by Lisa C. Greene

Note to readers: This article is what is called a “critical review” which is a review, or analysis, of a particular research article. This was a requirement for one of my college classes. Since I am interested both personally and professionally in the effects of the family of a child’s health issues, I chose a research paper by Thomas L. Campbell, M.D., the Chair of the Department of Family Medicine at University of Rochester Medical Center. All of the quotes I have included are from this one article and not from the original sources.

Campbell, T.L. (2003). The effectiveness of family interventions for physical disorders.   
     Journal of Marital and Family Therapy, 29 (2), 263.

This peer-reviewed journal article is not an empirical study but is a research synthesis which analyzes the “effectiveness of family interventions in the prevention and treatment of physical disorders.” The opening paragraphs provide a clear understanding of what this paper is about starting with a discussion on the role of the family in chronic physical illness and disability.

There is a growing amount of research that demonstrates that chronic and serious illnesses have a profound effect on other family members and on the family as a whole. It also works in reverse. There is also a growing body of evidence that shows families can have a beneficial or harmful effect on an individual family member’s health. The question being asked in this well-written paper is: Can family interventions be beneficial in the prevention or treatment of physical disorders?

This topic is timely with the billions of dollars that are spent each year to support and manage chronic medical conditions and illnesses. Health care costs are skyrocketing and the dollars available to pay for health care costs is dwindling.

There is compelling research that concludes: "Families have a powerful influence on health, equal to traditional medical risk factors." In fact, a 1988 Science Journal article by sociologist James House said: "The evidence regarding social relationships and health increasingly approximates the evidence for the 1964 Surgeon General's report that establish cigarette smoking as a cause or risk factor for mortality and morbidity from a range of diseases."

Of the three types of support (instrumental, informational, emotional and a sense of belonging), research shows that “Emotional support is the most important and influential type of support provided by families.” Furthermore, "For adults, marriage is the most influential family relationship on health. Marital status affects overall mortality, mortality from specific illnesses, and morbidity. Married individuals are healthier than the widowed, who are in turn healthier than either divorced or never married individuals. Separation and divorce is also associated with increased mortality.” (Campbell, 2003)

The type of emotional support is also very important. "Negative, critical, or hostile family relationships have a stronger influence on health than positive or supportive relationships." (Campbell, 2003) In the author's own words: "Being nasty is worse than simply not being nice." In several studies including schizophrenia, depression, smoking, weight management, asthma, diabetes, and migraine headaches, researchers found that conflict and criticism can have a profound negative influence.

It appears, the family environment does indeed have a huge impact on a person’s health status. The challenge for researchers and clinicians is that the way this effect takes place is not clear. The author discusses three general pathways that the family and social relationships can influence an individual’s health.

The first way is by a direct biological pathway. This includes the shared physical environment. People living in close proximity are at increased risk of transmitting airborne and blood-borne diseases. They share the same toxic environments including smoking and asbestos. Of course, there are also genetic influences.

Another pathway that influences health is health behavioral pathways. Our families strongly influence our health behaviors including smoking, exercise, diet, nutrition, and substance abuse. Parents have a strong influence on what kind of health behaviors their children or adolescents will adopt.

And the third general way that families can influence health is psychophysiological pathways.  "Family relationships can influence physical health by changes in cognition and emotion that results in physiological responses, which in turn can influence health outcomes." (Campbell, 2003) This includes the effect of stress on the immune system and psychosomatic illness. A very interesting study was done that showed a clear and directly-related increase in diabetic ketoacidosis in children with diabetes to the amount of stress and conflict in the home. (Minuchin et al. 1975, 1978). 

By understanding these pathways, medical and mental-health professionals can choose appropriate and effective family interventions to improve a patient's health status. The paper identified the different types of possible family interventions which include family education and support, family psychoeducation, and family therapy. This discussion included the strengths and shortcomings of the different types of interventions on health behaviors.

To analyze the effectiveness of family interventions, the author reviewed several studies in four areas: family caregiving of elders, childhood chronic illness, spouse involvement in chronic adult illnesses, and health promotion/disease prevention.

Family Caregiving of Elders
The author makes a compelling case for the magnitude of caring for older people with chronic and disabling conditions. With the population aging, longer lifespans, the rising rate of disabling conditions, and dwindling resources available for professional caregiving, the burden of caring for the elderly is falling to family members. "Research has demonstrated that caregiving exerts a heavy toll on family members. Family caregivers have a much higher morbidity and mortality than age matched controls. Caregivers suffer higher rates of multiple physical illnesses, depression, and anxiety." (Campbell, 2003) With some illnesses, such as Alzheimer's, caregivers may devote years of their own lives to caring for a family member. This causes a huge impact on finances, social lives, careers, retirement plans, and personal dreams for the future.

There have been family interventions developed for caregivers including combinations of counseling, education and support. Several such interventions and the corresponding research statistics were described in this research article. The author did a good job of showing research that covered a wide spectrum of illnesses with varying results. The end result is that the type of family intervention offered makes a big difference. Education about a condition and emotional support are helpful and necessary but "not sufficient to reduce their burden and improve their emotional health. Family caregivers need more intensive interventions that include skills training and assistance with problem solving." (Campbell, 2003) Based on the research presented, family psychoeducation is effective and usually includes "specific guidelines for illness management, assistance with problem solving skills, and expansion of the patients and families social network.” (MacFarlane et al., 1995)

