families and health: an empirical resource guide for researchers and practitioners

CHRISTINE M. PROULX AND LINLEY A. SNYDER The University of Missouri

Families and Health: An Empirical Resource Guide

for Researchers and Practitioners

As evidence mounts indicating that the qualityof family relationships affects family memberhealth and that the health of family membersinfluences the quality of family relationshipsand family functioning, it becomes crucial forfamily scientists to determine and understandthe mechanisms underlying these associations.An empirical resource guide for researchersand practitioners focusing on the complex rela-tionships between family relationships, context,health, intervention, and treatment is presented.

The bidirectional associations between ‘‘fam-ily’’ and ‘‘health’’ are of increasing interestto family scientists. As evidence mounts indi-cating that the quality of family relationshipsaffects family member health and that the healthof family members influences the quality offamily relationships and family functioning, itbecomes crucial for family scientists to deter-mine and understand the mechanisms underlyingthese associations. Better understanding of theseassociations is dependent on researchers andpractitioners becoming familiar with an inter-disciplinary literature base that spans the fieldsof family studies, psychology, medicine, healthpsychology, psychiatry, nursing, marriage andfamily therapy, and gerontology.

The University of Missouri, Department of HumanDevelopment & Family Studies, 314 Gentry Hall, Columbia,MO 65211 ([email protected]).

Key Words: couple health, families and health/illness, familycaregiving, health.

This annotated bibliography was intended toappeal to researchers, educators, and practition-ers, and as such includes articles emphasizingcontemporary research findings, theoretical con-tributions, and application. The goal of thisarticle was to review contemporary researchfocused on families and health in order to high-light what is known about the links betweenfamily processes, the contexts in which fami-lies are situated, and health outcomes. Particularinterest was placed on theoretically groundedresearch, research that contained direction forpractice or intervention, and research coveringtopics of current interests to researchers, prac-titioners, and funders alike. A subsidiary aimwas to offer a sampling of literature from acrossthe life course, and thus this review covers thelink between families and health from childhoodthrough old age. In line with the call for submis-sions for this special issue, a broad definition ofboth families and health is offered. Specifically,in searching for articles to include, family wasdefined as individuals related through blood,marriage, or choice. The literature in this areahas focused primarily on biological or marriedfamilies, and thus these family types are morefrequently represented in this review. Health wasconceptualized both at the broad level, includinggeneral health indicators and reports of overallhealth, and at the micro level, including specificdiseases that are currently well represented inthe literature on families and health (e.g., can-cer, diabetes, heart disease). The review includesresearch on both mental and physical health.Although this broad scope limits an in-depth

Family Relations 58 (October 2009): 489–504 489

490 Family Relations

review of each article, it maximizes the rele-vance of this review to a broader audience ofresearchers and practitioners.

Articles selected for review were published inthe last 10 years, were interdisciplinary in nature,and focused on at least one of the emphases listedabove. Articles were identified through onlinelibrary catalogs and electronic databases (e.g.,Academic Search Premiere, PsychInfo, Med-Line, Scopus), review of key journals in the field(e.g., Family Relations, Journal of Marriageand Family, Journal of Family Psychology,Child Development, Journal of Pediatric Psy-chology), and reference lists of review pieces.When searching electronic databases for lit-erature, combinations of the following searchterms were initially used: family, children, mar-riage, adolescence, health, pediatric, geriatric,well-being, psychological well-being, depres-sion, disease, disorder, and caregiving. Afterreviewing the articles identified with this search,as well as recent review articles in the field,additional searches for terms that would allowa focus on several specific diseases that appearfrequently in the literature, including diabetes,cancer, heart disease, and obesity, were con-ducted. To keep the scope of this bibliographymanageable, articles on severe mental disorderssuch as schizophrenia, as well as articles onaddictions (e.g., alcoholism, gambling), wereexcluded, although it is recognized that these arefamily health concerns that may have markedeffects on, and be influenced by, family func-tioning and well-being.

This annotated bibliography is organizedunder three main headings that reflect the contentof contemporary research on families and health.First, research emphasizing the importance offamily process and context in understanding thelink between families and health is reviewed.Here the focus is on family processes (e.g.,support, conflict), the contexts in which familyprocesses occur (e.g., family social environ-ments), and their links to health outcomes.Given the large amount of relevant literature,this section is further divided into three subhead-ings: the influence of early family experiences;families, context, and specific health conditions;and marital process, context, and health. Next,family and health research focused on families inwhich a caregiving situation exists is reviewed.A specific focus on caregiving within familiesis essential, given changing demographics in theUnited States and corresponding implications for

long-term care. Finally, studies pointing to spe-cific targets for family intervention or therapeu-tic processes are reviewed. Articles that could beplaced under more than one heading were cate-gorized on the basis of their primary emphasis.

Each section of this review begins with a sum-mary and critique of the identified literature. Inthese summaries, findings that cut across severalarticles, the theories used in the reviewed arti-cles, methodological strengths and limitationspresent in the literature, and directions or impli-cations for future research and practice are high-lighted. The review ends with a brief conclusiondrawn from the body of work annotated here.

FAMILY PROCESS, CONTEXT, AND HEALTH

This section highlights research that examinesthe processes that occur within families (e.g.,conflict, lack of support, coping), the context inwhich families exist (e.g., supportive or unsup-portive environments), and the health factors.This section begins with a review of a compre-hensive handbook on families and health. It isthen broken into several subheadings that exam-ine three distinct yet related bodies of literature.First is the Influence of Early Family Experi-ences, in which several contemporary reviewsof the literature on the associations betweenearly family interaction and environment andchildren’s later health outcomes are reviewed.Next is a section on the links between Fami-lies, Context, and Specific Health Conditions, inwhich family interaction, process, and contextsas they relate to specific health conditions suchas childhood cancer, asthma, and diabetes areconsidered. Finally, a focus on Marital Process,Context, and Health is taken to isolate reviewsand empirical work on the links between maritalinteraction and process, the contexts of spouses’marriages, and spouses’ health conditions.

Crane, D. R., & Marshall, E. S. (Eds.). (2005).Handbook of families and health: Interdisci-plinary perspectives. Thousand Oaks: Sage.

This sourcebook addresses theory, research,and practice on the associations between fami-lies and health. The book contains four primarysections, each emphasizing an interdisciplinaryview: (a) reviews of links between family char-acteristics and numerous mental and physicalhealth concerns, including chapters on specificrisk factors and ethnic groups; (b) issues of agingand caregiving, with an emphasis on end-of-lifeconcerns; (c) suggestions for advancing policy

Families and Health 491

and research on families and health, includingpolicy analysis, securing of research funding,and the cost of healthcare for families; and(d) interventions to improve family health acrossthe lifespan.

Influence of Early Family Experiences

The review articles below aggregate past liter-ature pertinent to the health of families withcertain characteristics, such as poor parentingor abuse, which leave offspring at risk forhealth problems. Discussions recognize geneticand biological processes, as well as psychoso-cial pathways underlying physical and mentalhealth across the lifespan. Additionally, spe-cific discussions of childhood caregiving andparticular illnesses are explored. Existing path-ways to health are examined and new modelsof the family context-health relationship areproposed. Although all articles are not theoreti-cally grounded and some reviews are qualitativewhereas others are quantitative (i.e., meta-analysis), this body of literature adds to the fieldby emphasizing intervention at different stages inthe life span. Prevention of stress and instabilityis highlighted as the preferable goal of researchand practice with at risk families, as all of the arti-cles touch on the risks associated with accumu-lated stress and advancing health complications.The feasibility of proposed behavioral and socialsupport interventions with families affected byadverse situations, however, is supported by theconclusions of the empirical articles on the rever-sal of psychopathology (e.g., McEwen, 2003).

