JOINING FORCES

Joining Families

Volume 11, Issue 4 • November 2010

R E A L W O R L D R E S E A R C H F O R F A M I LY A D V O C A C Y P R O G R A M S

F E AT U R E D I N T E R V I E W

Development of the Decision Tree Algorithm (DTA)
and Validity of the Definitions
Interview with Richard Heyman, PhD, and Amy Slep, PhD
Conducted by James McCarroll, PhD
Richard Heyman, PhD

Richard Heyman, PhD, is Research Professorof Psychology in the Department of Psychology
at Stony Brook University, State University of
New York. He has received more than 30 grants
or contracts from major U.S. funding agencies

In This Issue
This issue of Joining Forces Joining Families (JFJF) presents several
features on the development of the Decision Tree Algorithm (the DTA), theprotocol used to determine family maltreatment case substantiation by the
U.S. Army and the U.S. Air Force. JFJF was privileged to interview Richard
Heyman, PhD, and Amy Slep, PhD, of the State University of New York, Stony
Brook, who developed the DTA. Additional background regarding the development and implementation of the DTA is also included. The regular statistics
feature describes two basic psychometric processes used to characterize
instruments such as the DTA: reliability and validity.
We are also pleased to provide a special article with practical information
on supporting Soldiers and family members of Soldiers who have suffered
traumatic brain injury (TBI) or post-traumatic stress disorder (PTSD). We refer
to both of these conditions as the invisible injuries of war. Invisible injuries canbe as challenging and disabling as physical injuries that are visible, but often
require additional understanding and consideration frequently shown to individuals with visible injuries and to their families. Because many of our readers
work with families who may be struggling with invisible injuries, we thought
this information would be useful and valuable to all involved. As always, JFJF
recognizes the important work its readers are doing to enhance the psychological health and wellbeing of our nation’s soldiers and their families.
Contents
Development of the Decision Tree Algorithm (DTA) .........................................1
Building Bridges to Research: Psychometric Concepts..................................3
The Decision Tree Algorithm (DTA)................................................................4
The Impact of Invisible Injuries......................................................................5
Websites of Interest...........................................................................................8

on family topics including anger escalation incouples, the impact of family violence on children, community-level prevention of family
maltreatment, substance abuse, and suicidality.
Dr. Heyman has published over 90 scientificarticles and chapters. His work with the U.S.
Army (1994–1996) included base-level surveys
on intimate partner violence (IPV) and comparison of Army IPV rates to civilian rates. Since
1998, he has conducted research with the U.S. Air
Force on (a) innovative approaches to estimating
the prevalence of partner and child maltreatment; (b) creating and testing reliable criteria
for partner and child maltreatment; (c) risk andprotective factors for secretive problems (partnerand child maltreatment, suicidality, and alcoholand drug misuse); and (d) developing and testing
community approaches to prevention of secretive
problems. Dr. Heyman is a licensed psychologist
and maintains a private practice specializing in
couples therapy and depression.

Amy M. Smith Slep

Amy M. Smith Slep, PhD, is Research Associate Professor in the Department of Psychology at
Stony Brook University (SBU), State Universityof New York. She received her Ph.D. in ClinicalPsychology from SBU in 1995. With Dr. Heyman,she co-directs the Family Translational ResearchGroup, which includes over 20 research staff andstudents focused on understanding violence infamilies. Dr. Slep’s research focuses on the development of dysfunctional parenting, the connections between parenting and partner conflict, theContinued on page 2

Substantiation of analleged family advocacy
incident is based entirelyon the incident whereas
the kinds of services
that families need canbe very much driven byrisk, which might not betightly associated with
the incident.

dynamics of conflict escalation and de-escalationin productive and destructive conflicts, facets of
exposure to violence impacting children’s functioning and how these impacts can be buffered,and the prevention of family violence. Her workon standardizing definitions of maltreatment has
resulted in definitions that are now being used in
the U. S. Army and Air Force. She has publishedover 50 scientific articles and book chapters andhas received nearly 20 federal research grants.
She is a licensed clinical psychologist.
Dr. McCarroll: Your Family Translational
Research Group has a long history of working
with the military.
Dr. Slep: We started in 1997. All of ourresearch is focused on the family and, more
specifically, on family violence. Translational
research means translating basic research into
the applied setting. An example is taking treatment and prevention protocols and figuring
out how to make them work in real world
settings.
Dr. McCarroll: I believe that some of yourinitial work with the military was with theArmy on the prevalence of domestic violence.
Is that correct?

