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

Chapter: 7 The Military Family Readiness System: Present and Future

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Suggested Citation:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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:"7 The Military Family Readiness System: Present and Future." 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.

7 The Military Family Readiness System: Present and Future In this chapter,1 the committee presents a framework for building a more coherent, comprehensive approach to supporting the well-being and readiness of military families. The framework draws on established models for evidence-informed assessment and interventions, such as the population health framework, and reviews of the literature on human development, psychology, prevention science, dissemination and implementation science, and social work. It also integrates emergent research on the well-being of military-connected families. The chapter provides a roadmap with actionable steps that could transform the current support infrastructure—the Military Family Readiness System (MFRS)—into a coherent, comprehensive, complex, and adaptive support system designed for military families. Chapter 8 will draw on this chapter heavily as it focuses in on the specific implementation supports needed to implement an effective system in terms of policies, programs, services, resources, and strategies. THE STRUCTURE OF THE MILITARY’S SERVICE MEMBER AND FAMILY WELL-BEING SUPPORT SYSTEM Military families play a critical role in the strength and readiness of our nation’s military (DoD, 2012). As noted in Chapter 2, the resilience, readiness, and ability of military families to thrive throughout both the expected and the unexpected challenges and opportunities of military life impact individual service member’s readiness and attentiveness to their mission. The United States Department of Defense (DoD) implemented the MFRS to address this by establishing a comprehensive set of policies, programs, services, resources, and practices to support and promote family readiness and resilience. In short, the aim of the MFRS is to provide a support infrastructure that promotes family well-being and thereby fosters family readiness, which in turn enhances service members’ readiness. The MFRS offers a high level of support to address the demands of military service and the reliance on volunteers to serve. This level of support compares favorably to what is offered 1 This chapter draws partially on papers commissioned by the committee (Mohatt and Beehler, 2018; Thompson, 2018). PREPUBLICATION COPY, UNCORRECTED PROOFS 7-1

by large employers in the civilian sector. As described within this volume, the connection between “employee” and family member health is especially critical within DoD compared to other types of civilian employment, resulting in specialized emphasis on family programs. The DoD child care system is a prominent example: as stated in Chapter 4, 97% of DoD child development centers are nationally accredited, whereas overall only about 1 in 10 U.S. child care facilities meet this standard (DoD, 2017; Schulte and Durana, 2016, p. 6). Other notable features of the child care system include sliding subsidies, on-site trainers who work to maintain quality standards, and benefits and a career ladder for civilian federal employees. Another positive feature of existing MFRS policies, programs, services, resources, and practices is that they incorporate elements that target different needs at different life stages. In addition, an internal review and accreditation system promotes standardization and quality across military family programs. The vast array of social supports available to service members and their families is organized and provided at various levels within the military -- the DoD level, the service branch level, and in many cases the installation level. DoD-wide nonmedical counseling assistance and referrals are available to address areas of need that include the military life cycle (basic training, service, advancement, reenlistment, separation, transition/retirement), family and relationships, moving and housing, financial and legal aid, education and employment, and health and wellness. The Military OneSource website2 serves as a clearinghouse for information on programs. It posts links to and contact information for providers and maintains a database that can be searched by the type of support provided, name of installation, or general location (in 46 states, the District of Columbia, Guam, and 20 foreign locations). Additionally, the branches have their own programs and centralized sources of information. Table 7-1 lists examples of service-specific information, resources, and referral centers available through Military OneSource. 2 For more information see https://www.militaryonesource.mil/ PREPUBLICATION COPY, UNCORRECTED PROOFS 7-2

TABLE 7-1 Examples of Service-Specific Information, Resource, and Referral Centers Branch Program[s] Website[s] Army OneSource http://www.myarmyonesource.com Army https://www.armymwr.com/programs-and- U.S. Army MWR services/personal-assistance Navy Fleet and Family https://www.cnic.navy.mil/ffr/family_readiness/ Navy Support Program (FFSP) fleet_and_family_support_program.html Marine Corps Community http://www.usmc-mccs.org/ Marine Services (MCCS) Corps Marine & Family http://www.mccsmcrd.com/marine-family-programs/ Programs https://cs2.eis.af.mil/sites/10042 USAF Services Air note: unable to access; may require log-in Force Airman and Family https://www.afpc.af.mil/Benefits-and- Readiness Entitlements/Airman-and-Family-Readiness/ National Guard Family https://www.jointservicessupport.org/FP/Default.aspx Program Army Reserve Family http://www.usar.army.mil/ArmyReserveResources/ Programs Navy Reserve Family https://www.public.navy.mil/nrh/Pages/default.aspx National Readiness [Wellness tab] Guard https://www.marforres.marines.mil/Family- and Marine Corps Reserve Resources/ Reserves Family Resources https://www.marforres.marines.mil/General-Special- Staff/Marine-Corps-Community-Services/ U.S. Air Force Reserve Airman & Family http://www.afrc.af.mil/AboutUs/AirmanFamily.aspx Readiness SOURCE: Compiled by the Committee on the Well-Being of Military Families from Military OneSource, available at https://www.militaryonesource.mil Many installations offer their own services, which may or may not coordinate directly with their branch or DoD counterparts. These may be quite extensive and diverse, depending on the size of the garrison, the extent to which it is feasible for families to accompany service members to their posting, and the interests of garrison leadership. For example, Fort Bragg—the largest Army base in the world—maintains a website with links to 28 different community support facilities and 10 facilities and programs for child and youth services that are available to personnel and their families.3 However, smaller and more isolated posts may offer only modest services geared toward recreation opportunities for service members. Finally, there are nonprofit organizations operating across branches, such as the National Military Family Association4 and 3 https://bragg.armymwr.com/categories/community-support; https://bragg.armymwr.com/categories/cys- services 4 https://www.militaryfamily.org/ PREPUBLICATION COPY, UNCORRECTED PROOFS 7-3

the United Service Organization,5 and other nonprofits focused on specific branches.6 These nonprofits supplement all the military resources with their own sources of help and links to providers.7 Thus, there are many sources of support and information about support. What is unclear, though, is the extent to which service providers at the various levels of organization (i.e., DoD-wide, service branch level, installation level, and military-focused nonprofit) are aware of one another, and whether they can or do coordinate service provision. Moreover, as noted in prior Institute of Medicine reports (IOM, 2013; 2014) the vast majority of policies, programs, services, and resources they offer have not been evaluated for effectiveness. The committee did not identify any literature that directly addresses this question, although some studies do shed light on a more general, related issue: the extent to which DoD collects information on program implementation and effectiveness. Trail and colleagues (2017) note that evidence on the effectiveness of nonmedical counseling programs in the U.S. military is limited, “primarily due to the lack of coordinated monitoring and evaluation efforts” (p. 8). An earlier study focused on programs addressing psychological health and traumatic brain injury found that “no branch of service maintains a complete list of these programs, tracks the development of new programs, or has appropriate resources in place to direct service members and their families to the full array of programs that best meet their needs” (Weinick et al., 2011, p. 37). And results from a survey of 13 garrisons comprising more than 4,500 respondents suggest that coordination and communication problems are present at the installation level (Sims et al., 2018): Respondents also mentioned that soldiers do not always know where to go for help with their problems. … Given the timing of resource seeking—namely, when a soldier or family member is experiencing a problem—this trial-and-error process may be occurring at the least opportune time. Respondents concurred that some of this bouncing around could be avoided if there were more coordination and communication among service providers, and unfortunately respondents described experiences in which resource providers were unable to direct them appropriately (e.g., “The resource providers, if it is not about their program, they don’t really know to tell you where to go”). (Sims et al., 2018, p. 55) Therefore, while direct evidence is lacking, available information suggests that the success of the MFRS may be hampered because programs, services, and resources are siloed, lacking mechanisms to comprehensively monitor and coordinate their contributions. The policies, programs, services, and resources that comprise the MFRS fall under the purview of the Under Secretary of Defense for Personnel and Readiness (USD P&R)8, policies and programs 5 USO; https://www.uso.org/ 6 Army Emergency Relief [https://www.aerhq.org/]; Navy-Marine Corps Relief Society [http://www.nmcrs.org/]; Air Force Aid Society [https://www.afas.org/]) 7 DoD funds the Penn State Clearinghouse for Military Family Readiness [www.militaryfamilies.psu.edu] to perform outreach, training and support of service providers, and research on the effective delivery of services. This Clearinghouse partners with DoD and the branches to help improve the quality of services and promote evidence-based decision-making. While the center is oriented toward practitioners and research, its website includes information and links useful to military families, making it yet another source of support and information. 8 For more information see https://prhome.defense.gov (accessed October, 2018). PREPUBLICATION COPY, UNCORRECTED PROOFS 7-4

