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UCLA Semel Institute for Neuroscience and Human Behavior
The Time Has Come: Integrating Trauma‐informed Prevention within
Systems of CarePatricia Lester, MD
Nathanson Family Professor of PsychiatryDirector, Division of Population Behavioral Health
UCLA Semel Institute for Neuroscience and Human Behavior
UCLA Semel Institute for Neuroscience and Human Behavior
UCLA
Division of Population Behavioral Health
Pritzker Center for Strengthening
Children and Families
Nathanson Family Resilience Center
UCLA TIES for Families
Child Anxiety, Resilience, Education & Support
Semel Institute for Neuroscience and Human
Behavior
Luskin School of Public Affairs
David Geffen School of Medicine
Graduate School of Education and Information Studies
Leadership & Policy
Professional DevelopmentEducation & Training
InnovativeTechnology
TranslationalResearch
Division of Population Behavioral Health
Population Behavioral Health & Wellness
Family Development Program
Prevention within Systems: A Population Behavioral Health Approach to Well Being
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RECREATION CHILD WELFARE
HEALTH CARE
MENTAL HEALTH
EDUCATION
COMMUNITY
SPIRITUALITY
FAMILY
INDIVIDUAL
Ecological Framework for Prevention:Engaging with System of Support
RECREATION CHILD WELFARE
HEALTH CARE
MENTAL HEALTH
EDUCATION
COMMUNITY
SPIRITUALITY
FAMILY
INDIVIDUAL
Prevention Across a Continuum of Care: Opportunities to Support & Optimize Life Trajectories
Adapted from National Academy of Sciences, 2016
• Billions of dollars and decades of research have been invested in the development of practices, programs, guidelines, and interventions to affect individual‐level health‐related behavior and outcomes
• Benefits of preventive interventions to support positive developmental and well‐being outcomes in children and families has a strong research base, the translation of this evidence into practice has lagged far behind.
• Dissemination of existing EBP is low across most community and clinical settings, with research identifying a range of barriers to successful implementation.
(IOM 2009, Glasgow & Chambers, 2012; Kazdin & Blase, 2011; Rotheram‐Borus et al, 2012).
Translation Gap from Research to Practice: Preventive Intervention
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Common Elements Framework
Prevention researchers have increasingly proposed a paradigm shift is needed in how we apply, expand, and diffuse the evidence based of interventions.
“Common elements framework” is used to identify, coordinate and monitor the delivery of components from established EBP
• Focuses on professional training and development, • Supports a flexible approach to evidence informed delivery across
different settings and populations• Encourages tailoring informed by empirical evidence about
treatment efficacy and effectiveness, AND local evidence through the delivery process
(Chorpita & Daleiden, 2009; Becker et a, 2013, Mohr et al 2016)
Learning Community System: Using the “Adaptome” Model
Adaptome, a proposed set of approaches, processes, and infrastructure needed to advance the science of intervention adaptation and implementation
• Service Setting• Target Audience• Core Components• Mode of Delivery• Cultural Relevance
Chambers and Norton / Am J Prev Med 2016
PREVENTION PRACTICE LEARNING COMMUNITY
ADAPTOME DATA PLATFORM
INTERVENTION a
AdaptationCore
Components
INTERVENTION b
AdaptationCore
Components
INTERVENTION d
AdaptationCore
Components
INTERVENTION c
AdaptationCore
Components
Adaptome Data Commons
• Taxonomy of Adaptations• Core Components• Outcomes Data Capture• Contextual Factors• Analytic Strategies
Knowledge Development
• Science of Adaptation• Science of Implementation• Intervention Development• Designing for Evolution
EVIDENCE
INFLUENCE
ImprovedPractice
Delivery System
Chambers and Norton / Am J Prev Med 2016;51(4S2):S124–S131
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Trauma‐informed Service SystemsAdapted from National Child Traumatic Stress Network
• Recognize and respond to the impact of traumatic stress on those who have contact with the system
• Infuse and sustain trauma awareness, knowledge, and skills into organizational cultures, practices, and policies:
• Routinely screen for trauma exposure and related symptoms.
• Use evidence‐based, culturally responsive assessment and treatment for traumatic stress and associated mental health symptoms.
• Make resources available to clients and providers on trauma exposure, its impact, and treatment.
