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Background Depression causes significant morbidity, which impacts mental health, overall general health outcomes, everyday functioning and quality of life. This study aims to contribute to knowledge in the field through enhanced understanding of factors that influence depression response and remission, with consideration for design of treatment services to optimize depression outcomes within integrated care programs. Methods Using routine behavioral health screening and electronic health record data, we identified a retrospective cohort consisting of 615 adult patients receiving depression treatment within an integrated care program. Cohort member Patient Health Questionnaire (PHQ-9) data was analyzed for the 6 months following initiation of treatment. Multinomial regression models were estimated to identify factors associated with depression treatment response (PHQ-9 Results At 6 months, 47% of patients demonstrated treatment response and 16% demonstrated remission. Baseline trauma symptoms and suicidal ideation were significantly associated with decreased odds of achieving remission (Odds Ratio (95% CI) [OR] = 0.45 (0.23, 0.88) and OR = 0.49 (0.29, 0.82), respectively). In fully adjusted models, baseline suicidal ideation remained significant (OR = 0.53 (0.31, 0.89)) and some evidence of an association persisted for baseline trauma symptoms (OR = 0.51 (0.25, 1.01)). Conclusions After controlling for baseline depression symptoms, the presence of suicidal ideation is associated with reduced likelihood of remission. Increased understanding of factors associated with depression treatment outcomes may be employed to help guide the delivery and design of clinical services. Alongside routine screening for co-morbid anxiety, suicidal ideation and traumatic stress should be assessed and considered when designing depression treatment services.

Objectives: We sought to understand the stressors, the parent–child relationship and family processes, and experiences with services among families experiencing parental substance use disorders (SUDs) and homelessness. Methods: We conducted a total of 41 in-depth semistructured interviews with parents with a history of SUDs and homelessness (n = 16) and housing support staff (n = 25) from May 2017 until January 2018. Participants were recruited from transitional housing facilities across the Los Angeles metropolitan area, which served families experiencing homelessness and parental SUDs. The interviews were audio-recorded, transcribed, and themes coded with Dedoose. Results: We found a high burden of trauma and guilt among parents, and a fear of SUD disclosure. We found challenges with family processes important for SUD prevention, including communication, discussion of substance use, and family and youth goal setting. We also discovered unique stressors related to navigating housing and services within the community. Conclusion: Our findings demonstrate the need for a family-based SUD-preventive intervention for youth growing up in families with parental SUDs and experiencing homelessness, to address the heightened SUD risk. In addition, findings from our study can inform clinical and housing services for this important population.

BackgroundGiven the high rates at which patients present with behavioural health (BH) concerns in primary care (PC), this setting has become the de facto mental health system. As a result, screening for depression and other BH conditions in PC has become a critical target for improving patient outcomes. However, integration of screening into busy PC workflows can be challenging due to barriers such as limited time and resources.MethodologyA digital, cloud-based BH assessment tool, which included electronic health record enhancements, was developed and implemented in two urban PC practices as a prelude to a planned larger-scale implementation. The implementation strategies included a reorganisation of workflows within the PC setting, comprehensive training for staff and PC physicians, and institution of an incentive programme for PC clinic managers. To examine whether the introduction of the cloud-based BH assessment tool and associated implementation strategies was associated with increased screening rates, we compared rates of screening from January through June 2017 to rates of screening from January through June 2018 (subsequent to implementation). We also examined BH symptomatology reported by patients in PC.ResultsFollowing the implementation process, rate of BH screening with Patient Health Questionnaire-2 (PHQ-2) increased from 50.5% to 57% (pConclusionsResults suggest that a comprehensive implementation plan, including digitisation of BH assessment, reduced the burden of systematic screening. High rates of BH symptomatology underscore the need for comprehensive BH assessment and systems planning to address the high need for BH services among PC patients.

Pediatric cancer can disrupt the behavioral and emotional well-being of youth and their families, representing a potential psychological health risk for the entire family. Among ethnic minority families, cultural factors such as acculturation and language competency may affect the experience of this illness, which can, in turn, affect overall functioning. Integrating psychological health services within medical care settings is one method to enhance engagement in psychological health services and reduce barriers, including access and stigma. Given the paucity of evidence-based screening procedures and trauma-informed preventive interventions delivered within pediatric settings, the FOCUS consultation model was implemented within an outpatient pediatric oncology clinic. A case illustration is described to highlight the modifications made to the FOCUS consultation model to provide culturally sensitive and responsive treatment to Latino families. The article includes implications for future research ...