McEwen, B. S. (2003). Early life influenceson life-long patterns of behavior and health.Mental Retardation and Developmental Disabil-ities Research Reviews, 9, 149–154.

McEwen reviews and integrates researchfocused on the neurobiological pathway throughwhich early family environment influences thehealth of offspring later in life. Using animaland human models, the author discusses howstress from dysfunctional family environments(i.e., high in aggression, lacking in warmth,and/or characterized by over- or underregula-tion) can increase the activation of physiologicalresponses to stress, which may negatively affectthe body over time. This overload of chronicstress may change the brain structurally, leavingoffspring more vulnerable to negative healthoutcomes. The author emphasizes the needfor future studies to identify preventive and

treatment interventions to combat the neuro-biological effects of childhood adversity. Theauthor also shows that interventions such ashome visits during pregnancy and after birththat provide mothers with support and educationabout child care may reduce the incidence ofabuse or neglect, thereby lessening the impactof childhood adversity.

Repetti, R. L., Taylor, S. E., & Seeman, T. E.(2002). Risky families: Family social environ-ments and the mental and physical health of off-spring. Psychological Bulletin, 128, 330–366.

The authors present a model of the influ-ence of family-level factors on pediatric mentaland physical health conditions, including impactthroughout adolescence and adulthood. Themodel is focused on the vulnerabilities facedby children in families with explicit conflictand little nurturance. The authors propose thatfamilies with poor social environments mayaffect children’s emotional, social, and physi-cal outcomes. These effects can accumulate andpersist after childhood in the form of mentaland chronic physical health conditions, under-scoring the need for researchers to implementlongitudinal studies focused on families’ effectson children’s health throughout the life span.The authors suggest that practitioners developearly family-based interventions to decrease thepossibility of such problems.

Taylor, S. E., Lerner, J. S., Sage, R. M.,Lehman, B. J., & Seeman, T. E. (2004). Earlyenvironment, emotions, responses to stress, andhealth. Journal of Personality, 72, 1365–1393.

In this review, authors assess a model offamily environmental influence on self-ratedadult health of offspring from families char-acterized by conflict, aggression, and a lackof support in childhood. The authors confirmthat this family environment may interfere withemotional regulation and social interaction inchildren, thus affecting the body’s response tostress in a way that can contribute to riskyhealth behaviors and mental and physical healthproblems in adolescence and adulthood. Thefindings show that families not considered highrisk also may negatively influence children’sstress-related responses and long-term health.The authors suggest that early interventionsaddressing family risk factors, such as cold orinattentive parenting, may lessen negative healthconsequences later in life.

Wamboldt, M. Z., & Wamboldt, F. S. (2000).Role of the family in the onset and outcome of


childhood disorders: Selected research findings.Journal of the American Academy of Child andAdolescent Psychiatry, 39, 1212–1219.

The goal of this review article was to informclinicians about family factors affecting childand adolescent psychological well-being. Thereview details research methods and findings onbehavioral genetics, expressed emotion, and theinteraction between family dynamics and pedi-atric illness. Externalizing disorders are affectedby the shared environment influences of parentalmonitoring and punishment, whereas siblingdifferential treatment is important in the devel-opment of internalizing disorders. Additionally,children in families with critical communicationtend to have poor adherence to treatment vital forpediatric health. Implications for clinical prac-tice include examination of family processesaffecting children when assessing internalizingdisorders and recognition of a family’s positionin promoting treatment adherence.

Luecken, L. J., & Lemery, K. S. (2004). Earlycaregiving and physiological stress responses.Clinical Psychology Review, 24, 171–191.

Extending the understanding of how child-hood experiences may influence health out-comes, this review examines the relationshipbetween physiological responses to stress, theearly family environment, and susceptibility toillness later in life. The authors conclude thatfamily characteristics such as high levels ofconflict can increase children’s vulnerability tostress and, in turn, negative stress-related healthoutcomes via genetic, psychosocial, and cogni-tive pathways. Research implications include aneed for researchers to further explore the rela-tionship between early caregiving and healthlater in life and to develop a more interactivemodel of the involved processes.

Families, Context, and Specific HealthConditions

The articles annotated in this section focusprimarily on family process variables such asconflict and cohesiveness and link them to familyor individual well-being in families coping withand managing specific diseases. The empiricalstudies reviewed here are primarily cross-sectional and draw on samples recruited fromclinics and hospitals. Many use aspects of familysystems theory, either explicitly or implicitly, toexplain associations between family process andfamily or individual well-being. For example,

the importance of family roles and organizationis assessed in several articles and suggeststhat although role flexibility might be adaptivefor some family members (i.e., parents or illchildren; McCubbin, Balling, Possin, Frierdich,& Bryne, 2002), it may not be for others (i.e.,well siblings; Houtzager et al., 2004). Anothertheme in these articles is the role that familyconflict plays in ill family member’s adherenceto medical treatments. Several of the articlesacknowledge that non-ill family members (i.e.,a caregiving parent or a well sibling) are second-order patients who may require interventionsspecific to coping with the illness of a familymember. These articles also underscore the needfor samples that are more homogenous thantypically used in this literature. For example, tobest understand the association between familycohesiveness and childhood cancer patientoutcomes, it might be beneficial to sample anarrow age range or a particular cancer, as bothage and type of cancer may be related to familyand individual coping and outcomes. Finally,there appears to be a lack of consensus aboutwhether family process mediates or moderatesthe association between contextual variablesand health outcomes or whether contextualvariables mediate or moderate the associationbetween family process and health. Review ofthis research suggests that longitudinal studiesmay help clarify some of these mechanisms, aswould studies that replicate and extend previousfindings.

Cohen, M. S. (1999). Families coping withchildhood chronic illness: A research review.Families, Systems and Health, 17, 149–164.

The author begins with a review of the litera-ture on families coping with pediatric chronic ill-nesses and concludes that although the presenceof such conditions is a risk factor for negativeoutcomes among family members, this negativeassociation may be mediated by family function-ality. In addition to the increased risk for mal-adjustment in children with chronic conditions,their well siblings, and their parents, familiesmay face stress from permeable family bound-aries, increased role confusion, and heightenedmarital discord. The author emphasizes thatalthough families risk disempowerment whenfaced with the demands of childhood chronicillness, practitioners can encourage resiliencethrough interventions promoting medical treat-ment compliance and family coping in order todecrease stressors prompted by illness demands.


Fiese, B. H., & Everhart, R. S. (2006).Medical adherence and childhood chronicillness: Family daily management skills andemotional climate as emerging contributors.Current Opinion in Pediatrics, 18, 551–557.

Authors review eight correlational studiespublished in the previous 2 years on the effectsof family climate and management on children’sadherence to medical regimens for chronic con-ditions, such as asthma, diabetes, and cysticfibrosis. The authors report that family cohe-siveness and family investment in managinghealth-related behaviors, such as altering indi-vidual routines to accommodate illness demands,appear to support children’s medical adherence.In contrast, family conflict, criticism, and dis-engagement interfere with adherence. Althoughsome support exists for medical adherence as amediator between family processes and pediatrichealth outcomes, the authors encourage random-ized controlled clinical trials for future studiesof this relationship in order to promote moreeffective family-based health interventions.

