Patricia Lester

Families living with HIV

Abstract Given the historical emergence of the AIDS epidemic first among gay men in the developed world, HIV interventions have primarily focused on individuals rather than families. Typically not part of traditional family structures, HIV-positive gay men in Europe and the US lived primarily in societies providing essential infrastructure for survival needs that highly value individual justice and freedom. Interventions were thus designed to focus on at-risk individuals with programmes that were age and gender segregated. As the epidemic has unfolded, the early focus on individuals has become inadequate: families live with HIV, not just individuals. Families’ structure, economy, migration patterns, and developmental life cycles are affected by HIV, and these changes radiate throughout the community creating parallel stresses. Family-based, intergenerational models of detection, prevention and treatment services offer enhanced opportunities for effective interventions and suggest very different intervention settings and strategies. However, these models also require addressing the familys basic needs for survival and security in order to be successfully implemented and sustained over time. As HIV was an opportunity for marginalized persons in the developed world to ‘turn their life around’, the strengths of families in the developing world may be mobilized to contribute to the communitys long-term health, survival and security needs.

Evaluation of a Family-Centered Prevention Intervention for Military Children and Families Facing Wartime Deployments

OBJECTIVES We evaluated the Families OverComing Under Stress program, which provides resiliency training designed to enhance family psychological health in US military families affected by combat- and deployment-related stress. METHODS We performed a secondary analysis of Families OverComing Under Stress program evaluation data that was collected between July 2008 and February 2010 at 11 military installations in the United States and Japan. We present data at baseline for 488 unique families (742 parents and 873 children) and pre-post outcomes for 331 families. RESULTS Family members reported high levels of satisfaction with the program and positive impact on parent-child indicators. Psychological distress levels were elevated for service members, civilian parents, and children at program entry compared with community norms. Change scores showed significant improvements across all measures for service member and civilian parents and their children (P < .001). CONCLUSIONS Evaluation data provided preliminary support for a strength-based, trauma-informed military family prevention program to promote resiliency and mitigate the impact of wartime deployment stress.

When the Time Comes To Talk About HIV: Factors Associated With Diagnostic Disclosure and Emotional Distress in HIV-Infected Children

Objective: To determine factors related to the timing and probability of nondisclosure of HIV status to perinatally HIV‐infected children, and to explore factors associated with emotional distress in HIV‐infected children. Methods: This is a cross‐sectional study of 51 HIV‐infected children based on medical records, parent interviews, and child assessments. Results: 1) Probability of earlier age of disclosure is associated with higher child IQ (p = .04) and more family expressiveness (p = .01); 2) controlling for child age, disclosure status at time of study is associated with major life events, but not with medical status; and 3) factors associated with increased parent‐rated anxiety in HIVinfected children in univariate analyses are: HIV disclosure (p = .04), other major life events (p = .001), higher medication dose frequency (p = .01), and child age (p = .01). Increased depression is associated only with more medication doses (p = .02). Conclusion: These data indicate that higher child IQ and greater family expressiveness increase the probability of earlier diagnostic disclosure to HIV‐infected children. Factors associated with emotional distress highlight important areas of clinical attention. These data suggest that diagnostic disclosure may not necessarily minimize emotional distress, indicating the need for further evaluation of the appropriate timing and type of disclosure for pediatric HIV.

Families Overcoming Under Stress: Implementing Family-Centered Prevention for Military Families Facing Wartime Deployments and Combat Operational Stress

The toll of multiple and prolonged deployments on families has become clearer in recent years as military families have seen an increase in childhood anxiety, parental psychological distress, and marital discord. Families overcoming under stress (FOCUS), a family-centered evidence-informed resiliency training program developed at University of California, Los Angeles and Harvard Medical School, is being implemented at military installations through an initiative from Navy Bureau of Medicine and Surgery. The research foundation for FOCUS includes evidence-based preventive interventions that were adapted to meet the specific needs of military families facing combat operational stress associated with wartime deployments. Using a family narrative approach, FOCUS includes a customized approach utilizing core intervention components, including psychoeducation, emotional regulation skills, goal setting and problem solving skills, traumatic stress reminder management techniques, and family communication skills. The purpose of this study is to describe the development and implementation of FOCUS for military families. A case example is also presented.

Adolescent adjustment before and after HIV-related parental death.

The impact of HIV-related parental death on 414 adolescents was examined over a period of 6 years. The adjustment of bereaved adolescents was compared over 4 time periods relative to parental death and was also compared with the adjustment of nonbereaved adolescents. Bereaved adolescents had significantly more emotional distress, negative life events, and contact with the criminal justice system than nonbereaved youths; these behaviors did not remain significantly higher after parental death. Depressive symptoms and passive problem solving increased soon after parental death, as compared with nonbereaved adolescents. One year subsequent to parental death, depression and passive problem solving were similar to the levels of nonbereaved peers. Only sexual risk behaviors increased following parental death. These results suggest the importance of early family intervention soon after parental HIV diagnosis, prior to parental death, and sustained over time.