• Engage in efforts to strengthen resilience and protective processes
• Address parent and caregiver trauma and its impact on the family system.
• Emphasize continuity of care and collaboration across systems.
• Maintain an environment of care for staff that addresses secondary traumatic stress, and that increases staff wellness.
• Address the intersections of trauma with culture, history, race, gender, location, and language, acknowledge the compounding impact of structural inequity, and are responsive to the unique needs of diverse communities.
https://www.nctsn.org/resources/what‐trauma‐informed‐child‐and‐family‐service‐system
Informed by Resilience Processes to Elevate Life Course Trajectories
A shift from deficit to adaptive strength
Social Justice
Focus on the wins
Honoring and building
connections and belonging
Not just stabilizing or catching up
….flourishing
Applying the Adaptome Framework:Trauma‐ & Resilience‐Informed Approach to Prevention
Education Health Care Community Military Families
• Service Setting• Audience• Core Components
• Cultural Relevance• Mode of Delivery• Workforce Well‐being
Requires• Mapping & Monitoring Infrastructure for CQI• Learning System: Training & Technical Support
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RECREATION CHILD WELFARE
HEALTH CARE
MENTAL HEALTH
EDUCATION
COMMUNITY
SPIRITUALITY
FAMILY
INDIVIDUAL
Ecological Framework for Prevention:Engaging with System of Support
RECREATION CHILD WELFARE
HEALTH CARE
MENTAL HEALTH
EDUCATION SPIRITUALITY
FAMILY
COMMUNITY
INDIVIDUAL
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FOCUS is a trauma‐informed resilience‐building intervention adapted from this team’s evidence based preventive interventions for families facing adversity. It has been tailored for military families through a community participatory process.
FOCUS is delivered as a continuum of prevention services within military communities, including group, individual, family models, and through virtual and mobile platforms
FOCUS provides core resilience education and skills to help families, parents, youth, and couples:
• Understand the impact of transitions and challenges on families, including those facing physical or behavioral health injuries
• Identify, manage, and discuss emotions
• Develop problem‐solving and goal‐setting skills to enhance self‐efficacy
• Communicate effectively about the impact of transitions, deployments, trauma, and loss
• Strengthen couple/family relationships and functioning
• Enhance parenting and co‐parenting skills
FOCUS Resilience Model: Public Health Approach to Supporting Military Families in Transition
Implementation Science:
Public Health Prevention
Translating Research to Practice
Family Based Prevention
Science
Family Resilience Framework
Traumatic Stress and Developmental Systems
Research
FOCUS ResilienceEnhancing Intervention
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• Changes in social support and resources
• Community level stress
• Changes in family roles and routines
• Impact on children, parenting, and co‐parenting
• Concerns about safety and danger
• Anxiety and depression
• Geographic mobility
• Financial concerns
• Possible parental mental health problems, physical injury, or loss: caregiving burden for spouse
Audience: Starting with Military/Veteran Family Experiences, Voice & Research
• Well‐being of children and their families are inextricably linked
• Family members can play a significant role in enhancing or impeding the recovery of youth affected by trauma or adversity
• Families prefer family approaches over individual approaches for mental health care
• Cultural relevance of family readiness
MacDermid, Lester et al, 2013
Cultural Relevance of Family‐Centered Prevention for Military Families
• Family real time check‐up• Customizes services to family needs
• Family level education• PTSD, TBI, Injury education• Child Stress Reactions• Developmental guidance
• Individual and Family CBT Skill Building • Emotional Regulation, Communication, Goal Setting,
Problem Solving, Managing Trauma, Loss & Stress Reminders
• Family narrative timeline• Link skills to family (and child) experience• Develop shared family meaning• Bridge estrangements• Co‐parenting
FOCUS Core Elements(Lester et al, 2011; 2016; Saltzman, et al, 2011; Beardslee et al 2013)
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• Custom care delivery system for providers
• Assessment and clinical decision making tool from iPad
• Real‐time data analytics ensure programs are working
Embedded Screening Drives Personalized Delivery, Risk Screening & Stepped Care, & Continuous Quality Improvement
70%Program Completion
Mobile Platforms
Group‐level Briefings
Psychoeducation Workshops
Trauma‐informed Consultation
Skill‐building Groups
FOCUS Family Resilience Training
Mode of Delivery: FOCUS Core Elements as a Prevention Suite of ServicesLester et al, 2016; Beardslee et al 2011
FOCUS Impact on Family Psychological Health
• Children reported increased use of positive coping strategies in dealing with stressful events, including significant increases in problem solving (p = .0001) and emotional regulation on KidCope (p = .005).
