Pilot trial of Strength at Home Parents, a trauma-informed parenting support treatment for veterans

Abstract

PTSD is associated with compromised parenting which is not adequately addressed in available evidence-based PTSD treatments. Strength at Home – Parents (SAHP) is a trauma-informed parenting intervention which aims to improve parenting behaviors and overall parent-child functioning. Here we report pilot data obtained in a sample of veterans (N=21) with PTSD and parent-child functioning difficulties. Results support feasibility of study methods, and intervention acceptability, credibility and satisfaction. Movement on primary outcome measures suggested improved overall family functioning, a decrease in the use of dysfunctional parenting practices, an increase in positive parenting practices and a trend towards a reduction in parenting stress. Results should be interpreted with caution because of the small sample size and attrition at follow-up. Limitations withstanding, findings support further study of the intervention, which would provide insights into whether an efficacy trial is indicated.

Introduction

Post-traumatic stress disorder (PTSD) is prevalent in military veterans and service members and has a negative impact on parent-child functioning, with evidence for higher parenting stress, lower parenting satisfaction and overall family functioning difficulties (Creech et al., 2014 ). Additionally, PTSD is associated with ineffective parenting behaviors such as inconsistent discipline, decreased positive parenting, and harsh discipline and parenting practices, including physical aggression and child maltreatment (Gewirtz et al., 2010). Research suggests that children of a parent with PTSD are at increased risk for lifetime psychiatric disorders (Leen-Feldner et al., 2013) and poor psychosocial outcomes (Castro-Vale et al., 2020). Further, it appears that the relationship between PTSD symptom severity and family functioning difficulties is bi-directional: PTSD symptom severity, especially in the avoidance and emotional numbing clusters, is related to increases in family functioning difficulties, and family functioning difficulties predict greater PTSD symptom severity (Evans et al., 2003; Possemato et al., 2015).

Although evidence-based treatments for PTSD are increasingly available for veterans and military service members, these treatments do not specifically address parenting and overall family functioning, with impairments in these domains often persisting even when symptom remittance is achieved (Bryant et al., 2016). Several promising parenting interventions have emerged in recent years as there has been growing recognition of the unique challenges and treatment issues surrounding active duty military personnel and their families. The content of these interventions and their evidence bases are reviewed in detail elsewhere (Creech et al., 2014), but briefly existing interventions have been developed for active duty military families to help these families recover from deployment separation and stress. Despite this growth, there remains a gap in interventions designed specifically for use within VA healthcare settings. Further, evidence suggests that parenting interventions are less effective for veterans who have clinically significant PTSD symptoms (Chesmore et al., 2018). Thus, there is an opportunity to make parenting interventions more effective and applicable for veterans with PTSD by including trauma-specific components.

Strength at Home - Parents (SAHP) aims to address the significant unmet need for treatments that specifically address the influence of PTSD on parenting and parent-child functioning. The intervention is based on validated and trauma-informed relationship improvement treatments (Strength at Home - Veterans and Strength at Home- Couples; Taft, Macdonald et al., 2016; Taft, Creech, et al., 2016), which are based on a Social Information Processing model positing that trauma and trauma-related consequences produce biases and deficits in social information processing that negatively impact relationships and increase risk for aggression. SAHP also has theoretical foundations in the Cognitive-Behavioral Interpersonal Theory of PTSD (C-BIT; Dekel & Monson, 2010) and the Family Attachment Network model (Riggs & Riggs, 2011). C-BIT posits that specific cognitive, behavioral and emotional processes impact the development and maintenance of PTSD and impair family functioning, whereas the Family Attachment Network Model is a developmental-contextual theory positing that disruptions to attachment and a lack of clarity in family roles (e.g., parent-child role-reversal) are other mechanisms through which PTSD symptoms impact family functioning.

