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Evidence-based health interventions are frequently translated into real-world settings where practical needs drive changes to intervention protocols. Due to logistical and resource constraints, these naturally arising adaptations are rarely assessed for comparative effectiveness using a randomized trial. Nevertheless, when observational data are available, it is still possible to identify beneficial adaptations using statistical methods that adjust for differences among intervention groups. As implementation continues and more data are collected and assessed, we also require analysis methods that ensure low statistical error rates as multiple comparisons are made over time. This paper describes how to create a statistical analysis plan for evaluating adaptations to an intervention during ongoing implementation. This can be done by combining methods commonly used in platform clinical trials with methods used for real-world data. We also demonstrate how to use simulations based on previous data to decide the frequency with which to conduct statistical analyses. The illustration uses data from large-scale implementation of a school-based resilience and skill-building preventive intervention to which several adaptations were made. The proposed statistical analysis plan for evaluating the school-based intervention has potential to improve population-level outcomes as implementation scales up further and additional adaptations are anticipated. [ABSTRACT FROM AUTHOR]

The KidCOPE is a widely used measure designed to examine how children cope in the face of stressful events. The current study aimed to replicate the factor structure of the KidCOPE found in four prior studies. KidCOPE responses from children of military families (2256 children, ages 7–12 years, 47.9% female, Age M = 8.90, SD = 1.62) enrolled in the Families OverComing Under Stress (FOCUS) at baseline were used. No prior factor structure could be replicated. The sample was then split, and exploratory and confirmatory factor analyses were conducted. A 2-factor model including factors for generally positive and negative coping was identified; but not confirmed. Overall, this study supports prior research suggesting limitations of the KidCOPE as a valid measure of coping style. [ABSTRACT FROM AUTHOR]

Informed by models of resilience in military families, we explored factors theorized to be associated with social-emotional resilience and risk among young military-connected children. Our secondary analysis of cross-sectional data from 199 military-connected families (n = 346 parents) with at least one preschool-age child in the home (n = 199) led to the empirical identification of two distinct clusters: families with children demonstrating healthy social-emotional functioning and those showing indicators of less healthy social-emotional functioning when compared to the first group. We then identified factors associated with membership in each cluster to determine which deployment and parental well-being variables were salient for young child adjustment. Parent psychological symptoms, parenting, child behavior, and parent-child relationships were measured by parent report and observed interaction. Children with healthier social-emotional functioning were found to be residing with families experiencing less stress and distress. The importance of maternal trauma history is highlighted in our study, as elevated maternal symptoms across all three posttraumatic stress disorder symptom domains were associated with child social-emotional risk. Basic family demographic characteristics did not contribute significantly to the cluster distinctions, nor did military service factors such as active duty, reserve or veteran status, military rank or parent deployment history. These findings are important as the results deemphasize the importance of military service characteristics and highlight the importance of parent well-being when considering social-emotional risk and resilience of young children within military families. [ABSTRACT FROM AUTHOR]

Military-connected families face many challenges associated with military life transitions, including deployment separations. We report on a randomized controlled trial to evaluate the efficacy of Families OverComing Under Stress-Early Childhood (FOCUS-EC) delivered through an in-home, virtual telehealth platform. FOCUS-EC is a trauma-informed, family-centered preventive intervention designed to promote family resilience and well-being. Military-connected families with 3- to 6-year-old children (194 mothers; 155 fathers; 199 children) were randomized to FOCUS-EC or an online education condition. Parent psychological health symptoms, child behavior, parenting, and parent–child relationships were examined by parent-report and observed interaction tasks for up to 12 months. Longitudinal regression models indicated that FOCUS-EC families demonstrated significantly greater improvements than online education families in parent-reported and observational measures of child behavior, parenting practices, and parent–child interaction, as well as greater reductions in parent posttraumatic stress symptoms. Findings provide support for the benefit of a virtually-delivered preventive intervention for military-connected families. [ABSTRACT FROM AUTHOR]

