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Strengthening the Military Family Readiness System for a Changing American Society (2019)

Chapter: 5 Stress, Risk, and Resilience in Military Children

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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Suggested Citation:"5 Stress, Risk, and Resilience in Military Children." National Academies of Sciences, Engineering, and Medicine. 2019. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: The National Academies Press. doi: 10.17226/25380.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

5 Stress, Risk, and Resilience in Military Children Almost 70 percent of children in military families are younger than age 11, and 38 percent are age 5 or younger (DoD, 2017, p. vi). For children, the early years represent a developmental stage that is particularly vulnerable to stress and a time when the characteristics of the caregiving or parenting environment are key in developing their stress-regulating capacities (Blair, 2010). The committee’s charge, in part, was to provide information on children's social-emotional, physical, biochemical, and psychological development. Thus, in this chapter, the committee focuses on the impact of stressors on child development and how the developmental challenges of childhood and adolescence intersect with the unique experiences of military family life. We found no neurobiological research on military children, hence the review of the civilian literature. Applying the concepts and definitions of resilience introduced in chapters 1 and 2, we review the broader developmental literature on childhood resilience, pointing out key correlates and predictors and how they may be applied to the military child’s context. Special attention is given to recent resilience research, which looks at the neurobiological, behavioral, cognitive, and emotional processes that might underpin resilience. The chapter concludes with a discussion of evidence-based interventions1 to promote childhood resilience, highlighting prevention programs whose caregiving or parenting interventions have demonstrated the potential to be the most relevant to military children and families. THE IMPACT OF STRESS ON YOUTH DEVELOPMENT Stress commonly refers to an individual’s reaction to a challenge in the environment. Stress can be positive, as in the rewarding experience of rising to a challenge; it can be tolerable, as in difficult situations that are coped with in positive ways; or it can be severe, sometimes referred to as “toxic stress” (Center on the Developing Child, 2019; McEwen, 2017). In this section, the committee provides an overview of what is known about the specific effects of severe stressors on child development. Because overall development, and especially brain development, is so rapid and dynamic over the first two decades of life (Lenroot and Giedd, 2006), and because a large body of evidence has demonstrated the detrimental impact on later development of stressful early-life experiences, we focus on the impact of stress on childhood and adolescent development. 1 All interventions reviewed in this chapter are evidence-based. PREPUBLICATION COPY, UNCORRECTED PROOFS 5-1

While we are aware of no research on the ways typical military family life contributes to stress and stress-related outcomes, extensive research on the development of stress regulatory systems can significantly aid in understanding how military-specific stressors affect development among children in service families. While a certain amount of stress is necessary and even optimal for healthy functioning, excessive stress has been shown to impair functioning at multiple levels—epigenetic, biological, physiological, and behavioral—and to increase risk for later pathology. However, there is significant variability across individuals in how stress is perceived, with temperamental, biological, and social factors affecting both the experiences and the expressions of stress. Although the vast majority of stress research has been conducted with civilian families, it nevertheless demonstrates the crucial importance of the early caregiving/parenting environment for a child’s developing ability to regulate stress. While severe stressors such as maltreatment, parental psychopathology, and violence can have profound effects on children’s development, there is relatively little evidence suggesting that separations due to military deployments have these effects (Meadows et al., 2017). The effects on children of deployments and related military family transitions, such as extended occupationally-related separations and relocations, are more likely mediated through their impact on parents and the caregiving system (Meadows et al., 2017). Thus, for example, when a military parent’s combat exposure results in severe posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI), it is the service member’s compromised parenting—in concert with the child’s own vulnerabilities—that may increase the child’s risk for dysregulation and related difficulties. Similarly, increases in the risk of child maltreatment by the primary caregiver during a military parent’s deployment would likely be what precipitates child maladjustment. The body of literature on the impact parental deployment to war has on youths’ psychosocial development has grown significantly over the past 15 years and is reviewed in Chapter 4 of this volume, but many of the details regarding how military family stressors affect developmental processes both “above and below the skin” (e.g., observed behavior as well as physiological and biological processes) are still lacking. However, the broader child development literature can be informative in this context, in particular the study of how development goes awry, a field known as developmental psychopathology (Cicchetti, 1989). Studies examining the impacts of separation from or loss of a primary caregiver, maltreatment, and family violence on children’s developmental trajectories all provide some data applicable to the military context. Individual Differences In general terms, severe stressors affect youth through physiological, biological, genetic, behavioral, affective, and cognitive mechanisms. These stressors can include maltreatment, exposure to a threat of violence or death, or prolonged separation from a primary caregiver at a very young age, among others. Pre-existing risks and vulnerabilities, such as psychopathology, genetic vulnerability, or environmental risks such as poverty, may potentiate the impact of stress and trauma on development, while protective factors, such as effective caregiving, may lessen them. Diathesis-stress and differential susceptibility hypotheses offer explanations for how individuals differ in their responsiveness to stress. Diathesis-stress models suggest that some youth are more vulnerable than others to their caregiving environments; these youth fare worse PREPUBLICATION COPY, UNCORRECTED PROOFS 5-2

