Family Dynamics and

Assessment Tools

Dr. Oryzati Hilman Agrimon, MSc.CMFM, PhD (C)

PhD Candidate in General Practice/ Family Medicine,
the University of Adelaide, Australia
Lecturer
Department of Public Health and Family Medicine
Faculty of Medicine and Health Sciences
Universitas Muhammadiyah Yogyakarta

Discussion Topics
Family Structure
Family Dynamics
Family Assessment Tools

Family Structure (1)

(Goldenberg, 1980)
1. Nuclear Family (keluarga inti):
suami, istri, anak-anak kandung
2. Extended Family (keluarga besar):
suami, istri, anak2 kandung, sanak saudara:
baik vertikal maupun horizontal
3. Blended family (keluarga campuran):
suami, istri, anak-anak kandung & tiri
4. Common law family (kel menurut hukum
umum):
pria & wanita terikat hukum sipil, anak2 mereka
5. Single parent family (kel orang tua tunggal):
karena cerai, berpisah, ditinggal mati, tidak pernah
menikah & anak2 mereka

Family Structure (2)

(Goldenberg, 1980)
6. Commune family (kel hidup bersama):
berbagi hak, tanggung jawab & kekayaan bersama
7. Serial family (keluarga serial):
sudah bercerai, menikah lagi & mempunyai anak2,
dan menggangap satu keluarga
8. Composite family (keluarga gabungan):
poliandri & poligini dg anak-anaknya
9. Cohabitation family (keluarga tinggal
bersama):
tanpa ada ikatan perkawinan yg syah

Apa bentuk keluarganya?

Family Dynamics (1)

Five basic functions of families
(Goh et al, 2004; Pineda,1999)
1. Families provide support to each other
2. Families establish autonomy & independence for
each person in the system which enhance personal
growth of individuals within the family
3. Families create rules that govern the conduct of the
family & of the individuals within the family
4. Families adapt to change in the environment
5. Families communicate with each other

Family Dynamics (2)

Family dynamics

(Goh et al, 2004; Rakel, 1998)

The interactions & relationships among the
individual members of a family which reflect &
influence the physical, mental & spiritual health of
the individuals in a family:
The developmental or adaptive challenges that
face the family (e.g. birth of a child, coping with
loss of function through illness & injury)
The familys unique combination of resources &
burdens (e.g. educational & economic status,
available supports & vulnerabilities)

Family Dynamics (3)

Understanding of family dynamics:
helps the FD to diagnose the disease & illness
and recognize the factors that may help or hinder
the recovery of the patient
to formulate ways to help the family be more
effective & adaptive in their health tasks
Family dynamics may be assessed through:
family assessment tools

Family
Dynamics

Family
Assessment
Tools

?
Happy/
Functional
Family

Mid-range
Family

Unhappy/
Dysfunctional
Family

Happy/ Functional
Families

Mid-range
Families

Dysfunctional
Families

Radiate a sense of integrity &

caring

Most families exhibit fluctuating

mixtures of happy & unhappy
features

Communication often manifest disorganization &

rigidity

Adult members live by clear

human values, communicate
effectively & share power while
negotiating decisions.

Representing the majority of

families as referred by researchers
& family therapists

Family members behave in ways that indicate a

high level of chronic underlying anxiety &
regularly engage in negative, hostile, or critical
exchanges

All family members encouraged

to develop their own goals &
emotional independence while
staying connected with the
family

Each mid-range family has its own

strengths &vulnerabilities

They can be caring & considerate when life

circumstances are calm; when stressed, they
shift into counterproductive modes, avoiding
responsibility by clinging, attacking, or escaping

Cope relatively well with

adversity, often coming out of a
crisis stronger

Physicians can be most effective

by helping families capitalize on
their strengths & deal with
vulnerabilities in healthier ways

Personal values may be adopted uncritically from

authority figures or friends/ peers; Alternatively,
values may be formed & behavior shaped by
reacting in opposition to the espoused or actual
values of influential people

At one extreme, they often express intense

negative feelings which creates a hot, conflictual
family atmosphere.
At the extreme opposite, they shut off, blunt, or
hide their feelings, creating a cold, unfeeling
atmosphere, that masks an underlying emotional
intensity

Difficulty in dealing with stress

Family Assessment Tools (1)

Why do we need family assessment tools?
1. to assess family functioning
2. to assess coping mechanisms of the family
3. to assess resources
4. to assess family structure
5. to have a picture of the multigenerational patterns
of behavior or illnesses.
6. to assess the normal crisis or common illness to be
encountered in each stage of development.
7. to provide anticipatory care and guidance.

