9/14/2012

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FOCUS Family 

Resilience 

Training

Patrick Link, MD, MPH, MSHS

UCLA Semel Institute

September 17, 2012

No Disclosures

1

Acknowledgements

US Navy Bureau of Medicine and Surgery (BUMED)

US Marine Corps Combat Operational Stress Control 

Program (COSC)

Office of Military Community and Family Policy (OSD)

2

Acknowledgements

UCLA FOCUS Leadership:

• Patricia Lester, MD

• Lee Klosinski, PhD

• William Saltzman, PhD

• Norweeta Milburn, PhD

• Catherine Mogil, PsyD

• Blair Paley, PhD

• Peter Kung, MS

• Patrick Link, MD, MPH

• Edye Garcia, PsyD

• Jo Sornborger, PsyD

• FOCUS HQ Staff

• FOCUS Site Staff

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The impact of military family stressors, 

particularly parental deployment, on military 

children is a national public health concern.

4

Active Component

• 39% married with children

• 5.4% single parents

National Guard / Reserves

• 34% married with children

• 9.3% single parents

5

1. Department of Defense. Demographics 2010: Profile of the Military Community. 2010.

Military life challenges:

• Frequent family relocations

• Deployment of a family member to a combat theater

• Fears that this family member will be injured or killed 

Military children move, on average, six to nine times during 

their school career

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1. IOM. Returning home from Iraq and Afghanistan: preliminary assessment of readjustment needs 

of veterans, service members, and their families. 2010.

2. www.militaryk12partners.dodea.edu

The wars in Iraq and Afghanistan have 

significantly impacted military families.

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Over 2.1 million troops deployed to OEF/OIF/OND

• Roughly 44% are parents

Roughly 2 million children have been impacted by a parent 

deploying to OEF/OIF/OND

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1. Department of Defense. Report on the Impact of Deployment of Members of the Armed Forces on 

Their Dependent Children. October 2010.

2. www.militaryk12partners.dodea.edu

Unique features of these conflicts

• Multiple, prolonged deployments

• All-volunteer military

• Heavy reliance on National Guard and Reserves

• Higher proportion of female troops

• Higher survival rate among injured troops

• Continuous family communication during deployment

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1. IOM. Returning home from Iraq and Afghanistan: preliminary assessment of readjustment needs 

of veterans, service members, and their families. 2010.

2. Department of Defense. Report on the Impact of Deployment of Members of the Armed Forces on 

Their Dependent Children. October 2010.

Deployment to OEF/OIF/OND is associated with 

elevated rates of behavioral problems and 

emotional distress among the service members, 

non-deployed spouses, and their children.

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Parent deployment is associated with:

• Increased rates of mental health care visits among military children

• Increase number of mental illness diagnoses among military children

• Dose-response relationship between length of parent deployment 

and mental health diagnosis among children

• Elevated child depression and externalizing behaviors

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1. De Pedro KMT, et al. The Children of Military Service Members: Challenges, Supports, and Future 

Educational Research. Review of Educational Research. December 2011;81(4):566–618.

2. Gorman GH, et al. Wartime military deployment and increased pediatric mental and behavioral 

health complaints. Pediatrics. Dec 2010;126(6):1058-1066.

3. Mansfield AJ, et al. Deployment and mental health diagnoses among children of US Army 

personnel. Arch Pediatr Adolesc Med. Nov 2011;165(11):999-1005. 

4. Lester P, et al. The long war and parental combat deployment: effects on military children and athome spouses. J Am Acad Child Adolesc Psychiatry. Apr 2010;49(4):310-320.
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Families must be involved in any effort to 

significantly ameliorate the adverse effects of 

military-associated stressors on children.

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During deployment, social, academic, and emotional 

outcomes in military children are significantly impacted by 

the emotional and behavioral health of the non-deployed 

parent.

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1. Chandra A, et al. Children on the homefront: the experience of children from military families. 

Pediatrics. Jan 2010;125(1):16-25.

2. Chandra A, et al. The impact of parental deployment on child social and emotional functioning: 

perspectives of school staff. J Adolesc Health. Mar 2010;46(3):218-223.

3. Mmari KN, et al. When a Parent Goes Off to War: Exploring the Issues Faced by Adolescents and 

Their Families. Youth & Society. 2009;40(4):455-475.

4. Richardson A, et al. Effects of Soldiers’ Deployment on Children’s Academic Performance and 

Behavioral Health. Santa Monica, CA: RAND; 2011.

5. Flake EM, et al. The psychosocial effects of deployment on military children. J Dev Behav Pediatr. 

Aug 2009;30(4):271-278

Non-deployed caregiver status:

• His/her psychological distress is associated with child internalizing 

and externalizing symptoms

• His/her depression is associated with child depression symptoms

Active duty parent status:

• His/her posttraumatic stress symptoms are associated with child 

depression and internalizing and externalizing behaviors

• His/her depression and anxiety symptoms are associated with child 

internalizing behaviors

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1. Lester P, et al. The long war and parental combat deployment: effects on military children and athome spouses. J Am Acad Child Adolesc Psychiatry. Apr 2010;49(4):310-320.

