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The most important question in family approach: the potential of the resolve item of the family APGAR in family medicine

The most important question in family approach: the potential of the resolve item of the family... Background: We aimed to clarify what aspects of family function are measured by the Family APGAR by examining its correlations with the fourth edition of the Family Adaptability and Cohesion Evaluation Scale at Kwansei Gakuin (FACESKG IV ). Furthermore, we sought to confirm the usefulness of the Family APGAR in general practice. Methods: We recruited 250 patients (aged 13–76 years) from the general medicine outpatient clinic in a Japanese hospital between July 1999 and February 2000. We employed a cross-sectional design and administered the Family APGAR and the FACESKG IV-16 (i.e., the short version). The scores on the questionnaires were compared using correla- tion and multiple regression analyses. We then analyzed relationships between the questionnaires and family issues measures using Chi square, Mann–Whitney U, and logistic regression analyses. Results: The Family APGAR partially evaluates the Cohesion dimension of family functioning as measured by the FACESKG IV-16. Furthermore, we could measure family disengagement using the resolve and partnership items of the Family APGAR. Family dysfunction (excessive or impoverished Adaptability or Cohesion) was not related to the pres- ence of family issues. Nevertheless, there was a significant relationship between scores on the Resolve item and the family issues measure (χ = 6.305, p = 0.043). Conclusions: The Family APGAR, especially the Resolve item, has the potential for use in treating patients with family issues. Interventions could be developed according to the simple Family APGAR responses. Keywords: Family, Family research, Family members physicians hesitate to hold family conferences, which Background require considerable time and skill. A promising means Practicing family medicine relies on sufficient under - of circumventing this problem, however, would be to uti- standing of the biopsychosocial aspects of patients. In lize questionnaires. this context, family is considered the most important The Family APGAR has frequently been utilized as a aspect of patients’ social environments. However, cur- tool for assessing family function (Smilkstein [1]). Devel- rently, family approaches to medicine are not widespread oped in 1978, it is a 5-item questionnaire (with each among Japanese family physicians. This is likely because item rated on a 3-point scale) measuring five constructs: family medicine places excessive emphasis on the value “Adaptability,” “Partnership,” “Growth,” “Affection,” and of the family conference; more specifically, Japanese “Resolve.” Investigations of the reliability and validity of family physicians must treat 10–20 patients per hour in the questionnaire led to its revision by Smilkstein, Ash- outpatient clinics, which means that they must spend worth, and Montano in 1982 [2]. Because the Family roughly 3–6  min per patient. For this reason, many APGAR consists of only five questions, it is relatively easy and quick to administer; this has made it the preferred choice for evaluating family function in primary care and *Correspondence: ht69_nnw@aioros.ocn.ne.jp Takenaka Clinic, Osaka, Japan general medicine settings. However, Gardner et  al. [3] Full list of author information is available at the end of the article © 2016 Takenaka and Ban. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons. org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Takenaka and Ban Asia Pac Fam Med (2016) 15:3 Page 2 of 7 pointed out that it is somewhat unclear what the scale between the Family APGAR and the FACES II (Clover items actually measure. Nevertheless, the test remains et  al. [8]). One possible explanation for these conflicting widely (and perhaps blindly) utilized. In Japan, numerous results is that the dimensions of the FACES II are cur- university-based general practitioners and family nursing vilinear. In other words, moderate levels of Adaptability practices use the Family APGAR to educate students. and Cohesion are optimal, but too much or too little is The Family Adaptability and Cohesion Evaluation dysfunctional under normal circumstances. This accords Scale (FACES; Olson et  al. [4]) is another fairly simple with the properties of the Circumplex model, wherein instrument for assessing family function. The FACES the avoidance of extremes for either dimension is empha- is a companion measure for the Circumplex model of sized. However, evidence for curvilinearity in the FACES, marital and family systems (hereafter known as the Cir- FACES II, and FACES III has not yet been demonstrated. cumplex model; Olson et al. [5]), one of the most widely One Japanese research group was successful in iden- used yet highly controversial models of family function. tifying the curvilinearity of their original scale. Tatsuki This model emphasizes that optimal family functioning developed the FACES at Kwansei Gakuin (FACESKG) is a balance between two dimensions: “Cohesion” and series, which considers the cultural and social milieu of “Adaptability.” Cohesion is defined as the degree of emo - Japan [9]; the curvilinearity of the scale dimensions was tional bonding family members have with one another. identified in the 32-item fourth edition (FACESKG IV-32) Excessive closeness results in “enmeshment”—families by Tatsuki [10]. A shorter adaptation of the FACESKG exhibit extreme amounts of emotional closeness and may IV-32 was also created, called the FACESKG IV-16; this is be dependent on, and highly reactive to, one another. a 16-item Thurstone scale questionnaire [8] that is suited Additionally, high levels of family loyalty and consensus for use in a general medicine setting because it is succinct are required and there is little tolerance for private space and easy to administer. The scale results are based on the or relationships outside the family. Excessive separate- sum of the score of each question multiplied by a coef- ness, in contrast, causes “disengagement,” where fami- ficient appropriate for the content. However, Japanese lies exhibit little emotional closeness and instead remain clinics often comprise only a few staff members, such as a focused on individual experiences and activities. Further- physician, nurse, and clerk, which means that they would more, such families have limited commitment to family have little time to complete a questionnaire. Indeed, even interests, and members are often unable to turn to one questionnaires with few questions such as the FACESKG another for emotional or practical support or assistance. IV-16 would not be easy to administer in daily work in For Cohesion, balance would refer to “separated” or Japan. “connected” families, where both individual and group u Th s, the current study had three objectives. The first interests are valued [6]. Adaptability, on