The adaptation of SAHP started by retaining the structure, content and format of SAHC and SAHV (Taft, Macdonald et al., 2016; Taft, Creech, et al., 2016). This is intended to facilitate future implementation as SAHC and SAHV are already in use at nearly all VA hospitals therefore providers will be familiar with the basics of the new SAHP treatment. Certain SAHC content elements were retained with little adaptation such as PTSD symptom education, communication skills training, and identifying, understanding and expressing emotions, IPV education and time-outs to prevent escalation of arguments to physical violence. Other elements of SAHV were retained but heavily adapted to address emotional regulation more broadly (e.g. anger analysis sheets adapted to be emotion and parenting analysis sheets). Finally, based on our prior research, literature consensus and adapted CBIT model (Creech & Misca, 2017) new content to address key aspects of parenting that are impacted by PTSD symptoms was added (e.g. affective engagement, time together, attachment, positive parenting behaviors). We also included content suggested by our qualitative work with VA providers who had previously provided parenting education to veterans with PTSD such as need for education on child development, communication skills and emotion regulation (Creech et al., 2019). We also endeavored to retain core intervention techniques of SAH which are an inclusive, trauma informed environment, keeping intervention elements simple and to emphasize practicing new skills over time and while providing opportunities to benefit from group cohesion and feedback (Taft, Murphy & Creech, 2017).

Within the context of parental PTSD symptoms, each session of SAHP includes content that aims to increase the use of parenting behaviors associated with better child outcomes such as consistent discipline, communication and affective engagement (Chen, et al., 2019) and decrease use of parenting behaviors associated with poorer child outcomes such as coercion, corporal punishment, and abuse (Flouri & Midouhas, 2017; Sege & Siegal, 2018). SAHP integrates content specific to the challenges of veteran parents with PTSD, such as psycho-education about the influence of PTSD symptoms on parenting and attachment, and content and assignments focused on decreasing trauma-related avoidance of family activities while increasing emotional awareness and emotion management related to trauma triggers. In addition, SAHP includes content that addresses overall family and relationship functioning as couple satisfaction and conflict influences both partners’ parenting in the presence of service member PTSD (Giff et al., 2019). SAHP also includes content on understanding and addressing partner violence because partner violence is associated with PTSD (Taft et al., 2016) and has negative impacts on children (Gilbert et al., 2013). Finally, SAHP is delivered in a group setting to decrease stigma and promote social connectedness among veterans struggling with PTSD symptoms and parenting.

The model guiding this pre-efficacy treatment development research is the revised ORBIT model for developing behavioral treatments (Powell et al., 2021). To promote usability and eventual implementation a first draft of the content of SAHP was adapted using qualitative data obtained from VA providers with parenting intervention experience (Creech et al., 2019). In addition, emphasis was placed on creating gender-identity inclusive materials. The resulting manual was edited by an external panel of expert reviewers who each reviewed and provided written feedback on treatment sessions in their areas of expertise and convened twice as an advisory board for consensus. Here we review the results of a small N pilot trial of the first version of SAHP, which evaluated the credibility, feasibility, acceptability and initial outcomes of the intervention. We hypothesized that recruitment would be feasible, and that SAHP would demonstrate initial evidence of credibility, satisfaction and acceptability (primary outcomes for the pilot), and that the pilot would reveal ways to optimize study methods and materials. Lastly, a preliminary examination of changes in parenting, family functioning and parental/child psychopathology outcomes was also conducted (secondary outcomes for the pilot). We hypothesized that insufficient power would preclude significant changes on outcome measures, however we aimed to conduct a preliminary measurement of change in parenting, family functioning and parental/child psychopathology outcomes to inform a subsequent phase 1b open trial (e.g. Powell, et al., 2021).

