Engaging and retaining National Guard/Reserve families with very young children in treatment: The Strong Families Strong Forces Program
Authors: Ellen DeVoe, PhD, Abigail M. Ross, MSW, MPH
The combined wars in Iraq and Afghanistan represent the longest period of military engagement in the history of the United States. Since October 2001, approximately 1.9 million U.S. troops have been deployed to Afghanistan and Iraq through Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) (Committee on the Initial Assessment of Readjustment Needs of Military Personnel, 2010). The body of literature documenting concerns about the mental health and well-being of the most recent cohort of returning veterans and their families is growing rapidly. A number of studies indicate elevated prevalence rates of posttraumatic stress disorder (PTSD), depression, anxiety, substance abuse and difficulties with anger management in OEF/OIF veterans, (Hoge, Auchterlonie, & Milliken, 2006; Hoge et al., 2004; Milliken, Auchterlonie, & Hoge, 2007; Ramchand, Karney, Osilla, Burns, & Caldarone, 2008) all of which have been shown to interfere substantially with social functioning, family relationships and overall quality of life (Committee on the Initial Assessment of Readjustment Needs of Military Personnel, 2010; Gewirtz, Polusny, DeGarmo, Khaylis, & Erbes, 2010; Gorman, Fitzgerald, & Blow, 2010; Harrell & Berglass, 2011; Jordan et al., 1992; Koenan, Stellman, Sommer, & Stellman, 2008; Renshaw, Rodrigues, & Jones, 2008, 2009; Sayers, Farrow, Ross, & Oslin, 2009). Although most studies have focused primarily on the veteran, there is also compelling evidence indicating that military family members, including children, are significantly affected by the returning veteran’s mental health functioning and related impairments (Beckham, Lytle, & Feldman, 1996; Committee on the Initial Assessment of Readjustment Needs of Military Personnel, 2010; Dekel, 2007; Dirkzwager, Bramsen, Ader, & van der Ploeg, 2005; Evans, McHugh, Hopwood, & Watt, 2003; Gallagher, Riggs, Byrne, & Weathers, 1998; Gewirtz et al., 2010; Glenn et al., 2002; Gorman et al., 2010; King, King, & Vogt, 2003; Renshaw, Rodebaugh, & Rodrigues, 2010; Renshaw et al., 2008). In particular, very young children (ages birth to five) may be especially sensitive to parental deployment and reintegration challenges in part due to the developmental vulnerability and critical importance of attachment during early life (Berry, Stoyles, & Donovan, 2010; Chartrand, Frank, White, & Shope, 2008; Committee on the Initial Assessment of Readjustment Needs of Military Personnel, 2010; Cozza, Chun, & Polo, 2005; D. A. Gibbs, Martin, Kupper, & Johnson, 2007; McIntosh, 2006; McIntosh, Burke, Dour, & Gridley, 2009; Rentz et al., 2007; Sayers et al., 2009). Families with very young children have also been identified as among the highest risk groups for psychosocial challenges as a result of deployment (D. A. Gibbs et al., 2007; Rentz et al., 2006).
Despite the magnitude of these concerns, low rates of service utilization among veterans returning from Iraq and Afghanistan persist — even among those reporting clinically significant levels of distress (Erbes, Curry, & Leskela, 2009; Hoge et al., 2006; Hoge et al., 2004; Milliken et al., 2007; Stecker, Fortney, Hamilton, Sherbourne, & Ajzen, 2010). Studies estimate that approximately 50 percent of veterans in need do not initiate mental health services (Hoge, Terhakopian, Castro, Messer, & Engel, 2007; Tanielian & Jaycox, 2008). More recent research suggests that veterans are reluctant to seek help due to lack of interest, stigma, concerns about confidentiality and logistical/geographical barriers, the last of which is especially pronounced for members of the National Guard/Reserve (NG/R) (Dickstein, Vogt, Handa, & Litz, 2010; D.A. Gibbs, Olmsted, Brown, & Clinton- Sherrod, 2011; Gould et al., 2010; Greene-Shortridge, Britt, & Castro, 2007; Kim, Britt, Klocko, Riviere, & Adler, 2011; Kim, Thomas, Wilk, Castro, & Hoge, 2010; McFarling, D’Angelo, Drain, Gibbs, & Olmsted, 2011; Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009; Stecker et al., 2010; Vogt, 2011).
We know little about initiation and retention rates of prevention and intervention services aimed at supporting military families with young children. Aside from the from the New Parent Support Program (NPSP), most interventions for this demographic are in their early stages of development or adaption and have yet to be evaluated (Murphey, Darling-Churchill, & Chrisler, 2011). To date, a single evaluation of the NPSP, the only service available at installations across all branches of the Armed Forces for military families with very young children, has been conducted. Results revealed high levels of participant satisfaction and usefulness of content, but did not report initiation or retention rates (Kelley, Schwerin, Farrar, & Lane, 2006). There is more data available on engagement rates in non-military specific programming for young children. For example, an evaluation of nine voluntary home-based parenting programs revealed higher rates of service initiation and retention when compared with other studies of civilian and military specific services (Daro, McCurdy, & Nelson, 2005). Factors associated with higher rates of program initiation included parental perception of risk level of the child and self-reported capacity for parenting. Factors associated with higher rates of program retention included perceptions of helpfulness related to parental concerns, relevance and applicability of program information, and self-reported level of comfort/connection with the program. When developing interventions to support military families with young children, it is critical to consider characteristics of existing programs demonstrating high initiation and retention rates while simultaneously addressing military-specific barriers to engagement in the veteran population.