the other hand, was to clarify what aspects of family function are meas- is defined as the ability of a marital or family system to ured by the Family APGAR, by examining the correla- change its power structure, role relationships, and rela- tions between the Family APGAR and the FACESKG tionship rules in response to situational and developmen- IV-16, for which linearity and curvilinearity, respec- tal stress. Poor Adaptability leads to “rigidity,” wherein tively, have been established in the Japanese population. the family or couple relationship is unable to shift or In Japanese family practice, previous studies have noted evolve in response to change, whether that arising inter- that physicians do not like administering the full Fam- nally through individual members’ development or that ily APGAR, despite the fact that it comprises only five imposed by the environment. Excessive Adaptability, on questions. Therefore, we wanted to identify the particu - the other hand, results in “chaos,” with family members larly effective questions for analyzing family dysfunction, unable to create shared agreements that govern their thereby enabling the Family APGAR to be used in daily actions and inter-relationships, and thus providing no clinical practice more conveniently. As such, we analyzed firm base on which they can stand. In between these two the relations of each item score of the Family APGAR extremes lie the balanced options of “flexible” or “struc - with the FACESKG IV-16 in addition to the total Family tured” families, where the balance between rigidity and APGAR score. chaos is negotiated from the strong base of shared under- It is generally believed that family issues occur in standing of rules and roles within the relationship [6]. response to family dysfunction (i.e., excessive or impov- Foulke et  al. [7] administered the Family APGAR and erished functioning). As such, the second objective was FACES II (the second version of FACES) to 140 families to confirm the correlations between family dysfunction and found that the Family APGAR correlated with the and family issues, and to identify the particularly impor- relevant Circumplex model dimensions of the FACES II tant aspects of family function by investigating the cor- (Cohesion, r = 0.70; Adaptability, r = 0.59). However, in relations between FACESKG IV-16 scores and the family another study with 66 families, no association was found issues measured. Takenaka and Ban Asia Pac Fam Med (2016) 15:3 Page 3 of 7 The third and final objective was to confirm the valid - Chi square test, a Mann–Whitney U test, and a logis- ity of the Family APGAR as a basis for helping families tic regression analysis because setting family issues as cope with family issues; for this purpose, we examined the dependent variable required a binomial distribution the correlation between the Family APGAR and the fam- whereas the independent variables utilized a curvilinear ily issues measure. model. Data were analyzed using SPSS version 11.0. We defined “family dysfunction” as having a score of 2 or more on the absolute values of the Cohesion and Ethics Adaptability item scores of the FACESKG IV-16, and a Written informed consent was obtained from all sub- score of <8 on the total Family APGAR score (with <4 jects. We applied for ethical approval to the Institutional being indicative of severe dysfunction). We defined “fam - Ethical Review Board of the Kawasaki Medical School ily issues” as the suffering that participants experienced through the professor in charge; however, the board as a result of their family. deemed it exempt from ethical approval. We then sub- mitted it to the Ethical Review Board of the Osaka Soci- Methods ety of Family Practice, who approved the study protocol. Design The study design was cross-sectional and employed two Results questionnaires (the Family APGAR and the FACESKG- Participants were 311 patients, of whom 250 (80.4  %) IV) and one original question assessing family issues. gave complete responses. Participants (gender: 120 male, 126 female, 4 unknown) ranged in age from 13 to Setting and participants 76  years (M  =  49.2, SD  =  13.2) and had an average of The present study was conducted at the outpatient clinic 3.5 (SD  =  1.6) family members. One hundred six par- of a university hospital in Japan (Department of Primary ticipants had mental disorders, 45 had hypertension, 45 Care Medicine, Kawasaki Medical School, Kurashiki City, had hyperlipidemia, and 38 had diabetes mellitus. Sev- Okayama, Japan) between July 1999 and February 2000. enty-six patients (30.4  %) reported having some family Thirteen clinicians administered the questionnaires to issues. Specifically, family issues included health prob - their patients. Study participants completed the Family lems with their family member (n = 24), family lifecycle APGAR (translated into Japanese from the original Eng- issues (e.g., family death, aging; n  =  17), problems with lish version) and FACESKG IV-16. In order to evaluate family dynamics (n  =  6), substance abuse or addiction family issues, we devised an original question: “Do you (e.g., alcohol, gambling; n  =  5), work-related problems have any worries about your family? If you do, please (e.g., unemployment, irregularity of work; n  =  6), eco- tell us about them. You are free to decline to answer.” nomic problems (n  =  3), and unknown problems (i.e., We excluded patients who declined to participate, were the participant did not want to answer; n  =  20). Note unable to understand the scale items, did not provide that five participants reported two issues, which is why answers to all items on both questionnaires, were experi- there is a discrepancy in the number of participants for encing acute disease, or reported uncomfortable feelings family issues (with n  =  76 reporting family issues over- while responding to the scale items. all but n = 81 when summing the number of participants reporting specific issues). Procedures Figure  1 shows the family function of the partici- We explained the contents of the study and enrolled pants according to the Circumplex model. There were patients who agreed to participate. Written informed 68 (27.2  %) balanced families, 116 (46.4  %) mid-range consent was then obtained from all participants. Patients families, and 66 (26.4 %) unbalanced (i.e., dysfunctional) completed the questionnaire while waiting at the billing families. Figure  2 shows the distribution in Family department after their medical examinations. Completed APGAR scores; according to this measure, family func- questionnaires were then brought to the front desk of the tion can be categorized as “good” (scores from 7 to 10), outpatient clinic. “moderate dysfunction” (score from 4 to 6), or “severe dysfunction” (score from 0 to 3). In the present study, Statistical analyses 171 (63.3 %) patients reported good family function, 77 We employed correlation and multiple regression anal- (28.5 %) reported moderate dysfunction, and 22 (8.1 %) yses (the