McCubbin, M., Balling, K., Possin, P.,Frierdich, S., & Bryne, B. (2002). Familyresiliency in childhood cancer. Family Relations,51, 103–111.

This empirical article highlights familyresiliency factors that may enhance coping post-diagnosis of childhood cancer. The authorsinterviewed 25 mothers and 17 fathers from 26families of children receiving cancer treatmentsat a comprehensive cancer center in the upperMidwest in the previous 3 years. The authorssuggest that families’ capacity to act quicklyafter a diagnosis and endure changing patternsin family functioning, such as altering parentalwork roles, reflects positive family coping. Thefindings are framed in a family systems contextreflecting the families’ involvement in crisismanagement and emphasizing families’ abilityto recover after a childhood cancer diagnosis.Implications include the need for practitionersto assist family members in reorganizing familyroles and responsibilities after a diagnosis.

Houtzager, B. A., Oort, F. J., Hoekstra-Weebers, J. E. H. M., Caron, H. N., Grooten-huis, M. A., & Last, B. F. (2004). Coping andfamily functioning predict longitudinal psycho-logical adaptation of siblings of childhood can-cer patients. Journal of Pediatric Psychology,29, 591–605.

This empirical article relates family systemsfactors to the psychosocial outcomes of siblings

of children diagnosed with cancer. Authors col-lected data from 83 well siblings aged 7–19in 56 families at 1, 6, 12, and 24 months after asibling was diagnosed with cancer. The authorsemphasize that heightened distress felt by wellsiblings tends to decrease in the 6 months fol-lowing the cancer diagnosis. In families thatexhibit high levels of adaptability over a long-term period, however, well siblings experienceincreased emotional and behavioral problems,anxiety, insecurity, and loneliness. Identifyingfamily adaptability by the propensity of fami-lies to change relationship rules, role relations,and power structure when facing difficulties, theauthors suggest that the distress of well siblingsmay be related to the chronic, chaotic familysystem associated with long-term adaptability.Highlighting the vulnerability of well siblingsin these families, the article calls for interven-tions targeting specific family dynamics (e.g.,positive coping, cohesion) or subsystems (e.g.,parent-child relationships).

Kotkamp-Mothes, N., Slawinsky, D., Hinder-mann, S., & Strauss, B. (2005). Coping andpsychological well being in families of elderlycancer patients. Critical Reviews in Oncology/Hematology, 55, 213–229.

This article reviews research the authorsbelieved held the most promise for futureresearch on elderly cancer patients and the con-sequences of their disease for their partners andfamilies.

The review emphasizes the importance ofsocial support, particularly from family mem-bers, for patients’ mental and physical well-being. The review also addresses the conceptof family members as ‘‘second-order patients’’who are also in need of social support resourcesand caregiving reprieve. The authors concludewith recommendations for future research andpractice and highlight the need for health caresystems to recognize the role of the diseasefor caregiving family members and informalcaregivers.

Wickrama, K. A. S., Lorenz, F. O., Wallace,L. E., Peiris, L., Conger, R. D., & Elder, G. H.,Jr. (2001). Family influence on physical healthduring the middle years: The case of onset ofhypertension. Journal of Marriage and Family,63, 527–539.

In this empirical article, Wickrama et al.(2001) propose that some of the variance intime of onset of chronic conditions in middle


age is attributable to troubled family relation-ships. The authors draw on a sample of 367married women and 340 married men livingin rural north central Iowa who participated infive waves of data collection between 1989 and1994. Their findings support a ‘‘stress-illness’’paradigm in that marital stress predicts earlieronset of hypertension for both husbands andwives. In addition, parental stress independentlypredicts earlier onset for wives, suggesting thatwives’ physical health may be reactive to theiridentity with family roles. The authors suggestthat future research should replicate these find-ings with prospective clinical data on more urbanand diverse samples with different family struc-tures, and extend their findings by linking otherspecific types of stressors with specific diseasesand chronic conditions.

Logan, D. E., & Scharff, L. (2005). Relation-ships between family and parent characteristicsand functional abilities in children with recurrentpain syndromes: An investigation of moderatingeffects on the pathway from pain to disability.Journal of Pediatric Psychology, 30, 698–707.

The authors address how children’s function-ing with a pain syndrome is affected by family-level variables in this empirical article. Authorsused a sample of 78 children ages 7–17 yearswith recurrent pain syndromes (i.e., migraineheadaches or recurrent abdominal pain) recruitedfrom pediatric clinics, as well as 70 moth-ers and 60 fathers. Findings demonstrate thatparental distress and disruptions in family envi-ronment predict physical function with recurrentpain syndromes. Family conflict and enmesh-ment relate most closely to children’s functionaldisabilities. The authors posit that children’sdisability distracts from conflict in high-conflictfamilies and preserves the role of the caretaker inhighly enmeshed families. Family environmentmoderates the pain-functional abilities relation-ship only for children with migraines. Researchimplications include testing a mediating modelfor children’s pain-physical disability relation-ship.

Kaugers, A. S., Klinnert, M. D., & Bender,B. G. (2004). Family influences on pediatricasthma. Journal of Pediatric Psychology, 29,475–491.

The authors review literature on pediatricasthma to illustrate how families may con-tribute to asthma onset, exacerbation, or poormanagement. The review indicates two pos-sible mechanisms by which family processes

may contribute to poor asthma outcomes. First,family processes such as conflict or poorfamily organization may undermine effectiveasthma management thereby contributing tomore frequent and extreme asthma exacerba-tions. Second, the physiological sequelea ofpoor family functioning (i.e., activation of theimmune or autonomic nervous system) mayinitiate or exacerbate asthmatic episodes. Theauthors stress the need for longitudinal studiestesting possible mediating (e.g., secure attach-ment within the parent-child relationship) andmoderating (e.g., ethnicity) factors.

Lewin, A. B., Heidgerken, A. D., Geffken,G. R., Williams, L. B., Storch, E. A., Gelfand,K. M., & Silverstein, J. H. (2006). The relationbetween family factors and metabolic control:The role of diabetes adherence. Journal ofPediatric Psychology, 31, 174–183.

The authors test a model in which medi-cal adherence mediates the relationship betweenfamily-level variables and health outcomes ina study of 109 children and adolescents (53boys, 56 girls) with type 1 diabetes and theirprimary caregiver recruited from an outpatientdiabetes clinic. Measures of parental control,warm and caring parenting, family criticism andnegativity, and family responsibility for dia-betes regimen relate more strongly to metaboliccontrol than previously demonstrated. In olderchildren, adherence to a diabetes regimen medi-ates the relationship between family factorsand metabolic control. The authors suggest thatparent-child conflict increases in the absence offamily behaviors and attitudes positively relatedto diabetes health, thereby decreasing children’scompliance with medical regimens and lessen-ing parents’ ability to maintain glycemic control.The authors suggest that, instead of improvingonly adherence behaviors, therapy should alsofocus on improving processes such as familycommunication patterns and reducing factorsthat maintain conflictual family interaction pat-terns.