Pediatric illnesses
Parents, family structure and ability to function have an integral effect on the course of a child's illness or medical condition. There is a large amount of research that documents the many family variables that affect a child's health outcome. "For example, adequate control of diabetes and asthma is strongly correlated with healthy family functioning. Chronic family conflict, parental indifference, and low cohesion have all been associated with poor metabolic control in diabetes, while clear family organization and high parental self-esteem correlate with good control.” (Anderson & Kornblum, 1984; Gustafsson. Kjellman, & Cederblad, 1986)

Patterson (1991) identified nine important family elements which are associated with good outcomes in children with chronic illnesses and disabilities:  (a) balancing the illness with other family needs. (b) maintaining clear boundaries, (c) developing communication competence. (d) attributing positive meaning to the situation. (e) maintaining family flexibility, (f) maintaining family cohesiveness. (g) engaging active coping efforts, (h) maintaining social supports, and (i) developing collaborative relationships with professionals. In seminal studies, Minuchin et al. (1975, 1978) discovered a potentially destructive and unfortunately too common “specific pattern of interaction, characterized by enmeshment (high cohesion), overprotectiveness, rigidity, and conflict avoidance.”

Patterson et al. (1993) did some very important research with cystic fibrosis. They showed that "family variables predict the rate of decline of pulmonary function over a ten-year period." Based on this research, Bartholomew and Schneiderman (1982) developed psychoeducational interventions for families with CF and found that families reported  “improved knowledge, self-efficacy, self-management of the illness, and improved overall health status. This study suggests that family psychoeducation may actually be able to extend the lives of those who suffer from this disorder.”

In this research synthesis, Campbell also shares research on childhood cancer and congenital heart disease. With childhood cancer, research studies failed to show any significant decrease in parental distress even with interventions. However a study on children with leukemia showed that researchers were able to reduce the child's stress using a cognitive behavioral, family oriented intervention. With congenital heart disease, both studies with family interventions showed positive results in the children but no differences in the parent’s anxiety levels.

Adult Chronic Illness
The discussion on the impact of the family on adult chronic illness included several studies for different medical conditions including hypertension, cardiac rehabilitation, and diabetes. In all of these groups, psychoeducational family interventions seem to have the greatest effect on the emotional and physical status of the family members. Most of these studies focused on the marriage relationship. In a study by Gilden et al. (1989) on couples interventions for diabetes, "Patients with participating spouses showed greater improvement in knowledge, increase in family involvement, and more improvement in diabetic control than those without spouse involvement.”

Health Promotion and Disease Prevention
According to Campbell, "It has been estimated that over one-third of all deaths in the United States can be directly attributable to unhealthy behaviors, particularly smoking, lack of exercise, poor nutrition, and alcohol abuse, and are potentially preventable.”  The question is what is the impact of the family on these issues? Risky health behaviors tend to cluster within families because they share similar diets, environments, and habits. Campbell looks at the research findings in areas of risky health behavior including cigarette smoking, weight reduction, and nutrition and cardiovascular risk reduction.

One quote about smoking that I thought interesting: “Specific supportive behaviors such as providing encouragement and positive reinforcement predict successful quitting, while negative behaviors such as nagging or criticism predict failure to quit or relapse.” (Coppotelli & Orleans. 1985; Mermelstein, 1986) This shows the power of effective family support.

A similar result was found with weight reduction. “The greatest weight loss occurred in the group where the spouses were asked not to nag, criticize, or otherwise participate in their partner's efforts at weight reduction. These studies suggest that blocking partner criticism and addressing marital conflict and dissatisfaction may be more important than trying to increase supportive behaviors.” (Campbell, 2003) The results weren't all peachy for the long term. Even though many participants in these studies lost weight initially, most returned to act to their original weight after a year even with good spousal support. The good news is that family interventions for childhood obesity have been more successful and have shown that when parents get involved in weight reduction programs, it results in greater weight loss for both the child and the parent.

In this paper, Campbell did a very good job of discussing the possibilities for future research and direction. There is clearly a great need to develop effective programs for psychoeducational family interventions in the area of health. Campbell talked about the need for a family therapist and researchers to become involved in this important topic including more observational research, observational and intervention research based upon family theories and family science, and family intervention studies that focus on more than just a single disease by instead targeted across several chronic diseases that have some commonalities. He also discussed how future intervention studies should be structured, as well as the need to pay closer attention to gender effects, different family types, and families from different racial, ethnic and social economic backgrounds.

He provides suggestions for marriage and family therapists including being a part of health care team, providing family therapy training programs, and the need for family therapy trainees to work closer in a medical setting with healthcare providers. In this paper, Campbell concludes that his “review of family interventions for physical disorders suggests that there are effective family interventions for some physical disorders and promising ones of others.” The most commonly studied and effective type of family intervention is family psychoeducation which focuses on not only family support and education but also provides intensive assistance with specific problem solving and coping skills. “Overall one can conclude that there is some evidence that family interventions can improve health outcomes and physical disorders." (Campbell, 2003) However, there is certainly a need for more observational and interventional research.

As a family life educator who works with families of children who have chronic illnesses, I found this paper to be incredibly enlightening, informative, and inspiring. The classes that I currently teach do indeed have many elements of family psychoeducation. With a heavy focus on understanding the impact of chronic illness on family dynamics as well as providing specific, effective problem solving tools and coping skills, I believe that my material (co-developed with Foster Cline, M.D.) has the potential to save lives and families.

************  ************
 *********

Lisa C. Greene, MA CFLE
Lisa is an author, certified parent coach, parenting educator, and (most importantly), a parent of two children with cystic fibrosis. Lisa has a bachelor’s degree in business and is currently working on a Master’s Degree in Family Life Education. Lisa's mission is to help parents learn practical, easy-to-use tools to deal with the everyday challenges of raising kids. She wants you to know: "You can do it!"