Family Assessment Tools (2)

Family assessment tools
(perangkat penilaian keluarga)
(Mc.Daniel, 2005; Goh et al, 2004; Rakel, 2002,
Pineda,
1999; Samaniego, 1999)
1. Family genogram (Pohon keluarga)
2. Family life cycle (Siklus kehidupan keluarga)
3. Family map (Peta keluarga)
4. Family life line (Garis kehidupan keluarga)
5. Family APGAR (Penilaian fungsi keluarga)
6. Family SCREEM (Penilaian sumber daya keluarga)

1. Family Genogram:
A graphic representation of the family
structure/ anatomy, including: family tree,
functional chart, family illness/history)
2. Family life cycle:
Represents composite of the individual
developmental changes of family members, shows
the evolution of the marital relationship & presents
cyclic developmental changes of family members;
includes: stages of development, developmental
tasks & health implications

3. Family map:
Describes family system, relationships & interaction
patterns, boundaries between generations,
conflicts/alliances
4. Family life line:
Describes chronological stressful life/ clinical
events & coping (how they were handled)

5. Family APGAR (Adaptability, Partnership,

Growth, Affection, Resolve):
Screening instrument for family dysfunction,
individual satisfaction about family relationships
6. Family SCREEM (Social, Cultural, Religious,
Economic, Educational, Medical):
Describes available resources, assessment of
familys capacity to participate in the provision of
the health care or to cope with crisis

Genogram (1)
Pohon keluarga
biopsikososial yang
menggambarkan
siklus hidup keluarga,
penyakit dalam
keluarga dan
hubungan antar
anggota keluarga.
Biasanya genogram
ini dibuat 3 generasi.

Genogram (2)
Untuk mengetahui
secara cepat
hubungan diantara
anggota keluarga,
sebagai cara untuk
melihat masalah
medis dan psikologis
keluarga dan
sebagai alat untuk
mengerti keluarga
dari multigenerasi

Genogram (3)
1. Nama kepala keluarga
Bakri, as of 8 April 2010
ditulis diatas keluarga
2. Nama dan umur
setiap anggota
keluarga ditulis
dibawah symbol
1969
Ardi,68
I
3. Anggota keluarga
1970
yang menjadi fokus
pelayanan kesehatan
dokter keluarga
II
disebut sebagai
index pasien dan
ditandai dengan
III
panah
4. Tanggal pembuatan
genogram ditulis

Nia,64

Genogram (4)
5. Anggota keluarga
Bakri, as of 8 April 2010
yang tinggal dalam
satu rumah ditandai
dengan menggambar
lingkaran
6. Penyakit dalam
keluarga di tulis
dengan simbol
1969
Ardi,68
I
standar yang diberi
1970
keterangan dibawah
genogram
7. Waktu dan sebab
II
kematian anggota
keluarga ditulis
dengan symbol yang
diberi tanda silang
didalam lingkaran
atau bujur sangkar
III
8. Tanggal pernikahan
dan perceraian
dicantumkan pula

Nia,64

Standardized Symbols used in Family Genograms (1)

male

female

date of divorce

Date of death
abortion or miscarriage

Sex not specified

Deceased/death

Adopted female

date of birth

date of marriage

Induced abortion
Pregnancy-child in utero
Dizygotic twins

Monozygotic Twins

Standardized Symbols used in Family Genograms (2)

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

Standardized Symbols used in Family Genograms (3)

Symbols of diseases or situation

Obesity

Allergy
xxx

xxx

Alcoholism

Asthma

Hypertension

Heart disease
Stroke

Depression

War Casualty

Standardized Symbols used in Family Genograms (4)

Commonly used Abbreviations
ALC

Alcoholic

GI

GI tract disease

ALL

Allergy

HT

Hypertension

ART
H

Arthritis

MI

Myocard Infarction

CAD

Coronary Artery
Disease

MVP

Mitral Valve Prolapse

CVA

Cerebrovascular
Accident

PUD

Peptic Ulcer Disease

CA
DEP

Cancer

SLE

Systemic Lupus
Erythematosis

DM

Diabetes mellitus

TB

Tuberculosis

Depression

Genogram
Espinosa- Fernandez Family

Ca
Ernesto

H
JOLENE

Efron

54

48

Rizza

Jun

30

57

Joy

Ayn

Ivy

Lucil

Hazel

Salva

25

20

18

22

21

17

B
BRAYN

MAE

25

23

Reid
1

May 19,
2003

LEGEND:
Ca- Cancer
TB- Tbc
HP- Hepatitis
- HPN
A - Asthma
C - Care giver
B - Breadwinner
D - Decision maker

Family Life Cycle

Family Life Cycle
Stage

(Carter & McGoldrick,1989)

Emotional
process of
transition:

Key principles
Leaving home:
Single young
adults
The joining of
families through
marriage: The
new couple
Families with
young children
Families with
adolescents
Launching
children &
moving on
Families in later
life

Second Order
Changes in Family
Status required
to proceed
developmentally

First order
changes or
tasks involved

Problems
encountered at
each stage of
the cycle

Family Map (1)

This assessment tool was developed by a psychiatristfamily therapist Salvador Minuchin to facilitate the
communication of information about a family system to
colleagues through the use of symbols

Family Map (2)

A double line between two people
indicates a functional relationship

A single line with a break in the middle

indicates dysfunction

Family Map (3)

Three parallel lines between two people
denotes an over-involved relationship
where there is plenty of intrusion.