Objective This study evaluates the longitudinal outcomes of Families OverComing Under Stress (FOCUS), a family-centered preventive intervention implemented to enhance resilience and to reduce psychological health risk in military families and children who have high levels of stress related to parental wartime military service. Method We performed a secondary analysis of evaluation data from a large-scale service implementation of the FOCUS intervention collected between July 2008 and December 2013 at 15 military installations in the United States and Japan. We present data for 2,615 unique families (3,499 parents and 3,810 children) with completed intake and at least 1 postintervention assessment. Longitudinal regression models with family-level random effects were used to assess the patterns of change in child and parent (civilian and military) psychological health outcomes over time. Results Improvement in psychological health outcomes occurred in both service member and civilian parents. Relative to intake, parental anxiety and depression symptoms were significantly reduced postintervention, and these reductions were maintained at 2 subsequent follow-up assessments. In addition, we identified an improvement over time in emotional and behavioral symptoms and in prosocial behaviors for both boys and girls. We observed reductions in the prevalence of unhealthy family functioning and child anxiety symptoms, as well as parental depression, anxiety, and posttraumatic stress symptoms from intake to follow-up. Conclusion Longitudinal program evaluation data show sustained trajectories of reduced psychological health risk symptoms and improved indices of resilience in children, civilian, and active duty military parents participating in a strength-based, family-centered preventive intervention.

The conflicts in Iraq (Operations Iraqi Freedom and New Dawn) and Afghanistan (Operation Enduring Freedom) have resulted in the deployment of more than 2.6 million service members since 2001. Almost half of these service members had children at the time of deployment, and almost half experienced multiple deployments. Separations in the context of danger pose unique challenges for parenting at a distance, including civilian parental mental health problems that are in turn associated with disruptions in parenting and family relationships and increased mental health symptoms in children. Using an ecological framework, this chapter reviews the impact that more than a decade of war has had on children and their parents, identifying risk and protective factors in the context of parental deployment. Opportunities to maintain parenting during deployments across developmental stages for children are discussed, including the role of family-level programs and family services to support military parents and children.

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.

Background: An evidence-based trauma-informed resilience skills training program developed for deployed military personnel was adapted and pilot-tested with pediatric residents. We anticipated high satisfaction ratings and changes in knowledge, beliefs, and self-efficacy related to coping with stress and trauma. Methods: The intervention included 6 skill-based modules covering emotion regulation, communication with angry patients and parents, reflective narrative, inspirational goal setting, problem-solving, and developing a self-care toolbox. An optional survey was administered before and after the training. Results: After training, 76% rated resilience skills as important, 60% were satisfied, and 82% indicated the training changed how they will respond to patient-related grief and trauma. They became more likely to believe attendings are affected by patient deaths and to know what helps them cope when they disagree with the medical decision making of others, more skilled in recognizing signs of stress and trauma, and more knowledgeable about evidence-based interventions.

How are children's lives altered when a parent goes off to war? What aspects of combat deployment are most likely to put children at risk for psychological and other problems, and what resources for resilience can they tap to overcome such hardships and thrive? To answer these questions, Patricia Lester and Lieutenant Colonel Eric Flake first examine the deployment cycle, a multistage process that begins with a period of anxious preparation after a family receives notice that a parent will be sent into combat. Perhaps surprisingly, for many families, they write, the most stressful part of the deployment cycle is not the long months of separation that follow but the postdeployment period, when service members, having come home from war, must be reintegrated into families whose internal rhythms have changed and where children have taken on new roles. Lester and Flake then walk us through a range of theoretical perspectives that help us understand the interconnected environments in which military children live their lives, from the dynamics of the family system itself to the external contexts of the communities where they live and the military culture that helps form their identity. The authors conclude that policy makers can help military-connected children and their families cope with deployment by, among other things, strengthening community support services and adopting public health education measures that are designed to reduce the stigma of seeking treatment for psychological distress. They warn, however, that much recent research on military children's response to deployment is flawed in various ways, and they call for better-designed, longer-term studies as well as more rigorous evaluation of existing and future support programs.

