Recent studies have confirmed that repeated wartime deployment of a parent exacts a toll on military children and families and that the quality and functionality of familial relations is linked to ...force preservation and readiness. As a result, family-centered care has increasingly become a priority across the military health system. FOCUS (Families OverComing Under Stress), a family-centered, resilience-enhancing program developed by a team at UCLA and Harvard Schools of Medicine, is a primary initiative in this movement. In a large-scale implementation project initiated by the Bureau of Navy Medicine, FOCUS has been delivered to thousands of Navy, Marine, Navy Special Warfare, Army, and Air Force families since 2008. This article describes the theoretical and empirical foundation and rationale for FOCUS, which is rooted in a broad conception of family resilience. We review the literature on family resilience, noting that an important next step in building a clinically useful theory of family resilience is to move beyond developing broad “shopping lists” of risk indicators by proposing specific mechanisms of risk and resilience. Based on the literature, we propose five primary risk mechanisms for military families and common negative “chain reaction” pathways through which they undermine the resilience of families contending with wartime deployments and parental injury. In addition, we propose specific mechanisms that mobilize and enhance resilience in military families and that comprise central features of the FOCUS Program. We describe these resilience-enhancing mechanisms in detail, followed by a discussion of the ways in which evaluation data from the program’s first 2 years of operation supports the proposed model and the specified mechanisms of action.
This article describes the core principles and components of the FOCUS Program, a brief intervention for families contending with single or multiple trauma or loss events. It has been administered ...nationally to thousands of military family members since 2008 and has been implemented in a wide range of civilian community, medical, clinical, and school settings. Developed by a team from the UCLA and Harvard Medical Schools, the FOCUS Program provides a structured approach for joining with traditional and nontraditional families, crafting shared goals, and then working with parents, children, and the entire family to build communication, make meaning out of traumatic experiences, and practice specific skills that support family resilience. Through a narrative sharing process, each family member tells his or her story and constructs a timeline that graphically captures the experience and provides a platform for family discussions on points of convergence and divergence. This narrative sharing process is first done with the parents and then the children and then the family as a whole. The aim is to build perspective‐taking skills and mutual understanding, to reduce distortions and misattributions, and to bridge estrangement between family members. Previous studies have confirmed that families participating in this brief program report reductions in distress and symptomatic behaviors for both parents and children and increases in child pro‐social behaviors and family resilient processes.
En este artículo se describen los principios y los componentes fundamentales del programa FOCUS, una breve intervención para las familias que luchan contra una o varias circunstancias de trauma o pérdida. Dicho programa se ha suministrado a nivel nacional a miles de familiares de militares desde 2008, y se ha puesto en práctica en una amplia variedad de entornos civiles comunitarios, médicos, clínicos y escolares. Desarrollado por un equipo de las facultades de medicina de la UCLA y de Harvard, el programa FOCUS ofrece un enfoque estructurado para reunirse con familias tradicionales y no tradicionales, fijar objetivos comunes, y luego trabajar con los padres, los niños y toda la familia para facilitar la comunicación, dar sentido a las experiencias traumatizantes, y practicar habilidades específicas que estimulen la resiliencia familiar. A través de un proceso de intercambio de relatos, cada familiar cuenta su historia y construye una cronología que plasma gráficamente la experiencia y brinda una plataforma para charlas familiares sobre puntos de convergencia y divergencia. Este proceso de intercambio de relatos se realiza primero con los padres, luego con los niños y finalmente con toda la familia. La finalidad es fortalecer las habilidades de adopción de puntos de vista y la comprensión mutua, disminuir las distorsiones y las atribuciones erradas, y acercar a los familiares distanciados. Estudios previos han confirmado que las familias que participan en este breve programa informan disminuciones de la angustia y de los comportamientos sintomáticos en ambos padres y en los niños, así como mejoras en las conductas prosociales de los niños y en los procesos de resiliencia familiar.
