aDDressing family needs

1. aDDressing family needs The Lee Family

2. The Lees – vitals • Primary Characters • Nao Kao, father • Koua, mother • Lia, daughter • Location • From refugee camp in Thailand • Settled in Merced, CA, in the San Joaquin Valley (Central CA) • Predominantly immigrant neighborhood, changing from Hispanic to Hmong • 41.36% Latino (Lee & Pfeifer, 2006) • 12.37% Asian, mostly Hmong (Lee & Pfeifer, 2006) Fadiman, 1997

3. Falicov’s Multidimensional Ecosystemic Comparative Approach

4. Migration experience Foua and Nao Kao Lee Family originated from the country of Laos. They fled from Laos due to their country falling under the community rule. Before the Lees reached the United States of America, six of their children died from an assortment of causes. Their thirteenth child was born in a Thailand refugee camp. The family spent most of their time hopping around the United States. They landed in Hawaii from Thailand. Then, the Lees moved to Portland, Oregon before they lived in Merced, California within fifteen of the seventeen years in the United States.

5. Ecological context of family In The Spirit Catches You and You Fall Down (Fadiman, 1997) The Hmong culture conflicted with the American culture. Foua and Nao Kao Lee were devout followers of their religion and Hmong culture. They often went against the norm of American culture when in practicing medicine on their daughter Lia Lee. Lia struggled from epileptic seizures. Lia’s parents and the American doctors clashed with each other over the attended care given to Lia. The doctors believed that Lia needed to take her medicine to reduce the seizures. However, Lia’s parents believe in animal sacrificing and other spiritual methods to stop the convulsions. The doctors thought Foua and Nao Kao were neglecting her because they were not giving her the medications.

6. Family organization Foua and Nao Kao had seven children living at home and other the nine lived in a three-bedroom apartment. The Lee Family was very mistrusting of people outside of their family structure. They were tight-lipped about everything dealing with their family especially Lia. It was not until the family met Jeanine Hilt, when they revealed themselves to her about their culture and family life. Jeanine was Lia’s CPS worker who became close with the Lees. She realized the love they had for Lia. Jeanine’s relationship with her parents were estranged because of her sexual orientation.

7. Family life-cycle The Lees have a total of sixteen living children Foua and Nao Kao Lee lost six children and one child suffering from epileptic seizures. The Lees buried all of their children’s placentas under their house. They believe that since some of their children died, the placentas have been found by evil spirits.

8. ABCX Model of Family Stress and Coping & Multilevel Family Practice Model theoretical perspectives

9. The Lees – strengths • Function well as a unit within their system of established roles and rules • Love for each other and stability of family system has sustained them through great trials • Extended community of Hmong – Merced neighborhood, clan system, • Strong and deeply rooted beliefs of the world and events • Welfare dollars last throughout the month - financial needs are not a problem Fadiman, 1997

10. The Lees – weaknesses • No discipline or limits for Lia leads to behavioral issues outside of home • Being overweight hinders Lia’s care in emergencies • Affect on Yer for being blamed for slamming the door • Language barriers for family interaction within government and health systems • Cultural barriers impede understanding of responsibilities (e.g., medicine dosage) • Face discrimination due to race, language, culture, class Fadiman, 1997

11. Interactions with external systems • Merced Community Medical Center • No professional interpreters offered to Lees • Unethical practice by health professionals of having family sign documents incorrectly indicating that they understood symptoms and acknowledged treatments • Family had fundamental misunderstanding of how prescribed medication works (i.e., because one keeps taking it) • Over several years, Lees still had little understanding of epilepsy and treatment • Physician filed CPS petition

12. Interactions with external systems • Child Welfare System • No professional interpreters offered during screening or trial to help family • Personal reports (doctors, Dee, Jeanine) say parents are good caregivers • Jeanine Hilt, CPS social worker, visited the home, understood fears and anger, empathized with family • Dee, foster mother, very supportive of Lees and cared for Lia’s needs and violent outbursts Fadiman, 1997

13. Multilevel Family Practice Model • How family system is related to other institutions • Lees have strong extended family/clan • Lees have poor relationship with larger community and institutions • Incorporates social worker’s role in social justice – intervene in systems to make changes • Understand how systems interact with and perceive Hmong families • Assessments • Household income/expense report • FABR chart • Home visit & neighborhood walk • Geographic data map Hutchison, 2008, p. 361-365

14. ABCX model of family stress and coping • ABCX • A-event in family system (Lia’s epilepsy) • X-becomes a crisis (seizure that won’t stop) • B-understand family’s resources - internal and external – as the key to outcomes (strong kinship bonds and beliefs) • C- understand family’s definitions of event (hospital made Lia sicker, medicine makes her sick) • Double ABCX • Over time crises deplete family’s resources • Results in negative outcomes (Nao Kao tried to run out of hospital with Lia because of the way doctors referred to death) Hutchison, 2008, p. 360-361

15. Multilevel & ABCX interventions • Find the full story • Neighborhood walk – cow’s head on the stoop; animal sacrifices • Home visit – food, family, handicrafts, rituals, history • Family’s definition of Lia’s problems and treatment • Reframe family’s understanding of western medicine and medical community

16. Multilevel & ABCX interventions • Improve services through MCMC • Provide professional interpreter for communication • Cultural competency training for hospital staff • Start at the beginning to explain clearly disease and treatment to the family • Doctors anticipate “big one” and should explain that to family • Education must respect family’s belief system • Reframe medical professionals’ definition of family

17. Multilevel & ABCX interventions • Child Welfare • Wrap services around family • Nutrition education • Parenting for children with disabilities • School for Lia • Support group for Hmong with special health needs • Focus on understanding • Know family’s cultural framework • Explain procedures • Ensure that family comprehends what they are being told and what is happening • Training on Hmong for child welfare staff

18. references Fadiman, A. (1997). The spirit catches you and you fall down. New York: Farrar, Strauss, Giroux. Hutchison, E. D. (2008). Dimensions of human behavior: Person and environment. Thousand Oaks, CA: Sage. Lee, T. P., & Pfeifer, M. E. (2006). Building bridges: Teaching about the Hmong in our communities. Saint Paul, MN: Hmong Cultural and Resource Center. Retrieved October 25, 2008 from http://www.hmongnet.org/