Although current research recognizes robust interdependence among family members, it is not yet evident that such principles have fully integrated into existing systems of care for military and veteran families. Such gaps can create disadvantages in delivering effective support, prevention, and treatment, while including families may yield significant advantages. This article highlights theoretical frameworks and empirical evidence that illustrate the relevance of systemic approaches to supporting service members, veterans, and their families. We discuss examples of family-centered approaches already in place and identify gaps in existing systems of care.

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.

The toll of multiple and prolonged deployments on families has become clearer in recent years as military families have seen an increase in childhood anxiety, parental psychological distress, and marital discord. Families overcoming under stress (FOCUS), a family-centered evidence-informed resiliency training program developed at University of California, Los Angeles and Harvard Medical School, is being implemented at military installations through an initiative from Navy Bureau of Medicine and Surgery. The research foundation for FOCUS includes evidence-based preventive interventions that were adapted to meet the specific needs of military families facing combat operational stress associated with wartime deployments. Using a family narrative approach, FOCUS includes a customized approach utilizing core intervention components, including psychoeducation, emotional regulation skills, goal setting and problem solving skills, traumatic stress reminder management techniques, and family communication skills. The purpose of this study is to describe the development and implementation of FOCUS for military families. A case example is also presented.

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.

The objective of this study was to identify salient parent and adolescent psychosocial factors related to somatic symptoms in adolescents. As part of a larger intervention study conducted in New York, 409 adolescents were recruited from 269 parents with HIV. A longitudinal model predicted adolescent somatization scores six years after baseline assessment. Adolescent somatic symptoms were assessed at baseline and at 3-month intervals for the first two years and then at 6-month intervals using the Brief Symptom Inventory. Baseline data from adolescents and parents were used to predict adolescent somatic symptoms. Variables related to increased adolescent somatic symptoms over six years included being younger and female; an increased number of adolescent medical hospitalizations; more stressful life events; adolescent perception of a highly rejecting parenting style; more parent-youth conflict; no experience of parental death; and parental distress over their own pain symptoms. Our findings extend the literature by virtue of the longitudinal design; inclusion of both parent and child variables in one statistical model; identification of study participants by their potentially stressful living condition rather than by disease or somatic symptom status; and inclusion of serious parental illness and death in the study.

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.

Over the past decade, many children have experienced a parental deployment, increasing their risk for emotional and behavioral problems. Research in the general population has shown that while many services are available for families with children experiencing problems, the rate of service utilization is low. This study examined help-seeking processes in military families in relation to children's problems. We collected data on emotional and behavioral problems from a sample of military parents with children ranging in age from zero to 10 years. While prevalence of children with problems was similar to prior research, results in this study suggested that military parents were alert to problems. Although military parents' help-seeking processes were similar to those documented in civilian studies in many respects, we did not find a significant gender difference in the recognition of problems. Furthermore, we found that children's experiences of deployment were related to use of services. Families who used services most often relied on primary care providers. These findings suggest military families are mindful of the possibility of their children having problems. In addition, many families utilize civilian services. Therefore, it is important to ensure that front-line civilian providers fully understand the context of military family issues.

Given the historical emergence of the AIDS epidemic first among gay men in the developed world, HIV interventions have primarily focused on individuals rather than families. Typically not part of traditional family structures, HIV-positive gay men in Europe and the US lived primarily in societies providing essential infrastructure for survival needs that highly value individual justice and freedom. Interventions were thus designed to focus on at-risk individuals with programmes that were age and gender segregated. As the epidemic has unfolded, the early focus on individuals has become inadequate: families live with HIV, not just individuals. Families' structure, economy, migration patterns, and developmental life cycles are affected by HIV, and these changes radiate throughout the community creating parallel stresses. Family-based, intergenerational models of detection, prevention and treatment services offer enhanced opportunities for effective interventions and suggest very different intervention settings and strategies. However, these models also require addressing the family's basic needs for survival and security in order to be successfully implemented and sustained over time. As HIV was an opportunity for marginalized persons in the developed world to 'turn their life around', the strengths of families in the developing world may be mobilized to contribute to the community's long-term health, survival and security needs.