本文描述了FOCUS 项目的核心原则和组成部分。FOCUS是一个简短的针对面临单个或多重创伤或失去经历家庭的干预项目。从2008年其该项目在全国范围内应用于上千个军人家庭,并广泛在平民社区,医疗,临床和学校背景下得到实施。FOCUS项目由UCLA和哈佛医学院的一个小组发展起来,为联合传统和非传统家庭,制定共同目标,与家长,儿童以及整个家庭一起建立沟通渠道,理解创伤经历,并且实践支持家庭复原力的特定技巧提供了结构化方案。通过一个叙事分享过程,每个家庭成员讲述他/她的故事并构建一个时间轴来形象的捕捉其经历并为针对融合和分歧的家庭讨论提供平台。该叙事分享过程首先由家长完成,其次由孩子完成,最后由家庭整体完成。其目标是构建视角技能和相互理解,减少歪曲和错误归属,并在疏远的家庭成员之间架起桥梁。之前的研究已经证实参与该简短项目的家庭其家长和孩子的困扰以及症状行为都有所减轻,而其孩子的亲社会性和家庭复原力过程有所增强。
We evaluated the Families OverComing Under Stress program, which provides resiliency training designed to enhance family psychological health in US military families affected by combat- and ...deployment-related stress.
We performed a secondary analysis of Families OverComing Under Stress program evaluation data that was collected between July 2008 and February 2010 at 11 military installations in the United States and Japan. We present data at baseline for 488 unique families (742 parents and 873 children) and pre-post outcomes for 331 families.
Family members reported high levels of satisfaction with the program and positive impact on parent-child indicators. Psychological distress levels were elevated for service members, civilian parents, and children at program entry compared with community norms. Change scores showed significant improvements across all measures for service member and civilian parents and their children (P < .001).
Evaluation data provided preliminary support for a strength-based, trauma-informed military family prevention program to promote resiliency and mitigate the impact of wartime deployment stress.
Background EUS-guided FNA has been well documented to aid in the diagnosis of subepithelial lesions by providing cytologic material. Studies to date evaluating the sensitivity of EUS-FNA for the ...diagnosis of GI stromal cell tumors (GIST) have been small, and few have relied on surgical histologic diagnosis as the reference standard. Objective Our purpose was to determine the diagnostic yield and sensitivity of EUS-FNA for the diagnosis of GIST and to identify EUS features of GIST that are predictive of the ability to obtain adequate tissue by EUS-FNA. Design All patients with histologically confirmed, c-kit –positive GIST who underwent EUS-FNA from 1998 to 2006 were reviewed. EUS images were examined for mass size, shape, location, wall layer, heterogeneity, echogenicity, cystic spaces, lobulation, ulceration, and central umbilication. Needle gauge, number of needle passes, and presence of a cytologist during the EUS-FNA were recorded. Results A total of 37 patients (29 with diagnostic FNA cytology; 8 with nondiagnostic cytology) met the inclusion criteria. The diagnostic yield and sensitivity of EUS-FNA cytology for the diagnosis of GIST was 78.4% (29/37). The sensitivity was 84.4% (27/32) for GISTs located in the stomach, but poor for lesions located in the duodenum because none of these tumors yielded diagnostic cytology (n = 3). An increase in size up to 10 cm, round/oval shape, and identification of the origin of GIST within a specific sonographic wall layer were statistically significant in their ability to predict adequate tissue yield. Conclusions The sensitivity of EUS-FNA cytology for the diagnosis of GIST is 78.4% and is influenced by size, location, shape, and layer of origin.
Background The most common complication of uncovered biliary self-expandable metal stents (SEMSs) is tumor ingrowth. The addition of an impenetrable covering may prolong stent patency. Objective To ...compare stent patency between uncovered and partially covered SEMSs in malignant biliary obstruction. Design Multicenter randomized trial. Setting Four teaching hospitals. Patients Adults with inoperable distal malignant biliary obstruction. Interventions Uncovered or partially covered SEMS insertion. Main outcome measures Time to recurrent biliary obstruction, patient survival, serious adverse events, and mechanism of recurrent biliary obstruction. Results From October 2002 to May 2008, 129 patients were randomized. Recurrent biliary obstruction was observed in 11 of 61 uncovered SEMSs (18%) and 20 of 68 partially covered SEMSs (29%). The median times to recurrent biliary obstruction were 711 days and 357 days for the uncovered and partially covered SEMS groups, respectively ( P = .530). Median patient survival was 239 days for the uncovered SEMS and 227 days for the partially covered SEMS groups ( P = .997). Serious adverse events occurred in 27 (44%) and 42 (62%) patients in the uncovered and partially covered SEMS groups, respectively ( P = .046). None of the uncovered and 8 (12%) of the partially covered SEMSs migrated ( P = .0061). Limitations Intended sample size was not reached. Allocation to treatment groups was unequal. Conclusions There was no significant difference in time to recurrent biliary obstruction or patient survival between the partially covered and uncovered SEMS groups. Partially covered SEMSs were associated with more serious adverse events, particularly migration. (Clinical trial registration number: NCT01047332 .)