are overseen by separate Assistant Secretaries of Defense, and policies are interpreted and implemented by each military branch. This division of labor and responsibilities affects the MFRS’s ability to achieve a consistent, quality delivery across the system to address the needs of military families as they negotiate the military family life course. Historically, organizational limitations have also impeded full coordination between and among all of the agencies that are delivering services to individual service members and their families. The continuing post-9/11 conflict has required the MFRS to progressively adapt in order to meet the emerging needs of military families within an ever-changing political and budgetary landscape. Parallel with the rapid evolution of military family readiness programs, services, and resources is an expansion of research on the impact of military life on families and children, as well as research on approaches developed to enhance family well-being in the context of military life stressors. As Chandra and London (2013) note, there is an increasing need to “understand military children and families—their strengths and vulnerabilities, their ability to show resilience, and the systems that support them” (p. 188), yet the lack of available data and the fragmentation of the current data infrastructure limit the advancement of a coordinated effort that could enhance supports for military families. Without a coordinated effort related to (i) the design of services and programs that include standards (i.e., SMART [specific, measurable, attainable, relevant, and time bound] goals and objectives [Ogbeiwi, 2017], a theory of change, and a logic model) and (ii) data collection and analyses, the MFRS cannot ensure consistency in the current services, programs, and resources across population subgroups, service branches, and military status, nor can it respond with agility and efficiency to emergent threats to military family readiness. The committee recognizes that Military Community and Family Policy (MC&FP) leadership is tasked with the challenge of integrating the complex support systems within DoD to address emerging needs of families and their members that develop in a rapidly evolving context, often with limited available evidence. As such, the MFRS is best conceptualized as a complex adaptive system, one that evolves to meet the changing needs of the population. Simply put, a complex adaptive system is a structure with many dynamic, interacting relationships among components that are greater than the sum of its parts (Ellis and Herbert, 2010; Holland, 1995; Spivey, 2018). While much remains to be accomplished to achieve a true complex adaptive support system for military family readiness, the infrastructure that has been put in place provides a sound foundation on which to build one. Lipsitz (2012) asserts that the principles of complexity science need to be understood and applied to increase the success of a complex system, observing that nonlinear interactions in such a system can lead to an output that is greater than the sum of its parts. He writes: Failure to recognize this property is unfortunately one of the deficiencies of the health care system, which has established silos of care with relatively little attention to the patient transitions and communication channels between them. (p. 243) In an analogous manner, the siloing of programs, services, resources, and practices seen in the MFRS may result in insufficient attention being paid to familial transitions and to communication channels among its many separate parts. Thus, the MFRS would benefit by better fostering shared responsibility for military families across the military branches and the PREPUBLICATION COPY, UNCORRECTED PROOFS 7-5

various programs and services, improving inter-institutional communication, and increasing operational efficiency. Another principle of a complex adaptive system is the establishment of feedback loops that continuously guide the system toward improvement. Feedback loops are required for emergent self-organizing behavior to be evidence-informed. We address this topic later in this chapter, describing how to strengthen a complex adaptive MFRS to be more capable of integrating and generating evidence to advance a high-quality support system for military families. Additional operational information is provided in Chapter 8. A POPULATION-LEVEL SYSTEM PROMOTING WELL-BEING A population-level framework for military family readiness (as defined in Chapter 2) includes a classification model for policies, programs, services, resources, and practices that promotes positive development and health, both physical and mental, and ultimately fosters well- being. Prevention includes strategies to reduce the prevalence or severity of negative development and health outcomes and foster well-being in the context of risk and adversity. Extending a version of Gordon’s (1983) prevention model (i.e., universal, selective, and indicated), the committee’s model (see Figure 7-1) for categorizing military family readiness policies, programs, services, and resources is consistent with three prior Institute of Medicine (IoM) reports, including a report on military and family resilience and prevention (IoM, 1994; 2014; National Research Council and Institute of Medicine, 2009). While the origin of Figure 7- 1 was based on an approach to mental health (IoM, 1994), the figure has been re-envisioned as a model for a tiered continuum of support within a complex adaptive system such as the MFRS. Moreover, this adapted model has an explicit focus on promotional activities that foster competency, capacity, and skill building with individuals and families. PREPUBLICATION COPY, UNCORRECTED PROOFS 7-6

FIGURE 7-1 Continuum of coordinated support within the Military Family Readiness System SOURCE: Adapted from National Academies of Sciences, Engineering, and Medicine (2016, p. 180) The concept of a tiered continuum can be seen in the graded range of policies, programs, services, resources, and practices that connects the promotion dimension of support with the prevention, treatment, and maintenance dimensions of support (Springer and Phillips, 2007). Thus, the continuum of coordinated support underlying the MFRS includes policies, programs, resources, and practices that may fall into one or more levels of this tiered continuum. The continuum underscores the importance of continuity and consistency in what is offered and tailoring to fit the unique needs of stakeholders and the contexts in which these services, programs, and resources rest. The model highlights level of engagement and reach as critical components of a Continuum of Coordinated Support. Implementation research from the prevention science field has identified these as major road blocks to the successful scale-up of efforts (Baker, 2016; Biglan, 2015; Bumbarger and Perkins, 2008; Emshoff, 2008). The major consequence of poor participation rates and reach is that the likelihood of achieving outcomes is greatly diminished (Baker, 2016). Thus, to be effective MFRS will need to invest in multidimensional outreach efforts that include social media and partnerships with key trusted community stakeholders to actively promote engagement and increase reach. Central to this approach is a continuous identification and assessment of needs (e.g., through screening) to support the early identification of risks within military families, especially PREPUBLICATION COPY, UNCORRECTED PROOFS 7-7

risks to psychological health, the inclusion of selective9 and indicated10 preventive interventions, and treatment when warranted. The type of intervention needed is based on a staged hierarchy of interventions, known as stepped care, ranging from the least to the most intensive and matched to the individual’s or family's needs. Thus, the continuum provides a guide for identifying family groups with different support needs and aligning those needs with applicable policies, programs, and practices (National Research Council and Institute of Medicine, 2009). This continuum has been specifically adapted for military personnel and families as an essential part of the proposed population level framework in the context of combat operational stress, although similar models have been variably applied across service branches (Nash et al., 2010). Table 7-2 provides definitions of the Continuum of Coordinated Support within the MFRS, with examples of programs in these domains. In order to ensure that MFRS is addressing the various slices of the Continuum of Coordinated Support, a comprehensive and systematic mapping and alignment process can be conducted that links all policies, programs, services, resources, and strategies in terms of their placement on that continuum. This effort would be conducted regularly as part of continuous quality improvement, which is discussed later in this chapter and in Chapter 8. 9 Selective prevention interventions are aimed at individuals or families at risk of compromised well-being (e.g., single-parent or divorced families; families experiencing multiple deployments of a parent). 10 Indicated interventions target those already using or engaged in high-risk behaviors (e.g., substance abuse, maltreating parents). PREPUBLICATION COPY, UNCORRECTED PROOFS 7-8

