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The Howland Family NURS 480 Family Assessment Visual Report CSU San Marcos

Alice Howland Age: 50 Alice Howland is an acclaimed linguistics professor teaching at Columbia University and prides herself in her educational excellence. She has a loving husband and three children, all of which are full grown adults at this point. At the age of 50, she is diagnosed with hereditary early onset Alzheimer’s disease. As the disease progresses, she has a difficult time sustaining her sense of self. Although she tries to preserve her retentiveness through daily reminders and memory games, Alice grows frustrated at her inability to remember her friends and family, where she is at times, and how to effectively communicate her thoughts.

Alzheimer’s Disease Alzheimer’s disease is a degenerative disease characterized by memory loss, personality changes, cognitive impairment, lack of judgment, and declining visuospatial perception (Ignatavicius & Workman, 2015). According to Nussbaum et al., older age, gender (predominantly females), and genetics are major factors for Alzheimer’s disease (as cited in Ignatavicius & Workman, 2015, p. 947). In Alice’s case, she develops an early onset of Alzheimer’s disease at the age of 50. Most cases of Alzheimer’s disease occurs after the age of 65, but earlier onset cases have occurred between 40-60 years of age (Ignatavicius & Workman, 2015). Alice discovers that she was genetically predisposed to Alzheimer’s disease, prompting some of her children to get tested for the disease as well. According to Ignatavicius & Workman (2015), early onset hereditary Alzheimer’s disease is an autosomal dominant trait that is caused by defective presenilin 1 (PSEN1), presenelin 2 (PSEN2), and beta-amyloid precursor (APP) genes.

John Howland Age: 52 John is Alice’s husband and works as a medical researcher. He initially denies that Alice has Alzheimer’s disease but eventually accepts it as he attends more of Alice’s neurology appointments with her. He is supportive and loving throughout Alice’s rapid progression of Alzheimer’s disease but finds himself struggling to watch her declining state.

Anna Howland Age: 34 Anna is Alice’s oldest daughter. She had graduated with a law degree and is currently pregnant with fraternal twins. After Anna finds out about her mother’s diagnosis, she decides to get tested and finds out she is positive. She worries for the future of her own children, but it is never mentioned if the twins inherited the disease.

Tom Howland Age: 31 Tom is the middle child in the family and works as an ER physician. Although he has a busy schedule, he makes an effort to support her when he can and grows concerned when John wants to move from New York City to Minnesota for a job opportunity; he preferred that Alice stays in New York. Tom also decides to get tested for familial Alzheimer’s disease and finds out he is negative, much to his relief.

Lydia Howland Age: 25 Lydia is the youngest daughter and an aspiring actress who has moved to Los Angeles, much to Alice’s displeasure. Lydia’s refusal to attend college causes much tension with her mother, though Lydia empathizes with her mother more since the diagnosis. Lydia eventually decides to move back to New York to care for her mother during the late stages of Alzheimer’s disease.

Duvall’s Family Life Cycle In relation to Duvall’s stages of the family life cycle, the Howland family is in the Middle Aged Parents stage, which is characterized by having all children moving out of the house, focusing on marriage, ensuring financial security in later years, and maintain friendships (Kaakinen, Coehlo, Steele, Tabacco, & Hanson, 2015). At this point of Alice and John’s life, all of their children have moved out of the house and much of their focus has been on their marriage and respective careers, as well as ensuring financial security for retirement. Alice and John focus on spending time together through dinner dates, long runs, and walks by the beach together, especially before Alice’s condition worsens.

