2. Leading Change: A Plan for SAMHSA’s Roles and Actions Strategic Initiative #3: Military Families Stephanie Weaver, MSG, National Guard Counterdrug Liaison to SAMHSA

3. Welcome! The CAPT’s Southeast Resource Team Shannon Greer IT Specialist Iris E. Smith Coordinator Charline McCord T/TA Coordinator Adela Santana T/TA Specialist Carol A. Hagen Epidemiologist Carlos Pavao T/TA Specialist Deirdre Danahar T/TA Specialist LaShawn Martin Sr. Admin Assistant Donna Dent Associate Coordinator Bertha Gorham Evaluator Penny Deavers T/TA Specialist

4. Stephanie Weaver, MSG, National Guard Counterdrug Liaison to SAMHSA

5. Military Families Strategic Initiative (SI) Support America’s service men and women—Active Duty, National Guard, Reserve, and Veterans—together with their families and communities by leading efforts to ensure needed behavioral health services are accessible and outcomes are positive.

6. Goals of Military Families SI Goal 3.1: Improve military families’ access to community- based behavioral health care through coordination among SAMHSA, TRICARE, Department of Defense (DoD), and Veterans Health Administration services. Goal 3.2: Improve the quality of behavioral health prevention, treatment, and recovery support services by helping providers respond to the needs within the military family culture.

7. Goals of Military Families SI Goal 3.3: Promote the behavioral health of military families with programs and evidence-based practices that support their resilience and emotional health and prevent suicide. Goal 3.4: Develop an effective and seamless behavioral health service system for military families through coordination of policies and resources across Federal, national, State, Territorial, Tribal, and local organizations.

8. Priorities of Military Families SI Continue TRICARE credentialing and provider network development. Produce Policy academies and follow-up TA/support. Make available Military culture training for behavioral health (BH) providers/professional groups.

9. Priorities of Military Families SI Collect data regarding “military families” in grants and surveillance surveys, consistent with HHS and all Departments’ efforts, if possible. Focus on military families in other SIs, especially prevention and trauma & justice. Support other aspects of psychological health chapter of the President’s Report “Strengthening Our Military Families”.

10. Military Families A Sampling of Accomplishments Strong partnership with VA: National Suicide Prevention Lifeline and Veterans Crisis Line; Interagency Agreement. Member of Military/Veteran Task Force of National Action Alliance for Suicide Prevention, leading the momentum to engage faith-based communities in supporting Military Families. Conducted third Service Members, Veterans and their Families Policy Academy in December 2011.

11. Military Families A Sampling of Accomplishments Manage a national technical assistance center to help states/territories enhance their behavioral health care systems for service members, veterans, and their families. 22 out of the 30 current Access to Recovery (ATR) grantees have designated National Guard, Reserves, Active Duty, Veterans and their families as a priority population (treatment vouchers for substance abuse treatment). Military Cultural Competence: Train ATR grantees (webinars and Tennessee’s Operation Immersion). Operation Immersion has spread to at least four other states.

12. States Completed Policy Academy

13. Current Grants Support Military/Veterans Access to recovery (30 states/tribes) most have identified a priority to serve Military / Veteran and families –Voucher program for SA Tx and recovery support services Jail Diversion for mil/vet population –Jail Diversion programs from arrest to entry in FL, NM, NC, OH, PA, RI, and TX http://gainscenter.samhsa.gov/html/vets/vets_justice.asp http://gainscenter.samhsa.gov/html/vets/vets_justice.asp Military Families TA center –Provides TA to state level entities for improving the BH needs of Military / Veterans, and families National Center for Traumatic Stress Network –Resource center focused on Trauma and Military / Veterans, and families –http://www.nctsn.org/resources/topics/military-children-and-familieshttp://www.nctsn.org/resources/topics/military-children-and-families

14. Questions? Stephanie Weaver, MSG National Guard Counterdrug Liaison to SAMHSA 1 Choke Cherry Rd, Room 8-1006 Rockville, MD 20857 Email: Stephanie.weaver@samhsa.hhs.govStephanie.weaver@samhsa.hhs.gov Alt Email: stephanie.weaver@us.army.milstephanie.weaver@us.army.mil Phone: (240) 276-2233