in stressful circumstances but fare as well as others in routine, low-risk environments (e.g., Walker et al., 1989). The differential susceptibility hypothesis suggests that some youth (sometimes referred to as “orchids”) are more sensitive to or show more plasticity to both nurturing and high-risk caregiving environments than other youth (sometimes referred to as “dandelions”; Boyce and Ellis, 2005). Under high-risk conditions, the more sensitive “orchids” show poorer outcomes, but in enriching environments these same youth show stronger outcomes than their peers (Belsky and Pluess, 2009). More recently, scholars have suggested a third category of youth, referred to as “tulips,” who are moderately sensitive and responsive to their environments (Lionetti et al., 2018). It is important to note that research suggests that these variable sensitivities to environment are likely modifiable through epigenetic processes and/or through evidence-based targeted prevention interventions (see, for example, Bakermans- Kranenburg and van Ijzendorn, 2015). The concepts of multifinality and equifinality (Cicchetti and Rogosch, 1996) also illustrate the complexity of understanding the impact of a particular stressor on youth. Multifinality refers to the finding that one stressor, such as physical abuse, can have many different negative effects on development. For example, it may contribute to PTSD, anxiety, behavior problems, poor academic functioning, and social challenges, and that not all individuals will experience the same negative outcomes. Equifinality refers to the obverse—that the same single outcome, such as anxiety, social challenges, or poor academic functioning, can be evident following exposure to disparate stressor events, such as prolonged parental separation, relocation, or bullying. Providing tailored, adaptive, or personalized family-based programs, services, and supports makes it possible to respond to individual differences in risk and vulnerability (Collins and Varmus, 2015; Nahum-Shani and Militello, 2018). Chapter 8 provides examples of these adaptive interventions, including just-in-time adaptive interventions (JITAIs), that harness the potential of mobile health (mHealth) or mobile technologies to respond to individual child and family needs and preferences. The Biology of Stress Careful longitudinal examinations of stressful events and child/youth functioning, using data gathered through multiple methods, from multiple informants, and analyzed at multiple levels of analysis (biological, behavioral, etc.), have enabled researchers to specify with greater clarity the developmental pathways from stressor(s) to outcomes. As discussed above, there is significant variability in what is perceived as stressful and how individuals react to stressful situations, with physical, genetic, developmental, and psychosocial factors affecting these reactions (Sapolsky, 1994) as well as prior experiences (Cicchetti and Walker, 2001). From a biological perspective, excessive stress can be seen as a threat to the body’s homeostasis (its tendency to maintain internal equilibrium), a threat the body responds to by increasing autonomic nervous system activity and releasing hormone secretions to protect the body against (McEwen, 1994). The hypothalamic-pituitary-adrenal (HPA) axis is the biological system most closely linked to stress, and when individuals perceive stress it releases the hormone cortisol (Vázquez, 1998). Extensive research on the HPA axis’s response to stress has demonstrated that while it is adaptive, its chronic mobilization via hyper- or hypo-secretion of glucocorticoids is damaging to other bodily systems, including the brain’s structure and function (Cicchetti and Walker, 2001; Gunnar and Vazquez, 2001). PREPUBLICATION COPY, UNCORRECTED PROOFS 5-3

