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Int J Methods Psychiatr Res. Author manuscript; available in PMC 2015 June 17. Published in final edited form as: Int J Methods Psychiatr Res. 2015 June ; 24(2): 143–155. doi:10.1002/mpr.1464.
Establishing a Methodology to Examine the Effects of War-Zone PTSD on the Family: The Family Foundations Study Jennifer J. Vasterling, VA National Center for PTSD at VA Boston Healthcare System and Boston University School of Medicine
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Casey T. Taft, VA National Center for PTSD at VA Boston Healthcare System and Boston University School of Medicine Susan P. Proctor, U.S. Army Research Institute of Environmental Medicine and Boston University School of Public Health Helen Z. MacDonald, Emmanuel College Amy Lawrence, VA Boston Healthcare System and Boston University School of Medicine
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Kathleen Kalill, VA Boston Healthcare System and Boston University School of Medicine Anica P. Kaiser, VA National Center for PTSD at VA Boston Healthcare System and Boston University School of Medicine Lewina O. Lee, VA National Center for PTSD at VA Boston Healthcare System and Boston University School of Medicine Daniel W. King, VA National Center for PTSD at VA Boston Healthcare System and Boston University School of Medicine
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Correspondence concerning this article should be addressed to: Jennifer J. Vasterling, Psychology (116B), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130.
[email protected]; Phone: 857-364-6522; Fax: 857-364-4673. Jennifer J. Vasterling, VA National Center for PTSD, VA Boston Healthcare System; Department of Psychiatry, Boston University School of Medicine; Casey T. Taft, Psychology and VA National Center for PTSD, VA Boston Healthcare System; Department of Psychiatry, Boston University School of Medicine; Susan P. Proctor, U.S. Army Research Institute of Environmental Medicine; Department of Environmental Health, Boston University School of Public Health; Helen Z. MacDonald, Department of Psychology, Emmanuel College; Amy Lawrence, Research Service, VA Boston Healthcare System; Department of Psychiatry, Boston University School of Medicine; Kathleen Kalill, Research Service, VA Boston Healthcare System; Department of Psychiatry, Boston University School of Medicine; Anica P. Kaiser, VA National Center for PTSD, VA Boston Healthcare System; Department of Psychiatry, Boston University School of Medicine; Lewina O. Lee, VA National Center for PTSD, VA Boston Healthcare System; Department of Psychiatry, Boston University School of Medicine; Daniel W. King, VA National Center for PTSD, VA Boston Healthcare System; Department of Psychiatry, Boston University School of Medicine; Lynda A. King, VA National Center for PTSD, VA Boston Healthcare System; Department of Psychiatry, Boston University School of Medicine; John A. Fairbank, VA Mid-Atlantic (VISN 6) Mental Illness Research, Education and Clinical Center (MIRECC) at Durham VA Medical Center; UCLA-Duke National Center for Child Traumatic Stress and Department of Psychiatry and Behavioral Sciences, Duke University.
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Lynda A. King, and VA National Center for PTSD at VA Boston Healthcare System and Boston University School of Medicine John A. Fairbank VA Mid-Atlantic (VISN 6) Mental Illness Research, Education and Clinical Center (MIRECC) at Durham VA Medical Center, Duke University
Abstract
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Military deployment may adversely affect not only returning veterans, but their families, as well. As a result, researchers have increasingly focused on identifying risk and protective factors for successful family adaptation to war-zone deployment, re-integration of the returning veteran, and the longer-term psychosocial consequences of deployment experienced by some veterans and families. Posttraumatic stress disorder (PTSD) among returning veterans may pose particular challenges to military and military veteran families; however, questions remain regarding the impact of the course of veteran PTSD and other potential moderating factors on family adaptation to military deployment. The Family Foundations Study builds upon an established longitudinal cohort of Army soldiers (i.e., the Neurocognition Deployment Health Study) to help address remaining knowledge gaps. This report describes the conceptual framework and key gaps in knowledge that guided the study design, methodological challenges and special considerations in conducting military family research, and how these gaps, challenges, and special considerations are addressed by the study.
