rutinas
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Family routinesTRANSCRIPT
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Family routines and rituals in the context ofchronic conditions: A reviewCarla Crespo a , Susana Santos a , Maria Cristina Canavarro a , MagdalenaKielpikowski b , Jan Pryor b & Terezinha Féres-Carneiro ca Faculty of Psychology and Educational Sciences, University of Coimbra , Coimbra ,Portugalb Roy McKenzie Centre for the Study of Families, Victoria University of Wellington ,Wellington , New Zealandc Department of Psychology , Pontifical Catholic University of Rio de Janeiro , Riode Janeiro , BrazilPublished online: 15 Jul 2013.
To cite this article: Carla Crespo , Susana Santos , Maria Cristina Canavarro , Magdalena Kielpikowski , Jan Pryor& Terezinha Féres-Carneiro (2013) Family routines and rituals in the context of chronic conditions: A review,International Journal of Psychology, 48:5, 729-746, DOI: 10.1080/00207594.2013.806811
To link to this article: http://dx.doi.org/10.1080/00207594.2013.806811
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Family routines and rituals in the context of chronicconditions: A review
Carla Crespo1, Susana Santos1, Maria Cristina Canavarro1, Magdalena Kielpikowski2,Jan Pryor2, and Terezinha Feres-Carneiro3
1Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal2Roy McKenzie Centre for the Study of Families, Victoria University of Wellington, Wellington,
New Zealand3Department of Psychology, Pontifical Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil
T his paper is a systematic review of 39 empirical studies on family routines and rituals in the context of a chronic
condition of a family member. The search strategy encompassed a wide spectrum of chronic conditions affecting
family members from childhood/adolescence to adulthood. Twenty quantitative, 13 qualitative, 3 mixed-methods, and 3
intervention studies published between 1995 and 2012 were reviewed. A conceptual framework of routines and rituals as
key elements of family health was adopted, resulting in three main findings. First, a chronic condition in a family
member impacted the frequency and nature of family’s routines and rituals. Second, these whole-family interactions held
important functions for individuals and families, constituting strategic resources in the condition’s management and
opportunities for emotional support exchanges, and providing the family with a sense of normalcy amid the challenges
posed by chronic conditions. Third, family routines and rituals were linked to positive health and adaptation outcomes
for both patients and family members. Implications for future research include the need for the distinction between
routines and rituals against a conceptual background, use of validated assessment methods, and empirical examination of
predictors of changes in routines and rituals throughout the course of the condition and of the mechanisms linking these
family events to positive outcomes. Conclusions support the inclusion of routines and rituals in a family-centered care
approach to the understanding and treatment of chronic conditions.
Keywords: Routines; Rituals; Family; Chronic condition; Health.
C et article est un releve systematique de 39 etudes empiriques sur les routines et les rituels familiaux dans le
contexte de la maladie chronique d’un membre de la famille. La strategie de recherche englobait un large eventail
de problemes de sante chroniques affectant les membres de la famille de l’enfance / adolescence a l’age adulte. Vingt
methodes quantitatives, 13 methodes qualitatives, 3 methodes mixtes et 3 etudes d’interventions publiees entre 1995 et
2012 ont ete recensees. Un cadre conceptuel de routines et de rituels en tant qu’elements cles de la sante familiale a ete
adopte, ce qui a donne lieu a trois grandes conclusions. Premierement, une maladie chronique d’un membre de la famille
a une influence sur la frequence et la nature des routines et des rituels de la famille. Deuxiemement, ces interactions de
l’ensemble de la famille avaient des fonctions importantes pour les individus et les familles, constituant des ressources
strategiques dans la gestion du probleme de sante et les possibilites d’echanges de soutien affectif et en procurant a la
famille un sentiment de normalite dans le cadre des defis poses par les maladies chroniques. Troisiemement, les rituels et
les routines de la famille etaient lies a des resultats positifs pour la sante et l’adaptation a la fois pour les patients et les
membres de la famille. Les implications pour les recherches futures comprennent la necessite de distinguer les routines et
les rituels dans un cadre conceptuel, l’utilisation des methodes d’evaluation valides, l’examen empirique des facteurs
predictifs des changements dans les routines et les rituels tout au cours du probleme de sante et des mecanismes reliant
ces evenements familiaux a des consequences positives. Les conclusions confirment l’inclusion des routines et des rituels
dans une approche de soins axes sur la famille pour la comprehension et le traitement des maladies chroniques.
q 2013 International Union of Psychological Science
The authors would like to thank Sofia Gameiro, PhD for her insightful comments during the preparation of this review.
Correspondence should be addressed to Carla Crespo, Faculdade de Psicologia e de Ciencias da Educac�ao, Rua do Colegio Novo, Apartado
6153, 3001-802, Coimbra, Portugal. (E-mail: [email protected]).
International Journal of Psychology, 2013
Vol. 48, No. 5, 729–746, http://dx.doi.org/10.1080/00207594.2013.806811
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E ste artıculo es una revision sistematica de 39 estudios empıricos sobre rutinas y rituales familiares en el contexto de
una enfermedad cronica de un familiar. La estrategia de busqueda abarco un amplio espectro de enfermedades
cronicas que afectan a los miembros de una familia desde la infancia/adolescencia a la edad adulta. Se revisaron 20
estudios cuantitativos, 13 cualitativos, 3 de metodos mixtos y 3 estudios de intervencion publicados entre 1995 y 2012.
Se adopto un marco conceptual de las rutinas y rituales como elementos clave para la salud de la familia, resultando en
tres hallazgos principales. En primer lugar, la enfermedad cronica de un miembro de la familia afecta la frecuencia y
naturaleza de las rutinas y rituales de la familia. En segundo lugar, estas interacciones familiares mantienen funciones
importantes para los individuos y las familias, constituyendo recursos estrategicos en el manejo de la condicion y las
oportunidades de intercambio de apoyo emocional, y proporcionando a la familia un sentido de normalidad en medio de
los desafıos planteados por las enfermedades cronicas. En tercer lugar, las rutinas y rituales familiares estan vinculados a
la salud positiva y los resultados de adaptacion para los pacientes y los miembros de la familia. Las implicaciones para
futuras investigaciones incluyen la necesidad de distincion entre las rutinas y rituales en un contexto conceptual, el uso
de metodos de evaluacion validos, la examinacion empırica de los predictores de cambio en las rutinas y los rituales a
traves del curso de la enfermedad y de los mecanismos que vinculan estos eventos familiares con resultados positivos.
Las conclusiones apoyan la inclusion de las rutinas y rituales en una aproximacion de atencion centrada en la familia para
la comprension y el tratamiento de las enfermedades cronicas.
Family routines and rituals belong among the
universals of family life. Regardless of idiosyncrasies
embedded in the wider cultural and social ecology,
contemporary families across different cultures
similarly gather for meals, create routines around
household management and child-rearing, and mark
life-cycle transitions such as birth, marriage, and
death. Naturally occurring family routines and mean-
ingful rituals have been considered to hold important
functions for families, such as providing a predictable
structure to guide individual and group behavior and
promoting a sense of security and belonging (Fiese,
2006; Mead, 1973). Importantly, literature has also
suggested that family routines and rituals may play an
especially relevant role in fostering stability in times of
stress and transition (Wolin & Bennett, 1984). The
birth of a child with a chronic condition, or the onset of
such a condition in a previously healthy family
member, constitutes an important transition for the
family that is associated with increased stress and
burden not only for the patient, but for the family as a
whole.While the diagnostic phase of the disease can be
particularly taxing, the long-term duration of the
condition implies new demands and challenges calling
for a continuous adaptation. According to Rolland
(1987, 2003), families’ management of chronic
conditions is an ongoing process with specific
landmarks and transitions intertwined with the
individual and family developmental stages. Globally,
the incidence of chronic conditions is rising (World
Health Organization [WHO], 2002). Moreover, the
increasing number of children and adults surviving
with chronic conditions indicates that a growing
number of families worldwide will face a life in the
context of a specific illness. In the past two decades
there has been a shift in the approach tomanagement of
chronic conditions towards acknowledging the central
role played by families and advocating family-
centered care. This shift has prompted researchers
and clinicians to consider the impact that a chronic
condition can have on the family and also to identify
the natural resources available to families, such as
routines and rituals, to promote adaptation of families
and individuals.