15. www.militaryfamilies.psu.edu Using Evidence in Programs & Practices to Support Military Families Daniel F. Perkins, Ph.D. Professor of Family and Youth Resiliency and Policy Director of the Clearinghouse for Military Family Readiness The Pennsylvania State University

16. Greetings from: State College, Pennsylvania

18. Workshop Objectives Understand the Clearinghouse for Military Family Readiness Understand what “evidence-based” means and why it is important to military family-based interventions Review resiliency and how it relates to readiness Use appropriate strategies to identify, evaluate, and apply evidence- based programs/practices for military families in their communities Understand how to locate and use data about military families Other Tasks: Review military demographics Review important insights related to the military

19. Military Family Readiness Prepared to effectively navigate the challenges of daily living experienced in the unique context of military service; Equipped with the skills to competently function in the face of challenges; Awareness of the supportive resources available; and Able to utilize these skills and resources in managing challenges. Ready families contribute directly to the service member’s state of readiness to accomplish the mission at hand.

20. A distribution and implementation framework for professionals (practitioners and researchers) supporting military families. The Clearinghouse

21. The Clearinghouse is Designed to Promote and Support: (1)the use of research-based decision-making; (2)the selection, dissemination, and implementation of evidence- based or evidence-informed programs and practices; (3)the evaluation (process and outcome) of programs and the identification or creation of metrics; and (4)the continued education of professionals assisting military families.

22. The Clearinghouse Is an interactive resource center of research-based, real-world tested programs and practices for professionals to make informed decisions regarding how best to serve military families. Synthesizes existing and emerging research from a variety of sources. Provides quality technical assistance and proactive problem- solving services focused on implementation. Identifies metrics and conducts process and outcome evaluations of existing program.

23. It is not enough to be busy. So are the ants. The question is: What are we busy about? Henry David Thoreau

24. http://www.naswdc.org/practice/adolescent_health/shift/documents/case/Prevalence%20Data/Ed%201.swf What Does EVIDENCE-BASED Mean? Activity

25.  Evidence-based programs : theoretically sound innovations that have been evaluated using a well-designed study and have demonstrated significant improvements in the targeted outcome(s).  Evidence-informed practices: the integration of experience, judgment and expertise with the best available external evidence from systematic research.  Evidence-based practices as programs: being able to define questions search for answers evaluate the evidence apply the findings together with clients so that your process leads to the best possible intervention Evidence-Based: What Does it Mean?

26. Vulnerable Families? What are vulnerable families? Vulnerable families are defined as families that are more susceptible to harm because of the stress in their lives. Example of stressors?

27. Resilience is primarily defined in terms of the “Presence of protective factors (personal, social, familial, and institutional safely nets)” which address risk factors and enable individuals and families to resist life stress (adversity). Readiness = Resiliency Kaplan et al.(1996, p. 158)

28. Risk factors are causes of undesirable developmental outcomes. Risk factors generate negative change in or persistent (i.e., chronic) poor behavior or functioning. Risk factors are measurable characteristics or qualities of individuals, interpersonal relationships, contexts, and institutions. Risk Factors

29. Protective Factors Protective factor buffers or prevents the impact of the risk factor. Protective factors are characteristics with individuals, families, and social settings that serve as shields against risk factors and promote coping skills.

30. Vulnerable But Invincible (1982) Overcoming the Odds (1992) Journeys from Childhood to Mid-Life (2001) 1955 BIRTH COHORT RISKS Poverty Parental Discord Parental Psychopathology Perinatal Stress High Risk AGE 18 HIGH RISK BEHAVIORS Delinquencies Mental Health Problems Pregnancies Resilient High Risk AGE 32 & 41 SUCCESS IN Relationships/Marriage Work Parenthood Resilient High Risk Risk and Resilience The Kauai Study: Werner & Smith

