The recent Institute of Medicine (IOM) report reviewed evidence for prevention and promotion strategies for children and families (National Research Council and Institute of Medicine [NRCIOM]
2009), detailing developments in the field since the last report (NRCIOM
1994). Both in the IOM report (NRCIOM
2009) and in other commentaries (Proctor et al.
2002), there has been a call for greater study of how to implement and disseminate programs widely and effectively. The sustained operational tempo in Iraq and Afghanistan created an urgent national need to support military readiness by enhancing family resilience and provided an opportunity to test a new model of intervention development and dissemination.
About one million service members, approximately 43% of all military personnel, are parents (Office of the Deputy under Secretary of Defense
2007). Throughout wartime deployments, these families face many stressors, including repeated relocation, parental absence, and fears and concerns (Palmer
2008; Segal
1986). Several earlier studies suggest that military children typically exhibit resilience and well-being, despite these stressors (Cozza et al.
2005; Jensen et al.
1996). However, more current studies indicate increased child distress during parental deployment (Chartrand et al.
2008; Flake et al.
2009), risk for child maltreatment (McCarroll et al.
2000), and cumulative risk of deployment separation on adolescent emotional adjustment (Chandra et al.
2010). As a part of our team’s intervention development strategy, we conducted an assessment of the effects of deployments on families, which suggested that parental combat deployments have an impact that lasts beyond the duration of deployment and is associated with outcomes in children, predicted both by the length of deployment and the level of parental psychological distress (Lester et al.
2010b).
Furthermore, across a variety of intervention strategies, there has been strong endorsement for structured manual-based programs that enhance parenting and parent–child relationships (NRCIOM
2009; Sandler et al.
2010). A central tenant of developmental research is that effective caregiver-child relationships provide an essential framework for building child adaptive skills, including emotional and behavioral self-regulation (Nachmias et al.
1996; Rutter and Quinton
1984; Sroufe et al.
2005). Interventions that promote adaptive skills and behaviors in children and parents, particularly those that enhance parent–child communication, bonding, and family management, reduce problem behaviors and emotional distress in children throughout development (Feinberg and Kan
2008; Spoth et al.
2002). Given that military families have many existing strengths and that family factors play a central role in mediating childhood stress, it seemed prudent to design an intervention that built on these strengths, yet further enhanced protective family processes, particularly in light of the repeated deployments of the current conflicts.
FOCUS (Families OverComing Under Stress) was specifically developed as a family-centered preventive intervention strategy adapted for the needs of military families facing the stressors of multiple deployments. Strength-based approaches with families have a particularly strong evidence base (Beardslee and Knitzer
2003; NRCIOM
2009); therefore, the concept of resilience, which focuses on positive adaptation in the face of significant adversity, was central to FOCUS. Early conceptions of resilience focused on the role of individual traits contributing to childhood hardiness or “invulnerability” (Rutter
1985). Subsequent longitudinal studies that permitted more in-depth analyses of resilient processes highlighted the importance of attachment relationships as predictors of child resilience when exposed to hardship, trauma, or loss, the importance of families, and the need to understand the broader ecological context surrounding the child (Sroufe
2005; Werner
1993). In particular, children’s outcomes in the face of adverse events were significantly mediated by the quality of parenting and the caregiving environment (Masten
2004).
Chronology of Intervention Development
Given the urgent national need for a rapid, scalable framework of preventive services for military families, our military partners requested that FOCUS be developed and implemented without first conducting a randomized trial. Instead FOCUS was developed by adapting and consolidating key aspects of existing strength- and evidence-based interventions utilized in comparable contexts. From the beginning, FOCUS was conceived to be a trauma-informed, skill-based, family-centered prevention (selective and indicated) intervention designed to promote family resiliency and to mitigate the sequelae of highly stressful deployment-related events on children and parents. The early development of FOCUS was facilitated by collaboration between its developers at the UCLA Semel Institute/Children’s Hospital, Harvard University and the National Child Traumatic Stress Network (NCTSN), and was supported through funding from the Frederick R. Weisman Philanthropic Foundation. In order to meet the needs of the greatest number of military families, FOCUS was designed to be highly scalable. Additionally, the intervention had to be straightforward to deliver; only approaches that could be taught to a wide range of providers in a variety of settings could be considered. Finally, it needed to be highly portable and flexible so it could be quickly disseminated to a variety of very different communities, geographies, family types, and military service requirements.