Method

Participants

We aimed to recruit 20-32 participants across 2 male and 2 female (unyoked) pilot treatment groups. Although our recruitment target was partially constrained by pragmatic considerations, we believed that this sample size would allow us to test the feasibility of our recruitment methods and study procedures and give us sufficient quantitative and qualitative data on intervention reception. Ultimately, we recruited 12 female and 9 male Veterans. Participants self-referred through study flyers (n=5; 23.8%) or were recruited through letters sent to those veterans who met initial study eligibility based on medical record data (n=16; 76.2%). Study inclusion criteria were: 1) Age 18 years or older, 2) English speaking and able to provide written informed consent, 3) Parent to a child between the ages of 3 and 12, who resides with the participant or spends at least two days per week with the participant, 4) Elevated PTSD symptoms (at least moderate symptoms on PTSD Checklist for DSM-5, score>=31, Weathers, et al., 2013) and 5) Parent-child functioning problems (Parenting Stress Index-Short Form; Abidin, 1990, any subscale >=85th%). In addition, the following conditions were assessed at intake in order to identify persons in need of immediate referrals or stabilization prior to treatment: 1) Major neurocognitive disorder, including TBI (Ohio State Traumatic Brain Injury Identification Method.>=5; Corrigan & Bogner, 2007), 2) Untreated and/or poorly managed psychosis or substance dependence as assessed by corresponding Mini-International Diagnostic Interview subscales (MINI; Sheehan et al. 1998), and 3) Current suicide risk as established by the Beck Depression Inventory-II suicide item (BDI-II; Beck, et al., 1996) and clinician follow-up.

Study Design and Procedure

This was a non-randomized pilot trial. Research technicians established initial eligibility by phone. Eligible participants were scheduled for a 90-minute in-person assessment, where informed consent was obtained, and interview-based eligibility and baseline self-report measures were completed. Consenting participants who met full eligibility criteria were scheduled for eight weekly group treatment sessions, lasting 90-120 minutes each. In this study groups were held in-person within the mental health clinic of an urban VA outpatient setting. After each treatment session, participants completed a 10-minute self-report battery to assess credibility, acceptability and satisfaction with treatment. Upon completing the course of treatment, participants attended a 60-minute debriefing and post-treatment assessment. In most cases this occurred immediately after the last session. When needed, participants received referrals for non-study treatment resources. All assessments were completed by a post-doctoral fellow, and treatment groups were co-led by the study PI (a clinical psychologist) and a post-doctoral fellow. Assessment and treatment sessions took place at the Austin Outpatient Clinic and participants were compensated $180 for completing all study assessments. The study was approved by the Central Texas VA Healthcare System institutional review board and registered at ClinicalTrials.gov (NCT03403153).

Intervention content

SAHP consists of eight treatment sessions administered in groups separated by participant gender due to the potential for veterans who experienced military sexual trauma to feel uncomfortable in mixed gender settings (Kehle-Forbes, et al., 2017). Treatment sessions are two hours long and organized to start with homework review, followed by session content and homework assignment for the following week. All sessions address the role of PTSD and PTSD symptoms that may cause difficulties with the parenting behaviors, attachment, and family functioning that are the focus of that particular session. The initial phase (Sessions 1-2) of group provides psychoeducation on child development, attachment and common reactions to trauma, and there is a focus on goal-setting, enhancing motivational readiness for change, and building group cohesion and a positive therapist-participant working alliance. Parenting skills are introduced gradually, beginning with observation skills in the early sessions, and active skills later. The second phase (Sessions 3 and 4) focuses on emotion regulation and emotional engagement skills to help veterans understand the components of their emotions, learn improved emotion regulation skills, and to learn skills for emotional engagement and positive parenting, with consideration given to the numbing and avoidance symptoms of PTSD. Specific types of discipline are covered, with an emphasis on helping veterans to understand and utilize consistent and positive discipline. The third phase (Sessions 5-7) focuses on a range of communication skills, and management of family stress and safety. These communication skills help mitigate negative consequences of deficiencies in anger management and counter social information processing difficulties that can arise from PTSD symptoms. The final session focuses on gains achieved over the course of the treatment and plans for continued change. Across all of the sessions, group members complete in-session practice exercises and are provided “practice assignments” to consolidate information learned in group. See Table 1 for an overview of session content