Wysocki, T., Harris, M. A., Buckloh, L. M.,Mertlich, D., Lochrie, A. S., Taylor, A., Sadler,M., Mauras, N., & White, N. H. (2006).Effects of behavioral family systems therapy fordiabetes on adolescents’ family relationships,treatment adherence, and metabolic control.Journal of Pediatric Psychology, 31, 928–938.

The authors used a randomized treatmentdesign to evaluate potential family system effectsand individual health outcomes from the use


of a diabetes-specific behavioral family systemstherapy (BFST-D) in 104 families of adolescentswith type 1 diabetes. The BFST-D group showedsignificantly less diabetes-related family conflictand better treatment adherence and diabetic con-trol when compared with families only receivingstandard diabetic care (e.g., quarterly medicalappointments, meal plans) or those participatingin an educational diabetes support group, par-ticularly for adolescents who entered the studywith poor diabetic control. These results areencouraging because family conflict has beenrelated previously to poor diabetic outcomes inadolescents, but the current study only assessedthe outcome variables at baseline and 6 monthsafter the treatment was implemented. Thus, theauthors stress the need for further evaluation ofthis disease-specific intervention to determinelong-term effects.

Kitzmann, K. M., Dalton, W. T., III, & Bus-cemi, J. (2008). Beyond parenting practices:Family context and the treatment of pediatricobesity. Family Relations, 57, 13–23.

In contrast to generic family-based pedi-atric obesity interventions, this review examinestreatments tailored for individual families on thebasis of family context. The authors suggest thatfamily context moderates health outcomes byway of parenting style, family emotional climate,and family stress, which affects health-relatedparenting methods that impact treatment effec-tiveness. Research implications include testingthe moderating model in studies assessing pedi-atric obesity treatment effectiveness. The authorssuggest that practitioners incorporate questionsabout family context in early assessments, con-sider family context when recommending treat-ment, and utilize an interdisciplinary approachby including a family-oriented professional inthe intervention process.

Haworth-Hoeppner, S. (2000). The criticalshapes of body image: The role of culture andfamily in the production of eating disorders.Journal of Marriage and the Family, 62,212–227.

The author uses open-ended qualitative inter-views and a grounded theory approach to addressthe relationship between family, culture, and thedevelopment of eating disorders in 32 White,middle-class women, with and without eatingdisorders, aged 21– 44 years. Instead of famil-ial and cultural contexts having direct, separateeffects on eating disorder formation, findingssupport family as a mediator between cultural

ideas about weight and how those ideas are pre-sented to family members. Parental criticism ofweight or appearance, pressure from parent(s)to behave a certain way, an unloving parent-child relationship, and a family emphasis onweight or appearance relate to each other and tothe development of eating disorders. The authorsuggests that empirical studies be conducted totest that these and other family interactions medi-ate cultural ideas about weight, body image, andeating disorders.

Wickrama, K. A. S., & Bryant, C. M. (2003).Community context of social resources andadolescent mental health. Journal of Marriageand Family, 65, 850–866.

Recognizing that community and family con-texts can influence each other and youth devel-opment, this article describes how these rela-tionships may affect adolescent symptoms ofdepression. The authors’ analysis of in-homeinterview data from 14,500 adolescents and theirparents participating in Wave 1 of the NationalLongitudinal Study of Adolescent Health showthat community characteristics may moderatethe relationship between family-level factorssuch as warmth and acceptance and youth’sdepression in underprivileged communities bylimiting family members’ resources. Further,the association between warm and acceptingparent-adolescent relationships and adolescentsymptoms of depression is moderated by thedegree of adversity in the community, as positivefamily influences decrease depressive symptomsless in more disadvantaged communities whencompared with less disadvantaged ones. Theseresults emphasize the need for parenting inter-ventions in disadvantaged populations and forcommunity-specific social programs and poli-cies addressing issues such as the concentrationof poverty.

Sheeber, L., Hops, H., & Davis, B. (2001).Family processes in adolescent depression.Clinical Child and Family Psychology Review,4, 19–35.

Drawing from literature focused on the inter-personal context of depressive symptoms, thisreview addresses how family processes mayincrease adolescents’ vulnerability to depressionvia four mechanisms: family stress and sup-port, family social interaction, family’s effect onadolescent cognition, and family’s effect on ado-lescent regulation of affect. The authors criticallyreview each mechanism, outline potential weak-nesses and limitations of the existing literature


(i.e., a lack of father reports), and describe howfamily-level mechanisms could be interrelatedvia additive and overlapping effects. Recom-mendations for future research are presented,such as inclusion of father reports and a focuson adolescent and parent gender as possiblemoderators of the relationship between parentalaggressive behavior and adolescent depressivebehavior.

Pedersen, S., & Revenson, T. A. (2005).Parental illness, family functioning, and adoles-cent well-being: A family ecology framework toguide research. Journal of Family Psychology,19, 404–419.

In this review article, the authors use afamily ecological model to address adolescentmaladjustment risk in the presence of a parent’sserious illness. Drawing from literature acrossthe fields of psychology and family medicine,the authors emphasize pathways between aparent’s illness, family functioning, and youths’well-being. The redistribution of roles and thethreat from illness are included as family-levelmediators that affect family outcomes such ascohesion, which in turn influence youths’ well-being. Future research implications underscorethe need to examine what mediates the pathwaysto develop more effective family interventions.

Cummings, E. M., Keller, P. S., & Davies,P. T. (2005). Towards a family process modelof maternal and paternal depressive symptoms:Exploring multiple relations with child andfamily functioning. Journal of Child Psychologyand Psychiatry, 46, 479–489.

The authors address relationships betweenmaternal and paternal depressive symptoms andthe risks to family functioning and child adjust-ment in 235 community families with at leastone child in kindergarden, extending previousresearch focused solely on maternal depressionand child outcomes. Analyses of parental reportsof depressive symptoms and family functioningand parent and teacher reports of child socialadjustment and internalizing and externalizingproblems support past findings that marital rela-tionships partially mediate associations amongmaternal and paternal depression and child out-comes. Models including both marital attach-ment and conflict as mediators still yield directeffects between parental dysphoria and childoutcomes. The authors suggest that childrenmay perceive parental depressive symptomsas a danger to family stability even in low-conflict marital situations, and their anxiety may

contribute to adjustment problems, though addi-tional longitudinal studies are needed. Futureresearch implications include the need to employobservational measures in addition to parent andteacher reports when studying the mediatingeffects of parenting processes.

Marital Process, Context, and Health

Of the review and empirical articles anno-tated below, all but one (i.e., Mahrer-Imhof,Hoffmann, & Froelicher, 2007) examine thecausal influence of marriage on spouses’ healthand health behaviors, suggesting that manyresearchers in this area believe that marital pro-cess precedes changes in spouses’ health. Unlikearticles in the other sections of this review, noneof the articles reviewed here uses family sys-tems theory. Rather, when theory is used, itoften is mid-range theory or models that test rel-atively narrow components of the relationshipbetween marriage and health. Many of the stud-ies reviewed in this section use relatively diversesamples and draw on longitudinal data, perhapsowing to the fact that many are testing relation-ships that are causal in nature. Overall, the resultsof these studies show that negative processes inmarriage (e.g., conflict, strain) are negativelyassociated with spouses’ physical and mentalhealth. The studies present mixed results regard-ing whether positive processes in marriage arepositively related to spouses’ health and whetherlinks between marriage and health differ for menand women. Several of the works reviewed heresuggest that practitioners should acknowledgehealth problems or concerns in their clients so asto best address these issues in clinical practice.