To evaluate the comparative effectiveness of a classroom-based psychoeducation and skills intervention (tier 1) and a school-based trauma- and grief-focused group treatment (tier 2) of a three-tiered ...mental health program for adolescents exposed to severe war-related trauma, traumatic bereavement, and postwar adversity.
A total of 127 war-exposed and predominantly ethnic Muslim secondary school students attending 10 schools in central Bosnia who reported severe symptoms of posttraumatic stress disorder (PTSD), depression, or maladaptive grief and significant impairment in school or relationships were randomly assigned to one of two experimental conditions. These included either an active-treatment comparison condition (tier 1), consisting of a classroom-based psychoeducation and skills intervention alone (n = 61, 66% girls, mean age 16.0 years, SD 1.13) or a treatment condition composed of both the classroom-based intervention and a 17-session manual-based group therapy intervention (tier 2), trauma and grief component therapy for adolescents (n = 66, 63% girls, mean age 15.9 years, SD 1.11). Both interventions were implemented throughout the school year. Distressed students who were excluded from the study due to acute risk for harm (n = 9) were referred for community-based mental health services (tier 3).
Program effectiveness was measured via reductions in symptoms of PTSD, depression, and maladaptive grief assessed at pretreatment, posttreatment, and 4-month follow-up. Analysis of mean-level treatment effects showed significant pre- to posttreatment and posttreatment to 4-month follow-up reductions in PTSD and depression symptoms in both the treatment and comparison conditions. Significant pre- to posttreatment reductions in maladaptive grief reactions were found only in the treatment condition. Analyzed at the individual case level, the percentages of students in the treatment condition who reported significant (p <.05) pre- to posttreatment reductions in PTSD symptoms (58% at posttreatment, 81% at 4-month follow-up) compare favorably to those reported in controlled treatment efficacy trials, whereas the percentages who reported significant reductions in depression symptoms (23% at posttreatment, 61% at follow-up) are comparable to, or higher than, those found in community treatment settings. Lower but substantial percentages of significant symptom reduction were found for PTSD (33% at posttreatment, 48% at follow-up) and depression symptoms (13% at posttreatment; 47% at follow-up) in students in the comparison condition. The odds of significant symptom reduction were higher for PTSD symptoms at both posttreatment and 4-month follow-up and for maladaptive grief at posttreatment (no follow-up was conducted on maladaptive grief). Rates of significantly worsened cases were generally rare in both the treatment and comparison conditions.
A three-tiered, integrative mental health program composed of schoolwide dissemination of psychoeducation and coping skills (tier 1), specialized trauma- and grief-focused intervention for severely traumatized and traumatically bereaved youths (tier 2), and referral of youths at acute risk for community-based mental health services (tier 3) constitutes an effective and efficient method for promoting adolescent recovery in postwar settings.