• Children ages 6‐18 reported decreased anxiety symptom on MASC (p<0.01)
• Parents reported reductions in child conduct problems (p<.0001), Reductions in emotional symptoms (p=.001), such as anxiety and depressive symptoms, and improvements in child prosocial behaviors on SDQ (p=.01).
• Parents reported decreased levels of their own PTSD (PCL), depression (p<.01) and anxiety symptoms (BSI) (p=.002).
• Family functioning improved (problem solving, communication, roles, affective responsiveness, behavior control) on FAD (p < .0001).
Lester, Saltzman et al., “Evaluation of a Family Centered Prevention Intervention for Military Children and Families Facing Wartime Deployments.” Am J of Public Health, 2012.
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Families with Children: Child Adjustment over Time3,810 children ages 3‐18; 54% were boys
–1,426 (40.8%) Service Members and 2,073 (59.2%) Civilian Parents
Journal of the American Academy of Child & Adolescent Psychiatry 2016 55, 14‐24DOI: (10.1016/j.jaac.2015.10.009)
Parent Anxiety and Depression SymptomsOver Time
Couples Psychological Health (OSD)
Both service members and civilian spouse/partners showed statistically significant reductions in the prevalence of at‐risk levels of anxiety and depressive symptoms from Intake to Post Intervention.
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2019 FOCUS Site LocationsArizona
Marine Corps Air Station Yuma
California
Marine Corps Air Ground Combat Center
Twentynine Palms
Marine Corps Base Camp Pendleton
Naval Base Ventura County
Naval Base San Diego
Marine Corps Recruit Depot, San Diego
Naval Base Coronado
Marine Corps Logistics Base Barstow
Marine Corps Air Station Miramar
Florida
MacDill Air Force Base
Hawaii
Joint Base Pearl Harbor‐Hickam
Marine Corps Base Hawaii
Mississippi
Keesler Air Force Base
Naval Construction Battalion Center Gulfport
Stennis Space Center
New Mexico
Cannon Air Force Base
North Carolina
Marine Corps Base Camp Lejeune
Marine Corps Air Station Cherry Point
Marine Corps Air Station New River
South Carolina
Marine Corps Air Station Beaufort / Parris Island
Marine Corps Recruit Training Depot
Virginia
Marine Corps Base Quantico
Naval Station Norfolk
Joint Expeditionary Base Little Creek and Fort Story
Washington
Joint Base Lewis‐McChord
Naval Air Station Whidbey Island
Japan
Kadena Air Base
Marine Corps Base Okinawa
U.S. Army Garrison Torii Station
Marine Corps Air Station Iwakuni
• VTC Virtual Home visiting FOCUS early childhood‐ 6 session parenting coaching and dyadic model
• NICHD RO1 Randomized trial for Military Connected Families with young children – Virtual Home Visiting
(Mogil et al, 2014)
In Home Tele‐Behavioral Health Reaching Families Where They Live
FOCUS Early Childhood Tele‐HealthPreliminary Outcomes from a Randomized Trial
• Population Recruited: 199 children ages 3‐6194 mothers and 155 fathers
Primary caregivers in the FOCUS‐EC intervention reported relative to those in the control condition:
• Significantly greater improvements in self‐reported parent‐child relationships at 3, 6 and 12 months
• Significantly greater reductions in total parenting stress at 12 months
• Reductions in Parent PTSD symptoms from baseline to 6 months
• Mother‐child dyads in the intervention group were observed to have significantly greater improvements in parenting and parent‐child interactions among participants in the FOCUS‐EC intervention group relative to the control group.
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• Personalized delivery of high quality care management, scale and reach of care.
• Family‐centered care and prevention beyond traditional clinical settings.
• Research challenges in context of rapid innovations.