Proulx, C. M., Helms, H. M., & Buehler, C.(2007). Marital quality and personal well-being:A meta-analysis. Journal of Marriage andFamily, 69, 576–593.

The authors use meta-analytic techniques tosummarize research exploring the links betweenmarital quality and personal well-being (e.g.,depression, physical health) in 93 studies pub-lished between 1980 and 2005. Findings supporta moderate concurrent relationship between mar-ital quality and well-being, and a small tomoderate longitudinal association. Results fromthe longitudinal analyses suggest that the causaldirection is stronger from marital quality towell-being than for the reverse. Moderator anal-yses suggest that the choices researchers makewhen designing studies can affect the magnitude


of the association between marital quality andspouses’ health. Implications for practitionersinclude the potential utility of marital therapy forimproving the mental and physical well-being ofspouses.

Kiecolt-Glaser, J. K., & Newton, T. L. (2001).Marriage and health: His and hers. PsychologicalBulletin, 127, 472–503.

The article reviews 64 articles publishedbetween 1990 and 2000 whose primary emphasiswas on the pathway from the marital relationshipto physical health. The model guiding the reviewproposes that depression, health habits, and traithostility play a role in the links between mar-riage and physical health. Findings highlight thedifferences in this link for men and women andlinks between marriage and specific health out-comes (e.g., pain, blood pressure). The authorscontend that researchers should include behav-ioral data in their studies to enhance predictionand that positive and negative aspects of mar-riage be included, as they relate differentially tohealth outcomes for spouses. The authors sug-gest that marital therapy may be one way tolower spouses’ health risk but also point to thepotential limitations of marital therapy in thisregard (e.g., whether those couples most in needare able to access services).

Robles, T. F., & Kiecolt-Glaser, J. K. (2003).The physiology of marriage: Pathways to health.Physiology and Behavior, 79, 409–416.

This review of the literature on the associa-tion between marital relationships and spousalhealth uses a stress/social support model, whichaccounts for both protective and deleterioushealth correlates of marriage, to suggest thatphysiology is the mechanism through which themarital relationship impacts health. The authorsemphasize studies that support the mediatingrole of cardiovascular function, neuro-endocrinefunction, and immune function. The authorssuggest researchers design studies that simulta-neously assess cardiovascular, neuro-endocrine,and immune function as they relate to maritalinteractions that are both positive (e.g., support)and negative (e.g., conflict).

Umberson, D., Williams, K., Powers, D. A.,Liu, H., & Needham, B. (2006). You make mesick: Marital quality and health over the lifecourse. Journal of Health and Social Behavior,47, 1–16.

In this empirical article, the authors use alife course perspective to examine the associ-ation between marital quality and change in

self-reported health across the life course in asample of 1,049 continuously married adultsinterviewed across three waves in the Amer-icans’ Changing Lives panel survey. Resultsshow that marital strain accelerates the decline inself-reported health, especially for older spouses,but that positive marital experiences are notrelated to change in health. Findings show nogender differences in this pattern. The authorssuggest that future research in this area use multi-ple measures of health and well-being, includingobservational and biomedical data, to determinewhether the links between marriage and healthare consistent across measurement type. Theauthors also suggest that practitioners make noteof the importance of marital quality for thewell-being of older adults.

Hawkins, D. N., & Booth, A. (2005). Unhap-pily ever after: Effects of long-term, low-qualitymarriages on well-being. Social Forces, 84,451–471.

The authors explore the question of whetherthose in continuously unhappy marriages showlower levels of personal well-being than dothose who are continuously married, divorced, orremarried. They draw on a sample of 1,150 adultsfrom the Marital Instability over the Life Coursestudy who were continuously married (n = 972)or who divorced (n = 178) over the first fourwaves of the study. Compared with continuouslymarried individuals, those in unhappy marriagesreported poorer health and lower happiness,life satisfaction, and self-esteem. On severaldimensions, both those who were divorced andthose who were remarried had higher levels ofwell-being than did those who were unhappilymarried. The authors conclude that remainingunhappily married is not beneficial to psycholog-ical well-being or health for all the participantsin their study and suggest that future studies areneeded that focus on changing marital patternsover time to determine the reasons for the varietyof marital patterns that exist. They also suggestthat research focus on the effects of long-termunhappy marriages on children.

Lewis, M. A., McBride, C. M., Pollak, K. I.,Puleo, E., Butterfield, R. M., & Emmons,K. M. (2006). Understanding health behaviorchange among couples: An interdependence andcommunal coping approach. Social Science andMedicine, 62, 1369–1380.

In this theoretical article, the authors draw oninterdependence theory and the concept of com-munal coping to develop a theoretical model to


explain health-related behavioral change withincouples. This model proposes that couple-levelfactors (e.g., demographics, couple functioning)influence how spouses view a threat to onespouse’s health. How spouses view the healththreat then influences how they intend to copewith it, including their vision for shared action(i.e., those that they will take together). Thiscoping process in turn impacts the initiationand maintenance of health-enhancing behaviors,such as beginning an exercise regimen. Applica-tion of this model is necessarily dyadic, and theauthors suggest utilizing behavioral observationand daily diary, or experience sampling, tech-niques to assess a range of couples’ behavioralpatterns and changes. The authors also suggestthat confirmation of this model will assist inplanning interventions that include close othersin the health behavior change process.

Lewis, M. A., & Butterfield, R. M. (2007).Social control in marital relationships: Effect ofone’s partner on health behaviors. Journal ofApplied Social Psychology, 37, 298–319.

The actor-partner interdependence model isused to examine links between spouses’ useof social control tactics and spouses’ health-enhancing behavioral reactions in a conveniencesample of 109 married couples. Findings sug-gest that spouses’ use of positive, bilateral, anddirect social control tactics is more likely topromote health-enhancing behaviors than is theuse of tactics that are negative, unilateral, orindirect. Authors suggest that wives may bemore effective at social control, as their posi-tive and bilateral control tactics influenced theirown health-enhancing behaviors as well as theirspouses’. The authors suggest studying the samemechanisms in other close relationships, suchas friendship, to determine whether the findingswould replicate outside of marriage.

Mahrer-Imhof, R., Hoffmann, A., & Froe-licher, E. S. (2007). Impact of cardiac diseaseon couple relationships. Journal of AdvancedNursing, 57, 513–521.

The authors employ an interpretative phe-nomenological approach to explore the impact ofcardiac disease on the everyday lives of 24 mar-ried couples recruited from hospitals in whichone spouse received cardiac care treatment inthe previous year. The authors describe threerelational patterns: illness as a positive expe-rience that prompts transformation; illness asa threat/fearful experience for both partners;and illness as a series of missed chances, in

which spouses tend to become disenchanted withone another. The authors make several sugges-tions for clinical practice, including increasedinvolvement of both spouses in the early stagesof diagnosis and rehabilitation and short-termmarital therapy for couples who are burdenedby the illness experience. Because their sam-ple comprised mostly male patients and theirspouses, the authors also suggest further studyof couple experiences when the female is thepatient spouse.

Zhang, Z., & Hayward, M. D. (2006). Gender,the marital life course, and cardiovasculardisease in late midlife. Journal of Marriageand Family, 68, 639–657.

