Synonyms

Burden; Stress process model; Transactional models of stress

Definition

Caregiving has been broadly defined as the act of providing unpaid or informal support and assistance to an older person with physical, mental impairment, or both. This assistance might include personal care, emotional support, household activities, financial management, shopping and transportation, and supervising/monitoring care. Informal caregivers are mainly family members. Usually, spouses offer more assistance than adult children, and adult children tend to provide more care than other groups of informal caregivers, such as family friends or neighbors. Caregiving can last for a short period of time or, more commonly, extend over years. The act of caregiving is now seen as a normative life event, at least for spouses and adult children in most Western countries.

Caregiving had been described mainly as a burden or stressful experience. However, there is a lack of consensus and rigor in defining burden. This has led to development of more sophisticated conceptual models about what happens when stress demands exceed coping abilities, also called transactional approaches to stress. The stress process model is one of such models and considers caregiver stress as a process of multiple interrelated conditions, involving the proliferation of stress from direct care-related dimensions to other caregiver’s life domains.

Introduction

Forty years have passed since Fandetti and Galfand (1976) published one of the first articles about family caregiving in a prestigious scientific American journal dedicated to gerontology – The Gerontologist. The authors studied a sample of Italian and Polish residents to determine their attitudes toward caring for aged relatives. Since then, there has been a massive expansion of research on caregiving, which is still one of the most researched topics in gerontology.

As would be expected, along with the rapidly growing population of older adults worldwide, the number of persons with chronic diseases requiring ongoing support and supervision has also increased. Families provide the largest amount of informal long-term care and assistance. In the United States and most European countries, this family involvement in caregiving is due in part to the major emphasis of public policy aimed at promoting community care and delay institutionalization of dependent older persons. Thus, families have been considered the heart of these care systems.

A growing body of evidence has suggested the negative effects of caregiving on the caregivers’ physical and psychological health, social life, leisure, and finances. Chronic conditions in the person receiving care entail high caregiving demands and long-term dependency lead to more strains for family caregivers. Contemporary societal changes have also intensified the strains on families’ resources to provide care (Sales 2003; Zarit et al. 2007). First, older people are living longer after the onset of disabilities, which demands more extensive care. Usually, the caregiving role is assumed by an older spouse, who has frequently to cope with his/her own age-related limitations, or by adult children (often, a daughter) who have to deal simultaneously with several roles of worker, spouse, and parent of young children. Second, smaller family sizes and greater geographical distance may intensify the constraints of families to provide care. Third, changes in health-care policy, such as delaying institutional placement, have increased system’s reliance on family caregivers.

Family caregiving has been conceptualized as a complex and multidimensional experience, primarily explained in terms of stress. The impact of the caregiving process on the caregiver has been described in terms of the “caregiver burden,” a concept that encompasses multiple and inconsistent definitions. The following is an attempt to clarify the meanings and use of these two terms – burden and stress – which are often used interchangeably to describe the impacts of caregiving on the caregiver. The stress and burden approaches to understand the caregiving experience have informed, over the last two decades, the development of interventions targeted to attenuate the negative outcomes of this event.

Caregiver Burden

The concept of caregiver burden has become one of the core concepts of interest in the field of gerontology. Caregiver burden is typically defined as the physical, emotional, psychological, and financial difficulties experienced by family or informal caregivers as a consequence of older person’s disease and impairment. Researchers more or less agree on the need to distinguish the objective and subjective dimensions of burden. However, much less agreement is found about the conceptual definition of burden, which is often studied both as an outcome and a predictor of other caregiving outcomes. The lack of regular conceptualization and operational definition has led to inconsistency in burden measures and results across interventional studies. A clear understanding of burden has been further hindered by the tendency for researchers to use the term interchangeably with stress, impacts, consequences, or strain.

The concept of burden was first introduced by Grad and Sainsbury in regard to the community care for people with psychiatric disorders (Grad and Sainsbury 1996). The authors sought to assess how these patients affected their family life in terms of income, employment, social and leisure activities, domestic routines, health of the family members, and relations with neighbors. Not long after the work of Grad and Sainsbury, Hoenig and Hamilton (1966) suggested the need to distinguish between “objective” and “subjective” burden. The term “objective burden” was related to the adverse effects on the family, such as income loss, poorer health, or general changes in household routines. “Subjective burden” was defined as what families “felt and to what extent they considered the patient’s illness had been a burden to them” (p. 287).