Table 1:

SAH-P Session Content

Session	Description
1	Description of the group; group philosophy; group session topics; group expectations; learning about child development (e.g., age-normative cognitive development); homework: goals for the group/who is my child.
2	Common reactions to trauma and severe life stressors; fight-flight-freeze and parenting; decreasing avoidance related to family activities; noticing and praising desirable child behaviors; practicing giving children specific praise and ignoring negative behavior; homework: specific praise and ignoring practice.
3	Identifying, understanding and regulation of parental emotions; expressing feelings; tips for teaching children about feelings; decreasing avoidance and creating positive time with your child; homework: positive time together and specific praise and ignoring practice (Eyeberg & Robinson, 1982), emotion and parenting analysis.
4	Difference between punishment and discipline; positive discipline strategies; do’s for positive time-outs and discipline; logical consequences practice; homework: positive time together and specific praise and ignoring practice, emotion and parenting analysis (Shore, Murphy, Lai & Weingardt, 2013).
5	Tips for communicating with children; active listening; active listening and communication role-play; homework: positive time together and specific praise and ignoring practice, emotion and parenting analysis, active listening practice.
6	Balancing screen time and family; gun safety tips; tips for talking to your child about difficult or scary events such as PTSD; homework: positive time together and specific praise and ignoring practice, emotion and parenting analysis, making a screen time plan; supplemental material: Should I tell my kids about PTSD?.
7	Dealing with family conflict; tips for managing co-parent/family conflict in front of children; co-parent, partners and family time-outs: basic principles; what to do during a time-out, relaxation apps; homework: time outs: planning, preparing and prepping, continuing the change process.
8	Reviewing treatment gains and planning for the future; red flags that my child needs help.

Measures

Primary Outcome Measures

The Credibility/Expectancy Questionnaire (CEQ; Devilly & Borkovec, 2000) was administered after each session to assess participants perspectives on whether the intervention was logical and their expectations for the success of the intervention. There are 4 items scored on an 8-point scale (range 0-32), with higher scores representing greater credibility, and a reported mean score of 24.96 in standardization samples. Although CEQ session ratings were used to guide manual revisions, only CEQ scores at pre and post-treatment were evaluated for this report. The CEQ has high internal consistency and test-re-test reliability (Devilly & Borkovec, 2000). Internal consistency on the CEQ for this study ranged from α=0.87 (session 1) - α= 0.93 (session 8).

The SAHP satisfaction questionnaire was designed for this study and administered after each session to assess satisfaction with session components, overall session content, and homework. Sample questions include “The group exercise on child attachment was useful in understanding my child’s behavior” and “The number of take home practice assignments is reasonable”. Items are scored on a 9-point scale and averaged (range 0 -8) with higher scores representing greater treatment satisfaction. Additional qualitative feedback was obtained using open-ended questions. Internal consistency for this study ranged from (session 1) α = 0.92, (session 8) α = 0.83

The Client Satisfaction Questionnaire-8 (CSQ; Attkisson & Greenfield, 2004) was administered after the first session and after treatment completion to assess quality of services, treatment satisfaction, and willingness to recommend the treatment to others. There are 8 items scored on a 4-point scale (range 4-32), with higher scores representing greater acceptability. The CSQ has good psychometric properties, and has been shown to correlate with treatment engagement. In this study internal consistency on the CSQ was α = .99 at sessions 1 and 8.

Treatment Completion Treatment completion was defined as the proportion of veterans who initiated treatment and completed at least 5 out of 8 treatment sessions.

Secondary Outcome measures

The Parenting Stress Index, 4th edition (PSI; Abidin , 2012) has 120 items scored on a 5-point scale, yielding a parent and child domain scale measuring stress related to parent and child characteristics. These scale scores are combined to yield a total score. The PSI has high reliability coefficients, internal consistency, and test-retest reliability. The measure has been validated for use in various populations (Abidin, 2012).

