Key Points
• Control of the asthma patient must include an assessment of how the family functions.
• Prospective studies on family function should provide better knowledge of the patient with asthma and their progression.
• Assessing family function will provide a starting point for deciding and/or evaluating family therapy.
Many guides and consensuses have been produced all over the world on the diagnosis and treatment of asthma recommending different evaluation tools to optimise its management; the spirometer, which measures the effect on pulmonary function, the symptoms diary, which gives information on the impact of asthma, the use of relief medication by the patient and questionnaires on quality of life which can assess how asthma influences the quality of life of the patient and even of their carers. Research works currently include these tools to evaluate the response of the disease to different pharmacological and immunotherapy treatment and even therapeutic education. All using an approach very much directed at the disease, thus avoiding the biopsychosocial approach which must prevail in patient care, and forgetting to a certain extent the effects that asthma has on the family of which the patient forms a part.
Following the systematic theory of the family, if one of its members is ill, it can have consequences on the health of the family dynamics as the disease represents a stress situation to which not only the patient has to adapt but also all of their family. Research has shown that families who have a child with a chronic disease may lack cohesion, adaptability, and parent-child interaction. Also, there may be family conflicts and limited abilities to resolve conflicts. On the other hand, there are certain internal circumstances within families that make it difficult to adapt to stressful life events, such as a new family member, loss of employment, death of a near family member, etc. Depending on the family dynamics, this can have a direct positive or negative effect on the care that the family provides to the patient.
In the article that we are commenting on,2 the authors investigated changes in the family functioning of paediatric patients with asthma. For this, they used the family APGAR, a tool constructed to measure family functioning.
This tool was created in 1978 by Smilkstein3 as an attempt to respond to the need to assess family function, using a simple tool, which could be self-completed in very little time by people with a low educational level. Smilkstein used the acronym APGAR to highlight the 5 components of family function: adaptability, partnership, growth, affection, and resolve, and followed the comparison with the APGAR score of the newborn, giving scores of 0, 1, or 2 to each of the variables of this family APGAR. Once all the scores are added up, it is estimated that that there is a severe or mild dysfunction in a family when the total is between 0 and 3 or between 4 and 6, respectively.
If the score obtained is between 7 and 10, the person who answers perceives their family as functional. This tool has been criticised by other authors due to it having low sensitivity and specificity, with errors in assigning whether a family is dysfunctional or not. However, the family APGAR has been validated by Bellón et al,4 in our country, and was considered "a useful tool to find out the family situation and its possible role in the origin of conflicts and their solution, and given its simplicity, it is possibly the questionnaire of choice with this purpose in clinical practice." There are other questionnaires that probably could improve the validity of the family APGAR, but they have against them the high number of items which make them impractical in our overcrowded clinics. On the other hand, the performing of the family APGAR must not be a substitute for a good family anamnesis which should be practiced when opening and updating all the clinical histories.
Guzmán-Pantoja et al2 present a paper in which the families of patients with asthma (other chronic diseases excluded) had more family dysfunction than those with healthy children. To assess family function they used the family APGAR, which is a very rapid, specific and simple to use tool.
Although the design of their investigation did not allow the causality of these variables to be established, as they themselves recognise, their study opens new working practices in the management and follow up of the patient with asthma, highlighting new applications.
Gustaffson et al5 in 1994, using a fairly complex standardised family interview, carried out a prospective study on family dysfunction in a group of families from before the birth of their child. At 3 and 18 months from the birth, family function, and the appearance of respiratory problems in their child was investigated again, and it was observed that family dysfunction was significant in those families where their child suffered a respiratory disorder. Therefore, it concluded that respiratory disease was the cause of the family dysfunction and not the other way round.
After the work by Guzmán-Pantoja et al2 a new line of research should be open, by carrying out a prospective study with the family APGAR, a specific tool and suitable for use in primary care, to assess family functioning from birth. Its usefulness in detecting changes in family function will have to be demonstrated when there are stressful events in the family or there is a chronic disease such as asthma. At the same time it could help to identify families with a present or recently appeared family dysfunction due to asthma. A review by the Cochrane group6 concludes that family therapy can be a useful complement to drugs for children with asthma, but it adds that "this conclusion is limited, due to the small sample size of the studies and the lack of standardisation in the choice in the measurement of results." The studies on which this review was based were very limited, since this type of treatment is hardly used in the control of asthma.
One of the consequences mentioned on the applicability of studying family function with a tool such as the family APGAR is that, up until now, the majority of research work has been aimed at evaluating the response of the asthma to some type of pharmacological treatment, and other procedures such as family therapy have not been well researched and evaluated, due to having ignored the importance of having the family present in the treatment of asthma. Paraphrasing other authors2; "the evaluation of family dynamics must be considered a fundamental part in the integral approach of the paediatric patient with asthma" and we could add...with potential therapeutic implications.