TABLE 7-2 Definitions of the Continuum of Coordinated Support Domains and Program Examples Promotion Domain Program types Potential program audience Program examples Promotion and Targeted to the general military population or a specific Military and Family Support Centers; Youth positive military population (e.g., parents, spouses, children). Centers; Military OneSource; MWR; 4-H Program; development These services, programs, and resources aim to foster Girls and Boys Clubs; Girl Scouts; Boy Scouts; services, programs, children’s, youth’s, individuals’, and families’ parenting classes; child development centers; and or resources competence and mastery, well-being, and ability to after-school centers. thrive in the face of adversity. In addition, these interventions are focused on increasing protective factors that have been linked to resilience. Prevention Domain Program types Potential program audience Program examples Universal Targeted to the general military population or a specific Military OneSource, MWR; Purple Crying prevention services, military population (e.g., single parents or children) Campaign; Military Family Life Counselors; programs, or where the intervention would be desirable to the whole Family Support Centers; Strong Bonds; FOCUS resources group educational workshops and skills group training (Beardslee et al., 2011); After Deployment: Adaptive Parenting Tools Online program; youth centers; financial literacy programs. Selective prevention Targeted to individuals or groups who are at increased New Parent Support Program; Exceptional Family services, programs, risk for compromised functioning by virtue of exposure Member Program; After Deployment: Adaptive or resources to a stressful context (e.g., deployment, family Parenting Tools (Gewirtz et al., 2014); Families transitions) OverComing Under Stress (Beardslee, 2013; Lester et al., 2016); Operation Building Resilience and Valuing Empowered Families (Smith et al., 2013); Family Check-Up (Dishion et al., 2003; Fosco et al., 2013, 2016) PREPUBLICATION COPY, UNCORRECTED PROOFS 7-9

Indicated prevention Targeted to individuals or groups who have clear signs Strength at Home (Taft et al., 2016); Family services, programs, or exhibiting precursor behaviors signifying a trajectory Advocacy Program* prevention classes (anger or resources toward maladaptive behaviors or experiencing well- management, relationships) being issues (e.g., problematic functioning, excessive martial conflict, mental health challenges) Treatment Domain Program types Potential program audience Program examples Case management Targeted to individuals or groups who have exhibited Family Advocacy Program Case Manager; services, programs, maladaptive behaviors (e.g., anti-social behaviors, Domestic Abuse Victim Advocate or resources addictive behaviors, domestic violence) or are currently experiencing well-being issues (e.g., financial stability, reintegration role problems, parenting, anxiety, depression, suicide ideation). Case management efforts are about connecting individuals to the services and resources needed. Thus, case management is a set of social service functions (e.g., assessment, planning, linkage, monitoring, and advocacy) that helps clients access the services, programs, and resources they need to recover and overcome the issue and challenges (Center for Substance Abuse Treatment, 2000). Standard treatment Targeted to individuals or groups who have exhibited Cognitive Processing Therapy (Resick et al., 2017); services, programs, maladaptive behaviors (e.g., anti-social behaviors, Prolonged Exposure Therapy (Foa et al., 2018); or resources additive behaviors, domestic violence), or are currently Adaptive Disclosure (Litz et al., 2017); experiencing mental health issues (e.g., anxiety, Couple-based Cognitive Behavioral Therapy depression, suicide ideation). These services and (CBCT)(Monson et al., 2012) programs may involve therapy and counseling, and they are aimed at facilitating intra- and inter-personal change (Center for Substance Abuse Treatment, 2000). Maintenance Domain Program Types Potential Program Audience Program Examples PREPUBLICATION COPY, UNCORRECTED PROOFS 7-10

Compliance with Targeted to individuals or groups who have Ecological Momentary Interventions (Schulte and long-term treatment successfully completed treatment to overcome a Hser, 2015); and Mindfulness boosters (Witkiewitz and after-care maladaptive behavior or mental health issue. The aim of et al., 2013). Annual check-ups as seen in Drinkers these services, programs, and resources is to prevent Check-Up, Marriage Check-Up, and Family Check- recidivism, relapse, or reoccurrence of the behavior or Up issue. SOURCE: Adapted from National Research Council and Institute of Medicine, 2009. 0 *https://www.militaryonesource.mil/family-relationships/family-life/preventing-abuse-neglect/the-family-advocacy-program 1 PREPUBLICATION COPY, UNCORRECTED PROOFS 7-11

EVIDENCE-BASED AND EVIDENCE-INFORMED POLICIES, PROGRAMS, SERVICES, RESOURCES, AND PRACTICES As a complex adaptive system, the MFRS and its components (policies, programs, services, resources, and practices) are dynamic and evolving, because the needs, opportunities, and challenges facing military families are continuously changing. As noted in the Continuum of Coordinated Support within the Military Family Readiness System, a comprehensive family readiness system includes strategies to promote well-being and health, reduce the prevalence or severity of negative outcomes through prevention and treatment programs, and promote positive outcomes over time. A strategy for monitoring risk and a stepped-care approach is required to link families with increased risk to appropriate programs, services, and resources. Throughout this report, the committee emphasizes that MFRS programs, services, resources, and practices need to be grounded in the best available evidence. In an ideal world, there would be strong evidence of both the internal and the external validity of those components’ effectiveness in supporting military family readiness, resilience, and well-being, including their effectiveness at producing the desired effects reliably and in real-world conditions. However, as noted in Chapter 1, while randomized controlled trials (RCT’s) can provide strong evidence that interventions produce the desired effect for a specific context and population, there are limitations to the usefulness and appropriateness of RCTs in several contexts, depending upon the “exact question at stake, the background assumptions that can be acceptably employed, and what the costs are of different kinds of mistakes” (Deaton and Cartwright, 2018). For this report, the committee examined publicly available evidence with a focus on building on previous knowledge, including decades of prior research on prevention science and child development, and the committee incorporated available theoretical models, observational studies, as well as experimental and quasi-experimental designs conducted with military families that allow for causal inference (Centre for Effective Services, 2011; Glasgow and Chambers, 2012; Gottfredson et al., 2015; Graczyk et al., 2003; Howse et al., 2013; Kvernbekk, 2017; Schwandt, 2014). Programs, services, resources, and practices within the MFRS need to be grounded in sound conceptual and empirical foundations and require rigorous design, implementation, and evaluation. With regard to evaluation, the system has a responsibility to conduct rigorous evaluations and ongoing monitoring for all efforts, inclusive of evidence- informed and evidence-based programming (Chambers and Norton, 2016; Glasgow et al., 2012). Evidence-based and Evidence-informed Individual evidence-based practices (EBPs) are typically standardized through manuals that support fidelity and enable replication. Such a manual or curriculum will provide a detailed roadmap of the program or service and its session goals, describe the approach and activities to meet those goals, and provide guidelines to deal with intervention challenges (Kendall et al., 1998). EBPs have been found to work for a wide variety of problems and issues, for demographically diverse individuals and families, for varied treatment settings, and for different intervention approaches. Nevertheless, for any given issue, setting, or population, an established PREPUBLICATION COPY, UNCORRECTED PROOFS 7-12

specific EBP might not yet be available (see Chapter 8). EBPs are generally tested with a specific population and often in a different context from the one in which it had originally been developed, so there is often a need to engage in a systematic and culturally responsive adaptation process (detailed in Chapter 8). In addition, implementation of EBPs or evidence-informed practices should be supported by continuous quality improvement using ongoing data collection and monitoring, which are required as part of a complex adaptive system. The designation of evidence-informed, as defined in Chapter 1, describes a program, service, resource, strategy, component, practice, and/or process that (i) is developed or drawn from an integration of scientific theory, practitioner experience and expertise, and stakeholder input, using the best available external evidence from systematic research and a body of empirical literature; and (ii) demonstrates impact on outcomes of interest through the application of scientific research (although that research achieves a lower standard of proof as it does not allow for causal inference) (Centre for Effective Services, 2011; Glasgow and Chambers, 2012; Howse et al., 2013; Kvernbekk, 2017; Schwandt, 2014). Although RCT and quasi-experimental designs are the bedrock of rigorous evaluations, mixed methods with data source triangulation, as well as public health, epidemiological, and mixed-method case-nested case studies are also useful for addressing specific questions related to program implementation. These definitions do not set a hierarchy of standard. Rather, the use of both evidence- based and evidence-informed policies, programs, services, resources, and practices is necessary for a complex adaptive support system to achieve success. Given the fast-paced and ever- changing context of the military, the system is not in a position to conduct rigorous studies before it acts; therefore, application or implementation requires the use of promising policies, programs, services, resources, and practices grounded in the best available evidence. Thus, while adaptations or newly defined evidence-informed programs, services, resources, and practices may lack the level of scientific evidence of internal validity as EBPs have, they may nevertheless have the potential to be effective. Thus, within a complex adaptive MFRS, evidence-informed and new programs, services, and resources can be implemented using an embedded quality- monitoring process. Such a process would enable the system to test, measure, and evaluate emerging, culturally relevant, innovative practices that can then be evaluated for effectiveness in a scientifically rigorous manner, as described in Chapter 8. To help reduce some of the barriers to the selection and utilization of EBPs, several web- based repositories of evidence-based programs have been developed, such as the School Success Best Practices Database11 and Blueprints for Healthy Youth Development.12 Moreover, the DoD Office of Military Community and Family Policy, in collaboration with the National Institute for Food and Agriculture, has funded the development of the Clearinghouse for Military Family Readiness13 (hereafter, the Clearinghouse). The Clearinghouse is designed to provide professionals with tools to respond to the needs of military-dependent children, youth, and families. In addition to offering live technical assistance and support to providers concerning utilizing evidence in selecting and implementing programs, the Clearinghouse has developed a repository of information on more than 1,200 programs, and that number is growing. The 11 See https://web.archive.org/web/20180307165748/http:/www.schoolsuccessonline.com/ 12 See https://www.blueprintsprograms.org/ 13 See https://militaryfamilies.psu.edu/ for more information PREPUBLICATION COPY, UNCORRECTED PROOFS 7-13