The Alabama Parenting Questionnaire (APQ; Shelton, Frick & Wootton, 1996) is a 42-item measure on a 5-point scale. The APQ consists of two subscales measuring positive parenting practices (involvement and positive discipline) and three subscales measuring negative parenting practices (poor monitoring, inconsistent discipline and corporal punishment), with higher scores reflecting increased construct endorsement. For pre-school aged children the APQ-PR version was administered. The measure evidences satisfactory reliability (a = .80-.92), and discriminant and convergent validity (Elgar, et al.,2007).

The Family Assessment Device General Family Functioning Scale (FAD; Epstein, Baldwin, & Bishop, 1983) is a 12-item measure on a 4-point scale measuring general family functioning. Items are averaged (range 1 to 4), with higher scores reflecting impaired family functioning. The FAD has high Cronbach’s alpha (.86), and split-half reliability (.83) (Byles, et al., 1988). Consistency between responses to the 12-item FAD, and related family variables provides validity evidence.

The Pediatric Symptom Checklist (PSC; Jellinek, et al., 1986) is a 35-item measure on a 3-point scale assessing parents’ impressions of their child’s psychosocial functioning. Scores range from 0 to 70, with higher scores reflecting greater psychosocial problems and impairment. The PSC converges with the Child Behavior Checklist, an established self-report measures of child psychosocial difficulties (Jellinek et al., 1986).

The Parenting Scale (PS; Arnold, et al., 1993) is a 30-item measure on a 7-point scale assessing parenting practices. Scores are averaged (range 1 to 7), with higher scores reflecting more dysfunctional parenting practices. The PS has three distinct factors: hostility, over-reactivity and laxness. Adequate internal consistency and reliability have been demonstrated, and the scale correlates well with observational measures of dysfunctional discipline and child misbehavior (Arnold et al. 1993).

Beck Depression Inventory-II (BDI-II; Beck et al. 1996) is a 21-item measure on a 4-point scale assessing depression symptom severity. Scores range from 0 to 63 with higher scores reflecting increased endorsement of depressive symptoms. The BDI-II has high internal consistency, good test-retest reliability (.94), and correlates highly with other interview-based measures of depression (Sprinkle et al., 2002).

PTSD Checklist for DSM-5 (PCL-5; Weathers et al. 2013) is a 20-item measure on a 5-point scale assessing PTSD symptom severity. Scores range from 0 to 80 with higher scores reflecting increased endorsement of PTSD symptoms. The measure has good internal consistency, test-retest reliability and convergent and discriminant validity (Blevins, et al., 2015). The PCL-5 is as sensitive to clinical change that occurs between pre-and post-treatment as golden standard interview-based measures of PTSD symptoms (Worthmann et al., 2016).

Analyses

Missing items were prorated with the mean of other scale items if less than 20% of item data was missing. After proration six participants continued to have partially missing outcome data on one (n=5) or five (n=1) questionnaires, and these participants were excluded from analyses when these values were required. Preliminary analyses examining changes in outcomes from baseline to post-treatment were conducted with paired t-tests. The distributions of the FAD, PS total and PS laxness and hostility subscales were non-normal, and these variables were logarithmically transformed. The distributions of the PCL-5, PSC, PSI-child, and APQ involvement and inconsistent discipline subscales remained non-normal after transformation, and these variables were analyzed with non-parametric Wilcoxon signed rank or Sign tests, as appropriate. We did not complete formal qualitative analyses of open-ended response regarding on the SAHP measure, but these were reviewed for content and face-value assessment of satisfaction with the program.