In this empirical article, the authors suggestthat the marital life course, beyond the statusof being married, is important to consider inthe risk of onset of specific diseases, particu-larly those that develop slowly, such as heartdisease. Results from analyses on 8,247 middle-aged adults who participated in five waves of theHealth and Retirement Study show that men andwomen who have had a marital loss (i.e., divorceor widowhood) have a higher prevalence of heartdisease than those who are continuously married.Remarried men had a lower risk of cardiovascu-lar disease than continuously married men, butthis pattern did not hold for women. The authorssuggest that marital loss results in prolongedstress that can have negative effects on physi-cal health, especially for women. The authorsemphasize the need for research on the associa-tion between health and marriage throughout thelife course, and for inclusion of detailed infor-mation about couple stressors, personal charac-teristics, social support, and marital conflict.

CAREGIVING

The caregiving literature annotated below isdrawn from the literature on caring for an elderlyfamily member or a grandchild, two of themost often studied caregiving roles. The articlesreviewed here draw primarily on adaptationsof two theoretical orientations: life course the-ory and the stress process model (Pearlin et al.,1990). Several articles conceptualize caregivingas a stressor (e.g., Gaugler, Anderson, Zarit, &Pearlin, 2004), although notable exceptions tothis include Marks’ (1998) use of the term care-giver to describe a role that comes and goesthroughout adulthood and is not always associ-ated with elevated stress levels. Indeed, several


of these articles suggest that future work shouldincrease the emphasis on the positive aspects ofcaregiving. Samples used in these studies weretypically diverse in terms of racial and ethnic sta-tus, but tended to be entirely or predominantlyfemale and middle-aged, perhaps reflecting thetrend of who provides care in American fami-lies. As a whole, the studies annotated in thisreview suggest that caregivers are at an increasedrisk for adverse physical and mental health out-comes. It appears, however, that specific factorssuch as personal characteristics and vulnerabil-ities (Vitaliano, Jianping, & Scanlan, 2003) andwork-family conflict (Marks, 1998) may moder-ate the positive association between caregivingand decreased levels of personal well-being.Several of these studies were longitudinal indesign, but included only two waves of data,limiting the causal claims that can be madeabout the association between caregiving andcaregiver well-being. By taking advantage ofrecent methodological advances in the study ofchange within dyads (e.g., Bryk & Raudenbush,1992), future research can refine the literaturesupporting or refuting theoretical models of therelationship between caregiving and personalwell-being.

Vitaliano, P. P., Jianping Z., & Scanlan, J. M.(2003). Is caregiving hazardous to one’s physicalhealth? A meta-analysis. Psychological Bulletin,129, 946–972.

This meta-analysis summarizes the results of23 studies examining levels of well-being ininformal caregivers of persons with demen-tia compared with demographic controls. Theauthors propose a model that encompasses care-giver stress, psychosocial distress, risky healthhabits, physiological mediators, and subsequenthealth problems. Overall, results showed thatcaregivers have a 9% greater risk of health prob-lems than demographic controls. The authorsargue for several advances in the field, includingrecognition of the positive aspects of caregiv-ing and of potential moderating variables suchas personal characteristics and vulnerabilities,which could be used to help develop cost-effective treatments and interventions.

Marks, N. F. (1998). Does it hurt to care?Caregiving, work-family conflict, and midlifewell-being. Journal of Marriage and the Family,60, 951–966.

Rather than conceptualize caregiving as a pre-defined stressor, Marks employs a life courserole identity perspective that suggests the role

of caregiver is likely to enter and exit once,or several times, during adulthood. The authorused a sample of 5,782 employed, middle-aged adults from the Wisconsin LongitudinalStudy. Across a broad range of caregiver rela-tionships (e.g., parent-disabled child, spousal),results suggested that male and female care-givers experience more work-family conflictthan noncaregivers and that controlling for thiswork-family conflict attenuates many of the neg-ative associations between caregiving and psy-chological well-being. Findings also suggest thatin some cases, caregiving has positive associa-tions with psychological well-being, providingsupport for Marks’ contention that caregivingcan provide benefits to adults in midlife. Theauthor stresses that these findings need to bereplicated in more diverse samples, in youngerpopulations, and over time. The author also sug-gests that researchers and practitioners look forways to ameliorate work-family conflict amongcaregivers, including more flexible work sched-ules and additional services and day programsfor disabled older persons.

Dilworth-Anderson, P., Goodwin, P. Y., &Williams, S. W. (2004). Can culture help explainthe physical health effects of caregiving overtime among African American caregivers?Journals of Gerontology Series B: PsychologicalSciences and Social Sciences, 59, S138–S145.

The authors draw on Pearlin et al.’s (1990)stress and coping model to examine whethercultural beliefs and values of African-Americancaregivers to the elderly influence health out-comes over 3 years. A sample of 107 African-American caregivers whose care recipient was amember of the Duke Established Populations forEpidemiologic Studies of the Elderly was usedin this study. The stress and coping model positsthat combinations of background factors, stres-sors, and resources influence an individual’sreaction to stress, and the authors conceptu-alize cultural beliefs and values as caregiverresources. Results show that having very weakor very strong cultural justification for caregiv-ing is related to poorer psychosocial health but isnot related to physical functioning. The authorssuggest future research should utilize qualitativemethods to better understand why cultural jus-tification may be linked to poorer psychologicalhealth. They also suggest that the results of stud-ies on African-American caregivers will helpidentify those who are at risk for poor healthoutcomes and consequently might not be able


to provide adequate care and support to theirdependent family members.

Sorensen, S., & Pinquart, M. (2005). Racialand ethnic differences in the relationship ofcaregiving stressors, resources, and sociodemo-graphic variables to caregiver depression andperceived physical health. Aging and MentalHealth, 9, 482–495.

The study examines the associations amongcaregiver stressors, available resources, sociode-mographic variables, depressive symptoms, andphysical health in African-American (n = 278),Hispanic (n = 218), and non-Hispanic White(n = 650) caregivers of family members withdementia participating in the first wave of theREACH project. Results show that predictorsof caregiver well-being are similar across thethree ethnic groups, with few exceptions. Themost consistent exceptions were for backgroundand sociodemographic characteristics such asincome. Because the authors only examineddirect effects of predictors on caregiver well-being, they suggest that future research shouldalso examine the potential mediating and mod-erating role of various resources and sociode-mographic variables. The authors highlight theneed for careful attention to provision of ade-quate caregiver resources for all ethnic groupswhen planning interventions.

Gaugler, J. E., Anderson, K. A., Zarit, S. H.,& Pearlin, L. I. (2004). Family involvement innursing homes: Effects on stress and well-being.Aging and Mental Health, 8, 65–75.

The authors draw on the stress process modelto frame their study on the well-being of 185adults in the Caregiving Stress and Coping Studywho have placed spouses or parents/parents-in-law diagnosed with dementia in nursing homes.Findings from their study suggest that caregiv-ing behaviors after institutionalization are notlinked with increases in depressive symptomsacross the transition, but other factors, suchas feelings of role overload and role captivity,are linked with increased depressive symptoms.The authors suggest that future research shouldexpand on predictors of caregiver well-being toinclude such aspects of the process as monitor-ing or directing the care received at the nursinghome. Results also suggest that encouragingcontinued involvement by the family caregiverafter institutional placement may be beneficialfor caregiver well-being.