Family Dynamics In light of Alice’s diagnosis, the Howland family remains supportive throughout the entirety of the movie. John is a constant source of support for Alice by attending her appointments for her, helping her change into her clothes each day, and calming her down when she is anxious and confused. Anna, Tom, and Lydia all express concern for her wellbeing and prognosis. Anna and Lydia have a tendency to argue over how to approach Alice’s care. For example, Alice asked Lydia about the location and time of her play, so that she can enter a reminder on her phone. Anna insists it’s not necessary to tell Alice the information because she will forget it anyways and Anna will take Alice to the play. Lydia argues that Alice should at least have some autonomy to do things for herself, which angers Anna. Yet despite occasional differences in opinion, the rest of the family makes an effort to come together for important events, such as attending Alice’s speech at the Alzheimer’s Disease Association. Alice and John are quite proud of their children’s achievements, though Alice harbors concern at Lydia’s choice to pursue acting, Alice insists that Lydia attend college to have a “plan B” despite Lydia’s constant rejection of the idea. After seeing Lydia’s play and momentarily forgetting that Lydia is her daughter, Alice compliments Lydia’s superb performance. When John decides to accept a job offer in Minnesota, Lydia moves back to New York to care for her mother and strengthening their bond.

Culture and Religion The Howland family do not participate in any particular religious traditions or practices. They are strongly connected and supportive of each other despite busy schedules and distances. Every once in awhile, the family makes an effort to have family get-togethers and meals, such as the holidays or when Lydia flies in from California.

Strengths and Challenges Strengths


The family is supportive and makes a conscious effort to be present when Alice needs them

The family struggles to adapt to Alice’s changes at certain times, such as when Alice forgets who they are

The family is fairly affluent and can afford Alice’s treatments and doctor’s visits

John and the children have trouble balancing work and Alice’s care

The family is constantly tries to look out for Alice’s best interest

There are occasional disagreements about Alice’s care, such as if Alice should move to Minnesota with John or stay in New York

The family encourages and helps Alice preserve her sense of self (e.g. helps Alice with writing a speech)

Alice fears becoming a burden to her family and attempts suicide through overdosing on pills (though it fails)


Verbal: For the most part, the family fosters a sense of open and truthful communication. Alice opens up to John about seeing a neurologist and her fears about her diagnosis. The family converses with each other about Alice’s future and her care, though at times has left Alice and Lydia out of the conversation. The family openly informs each other of other events happening in their lives, such as Lydia’s upcoming plays and Anna’s process of in vitro fertilization to have children. Nonverbal: The family displays many caring nonverbal cues such as hugging and kissing. During times of concern, they give each other empathetic looks, touch each other’s hand or shoulder, and wipe away tears.

Nursing Theory: Chronic Illness Framework In order to understand and care for the Howland family in regards to Alice’s Alzheimer’s disease, the Chronic Illness Framework can be applied for the situation. Developed by Rolland in 1987, this framework focuses on the effects of chronic illness on the family (Kaakinen, Coehlo, Steele, Tabacco, & Hanson, 2015). It is particularly useful to nurses in the way that it prompts nurses to consider various influences of illness and the impact on the family (Kaakinen et al., 2015). The Chronic Illness Framework primarily focuses on 3 elements: the type of illness, family functioning, and time phases of the illness (Kaakinen et al., 2015). Type of Illness:

Time Phases:

Family functioning:

Alice began to first notice symptoms shortly after her 50th birthday. Since the onset, her Alzheimer’s disease has had a gradual onset. Her disease has a rapid progression , which worries her family tremendously. Due to the nature of Alzheimer’s disease, the disease will incapacitate Alice cognitively and affect her quality of life.

The Howland family is currently going through the mid-phase. As John points out to his children, Alice is having just as many bad days as there are good days. Alice’s cognitive function has rapidly declined to the point where she can barely speak, and John experiences some burnout as he painfully watches her deteriorate. Lydia has also stepped up to care for Alice when John leaves for his job in Minnesota.

Since the onset of the disease, the Howland family had come together to discuss ways in which to help with Alice’s disease, provide unconditional support for her, and communicate their concerns to one another. John assists Alice in helping her get ready in the morning, calming her anxiety, and is patient when Alice repeatedly asks the same questions. Lydia moves back home to care for Alice. Though Anna and Tom are busy with their own lives, they are readily available when needed and visit their mother often.