Rapid response 

to a public 

health crisis.

2004: UCLA partners with USMC, 

Naval Medical Center, Madigan Army 

Medical Center

2008: Project FOCUS implementation 

by BUMED for USMC/USN initiated

2008: NMFA and UCLA partner to 

develop FOCUS Curriculum

2009: DOD Office of Military 

Community and Family Policy funds 

pilot for Army/Air Force families

2009: Collaboration with Military 

Family Research Institute: FOCUSCouples
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FOCUS

Traumatic 

Stress 

Research

Family 

Resilience 

Models

Foundational 

EvidenceBased 

Prevention 

Interventions Implementation 

Across the 

Prevention 

Continuum

Rapid 

Implementation 

and Scale-Up

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Sequelae of Trauma Include:

• Reexperiencing

• Avoidance

• Hyperarousal

• Inaccurate assimilation

• Inaccurate over-accommodation

Trauma-Informed Interventions:

• Education about effects of trauma 

• Management of trauma reminders

• Discourage avoidance

• Management of anxiety

• Address cognitive distortions

Traumatic 

Stress 

Research

FOCUS

18

What is family resilience? 

Coping with and overcoming 

adversity through:

• Open and effective communication

• Collaboration and problem solving

• Development of a shared sense of 

meaning

• Effective mobilization of support

Family Resilience Models

• Strengths-Based, Family-Centered

• Reduces stigma around care-seeking

Family 

Resilience 

Models

FOCUS

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Children with a depressed 

parent

• Beardslee, WR, et al. (2003). A family-based 

approach to the prevention of depressive symptoms 

in children at risk: Evidence of parental and child 

change. Pediatrics, 112: e119-e131.

Children with medically ill parent

• Rotheram-Borus, MJ, et al. (2004). Six year 

intervention outcomes for adolescent children of 

parents with HIV. Archives of Pediatrics & Adolescent 

Medicine, 158, 742-748.

• Lester, P, et al. (2008). TALK: Teens and adults 

learning to communicate. In C.W. LeCroy (Ed.), 

Evidence-based treatment manuals for children and 

adolescents. (pp. 170-285). New York, NY: Oxford 

University Press.

Children affected by war

• Layne, CM, et al. (2008). Effectiveness of a schoolbased group psychotherapy program for war-exposed 

adolescents: a randomized controlled trial. Journal of 

the American Academy of Child and Adolescent 

Psychiatry, 47, 1048-1062.

Foundational 

EvidenceBased 

Prevention 

Interventions

FOCUS
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FOCUS Core 

Components

Family real time check-up

Family level education

Family deployment timeline

Family level resiliency 

skills

 Family real time check-up: Customizes services to 

family needs

 Family level education: Combat Operational Stress 

Continuum, developmental guidance

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 Family level resiliency skills

 Emotional regulation

 Problem solving

 Communication

 Establishing Readiness and Goal setting 

 Managing deployment/trauma/loss reminders

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 Family deployment timeline

 Link skills to family (and child) experience

 Develop shared family meaning

 Bridge estrangements

 Encourage co-parenting – foundation for family 

leadership

 Appreciate children’s experiences 

 Clarify confusion and misunderstandings

 Maintain the parent-child relationship

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IOM Prevention Continuum

• Universal

• Selective

• Indicated

Marine Corps COSC Model

FOCUS

Implementation 

Across the 

Prevention 

Continuum

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IOM Prevention Taxonomy

Three Target Populations for Prevention Interventions

Everyone in a population Subgroups of the 

population at heightened

risk

Individuals suffering 

subclinical distress or 

impairment

1. IOM. Reducing risks for mental disorders : frontiers for preventive intervention research.1994. 

2. Slide adapted from presentation given by Dr. William Nash, Marine Corps COSC Program

Community and 

Leadership Briefs

Educational 

Workshops

Consultations

Skill Building 

Groups

Family 

Resiliency 

Training

FOCUS Suite of Services

Universal

Indicated
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FOCUS: Individual Family 

Training

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Sessions 1 & 2 Sessions 3 & 4 Session 5 Sessions 6  8

Parents only Children only Parents only Family Sessions

Parent Timeline

 Before Deploy 1 Home Deploy 2 Past Month

+

-

Wildfires at 

home

Departure 

Delay

Family 

avoidant

Daughter 

New Fears Painful 

Goodbye

Delayed 

Homecoming 

Child Timeline

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Centrally implemented from UCLA, in 

partnership with military branches

Defined implementation stages

Placement of a local team on each 

installation

Identification of a FOCUS Point-ofContact for each installation

Outcomes-based management

Cloud computing system

Grew from 8 

initial sites in 

2008 to over 20 

installations by 

2011.

