Programs for Military Families

Family-Centered Care for Military and Veteran Families Affected by Combat Injury

Stephen J. Cozza • Allison K. Holmes •

Susan L. Van Ost

Published online: 27 June 2013

� Springer Science+Business Media New York (Outside the USA) 2013

Abstract The US military community includes a popu-

lation of mostly young families that reside in every state

and the District of Columbia. Many reside on or near

military installations, while other National Guard, Reserve,

and Veteran families live in civilian communities and

receive care from clinicians with limited experience in the

treatment of military families. Though all military families

may have vulnerabilities based upon their exposure to

deployment-related experiences, those affected by combat

injury have unique additional risks that must be understood

and effectively managed by military, Veterans Affairs, and

civilian practitioners. Combat injury can weaken interper-

sonal relationships, disrupt day-to-day schedules and

activities, undermine the parental and interpersonal func-

tions that support children’s health and well-being, and

disconnect families from military resources. Treatment of

combat-injured service members must therefore include a

family-centered strategy that lessens risk by promoting

positive family adaptation to ongoing stressors. This article

reviews the nature and epidemiology of combat injury, the

known impact of injury and illness on military and civilian

families, and effective strategies for maintaining family

health while dealing with illness and injury.

Keywords Military family � Military child � Combat injury � Post-traumatic stress disorder � Traumatic brain injury � Family resilience

Introduction

Since the start of combat operations in Iraq and Afghani-

stan, over 50,000 men and women have been injured in

combat with varying levels of severity (www.defense.gov/

news/casualty, accessed January 17, 2013). Advances in

medical practice have increased the rates of injury survival

during Operation Enduring Freedom (OEF, combat oper-

ations in Afghanistan) and Operation Iraqi Freedom (OIF,

combat operations in Iraq) to as high as 90 % (Congres-

sional Budget Office 2007), far more than previously

experienced in war (Gawande 2004). The relatives of these

survivors are often left to cope with their loved one’s

extensive injuries, long-term recovery, permanent disabil-

ity, and changed behavior. Protecting and ensuring the

health of these families is critical to the rehabilitation of

service members and to prevention of mental health

problems in all family members.

Nature of Combat Injuries

Injuries are broadly categorized as either visible or invisible

in nature. The distinction of these injury types is important,

given their unique and differential impact on families and

children, and familial relationships. Visible injuries are those

easily identified by others, such as amputations (1,184

amputations through 2009, approximately 1 % of all inju-

ries; CRS 2009), other musculoskeletal injuries, shrapnel

injuries, blindness or eye injuries (10–13 % of all injuries;

Owens et al. 2008), auditory damage (approximately 10 %

of all blast injuries; Ritenour et al. 2008), and burns

(approximately 1 % of injuries). Due to improvised explo-

sive devices (IEDs) and use of vital-organ-sparing body

armor, an individual may suffer multiple visible injuries to

S. J. Cozza (&) � A. K. Holmes � S. L. Van Ost Center for the Study of Traumatic Stress, Uniformed Services

University of the Health Sciences, Bethesda, MD, USA

e-mail: [email protected]

123

Clin Child Fam Psychol Rev (2013) 16:311–321

DOI 10.1007/s10567-013-0141-3

the extremities (54 %) and head and neck (29 %) (Owens

et al. 2008). This pattern of injury increases the likelihood of

multiple injuries as well as co-morbid psychological trauma,

causing both visible and invisible wounds.

Invisible injuries are without external indication of

trauma but include symptoms that are presented through

cognitive, behavioral, and social dysfunction (Jones et al.

2010). These include neurological and psychological

wounds, such as traumatic brain injury (TBI), post-trau-

matic stress disorder (PTSD), and other combat-related

mental health disorders (e.g., depression, substance use

disorders). Notably, 33 % of all service members who

return from combat are reported to suffer from TBI, PTSD,

or depression; and 5 % meet criteria for all three diagnoses

(Tanielian and Jaycox 2008).

The incidence of combat-related TBI has been variably

reported in the literature, depending upon the source of

information, screening criteria and threshold of diagnostic

clarity, as well as severity level (i.e., mild, moderate or

severe). The military health system has reported the cumu-

lative number of diagnosed cases of TBI in military service

members to be over 250,000 through the second quarter of

2012 (http://www.health.mil/Research/TBI_Numbers.aspx).

Others have estimated the number of TBI cases to total 19

percent, or 320,000 veterans of OIF and OEF through 2007

(RAND 2008), a significantly higher incidence. TBIs are not

always immediately identified, diagnosed, and treated when

service members return from combat. Therefore, families

may not be aware of causes for the behavioral and cognitive

changes they see in their returning service members.

Longitudinal data suggest that those having physical or

‘‘visible’’ combat injury are at significant risk of the

eventual development of additional psychiatric problems

such as PTSD and depression (Koren et al. 2005; MacGr-

egor et al. 2009). These invisible injuries present cognitive,

behavioral, and interpersonal challenges. For example, one

study found that of OIF/OEF veterans with amputations,

58 % and 24 % were diagnosed with PTSD and depression,

respectively (Reiber et al. 2010). In addition, mental health

symptoms are not always immediately apparent. Grieger

et al. (2006) reported that nearly 80 % of combat-injured

who screened positive for either PTSD or depression at

seven months post-injury had previously screened negative

for both conditions at one month post-injury (Grieger et al.

2006). This suggests that either the physically injured

population’s mental status changes throughout the recovery

period or initial sub-clinical symptoms go unnoticed.

