Family Life Cycle: Understanding Stages and Implications for Family Practice, Study notes of Medicine

Download Family Life Cycle: Understanding Stages and Implications for Family Practice and more Study notes Medicine in PDF only on Docsity! The Family Life Cycle and Its Implications for Family Practice Jack H. Medalie, MD, MPH Cleveland, Ohio The content of family medicine is based not only on information from many basic and clinical sciences, but also on its own specific body of knowledge and skills, which is the hallmark of every academic discipline. This specific body of knowledge is developing rapidly and includes many new medical concepts which we need to examine in depth in order to apply them to our clinical work. This article will address itself to one of these concepts—the family life cycle—and its implications for family practice. The family life cycle perspective as a tool in family diagnosis began with Paul Glick, Duvall, and Hill.12 The essential emphasis is on the chang­ ing experience of families over time. For practical purposes, it assumes that families have a begin­ ning and an end and between these two points the family goes through a life span development in which a number of distinct sequential stages or phases may be recognized. In each of these phases a number of specific developmental tasks may be delineated.13 As families pass through each phase and from one stage to the next, they will go through a number of normal and expected transi­ tions, as well as occasionally an unexpected crisis. These changes during the life cycle provide a per­ spective that there is a transmission of certain biologic components as well as behavioral and so­ cial processes throughout the cycle and from one generation to the next within the family4 (Table 1). The pulse of family life over time is marked by irregular fluctuations on an annual or monthly or even a daily basis. Some families have small fluc­ tuations in their pattern while others vary greatly in a manner which, if it were plotted, might remind us of the irregularity of atrial fibrillation. This fluc­ tuation occurring against a larger background of Dr. Medalie is Chairman and Dorothy Jones Weatherhead Professor, Department of Family Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio. periodicity makes up a family developmental pat­ tern which flows from the growing stage of family formation, through the expanding stages of child bearing, child rearing, and child launching, to the contracting periods of the empty nest, widow­ hood, and termination (Figure 1). This process of family development is highly interrelated with the individual life development of each individual member. Table 2 is an attempt to correlate the individual and family life cycles to age. This se­ quence of development is based on the nuclear family with all its variations. The nuclear family is an appropriate model because despite changes in life-style, the vast majority (±80 percent) of the American population still live in intact, nuclear families (Tables 3 and 4). I believe that the princi­ ples of the developmental family life cycle ap­ proach can, with slight modifications, be applied to almost every type of family structure except perhaps a few “way-out” ones. Despite this uni­ versal concept of family life cycle development, each individual family lives out its life cycle in its own unique fashion within the overall pattern. Many years ago, Shakespeare, in his perceptive and brilliant manner, divided the individual into seven ages of man.7 Similarly, the family life cycle has been divided into stages with various authors using different markers and thus numbers of di­ visions to outline the stages. Sorokin and Kirkpatrick used a 4-stage cycle, Bigelow 7, Duval 8, and Rodgers went to the other extreme of 22. These stages are only a convenient division for study of a process which in real life flows on in a continuous, albeit irregular, fashion. When I started teaching in a medical school I used a four-stage cycle, but as our knowledge of its application increased and our teaching became more accepted, we subdivided a little more, and presently I favor the scheme shown in Table 5. I have, however, no argument with those who pre­ fer a shorter or longer stage cycle. In the majority of families, their life cycle 0094-3509/79/070047-10$02.50 0 1979 Appleton-Century-Crofts THE JOURNAL OF FAMILY PRACTICE, VOL. 9, NO. 1: 47-56, 1979 47 FAMILY LIFE CYCLE Table 1. Key Points of Family Life Cycle Concept 1. Changes over tim e 2. A beginning and an end 3. Family developm ent w ith sequential stages/phases 4. Phase-specific developm ental tasks 5. Normal transitions and unexpected crises 6. Transmission of b iologic, behavioral, and social processes passes through each stage in succession, but there are many families which do not. For example, an elderly couple (both in their 60s) who marry will be in both the pre and postmarital, as well as middle- age stages, simultaneously. They will then move to late adulthood without the intervening Stages II to IV (Table 5). Another example is divorced people with children who remarry