epee \ 1 i ose ise rae ‘ns. The Family APGAR: A Proposal for a Family Function Test and Its Use by Physicians Gabrie! Smitkstein, MD Seattle, Washington Understanding family function is an important aspect of patient care, yet a practical approach to the evaluation of fam- ily function by the physician has not been devised. This paper introduces @ brief questionnaire that is designed to test five areas of family function. The acronym APGAR has been applied to the functional components of Adaptability, Partner- ship, Growth, Affection, and Resolve. The use of the Family APGAR is discussed, as well as ways of assessing family re- ‘sources and reporting data in a family problem-oriented rec- ‘ord. These guidelines are offered for the management of the family in trouble, so that the physician may view the use of the ine AF 30, Un Sok Wastgion Schoa of Ketian, Sear, WA REID Family APGAR in the context of clinical practice. Richardson, in 1948, was among the first 10 stress the necessity for physicians to view the patient in the context of family, In his seminal book on family dynamics in health care he noted, ‘To say shat patients have fumites is like soying that the isensed organ ix pact of the individual. Both facts seem too obviovs to discuss, yet for along time neither re- ceived due recopnition from the medical profession ‘The significance of the patient as a family ‘member was elaborated further by Minuchin who ‘wrote, “The family, as an open socio-cultural system, is eontin~ ually faced by demands for change. These demands sre sparked by bio-psychologleal changes in one or more of ts members... from the Ooparimart of Fay Meng, Unive, of Washington School of Medicina, Se is Westingea 3 Ibe Por vopnn sno bocca gy Ge Biles, Sleiman! tt Fenty Maciel BE 30,0 18 JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 6. 1978 Today, although the concept of the pationt aan interacting member of a fuity anit ix well ae> cepted, a pructical method still hax not been de- vised for the physician to use to collect data that will facilitate managing the family in trouble, ‘A host of examinations anu tests is available to the physician for evaluating a diseased organs functional state, Similarly, in evaluating the fam ily, many questionnaires and procedures have een devised to’ establish the sate of functional integrity of the fumily.®* However, none of these methods For testing the family has proven of prac tical value for daly use in the physician's office: ‘This paper will introduce a. brief: sefeening ‘questionnaire called Family APGAR. which is de- Signed to elicit a data hase, thot will relleet a” patient's view of the functional state of his or her family, Jt will also discuss. ways.of assessing fam- ily ‘resources: and: the Use: of a: family, probleri- ofiented record that may be used by the physician to improve family stidy, diagncss, aid masage- cent Bes < aTHe PAM PGA Component Aataptation “Fable 1. Definitions of Family APGAR Components Definition ‘Adaptation is the utilization of intrs and extrofamitiat resources for argblers solving when family equi f@ atrossed curing a crisis, Definition of Family and Family Function Whea the physics inierviews a patient for a ealth problem, tke usual proceatire is to gather ‘only information caacerning the patient's fomity that is pertinent te understanding « particular complaint. 19 fist instances, the physician needs rainimal or mio unify data to hanelle she compa Nevertheless, in some silustions, knowledge of the stescture sa Finetion of the patient's family may, be required to resolve the heal: problem. For cumple, ip evahuting 2 middle-aped man swith chest pain. il is important for the physician to Inquire whether aayone in the patient's genetic ansily its hast voromary artery disease as wells to-determine the strucnure and the function of the family to which the patient will retin. ‘Since Gaimily siracture acd function play a part Je understariding ied svanaging. the complaint. of the individual patigne as well gs of the family ia trouble, the- following operational definition, of family is recommended for the physician involved jn Eainily.anilysis: ‘The faanifs is @ pavetioxecial ai? Porinarshin Partnership ig the sharing of decision makina and ‘nurturing reaponsibilites by family members. Grom Growth is the physical and emotional maturation arta selFuififmnent that ie achieved by family members through mutual support and guidance. Alfection ‘Aifuctin Is the eating o¢ loving relationship shat txists among family members. Resolve Resolve is the commitmant to devote time to other rmambos af the family foe physical and emotional