The present review describes and discusses
empirical research addressing family routines and
rituals in families experiencing a chronic condition of
one of their members. A wide-ranging review strategy
was deliberately adopted in order to connect data from
different traditions and fields of research so that a
comprehensive picture of the extant literature could
be obtained. This review assembles 39 diverse studies
that employed quantitative, qualitative and interven-
tion-type methodologies. We have included studies
with families with either child or adult patients and
have adopted a broad conceptualization of chronic
condition endorsed by the WHO and encompassing
health problems requiring healthcare management
across time, including persistent noncommunicable
and communicable conditions, long–term mental
illness, and ongoing physical/structural impairment
(e.g. WHO, 2002).
CONCEPTUAL FRAMEWORK
In recent years, there has been a paradigm shift in the
understanding and treatment of chronic conditions
(Bullinger, Schmidt, Petersen, & Ravens-Sieberer,
2006; Kazak, Simms, & Rourke, 2002; Rolland,
2003). A change in the criteria used to evaluate medical
outcome prompted a progressive consideration of
patient-centered outcomes such as wellbeing and
quality of life, in addition to typical endpoints, such as
symptom control and other clinical indicators. The
focus has also shifted from a narrow examination of the
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individual patient to an inclusion of the patient’s
caregivers and the overall family context.Thiswidening
of focus was supported by the recognition that a chronic
condition affects not only the patient but also the family
as a system, and, complementarily, that a lot is to be
gained from involving the family in treatment. A
positive and supportive family environment can reduce
patients’ stress, and the involvement of multiple family
members in the condition’s management can contribute
to better adherence to medical regimens (Denham,
2003; Fiese, 2006; Rolland, 2003).
Next, we focus specifically on family routines and
rituals. First, we review the conceptual distinction
between routines and rituals; second, we discuss how
they have been conceptualized in the literature on
family and health. Family routines and rituals are
events that include specific and predictable family
interactions involving two or more of its members
(Fiese, 2006). Although routines and rituals are both
important family organizers, they are not the same.
The seminal review by Fiese and colleagues (2002)
marked the need for a conceptual distinction between
these two constructs, proposing that they can be
contrasted along the dimensions of communication,
commitment, and continuity. Family routines involve
instrumental communication between family mem-
bers about specific tasks, are circumscribed by a
specific time frame, and are repeated regularly.
However, family members do not ascribe a special
meaning to these interactions. In contrast, communi-
cation during family rituals involves meaning that is
shared by the members of the family, who are
affectively committed to these events. Family rituals
convey representations and beliefs about the family’s
identity and thus can be passed on to the next
generations. While family routines are easily
observable and decoded by outsiders, the symbolic
meaning guiding behavioral interactions during ritual
events can only be fully interpreted by the insiders—
the family members with a shared history.
In the daily lives of families, certain activities can
be the setting for both routines and rituals. For
instance, one of the most frequently examined family
settings in the literature is mealtimes. Family
mealtimes usually follow a predictable script that
may involve a pre-established schedule and assigned
roles around specific tasks such as preparing food,
clearing the table and cleaning up the kitchen; these
instrumental interactions can be considered part of
mealtime routines. In addition, family members may
attach a special meaning to sharing a meal with each
other, a time when they may tell each other about how
their day went, share stories and jokes and prepare
traditional or particular foods to acknowledge special
dates. These interactions contain a symbolic meaning
and can be considered part of mealtime rituals.
Literature has suggested that one of the first
indicators of families experiencing a major stressor,
such as the onset of an illness, is the disruption of their
usual routines and rituals (Reiss, 1982; Steinglass,
1998). Such periods call for a reorganization of daily
living to accommodate the new demands associated
with the condition, signifying what Rolland (1987)
called the “process of socialization to illness.”
Changes are pervasive along different layers of
family life: mealtime schedules and, depending on the
illness, food consumption habits may be altered.
Children’s daycare arrangements may be reorganized
to fit their or their parents’ healthcare appointments,
and usual weekend family activities may be
interrupted or abandoned if incompatible with the
newly diagnosed condition. Besides the practical need
for specific changes to take place, family members’
heightened distress in a condition’s initial stage can
also explain the emotional withdrawal from
certain activities associated with past pleasurable
experiences: They may not be willing to attend
family gatherings or the weekly family outing or
holidays.
While recognizing that family routines and rituals
can be affected by the onset of a health condition,
scholars in the family field have pointed out that these
elements of family life can be vital resources at times
of illness (Roberts, 2003a, 2003b). This idea gained
increased attention when family routines and rituals
were identified as key elements in family health
(Denham, 2003; Fiese, 2006, 2007). Denham (2003)
considered family health a group-level phenomenon
and described how family health routines—i.e.,
dynamic patterned behaviors relevant to individual
and family health—were part of the household
production of health. Drawing on Denham’s (2003)
work, Fiese (2007) further developed the concept of
family health, defining it as “the ways in which the
household, as a whole, engages in daily activities to
promote the well-being of its members and is
emotionally invested in the maintenance of health
over time” (p. 41S).
A growing body of empirical evidence adds support
to the conceptualization of family health, by showing
that predictability and order in the household are
associated with positive health outcomes for children,
adolescents, and adults (Fiese, 2006). The processes by
which these links occur are yet to be fully examined
and understood, with Fiese (2006) advancing three
possible explanatory mechanisms. The first mechan-
ism is the modification of health behavior through the
implementation of regular routines to conform to the
medical regimen of a specific condition. Examples are:
measuring sugar levels at specific times of the day and
altering food consumption (e.g. with diabetes), and
avoiding allergen stimuli and infection risks through
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regular housecleaning (e.g. with asthma and cancer).
The adaptation of old and creation of new routinesmay
promote adherence to treatment protocol, conse-
quently resulting in symptom reduction and better
overall health.
The second mechanism is family involvement and
monitoring of behavior. When the family as a whole is
involved in specific routines, family members are
more likely to engage in health-promoting behaviors.
For instance, a family meal may be a time when
family members check if the patient took the daily
medication, inquire about medical appointments and
ensure that healthy nutrition is being maintained.
Finally, the third mechanism described by Fiese
(2006) consists of involvement and affective connec-
tions present in family rituals. For some families,
reorganizing everyday life to manage a chronic
condition can be burdensome and costly. As time
unfolds, if family time is absorbed by condition-related
activities and talk, the family’s identity may be
affected in that it becomes restricted by the condition
(e.g. the diabetic or asthmatic family). In such
situations, one of the ways of “putting the disease in
its place” (Steinglass, 1998) is via the enactment of
family rituals. By engaging in these meaningful and
positive interactions, family members can experience
relief (Fiese, 2006), maintain a sense of continuity and
stability, and therefore prevent an exclusive focus on
the condition (Roberts, 2003). In sum, literature
suggests that family routines and rituals can (a) be
affected by the reorganization needed at the onset of a
chronic condition and by the burden associated
through its development over a long period of time,
and (b) constitute important resources for individual
and family adaptation to chronic conditions. Empirical
research on the topic of routines and rituals in the
health context is scarce. It is also diverse given the
multiplicity of conditions assessed and also of the
scientific disciplines which serve as contexts for this
research. The present review attempts to gather
findings from this heterogeneous body of empirical
research and thus to advance crossfertilization between
the fields of family routines and rituals and chronic
health conditions.