The Internet has become an increasingly important part of teen culture; however, there still remains little in the medical/psychiatric literature pertaining to the impact of the Internet on adolescent development. Despite the potential problems associated with communication online, the Internet offers a variety of positive opportunities for teens. In this report, we present a case study that illustrates the Internet as a helpful tool in a 15-year-old adolescent boy with a history of chronic neurological illness accompanied by refractory psychosis. Although the case emphasizes some of the ways in which the Internet may have a positive impact on adolescent development, further research is indicated to evaluate the contexts in which the Internet serves healthy developmental processes and those in which its influence is potentially deleterious.

The objective of this study was to assess parental decision-making about illness disclosure to human immunodeficiency virus (HIV)-infected children. This is a cross-sectional study of 51 children with HIV infection based on parent interviews, child cognitive testing, clinical assessments and medical records. Only 43% of children had been told their HIV diagnosis. Qualitative analysis of parental decision- making about illness disclosure varied by child developmental level. Factors influencing parental decision to disclose the child’s HIV status including parental communication style, parental illness, child’s rights, treatment adherence, child questions and provider pressures, whereas concerns about HIV stigma and potential emotional distress were most frequently identified as reasons for non- disclosure. Central decision-making factors for parental HIV disclosure and reported outcomes of disclosure are described. Pediatric HIV disclosure represents a complex task for parents caring for the HIV-infected child, one in which the child’s development and the family’s community should be considered in the setting of a potentially stigmatizing infectious illness.

OBJECTIVES: Falls increase morbidity and mortality among nursing home residents and have varied causes and risk factors. The purpose of this study was to assess whether falls in nursing home residents were more prevalent at particular times of the day. DESIGN/PARTICIPANTS: This study was a retrospective chart review for falls in a skilled nursing facility in New York from January to June, 2007. RESULTS: There were 220 falls during the 6-month period. Most falls (66%) occurred in the resident's room and almost half (48%) resulted in an injury. Falls during the evening were likely to result in a more serious injury than daytime falls (P = .03). A statistically significant higher percentage of falls (27%) occurred between 4 pm and 8 pm (compared with expected number in a 4-hour period, P < .001). Among the 3 nursing shifts, the lowest percentage of falls occurred during the 11 pm to 7 am night shift (16%). CONCLUSION: This study reveals a variation in the prevalence of falls in the nursing home based on time of day that is different from the pattern of falls in the hospital setting. More research is needed to evaluate possible causes of this temporal pattern of falls in the nursing home. Perhaps these data can be used to implement specific interventions at times when falls are more common to reduce the risk of falls. Language: en

As the longest war in US history winds down, military families are preparing for a new phase of dealing with its impact: the enduring consequences of deployment separations, physical and psychological injuries, and loss. The urgency and uniqueness of two simultaneous wars of long duration fought by an all-volunteer military have propelled the rapid evolution of research and practice regarding the impact of war on military families. Consistent with existing developmental and prevention science research, data emerging from the study of military and veteran families suggest that both stress and resilience reverberate across the family system. There is growing evidence that the impact of war and its sequelae are experienced by not only the service member or veteran, but also their children, partners, and other family members. Recognizing that the implications of these experiences do not end with active duty service, but may cascade for decades underscores the need for ongoing research focused not only on the impact of wartime military service on children and families, but also on shaping a science-informed approach to costeffective, and scalable behavioral health preventive interventions and treatment for military and veteran families. The scale and tempo of this war has left our country with a large social, psychological, and medical footprint that now must be addressed by our systems of care; an undertaking that may well require unprecedented levels of support and coordination across military, veteran and public health institutions for years to come. Both Parts 1 and 2 of this special issue are designed to contribute to the current national dialogue on how best to plan for and provide services for our military families. Part 1

Objectives. We evaluated the Families OverComing Under Stress program, which provides resiliency training designed to enhance family psychological health in US military families affected by combat- and deployment-related stress. Methods. We performed a secondary analysis of Families OverComing Under Stress program evaluation data that was collected between July 2008 and February 2010 at 11 military installations in the United States and Japan. We present data at baseline for 488 unique families (742 parents and 873 children) and pre–post outcomes for 331 families. Results. Family members reported high levels of satisfaction with the program and positive impact on parent–child indicators. Psychological distress levels were elevated for service members, civilian parents, and children at program entry compared with community norms. Change scores showed significant improvements across all measures for service member and civilian parents and their children (P Conclusions. Evaluation data provided preliminary support for a strength-based, trauma-informed military family prevention program to promote resiliency and mitigate the impact of wartime deployment stress.