step-down procedure) to compare Family reported severe dysfunction. Thus, the results indicated APGAR measures with scores on the FACESKG IV-16. that the definition of family dysfunction differs sub - We then analyzed the relationships between FACESKG stantially between the FACESKG IV-16 and the Family IV-16, the Family APGAR, and family issues by using a APGAR. Takenaka and Ban Asia Pac Fam Med (2016) 15:3 Page 4 of 7 with Family APGAR scores. The total Family APGAR Low cohesion High score and the Adaptability, Partnership, Growth, and Chaotically Chaotically Affection item scores were all significantly and negatively Disengaged Enmeshed Chaotically Chaotically 9 Separated Connected 5 correlated with the FACESKG IV-16 Adaptability score 3 4 (p  <  0.05); the largest correlation was with the Partner- ship item (r = −0.210). Scores on the Resolve item were High Flexibly Flexibly Flexibly Flexibly not significantly correlated with the FACESKG IV-16 Disengaged Separated Connected Enmeshed Adaptability score, but were significantly correlated with 10 8 42 63 adaptability Structurally Structurally Structurally Structurally the squared values of the Adaptability score (p  <  0.01). Disengaged Separated Connected Enmeshed These results indicate that the Resolve item of the Family 6 5 13 15 Low APGAR measures family disengagement and chaos, and partially measures rigidity (Fig.  5). However, the Family Rigidly Rigidly Separated Separated APGAR could not measure enmeshment or fully meas- Rigidly Rigidly 3 12 Disengaged Enmeshed ure rigidity. 7 45 Additional file  3: Table S3 shows the results of the Fig. 1 Family functioning on the circumplex model multiple regression analysis using the step-down pro- cedure. In the best-fit model, the predictor variable was the FACESKG IV-16 Cohesion score while the outcome variables were the Partnership and Resolve item scores 㻝㻜㻜 from the Family APGAR (Adjusted R  = 0.322, p < 0.01). The regression equation was as follows: Cohesion 㻤㻜 score = 0.191  ×  Partnership score  +  0.472  ×  Resolve score  −  2.982. The regression analysis showed that Adaptability was not significantly explained by the Family 㻢㻜 APGAR items. Thus, family cohesion can be assessed uti - lizing only two questions—the Partnership and Resolve 㻠㻜 items of the Family APGAR—but family adaptability can- not be assessed using the Family APGAR. Then, we analyzed the sensitivity and specificity of the 㻞㻜 S.D. = 2.36 total Family APGAR score in predicting the FACESKG Average = 7.10 IV-16. The sensitivity of the total Family APGAR score for predicting the Cohesion score of the FACESKG IV-16 㻜㻚 㻜 㻞㻚 㻜 㻠㻚 㻜 㻢㻚 㻜 㻤㻚 㻜 㻝㻜 was 24.1  % and the specificity was 70.3  %. The sensitiv - 㻭㻼 㻳㻭 㻾 ity of the total Family APGAR score in predicting the Fig. 2 The distribution of the total family APGAR score Adaptability score of the FACESKG IV-16 was 31.8  % and the specificity was 77.4 %. These results indicate that the Family APGAR partially measures family cohesion What aspects of family function does the Family APGAR and the Resolve and Partnership items could be used to measure? capture family disengagement; however, the sensitivity of Figure  3 shows a scatter diagram between the Cohe- the total Family APGAR score for family adaptability was sion score on the FACESKG IV-16 and the total Family only 24.1  %. Therefore, we might utilize the total Family APGAR score. Additional file  1: Table S1 shows results APGAR score only to exclude the possibility of family for the correlation analysis for the Cohesion score on disengagement. the FACESKG IV-16, the total Family APGAR score, and each Family APGAR item score. The total Family APGAR The correlations between family dysfunction and family score and each item score were significantly correlated issues with the FACESKG IV-16 Cohesion score (p < 0.01). The We concluded our investigation by analyzing the rela- largest correlation was with the Resolve score of the Fam tionships between family dysfunction (as measured by ily APGAR (r  =  0.549). Figure  4 shows the scatter dia- the FACESKG IV-16) and family issues utilizing a Chi gram between the Adaptability score on the FACESKG square test. Interestingly, neither dysfunctional Cohesion IV-16 and the total Family APGAR score, while Addi- (excessive or impoverished) nor dysfunctional Adaptabil- tional file  2: Table S2 shows the results for the correla- ity was significantly related to family issues. This indicates tion analysis of the FACESKG IV-16 Adaptability score that family dysfunction (i.e., excessive or impoverished 㻚㻜 Takenaka and Ban Asia Pac Fam Med (2016) 15:3 Page 5 of 7 Fig. 3 The scatter diagram between the Cohesion score on the FACESKG IV-16 and the total Family APGAR score Fig. 4 The scatter diagram between the Adaptability score on the FACESKG IV-16 and the total Family APGAR score Cohesion and Adaptability) does not always occur in the with family issues were significantly lower than were presence of family issues. the scores for families without family issues (p  <  0.05). Next, we analyzed the relationships between each item The validity of the Family APGAR in measuring ability of the Family APGAR and the family issues measure by to cope with family issues utilizing a Chi square test. The results for the Adapt - 2 2 Figure  6 shows a scattergram of the relationships ability (χ   =  0.946, p  =  0.623), Partnership (χ   =  2.314, between the total Family APGAR scores and family p = 0.314), Growth (χ  = 2.467, p = 0.291), and Affection issues. The results of a Mann–Whitney U (ranking) test (χ   =  3.076, p  =  0.215) items were all non-significant. showed that the total Family APGAR scores of families However, there was a significant relationship between Takenaka and Ban Asia Pac Fam Med (2016) 15:3 Page 6 of 7 issues. It is possible that excessive or impoverished family Low cohesion High cohesion and adaptability are not dysfunctions but rather Chaotically are coping styles for dealing with family issues. In that Enmeshed case, changing family dynamics might weaken the fam- ily’s style of coping with their issues. Thus, family physi - cians should avoid blindly attempting to change family High Flexibly dynamics. Enmeshed We found that the Family APGAR, especially the adaptability Structurally Resolve item, has the potential to become a tool for meas- Enmeshed uring family function, at least in terms of family issues. Low Most importantly, the Resolve item was able to distin- guish patients with family issues from those with no such Rigidly Rigidly Separated Separated issues. This finding may be important to general practi - Rigidly Rigidly 3 12 Disengaged Enmeshed tioners who operate busy clinics or are inexperienced 7 45 with the family approach. Applying the simple Resolve Fig. 5 The range that the family APGAR measures item—“Are you satisfied with the way you and your fam - ily share time together?”