Family Interventions ❖

Problem: Alice attempts to commit suicide through overdosing on pills by recording a video that gives herself instructions on how and where to obtain the pills.

Intervention: Educate the family about suicidal behaviors and provide guidelines on managing self-harm behaviors

Rationale: Client safety is a priority and families may be emotionally stressed and unsure of how to prevent suicidal attempts (Ackley & Ladwig, 2014). Outcome: The family will verbalize signs of suicide and establish a plan to utilize when signs manifest. ❖

Problem: John and Lydia find it difficult to watch the progression of Alzheimer’s disease in Alice and start to experience moments of burnout.

Intervention: Encourage John and Lydia to utilize community-based caregiver support groups

Rationale: Caregiver support groups have shown to provide social and emotional support and increased knowledge through difficult times of caregiver strain (Bartfay & Bartfay, 2013). Outcome: John and Lydia will report reduced feelings of burden and stress after 3 group sessions. ❖

Problem: Alice finds it more and more difficult to effectively communicate to her family and vice versa. Intervention: Teach family members to give Alice time to speak and respond. Encourage both sides to engage in regular communication and use special mementos from the client’s past.

Rationale: By using objects with sentimental meaning, the patient may better convey information if they struggle to communicate verbally (Ackley & Ladwig, 2014; Czekanski, 2017). Outcome: Alice and family will use effective communication techniques and demonstrate understanding.

References Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide

to planning care. Maryland Heights, Mo: Elsevier. Bartfay, E., & Bartfay, W. J. (2013). Quality of life outcomes among Alzheimer’s disease family caregivers following community-based intervention. Western Journal of

Nursing Research, 35(1), 98-116. Czekanski, K. (2017). The experience of transitioning to a caregiving role for a family member with Alzheimer’s disease or related dementia. American Journal of Nursing,

117(9), 24-32. doi: doi: 10.1097/01.NAJ.0000524517.60352.84 Ignatavicius, D. D. & Workman, M. L. (2013). Medical-surgical nursing: Patient-centered

collaborative care (7th ed.). St. Louis, MO: Elsevier. Kaakinen, J. R., Coehlo, D. P., Steele, R., Tabacco, A., & Hanson, S. M. H. (2015). Family Health

Care Nursing: Theory, Practice, and Research (5th ed.). Philadelphia, PA: F. A. Davis Company. [Untitled Image of Howland dinner party] Retrieved March 11 from or-dr-alice-howland-played-by-julianne-moore.jpg [Untitled Image of John and Alice] Retrieved March 11 from JGk2EvjVopnx8KskUaa-1bHW6paWYwn.jpg [Untitled Image of Alice and Tom] Retrieved March 11 from [Untitled Image of Alice, Anna, and Lydia] Retrieved March 11 from /s1600/kmkmk.jpg [Untitled Image of Alice teaching] Retrieved March 11 from SQ/s1600/Alice.jpg

References [Untitled Image of John] Retrieved March 11 from /s320/02%2BAlec%2BBaldwin%2Bas%2BJohn%2BHowland.jpg [Untitled Image of Anna] Retrieved March 11 from [Untitled Image of Tom] Retrieved March 11 from [Untitled Image of Lydia] Retrieved March 11 from [Untitled Image of Alice and John] Retrieved March 11 from FC5nqhkg66x.jpg [Untitled Image of Alice and family at dinner] Retrieved March 11 from [Untitled Image of Alice and Tom] Retrieved March 11 from g [Untitled Image of Alice wiping Lydia’s tears] Retrieved March 11 from 8KMu2dyLt9Vz7KGOwAbFFfSVmDTnG [Untitled Image of Alice and John walking down stairs] Retrieved March 11 from 23CnekiMl.jpg [Untitled Image of Alice and Lydia at the park] Retrieved March 11 from [Untitled Image of Tom, Anna, and Anna’s husband] Retrieved March 11 from es-alzheimers-diagnosis.jpg

480 Howland Family Assessment  
480 Howland Family Assessment