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.
Beckham, J. C., Lytle, B. L., & Feldman, M. E. (1996). Caregiver burden in partners of Vietnam War veterans with posttraumatic stress disorder. J Consult Clin Psychol, 64(5), 1068-1072.
Berry, L., Stoyles, G., & Donovan, M. (2010). Postseparation parenting education in a family relationship centre: A pilot study exploring the impact on perceived parent–child relationship and acrimony. Journal of Family Studies, 10, 224-236.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(77-101).
Chartrand, M. M., Frank, D. A., White, L. F., & Shope, T. R. (2008). Effect of parents' wartime deployment on the behavior of young children in military families. Archives of Pediatric and Adolescent Medicine, 162(11), 1009-1014. doi: 162/11/1009 [pii]10.1001/archpedi.162.11.1009
Committee on the Initial Assessment of Readjustment Needs of Military Personnel, V., and Their Families; Board on the Health of Selected Populations; Institute of Medicine. (2010). Returning home from Iraq and Afghanistan: Preliminary assessment of readjustment needs of veterans, service members, and their families. Washington, D.C.: National Academy of Sciences.
Cozza, S., Chun, R. S., & Polo, J. A. (2005). Military families and children during Operation Iraqi Freedom. Psychiatric Quarterly, 76(4), 371-378. doi: 10.1007/s11126-005-4973-y
Daro, D., McCurdy, K., & Nelson, C. (2005). Engagement and retention in voluntary new parent support programs: final report. Chicago, Ill.: Chapin Hall Center for Children at the University of Chicago.
Dekel, R. (2007). Posttraumatic distress and growth among wives of prisoners of war: the contribution of husbands' posttraumatic stress disorder and wives' own attachments. Am J Orthopsychiatry, 77(3), 419-426. doi: 2007-11621-011 [pii]10.1037/0002-9422.214.171.1249
Dickstein, B. D., Vogt, D. S., Handa, S., & Litz, B. T. (2010). Targeting self-stigma in returning military personnel and veterans: A review of intervention strategies. Military Psychology, 22, 224-236.
Dirkzwager, A. J., Bramsen, I., Ader, H., & van der Ploeg, H. M. (2005). Secondary traumatization in partners and parents of Dutch peacekeeping soldiers. J Fam Psychol®, 19(2), 217-226. doi: 2005-06518-006 [pii]10.1037/0893-3126.96.36.199
Erbes, C. R., Curry, K., & Leskela, J. (2009). Treatment presentation and adherence of Iraq/Afghanistan era veterans in outpatient care for posttraumatic stress disorder. Psychological Services, 6(3), 175-183.
Evans, L., McHugh, T., Hopwood, M., & Watt, C. (2003). Chronic posttraumatic stress disorder and family functioning of Vietnam veterans and their partners. Aust N Z J Psychiatry, 37(6), 765-772. doi: 1267 [pii]
Gallagher, J. G., Riggs, D. S., Byrne, C. A., & Weathers, F. W. (1998). Female partners' estimations of male veterans' combat-related PTSD severity. J Trauma Stress, 11(2), 367-374. doi: 10.1023/A:1024411422586
Gewirtz, A. H., Polusny, M. A., DeGarmo, D. S., Khaylis, A., & Erbes, C. R. (2010). Posttraumatic stress symptoms among National Guard soldiers deployed to Iraq: Associations with parenting behaviors and couple adjustment. Journal of Consulting and Clinical Psychology®, 78, 599-610.
Gibbs, D. A., Martin, S. L., Kupper, L. L., & Johnson, R. E. (2007). Child maltreatment in enlisted soldiers' families during combat-related deployments. Journal of the American Medical Association, 298(5), 528-535.
Gibbs, D. A., Olmsted, K. L., Brown, J. M., & Clinton- Sherrod, A. M. (2011). Dynamics of stigma for alcohol and mental health treatment among Army soldiers. Military Psychology, 23, 36-51.
Glenn, D., Beckham, J. C., Feldman, M. E., Kirby, A. C., Hertzberg, M. A., & Moore, S. D. (2002). Violence and hostility among families of Vietnam veterans with combat-related Post-traumatic Stress Disorder. Violence and Victims, 17, 473-489.