nurturing, also usually Involves 8 decision 10 ‘hace wealth aad space. grenp consisting of He patient and ee or wave persia, elldren or aut, dn whiel there is a Crominiinient for members to nurture cach other In this definition, family structure is defined simply as the patient and one or more persons Becusse stuctural or instinational relationships among members are not specified, there is room for a wide range of fai lifesstyles, including the Ceauitignal nuclear family. communal groups, wal rnonmaivied partners, whether heterosexual or hhomosexoi Also in this definition the process of srurtuning is equated with family funtion that promotes emotional and physical growth aad mat- ‘uration of all members. In order 10 establish the parameters by which a family’s functional health can be measured, five ‘asic components of family funetion were chosen. ‘Thiese components, which are defined in Table 1, were elected by the author sines they appear 10 represent common themes in the social sefence lit- erature thit deals with families. ‘This empirical decision allowed the Uevelopment of a.famity function paradigm that aay he Tikened to" the “Tile JOURNAL, OF FAMILY PRACTICE, VOL. 6, NO. 6, 1978, iOO THe FAMILY AOGAR rable 2 Open-Ended Requests for Family Function Information ‘Component Tela On End atone i ree aay ave fy arr atv Mot eae doom are Partnership How do family members communicate with each other about such maltiers es vacations, finances, medical ‘cere, large purchases, and personal problems? Growth Howhave family members changed during the past years? How has this change baon accepted by family membors? In what ways havo family members aided each other in ‘growing oF davoloping independent lfe-sylea? How have tamnily members reacted! to your desires for change? Affection How have members of yaur family responded to emotional ‘expressions such ae affection, $ove, sorrow, oF anger? Resolve How do members of your farnily shave time, space, and money? body's ongan system, in that each component bas 1 unigue function, yet each is interrelated to the ‘whole, The family in health may be considered 10 be nurturing unit that demonstrates integrity of the components of (1) Adaptability, 2) Partner ship, (3) Growth, (4) Affection, and (3) Resolve (APGAR). Family Function Questionnaire When a family member reports the history of a cevisis to. physiejan, the general status ofthis fim- ily's function can usually be discovered, Consid: rable information about family function may be obtained when the patient describes how family ‘members eat, sleep, and.carry out home, school, and job responsibilities. Evidence of dysfunction in these activities should alert the physician to the ‘aged (9 evaluate family function in greater depth: ‘THE JOURNAL. OF FAMILY PRACTICE, VOL? 6, NO.6, 1978 ‘To obtain more definitive data, the physicias must ase questions that ate lkely'to elicit peri- nent information an the Five components of fanily function. Table 2 lists some relevant open-ended requests For information on family function, Ak though open-ended questions are preferable be- cause they can lead 10 the most detailed flow of Inforination, they often require more time thea the physician has avaiable. Consequently, closed ended questions, while limiting the scope-of the patient's responses, can give dat in afew-mninutes that highlight the quifity of the patient's interac: tion with-his or her emily afd do not overburden the busy clinician. 2 ~ Io 1973, Ploss. dnd Satterwhite introduced a Family Function Inded (FFT) that was developed a5a"simple, cally administeted (esto reflect the ‘dynamics of family interaction.” The FFI con- sists of 15 questions and requires about 18 minutes aTHE SAMAILY APGAR fo 1 om satistied with the help that roceive from my farnily® when something is troubling me. | am satisfied with the way my interest and shares problem salving with me. wishas to take on new activities ‘07 make changes in my iife-stvlc 1 om satistiod with the way my tamily* expresses attection and responds to my feekings such as anger, sorrow, and love. | am satistid vith the amount ‘of time my farsily* and I spend rogetnor. “ablw 3, Family APGAR Questionnaire family" discusses items of common Lin that my family” accepts my ‘Almost Some of Haedly ‘always thetime over follows: “Almost always’ [2 4 to 6 auggosts 2 moderate bther, paronts, at children. ‘Scoring: The patient checks one of three choices which are scored as "Some of the time” (1) point, oF Mardi evar (0), The peores for each of the five, questions are then, Aotalag, score of7 t0 10 suggests a highly functional ‘dystunetional farnly. A