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The Need for an Evidence Base for Interventions to Support Resilience Among Military-Connected Children
EDITORIAL The Need for an Evidence Base for Interventions to Support Resilience Among Military-Connected Children Bonnie Y. Ohye,
I
PhD, AND
n this issue of the Journal, Lester et al.1 report the results of a large-scale open evaluation of a family-based preventive intervention delivered to more than 2,600 US active-duty military families from December 2008 to July 2013. The post–September 11 operations (Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn) have been characterized by repeated and extended deployments that have not been seen since World War II, resulting in more than 700,000 children having experienced at least 1 parental deployment in support of these operations.2 Deployment and reintegration are accompanied by unique stressors for all members of the military family (e.g., Chandra et al.3). In addition, estimates are 1 in 3 service members returns with deployment-related conditions, such as posttraumatic stress disorder, depression, or traumatic brain injury, that markedly change the individual and significantly strain his or her relationship with his or her family.4 In fact, research consistently shows that when a parent is deployed, children are at increased risk of developing academic, mood, behavior, and social difficulties.5,6 This increased risk occurs in the context of extremely limited mental health resources for children and other members of the service member’s or veteran’s family.7 The role that parents play in symptom expression, management, and treatment of childhood psychiatric disorders is a central assumption in child psychiatric clinical practice and science. It is well established that parental emotional challenges and psychiatric disorders significantly affect children’s development and psychological health. Understanding a child’s functioning in the context of the parent–child relationship and developing methods to engage the parent’s strengths, as well as to mitigate their negative influence on development and recovery underpin the design of a growing number of treatment approaches. Thus, family intervention has been consistently found efficacious in treating different childhood disorders, including conduct disorders, anxiety, or depression,8 and is the gold-standard treatment approach for childhood posttraumatic stress.9 Families OverComing Under Stress (FOCUS) is a manual-based 8-session program developed to promote child and family communication, problem solving, and emotion regulation, skills that underpin effective coping in children and adolescents.10 Lester et al. reported significant improvements in parental mental health (symptoms of depression, anxiety, and posttraumatic stress disorder),
10
www.jaacap.org
Eric Bui,
MD, PhD
child mental health (parent report of prosocial behavior; child self-report of anxiety), and general family functioning from baseline to the end of intervention that were maintained at 1-month and at 4- to 6-month follow-up. The systemic locus of FOCUS illustrates the potential of targeting the reciprocal, mutually reinforcing subsystem relationships (viz. parent to parent, parent to child, child to child) within a family unit to improve individual, subsystem, and whole-family functioning and increase adaptation to stress. Although evidence-based interventions to support military children are much needed, it is important to note the data reported by Lester et al. are based on an implementation of FOCUS for active-duty families at military installations. Because most military children live off military installations, and Reserve components make up 43% of the US Armed Forces, a significant need remains for interventions to complement programs such as FOCUS to reach the underserved population of children and parents serving in the Reserve and National Guard. For example, a recently developed parenting intervention, After Deployment: Adaptive Parenting Tools (ADAPT), specifically designed for National Guard families, aims to address this gap.11 Training community child and family mental health clinicians to routinely ask about a family history of military involvement, and training them in the mental health concerns of military parents and children, represent a means of ensuring access to timely, high-quality care for children. Another cost-effective approach involves educating professionals already trained and skilled in the development and mental health needs of children, such as pediatricians, teachers, school nurses, and coaches about the unique challenges of military family life. These “first responders” in the lives of children are ideally situated to identify early signs of coping stress and to make appropriate mental health referrals.12 Currently, the evidence base for community-based interventions to support the resilience of military-connected children is not well established. Building an evidence base for a full range of preventive and treatment interventions to protect resilience and address the negative effects of parental deployment stress and war-related health and mental health conditions on children and adolescents is a current, urgent matter as US Armed Forces continue their military presence in Afghanistan and our nation remains engaged in the longest continuously waged war in its history. &
JOURNAL
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 55 NUMBER 1 JANUARY 2016
EDITORIAL
Accepted October 26, 2015. Drs. Ohye and Bui are with the Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, and Harvard Medical School, Boston. The authors’ research effort has been supported by the Red Sox Foundation and Massachusetts General Hospital Home Base Program.
Correspondence to Bonnie Ohye, PhD, Red Sox Foundation/Massachusetts General Hospital Home Base Program, 101 Merrimac Street, Suite 250, Boston, MA 02114; e-mail: [email protected] 0890-8567/$36.00/ª2016 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2015.10.010
Disclosure: Dr. Bui has received funding from the Osher Center for Integrative Medicine. Dr. Ohye reports no biomedical financial interests or potential conflicts of interest.