Leveraging Mobile Technology for Behavioral Health Continuum of Care
Setting and Audience: UCLA/VA Veteran Family Wellness Center
• Translating family and relationship‐centered care to the VA system
• Utilizing a wellness approach to engage Veterans and families
• Continuum of in person and tele‐wellness services and connection
• Academic‐VA‐Community Partnerships
Family Centered Resilience & Prevention
Screening Relationship Enhancement
CaregiversCouplesChildrenFamily
Health & WellnessMindfulness
YogaMeditation
Arts Programs
In‐Home Virtual
ResourcesCommunity Resources
UCLA/VAVeteran Family Wellness Center
Life‐SkillsParenting ClassesSchool Readiness
RecreationSports Programs to support
family and community connections
Family Peer Navigation
Community & VA Care
mHealth & WellnessMobile Apps
Web‐based Platforms
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RECREATION CHILD WELFARE
HEALTH CARE
MENTAL HEALTH
EDUCATION
COMMUNITY
SPIRITUALITY
FAMILY
INDIVIDUAL
Ecological Framework for Prevention:Engaging with School Mental Health to Children & Families
RECREATION CHILD WELFARE
HEALTH CARE
MENTAL HEALTH
COMMUNITY
SPIRITUALITY
FAMILY
INDIVIDUALEDUCATION
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Research on Setting & Population: Traumatic experiences take a measurable toll on academic achievement
Decreased IQ and reading
ability
More suspensions, expulsions
Lower GPA Decreased high‐school graduation
rates
More days absent from
school
SOURCES (left to right): Delany‐Black et al., 2003; LAUSD survey, 2006; Hurt et al., 2001; Hurt et al., 2001; Grogger, 1997.
618,970 Students
80% Living in poverty
94 Languages spoken
157,619 English language learners
7,000+ Students in foster care18,000 Students homeless
Adaptation for Los Angeles Unified School District
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Universal screen of risk and protective
factors
Universal prevention curriculum
Targeted mental health screening
Tier 2 and Tier 3
evidence‐based
intervention
Resilience Check‐In FOCUS Resilience Curriculum
Wellness Check‐Up
Groups (CBITS)
A Population Health Approach Developed in Partnership with LAUSD
Trauma‐ & Resilience‐Informed School Community
School
Classroom
Family
Student
• Professional Development for teachers/staff (trauma & self‐care)
• FOCUS Resilience Curriculum, a skill‐building classroom curriculum
• FOCUS on Parenting groups
• Cognitive Behavioral Intervention for Trauma in Schools (CBITS)
• Individual counseling
• Data collection & management tool replaced paper screening
• School Mental Health Staff records interviews, assessments, and scores electronically
• Link to academic data and reporting
Interpretation, scoring, and management done in Real time‐managed by school team
Tracking student wellness across the District
Continuous Quality Improvement Requires Data Monitoring Infrastructure
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Brief universal survey of risk and resilience factors that assesses:
• Social skills
• Empathy
• Problem‐solving
• Self‐efficacy & Self‐awareness
• School safety
• Traumatic stress risk
• Help‐seeking behaviors
• School support
Resilience Check‐In
48% of Students were Found to be at Moderate/High Risk for PTSD (n=9196)
High risk for PTSD significantly associated with low GPAHigh Risk for PTSD significantly associated with low attendance
Adapting Core Components with LAUSD Partners: FOCUS Resilience Curriculum(Ijadi‐Maghsoodi et al, 2016)
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RECREATION CHILD WELFARE
HEALTH CARE
MENTAL HEALTH
EDUCATION
COMMUNITY
SPIRITUALITY
FAMILY
INDIVIDUAL
Ecological Framework for Prevention:Engaging with Health Systems
RECREATION CHILD WELFARE
MENTAL HEALTH
EDUCATION
COMMUNITY
SPIRITUALITY
FAMILY
INDIVIDUAL
HEALTH CARE
Trauma‐Informed Health Systems: Integrating WorkforceWell‐Being within Training & Practice
Addressing secondary trauma
Enhancing Wellness & Resilience
Attention to MoralDistress/Injury
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Mental Health Treatment
2 ‐ Resilience Training
3 ‐ Trained Peer Support
General Wellness Initiatives
1 ‐ Wellness App Connectd – A Self Care ToolA
mount of effort targeting
individuals at risk
General Education & Outreach:Preventative before an event
Evidence‐based Skilled Peer Support:Preventative
Professional Mental Health Services: Interventional after symptoms
Evidence‐based Education & Self Help:Preventative & Interventional
UCLA Professional Resilience Package
Brenda Bursch, PhD
Workforce Well‐Being: Trauma‐Informed Prevention Across the Health System
Self Assessment Anonymous screens for
anxiety, depression, trauma, burnout, alcohol use, and health behaviors
Track scores over time
Evidence‐based Education and Tools
Local Resources
“Connectd” –Adapted as UCLA Professional Wellness App
Scalable evidence‐based resilience skills training to mitigate against exposure to high stress and trauma: Reflective Narrative Timeline Emotion Regulation Communication with Angry Individuals Effective Boundary Management Depression, Anxiety, Trauma, Personal
Toolbox
Adapted from FOCUS program, found to be effective with military personnel and their families.