The impact of stress varies in regard to timing and duration (see Chapter 1 of this report for a discussion of these concepts). The experience of extreme stress during development likely increases vulnerability to lifetime disease, but what constitutes a sensitive period for early life stress has not yet been determined (Leneman and Gunnar, 2019). In a review highlighting the differential effects of stress across development, Lupien and colleagues (2009) describe how the effects of both chronic and acute stressors may vary depending on the areas of the brain that are developing at the time of the stress exposure. For example, prenatal stress affects the development of regions of the brain associated with the development of the HPA axis (i.e., the hippocampus, amygdala, and frontal cortex), whereas stress in early postnatal life affects the production of glucocorticoids. The hippocampus develops from birth to age two; thus, stress during infancy might increase hippocampal vulnerability (e.g. by reducing hippocampal volume). In contrast, the amygdala and frontal cortex continue to develop throughout childhood and adolescence; stress during this time period might then be associated with reductions in amygdala volume. Adolescents are very vulnerable to the impact of stress, likely because of increases in frontal cortex volume that occur at this stage, as well as protracted glucocorticoid responses that continue into emerging adulthood (Lupien et al., 2009), the period during which many youth join the military. Although emerging and early adulthood is not the focus of this chapter, neurobiological development, particularly in the prefrontal cortex, continues into the late 20s and beyond (Giedd et al., 2015). Impulse control, self-regulation, and the ability to delay gratification all continue to develop throughout adolescence and emerging adulthood, with the capacity to plan and anticipate consequences peaking only by age 25 (Giedd et al., 2015; Steinberg et al., 2009). These findings are highly relevant for understanding and effectively serving younger service members and their families. HOW PARENTING AFFECTS THE DEVELOPMENT OF STRESS REGULATORY CAPACITIES The caregiving or parenting environment is key to the development of a child’s stress regulatory capacities. It can result in changes in gene expression, that is, in epigenetics, the turning of genes “on” and “off” by environmental stimuli, which in turn lead to biological and behavioral changes (Romens et al., 2015; Slavich and Cole, 2013). Nowhere is this more evident than in findings regarding the impact of childhood abuse and neglect on children’s development (Cicchetti et al., 2010). Extensive research on child abuse and neglect has demonstrated how child victims develop ideas of the world as a place that is dangerous and unpredictable, resulting in enhanced appraisals of threat, increasing risk for both anxiety and aggression-related psychopathology (Shackman and Pollak, 2014). For example, child maltreatment is consistently associated with disruptions in the functioning of the HPA axis (Loman et al., 2010), and this in turn has been implicated as a causal factor in a range of psychopathology (Heim et al., 2008). Additionally, a recent study of the effects of child maltreatment found epigenetic changes to the glucocorticoid receptor gene in the whole blood of 56 young adolescents (ages 11 to 14). Compared with children who had not been maltreated, those who had been exposed to physical PREPUBLICATION COPY, UNCORRECTED PROOFS 5-4

abuse showed greater methylation within the NR3C1 promoter region2 and the NGFI-A (nerve growth factor) binding site of the gene. This increased methylation3 likely contributes to fewer glucocorticoid receptors in the brain and blood, disrupting the physiology of stress regulation among these youth (Romens et al., 2015). Parenting practices and parental functioning both directly and indirectly affect children’s HPA axis regulation. For example, maternal depression and anxiety (both prenatally and following birth) are associated with higher, or poorer, basal activity in children’s HPA axis throughout the childhood years (O’Connor et al., 2005; Swales et al., 2018). Youth age 13 whose mothers experienced postnatal depression evidenced higher and more variable levels of morning cortisol than those whose mothers did not experience depression (Halligan et al., 2004). These cortisol differences at age 13 were associated with subsequent depression at age 16 (Halligan et al., 2007). Children living in poverty show worse psychological and physical outcomes than children in higher-SES environments, partly due to poorer HPA axis regulation (Koss and Gunnar, 2018). However, attachment status appears to buffer the detrimental impact of poverty: secure (but not insecure) attachment was associated with lower (healthier) basal cortisol in a sample of very young children (ages 12 to 22 months) attending immunization appointments (Johnson et al., 2018). Using multiple-method and informant data to examine stress and health outcomes from childhood into adulthood, Farrell and colleagues (2017) assessed stress in children using coder- rated interviews at five developmental stages: early- and middle-childhood, adolescence, young adulthood, and age 32. They also observed parenting quality at seven time points from birth through age 13. Early-childhood, adolescent, and concurrent stress were associated with poorer physical health at age 32, but higher parenting quality (measured as maternal sensitivity) protected against these relationships (Farrell et al., 2017). In sum, effective parenting practices protect and nurture children’s stress-regulatory capacities, whereas maltreatment and other severe stressors disrupt children’s regulation of stress. While severe stressors have been shown to disrupt children’s ability to manage stress by interfering with development at multiple levels—epigenetic, biological, physiological, and behavioral—many of the changes in children in response to stress are not absolute or permanent. Stress research demonstrates the crucial importance of the caregiving and/or parenting environment for a child’s developing ability to regulate stress. For example, the impact of prenatal stress on infants is often moderated by the quality of postnatal caregiving (Austin et al., 2017). Hypocortisolism,4 a disorder that emerges in response to severe abuse and neglect, has been shown to be reversible with subsequent sensitive and supportive caregiving (Flannery et al., 2017). Moreover, as noted above, there is significant variability across individuals in how stress is perceived, with temperamental, biological, and social factors affecting experiences of stress. And for military families, the effects of deployments and related military family transitions are mediated through their impact on parents and the caregiving system (Creech et al., 2014). 2 This is also known as a glucocorticoid receptor and is the receptor to which cortisol and other glucocorticoids bind. 3 DNA methylation is “an epigenetic mechanism that occurs by the addition of a methyl (CH3) group to DNA, thereby often modifying the function of the genes and affecting gene expression.” (See https://www.whatisepigenetics.com/dna-methylation/) 4 Also known as adrenal insufficiency, defined by the National Institute of Diabetes and Digestive and Kidney Diseases as “a disorder that occurs when the adrenal glands don’t make enough of certain hormones. These include cortisol, sometimes called the ‘stress hormone,’ which is essential for life.” (Accessed at https://www.niddk.nih.gov/health-information/endocrine-diseases/adrenal-insufficiency-addisons-disease ) PREPUBLICATION COPY, UNCORRECTED PROOFS 5-5