The three foundational programs from which FOCUS was developed all had a family-level, rather than an individual-level, perspective. They were all directed toward children and parents who were at risk for mental disorders or serious life impairment, and yet none were conceived to provide treatment for a mental disorder. They were selective or indicated preventive interventions, as defined by the IOM Committee on Prevention of Mental Disorders (Mrazek and Haggerty
1994) and endorsed by the recent IOM prevention report (2009).
The first intervention, Project TALK (Teens and Adults Learning to Communicate), is a manualized, family-centered, prevention intervention developed to promote positive psychological adjustment in adolescents affected by parental illness (Lester et al.
2008; Rotheram-Borus et al.
2001,
2004,
2006). Project TALK contributed a proven model for a modularized prevention intervention, as well as the implementation of cognitive-behavioral skills delivered in a prevention framework across the family system. Additionally, Project TALK informed FOCUS developers regarding risk and protective factors operating in stressed families (Lester et al.
2003,
2010c). The second preventive intervention strategy on which FOCUS was founded was the UCLA Trauma-Grief Intervention, a school-based, trauma-focused, cognitive-behavioral therapy program developed in post-war Bosnia for children and parents exposed to trauma and loss in war zones and other violent community settings (Layne et al.
2001). FOCUS incorporated from this intervention core elements of trauma-informed psychoeducation and skill-building techniques. Family Talk, the third foundational component of FOCUS, is a brief, family-based preventive intervention that addresses obstacles to communication and the lack of attention to parenting common in families affected by parental depression (Beardslee et al.
2003,
2007; Beardslee and Gladstone
2001; D’Angelo et al.
2009). The Family Talk intervention contributed to FOCUS a systematic approach to sharing a family narrative, as well as practical strategies to building resilience.
Crucial to intervention uptake, the FOCUS framework was then integrated with the military’s public health model for operational stress in which service members were already being instructed. The central prevention and resiliency framework being developed in the U.S. Navy (USN) and U.S. Marine Corps (USMC) concurrently with FOCUS—and which informed implementation of FOCUS—is the Stress Continuum Model, a destigmatizing heuristic for recognizing significant but preclinical levels of distress and functional impairment in service members and their spouses and children (Nash
2011). The Stress Continuum Model and an early intervention model, Combat and Operational Stress First Aid, have been disseminated as the core of organization-wide, leader-directed Combat and Operational Stress Control (COSC) efforts (U.S. Marine Corps & U.S. Navy
2010). FOCUS incorporated the COSC Model into its assessment components, promoting a classification of family and family-member strengths and vulnerabilities according to their severity and relative need for interventions. FOCUS also utilizes the language of the COSC Model in its psychoeducational components and skill-building exercises.
An initial FOCUS manual integrating elements from the source interventions and the COSC model, as well as a set of key informant interviews, family focus groups, and environmental and systems assessment, was finalized in 2007 (Saltzman et al.
2007) after piloting with USMC families at Camp Pendleton, California during the early years of the Afghanistan and Iraq wars (Saltzman et al.
2009). In 2008, the Navy Bureau of Medicine and Surgery (BUMED) funded FOCUS as a service program for selected USN and USMC installations through a contract with the UCLA Semel Institute Intervention Team.
Intervention Implementation
Evaluation Strategy
Evaluation efforts were focused on providing real-time assessment data for each family that could be used to immediately customize the intervention according to the family’s specific needs and wishes, to track effectiveness of the program in key targeted domains, and to guide outreach efforts and further program refinement. To render the family’s assessment data immediately useful to the Resiliency Trainer and family, a color-coded flagging system consistent with the COSC Model was used; when family members filled out the measures on computers, their responses were automatically scored and a report provided with feedback on relative family strengths and ways in which the intervention should be customized.
This on-line family “check-up” assessed parent (service member and spouse report), child (parent report and child self-report) and family adjustment at time of entry into the program, as well as at program exit and follow-up, using standard, widely used measures where available. Specific domains assessed include parent and child psychological symptoms, general family functioning, loss and grief reactions, coping skills, and strengths/resiliency. An additional set of ratings measured each parent’s satisfaction and perception of the impact of the FOCUS intervention. To evaluate the families’ responses to FOCUS, we have examined the initial implementation results of IFRT completed with 488 families (742 parents and 873 children). Described previously in the
American Journal of Public Health (Lester et al.
