EDITORIAL

Is the Family APGAR dead? A reappraisal of family assessment tools in Portugal

John Yaphe*

*Associate Professor, Community Health, School of Health Sciences, University of Minho

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When a monarch dies, there is a tradition of announcing: “The King is dead. Long live the King.” This assures continuity of leadership after a loss. We need a similar process in family medicine when we notice that many of our long-revered tools of family assessment such as the Family APGAR¹ and the Duvall Family Life Cycle² appear lifeless. In this editorial I would like to propose ways to resuscitate this fascinating field.

Tests of family function were in vogue in English speaking countries in the 1980s. Publications on family function tools mentioned here come from that time, suggesting that they describe research done 50 years ago. I was trained in medicine at McGill University in Canada in the late 1970s by teachers like Janet Christie-Seely, whose PRACTICE model³ of family function still enriches my teaching today and in family medicine in Israel in the 1980s by inspiring mentors like Jack Medalie. We learned the tools of family assessment as if they were valid and reliable instruments. These include the Family APGAR of Smilkstein, the Duvall family life cycle, the Circumplex model of Olson, the genogram, and the Thrower family circle. The reader is referred to the dossier published in this journal in 2007 that discusses their use.⁴ We did not use the family assessment tool of Segovia-Dryer,⁵ which oddly has found its way into computerized medical records in family medicine in Portugal, but does not seem to be used elsewhere. The utility of this unpublished, non-validated risk assessment tool is puzzling. Trainees tell me: “We have to use it.” Specialists tell me: “We never use it.” Perhaps it is time to get rid of it.

I do not reject the evidence for the reciprocal relationships between family and health. Ribeiro⁶ and others have reviewed the evidence for this axiom of family medicine. I now suggest a careful re-examination of the tools we use to assess family function and the diagnostic, therapeutic and predictive value of these tools in the light of current clinical practice in Portugal.

There is evidence that the APGAR lacks validity and predictive value. A number of studies in large research networks have shown that APGAR scores have little correlation with family dysfunction and are poor predictors of family outcomes over time.

When Gardner et al. asked in 2001 “does the family APGAR effectively measure family functioning?” the answer was no.⁷ In 22,000 office visits made by 401 primary care physicians there was a poor correlation between initial and follow-up scores and discrepancies between test scores and physician assessment of families. Murphy et al. in a study of 9000 children found that “the Family APGAR was not a sensitive measure of child psychosocial problems”.⁸

Case reports in the Portuguese literature suggest that the APGAR does not work. Martins et al. commented that it was difficult to apply to the family they studied and that it produced invalid results.⁹

A Medline search using the term “family APGAR” produces a list of about 50 publications with mixed results. For example, there was no significant correlation found between the APGAR and low back pain,¹⁰ no association with caregiver strain in families with a child with cancer,¹¹ and no correlation with dental caries in children.¹² There may be significant association between the APGAR and alcoholism, drug use, and frequent attendance in clinics.

Why then does its ritualistic use persist in teaching, clinical practice, and case reports? We need to look critically at clinical data and see if APGAR scores have any relevance. I will be happy to share my collected references with any researcher willing to do a systematic review of this topic. That has a good chance of being published here.

The same is true for the Duvall family life cycle model. Our students say: “We tried to apply the Duvall model but it does not fit for our family”. Since Evelyn Duvall did her work in the US in the 1940s, it would make sense that this model might not apply to Portugal in 2013. The census data of 2011¹³ tell us that family size is shrinking, the number of common law couples is rising, the number of people living alone is rising, as are the numbers of childless couples. Caniço described this in his recent book.¹⁴ Perhaps it is time to create a new model to describe the current, normative family life cycle in this country.

These tools may have value in teaching students and trainees about the reciprocal relations between family and health. We use the genogram and the PRACTICE model to teach students basic concepts in family sociology. José Nunes describes them as an abre lata (can opener) or saca rolhas (corkscrew) that helps the doctor explore fruitful areas of family function with the patient. The routine use of the other tools is questionable. I challenge our readers to come up with evidence for their utility. A qualitative study of their application by family doctors in Portugal might be helpful. We are willing to publish your findings to add to the debate.

 

REFERENCES

1. Smilkstein G. The Family APGAR: a proposal for a family function test and its use by physicians. J Fam Pract 1978 Jun; 6 (6): 1231-9.         [ Links ]

2. Duvall EM. Marriage and Family Development. Philadelphia, PA: JB Lippincott Company; 1977.         [ Links ]

3. Christie-Seely J. Teaching the family system concept in family medicine. J Fam Pract 1981 Sep; 13 (3): 391-401.         [ Links ]

4. Rebelo L. Família e cuidados de saúde. Rev Port Clin Geral 2007 Mai-Jun; 23 (3): 295-7.         [ Links ]

5. Segovia Dreyer IE. Estudo piloto do uso de três fichas familiares diferentes num centro de medicina familiar. 11ªs Jornadas Internacionais de Medicina Familiar das Américas. Espanha e Portugal. Panamá; 1984.         [ Links ]

6. Ribeiro C. Família, saúde e doença: o que diz a investigação. Rev Port Clin Geral 2007 Mai-Jun; 23 (3): 299-306.         [ Links ]

7. Gardner W, Nutting PA, Kelleher KJ, Werner JJ, Farley T, Stewart L, et al. Does the family APGAR effectively measure family functioning? J Fam Pract 2001 Jan; 50 (1): 19-25.         [ Links ]

8. Murphy JM, Kelleher K, Pagano ME, Stulp C, Nutting PA, Jellinek MS, et al. The family APGAR and psychosocial problems in children: a report from ASPN and PROS. Fam Pract 1998 Jan; 46 (1): 54-64.         [ Links ]

9. Martins C, Mauroy de Fonseca I, Costa P. Uma avó e dois netos adolescentes: um «agregado» de problemas. Rev Port Clin Geral 2000 Jul-Ago; 16 (4): 313-28.         [ Links ]

10. van Vuuren B, van Heerden HJ, Zinzen E, Becker P, Meeusen R. Perceptions of work and family assistance and the prevalence of lower back problems in a South African manganese factory. Ind Health 2006 Oct; 44 (4): 645-51.         [ Links ]

11. Panganiban-Corales AT, Medina MF Jr. Family resources study: part 1: family resources, family function and caregiver strain in childhood cancer. Asia Pacific Fam Med 2011 Oct 31; 10 (1): 14.         [ Links ]

12. Díaz-Cárdenas S, González-Martínez F. Prevalencia de caries dental y factores familiares en niños escolares de Cartagena de las Índias, Colombia (The prevalence of dental caries related to family factors in school-children from the city of Cartagena in Colombia). Rev salud pública (Bogotá) 2010 Oct; 12 (5): 843-51.         [ Links ]

13. Instituto Nacional de Estatística, I.P. Censos 2011 Resultados Definitivos - Portugal. Lisboa. Disponível em: http://www.ine.pt (acedido em 18/02/2013).         [ Links ]

14. Caniço H, Bairrada P, Rodríguez E, Carvalho A. Novos Tipos de Família, Plano de Cuidados. Coimbra: Imprensa da Universidade de Coimbra; 2010.         [ Links ]

 

Endereço para correspondência | Dirección para correspondencia | Correspondence

yonahyaphe@hotmail.com

 

Conflict of interest

None.