

 Medical care is available through medical care or is unable to use health
channels that are easily established care facilities due to problems such as
and have previously been experienced unwillingness to seek care, inadequate
satisfactorily. finances, absence of transportation.
SCREEM Family Resource Survey (SCREEM-RES) Strongly Agree (2) Disagree Strongly
Questions Agree (3) (1) Disagree
(0)

• Social
• We help each other in our family
• We are helped by friends and other members of the
community
• Cultural
• Our culture gives our family strength
• A culture of helping and cooperation in our
community helps our family
• Religious
• Our faith and religion helps our family
• We are helped by members of our church or other
religious groups
• Economic
• Our family’s savings is adequate for our needs
• Our family’s income is adequate for our needs
• Educational
• Our education/knowledge is adequate to
understand information about the illness
• Our education/knowledge is adequate to care for
the patient
• Medical
• It is easy to access medical help in our community
• We are helped by doctors, nurses, and health
workers
SCREEM FAMILY RESOURCE SURVEY
12-item self-administered family resources questionnaire in Filipino
based on SCREEM.
Aids in assessing the family's capacity to participate in the provision
of health care or cope with crisis.

Scoring
0 to 6 = family has severely inadequate family resources
7 to 12 = moderately inadequate family resources
13 to 18 = adequate family resources
FAMILY MAP
This tool facilitates the communication of information about the family
system and its dynamics in order to address psychosocial issues.
The following family processes are involved:
 Enmeshment – one has to explore whether family members seldom act
independently or get overinvolved with each other. =========
 Disengagement – one has to explore whether family members are isolated
from each other or have little emotional response from each other.
…………….
 Triangulation – one has to explore whether the family members talk
directly to each other about personal matters. 
 Coalition – one has to explore whether one member of the family is siding
with another member. { }
FAMILY MAP
Reflects family relationships and interaction patterns.
FAMILY LIFELINE
Shows the significant events in a family over a period of time in a chronological
sequence.
Allows for exploration of certain family issues.
Includes how the family coped with the stressful events
It includes both normative and non-normative crisis.
It is sometimes placed side-by-side with the illness history.
It helps provess how flexible the family is when dealing with these changes.
Allows for a quick retrieval of information that identifies the factors that may affect
the health of the family
Useful when anticipating a long-term illness, the presence of difficult caregiving, non-
adherence to treatment strategies, and in situations where the doctor needs to
“think family”
FAMILY LIFELINE
Year Age Event Headache severity
2004 17 Father died **
2003 18 Entered college – lived at home ***
2004 19 Brother died **********
2005 20 Difficulty with school *****
2007 22 Graduated from college **
2008 23 First relationship *
2009 24 Began first job – Difficult boss *********
2010 25 Changed jobs ****
2011 26 Married *
ECOMAP
A pictorial representation of a family’s
connections to persons and/or systems in
their environment.
It can illustrate 3 separate dimensions for each
connection
STRENGTH of connection (weak,
tenuous/uncertain, strong)
IMPACT of connection (none, draining resources
or energy, providing resources or energy)
QUALITY of connection (stressful, not stressful)
ECOMAP

Purpose:
To support classification of family needs and
decision-making about potential interventions
To create shared awareness of the family’s
significant connections and the constructive or
destructive influences those connections may
be having
ECOMAP
VA LUA B L E B E C AU S E I T:
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 and weaknesses
Summarizes complex data and
information into a visual,
easy to understand format.
Illustrates nature of
connectedness and impact
of interactions.
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.
ECOMAP
Purpose:
To support classification of family needs and
decision making about potential interventions
To create shared awareness (between family
and their social workers) of the family’s
significant connections, and the constructive or
destructive influences those connections may
be having
ECOMAP
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.
ECOMAP
 There are some domains that will, for some families,
apply at the household level, or for all individuals in the
family. These can be charted at the household level and
do not need to be charted for each individual.

 Each individual can be “brought out of the center” into

its own circle and then domains that need to be
addressed for that individual can be. The “household
can be brought out of the center onto its own circle for
clarity if needed.
ECOMAP
 If a family or an individual is so complex that the ecomap becomes
messy, you can illustrate any individual or the household on its
own, separate page. On the front page, simply note “Refer to page
x” for the individual in question.