score of 9 to 3 usigests 2 severely dystunctional femilv, see Stding to which Marner af the family is being interviewed the physicion thay substitate for the word amily’ either spouse, significant family. Ascore of to administer, It estimates family functiva by evaluating aves of nuclear Ramily interaetion such ‘ay muvital satisfaction, frequency of disagreement, eommunicntion, problem solving, and feelings of appiness and etoseress. The reliability of the FFL was established hy compating index scores with atings of the same families by experienced case workers. ‘Phe FEL has been aved to study the a= clear futnilies. of children with chronic physical disorders, andit ix cluimed by is authors to iden- tify accurately. which chronically ill childven are likely to experience secondary psychological diffi- culties. . ‘The Family APGAR: a questionnaire that fea ‘inves five closéd-eaded questions, is introduced by the author as u screening test.to give a rapid over- view of the components of fanity fonetion. Table 3 “demonstrates this new questionnaire, It is de- Signed x0. be given to members of either vase nuclear or ultemutive lifestyle families. The 'APGAR acronym has been applied since it is felt ‘that the Familiarity that physicians have with the Apaat® evaluation of the newborn will encourage them to remember a similar format that seores the. functional status of a family. Field tests with the Family APGAR are presently being conducted and early results are promising, A validity index for this questionnaire is now being established utiliz~ jing both Pless and Satterwhite’s FEE and the ‘evaluation of family function by social workers and psychologists. ‘What Does the Family APGAR Measure? ‘The questions in the Family APGAR are de- signed 10 permit qualitative measurement of: the amily member's satisfaction with euch of the five ‘basic components of family function. Table 4 fists tte functional components of the. Family APGAR. “THE JOURNAL OF FAMILY PRACTICE, VOL. 6..NO. 6, 1928:— | THE FAMILY APGAR “Table 4, What is Measured by the Family APGAR? ‘Component ee ‘Adaptation How resources ere shared, or the degree to which @ member is satisfied with the assistance received valion Family resources are needed. Partnership How decigiona are shared, or the meinbsr's satisfaction ‘witn mutuality in family communication and pprobiem solving. Growth How nuturing is shared, or the member's satisfaction. with the freedom availabe within the family to change roles and attain physical and emotional growth or maturation. Afioction Hw emotional experiences are shared, or the member's satisfaction with the intimey and emotional interaction that exists in 9 family, Resolve How time land apace and money*? is shared, oF the member's satisfaction with the time commitment that has been made to the femily by its members. “Besides shaving time, fomily members usually Nave @ commitment to share space and honey. Becauso ofits primacy, time was the only dem included In the Family APGAR; however, the’ physician who is con- Eorned with tomily function wil enlarge fisher understanding of the farmiiy’s foxolve #f ho trquiros about femily member's sotstaction with shared space and money sand indicates the q gained lative dati that may be ctidren, ages & to 15, participated in household chores and mutual support activities. ‘The Following vignettes are examples of putient problems that have been evsiuated by the Family, APGAR, Case 1 Fiamily crisis: A 40-year-old father died asa re sult of metastatic jung cancer after a hospital stay ‘of three months, ‘The physician record indicated a Family APGAR score of 10. The questionnaire was completed by hoth spouses prior to the bus- band's hospitalization. The physieian anticipated that cxinting resources would maintain the fim: ily's ucturing functions. tavestigation of the APGAR components revesled the following: ‘Adaptahility: ‘The mother spent most, of her. time in the hospital during the father's illness, Refatives were caited in as resources, and-the four: SHE JOURNAL OF FAMILY PRACTICE, VOL, 6. NO/6. 1876 Partnership: There were weekly family mect- ings to discuss problems such as allowances, bor- sawing clothes, and household responsibilities, Growth: Roles in the Family were well defined. ‘and rather classical for a nucleus middle class fam- ily; however, all family. members had the oppor- tunity to discuss change during Sunday night meet- ings. ‘Affection: A great deat of warmth and under: standing was demonstrated by the parents with af. ‘open display of affection, ‘The ehildren were af forded much: physical touching and, seassuranice when needed: Resolve: The family functioned well asa unit. Porenté. demonstrated .