Marks, N. F., Lambert, J. D., Heyjung, J., &Jieun, S. (2008). Psychosocial moderators of the

effects of transitioning into filial caregiving onmental and physical health. Research on Aging,30, 358–389.

This study used a life course perspective toexamine psychosocial moderators that mightdecrease well-being when adults with one sur-viving parent transition into a caregiver rolefor that parent. The authors draw on a sam-ple of 1,062 adults who participated in the firsttwo waves of the National Survey of Familiesand Households (NSFH) and met their studycriteria for transitioning into a filial caregiverrole between those two waves of data collection.When examined as a main effect, transitioningto the role of filial caregiver is associated with agreater risk for increased depressive symptomsover time for both sons and daughters. Moderatorresults showed a different patterning of resultsfor the dimensions of mental versus physicalhealth, as well as for male and female caregivers.Discussion centers on potential additional vari-ables for future research that may account forcaregiver well-being, including number of sib-lings and their geographic location in referenceto the primary caregiver. The authors also sug-gest combining population-based studies, suchas their own, with more in-depth clinical studiesto best understand declines in caregiver well-being.

Grinstead, L. N., Leder, S., Jensen, S., &Bond, L. (2003). Review of research on thehealth of caregiving grandparents. Journal ofAdvanced Nursing, 44, 318–326.

Grinstead, Leder, Jensen, & Bond (2003)review the literature on the health of caregiv-ing grandparents published between 1990 and2002. Most studies reviewed focus on African-American and Caucasian grandmothers living inthe United States. Main themes of the literaturewere identified, including health of and stressfaced by caregivers and potential mediators ofthe association between caregiving and healthsuch as social support, coping, and feelings ofempowerment. The authors suggest that addi-tional longitudinal research is needed to betterunderstand changes in caregivers’ physical andmental well-being as they transition into thecaregiver role. They also suggest that evalua-tion studies are needed to examine the impact ofavailable resources, such as support groups, oncaregiver health and stress.

Backman, H. J., & Chase-Landale, P. L.(2005). Custodial grandmothers’ physical, men-tal, and economic well-being: Comparisons of


primary caregivers from low-income neighbor-hoods. Family Relations, 54, 475–487.

The authors use Erikson’s (1963) theory ofpsychosocial development along with Burtonand Stack’s (1993) work on familial expecta-tions for labor to frame their study of low-incomecustodial grandmothers (n = 90) and biologicalmothers (n = 1, 462). Custodial grandmothersreported more physical limitations and chronicdisabilities and fewer mental health problemsthan did mothers. Although disparity in chronicdisability was largely attributed to race/ethnicityand employment status, differences in physicaland mental health remained after controlling forseveral possible confounds. The authors high-light several key areas for intervention, includingservices targeted to both custodial grandmothersand the children for whom they care.

FAMILIES, HEALTH, AND INTERVENTION

The final section of this review recognizes theimportance of translating research findings intopractice to improve the lives of families who arecoping with a variety of illnesses. The major-ity of the articles presented below are reviewsof the current literature on intervention acrossthe life course or case study examples of theutility of specific interventions. The majority ofthe authors suggest that contemporary interven-tions have emphasized problem solving withinfamilies, communication patterns, and/or con-flict resolution, and most present evidence thatthese interventions have been at least moderatelysuccessful in helping families cope with illness.What is less clear after reviewing these articles isat what point during diagnosis/treatment inter-vention is needed and how best to determinewhich interventions may work for certain fam-ilies (or certain diagnoses). In addition, severalauthors identify a lack of empirical evaluations(e.g., experimental designs) as a detriment todesigning improved interventions and provid-ing them to the families most in need. As awhole, the literature reviewed here suggests thatmore empirical investigations of interventionsare needed in which control groups are usedand longitudinal results are examined. Althoughsome of the articles below highlight literaturein which this occurs, it is more often the casethat solitary studies or examples are highlightedwithout empirical evaluation to back up theirefficacy. Thus, this literature suggests that futurework in this area should emphasize empirical

evaluation of existing programs and the design ofprograms that compliment and extend those thatfocus on communication skills within families.

Franck, L. S., & Callery, P. (2004). Re-thinking family-centered care across the con-tinuum of children’s healthcare. Child: Care,Health, and Development, 30, 265–277.

Citing inconsistency across pediatric healthcare literature concerning family-based care,the authors review the literature and discussthe extent to which family-based practices areinformed by research. The authors show dis-crepancies in the use and definition of conceptsand point to inconsistent application in docu-mented care practices. By mapping the rela-tionships between concepts and constructs ofthe literature and the empirical evidence for theinvolved theories, the authors demonstrate gapsin theory-application relationships supportingfamily-centered care. Future research implica-tions focus on examining these gaps to form astronger empirical basis from which to informchildren’s family-centered health care.

Hoagwood, K. E. (2005). Family-based ser-vices in children’s mental health: A researchreview and synthesis. Journal of Child Psychol-ogy and Psychiatry, 46, 690–713.

This systemic review of 41 studies centers onfamily interventions in pediatric mental healthservices. The article includes three main topics:families receiving interventions, family mem-bers’ roles as co-therapists, and how families getinvolved in interventions and services. Althoughthe chosen studies appear to demonstrate thepositive effects of family-based interventionson family interactions, the author suggests thattoo few experimental (i.e., randomized trial)studies examining the effects of family-basedinterventions on children’s mental health exist,preventing conclusions from being drawn abouttheir efficacy. The author asserts that family-based models of intervention for adult mentalhealth issues should be tested more rigorouslyvia controlled experiments assessing a varietyof process variables across the field of pediatricmental health research in order to move towarda more rational and beneficial mental health caresystem for youth and their families.

Diamond, G., & Josephson, A. (2005).Family-based treatment research: A 10-yearupdate. Journal of the American Academy ofChild and Adolescent Psychiatry, 44, 872–887.

This review focuses on clinical trial litera-ture of families in which the parents were key


participants in their youth’s treatment for psy-chiatric problems. Although the authors reviewliterature addressing a variety of specific dis-eases, the majority of their conclusions relateto overall family treatment applicable acrossdisease. Having noted negative family processesshared across disorders, such as conflict and crit-icism, the authors suggest that interventions bedirected at family processes and context ratherthan at individual symptoms. The need for moreresearch centered on this area and on the mech-anisms of family intervention is recommendedin order to understand more about the effec-tiveness of family-based treatment for child andadolescent psychiatric disorders.

Kazak, A. E., Simms, S., & Rourke, M. T.(2002). Family systems practice in pediatricpsychology. Journal of Pediatric Psychology,27, 133–143.

Written primarily for pediatric psychologyclinicians integrating families into their practice,this article presents a family systems approachto clinical practice on the basis of review of pastfamily systems literature. The authors emphasizefamilies’ inclusion throughout the consultationprocess and recognize the importance of thechild, family, and care team triad in helping thefamily as a unit beyond the pediatric pathology.A treatment framework is outlined to encour-age effective emotional feedback, sustainedtrust, and conflict resolution during consulta-tion, and is demonstrated by accounts from theauthors’ practices. Compatible with other ther-apeutic approaches and models in the medicaland psychological fields, the presented modelemphasizes collaboration and recognizes fam-ily strengths and contextual factors affecting itsmembers. The authors suggest several avenuesfor future research and practice, including evalu-ation of the cost-effectiveness of family systemsconsultation models and the development oftraining objectives for family systems models inpediatric psychology.

