n
E. Marie
The Cenogram: A Strategy for Assessment Visscher,
EdD,
RN, and Ellen
Rudy Clore,
MSN,
. RN, FNP
One of the strongest components of the role of the pediatric nurse practitioner (PNP) is that of assessing pediatric clients and their families. Many tools have been developed to assist the PNP in assessing family relationships and dynamics to formulate plans of care that promote physical and mental health. This article explores the use of the genogram as a tool for successful family assessment. A case study is presented to guide the PNP to incorporate the technique into the practice setting. J PEDIATRIC HEALTH CARE. (1992). 6, 361-367.
0
ne of the most important dimensions of the role of the pediatric nurse practitioner (PNP) is that of assessment. The PNP is in an excellent position to detect problems early because some type of rapport with the client and the family has probably already been established. By nature of the practitioner’s education, basic issues can be recognized and managed. In addition, the PNP is prepared to assessphysical and psychologic impairments that may require referral of the client to other professionals. Assessments are done continuously, and diagnoses and interventions may be changed as progress occurs. The effective PNP will assist the client in describing and analyzing situations and formulating the response to those situations. The PNP can also aid in clarifying and understanding some of the responses of the client and assisting that client to examine the family’s usual way of responding to specific situations. This article explores the use of the genogram as a strategy that the PNP can use with children and adolescents and their families for assessment. A case study is presented so that readers may understand how to actually incorporate this tool into their practices. n
THE GENOCRAM
Over the last 10 years many tools, particularly those involving forms of drawings, have been developed to assist in the collection of data about the child and family. Wilson and Ratekin (1990) report the use of children’s drawings to be helpful communication tools with oncology patients and sexually abused children and for investigation of children’s perceptions of anxiety, death,
E. Marie Visscher is an associate professor and director of the Orlando Campus of the University of Florida College of Nursing in Orlando, Ellen Rudy Clore is an assistant of Nursing in Orlando, Florida.
professor
Reprint requests: E. Marie Visscher, Orlando Satellite Campus, University Estelle Dr., Orlando, FL 32803.
at the University
EdD, RN, Associate Professor, of Florida, College of Nursing,
25/l/35090
JOURNAL
OF PEDIATRIC
of Florida
HEALTH
CARE
Satellite Florida. College Director, 711 Lake
nuclear war, and hospitalization. Although these drawings are useful assessment tools, they are drawn by the child and are therefore child-oriented. The genogram, however, is more family oriented because all family members are encouraged to participate to “draw” the final picture and to discuss feelings and relationships. The genogram is a depiction of the relationships among family members for several generations. In the construction of a genogram the family members, assisted by the PNP, graphically delineate the actions and relationships that have occurred over three generations, identifying possible internal and external stressors such as loss of family members, illness, or unemployment (Starkey, 1981). The emphasis is not so much on the ages and facts used in a medical family tree; rather, the emphasis is on the relationships among persons.
T
he genogram is a depiction of the relationships among family members for several generations.
Common stressors occurring in many families, as a result of modern societal conditions, may be identified while developing the genogram and may assist the PNP in the assessment of family problems. Strong negative peer-group pressure (pressure to joint cults or gangs, pressure to use crack cocaine, pressure to carry lethal weapons), teenage pregnancy, and latch-key status may also be important stressors affecting the family today. Use of the genogram facilitates understanding of patterns of family behavior that have been learned and passed on from previous generations (Marlin, 1989). It can be useful both for assessment and for intervention. PNPs are strongly encouraged to develop the genogram informally so that the children can be included in the process. To construct the family genogram the PNP draws a basic family tree with the involved family. Initially, basic data regarding age, parental occupations, and major 361
362
Volume 6, Number 6 November-December 1992
Visscher & Clore
l
BOX
STATEMENTS
AND QUESlIONS
TO USE WHEN DEVELOPlNG
A GENCKZAM
1. 2. 3. 4.