Gorman, L. A., Fitzgerald, H. E., & Blow, A. J. (2010). Parental combat injury and early child development: A conceptual model for differentiating effects of visible and invisible injuries. Psychiatr Q, 81, 1-21.
Gould, M., Adler, A., Zamorski, M., Castro, C., Hanily, N., Steele, N., . . . Greenberg, N. (2010). Do stigma and other perceived barriers to mental health care differ across Armed Forces? J R Soc Med, 103(4), 148-156. doi: 103/4/148 [pii]10.1258/jrsm.2010.090426
Greene-Shortridge, T. M., Britt, T. W., & Castro, C. A. (2007). The stigma of mental health problems in the military. Military Medicine, 172(2), 157-161.
Grienenberger, J. F., Kelly, K., & Slade, A. (2005). Maternal reflective functioning, mother-infant affective communication, and infant attachment: exploring the link between mental states and observed caregiving behavior in the intergenerational transmission of attachment. Attach Hum Dev, 7(3), 299-311. doi: T16736R7230257Q4 [pii] 10.1080/14616730500245963
Harrell, M., & Berglass, N. (2011). Losing the battle: the challenge of military suicide. In C. f. a. N. A. Security (Ed.). Washington, D.C., USA: Center for a New American Security.
Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, 295(9), 1023-1032.
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13-22. doi: 10.1056/NEJMoa040603351/1/13[pii]
Hoge, C. W., Terhakopian, A., Castro, C. A., Messer, S. C., & Engel, C. C. (2007). Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. American Journal of Psychiatry, 164(1), 150-153. doi: 164/1/150 [pii] 10.1176/appi.ajp.164.1.150
Jordan, B. K., Marmar, C. R., Fairbank, J. A., Schlenger, W. E., Kulka, R. A., Hough, R. L., & Weiss, D. S. (1992). Problems in families of male Vietnam veterans with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 60(6), 916-926.
Kelley, M., Schwerin, M., Farrar, K., & Lane, M. (2006). A participant evaluation of the U.S. Navy Parent Support Program. Journal of Family Violence, 21, 301-310. doi: DOI 10.1007/s10896-006-9031-5
Kim, P. Y., Britt, T. W., Klocko, R. P., Riviere, L. A., & Adler, A. B. (2011). Stigma, negative attitudes about treatment, and utilization of mental health care among soldiers. Military Psychology, 23, 65-81.
Kim, P. Y., Thomas, J. L., Wilk, J. E., Castro, C. A., & Hoge, C. W. (2010). Stigma, barriers to care, and use of mental health services among active duty and National Guard soldiers after combat. Psychiatr Serv, 61(6), 582-588. doi: 61/6/582 [pii]10.1176/appi.ps.61.6.582
King, D. W., King, L. A., & Vogt, D. S. (2003). Manual for the Deployment Risk and Resilience Inventory (DRRI): A collection of scales for studying deployment-related experiences in military veterans. Boston, Mass.: National Center for PTSD.
Koenan, K. C., Stellman, S. D., Sommer, J. F., & Stellman, J. M. (2008). Persisting posttraumatic stress disorder symptoms and their relationship to functioning in Vietnam veterans: A 14-year follow-up. Journal of Traumatic Stress, 21(1), 49-57.
McFarling, L., D’Angelo, M., Drain, M., Gibbs, D. A., & Olmsted, K. L. (2011). Stigma as a barrier to substance abuse and mental health treatment. Military Psychology, 23, 1-5.
McIntosh, J. E. (2006). The children’s cases pilot project: An exploratory study of outcomes for parenting capacity and child well-being: Final report to the Family Court of Australia. Melbourne, Australia.
McIntosh, J. E., Burke, S., Dour, N., & Gridley, H. (2009). Parenting after separation: A position statement prepared for the Australian Psychological Society. Melbourne, Australia: Australian Psychological Society.
Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Journal of the American Medical Association, 298(18), 2141-2148.
Murphey, D. A., Darling-Churchill, K. E., & Chrisler, A. J. (2011). The well-being of young children in military families: A review and recommendations for further study. Child Trends Publication.
