Family Systems Framework

In the beginning, when Dr. Wu informed Ned and Renee of newborn Cassie's
condition, their denial reflected a challenge to the hopes and dreams they had
individually and as a family for their newborn daughter. Rud and Ann Turnbull (2001)
have developed a family systems framework that provides invaluable insight for
nurses working with families of children with disabilities. Key components of this
model include:
Family Characteristics
The Turnbulls use four categories to describe the characteristics of the family as a whole:
 size and form
 cultural background
 socioeconomic status
 geographic location
For the most part, nurses are familiar with
these categories from the nursing process
learned in school. When working with the
family of a child with special needs, it’s a
good idea to gather relevant information
about the family’s characteristics in a
gradual manner. Even knowing that
professionals have the best intentions and
are there to assist the child, parents may
feel that their privacy and autonomy has
been stripped away.
In the first interaction with the family, focus
on establishing a rapport, rather than
extensive assessment of the family
characteristics. In many cases, nurses are
required to complete paperwork with
specified information about family size and form. If possible, leave the more intrusive questions for
the end of the first interview; it’s never a good idea to lead off with personal questions that may
offend the parents or raise their defenses right away.

Family Interactions
Turnbull and Turnbull identify four major subsystems of interactions within the traditional nuclear
family structure:
 marital interactions
 parent and child interactions
 child and child interactions (siblings)
 extended family interactions
While these subsystems don’t apply to every family (for example, when the child with special
needs has no siblings), it’s important for nurses to assess the type of interactions within the family
that influence the child with disabilities. During this assessment, the nurse can focus on the degree
of cohesion within the family. Cohesion refers to the emotional bonding between family members
and the level of independence members feel within the family. In highly-cohesive families, the child
with disabilities will have significant emotional support and friendship from other family members.
In some cases, however, highly cohesive families can be overly-protective of the youngster with
special needs to the point of blocking his pathway toward independence. 
The nurse will also want to look at the family’s adaptability, or ability to change in response to
situational and developmental stress. When parents are unwilling or unable to adapt to the many
changes that follow the birth of a child with disabilities, the nurse’s work is more difficult. It may
take a great deal of time to establish rapport with the family, gently probe for resistance to change,
and obtain favorable outcomes. On the other hand, some families are too adaptable, constantly
changing in a manner that produces confusion and lack of support for the individual with
disabilities. When working with families, it’s important to determine who makes the decisions and
rules for the family. Unless that individual is included in the nursing process and the changes that
are a natural outcome of that process, nursing interventions will almost certainly fail. 

Family Functions
Turnbull and Turnbull postulate that families exist to meet the needs of individuals within the family
unit, as well as the overall needs of the family itself. The tasks that families carry out in order to
meet these needs are referred to as family functions; the authors divide these into eight categories:
 affection
 self-esteem
 spiritual
 economics
 daily care
 socialization
 recreation
 education
As nurses are well aware, these family functions are interrelated, and a problem in one area can
have implications for other family functions. If a family has financial problems (economics), parents
may not be able to afford appropriate outings (recreation) or even food and shelter (daily care) for
their children.
If the parents are depressed about their money problems, they may feel badly about themselves
as providers (self-esteem) and feel isolated from their children (affection) or church (spiritual).
When families have serious problems in one or more areas of function, it’s not uncommon for them
to ignore a child’s poor grades (education) or behavioral problems (socialization).

Family Life Cycle

Families change in a predicable manner over time, moving from one stage to the next, with
identifiable transitions between one stage and the next. Turnbull and Turnbull categorize these
stages as follows:
 birth and early childhood
 childhood
 adolescence
 adulthood

Nurses are familiar with these stages from their

own life experiences, as well as the sociological
content learned during their basic nursing
education. When working with families who have
a child with disabilities, there are additional
implications for each stage within the family life
cycle.
Birth and Early Childhood: During the birth and
early childhood years, parents of children with
special needs are faced with the same
tremendous emotional adjustments and learning
curve that all new parents face. In addition, they
will be involved in the momentous task of
discovering and coming to terms with their child’s
special needs. If the child is diagnosed with
developmental delays, or is at risk for these
delays, the parents will be plunged into the complex world of the early intervention system. Nurses
working with the family can provide information and support as the family struggles to adjust to
these major issues. 
 

Childhood: As the child with special needs grows into childhood and enters elementary school,
family members share a greater wealth of experiences. It is during these years that parents, and to
a lesser extent, other family members, develop a vision for the child’s future. The intellectual and
emotional energy required to form this vision can be quite draining to the family. 
Nurses who have established a trusting relationship with the parents can serve as a valuable
sounding board for thoughts and perceptions, while providing realistic information to ground the
process. During the early school years, parents also face the dilemma of how appropriate (and to
what degree) inclusion is for their child. Is the child best-served by being fully included in school
classes and activities or will he do better in an adapted educational environment? Again, nurses
familiar with the child’s abilities and the school system can provide a reality check for parents and
facilitate their decision-making.

Adolescence: The teen years are difficult enough for families of typically developing adolescents.
When the teen has a disability, the normal process of establishing an identity and separating from
parents can be even more complex. The teen years are generally a time to expand self-
determination skills, which include the motivation, knowledge, skills, and responsive content to live
life according to the individual’s values, preferences, strengths, and needs.
Nurses who work with families of adolescents with disabilities can provide information, resources,
and support to help parents overcome the four obstacles that Powers (1993) identifies as
impediments to self-determination in individuals with disabilities:
 not knowing how much self-determination to expect from the teen
 being unfamiliar with methods to teach self-determination to the teen
 overcoming cultural differences that interfere with the expression of self-determination
 dealing with the teen’s disabilities and perhaps making self-determination a lower priority

Adulthood: Since individuals receiving special education services can stay in the school system
until age 22, many families identify that milestone as the time for transition into adulthood. Under
IDEA, planning for the transition at age 22 should begin at 14. While most families do begin the
process at that time, the full reality of the situation may not hit home until the individual with
disabilities nears the magic age of 22 years. At that time, the family faces a significant number of
issues that require complex planning and implementation.
Post-secondary educational programs and supports, supported living environments, and supported
employment are key areas of focus. The nurse who is knowledgeable about these programs and
options is in an excellent position to coach and support the individual and his family.