Tell me about our family. Tell me about your parents. Tell me about your family, the family you and your husband have. Are there special issues or events that have occurred from the time of your grandparents to your present family such as: Anxiety problem Family celebrations Special attitudes Money issues Family secrets Drinking issues Family rules Medical problems Special tensions Educational issues Emotional cut offs (The list can be shortened or lengthened to further understand the family.) 5. How would you describe the relationships among members of your family? (A relationship may be described as close, distant, loving, conflicted, estranged, or excessively close.) 6. Describe the relationship between spouses, between each parent and each child, between siblings, and between grandparents and grandchildren. (This needs to be completed for the three generations,)
health issues are depicted for the parents and children of the present nuclear family. The family tree is then extended to the grandparent generation indicating siblings, spouses, divorces, and deaths. In some cases with this basic information depicted on a single page, having the family, possibly the mother, take the family tree home and complete more details with other family members is useful. Once family tree facts are committed to paper, the PNP may review the family drawing and elicit information about family relationships. Typical questions include ‘What do you remember or have you heard about the kind of relationship the grandparents had with each other, with each of their children, and with each grandchild?” This same line of inquiry may be followed regarding the relationships with the parents, their siblings, and their own children.
B y associating
the relationships . . . with different colors and different types of lines, the patterns repeated from one generation become clear . . .
By associating relationships, such as distant, close, loving, conflicted, estranged, or too close, with different colors or different types of lines, the patterns repeated from one generation to another become clear and is useful information for the PNP in making the assessment and intervention. After the initial assessment, the PNP must clearly make selected interventions or might suggest referral to a mental health care professional if required. Because the questions are posed by the practitioner, the family members including children are invited to select colors to indicate the type of relationships (for example, blue for loving relationships, red for conflicted
relationships, or black for distant relationships). Gathering information as fully as possible is important. At the completion of questions, when family patterns have emerged, the interviewer can share and clarify the observations with the family. n
CASE STUDY
Ms. Patton, RN, PNP, has been following the Shelly family for approximately 2 years. The family consists of Jane (mother, age 24), Fred (father, age 26), Scott (age 3), and Larry (age 5). Fred is a construction worker, and Jane is head manager of a large secretarial pool for a large corporation. Today Jane brings the children to the office for their regular well child visit. During the interview Jane appears very distressed and relates the following information. Assessment: Visit 1 1. Medically, everything on physical examination for both children is normal. 2. Larry has been behaving inappropriately in school; Jane has received numerous notes from Larry’s teacher concerning this misbehavior over the past 3 weeks. He has been hitting other children, throwing toys, and bolting out of the room. Three weeks previously he was a wellmannered and cooperative child. This is his first school experience. 3. Neighbors have complained that Larry is fighting with their children with whom he has always had a good relationship. 4. Time-out and spankings are no longer effective punishment techniques for Larry. 5. Larry, who is present at the appointment, states he “hates school” because “nobody likes me.” 6. Larry’s teacher indicates that Larry is not progressing as are the other students.
Journal of Pediatric Health
The Genogram
Care
DRINKER
363
OVER PROTECTIVE
FRED (2g
YEARS)
Unemployed
Office
8 months
Uanagw
J-
--
7 SCOTT
(3 YEARS)
PRETERY
L
RELATIONSHIP
KEY
STRONG, LOVE
LOVING
I HATE
ABUSIVE 11111111111111 -we--
i
EMOTIONAL
CUT - OFF
DOMINEERING
+++++
JEALOUSY R
FIGURE
1
Immediate
family.
(Drawn
by James Shelton.)