METHOD
Data sources and literature search
A systematic search of PubMed and PsycINFO
databases was carried out for literature from 1946 to
31 July 2012, using combinations of the following
terms: (family routines OR family rituals) AND
(“illness” OR “health” OR “disease”). MeSH (medical
subject headings) terms were used in PubMed. No
limitation regarding the type of publication, date, or
language was created during the searches. Following
the electronic search, reference lists of selected articles
were manually examined in order to identify other
potentially relevant studies for the review.
Selection of studies
EndNote (Thomson Reuters, USA) was used to merge
the results of the searches and to remove duplicated
records. The first two authors screened the titles,
abstracts, and, when needed, the full text of the studies
identified by both electronic and manual search
strategies. The following broad criteria for inclusion
were applied: (1) empirical studies using either
qualitative or quantitative methodology, or both; (2)
assessment of family rituals and/or family routines as
a variable (quantitative studies) or theme/category
(qualitative studies); (3) studies whose participants
were individuals with a chronic condition and/or their
family members. A total of 1081 nonduplicated
studies were identified initially through electronic
searches, of which 1046 were excluded; Figure 1
depicts information about the decision process and
reasons for exclusion. Four new studies were added to
the initial 35: two were identified via the examination
of selected papers’ references, one was selected
through other literature sources’ references, and one
was an article currently in press authored by the first
three authors of the present review (Santos, Crespo,
Silva, & Canavarro, 2012).
RESULTS
Descriptive characteristics
The database and manual search yielded 39 records
that met the inclusion criteria for the present review.
The studies were carried out between 1995 and 2012
(five between 1995 and 1999, five between 2000 and
2004, and 29 between 2005 and 2012) and originated
from seven countries: 25 were conducted in the USA,
seven in Australia, two in Canada and in the United
Kingdom, and one each in Portugal, the Netherlands,
and Lesotho.1 Figure 2 depicts the characteristics of
the selected studies in terms of context, methodology,
and design and whether they focused on family
routines, rituals, or both. The majority of studies
employed a quantitative methodology (n ¼ 20) and
focused on family routines only (n ¼ 24). The settings
for family routines and rituals differed widely across
1For simplicity, data reported throughout the review were obtained among American samples unless otherwise mentioned.
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studies and included both generic family routines and
rituals. The most often examined were bedtime and
mealtime, and disease-related routines and rituals.
Regarding assessment, among the quantitative
studies, the most frequently used instrument to assess
routines and rituals was the Family Ritual Ques-
tionnaire (Fiese & Kline, 1993) (n ¼ 7), followed by
the Family Routine Inventory (Jensen, James, Boyce,
& Hartnett, 1983) (n ¼ 4), the Child Routines
Questionnaire (Sytsma, Kelley, & Wymer, 2001)
(n ¼ 2), and the Family Time and Routine Index
(McCubbin, Thompson, & McCubbin) (n ¼ 1). Two
instruments were used to assess disease-related
routines, namely the Asthma Routine Questionnaire
(Fiese, Wamboldt, & Anbar, 2005) (n ¼ 3) and the
Pediatric Diabetes Routine Questionnaire (Pierce &
Jordan, 2012) (n ¼ 1). Five studies used items or
indexes generated for the study. Among mixed-
methods and qualitative studies, routines and rituals
were assessed via interviews with patients and family
•••••
Potentially relevant studies identified from electronic databases (N = 1141)PubMed (n = 724) PsycINFO (n = 417)
Studies excluded that did not meet broad criteria (n = 74)Reasons:•
••••••
•
•••
Family routines/Family rituals not included as a study variable orcategory/theme (n = 37)Insufficient or unspecified data on family routines/rituals (n = 12)Unclear or inconsistent data on family routines/rituals (n = 5)Assessment of other type of routines/rituals (n = 8)Instrument development (n = 2)Full text not accessible (n = 10)
First screening (title and abstract): Potentially relevant studies identified after duplicatesremoved (n = 1081)
Studies excluded that did not meet broad criteria (n = 972)Reasons:
Book chapters (n = 48)Books (n = 6)Book reviews (n = 7)Dissertations (n = 71)Case studies (n = 20)Editorial comments (n = 4)Erratum/Reprinted (n = 2)Reviews (n = 92)Theoretical/non-empirical articles (n = 177)Family routines/Family rituals assessment or chronic condition context notincluded (n = 545)
Second screening (full-text retrieval): Potentially relevant studies (n= 109)
Studies added from bibliography (n = 2)
Studies added from other source (n = 1)
Studies selected for systematic review (n = 39)
Unpublished studies (n = 1)
IDE
NT
IFIC
AT
ION
SCR
EE
NIN
GE
LIG
IBIL
ITY
INC
LU
DE
D
Figure 1. Flow chart of the study-selection process.
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Figure
2.Synthesisofthemaincharacteristicsofthestudiesreviewed.
Tota
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Ad
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members. In the single randomized control trial
intervention study, family routines and rituals were
assessed with the Family Time and Routine Index
(McCubbin et al., 1996).
Of the 39 studies, the majority (n ¼ 32) were
carried out in the context of a pediatric chronic
condition, whereas seven referred to adult chronic
conditions. In pediatric chronic conditions, studies’
samples were heterogeneous in respect of participants
and of who reported on family routines and/or rituals.
Parents/primary caregivers (mainly mothers) were the
only family members who reported on family routines
and/or rituals in the majority of studies (n ¼ 25), with
three studies including both parents’/caregivers’ and
children’s reports. Among the four remaining studies,
one comprised several family members, not including
the child; one comprised several family members
including the child; one study examined children’s
reports only; and one examined one sibling’s reports
only.
The age of children affected by a chronic condition
ranged from 1.5 to 26 years, with only three studies
including participants over 18 years. In two of the 32
studies on pediatric chronic conditions, children’s age
range was not reported. With regard to adult chronic
conditions (n ¼ 7), patients and spouses reported on
routines and/or rituals in three studies; the remaining
studies’ reports were provided by the patient and a
family support member (n ¼ 1), patients, friends,
medical doctors, and family members (n ¼ 1), family
caregivers only (n ¼ 1), and adolescent children
(n ¼ 1). Patients’ age in these studies ranged from 21
to 86 (in two of the seven studies adult patients’ age
range was not provided). Among the quantitative
studies, 11 examined associations between family
routines and rituals and participants’ age, and four
between the former and gender. For quantitative
studies in pediatric chronic conditions, six did not find
an association between age and routines/rituals, three
found a negative significant link, and one found that
mothers of younger children reported more difficul-
ties in bedtime and mealtime routines (Eiser, Zoritch,
Hiller, Havermans, & Billig, 1995). One of the four
studies with adult patients found that shared meals
were more frequent in older couples (Franks et al.,
2012). None of these studies found a significant
association between family routines and rituals and
participants’ gender.
The impact of a chronic condition on familyroutines and rituals
We identified three ways used in the studies selected
for this review to assess the impact of chronic
conditions on family routines and rituals. The first two
ways, endorsed mainly in quantitative research, were:
(a) comparing the degree of change in family routines
and in the meaning of rituals experienced by families
with a chronically ill member to the situation of
healthy families, and (b) examining whether routines
and rituals changed according to the conditions’
severity and time since diagnosis. The third way,
undertaken mostly in interview-based qualitative
research, was to examine patients’ and family
members’ perceptions of family routines and rituals
along the dimensions of continuity and change.
Among the four studies including comparisons with
healthy families, two found no differences with regard
to routines’ and rituals’ meaning. In Australia,
Wright, Tancredi, Yundt, and Larin (2006) found
that although caregivers of children with physical
disabilities reported more sleep problems than
caregivers of typically developing children, the most
frequently cited strategy used by caregivers in both
groups was the establishment and maintenance of a
consistent bedtime routine. In addition there were no
differences between these groups in the amount of
time needed for the bedtime routine to take place.
Markson and Fiese (2000) reported no differences in
the meaning of family rituals between parents of
children with asthma and parents in a healthy
group. However, two other studies found differences
in one of the several dimensions of routines assessed.