JOINING FORCES
Joining Families
Editor-in-Chief
James E. McCarroll, PhD
Email: jmccarroll@usuhs.mil
EditorJohn H. Newby, MSW, PhD
Email: jnewby@usuhs.mil
Joining Forces Joining Families
is a publication of the U. S.
Army Family Morale, Welfare
and Recreation Commandand the Family Violence andTrauma Project of the Centerfor the Study of TraumaticStress (CSTS), Bethesda,
Maryland 20814-4799, tel.
301-295-2470. CSTS is a partof the Dept. of Psychiatry,
USUHS, and a partnering
center of the Defense Centersof Excellence (DCoE).

2 • Joining Forces/Joining Families

Editorial Advisor
LTC Ben Clark, Sr., MSW, PhD
Family Advocacy Program Manager
Headquarters, Department of theArmy
E-mail: Ben.Clark@fmwrc.army.mil
Editorial Consultants
David M. Benedek, MD, COL, MC, USA
Professor and Scientist
Center for the Study of Traumatic Stress
Uniformed Services University of the
Health Sciences
dbenedek@usuhs.mil
Nancy T. Vineburgh, MA
Director, Office of Public Education
and Preparedness
Center for the Study of Traumatic Stress
Email: nvineburgh@usuhs.mil

Dr. Heyman: Yes. The Army wanted toknow how the rates of domestic violence in the
military compared with rates in the U.S. civiliansociety. That work was initially done with Peter
Neidig (Heyman & Neidig, 1999). It was reallyhis data set that I was working on with him
when the Army wanted to make a comparison
with the civilian prevalence data controlling for
demographic factors. Pete, unfortunately at thatpoint was quite ill, so I finished that work on
my own. [Editor’s note: The Heyman and Neidig
study is still the only published comparison of
the prevalence of domestic violence in the civilian and military communities.]
Dr. McCarroll: You developed the decision tree
algorithm (DTA) that is now used by the U.S.
Air Force and the U.S. Army for making casesubstantiation decisions. [Editor’s note: See
accompanying article in this edition of JFJF fora description of the DTA.]
Dr. Heyman: Amy and I began work together with this Air Force project a couple of years
after the Army prevalence project. The DTA wasactually based on an earlier request by the Air
Force. They also wanted a way to compare thecommunity prevalence of domestic violence at
the installation level to the reported domestic
violence cases that came before the Central
Registry Board (CRB) at that same installation.
However, before they could do that they had tostandardize the definitions of domestic violence
used by the CRBs. That led to the developmentof the DTA for the use by the CRBs to produce
reliable data. So, it was a round-about process.
The Air Force wanted to be able to predict
the sensitive outcomes (in this case, the prevalence of partner and child maltreatment) from
non-sensitive data that is collected on a regularbasis. We took on this project by first using a
number of archival data sets to determine if
the approach would work before collecting
data. The approach worked and is explained ina publication that is due to come out in printsoon, but is currently available on line (Heyman& Slep, 2010).
To be able to make good current estimations, the Air Force would need to collect thesensitive data at least one time to compare to
the non-sensitive data. In other words, theestimation program needs to have data on boththe predictors and the outcomes. So, we had todetermine exactly what self-report measures
should constitute maltreatment on the anonyContinued on p. 3

November 2010

Building Bridges to Research: The Psychometric
Concepts of Reliability and Validity
By James E. McCarroll, PhD
The term, ‘psychometricproperties’, refers
to characteristics ofmeasures that havebeen ob¬tained in
the development of
an instrument. At aminimum, these include
reliability and validity.