—might be the most efficient way to assess whether patients have family issues. For example, in a daily clinical setting, a family physician 㻝㻞 might ask a patient “Do you have any worries about your 㻝㻜 family?” If the patient affirms this, the physician might go on to ask the Resolve item. The Resolve item may be useful for identifying patients for whom a family confer- ence—wherein the physician assembles family members and encourages them to communicate without employ- ing special techniques—would be beneficial, and can be the first step in implementing a family approach for phy - sicians who might normally avoid it. As such, the Resolve item of the Family APGAR may be a highly useful tool in family medicine. We note several limitations to our study. First, the 㻙㻞 Families without Families with 㻙㻚 㻞 㻜㻚 㻜 㻝㻚 㻜 㻝㻚 㻞 cross-sectional design did not allow us to examine family issue family issue changes in family function over time. We also excluded Fig. 6 Scatter diagram between the total Family APGAR score of participants with acute disease because their conditions families with issue and without one precluded their answering the questionnaire. In addition, this study was conducted in Japan in a specialized envi- ronment wherein physicians must treat 10–20 patients scores on the Resolve item and the family issues measure 2 per hour, and relied heavily on Japanese cultural values (χ  = 6.305, p = 0.043). A further Mann–Whitney U test concerning spending time with one’s family. Further revealed that patients with family issues had significantly study will be required to confirm whether the results lower scores on the Resolve item than did patients with generalize across cultures. no family issues (p < 0.05). A further limitation concerns the publication of our Differences by gender, age, or disease were not results, which has taken a considerable amount of time observed in any of the analyses. and effort because of a struggle to translate our findings into English while also performing our clinical duties. Discussion Considering the extensive gap between data collection We found that the Family APGAR partially meas- and publication, it is possible that the Japanese family ured family cohesion. Furthermore, family issues did structure and social context differ nowadays compared to not always occur in the presence of family dysfunction when the study was first conducted. In order to translate (excessive or impoverished Cohesion and Adaptability). our ideas successfully, we required repetitive checking This latter result is important because in the past it was and translation by a native English speaker. However, this generally believed that family issues occur in response process was highly costly. Furthermore, there were few to family dysfunction, while our results indicate that specialists available to us who were familiar with general improving family function might not help solving family 㻭㻼 㻳㻭 㻚㻤 㻚㻢 㻚㻠 㻚㻞 Takenaka and Ban Asia Pac Fam Med (2016) 15:3 Page 7 of 7 Authors’ contributions medicine and family approaches and who were native Dr. Takenaka is the corresponding author. He wrote this manuscript and English speakers. Thus, we experienced little recognition researched data, contributed to written informed consent, and discussion. Dr. of the necessity of and accompanying financial support Ban contributed to discussion, edited and helped translation. Both authors read and approved the final manuscript. for this study. In addition, all authors of this study were both researchers and practicing physicians, which made Author details 1 2 it difficult to complete the manuscript. It must be noted Takenaka Clinic, Osaka, Japan. Department of General Medicine/Family & Community Medicine, Nagoya University Graduate School of Medicine, that our study remains important despite the time taken Nagoya, Japan. to publish it. We are releasing these results because of their importance; however, we do intend to perform fol- Acknowledgements We appreciate the work of everyone who supported us and all participated in low-up studies to further validate them. this study. Conclusions Competing interests The authors declare that they have no competing interests. The Family APGAR partially evaluates the Cohesion dimension of family functioning as measured by the Received: 8 December 2014 Accepted: 22 April 2016 FACESKG IV-16; furthermore, its Resolve and Partner- ship items are able to capture family disengagement. In addition, family dysfunction (excessive or impoverished Adaptability or Cohesion) was not related to the pres- References ence of family issues. Nevertheless, the Family APGAR, 1. Smilkstein G. The Family APGAR: a proposal for a family function test and especially the Resolve item, has some potential for treat- its use by physicians. J Fam Pract. 1978;6:1231–9. ing patients with family issues. Thus, interventions could 2. Smilkstein G, Ashworth C, Montano D. Validity and reliability of the Family APGAR as a test of family function. J Fam Pract. 1982;15:303–11. be developed according to the simple Family APGAR 3. Gardner W, Nutting PA, Kelleher KJ, Werner JJ, Farley T, Stewart L, et al. responses. Does the Family APGAR effectively measure family functioning? J Fam Pract. 2001;50:19–25. Additional files 4. Olson DH, Bell R, Portner J. FACES: Family adaptability and cohesion evaluation scale. St Paul: University of Minnesota; 1978. 5. Olson DH, Sprenkle DH, Russel CS. Circumplex model of marital and Additional file 1: Table S1. Correlation analysis between cohesion score family systems: cohesion and adaptability dimensions, family types and of FACESKG IV and total family APGAR score. clinical applications. Fam Process. 1979;18:3–28. 6. Olson DH. Circumplex model of marital and family systems. J Family Additional file 2: Table S2. Correlation analysis between adaptability Therapy. 2000;22:144–67. score of FACESKG IV and the total family APGAR score. 7. Foulke FG, Reeb KG, Graham AV, Zyzanski SJ. Family function, respiratory Additional file 3: Table S3. Multiple regression analysis (the dependent illness, and otitis media in urban black infants. Fam Med. 1988;20:128–32. valuable was the cohesion score of FACESKG IV ). 8. Clover RD, Abell T, Becker LA, Crawford S, Ramsey CN Jr. Family func- tioning and stress as predictors of Influenza B infection. J Fam Pract. 1989;28:535–9. Abbreviations 9. FACESKG Homepage [http://tatsuki-lab.doshisha.ac.jp/~statsuki/FAC- FACES: the family adaptability and cohesion evaluation scale; FACESKG: the ESKG/FACES_Eng_index.htm]. family adaptability and cohesion evaluation scale-Kwansei Gakuin; FACESKG 10. Tatsuki S. Theoretical and empirical studies of family systems: construct IV: the family adaptability and cohesion evaluation scale-Kwansei Gakuin validations of David Olson’s Circumplex Model. Tokyo: Kawashima Shoten; version 4. 1999. 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The most important question in family approach: the potential of the resolve item of the family APGAR in family medicine

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Springer Journals