Ms. Patton encourages Jane to make an appointment as soon as possible with Larry’s kindergarten teacher to discuss his behavior and possible discipline measures. She also discusses the use of the genogram as a tool for assessing family relationships. They set another 30&nute appointment for the next week. In the meantime, Jane is urged to meet with the teacher, observe and record Larry’s inappropriate behavior, schedule 15 minutes each day for special time together, and praise Larry for “good” behavior. Jane returns with the children for the appointment the next week., and the genogram assessment of the immediate family is begun. ‘Tell me about your family’ is usually a good first suggestion, because it allows the
interviewee latitude. Other typical suggestions are included in the Box. During the discussion of family relationships the following information is ascertained. Assessment: Visit 2-Immediate
Family (Figure
1)
1. The relationship between Larry and Fred is very strong. 2. The relationship between Scott and Jane is very strong. 3. Scott was born prematurely, and Jane seeshim as“more fragile” and therefore is overprotective. Jane feels Fred’s favorite child is Larry. 4. A love-hate relationship exists between Fred and Jane, who have stayed married for the children’s sake. 5. Fred drinks two to three six packs of beer every night. He constantly “picks” on the children, throws objects
364
n
Volume 6, Number 6 November-December 1992
Visscher & Clore
TABLE FAMILY
Identification PRC3M.EM
Alcohol abuse by father with accom-
wWv3 A. Spouse abuse B. Child abuse
of problems
and interventions
GOAL
Achieve sobriety. Promote safe and healthy environment for mother and children.
PNP lNTERVENTlONS
(1) Refer Fred for treatment for alcohol abuse. Refer Jane to spouse abuse agency.
(1) Assess follow through of
(2) Advise Jane to remove children if Fred becomes drunk and abusive.
(2) Document
(3) Encourage Jane to contact and attend ALANON.
Dysfunctional family dynamics accompanied by A. Low self esteem of Jane and children.
Achieve functional family relationship.
B. Emotional cutoffs by family members. Dysfunctional relationship
marital
Improve marital communication or consider separation and/or divorce.
EVAllJATK)N
(1) Schedule Jane for short-term individual appointments with PNP to focus on development of parenting skills. (2) Advise Jane to contact Larry’s teacher to evaluate behavior in school and discuss appropriate discipline measures. (3) Observe and record Larry’s inappropriate behavior at home and in neighborhood. (4) Have Jane schedule 15 minutes daily with Larry for special time together. (1) Provide feedback to Larry to validate his worth, using positive affirmation rather than criticism. (1) Refer Jane and Fred for marriage and family counseling with focus on: (a) Assertive communication skills (b) Verbal expression of feelings
at them, and gets angry when Jane tries to interfere. Fred has actually hit Jane a few times, often in front of the children who cry and beg their father to stop Uhurting mommy.” 6. Fred has been unemployed for about 8 months and has been caring for the children and cleaning the house.
The PNP can then draw the types of lines that depict various relationships among family members. Colored markers can be used to emphasize specific relationships. Children are also asked to ‘TeJl me about your dad, mom, brothers, etc.” Fifteen minutes were scheduled at the first appointment, at which time Larry had Jane’s
referrals and assess for indications of safe and healthy environment in 1 month. frequency of occurrence as indicated by Jane on monthly basis. (3) Assess with Jane the frequency and outcomes of ALANON contact in 1 month. (11 Assess progress of parenting skills monthly.
(2) Assess with Jane changes in Larry’s behavior 1 month after meeting with teacher. (3) Review records at each visit. (4) Assess with Jane and Larry activities in special time. (1) Assess with Larry and Jane outcomes related to affirmation instead of criticism monthly. (1) Assess progress as reported by Jane in monthly visits.
undivided attention; Jane was able to accomplish this. The record of Larry’s inappropriate behavior reveals it occurs early in the afternoon after school. Jane has been praising Larry for good behavior. Additional interventions are established to help Jane cope with the problems that were identified in this visit (Table). Another appointment is set for 7 days later, and the PNP encourages Jane to bring Fred because the next step in the genogram will be to assessFred’s family. Seven days later Jane arrived by herself for another follow-up session. Jane reports accomplishments of interventions suggested by the PNP the previous week.
Journal of Pediatric Health
The Genogram
Care
365
JOHN
GEORGE
n
FIGURE 2 Fred’s family. See Figure 1 for explanation
Fred refused to accompany her for this visit. Therefore assessment of the relationships among Fred’s family members were obtained from Jane. Assessment:
Visit
3-Fred’s
Family
(Figure
2)
1. Fred definitely desires approval from his own father (John). Fred is spending money, which they do not have, to build a racing car becausehis father likes this Sport.