Although youth are at risk for exposure to adversity and trauma, many youth, especially ethnic and racial minorities, do not have access to mental health care. Resilience-building curriculums can teach important internal resilience skills and provide support to students who may not receive prevention or treatment services. We adapted a resilience curriculum initially used for military-connected youth facing adversities related to parental wartime deployments, to meet the needs of low-income, predominantly racial and ethnic minority students in a large urban school district. In this article, we describe the cultural adaptation, the implementation process, and the evaluation of the trauma-informed resilience curriculum using pre-post surveys and focus group discussions. We found significantly improved overall internal resilience scores, as well as significantly improved scores on subscales of problem-solving and empathy among students receiving the curriculum. The focus groups revealed that the curriculum enhanced connections among students, as well as students and teachers, and served as a way to destigmatize mental health issues. The acceptability of the curriculum as well as implementation successes and challenges are described. We provide suggestions for future steps for school psychologists and school social workers for implementing this curriculum. [ABSTRACT FROM AUTHOR]

Since 9/11, military service in the United States has been characterized by wartime deployments and reintegration challenges that contribute to a context of stress for military families. Research indicates the negative impact of wartime deployment on the well being of service members, military spouses, and children. Yet, few studies have considered how parental deployments may affect adjustment in young children and their families. Using deployment records and parent-reported measures from primary caregiving (N = 680) and military (n = 310) parents, we examined the influence of deployment on adjustment in military families with children ages 0-10 years. Greater deployment exposure was related to impaired family functioning and marital instability. Parental depressive and posttraumatic stress symptoms were associated with impairments in social emotional adjustment in young children, increased anxiety in early childhood, and adjustment problems in school-age children. Conversely, parental sensitivity was associated with improved social and emotional outcomes across childhood. These findings provide guidance to developing preventive approaches for military families with young children. [ABSTRACT FROM AUTHOR]

The risk for mental health problems and relational difficulties in military service members, spouses, and children is well-established. Yet, few services are available for families, particularly during the formative preschool years, when healthy parent-child relationships are crucial to the attainment of major socio-emotional milestones that form the foundation for later development. This paper describes the adaptation of a previously established military and trauma-informed preventive intervention, Families OverComing Under Stress (FOCUS) for use with families with a preschool-aged child (FOCUS for Early Childhood; FOCUS-EC). Grounded in theory and research on family resilience, FOCUS-EC aims to support parents as leaders of the family by providing developmental guidance and psychoeducation on deployment and reintegration, facilitate the construction of a family narrative, and enhance parenting strategies and the parent-child relationship. Furthermore, FOCUS-EC was adapted for use in a telehealth platform, enabling clinicians to reach military and veteran families in their homes, which is particularly useful for high-risk civilian-dwelling military families (including Reserve and National Guard). Pilot work and ongoing data collection as part of a randomized control trial suggest that FOCUS-EC is acceptable and feasible for military and veteran families with preschoolers. [ABSTRACT FROM AUTHOR]

In response to the needs of military families confronting the challenges of prolonged war, we developed Families OverComing Under Stress (FOCUS), a multi-session intervention for families facing multiple deployments and combat stress injuries adapted from existing evidence-based family prevention interventions (Lester et al. in Mil Med 176(1): 19–25, 2011 ). In an implementation of this intervention contracted by the US Navy Bureau of Medicine and Surgery (BUMED), FOCUS teams were deployed to military bases in the United States and the Pacific Rim to deliver a suite of family-centered preventive services based on the FOCUS model (Beardslee et al. in Prev Sci 12(4): 339–348, 2011 ). Given the number of families affected by wartime service and the changing circumstances they faced in active duty and veteran settings, it rapidly became evident that adaptations of this approach for families in other contexts were needed. We identified the core elements of FOCUS that are essential across all adaptations: (1) Family Psychological Health Check-in; (2) family-specific psychoeducation; (3) family narrative timeline; and (4) family-level resilience skills (e.g., problem solving). In this report, we describe the iterative process of adapting the intervention for different groups of families: wounded, ill, and injured warriors, families with young children, couples, and parents. We also describe the process of adopting this intervention for use in different ecological contexts to serve National Guard, Reserve and veterans, and utilization of technology-enhanced platforms to reach geographically dispersed families. We highlight the lessons learned when faced with the need to rapidly deploy interventions, adapt them to the changing, growing needs of families under real-world circumstances, and conduct rigorous evaluation procedures when long-term, randomized trial designs are not feasible to meet an emergent public health need. [ABSTRACT FROM AUTHOR]