Adecade of war has heightened the national awareness of the challenges faced by U.S. military children and families. Military families have faced a “high operational tempo,” defined not only by recurrent deployments to combat theater but also by a range of stressors associated with these deployments, including greater demands on the personnel and services to support the infrastructure and activities associated with war. Recent research findings documenting military families’ increased risk of psychological health problems and service usage have emerged in the public discourse. 1 Responding effectively to the needs of military families requires the development of an integrated research and service strategy at the national level, one that translates and extends established research on child and family resilience, developmental psychopathology, family-centered prevention, and implementation science. This article provides a translational framework and family-centered public health model for mitigating stress and promoting resilience in military families and children exposed to wartime deployments, psychological and physical injuries, and loss.

There is growing evidence to support developing new typologies for homeless adolescents. Current typologies focus on the risks associated with being homeless, with less consideration of the positive attributes of homeless adolescents. The authors examined both risk and protective factors in a sample of newly homeless adolescents. Using cluster analysis techniques, they identified three distinct clusters of newly homeless adolescents: those who are protected and doing relatively well while out of home with more protective than risk factors, those who are at-risk, and those who are risky with more risk than protective factors. Over half (51.9%) of these newly homeless adolescents were in the protected cluster. This typology has implications for the design and implementation of services and interventions for newly homeless adolescents to reconnect them with stable housing situations. © 2009 Wiley Periodicals, Inc.

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.

Purpose To assess predictors of adjustment of adolescents of parents with HIV (PWH) at three and six years after the delivery of either a coping skills intervention or a standard care condition. Methods A randomized controlled intervention trial was conducted with 288 parents with human immunodeficiency virus (HIV) and their adolescent children. Indicators of adolescent adjustment at both three and six years were examined as a function of intervention condition, demographics, prior behaviors, and parental bonds using structural equation modeling (SEM). Adolescent adjustment at six years was also examined as a function of death of the PWH. Results Protective factors: Youth in the intervention condition reported significantly less substance use three and six years later. In addition, positive parental bonds reported at baseline reduced emotional distress at three years and increased positive future expectations at six years. Risk factors: Substance use at three years predicted heightened sexual risk behaviors, continued substance use, and lower future expectations at six years. Early emotional distress and being Latino predicted increased emotional distress at three years. Parental death by three years predicted more sexual risk behavior and lowered future expectations at six years. Conclusions A time-limited, family based intervention with adolescents of PWH demonstrated both direct and indirect benefits lasting into early adulthood, especially in decreasing substance use, and identifies key risk factors for problematic adjustment, including the death of a PWH.

Stopping transmission of HIV to new partners has been the primary focus of HIV prevention for positive individuals. 1 Yet, transmission acts among seropositive persons in the United States have dropped from 100% in the 1980s to approximately 5% of seropositive persons transmitting currently. 2 Transmission acts among seropositive women are far less common. Only 30% of seropositive women have unprotected sex with an HIV-negative partner. 3 Internationally, where 90% of the epidemic occurs from heterosexual transmission, transmission risk is even lower. Among HIV-positive women in Africa, 60% to 80% have only had 1 lifetime sexual partner; in Asia, more than 90% have had only 1 lifetime sexual partner. 4 The challenge of reducing transmission is important, but the societal challenges to the families, partners, and caregivers of persons living with HIV are even greater. The goal of this article is to encourage a broader agenda for prevention for positive persons, considering imitative transmission, mental health consequences, and problematic adjustment with the infected person’s network. IMITATIVE TRANSMISSION OF HIV Globally, unprotected sex with a partner and sharing needles are the most common direct routes of HIV infection. There is suggestive evidence that adolescents are imitating their parents’ risk behaviors and contracting HIV, however. The negative societal consequences of HIV extend and radiate through the family, particularly to adolescent children. Among young people living with HIV (adolescents aged 12–23 years), 19% report parents who are also HIV infected. 5 Families are the primary source of all health-related behavior patterns, 6 including HIV, 7 and parents are perhaps modeling risky behavioral styles of coping with life stressors that may be imitated by young people. The New England Journal of Medicine 8 recently reported 1 physician’s feelings of hopelessness in treating an HIVpositive adolescent mother after having cared for the daughter’s mother living with HIV 10 years earlier. Young women, primarily of ethnic minority heritage, who live in neighborhoods with high drug abuse are becoming infected by their 1 partner. 9 These women do not prioritize caring for their HIV infection: survival and security needs (eg, housing, child care, food) are far more important. 8 The emerging HIV infections among a second generation of families coping with HIV highlight the importance of addressing imitation of HIV transmission among families living with HIV.

