Family Assessment: At the Interface of Nature and Nurture Stands the Family (page 2)
A child's environment
"A family is to a child as water is to a fish."
The 'nurturing system' that is the family is the most basic, most central context for a child's well-being and development. The emotional, caring surrounding that a family provides for a child is probably the single most important factor in that child's life. Nurturing systems, whether we call them families or not, come in all shapes and sizes and have a wonderful flexible variety as to the way they can work towards the common goal of the welfare of children. This idea is certainly not a new one; in many respects it has become a taken-for-granted assumption. Yet families who bring their child to a mental health professional often approach that event with a mixture of feelings. Will they feel welcomed, helped, criticized, even blamed? The psychiatric evaluation process should ideally be a family-friendly one. Since families are the most important context for the child, they should be welcomed and actively involved in the evaluation process as collaborators in a joint endeavor to create the best treatment approach for their child.
What is a family assessment?
The family stands at the interface of nature and nurture. The relationship between the biological givens of the child and the environmental influences of the family (including the biological givens of the various members) come together in a system of complex, mutual influence. Just as the 'nurture' of the family shapes the development of the child, the nature of the child shapes the expressions of nurture of the family. It is a reciprocal process of 'co-evolution," one that optimally creates a 'good-enough' fit for all members of the family.
As the meeting place of nature and nurture, the family should be a central part of the evaluation process when a child is brought for a psychiatric evaluation. Having said this, it is vitally important to emphasize that mental health professionals are not interested in blaming a family for a child's psychological, emotional, or behavior difficulties. Families need support, not blame, affirmation for their efforts and what they are doing right, not criticism or judgment.
A family assessment should proceed in the spirit of joint inquiry and collaboration. Families are experts on their own children. Professionals have expertise in diagnosis, assessment, and various forms of treatment. Family members should have their ideas and perspectives elicited and respected. Each family member, even small children, have unique perspectives that can be usefully included in developing a constructive plan of action. Therefore, as many family members and relevant others as possible (including ancillary members, extended family, even professionals who play key roles in managing or affecting the child and his/her problem) should participate.
A family assessment looks closely at the nurturing 'ecology' of the child and family, integrating family systems theory with newly emerging understandings about human behavior from such domains as neuroscience, biological psychiatry, trauma research, genetics, and infant developmental research. Each of these domains of knowledge defines an aspect of human development and experience that exists in a mutually shaping relationship with all other aspects. Like the Sufi story of the eight blind men who each understand only their piece of the elephant without the benefit of seeing the whole elephant, each of a child's domains offers a partial description of what it is to become a person. A family assessment, using the framework of systems theory, creates a 'ninth observer' who can see the entire elephant and how all the parts fit into a whole.
Families seeking help often present with what is called a 'problem-saturated' version of who they are. Families, too, can fall prey to the limitations of the blind men and the elephant, seeing only one aspect of their lives because this aspect has become so prominent and dominant. Their lives have been so consumed by the demands of dealing with a child's problem that the stories that shape their identity begin to consolidate around the problem and their struggle to cope. A family assessment should help family members adjust their perspective and see that although the problem is a big part of their lives, it is not the whole of their lives.
What to expect in a family assessment
As mentioned above, as many family members and relevant others that can attend should be invited. Although the ideal is for three sessions, most assessments occur in the course of a single interview. The following are some of the areas that are addressed:
Family life in general. Since families come in all shapes and sizes and from a variety of cultural backgrounds and configurations, a family assessment will seek to understand how a family functions.
- On a specific level, the assessment will look at how the child's problem affects the family, and how the family's process affects the problem. An example might be how the child's difficulties impact on the parents' relationship, and how the parents' relationship ameliorates or exacerbates the child's problem.
- Family members are often unaware of the degree to which behavior at home gets patterned around a child's difficulties. These frustrating, repetitive sequences can organize family life. An awareness of this patterning process can lead to many constructive ideas for change.
Family history, both general and specific to the problem
- Family therapists use a tool called the 'genogram' to organize family information. Much like a 'family tree' the genogram vividly depicts family relationships over time, spanning a few generations. Looking at history is not for the purpose of finding the causes of a problem, but rather, to help locate the problem in the larger context of a family's past and present life.
How family members 'fit together'
- In examining the 'goodness of fit' among family members, particularly between parents and the child, the therapist is looking for ways in which the 'fit' may affect the expression and course of the child's problem. This domain is very important in later guiding how therapy can help to create an optimal fit for the parents and the child's overall well-being.
Family strengths and resources are a fundamental area of importance in the assessment. Families are the primary resource for the child, and all families have strengths, even if these strengths are underidentified and underutilized. Since helping a child with a psychiatric disorder will always require the participation of family members, family resources need to be mined, even if they are not immediately obvious and apparent.
- Similarly, children should become active agents in their own treatment. A family assessment sets the stage for families to engage their kids to be creative participants in problem-solving. A collaborative approach that calls for all family members, including the child, to become partners in the endeavor to come up with viable strategies for change is advocated.
Psychoeducation: As part of the assessment, a therapist will want to discuss with the family and child how he/she and others are thinking about the child's difficulties. At times, psychiatric diagnoses are confusing and upsetting. Psychoeducation should be a dialogue, a conversation in which the family's ideas are as important as those of the professionals. A family assessment should promote a climate of respectful interest in everyone's ideas and allow room for disagreement and difference of opinion. Family members should not feel 'talked down to' or lectured. Family members possess important 'local knowledge' of their child that, when combined with the 'professional knowledge' of the therapist, offers a richer variety of ideas than one or the other alone.
Like any assessment, a family assessment should provide a greater sense of clarity and direction for families as to how best help their child. Hopefully it will also offer a different perspective on their child and a different perspective on themselves as a whole. An action plan should follow that will offer concrete recommendations for treatment such as one or combination of the following:
- Family or couples therapy
- Individual therapy
- Group therapy
- Psychopharmacology evaluation
- Neuropsychological and/or educational evaluation
- Family-School consultation
Families who go through this process should expect to have one central professional acting as 'point person' and liaison to coordinate the treatment plan as a whole.
About the Author
Andrew Roffman, LCSW, Co-assistant Director of the Family Studies Program at the NYU Child Study Center, is a therapist, supervisor, and teacher of family and couples therapy. His current areas of interest include asthma and the family, men and anger, and the applications of systems theory to the emotions in therapy. He is the author of a number of publications in both professional journals and parenting magazines.
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About the NYU Child Study Center
The New York University Child Study Center is dedicated to increasing the awareness of child and adolescent psychiatric disorders and improving the research necessary to advance the prevention, identification, and treatment of these disorders on a national scale. The Center offers expert psychiatric services for children, adolescents, young adults, and families with emphasis on early diagnosis and intervention. The Center's mission is to bridge the gap between science and practice, integrating the finest research with patient care and state-of-the-art training utilizing the resources of the New York University School of Medicine. The Child Study Center was founded in 1997 and established as the Department of Child and Adolescent Psychiatry within the NYU School of Medicine in 2006. For more information, please call us at (212) 263-6622 or visit us at www.AboutOurKids.org.
Reprinted with the permission of the NYU Child Study Center. © NYU Child Study Center.
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