Keywords
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warzone veterans; family; PTSD; longitudinal; risk factors
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Over 2.6 million US military service members have deployed in support of Operations Enduring and Iraqi Freedom and Operation New Dawn (OEF/OIF/OND; Defense Manpower Data Center [as cited by Department of Veterans Affairs, 2014]), over 40% deploying more than once (Institute of Medicine [IOM], 2014). As summarized in a 2013 IOM report (IOM, 2013), recent increases in the length of deployments and number of redeployments have placed considerable strain on military families (e.g., Andres, 2014; Chandra et al., 2008; Gorman et al., 2011; Mansfield et al., 2010; Riviere et al., 2012; Schmaling et al., 2011). On a national survey of 819 randomly selected OEF/OIF/OND veterans conducted by The Washington Post and Kaiser Family Foundation (2014), 45% of respondents endorsed “sometimes” or “often” having relationship problems with their spouse or partner, and 19% reported relationship problems with their children. This is during a time in which over two-thirds of officers and over half of enlisted service members are married, and 44% of regular active duty enlisted personnel and 43% of reservists have dependent children (Department of Defense [DoD], 2012). Yet, gaps in knowledge impede the progress in optimizing service provision to the families of military personnel and veterans who deployed to war zones.
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The purpose of this report is to describe the Family Foundations Study, an on-going observational cohort study established to increase understanding of the mental health functioning of the families of military personnel and veterans who deployed since 2003 to a war zone. The paper describes the conceptual framework and key knowledge gaps that guided the study design, methodological challenges, and special considerations in conducting military family research, and how the study addresses these issues.
Definitions and Objectives
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For brevity, we use “veteran” in reference to prior experience in the war zone. Therefore, we refer to both current and former service members who served in a war zone “war-zone veterans,” or “veterans,” regardless of their current military status. We refer to cohabitating intimate partners, regardless of whether legal spouses or not, as “partners.” The outcome domain, family mental health adaptation, is defined as mental health outcomes among intimate partners (e.g., mood and anxiety disorders) and dependent children (e.g., behavioral problems) within the household, as well as overall family cohesion. The study specifically examines family mental health adaptation in relation to: (a) current war-zone veteran PTSD symptoms and (b) varying longitudinal trajectories of war-zone veteran PTSD symptoms (beginning pre-deployment and extending 6–8 years post-deployment).
Background
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A growing literature indicates that family members of deployed military personnel experience more mental health problems and less family cohesion than families of nondeployed service members and veterans. In one study (Eaton et al., 2008), military spouses of OEF/OIF-deployed service members seeking care in military primary care settings reported mental health problems at rates comparable to their service member spouses. Mansfield et al. (2010), examining the medical records of over 250,000 military wives, likewise found sharply elevated rates of depression among the spouses of deployed service members. Similar patterns have emerged among National Guard samples (Gorman et al., 2011).
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Children of deployed parents have likewise shown more behavioral problems, as compared both with children whose military parents were not deployed (Barker & Berry, 2009; Chandra et al., 2008; Chartrand et al., 2008; Lester et al., 2010) and with a representative national sample of children (Chandra et al., 2010). Problems among children with deployed parents can rise to the level of serious mental health concerns, as demonstrated by a 10% increase in psychiatric hospitalizations among children aged 9–17 when a military parent was recently deployed (Millegan et al., 2013). Similarly, children of deployed or recently deployed military personnel report greater substance abuse, as compared with children from nonmilitary families (Acion et al., 2013). As aspects of recent military operations “draw down,” the children of military personnel are increasingly challenged by how to adjust to the re-integration of their parent(s) into non-deployed life and, in many cases, fully into civilian life as service members separate from the military (Chandra et al., 2011). The emotional distress of service members returning from war zones may contribute significantly to poor family outcomes. Posttraumatic stress disorder (PTSD) may be Int J Methods Psychiatr Res. Author manuscript; available in PMC 2015 June 17.
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particularly problematic. Described as a “signature injury” of OIF/OEF, with prevalence estimates as high as 20% in some OEF/OIF samples (Ramchand et al., 2010), PTSD has been identified as a key determinant of family outcomes following contemporary deployments (Erbes et al., 2012; Lambert et al., 2012; Tsai et al., 2012). However, much of the research on family adjustment to military life, deployment, and combat-related PTSD is based on earlier veteran cohorts and has been limited by small convenience samples and cross-sectional methodology (IOM, 2013). There is less understanding of family problems related to contemporary deployments, which differ in the pace and number of deployments per service member, involve a higher proportion of women, single parents, and dual military career couples than earlier deployments (IOM, 2013; Sheppard et al., 2010), and differ in the nature of communications with family members during deployment. The lack of longitudinal veteran data also significantly limits knowledge about how the course of warzone veterans’ PTSD symptoms influences family functioning and how risk and protective factors may interact with PTSD symptom change to affect the likelihood of developing family adjustment difficulties. This study complements other, on-going work (e.g., CrumCianflone et al., 2014) in its inclusion of family clinical interviews in addition to written surveys, the archived veteran PTSD assessments timed specifically around prior deployments, the availability of archived veteran clinical interviews and performance-based neuropsychological data, and its related conceptual emphasis on associations between veteran PTSD trajectories and family mental health outcomes.