A solid line perpendicular to the

relationship line symbolizes a rigid
boundary where the rules are but nonnegotiable

Family Map (4)

Jun

JOLENE
MAE
Efron

Rizza

Joy

Lucil

Salva

Ayn
Hazel

Ivy
BRIAN

LEGEND:

= functional
= dysfunctional

= clear but

negotiable
boundaries

Family Lifeline (Stressful life

events)

Family APGAR (Family function)

Component

Indicator

Score:
0-2

ADAPTATION

The capability of the family to utilize & share inherent

resources, either intra-familial or extra-familial

PARTNERSHIP

The sharing of decision-making. This measures the

satisfaction attained in solving problems by
communicating

0-2

GROWTH

It refers to both physical & emotional growth. This

measures the satisfaction of the available freedom to
change

0-2

AFFFECTION

How emotions like love, anger, and hatred are shared

between members. This measures the members
satisfaction with the intimacy & emotional recation that
exist in the family.

0-2

RESOLVE

Refers to how time, space, money are shared. This

measures the members satisfaction with the
commitment made by other members of the family.

0-2

Total
Scoring:
2 = almost always
1 = some of the time
0 = hardly ever

0-2

0-10

APGAR Score:
8-10 = Highly functional family
4-7 = Moderately dysfunctional family
0-3 = Severely dysfunctional family

APGAR (1)
Metode ini digunakan dengan menilai lima
fungsi keluarga sehingga dapat diketahui
apakah sebuah keluarga fungsional atau tidak
fungsional.

Adaptasi (Adaptation)
Dinilai tingkat kepuasan anggota keluarga
dalam menerima bantuan yang diperlukannya
dari anggota keluarga yang lain.

Kemitraan (Partnership)
Saling berpartisipasi dalam pengambilan
keputusan dan komunikasi yang baik.

APGAR (2)
Pertumbuhan (Growth)
Dinilai tingkat kepuasan anggota keluarga terhadap
kebebasan yang diberikan keluarga dalam pertumbuhan
dan perkembangan fisik dan emosi anggota keluarga.

Kasih sayang (Affection)

Dinilai tingkat kepuasan anggota keluarga terhadap
kasih saying serta interaksi emosional antar anggota
keluarga

Kebersamaan (Resolve)
Dinilai tingkat kepuasan anggota keluarga terhadap
kebersamaan dalam membagi waktu, materi/ uang dan
ruang untuk privacy

Interpretasi Nilai APGAR

Keluarga

8-10 poin menggambarkan bahwa

fungsi keluarga baik (Highly functional
family)
4-7 poin menggambarkan bahwa
fungsi keluarga kurang baik
(Moderately dysfunctional family)
0-3 poin menggambarkan keluarga
tidak fungsional (Severely
dysfunctional family)

Family SCREEM (Family Resources)

An important tool to assess a familys capacity
to participate in the provision of health
(1)
care or to cope with crisis. It makes use of 6 factors which can be considered as
resource or as pathology

Resources
Social interaction is evident
among family members
Family members have wellbalanced lines of
communication with extrafamilial social groups such
as friends, sports, clubs &
other community groups

SOCIAL

CULTURAL

RELIGIOUS

Pathology
Isolated from extra-familial
Problem of overcommitment

Cultural pride or satisfaction

can be identified, especially
in distinct ethnic group

Ethnic/ cultural inferiority

Religion offers satisfying

spiritual experience and
contacts with an extrafamilial support group

Rigid dogma/ rituals

Low faith (iman)

Family SCREEM (Family Resources)

(2)
Resources

Pathology

Economic stability is sufficient to

provide both reasonable satisfaction
with financial status and an ability to
meet economic demands of
normative life events.

Education of family members is

adequate to allow members to solve
or comprehend most of the problems
that arise within the formal lifestyle
established by the family

Handicapped to
comprehend

Health care is available through

channels that easily established and
have previously been experienced in
a satisfactory manner

Not utilizing health care

facilities/ resources

ECONOMIC

EDUCATION

MEDICAL

Economic deficiency
Inappropriate economic
plan

Learning Points...???

Latihan di Kelas

1.Family Structure
2.Family Life Cycle
3.Genogram
4.APGAR
5.SCREEM

 Thank you for your attention!

Questions are most welcome!

Wassalamu alaikum Wr.Wb