2. John is always comparing Fred to his older brother, George. Fred appears jealous of George. 3. John kicked Fred’s younger brother, Alan, out of the house 2 years ago and has not spoken to him because Alan is homosexual. 4. Fred has a strong relationship with his mother (Sara) and sister (Debbie).
Jane returns in 1 week for another session. At this point in time she has started taking the children for a long walk when Fred becomes drunk and abusive. She has started attending ALANON and is considering a divorce. She is open to the idea of marriage-and-family counseling, although she reports Fred will definitely not attend. She is still somewhat afraid to verbalize her feelings to Fred. During this visit a genogram of Jane’s family is made.
of types of lines. (Drawn Assessment:
Visit
4-Jane’s
by James Shelton.) Family
(Figure
3)
1. Both of Jane’sparents work and get along well. 2. Jane’smother (Peggy) was extremely upset when Jane and her family moved from Tennesseeto Florida. Peggy filed child-abuse charges to gain custody of her only grandchildren. 3. Abuse charges were dropped, but Jane has not had contact with her mother since the investigation. 4. Jane’s father (Joe) communicates with her regularly, and they are very close. 5. Jane is an only child.
The PNP can assesssimilarities in relationship patterns among Jane’s immediate family and Fred’s immediate family. Neither Jane and Fred or Fred’s parents (John and Sara) have strong relationships. Not one family of the three has parents who have close relationships with all their children. Both parents and grandparents seem to have teamed up with individual children, and emotional cut-off, domination, and jealousy prevade the family structures. The completed genograrn of this family is shown in Figure 4. Normally the PNP would pursue information about the third generation of this family. However, for the sake of space the additional information has not been included in this article. If the PNP determines that more input is necessary, pursuing
366
Volume 6, Number 6 November-December 1992
Visscher & Clore
JOE
/
n
FIGURE
3 Jane’s family. See Figure 1 for explanation
/
/
T
of types of lines. (Drawn
by James Shelton.)
JOE
-II I I I
illlllllllllllll
FRED
=I1
111111111 “\-
lllllllt n
FIGURE
4
Complete
I
Llffy I
Shelton.)
I
I
family. See Figure 1 for explanation
1
I
of types of lines. (Drawn
by James
Journal of Pediatric Health
The Genogram
Care
information about a fourth or fifth generation may prove useful. According to family system theory, when one member of the family has symptoms, the pain involves the whole family (Bowen, 1978). Thus, the following family problems are identified: (1) alcohol abuse with accompanying spouse and child abuse; (2) dysfunctional family dynamics with low self-esteem and emotional cut-og, and (3) dysfunctional marital relationship (dominance/submission). The Table contains the complete treatment plan. The family problems are identified, and the goals to be achieved and the specific PNP interventions were developed to guide the course of treatment. Further specificity regarding target dates for interventions and evaluations can be added for the working plan to be used by the PNP.
n
367
SUMMARY
The genogram represents an excellent tool that the PNP can use for assessing relationships and assisting clients and their families. It can be helpful for assessing problems and determining PNP interventions that promote physical and mental health. n REFERENCES Bowen, M. ( 1978). Family therapy in &.iazlpractice. New York: Jason Bronson. Marlin, E. (1989). Geqrams. Chicago: Contemporary Books. Starkey, P.J. (1981). Genograms: A guide to understanding one’s own family system. Pevspectives in Psyhttic Cure, 19, 164-173. Wilson, D., & Ratekin, C. (1990). An introduction to using children’s drawings as an assessment tool. Nrrrse Pructitkmer, 15, 23-25.
Bound Volumes Available to Subscribers
Bound volumes of the JOURNAL OF PEDIATRIC HEALTH CARE are available to subscribers (only) for the 1992 issues from the Publisher, at a cost of $28.00 ($35.96 for Canadian and $34.00 for international) for Vol. 6 (January-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in gold on the spine. Payment must acmmpany all or&. Contact Mosby-Year Book Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; phone (800)325-4177, ext. 4351, (314)453-4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.