As noted in the background article on thedecision tree algorithm (DTA) and interview
with Drs. Heyman and Slep, reliability of maltreatment definitions and criteria were primarygoals of their research. Reliability and validity
are basic psychometric properties of measuresand are the subjects of this article.
The term, ‘psychometric properties’, refers
to characteristics of measures that have beenobtained in the development of an instrument. At a minimum, these include reliability
and validity, two basic concepts in test development and measurement. There are many
types of reliability and validity. Psychometricproperties are usually considered on two levels,
conceptually and mathematically. Another way
of stating this is that these are both qualitative(the concept) and quantitative (the mathematical analysis) approaches to constructing andevaluating such measures.
Reliability is generally the first research priority when developing a measure of a concept
of interest. Reliability refers to the consistencyof a measurement. An example is test-retest
reliability, the extent to which agreement isachieved when a measure is given on two different occasions. For example, an intelligencetest given on two separate occasions should
produce approximately the same results. Interrater reliability is a measure of the degree of
Featured Interview, from page 2

mous Air Force-wide survey. This led to thedevelopment of the DTA. The next step would
be to collect the actual prevalence of family
maltreatment data and non-sensitive data,
develop the final estimation equations, and test
their accuracy.
Dr. McCarroll: Has the Air Force measured
how the use of the DTA has impacted theirprevalence or severity rates?
Dr. Slep: Yes, indeed.
Dr. Heyman: It looks like it has decreased
the prevalence probably due to three things.
First, with child neglect, the most prevalent
form of child maltreatment, standardizing thedefinitions allowed them to decrease variability

http://www.CSTSonline.org

agreement of two or more persons rating thesame event. An example of inter-rater reliability
is the degree of agreement between persons
who judge candidates for a job.
Validity is the degree to which an instrument measures the concept that one is attempting to measure. There are several types ofvalidity. Predictive validity indicates how wella test predicts some criterion. For example, in
maltreatment research, we would like to have ameasure with high predictive validity for recidivism. That is, it would predict recidivism risk
with high probability. High predictive validity
is generally required for clinical use. Concurrent validity is the degree of agreement of a newmeasure, (i.e., a test), with one that has alreadybeen validated. Content validity is the degree towhich a measure appears to match the concept
in question. Face validity is like face value — it
looks like it is appropriate to the concept measured and appears to be valid.
For further discussion and examples ofpsychometric concepts, please consult Building Bridges: Using Statistics in Family Program
Research. (2008). Center for the Study ofTraumatic Stress, Department of Psychiatry,
Uniformed Services University of the Health
Sciences, Bethesda, MD 20814. This publication
can be obtained free of change from the addresses on the second page of this newsletter.

among bases and to clarify the level of clinicalseriousness required for case substantiation.
Second, there was a perception within the CRBs
that cases had to be substantiated for families
to get services. However, the Air Force made it
clear that families could get services even if thecase was not substantiated. Finally, the reduction in recidivism is also likely due to the way
the new system is structured and the likely
oversight that is coming from the chain ofcommand. The community is taking note andis intent on not having maltreatment reoccur.
Dr. Slep: Also, having clearer criteria hashelped their outreach for community education
about FAP. In the process of developing the definitions, they decided they had to completely disContinued on p. 6
Joining Forces/Joining Families • 3

The Decision Tree Algorithm (DTA): Developmentof Family Advocacy Program (FAP) Substantiation
Decisions
By James E. McCarroll, PhD, and Rene Robichaux, PhD*
Substantiation of analleged family advocacy
case now requires two
separate decisions:(1) whether the act ofmaltreatment occurredand (2) the impact(which may include
actual injury, reasonable
potential for injury, or
fear reaction on the partof the victim) of the act.

*René J. Robichaux, PhD, LCSW
Social Work Programs Manager
Behavioral Health Division
Us Army Medical Command
San Antonio, Texas