An Australian study comparing reports of mothers of
children with autism spectrum disorder (ASD) and
mothers of typically developing children along
several family settings found that the only significant
difference was that the former reported lower levels of
routines and ritual meaning linked to family vacations
than the latter (Rodger & Umaibalan, 2011). Finally,
Australian parents of pediatric liver transplant
recipients, compared to parents of nontransplant
children, made significantly more adjustments to
family routines related to childcare to accommodate
their children, with no differences found for the other
eight dimensions of routines in family life (Denny
et al., 2012).
Among quantitative studies, only three addressed
the associations between time since diagnosis and
families’ endorsement of routines. Two studies did not
find an association between time since the diagnosis of
diabetes type I in children with generic routines
(Greening, Stoppelbein, Konishi, Jordan, & Moll,
2007) and disease-related routines after controlling for
participants’ age (Pierce & Jordan, 2012). In contrast,
Denny and colleagues (2102) reported that families
with more years post-transplant made more adjust-
ments in routines to accommodate the child’s needs
than families where the transplant had taken place
more recently. Of the six studies assessing links
between family routines and the severity of the
condition, while three reported no association between
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these variables, the other three showed a significant
relationship. On one hand, two studies found no
significant associations between asthma severity and
asthma-related routines (Peterson-Sweeney, Halter-
man, Conn, & Yoos, 2010) or rituals in Portugal
(Santos et al., 2012); also, in the context of cystic
fibrosis, a study in the UK did not find an association
between routines and child’s health status. On the other
hand, two studies found a positive link between the
burden of asthma routines and asthma severity (Fiese
et al., 2005; Fiese, Winter, Anbar, Howell, & Poltrock,
2008). Findings from a longitudinal study conducted
with adolescents affected by maternal HIV/AIDS
showed a significant association between mothers’
physical wellness and family routines; as mothers’
bodily pain decreased and physical functioning and
vitality increased, family routines increased over time
(Murphy, Marelich, Herbeck, & Payne, 2009).
Eleven qualitative studies, one mixed-methods
study, and one report describing an educational
intervention provided information about family
members’ perceptions of how routines and rituals
were influenced by living with a chronic condition.
Reports of parents of children with ASD were
examined in five studies, indicating that, in these
families, there were restrictions to routines’ and
rituals’ frequency and there were difficulties associ-
ated with these events. Changes in weekly routines to
accommodate spontaneous or new activities outside
the home were difficult to implement, and weekend–
weekday variations were taxing (Larson, 2006;
Schaaf, Toth-Cohen, Johnson, Outten, & Benevides,
2011). Families participated less than desired in
activities such as shopping, eating out, taking a day
trip or going on vacations, with mothers perceiving
the costs associated with participation in these events
as greater than the benefits (Gray, 1997; Larson,
2006). In Marquenie, Rodger, Mangohig, and
Cronin’s Australian (2011) study, mothers described
disruptions associated with dinnertime and bedtime
routines, stressing the particular challenge associated
with dinnertime. Children with ASD did not easily
accommodate to the family’s meal routine and were
often exempt from rules and acceptable behaviors
expected from the rest of the family. According to
these authors, mothers’ descriptions portrayed a sense
of chaos during dinnertime; the need to address their
children’s challenging behaviors impeded mothers’
focus on dinnertime, an event that lacked predict-
ability and structure. Family rituals were also affected
given the unpredictability of the child’s participation
in occasions such as birthday parties and holiday and
family celebrations. Families reduced the number of
family events attended or restructured them to
accommodate the child’s needs, which could result
in distancing from extended family. According to
mothers, withdrawing from family events was an
uneasy compromise between the child’s needs and
family togetherness (DeGrace, 2004). Overall, reports
of parents of children with ASD showed that family
routines and rituals were devoid of spontaneity
(DeGrace, 2004; Gray, 1997; Larson, 2006). The
constant need to introduce changes to accommodate a
child’s needs contributed to a sense that families had
limited options to organize such events and that
family life revolved around autism (DeGrace, 2004;
Marquenie et al., 2011; Schaaf et al., 2011).
Research with families of diabetic patients demon-
strated the impact of diabetes on preparing and
conducting family meals. Studies reported changes in
routines linked to mealtime, such as scheduling daily
activities to balance meals/snacks and insulin intake in
children (Faulkner, 1996), and patients and other
familymembers adopting new roles, such as acting like
“dietitians” (Gerstle, Varenne, & Contento, 2001). A
study with adult participants from the Appalachian
region in the US with type 2 diabetes (Denham,
Manoogian, & Schuster, 2007) and family support
members found that healthy dietary requirements for
this condition often conflicted with cultural eating
patterns associated with food. Intergenerational
traditions interfered with the needed changes in family
mealtimes, with patients and their spouses reporting
difficulties in changing deeply rooted rituals, which in
some cases were linked to family identity as depicted
by a family support member—“It’s a family that likes
to eat” (Denham et al., 2007, p. 41). Families tried to
balance the need for a healthy diet with honoring
family heritage by allowing certain traditions regard-
ing food to be kept during family celebrations in
contrast to more restricted everyday dietary patterns.
In the context of pediatric cancer, the UK study by
Sloper (2000) found that six months postdiagnosis
siblings of children with cancer reported a loss of their
own and family routines, which at 18 months dropped
to 40% of the prediagnosis status. In the context of
adult cancer, patients and spouses, reflecting on initial
adjustment to life with cancer, described disruption to
their caregiving routines (stronger for children not
attending school full-time), and changes in family
rituals such as holidays and birthday celebrations
(Buchbinder, Longhofer, & McCue, 2009).
Apart from examining the loss and disruption of
routines and rituals in the face of a family member’s
diagnosis with diabetes or cancer, the last three
studies mentioned (Buchbinder et al., 2009; Denham
et al., 2007; Sloper, 2000) also provided insight into
the occurrence of positive changes. Some families
welcomed the healthy changes in dietary routines
following the family member’s diagnosis of diabetes
(Denham et al., 2007). One fifth of siblings of UK
children with cancer reported an increase in family
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activities 18 months after the diagnosis (Sloper,
2000). Additionally, Buchbinder and colleagues
(2009) found that families developed new routines
and rituals around the experience of cancer, such as
cancer caregiving routines (e.g. children swabbing the
parent’s skin with alcohol in preparation for an
injection) and rituals (kissing a parents’ scar), sharing
knowledge and information about the progress of the
condition (e.g. discussions during family morning
routines), coping rituals such as evening prayers, and
family celebrations for marking treatment milestones.
In the UK, parents of children with cancer (Kars,
Duijnstee, Pool, van Delden, & Grypdonck, 2008)
also reported that new comforting rituals were
introduced so that the child could handle new
burdensome interventions and experiences. Ott
(2005) described a developmentally based edu-
cational plan created for families of children with
chronic viral hepatitis aiming at reducing the pain and
difficulties associated with the interferon injections
assigned in the treatment protocol. This plan, created
for each family with the help of a nurse practitioner,
involved the development of coping rituals during the
procedures (e.g., parents having a “pretend” shot first)
and family celebrations afterwards (e.g., always going
out to lunch after appointments), both of which were
praised by the children and their parents. Finally,
changes in rituals around food in a sample of
caregivers of HIV and AIDS patients in Lesotho were
described by Makoae (2011), who found that the role
of food in family caregiving and the importance of
eating to slow the disease progression and support
medical efficacy led to the development of ritualized
behavior around food in the exchanges between
patients and caregivers.
Perceived functions of family routines andrituals
Qualitative studies included in this review enabled the
examination of family members’ perceptions of
functions that routines and rituals played for them
and for their families. Based on eight qualitative and
three mixed-methods studies, three main functions
were identified. Family routines and rituals consti-
tuted strategic resources, provided a sense of family
normalcy, and promoted emotional support.