In summary, extensive research in the civilian realm on the development of children’s stress regulatory systems can significantly aid in understanding how military family stressors affect children’s development. Severe stressors (e.g., parental physical injury, parental psychological trauma and maladaptive responses, parental death, or family violence) may have complex influences on child development across multiple domains, including physiological, biological, behavioral, social-emotional, and cognitive functioning. It should be noted, too, that the vast majority of the parenting literature in this area focuses on mothers, while far less research has been done on fathers and fathering (Lamb, 2004). The fact that the majority of service member parents are fathers provides an important opportunity to begin to examine the special role of military fathers in their children’s development (DeGarmo, 2016). RESILIENCE IN CHILDREN’S DEVELOPMENT We refer the reader back to chapters 1 and 2 for definitions of resilience and the distinctions between resilience processes/mechanisms, factors, and outcomes. In this chapter, our focus is on resilience processes/mechanisms and the factors that shape them in children and youth. Systematic, theory-driven research on resilience among youth has been ongoing since the 1970s and has accelerated with recent advances in prevention and intervention science as well as advances in genetics and neurobiology (see Masten [2018] for a review of the literature). Resilience researchers initially focused on variations in adaptation among children—that is, on how, among children experiencing high-risk conditions in the family and broader environment, some children fared better than their peers. In several early studies, as many as one-third of youth exposed to early stressors (e.g., parental mental illness, poverty, violence, single parenthood, and multiple children in a household) fared as well as their low-risk peers (Masten, 2001; Werner, 2012). Although this early literature suggested that resilient children were viewed as “invincible” (Werner, 1997), the research consensus today is that resilience in childhood is more appropriately viewed as what Masten (2001) has termed “ordinary magic.” That is, child/youth resilience is a function of key ordinary—or typical—psychological processes that operate well, despite high-risk conditions. Youth who do as well as their low-risk peers, despite their exposure to stressful conditions in the home and the broader environment, are considered resilient. The processes involved in childhood resilience operate across multiple domains both within and beyond the child. As such, there is no single resiliency trait (Masten and Gewirtz, 2006). In parallel, then, there is no single measure of child resilience. Rather, measurement of childhood resilient outcomes is best accomplished via multi-dimensional assessments at multiple levels of analysis, using multiple methods (e.g., self-reporting, behavioral observation, physiological measures) and multiple informants, including children, parents, and teachers. Measuring resilience in children also requires an understanding of the developmental context. For example, developmental tasks for school-age children include functioning adequately in schools or in academics; functioning well with peers (social competence); and functioning well behaviorally and emotionally. Assessing resilience in school-age children, then, would require using reports and objective assessments of functioning, such as test scores and observations of playground behavior, across these domains, preferably based on observations from teachers, parents, children themselves, and even peers. PREPUBLICATION COPY, UNCORRECTED PROOFS 5-6