Results

Participants and Feasibility

Recruitment was conducted between 2/27/2019 and 11/8/2019. There were 50 Veterans who completed an eligibility screen, and 21 Veterans (42.0%) met initial eligibility criteria and completed an intake assessment. Participants who did not meet initial ineligibility criteria reported logistical barriers that would not allow them to complete the study (N=6), did not have children in the study age range or did not live with their children (N=9), or had insufficient scores on PTSD or parent-child dysfunction measures (N=14). All participants completing the intake assessment met eligibility criteria and 20 participants (95.2%) elected to participate in treatment sessions. Participants were 57.1% (N=12) female, 57.1% (N=12) of participants as white, 9.5% (N=2) as black, and 33.5% (N=7) as multiracial/other. The vast majority of participants (81%, N=17) completed at least some college education. Treatment adherence (attending => 5 scheduled treatment sessions) was achieved by 11 participants (52.4%), and 13 participants (61.9%) were study completers, who were retained at post-treatment. There were no significant differences on key demographics, parental functioning or PTSD symptomatology (all p>0.1) between those who completed post-treatment questionnaires and those who did not. Participants who were not retained at post-treatment cited logistical reasons for discontinuing in the study (e.g., work/school conflicts, travel time), and these participants mostly (N=5) withdrew without attending any sessions. The remaining two participants withdrew after attending one session, and there was no indication that they were dissatisfied with the treatment received, with an average satisfaction rating of 7.4 on a scale from 0-8. Descriptive statistics are reported in Table 2.

Table 2:

Descriptive statistics for Completer Sample (N=13)

	Baseline	Post-Treatment
	M (SD)	M (SD)	p-value
BDI-II	28.4 (9.22)	24.6 (13.7)	0.24
FAD	2.07 (0.5)	1.77 (0.51)	<.01
PS- Total	3.54 (0.86)	2.87 (0.71)	0.02
PS- Hostility	2.69 (1.57)	1.69 (0.63)	0.02
PS- Overreactivity	3.85 (1.37)	2.88 (1.6)	0.11
PS- Laxness	3.12 (1.34)	2.52 (0.86)	0.05
PSI – Total	315 (44.3)	283 (75.8)	0.10
PSI- Parent	174 (25.9)	157 (43.2)	0.14
APQ- Positive Discipline	24 (5.75)	25.7 (4.37)	0.04
APQ- Monitoring	14.2 (2.92)	13.6 (4.03)	0.49
APQ- Corporal Punishment	6.7 (2.50)	4.6 (0.97)	<.01
	Median (IQR)	Median (IQR)
PCL-5	48 (4)	45 (24)	0.77
PSC	23 (13)	29 (20)	0.23
APQ- Inconsistent Discipline	14 (5)	13 (3.6)	0.34
APQ- Involvement	35 (2.75)	40 (8.5)	0.02
PSI- Child	142 (23.5)	130 (22)	0.08

Intervention Satisfaction, Acceptability and Credibility (Primary Outcomes)

CEQ ratings indicated high treatment credibility and acceptability, both after the initial session (M=27.7, SD=4.72), and upon the completion of treatment (M=28.9, SD=4.01). SAHP-specific satisfaction ratings (M= 6.65, SD=1.15 averaged over all sessions) and CSQ scores (M= 29.9, SD=2.78) indicated high treatment satisfaction. These ratings aligned with participant’s qualitative assessment of session satisfaction (See Table 3).

Table 3:

Qualitative feedback from participants (N=8)

• “These types of sessions should be necessary for redeployment and ETS.”  Male veteran, parent of child age 12

• “I have realized I need to work more on myself”  Male veteran, parent of child age 11

• “My thought processes have changed, especially during fight or flight situations.”  Male veteran, parent of child age 5

• “I feel better and more hopeful. This group meant a lot for me, and I met wonderful individuals”  Female veteran, parent of child age 4

• “The framework the group provided has been immensely valuable to me as a parent…My relationship is stronger and healthier than it was because of what I learned here. My child is happier and healthier.”  Male veteran, parent of child age 12