2011b), initial outcomes have demonstrated significant reductions in child emotional and behavioral distress, as well as statistically significant improvements in prosocial behaviors (Strengths and Difficulties Questionnaire; Goodman et al.
2000). Children participating in FOCUS reported significantly increased use of positive coping strategies, including dealing with stressful life events, problem solving, and emotion regulation (Kidcope; Spirito et al.
1988). Significant reductions in both service member and civilian parent psychological symptoms through assessment of change scores and prevalence rates were found on the Brief Symptom Inventory (Derogatis
1993). Family functioning improved in the problem solving, communication, roles, affective responsiveness, and behavior control areas on the McMaster Family Assessment Device (Ryan et al.
2005). These were particularly important as they were specific dimensions targeted by resiliency training. Furthermore, ratings of program satisfaction were very high, and families reported positive perceptions of change for all key intervention domains.
Due to the FOCUS suite of services as well as community satisfaction, the intervention reaped a large number of families. Table
1 describes the range of activities and provides an account of participants in each activity. Table
2 provides statistics on the number of participants for the family resiliency training services for the same period of time, including both skill-building groups and IFRT. The large increase in Year 2 over Year 1 was due in part to more sites being involved, and by the beginning of Year 2, to all original sites being fully operational. While customized IFRT was a central facet of the service mission, it should be noted that a greater number of people engaged FOCUS through community briefings and educational workshops.
Table 1
Participation in FOCUS services: community outreach and education
Total Community Group Briefings | 339 | 515 | 854 | 17707 | 28458 | 46165 |
Provider Group Briefings | 179 | 270 | 449 | 3712 | 6667 | 10379 |
Indirect Outreach/Presentations | 225 | 507 | 732 | 22061 | 34240 | 56301 |
FOCUS Consultations | 207 | 406 | 613 | 781 | 1300 | 1581 |
FOCUS Educational Workshops | 52 | 372 | 424 | 1928 | 9707 | 11635 |
Table 2
Participation in FOCUS services: FOCUS resiliency training
FOCUS Family Skill-Building Groups | 173 | 553 | 726 | Adults | 691 | 1232 | 1923 |
Children | 894 | 2954 | 3848 |
Total | 1584 | 4186 | 5770 |
FOCUS Individual Family Resiliency Training (IFRT) Enrollment | 306 | 581 | 887 | Adults | 481 | 916 | 1397 |
Children | 575 | 990 | 1565 |
Total | 1056 | 1906 | 2962 |
Families found their way to FOCUS through a variety of different pathways (Table
3). The greatest number of participants was self-referred, followed by referrals from schools, military social services, military health providers, and other military sources. This indicates both that families had an awareness of what they needed and that the military service systems supported FOCUS. Notably, it was not uncommon for some family members to need clinical intervention or other support service referrals; these were provided and tracked in order to support greater access to care for service members and their families (Table
4). The data on referrals emphasizes that FOCUS often provided a gateway to engaging individuals in other services and demonstrated how selective and indicated psychological health prevention services may fit into a continuum of care. Furthermore, the suite of services has ensured that FOCUS will be able to realign and integrate itself into a critical role in the evolving world of military family services.
Table 3
Referral sources to FOCUS through June 2010
Workshops | 3% | 2% | 2% |
Chaplain | 3% | 3% | 3% |
Health Care Provider | 4% | 5% | 6% |
Skill-Building Groups | 4% | 6% | 6% |
Other | 11% | 8% | 9% |
Military | 6% | 8% | 7% |
Mental Health Provider | 8% | 8% | 8% |
Military Social Services | NA | 14% | 13% |
School | 18% | 10% | 11% |
Self-Referred | 43% | 37% | 36% |
Table 4
Referral sources by FOCUS through June 2010
Community Referrals |
Other | 3 | 0.54% |
Healthcare Provider-Community | 6 | 1.08% |
Health and Wellness Services | 10 | 1.80% |
Additional FOCUS Services | 12 | 2.16% |
Informational Resources-Community | 22 | 3.96% |
Social Services-Community | 26 | 4.68% |
School Services | 36 | 6.49% |
Mental Health Provider-Community | 117 | 21.08% |
Military Referrals |
Chaplain | 12 | 2.16% |
Military One Source | 15 | 2.70% |
Informational Resources-Military | 21 | 3.78% |
Healthcare Provider-Military | 22 | 3.96% |
Mental Health Provider-Military | 103 | 18.56% |
Social Services-Military | 150 | 27.03% |
Total | 555 | 100.00% |