and repeat Stage I while also being in Stage III or IV, and later they go into Stage II (expectant couple). For these examples I would like to give the name of reconsti­ tuted family life cycles. In other words, the usual 48 family life cycle applies to the majority of families that pass successively through the cycle, whereas the reconstituted family life cycle applies to the modifications as mentioned. A further principle of this developmental family life cycle approach is that during each stage, as well as during the transition from one stage to an­ other, there will be certain events which can be predicted and which the majority of families will experience. These include: marriage, pregnancy, birth, parenthood, beginning school, adolescence, school graduation, leaving for college, starting THE JOURNAL OF FAMILY PRACTICE, VOL. 9, NO. 1, 19?9 FAMILY LIFE CYCLE Table 4. Distribution of Types of Families: 19756 Families No. in thousands % White Black Total 55,712 100.0 100% 100% Husband-wife fam ilies 46,971 84.3 86.9 60.9 Families w ith male head 1,499 2.7 2.6 3.8 Families w ith female head 7,242 13.0 10.5 35.3 port he receives from his wife; his family of orien­ tation and peers. An additional important point is, whether he wanted the pregnancy at that time. We have all experienced couples in which he wanted the pregnancy and she did not; where she wanted it and he did not; as well as those where both rejected, or in the majority of cases, both desired the pregnancy. The ease of management was, of course, clearly related to this last point. Some of the variations in the husband’s metabolism that I have noticed are related to: sleep patterns, appetite, blood pressure, libido, bowel habits, and emotional variability. Thus, some of the common problems encountered were: congestion of the testes (easy cure); tension head­ aches; early morning waking; epigastric pain; tiredness; anxiety; elation; rise in blood pressure (which, except in one instance, reverted to ac­ ceptable levels after the birth), and changes in fre­ quency of sexual demands. In addition, other conditions recurred, or were aggravated and oc­ casionally helped during this stage, eg, asthma, psoriasis, alcoholism, and emotional instability. Occasionally the changes in the husband (eg, rise in blood pressure) occurred at the same time as his wife’s, but sometimes they differed in their timing. The management of the couple was thus very much related to both the wife’s and husband’s state of health as well as their complementary or conflicting relationships. This management was complicated further if an unexpected crisis oc­ curred, whether it was the discovery in the woman of diabetes or hemorrhage, or the misfortune of the husband, eg, accident, loss of job; or, of both, when there was a death of a close friend or rela­ tive. One further point is important. When we encourage our pregnant patients to reduce or the JOURNAL OF FAMILY PRACTICE, VOL. 9, NO. 1, 1979 Table 5. Family Life Cycle Stages Used in Medical School Teaching I. Pre and postmarital II. The expectant couple III. The first child IV. M ultip le children and early adulthood A. W ithout adolescents present B. W ith adolescents V. M iddle age (adulthood) VI. Late adulthood Old age VII. W idowhood Termination (death and dying) cease smoking,1112 account must be taken of the husband’s smoking habits. If she ceases and he does not, studies indicate that she probably in­ hales a great deal as a “passive smoker/inhaler” with similar deleterious effects on the fetus. This approach by the physician to the expectant couple is often an important added factor in their “ support system” 13 which improves pregnancy outcome figures.14 The Middle-Age Period: The Contracting Family (Stage V) Grow Old along with me! The best is yet to be, The last of life, for which the first was made. . . Robert Browning This is the period when child launching is com- 51 FAMILY LIFE CYCLE Table 6. Changes of Selected Factors During Middle Age (Males) Age No. Examinations 40-44 (3,307) 50-54 (2,176) 60 + (961) Variables W eight/height2 2.59 2.60 2.55 Hand-strength 43 40 35 (kg) Vital capacity 93.8 92.6 90.1% Systolic blood pressure 129 137 149 mmHg Diastolic blood pressure 81 85 87 mmHg Total serum cholesterol 294 213 215 mg/100 ml Casual glucose 86 90 95 mg/100 ml Total calories 2,907 2,666 2,435 per day Total fat 97 88 77 gm/day Total carbohydrates 396 362 331 gm/day Total proteins 110 103 98 gm/day pleted, ie, the last child leaves home and the nu­ clear family is contracting in the sense that the parents are left alone. This stage is often called the “ empty-nest” period, but the connotation that it is an empty or negative period is not always true.15 On the contrary, many couples feel that it is a “ second honeymoon” and others that it is the “ age of fulfillment” as suggested in the above quo­ tation from Browning. This stage spans about 20 years and lasts until approximately the age of re­ tirement of one or both partners. It is during this stage that the important transitions of the menopause and the “ midlife (50) crisis” occur.16’17 It is important to