Addresses stigma with use of actual events.
Selective Prevention UCLA Resilience Training
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RECREATION CHILD WELFARE
HEALTH CARE
MENTAL HEALTH
EDUCATION
COMMUNITY
SPIRITUALITY
FAMILY
INDIVIDUAL
Ecological Framework for Prevention:Training Center of Excellence with Los Angeles County
RECREATION CHILD WELFARE
HEALTH CARE
EDUCATION
COMMUNITY
SPIRITUALITY
FAMILY
INDIVIDUAL
MENTAL HEALTH
Creating Learning Communities
Practice‐Based Adaptation &
Cultural Customization
Consultation & Coaching
Partnership & Collaboration
Continuous Quality Monitoring
Interactive Online Learning Platforms
Prevention Training Center of Excellence
DHS
DPH
School Districts
Libraries
Parks and Recreation
DCFS
Juvenile Justice
DPSS
Child Care Providers
DMH
Resource Centers
Early Education Centers
Prevention Training Center
Of Excellence
Trauma/Resilience Informed Care
Training
Core Principles of Trauma /Resilience‐Informed Care• Safety• Trust and transparency• Peer support• Collaboration and
mutuality• Voice, choice, and self
agency• Culturally, historically,
sexual identity, gender‐identity appropriate
• Dissemination of best practices
• Understanding the many systems that impact individuals & families
• Intra‐agency referrals
Creating a “Learning” Community System
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• Adapting EBI Core Components
• Community Partnered Participatory Processes
• Continuous Data Monitoring: Leverage Cloud Computing Technology and Real Time Screening
• A “Learning” Training Institute/On Line Hub: to support and sustain community practice
• Flexible Platforms: Utilization of Suite of Services along Public Health Continuum‐ Multiple Delivery Platforms
• Workforce Well‐being: Integrating professional development and management tools that address secondary stress & burnout.
• Engagement Strategies: Materials Development, Partnered Marketing, Community Training; Mobile Tools, Continuous feedback through implementation monitoring/partnered practicesHealthcare Professional Wellness
Program
School‐Based Resilience Curriculum
FOCUS for Military Families
Lessons Learned from Integrating Prevention into Systems of Care
Patricia Lester, MD
[email protected]://dpbh.ucla.edu
Foundational & Outcome Research for FOCUS ProgramLester P, Peterson K, Reeves J, et al. The long war and parental combat deployment: Effects on military children and at‐home spouses. Journal of the American Academy of Child and Adolescent Psychiatry. 2010;49(4): 310‐320.
Mogil C, Paley B, Doud B, …. Lester P. Families OverComing Under Stress (FOCUS) for early childhood: Building resilience for young children in high stress families. Journal of Zero to Three. 2010;31(1):10‐16.
Lester P, Mogil C, Saltzman W, et al. FOCUS (Families OverComing Under Stress): Implementing family‐centered prevention for military families facing wartime deployments and combat operational stress. Military Medicine. 2011; 176(1):19‐25.
Beardslee W, Lester P, Klosinski L, Saltzman W, Woodward K, Nash W, Mogil C, Koffman R, & Leskin G. Family‐centered preventive intervention for military families: Implications for implementation science. Prev Sci. 2011 Dec;12(4):339‐48.
Lester P, & Bursch B. The long war comes home: Mitigating risk and promoting resilience in military children and families. Psychiatric Times. 2011; 28(7).