Campbell, T. L. (2003). The effectivenessof family interventions for physical disorders.Journal of Marital and Family Therapy, 29,263–281.

Potential health outcomes related to familyinterventions for the prevention or treatment ofphysical disorders are assessed in this review.The author highlights gaps in family-based inter-ventions such as a lack of programs tailored forspecific chronic illnesses as well as ones focusedon coping and problem-solving techniques. The

author proposes that family interventions uti-lized when children have disorders such asdiabetes or asthma appear to have positive med-ical and psychosocial effects on children, butresearch on interventions applied to familiesfacing adult illness are too deficient to dis-cuss definitive outcomes. Overall, this articlesuggests that the current shortcomings of inter-ventions imply a need for more researcher andclinician involvement to better understand howfamilies can be an asset in health outcomes.

Martire, L. M., & Schulz, R. (2007). Involvingfamily in psychosocial interventions for chronicillness. Current Directions in PsychologicalScience, 16, 90–94.

The authors summarize their findings fromtwo recent reviews of randomized, controlledstudies evaluating the effectiveness of familyinterventions across a variety of chronic ill-nesses. Findings suggest that for patients andfamily members, family-oriented interventionsgenerally contributed to small improvements inoutcomes, although this relationship was some-times qualified by other variables, such as genderor type of intervention. The authors suggest thathelping family members and patients under-stand autonomy support and social control mayincrease intervention efficacy.

Kowal, J., Johnson, S. M., & Lee, A.(2003). Chronic illness in couples: A case foremotionally focused therapy. Journal of Maritaland Family Therapy, 29, 299–310.

This article begins with a brief review of theliterature on the links between chronic illness incouples and relationship status (e.g., married,unmarried), quality, and specific relationshipbehaviors (e.g., social support, hostility). Theauthors then highlight theoretical work that linksattachment theory to onset and exacerbation ofchronic illness. The article emphasizes the util-ity of an emotionally focused therapy approachfor couples facing chronic illness by outliningits emphasis on intrapsychic and interpersonalprocesses and by presenting a case study ofa couple assisted by emotionally focused ther-apy. The authors suggest that future researchshould further explore attachment behavior inthe context of chronic illness. The authors alsosuggest that a number of theoretical approachesmay be suitable in clinical work, but the lackof empirical data regarding the efficacy of theseapproaches limits conclusions about which maybe most effective.


Dankoski, M. E., & Pais, S. (2007). What’slove got to do with it? Couples, illness, and MFT.Journal of Couple and Relationship Therapy, 6,31–43.

The authors reviewed the literature on cou-ples and health with a focus on the biological,psychological, and social components of therelationship. The authors specifically target mar-riage and family therapists whose knowledge ofmedical family therapy may be limited. They usebreast cancer as an example of how marriage andfamily therapy may be helpful to couples copingwith chronic disease. The authors emphasize thatpracticing marriage and family therapists shouldbe aware of their clients’ existing and potentialhealth issues and their reciprocal influences withmarriage.

CONCLUSIONS

The goal of this article was to review con-temporary research in the field of families andhealth to highlight what is known about thelinks between family processes, the contextsin which families are situated, and variousmental and physical health outcomes. Severalsimilarities that emerged in this review of theliterature are worth noting. Overwhelmingly,researchers point to possible mediators and mod-erators of the association between families andhealth and suggest that future research shouldcontinue to explore these contextual variables.Potential moderators drawn from this literatureinclude personal characteristics, such as neu-roticism or role overload (Gaugler et al., 2004;Vitaliano et al., 2003); external stressors (e.g.,work; Marks, 1998); demographic variables(e.g., Sorensen & Pinquart, 2005); physiological,biological, or genetic processes (e.g., McEwen,2003); and availability of resources (e.g., Wick-rama & Bryant, 2003). It is important to notethat not all of the literature reviewed here con-ceptualized family process as an independentor dependent variable, and additional researchis needed to determine whether family processitself is a mediator or moderator of the associ-ations between contextual variables, health, andthe well-being of family members (e.g., Cohen,1999). The literature supports the hypothesisthat family members influence patients’ treat-ment adherence, perhaps most notably in theform of conflict and lack of cohesion, and itappears important for practitioners to make fam-ily members aware that their relationships can

debilitate, or facilitate, their loved ones’ copingand recovery process.

The studies reviewed here drew on numer-ous theories (e.g., life course, family systems,stress and coping models) and proposed sev-eral theoretical frameworks or models to explainresults or organize the literature. These theorieswere mostly supported, with evidence suggest-ing that associations between family and healthare robust throughout the life course, are relatedto systems concepts such as boundaries andmember roles, and are impacted by families’abilities to manage stress and facilitate cop-ing. Taken together, there is evidence acrossthe articles reviewed here that families influ-ence members’ health via multiple processes(e.g., conflict, support), and there also is evi-dence that family members’ health influencesfamily functioning (e.g., via coping) and familymember well-being (e.g., in caregiver situa-tions). Although several studies included in thisbibliography were longitudinal, many drew ononly two waves of data, limiting the claimsthat can be made about theoretical support andcause and effect. If the quality of the interven-tions and treatments provided to families is tobe improved, a better understanding of whichprocesses precede which outcomes, and wherealong that continuum intervention or preventionmay be most successful, is needed. Crucial tothis process will be replication of many of thefindings reviewed here. Multidisciplinary workwill be necessary to uncover the mechanismsthrough which the associations between familiesand health emerge. For example, research thatexamines the neurobiological effects of familyinteraction patterns bridges the fields of familyscience and neurobiology with a common goalof improving the long-term health of familymembers. Research such as this will not onlyadvance the field scientifically, but also providepractitioners with insight into the mechanismsvia which their interventions may be successful.

Although these annotations include a sizablenumber of review articles, only two of these weremeta-analyses. The field is in need of additionalstatistical confirmation of associations found inthese studies and, for literatures large enough towarrant them, statistical summaries of the resultsthat have been found thus far. Progress in thisarea, particularly in identifying the direct rela-tionships that exist between specific independentand dependent variables, would assist in refin-ing interventions meant to enhance coping and


would provide researchers an orientation fromwhich to continue mediator/moderator research.

Several implications for practice can begenerated from this review. First, the researchreviewed suggests that family interaction andcircumstances have a long-term impact on themental and physical well-being of children(e.g., Taylor, Lerner, Sage, Lehman, & Seeman,2004) and spouses (e.g., Kiecolt-Glaser &Newton, 2001). Early intervention for couplesand families thus appears crucial and may havelong-term benefits for children and spouses thathave yet to be discovered. As several researcherssuggested, improved empirical evaluation ofexisting interventions is necessary. Severalresearchers (e.g., Kitzmann, Dalton, & Buscemi,

2008) also encourage awareness of familyinteraction on the part of medical practitionerswhen treating children or families, suggestingthat inquiries about family process may helptailor treatment plans that are more effective.Lastly, it appears that interventions need tomeet the needs of all family members, not justthe ill member and their parents or spouses.Well siblings, children of ill parents, and familycaregivers will have different needs than the illfamily member and may have access to different(or fewer) resources. Interventions/preventativemeasures that account for all family membersmay in turn benefit family interaction, whichcould improve the well-being of all familymembers.

families and health: an empirical resource guide for researchers and practitioners

Documents