programs on the Clearinghouse website cover a wide range of health and well-being issues relevant to both military and civilian families. These include, but are not limited to, parenting practices, family communication, coping and resilience, child and youth behavior, obesity intervention, prevention of alcohol and substance use, and treatment of mental health issues such as post-traumatic stress disorder (PTSD) and depression. As with other web-based repositories, the Clearinghouse reviews and places programs along a continuum of evidence derived from established criteria. Placements are rigorous, based on peer-reviewed research, and adhere to a systematized process and clearly articulated criteria. The Clearinghouse is unique in reviewing programs that are designed for and tested with service members and their families. It also reviews programs developed in nonmilitary contexts that may be relevant for military family populations. To ensure relevance and based on current research, the Clearinghouse reassesses programs on the Continuum of Evidence every five years. The Clearinghouse’s Continuum of Evidence was developed to provide a well-defined and useable resource to identify relevant evidence-based programs (Karre et al., 2017; Perkins et al., 2015). To be placed in this continuum, studies of programs are reviewed in accordance with specific criteria. Certain requirements determine whether each program qualifies as Effective, Promising, Unclear, or Ineffective for each individual criterion. Using the Continuum of Evidence, existing programs are reviewed and, based on the empirical evidence, each is placed into one of these categories: Effective (RCT and Quasi); Promising; Unclear (+) with Potentially Promising Features; Unclear (Ø) With No Evaluations or Mixed Results; Unclear (−) with Potentially Ineffective Features; or Ineffective. Box 7-1 describes the major criteria for these program placements on the Continuum of Evidence. As is the case with most EBP registries, the criteria emphasize research designs that demonstrate internal validity but not external validity. Many EPBs are tested in specific contexts, and thus the relevance or applicability of an individual program within diverse, rapidly evolving, and complex community contexts and delivery systems (external validity) may be challenging to establish. Given the importance of adaptability to military family readiness, these issues are addressed briefly below and in detail in Chapter 8. BOX 7-1 Clearinghouse for Military Family Readiness: Major Criteria for Program Placements on the Continuum of Evidence 1. Significant effects. For a program to qualify as having Effective or Promising for Significant Effects, it must demonstrate rigorous, statistically significant evidence (e.g., p < 0.05 in a two-tailed test). Proper statistical adjustments are made when multiple tests are conducted of a change in a highly desired outcome with no iatrogenic effects (i.e., a negative consequence of the program). To qualify as Unclear, the program must show mixed effects or no evidence due to a lack of peer-reviewed evaluations. To qualify as Ineffective, a program evaluation must fail to demonstrate a significant effect or must have an iatrogenic effect. 2. Sustained effects. For a program to qualify as Effective, the evaluation must demonstrate effects lasting at least two years from the beginning of the program or one PREPUBLICATION COPY, UNCORRECTED PROOFS 7-14

year from the end. To qualify as Promising, the evaluation must demonstrate effects lasting at least one year from the beginning of the program or six months from the end. To qualify as Unclear, the maintenance of effects must not have been assessed. To qualify as Ineffective, a program’s initial effects must diminish to nonsignificant over a specified period of time. 3. Successful external replication. For a program to qualify as Effective for External Replication, there must be at least two independent evaluations (at least one of which has been undertaken by a team with no connection to the program developer) that demonstrate positive results on the same outcome; both evaluations must qualify the program as Effective on each of the other Continuum criteria. To qualify as Promising or Unclear, a replication is not necessary. To qualify as Ineffective, there must be no evidence of a successful external replication. 4. Study design. For a program to qualify as Effective or Ineffective, the evaluation must be a randomized controlled trial (RCT) or a well-matched quasi-experimental design (i.e., the intervention group and the control group must be matched on demographic and pretest variables). To qualify as Promising, the evaluation must be at least a quasi- experimental design. To qualify as Unclear, the evaluation can lack a comparison group. Note that use of an RCT does not guarantee consideration of Effective for Study Design. If an RCT is poorly implemented, for example, or is analyzed in a manner that makes it effectively a study with no comparison group, it would not be considered Effective for Study Design. 5. Additional criteria regarding study execution. Currently, for a program to qualify as Effective or Ineffective, the evaluation must meet all four additional criteria. Thus, the program evaluation must have a representative sample (i.e., accurately represent the population that the program purportedly targets); modest attrition (i.e., have an acceptable level of attrition, or analyses of differential attrition are conducted); use adequate outcome measures (i.e., use reliable and valid measures); and discuss practical significance (i.e., account for the magnitude of effects). To qualify as Promising, a study must meet two or three additional criteria. If a study meets zero or one additional criterion, it qualifies for Unclear. SOURCE: Karre et al., 2017. Examples of Evidence-Based Programs In this section, to highlight the use of various evidence-based and evidence-informed programs within MFRS, we present seven examples of programs for which evaluations have indicated efficacy or effectiveness. First, we summarize three research-based caregiving/parenting interventions noted in Chapter 5. Then we review an intervention relevant to the MFRS Family Advocacy Program, followed by two couple programs and one bullying prevention program. Finally, we review an example of a population-level approach, one that was tested within active duty Air Force installations. Strong Families Strong Forces (Strong Families) is a reflective parenting program designed to support military parents and their young children throughout the deployment cycle. In one RCT, the efficacy of Strong Families was confirmed with families of National Guard and PREPUBLICATION COPY, UNCORRECTED PROOFS 7-15

Reserves service-member parents, who reported significantly reduced parenting stress and enhanced reflective capacity in relation to their young children (DeVoe et al., 2017). Moreover, service-member parents who endorsed higher levels of trauma symptoms also reported increased parental self-efficacy relative to waitlist control participants. Among at-home spouses, Strong Families had a positive impact on self-reported relationship satisfaction with the service member partner (Kritikos et al., 2019).14 Families OverComing Under Stress (FOCUS) is a family-centered preventive intervention designed to enhance resilience, which was initially adapted for military families with school-age and adolescent children from two established evidence-based preventive interventions. These interventions employed core components using a community-participatory framework and implemented at scale using a tiered public health approach (Beardslee et al., 2011; Beardslee, 2013; Lester et al., 2016; Saltzman et al., 2011, 2016). The FOCUS model has been used for early childhood (FOCUS-EC), specifically for families with a child between the ages of three and five (Mogil et al., 2010). An RCT of FOCUS-EC, delivered as an in-home tele- health preventive intervention, had several positive significant findings. Parents who participated in FOCUS-EC experienced greater reductions in PTSD symptoms compared to parents using a web-based curriculum. Primary caregivers reported significantly greater improvements in parent- child relationship quality and significant reductions in total parenting stress relative to the control group. Moreover, observed parenting and parent-child interactions were also significantly improved in the FOCUS-EC intervention group at 12 months (Lester et al., 2018). After Deployment, Adaptive Parenting Tools/ADAPT is a parenting program, based on the Parent Management Training-Oregon Model (Forgatch and Gewirtz, 2017), aimed at strengthening resilience in children ages 4 to 13 living in families in which a parent has been deployed to one of the recent conflicts. Four RCTs of ADAPT are complete or underway. Results to date from intent-to-treat analyses of a large-scale RCT with 336 military families demonstrate the program’s effectiveness in strengthening children’s emotional, behavioral, and social/peer functioning, and reducing youth substance use, based on parent, teacher, and child reports, from 12 to 24 months post-baseline (6 to 18 months after the end of program delivery), with these improvements mediated through strengthened observed parenting practices and improved parenting self-efficacy (Gewirtz et al., 2018; Piehler et al., 2016; Gewirtz and DeGarmo, in preparation). Additional findings demonstrate the program’s salutary effects on parental well-being (i.e., reductions in parental depression, PTSD symptoms, and suicidality) (Gewirtz et al., 2016, 2018). Couples Therapy for Domestic Violence: Finding Safe Solutions is a curriculum designed to provide assessment of and treatment for couples who choose to stay in a relationship after one or both individuals have been violent. Results from one RCT showed that at six months after program completion, couples in a multicouple group showed significantly lower rates of male violence recidivism, marital aggression, and acceptance of wife battering and higher rates of marital satisfaction than those in an individual couple group or a comparison group. Two years after program completion, females reported that males who participated in either the multi- 14 Note that as of this writing, a second RCT is near completion, involving a sample of active duty Army families with very young children. PREPUBLICATION COPY, UNCORRECTED PROOFS 7-16