31. The RISK/Protective Factor Activity Supplies: Paper

32. Some Resources for Professionals Working with Military Families – Penn State Clearinghouse for Military Family Readiness www.militaryfamilies.psu.edu www.militaryfamilies.psu.edu – University of Arizona, REACH – Supporting Military Families Through Research and Outreach http://reachmilitaryfamilies.arizona.edu/ http://reachmilitaryfamilies.arizona.edu/ – Defense Technical Information Center http://www.dtic.mil/dtic/http://www.dtic.mil/dtic/ Including list of resources to decipher government and military acronyms and abbreviations http://www.dtic.mil/dtic/customer/acronyms.html http://www.dtic.mil/dtic/customer/acronyms.html – National Military Family Association www.militaryfamily.orgwww.militaryfamily.org Including an intro to military culture http://www.militaryfamily.org/get-info/new-to-military/military- culture/ http://www.militaryfamily.org/get-info/new-to-military/military- culture/

33. AD Military Demographics The men and women of America's all-volunteer military do not come disproportionately from disadvantaged backgrounds. Both active-duty enlisted troops and officers come disproportionately from high-income neighborhoods: a trend that has increased since 9/11. America's troops are also highly educated. The racial composition of the military is similar to that of the civilian population, although whites and blacks are slightly overrepresented among enlisted recruits. Active Duty: Army (39%), AF (23%), Navy (22%), Marine Corps (14%). National Guard & Reserve: AR (26%) ANG (34%), AFR (10%), AFNG (10%), NR (10%), MCR (9%), CGR (1%). Watkins, Sherk, & Watkins. (2008). Who Serves in the U.S. Military? The Demographics of Enlisted Troops and Officers. The Heritage Foundation. http://www.heritage.org/Research/Reports/2008/08/Who-Serves-in-the-US-Military-The-Demographics-of-Enlisted-Troops- and-Officers Demographics 2010: Profile of Military Community (2011). Defense Manpower Data Center.

34. Active and Reserve Components Active Component (AC): Works “full-time” for the military Full-time hours, full-time benefits On-call 24 hrs/day, 365 days a year Permanent force of the military 1.38 million members for FY2006 (includes Enlisted, Warrant Officers, Commissioned Officers, Cadets/Midshipmen) Reserve Component (RC): Reserves and National Guard Part-time duties One weekend per month, 2 weeks per year Can be activated to augment AC 7 components – Army, Navy, USMC, AF, CG Reserves – Army & AF Guard National Guard – dual mission: state and federal

35. Military Demographics ActiveNG & R Total Number: 1.4m860k Age: (25 Years or Younger)44%33% Mean age = 28 37% of USMC 18-21 Gender: (Female)14%18% ( 20% AF; 6% USMC) Minority 30%24% Education: (=>BS)18%19% Married 56%48% Demographics 2010: Profile of Military Community (2011). Defense Manpower Data Center.

36. AD Military Demographics Married 56% married (49% USMC to 59% AF) 54% enlisted & 70% officers 63% AD members have children ~726k spouses & 1,247m children (0-18) Total: 1.9 Demographics 2010: Profile of Military Community (2011). Defense Manpower Data Center.

37. NG & R Military Demographics Married 48% married 44% enlisted & 71% officers 43% AD members have children ~413k spouses & 746k children (0-18) Total: 1.2 Demographics 2010: Profile of Military Community (2011). Defense Manpower Data Center.

38. Unique Demands of the Military Lifestyle Recurring impact of mobility, frequent moves and separation – Potential for isolation – Spouse employment and managing the two-income household – Child education concerns Behavioral expectations Risk of injury or death

39. Unique Demands of the Military Lifestyle Guard and Reserve Service Members and their Families Unique stressors due to part-time status Citizen soldiers Mobilization & deployment Separation from family, jobs, community Demobilization Children from reserve component families reported – more trouble interacting with peers and teachers (who didn’t “get” their experience) – more difficulties with parent readjustment after deployment More likely not connected to a military community/resources

40. Unique Demands of the Military Lifestyle Deployment Frequent deployments into war zones Uneven exposure to deployments (highest for young enlisted) More deployments as “IAs” without a unit connection Uneven family support but growing number of services

41. Impact of Deployment Deployed 2.1m AD and Reserve Component service members since 2001 7.5% - 18% diagnosed with PTSD Increasing suicide rates, especially in Army and USMC Spouse mental health suffers with increased months of deployment- related separations Higher rates of depression, loneliness, irritability, sleeplessness and greater use of medical care Only about half of spouses and children coped well during the most recent deployments – Highest for upper ranks, lower for lowest enlisted ranks