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Copyright © 2016 by Takenaka and Ban.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: We aimed to clarify what aspects of family function are measured by the Family APGAR by examining its correlations with the fourth edition of the Family Adaptability and Cohesion Evaluation Scale at Kwansei Gakuin (FACESKG IV ). Furthermore, we sought to confirm the usefulness of the Family APGAR in general practice. Methods: We recruited 250 patients (aged 13–76 years) from the general medicine outpatient clinic in a Japanese hospital between July 1999 and February 2000. We employed a cross-sectional design and administered the Family APGAR and the FACESKG IV-16 (i.e., the short version). The scores on the questionnaires were compared using correla- tion and multiple regression analyses. We then analyzed relationships between the questionnaires and family issues measures using Chi square, Mann–Whitney U, and logistic regression analyses. Results: The Family APGAR partially evaluates the Cohesion dimension of family functioning as measured by the FACESKG IV-16. Furthermore, we could measure family disengagement using the resolve and partnership items of the Family APGAR. Family dysfunction (excessive or impoverished Adaptability or Cohesion) was not related to the pres- ence of family issues. Nevertheless, there was a significant relationship between scores on the Resolve item and the family issues measure (χ = 6.305, p = 0.043). Conclusions: The Family APGAR, especially the Resolve item, has the potential for use in treating patients with family issues. Interventions could be developed according to the simple Family APGAR responses. Keywords: Family, Family research, Family members physicians hesitate to hold family conferences, which Background require considerable time and skill. A promising means Practicing family medicine relies on sufficient under - of circumventing this problem, however, would be to uti- standing of the biopsychosocial aspects of patients. In lize questionnaires. this context, family is considered the most important The Family APGAR has frequently been utilized as a aspect of patients’ social environments. However, cur- tool for assessing family function (Smilkstein [1]). Devel- rently, family approaches to medicine are not widespread oped in 1978, it is a 5-item questionnaire (with each among Japanese family physicians. This is likely because item rated on a 3-point scale) measuring five constructs: family medicine places excessive emphasis on the value “Adaptability,” “Partnership,” “Growth,” “Affection,” and of the family conference; more specifically, Japanese “Resolve.” Investigations of the reliability and validity of family physicians must treat 10–20 patients per hour in the questionnaire led to its revision by Smilkstein, Ash- outpatient clinics, which means that they must spend worth, and Montano in 1982 [2]. Because the Family roughly 3–6  min per patient. For this reason, many APGAR consists of only five questions, it is relatively easy and quick to administer; this has made it the preferred choice for evaluating family function in primary care and *Correspondence: ht69_nnw@aioros.ocn.ne.jp Takenaka Clinic, Osaka, Japan general medicine settings. However, Gardner et  al. [3] Full list of author information is available at the end of the article © 2016 Takenaka and Ban. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons. org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Takenaka and Ban Asia Pac Fam Med (2016) 15:3 Page 2 of 7 pointed out that it is somewhat unclear what the scale between the Family APGAR and the FACES II (Clover items actually measure. Nevertheless, the test remains et  al. [8]). One possible explanation for these conflicting widely (and perhaps blindly) utilized. In Japan, numerous results is that the dimensions of the FACES II are cur- university-based general practitioners and family nursing vilinear. In other words, moderate levels of Adaptability practices use the Family APGAR to educate students. and Cohesion are optimal, but too much or too little is The Family Adaptability and Cohesion Evaluation dysfunctional under normal circumstances. This accords Scale (FACES; Olson et  al. [4]) is another fairly simple with the properties of the Circumplex model, wherein instrument for assessing family function. The FACES the avoidance of extremes for either dimension is empha- is a companion measure for the Circumplex model of sized. However, evidence for curvilinearity in the FACES, marital and family systems (hereafter known as the Cir- FACES II, and FACES III has not yet been demonstrated. cumplex model; Olson et al. [5]), one of the most widely One Japanese research group was successful in iden- used yet highly controversial models of family function. tifying the curvilinearity of their original scale. Tatsuki This model emphasizes that optimal family functioning developed the FACES at Kwansei Gakuin (FACESKG) is a balance between two dimensions: “Cohesion” and series, which considers the cultural and social milieu of “Adaptability.” Cohesion is defined as the degree of emo - Japan [9]; the curvilinearity of the scale dimensions was tional bonding family members have with one another. identified in the 32-item fourth edition (FACESKG IV-32) Excessive closeness results in “enmeshment”—families by Tatsuki [10]. A shorter adaptation of the FACESKG exhibit extreme amounts of emotional closeness and may IV-32 was also created, called the FACESKG IV-16; this is be dependent on, and highly reactive to, one another. a 16-item Thurstone scale questionnaire [8] that is suited Additionally, high levels of family loyalty and consensus for use in a general medicine setting because it is succinct are required and there is little tolerance for private space and easy to administer. The scale results are based on the or relationships outside the family. Excessive separate- sum of the score of each question multiplied by a coef- ness, in contrast, causes “disengagement,” where fami- ficient appropriate for the content. However, Japanese lies exhibit little emotional closeness and instead remain clinics often comprise only a few staff members, such as a focused on individual experiences and activities. Further- physician, nurse, and clerk, which means that they would more, such families have limited commitment to family have little time to complete a questionnaire. Indeed, even interests, and members are often unable to turn to one questionnaires with few questions such as the FACESKG another for emotional or practical support or assistance. IV-16 would not be easy to administer in daily work in For Cohesion, balance would refer to “separated” or Japan. “connected” families, where both individual and group u Th s, the current study had three objectives. The first interests are valued [6]. Adaptability, on the other hand, was to clarify what aspects of family function are meas- is defined as the ability of a marital or family system to ured by the Family APGAR, by examining the correla- change its power