couple or individual couple therapy had lower rates of recidivism than men in the comparison group (Stith et al., 2004). Prevention & Relationship Enhancement Program (PREP) for Strong Bonds is a community-based program designed to help couples in the military strengthen their relationships and prevent or minimize marital concerns, including those that might be unique to military families. At site 1, where couples were at higher risk for relationship problems (e.g., younger, married for a shorter time, had a lower income, and had husbands with lower military rank and higher rates of deployment), there were significant positive effects in the treatment group on communication skills, confidence, bonding, and satisfaction. However, no differences were found between the treatment and control groups concerning forgiveness, dedication, or negative communication. At site 2, among lower-risk couples, there was a significant effect only on communication skills. Separate analyses found that divorce rates in the treatment group at site 1 were lower than in the control group up to two years post-intervention, and this effect was strongest for minority couples. There was no difference in divorce rates between treatment and control groups at site 2. There was no effect on overall relationship quality, communication skills, or positive bonding at either site. In addition, data from both sites combined showed an intervention effect on mitigating the risk of divorce linked to cohabitation before making a marital commitment (Allen et al., 2011; Rhoades et al., 2015; Stanley et al., 2010, 2014). Green Dot, a violence prevention and intervention program, is designed to change social norms related to violence, increase proactive bystander behaviors, reduce acts of personal violence, and promote safe communities. Multiple evaluations by the program developers have been conducted of the high school and college versions of the Green Dot program. Survey data from first-year students in a multiyear quasi-experimental evaluation of Green Dot on one college campus indicate that the intervention campus experienced lower rates of self-reported unwanted sexual victimization, sexual harassment, stalking, and psychological dating violence victimization and perpetration relative to two comparison campuses. However, there were no differences between intervention and comparison campuses in self-reported rates of coerced sex, physically forced sex, physical dating violence, or unwanted sexual perpetration. Results from a multiyear-cluster RCT of Green Dot in 26 high schools indicate that intervention schools experienced lower rates of self-reported sexual violence perpetration and victimization and reductions in dating violence acceptance and sexual violence acceptance relative to comparison high schools. However, these results differed by gender and were generally strongest in year 3 of program implementation, with some fading of effects in year 4 (Coker et al., 2011, 2015, 2016, 2017, 2018). The New Orientation to Reduce Threats to Health from Secretive Problems That Affect Readiness (NORTH STAR) program is a population-level approach to enhance the ability of base, major command, and Air Staff Integrated Delivery Systems to reduce death, injury, and degraded force readiness by (i) disseminating the prevalences of secretive problems at three levels -- local (Air Force base), Major Command, and Air Force–wide; (ii) providing base-level information to identify and prioritize risk and protective factors; (iii) assisting bases in selecting and implementing evidence-informed and evidence-based interventions; and (iv) evaluating whether prevalences were lowered (Slep and Heyman, 2008). Researchers conducted a randomized, controlled prevention trial to test the effectiveness of the NORTH STAR framework in reducing targeted risk factors; increasing targeted protective factors; and reducing base PREPUBLICATION COPY, UNCORRECTED PROOFS 7-17

prevalences of family maltreatment, suicidality, and problematic alcohol and drug use. Twelve matched pairs of Air Force bases were randomly assigned to either (a) the NORTH STAR implementation condition or (b) the control condition (receiving comparable prevalence and risk/protective factor information but not NORTH STAR)(Heyman et al., 2011). These programs have demonstrable albeit varied levels of effectiveness, and their use with military families provides a clear indication of their feasibility within MFRS. Nevertheless, an ongoing protocol and process for accountability is needed to ensure continuous quality improvement. ACCOUNTABILITY AND MEASUREMENT Accountability represents a complex adaptive system’s responsibility for measuring its actions (i.e., its policies, programs, services, resources, and practices) (Patton and Blandin Foundation, 2014). Although programs, services, or resources may be effective in one context that does not necessarily mean they will work universally in all contexts. Thus, in order to be accountable, MFRS needs to assess the transportability, effectiveness, and efficiency of policies, services, programs, resources, and practices within and across the military (Damschroder et al., 2009). A critical element of accountability is demonstrating the need to adapt or tailor as well as assessing whether the benefit of tailoring would warrant the additional investment. The adaptation process is discussed below and in detail in Chapter 8. Accurate measurement is a vital part of accountability for any complex adaptive system, like the MFRS, so that it can continuously learn and improve in its efforts to increase well-being and resilience. Measurement implies both the use of evidence-based assessment and the tracking of data outcomes essential for delivering and monitoring the effectiveness of programs, services, resources, and practices (IOM, 2013). A useful measurement frame for assessing the quality of military family readiness services is Donabedian’s (2005) classic paradigm for assessing quality of care, which is based on a three-component approach focusing on structure, process, and outcome (see Figure 7-2). Donabedian’s paradigm proposes that each component has a direct influence on the next, as represented by the arrows in the figure. FIGURE 7-2 Donabedian paradigm SOURCE: IOM, 2014, p. 26. Structure refers to the attributes of the settings in which providers deliver programs and services, including material resources, such as service-delivery records, human resources, such as staff expertise and training, and organizational structure, for example whether the setting is a child development center, school, or community setting. The premise is that the structure can be PREPUBLICATION COPY, UNCORRECTED PROOFS 7-18

a strong determinant of service quality and that given the proper structure, good care will follow. For example, one would expect care to be of higher quality when providers and staff are trained in utilizing evidence-based programs or evidence-informed strategies and their competencies are assessed in an ongoing manner. Process refers to the services that are delivered and received. This can include anything that is done as part of the encounter between an individual or family and the delivery system, including interpersonal processes such as providing information or resources, skill-building activities, and (or) employing evidence-informed care strategies, as well as involving individuals in decisions in a way that is consistent with their cultural backgrounds and lived experiences. Traditional process measures assess the quality of support and service that an individual or family received and the fidelity with which it was delivered (IOM, 2014). Finally, Outcome refers to how an individual’s or family’s outcomes are affected by engagement with a program, service, or resource. There are both proximal outcomes (short-term consequences) and distal outcomes (long-term consequences). An example would be improved parenting, a proximal outcome that could eventually translate into a child’s improved social- emotional functioning, a distal outcome (IOM, 2014) Figure 7-3 is a model adapted from the IOM (2014) report to organize concepts related to the Continuum of Coordinated Support of MFRS and the measurement constructs presented in the above paragraphs, including evidence-informed and evidence-based programs, services, resources, and practices, the types of those efforts, the socio-ecological model, and performance measures. The model is not intended to capture all of the complex pathways that characterize program development and measurement but to serve as a general guide for thinking about the complex process of identifying the best metrics for assessing military family readiness services. (IOM, 2014). PREPUBLICATION COPY, UNCORRECTED PROOFS 7-19