Strategic resources
Families used routines and rituals intentionally to
address specific needs in the context of chronic
condition management. Some studies focused on how
typical routines and rituals (e.g., during mealtimes,
bedtimes) were used as strategies, while others
focused on how new routines and rituals were
developed to meet the condition’s challenges. In two
studies with pediatric samples, one in the context of
physical disabilities (Wright et al., 2006) and the other
of ASD (Larson, 2006), parents reported that
implementing a bedtime routine was a strategy to
improve children’s sleep by providing a sense of
comfort and predictability. Mothers of children with
ASD considered bedtime routine helpful in managing
their children’s anxiety (Larson, 2006; Marquenie
et al., 2011). In Marquenie and colleagues’ (2011)
study, mothers reported that bedtime also allowed for
the development of meaningful rituals; storytelling or
lying down with their children during bedtime routine
was pleasurable, as the child was calm and might have
shown affect and appreciation. Another study of
pediatric ASD explored the impact of children’s
sensory-related behaviors and showed that family’s
planning of routines revolved around increasing
predictability and decreasing unexpected sensory
stimuli, which could augment the child’s distress
(Schaaf et al., 2011). Morning and bedtime routines
were kept consistent and weekends were structured,
so that the child would know what to expect.
With regard to childhood asthma, a study with
African-American families (Yinusa-Nyahkoon,
Cohn, Cortes, & Bokhour, 2010) identified four
routines parents used: giving young children respon-
sibility for medication use, monitoring the availability
of the school nurse, managing air quality within their
inner-city homes, and frequently cleaning the home.
These routines were considered adaptive in the
context of ecological barriers and social forces these
families faced in their daily lives. For diabetic
patients, mealtime routines were especially important
to address the condition’s dietary requirements. In
Denham and colleagues’ study (2007), one of the
ways that patients and family support members
managed the condition was to conform to dietary
patterns by engaging in regular and healthy meals.
Following nutrition education, women with diabetes
and family members also implemented a series of
changes aimed at managing the condition (Gerstle
et al., 2001). These included food tasks, such as
buying healthier meal ingredients and planning
holiday meals with sugarless desserts; patient care
tasks, such as family members accompanying women
to their appointments; management tasks, such as
scheduling doctor’s appointments, meals, and medi-
cation intake; and medical advice tasks, which
referred to family members’ encouragement of
treatment adherence and patients’ self-care. Finally,
in Buchbinder and colleagues’ study (2009), new
routines were created in order to share information
and knowledge about cancer between adult patients
and spouses and their children. Examples were
families including regular morning discussion about
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the father’s disease progress and moments where the
mother would read about the condition and children
would gather around and ask questions regarding
cancer.
Sense of family normalcy
The carrying out of family rituals and routines was
also perceived as a means of ensuring a sense of
normalcy in the family. Family members appraised
their family based on ideas about what a family is like
(“we’re just like other families”) and also on
comparisons with the family before the onset or
progress of a chronic condition (“we do things like we
used to”). Gray (1997) found that the third most cited
factor given as evidence of family normality by
parents of children with ASD in Australia was family
ritual and routine activities. According to the author,
most families in the study operated under high levels
of stress and regular rituals, such as eating together,
were considered critical in maintaining parents’
perceptions of their family as normal. In another
study of pediatric ASD, Schaaf and colleagues (2011)
found that parents reported efforts to maintain family
activities similar to those of other families, with one
participant stating that “We do stuff because we just
don’t want his disability to impact our family” (p. 12).
DeGrace found that families with children with ASD
felt a sense of having been robbed because, due to the
challenges of the condition, they had difficulty doing
things families often do together. A similar result was
reported by Mellin, Neumark-Sztainer, Patterson, and
Sockalosky (2004), as families of adolescent girls
with type 1 diabetes, who reported less frequent and
structured meal patterns, considered this a loss for
their family lives. Maintaining rituals around provid-
ing food to ill family members was also regarded as
part of the caregiver’s efforts to maintain normality in
a sample of caregivers of family members with HIV
and AIDS in Lesotho (Makoae, 2011).
In families where an adult member has been
diagnosed with cancer, patients and spouses indicated
that one way to maintain a sense of normalcy amid the
disruption in family life was through stabilizing
routines and by adapting old and creating new rituals
(Buchbinder et al., 2009). In order to maintain a sense
of normalcy in the household, parents attempted to be
present during key daily events such as bedtime or
dinnertime. Families in the study reported that the
support of family and friends was essential to being
able to maintain established routines and deal with the
physical and emotional challenges of cancer. Changes
in pre-established routines and rituals were also
implemented in order to maintain a sense of
continuity while adapting to new circumstances. In
addition, parents pursued specific new normalization
strategies by involving children in cancer manage-
ment tasks such as wheeling a parent in the hospital,
taking temperature, or replacing bandages.
Emotional support
Family routines and rituals were considered vital
opportunities for family members to provide
emotional support to each other, contributing to an
overall positive environment and a perception of the
family as a secure and supportive context. Despite
challenges associated with implementing routines and
developing meaningful rituals, mothers of children
with ASD suggested that the regularity of routines
was relevant and provided their children, with and
without ASD, with a sense of security (Larson, 2006).
Routines and rituals were considered ways of
expressing “being there” for their children by parents
of children with acute lymphoblastic leukemia in the
UK (Kars et al., 2008). Parents reported the
importance of continuity in routines and rituals so
that their children perceived daily living as familiar;
and of change, by creating new comforting rituals to
help face the new adverse experiences related to the
condition, such as complex and painful treatment
procedures. New rituals as a way of coping with
cancer in the family were also developed in families
of adult cancer patients, such as evening prayers, and
the acquisition of a canvas punching bag with “I hate
breast cancer” written on it for children to use as a
way of expressing their feelings (Buchbinder et al.,
2009). Another function of the newly developed
rituals found by this study was to regulate time and
mark transitions in the cancer journeys. Families
opted to acknowledge cancer milestones with specific
family celebrations, one example being a husband
bringing home half a cake when his wife was halfway
through chemotherapy, with the family planning to
celebrate with a whole cake when treatment was
complete (Buchbinder et al., 2009).
Specific support to patients can be provided
through caregiving tasks. Some of these tasks were
attributed to children who spontaneously developed
meaningful rituals around parents’ cancer manage-
ment (Buchbinder et al., 2009). Participation in these
tasks was seen as beneficial to the children (e.g., by
helping to mitigate fears around medical technology)
and to the parents. The symbolic meaning of such
interactions, such as kissing a parent’s scar,
contributed to building a connection between parent
and child around the shared experience of cancer. For
family members of patients with HIV and AIDS in
Lesotho, ritualized behavior around feeding patients
was at the core of the identity of the caregivers, who
experienced positive emotions when patients enjoyed
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food and stress when they were reluctant or unable to
eat (Makoae, 2011).
Associations with health and adaptationoutcomes
Twenty-one studies (19 quantitative, one mixed-
methods, and one intervention study) examined the
links between families’ endorsement of routines and
rituals and a range of outcomes for patients and family
members, which we describe next.
Adherence to treatment and clinicaloutcomes
One area that has received empirical attention is
how routines and rituals associate with adherence and,
directly and indirectly, to chronic conditions’ clinical
outcomes. Two studies found that family routines
related to asthma were linked to better adherence to
children’s prescribed asthma medication regime as
measured by electronic monitoring (Fiese et al., 2005)
and parents’ reports (Fiese et al., 2005; Peterson-
Sweeney et al., 2010). Another study by Peterson-
Sweeney (2009) showed that a higher degree of
routines in the household was linked to asthmatic
children’s better adequacy of medication regimen,
assessed by nurse rankings based on parental
information. While one study found a relationship
between family routines and asthma-trigger exposure
in families of asthmatic children (Peterson-Sweeney
et al., 2010), another reported no significant links
between these variables (Peterson-Sweeney, 2009).