structure, role relationships, and rela- tions between the Family APGAR and the FACESKG tionship rules in response to situational and developmen- IV-16, for which linearity and curvilinearity, respec- tal stress. Poor Adaptability leads to “rigidity,” wherein tively, have been established in the Japanese population. the family or couple relationship is unable to shift or In Japanese family practice, previous studies have noted evolve in response to change, whether that arising inter- that physicians do not like administering the full Fam- nally through individual members’ development or that ily APGAR, despite the fact that it comprises only five imposed by the environment. Excessive Adaptability, on questions. Therefore, we wanted to identify the particu - the other hand, results in “chaos,” with family members larly effective questions for analyzing family dysfunction, unable to create shared agreements that govern their thereby enabling the Family APGAR to be used in daily actions and inter-relationships, and thus providing no clinical practice more conveniently. As such, we analyzed firm base on which they can stand. In between these two the relations of each item score of the Family APGAR extremes lie the balanced options of “flexible” or “struc - with the FACESKG IV-16 in addition to the total Family tured” families, where the balance between rigidity and APGAR score. chaos is negotiated from the strong base of shared under- It is generally believed that family issues occur in standing of rules and roles within the relationship [6]. response to family dysfunction (i.e., excessive or impov- Foulke et  al. [7] administered the Family APGAR and erished functioning). As such, the second objective was FACES II (the second version of FACES) to 140 families to confirm the correlations between family dysfunction and found that the Family APGAR correlated with the and family issues, and to identify the particularly impor- relevant Circumplex model dimensions of the FACES II tant aspects of family function by investigating the cor- (Cohesion, r = 0.70; Adaptability, r = 0.59). However, in relations between FACESKG IV-16 scores and the family another study with 66 families, no association was found issues measured. Takenaka and Ban Asia Pac Fam Med (2016) 15:3 Page 3 of 7 The third and final objective was to confirm the valid - Chi square test, a Mann–Whitney U test, and a logis- ity of the Family APGAR as a basis for helping families tic regression analysis because setting family issues as cope with family issues; for this purpose, we examined the dependent variable required a binomial distribution the correlation between the Family APGAR and the fam- whereas the independent variables utilized a curvilinear ily issues measure. model. Data were analyzed using SPSS version 11.0. We defined “family dysfunction” as having a score of 2 or more on the absolute values of the Cohesion and Ethics Adaptability item scores of the FACESKG IV-16, and a Written informed consent was obtained from all sub- score of <8 on the total Family APGAR score (with <4 jects. We applied for ethical approval to the Institutional being indicative of severe dysfunction). We defined “fam - Ethical Review Board of the Kawasaki Medical School ily issues” as the suffering that participants experienced through the professor in charge; however, the board as a result of their family. deemed it exempt from ethical approval. We then sub- mitted it to the Ethical Review Board of the Osaka Soci- Methods ety of Family Practice, who approved the study protocol. Design The study design was cross-sectional and employed two Results questionnaires (the Family APGAR and the FACESKG- Participants were 311 patients, of whom 250 (80.4  %) IV) and one original question assessing family issues. gave complete responses. Participants (gender: 120 male, 126 female, 4 unknown) ranged in age from 13 to Setting and participants 76  years (M  =  49.2, SD  =  13.2) and had an average of The present study was conducted at the outpatient clinic 3.5 (SD  =  1.6) family members. One hundred six par- of a university hospital in Japan (Department of Primary ticipants had mental disorders, 45 had hypertension, 45 Care Medicine, Kawasaki Medical School, Kurashiki City, had hyperlipidemia, and 38 had diabetes mellitus. Sev- Okayama, Japan) between July 1999 and February 2000. enty-six patients (30.4  %) reported having some family Thirteen clinicians administered the questionnaires to issues. Specifically, family issues included health prob - their patients. Study participants completed the Family lems with their family member (n = 24), family lifecycle APGAR (translated into Japanese from the original Eng- issues (e.g., family death, aging; n  =  17), problems with lish version) and FACESKG IV-16. In order to evaluate family dynamics (n  =  6), substance abuse or addiction family issues, we devised an original question: “Do you (e.g., alcohol, gambling; n  =  5), work-related problems have any worries about your family? If you do, please (e.g., unemployment, irregularity of work; n  =  6), eco- tell us about them. You are free to decline to answer.” nomic problems (n  =  3), and unknown problems (i.e., We excluded patients who declined to participate, were the participant did not want to answer; n  =  20). Note unable to understand the scale items, did not provide that five participants reported two issues, which is why answers to all items on both questionnaires, were experi- there is a discrepancy in the number of participants for encing acute disease, or reported uncomfortable feelings family issues (with n  =  76 reporting family issues over- while responding to the scale items. all but n = 81 when summing the number of participants reporting specific issues). Procedures Figure  1 shows the family function of the partici- We explained the contents of the study and enrolled pants according to the Circumplex model. There were patients who agreed to participate. Written informed 68 (27.2  %) balanced families, 116 (46.4  %) mid-range consent was then obtained from all participants. Patients families, and 66 (26.4 %) unbalanced (i.e., dysfunctional) completed the questionnaire while waiting at the billing families. Figure  2 shows the distribution in Family department after their medical examinations. Completed APGAR scores; according to this measure, family func- questionnaires were then brought to the front desk of the tion can be categorized as “good” (scores from 7 to 10), outpatient clinic. “moderate dysfunction” (score from 4 to 6), or “severe dysfunction” (score from 0 to 3). In the present study, Statistical analyses 171 (63.3 %) patients reported good family function, 77 We employed correlation and multiple regression anal- (28.5 %) reported moderate dysfunction, and 22 (8.1 %) yses (the step-down procedure) to compare Family reported severe dysfunction. Thus, the results indicated APGAR measures with scores on the FACESKG IV-16. that the definition of family dysfunction differs sub - We then