E. Marie
The Cenogram: A Strategy for Assessment Visscher,
EdD,
RN, and Ellen
Rudy Clore,
MSN,
. RN, FNP
One of the strongest components of the role of the pediatric nurse practitioner (PNP) is that of assessing pediatric clients and their families. Many tools have been developed to assist the PNP in assessing family relationships and dynamics to formulate plans of care that promote physical and mental health. This article explores the use of the genogram as a tool for successful family assessment. A case study is presented to guide the PNP to incorporate the technique into the practice setting. J PEDIATRIC HEALTH CARE. (1992). 6, 361-367.
0
ne of the most important dimensions of the role of the pediatric nurse practitioner (PNP) is that of assessment. The PNP is in an excellent position to detect problems early because some type of rapport with the client and the family has probably already been established. By nature of the practitioner’s education, basic issues can be recognized and managed. In addition, the PNP is prepared to assessphysical and psychologic impairments that may require referral of the client to other professionals. Assessments are done continuously, and diagnoses and interventions may be changed as progress occurs. The effective PNP will assist the client in describing and analyzing situations and formulating the response to those situations. The PNP can also aid in clarifying and understanding some of the responses of the client and assisting that client to examine the family’s usual way of responding to specific situations. This article explores the use of the genogram as a strategy that the PNP can use with children and adolescents and their families for assessment. A case study is presented so that readers may understand how to actually incorporate this tool into their practices. n
THE GENOCRAM
Over the last 10 years many tools, particularly those involving forms of drawings, have been developed to assist in the collection of data about the child and family. Wilson and Ratekin (1990) report the use of children’s drawings to be helpful communication tools with oncology patients and sexually abused children and for investigation of children’s perceptions of anxiety, death,
E. Marie Visscher is an associate professor and director of the Orlando Campus of the University of Florida College of Nursing in Orlando, Ellen Rudy Clore is an assistant of Nursing in Orlando, Florida.
professor
Reprint requests: E. Marie Visscher, Orlando Satellite Campus, University Estelle Dr., Orlando, FL 32803.
at the University
EdD, RN, Associate Professor, of Florida, College of Nursing,
25/l/35090
JOURNAL
OF PEDIATRIC
of Florida
HEALTH
CARE
Satellite Florida. College Director, 711 Lake
nuclear war, and hospitalization. Although these drawings are useful assessment tools, they are drawn by the child and are therefore child-oriented. The genogram, however, is more family oriented because all family members are encouraged to participate to “draw” the final picture and to discuss feelings and relationships. The genogram is a depiction of the relationships among family members for several generations. In the construction of a genogram the family members, assisted by the PNP, graphically delineate the actions and relationships that have occurred over three generations, identifying possible internal and external stressors such as loss of family members, illness, or unemployment (Starkey, 1981). The emphasis is not so much on the ages and facts used in a medical family tree; rather, the emphasis is on the relationships among persons.
T
he genogram is a depiction of the relationships among family members for several generations.
Common stressors occurring in many families, as a result of modern societal conditions, may be identified while developing the genogram and may assist the PNP in the assessment of family problems. Strong negative peer-group pressure (pressure to joint cults or gangs, pressure to use crack cocaine, pressure to carry lethal weapons), teenage pregnancy, and latch-key status may also be important stressors affecting the family today. Use of the genogram facilitates understanding of patterns of family behavior that have been learned and passed on from previous generations (Marlin, 1989). It can be useful both for assessment and for intervention. PNPs are strongly encouraged to develop the genogram informally so that the children can be included in the process. To construct the family genogram the PNP draws a basic family tree with the involved family. Initially, basic data regarding age, parental occupations, and major 361
362
Volume 6, Number 6 November-December 1992
Visscher & Clore
l
BOX
STATEMENTS
AND QUESlIONS
TO USE WHEN DEVELOPlNG
A GENCKZAM
1. 2. 3. 4.
