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SAN ANTONIO– As foreign wars wind down, and more families of military members and veterans receive care in civilian settings, an intervention used successfully on military bases to help families reduce risk of serious psychological disorders is being extended to civilian practices.
In the past decade, some 650,000 military and veteran family members have gone through Families Overcoming Under Stress, or FOCUS, a group of family-based interventions developed by a team led by psychiatrist Dr. Patricia E. Lester, director of the Nathanson Family Resilience Center at UCLA Health in Los Angeles.
Dr. Lester and her UCLA colleagues first adapted FOCUS at Marine Corps Base Camp Pendleton, San Diego, in 2006. Two years later, they implemented the program for the U.S. Navy Bureau of Medicine and Surgery at 22 Navy, Marine, Army, and Air Force installations in the United States and overseas. Now, with as many as 70% of active-duty military members living in civilian communities and about half of military-affiliated children getting health care in the civilian system, the program is being adapted to follow veterans’ families as they transition home.
The UCLA FOCUS team also is training community providers and extending technology platforms “to deliver our programs, monitor them, and put them in the hands of people where they live,” Dr. Lester said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.
New research from a longitudinal observational study assessing more than 2,600 families with children who participated in the program in the United States and Japan on military bases, published recently online, shows that the intervention has been well received, with about 70% of families completing it. In addition, its positive impact on psychological health outcomes for parents and children was sustained (J Am Acad Child Adolesc Psychiatry. 2015 [doi: http://dx.doi.org/10.1016/j.jaac.2015.10.009]).
“Consistently what we’ve found is that doing a preventive educational program early on is an opportunity to engage families before they may need mental health treatment – reducing anxiety, depression, and [posttraumatic stress disorder] in adults, strengthening family functioning, and improving internalizing and externalizing symptoms in kids,” Dr. Lester said.
The latest research is based on a secondary analysis of FOCUS data collected between 2008 and 2013. Significant improvements for parental anxiety, posttraumatic stress, and depression symptoms occurred in service member and civilian parents, and child anxiety symptoms improved in boys and girls. Importantly, those reductions were maintained 6 months after the intervention ended.
Roots of intervention
The model for FOCUS derives from two civilian interventions developed over the past 15 years, one of them for families in which a parent is depressed, and another for those in which a parent is medically ill. FOCUS also incorporated elements of a third intervention used with families living in postwar Bosnia-Herzegovina and in New York City after the terrorist attacks of Sept.11, 2001.
“We know from decades of developmental literature that if a parent is not doing well in terms of depression, anxiety, or PTSD, it represents an ongoing risk for children,” Dr. Lester said. In military and veteran populations, “family approaches are critical.”
About a third of combat service members and veterans are estimated to have depression, PTSD, or a traumatic brain injury – and an emerging body of research is showing that their children are at elevated risk for social, academic, and emotional problems.
The FOCUS program, which generally lasts 8 sessions over 6-8 weeks, starts with real-time web-based screening of psychological health measures, using a set of standardized behavioral health, family adjustment, and coping assessments to assess risk and customize the intervention. “We sit down with the family; we identify their strengths and where they may be having difficulties,” Dr. Lester said.
About a quarter of the parents in Dr. Lester’s study had clinically meaningful anxiety or depression symptoms at intake, with civilian spouses reporting slightly more than military members. Also, some 31% of civilian spouses had PTSD symptoms at baseline, compared with 26% of military members – an unexpected finding, Dr. Lester said. Among children, 35% of boys and 25% of girls had social difficulties at baseline.
Location of intervention is key
Rolling FOCUS out on military installations required attention to military family culture. A voluntary program, it was implemented to service members as a form of training, rather than counseling or a mental health intervention, though part of its objective was to help to bridge gaps to mental health treatment for those who needed it.
Importantly, the intervention was delivered in community centers or retail spaces in lieu of mental health facilities on bases. “Military families may be reluctant to come for behavioral health services because of stigma or concern about their job – the same barriers we see in civilian communities but amplified, because the risks are quite concrete,” Dr. Lester said.
Having the command structure embrace the program went a long way toward broadening adoption. “It was really important to get commanders to support the program and even to share that they have participated with their own children,” she said.
In the program, initial screening is followed by informational sessions with the UCLA-trained providers on the impact of military-related stressors on children, parents, and families.