analyzed the relationships between FACESKG stantially between the FACESKG IV-16 and the Family IV-16, the Family APGAR, and family issues by using a APGAR. Takenaka and Ban Asia Pac Fam Med (2016) 15:3 Page 4 of 7 with Family APGAR scores. The total Family APGAR Low cohesion High score and the Adaptability, Partnership, Growth, and Chaotically Chaotically Affection item scores were all significantly and negatively Disengaged Enmeshed Chaotically Chaotically 9 Separated Connected 5 correlated with the FACESKG IV-16 Adaptability score 3 4 (p  <  0.05); the largest correlation was with the Partner- ship item (r = −0.210). Scores on the Resolve item were High Flexibly Flexibly Flexibly Flexibly not significantly correlated with the FACESKG IV-16 Disengaged Separated Connected Enmeshed Adaptability score, but were significantly correlated with 10 8 42 63 adaptability Structurally Structurally Structurally Structurally the squared values of the Adaptability score (p  <  0.01). Disengaged Separated Connected Enmeshed These results indicate that the Resolve item of the Family 6 5 13 15 Low APGAR measures family disengagement and chaos, and partially measures rigidity (Fig.  5). However, the Family Rigidly Rigidly Separated Separated APGAR could not measure enmeshment or fully meas- Rigidly Rigidly 3 12 Disengaged Enmeshed ure rigidity. 7 45 Additional file  3: Table S3 shows the results of the Fig. 1 Family functioning on the circumplex model multiple regression analysis using the step-down pro- cedure. In the best-fit model, the predictor variable was the FACESKG IV-16 Cohesion score while the outcome variables were the Partnership and Resolve item scores 㻝㻜㻜 from the Family APGAR (Adjusted R  = 0.322, p < 0.01). The regression equation was as follows: Cohesion 㻤㻜 score = 0.191  ×  Partnership score  +  0.472  ×  Resolve score  −  2.982. The regression analysis showed that Adaptability was not significantly explained by the Family 㻢㻜 APGAR items. Thus, family cohesion can be assessed uti - lizing only two questions—the Partnership and Resolve 㻠㻜 items of the Family APGAR—but family adaptability can- not be assessed using the Family APGAR. Then, we analyzed the sensitivity and specificity of the 㻞㻜 S.D. = 2.36 total Family APGAR score in predicting the FACESKG Average = 7.10 IV-16. The sensitivity of the total Family APGAR score for predicting the Cohesion score of the FACESKG IV-16 㻜㻚 㻜 㻞㻚 㻜 㻠㻚 㻜 㻢㻚 㻜 㻤㻚 㻜 㻝㻜 was 24.1  % and the specificity was 70.3  %. The sensitiv - 㻭㻼 㻳㻭 㻾 ity of the total Family APGAR score in predicting the Fig. 2 The distribution of the total family APGAR score Adaptability score of the FACESKG IV-16 was 31.8  % and the specificity was 77.4 %. These results indicate that the Family APGAR partially measures family cohesion What aspects of family function does the Family APGAR and the Resolve and Partnership items could be used to measure? capture family disengagement; however, the sensitivity of Figure  3 shows a scatter diagram between the Cohe- the total Family APGAR score for family adaptability was sion score on the FACESKG IV-16 and the total Family only 24.1  %. Therefore, we might utilize the total Family APGAR score. Additional file  1: Table S1 shows results APGAR score only to exclude the possibility of family for the correlation analysis for the Cohesion score on disengagement. the FACESKG IV-16, the total Family APGAR score, and each Family APGAR item score. The total Family APGAR The correlations between family dysfunction and family score and each item score were significantly correlated issues with the FACESKG IV-16 Cohesion score (p < 0.01). The We concluded our investigation by analyzing the rela- largest correlation was with the Resolve score of the Fam tionships between family dysfunction (as measured by ily APGAR (r  =  0.549). Figure  4 shows the scatter dia- the FACESKG IV-16) and family issues utilizing a Chi gram between the Adaptability score on the FACESKG square test. Interestingly, neither dysfunctional Cohesion IV-16 and the total Family APGAR score, while Addi- (excessive or impoverished) nor dysfunctional Adaptabil- tional file  2: Table S2 shows the results for the correla- ity was significantly related to family issues. This indicates tion analysis of the FACESKG IV-16 Adaptability score that family dysfunction (i.e., excessive or impoverished 㻚㻜 Takenaka and Ban Asia Pac Fam Med (2016) 15:3 Page 5 of 7 Fig. 3 The scatter diagram between the Cohesion score on the FACESKG IV-16 and the total Family APGAR score Fig. 4 The scatter diagram between the Adaptability score on the FACESKG IV-16 and the total Family APGAR score Cohesion and Adaptability) does not always occur in the with family issues were significantly lower than were presence of family issues. the scores for families without family issues (p  <  0.05). Next, we analyzed the relationships between each item The validity of the Family APGAR in measuring ability of the Family APGAR and the family issues measure by to cope with family issues utilizing a Chi square test. The results for the Adapt - 2 2 Figure  6 shows a scattergram of the relationships ability (χ   =  0.946, p  =  0.623), Partnership (χ   =  2.314, between the total Family APGAR scores and family p = 0.314), Growth (χ  = 2.467, p = 0.291), and Affection issues. The results of a Mann–Whitney U (ranking) test (χ   =  3.076, p  =  0.215) items were all non-significant. showed that the total Family APGAR scores of families However, there was a significant relationship between Takenaka and Ban Asia Pac Fam Med (2016) 15:3 Page 6 of 7 issues. It is possible that excessive or impoverished family Low cohesion High cohesion and adaptability are not dysfunctions but rather Chaotically are coping styles for dealing with family issues. In that Enmeshed case, changing family dynamics might weaken the fam- ily’s style of coping with their issues. Thus, family physi - cians should avoid blindly attempting to change family High Flexibly dynamics. Enmeshed We found that the Family APGAR, especially the adaptability Structurally Resolve item, has the potential to become a tool for meas- Enmeshed uring family function, at least in terms of family issues. Low Most importantly, the Resolve item was able to distin- guish patients with family issues from those with no such Rigidly Rigidly Separated Separated issues. This finding may be important to general practi - Rigidly Rigidly 3 12 Disengaged Enmeshed tioners who operate busy clinics or are inexperienced 7 45 with the family approach. Applying the simple Resolve Fig. 5 The range that the family APGAR measures item—“Are you satisfied with the way you and your fam - ily share time together?”