Tell me about our family. Tell me about your parents. Tell me about your family, the family you and your husband have. Are there special issues or events that have occurred from the time of your grandparents to your present family such as: Anxiety problem Family celebrations Special attitudes Money issues Family secrets Drinking issues Family rules Medical problems Special tensions Educational issues Emotional cut offs (The list can be shortened or lengthened to further understand the family.) 5. How would you describe the relationships among members of your family? (A relationship may be described as close, distant, loving, conflicted, estranged, or excessively close.) 6. Describe the relationship between spouses, between each parent and each child, between siblings, and between grandparents and grandchildren. (This needs to be completed for the three generations,)
health issues are depicted for the parents and children of the present nuclear family. The family tree is then extended to the grandparent generation indicating siblings, spouses, divorces, and deaths. In some cases with this basic information depicted on a single page, having the family, possibly the mother, take the family tree home and complete more details with other family members is useful. Once family tree facts are committed to paper, the PNP may review the family drawing and elicit information about family relationships. Typical questions include ‘What do you remember or have you heard about the kind of relationship the grandparents had with each other, with each of their children, and with each grandchild?” This same line of inquiry may be followed regarding the relationships with the parents, their siblings, and their own children.
B y associating
the relationships . . . with different colors and different types of lines, the patterns repeated from one generation become clear . . .
By associating relationships, such as distant, close, loving, conflicted, estranged, or too close, with different colors or different types of lines, the patterns repeated from one generation to another become clear and is useful information for the PNP in making the assessment and intervention. After the initial assessment, the PNP must clearly make selected interventions or might suggest referral to a mental health care professional if required. Because the questions are posed by the practitioner, the family members including children are invited to select colors to indicate the type of relationships (for example, blue for loving relationships, red for conflicted
relationships, or black for distant relationships). Gathering information as fully as possible is important. At the completion of questions, when family patterns have emerged, the interviewer can share and clarify the observations with the family. n
CASE STUDY
Ms. Patton, RN, PNP, has been following the Shelly family for approximately 2 years. The family consists of Jane (mother, age 24), Fred (father, age 26), Scott (age 3), and Larry (age 5). Fred is a construction worker, and Jane is head manager of a large secretarial pool for a large corporation. Today Jane brings the children to the office for their regular well child visit. During the interview Jane appears very distressed and relates the following information. Assessment: Visit 1 1. Medically, everything on physical examination for both children is normal. 2. Larry has been behaving inappropriately in school; Jane has received numerous notes from Larry’s teacher concerning this misbehavior over the past 3 weeks. He has been hitting other children, throwing toys, and bolting out of the room. Three weeks previously he was a wellmannered and cooperative child. This is his first school experience. 3. Neighbors have complained that Larry is fighting with their children with whom he has always had a good relationship. 4. Time-out and spankings are no longer effective punishment techniques for Larry. 5. Larry, who is present at the appointment, states he “hates school” because “nobody likes me.” 6. Larry’s teacher indicates that Larry is not progressing as are the other students.
Journal of Pediatric Health
The Genogram
Care
DRINKER
363
OVER PROTECTIVE
FRED (2g
YEARS)
Unemployed
Office
8 months
Uanagw
J-
--
7 SCOTT
(3 YEARS)
PRETERY
L
RELATIONSHIP
KEY
STRONG, LOVE
LOVING
I HATE
ABUSIVE 11111111111111 -we--
i
EMOTIONAL
CUT - OFF
DOMINEERING
+++++
JEALOUSY R
FIGURE
1
Immediate
family.
(Drawn
by James Shelton.)