During the1970s and 1980s, Zarit and colleagues (1980) made great strides in establishing and clarifying the concept of burden. Within their work on dementia caregiving, they have defined burden as the caregiver’s feelings about their emotional, physical health, social life, and financial status as a result of caring for their family members. Zarit et al. (1980) viewed caregiver burden as a subjective process and not necessarily as a negative consequence of caregiving. The authors developed one of the most widely used measures of caregiving burden: the Zarit Burden Interview. This self-reported inventory covered several dimensions of burden, including caregiver’s health and psychological well-being, social life, finances, and the relationship between the caregiver and the cared-for person.

Subsequent to the work of Zarit et al. (1980), several attempts to refine the conceptualization of caregiving burden had been made. For instance, Poulshock and Deimling (1984) considered burden as the caregiver’s appraisal of “the tiring, difficult, or upsetting nature of caregiving tasks” (p. 233). George and Gwyther (1986) defined caregiver burden as the “physical, psychological or emotional, social, and financial problems that can be experienced by family members caring for impaired older adults” (p. 253).

Later, studies have tried to clarify the differences between objective and subjective caregiver burden. Objective burden refers to the events and changes in caregivers’ various life domains which result from the caregiving role. These include the direct tasks of care (e.g., helping patients with the activities of daily living, supervising care), indirect tasks of care (e.g., domestic tasks or financial management previously performed by the patient), providing emotional support to the cared-for person, and the effects on other life roles (e.g., family routines, leisure, social relations, finances, job career) (Sales 2003). The subjective burden is related to the caregivers’ reactions or emotional responses to care demands. Some argue that objective and subjective burden can be analyzed separately (Montgomery et al. 1985). Others consider that most measures of objective burden rely on caregiver’s self-report/subjective perceptions of the extent of their caregiving tasks, which is far from being objective (Sales 2003). Furthermore, while some consider the consequences of caregiving on various life domains as objective (Montgomery et al. 1985), others regard it as subjective (Braithwaite 1992).

The critical need to document caregiving burden has been shown by the variety of instruments developed to measure it. Some authors argue that burden is a unique domain of the caregiving experience that is not captured by more generic measures of well-being (Stull et al. 1994). There are currently about 30 instruments described in scientific literature to assess the caregiver burden (Van Durme et al. 2012). Most of these measures are multidimensional, assess both objective and subjective burden, and are administrated to the primary caregiver. However, as burden is conceptualized differently by various authors, the tools used to measure it differ as well, leading to findings that are difficult to integrate across studies and limiting the ability to inform clinical and policy settings (Bastawrous 2013).

Nevertheless, decades of research on chronic conditions such as dementia, cancer, or stroke have suggested that caregiver’s burden increases the risk of negative physical, psychological, and physiological outcomes. However, a number of comparative studies propose that different chronic conditions present different caregiving demands; hence, research needs to distinguish each disease’s specificities from the common aspects of caregiving. For instance, chronic diseases characterized by cognitive impairments (e.g., Alzheimer’s disease) have been found to be more burdensome (Papastavrou et al. 2012). In addition, disorders with an unpredictable course (e.g., cancer) present more physical burden and psychological distress for caregivers than those with an expected trajectory (e.g., diabetes) (Kim and Schulz 2008).

While many earlier scientific studies on caregiver burden were not based in theory, more recent work has been developed in an attempt to anchor caregiver burden in a broader theoretical framework and to outline some of its basic dimensions, as well as the links among those dimensions. The stress process model, developed by Pearlin and his colleagues (1990), is one of those frameworks, where burden can be treated as a primary stressor. How burden fits within this model and other the stress process theories is explained in the following section.

Caregiver Stress in the Context of Transactional Models

Perhaps the first theoretical conceptualization of the term “stress” was introduced by Hans Selye (1956). He defined stress as a response to an antecedent stimulus or event. The underlying assumption is that stress is linearly determined by the nature of the event itself.