—might be the most efficient way to assess whether patients have family issues. For example, in a daily clinical setting, a family physician 㻝㻞 might ask a patient “Do you have any worries about your 㻝㻜 family?” If the patient affirms this, the physician might go on to ask the Resolve item. The Resolve item may be useful for identifying patients for whom a family confer- ence—wherein the physician assembles family members and encourages them to communicate without employ- ing special techniques—would be beneficial, and can be the first step in implementing a family approach for phy - sicians who might normally avoid it. As such, the Resolve item of the Family APGAR may be a highly useful tool in family medicine. We note several limitations to our study. First, the 㻙㻞 Families without Families with 㻙㻚 㻞 㻜㻚 㻜 㻝㻚 㻜 㻝㻚 㻞 cross-sectional design did not allow us to examine family issue family issue changes in family function over time. We also excluded Fig. 6 Scatter diagram between the total Family APGAR score of participants with acute disease because their conditions families with issue and without one precluded their answering the questionnaire. In addition, this study was conducted in Japan in a specialized envi- ronment wherein physicians must treat 10–20 patients scores on the Resolve item and the family issues measure 2 per hour, and relied heavily on Japanese cultural values (χ  = 6.305, p = 0.043). A further Mann–Whitney U test concerning spending time with one’s family. Further revealed that patients with family issues had significantly study will be required to confirm whether the results lower scores on the Resolve item than did patients with generalize across cultures. no family issues (p < 0.05). A further limitation concerns the publication of our Differences by gender, age, or disease were not results, which has taken a considerable amount of time observed in any of the analyses. and effort because of a struggle to translate our findings into English while also performing our clinical duties. Discussion Considering the extensive gap between data collection We found that the Family APGAR partially meas- and publication, it is possible that the Japanese family ured family cohesion. Furthermore, family issues did structure and social context differ nowadays compared to not always occur in the presence of family dysfunction when the study was first conducted. In order to translate (excessive or impoverished Cohesion and Adaptability). our ideas successfully, we required repetitive checking This latter result is important because in the past it was and translation by a native English speaker. However, this generally believed that family issues occur in response process was highly costly. Furthermore, there were few to family dysfunction, while our results indicate that specialists available to us who were familiar with general improving family function might not help solving family 㻭㻼 㻳㻭 㻚㻤 㻚㻢 㻚㻠 㻚㻞 Takenaka and Ban Asia Pac Fam Med (2016) 15:3 Page 7 of 7 Authors’ contributions medicine and family approaches and who were native Dr. Takenaka is the corresponding author. He wrote this manuscript and English speakers. Thus, we experienced little recognition researched data, contributed to written informed consent, and discussion. Dr. of the necessity of and accompanying financial support Ban contributed to discussion, edited and helped translation. Both authors read and approved the final manuscript. for this study. In addition, all authors of this study were both researchers and practicing physicians, which made Author details 1 2 it difficult to complete the manuscript. It must be noted Takenaka Clinic, Osaka, Japan. Department of General Medicine/Family & Community Medicine, Nagoya University Graduate School of Medicine, that our study remains important despite the time taken Nagoya, Japan. to publish it. We are releasing these results because of their importance; however, we do intend to perform fol- Acknowledgements We appreciate the work of everyone who supported us and all participated in low-up studies to further validate them. this study. Conclusions Competing interests The authors declare that they have no competing interests. The Family APGAR partially evaluates the Cohesion dimension of family functioning as measured by the Received: 8 December 2014 Accepted: 22 April 2016 FACESKG IV-16; furthermore, its Resolve and Partner- ship items are able to capture family disengagement. In addition, family dysfunction (excessive or impoverished Adaptability or Cohesion) was not related to the pres- References ence of family issues. Nevertheless, the Family APGAR, 1. Smilkstein G. The Family APGAR: a proposal for a family function test and especially the Resolve item, has some potential for treat- its use by physicians. J Fam Pract. 1978;6:1231–9. ing patients with family issues. Thus, interventions could 2. Smilkstein G, Ashworth C, Montano D. Validity and reliability of the Family APGAR as a test of family function. J Fam Pract. 1982;15:303–11. be developed according to the simple Family APGAR 3. Gardner W, Nutting PA, Kelleher KJ, Werner JJ, Farley T, Stewart L, et al. responses. Does the Family APGAR effectively measure family functioning? J Fam Pract. 2001;50:19–25. Additional files 4. Olson DH, Bell R, Portner J. FACES: Family adaptability and cohesion evaluation scale. St Paul: University of Minnesota; 1978. 5. Olson DH, Sprenkle DH, Russel CS. Circumplex model of marital and Additional file 1: Table S1. Correlation analysis between cohesion score family systems: cohesion and adaptability dimensions, family types and of FACESKG IV and total family APGAR score. clinical applications. Fam Process. 1979;18:3–28. 6. Olson DH. Circumplex model of marital and family systems. J Family Additional file 2: Table S2. Correlation analysis between adaptability Therapy. 2000;22:144–67. score of FACESKG IV and the total family APGAR score. 7. Foulke FG, Reeb KG, Graham AV, Zyzanski SJ. Family function, respiratory Additional file 3: Table S3. Multiple regression analysis (the dependent illness, and otitis media in urban black infants. Fam Med. 1988;20:128–32. valuable was the cohesion score of FACESKG IV ). 8. Clover RD, Abell T, Becker LA, Crawford S, Ramsey CN Jr. Family func- tioning and stress as predictors of Influenza B infection. J Fam Pract. 1989;28:535–9. Abbreviations 9. FACESKG Homepage [http://tatsuki-lab.doshisha.ac.jp/~statsuki/FAC- FACES: the family adaptability and cohesion evaluation scale; FACESKG: the ESKG/FACES_Eng_index.htm]. family adaptability and cohesion evaluation scale-Kwansei Gakuin; FACESKG 10. Tatsuki S. Theoretical and empirical studies of family systems: construct IV: the family adaptability and cohesion evaluation scale-Kwansei Gakuin validations of David Olson’s Circumplex Model. Tokyo: Kawashima Shoten; version 4. 1999. Submit your next manuscript to BioMed Central and we will help you at every step: • We accept pre-submission inquiries • Our selector tool helps you to find the most relevant journal • We provide round the clock customer support • Convenient online submission • Thorough peer review • Inclusion in PubMed and all major indexing services • Maximum visibility for your research Submit your manuscript at www.biomedcentral.com/submit

Journal

Asia Pacific Family MedicineSpringer Journals

Published: May 5, 2016

References