&: commitment: of time; cand:mariey, and they clearly indicaled to ‘the children'that the family came before work fe- 1298h : THe Pausny arcan sponsibilities, During. the the father's death there wis a rupiel gathering of re: sources, eg, minister, relatives, and friends. Fim ity dysh wil, ‘The chiltren mained at homie to assist the mother during the funetol and) memorial services. The grief process ‘vas shared by all menibers of the family. This family required litte in the way of support from the family physician, Intra and exteafamitial resources continued fo muintain the fimity unit during the post crisis period. ly cvisis: A M6-year-old daughter rested fov shoplifting. ‘The juvenite officer recom meted individual counseling for the daughter. "The funly physician was consulted by the mother. ACihe time of consutation a severely dys- Ainetivnal family wax anticipated when a Fanuily APGAR score of 1 as obvained from the davghe ter, while the mother. age 39, scored 3. The Father Fefised to see the physician complete the 1K questionnaire, ‘The physivian Fores a family that would require much aid in the way of ‘extralamilial resousces. {investigation of the APGAR amily eeveated the following: ‘Adapubility: The mother was in charge of che family. but she claimed she received Tittle or no Support from her daughter or husband. A son aged 10. wis cooperative but his msistance was listed since he: had cerebral palsy and eeguiredd & ‘wheelchair for wmbutation. Father and daughter did-their own “ihing”* and left mother to manage ‘midst of the home. problems. ‘There were mo e3- tended family members in the community. Partoership. Mother and daughter shared opin- ing, bial their differences were so marked. there ‘was litle cooperation, Daughter and father were ssually. ab odds. Ruther indicated: that he would Tike to.see the dauighter removed fram the home especially after the shoplifting episode). Mother ‘and son had at close Yelationship nod exchanged ideas’ and. Teeliigs. The. husband mide desisions regarding his activities, bat he left household de- cisions t0 the’ wife, s ‘Growth: Daughter hed been allovied imiteh ree= doin outside the hoe since ge 12; however: her home activities were restricted by the fither. For examplev-he did not allow her t0.watch television. eyponcnts of this 1236 8 Shoplitting was the third anrest experienced by the Uouphter, Het previous iwo experiences with the: police were for drunken and disorderly conduct fan being a runaseay, Mother bad high educational t2oals for the children: however, danghier had aD average, aad although the son tried, bis educa rion! accomplishments were limited. “Affection; There was eo evidence of physical affection when family members were together. Husband aed wife apparently related well ats sexual level, bol there was little efse im the way of ‘emotional interchange. Mother and son seemed to demonstrate some mteasure of intimacy Resolve: Husband helped meet physical needs ‘of home and family, but he tended to spend as tittle time at home as possible, He shaved most of his paycheck with his wife, The daughter spent much ‘of her time either isplated in her roam or out of the. house with her peers. “The Family APGAR scores of F and 3 obtained from the daughter and mother indicated to the physician the gravity of family dysfunction. The physician elected to act as a facilitator and refer this family tw» a mental health clinic for family therapy, The father initially Would not cooperate with the counselor, but he was finally convinced by the physician and juvenile officer to participate in a family discussion, Roles were discussed and 3. more equitable distribution of household tasks was arranged. The I6-yearold daughter was assigned san advocate (eoflege student us role model) by the juvenile officer. The advocate reported that after throe montbs the daughter hau demonstrated some improvement in her school work and claimed to have extablished an improved relationship with both her father and mother When Should the Family APGAR Ques- tionnaire be Used? “Thice situations have been identified in whic the physician may need information on the func- ‘ional state of the patient's family. 