However, the experience of caring for an older family member has been conceptualized within the context of transactional models of stress. Among those models, Lazarus and Folkman’s model of stress and coping (Lazarus and Folkman 1984) and Pearlin and colleagues’ stress process model (Pearlin et al. 1990) have anchored family caregiving research on a stronger conceptual foundation. Lazarus and Folkman (1984) have defined stress as “a relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (p. 17). This definition emphasizes the relationship between the person and the context, considering the characteristics of both. From this perspective, stress is viewed as a process rather than simply a reaction to an environmental stimulus. The authors acknowledge the role of individuals’ cognitive appraisals which are more important than the actual stressors. So, an event only becomes a stressor if the person interprets it as such. Within their transactional model of stress, Lazarus and Folkman (1984) described three steps: primary appraisal, whereby a potential stress can be perceived as irrelevant, benign-positive, or stressful (harm/loss, threat or challenge); secondary appraisal, as the person identify coping strategies/resources and their effectiveness to deal with the potential stressor; and reappraisal, which refers to a changed appraisal considering the new information from the environment, from the person’s own reactions, or both. This three-step stress and coping process involves asking: “Is this event something that I need to respond? Does it pose a threat, harm or challenge?” If the answer is “no,” then no action is necessary. But if the answer is “yes,” then a secondary appraisal arises. By this time the question that occurs is: “Which strategies or resources do I have to cope with the event?” The person then selects the mechanism (coping) to deal with the stressor. Next, a reappraisal is made to see if the response has worked, thereby either reducing the perceived threat or leading to a new approach to coping strategies if the perceived threat is not sufficiently reduced (Nolan et al. 1996).

The caregiving literature has moved increasingly toward transactional models of stress. Largely grounded in sociological perspectives of stress, the stress process model proposed by Pearlin and colleagues (1990) is perhaps the most used approach to understand the caregiving experience. Both models proposed by Lazarus and Folkman (1984) and Pearlin et al. (1990) conceptualize stress in terms of transactions between the person and the environment. However, Lazarus and Folkman’s work emphasizes cognitive appraisals and the microlevels of the stress process, whereas Pearlin and colleagues’ stress process model is more concerned with the contextual and macro-levels (Kinney 1996). This stress process model presents caregiver stress as a multidimensional and interrelated process involving four components (Pearlin et al. 1990): background characteristics and context, stressors, moderators, and outcomes. According to the authors, the caregiving experience is shaped by key characteristics of the caregiver (e.g., gender, age, education, occupational and economic conditions), the caregiving history (e.g., relationship between caregiver and care receiver dyad), the family network, and program/resources’ availability in the community. Pearlin et al. (1990) have defined stressors as “the conditions, experiences, and activities that are problematic for people” (p. 586). These are conceptualized as primary and secondary in nature. The primary stressors are those that arise directly from providing care to a dependent relative, involving both the objective conditions of caregiving (e.g., supporting ADL) and subjective reactions incited by these objective conditions (e.g., a sense of role overload or captivity). The secondary stressors consist of those difficulties that derive from the caregiving (but do not directly entail the provision of care) and proliferate into other dimensions of the caregiver’s life. These include role strains that are found in activities and roles outside the caregiving situation (e.g., family conflict, financial strain, work conflict) and intrapsychic strains which, for the most part, involve dimensions of self-concept (e.g., doubts about one’s competence or mastery). The moderators regulate not only the focal stressor-outcome relationships but also the processes whereby stressors generate more stressors. Coping skills and social support are usually regarded as the two main moderators. The final major components of the stress process are the outcomes, in terms of caregivers’ well-being, physical and mental health, and their ability to sustain themselves in their social roles.

In the light of the stress process model, burden is treated as a primary stressor affected by the caregiver’s background and the caregiving context. Burden, in turn, affects directly outcomes such physical and mental health, as well as indirectly through secondary role strains and intrapsychic strains. Coping and social support moderate these interactions and explain differences in outcomes among caregivers experiencing similar situations.

While Pearlin et al. (1990) conceptualize burden as a primary stressor; Yates et al. (1999) suggest that burden should be treated as a secondary appraisal variable based on the argument that it is equal to subjective burden perception. Yates et al. (1999) considered the primary stressors from the Pearlin model (e.g., number of hours of informal care) as a primary appraisal variable that leads indirectly to secondary appraisal of caregiver overload (burden) and depression.

Although the stress process model was developed from research on dementia caregiving, it is considered one of the most comprehensive caregiving theoretical frameworks and has been widely applied to conceptualize and interpret observational and interventional research in a broad range of other caregiving settings such as stroke (Cameron et al. 2014), cancer (Gaugler et al. 2005), and chronic liver disease (Nguyen et al. 2015).