Rapid 

Implementation 

and Scale-Up

FOCUS
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Project FOCUS Sites

 California

 MCB Camp Pendleton

 MCAGCC Twentynine Palms

 Naval Base Ventura County

 Naval Base San Diego

 NSW/EOD West

 Hawaii

 MCB Hawaii

 Joint Base Pearl Harbor-Hickam

 Schofield Barracks

 Wheeler Army Airfield

 Japan 

 MCB Okinawa

 Kadena AB

 Torii Station

 Mississippi

 Naval CBC Gulfport

 Keesler Air Force Base

 Camp Shelby

 North Carolina

 MCB Camp Lejeune

 Virginia

 MCB Quantico

 NAVSTA Norfolk

 NSW/EOD East

 Washington

 NAS Whidbey Island

 Joint Base Lewis-McChord

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FOCUS 

Evaluation

Pre-Post Evaluations from 

Project FOCUS

On-going RCT

Implementation 

Evaluations

Project FOCUS Evaluation Plan

 Program evaluation via real-time family assessments

 Entry, exit, and follow-up 

 Family member satisfaction

 Perception of change

 SDQ, PCL, BSI, Kid Cope, FAD, GAF

 Multiple reporters

 Impact over time

 Flagging system for suicide risk

 Interventions tailored to assessment results

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FOCUS Impact on Family 

Psychological Health

 Children reported increased use of positive coping strategies in dealing with 

stressful events, including significant increases in problem solving (p = .0001) and 

emotional regulation (p = .005).

 Parents reported reductions in child conduct problems (p<.0001), reductions in 

emotional symptoms (p=.001), such as anxiety and depressive symptoms, and 

improvements in child prosocial behaviors (p=.01).

 Parents reported decreased levels of their own depression (p<.01) and anxiety 

symptoms (p=.002).

 Family functioning improved (problem solving, communication, roles, affective 

responsiveness, behavior control) (p < .0001).

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1. Lester P, et al. Evaluation of a family-centered prevention intervention for military children and 

families facing wartime deployments. Am J Public Health. Mar 2012;102 Suppl 1:S48-54.
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Mean Parent Distress at Intake 

and Post-Intervention

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PARENT 

BSI

Non Active Duty Parent Active Duty Parent

Mean (SD) Pre Posta Mean

Change

(t-valuea)

Norm

Female

Pre Posta Mean

Change

(t-valuea) 

Norm

Male

Global 

Severity 

Index

10.19

(10.15)

5.28

(5.89)

-4.84***

(-7.77)

8.00 8.50

(9.43)

4.04

(6.41)

-4.42***

(-4.72)

5.00

Anxiety 3.96

(3.99)

2.22

(2.55)

-1.74***

(-6.64)

2.50 3.19

(3.56)

1.90

(2.79)

-1.31**

(-3.32)

3.00

Depression 4.09

(4.17)

1.94

(2.84)

-2.15***

(-8.12)

3.00 3.63

(4.03)

1.24

(2.11)

-2.39***

(-5.56)

3.00

*p<.05 **p<.01 ***p<.001

BSI = Brief Symptom Inventory

Prevalence of Clinically Significant 

Anxiety and Depression

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0%

10%

20%

30%

Anxiety** Depression*** Anxiety** Depression***

Non-Active Duty Caregiver Active Duty Caregiver

Military Status

Intake Post-Intervention

 **p<.01 

 **p<.001

Brief Symptom Inventory (BSI)

Prevalence of Unhealthy Family 

Adjustment

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McMaster Family Assessment Device (FAD)

44%

29%

54%

39%

0

10

20

30

40

50

60

Non-Active Duty Caregiver

Intake Post Intervention Intake Post Intervention

Active Duty Caregiver

N= 131

N= 86

N= 90

N= 64

Percentage in Unhealthy Range

Prevalence of Children with 

Significant Difficulties

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Strengths and Difficulties Questionnaire (SDQ)

*** p < .001

35.5%

25.4%

14.4%

9.7%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Boys Girls

Intake Post-Intervention

***

***
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FOCUS Services: Family 

Satisfaction Ratings

Individual Family Resiliency Training

 Adults reported mean satisfaction scores between 6.5-6.7 on 

scale of 1-7 (1=lowest---7=highest)

Group Family Resiliency Skill Building

 Adults provided strongly positive feedback on the response 

items, with mean responses from 1.3 to 1.6 on a scale of 1-5 

(1=strongly agree, 5=strongly disagree) 

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FOCUS 

Adaptations

Couples (MFRI)

Early Childhood

Wounded Warriors (USUHS)

“Purple” Expansion (OSD)

FOCUS World

Veterans

National Guard / Reserves

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Veterans, National Guard, and 

Reserves

UCLA Welcome Back Veterans

 Randomized Controlled Trials:

 Individual family resiliency training (IFRT) vs. waitlist

 Couple Counseling for Combat Veterans (CCCV) vs. waitlist

Operation Mend / UCLA WBV

 Community Capacity Building

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Veterans, National Guard, and 

Reserves

VA Long Beach HCS FOCUS Couples Pilot

VA FOCUS Parenting Pilot

LAUSD / LACDMH Pilot

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FOCUS 

Proposals

FOCUS Home Visiting, 

Early Childhood Model

FOCUS School-Based 

Model

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UCLA Nathanson Family Resilience Center

www.focusproject.org