FIGURE 7-3 Model for development and measurement of coordinated support policies, programs, services, resources, and practices SOURCE: Adapted from IOM, 2014, p. 29. Translating evidence into an effective program also requires attending to the myriad implementation processes that ensure high quality and relevance, including a balance among the fidelity, adaptation, tailoring, and cost-effectiveness of the program, service, resource, or practice. Community-engaged and participatory strategies are a key part of the implementation process (which will be addressed in detail in Chapter 8). As illustrated in Figure 7-3 by the dotted line leading to “Types of Measures,” program performance can be assessed using structure, process, outcome, and cost measures (IOM, 2014). Selected measures or instruments should meet methodological standards to ensure valid and reliable measurement. In particular, attention to measurement of child well-being is central to developing an effective military family readiness system. The committee recognizes that there is no single measure of child well-being, but rather multiple subjective, objective, and functional domains that are central to the mapping and monitoring of well-being over the trajectory of development. While a detailed review of measures of adult or child well-being and resilience is beyond the scope of this report, the committee relies on the Institute of Medicine’s Preventing Psychological Disorders in Service Members and Their Families: An Assessment of Programs (IOM, 2014), where this is discussed in Chapter 5. The feedback loop in Figure 7-3 represents the cycle of using measurement results to continuously inform the empirical evidence and to improve program implementation and system level accountability (IOM, 2014). PREPUBLICATION COPY, UNCORRECTED PROOFS 7-20

Attaining a high-quality, complex adaptive MFRS depends upon the development of an integrated data infrastructure that supports population-level monitoring and mapping of family well-being, as well as effective program implementation and quality monitoring (see Figure 7-4). Ongoing evaluation of a system’s policies, services, programs, and resources is essential to an embedded measurement approach to accountability and continuous quality improvement. The evaluation designs, employed to assess the effectiveness of the policy, service, program, resource, or practice in achieving outcomes, need to balance rigor and practicality with respect to both internal and external (e.g., ecological) validity (Glasgow et al., 2012). FIGURE 7-4 Integrated information infrastructure to support a complex adaptive system, such as MFRS SOURCE: Adapted with permission from ZS Associates, Inc., 2019. As already noted, the measuring and ongoing tracking of outcomes at various levels is essential in order to rigorously evaluate the effectiveness and comprehensively assess the impact of a dynamic complex adaptive system. There are three major types of outcomes to be evaluated within a human service system like MFRS: implementation, service, and client/participant outcomes (see Figure 7-5) (Proctor et al., 2011). Often, the evidence-based terminology is linked to whether a program, service, resource, or practice achieves success in improving or reducing client or participant outcomes. However, simply capturing client or participant outcomes does not provide information on what part or parts of the program, service, resource, or practice PREPUBLICATION COPY, UNCORRECTED PROOFS 7-21

worked and for whom. Thus, for more than a decade, translational research has demonstrated the importance of assessing implementation outcomes for the goal of quality scale-up (Estabrooks et al., 2018). Central to this approach is the development of feedback processes that support the implementation and adaptation of multiple and tiered EBP and EIP interventions to support military family needs. Such data analytics infrastructure and processes are foundational to fostering learning and adaptation across the MFRS. They would support a complex adaptive system with the data and information capabilities needed to develop greater insight into monitoring and addressing system-level interactions between programs and policies and the ways that may lead to improved outcomes and, ultimately, to increased readiness across the MFRS. As seen in Figure 7-5, implementation outcomes precede both service and client outcomes. The service outcomes noted here are drawn from the Institute of Medicine report entitled, Crossing the Quality Chasm (IOM, 2001). PREPUBLICATION COPY, UNCORRECTED PROOFS 7-22

FIGURE 7-5 Types of outcomes in implementation research SOURCE: Proctor et al., 2011, p 66. Monitoring For a system to be accountable and foster continuous quality improvements, an active monitoring protocol needs to be operationalized and implemented. Monitoring serves as the checklist for assessing implementation (Langley et al., 2009). That is, regular monitoring is required for a system to proactively identify those aspects of an implementation that need to be adapted to the new context to optimize effectiveness and lessen the potential for failure (Schwartz et al., 2015). Monitoring should be part of a broader data-driven accountability strategy, one that involves collecting data, identifying patterns and facts from those data, and employing those facts to make inferences that influence both implementation (Knight et al., 2016) and decision- making (Shen and Cooley, 2008). The broader data-driven accountability includes data drawn from monitoring, evaluation, and administrative information (e.g., budgets and staffing). Details about what should be monitored and how is discussed in Chapter 8. The premise of ongoing monitoring is not to find fault or blame, but to promote a culture of learning in the system through data-driven feedback loops that support continuous quality improvement. The military’s universal use of After Action Reports represents one part of a monitoring protocol. Because monitoring from quantitative measurements alone often fails to capture the cultural and contextual adaptations that would be needed to enhance implementation with diverse families, community engagement and participatory processes are useful, as they can address these gaps in data-driven feedback loops. PREPUBLICATION COPY, UNCORRECTED PROOFS 7-23

COMMUNITY ENGAGEMENT AND PARTICIPATORY PARTNERSHIPS Community engagement involves identifying and collaborating with key stakeholders, including military family members, service members and veterans, all layers of military leadership across the services, and community leaders and providers. It is a multilevel continuum that begins prior to or early in program development and continues through all phases of program implementation. As described in Chapter 4, DoD does not have good visibility regarding the variety of military families, so by utilizing engagement and participatory strategies it could develop a better understanding and better identify needs among diverse family constellations. Community engagement can also help in developing a more accurate and nuanced picture of the specific circumstances, concerns, and cultures of families within the varied local contexts, inadequate knowledge of which may be hampering access to evidence-based programming. By understanding local needs and resources, programs can develop strategies to remove barriers for families and increase program use (True et al., 2015). Furthermore, by collaborating with communities to assess barriers and opportunities, service providers can build local capacity to sustain effective outreach and engagement efforts (Huebner et al., 2009). An important challenge for the military is how to maintain the vertical command structure that is necessary for mission readiness while also empowering “horizontal” initiatives to promote local leadership, community stakeholders, and military families themselves to define their needs and influence program development, adaptation, and implementation. A primary function of community engagement is to enhance access to and participation in programs that are known to be effective in supporting military family well-being. Improving access to care in this way may be part of the answer to the challenge of improving military family well-being. Engagement approaches are especially needed in communities where National Guard/Reserve families live and in more rural areas of the country, as well as for those who cannot access installation-centered care. The DoD service system also would benefit from the sharing of resources, successful programming, and data across the service branches to better support military families. As is the case for civilian program efforts, a critical challenge in delivering services for military families and service members is low rates of service utilization and retention (DeVoe et al., 2012; Hoge et al., 2014; Shenberger-Trujillo and Kurinec, 2016; Steenkamp et al., 2015). Programs, services, resources, and practices cannot lead to population-level change if the target population will not engage in the opportunities being offered. As part of a quality-monitoring system, it is essential to comprehensively examine the reasons for low participation or high dropout rates (or both) among evidence-based programs and services, as these rates may illuminate poor program-community alignment. In this context, ongoing, iterative community and family engagement may be useful for improving the fit of evidence-based programs within local cultural contexts and lead to increased utilization across services. In particular, community engagement approaches can help shape effective outreach, leverage local resources, tailor services to the most pressing issues as identified by local families, and address specific barriers to services. PREPUBLICATION COPY, UNCORRECTED PROOFS 7-24