• “This group meant so much to me; I have been in denial in the past, but this class has taught me a lot about self-care to be able to help my children. I needed this class – it was profound. I am now starting my journey of self-recovery.”  Female veteran, parent of child age 7

• “The group has given me knowledge about what impacts I have on my child on how I handle conflicts, the group has given me motivation & reassurance to focus on positive behavior.”  Male veteran, parent of child age 5

• “I am going to lead a totally different life. I even thought about having another child. For the first time I feel qualified to do it…Ultimately, this program has not only improved my ability to be a mom, but it has also alleviated many of the symptoms of my PTSD that were exacerbated by being a mom.…I can only say that this has alleviated my stress by teaching me effective methods to parent that garner the best results with the least amount of wasted energy and conflict.”  Female veteran, parent of child age 8

Secondary Outcomes

Significantly lower FAD scores were reported at post-treatment (t(11)= 4.44, p<0.01, d=1.28), indicating improvement in general family functioning. There was also a significant reduction in dysfunctional parenting behaviors, with PS total scores being significantly lower at post-treatment (t(12)= 2.71, p=0.02, d=0.75). When PS subscales were examined, the hostility subscale was significantly lower at post-treatment (t(12)= 2.71, p=0.02, d=0.59), with a trend towards lower scores on the laxness (t(12)= 2.13, p=0.05, d=0.59) and over-reactivity (t(12)= 1.73, p=0.11, d=0.48) subscales.

Positive parenting practices as measured with the APQ significantly increased (involvement; V=3.5, p=0.02, n=10, r=0.78, positive discipline; t(9)= −2.36, p=0.04, d=0.75). The use of corporal punishment as measured with the corresponding APQ subscale significantly decreased (t(9)= 3.58, p<0.01, d=1.13). There were no significant changes on the APQ inconsistent discipline (S(10)=7, p=0.34) and APQ poor monitoring (t(7)= 0.723, p=0.49, d=0.26) subscales. There was a trend towards reductions in parenting stress, with PSI total scores being marginally lower at post-treatment (t(11)= 1.80, p<0.10, d=0.52). At baseline, 7 participants had scores in the clinical range on the PSI (=>85th percentile), which decreased to 4 participants at post-treatment. When subscales were examined, there was a trend towards a reduction in child stress (PSI child subscale total; V=53.5, p=0.08, n=12, r=0.52), but no significant difference in parent stress (PSI parent subscale total; t(11)= 1.59, p=0.14, d=0.46). There were no significant post-treatment changes in child psychosocial outcomes (PSC; S(11)=3, p=0.23) or in parent psychopathology (BDI; t(12)= 1.23, p=0.24, d=0.33 , PCL-5; S(13)=7, p=0.77).

Discussion

PTSD is associated with ineffective parenting practices, poor parent-child functioning, and suboptimal child outcomes. Despite these well-documented associations, family functioning is not an explicit treatment target in available evidence-based treatments for PTSD, and there are no parenting interventions available within VA that specifically address trauma symptoms and their influence on parenting and overall family functioning. To fill the treatment gap, we developed SAHP, a trauma-informed parenting intervention delivered to veterans in a VA setting. Here, we describe results of a pilot study of SAHP, examining feasibility of recruitment and retention, intervention satisfaction, credibility and acceptability, and preliminary outcomes.

Results indicated that recruitment of veteran parents using study procedures, including approaching veterans based on data obtained from the medical record, was feasible and allowed for the recruitment of an adequate sample of veterans within the designated timeframe. Although a significant portion of veterans (38.1%) were not retained at post-treatment, rates were similar to those reported elsewhere for veterans engaging in mental health treatment (Harpaz-Rotem & Rosenheck, 2011). Further, attrition in this study might be due to difficulty balancing demands of attending in-person treatment and childcare obligations. However, high attrition is a limitation of the current study and might introduce bias in our results. Follow-up studies of SAHP should adjust treatment delivery methods and procedures to minimize attrition. For example, clear study completion deadlines and pre-scheduled post-treatment assessments have been shown to reduce attrition (Andersson, 2016), and motivational enhancement interventions can be leveraged to improve adherence to treatment (Murphy et al., 2009). Considering that this study was a feasibility study, future research will utilize video-conferencing and online assessments to minimize participant burden and improve adherance and retention. We will also leverage greater use of digital communication to facilitate completion of study assessments.