The scope of sustained military operations in Iraq and Afghanistan has placed great demands on the Armed Forces of the United States, and accordingly, military families have been faced with deployments in more rapid succession than ever before. When military parents fulfill occupational duties during wartime, military children and families face multiple challenges, including extended separations, disruptions in family routines, and potentially compromised parenting related to traumatic exposure and subsequent mental health problems. Such challenges can begin to exert a significant toll on the well-being of both individuals and relationships (e.g., marital, parent-child) within military families. In order to respond more effectively to the needs of military families, it is essential that mental health clinicians and researchers have a better understanding of the challenges faced by military families throughout the entire deployment experience and the ways in which these challenges may have a cumulative impact over multiple deployments. Moreover, the mental health field must become better prepared to support service members and families across a rapidly evolving landscape of military operations around the world, including those who are making the transition from active duty to Veteran status and navigating a return to civilian life and those families in which parents will continue to actively serve and deploy in combat zones. In this article, we utilize family systems and ecological perspectives to advance our understanding of how military families negotiate repeated deployment experiences and how such experiences impact the well-being and adjustment of families at the individual, dyadic, and whole family level. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editors discuss various reports within the issue on topics including research on social ecological frameworks and family systems, the long-term needs of military-connected children and families, and the challenges face by civilian families.

We draw upon family resilience and narrative theory to describe an evidence-based method for intervening with military families who are impacted by multiple wartime deployments and psychological, stress-related, or physical parental injuries. Conceptual models of familial resilience provide a guide for understanding the mechanics of how families respond and recover from exposure to extreme events, and underscore the role of specific family processes and interaction patterns in promoting resilient capabilities. Leading family theorists propose that the family's ability to make meaning of stressful and traumatic events and nurture protective beliefs are critical aspects of resilient adaptation. We first review general theoretical and empirical research contributions to understanding family resilience, giving special attention to the circumstances, challenges, needs, and strengths of American military families. Therapeutic narrative studies illustrate the processes through which family members acquire meaning-making capacities, and point to the essential role of parents' in facilitating discussions of stressful experiences and co-constructing coherent and meaningful narratives. This helps children to make sense of these experiences and develop capacities for emotion regulation and coping. Family-based narrative approaches provide a structured opportunity to elicit parents' and children's individual narratives, assemble divergent storylines into a shared family narrative, and thereby enhance members' capacity to make meaning of stressful experiences and adopt beliefs that support adaptation and growth. We discuss how family narratives can help to bridge intra-familial estrangements and re-engage communication and support processes that have been undermined by stress, trauma, or loss. We conclude by describing a family-based narrative intervention currently in use with thousands of military children and families across the USA. [ABSTRACT FROM AUTHOR]

In this paper, we report on the development and dissemination of a preventive intervention, Families OverComing Under Stress (FOCUS), an eight-session family-centered intervention for families facing the impact of wartime deployments. Specific attention is given to the challenges of rapidly deploying a prevention program across diverse sites, as well as to key elements of implementation success. FOCUS, developed by a UCLA-Harvard team, was disseminated through a large-scale demonstration project funded by the United States Bureau of Navy Medicine and Surgery (BUMED) beginning in 2008 at 7 installations and expanding to 14 installations by 2010. Data are presented to describe the range of services offered, as well as initial intervention outcomes. It proved possible to develop the intervention rapidly and to deploy it consistently and effectively. [ABSTRACT FROM AUTHOR]