42. Military Children “Children of deployed parents experience behavioral and emotional difficulties at rates above the national averages,” with anxiety being a specific problem (Hosek, Kavanagh, & Miller, 2011, p. 42) – One-third of the children reported elevated anxiety – This is double the national average

43. Military Children Castaneda et al. (2008) identified several factors affecting risks for behavioral and emotional difficulties during parental deployments: Age (older teens experienced more difficulties) Gender (girls reported more difficulty during integration) Length of deployment (longer was worse) Emotional health of the non-deployed parent (better emotional health of parent translated to fewer difficulties for child)

44. Understanding Deployment and Kids Commissioned research by National Military Family Association and conducted by RAND Largest study of cross-services families to date Children on the Homefront: The Experience of Children from Military Families, published in the journal Pediatrics; http://pediatrics.aappublications.org/ Addressed two key questions: - How are school-age military children faring? - What types of issues do military children face related to deployment?

45. Study Approach Sample: 1507 families Designed to represent deploying personnel by service and component Children ages 11-17 Racial/ethnic and gender mix (28% minorities, 47% girls) Multiple waves of data collection –Phone survey with child and non-deployed parent –June 2008 to August 2009

46. Deployment Impact: Four Risk Factors Significant FactorMost at Risk AgeOlder teens GenderGirls Months of Deployment Children whose parents had longer cumulative deployments Parent Mental Health Children whose non-deployed parent had poorer mental health

47. Military Spouses Hosek (2011) listed the most frequent deployment problems reported by military spouses (in order of decreasing frequency): – Household responsibilities – Emotional or mental – Children’s issues – Health care – Employment – Marital – Education

48. CA OR UT AZ NV WA ID MT WY CO NM TX KS OK ND AK SD NE IA MO AR LA AL MS HI WI MN IL IN TN KY GA SC FL PA OH NC VA WV NY ME VT NH CT RI MA MD DE NJ MI California, North Carolina, Texas, Indiana, Florida, Georgia, Illinois, Louisiana, New York, Virginia, Missouri, Ohio, Pennsylvania, Minnesota, South Carolina, Tennessee, Washington, Michigan, Mississippi, Alabama States Most Highly Impacted by Deployments States with the highest rates of deployments among all components, including Reserve & Guard Legend

49. CA OR UT AZ NV WA ID MT WY CO NM TX KS OK ND AK SD NE IA MO AR LA AL MS HI WI MN IL IN TN KY GA SC FL PA OH NC VA WV NY ME VT NH CT RI MA MD DE NJ MI Washington State University, University of Arizona, University of Minnesota, University of Nebraska, Kansas State University, Purdue University, Ohio State University, Southern, Cornell, Penn State University, West Virginia State University, West Virginia University, Virginia Tech, University of Maryland, North Carolina State University, University of Georgia, Michigan State University Partnership Project Lead States Participating states; includes representatives from 1862 & 1890 institutions Legend

50. 50 Delivering correct, user-friendly information Reaching Guard and Reserve families Reaching geo-isolated families Reaching the single service members Meeting emerging expectations of new generations Building a worldwide, trusted communication system to connect with troops and families Challenges: Changing Community = Changing Services

51. Prevalence of Any Secretive Problem: Is the ‘stigma’ v. help-seeking real? Young service members (E1-E4) and their families 10-Jun-2009 Known to community Not known to community 51Stony Brook - NORTH STAR

52. The Military Services Human Service Systems Air Force A&FRC FRG FRP CDC FCCP EFMP FAP SARC HAWC AFAS BH YC YA ARC ADAPT Army ACS AFTB EFMP FAP FR RAP SFAC BH FAP SARC CDC YC ARC ADAPT AMEDD Navy FFSC SEAP TAP FAP EFMP YC NR ARC FR SARC CDC MWR FFR RAP TAP FR