Qualitative and quantitative measures suggested that veterans found the intervention to be highly credible, acceptable and satisfactory. Preliminary results suggested improvements in post-intervention parenting practices and overall family functioning, and a trend towards reductions in parenting stress. Changes in parental psychopathology and child psychosocial outcomes did not reach significance at post-treatment, however we were underpowered to detect changes in these outcomes. Although qualitative feedback was positive, several changes were also made to the treatment manual based on participant requests for material (adding “red flags that my child needs help” and “talking to children about difficult or scary things”), and based on practical feedback regarding session order (communication skills should come earlier on in treatment.)

Although the initial findings reported here are promising, they need to be interpreted with caution given the small sample size, high attrition rates, and self-report nature of outcomes. For example, patterns of missing data could not be explored with the small sample size. If results are replicated in an adequately powered sample, it would support testing SAHP against treatment-as-usual in a randomized trial. Limitations withstanding, this pilot data indicates feasibility of study procedure, and intervention satisfaction, acceptability and credibility. The preliminary results suggesting improvement in parenting outcomes support continued study of SAHP in a larger sample.

Clinical Implications

This study has several clinical applications for veteran care within the Veterans Health Administration (VHA). VA’s transition to increased emphasis on family centered care began in 2004, after the President’s New Freedom Commission on Mental Health made this a priority. Prior to that time, mental health services at VHA were focused on individual treatment models to the exclusion of the family system. These policy changes have allowed for the expansion of marital and family therapy services at VHA, and the last decade has seen a transformation in VA culture culminating in large scale dissemination of evidence based family and couples’ therapies, with an emphasis on providing these services to Veterans with PTSD (Glynn, 2013). However, no parenting training program is currently available nationally. The VA mandate specifies that family services are offered, therefore, parenting treatment focused on child behavior problems and that include dyadic parent-child models are currently mostly provided through community partners. However, limited funding and limited community expertise with Veterans in general, and in areas such as military related PTSD specifically, will likely continue to drive Veterans to the VA.

The data presented here gives preliminary support to feasibility of recruitment, and evidence for satisfaction, credibility and acceptability of a parent training program that meets the unique needs of veterans and VHA clinicians. There was also significant movement on parenting outcomes, suggesting that time-limited parenting treatment specifically developed for veterans with PTSD is potentially effective for improving parenting and family functioning. This in an important finding, as it has been suggested that PTSD symptoms might attenuate improvement following parenting interventions. Therefore, these results underscore the importance of developing parenting interventions tailored to veterans with PTSD and infused with trauma specific content. Despite these promising initial results, one of the limitations of this study is the high attrition rates. Clinicians and researchers need to be mindful of the high likelihood of discontinuation of treatment, and take appropriate steps to increase treatment motivation and engagement. Following the COVID-19 pandemic, the VA has increased their use of video conferencing for the delivery of care, and this technology can be leveraged to improve veteran retention in parenting interventions. Overall, these promising pilot results suggest that SAHP has the potential to fill an important treatment gap in VHA care, and continued study of this intervention in a larger sample is merited. Future extensions of this work also include optimizing delivery of material to co-parents while maintaining accessibility of the treatment.

Public Significance Statement:

PTSD is highly prevalent in military veterans and is associated with parenting role functioning difficulties which can convey risk for poor outcomes to children and increase PTSD symptoms in parents. There is a gap in accessible, trauma-informed and evidence-based parenting support interventions for veterans within VA. This study describes pilot findings from a trauma-informed parenting support program delivered at VA.