Recent studies have confirmed that repeated wartime deployment of a parent exacts a toll on military children and families and that the quality and functionality of familial relations is linked to force preservation and readiness. As a result, family-centered care has increasingly become a priority across the military health system. FOCUS (Families OverComing Under Stress), a family-centered, resilience-enhancing program developed by a team at UCLA and Harvard Schools of Medicine, is a primary initiative in this movement. In a large-scale implementation project initiated by the Bureau of Navy Medicine, FOCUS has been delivered to thousands of Navy, Marine, Navy Special Warfare, Army, and Air Force families since 2008. This article describes the theoretical and empirical foundation and rationale for FOCUS, which is rooted in a broad conception of family resilience. We review the literature on family resilience, noting that an important next step in building a clinically useful theory of family resilience is to move beyond developing broad 'shopping lists' of risk indicators by proposing specific mechanisms of risk and resilience. Based on the literature, we propose five primary risk mechanisms for military families and common negative 'chain reaction' pathways through which they undermine the resilience of families contending with wartime deployments and parental injury. In addition, we propose specific mechanisms that mobilize and enhance resilience in military families and that comprise central features of the FOCUS Program. We describe these resilience-enhancing mechanisms in detail, followed by a discussion of the ways in which evaluation data from the program's first 2 years of operation supports the proposed model and the specified mechanisms of action. [ABSTRACT FROM AUTHOR]

Mothers living with HIV (MLH) are at high risk for acute and chronic stress, given challenges related to their HIV status, ethnicity, economic and urban living conditions. Biomarkers combined into a composite index show promise in quantifying psychosocial stress in healthy people, but have not yet been examined among MLH. According, we examined potential biomarker correlates of stress [cortisol and catecholamines from home-collected urine and basic health indicators (blood pressure, height and weight, waist-to-hip ratio) measured during an interview] among 100 poor African American and Latina mothers MLH and demographic-matched control mothers without HIV ( n = 50). Participants had been enrolled in a randomized controlled trial about 18 months earlier and had either received (MLH-I) or were awaiting (MLH-W) the psychosocial intervention. Participation was high, biomarkers were correctly collected for 93% of cases, and a complete composite biomarker index (CBI) calculated for 133 mothers (mean age = 42). As predicted, MLH had a significantly higher CBI than controls, but there was no CBI difference across ethnicity or intervention group. CBI predicted CD4 counts independently after controlling for age, years since diagnosis, prior CD4 counts, medication adherence, and depression symptoms. The study demonstrates acceptability, feasibility and potential utility of community-based biomarker collections in evaluating individual differences in psychosocial stress. [ABSTRACT FROM AUTHOR]

Centers for Disease Control and Prevention (CDC) has recommended integrating behavioral interventions into medical care settings for persons living with HIV. Delivering an intensive, family-based intervention for mothers living with HIV (MLH) ( n = 173) and their adolescent children ( n = 116) integrated into medical care was problematic. Despite the fact that nearly half of MLH were recruited at HIV/AIDS clinics, community centers and children’s hospitals were the most popular and most successful sites for the delivery of the intervention. We provide recommendations for how to integrate intensive interventions into medical care, given the needs of MLH, their adolescents, and the organizations serving them. [ABSTRACT FROM AUTHOR]

Clinical practice and research indicate an important role for family-based interventions for child traumatic stress. However, the field lags behind family-based intervention science for other childhood mental health problems and individual treatment for child traumatic stress. This study describes the current practice of family-based interventions for child traumatic stress across a national network of programs serving traumatized children. Although most programs delivered at least one family-based intervention, less than a third of interventions identified had a treatment manual, and few had data to support intervention efficacy. More detailed information is needed on matching the family-based interventions to clinical contexts, establishing effective family engagement strategies, identifying culturally specific adaptations, as well as developmentally matched protocols for child traumatic stress. [ABSTRACT FROM AUTHOR]