In Canada, Schreier and Chen (2010) found that youth
with more family routines in their home environment
showed decreases in IL-3, an asthma inflammatory
marker, over an 18-month time period, regardless of
asthma severity. Results showed that after controlling
for daily use of medication, family routines no longer
predicted IL-production. The authors suggested that
the presence of routines could explain why some
youth used their prescribed medication more reg-
ularly, which in turn would affect clinical asthma
outcomes. Different findings were shown in a
qualitative study with children infected with HIV
and their guardians, who identified family daily
routines as one of the barriers to adherence to
antiretroviral medication (Roberts, 2005). Examples
were falling asleep before taking medication at night,
and sleeping through/not having enough time to take
morning doses. Also, deviations from usual schedule,
for instance when the family went on vacations, were
identified as problematic for keeping a regular
medication intake.
In families of children with type 1 diabetes,
mealtime rituals were linked to hemoglobin A1c
levels, a measure of average glycaemia over the past 2
to 3 months (Ievers-Landis, Burant, & Hazen, 2011).
However another study found no correlations between
routines in the child’s life and the same measure
(Greening et al., 2007). Two studies found a
significant positive relationship between generic
routines (Greening et al., 2007; Pierce & Jordan,
2012), diabetes-related routines, ritual meaning
(Pierce & Jordan, 2012), and adherence to treatment
for diabetes type I reported by parents. Moreover, a
study with adult patients showed that when patients
shared meals with their spouses, they also reported
better diet adherence and glycemic control assessed
via hemoglobin A1c (Franks et al., 2012). Results of a
study combining interview data and assessment of
glycemic control (hemoglobin A1c) showed that
following a nutrition education programme among
women with improved glycemic control, the home
and family routines had changed to adjust to the
condition’s diet and treatment requirements. Finally, a
study using a national representative sample in the US
(Anderson & Whitaker, 2010) found that children
exposed to three routines of regularly eating the
evening meal as a family, obtaining adequate
nighttime sleep and having limited screen-viewing
time had a ,40% lower prevalence of obesity (body
mass index [BMI] $ 95th percentile).
Quality of life and psychologicaladjustment
Studies addressing links between quality of life and
psychological adjustment considered both the suf-
ferers of chronic conditions and the members of their
families. We describe them next.
Patients. The burden of routines related to asthma
was correlated with lower quality of life (Fiese et al.,
2005; Fiese et al., 2008) and anxiety (Fiese et al.,
2008) of asthmatic children. In addition, mothers’
endorsement of ritual meaning and fathers’ endorse-
ment of routines were related to lower levels of
anxiety (Markson & Fiese, 2000). Two studies
identified pathways through which routines and
rituals were linked to children’s adaptation outcomes.
Fiese and colleagues (2008) found that routine burden
was associated with lower quality of life through
mother–child rejection/criticism assessed via a
dyadic interaction task. In Portugal, family ritual
meaning reported by children and adolescents was
associated with better quality of life and lower levels
of emotional and behavioral problems through
perceptions of stronger family cohesion and lower
levels of family conflict (Santos et al., 2012).
Additionally, when families reported having made
fewer adjustments to family routines following a
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child’s liver transplant, children’s quality of life was
higher (Denny et al., 2012). Finally, in the context of
adult chronic conditions, sharing meals with partners
was negatively related to patients’ levels of stress
related to diabetes (Franks et al., 2012).
Family members. The level of routines in the home
as assessed by nurse rankings was linked to better
quality of life in parents and to low levels of asthma-
related burden (Peterson-Sweeney, 2009). While
Peterson-Sweeney and colleagues (2010) did not
find a significant association between specific family
routines related to asthma and parents’ quality of life,
another study showed that the burden of routines
associated with asthma was linked to parents’ lower
quality of life (Fiese et al., 2005). In the context of
pediatric cancer, Manne, Miller, Meyers, and Wollner
(1996) found that although family routine endorse-
ment was related to lower levels of depressive
symptoms, this link did not hold in regression
analyses where other predictors, such as assistance
from spouses, were found to be significant. For
siblings of children with disability in Australia, one of
the factors accounting for the variance in adjustment
difficulties was family time and routines, with higher
levels of the variable being associated with lower
levels of adjustment difficulties (Giallo & Gavidia-
Payne, 2006). For middle adolescents affected by
maternal HIV/AIDS in families endorsing more
family routines, several negative outcomes were
found over a 30month period, namely lower rates of
aggressive behavior, anxiety/worry, depressive symp-
toms, conduct disorder behaviors, and binge drinking
(Murphy et al., 2009).
Other health outcomes
Research included in this review also addressed
other health outcomes, such as disordered eating, sleep
issues, and health-related whole-family variables.
Mellin and colleagues (2004) found that families
with adolescent girls with type 1 diabetes, who
presented disordered eating behaviors, were more
likely to have a high level of meal structure, including
more frequent family meals. A telephone-based diary
study with 47 families of children with asthma allowed
examining whether over a period of one year
fluctuations in family dinnertime and bedtime routines
(among other variables) distinguished nights when
childrenwoke up from nights when they did not (Fiese,
Winter, Sliwinski, & Anbar, 2007). The findings
indicated that while disruptions in dinnertime routines
were not associated with nighttime waking for
children, disruptions in bedtime routines showed a
significant association. Parents reporting a deviation
from the bedtime routine’s schedule within a 24 h
period were 66% more likely to report their children
waking up during the night. An intervention study
aimed at reducing sleep problems in children with
ASD and fragile X syndrome included parental
establishment of a bedtime routine previously
discussed with a therapist. Three out of 10 children
showed positive changes in sleep after the introduction
of a bedtime routine (see Weiskop, Richdale, &
Matthews, 2005 for detailed results); for the majority
of the participants positive changes took place only
when extinction techniques (removing reinforcement
to reduce a behavior) were implemented. The study did
not report if there were interaction effects between
bedtime routines and extinction techniques.) With
regard to variables at the family level, Bush and
Pargament’s (1997) patients with chronic pain and
their spouses were asked about their perceptions of
positive effects of chronic pain on family life (e.g.,
“The chronic pain experience has positive effects on
our family”) and patients reported about positive
effects on themselves. Results showed that spouses’
scores on ritual meaningwere positively linked to their
perceptions of positive family outcomes with regard to
chronic pain. Additionally, dyadic effects were found:
When spouses reported clear duties and routines,
patients perceived more positive outcomes for
themselves and their families with regard to chronic
pain. Finally, Pierce and Jordan (2012) found that for
youth with type 1 diabetes both the routines related to
diabetes and the generic ritual meaning and routines
were associated positively with family supportive
diabetes-specific behaviors and negatively with non-
supportive diabetes-specific behaviors.
DISCUSSION
The literature on family routines and rituals in the
context of chronic conditions revealed that these
family universals undergo changes according to the
characteristics and course of a specific condition, that
they perform important functions for families, and
that they are associated with health and adaptation
outcomes for patients and family members.
Research examining the impact of a chronic
condition on family routines and rituals entailed
comparisons between families (healthy families vs.
families with a member with a chronic condition;
families at different points of the spectrum of a
condition’s severity) and within families (comparing
the present moment to the prediagnosis stage).
Findings for comparisons among families were mainly
provided by a small number of quantitative studies.
Themost common result was the absence of significant
differences. However, when differences did occur,
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they were circumscribed by specific settings of family
life and showed that families living with a chronic
condition, especially when the condition’s severity
was higher, engaged less in family routines and rituals
than healthy families. Although preliminary, these
results indicate that some, but not all, familiesmight be
at risk for lower levels of investment in routines and
rituals, and consequently for lower benefits identified
for families engaging in these events.
A more complex picture emerged from qualitative
studies addressing within-family changes through the
course of the condition. In accordance with literature
(Reiss, 1982; Steinglass, 1998), the postdiagnosis
phase, especially in life-threatening conditions such
as cancer, was a time where some routines and rituals
were interrupted, and others had to be altered to meet
life’s new reality. As the families went through an
adaptation period, the organization of their routines
and rituals in the fabric of family daily life reached a
new stability in the chronic “long haul” stage
(Rolland, 2003). However, achieving a new stability
in this stage was particularly difficult in the context of
certain conditions that, due to their idiosyncratic
characteristics, interfered more closely with family
life. Two examples were pediatric ASD and diabetes.