REFERENCES
1. Lester P, Liang L-J, Milbum N, et al. Evaluation of a family-centered preventive intervention for military families: parent and child longitudinal outcomes. J Am Acad Child Adolesc Psychiatry. 2016;55:14-24. 2. President’s Commission. Strengthening Our Military Families: Meeting America’s Commitment. Washington, DC: US Department of Defense; 2011. 3. Chandra A, Lara-Cinisomo S, Jaycox L, et al. Views from the Homefront: The Experiences of Youth and Spouses from Military Families. Santa Monica, CA: RAND Corporation; 2011. 4. Tanielian T, Farris C, Epley C, et al. Ready to Serve: Community-Based Provider Capacity to Deliver Culturally Competent, Quality Mental Health Care to Veterans and Their Families. Santa Monica, CA: Rand Corporation; 2014. 5. Card NA, Bosch L, Casper DM, et al. A meta-analytic review of internalizing, externalizing, and academic adjustment among children of deployed military service members. J Fam Psychol. 2011;25:508-520. 6. White CJ, de Burgh HT, Fear NT, Iversen AC. The impact of deployment to Iraq or Afghanistan on military children: a review of the literature. Int Rev Psychiatry. 2011;23:210-217.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 55 NUMBER 1 JANUARY 2016
7. Kudler H, Porter RI. Building communities of care for military children and families. Future Child. 2013;23:163-185. 8. Diamond G, Josephson A. Family-based treatment research: a 10-year update. J Am Acad Child Adolesc Psychiatry. 2005;44:872-887. 9. Cohen JA, Mannarino AP. Trauma-focused cognitive behavior therapy for traumatized children and families. Child Adolesc Psychiatr Clin N Am. 2015;24:557-570. 10. Masten AS, Powell JL. A resilience framework for research, policy, and practice. In: Luthar S, ed. Resilience and Vulnerability: Adaptation in the Context of Childhood Adversities. Cambridge: Cambridge University Press; 2003:1-25. 11. Gewirtz AH, Erbes CR, Polusny MA, Forgatch MS, Degarmo DS. Helping military families through the deployment process: strategies to support parenting. Prof Psychol Res Pract. 2011;42:56-62. 12. Ohye B, Kelly H, Chen Y, Simon N, Zakarian R, Bui E. Staying Strong with Schools: a civilian school-based intervention to promote resilience for military connected children. Mil Med. 2015 (in press).
www.jaacap.org
11
I
PhD, AND
n this issue of the Journal, Lester et al.1 report the results of a large-scale open evaluation of a family-based preventive intervention delivered to more than 2,600 US active-duty military families from December 2008 to July 2013. The post–September 11 operations (Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn) have been characterized by repeated and extended deployments that have not been seen since World War II, resulting in more than 700,000 children having experienced at least 1 parental deployment in support of these operations.2 Deployment and reintegration are accompanied by unique stressors for all members of the military family (e.g., Chandra et al.3). In addition, estimates are 1 in 3 service members returns with deployment-related conditions, such as posttraumatic stress disorder, depression, or traumatic brain injury, that markedly change the individual and significantly strain his or her relationship with his or her family.4 In fact, research consistently shows that when a parent is deployed, children are at increased risk of developing academic, mood, behavior, and social difficulties.5,6 This increased risk occurs in the context of extremely limited mental health resources for children and other members of the service member’s or veteran’s family.7 The role that parents play in symptom expression, management, and treatment of childhood psychiatric disorders is a central assumption in child psychiatric clinical practice and science. It is well established that parental emotional challenges and psychiatric disorders significantly affect children’s development and psychological health. Understanding a child’s functioning in the context of the parent–child relationship and developing methods to engage the parent’s strengths, as well as to mitigate their negative influence on development and recovery underpin the design of a growing number of treatment approaches. Thus, family intervention has been consistently found efficacious in treating different childhood disorders, including conduct disorders, anxiety, or depression,8 and is the gold-standard treatment approach for childhood posttraumatic stress.9 Families OverComing Under Stress (FOCUS) is a manual-based 8-session program developed to promote child and family communication, problem solving, and emotion regulation, skills that underpin effective coping in children and adolescents.10 Lester et al. reported significant improvements in parental mental health (symptoms of depression, anxiety, and posttraumatic stress disorder),
10
www.jaacap.org
Eric Bui,
MD, PhD
