child, adolescent & family behavioral health proponency (caf-bhp) child, adolescent & family...

Child, Adolescent & Family Behavioral Health Proponency (CAF-BHP)


Support Services for Military Kids & Families

Presented by:

Mona M. Johnson MA, CPP, CDPDirector School Behavioral Health

US Army Medical Command Child, Adolescent & Family Behavioral Health Proponency

[email protected]://brainhealth.army.mil/SBH

mailto:[email protected]



• What do we know about the effects of War on Military Children, Youth and Families?



Data on the Army Challenges• Inadequate TRICARE resources in most areas near installations

• Effect of War/ Deployment on Children and Families 1 of 3 school-aged child at risk for psychosocial problems. About 33% of

children have significantly increased anxiety Psychological problems of parents predicts problems in children Cumulative length of deployment increases child’s risk of depression and

externalizing symptoms—stress builds in across wartime deployments in parents and children 1,2

Children 3 years and older of have significantly more behavioral problems 2,3

Increases in Child Maltreatment 4

Increases in Youth referrals• TAMC—89 / 326 (27%) related to OIF and/or OEF5

• Schofield—126 / 206 (61%) related to OIF/OEF6


The “New” Emotional Cycle of Deployment• Each stage is characterized by time frame and specific

emotional challenges• Failure to negotiate successfully can lead to strife• Seven distinct stages:

– Stage One: Anticipation of Departure– Stage Two: Detachment & Withdrawal– Stage Three: Emotional Disorganization– Stage Four: Recovery & Stabilization– Stage Five: Anticipation of Return– Stage Six: Return Adjustment & Renegotiation– Stage Seven: Reintegration & Stabilization


Stage One: Anticipation of Departure

• Timeframe: When family members receive orders• Increased feeling of stress in home• Reality of change ahead is “sinking in”• Denial & anticipation of loss• Focus is on completing family pre-deployment activity

checklist • Members may feel more emotional• In case of multiple deployments . . . new cycle may begin

before family has had time to renegotiate shared vision from last deployment


Stage Two: Detachment & Withdrawal

• Timeframe: Last week before Service Member leaves• Service Member is focused on preparing for mission and may

distance self from family• Anger, arguments may occur as family prepares to protect

themselves from “hurt” of separation• Communication may be difficult• In preparation for loss, family may begin to act like Service

Member is already gone• Multiple deployments can result in need to repeatedly

create distance; to feel “numb” and avoid emotional connection


Stage Three: Emotional Disorganization

• Timeframe: 1-6 weeks into deployment• Life without Service Member may initially feel overwhelming• Routines change, responsibilities added • Kids may feel . . .

– Numb and not interested in doing much– More irritable than usual– Have difficulty concentrating – particularly at school– Wish things would go back to “normal”– Surprised because things seem to be moving more smoothly

now that Service Member is gone


Stage Four: Recovery & Stabilization• Timeframe: Usually between weeks 3 and 5 after deployment• Family finally starts to settle into routine of life without

Service Member• Coping with changes can be positive for kids

– May enjoy new found responsibilities– Sense of independence – Relief that family is functioning well

• Coping with changes can be challenging for kids– Difficult time accepting changes– Stressed, depressed, and having difficulty getting things done– Feel unsupported and worried how will make it through

• Most of the time there is a mixture of both responses!


Stage Five: Anticipation of Return

• Timeframe: About 6 weeks before the Service Member Returns

• Homecoming is coming!• Family is happy, excited, and feeling boost of energy• Trying to make everything “perfect” for return• Sense of relief that Service Member will be home combined

with worries about whether or not they will be the same• If Service Member came home on leave at some point

during deployment, that experience may be what family members expect:– Positive Leave Experience = Positive Homecoming– Challenging Leave Experience = Challenging Homecoming


Stage Six: Return Adjustment and Renegotiation

• Timeframe: About 6 weeks after the Service Member returns• During time of separation Service Member and all family

members have changed • Changes may hold pleasant surprises or may cause conflict• Family members may feel overwhelmed by Service Member

attempts to get to know everyone again• Everyone needs space and time to readjust• Entire family must begin to renegotiate how household will

look now that everyone is together again


Stage Seven: Reintegration & Stabilization

• Timeframe: Up to 6 month (and beyond) after the Service Member returns

• Family continues to adjust to having Service Member home• A “new normal” is established regarding routines and

expectations• Members may begin to feel secure, relaxed, and

comfortable with one another again • If readjustment challenges resurface, support is

important. . . It’s okay to ask for help if you need it!