53. 1 Adapted from two sources: (1) Blueprints for Violence Prevention (http://www.colorado.edu/cspv/blueprints/) and (2) OJP What Works Repository (http://www.ncjrs.gov/pdffiles1/nij/220889.pdf.http://www.colorado.edu/cspv/blueprints/ 2 This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, under Agreement No. 2010-488869-20781 as part of the USDA National Institute of Food and Agriculture - Department of Defense Military Community and Family Policy Partnership. CONTACT US: 1-877-382-9185; Clearinghouse@psu.edu Clearinghouse for Military Family Readiness Continuum of Evidence 1 2 Placement Effective PromisingUnclear 3 Ineffective Criteria Significant Effect Rigorous statistical evidence of a change in highly desired behavioral outcome that was considered significant, with no negative effects found. Effects are unclear due to mixed results or limited evaluation design. An appropriate evaluation has failed to demonstrate a significant effect, or has negative effects. Sustained Effect Effect(s) lasting ≥ two years from the beginning of the program, or > one year from program completion. Effect(s) lasting ≥ one year from the beginning of the program, or > 6 months from program completion. Noted considerations may be given for programs that have not had sufficient time to demonstrate long-term effects. Sustainability not assessed or established. Program effects not sustained. Successful External Replication Program was found effective in at least one other randomized controlled trial (RCT) conducted by an implementation team that was *independent of the program developer. No evidence of external replication, or limited replication criteria (i.e., lacking significant/ sustained effect, inadequate study design, etc.). No evidence of external replication. No evidence of successful external replication. Study Design Randomized controlled designUses at least a quasi-experimental design Uses at least a quasi- experimental or pre-post-test design, or purely descriptive Experimental or quasi- experimental design Additional Criteria Regarding Study Execution Most (i.e., ≥ 50% [4/8]) of the additional criteria has been addressed (see pages 2-3). Some (i.e., 25% to 49% [2/8]) of the additional criteria has been addressed (see pages 2-3). Little to none (i.e., <24% [< 2/8]) of the additional criteria has been addressed (see pages 2-3). Most (i.e., ≥ 50% [4/8]) of the additional criteria has been addressed (see pages 2-3). Continuum of Evidence E FFECTIVE Continuum of Evidence P ROMISING Continuum of Evidence U NCLEAR Continuum of Evidence I NEFFECTIVE

54.  Evidence on effectiveness helps you select what to implement for whom.  Evidence on outcomes does not help you implement the program.  The usability of program or practice has nothing to do with the weight of the evidence regarding it.  Evidence on outcomes helps but does not guarantee sustainability of a program.

55. Challenges to Using Evidence-based Programs Cost - if you can’t a ffor d it, it doesn’t matter how good it is! Learning something new - most people like to use what they know Fidelity - research has shown that many (most?) aren’t being implemented with sufficient quality or fidelity Adaptation - there is tension between advocates of strict fidelity and those who encourage local adaptation Sustainability - remains a challenge – no permanent infrastructure

56. Finding an Evidence-based Program You know the issue you need to address…now what? Visit the Clearinghouse: www.militaryfamilies.psu.edu www.militaryfamilies.psu.edu  A searchable database  Engage in conversations about what you need via: Email, Live chat, 1-800 number for a phone conversation with a real person What would you be most likely to use?  Proactive technical assistance on issues identifying evidence-based programs and practices, implementation, evaluation, and sustainability

57. It is not enough to be busy. So are the ants. The question is: What are we busy about? Henry David Thoreau

59. Thank You! For more information on the Clearinghouse, contact: Daniel Perkins at dfp102@psu.edudfp102@psu.edu Clearinghouse for Military Family Readiness The Pennsylvania State University 002 Allenway Building University Park, PA 16802 clearinghouse@psu.edu www.militaryfamilies.psu.edu Toll Free: (877) 382-9185

60. Questions? Additional Comments?

61. Thank You! The CAPT’s Southeast Resource Team Shannon Greer IT Specialist Iris E. Smith Coordinator Charline McCord T/TA Coordinator Adela Santana T/TA Specialist Carol A. Hagen Epidemiologist Carlos Pavao T/TA Specialist Deirdre Danahar T/TA Specialist LaShawn Martin Sr. Admin Assistant Donna Dent Associate Coordinator Bertha Gorham Evaluator Penny Deavers T/TA Specialist