Impact of Combat Injury on Children and Families

Starting with the initial shock of injury notification to longer-

term injury adjustment problems, children and families face

difficult emotional and practical challenges (Cozza and Gui-

mond 2011). Anecdotal reports (Cozza et al. 2005, 2010;

Cohen et al. 2006) describe combat-injured families that are

stressed by the injury itself, as well as the tasks inherent in

providing both physical care and emotional support to their

injured service member. The degree of reported stress likely

depends upon time from the original injury, injury type, injury

severity, and functional impact on the injured parent; the

developmental status of the children; family composition; and

preexisting parent, child, or family characteristics.

Though the course of recovery includes advances and

setbacks, the overall sequence can be conceptualized as an

injury recovery trajectory (Cozza and Guimond 2011).

Within this rubric, there are four phases: acute care,

medical stabilization, transition to outpatient care, and

long-term rehabilitation and recovery. During acute care,

life-saving and life-sustaining medical interventions are

provided on the battlefield and in combat hospitals. Med-

ical stabilization, often occurring at great distances from

families’ residences, includes definitive medical/surgical

care that prepares the injured service member to function or

receive care outside of a hospital environment. In a 2007

report (President’s Commission on Care for America’s

Returning Wounded Warriors), 33 % of active-component,

22 % of reserve-component, and 37 % of retired combat-

injured veterans reported that a family member or friend

relocated temporarily to spend time with them while he or

she was in the hospital. This creates upheaval for partners

who leave households and employment to visit the hospital,

for children who accompany the partner, and for children

who remain at home with different caretakers or who

relocate to the residences of friends and extended family

members.

High injury severity leads to complex courses of

treatment that are distressing to families. There may be

alternating periods of medical stability and instability when

complications occur, recovery progress is limited, or

additional treatments (such as multiple reconstructive sur-

geries; Reiber et al. 2010) increase family distress (Hal-

comb and Davidson 2005). Polytrauma rehabilitative

centers have noted that multi-trauma injuries due to blasts

(Friedemann-Sanchez et al. 2008), and high rates of co-

morbidity among visible and invisible injuries, make

treatment complex and family adjustment difficult (Weaver

et al. 2009). Amputation, musculoskeletal injuries, burns,

or ocular injuries are likely to lead to temporary or per-

manent functional loss requiring prosthetic assistance or

extensive rehabilitative care. Depending upon the condi-

tion, functionality may be partially or completely regained.

The President’s Commission on Care for America’s

Returning Wounded Warriors (2007) found that 21 % of

active-component, 15 % of reserve-component, and 24 %

of combat-injured veterans in a random sample of OEF/

312 Clin Child Fam Psychol Rev (2013) 16:311–321

123

OIF participants had a family member or friend who was

forced to leave a job to provide full-time care. While the

combat-injured service member is healing physically and

psychologically, family members must manage their own

reaction to the injury, while ensuring the service member’s

care during the outpatient and rehabilitation phase of

recovery. This may require change in residence to be closer

to medical care, altered caretaking responsibilities,

adjustments in employment and financial support, and

changes in child care and schooling arrangements.

Transition to outpatient care begins prior to discharge,

as follow-up treatment and ongoing rehabilitation are

planned. This transition can often be challenging to fami-

lies as they lose resources that were available to them in the

hospital setting and must take on additional roles and

responsibilities themselves. Rehabilitation and recovery is

the longer-term period in which service members and

veterans learn to adapt to their injury and settle into their

new lives. During this phase, families often must transition

to new communities and engage new healthcare providers.

Over time, continuity of care may be complicated by

changes in healthcare facilities (e.g., recurring hospital-

based treatments, rotating clinical staff, outpatient reha-

bilitative services), as well as changes in family living

arrangements and associated disruptions in community

connection (Chesnut et al. 1999).

Each stage of the injury recovery trajectory can also have

early and lasting effects on the service member’s children.

Beginning with the initial notification of injury, children

may be exposed to uncensored injury information, care-

givers’ emotional responses, medical providers’ comments,

other ill or injured individuals in the hospital setting, and

evidence of medical procedures. For example, a small study

of combat-injured families that were several years past

injury found that 15 % of children evidenced clinical levels

of emotional and behavior problems (Cozza et al. 2011b).

Children’s reactions vary by their age and developmental

abilities (Cozza 2009; Cozza et al. 2010, 2011a; Cozza and

Feerick 2011). Exposure to the injured parent may induce

sadness, anxiety, or confusion, because children expect the

parent to return home from deployment safely. Younger

children may develop behavioral symptoms, loss of control,

and regression requiring adult support and patience. Older

children may assume responsibility for their parents’ inju-

ries, and adolescents may disengage from family interaction

(Cozza and Feerick 2011). Importantly, children of all ages,

infants to adolescents, respond to the injury, changes in the

injured parent, changes in the non-injured parent (e.g.,

availability, emotional responses), and changes in the

family routine. Because relationships within the family

system bidirectionally impact individual and relationship

functioning (e.g., Bronfenbrenner and Morris 2006; Cox

and Paley 1997; MacDermid Wadsworth et al. 2013),

service providers can promote health and recovery in the

combat-injured population through support to their spouses

and children.

Assessment and Treatment of Clinical Disorders

While this article focuses on family prevention strategies to

promote child and family health, clinicians must be pre-

pared to identify children or adults whose symptoms

indicate the presence of clinical disorders and to refer them

to competent evaluation and treatment, whether that be for

depression, anxiety, trauma-related, or other required care.