Ms. Patton encourages Jane to make an appointment as soon as possible with Larry’s kindergarten teacher to discuss his behavior and possible discipline measures. She also discusses the use of the genogram as a tool for assessing family relationships. They set another 30&nute appointment for the next week. In the meantime, Jane is urged to meet with the teacher, observe and record Larry’s inappropriate behavior, schedule 15 minutes each day for special time together, and praise Larry for “good” behavior. Jane returns with the children for the appointment the next week., and the genogram assessment of the immediate family is begun. ‘Tell me about your family’ is usually a good first suggestion, because it allows the
interviewee latitude. Other typical suggestions are included in the Box. During the discussion of family relationships the following information is ascertained. Assessment: Visit 2-Immediate
Family (Figure
1)
1. The relationship between Larry and Fred is very strong. 2. The relationship between Scott and Jane is very strong. 3. Scott was born prematurely, and Jane seeshim as“more fragile” and therefore is overprotective. Jane feels Fred’s favorite child is Larry. 4. A love-hate relationship exists between Fred and Jane, who have stayed married for the children’s sake. 5. Fred drinks two to three six packs of beer every night. He constantly “picks” on the children, throws objects
364
n
Volume 6, Number 6 November-December 1992
Visscher & Clore
TABLE FAMILY
Identification PRC3M.EM
Alcohol abuse by father with accom-
wWv3 A. Spouse abuse B. Child abuse
of problems
and interventions
GOAL
Achieve sobriety. Promote safe and healthy environment for mother and children.
PNP lNTERVENTlONS
(1) Refer Fred for treatment for alcohol abuse. Refer Jane to spouse abuse agency.
(1) Assess follow through of
(2) Advise Jane to remove children if Fred becomes drunk and abusive.
(2) Document
(3) Encourage Jane to contact and attend ALANON.
Dysfunctional family dynamics accompanied by A. Low self esteem of Jane and children.
Achieve functional family relationship.
B. Emotional cutoffs by family members. Dysfunctional relationship
marital
Improve marital communication or consider separation and/or divorce.
EVAllJATK)N
(1) Schedule Jane for short-term individual appointments with PNP to focus on development of parenting skills. (2) Advise Jane to contact Larry’s teacher to evaluate behavior in school and discuss appropriate discipline measures. (3) Observe and record Larry’s inappropriate behavior at home and in neighborhood. (4) Have Jane schedule 15 minutes daily with Larry for special time together. (1) Provide feedback to Larry to validate his worth, using positive affirmation rather than criticism. (1) Refer Jane and Fred for marriage and family counseling with focus on: (a) Assertive communication skills (b) Verbal expression of feelings
at them, and gets angry when Jane tries to interfere. Fred has actually hit Jane a few times, often in front of the children who cry and beg their father to stop Uhurting mommy.” 6. Fred has been unemployed for about 8 months and has been caring for the children and cleaning the house.
The PNP can then draw the types of lines that depict various relationships among family members. Colored markers can be used to emphasize specific relationships. Children are also asked to ‘TeJl me about your dad, mom, brothers, etc.” Fifteen minutes were scheduled at the first appointment, at which time Larry had Jane’s
referrals and assess for indications of safe and healthy environment in 1 month. frequency of occurrence as indicated by Jane on monthly basis. (3) Assess with Jane the frequency and outcomes of ALANON contact in 1 month. (11 Assess progress of parenting skills monthly.
(2) Assess with Jane changes in Larry’s behavior 1 month after meeting with teacher. (3) Review records at each visit. (4) Assess with Jane and Larry activities in special time. (1) Assess with Larry and Jane outcomes related to affirmation instead of criticism monthly. (1) Assess progress as reported by Jane in monthly visits.
undivided attention; Jane was able to accomplish this. The record of Larry’s inappropriate behavior reveals it occurs early in the afternoon after school. Jane has been praising Larry for good behavior. Additional interventions are established to help Jane cope with the problems that were identified in this visit (Table). Another appointment is set for 7 days later, and the PNP encourages Jane to bring Fred because the next step in the genogram will be to assessFred’s family. Seven days later Jane arrived by herself for another follow-up session. Jane reports accomplishments of interventions suggested by the PNP the previous week.
Journal of Pediatric Health
The Genogram
Care
365
JOHN
GEORGE
n
FIGURE 2 Fred’s family. See Figure 1 for explanation
Fred refused to accompany her for this visit. Therefore assessment of the relationships among Fred’s family members were obtained from Jane. Assessment:
Visit
3-Fred’s
Family
(Figure
2)
1. Fred definitely desires approval from his own father (John). Fred is spending money, which they do not have, to build a racing car becausehis father likes this Sport.