• Combat Stress - Term used to describe “normal physiological, behavioral, and psychological reactions experienced before, during, or after combat”

• Traumatic Brain Injury (TBI/mTBI) - “ Occurs when a sudden trauma causes focal or diffuse damage to the brain; Type of concussion; Physical damage not always visible.”

• National Institute of Health and Dr. Kris Peterson, Madigan Army Medial Center

• Post Traumatic Stress - “A psychiatric disorder that occurs after witnessing life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape.” National Center Post Traumatic Stress Disorder

Deployment/Reunion Stress Related Issues


• Compassion Stress• Stress resulting from helping or wanting to help a suffering

or traumatized person• Compassion Fatigue

• A state of exhaustion and dysfunction, biologically, physiologically, and emotionally, as a result of prolonged exposure to compassion stress

• Compassion Satisfaction• A powerful sense of satisfaction with trauma work;

Development of personal strengths and feelings as a result. –Dr. Charles Figley

Deployment/Reunion Stress Related Issues for Families


• Physical, mental, emotional and social development is appropriate for age and stage of infant/child/youth• Able to connect with parents/caring adults • Fosters maturity• Encourages independence, flexibility, adaptability• Builds skills for adjusting to separation and losses faced later in life• Strengthens family bonds• Civics—relationship with community• Able to identify and verbalize feelings• What other strengths may result

from deployment?

Strengths for Children & Youth Resulting From Deployment


Symptoms of Deployment/ReunionStress In School Setting

• Unable to resume normal class assignments/activities

• Continued high levels of emotional response (i.e., crying and intense sadness)

• Difficulty concentrating in school

• Express violent or depressed feelings verbally or through drawings/play

• Intentionally hurt self or others

• Gain or lose significant amount of weight in period of weeks

• Discontinue care of personal appearance

• Exhibit possible alcohol/drug abuse problem

• Frequent absences• Experience decline in

performance and grades that does not improve over time


The Impact of Multiple Deployments & Stress

BehaviorsReactions

CommunicationInteractions


• Behaviors• Fussiness, uncharacteristic crying, neediness• Generalized fear• Heightened arousal and confusion

• Reactions• Helplessness and passivity• Avoidance of trauma-related reminders• Exaggerated startle response• Regressive symptoms• Somatic symptoms• Sleep disturbances, nightmares

Infant to 5 Years: Signs of Stress


• Communication• Cognitive confusion• Difficulty talking about event; lack of verbalization• Trouble identifying feelings• Unable to understand event as permanent• Anxieties about death

• Interactions• Separation fears and clinging to caregivers• Grief related to abandonment by caregiver

Infant to 5 Years: Signs of Stress


• Behaviors• Spacey or distracted• Changes in behavior, mood, personality• Regression to behavior of young child• Aggressive behavior, angry outbursts

• Reactions• Reminders trigger disturbing feelings• Responsibility and guilt• Safety concerns, preoccupation with danger• Obvious anxiety and general fearfulness• Somatic symptoms• Sleep disturbances, nightmares

6 to 11 Years: Signs of Stress


• Communication• Confusion and inadequate understanding of events• Magical explanations to fill in gaps of understanding• Withdrawn and quiet

• Interactions• Worry and concern for others• Separation anxiety• Repetitious traumatic play and retelling• Loss of ability to concentrate• School avoidance• Loss of interest in activities



• Behaviors• Self-consciousness• Depression• Trauma-driven acting out; sexual acting out or

recklessness; risk-taking; substance use/abuse• Accident proneness

• Reactions• Efforts to distance from feelings• Wish for revenge and action-oriented responses• Life-threatening re-enactment• Decline in school performance• Sleep and eating disturbances



• Communication• Increased self-focusing• Social withdrawal

• Interactions• Flight into driven activity/involvement with others OR

retreat from others in order to manage inner turmoil• Rebellion at home and school• Abrupt shift in relationships



• Create a safe environment • Provide consistency• Offer reassurance and support• Be honest about what has happened• Explain what officials are doing (state, federal, police,

firefighters, hospital, etc.) to address the issues/concerns• Manage your own anxiety• Help put the event in perspective• Ask “how are you doing?” and “what can I do for you

now?”