This may be particularly true for family members with

preexisting psychiatric conditions, where the stress of

injury can worsen symptoms. When children report clini-

cally significant levels of traumatic response, they should

be referred to a structured evidence-based trauma-informed

intervention such as Trauma-Focused Cognitive-Behav-

ioral Therapy (TF-CBT; Cohen et al. 2012) or Cognitive-

Behavioral Intervention for Trauma in Schools (CBITS;

Stein et. al. 2003). Both programs employ cognitive-

behavioral strategies, including psycho-education about

reactions to trauma and stress, relaxation training to reduce

anxiety, as well as cognitive and exposure-based approa-

ches. TF-CBT has been refined for use in military popu-

lations (Cohen and Cozza 2012), as well. When clinically

indicated, all treatment interventions can occur in con-

junction with family-centered interventions that are

described below.

Disruption to Parenting and Family Function

Parental injury can produce impairments in parenting and

family functioning. For example, the injured parent may be

unable to engage in prior enjoyable activities or take part in

household routines, leading to increased responsibilities for

other adults or children in the family. Prior to injury, many

young military service members were physically active

individuals who incorporated such traits in their parenting

activities. Anecdotally, we know that physical activities

(hiking, backpacking, and camping), hands-on activities

(playful wrestling), and athletic activities (ball throwing,

skiing, and golfing) were all likely modes of pre-injury

interaction between young military fathers and their chil-

dren (Cozza and Guimond 2011). Depending upon the

nature of the injury, those modes of engagement either may

no longer be possible or may require significant modifi-

cation to continue.

When profound alterations in parenting activities are

necessary, injured parents must modify a previously held,

idealized sense of themselves as parents and mourn any

Clin Child Fam Psychol Rev (2013) 16:311–321 313

123

related body change or functional loss. Similarly, as

described above, the non-injured parent may be attending

to the injured parent’s needs, also limiting parental avail-

ability and engagement to fulfill the child’s emotional and

basic physical or social needs. The physical absence and

emotional unavailability of both the injured and non-

injured parents, created by the prolonged hospitalization

and rehabilitation associated with injury, can seriously

limit a parent’s ability to effectively interact with his or her

children (Power 1979; Peters and Esses 1985; LeClere and

Kowalewski 1994; Kelley and Sikka 1997; Kotchick et al.

1997). Thus, the injury can alter the injured and non-

injured parents’ engagement in parenting.

High rates of TBI in the combat veteran population and

the unique consequences of the disorder bear additional

attention. According to Urbach and Culbert (1991), psy-

chiatric sequelae associated with TBI tend to be more dis-

tressing to family members and disruptive to family

functioning compared to other physical and non-neurolog-

ical impairment. The most troublesome symptoms include

personality alterations, behavioral dyscontrol, erratic emo-

tional expression, irritability, anger, apathy, and lack of

energy (Weinstein et al. 1995). Veterans who sustain TBI

may find that their parenting and interpersonal skills are

limited by a neurological incapacity for multitasking and

intolerance for overstimulation (Resnik and Allen 2007).

Non-injured parents, who must assume responsibilities

formerly shouldered by the injured spouse (Verhaeghe et al.

2005) are at high risk of depression and anxiety (Kreutzer

et al. 2009a, b; Pessar et al. 1993; Ponsford et al. 2003) and

therefore may find that their own parenting capacity is

undermined. Parental individual well-being, adaptive par-

enting, and the marital relationship may be compromised

due to the nature of the injury. Veterans diagnosed with TBI

report difficulties engaging in social settings because of

communication problems, low frustration levels, poor anger

management, and difficulty with emotional and behavioral

regulation (Resnik and Allen 2007). Due to an inability to

connect, veterans with TBI may withdraw from family

members to protect children and other loved ones from their

own unintended emotional reactivity. Interactions with TBI

parents pose unique challenges for children who may

remember their parent’s pre-injury behavior and errone-

ously blame themselves for parental outbursts, loss of

control, or emotional aloofness.

Studies of non-military families have shown that

parental TBI has detrimental effects on children. In a study

relying on retrospective reports from the civilian non-TBI

parent, children displayed increased acting-out behavior as

well as emotional and post-traumatic stress following the

parental TBI. In addition, parental TBI correlated with

compromised parenting in both partners and depression in

the non-TBI parent (Pessar et al. 1993). Comparison of

children in civilian families having a TBI parent to children

having a diabetic parent found higher levels of post-trau-

matic symptoms in children from TBI families, but no

differences between these groups with respect to child

depression or anxiety (Kieffer-Kristensen et al. 2011). This

suggests that parental TBI may have distinct traumatic

effects on children.

In qualitative studies of TBI, children have reported

feelings of loss and grief at the change in the injured parent

(Butera-Prinzi and Perlesz 2004), as well as a sense of

isolation (Charles et al. 2007). As described by one

12-year-old girl whose father had brain injury ‘‘I basically

just feel sad, because he’s there physically. I suppose I’ve

got a Dad but he’s not my Dad’’ (Butera-Prinzi and Perlesz

2004, p. 89). Factors related to impact on children include

TBI symptom severity, chronicity, and stability; existing

parent, child, and family functioning and relationships;

children’s developmental level and gender; family cohe-

sion, adaptability, resources, and conflict; and degree of

disruption to routine, residence, and household composi-

tion (Verhaeghe et al. 2005; Urbach and Culbert 1991).

Unlike other physical injuries, the impact of TBI on

children and families may not remit or improve. Verhaeghe

et al. (2005) underscored the very long-term impact on

family stress caused by a TBI and the continued need for

intervention by professionals 10–15 years after injury. In

this study, a key factor was the TBI’s impact on the injured

adult’s cognitive and interpersonal functional capacities. In

addition, the non-TBI partner’s experience was heavily

affected by the inability to have a reciprocal emotional

relationship and effective communication. Young families

with the least financial and social support were found to be

at the highest risk. Therefore, both practical (financial,

housing, social, and employment) and professional sup-

ports were deemed critical for caregivers and families of

long-term TBI sufferers (Verhaeghe et al. 2005).