Caregiving and Ethnicity

A growing body of research has explored how culture and ethnicity influence the caregiving experience. Despite apparent inconstancy in results, this research generally suggests that the caregiving role is experienced differently by different ethnic groups. Ethnic variations in the caregiving experience may be attributable to differences in the levels of stressors, coping strategies, social support, as well as different perceptions of family obligations. For instance, a number of systematic reviews have found that, compared to other ethnic groups, African-American caregivers appear to have lower levels of burden and depression (Pinquart and Sörensen 2005; Dilworth-Anderson et al. 2002) and higher levels of uplifts and subjective well-being (Pinquart and Sörensen 2005). Several studies reported that African-American caregivers receive more informal support than White caregivers. Others suggest that African-American caregivers might be better able to cope with caregiving because they have learned to cope with adversity in their lives and because of their strong religious orientation and the use of more positive reappraisal (Pinquart and Sörensen 2005).

Also, Asian-American caregivers were found to be more depressed than White-American caregivers (Pinquart and Sörensen 2005). Pinquart and Sörensen (2005) reported that Asian-American caregivers used significantly less formal support than Whites. Sampling bias or language barriers might account to partially justify these results. However, the cultural value of filial piety can also add some explanation to these findings. Filial piety is a fundamental Confucian value common among many Asian cultures and historically instructs people to be respectful to their parents, emphasizes intergenerational relationships, and places family needs over individual interests. Adult children are expected to sacrifice their financial, physical, and social needs for the benefits of their aging parents (Miyawaki 2015). In this sense, the cultural expectation of caring for aging parents might pressure some Asian caregivers to perceive the use of formal services as losing face or an evasion of one’s own responsibility, resulting in an underutilization of formal support (Lai 2010). Filial piety was also found to significantly predict the appraisal of the caregiving experience as rewarding among Chinese-Canadian caregivers, although no significant direct effect on caregiving burden was found (Lai 2010).

Research has also explored the experience of caregiving for Latino or Hispanic-American caregivers. This research suggest that, compared to Caucasian-American caregivers, Latino dementia caregivers reported lower levels of perceived burden (Montoro-Rodriguez and Gallagher-Thompson 2009) and lower appraisals of stress (Coon et al. 2004). Latino caregivers also reported higher levels of self-efficacy in managing disruptive behaviors of the patients and controlling upsetting thoughts (Montoro-Rodriguez and Gallagher-Thompson 2009), as well as appraised caregiving to be a significantly more positive experience than Caucasian caregivers (Coon et al. 2004). These findings might be influenced by a cultural perspective that sees the act of caring for an older relative as congruent to the Latino cultural value of familism wherein reciprocity and solidarity among family members help support caregivers and their roles. In addition, Latino caregivers’ appraisal of stress may be more related to the degree of disruption caregiving eventually brings to their families rather than to themselves as individuals. Also, Latino caregivers were more likely to rely on religious and spiritual activities, which may serve as effective coping strategies for them to help buffer against the daily stress of caregiving throughout their promotion of social integration, social support, and relationship with God (Coon et al. 2004).

The caregiving experience has also been researched in cross-country studies. For instance, high ratings of burden and lower health-related quality of life have been recently found among caregivers of people with dementia in eastern and southern European countries, compared to north or central European countries (Bleijlevens et al. 2015). Differences in health and social care systems may account for variation in these outcomes. In general, the provision of formal support is lower and informal care is higher in southern and eastern European countries. In Spain, family caregiving plays a more central role compared to other countries. On the other hand, countries like the Netherlands or Sweden offer as extensive health and social care system, and long-term care is primarily considered a responsibility of country councils and municipalities (Bleijlevens et al. 2015).

Together, all these studies underscore the relevance of understanding how social and cultural factors influence both caregivers’ outcomes and mediator variables.