2. John is always comparing Fred to his older brother, George. Fred appears jealous of George. 3. John kicked Fred’s younger brother, Alan, out of the house 2 years ago and has not spoken to him because Alan is homosexual. 4. Fred has a strong relationship with his mother (Sara) and sister (Debbie).
Jane returns in 1 week for another session. At this point in time she has started taking the children for a long walk when Fred becomes drunk and abusive. She has started attending ALANON and is considering a divorce. She is open to the idea of marriage-and-family counseling, although she reports Fred will definitely not attend. She is still somewhat afraid to verbalize her feelings to Fred. During this visit a genogram of Jane’s family is made.
of types of lines. (Drawn Assessment:
Visit
4-Jane’s
by James Shelton.) Family
(Figure
3)
1. Both of Jane’sparents work and get along well. 2. Jane’smother (Peggy) was extremely upset when Jane and her family moved from Tennesseeto Florida. Peggy filed child-abuse charges to gain custody of her only grandchildren. 3. Abuse charges were dropped, but Jane has not had contact with her mother since the investigation. 4. Jane’s father (Joe) communicates with her regularly, and they are very close. 5. Jane is an only child.
The PNP can assesssimilarities in relationship patterns among Jane’s immediate family and Fred’s immediate family. Neither Jane and Fred or Fred’s parents (John and Sara) have strong relationships. Not one family of the three has parents who have close relationships with all their children. Both parents and grandparents seem to have teamed up with individual children, and emotional cut-off, domination, and jealousy prevade the family structures. The completed genograrn of this family is shown in Figure 4. Normally the PNP would pursue information about the third generation of this family. However, for the sake of space the additional information has not been included in this article. If the PNP determines that more input is necessary, pursuing
366
Volume 6, Number 6 November-December 1992
Visscher & Clore
JOE
/
n
FIGURE
3 Jane’s family. See Figure 1 for explanation
/
/
T
of types of lines. (Drawn
by James Shelton.)
JOE
-II I I I
illlllllllllllll
FRED
=I1
111111111 “\-
lllllllt n
FIGURE
4
Complete
I
Llffy I
Shelton.)
I
I
family. See Figure 1 for explanation
1
I
of types of lines. (Drawn
by James
Journal of Pediatric Health
The Genogram
Care
information about a fourth or fifth generation may prove useful. According to family system theory, when one member of the family has symptoms, the pain involves the whole family (Bowen, 1978). Thus, the following family problems are identified: (1) alcohol abuse with accompanying spouse and child abuse; (2) dysfunctional family dynamics with low self-esteem and emotional cut-og, and (3) dysfunctional marital relationship (dominance/submission). The Table contains the complete treatment plan. The family problems are identified, and the goals to be achieved and the specific PNP interventions were developed to guide the course of treatment. Further specificity regarding target dates for interventions and evaluations can be added for the working plan to be used by the PNP.
n
367
SUMMARY
The genogram represents an excellent tool that the PNP can use for assessing relationships and assisting clients and their families. It can be helpful for assessing problems and determining PNP interventions that promote physical and mental health. n REFERENCES Bowen, M. ( 1978). Family therapy in &.iazlpractice. New York: Jason Bronson. Marlin, E. (1989). Geqrams. Chicago: Contemporary Books. Starkey, P.J. (1981). Genograms: A guide to understanding one’s own family system. Pevspectives in Psyhttic Cure, 19, 164-173. Wilson, D., & Ratekin, C. (1990). An introduction to using children’s drawings as an assessment tool. Nrrrse Pructitkmer, 15, 23-25.
Bound Volumes Available to Subscribers
Bound volumes of the JOURNAL OF PEDIATRIC HEALTH CARE are available to subscribers (only) for the 1992 issues from the Publisher, at a cost of $28.00 ($35.96 for Canadian and $34.00 for international) for Vol. 6 (January-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in gold on the spine. Payment must acmmpany all or&. Contact Mosby-Year Book Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; phone (800)325-4177, ext. 4351, (314)453-4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.