Family Theory that Informs Intervention

Of theoretical and practical interest are the mechanisms or

processes by which parental impairment impacts overall

child adjustment and family functioning. For example,

Rutter and Quinton (1984) found that exposures to parental

irritability, aggression, and hostility were highly predictive

of poor child adjustment. Using a family systems per-

spective, MacDermid Wadsworth et al. (2013) noted that

the behavior and reactions of each family member affect

everyone in the system (both adults and children) in a

reciprocal fashion. These interactions potentially support

family equilibrium or lead to greater disequilibrium. As a

result, military healthcare services directed solely to the

individual service member or veteran miss the opportunity

314 Clin Child Fam Psychol Rev (2013) 16:311–321

123

to address the family context where the injured parent

receives the bulk of emotional support.

By describing the processes by which family and par-

enting dysfunction impact adult and child adjustment,

several key theorists have targeted the interactive skills and

routines which tend to protect family members and there-

fore promote health in spouses and children during times of

stress or trauma. Walsh’s (2006) Family Resilience Theory

emphasizes the family’s need to develop and preserve

shared beliefs, constructive communication, and healthy

patterns of organization. Based on their work with families

undergoing the stress of military deployment and separa-

tion, Saltzman et al. (2011) affirmed and expanded on these

concepts by hypothesizing that intervention should pro-

mote: (1) increased understanding, support, and forgive-

ness among family members; (2) improved communication

and cohesion; (3) coordinated parental leadership; (4)

defined but adjustable roles and responsibilities; and (5)

development of shared goals and beliefs.

Models of parental illness and combat injury (Armistead

et al. 1995; Gorman et al. 2010) highlight the need for such

a framework, proposing that the impact of parental physical

injury on child functioning is mediated by its disruption of

the marital dyad, parenting, and parent–child relationships

(attachment, parental responsiveness to the child’s needs).

Among children of parents suffering from a stroke, parent-

reported internalizing symptoms in their children and child

self-reported depressive symptoms have been associated

with caregiver strain and depression. Prior child depression

as well as depression and marital dissatisfaction in the well

parents contributed to greater risk in these families (Visser-

Meily et al. 2005). Among children of parents with mul-

tiple sclerosis, child internalizing and externalizing symp-

toms were associated with parental impairment and family

functioning, respectively (Diareme et al. 2006). In a small

hospitalized combat-injured population, greater levels of

parentally reported child distress were associated with pre-

injury deployment-related family distress as well as post-

injury family disorganization (e.g., disrupted schedules,

change in living arrangements) (Cozza et al. 2010, 2011a).

In combination, early and ongoing emotional and behav-

ioral challenges to children of combat-injured are associ-

ated with the disruption of parenting and family

relationships that occur under the stress of adjusting to an

injury.

The powerful and defining effect that severe combat

injury has on families, its capacity to generate toxic levels

of distress, undermine parenting, and disorganize family

roles and functions requires careful application and

expansion of the above principles. Treatment of combat-

injured families must also include linkage to supportive

community and military services, as well as improved

family routine and role definition, understanding of the

impact and meaning of the injury to family members, and

fostering a sense of future hopefulness despite experiences

of loss.

Family-Centered Intervention Strategies

The following strategies have been developed to promote

family equilibrium and resilience under the stress of

combat injury and its sequelae: (1) educate adults and

children about the impact of injury and the expected

recovery process. The family should be encouraged to

locate their progress within the injury recovery trajectory

while acknowledging that setbacks may occur (see above);

(2) reduce family distress and disorganization through

family care management (Cozza and Feerick 2011) and

provision of practical and socioeconomic support; (3)

develop emotion regulation skills necessary for ongoing

dialogue and collaboration; (4) promote helpful and

ongoing communication about the injury that incorporates

developmentally appropriate language (injury communi-

cation); (5) encourage optimism through development of

successful problem-solving and shared future goals. Each

of these approaches is detailed in the following paragraphs.

1. Educate Adults and Children About the Impact

of Injury and the Expected Recovery Process

To further reduce the family’s sense of uncertainty and

distress, professional guidance must include information

about the typical course of family recovery from combat

injury. After a serious injury, family members often

describe a sense of chaos and confusion, with little

awareness that this frenzied experience can be organized

into a predictable sequence: emotional shock, family sep-

arations, hospital visits, variable courses of recovery, out-

patient rehabilitation, and transitions to civilian life.

Families therefore can be helped to locate their experiences

within the injury recovery trajectory, as they progress from

acute care through medical stabilization and into outpa-

tient and long-term rehabilitation/recovery. Though out-

patient treatment and rehabilitation often includes re-

hospitalizations and repeated surgery, placing these expe-

riences in the framework of an injury recovery ‘‘journey’’

provides a sense of predictability and hope. An added sense

of normality can develop from exchanges with other

combat-injured families as they, too, move through broadly

defined phases of recovery toward definition of a new

lifestyle.

Equipped with information about what to expect, fami-

lies and providers must work together to manage the dif-

ferent challenges associated with each phase of the

recovery process (Cozza et al. 2011b). During acute care,

Clin Child Fam Psychol Rev (2013) 16:311–321 315

123

decisions must be made about providing information

appropriate to the different developmental levels of the

children, whether to include them in hospital visits, and

how to arrange for their care and maintain the family

household. During the period of in-hospital medical sta-

bilization, professional intervention must insure that hos-

pital-based accommodations are family friendly and that

practical resources are available (housing, travel, child

care, finances) for an extended stay. Further interventions

must include education about the injury, screening of

family members for possible psychiatric intervention,

counseling to reduce conflict among family members, and

help with planning the transition to outpatient care.