1. Functional information is needed when the fimity willbe involved with the patient's care. AIL illzesgos and injuries represent some measure of stress to the family. An understanding of the baseline level of family function is necessary ‘whenever: the physician wishes to involve the farliy in the care of the patient. In the case of patient with coronary arcery disease, information ‘0p family function would assist in ascertaining the “THE JOUAHAL,OF FAMILY PRACTICE, WOU. 8, NO. 6, 1978TO patient's ability to return homie aod play the role oF passive convalescent. A high Family APGAR Score wautld suggest that the family could ackipt to the crisis of the patient's ithness and role change, A ow score would warn the physician that the Rome. environment might be stressful 10 the coronary: patient, The physician might then wish 10 take a closer Hook at family member interaction hefore sending the patient home, 2, Family fumetion data may be needed when a new patient is intvoduced into a physicians prac~ tice. There is merit in sveingy the family ns u unit on at least one occasion,” since sisch an encounter allows the physician to meet tbe family members and gsin some insight into family interaction, White the interview process does not usually allow the physician time to gaim an adequate view of the status of family function, giving the Family APGAR questionnaire (o the whole family permits the physicians to establish a baseline view of family function (See Case 3). Just ats the pediatric ‘Apgar uses one and five-minute evaluations 10 judge the progress of s newborn snfunt, the family physician may wish to administer the Family APGAR ut the ftst visit and repeat it in five years to judge the changes in flmetional status of a famn- ily under hisiier cure. A. Family function information is. estentiat when the physician is involved im managing a fum- ily in trouble, When a patient reports a family crisis to the physician, it usualy indicates that the family's resounves are inadequate to cope with the problem, In this situation the Family APGAR ‘questionnaire can highlight specific areas of weak ress in fumily function that interfere with the wb ity of family members to communicate or identity resaurces. Furthermore, the family member's re- sponse lo a given item may provide # lead in ‘oitiating a discussion. For example, if the patient scores 0 on the question of “tam satisfied with the amount of time my family and f spend together, the physician could use an open-ended question such as, “T see that you have a problem with the amount of time that your family spends together Tell me about it.” Thus, the questionnaire serves. ‘asa timesnving device that will belp the physician focus on the critical problems of the family i ‘wouble, 5 What Are Family Resources? ‘The family’s ability to adapt to or cope. with a THE PABILY APGAR crisis depends largely on its resourves. Singe the physician fs usually consulted only whet the fam- ily members are unable by themselves 10 identify or utilize resources 19 meet a crisis situation, the physician who wishes to give suppostive therapy for make wn appropriate referral for the dysfunc- tional Family will need to help family members idemtify and assess their pesources. ‘The major family resources are Social, Cultural, Religious, KEeonanie, Educational, ant’ Mediew!. ‘The renyin SCREEM may serve 10 remind the phy cian of the family resources. ‘These resources are considered elective in afamily when the following. conditions are met: 1, Social iateraction is evidemt among family members, Family members have wel-balanced lines of communication within areas of extrafamil- ial secfal interaction such ss friends, sport groups, elobs, and other corumunity organizations. 2. Cultural pride or sutistuction eun be iden tified, especially in distinct ethnic groups. 3. Religion offers satisfying spicitual experi- ences as well as contacts with an extrafamiial Suppor! group. 4, Economic stability is sufficient 10 provide both reasonable satisfaction with financial status ‘andl an ability to meet the economic deotands of rhoranal life events 5, Education of family. members is adequate to, allow members to solve or comprehend most of the problems tbat arise within the format of the life-style established by the farniy. 6 Medical care is available through channels ‘that ate easily established and have previously beet experienced sitisfactority. Pathology in the various fimnily resources is considered 10 exist when the'Tollowing conditions are present > 1, Social: The family is socially isolated from ‘exttafumilial groups. If extrafamilial aid, ix. re- aquired the resource-poor fumily may not. kridw ‘whom to turn to for assistance. This situation is ‘not uncommon when a-fannily wndergoes i crisis shoitly after moving fo a new community. AL thE” ‘ther end of the spectrim of social activity is the problem. Of overcommnitment. Under these cir, cumatances family members are so involved. with Activities outside the home that they become dis: associated from their own. family and. may be sin: ‘ivailable ax resbucces in times of family need. 2..Caluitals: Fhe “family '“has feelings - of waar ilTHE FaNMILY APGAR culturabethni¢ inferiority or shame, often a a ‘consequence of having been subjected 10 years of ghettoization as well as vocational and educational discrimination. 