The decision to substantiate a case of
maltreatment results in the information about
the offender and victim being entered intoa military service central registry. From theperspective of the family, it is one of the mostimportant decisions made by the military Family Advocacy Program (FAP). Such decisions
have the potential to impact many domains of
the service member’s life and career including
assignment, security clearance, and command
actions related to punishment. Entry of substantiated cases into a service central registry
also provides trend data on maltreatment foreach service and for Congress.
The Decision Tree Algorithm (DTA) isbased on the work of Heyman and Slep who
conducted a series of studies to improve thereliability of substantiation decisions for the
military (see Heyman & Slep, 2006 and Slep &Heyman, 2006). Their work is an excellent example of evidence-based research sponsored by
the FAP. Heyman and Slep reviewed maltreatment criteria from a wide variety of sources
including experts in the field, active clinicians,
and state standards and criteria used in law
enforcement and research. They found thatstate definitions of maltreatment are highlyvariable and many factors unrelated to theactual incident itself (i.e., a specific risk factor
like alcohol abuse) can influence the substantiation decision. Their research was directed
toward evaluating and improving the reliabilityof substantiation determinations. They tested
if (a) more reliable substantiation definitions
and processes could be developed and (b)case workers would be comfortable with andaccepting of a new approach in making thedetermination.
Their research resulted in new conceptualizations of partner and child physical,
emotional, and sexual abuse, and child neglect
and their impacts or potential impacts. Draft
definitions and criteria were field tested basedon 650 cases. Field testing allowed fine-tuningof the definitions and criteria, which were
subsequently tested in a second field test. Thesestudies were conducted in partnership with the

4 • Joining Forces/Joining Families

U.S. Air Force, but the DTA criteria have since
been adopted by the U.S. Army as well. In theArmy, there are exclusions to the DTA and casereview committees (CRCs) are permitted to use
their own judgment in rare or unusual cases
and not required to adhere to the DTA in all
instances. (An example of an exclusion for childphysical abuse is those acts committed during
developmentally appropriate physical play suchas horseplay and wrestling.)
The result of Heyman and Slep’s researchhas been a sea change in U.S. Army and U.S. Air
Force FAP procedures. In the DTA process, maltreatment criteria are applied by a CRC to an alleged incident of family maltreatment in orderto make a substantiation decision. Substantiation of an incident now requires two separate
decisions: (1) whether the act of maltreatment
occurred, and (2) the impact of the act, which
may include actual injury, reasonable potential
for injury, or fear reaction on the part of thevictim on whom the act was perpetrated. If theincident meets the criteria specified in the DTA,
the case is considered to have met criteria and issubstantiated. Decisions on case severity (mild,moderate, or severe) are set by Army Regulation
608–18. [Editor’s note: See interview of Heyman
and Slep in this edition of JFJF for their planson research to develop severity criteria.]
Regardless of the substantiation decision,
services are provided to high risk families when
the incident fails to reach the criteria established by the DTA algorithm. These services
are practically indistinguishable from services
provided when the incident meets criteria.

References
Heyman RE & Slep AMS. (2006). Creating andfield-testing diagnostic criteria for partner andchild maltreatment. Journal of Family Psychology; 20:397–408.
Slep AMS & Heyman RE. (2006). Creating andfield-testing child maltreatment definitions:Improving the reliability of substantiation determinations. Child Maltreatment; 11:217–236.

November 2010

The Impact of Invisible Injuries: Helping Affected
Families and Children

Invisible injuries suchas post traumatic stressdisorder or traumaticbrain injury can beespecially difficult forfamilies because theyoften result in significant
changes in personality
and behavior withoutchanges in the Soldier’s
appearance.

Adapted from Courage to Care by Nancy T.
Vineburgh
The injuries of war change the lives of Soldiers, families and children. Invisible injuries
such as posttraumatic stress disorder (PTSD)
or traumatic brain injury (TBI) can be especially difficult for families because they often
result in significant changes in the injured
service member’s personality and behavior
without changes in the Soldier’s appearance. A
service member with PTSD or TBI may havemood swings, or certain environments may
trigger responses that do not seem appropriate
to the situation. These kinds of events can beespecially troubling for children and embarrassing for the family. While injuries cannot becompared or judged, invisible injuries, unlike
those that are visible (i.e., loss of limb, burns)
may not elicit the same level of support fromoutsiders who may not even realize a medical
problem exists. As a result, the Soldier withinvisible injuries, as well as his/her family may
feel isolated from friends and one’s community. There are steps that families and friends
can take to manage such challenges.
Distress of a Soldier with an invisible injury
and distress of family members is normal andshould be expected. Family members can beespecially helpful to each other during thesetimes by recognizing their distress and helping
each other cope with it. Younger children arelikely to need special help due to their lack ofunderstanding complex medical and psychological conditions. The following are among
the distress responses that children may show.
■■ Increased acting out behaviors, such as
disobedience, tantrums, or risk-taking
behaviors■■ Emotional distress, such as crying, increased anxiety, or withdrawal■■ Feelings of loss and grief related to thechanges in the injured Soldier parent■■ Feelings of isolation■■ Taking on additional responsibilities, suchas caring for younger children, householdtasks, and caring for the injured Soldier■■ Feelings of embarrassment about the injured Soldiers’ appearance or behavior