During outpatient and longer-term care, families tran-

sition from the supportive hospital environment toward

having to independently shoulder the bulk of daily care.

Because the injured parent may be unable to resume pre-

vious roles and responsibilities, families must accept that

their relationships and routines may be permanently

changed. Professional guidance must facilitate adaptive

problem-solving while at the same time promoting a pro-

cess by which the family can accept and embrace this

changed reality.

Because the injured family member’s changed behavior

is typically a direct result of the injury, providers must

offer helpful psycho-education about diagnoses and likely

long-term outcomes. Clinicians often need to remind

family members to attribute new and unexpected interac-

tions with the service member or veteran to the injury or

combat-related illness rather than to a change in the emo-

tional commitment of the relationship or to some action of

their own. A key principle is that everyone, parents and

children alike, is affected by the injury. Children, espe-

cially, must be reminded that the tension they see at home

is not their fault and that it is not their responsibility to

‘‘fix’’ it. Adolescents should be relieved of adult respon-

sibilities that conflict with academic, occupational, or

emotional development. In general, parents must provide

their children with opportunities for normal growth and

development that are independent from any struggle the

family is having with injury recovery.

2. Reduce Family Distress and Disorganization

Through Family Care Management and Provision

of Practical Support

Family care management (FCM) is modeled on Zatzick’s

(Zatzick et al. 2004) evidence-based ‘‘early combined

collaborative care’’ (ECCC) treatment approach that has

demonstrated benefit to civilian trauma patients of con-

tinuous post-injury case management over usual care. Za-

tick’s model aims to prevent post-trauma mental health

problems through development of a care plan that

simultaneously addresses the medical and psychosocial

complications of the injury. This is done by creating

linkages across medical-surgical, primary care, mental

health, and community support resources so that changing

needs are addressed as patients move from the hospital to

outpatient care. Services are delivered in a ‘‘stepped’’

manner which allows for an increase or decrease in support

as family needs wax and wane over time. ‘‘Collaborative’’

delivery means that services occur only when the family

agrees that they are clearly necessary and is therefore more

likely to favorably receive them (Zatzick et al. 2001).

Similarly constructed, FCM expands the ECCC model

by shifting the focus of preventive intervention from the

injured patient to his or her family as transition is made

from the hospital to the community setting. Consistent with

Zatzick’s collaborative care model, FCM incorporates

motivational interviewing techniques (eliciting change and

commitment talk, increasing awareness of personal dis-

crepancies, clarifying goals, making change plans) to

facilitate the family’s awareness of and interest in unrec-

ognized issues (substance abuse, clinically significant

mental health problems) that can undermine family rela-

tionships. Case management services are prioritized based

on the family’s expressed satisfaction or concern with

services in physical health, medical access, psychological/

mental health, social interactions, child care/education,

health, work/finance, housing, military status, and legal.

This paradigm is currently being studied in clinical trials

(FOCUS-CI Research and Training Manual 2012).

Effective management of these basic needs provides a

sense of order and predictability that allows family mem-

bers to be less distracted, function more effectively, and be

supportive of each other as the family moves through the

course of injury recovery. Continuous coordination of

services promotes family organization by reducing worry

about basic needs and providing overburdened caretakers

with support and respite. Adults are calmer, and the fre-

quency of impulsive, threatening, or disruptive behavior

among family members is reduced when there is access to

systems for household maintenance, meals, medical care,

money management, and child care. Children are calmer

when adults provide a predictable daily routine and model

restraint.

3. Develop Emotion Regulation Skills Necessary

for Ongoing Dialogue and Collaboration

Similar to all families, interpersonal transactions and

communication will be more effective in combat-injured

families if delivered in a measured, calm manner. Given

the higher likelihood of emotional dysregulation in com-

bat-injured families, particularly those with PTSD or TBI,

there is greater need for clinical attention. As a result,

316 Clin Child Fam Psychol Rev (2013) 16:311–321

123

children and adults should be taught to practice personally

effective stress reduction strategies. This training includes

instruction on how to monitor changes or extremes in

emotional states by first learning to label and express

feelings, then to identify when and how positive or nega-

tive responses are precipitated. An example of this strategy

is the FOCUS program’s use of the ‘‘feeling thermometer’’

and the association of colors with different intensities of

feeling (green = calm; yellow = mild discomfort;

orange = significant discomfort; red = severe discomfort)

(Lester et al. 2011). Use of colors to describe beginning or

growing intensities of feeling gives individual family

members a quick and mutually understood vocabulary to

identify and talk about emotions as they occur in response

to various situations and stressors. This facilitates decision-

making by allowing family members to anticipate and plan

for situations and times of day that are positive or stressful

for each individual.

Emotion regulation activities can be taught to families,

couples, and parent–child dyads, as well as individuals.

Though identifying and sharing feelings is a first step toward

the control of emotion, families also must use this informa-

tion to develop and encourage individual and group activities

that promote calm and relaxation. Individuals can be taught

to reduce worry and tension by engaging in positive self-talk,

allowing themselves breaks as needed, developing more

realistic expectations, and setting priorities. Families can

increase a sense of unity and mutual support by sharing

enjoyable activities. Similarly, couples and parent–child

dyads can be encouraged to jointly identify and engage in

activities that are calming for both participants.

Preventive strategies designed to minimize family dys-

regulation can be very helpful to combat-injured families.