We draw upon family resilience and narrative theory to describe an evidence-based method for intervening with military families who are impacted by multiple wartime deployments and psychological, ...stress-related, or physical parental injuries. Conceptual models of familial resilience provide a guide for understanding the mechanics of how families respond and recover from exposure to extreme events, and underscore the role of specific family processes and interaction patterns in promoting resilient capabilities. Leading family theorists propose that the family’s ability to make meaning of stressful and traumatic events and nurture protective beliefs are critical aspects of resilient adaptation. We first review general theoretical and empirical research contributions to understanding family resilience, giving special attention to the circumstances, challenges, needs, and strengths of American military families. Therapeutic narrative studies illustrate the processes through which family members acquire meaning-making capacities, and point to the essential role of parents’ in facilitating discussions of stressful experiences and co-constructing coherent and meaningful narratives. This helps children to make sense of these experiences and develop capacities for emotion regulation and coping. Family-based narrative approaches provide a structured opportunity to elicit parents’ and children’s individual narratives, assemble divergent storylines into a shared family narrative, and thereby enhance members’ capacity to make meaning of stressful experiences and adopt beliefs that support adaptation and growth. We discuss how family narratives can help to bridge intra-familial estrangements and re-engage communication and support processes that have been undermined by stress, trauma, or loss. We conclude by describing a family-based narrative intervention currently in use with thousands of military children and families across the USA.
Over the past decade, studies into the impact of wartime deployment and related adversities on service members and their families have offered empirical support for systemic models of family ...functioning and a more nuanced understanding of the mechanisms by which stress and trauma reverberate across family and partner relationships. They have also advanced our understanding of the ways in which families may contribute to the resilience of children and parents contending with the stressors of serial deployments and parental physical and psychological injuries. This study is the latest in a series designed to further clarify the systemic functioning of military families and to explicate the role of resilient family processes in reducing symptoms of distress and poor adaptation among family members. Drawing upon the implementation of the Families Overcoming Under Stress (FOCUS) Family Resilience Program at 14 active‐duty military installations across the United States, structural equation modeling was conducted with data from 434 marine and navy active‐duty families who participated in the FOCUS program. The goal was to better understand the ways in which parental distress reverberates across military family systems and, through longitudinal path analytic modeling, determine the pathways of program impact on parental distress. The findings indicated significant cross‐influence of distress between the military and civilian parents within families, families with more distressed military parents were more likely to sustain participation in the program, and reductions in distress among both military and civilian parents were significantly mediated by improvements in resilient family processes. These results are consistent with family systemic and resilient models that support preventive interventions designed to enhance family resilient processes as an important part of comprehensive services for distressed military families.
Durante la última década, los estudios sobre el efecto que tiene la movilización militar en tiempos de guerra y las adversidades relacionadas con dicha movilización en los militares y en sus familias, han servido como respaldo empírico para modelos sistémicos de funcionamiento familiar y para comprender más sutilmente los mecanismos mediante los cuales el estrés y el trauma repercuten en las relaciones con la familia y la pareja. También han potenciado nuestra opinión sobre las maneras en las cuales las familias pueden contribuir a la resiliencia de los niños y los padres que luchan contra los factores de estrés producidos por las movilizaciones militares en serie y los daños psicológicos y físicos de los padres. El presente estudio es el último en una serie diseñada para aclarar mejor el funcionamiento sistémico de las familias de militares y para explicar la función que cumplen los procesos familiares resilientes a la hora de disminuir los síntomas de angustia y de una adaptación deficiente entre los miembros de la familia. Sobre la base de la implementación del “Programa FOCUS de Resiliencia Familiar” (FOCUS Family Resilience Program) en 14 instalaciones militares en servicio activo en distintos puntos de Estados Unidos, se realizaron modelos de ecuaciones estructurales con datos de 434 familias de infantes de marina de la armada en servicio activo que participaron en el programa FOCUS. El objetivo era comprender mejor las maneras en las cuales la angustia de los padres repercute en los sistemas familiares de los militares y, a través del modelado analítico de trayectoria longitudinal, determinar las vías del efecto del programa en la angustia de los padres. Los resultados indicaron una influencia cruzada significativa de la angustia entre los padres militares y los civiles dentro de las familias; las familias con padres militares más angustiados fueron más propensas a mantener su participación en el programa; y las reducciones de la angustia entre los padres militares y los civiles estuvieron mediadas considerablemente por mejoras en los procesos familiares resilientes. Estos resultados coinciden con los modelos familiares resilientes y sistémicos que fomentan las intervenciones preventivas diseñadas para mejorar los procesos familiares resilientes como una parte importante de los servicios integrales para familias militares angustiadas.