3. Religious: Rogma and rituals are so rigid th they fimit the family's problem solving capacity. ‘The physician must consider ethical questions when a erisis involves religions beliefs. Difficulties often arise when dealing with questions such as conttaception, abartion, and blood transfusions, Overcommitment to religious activities by one Family member may fimit histher value as a re souree 10 the rest of the family 4, Eeonomie: Financial problems may make it difficult For the farnly G meet the monetary Je mands of erisis, The physician must te aware of the tamily’s ubility or inability 10 meet the eco nomic requireraents oF any pan that be designs. 1 the physician's phn, however ideal for the prob- fem, iseconomically inappropriate, the plan i fess. 'S. Educational: Handicaps fimit the ability of Exnily members to comprehend the problem or the recommended sohttion, Unless the physietan or an ippwupriate counselor can expla to the famity the ature of the problem and its solution, she family members eangot be expected to participate as souiees in problem solving. 6. Medical: A family bay not established fines ‘of medical care or ix unable to use health-care ficilities doe (o problems such as unwillingness £0 seek care, inadequate Finances. Fangunige barriers. absence of (sansportation, refusal of care by a Teal practitioner, oF fong-term or recurrent illness seg that deplete family reserves. How Should a Data Base on the Family in ‘Trouble be Collected? in’ practice, of course, the funily is rarely interviewed as.a unit, ‘The family data base, ob- tained ffom:as many family members as possible, ‘will therefore be a cumulative record that must be modified as vatious, members of the family con~ tribaie to the account of the family's erises, Nanc- tions, and resourves, “The-workup of the family in rouble requires (1) identifying and evaluating the family’s crises, pres cent sind: past, 2) determining the tevel of family funétion through the Family APGAR, and.G) as- certaining the family's negourees through. the gsessment of furnily resources. This, information should be noted in a pea ing system. "The probiem-oriented recon has been chosen by increasing sumbers of physicians as an effec: tive method of recording a patient's health status, To make this concept useful For family study and diagnosis, the problem-oriented record for the in- dlividsal is modified so that the format (data base, ‘numbered problem lis, titled plan, and follow-up) may be applied to the family. ‘The goal of the Fanr ily Problem-Oriented Record (Family POR)’ is to provide a vehiele that will systematize the sturdy of the family and enhance the exchange of infarma- tion among health science students, teachers, and practitioners. “The data hase of the Family POR is « record of three areas: the present and past family crises, the and extrafamilial resources, and the APGAR components of family function. ‘The ussersment is a teport of (1) the cance of various crises 10 family mem bers."""42) the level of Family APGAR function, and (3) the status of family resources (SCREBM ms). “The pluat should note the intra and extrafamilial resources the physician will recommend to tssist members in improving family function. “The follow-ap will record whether the plan was effective oF nol, as well as the physicians future plas far the family Guidelines for the Management of the Family in Trouble ‘The primary responsibility of physicians in- volved in family therapy is to mateh their personal resources (skills, knowledge, and attitudes in fum- ily counseling) against the severity and complesity of « family's functional disability. The Famity 'APGAR serves as « screening test for functional disability: however, ws in ail phases of medical in- ‘vestigation, the test raust be put into perspective by the physieian. In family therapy this is clone by assessing the overall pattern of family function. Mild functional disability exists ina family whose life-style may be adversely affected but which remains functionally intact; that is, there is a continuation of most nurturing activities. In these circumstances, the plan requires that the family be given assistance in improving communi- ‘cation and identifying those sesources needed to help resolve the crisis episode. Supportive coun- fcal and graphic record ‘THE JOURNAL OF FAMILY PRACTICE, VOL. 8, NO. 6, 1978| i i { t i ~ indieated ‘ther and son, and apparently an improvement in: | seling may also be instituted to assist the family members most affected by the crisis Case 3 A family was evaluated as a unit as new em bers of a practice. The Family APGAR scores ‘were as follows: Father, age 58, 7; mother, age 54, 9; son, age 22. 