While all families have ‘‘hot spots’’ or issues that tend to

provoke more intense emotional responses when they arise

(homework, chores, finances, etc.), physical injury, PTSD,

and TBI can contribute to greater reactivity and therefore

leave combat-injured families more easily upset by ordin-

ary stressors. In addition, reminders or ‘‘triggers’’ can

prompt memories of previous losses and traumas. For

example, the occurrence of an unexpected noise (a child’s

shout) may agitate a combat veteran who suffered injury

due to an IED. A child might become upset at the unan-

nounced absence of his father, because this is a reminder of

when the father was in the hospital. Each family member

brings hypersensitivities to their mutual interaction that can

disrupt the calm of their time together. Professionals must

help identify hot spots and triggers so that family members

are able to anticipate the service member’s reactions to

such events, as well as their own. For example, family

members can be helped to control their reaction to a service

member’s provoking behavior by not taking the triggered

behavior personally and by prompting the SM to employ

previously developed strategies for calming or controlling

the reaction.

A related treatment issue is the timing and choice of

mutually enjoyable and relaxing activities. Due to medica-

tion timing or sleep problems, the injured service member or

veteran may experience daily fluctuations in pain, alertness,

and irritability. The caregiving spouse or relative may value

personal rest and respite rather than an energetic outing with

children. Knowledge of these factors allows families to

identify and take advantage of ‘‘windows of availability’’ for

mutually enjoyable activity and interaction. Providers must

therefore assist family members to identify daily and weekly

intervals when they are more or less likely to successfully

enjoy themselves and each other’s company.

4. Developing a Shared Understanding Using Injury

Communication

Given injury-related distress and the amount of information

that must be shared among loved ones and with profes-

sionals, combat-injured families face unique challenges

that can compromise communication. Injury communica-

tion refers to the process of effective communication

regarding injury-related topics, both within and outside the

family (Cozza and Guimond 2011). This process begins at

or near the time of notification and continues through the

recovery period. A primary goal of this communication, to

be achieved over time through frequent discussion, is to

foster the family’s shared understanding of the injury’s

impact on the service member’s behavior and ability to

fulfill family responsibilities, define how these changes

affect each family member and how family life and rou-

tines will change or adapt as a result of the injury.

The following are key principles of injury commu-

nication:

Judicious Communication is Ongoing and Must Occur

Across a Variety of Relationships Injury-related discus-

sions must occur between multiple parties: the injured and

spouse, family members (including children), friends,

medical personnel, and other community professionals.

The detail and amount of information to be shared must be

tailored to each recipient’s ‘‘need to know’’ and ‘‘capacity

to know.’’

Though injury communication with outside resources

(extended family, neighbors, care systems, schools, clergy,

etc.) is essential to the family’s sense of safety and

stability, it must also respect the family’s need for a

measure of privacy. Some families adopt the strategy of

having a ‘‘point person’’ who answers the questions of

interested relatives and friends. Other families might use a

Web site or telephone tree to convey information or request

timely assistance and support.

Clin Child Fam Psychol Rev (2013) 16:311–321 317

123

Children and adults alike should adopt a brief, clear,

easily repeated, and general description of the injury and

injury story when speaking teachers, coaches, and other

concerned adults. When speaking with a coach, a child can

be taught to say that ‘‘My Dad would love to see me play

but can’t be here today because he is a soldier who was

injured in the war.’’ If asked for more information, the

child might learn to respond with ‘‘My Dad lost his legs in

the war and is getting better’’ or ‘‘My Dad was injured in

the war, so gets bothered by crowds.’’

Healthcare professionals can help combat-injured fami-

lies develop the messages that they will use to convey their

experience. Because different factions of the same family

may have conflicting interests and agendas with regard to the

service member, professional consultation can facilitate

communication and cooperation between parents, grandpar-

ents, in-laws, and children regarding such critical issues as

transportation to medical appointments and school activities,

balance of employment and child care, and maintenance of a

predictable household schedule. For example, the family

may decide that an unmarried service member or veteran

may reside with parents or siblings or friends. The spouse of

an injured service member or veteran may require the

support of extended family to care for children while also

sustaining employment and providing injury care.

Because recovery often proceeds over a period of years,

the explanation to children must account for the service

member’s changing capacities and be commensurate with

each child’s increasingly sophisticated ability to under-

stand. Professionals who maintain an ongoing supportive

role with the family can assist with this process of

clarification to children as they develop.

Injury Communication is Developmentally Appropriate The

most important communication to children of any age is

that they are safe and that important adults will remain

available to them. The Workgroup on Combat Injured

Families (Cozza 2009) has proposed that parents and pro-

fessionals be aware of the following guidelines: (a) The

importance of speaking with children as soon as possible

after the injury. Children infer from adult behavior that

something has happened and can be protected from

unfounded worry if informed in a timely manner.

(b) Adults should speak in a calm and matter-of-fact

manner using language that is comprehensible to the child

but excludes unnecessary or frightening detail. When

speaking with younger children, it may be helpful to use a

doll or puppet to show the location of the injury. (c) The

type of provided information will vary with each child’s

developmental status. For younger children, reassurance

about the care being administered to the injured parent and

about the ongoing safety of both the child and the uninjured

parent are important. Teenagers will require more detailed

and logical explanations of the injury, its impact on the

family, and reasons for carefully calibrated expansions of

their own household responsibilities. (d) Create a family

atmosphere in which discussion is encouraged regarding

the injured parent’s changed behavior. When they are

prompted to express confusion or voice questions, children

can be relieved of feeling personally responsible for

changed interactions between the injured parent and other

household members. Maintaining this dialogue allows

children and adults alike to develop an ongoing under-

standing of how the recovery process differentially affects

each family member.

5. Develop Optimism and Future Hopefulness

During injury recovery, the family often must engage in a

process of grieving their previous life while developing hope

and optimism about a changed future. The changed per-

sonality and interpersonal skills of a service member suf-

fering from TBI and/or PTSD can create a sense of grief in

family members who mourn their previous relationship.