Conceptual Framework
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Figure 1 depicts the conceptual framework for study methods and hypotheses. In sum, we hypothesize that higher levels of war-zone veteran PTSD symptoms lead to poorer family adaptation. We further hypothesize that a number of key factors (e.g., social support, veteran traumatic brain injury [TBI], veteran alcohol use) moderate the impact of veteran PTSD symptoms on family outcomes, serving as protective or risk factors. We base these hypotheses on the literature summarized below. PTSD and Family Functioning
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In a survey of US Army spouses, 43% indicated that adjusting to changes in the soldier’s “mood/personality” upon return from deployment was one of their greatest challenges (Booth et al., 2007). This finding mirrors a broader literature suggesting that negative consequences for the family increase with a service member’s exposure to psychologically traumatic events (IOM, 2013) and when service members display negative psychological symptoms (de Burgh et al., 2011). PTSD is particular concerning, as it has been shown to represent the most important determinant of family adjustment difficulties in prior military populations (Jordan et al., 1992) and occurs in significant subsets of veterans of contemporary military operations. Recent cross-sectional evidence indicates that PTSD symptoms among active duty Army soldiers are related to lower marital adjustment, commitment, and confidence in the relationship, lower parenting alliance, and more negative family communication (Allen et al., 2010). Service member PTSD is also moderately associated with partner psychological distress, as indicated by a recent meta-analysis (Lambert et al., 2012). As reviewed by Int J Methods Psychiatr Res. Author manuscript; available in PMC 2015 June 17.
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Monson et al. (2009), these findings reflect a larger literature obtained from samples of veterans from previous wars indicating that the negative effects of military-related PTSD on family mental health outcomes extend to marital dysfunction, indexed by divorce, separation, infidelity, and intimate partner violence (Gimbel & Booth, 1994), poorer family adjustment, more relationship problems, more problems with intimacy, higher levels of relationship distress, more parental problems, lower family cohesiveness, and less constructive communication behaviors (Carroll et al., 1985; Cook et al., 2004; Jordan et al., 1992; Riggs et al., 1998; Ruscio et al., 2002; Solomon et al., 1987).
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Work pertinent to contemporary war-zone veterans also indicates that the presence of PTSD in veterans may adversely affect family outcomes, one study suggesting that veteran PTSD may largely determine whether combat exposure leads to poorer relationship adjustment (Pietrzak & Southwick, 2011). Another study that prospectively examined PTSD symptoms clusters in 522 National Guard soldiers who deployed to Iraq found that dysphoric symptoms in particular predicted relationship dysfunction as long as one year after deployment (Erbes et al., 2011).
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As compared with studies examining the relationship of military PTSD to spousal outcomes and family interactions, much less is known about associations of parental PTSD with child outcomes. PTSD symptoms in veterans of prior military conflicts, however, have accounted for the impact of combat exposure on family violence and aggression (Byrne & Riggs, 1996), lower parenting satisfaction, and more child behavior problems (Caselli, & Motta, 1995; Harkness, & Giller, 1995; Jordan et al., 1992; Samper et al., 2004). The parental distress of either the deployed parent or the non-deployed spouse may also adversely impact child mental health outcomes. Consistent with research from the 1991 Gulf War (Cozza et al., 2005), parental distress was a potent predictor of child psychosocial functioning (Flake et al., 2009), anxiety (Lester et al., 2010), difficulties during deployment, and emotional, social, and academic problems among children of parents deployed to Iraq or Afghanistan (Chandra et al., 2011).