Overview of the Research Process
Strong Families Strong Forces (SFSF), an eight-module home-based reintegration program for returning veterans and their young children and families, was initiated with the above-named factors in mind. The multi-year project was funded by the Department of Defense and aimed to develop and evaluate the efficacy of this reflective parenting program among returning OEF/OIF service members with very young children, primarily in NG/R communities. To maximize feasibility, acceptability and utility, we employed a community-based participatory approach (CBPR) to program development and study implementation, and are in the final phase of a three phase project. In Phase One, we conducted an extensive exploratory study via qualitative interviews with 80 service members and/or military spouses who are parents of very young children. Our purpose was to learn directly from parents about the challenges of deployment and reintegration, parenting throughout the deployment cycle, and service needs and gaps. In Phase Two, a pilot of SFSF was conducted with nine military families. In Phase Three, we conducted a randomized clinical trial (N=116 families) with randomization to the treatment (SFSF) condition or to a wait-list comparison (WLC) group (with the option to receive SFSF after the WL period). Research assessments were conducted at three time points: pre-randomization, post-test and three month follow-up.
SFSF Core Conceptual Elements
SFSF focuses on constructs of parental reflective capacity, attachment and developmental relevance. Parental reflective functioning (RF) is defined as the parent’s ability to identify, monitor and respond to his/her own and his/her child’s emotional states (Grienenberger, Kelly, & Slade, 2005; Slade, 2006; Slade, Grienenberger, Bernbach, Levy, & Locker, 2005). RF is an important mechanism that has been shown to contribute to parenting behaviors and the quality of the parent-child relationship (Grienenberger et al., 2005; Slade et al., 2005; Slade & Sadler, 2006, December; Suchman et al., 2010). Research indicates that parents who possess (or develop) these internal reflective capacities are better able to understand child distress, and to respond with acceptance and openness (Rosenblum, McDonough, Sameroff, & Muzik, 2008). Further, higher levels of RF have been associated with the development of adaptive means of self-regulation and the establishment of healthy interpersonal relationships in both parents and children (Slade, 2006; Slade et al., 2005). In the context of stressful or toxic environments, parental reflective capacity can operate as a buffer for the child. By contrast, parents with lower reflective capacity may have inflexible or distorted internal representations of their young child’s underlying emotions and respond less sensitively to child distress (Grienenberger et al., 2005). Working to improve parental RF in a family intervention optimizes the likelihood of changing a parent’s understanding of his/her child’s mental states and intentions, and may ultimately change his/her parenting behavior.
In Phase One, initial thematic analysis (Braun & Clarke, 2006) revealed parenting needs, reintegration challenges and logistical barriers to help-seeking perceived by military parents. These findings informed protocol, study design and program content for the randomized clinical trial. In both the pilot and randomized clinical trials, rates of engagement with the study population and treatment completion have been very high. Specifically, the pilot trial (n=9 families) yielded a 100 percent retention and completion rate. In the RCT, approximately 1200 home-visits have been conducted. Currently, the study has a retention rate of 97 percent within the treatment arm. Preliminary qualitative analysis for treatment completers reveals increases in parental (81.3 percent), self (68.0 percent) and couple reflective capacities (62.7 percent), as well as improved couple communication (80.0 percent) and co-parenting practices (74.1 percent).
Under-utilization of needed services is well documented among returning service members and their families. Supports for NG/R families with very young children have been sparse. The combination of using a CBPR approach to program development with home-based service delivery may be a viable solution to circumventing existing barriers to service initiation and retention in military populations with very young children.
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Ellen DeVoe, PhD, MSW, is an associate professor at Boston University School of Social Work in Clinical Practice and founding director of the Trauma Certificate Program for students in advanced practice. She received her PhD from the University of Michigan in Social Work and Psychology and completed a National Institute of Mental Health post-doctoral fellowship in family violence research at the University of New Hampshire. DeVoe’s research focuses on the impact of violence and traumatic exposure on young children, parents and parenting processes, and the development of intervention to address these effects. Her work has been supported by grants from the NIMH, SAMHSA, Centers for Disease Control, and the Robert Wood Johnson Foundation. Currently, Dr. DeVoe is principal investigator of Strong Families Strong Forces, a multi-year project funded by the Department of Defense, to develop and evaluate a home-based reintegration program for returning service members and their young children.
Abigail M. Ross, MSW, MPH, is a doctoral student in the Interdisciplinary Social Work and Sociology program at Boston University. Her areas of interest include community based participatory research and family-based intervention development. Currently, she is the project director of a four year study funded by the Department of Defense to develop and test a home-based program, Strong Families Strong Forces, for military parents returning from Iraq and/or Afghanistan who have children birth to five.