Detailed recommendations for tailoring evidence-based programs to different community settings (see Miller et al., 2012), cultures (see Castro et al., 2010) and populations (see Lee et al., 2008) have been published. Other areas of literature can inform the assessment of influential aspects of social settings (Tseng and Seidman, 2007) and social networks (Neal et al., 2011) to support high-quality adaptation to local circumstances. In addition, programs implemented across service settings need to carefully attend to military culture, including intersectional and military identities, behaviors, language, norms, and values, as well as the varied ways that culture may be expressed in different geographic locations. Cultural differences within military groups may be significant, for example, between U.S.-based locations and locations abroad. Cultural differences may also be significant within the United States between rural and urban settings, between active duty members and the reserve component, and among settings such as health care clinics vs. employment settings, and military vs. nonmilitary environments. Even as more programs are developed specifically for military populations, it cannot be assumed that the same cultural elements will be salient across the services or across diverse settings, populations, and issues (Castro et al., 2010; Kirmayer, 2012). Community engagement strategies can support the goals of adapting programs to local contexts and increasing program uptake and implementation. The majority of military families live in civilian communities (Whitestone and Thompson, 2016). Thus, to support and enhance military family well-being, it is essential to achieve the engagement and cooperation of organizations within the civilian settings and their collaboration with MFRS in the effort to build, adapt, and sustain relevant programming (Gil-Rivas et al., 2017). In addition, collaborative and community processes are key elements to close the significant research-to-practice gap in the integration of new evidence and evidence-based programs and to assure ‘program to community alignment’ (Mistry et al., 2009) in the dissemination of family programs. In the post-9/11 era, DoD, National Institutes of Health, and the U.S. Department of Veterans Affairs have all invested in the development of research-based family programs that have been found to be effective, yet many of these programs have not been implemented in routine military- or civilian-practice settings or disseminated broadly. Community engagement and participation may be critical processes with the potential to address these significant adaptation, implementation, and dissemination challenges. Given that less than one percent of the American population serves in the all-volunteer force, many scholars and policy makers also have raised concerns about a growing military- civilian divide wherein nonmilitary communities—communities that do not have a military installation nearby—have been disconnected from the post-9/11 conflicts and the realities of military service members and their families. While there has been increased attention to building military cultural competence among civilian providers, capacity building in multiple and interconnected civilian sectors is critical to bridging this divide in support of military and veteran families (Bowen et al., 2013). Some scholars have observed that military and civilian communities do not understand or communicate well with each other and that civilian providers may assume that military families are able to access military-specific supports (e.g., Hoshmand and Hoshmand, 2007). Since 9/11, PREPUBLICATION COPY, UNCORRECTED PROOFS 7-25

there have been several initiatives, such as AmericaServes15 and the Cohen Veteran Network,16 that leverage civilian academic, community mental health, and school systems to provide examples for advancing care (Renno and Shelton, 2017; Tanielian et al., 2017). There have likewise been initiatives to improve professional training in civilian sectors, such as the STAR Behavioral Health Providers Program17 and PsychArmor.18 In addition to such cross-sector collaboration, in order for the MFRS to successfully develop, implement, and sustain programs, services, and resources promoting military family well-being, a deeper understanding of specific communities and their resources is necessary, along with culturally specific knowledge of the diverse subgroups of military families (see Box 7-2). BOX 7-2 Community Engagement and Community Participatory Research There is a growing recognition of the value of community-engaged research (CER) and community-based participatory research (CBPR) for addressing a wide range of scientific questions and with diverse communities (Blumenthal, 2011; Trickett and Espino, 2004; Trickett, 2011; Wallerstein and Duran, 2006). Over the last two decades, community-engaged research approaches have gained traction at the National Institutes of Health (NIH) as an effective approach for reducing health disparities (Wallerstein and Duran, 2006, 2010). In 2008, the National Institute of Minority Health and Development (NIMHD) launched the Community-Based Participatory Research Program to support research in which the community “is involved in the CBPR program as an equal partner with the scientists.”19 The Centers for Disease Control and Prevention (Faridi et al., 2007; IOM, 2000, 2003), and the Agency for Healthcare Research and Quality (Viswanathan et al., 2004) have both published recommendations for employing these methodologies. SOURCE: Compiled by the Committee on the Well-Being of Military Families. There is emerging interest in using community engagement and participatory strategies to address and support well-being challenges in military populations (DeVoe et al., 2012; Haynes, 2015; Hoshmand and Hoshmand, 2007; Huebner et al., 2009; Shenberger-Trujillo and Kurinec, 2016). Hoshmand and Hoshmand (2007) emphasize the important role that multilevel engagement and participatory processes can play in bridging military and civilian settings that service members and their families navigate on a daily basis. Huebner and colleagues (2009) discuss how both can increase cross-sector community capacity to support military families. Shenberger-Trujillo and Kurinec (2016) identify a number of research-to-practice gaps and argue 15 For more information see https://americaserves.org/ 16 For more information see https://www.cohenveteransnetwork.org/ 17 For more information see https://www.starproviders.org/ 18 For more information see https://psycharmor.org/ 19 For more information see https://www.nimhd.nih.gov/programs/extramural/community-based- participatory.html PREPUBLICATION COPY, UNCORRECTED PROOFS 7-26

that the local knowledge and engagement developed through community engagement can help fill these gaps. Further, there is a growing recognition that challenges facing military populations demand a public health approach to prevention and intervention. This too requires locally engaged and community-based intervention strategies in addition to clinically situated interventions (Brenner et al., 2018; Knox et al., 2010; Murphy and Fairbank, 2013; U.S. Department of Veterans Affairs, 2018).20 Collaborative Stance and Outreach Institutionalized collaboration, both formal and informal, between MFRS and its programs, services and resources, community networks, researchers, and military families is essential to the well-being of military families, because each stakeholder group possesses unique knowledge and resources critical to this effort. An authentic “collaborative stance” brings in stakeholder voices and expertise to increase the likelihood that promotion, programs, resources, and services are responsive to complex and diverse military families. As Kudler and Porter (2013) conclude: “Summarizing the clinical and public health models…we might well say that the secret of care for military children [and their families] is creating communities that care about military children. This will require [collaborative] effort and [shared] time, but we believe it is a highly achievable goal” (Kudler and Porter, 2013, p. 182). Successful outreach includes effective marketing of the available programs, services, and resources. Community engagement approaches also place an emphasis on the kind of outreach that is distinct from marketing—that is, going to where military families live, congregate, and interact on a daily basis (Huebner et al., 2009). In addition to reaching out to make contact with different locations and at different times and aligning with community events, outreach also includes engaging with community gatekeepers and stakeholders who maintain a high degree of authority and are trusted by military families. Collaborating with key community members, whom others look to for guidance and leadership, will improve the broader community’s trust in a program (Wallerstein and Duran, 2010). Therefore, accessing local social networks to identify and conduct outreach through key network members may help spread the use of evidence-based programs and resources (Neal et al., 2011). Lastly, community engagement emphasizes that meeting service members, veterans, and their families where they are is also about assessing and understanding both the local culture and the ways military connectedness influences their lives and the services they seek (Kilpatrick et al., 2011). Engaging community stakeholders at all phases of program, service, and resource development, delivery, and implementation increases the likelihood of the efforts’ relevance and contextual soundness. Local stakeholders possess knowledge about how programs, services, and resources interrelate, including challenges in continuity of care across military settings. Yet local families and providers may not possess the authority to control or fix the system issues they identify, and military leadership with the authority to address continuity across the military may remain unaware of local issues and conditions and therefore of their possible solutions. In this regard, collaborative engagement approaches can help military leaders identify challenges and 20 See Chapter 8 for a discussion of implementation science. PREPUBLICATION COPY, UNCORRECTED PROOFS 7-27

solutions that meet the needs of military families. Given communities’ varying availability of resources and varying abilities to allocate existing resources, localized adaptation of the MFRS can foster both the capacity and the sustainability of programs and service provision. Several researchers emphasize the benefits to military families of programs that take a community capacity development approach (Huebner et al. 2009; Mancini and Bowen, 2014; Mancini et al., 2018). Community capacity building through informal social networks is based on the principles of shared responsibility for family and community well-being and collective competence, which in turn reflect a community’s ability to recognize and mobilize community resources to support well-being (Huebner et al., 2009, p. 219). These scholars argue that programs must be integrated into rather than set apart from the communities in which military families live, work, and play, and that effective military-civilian partnerships must involve the sharing of social capital, information and resource exchange, and orientation toward effective and relevant outcomes. Moreover, Mancini and colleagues (2018) suggest that formal policies, programs, and services need to target growing informal networks, and their success should be gauged by how well they establish a network of support for families. At the national level, through formal collaborations, programs such as 4-H/Army Youth Development have been able to create local opportunities to expand evidence-based programming. In these examples, national military-private initiatives were set up to expand local services. Improvements in access to care, such as through transportation assistance and growth in local volunteers and clubs, emerged from these initiatives’ ability to increase community capacity. In the same way, community engagement approaches build on existing community resources to embed service and program development at the local level, which increases the availability, accessibility, and relevance of programs to the daily lives of military families. Participatory approaches rely on collaborations that involve end-users in defining their strengths, needs, and problems and contributing to (i) developing programs that target these identified needs and problems; (ii) determining the conditions under which programs can be accessed and effective; and (iii) identifying the extent to which programs align with and are culturally responsive to diverse military families. The Institute of Medicine and several researchers have lamented the lack of evaluation of such programs and are calling for research and evaluation processes that are more rigorous and address cultural responsiveness (Easterbrooks et al., 2013; Gewirtz, 2018; IOM, 2013). Given the diversity and complexity of contemporary military families, there is a need for caution in assuming what works, why/how, where, when, and for whom. Collaborating with military families to clarify the well-being construct and variants across different military family subgroups and contexts may be valuable in selecting, developing or adapting evidence-based programs that can be tailored. The process of continuous quality improvement must include methods to incorporate evaluations of programs’ relevance and validity for specific family types, constellations, and needs. Similarly, if existing programs have been based on intervention theories and evidence developed in civilian settings, evaluation might focus on understanding the specific context of well-being in military families and diverse communities, because mechanisms for developing family well-being may differ between military and nonmilitary families. Finally, there is a critical question about the extent to which programs, services, resources, or practices, under the best conditions, contribute to military family well- being. To be effective, they must be relevant to the population to be served. Relevance is more PREPUBLICATION COPY, UNCORRECTED PROOFS 7-28