Key Correlates and Predictors of Childhood Resilience Decades of resilience research has demonstrated that resilience is associated with core promotive and protective processes (see Chapter 2 of this volume for definitions); these processes galvanize positive adaptation across developmental domains. Masten and Cicchetti (2016), in their comprehensive review of childhood resilience and developmental psychopathology, outline six core correlates of resilience that have emerged from longitudinal studies. As discussed in earlier chapters, and consistent with the theoretical models outlined in this report, childhood resilience develops in multiple contexts: individual, family, school, and culture. The primary focus in this chapter is on the key correlates of childhood resilience that are most proximal, that is, those that lie within the child and the family. First and foremost, sensitive, responsive, loving, predictable, and protective parents and caregivers help the development of a secure attachment relationship in infancy and early childhood (Bowlby, 1988). Throughout childhood and adolescence, effective parents help their children to understand and navigate the world by teaching prosocial skills, providing safety, limits, and routines, monitoring behavior, and helping children make meaning of life (Collins et al., 2000.) Early relationships with parents and other caregivers provide a template for how the child navigates later relationships with peers, noncaregiving adults such as teachers, and intimate partners (Feldman et al., 2013; Sroufe, 1979). Peer and other relationships, in turn, influence the child’s trajectory into adolescence and beyond (Dishion and Tipsord, 2011). Caring relationships with nonparental adults also are important for youth (e.g., Perkins and Borden, 2003) and may be particularly relevant for military youth experiencing multiple transitions (Masten, 2001). A secure attachment relationship not only provides a child with an internal working model of healthy relationships, it also provides a secure base from which a child can explore and feel effective in the outside world (Bowlby, 1988). Neurobiological and genetic research has uncovered the power of the attachment relationship; the hormone oxytocin and the oxytocin receptor gene (OXTR), among others, appear to be implicated in the core promotive and protective processes of the parent-child relationship (Feldman et al., 2014; Priel et al., 2019). For example, in a longitudinal study of children and parents exposed to ongoing political violence and war, a combination of parenting and genetic risk predicted PTSD symptoms in young children (Feldman et al., 2014). The second key correlate of resilience is self-regulation, the ability to monitor and regulate one’s behavior, attention, thoughts, and emotions. This is a crucial developmental task that begins to develop in early childhood and continues developing through emerging adulthood (Zelazo and Carlson, 2012). Children with effective self-regulation are at lower risk for behavioral and emotional problems and are able to be more successful in school because they can follow and comply with teacher directions. Executive functioning, a key indicator of self- regulation, predicts both concurrent and future adjustment in children (Zelazo et al., 2004). Effective self-regulation may be particularly important in high-risk settings (Duckworth, 2011; Masten and Coatsworth, 1998; Rothbart et al., 2011). Mastery-motivation is a third key correlate of resilience (Masten et al., 1995). Effective parenting and/or caregiving likely galvanizes a child’s mastery-motivation system, the adaptational system associated with the development of self-efficacy, and possibly also motivating persistence in children. Mastery-motivation refers to feelings of mastery as a consequence of successful interactions with the outside environment. For example, in observing young children learning to walk one can see that successfully standing first, and then walking, is PREPUBLICATION COPY, UNCORRECTED PROOFS 5-7  