note that in extended families and some other extended kin networks, there is never really an “ empty-nest” because the parent or parents are not left alone even if their own chil­ dren leave.18 It is interesting to speculate if the menopause and midlife crises are easier to adjust to in these extended families. Lidz15 believes that middle age is a stage of the mind when “ there is an awareness that the peak years of life are passing.” The body is slowing down and it is time for stock taking and evalua­ tion. What one wished to become (expectations, hopes, and wishes) is weighed against what one has become (reality), and one wonders if the im­ balance will ever be rectified. The developmental tasks of this stage may be summarized: 52 1. Adjusting to the body’s physical and physi­ ological changes 2. Adjusting to the reality of the work situation 3. Helping children leave home and become responsible adults 4. Maintaining contact with children and grandchildren 5. Reorganizing own living arrangements 6. Readjusting to being a couple again 7. Assuring own economic security for old age 8. Maintaining and even increasing participa­ tion in community life 9. Assuring adequate and satisfactory medical supervision for old age 10. Making adequate living arrangements for own parents (some couples, even at this age, have this responsibility). It is extremely important for family physicians to understand the physiologic changes that occur during this period of life, in order to clear up mis­ understandings and help middle-aged people ad­ just to the reality of the changes. During our long­ term study of 10,000 men, we were able to record the changes that occurred in some biologic and behavioral characteristics19 and these are depicted in Tables 6 and 7. Based on the literature20’21 and our clinical experience, the sexual changes that occur are presented in Table 8. Emotional and social changes play an important role in middle-age, and it is said that although per- THE JOURNAL OF FAMILY PRACTICE, VOL. 9, NO. 1, 1979 FAMILY LIFE CYCLE Table 7. Changes During Middle Age Decrease in: Sleep Sexual activity Physical activity Smoking Visual acuity Hearing acuity Increase in: Sensitiv ity to drugs sonality is continuous over time, at this stage of the life cycle, central characteristics become more clearly delineated and perhaps inflexible, while cherished values become even more salient.22 To account for these personality changes, Cumming and Henry23 proposed the “disengagement theory" (Table 9). Briefly stated, the circle of friends be­ comes more and more constricted and limited. Most workers in the field agree with the process of disengagement, but few believe it is either inevi­ table or desirable. Figure 2 shows a spectrum or scale of Erikson’s middle-age development with generativity at one end and self-absorption or dis­ engagement at the other.10 An interesting clinical feature which is not rarely seen is the difference between the partners in a middle-aged couple. Very often the females have become more self- confident, more expansive, and more talkative than previously; while the males have tended to move toward the other end of the scale and have become quieter and perhaps more self-absorbed. As a number of studies have shown,24 there is a high correlation between the quality of their rela­ tionship, from complementarity to conflict, and their satisfaction with their lives (Table 10). Table 11 shows the realities of the occupational sphere for the middle-aged male and, more and more these days, the female also. All the previously mentioned points are poten­ tial areas for stress, conflict, maladjustment, and crisis. An important factor in the maintaining of the homeostasis and health of the couple is the quality of their relationship and therefore the mutual “ support” they receive from each other. If the intrafamilial support is inadequate or totally Table 8. Middle-Age Sexual Changes Diminution in size o f organs Increase in fib ro tic tissue Decrease in secretion of sex hormones Male Erection takes longer Orgasm slower in coming Ejaculation less forceful Libido—great variation Female Most inhibitions overcome Orgasm— ? less forceful more regular Libido—great variation Intercourse Routine/unexciting or More satisfying than before Table 9. The Disengagement Theory 1. Alteration in perception o f time - is running out - definite end point 2. Constriction of ego boundaries - outer-dinner orientation - decrease of social contacts lacking, a substitute support system might be other relatives, friends, religious ministers, or the personal physician/health care team. The absence of a meaningful support system has been shown to affect the individual and the couple’s health status. One example of this is the effect of husbands’ per­ ception of their wives’ support or lack of it, as related to the subsequent development in the next five years, of angina pectoris in the male (Table 12). With support, the high-risk group had a con­ siderably reduced incidence of angina pectoris. This support, it must be emphasized, was per- THE JOURNAL OF FAMILY PRACTICE, VOL. 9, NO. 1, 1979