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Knowledge Gap 1: Associations between the longitudinal course of veteran PTSD and family adaptation—The course of stress reactions, including PTSD symptoms, is not uniform across individuals following trauma exposure (Dickstein et al., 2010) and may alter family outcomes significantly depending on the onset and duration of veteran PTSD symptoms in relation to the age and characteristics of the family (e.g., duration of the family as a unit). Although understanding the relationship of veteran PTSD course to family outcomes potentially holds implications for optimizing the timing of family interventions, there is no research to date examining whether, and how, the course of stress reactions (e.g., delayed symptom onset, recovery, or chronic symptoms) influences family adaptation. Risk and Protective Factors Most available information on risk and protective factors for adverse mental health outcomes following trauma exposure centers on factors that moderate the relationship between trauma exposure and psychological sequelae within the exposed individual. For
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example, although little work has examined the effects of social support on the families of stress-exposed individuals, social support has emerged as one of the most consistent protective factors against development and maintenance of PTSD within the trauma-exposed individual (Brewin et al., 2000; Ozer et al., 2003). In the context of a chronic stressor such as deployment, which affects both the individual and family, it could be hypothesized that adequate social support buffers the negative impact of the returning veteran’s emotional distress on overall family functioning. Parallels can be drawn from the literature on healthrelated stressors, one study indicating that concurrent social support reduced not only individual parental distress following a child’s hospitalization for head trauma but also enhanced the quality of the mother-child relationship and the family’s adaptability (Youngblut & Brooten, 2008).
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In contrast to potentially protective factors such as social support, other factors such as veteran TBI and neuropsychological deficits may exacerbate the adverse effects of PTSD on both the individual (i.e., the veteran) and family. With approximately 44% of OIF soldiers who experience TBI with loss of consciousness also meeting criteria for PTSD (Hoge et al., 2008), TBI and neuropsychological functioning constitute a class of risk factors for family dysfunction of particular significance to contemporary combat deployments. Rates of TBI among physical interpersonal violence perpetrators, ranging from 40% to 61%, are significantly higher than those found in the general population (Rosenbaum & Hoge, 1989; Rosenbaum et al., 1994). Head-injured men also report significantly more loss of temper and control, increased difficulty communicating verbally, and more relationship problems compared to controls (Warnken et al., 1994), factors all potentially eroding family wellbeing. Neuropsychological dysfunction, a correlate of some TBIs, may contribute to interpersonal dysfunction. Even outside the context of TBI, neuropsychological impairment is associated with aggressive and other maladaptive behaviors potentially affecting family interactions (Cohen et al., 1999). Knowledge Gap 2: Moderators of PTSD and Family Outcomes—The identification of modifiable risk and protective factors has implications for the development of preventive interventions geared at families, whereas the identification of fixed factors has implications for resource allocation to high-risk subsets. Yet, little is known about risk and protective factors that moderate the effects of PTSD on family well-being.
Addressing Knowledge Gaps
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The Family Foundations Study builds on existing literature by assessing the family members of a cohort of OIF/OEF veterans who have been followed longitudinally since prior to their first deployment, with a particular focus on associations of veterans’ PTSD symptoms (and their course), and moderating factors (both historical and current), with current indices of family functioning. Specifically, we address limitations of prior work by applying innovative statistical modeling to a prospective design in which psychological trauma, PTSD symptoms, and other risk and resilience factors will have been assessed in veterans at three time points: pre-deployment (Time 1; previously collected), immediately postdeployment (Time 2; previously collected), and 6 to 8 year follow-up (Time 3; collected within close temporal proximity to Family Foundations).
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The Family Foundations study has three main hypotheses:
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more severe current veteran PTSD symptoms will be associated with poorer family outcomes;
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as compared with longitudinal PTSD symptom trajectories associated with resilience or recovery, longitudinal trajectories in veterans consistent with chronicity and delayed onset PTSD will be associated with poorer family outcomes;
3.
risk and protective factors (e.g., veteran TBI, social support) will moderate the relationships between veteran PTSD symptoms (both current and symptom trajectories) and family outcomes.
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The next section describes how we designed the methods around these hypotheses and the challenges and special considerations inherent to the study population.
Methods Design
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Family Foundations is an observational, cohort study of service members and military veterans and their families (anticipated N = 380 total families and N = 261 families with children, based on US Army estimates [Booth et al., 2007]). The study draws upon the Neurocognition Deployment Health Study (NDHS) (Vasterling et al., 2006), an established cohort of Army soldiers who have been followed longitudinally since before their first OIF deployment and most recently for a 6 to 8 year follow-up as part of Department of Veterans Affairs (VA) Cooperative Study Program (CSP) #566 (Aslan et al., 2014), which was designed specifically to examine longer-term longitudinal outcomes and individual growth trajectories over time within the context existing, archived shorter-term outcome data. Created in April, 2003, the NDHS cohort is now comprised of both current and former service members. The Family Foundations Study represents the first assessment of NDHS cohort family members and continues assessment of NDHS cohort members. Sampling and recruitment
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War-zone veterans—A full description of NDHS sampling methods can be found elsewhere (Brailey et al., 2007; Vasterling et al., 2006). In summary, the NDHS sampled regular active duty US Army soldiers and activated Army National Guard soldiers at the battalion level to represent a range of military functions and war-zone experiences. The NDHS design included pre- and post-deployment assessment and longer-term follow-up via VA CSP #566. The NDHS cohort includes both participants who deployed since their baseline assessment and those who have never deployed. The Family Foundations Study draws upon NDHS cohort members who (a) deployed to Iraq or Afghanistan, (b) have an English- or Spanish-speaking spouse or partner who has lived within their household for ≥ 1 year, and (c) consent to allow access to archived NDHS assessment data. Intimate partners—Following veteran consent, the partner is contacted to request consent to participate.