Ambiguous loss (Boss 2002, 2004) is a particularly useful

way of referencing a family’s grief and confusion over the

presence of someone who resembles the previously loved

person, but no longer behaves in a way that is similar to prior

experience. Grief over this relationship loss is further com-

plicated by confusion about whether some semblance of the

prior connection might be recovered over time. The service

member’s unclear prognosis and fluctuating behavior/

capabilities create a sense of longing and sadness among

family members who remember their previously shared life.

Professionals can encourage acceptance of this changed

reality while developing the family-based skills by which

to create a positive, though different future. If a family can

develop a sense of safety and competency in their man-

agement of daily life with the injured loved one (through

the strategies described above), then it can look to the

future with greater hope. In addition, when families reduce

isolation and feel embedded in a larger, potentially helpful

context of interested people and connections, they develop

greater self-advocacy and confidence about their ability to

manage future challenges. Future hopefulness also devel-

ops when families are able to share new and positive

experiences together while recognizing and respecting

changes brought about by the illness or injury.

Moving forward by trying new activities or thinking

about the future is not always easy for injured families, and

many barriers to progress can get in the way. Family

growth can be complicated by the injured parent’s pain,

fatigue, immobility, trauma triggers, and other pressing

needs and worries (finances, employment). Spouses may

feel severely pressed for time due to the conflicting

318 Clin Child Fam Psychol Rev (2013) 16:311–321

123

demands of children and caring for the injured parent.

Children may have trouble understanding and coping with

their injured parent’s behavior while at the same time

struggling to adjust to new schools, neighborhood, and peer

groups. In addition, a child’s ability to grasp the implica-

tions of the injury will vary and change based on his or her

evolving emotional and cognitive maturity.

Readiness, defined as an injured family’s ability to con-

fidently try new activities and develop mutually shared

goals, is critical to the development of optimism about the

future. To feel that future plans are possible and realistic,

individual family members must feel competent to effec-

tively manage personal stress. The family as a group must

have effective routines for the management of differences

and conflict. When individuals vary in their ability to move

forward at the same time, conflict and frustration can

develop. Family members must accept these individual

differences in readiness, develop an understanding of why

some may be less capable of moving forward, and pace

changes accordingly. In addition, professional intervention

should help families translate hopes for the future into

clearly stated and achievable goals that all can agree to. This

process builds individual agreement on family priorities,

prevents working on too many things at once, and provides a

framework from which to recognize and evaluate progress.

Conclusion

Increased rates of survival from injuries suffered in the

current wars have changed the lives of children and fami-

lies who must cope with the long-term disability of their

injured family member. In addition to the challenges posed

by physical or ‘‘visible’’ injuries, the ‘‘invisible’’ injuries

caused by TBI and PTSD can change the injured family

member’s cognition and interpersonal behavior in ways

that are disruptive to intra-familial relationships and family

functioning.

Family theorists have noted that positive family function

is often characterized by mutual understanding, coordi-

nated leadership, defined roles and responsibilities, and

development of shared goals. Intervention with combat-

injured families should be informed and guided by an

awareness of these processes, with attention to the unique

challenges posed to combat-injured families. Effective

strategies should: (1) reduce family distress and disorga-

nization through FCM and provision of instrumental sup-

port; (2) develop emotion regulation skills necessary for

ongoing dialogue and collaboration; (3) educate adults and

children about the impact of injury and the expected

recovery process; (4) develop a shared understanding

through helpful and developmentally appropriate injury

communication; and (5) encourage optimism, readiness,

and hopefulness about the future through successful stress

management, and development of shared future goals.

Adult, child, and family service providers, whether they

work in military, VA, or civilian settings, should utilize

these perspectives while providing care during all phases of

recovery. Combat-injured families live within communities

around the country where their significant needs may go

unnoticed or unmet. Family-centered intervention strate-

gies can support the well-being of both adults and children

in these families.

References

Armistead, L., Klein, K., & Forehand, R. (1995). Parental physical

illness and child functioning. Clinical Psychology Review,

15(1995), 409–422.

Boss, P. (2002). Stress management: A contextual approach. New-

bury Park, CA: Sage.

Boss, P. (2004). Ambiguous loss research, theory, and practice:

Reflections after 9/11. Journal of Marriage and Family, 66,

551–566.

Bronfenbrenner, U., & Morris, P. A. (2006). The bioecological model

of human development. In W. Damon & R. Lerner (Eds.), The

handbook of child psychology (6th ed., Vol. 1, pp. 793–828).

New York: Wiley.

Butera-Prinzi, F., & Perlesz, A. (2004). Through children’s eyes:

Children’s experience of living with a parent with an acquired

brain injury. Brain Injury, 18, 83–101.

Charles, N., Butera-Prinzi, F., & Perlesz, A. (2007). Families living

with acquired brain injury: A multiple family group experience.

NeuroRehabilitation, 22, 61–76.

Chesnut, R. M., Carney, N., Maynard, H., Patterson, P., Mann, N. C.,

& Helfand, M. (1999). Rehabilitation for traumatic brain injury.

Rockville, MD: Agency for Health Care Policy and Research.

Cohen, J. A., & Cozza, S. J. (2012). Children in military families. In J.

A. Cohen, A. P. Mannarino, & E. Deblinger (Eds.), Trauma-

focused CBT for children and adolescents: Treatment applica-

tions (pp. 199–224). New York: Guilford Press.

Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating

trauma and traumatic grief in children and adolescents: A

clinicians guide. New York: Guilford Press.

Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2012). Trauma-

focused CBT for children and adolescents: Treatment applica-

tions. New York: Guilford Press.