Saltzman WR, Lester P, Beardslee WR, Layne C M, Nash WP. Mechanisms of risk and resilience in military families: Theoretical and empirical basis of a family‐focused resilience enhancement program. Clin Child Fam Psychol Rev. 2011 Sep; 14(3):213‐30.
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Foundational & Outcome Research for FOCUS ProgramLester P, Saltzman W, Woodward K, et al. Evaluation of a family‐centered prevention intervention for military children and families facing wartime deployments. Am J Public Health. 2012 Mar;102 Suppl 1:S48‐54. Epub 2011 Nov 28.
Lester P. War and military children and families: Translating prevention science into practice. J Am AcadChild Adolesc Psychiatry. 2012; 51(1):3‐5.
Green S, Nurius PS, Lester P. Spouse Psychological Well‐Being: A Keystone to Military Family Health. Journal of Human Behavior in the Social Environment. 2013; 23, (6): 753‐768.
MacDermid SW, Lester P, Marini C, Cozza S, Sornborger J, Strouse T, Beardslee W. Approaching Family‐Focused Systems of Care for Military and Veteran Families. Military Behavioral Health. 2013; 1, 1‐10.
Lester P, Stein J A, Saltzman W, Woodward K, MacDermid SW et al. Psychological health of military children: Longitudinal evaluation of a family‐centered prevention program to enhance family resilience. Military Medicine. 2013; 178 (8), 838‐845.
Foundational & Outcome Research for FOCUS ProgramLester P, Paley B, & Saltzman W. Military Service, War, and Families: Considerations for Child Development, Prevention and Intervention, and Public Health Policy. Clinical child and family psychology review.2013; 16(3), 229‐232.
Saltzman WR, Pynoos RS, Lester P, Layne CM, & Beardslee WR. Enhancing family resilience through family narrative co‐construction. Clinical Child and Family Psychology Review.2013; 16, (3), 294‐310.
Paley B, Lester P, & Mogil C. Family Systems and Ecological Perspectives on the Impact of Deployment on Military Families. Clinical Child and Family Psychology Review. 2013; 16 (3), 245‐265.
Lester P, Flake E. How Wartime Military Service Affects Children and Families. The Future of Children: Military Children and Families. 2013; 23(2), 121‐142.
Beardslee WR, Klosinski LE, Saltzman W, Mogil C, Pangelinan S, McKnight CP, & Lester P. Dissemination of Family‐Centered Prevention for Military and Veteran Families: Adaptations and Adoption within Community and Military Systems of Care. Clinical Child and Family Psychology Review. 2013;16 (4), 394‐409.
Garcia E, De Pedro K, Astor RA, Lester P, & Benbenishty R. FOCUS School‐Based Skill‐Building Groups: Training and Implementation. Journal of Social Work Education.2015: 51:sup1, S102‐S116.
Foundational & Outcome Research for FOCUS ProgramMogil C, Hajal N, Garcia E, Kiff C, Paley B, Milburn N, & Lester P. FOCUS for Early Childhood: A virtual home visiting program for military families with young children. Journal of Contemporary Family Therapy. 2015; 37(3), 199‐208.
Flittner O’Grady AE, MacDermid Wadsworth S, Willerton E, Cardin JF, Topp D, Mustillo S, & Lester P. (2015). Help seeking by parents in military families on behalf of their young children. Psychological services, 2015;12(3), 231.
Wadsworth SM, Cardin JF, Christ S, Willerton E, O'Grady AF, Topp D, ... & Mustillo S. Accumulation of Risk and Promotive Factors among Young Children in US Military Families. American journal of community psychology, 2016; 57(1‐2), 190‐202.
Lester P, Liang LJ, Milburn N, Mogil C, Woodward K, Nash W, ... & Beardslee W. Evaluation of a family‐centered preventive intervention for military families: Parent and child longitudinal outcomes. Journal of the American Academy of Child & Adolescent Psychiatry, 2016; 55(1), 14‐24.
Saltzman WR, Lester P, Milburn N, Woodward K, & Stein J. Pathways of Risk and Resilience: Impact of a Family Resilience Program on Active‐Duty Military Parents. Family Process. 2016; Dec 1;55(4):633‐46.