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Children—Among families with eligible children, the Family Foundations Study examines the outcomes of one child, selected via a stratified randomization procedure. The “focus child” must be 6 to 17 years old and have lived at least 50% of the time within the veteran’s primary household for at least one year. We stratify according to age group (6–12 vs. 13–17 years) to help obtain equal representation of younger children and adolescents. This strategy facilitates representativeness by age while allowing sub-analysis by age group. Because adolescent children have opportunity to participate in direct assessment, with their guardian’s informed consent, they are also approached to give their own assent to participate directly in the study.
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Special considerations and challenges—Inherent to any study enrolling multiple family members, there is a possibility that coercion or subtle pressures to participate transpire among family members. This is especially challenging in a nationally dispersed sample with remote recruitment and consent procedures. To minimize this possibility, family members are asked if they have adequate privacy at the time of consent. Veterans are not informed whether their family members have agreed to participate, and no family member is given the status of the completion of study procedures among other enrolled participants in the family.
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Establishing eligibility criteria within a family raises several scientific and pragmatic questions. Regarding partners, the Family Foundations Study requires co-habitation of at least one year to capture long-standing relationships but does not require legal marriage. We anticipate that inclusion of non-married partners (both opposite and same sex) will facilitate a more representative sample of relationships and family structures. Although entrance into US military service requires English language competency, this requirement does not preclude non-English speaking partners. Therefore, the study includes Spanish-speaking partners to facilitate representativeness of the sample. In regards to children, we considered asking adult participants to report on all children ages 6 to 17 but decided against this strategy due to excessive respondent burden. We also considered extending the minimum child age downward but decided against this because many of the measures applicable to the constructs of interest are not validated on younger children, and assessment approaches for very young children often require direct observation by the study team, which would not be feasible in a geographically-dispersed sample.
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The timing of deployments and possible PTSD onset will vary in relation to the duration of family structures and ages of focus children. Such timing variables will be taken into consideration as potential covariates in the analyses.
Procedures Overview Veterans are contacted for recruitment immediately after their participation in VA CSP #566 is complete, as applicable. Other potential participants are recruited in random order from NDHS cohort members. Participation in CSP #566 offers the advantage of recently acquired
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veteran data (e.g., veteran PTSD symptomatology) relevant to Family Foundations scientific questions. Only veterans who provided written consent for further contact by previous NDHS participation, including CSP #566 as applicable, are contacted for potential participation in the Family Foundations Study. Because the NDHS cohort is nationally dispersed, Family Foundations Study participants complete all study procedures remotely. Procedures include telephone interview of veterans who did not have a recent CSP #566 assessment, partners, and adolescent children, as well as completion of psychometric survey instruments by veterans and partners. Upon completion of study procedures, a thank you letter accompanied by participant compensation is mailed to the participant. Special considerations and challenges
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Because some hypotheses are cross-sectional, there are challenges to coordinating remote data collection across veterans, partners, and adolescent children and, within an individual, collecting interview data in temporal proximity to questionnaire data. Although important in all studies, an issue especially relevant to a study in which data are collected from dyads is the completion (in relative close temporal proximity) of study measures by both veterans and partners. This challenge is heightened within military populations, in which the veteran may be deployed at the time of initial study contact. To minimize temporal gaps in data collection, we allow for interviews to occur outside of normal business hours and encourage timely completion of study procedures via a recurrent raffle for participants completing all study procedures. If a veteran is currently deployed, study procedures are delayed until the veteran returns, given that the immediate effects of a current deployment are not a study objective. We also provide participants with the option of mailed written and on-line surveys to promote convenience. Such flexibility in mode of survey completion additionally facilitates privacy for family members.
