A multiproblem family has needs in several areas simultaneously: difficulty in achieving developmental tasks, illness or loss, inadequate resources and support, disturbances in internal dynamics, or environmental stressors (see Box 13-6). Multiproblem families are families in which combinations of low functional level, multiple stresses, multiple symptoms, and lack of support interact to threaten or destroy the family’s ability to meet the physical, social, and emotional needs of its members. A family does not need to have disturbances in family dynamics to have multiple problems. Circumstances beyond the family’s control and a pileup of demands can result in a family’s having multiple problems. However, disturbances in internal dynamics predispose a family to having multiple problems.

The multiproblem family in the following example has needs in at least four categories: developmental tasks, illness or loss, inadequate support, and internal dynamics

Developmental needs exist for the school-aged child, Keith, his cousins, and the adult family members. Illness needs are related to Keith’s muscular dystrophy, and family resources for Keith’s physical care are inadequate. Underlying all the other needs are disturbances in family dynamics manifested as child abuse, substance abuse, illegal behavior, and emotional cutoffs.

Vulnerable families are families at increased risk because of the intensity and clustering of stressors associated with life events (Gillis, 1991; Janko, 1994). Examples of families at high risk for future health problems are families with members who are chronically ill or have Down syndrome or alcoholism. Women receiving Temporary Assistance for Needy Families often have health-related barriers that threaten their ability to leave welfare for work (Kneipp et al., 2011). These health-related conditions which are at higher rates than women in the general population include major depression, domestic violence, substance abuse, and poor general health. Special events such as assaults, teen pregnancy, and sexual abuse can also predispose a family to subsequent physical, emotional, and social problems. Many vulnerable families live in social situations in which loss of members through death, institutionalization, abandonment, or incarceration is common. The combination of intense stressors and depletion of resources can push the family beyond its capacity to cope.

Community/public health nurses assist families in coping with stress by helping them identify their previous coping style, their resources, and their alternatives for action. For some families, however, coping with stress remains a problem even after nursing intervention because the choices for action are all negative (Wilson, 1989). In some instances, none of the available choices will modify the problem, and sometimes the consequences of the choices are all negative and create more problems. For example, suppose a family is dealing with a husband and father who has Alzheimer disease. The wife, who has assumed the caregiver role, is exhausted and needs to spend some time out of the house. However, her husband becomes anxious and more confused whenever any other person takes over his care. None of the choices available to this family solves or completely alleviates the problem. The wife must choose among solutions with negative implications. Families that must cope when all the choices are undesirable are also a special-risk group.

The impact of poverty, or living in a resource-depleted, hazardous, or hostile environment, is also a factor that affects family coping. The poor, as individuals and as a group, are continually faced with multiple and chronic stressors, including frustration over employment options, inadequate and unsafe housing conditions, repeated exposure to violence and crime, inadequate child care assistance, and insensitive attitudes and responses of health and social service agencies (Berne et al., 1990). As family coping abilities are strained by unpredictable and unrelenting stressors, mastery of the situation decreases. Relationships are strained, feelings of helplessness and hopelessness increase, and self-esteem suffers (Cutrona et al., 2003). The spiral continues, as people become anxious and depressed, feel powerless, and thus are less able to marshal energy to meet the next day’s problems.

Poverty also brings its own set of health problems. Correlates of poverty include increased incidence of communicable diseases, especially tuberculosis and human immunodeficiency virus (HIV) infection; more episodes of illness; less use of preventive care; and higher rates of chronic disease, premature death, occupational hazards, and unsafe housing. Unfortunate correlates for children include delayed development, childhood depression and anxiety, and increased separation from families into foster care. Poor neighborhoods may also have greater environmental risks such as those from industrial sites, landfills, and toxic waste sites. Living within a poor area may contribute to excess mortality, independent of an individual’s own health behaviors (Waitzman & Smith, 1998). Poor individuals are also more likely to be homeless and to lack access to health care (Berne et al., 1990). The recent large increase in the number of working poor and unemployed in the United States is notable. In 2010, the poverty rate in the United States was the highest since 1993 (U.S. Census Bureau, 2011). The number of families in poverty was 9.2 million (11.7%). The number of families in poverty and the poverty rate increased for both married-couple families (3.6 million, 6.2%) and female-headed households with no spouse present (4.7 million, 31.6%).

Differences in family structures in poor families are often mentioned as the cause or source of multiple family problems. In actuality, family structures can serve to strengthen resilience rather than undermine it. Many multiproblem poor families have strong ongoing family connectedness even though single parenthood or teenage birth is the norm. The three-generational nature of these families adds support and buffers some of the stress (Chatman, 1996; Cooley & Unger, 1991). At times, however, the burden on the grandmother who is caring for younger family members can be stressful for her and lead to poor outcomes for others in the family (Unger & Cooley, 1992). Poor families often have developmental phases or attitudes that are different from those of other families. For example, Sachs and colleagues (1997) found that many low-income single mothers with young children held unrealistic expectations for child behavior, viewed their own parenting responsibilities as overwhelming, and perceived their children as unappreciative of the family unit. Discipline was often punitive.

Fulmer (1989) describes the family life cycle of poor families enmeshed in chronic unemployment and discrimination, vulnerable to problems, and intruded on by various agencies that affect their lives. Constantly reminded of their lack of power in the current system, some families turn to illegal activities to meet their basic needs. Hines (1989) cautioned that many variations can be found in poor families and described a shorter life cycle with three predominant phases (outlined in Table 14-1). The four characteristics are: (1) the life cycle is more truncated (less time is available to allow unfolding of developmental stages), and life transitions are not clearly delineated; (2) households are frequently headed by women and include extended family members; (3) the life cycle is punctuated by numerous unpredictable life events; and (4) families have few resources available and must rely on governmental assistance to meet basic needs.