Family Systems and Ecological Perspectives on the Impact of Deployment on Military Families

The scope of sustained military operations in Iraq and Afghanistan has placed great demands on the Armed Forces of the United States, and accordingly, military families have been faced with deployments in more rapid succession than ever before. When military parents fulfill occupational duties during wartime, military children and families face multiple challenges, including extended separations, disruptions in family routines, and potentially compromised parenting related to traumatic exposure and subsequent mental health problems. Such challenges can begin to exert a significant toll on the well-being of both individuals and relationships (e.g., marital, parent–child) within military families. In order to respond more effectively to the needs of military families, it is essential that mental health clinicians and researchers have a better understanding of the challenges faced by military families throughout the entire deployment experience and the ways in which these challenges may have a cumulative impact over multiple deployments. Moreover, the mental health field must become better prepared to support service members and families across a rapidly evolving landscape of military operations around the world, including those who are making the transition from active duty to Veteran status and navigating a return to civilian life and those families in which parents will continue to actively serve and deploy in combat zones. In this article, we utilize family systems and ecological perspectives to advance our understanding of how military families negotiate repeated deployment experiences and how such experiences impact the well-being and adjustment of families at the individual, dyadic, and whole family level.

The Relationship between Adjustment of Mothers with HIV and their Adolescent Daughters

The emotional distress, self-esteem and problem behaviors of adolescent daughters aged 11–18 years ( n = 121) and their mothers with HIV were examined and related to reports of parental disclosure of serostatus and adolescents’ perceived bonds with their parents. Most mothers with HIV reported emotional distress in the clinical range (70%). The levels of emotional distress, self-esteem and drug use were significantly correlated between mothers and daughters. Adolescent’s emotional distress was significantly related to maternal disclosure of HIV status. Daughters who perceived their mothers as highly caring also perceived them as low in overprotection. Daughters who perceived their mothers as low in caring were more emotionally distressed and reported more conduct problems and lower self-esteem. Interventions to enhance adjustment of daughters in families coping with HIV must focus on mental health symptoms and mother–daughter bonds.

How Wartime Military Service Affects Children and Families

How are children’s lives altered when a parent goes off to war? What aspects of combat deployment are most likely to put children at risk for psychological and other problems, and what resources for resilience can they tap to overcome such hardships and thrive? To answer these questions, Patricia Lester and Lieutenant Colonel Eric Flake first examine the deployment cycle, a multistage process that begins with a period of anxious preparation after a family receives notice that a parent will be sent into combat. Perhaps surprisingly, for many families, they write, the most stressful part of the deployment cycle is not the long months of separation that follow but the postdeployment period, when service members, having come home from war, must be reintegrated into families whose internal rhythms have changed and where children have taken on new roles. Lester and Flake then walk us through a range of theoretical perspectives that help us understand the interconnected environments in which military children live their lives, from the dynamics of the family system itself to the external contexts of the communities where they live and the military culture that helps form their identity. The authors conclude that policy makers can help military-connected children and their families cope with deployment by, among other things, strengthening community support services and adopting public health education measures that are designed to reduce the stigma of seeking treatment for psychological distress. They warn, however, that much recent research on military children’s response to deployment is flawed in various ways, and they call for better-designed, longer-term studies as well as more rigorous evaluation of existing and future support programs.

Diagnostic Disclosure to HIV-Infected Children: How Parents Decide when and what to Tell:

The objective of this study was to assess parental decision-making about illness disclosure to human immunodeficiency virus (HIV)-infected children. This is a cross-sectional study of 51 children with HIV infection based on parent interviews, child cognitive testing, clinical assessments and medical records. Only 43% of children had been told their HIV diagnosis. Qualitative analysis of parental decision- making about illness disclosure varied by child developmental level. Factors influencing parental decision to disclose the child’s HIV status including parental communication style, parental illness, child’s rights, treatment adherence, child questions and provider pressures, whereas concerns about HIV stigma and potential emotional distress were most frequently identified as reasons for non- disclosure. Central decision-making factors for parental HIV disclosure and reported outcomes of disclosure are described. Pediatric HIV disclosure represents a complex task for parents caring for the HIV-infected child, one in which the child’s development and the family’s community should be considered in the setting of a potentially stigmatizing infectious illness.

Family-Centered Preventive Intervention for Military Families: Implications for Implementation Science

In this paper, we report on the development and dissemination of a preventive intervention, Families OverComing Under Stress (FOCUS), an eight-session family-centered intervention for families facing the impact of wartime deployments. Specific attention is given to the challenges of rapidly deploying a prevention program across diverse sites, as well as to key elements of implementation success. FOCUS, developed by a UCLA-Harvard team, was disseminated through a large-scale demonstration project funded by the United States Bureau of Navy Medicine and Surgery (BUMED) beginning in 2008 at 7 installations and expanding to 14 installations by 2010. Data are presented to describe the range of services offered, as well as initial intervention outcomes. It proved possible to develop the intervention rapidly and to deploy it consistently and effectively.