In subsequent sessions, families start building a graphic family narrative timeline, with children over 6 and parents contributing their individual interpretations of past events – moves, deployments, life changes. On the military installations, the timelines are drawn on paper; many families in civilian settings, meanwhile, have worked remotely from their homes with providers at UCLA to create timelines on the computer.
“Then we do individual and family-level cognitive-behavioral skill building, such as emotional regulation, goal setting and problem solving,” Dr. Lester said. “We also help parents and children recognize and manage deployment reminders – including trauma and loss reminders,” she said. Family members work together to articulate their collective goals.
Benefits are sustained
Dr. Lester’s study looked at 3,499 parents and 3,810 children (average age, 7) who participated. Families averaged 4.5 deployments before taking part in the program.
At exit, percentages of clinically meaningful anxiety and depression symptoms decreased from approximately 23% of all parents at intake to about 11%, and remained similarly low at 1 month and 6 months after program completion (range of adjusted odds ratios: 0.29-0.36).
Both civilian and service member parents reported clinically meaningful and statistically significant decreases in PTSD symptoms, which was notable because the intervention was not designed as a clinical treatment program but rather a psychoeducation program.
Children older than 8 years saw significant improvements in self-reported anxiety symptoms, with prevalence from 14.5% at intake to 11.8% at follow up.
Transitioning with families
After its initial adaptation from civilian interventions, then its broad application and scaling up over a decade in military settings, FOCUS must now transition to communities where military and veteran families live.
Between 3 and 4 million military-connected children live in the United States, with about 2 million in families that have transitioned out of active-duty military. “In the population that we serve, the average 10-year-old kid has been through at least four deployments, two of them combat related,” with many individual and community level exposures to trauma and loss, Dr. Lester explained.
A parent’s leaving active duty does not necessarily change risk for families, she said in an interview. “Our observation is that there’s a lot of reactivity and reminders in these families that persist – when somebody comes back highly activated, when there are threats of separation, and fear and danger, and if you do have underlying PTSD risk, that reactivity can be reactivated even after transition to civilian life.”
Teams at UCLA work to train providers in the FOCUS interventions and certify them in the different models for couples or families with children. The UCLA team will travel to conduct training, or practitioners can train at UCLA.
“We’re taking these components that have been most effective and continuing to refine them and integrate them into systems so that they reach people where they’re living,” Dr. Lester said, adding that she would encourage any clinician working with military families to get in touch via the program’s website.
She said some of the lessons learned from adapting to a military setting apply in civilian contexts as well – including the emphasis of the program as training, rather than diagnosis and treatment.
“I don’t think it reduces the impact or relevance of the intervention to have [FOCUS] inside a traditional mental health setting,” she said. “But in settings where it is essential to reach out and engage people who might not be coming into the clinic, it is important to highlight that this is an educational preventive program.”
Dr. Lester’s group is now conducting a research study of one FOCUS early childhood intervention in community settings.
Like military families, civilian families also embrace the concept of preparedness, she said. “They want to feel they have the skills to navigate whatever challenges come their way.”
SAN ANTONIO– As foreign wars wind down, and more families of military members and veterans receive care in civilian settings, an intervention used successfully on military bases to help families reduce risk of serious psychological disorders is being extended to civilian practices.
In the past decade, some 650,000 military and veteran family members have gone through Families Overcoming Under Stress, or FOCUS, a group of family-based interventions developed by a team led by psychiatrist Dr. Patricia E. Lester, director of the Nathanson Family Resilience Center at UCLA Health in Los Angeles.
Dr. Lester and her UCLA colleagues first adapted FOCUS at Marine Corps Base Camp Pendleton, San Diego, in 2006. Two years later, they implemented the program for the U.S. Navy Bureau of Medicine and Surgery at 22 Navy, Marine, Army, and Air Force installations in the United States and overseas. Now, with as many as 70% of active-duty military members living in civilian communities and about half of military-affiliated children getting health care in the civilian system, the program is being adapted to follow veterans’ families as they transition home.
The UCLA FOCUS team also is training community providers and extending technology platforms “to deliver our programs, monitor them, and put them in the hands of people where they live,” Dr. Lester said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.
New research from a longitudinal observational study assessing more than 2,600 families with children who participated in the program in the United States and Japan on military bases, published recently online, shows that the intervention has been well received, with about 70% of families completing it. In addition, its positive impact on psychological health outcomes for parents and children was sustained (J Am Acad Child Adolesc Psychiatry. 2015 [doi: http://dx.doi.org/10.1016/j.jaac.2015.10.009]).
