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.”