Hypothesis Having a parent with the human immunodeficiency virus has a significant negative impact on an adolescent child's adjustment. Objective To assess the adjustment of adolescent children to having a parent with the human immunodeficiency virus over 6 years, following the delivery of a coping skills intervention. Design A randomized controlled trial with repeated evaluations that was analyzed with an intention-to-treat analysis. A skill-based intervention was delivered in 3 modules over 24 sessions, with the third module being delivered only if parents died. Setting and Patients A representative sample of parents with the human immunodeficiency virus (n = 307) and their adolescent children (n = 423) was recruited from the Division of AIDS Services in New York City; 51.5% (n = 158) of the parents died. Main Outcome Measures Employment and school enrollment, receiving public welfare support, early parenthood, mental health symptoms, and the quality of romantic relationships. Results Over 6 years, significantly more adolescents in the intervention condition than the control condition were employed or in school (82.58% vs 68.94%), were less likely to receive public welfare payments (25.66% vs 36.65%), were less likely to have psychosomatic symptoms (mean, 0.24 vs 0.31), were more likely to report better problem-solving and conflict resolution skills in their romantic relationships (mean score, 4.38 vs 4.20), expected to have a partner with a good job (mean, 4.57 vs 4.19), and expected to be married when parenting (mean, 3.05 vs 2.40). With marginal significance, the percentage of parents in the intervention condition (34.6%) was less than in the control condition (44.1%). Conclusion Physicians must consider the psychosocial consequences of illness-related challenges on children and provide interventions.

Longitudinal behavioral research with underserved and HIV-affected populations presents enormous challenges to community researchers. Recruitment and retention of participants into intervention trials is vital for the development of empirically validated treatments and prevention programs. Successful recruitment and retention of participants is highly dependent on an effective structural and motivational system designed to engage and reward individuals at every level of the investigation, including community organizations, project managers, field staff, and participants. This article outlines some of the key elements in developing and maintaining high quality research efforts.

Objective: To determine factors related to the timing and probability of nondisclosure of HIV status to perinatally HIV-infected children, and to explore factors associated with emotional distress in HIV-infected children. Methods: This is a cross-sectional study of 51 HIV-infected children based on medical records, parent interviews, and child assessments. Results: 1) Probability of earlier age of disclosure is associated with higher chil dI Q (p .04) and more family expressiveness (p .01); 2) controlling for child age, disclosure status at time of study is associated with major life events, but not with medical status; and 3) factors associated with increased parent-rated anxiety in HIVinfected children in univariate analyses are: HIV disclosure (p .04), other major life events (p .001), higher medication dose frequency (p .01), and child age (p .01). Increased depression is associated only with more medication doses (p .02). Conclusion: These data indicate that higher child IQ and greater family expressiveness increase the probability of earlier diagnostic disclosure to HIV-infected children. Factors associated with emotional distress highlight important areas of clinical attention. These data suggest that diagnostic disclosure may not necessarily minimize emotional distress, indicating the need for further evaluation of the appropriate timing and type of disclosure for pediatric HIV. Key Words: Pediatric HIV—Anxiety— Diagnostic disclosure.

SummaryAs more women of childbearing age are affected by the human immunodeficiency virus (HIV), many providers have demanded routine perinatal HIV screening, arguing that the medical benefits of testing outweigh the socioeconomic, medical, and psychological risks of a positive HIV test for women. I

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.