Pietrzak, R. H., Johnson, D. C., Goldstein, M. B., Malley, J. C., & Southwick, S. M. (2009). Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans. Psychiatr Serv, 60(8), 1118-1122. doi: 60/8/1118 [pii]10.1176/appi.ps.60.8.1118
Ramchand, R., Karney, B. R., Osilla, K. C., Burns, R. M., & Caldarone, L. B. (2008). Prevalence of PTSD, depression, and TBI among returning service members. In T. Tanelian & L. H. Jaycox (Eds.), Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery (pp. 35-85). Santa Monica, Calif.: RAND Corporation.
Renshaw, K. D., Rodebaugh, T. L., & Rodrigues, C. S. (2010). Psychological and marital distress in spouses of Vietnam veterans: Importance of spouses' perceptions. Journal of Anxiety Disorders, 24(7), 743-750.
Renshaw, K. D., Rodrigues, C. S., & Jones, D. H. (2008). Psychological symptoms and marital satisfaction in spouses of Operation Iraqi Freedom veterans: relationships with spouses' perceptions of veterans' experiences and symptoms. Journal of Family Psychology, 22(4), 586-594. doi: 2008-10898-010 [pii]10.1037/0893-3188.8.131.526
Renshaw, K. D., Rodrigues, C. S., & Jones, D. H. (2009). Combat exposure, psychological symptoms, and marital satisfaction in National Guard soldiers who served in Operation Iraqi Freedom from 2005 to 2006. Anxiety Stress Coping, 22(1), 101-115. doi: 902386166 [pii]10.1080/10615800802354000
Rentz, E. D., Marshall, S. W., Loomis, D., Casteel, C., Martin, S. L., & Gibbs, D. A. (2007). Effect of deployment on the occurrence of child maltreatment in military and nonmilitary families. American Journal of Epidemiology, 165(10), 1199-1206. doi: kwm008 [pii]10.1093/aje/kwm008
Rentz, E. D., Martin, S. L., Gibbs, D. A., Clinton-Sherrod, M., Hardison, J., & Marshall, S. W. (2006). Family violence in the military: A review of the literature. Trauma, Violence, & Abuse, 7(2), 93-108. doi: 7/2/93 [pii] 10.1177/1524838005285916
Rosenblum, K., McDonough, S., Sameroff, A., & Muzik, M. (2008). Reflection in thought and action: Maternal parenting reflectivity predicts mind-minded comments and interactive behaviour. Infant Mental Health Journal, 29(362-376).
Sayers, S. L., Farrow, V. A., Ross, J., & Oslin, D. W. (2009). Family problems among recently returned military veterans referred for a mental health evaluation. Journal of Clinical Psychiatry, 70(2), 163-170. doi: ej07m03863 [pii]
Slade, A. (2006). Reflective Parenting Programs: Theory and Development. Psychoanalytic Inquiry, 26(4), 640-657.
Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2005). Maternal reflective functioning, attachment, and the transmission gap: a preliminary study. Attach Hum Dev, 7(3), 283-298. doi: G484850846356414 [pii] 10.1080/14616730500245880
Slade, A., & Sadler, L. (2006, December). Minding the baby: Enhancing reflective functioning in a nursing/mental health home visiting program. Paper presented at the Zero to Three National Training Institute, Albuquerque, New Mexico.
Stecker, T., Fortney, J., Hamilton, S., Sherbourne, C., & Ajzen, I. (2010). Engagement in mental health treatment among veterans returning from Iraq. Patient Preference and Adherence, 4, 45-49.
Suchman, N. E., DeCoste, C., Castiglioni, N., McMahon, T. J., Rounsaville, B., & Mayes, L. (2010). The Mothers and Toddlers Program, an attachment-based parenting intervention for substance using women: Post-treatment results from a randomized clinical pilot. Attachment and Human Development, 12(5), 483-504.
Tanielian, T., & Jaycox, L. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, Calif.: RAND Corporation.
Vogt, D. (2011). Mental health-related beliefs as a barrier to service use for military personnel and veterans: a review. [Research Support, U.S. Gov't, Non-P.H.S. Review]. Psychiatr Serv, 62(2), 135-142. doi: 10.1176/appi.ps.62.2.135
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.