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Measures
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Overview—Because the study maps longitudinal veteran risk factors with current family outcomes, measures include both archived veteran data and new primary data collected from veterans and family members. Measures can be broadly categorized into historical and current veteran and partner risk and protective factors (e.g., PTSD symptoms, deployment history), veteran and partner-reported family outcomes (e.g., relationship problems), and partner and adolescent child-reported individual outcomes (e.g., distress, behaviors). The study additionally uses archived and currently acquired demographic data on both veterans and family members, as well as military information on veterans. The available veteran archived data are notable for an enriched data set characterized by multiple (two to four) longitudinal assessment episodes including pre-deployment assessment, as well as a broad set of relevant measures, including psychometric assessment of non-PTSD psychiatric symptoms (e.g., depression symptoms), interview data (e.g., diagnostic screening), and performance-based neuropsychological tests (see Aslan et al., 2014 and Vasterling et al., 2006 for complete lists of CSP #566 and NDHS measures).
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Table 1 summarizes the constructs, measures collected, and data sources for variables of primary interest. Psychometric measures and structured interviews include the: Clinician Administered PTSD Scale (Blake et al., 1995), PTSD Checklist-civilian version (Ruggiero et al., 2003), Conflicts Tactics Scale-2 (Straus, 1996), Alcohol Use Disorders Identification Test (Saunders et al., 1993), Deployment Risk and Resilience Inventory (selected modules; King et al., 2006), Multidimensional Scale of Perceived Social Support (Zimet et al., 1988), Everyday Stress Index (Hall & Farel, 1988; Hall et al., 1985), The Life Events Scale (Coddington, 1972), Family Adaptability and Cohesion Evaluation Scales-IV (Olson et al., 1978), Dyadic Adjustment Scale (Kurdek, 1992; Spanier, 1976), Depression Anxiety Stress Scale-21 (Henry & Crawford, 2005: Lovibond & Lovibond, 1995), State-Trait Anger Expression Inventory-2 (Spielberger, 1999), MINI International Neuropsychiatric Interview (Lecrubier et al., 1997; Sheehan et al., 1997), Children’s Depression Inventory-2 (Kovacs, 1980), Screen for Child Anxiety Related Disorders-Revised (Birmaher et al., 1997; Muris et al., 1999), UCLA PTSD Index for DSM-IV (Rodriguez et al., 1999); Strengths and Difficulties Questionnaire (Goodman, 1997; Goodman & Scott, 1999), and Pediatric Quality of Life Inventory (Varni et al., 1999). Performance-based measures of neuropsychological functioning, obtained before and after OIF deployment on veterans, include memory tests, estimates of general intelligence, and tests of attention, working memory, executive functions, and fine motor skills (see Vasterling et al., 2006, for details). Available neuropsychological variables will be subjected to a principal components analysis to create a finite set of continuous measures of general intelligence, inhibitory, attention, and executive functions for inclusion in data analyses.
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Special considerations and challenges—The most significant challenge to measure selection was the identification of child measures that could be applied to a broad age range. In most cases, this was accomplished via selection of instruments with multiple ageappropriate versions. Because we wished to make our study more culturally sensitive by including Spanish-speaking partners, we translated (with associated back-translation procedures) consent procedures and use Spanish versions of interview and questionnaire measures. Data analytic approach
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Overview—The rich set of cross-sectional and longitudinal data lends itself to innovative quantitative methodologies. This study examines both cross sectional and longitudinal relationships between predictive variables and family outcomes. Both will be examined within a structural equation modeling (SEM) framework using maximum likelihood estimation procedures. One major advantage of this approach over ordinary least squares multiple regression analyses and ANOVA-based approaches is that measurement error can be controlled by examining relationships with latent variables that are measured by multiple indicators: latent variables are presumably reliable. For example, a PTSD latent variable derived from specific PTSD symptom cluster scores is more reliable than using one PTSD score formed by summing the items of a particular PTSD scale. As a result, estimates of parameters (i.e., structural coefficients) are unbiased and afford more power to detect hypothesized relationships. In addition, SEM allows evaluation of multiple measurement
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models to understand exactly how the measured variables relate to each other before examining structural relationships among constructs. This may be particularly useful in determining the viability of modeling particular aspects of family or child functioning that are assessed from multiple family members as single latent variables or whether these reports are too divergent and need to be modeled as separate variables.