“Consistently what we’ve found is that doing a preventive educational program early on is an opportunity to engage families before they may need mental health treatment – reducing anxiety, depression, and [posttraumatic stress disorder] in adults, strengthening family functioning, and improving internalizing and externalizing symptoms in kids,” Dr. Lester said.
The latest research is based on a secondary analysis of FOCUS data collected between 2008 and 2013. Significant improvements for parental anxiety, posttraumatic stress, and depression symptoms occurred in service member and civilian parents, and child anxiety symptoms improved in boys and girls. Importantly, those reductions were maintained 6 months after the intervention ended.
Roots of intervention
The model for FOCUS derives from two civilian interventions developed over the past 15 years, one of them for families in which a parent is depressed, and another for those in which a parent is medically ill. FOCUS also incorporated elements of a third intervention used with families living in postwar Bosnia-Herzegovina and in New York City after the terrorist attacks of Sept.11, 2001.
“We know from decades of developmental literature that if a parent is not doing well in terms of depression, anxiety, or PTSD, it represents an ongoing risk for children,” Dr. Lester said. In military and veteran populations, “family approaches are critical.”
About a third of combat service members and veterans are estimated to have depression, PTSD, or a traumatic brain injury – and an emerging body of research is showing that their children are at elevated risk for social, academic, and emotional problems.
The FOCUS program, which generally lasts 8 sessions over 6-8 weeks, starts with real-time web-based screening of psychological health measures, using a set of standardized behavioral health, family adjustment, and coping assessments to assess risk and customize the intervention. “We sit down with the family; we identify their strengths and where they may be having difficulties,” Dr. Lester said.
About a quarter of the parents in Dr. Lester’s study had clinically meaningful anxiety or depression symptoms at intake, with civilian spouses reporting slightly more than military members. Also, some 31% of civilian spouses had PTSD symptoms at baseline, compared with 26% of military members – an unexpected finding, Dr. Lester said. Among children, 35% of boys and 25% of girls had social difficulties at baseline.
Location of intervention is key
Rolling FOCUS out on military installations required attention to military family culture. A voluntary program, it was implemented to service members as a form of training, rather than counseling or a mental health intervention, though part of its objective was to help to bridge gaps to mental health treatment for those who needed it.
Importantly, the intervention was delivered in community centers or retail spaces in lieu of mental health facilities on bases. “Military families may be reluctant to come for behavioral health services because of stigma or concern about their job – the same barriers we see in civilian communities but amplified, because the risks are quite concrete,” Dr. Lester said.
Having the command structure embrace the program went a long way toward broadening adoption. “It was really important to get commanders to support the program and even to share that they have participated with their own children,” she said.
In the program, initial screening is followed by informational sessions with the UCLA-trained providers on the impact of military-related stressors on children, parents, and families.
In subsequent sessions, families start building a graphic family narrative timeline, with children over 6 and parents contributing their individual interpretations of past events – moves, deployments, life changes. On the military installations, the timelines are drawn on paper; many families in civilian settings, meanwhile, have worked remotely from their homes with providers at UCLA to create timelines on the computer.
“Then we do individual and family-level cognitive-behavioral skill building, such as emotional regulation, goal setting and problem solving,” Dr. Lester said. “We also help parents and children recognize and manage deployment reminders – including trauma and loss reminders,” she said. Family members work together to articulate their collective goals.
Benefits are sustained
Dr. Lester’s study looked at 3,499 parents and 3,810 children (average age, 7) who participated. Families averaged 4.5 deployments before taking part in the program.
At exit, percentages of clinically meaningful anxiety and depression symptoms decreased from approximately 23% of all parents at intake to about 11%, and remained similarly low at 1 month and 6 months after program completion (range of adjusted odds ratios: 0.29-0.36).
Both civilian and service member parents reported clinically meaningful and statistically significant decreases in PTSD symptoms, which was notable because the intervention was not designed as a clinical treatment program but rather a psychoeducation program.
Children older than 8 years saw significant improvements in self-reported anxiety symptoms, with prevalence from 14.5% at intake to 11.8% at follow up.
Transitioning with families
After its initial adaptation from civilian interventions, then its broad application and scaling up over a decade in military settings, FOCUS must now transition to communities where military and veteran families live.
Between 3 and 4 million military-connected children live in the United States, with about 2 million in families that have transitioned out of active-duty military. “In the population that we serve, the average 10-year-old kid has been through at least four deployments, two of them combat related,” with many individual and community level exposures to trauma and loss, Dr. Lester explained.