clearly defined as the degree to which they are useful to families. Thus, core elements of relevant programming require inclusiveness, adaptability, and agility in the development of programs, services, and resources to ensure relevance and enable effectiveness (Nembhard and Edmonson, 2006). Given the tremendous diversity of military families, maintaining program relevance is a critical and never-ending process. Castro and colleagues (2004) describe a “dynamic tension” within prevention science related to a need for fidelity in the implementation of evidence-based programs balanced against the need for adaptation to ensure the relevance and fit of a program to the needs of the community (p. 41). To ensure appropriate balance, scholars suggest the development of adjustable or adaptable programs that can be tailored to the local cultural context (detailed in Chapter 8). The Joint Responsibility of MFRS and the Community in Responding to the Dynamic and Diverse Realities of Military Families The policies, programs, services, resources, and practices of the MFRS as well as community-based programs, services, and resources are profoundly important in providing military children and families with connections, support, and continuity. Frequent moves and changing schools add to a child’s sense of uncertainty and anxiety. If a service member’s child was involved in programs such as arts, clubs, or sports, there may be financial or logistical challenges to continuing these activities after the parent’s discharge from the service or after a relocation. Families may need help planning for involuntary transitions, particularly during the stressful time of caring for an injured service member. Local programs, youth organizations, and activities sometimes offer connections and assistance to address these challenges (Cozza et al., 2017, p. 323). Box 7-3 includes just some of the many military family voices that acknowledge these challenges. BOX 7-3 Military Family Voices 1. “In reality it is their self-sufficiency that determines whether they will be able to fill the gaps between what is available and how they function as a military family.” (Ellyn Dunford, spouse of General Joseph F. Dunford, Chairman of the Joint Chiefs of Staff*) 2. “You want to protect your children, but you bring your family along with your career’s progressions.” “It hasn’t been without challenges, and we have needed to look outside of just our family unit and to those who can help make a difference and help define what this new normal is.” (Lieutenant Colonel Eric M. Flake, US Air Force, as quoted in Military Child Education Coalition [2016, p 16]). 3. “Still, families don’t just need programs…they need people.” (Colonel Anthony Cox, Army (retired), former manager, HQDA Family Advocacy Program*) 4. “Well, I also started making friends because I got involved in a lot of the clubs and sports.” (John Doe, military-connected student, as quoted in Military Child Education Coalition [2012], p. 139) PREPUBLICATION COPY, UNCORRECTED PROOFS 7-29

5. “Communities outside the gate are the first line of defense, especially for the families of the National Guard and Reserves.” (Ellyn Dunford*) SOURCE: Compiled by the Committee on the Well-Being of Military Families *Speaker at a public information gathering session held on April 24, 2018, at the National Academies of Sciences, Engineering, and Medicine. See Appendix B for full agenda. The military has long been a leader and innovator in social policies and supports, including in the area of child and family readiness programming, two examples being child care supports and domestic violence prevention. A commitment to understanding how military families experience their loved ones’ service and to developing more efficient and effective systems to support readiness benefits from collaborations with civilian systems of support. Strong, reciprocal collaborative relationships with civilian systems and their data monitoring agencies, such as local public education systems and child welfare and community mental health agencies, are central to creating a comprehensive continuum of support that reaches beyond installation facilities and into the communities where families live, work, and play. The challenge is that, more often than not, these collaborative efforts happen by chance, rather than by intent (Gravens and Keller, 2018). CONCLUSIONS CONCLUSION 7-1: The Department of Defense has developed a Military Family Readiness System that includes a number of policies, services, programs, resources, and practices. This system is complex, multifaceted, and tiered, and is to be lauded insofar as there is nothing comparable in the U.S. civilian sector. CONCLUSION 7-2: The current Military Family Readiness System is siloed, with a diffusion in its division of labor and responsibility, and its delivery of services is fragmented in some instances. The system lacks a comprehensive, coordinated framework to support individual and population well-being, resilience, and readiness among military families. Addressing this deficit could improve quality, encourage innovation, and support effective response capabilities. The current system also lacks the processes and structures necessary to support ongoing population-level monitoring and mapping of family well-being, including a grounding in the continuum of promotion, prevention, treatment, and maintenance dimensions and integrated data infrastructure, accompanied by validated and appropriate assessments. Finally, as noted earlier, diffusion of the division of labor and responsibilities has to do with what entity “owns” which part of the policies, programs, services, and resources that comprise the MFRS. For instance, these efforts are under the purview of the Under Secretary of Defense for Personnel and Readiness (USD PREPUBLICATION COPY, UNCORRECTED PROOFS 7-30

P&R),21 yet policies and programs are overseen by separate Assistant Secretaries of Defense, and policies are interpreted and implemented by each military branch. CONCLUSION 7-3: Utilizing a dynamic complex adaptive support-system approach would improve the ability of the Military Family Readiness System to respond to the needs of military families. Evidence-based and/or evidence-informed practices, resources, services, programs, and policies are foundational to a complex adaptive system. A continuous quality monitoring system that utilizes solid measurements is needed to ensure a complex adaptive system that continues to progress in its effectiveness and relevance. The Military Family Readiness System can learn from community engagement and participation examples for potential incorporation of adaptation strategies and tailoring of promotion, prevention, and intervention efforts to ensure continuous alignment, relevance, and effectiveness of programs, services, resources, policies, and practice for stakeholders with a sensitivity to local contexts. CONCLUSION 7-4: Community engagement and meaningful collaboration with key stakeholders are critical from the beginning and throughout the implementation process to identify relevant targets for the continuum of support (i.e., promotion, prevention, and intervention efforts), ensure program alignment with diverse family needs and constellations, assure family engagement and program participation, and build community capacity to support military family well-being and readiness. REFERENCES Allen, E. S., Stanley, S. M., Rhoades, G. K., Markman, H. J., and Loew, B. A. (2011). Marriage education in the Army: Results of a randomized clinical trial. Journal of Couple & Relationship Therapy: Innovations in Clinical and Educational Interventions, 10(4), 309–326. Baker, S. (2017). Broadening the Reach of Evidence-Based Parenting Interventions: Evaluation of a Brief Online Version of the Triple P–Positive Parenting Program. Dipl. Psych. A thesis submitted for the degree of Doctor of Philosophy at The University of Queensland, Australia, in 2016 School of Psychology. Beardslee, W., Lester, P., Klosinski, L., Saltzman, W., Woodward, K., Nash, W., Mogil, C., Koffman, R., and Leskin, G. J. P. S. (2011). Family-centered preventive intervention for military families: Implications for implementation science. 12(4), 339–348. Beardslee, W.R. (2013). Military and veteran family-centered preventive interventions and care: Making meaning of experiences over time. Clinical Child and Family Psychology Review, 16(3), 341–343. 21 For more information see https://prhome.defense.gov (accessed October, 2018). PREPUBLICATION COPY, UNCORRECTED PROOFS 7-31

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Strengthening the Military Family Readiness System for a Changing American Society Get This Book
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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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