The unpredictability associated with ASD interfered
with the frequency and regularity of family and
household routines and the enjoyment and meaning of
family rituals. Although families of children with
ASD relied on regular routines and rituals to organize
family life, they could not be certain that these events
would go smoothly, and adopted a “day by day”
approach, which was considerably taxing for every-
one involved, including the ASD child. A breach of
expectations occurred when typically enjoyable and
emotionally rich occasions, such as outings and
gatherings with extended family, had to be restricted
and often revolved around the child’s needs.
Literature on family rituals has shown that these
events are formed by both closed and open parts; e.g.,
invariant parts that embody familiar and known
components of rituals and provide a structure to fluid
and open parts, which allow room for change and
foster rituals’ flexibility across time (Roberts, 2003a).
In the case of families of ASD children, a desired
balance between these parts was difficult to achieve;
the introduction of new elements was usually
disrupting for the child, impairing the desired
spontaneity for other family members associated
with family events. In the case of diabetes, necessary
changes in mealtimes were difficult to implement,
especially if they interfered with intergenerational
traditions conveying special meanings associated with
food. The closed parts of family rituals (e.g. eating a
special dish)—those that cannot be changed in order
to assure the meaning is retained during these
events—collided with the condition’s regimen,
creating a recurrent tension for patients and their
families.
Reaching beyond the traditional exclusive focus on
disruption and chaos in the family following a chronic
condition diagnosis, studies included in this review
also shed light on the positive impact of the condition
on families’ routine and rituals. Findings support the
key role of routines and rituals in family health; given
the interdependence among family members, when a
patient adopted new healthy behaviors (e.g., healthy
diet), the whole family could benefit from the change.
The adaptation and creation of new routines and rituals
signaled that the family was successfully coping with
the condition by responding to new demands in a
proactive and resourcefulway. The fact that families of
the chronically ill spontaneously invented new
elements or totally new routines and rituals supports
the idea that these are natural resources that families
make use of when facing not only the expected but also
the unexpected transitions across the life cycle. In sum,
evidence demonstrates that a chronic condition affects
family routines and rituals and that this impact can
include both positive and negative changes as
perceived by families. Given the heterogeneity of
research in this field, in order to understand and map
out the nature and extent of this impact, it is critical to
assess the interactions among the characteristics of the
condition, the condition’s phase and the patient’s and
the family’s developmental phases.
Three main functions of family routines and rituals
were identified via interview-based studies. Family
members perceived them as strategic resources to
manage the condition; they allowed the expression of
emotional support, and provided a sense of normalcy
countering the condition’s idiosyncrasy. The first two
of these functions correspond to the mechanisms
proposed by Fiese (2006), by which routines and
rituals contribute to health outcomes. Families are seen
as the privileged context for informal caregiving of
children and adults with a chronic condition. When
new demands are introduced, the family must
reorganize itself in order to incorporate new tasks in
daily lives, such as changing their shopping and
cooking habits to adhere to a new diet, learn to perform
new procedures (e.g., injections), keep the house clean
or restructure their schedules to adjust to medication
intake. Research showed that families strategically
used routines and rituals, both old and new, as
resources to promote and monitor health-related
behaviors (Fiese, 2006). In the case of pediatric
ASD, routines and rituals were used as resources to
deal with the child’s specific need for predictability in
the household schedules.
Routines and rituals were also identified as
opportunities for emotional support exchanges
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among family members, corroborating Fiese’s (2006)
view of the role of involvement and connection in
ritual events. Studies included either routines and
rituals or rituals alone, making it difficult to determine
whether emotional support was a specific function of
rituals or could be also attributed to routines. Given
that certain settings can include both routine and ritual
elements, it seems legitimate to expect, considering
literature on the domain (Fiese, 2006), that emotional
support was derived from the symbolic meaning that
characterizes rituals. Unfortunately, routines and
rituals in family settings can be particularly difficult
to distinguish in data from interviews not specifically
designed for this purpose. Studies revealed that
emotional support was conceptualized at the family’s
systemic level; both patients and other family
members received and provided support from and to
one another. Rituals involving caregiving, for
example, were mutually beneficial for the patient
and for the caregiver. It is possible that ritual
interactions provide a framework of meaning that
buffers the burden often associated with caregiving
tasks. The enactment of meaningful rituals was also a
way for families to find support and containment for
strong emotions (Roberts, 2003a, 2003b), which was
particularly relevant in life-threatening conditions
such as cancer. Emotional support was strengthened
by old regular rituals and also by newly developed
ones that differed widely across families and
conditions. The way family members used rituals to
cope with the condition and to meet higher demands
of emotional support from one another was unique to
each family, in keeping with the views that rituals are
creative acts (Cheal, 1988) that encapsulate family
identity (Fiese, 2006).
Finally, this review identified a new possible
mechanism linking routines and rituals and health
outcomes for families dealing with a chronic
condition, namely providing the family with a sense
of normalcy. The onset of a chronic condition before
late adulthood is an unexpected life transition for
which families and, often, extended support systems
are not prepared. Due to the condition’s challenges,
certain developmental tasks may be compromised or
delayed, such as growing autonomy for children and
adolescents and full exercising of parenthood for
adults. Families experiencing non-normative devel-
opmental contexts of chronic conditions need
reassurance that they are handling the illness normally
(Rolland, 2003) and that such handling can be
achieved by carrying out routines and rituals. On one
hand, the universality of these events allows the
family members perceptions and feelings of being like
“any other family” (including their own family before
the onset of a chronic condition); on the other hand,
the choice families have in designing their own
routines and rituals allows each family to attend to
their specific needs and unique characteristics.
The majority of quantitative studies included in this
review conceptualized routines and rituals as influential
factors affecting a range of health and adaptation
outcomes. This approach and the resulting findings
confirm the shift in the research into chronic conditions
from a pathologizing view of family dynamics
associated with negative health outcomes, such as
poor adherence, to a view of healthy family coping and
adaptation (Rolland, 2003). Specifically, research has
found consistent links between routines and rituals and
better adherence to treatment, such as medication
intake, controlling exposure to triggers, and compliance
with dietary restrictions. Moreover, when families
invested more in routines and rituals, the clinical
outcomes such as glycemic control (diabetes), inflam-
matory markers (asthma), and BMI (obesity) were
better. As hypothesized by some scholars, it is possible
that routines and rituals are linked to better clinical
outcomes via their positive effect on adherence and
overall healthy behaviors; however, further studies are
warranted for more solid conclusions. It is noteworthy
that one study provided contradictory evidence by
identifying routines and rituals (e.g., going away on
holidays) as barriers to a regular medication intake
(Roberts, 2005); however, it is possible that the findings
of this study refer to situations where there is a lack of
integration of the condition’s demands into the daily and
exceptional eventsof family life. For routines and rituals
to actually work as strategic resources it is important
that families adapt them in a purposeful way. Taken
together, research supported the idea that adherence and
disease control are awhole-family affair; for both adults
and child patients, family members were involved in or
encouraged the accomplishment of necessary tasks.
Mirroring the findings of research on normative
processes of development (e.g., Fiese et al., 2002;
Spagnola & Fiese, 2007), engaging in routines and
rituals was associated with increased quality of life,
psychological adjustment and other outcomes, such as
healthy eating and sleeping patterns in families coping
with a chronic condition. However, given that literature
has shown that patients with a chronic condition and
their families may be at special risk for adjustment
difficulties, quality of life and overall health and
wellbeing, these findings highlight the importance of
routines and rituals as valuable resources to be
especially utilized by these particular families.