http://www.CSTSonline.org■■ Misinterpreting the Soldier’s distress (suchas shown by fatigue and apathy) as indicators that the Soldier parent no longer loves
them■■ Feelings of anger or resentment about new
responsibilities or changes in the family■■ Feelings of self-blame for the Soldier’ injury
and for the distress

What Families Can Do to Understand andCope with the Injury
Families can:■■ Seek out resources and support. Examples
are sports, organizations, and educational
programs that provide social support andstructured activities.
■■ Discuss the injury as a family and with others in the community, including health careproviders, in order to access resources orappropriate health care treatment.
■■ Help children to express their emotions,
to relax, or to calm themselves. Children
should be encouraged to ask questions
about the injury. Parents can help children
by teaching them to label and express theiremotions and by giving them specific strategies for dealing with strong emotions and/or stress.
■■ Share information with children about
the injury in a way they can comprehend.
Information helps children understandthe injury and its effects in terms of parent
functioning and what to expect over time.
■■ Children may need reassurance that theparent’s injury is not their fault.

What Health Care and Family Support
Professionals Can Do to Help Families
Understand and Cope with the Injury■■ Spend time talking with the Soldier and thefamily. Families will feel most comfortablewith a provider or caregiver who has beenin contact with them and with whom trust
has been established.
■■ Explain the nature of the injury to families.
Continued on p. 8
Joining Forces/Joining Families • 5

Featured Interview, from page 3

There are already
empirically-supported
interventions thatcan be done at a
community level andby driving down therisk at an overall level,
one is able to reduce
the prevalence morethan you ever would
be in trying to serve
people on a one by one
basis.

entangle the substantiation determination fromclinical services. Substantiation is based entirelyon the incident whereas the kinds of services
that families need can be very much driven byrisk, which might not be tightly associated with
the incident. For example, a very risky family
could have a really minor incident. So, the goal
was to stop conflating those two. Service recommendations are supposed to be driven more byrisk assessment and the clinical picture of thefamily and not by substantiation status.
Dr. McCarroll: Please describe how you are
determining the validity of the definitions ofmaltreatment.
Dr. Slep: We believe we have done a goodjob of investigating the reliability of the decisions. The definitions, thresholds, and thecriteria have been evaluated for face validity(the degree to which the measures appear
to fit the concept) and also content validity (how well all aspects of the concept are
taken into account), but that does not help us
know whether we have more criteria than wereally need or, whether our ability to isolate agroup of perpetrators would be improved if
we changed the number of criteria. To be able
to do that, we have to study some people whohave allegations of family maltreatment, notnecessarily substantiated cases. We would dosome detailed interviewing to help us makesome of those distinctions so that our computer models can adjust the thresholds thatare currently part of the definitions. We would
then look across a couple of hundred families
and see whether we get better relationships
with external variables if we make changes versus keeping the thresholds and criteria exactly
the way they are.
This project has not yet started. The interviews would be anonymous. We would ask
participants very detailed questions about theincident on which an allegation is based. Theinterview would match the criteria, but ask
open ended questions with more detail, as you
would in a clinical assessment. The criterion
includes fear of bodily injury and symptoms
that last at least 48 hours. For example, wewould ask about concentration, difficulty
sleeping, how long the disruption has lasted
and how significant it has been. We would finda very full picture of the nature and impactof the maltreatment with respect to all thecriteria.