8; daughter, age 20, 9; and son, age 16, 6. The physician recognized that with the ex- ception of the 16year-ald som, and perhaps the father, the Family APGAR scores suggested « Family that fanctioned well The physician elected to speak with the parents ‘bout the test results, ‘The father indicated that he tad been having some disciplinary problems with his J6-year-old son. Permission was granted the physician to invite the son to the office to discuss the Family APGAR test, The son was intially hesitant but he did comply, After an introductory discussion about the son’ routine health stalus and activities, open-ended questions were asked related to the items that were scored low on the Family APGAR, eg, "You indieated on your {questionnaire that you were not entirely satisfied with the way your family aecepted your desires to take on new dctivities.” This question led to a discussion of how strict the father had been 1e- garding the son's social activities, dress, homework, vind television use. The I6-year-ald chimed that he was responsible for most of the yard work, yet he received litle recognition for his efforts, Father-son arguments hal apparently been ‘escalating for about a year, and according to the son, in recent months the father seemed to be erit- iea! almost il the time Permission was granted to the physician by the son to tak over the situation with the father. One ilminute session was held during whieh time the father ventilated his feelings regarding his ait tudes about his youngest son, The phy cian spent ‘an equal amount of time counseling the father on parenting a teenager. Major erophasis was given to offering recognition and rewards for positive ac~ somplishments, drawing up limited guidelines for ‘behavioral expectations, and giving the tesnages that degree of independence that seemed appro: priate for his age. The fatlier was able to arrange a “contract” with his son. A three-month report iniproved communication - between ‘imily~ function (son's’ three-month Family {HE JGURNAL OF FAMILY PRACTICE: VOL: 8,90. 6.1978. sytem Soe Cosewotk TH FAMILY APGAR APGAR was 10), ‘This family bad a limited problem, Total family involvement was not necessury, In this ease the consequences of the resolution of the futher-son conflict was improventeat of total famity function. Severe functional disabitty, in which all or most members of the family no Jonges fulfill mu turing activities, requires that therapy be initiated for the entive family, Its essential that the physi- iam recognize the gravity of such situations and (ol offer placebos or uncealistic interim solutions (See Cave 2). Consultation with a family therapist for families, swith severe fanetional disability will Freqdcntly be recommended. The physician's decision to obt ‘consultation requizes examination of such fuctors ts (1) the wishes of the family members, (2) the severity of the Eamily's dysfunction, (3) the physi- cian’s intorest and training i family counseling, (4) the physician's time commitments, (5) tbe r= source needs of the family, and 46} the resources aveilable in the community Physicians should recognize that not al fail re salvageable, When the processes of diagnos therapy, and consultation have failed (@ evoke an improvement in family function, separation of di vorve may have to be accepted as én appropriate solution. But, to the extent physicians cxn identify and respond specifically 10 funy problems, they shoul benefit many families in which these prob= lems are a major contributor to difficulties. with family nurturing and effective health care Hoferences 1, Bichordson HA: Pations nave Fumes. Crnbridge, asa’ Commonwealth Fund Harsapd Usivority P1888 ‘a 2. Minchin $i Fares and Family Ahorapy, Cate sae te aga ery Press, de M6 ‘Staay Alas Family‘ Moocurement. Tesh Anais ol Pubinked.marments a 188. feapolis Minnosot, University of Minncsota Press, 1 oP Bigg Br Satiornhta B.A measure of famiy Juno. picatan See Sees T:619, 1979 eran Be Far fenetiog and Fy igerty Rs, Roughman Ky. Frese Bt She Cowimunty. Mew York seh Wiley Egat ptopoel er ems ot wal ay Poa Cathe Raa nl 3265 3, Baurian Mi, Grae NT Est proses an arity Fam Pract W224, 1974 mes ok : in woe: How oh uae 30139, 1 "0. Kluonola ep: Va 239) tion 4