highly motivating to a child, reinforcing more practice and ultimately further success. In middle childhood, even small successes in school, academics, sports, or social activities motivate a child to further engage in the activity, resulting in yet more success and greater activation of the mastery-motivation system. Feelings of self-efficacy likely drive this positive cycle of practice and success (Bandura, 1997). Among a sample of military parents, for example, a parenting intervention strengthened both maternal and paternal parenting self-efficacy, leading to subsequent gains in both parent and child positive adjustment (Gewirtz et al., 2016; Piehler et al., 2016). There is a relative dearth of research on this issue, but the limited available research suggests that feelings of self-efficacy may also drive persistence or perseverance of effort (e.g., Skaalvik et al., 2015). Across early to middle childhood, persistence also appears related to sensitive or effective parenting and to self- regulation (Chang and Olson, 2016). Across multiple studies of high-risk children, cognitive abilities, typically assessed through tests of intelligence quotient (IQ) or problem-solving capacity, appear to be significantly associated with resilience (Luthar et al., 2006; Masten, 2015). Better cognitive functioning is both promotive and protective for children and youth, and is likely related to the ability to succeed in schoolwork, in navigating novel situations, and in flexible problem-solving, as well as being protective for youth at risk of behavior problems (Lösel and Farrington, 2012; Masten and Tellegen, 2012; Werner and Smith, 1992, 2001). Cognitive skills also are associated with resources such as socioeconomic status, access to better education and more books at home, and competent parents (Masten and Cicchetti, 2016; National Academies of Sciences, Engineering, and Medicine, 2016). Conversely, highly stressful early environments (“toxic stress”) such as those characterized by maltreatment, parental psychopathology, or caregiving disruptions, can impair cognitive development (Shonkoff, 2011). Finally, hopefulness (or positive outlook) and meaning-making may also be associated with resilience, although less empirical research has been conducted on these two constructs. In both observations of resilient children after they have grown up and anecdotal accounts of resilience, hope or a positive perspective is a key theme (Maholmes, 2014; Werner and Smith, 1992, 2001). While limited longitudinal research has been done to examine this association, one longitudinal study found that self-reported hope among children ages 10 to 18 was associated with subsequent positive life satisfaction and fewer internalizing symptoms (Valle et al., 2006). There also is a dearth of research on the association of meaning-making with resilience in youth, although developing a narrative about life’s meaning or one’s own purpose in life appears to be a core theme in discussions of resilience (Masten and Cicchetti, 2016). Meaning-making is likely associated with the development of narratives about one’s life, and research evidence suggests that narratives also provide an opportunity for healing after a traumatic event (Neuner et al., 2008). Both resiliency research and youth development research find that opportunities to contribute or otherwise to “matter”—meaning-making within one’s context— are linked with successful outcomes in adolescents (National Research Council and Institute of Medicine, 2002; Villarruel et al., 2003). For instance, Werner and Smith (1992) examined “required helpfulness” at home and found that the key to a sense of helpfulness is for assigned work such as chores to be viewed as not just “helping out” around the house, but as necessary for the household (if not human) functioning. These acts provide youth with an opportunity to gain a sense of generosity and self-worth, as well as an opportunity to overcome the egocentric thinking so prevalent in adolescence (Perkins et al., 2018). PREPUBLICATION COPY, UNCORRECTED PROOFS 5-8

However, meaning-making may not always be associated with positive adjustment and prosociality, especially when meaning is found in extremism, such as in terrorism, gangs, and/or dangerous religious sects (Masten and Cicchetti, 2016). The links between meaning-making and resilience are complex and need far more longitudinal study (Park, 2011). Resilience in Military Children We are aware of no published longitudinal empirical studies focused on examining the correlates of resilience in military children. However, many papers have discussed or proposed frameworks for understanding resilience among military youth, with calls for more research to understand the correlates of resilience in this population (e.g., Easterbrooks et al., 2013; Masten, 2013; Park, 2011). Moreover, as Easterbrooks and colleagues (2013) note, “most military children turn out just fine” (p. 99). It is likely that the same sources of resilience found across multiple studies and described above are relevant to military children and youth. However, it is important to identify military-specific aspects of life that may help to confer resilience among children and youth in the face of stressors such as a parent’s deployment, multiple moves, parental psychopathology, and family violence. It may be the case, for example, that a parent’s pride in affiliation with the military provides the children with a sense of meaning and purpose (Gewirtz and Youssef, 2016a). Similarly, the resilience-focused approaches of much military training (e.g., Bowles et al., 2015; Lester et al., 2011) may convey the importance of hope, optimism, or a positive outlook on life to parent service members, who may in turn share this outlook with their children. Several elements of the military support system, particularly for families living on or near installations, or among other military families, may help support children’s resilience. A detailed discussion of them is beyond the scope of this chapter, but they would include social and parenting support, comprehensive services, including early identification and intervention with children at-risk for poor developmental outcomes, and early childcare support. For example, teachers and other caregiving adults may be particularly important for children’s resilience during transitions such as moves between installations (Permanent Changes of Station) and temporary separations from a caregiver, though there is a dearth of research on the role of extrafamilial caregivers for military child resilience. These and related supports, which are embedded in the military context, are discussed in chapters 4 and 7 of this report. The most powerful way to identify sources of resilience is through experimental studies of preventive interventions designed to promote resilience and to prevent maladjustment in the face of risks. Because of their design, experimental intervention studies hold the promise not only to improve children’s resilience but also to uncover causal factors in resilience among military children and families (Gewirtz, 2018). Unfortunately, to date few such experimental (randomized controlled) intervention studies have been conducted among military children and families. Interventions to Promote Children’s Resilience In this section, the committee reviews the empirical literature on what has been termed the “third wave” of resilience research—aimed at addressing whether and how interventions can actually nurture and strengthen children’s resilience. Over the past three decades, a large body of evidence-based preventive interventions aimed at strengthening child well-being and resilience PREPUBLICATION COPY, UNCORRECTED PROOFS 5-9