We have been asked by the Departmentof Defense to develop a scale to make reliable
judgments of the severity of the different formsof maltreatment. These severity definitions canbe used by the services when they make thesubstantiation decision. The goal is to develop
a severity rating and that is as reliable as thesubstantiation decisions. Once the scale isdeveloped, we will see if it can be implemented
in the field. We are currently piloting it at four
installations across the services. We think weare close to having the final version of the scale.
Currently, we discuss every case at these installations with the assessing clinician and make severity ratings on their cases. We talk about what
is not clear or should be changed. Soon, we willtransition from this phase where it is about
trying to make everything work into more ofa research phase. In that phase, we will makeratings along with the clinicians, but not discuss
them, and then compare clinicians’ decisions
with our own.
Dr. McCarroll: I wondered if the severity ofmaltreatment by female offenders might
be judged in a different way than for males
because males are generally stronger and are
more likely to produce injury.
Dr. Heyman: It is hard to know for sure. The
intent in setting up the maltreatment criteria
was to make them gender-sensitive. For example, for physical abuse you need to have an
act and an impact. If a woman pushes or grabs
a man (act) and he is not injured or afraid ofher (impact) and there is nothing about thesituation that would have made that inherently
dangerous, (she was not pushing him while hewas on a balcony), then that incident would notmeet the criteria for abuse.
Dr. Slep: That said, we have no problem
with an incident in which there is alleged
maltreatment by both of the people. So, if they
were fighting and both hurt each other, then theappropriate way to handle that is to substantiate
both as perpetrators.
Dr. McCarroll: Let’s spend a few minutes on
psychological abuse or emotional abuse.
Dr. Heyman: Having acts and impacts inthe definitions has helped substantially. I thinkthat one of the biggest problems is that withemotional abuse you are only looking at the act.
You have no way of easily being able to measure
the impact of what was said or whether it isemotionally abusive. The prevalence is muchContinued on page 7

6 • Joining Forces/Joining Families

November 2010

lower than you would get if you were using something likethe psychological abuse items from the Conflict Tactics Scale(Straus, 1979), in which almost everybody says that somebody
yelled at them or they yelled at their partner or their child.
Using the maltreatment definitions, the prevalence of substantiated, self-reported emotional abuse in the community
is slightly over 10% in both directions — male-to-female andfemale-to-male. We looked at the items that they reported interms of the impact, such as whether the person felt depressedor felt substantially stressed due to these behaviors by theirpartner in the last year. The reports seem to work out in a waythat appears to be valid. They are internally consistent andthey relate to outcomes like depression and health and a variety of other kinds of outcomes in a way that one would expect
clinically significant emotional abuse to work.
Dr. McCarroll: Please give me some examples of otherprojects you are currently working on.
Dr. Heyman: We just finished a large-scale community
prevention trial with the Air Force that was trying to improve
community risk and protective factors. This project is called
NORTH STAR. We also have a small grant to do the samething at our university.
The goal of this study is to decrease risk factors such as
alcohol abuse, prescription drug misuse and illicit drug use,suicidality, partner emotional and physical abuse and childemotional and physical abuse.
It is based on the Air Force’s Community Assessment data
set for active duty members and spouses. This is a very large
anonymous survey of individual functioning that includes
measures of mental and physical health, family factors, relationship satisfaction, parent-child satisfaction, the workplaceenvironment, support from leadership, work group cohesion and hours worked per week, and community factors.
The community factors include community safety and unity,social support, intimate partner violence, child maltreatment,
alcohol problems, prescription drugs and illicit drug use, andsuicidality and suicide attempts. Using this data set, we arelooking at risk factors and the factors that buffer risk for thoseoutcomes.
The data on risk and protective factors and outcomes areused for empirically guided prevention planning and prevention. People do not want to admit sensitive issues like family
maltreatment, alcohol and substance abuse and suicidality.
These are all things that people try to keep secret and they do
not tend to participate in prevention or intervention services
unless they are forced to do so. So, to prevent these negative
outcomes, rather than trying to drive them into formal services, another approach would be to develop a better understanding of how risk and protective factors relate to these multiple negative outcomes. A community prevention team would
then choose the factors that would have the greatest impact at
the community level and work on these less stigmatizing risk
and protective factors at a community level.