child mental health (parent report of prosocial behavior; child self-report of anxiety), and general family functioning from baseline to the end of intervention that were maintained at 1-month and at 4- to 6-month follow-up. The systemic locus of FOCUS illustrates the potential of targeting the reciprocal, mutually reinforcing subsystem relationships (viz. parent to parent, parent to child, child to child) within a family unit to improve individual, subsystem, and whole-family functioning and increase adaptation to stress. Although evidence-based interventions to support military children are much needed, it is important to note the data reported by Lester et al. are based on an implementation of FOCUS for active-duty families at military installations. Because most military children live off military installations, and Reserve components make up 43% of the US Armed Forces, a significant need remains for interventions to complement programs such as FOCUS to reach the underserved population of children and parents serving in the Reserve and National Guard. For example, a recently developed parenting intervention, After Deployment: Adaptive Parenting Tools (ADAPT), specifically designed for National Guard families, aims to address this gap.11 Training community child and family mental health clinicians to routinely ask about a family history of military involvement, and training them in the mental health concerns of military parents and children, represent a means of ensuring access to timely, high-quality care for children. Another cost-effective approach involves educating professionals already trained and skilled in the development and mental health needs of children, such as pediatricians, teachers, school nurses, and coaches about the unique challenges of military family life. These “first responders” in the lives of children are ideally situated to identify early signs of coping stress and to make appropriate mental health referrals.12 Currently, the evidence base for community-based interventions to support the resilience of military-connected children is not well established. Building an evidence base for a full range of preventive and treatment interventions to protect resilience and address the negative effects of parental deployment stress and war-related health and mental health conditions on children and adolescents is a current, urgent matter as US Armed Forces continue their military presence in Afghanistan and our nation remains engaged in the longest continuously waged war in its history. &
JOURNAL
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 55 NUMBER 1 JANUARY 2016
EDITORIAL
Accepted October 26, 2015. Drs. Ohye and Bui are with the Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, and Harvard Medical School, Boston. The authors’ research effort has been supported by the Red Sox Foundation and Massachusetts General Hospital Home Base Program.
Correspondence to Bonnie Ohye, PhD, Red Sox Foundation/Massachusetts General Hospital Home Base Program, 101 Merrimac Street, Suite 250, Boston, MA 02114; e-mail: [email protected] 0890-8567/$36.00/ª2016 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2015.10.010
Disclosure: Dr. Bui has received funding from the Osher Center for Integrative Medicine. Dr. Ohye reports no biomedical financial interests or potential conflicts of interest.
REFERENCES
1. Lester P, Liang L-J, Milbum N, et al. Evaluation of a family-centered preventive intervention for military families: parent and child longitudinal outcomes. J Am Acad Child Adolesc Psychiatry. 2016;55:14-24. 2. President’s Commission. Strengthening Our Military Families: Meeting America’s Commitment. Washington, DC: US Department of Defense; 2011. 3. Chandra A, Lara-Cinisomo S, Jaycox L, et al. Views from the Homefront: The Experiences of Youth and Spouses from Military Families. Santa Monica, CA: RAND Corporation; 2011. 4. Tanielian T, Farris C, Epley C, et al. Ready to Serve: Community-Based Provider Capacity to Deliver Culturally Competent, Quality Mental Health Care to Veterans and Their Families. Santa Monica, CA: Rand Corporation; 2014. 5. Card NA, Bosch L, Casper DM, et al. A meta-analytic review of internalizing, externalizing, and academic adjustment among children of deployed military service members. J Fam Psychol. 2011;25:508-520. 6. White CJ, de Burgh HT, Fear NT, Iversen AC. The impact of deployment to Iraq or Afghanistan on military children: a review of the literature. Int Rev Psychiatry. 2011;23:210-217.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 55 NUMBER 1 JANUARY 2016
7. Kudler H, Porter RI. Building communities of care for military children and families. Future Child. 2013;23:163-185. 8. Diamond G, Josephson A. Family-based treatment research: a 10-year update. J Am Acad Child Adolesc Psychiatry. 2005;44:872-887. 9. Cohen JA, Mannarino AP. Trauma-focused cognitive behavior therapy for traumatized children and families. Child Adolesc Psychiatr Clin N Am. 2015;24:557-570. 10. Masten AS, Powell JL. A resilience framework for research, policy, and practice. In: Luthar S, ed. Resilience and Vulnerability: Adaptation in the Context of Childhood Adversities. Cambridge: Cambridge University Press; 2003:1-25. 11. Gewirtz AH, Erbes CR, Polusny MA, Forgatch MS, Degarmo DS. Helping military families through the deployment process: strategies to support parenting. Prof Psychol Res Pract. 2011;42:56-62. 12. Ohye B, Kelly H, Chen Y, Simon N, Zakarian R, Bui E. Staying Strong with Schools: a civilian school-based intervention to promote resilience for military connected children. Mil Med. 2015 (in press).
www.jaacap.org
11