A parent’s leaving active duty does not necessarily change risk for families, she said in an interview. “Our observation is that there’s a lot of reactivity and reminders in these families that persist – when somebody comes back highly activated, when there are threats of separation, and fear and danger, and if you do have underlying PTSD risk, that reactivity can be reactivated even after transition to civilian life.”
Teams at UCLA work to train providers in the FOCUS interventions and certify them in the different models for couples or families with children. The UCLA team will travel to conduct training, or practitioners can train at UCLA.
“We’re taking these components that have been most effective and continuing to refine them and integrate them into systems so that they reach people where they’re living,” Dr. Lester said, adding that she would encourage any clinician working with military families to get in touch via the program’s website.
She said some of the lessons learned from adapting to a military setting apply in civilian contexts as well – including the emphasis of the program as training, rather than diagnosis and treatment.
“I don’t think it reduces the impact or relevance of the intervention to have [FOCUS] inside a traditional mental health setting,” she said. “But in settings where it is essential to reach out and engage people who might not be coming into the clinic, it is important to highlight that this is an educational preventive program.”
Dr. Lester’s group is now conducting a research study of one FOCUS early childhood intervention in community settings.
Like military families, civilian families also embrace the concept of preparedness, she said. “They want to feel they have the skills to navigate whatever challenges come their way.”
SAN ANTONIO– As foreign wars wind down, and more families of military members and veterans receive care in civilian settings, an intervention used successfully on military bases to help families reduce risk of serious psychological disorders is being extended to civilian practices.
In the past decade, some 650,000 military and veteran family members have gone through Families Overcoming Under Stress, or FOCUS, a group of family-based interventions developed by a team led by psychiatrist Dr. Patricia E. Lester, director of the Nathanson Family Resilience Center at UCLA Health in Los Angeles.
Dr. Lester and her UCLA colleagues first adapted FOCUS at Marine Corps Base Camp Pendleton, San Diego, in 2006. Two years later, they implemented the program for the U.S. Navy Bureau of Medicine and Surgery at 22 Navy, Marine, Army, and Air Force installations in the United States and overseas. Now, with as many as 70% of active-duty military members living in civilian communities and about half of military-affiliated children getting health care in the civilian system, the program is being adapted to follow veterans’ families as they transition home.
The UCLA FOCUS team also is training community providers and extending technology platforms “to deliver our programs, monitor them, and put them in the hands of people where they live,” Dr. Lester said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.
New research from a longitudinal observational study assessing more than 2,600 families with children who participated in the program in the United States and Japan on military bases, published recently online, shows that the intervention has been well received, with about 70% of families completing it. In addition, its positive impact on psychological health outcomes for parents and children was sustained (J Am Acad Child Adolesc Psychiatry. 2015 [doi: http://dx.doi.org/10.1016/j.jaac.2015.10.009]).
“Consistently what we’ve found is that doing a preventive educational program early on is an opportunity to engage families before they may need mental health treatment – reducing anxiety, depression, and [posttraumatic stress disorder] in adults, strengthening family functioning, and improving internalizing and externalizing symptoms in kids,” Dr. Lester said.
The latest research is based on a secondary analysis of FOCUS data collected between 2008 and 2013. Significant improvements for parental anxiety, posttraumatic stress, and depression symptoms occurred in service member and civilian parents, and child anxiety symptoms improved in boys and girls. Importantly, those reductions were maintained 6 months after the intervention ended.
Roots of intervention
The model for FOCUS derives from two civilian interventions developed over the past 15 years, one of them for families in which a parent is depressed, and another for those in which a parent is medically ill. FOCUS also incorporated elements of a third intervention used with families living in postwar Bosnia-Herzegovina and in New York City after the terrorist attacks of Sept.11, 2001.
“We know from decades of developmental literature that if a parent is not doing well in terms of depression, anxiety, or PTSD, it represents an ongoing risk for children,” Dr. Lester said. In military and veteran populations, “family approaches are critical.”
About a third of combat service members and veterans are estimated to have depression, PTSD, or a traumatic brain injury – and an emerging body of research is showing that their children are at elevated risk for social, academic, and emotional problems.
The FOCUS program, which generally lasts 8 sessions over 6-8 weeks, starts with real-time web-based screening of psychological health measures, using a set of standardized behavioral health, family adjustment, and coping assessments to assess risk and customize the intervention. “We sit down with the family; we identify their strengths and where they may be having difficulties,” Dr. Lester said.