has been developed and rigorously evaluated in randomized controlled trials (RCTs). These interventions have provided valuable information on the malleability of resilience processes in development. Although very few of these interventions have been specifically developed and tested for military children and families (see Chapter 7 for more information about the applicability of interventions to different populations), emerging evidence from RCTs funded by the National Institutes of Health and the U.S. Department of Defense has provided valuable information about malleable factors associated with resilience in military children (DeVoe et al., 2016; DiNallo et al., 2016; Youssef et al., 2016). Interventions to promote resilience focus on strengthening protective and promotive factors empirically associated with or predictive of youth resilience. These represent a shift away from disease models of intervention and toward strengths-based and empowerment-focused positive psychology models of intervention (see Figure 7-1 in Chapter 7). As Masten and Cicchetti (2016) note: prevention research can be conceptualized as true experiments in altering the course of development, thereby providing insight into the etiology and pathogenesis of disordered outcomes and to the promotion of resilience (Cicchetti and Hinshaw, 2002; Howe, Reiss, and Yuh, 2002). The experimental nature of randomized clinical trials (RCTs) provides an unparalleled opportunity to make causal inferences in resilience research (p. 307). Below, we briefly review selected evidence-based interventions with RCT data targeting the malleable factors associated with youth resilience described above. Because of the sizeable volume of prevention and intervention research, we highlight those interventions of most relevance to military children and families and those with data demonstrating long-term change or change at multiple levels (e.g., biological, genetic, behavioral), or both. Most of these interventions focused on parenting/caregiving and the parent-child relationship, and unsurprisingly, very few of them were developed and tested with military populations. (Chapter 7 provides detailed information on evidence-based programs evaluated with military populations). We follow the order of the key resilience processes outlined above, with recognition that far more evidence-based prevention interventions focus on improving caregiving and parenting processes than on targeting children’s resilience alone. This is likely because programs aimed at improving children’s resilience have demonstrated crossover and cascading effects, improving both parental well-being and overall family well-being (e.g., Forehand et al., 2014; Gewirtz et al., 2016; Patterson et al., 2010; Sandler et al., 2011, 2015). For example, effective parents nurture their children’s self-regulation skills through consistency, love, and limits; they develop their children’s cognitive skills by reading to their children, modeling effective problem-solving, and structuring after-school time for homework and other activities. Parents, teachers, and other key adults help children develop mastery-motivation using positive reinforcement for persistence and effort, as well as tasks well done. Finally, although meaning making, hope, and other traits associated with resilience are individual characteristics, they also may be nurtured in family interactions. PREPUBLICATION COPY, UNCORRECTED PROOFS 5-10  