Research critique: Strengths, gaps, andfuture directions
This review included a wide range of research from
different domains, using distinct conceptual back-
grounds to formulate hypotheses and interpret
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findings, as well as different methodological
approaches. This heterogeneous body of research
provided a rich picture of routines and rituals in the
context of chronic conditions, yet some gaps and
caveats need to be identified. A major concern is the
need for studies to outline operational definitions of
the constructs and a clear conceptual distinction
between routines and rituals. Given that family
settings (e.g., mealtimes, bedtimes) can include both
routine and ritual elements, it is crucial that future
research clarifies which dimension is being assessed
and provides information about how the use of a
specific methodology allows the distinction to be
made. For quantitative studies, it is important to use
validated assessment instruments with known psy-
chometric qualities, in preference to indexes gener-
ated for individual studies. For qualitative studies one
possible fruitful avenue is to include questions about
the symbolic meaning of family interactions, the main
feature that distinguishes rituals from routines.
Most of the reviewed qualitative research focused on
the impact of a chronic condition on the family and on
understanding how routines and rituals played key
functions for families. In contrast, the quantitative
studies examined mainly the outcomes in terms of
health and adaptation. Research establishing links
between processes and outcomes would be advan-
tageous for advancing our present knowledge. One way
of achieving this goal is via mixed-methods studies
designed for that specific purpose. The use of mixed
methodology is still scarce; in this review, out of 39,
only three studies used this approach.Anotherway is via
the examination of possible mediation mechanisms
linking family routines and rituals to specific outcomes.
The identification of these mechanisms can be derived
from theory (cf. Fiese, 2006) and from qualitative
research findings that could then be examined in
quantitative studies. A feedback dialogue between
theory and data derived from studies conducted with
different methodologies seems a fertile way forward.
Quantitative research has conceptualized routines and
ritualsmainly as influential factors; e.g., predictors—an
approach that is theoretically supported. However, the
majority of studies used cross-sectional designs and so
issues remain concerning the direction of causality
between routines and rituals that need to be addressed in
longitudinal research. In addition, research has seldom
examined predictors of family routines and rituals; e.g.,
we know very little about what factors explain why
some families differ in how rapidly and adequately they
are able to transform their existing routines and rituals
and create new ones to address the demands of the
condition. It is legitimate to expect that prior whole-
family dynamics such as flexibility, conflict, cohesion
(see Crespo, Kielpikowski, Jose, & Pryor, 2011) or
relationship workingmodels (Crespo, Davide, Costa, &
Fletcher, 2008; Leon & Jacobvitz, 2003) interact with
the chronic condition’s characteristics to explain
processes of change in family routines and rituals over
the course of the disease. Further research addressing
this gap will be particularly illuminating to identify
families at risk of poor functioning and adaptation
following the diagnosis of a chronic condition.
In our review, we identified only three intervention
studies. One randomized control trial showed that
family time and routines improved after a 6-week
psychoeducational intervention with Australian sib-
lings of children with a disability/chronic condition
and their parents (Giallo & Gavidia-Payne, 2008); one
Australian study provided modest evidence for the
efficacy of bedtime routines in addressing sleeping
problems (Weiskop et al., 2005), and a US study
described positive results in relation to the use of
rituals in painful medical procedures (Ott, 2005).
These studies do not allow conclusions about the
utility of routines and rituals as intervention tools.
Nonetheless, they encourage future research to
explore this avenue. A growing body of research
shows the relevance of routines and rituals in both
normative and non-normative family contexts. Thus,
there is support for creating and evaluating empiri-
cally based interventions promoting families’ adap-
tation through the use of these resources.
This review highlighted two skews in the existing
research. More studies have been conducted in the
context of pediatric chronic conditions compared to
chronic conditions in adulthood, andmore research has
been conducted on chronic physical conditions than on
mental health problems (in this review only studies on
pediatric ASDwere included). The first skewmight be
explained by contextual reasons; family influences on
children with a chronic condition have received more
empirical attention than adult patients and, in addition,
research on the role of routines and rituals has mainly
examined their benefits for children’s and adolescents’
development. Nevertheless, the theoretical compasses
offered by routines and rituals provide frameworks for
examining their importance for the health and well-
being of individuals in other developmental stages,
such as adulthood and old age, and, consequently,
future studies with adult patients are recommended.
The reasons for the second skewmight include the fact
that the topic of family routines and rituals, although
not new, has received increased attention only recently
(Fiese et al., 2002), and that traditionally, research has
focused mainly on negative family dynamics (e.g.,
conflict, enmeshment) as risk/vulnerability factors for
mental health problems.
A noncategorical approach to chronic conditions
(Stein & Jessop, 1989) affirms that there are common
challenges and demands associated with different
conditions, with findings of this review showing that
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routines and rituals play key functions and are
associated with positive outcomes in the context of all
those that were assessed. Even so, it was also possible
to identify distinct aspects that were unique to each
condition. This implies that future research should
maintain efforts to understand how routines and
rituals can be differentially affected by each condition
and what associations exist with disease-specific
outcomes. The way family routines and rituals
function in the diversity of conditions in terms of
their onset, course, expected outcomes, and degree of
incapacitation (Rolland, 1987, 2003) is yet to be
addressed. Moreover, future research can also benefit
from mapping out the specific functions and benefits
of generic routines and rituals, such as the ones
present during mealtimes and bedtimes, which exist in
every family and those of disease-related interactions,
as it is likely that both offer unique contributions to
patients and their families. Finally, regarding samples,
future research would benefit from including a more
diverse range of participants in respect of age,
parental gender, and family structure (single, step and
extended families), among other characteristics, in
order to examine the importance and benefits of
routines and rituals for different individuals and
families. Given that routines and rituals are embedded
in families’ wider ecological backgrounds, the
broadening of research to participants from different
ethnic and national origins would be of special
relevance. In addition, crosscultural research could
provide a more complex insight into differences and
similarities among families from various cultural
environments in dealing with a chronic condition.
CONCLUSION
The goal of this review was to investigate how
empirical literature has conceptualized and examined
family routines and rituals in the context of a chronic
condition. Findings support scholars’ advocacy of the
study of these family interactions. Fiese and
colleagues proposed that one of the reasons why
researching family routines and rituals was informa-
tive was that these events highlighted the intersection
between individual- and family-level factors (Fiese,
2006; Fiese et al., 2002). Studies in this review
illustrated how a chronic condition in one family
member affects the whole family, by impacting on
whole-family interactions such as family routines and
rituals. Second, studies also revealed that routines and
rituals played key functions for families and were
associated with positive outcomes in health and
psychological domains for patients and family
members, demonstrating how whole-family inter-
actions can affect family members individually.
According to Rolland (1987, 2003), when facing a
chronic condition, a basic task for families is to create
a meaning for the illness situation that preserves their
sense of competency and mastery. Studies included in
this review provided evidence for claiming that
routines and rituals are natural resources available to
families to achieve such a task. Similarly to Rolland’s
(2003) view on cohesion, routines and rituals should
not be conceptualized as intrinsically healthy or
unhealthy (Spagnola & Fiese, 2007), with the
question to be asked being “What routines and rituals
will work for this family with this condition?” When
and if families are successful in the process of
introducing necessary changes to these events
embedded in their family lives, the regularity of
routines and the meaning of rituals provide a sense
of mastery over the condition via the achievement of
positive outcomes. At the same time they sustain a
family’s identity throughout time, linking the family’s
past, the present, and the expected future. Finally,
implications of this review provide further evidence
for the relevance of family-centered care in the
context of chronic conditions, an approach that
privileges sharing information with patients’ families,
supporting their decision making and respecting their
choices. For better or for worse, the patient is not
alone in dealing with a chronic condition; families can
be sources of strain as well as providers of positive
resources. Routines and rituals, as potentially
modifiable factors at the family level, emerge as key
factors to consider in the understanding and treatment
of chronic conditions, a worldwide public health
concern.
Manuscript received December 2012
Revised manuscript accepted April 2013
First published online July 2013
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