Some multiproblem families have disturbances in internal dynamics. Such families are often unable to provide for security, physical survival, emotional and social functioning, sexual differentiation, training of children, and promotion of growth of individual members (North American Nursing Diagnosis Association [NANDA], 2009; Tapia, 1997). These families are characterized by insufficient internal support, frequent or intense emotional conflict, inability to conform to societal expectations, and acting out of family members. It is unclear if disturbances in dynamics lead to more family problems or if response to problems leads to unhealthy family dynamics.

Family systems theory provides some thoughts about how the level of health of a family might develop. Multigenerational patterns that are passed down from one generation to another can be adaptive or maladaptive. There is a great tendency to repeat these patterns, especially considering that the family members have known no other family experience. Doing what an individual knows, even if it brings unhappiness and failure, is often easier than is changing behavior to something unfamiliar and unknown.

The level of differentiation of a family is a crucial variable in the appearance of symptoms (Kerr & Bowen, 1989). Families have varying levels of differentiation or ability to separate emotion from thought. Families on the low end of the continuum have greater difficulty living their lives in a thoughtful way. Instead, these families respond to situations automatically in attempts to manage their high levels of anxiety. At the opposite end of the continuum are families with the ability to distinguish thought from feeling. These families have members who are able to think of themselves as separate persons as well as group members and who can define life goals and pursue them in a thoughtful way. Families on the thoughtful end of this continuum have fewer life problems than do families that are caught in automatic emotional reactivity. Most multiproblem families tend to fall on the more emotional side of differentiation of self. Family theory suggests that these levels of differentiation are transmitted from generation to generation through the process of projection, which is the degree of the child’s relationship dependence or the extent to which each child is involved in maintaining the emotional lives of the parents. Some researchers suggest that stressors and events that occur during the formation of early attachments predispose the parent–child relationship to problems. Separation of premature infants from their parents, prolonged hospitalizations or illness, unexpected crises such as homelessness or imprisonment, deaths, and emotional illnesses are examples of disruptions in family life that can interfere with parenting and the child’s early development. Tension or lack of nurturing during the child’s earliest interactions influences the growth and development of the child and the child’s subsequent ability to nurture his or her own children. Not only multigenerational patterns but also perhaps even basic emotional health is passed from generation to generation.

Box 12-4 contains a list of healthy family characteristics. A comparison list of characteristics of families with disturbed internal dynamics is presented in Box 14-2. The multiproblem family may have disturbances in many of these areas, for example, inadequate support, multiple stressors, and high levels of anxiety. Multiproblem families with disturbances in internal dynamics may also have dysfunctional family boundaries, unhealthy communication patterns, dysfunctional expression of emotion, inadequate problem-solving skills, underorganization or rigid organization, unclear roles, and repetitive patterns of interaction that blame or shift responsibility.

Most of the time, but not always, multiproblem families operate at a low level of functioning, according to Tapia (1997) (see Table 13-5). Families at level I (chaotic families) are characterized by disorganization in all areas of life. In these extremely immature families, adults may be unable to fulfill their roles and responsibilities. Children or others may be expected to assume these roles, which is inappropriate and interferes with normal growth and fulfillment of nurturing needs. Physical and emotional resources may be inadequate. Family members are often depressed, with a sense of hopelessness and powerlessness. These individuals may have little self-esteem, a high sense of failure, and little reason to trust another health care worker who comes with promises that are most often unfulfilled.

Families at Tapia’s level II (intermediate families) are able to meet their basic survival needs but are immature and unable to meet many needs of family members. These individuals are often defensive, unable to trust, and alienated from the community. However, these families retain some hope and have some capacity to change and improve their functioning.

Assessment of multiproblem families includes a three-generational time frame because many families are cooperating across generations to meet basic needs. Assessment should especially evaluate the interactions among the family’s many needs, strengths, styles, functional level, coping patterns, resources and supports, and past experiences with health care workers (see Chapter 13). Special areas of focus should include the number and duration of stressors the family has experienced over time, the family’s perception of the events, an estimation of the severity of any symptoms the family may be experiencing (e.g., depression, alcohol use, physical abuse), and contacts with other health care resources. Tools such as the Family Inventory of Life Events (FILE) by McCubbin and Thompson (1987) or the Family Systems Stressors–Strength Inventory (Mischke & Hanson, 1991) may be especially helpful. The Family Coping Index (Lowe & Freeman, 1981) helps determine coping patterns, and the eco-map (Hartman, 1978) helps describe the family’s connection with resources.

After analyzing the data, the nurse will have a better understanding of realistic goals and expectations of what will happen in his or her encounters with the family. Perfection should not be sought. Goals should be concrete and realistic and mutually defined by the family and the nurse. In the presence of what seem to be overwhelming problems, identifying family strengths is sometimes difficult for a nurse. The nurse’s values set up expectations that block his or her identification of strengths. As the community health nurse truly listens and asks the family to identify its strengths, they become more apparent. As discussed in Box 12-3, Otto (1973) was one of the first to emphasize family strengths. Karpel (1986) suggested that some personal strengths such as self-respect, protectiveness, caring in action, hope, tolerance, affection, humor, and playfulness are often hidden. Relational strengths include respect, reciprocity, reliability, the ability to repair, flexibility, and family pride. Karpel also suggested that loops of family interactions repeat themselves to amplify resources and that symptoms can be reframed to allow people to see the situation in a positive way. For example, suppose one of the daughters loses her job. When her sisters and brothers become aware of this, the situation is redefined as one that allows her to spend more time with her young children. The sisters and brothers engage in a series of telephone calls and conversations in which all agree to offer a little financial help and a lot of emotional support until the situation improves. This family has maximized its resources.