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Examining longitudinal trajectories of PTSD as predictors of later family functioning is a unique component of the study. This type of analysis is more readily handled by growth curve procedures conducted within an SEM framework than other growth curve techniques (e.g., growth curve modeling with multilevel regression or hierarchical linear modeling). Because we anticipate identifying multiple, qualitatively different classes of veteran PTSD symptom trajectories (e.g., resilience, recovery, delayed onset), we will use growth mixture modeling (GMM), which is a specialized form of growth curve modeling that identifies qualitatively distinct subclasses of individuals based on heterogeneity in change over time (Ram & Grimm, 2009). Specifically, we will first evaluate an unconditional model (i.e., a model only involving change parameters and not including predictors or distal outcomes) to determine the number of trajectory classes present. Based on past research (Bonanno et al., 2012; Dickstein et al., 2010; Elliott et al., 2005; Orcutt et al., 2004) and theoretical models of adaptation after trauma (Bonanno, 2004), we expect to find two to four distinct groups representing chronic, delayed, recovered, and resilient trajectory classes. Once the correct number of classes is identified, we will evaluate models with trajectory class membership as predictors of family adjustment. Finally, a model examining interactions between trajectory class membership and risk and resilience variables will be evaluated to test potential moderation and main effects for variables such as social support, life stressors, and deployment TBI.
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Special considerations and challenges—Some measures have multiple reporters (e.g., veteran and partner; parent and adolescent). A recent examination of the concordance of veteran and partner reports of intimate partner aggressions revealed only low to moderate agreement between veterans and their partners (LaMotte et al., 2014). Thus, for measures with multiple reporters in which the reports are sufficiently divergent that it is not possible to create a single latent variable, following a common method in family research (e.g., Taft et al., 2010), an item will be considered endorsed when either reporter endorses it, creating a single summary score for that variable. We will also perform exploratory analyses to examine the potential influence of number of reporters on these scales. If influential, number of reporters will be included as a covariate.
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Only a subset of the families will have children, and those children are stratified into young and adolescent age groups. Our analytic approach takes into consideration three types of family structures in our sample: families without children, families with young children (ages 6–12) and families with adolescents (ages 13–17). For families without children, statistical models will evaluate associations between veteran PTSD and partner and family measures. For families with children, statistical models are expanded to include child measures. We will examine pathways from veteran PTSD, to partner/family functioning, and to child functioning in an SEM framework. To accommodate the stratification of children into young and adolescent age groups, multiple-group SEM models will be used to Int J Methods Psychiatr Res. Author manuscript; available in PMC 2015 June 17.
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evaluate whether the associations differ by age group. Across all types of family structure, we will examine whether the presence of children moderates the association between veteran PTSD and family outcomes.
Discussion
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The Afghanistan and Iraq Wars have taken a toll on the families of deployed service members. Much of the strain on families occurs during deployment, including long and sometimes repeated periods of separation, uncertainty about deployed loved ones, and the increased burdens of managing households as single parents. However, even as the pace of deployments and number of deployed military personnel decrease, many returning veterans and their families struggle with enduring repercussions of deployment. The mental health concerns of veterans rank high among these. The Family Foundations Study was designed to focus on the relationship of veteran PTSD to barriers in successful family adaptation to military deployment. More specifically, it builds on an established longitudinal cohort study of US Army personnel to understand how veteran PTSD trajectories and veteran and familylevel risk and protective factors influence family cohesion, partner aggression, family and relationship problems, child maltreatment, and intimate partner and child mental health concerns.
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Through its cohort design and assessment of a broad array of risk and protective factors in relation to both the individual and the family, the Family Foundations Study will address several gaps in knowledge regarding the adaptation of contemporary military families to deployment. However, remaining gaps in knowledge include special considerations such as two-military career families, non-traditional families, and differences in challenges to the families of deployed service women versus men and according to the duty status (i.e., reservist versus regular active duty) from which a service member deploys. Although the Family Foundations Study incorporates pre-deployment mental health data on service members, it does not include prospective data on family well-being or examine positive growth as a potential outcome. Knowledge about pre-deployment family level and individual partner and child risk and protective factors would help inform prevention efforts prior to deployment. Although PTSD perhaps ranks more highly than other single adverse mental health consequence of deployment, future studies would also benefit from examining a broader range of veteran psychological symptoms in relation to family outcomes. Other on-going efforts such as the Millennium Cohort Family Study (Crum-Cianflone et al., 2014) and the Deployment Life Study (RAND, 2014) will help address some of these questions and complement the data obtained by the Family Foundations Study.