Interventions for Caregivers

The last two decades has seen a substantial increase in the development of caregiver interventions designed to reduce both the adverse effects of care and early nursing-home placement of the dependent older person. Increasingly, these interventions have applied the transactional models of stress, particularly Pearlin’s stress process model, to identify modifiable variables of the stress process that can lead to improved outcomes. The approaches to caregiver interventions can be divided into two main groups (Sörensen et al. 2002): (i) those aimed at reducing the objective burden or amount of care provided by caregivers (e.g., respite care) and (ii) those aimed to improve caregiver’s well-being and coping skills, generally called psychosocial interventions (e.g., support groups, psycho-education, psychotherapy). More recently, an integrated approach has emerged, combining a range of strategies, and is classified as multicomponent.

Respite care was designed to relieve caregivers periodically or temporarily from the provision of care to their dependent relative. This rest allows the caregiver to take some time for his/her own and carry out other activities. The main types of respite services include (Figueiredo 2009):

  1. (a)

    In-home respite, which provides relief in the home by workers with suitable training. Examples of the type of care provided are help with personal care and housework, companionship, and supervision. This is, perhaps, the most widely used type of respite services.

  2. (b)

    Day care centers, which are structured, comprehensive community-based centers that provide a variety of social and health-care services in a supervised setting during part of the day, freeing the caregiver for other activities or rest.

  3. (c)

    Overnight respite, which involves the admission of the dependent person for a night, weekend, or longer in a residential care facility or nursing home, depending on the needs of the caregiver.

  4. (d)

    Institutional respite and vacation/emergency respite, which includes round-the-clock substitute care, usually used for longer, continuous periods of time, often when caregivers need to be away for short periods of time (e.g., when they need a holiday, become temporarily ill, or in emergency situations such as a death in the family).

In general, there is some evidence that caregivers do not use respite services or use them too little or too late in the caregiving trajectory (Figueiredo 2009). Yet, while Sörensen et al. (2002) observed respite care effectiveness in terms of dementia caregiver burden, depression, or subjective well-being, more recent reviews (Schoenmakers et al. 2010) found that respite was associated with an increase in burden, probably due to family caregivers’ concerns about respite care quality and difficulties to accept handing over their dependent older relative. Also, Mason et al. (2007) observed that the effects of all types of respite care upon caregivers were generally small, with better-controlled studies finding modest benefits only for certain subgroups. Further, empirical evidence suggests that respite does not delay institutional placement.

Psycho-education includes structured interventions designed to provide information on the disease process, symptoms management and community support resources, and training to provide care and respond to disease-related problems. It also includes a supportive component aiming to normalize experiences, give mutual support, and provide problem-solving and emotional-management strategies for coping with the disease demands. Systematic reviews and meta-analysis studies have shown that psycho-educational interventions have consistent short-term effects on a wide range of dementia caregiver’s outcome indicators (Sörensen et al. 2002; Pinquart and Sörensen 2006; Parker et al. 2008). Similar findings were found for stroke family caregivers; however, evidence is limited (Cheng et al. 2014).

Support group interventions might include both professionally led and peer-led unstructured support which focuses on building up a rapport among participants and developing opportunities to share experiences of caregiving. In these groups, peers provide emotional support as well as insights into successful strategies for dealing with several aspects of the caregiving role. In contrast to psycho-educational programs, support group interventions are seldom standardized and education is not their primary focus. In their meta-analysis, Chien et al. (2011) found that support groups had a significant positive effect on dementia caregivers’ psychological well-being, depression, burden, and social outcomes.

Psychotherapy involves establishing a therapeutic relationship between the caregiver and a trained professional. Most psychotherapeutic interventions with caregivers adopt a cognitive-behavioral approach in which therapists aim to (Sörensen et al. 2002) improve self-monitoring, challenge negative thoughts and appraisals, help caregivers to develop problem-solving skills, and reengage in positive experiences. As with psycho-educational interventions, Sörensen et al. (2002) found that psychotherapy have the most consistent short-term effects over different types of outcomes. Specifically, cognitive-behavioral therapy was found to have a large effect on decreasing depression and a small to moderate effect on lowering burden (Pinquart and Sörensen 2006).

Multicomponent interventions include the combination of several strategies (e.g., education, respite, psychotherapy) and target multiple outcomes. Multicomponent interventions seem to be more effective in improving caregivers’ well-being and reducing burden compared to more narrowly targeted interventions (Sörensen et al. 2002; Parker et al. 2008).