About a quarter of the parents in Dr. Lester’s study had clinically meaningful anxiety or depression symptoms at intake, with civilian spouses reporting slightly more than military members. Also, some 31% of civilian spouses had PTSD symptoms at baseline, compared with 26% of military members – an unexpected finding, Dr. Lester said. Among children, 35% of boys and 25% of girls had social difficulties at baseline.
Location of intervention is key
Rolling FOCUS out on military installations required attention to military family culture. A voluntary program, it was implemented to service members as a form of training, rather than counseling or a mental health intervention, though part of its objective was to help to bridge gaps to mental health treatment for those who needed it.
Importantly, the intervention was delivered in community centers or retail spaces in lieu of mental health facilities on bases. “Military families may be reluctant to come for behavioral health services because of stigma or concern about their job – the same barriers we see in civilian communities but amplified, because the risks are quite concrete,” Dr. Lester said.
Having the command structure embrace the program went a long way toward broadening adoption. “It was really important to get commanders to support the program and even to share that they have participated with their own children,” she said.
In the program, initial screening is followed by informational sessions with the UCLA-trained providers on the impact of military-related stressors on children, parents, and families.
In subsequent sessions, families start building a graphic family narrative timeline, with children over 6 and parents contributing their individual interpretations of past events – moves, deployments, life changes. On the military installations, the timelines are drawn on paper; many families in civilian settings, meanwhile, have worked remotely from their homes with providers at UCLA to create timelines on the computer.
“Then we do individual and family-level cognitive-behavioral skill building, such as emotional regulation, goal setting and problem solving,” Dr. Lester said. “We also help parents and children recognize and manage deployment reminders – including trauma and loss reminders,” she said. Family members work together to articulate their collective goals.
Benefits are sustained
Dr. Lester’s study looked at 3,499 parents and 3,810 children (average age, 7) who participated. Families averaged 4.5 deployments before taking part in the program.
At exit, percentages of clinically meaningful anxiety and depression symptoms decreased from approximately 23% of all parents at intake to about 11%, and remained similarly low at 1 month and 6 months after program completion (range of adjusted odds ratios: 0.29-0.36).
Both civilian and service member parents reported clinically meaningful and statistically significant decreases in PTSD symptoms, which was notable because the intervention was not designed as a clinical treatment program but rather a psychoeducation program.
Children older than 8 years saw significant improvements in self-reported anxiety symptoms, with prevalence from 14.5% at intake to 11.8% at follow up.
Transitioning with families
After its initial adaptation from civilian interventions, then its broad application and scaling up over a decade in military settings, FOCUS must now transition to communities where military and veteran families live.
Between 3 and 4 million military-connected children live in the United States, with about 2 million in families that have transitioned out of active-duty military. “In the population that we serve, the average 10-year-old kid has been through at least four deployments, two of them combat related,” with many individual and community level exposures to trauma and loss, Dr. Lester explained.
A parent’s leaving active duty does not necessarily change risk for families, she said in an interview. “Our observation is that there’s a lot of reactivity and reminders in these families that persist – when somebody comes back highly activated, when there are threats of separation, and fear and danger, and if you do have underlying PTSD risk, that reactivity can be reactivated even after transition to civilian life.”
Teams at UCLA work to train providers in the FOCUS interventions and certify them in the different models for couples or families with children. The UCLA team will travel to conduct training, or practitioners can train at UCLA.
“We’re taking these components that have been most effective and continuing to refine them and integrate them into systems so that they reach people where they’re living,” Dr. Lester said, adding that she would encourage any clinician working with military families to get in touch via the program’s website.
She said some of the lessons learned from adapting to a military setting apply in civilian contexts as well – including the emphasis of the program as training, rather than diagnosis and treatment.
“I don’t think it reduces the impact or relevance of the intervention to have [FOCUS] inside a traditional mental health setting,” she said. “But in settings where it is essential to reach out and engage people who might not be coming into the clinic, it is important to highlight that this is an educational preventive program.”
Dr. Lester’s group is now conducting a research study of one FOCUS early childhood intervention in community settings.
Like military families, civilian families also embrace the concept of preparedness, she said. “They want to feel they have the skills to navigate whatever challenges come their way.”
EXPERT ANALYSIS AT THE AACAP ANNUAL MEETING