Preventive Interventions Targeting Resilience Through Parenting/Caregiving We highlight here two research-based prevention programs demonstrating the potential of caregiving/parenting interventions to promote the resilience of diverse youth across development. Early childhood programs have targeted the parent-child attachment relationship, as well as providing parents with early childcare skills and knowledge (e.g., Fisher et al., 2006; Toth et al., 1992). For example, the Nurse-Family Partnership provides skills and knowledge for new parents from the second trimester of pregnancy (Olds, 2006). Tested in three randomized controlled trials with diverse low-income mothers in three cities, long-term follow-up has demonstrated reductions in child maltreatment, benefits to family socioeconomic status, and improvements across multiple domains of child and youth functioning over more than 15 years, including improved school readiness, reduced substance use and psychopathology, fewer injuries, and improved academic achievement (Eckenrode et al., 2017; Olds et al., 2010). Other RCTs of both attachment-based and behavioral early childhood interventions with maltreated youth have demonstrated both behavioral and physiological improvements as a result of improvements in parenting. These include the normalization of diurnal cortisol patterns (Fisher et al., 2007) and improvements in executive functioning (Lind et al., 2017). Parenting interventions targeting middle childhood also have shown long-term benefits for diverse youth both “above and below the skin” (Patterson and Forgatch, 1987; Sandler et al., 2015). For example, Brody and colleagues (2009) examined the Strong African American Families seven-week parenting program among rural families with pre-adolescent children in the southern United States. RCT results indicated improvements on multiple child health and development indicators, including self-regulation, behavioral risks (substance use, antisocial, and risky sexual behaviors), and school attendance. A follow-up study of the youth at age 19 revealed that those who participated in the intervention showed significantly lower physical inflammation (indexing lower risk of health problems, particularly those associated with poverty) than those assigned to the control condition. Inflammatory markers were lowest in youth whose parents showed improved positive parenting and reduced coercive parenting as a result of the intervention (Miller et al., 2014). Other studies have demonstrated that the Strong African American Families intervention was particularly beneficial for families with parents and/or youth demonstrating higher genetic risk for poor outcomes. For example, Brody et al. (2009) demonstrated that this program was particularly protective for youth with genetic vulnerability to risky behaviors; youth with genetic vulnerability in the intervention group were only half as likely to initiate risky behaviors as genetically vulnerable youth in the control condition. Prevention Programs Targeting Child Self-Regulation Programs directly targeting children’s self-regulatory processes also have shown positive effects. These programs typically use school and community environments to boost the executive functioning, emotion regulation, and problem-solving skills of youth. These social-emotional learning (SEL) interventions include enrichments to Head Start and Early Head Start programs, such as Head Start REDI (Bierman et al., 2017; Sasser et al., 2017), which provided enrichment to the standard Head Start curriculum. The RCT, which followed four-year-old children for five years, demonstrated improvements in children’s academic outcomes by 3rd grade, and for the PREPUBLICATION COPY, UNCORRECTED PROOFS 5-11

children lowest in baseline executive functioning skills it demonstrated significant and sustained improvements in executive functioning over five years. For school-age children, SEL curricula also have demonstrated improvements to executive functioning. Promoting Alternative Thinking Strategies, for example, is a classroom- after-school and/or summer camp-based program aimed at reducing conflict among youth by improving outcomes such as executive functioning (Greenberg et al., 1998). Outcome analyses indicated that the program resulted in improvements to students’ verbal fluency and inhibitory control after one year. Improvements to inhibitory control, in turn, mediated improvements in teacher reports of youths’ behavioral and emotional problems after one year as well (Greenberg, 2006). We are aware of no programs with RCT evaluations that target mastery-motivation, meaning-making, or hope. As noted above, these correlates of resilience typically are incorporated into broader programs. CONCLUSIONS CONCLUSION 5-1: Early childhood and adolescence are particularly vulnerable periods for the capacity to cope with stress because of rapid brain development during these periods. This important consideration is not fully recognized in program and policy development. CONCLUSION 5-2: There are evidence-based practices and programs that can mitigate disruptions to children’s capacity to cope with stress caused by traumatic and highly stressful events, but few interventions have been developed and tested with military populations. CONCLUSION 5-3: Childhood resilience is multidimensional, and its measurement requires an understanding of the developmental context. Key correlates of childhood resilience include effective parenting or caregiving, self-regulation and mastery-motivation skills, strong cognitive abilities, hope/optimism, and making meaning of one’s experience. CONCLUSION 5-4: Resilience can be strengthened among youth exposed to stress or trauma. Rigorous evidence-based programs strengthening key predictors of resilience across multiple contexts (predominantly parenting/caregiving, parent- child relationship quality, and self-regulation) have demonstrated long-term improvements to children’s emotional, behavioral, cognitive, physiological, and biological functioning. REFERENCES Austin, M. P., Christl, B., McMahon, C., Kildea, S., Reilly, N., Yin, C., Simcock, G., Elgbeili, PREPUBLICATION COPY, UNCORRECTED PROOFS 5-12

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The U.S. military has been continuously engaged in foreign conflicts for over two decades. The strains that these deployments, the associated increases in operational tempo, and the general challenges of military life affect not only service members but also the people who depend on them and who support them as they support the nation – their families.

Family members provide support to service members while they serve or when they have difficulties; family problems can interfere with the ability of service members to deploy or remain in theater; and family members are central influences on whether members continue to serve. In addition, rising family diversity and complexity will likely increase the difficulty of creating military policies, programs and practices that adequately support families in the performance of military duties.

Strengthening the Military Family Readiness System for a Changing American Society examines the challenges and opportunities facing military families and what is known about effective strategies for supporting and protecting military children and families, as well as lessons to be learned from these experiences. This report offers recommendations regarding what is needed to strengthen the support system for military families.

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