Caregivers can rely on several of interventions and services developed to help them to cope with the caregiving role. However, intervention studies designed to prevent stress and alleviate burden present inconsistent results and have shown only modest effects. No single intervention is completely successful in responding to all the needs and difficulties of caregivers. Some interventions (psycho-education, psychotherapy, multicomponent) seem to have broad, nonspecific effects over several outcomes, while others have more specific effects on target outcomes (respite).

Conceptual and methodological issues have been identified as main reasons to explain inconsistency in results. Some argue that the outcome measures used may be sensitive to change to greater or lesser degrees (e.g., caregiver burden appears to be less changeable than subjective well-being). In addition, studies frequently include outcome measures that do not have obvious relationship or that do not match the intervention goals. Moreover, caregivers are a heterogeneous population with diverse risk profiles, cultural backgrounds, resources, and experiences of stress and burden. Thus, the “one size fits all” approach is not appropriate for caregiving intervention (Zarit and Femia 2008). In some cases, studies use multidimensional measurements of burden but fail to address the distinction between objective and subjective burden, which might mitigate the findings of interventional research (Bastawrous 2013). Finally and perhaps the most basic constraint in caregiving intervention research is viewing caregiving as if it were a psychiatric disorder like major depression (Zarit and Femia 2008). This means that, basically, participants are enrolled in the intervention studies because they are caregivers, independently of feeling or not feeling burdened, depressed, or having other negative outcomes. There are two major consequences of this approach. First, when the goal of treatment is to reduce burden depression, but some of the participants are not burdened or depressed, that means that a part of the sample will not show improvements after the treatment, leading to a loss of statistical power to detect change. Second, it is possible that treating participants for a problem they do not present may actually worsen their situation (Zarit and Femia 2008).

Many other factors related to intervention characteristics, the caregiving situation, or research design can mediate the effectiveness of interventions, such as the dosage and length of treatment, individual interventions as opposite to group interventions, the characteristics of the cared-for person (e.g., interventions for caregivers of people with dementia are less successful than those designed for caregivers of older people with other chronic conditions), the relationship with the care receiver (adult-children interventions as opposed to spouse interventions), and the extent to which participants adhere to the treatment (regularity of attendance or dropout rate).

Future Directions

With the current demographic trends on the growth of older people population, the role of informal caregivers is expected to continue to assume a great importance. Research has conceptualized informal caregiving as a stressful event, likely to involve significant burden. Based on this approach, several burden indicators have been developed, and findings have showed that many caregivers experience high levels of burden, depression, anxiety, social isolation, and financial strain. Conceptualizing the caregiving experience in the light of stress and burden paradigms has unquestionably become a major contributor to understanding this complex phenomena, but has also hindered the opportunity to find out more about the neutral and the positive aspects of care and to promote them. There is, however, growing evidence that positive outcomes or rewards, such as a sense of reciprocity or personal growth, can be derived from the caregiving experience, despite of the stressful situation. The rewards of providing care have been associated with better caregivers’ well-being (Cohen et al. 2002), but their role in buffering stress is still unexplored. Furthermore, as theoretical models for the negative caregiving outcomes have been strongly developed, there is a need for conceptual frameworks that explain and predict positive outcomes.

Viewing caregiving as stressful and burdensome event has encourage researchers and practitioners to develop interventions based on a deficit approach in which caregivers are assumed not to have the necessary resources, skills, and competences to cope successfully with their stressful situations (Figueiredo 2009). This negative view, alongside research design and methodological issues, might in part explain the incongruent findings of intervention studies. A more salutogenic approach could provide a focus on the strengths rather than on the burdens, in order to enhance caregivers’ resilience and personal empowerment.

Moreover, the stress/burden paradigm can be reductionist. It has emphasized individuals in their caregiving role and had not really examined the cared-for person and the family as a system, as data has been obtained mainly from the primary caregiver. A family systems approach would be focused on the analysis of family dynamics and adaptations, relationships, and patterns of interactions, providing a more comprehensive picture of the caregiving experience. Interventions should be targeted at the family as a system, involving all family members, as they all take part in the adjustment to care demands.

Finally, the dominant focus has been on the use of cross-sectional designs, ignoring the changes in the cared-for person needs and chronic disease trajectory over time. The challenges of families when dealing with the diagnosis or acute phase are different from those of the chronic or terminal phase of the disease. These cross-sectional data hinders to understand how the demands, needs, and coping mechanisms of all family members change over time.

Cross-References