General Coping Strategies


• Maintain calm atmosphere• Keep familiar routines• Avoid unnecessary separations from caregivers• Minimize exposure to reminders of trauma—don’t keep TV

news on• Expect children to temporarily regress; don’t panic• Help children give simple names to big feelings• Talk about event in simple terms during brief chats• Provide simple props (doctor’s kit, toy ambulance) if trying

to play out frightening situation• Provide soothing activities

Specific Coping Techniques: Infant to 2 ½ Years


• Maintain familiar routines• Don’t introduce new and

challenging experiences• Avoid nonessential

separations from important caregivers

• Listen to and tolerate retelling of events

• Accept and help them name strong feelings during brief conversations• Respect fears and give time to cope

• Expect regressive and uncharacteristic behaviors—maintain rules

• Protect from re-exposure and reminders through media

• Provide opportunities and props for play

• If kids have nightmares, explain that bad dreams aren’t real and they’ll happen less and less

Specific Coping Techniques: 2 1/2 to 5 Years


• Listen to and tolerate retelling of events• Respect fears; give them time to cope• Increase awareness and monitoring of play they may secretly

reenact events with peers• Set limits on scary or hurtful play• Permit children to try out new ideas to deal with fearfulness at

nap or bedtime to feel safe (i.e., nightlight, radio, extra reading time)

• Reassure that feelings of fear, or behaviors that feel out of control, are normal after a frightening experience

Specific Coping Techniques: 6-11 Years


• Encourage discussions about stress with each other and adults they trust

• Reassure that strong feelings—guilt, shame, embarrassment, desire for revenge—are normal

• Provide opportunities to spend time with supportive friends and peers

• Help find activities that offer opportunities to experience mastery, control, self-esteem, and pleasure (i.e., sports, art, acting, etc.)

Specific Coping Techniques: 12-18 Years


Helpful Resources for Educators

Tough Topics Series and Booklet:http://brainhealth.army.mil/SBH

http://brainhealth.army.mil/SBH


Tough Topics - Deployment


Tough Topics – Homecoming & Reunion


Tough Topics – Coping with Stress


Tough Topics – Grief, Loss and Trauma


Tough Topics – Coping with Death


Tough Topics – Talking About Violence, Trauma & War


Tough Topics – Fostering Resilience


So, what’s being done to help?

*Military Initiatives*Civilian Resources & Assistance



The Army Family Covenant

• “We are committed to Improving Family Readiness by increasing accessibility and quality of health care.”

• “We are committed to Improving Family Readiness by ensuring excellence in schools, youth services and child care.”



CAF-BHP “Family Strong” Mission

As an integral part of the Army’s force generation and deployment processes, the Proponency supports and sustains comprehensive and integrated behavioral health systems of care for Military Children and their Families at installations throughout the Army.



Director CAF-BHP Intent Purpose: To support the implementation of an integrated

comprehensive behavioral health system of care for Military Children and Families across the Army Medical Command that promotes prevention, resiliency building, and timely intervention.

End State: (1) Improved access to care (coordinated, accessible behavioral

health services for military children and families with improved capacity);

(2) Reduction in stigma and increase in health seeking behaviors;(3) Improved outcomes (decrease in family member psychiatric

hospitalizations, more resilient and healthy Army community, overall decrease in use of medical services);

(4) Healthier sustainable culture for Army families.



Director CAF-BHP IntentKey Tasks:• Promote coordination and integration of child and family programs at the

Army and installation level • Develop and provide behavioral health models for schools and civilian

communities that promote prevention, early detection, and delivery of care

• Provide coaching and training programs for primary care clinicians in the evaluation and management of common behavioral health disorders

• Serve as a repository of knowledge and clearinghouse for overarching guidelines and information for operation of state-of-the-art behavioral health systems and evidence based behavioral health care for Army Children and Families.

• Centralize and standardize data collection for needs identification, outcomes



Child and Family Assistance Center (CAFAC)

• Provides direct Behavioral Health Support for Army Children and their Families, promoting optimal military readiness, wellness, and resilience in Army Children and Families.

•Multiple mental health resources are integrated under a single umbrella organization to facilitate coordination of services, and increase capacity and flexibility in delivery of these services (eliminating stove-piping of services).• A single point of entry can be established to make access

to care easy and simple.



CAFAC: A Community of Practice

1. Patients call ONE number = (???) ???-????

2. Call answered by credentialed provider = 24 / 7

Gateway/Rapid TriageChild and Adolescent

Services

ACS

Adult Services

ChaplainFAP/Social Work

SARD

Community Resources

School BBH

Marriage/Family



School Behavioral Health (SBH)•A comprehensive array of school behavioral health programs and services to support Children, their Families, and the Army Community at the schools and Child Development Centers (CDCs), directed at promotion of optimal military readiness, and wellness and resilience in Army Children and Families.