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Acknowledgments The Family Foundations Study is supported by the National Institute for Mental Health (1R01MH094422-02). A related pilot phase was supported by the VA National Center for PTSD. Interface with VA Cooperative Study Program #566 has been greatly facilitated by the VA Cooperative Studies Program Central Office and the Clinical Epidemiological Research Center at VA Connecticut Healthcare System. We also appreciate the assistance of Ms. Molly Franz in initiating the study, the assistance of Ms. Rebecca Wilken in both the on-going conduct of the study and manuscript preparation, and the contributions of Dr. Michael Suvak to a previous version of the quantitative methodology.
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The manuscript underwent scientific and administrative review at the U.S. Army Research Institute of Environmental Medicine. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army or Department of Veterans Affairs.
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Author Manuscript Figure 1.
Conceptual model for the Family Foundations Study. OEF = Operation Enduring Freedom. OIF = Operation Iraqi Freedom. PTSD = posttraumatic stress disorder. TBI = traumatic brain injury.
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Table 1
Author Manuscript
Family Foundations Primary and Archived Assessment Data Construct
Measure
Data Source
Respondent
Current veteran* PTSD severity
Current CAPS
Archived (current)**
veteran
Veteran PTSD symptom trajectory
Pre-, post-deployment, current PCL-C
Archived (pre- and postdeployment, current)**
veteran
Veteran aggression
Conflict Tactics Scale-2
Questionnaire
partner, veteran
Alcohol use
AUDIT
Questionnaire
partner, veteran
Veteran deployment history
deployment interview, DMDC
Archived (post- deployment, current)**
veteran
Veteran military history
constructed questions
Questionnaire
veteran
Veteran baseline cognitive resources
Performance-based neuropsychological tests
Archived (pre- deployment)**
veteran
Veteran post-deployment \ social support
DRRI Post-Deployment Support
Archived** (post- deployment
veteran
Veteran current social support
MSPSS
Questionnaire
veteran
Partner current social support
MSPSS
Questionnaire
partner, veteran
Veteran TBI
TBI interview
Archived (post- deployment, current)**
veteran
Partner stressful life events
DRRI Life Events
Phone Interview
partner
Partner everyday stressors
Everyday Stress Index
Questionnaire
partner
Child stressful life events
The Life Events Scale
Phone Interview
partner, adolescent
Risk and protective factors for family outcomes
Author Manuscript
Family outcomes Family problems
FACES-IV
Questionnaire
partner, veteran
Relationship problems
Dyadic Adjustment Scale
Questionnaire
partner, veteran
Partner and child individual outcomes
Author Manuscript
Partner distress: Depression, anxiety, tension/stress
DASS-21
Questionnaire
partner
Irritability/anger
STAXI-2
Questionnaire
partner
PTSD symptoms
PCL-C
Phone Interview
partner
Mental disorders
MINI 5.0
Phone Interview
partner
Depression
CDI-2
Questionnaire
partner
Anxiety
SCARED
Questionnaire
partner
PTSD symptoms
UCLA PTSD-I
Questionnaire
partner
Child behaviors
SDQ
Phone Interview
partner, adolescent
Child peer/family functioning
PedsQL
Questionnaire
partner, adolescent
Child emotional distress:
*
Author Manuscript
Veteran refers to war-zone veterans, regardless of current duty status (i.e., includes both current service members and military veterans).
**
For veteran participants who did not recently complete measures as part of the associated VA Cooperative Studies Program #566, these measures are re-administered to the veteran to obtain a cross-sectional index of the relevant construct. PTSD = Posttraumatic stress disorder; CAPS = Clinician Administered PTSD Scale (Blake et al., 1995); PCL-C = PTSD Checklist-Civilian; AUDIT = Alcohol Use Disorders Identification Test; DMDC = Defense Manpower Data Center; DRRI = Deployment Risk and Resiliency Inventory; MSPSS = Multidimensional Scale of Perceived Social Support; TBI = traumatic brain injury; FACES-IV = Family Adaptability and Cohesion Evaluation Scales-IV; DASS-21 = Depression Anxiety Stress Scales (21-item version); STAXI-2 = State-Trait Anger Expression
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Inventory-2; MINI = Mini International Neuropsychiatric Interview 5.0; CDI-2 = Children’s Depression Inventory-2; SCARED = Screen for Child Anxiety Related Disorders; UCLA-PTSD-I = UCLA PTSD Index for DSM-IV; SDQ = Strengths and Difficulties Questionnaire; PedsQL = Pediatric Quality of Life Inventory (Generic Core Scales).
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