 To illustrate the existence of a connection, and the strength of it,

use one of the following 3 types of lines. No line indicates no
connection.
 Strong ___________
 Tenuous/uncertain ………………..
 Weak -----------------
ECOMAP
 To illustrate the impact of a connection, place an arrow
on the end of the line indicating whether the resources
and energy are flowing to a person or away from a
person. No arrow indicates no impact, no flow of energy
or resources either way.
 J Resources being drained from person
 J Resources being provided to person
ECOMAP
 If the connection is stressful, illustrate with a jagged line
superimposed on the connection line. No jagged line, not stressful.

 Brief summary comments may be written inside the domain circles

– but they should not be very detailed. The details should be in the
risk assessment.

 Domains should be identified on the ecomap.

 Domains: Neighborhood, community services, social groups,
education, significant personal relationships and employment
 Using color – no need to write the name of the domain
 Black and white – domain should be labeled
 ECOMAP
Neighborhood
• How well do you know your
neighborhood?
• What neighborhood activities do
you attend?
• Do your children play with other
neighborhood children?
• How long have you lived there?
• What do you get from your
neighborhood?
Education
• Who in your family goes to school?
• How long? What is their status?
What is their goal?
• How do they feel about it?
• With whom do you have a
relationship? Who gives you
support?
Community services
• What community organizations or
agencies are you involved?
• How long have you been involved?
What frequency?
• With whom do you have a
relationship? Who gives you
support?
• What services work best for you?
• How do you feel about your
involvement?
Significant Personal Relationships
• With whom do you have significant
personal relationship? Includes
extended family members, friends,
etc?
• How long has your relationship
lasted?
• What do you do together?
• How do you feel about it?
• What do you get from it?
Social Groups
• With which social groups are you
involved?
• How long have you been involved?
What frequency?
• With whom do you have a
relationship? Who gives you
support?
• What services work best for you?
• How do you feel about your
involvement?
Employment
• Who in your family works?
• How long? What is their status?
• How do they feel about it?
• With whom do they have a
relationship? Who gives them
support?
FAMILY LIFE CYCLE
A description of the family dynamics through clearly
defined stages of development
Help form the hypotheses about the problems
experienced by patients at a particular stage
It is very important to look at the different stages
because specific issues are normal in the
development of a family as it moves through them.
Provides predictable and chronological sequence of
events and to the health maintenance of family
members
FAMILY LIFE CYCLE

1. Leaving home (unattached adult)

2. Newly married couple
3. Family with young children
4. Family with adolescent
5. Launching family
6. Family in later life
FAMILY LIFE CYCLE
STAGE TASK HEALTH IMPLICATIONS
• establishing personal • episodic medical problems
Leaving Home independence
• STDs
(Unattached Adult) •beginning emotional
separation from parents •Unwanted pregnancy
• establishing an intimate • Early Pregnancy
relationship with spouse
• STDs
Newly Married Couple •developing further the
•Infertility
emotional separation from
parents •Gynecologic Problems
• accidents
• Opening the family to
•poisoning
Family with Young Children include a new member
•mental retardation
• dividing the parenting role
•behavioral problems
 STAGE TASK HEALTH IMPLICATIONS
• drug and other substance
abuse
• Increasing the flexibility of
the family boundaries to allow • STDs
Family with Adolescent the adolescent(s) move in and •Gynecologic problems
out of the family system •Skin diseases
(independence) •Menstrual problems
•circumcision
• accepting multitude of exits • Pre/post menopausal
from and entries into the family syndromes
Launching Family system
• Degenerative diseases
• adjusting to the ending of
parenting roles •Malignancies
• adjusting to the ending of the
wage-earning roles • degenerative diseases
• dealing with lessening •chronic illnesses
abilities and greater
Family in Later Life •malignancies
dependence on others
• dealing with losses of friends, •gynecologic/urologic
problems
family members, and eventually
each other
LEVELS OF FAMILY INVOLVEMENT

Describes the levels of involvement physicians

can enter in delivering health care efficiently
These levels are dependent on how deep the
physicians want to be involved in their
patient’s family
In the health care system of the Philippines, it is
best for any medical practitioner to be at least
at level III.
LEVELS OF FAMILY INVOLVEMENT
Levels
Level I Minimal emphasis on the family in the delivery of health
care.
Level II Ongoing medical information and advice. Works
collaboratively with patients and families, and
understands the triangular nature of the patient-doctor-
family relationship.
Level III Feelings and support. The physician understands normal
family development and how families react to stress.
Level IV Assessment of family dysfunction and provision of
intervention. It is the most common involvement among
patients who are alcohol or drug abusers.
Level V Family Therapy