•Multiple behavioral health resources at the schools will be developed and integrated through a Memorandum of Agreement (MOA) between the MTF and the local school district(s) to facilitate coordination of services, and increase capacity and flexibility in delivery of these services (eliminating stove-piping of services).


Advisory Board: Regional. Provides overall guidance and direction, quality assurance.

Advisory Group: At each school. Provides specific advise to the SBH program, policy development, performance improvement. Ensures effective collaboration of all care providers.

Triage Team: At each school. Responsible for clinical case/problem review – referral, management, monitoring.

Key Features:-- Early detection-- Care and prevention provided where the child is located-- Integrated Effort; Compliment to School Liaison Officers, Military Family Life Consultants, etc.-- Opportunities for training and education

Prevention, Intervention, Training & Education

School District Advisory Council

School Building Advisory

Group


Group

Triage Team

Triage Team


Group

Triage Team

Triage Team


Group

School Behavioral Health Organizational Structure

Process Action Team

Process Action Team

Process Action Team

Process Action Team


TeacherCounselor

SPEDPrincipal

SBBH Psychologist

SocialWorker

SBH Triage Team: An All Inclusive Group

Psychiatrist



School Behavioral Health Clinician• Consultation to school staff and parents• Behavioral Health Screening and Assessments • Individual Counseling for students• Educator, Parent, and Community Member

Trainings on Behavioral Health Issues• Educational Support Groups and Counseling• Collaboration with team members within and

outside of the school setting to support behavioral health prevention, intervention, treatment and insure student academic success



Current SBH Rollout Status

• Ongoing: Schofield Barracks, Joint Base Lewis McChord, Fort Meade, Fort Campbell (SBH), Ft. Carson, Germany (Baumholder & Bavaria)

• Proposed for FY 11: Fort Hood, Ft. Carson, Ft. Bliss


• CAF-BHP School Behavioral Health http://brainhealth.army.mil/SBH

• Army Child, Youth and School Services http://www.armymwr.com/family/childandyouth/default.aspx

• School Liaison Officers & Military Family Life Consultants

• Military One Source – www.militaryonesource.com • Operation: Military Kids – www.operationmilitarykids.org • Substance Abuse and Mental Health Services Administration

(SAMHSA): 10 Strategic Initiatives – www.samhsa.gov • Center for School Mental Health -

http://csmh.umaryland.edu/

Helpful Resources:


http://www.armymwr.com/family/childandyouth/default.aspx

http://www.militaryonesource.com/

http://www.operationmilitarykids.org/

http://www.samhsa.gov/

http://csmh.umaryland.edu/



Questions, Comments or Thoughts?



Child, Adolescent and Family Behavioral Health Proponency

Mona M. Johnson MA, CPP, CDPDirector School Behavioral [email protected]

253.968-4440 (direct)253. 968-4745 (main)

Website: http://brainhealth.army.mil/SBH

mailto:[email protected]



TOUCH POINT #4In-theater prior to re-deployment: 15-90 days screening for risk assessment.• Soldier completes joint

questionnaire about Family

TOUCH POINT #7Reintegration PDHRA: 90-180 days post re-deployment screening and intervention for risk assessment with additional BH assessment and wellness intervention.• Soldier completes joint questionnaire about Family

TOUCH POINT #1 Pre-deployment Health Assessment: 120-60 days pre-deployment screening and intervention for Soldier’s deployability and both family & Soldier risk assessment.• Soldier completes questionnaire about

family.

TOUCH POINT #5Reintegration PDHA: 6-30 days (before block leave) redeployment screening for risk assessment with additional BH assessment and wellness intervention.• Soldier completes joint

questionnaire about Family

TOUCH POINT #2Pre-deployment brief : Family training. Encouraged to take Global Assessment Tool and Comprehensive Resiliency Modules

TOUCH POINT #3 Family deployment training and voluntary screening

TOUCH POINT #8 Re-deployment brief #2: Post Honeymoon Family training and voluntary screening TOUCH POINT #6

Re-deployment brief #1: Family training and voluntary screening

Train/Ready

Available/Deployed

Reset

The Army Force Generation Process

child, adolescent & family behavioral health proponency (caf-bhp) child, adolescent & family...

Documents

family members

family anger

behavioral problems

child maltreatment

deployment slide

anticipation of return

schoolaged child

detachment withdrawal