http://www.CSTSonline.org

Dr. Slep: There are already empirically-supported interventions that can be done at a community level and by driving
down the risk at an overall level, one is able to reduce theprevalence more than you ever would be in trying to serve
people on a one by one basis.
Dr. McCarroll: Do you think that the same risk factors areapplicable in both the civilian and military environments?
Dr. Slep: We just finished collecting the survey data at theuniversity and so we have not yet analyzed it. At this point,
there is nothing to suggest that there is any finding that is
unique to the military.
Dr. Heyman: We have two studies looking at transition toparenthood in civilian samples — intervention studies of aprevention program for parents of new babies.
We have another project funded through the National
Institute of Child Health and Human Development and the
National Institute of Dental and Craniofacial Research to doa prospective longitudinal study of a sample of families thatare in our county looking at the effects of family environment,
including detailed measures of the impact of conflict andviolence on the adults and kids in the family. We are looking
at the psychological impact, the impact on cognitive development and the impact of neuro-immune functioning andautonomic nervous system reactivity and oral health.
Dr. McCarroll: Thank you for the interview and for the work
you are doing for the military.
Drs. Heyman and Slep: You are welcome.

References
Heyman RE & Neidig PH. (1999). A comparison of spousal aggression prevalence rates in U.S. Army and civilian representative samples. Journal of Consulting and Clinical Psychology;
67:239-242.
Heyman RE & Slep AMS. (2010). Estimating prevalencesof sensitive problems from non-sensitive data. Journal ofInterpersonal Violence and published on March 17, 2010 as
doi:10.1177/0886260510362881
Straus, M. A. (1979). Measuring intrafamily conflict and violence. The conflict tactics scales. Journal of Marriage and theFamily; 41:75–88.

I think that one of the biggest problems is that with emotional
abuse you are only looking at the act. You have no way ofeasily being able to measure the impact of what was said orwhether it is emotionally abusive.

Joining Forces/Joining Families • 7

Websites of Interest
The Centers for Disease Control and Prevention (CDC) has
a manual for uniform child maltreatment definitions entitledChild Maltreatment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements (see http://www.
cdc.gov/ncipc/dvp/cmp/cmp-surveillance.htm). The definitions
and data elements in this document are intended to promote
and improve consistency of child maltreatment surveillance forpublic health practices. [Editor’s note: Surveillance is a type ofoversight that is used in public health to determine the extent
of a condition or disease. Case substantiation is performed bya jurisdictional body such as the military or a state.] The CDC
manual is designed to be used by state and local health department staff to assist in and provide a framework for the collection of data on child maltreatment. Since child maltreatment
is a matter of State (and sometimes Federal) law, CDC cannot
mandate these definitions whereas the military can do so within
its jurisdiction. The CDC definitions draw upon definitions
currently in the literature, and were adapted in collaboration
with a panel of experts on child maltreatment and public healthsurveillance. The definitions and data elements are designed
as flexible tools for developing an ongoing surveillance system.
Agencies that use the document can modify data elements to
fit their system. The website has links to other child maltreatment and health resources including data and statistics, injury,
violence prevention, and others.
The Report to Congress of the Fourth National Incidence
Study of Child Abuse and Neglect (NIS-4) can be found at
http://www.acf.hhs.gov/programs/opre/abuse_neglect/natl_incid/ nis4_report_congress_full_pdf_jan2010.pdf. The NIS-4 isa Congressionally mandated, periodic research project fundedby the United States Department of Health and Human Services
to provide updated estimates of the incidence of child abuse
and neglect in the United States and to measure changes inincidence from earlier NIS studies.

The Impact of Invisible Injuries, from page 5

It is particularly important for health-related language to
be at the level of the family member, especially children.
For those providers who are uncomfortable with thissometimes difficult task, help may be requested from other providers who are comfortable working with children
such as pediatricians and some mental health workers.
■■ Describe the types of support that can help the soldier
and the family over a long period of time. This requires
an explanation of the long-term course of the injury andthe types of support that may be necessary in different
periods of time. The provider can help the family directly
and refer them to services that may be required in the
future.

8 • Joining Forces/Joining Families■■ Provide a sense of hope and optimism for recovery.
Through the course of a difficult situation such as an invisible injury, soldiers and families will have to manage most
aspects of recovery on their own. A sense of realistic hope
can help them greatly during difficult times.

Acknowledgements:
This information is taken from a health communication
fact sheet, Courage to Care, developed by experts in injury
communication at the Center for the Study of TraumaticStress. To view electronic versions of this information in a
Courage to Care fact sheet that can be given to families withwhom you are working, go to: www.cstsonline.org and accessResources > Category Listing > Courage to Care series.

November 2010