在过去的十年中,关于战时部署和其相关的困难对于服役军人及其家庭影响的研究为家庭功能系统模型提供了实证支持,并对压力和创伤在家庭和伴侣关系中的传递机制提出了更细微的理解。这些研究还促进了我们对于家庭是如何帮助那些与一系列部署和家长身体,心理伤害抗衡的儿童和家长增强韧性的理解。该研究是一系列针对进一步阐明军人家庭系统功能以及解释韧性家庭过程在减轻压力和家庭成员适应不良现象中的作用的研究中最新的一个。根据在全美国14个现役军队设施中实施的FOCUS家庭韧性项目,我们使用从434个参与FOCUS项目的海军以及海军陆战队家庭中得出的数据,构建了结构方程式模型。其目的是更好的理解家长困扰如何在军人家庭系统中传递,并通过纵向途径分析模型,决定该项目对家长困扰影响的途径。研究发现表明家庭内部军人家长和平民家长之间存在明显困扰相互影响。有受困扰军人家长的家庭更有可能持续参与项目;军人和平民家长中困扰减轻明显受到韧性家庭过程的影响。这些结果与支持旨在将提升家庭韧性过程作为针对受困扰军人家庭全面服务的一个重要部分的家庭系统和韧性模型一致。
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Study objective Randomized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics-first is safe. No trial has evaluated outpatient treatment and no US randomized ...trial has been conducted, to our knowledge. This pilot study assessed feasibility of a multicenter US study comparing antibiotics-first, including outpatient management, with appendectomy. Methods Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were randomized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole. Stable antibiotics-first-treated participants older than 13 years could be discharged after greater than or equal to 6-hour emergency department (ED) observation with next-day follow-up. Outcomes included 1-month major complication rate (primary) and hospital duration, pain, disability, quality of life, and hospital charges, and antibiotics-first appendectomy rate. Results Of 48 eligible patients, 30 (62.5%) consented, of whom 16 (53.3%) were randomized to antibiotics-first and 14 (46.7%) to appendectomy. Median age was 33 years (range 9 to 73 years), median WBC count was 15,000/μL (range 6,200 to 23,100/μL), and median computed tomography appendiceal diameter was 10 mm (range 7 to 18 mm). Of 15 antibiotic-treated adults, 14 (93.3%) were discharged from the ED and all had symptom resolution. At 1 month, major complications occurred in 2 appendectomy participants (14.3%; 95% confidence interval CI 1.8% to 42.8%) and 1 antibiotics-first participant (6.3%; 95% CI 0.2% to 30.2%). Antibiotics-first participants had less total hospital time than appendectomy participants, 16.2 versus 42.1 hours, respectively. Antibiotics-first-treated participants had less pain and disability. During median 12-month follow-up, 2 of 15 antibiotics-first-treated participants (13.3%; 95% CI 3.7% to 37.9%) developed appendicitis and 1 was treated successfully with antibiotics; 1 had appendectomy. No more major complications occurred in either group. Conclusion A multicenter US trial comparing antibiotics-first to appendectomy, including outpatient management, is feasible to evaluate efficacy and safety.
To date, the US military has made major strides in acknowledging and therapeutically addressing trauma and post-traumatic stress disorder (PTSD) in service members and their families. However, given ...the nature of warfare and high rates of losses sustained by both military members (e.g., deaths of fellow unit members) and military families (e.g., loss of a young parent who served in the military), as well as the ongoing threat of loss that military families face during deployment, we propose that a similar focus on
grief
is also needed to properly understand and address many of the challenges encountered by bereaved service members, spouses, and children. In this article, we describe a newly developed theory of grief (multidimensional grief theory) and apply it to the task of exploring major features of military-related experiences during the phases of
deployment
,
reintegration
, and
the aftermath of combat death
—especially as they impact children. We also describe implications for designing preventive interventions during each phase and conclude with recommended avenues for future research. Primary aims are to illustrate: (1) the indispensable role of theory in guiding efforts to describe, explain, predict, prevent, and treat maladaptive grief in military service members, children, and families; (2) the relevance of multidimensional grief theory for addressing both losses due to
physical death
as well as losses brought about by
extended physical separations
to which military children and families are exposed during and after deployment; and (3) a focus on military-related grief as a much-needed complement to an already-established focus on military-related PTSD.
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