Congressional Budget Office. (2007). Projecting the costs to care for

veterans of US military operations in Iraq and Afghanistan.

Testimony presented by Matthew S. Goldberg, Deputy Assistant

Director for National Security, before the US House of

Representatives Committee on Veterans Affairs. Washington,

DC. Accessed January 31, 2013 from http://www.cbo.gov/

ftpdocs/87xx/doc8710/10-17-VAAdmin_Testimony.pdf.

Congressional Research Service. (2009). United States military

casualty statistics: Operation Iraqi freedom and operation

enduring freedom. Washington, DC. http://fas.org/sgp/crs/

natsec/RS22452.pdf.

Cox, M. J., & Paley, B. (1997). Families as systems. Annual Review

of Psychology, 48(1), 243–267.

Cozza, S. J. (Ed.) (2009). Proceedings: Workgroup on intervention

with combat injured families. Center for the Study of Traumatic

Stress, Uniformed Services University of the Health Sciences,

Bethesda, MD.

Clin Child Fam Psychol Rev (2013) 16:311–321 319

123

Cozza, S. J., Chun, R. S., & Miller, C. (2011a). The children and

families of combat-injured service members. In E. C. Richie

(Ed.), War psychiatry (pp. 503–533). Washington: Borden

Institute.

Cozza, S. J., Chun, R. S., & Polo, J. A. (2005). Military families and

children during operation Iraqi freedom. Psychiatric Quarterly,

76, 371–378.

Cozza, S. J., & Feerick, M. M. (2011). The impact of parental combat

injury on young military children. In D. Osofsky (Ed.), Clinical

work with traumatized young children (pp. 139–154). New York:

Guilford Press.

Cozza, S. J., Feerick, M. M., Saltzman, W. R., Lester, P., Zatzick, D.

J., Schmidt, J. A., et al. (2012). FOCUS-CI, families overcoming

under stress: Combat injured, research and training manual.

Bethesda: Center for the Study of Traumatic Stress, Uniformed

Services University.

Cozza, S. J., & Guimond, J. M. (2011). Working with combat-injured

families through the recovery trajectory. In S. MacDermid

Wadsworth & D. Riggs (Eds.), Risk and resilience in US military

families (pp. 259–277). New York: Springer.

Cozza, S. J., Guimond, J. M., McKibben, J. B. A., Chun, R. S., &

Ursano, R. J. (2010). Combat-injured service members and their

families: The relationship of child distress and spouse-perceived

family distress and disruption. Journal of Traumatic Stress,

23(1), 112–115.

Cozza, S. J., Holmes, A. K., Feerick, M. M., Schmidt, J. A., Harris, A.

M., Mendelson, M. L., et al. (2011b). The impact of combat

injury on the adjustment of military service members, spouses,

and their children. Baltimore, MD: Poster session presented at

the annual meeting of the International Society for Traumatic

Stress Studies.

Diareme, S., Tsiantis, J., Kolaitis, G., Ferentinos, S., Tsalamanios, E.,

Paliokosta, E., et al. (2006). Emotional and behavioural

difficulties in children of parents with multiple sclerosis: A

controlled study in Greece. European Child and Adolescent

Psychiatry, 15, 309–318.

Friedemann-Sanchez, G., Sayer, N. A., & Pickett, T. (2008). Provider

perspectives on rehabilitation of patients with polytrauma.

Archives of Physical Medicine Rehabilitation, 89, 171–178.

Gawande, A. (2004). Casualties of war—military care for the

wounded from Iraq and Afghanistan. New England Journal of

Medicine, 351, 2471–2475.

Gorman, L. A., Fitzgerald, H. E., & Blow, A. J. (2010). Parental

combat injury and early child development: A conceptual model

for differentiating effects of visible and invisible injuries.

Psychiatry Quarterly, 81, 1–21.

Grieger, T. A., Cozza, S. J., Ursano, R. J., Hoge, C., Martinez, P. E.,

& Engle, C. C. (2006). Posttraumatic stress disorder and

depression in battle-injured soldiers. American Journal of

Psychiatry, 163, 1777–1783.

Halcomb, E., & Davidson, P. (2005). Using the illness trajectory

framework to describe recovery from traumatic injury. Contem-

porary Nurse, 19, 232–241.

Jones, K. D., Young, T., & Leppma, M. (2010). Mild traumatic brain

injury and posttraumatic stress disorder in returning Iraq and

Afghanistan war veterans: Implications for assessment and

diagnosis. Journal of Counseling and Development, 88,

372–376.

Kelley, S. D., & Sikka, A. (1997). A review of research on parental

disability: Implications for research and counseling practice.

Rehabilitation Counseling Bulletin, 41, 105–121.

Kieffer-Kristensen, R., Teasdale, T. W., & Bilenberg, N. (2011). Post-

traumatic stress symptoms and psychological functioning in

children of parents with acquired brain injury. Brain Injury, 25,

752–760.

Koren, D., Norman, D., Cohen, A., Berman, J., & Klein, E. M. (2005).

Increased PTSD risk with combat-related injury: A matched

comparison study of injured and uninjured soldiers experiencing

the same combat events. American Journal of Psychiatry, 162,

276–282.

Kotchick, B. A., Summers, P., Forehand, R., & Steele, R. G. (1997).

The role of parental and extrafamilial social support in the

psychosocial adjustment of children with a chronically ill father.

Behavior Modification, 21, 409–432.

Kreutzer, J. S., Stejskal, T. M., Ketchum, J. M., Marwitz, J. H.,

Taylor, L. A., & Menzel, J. C. (2009a). A preliminary

investigation of the brain injury family intervention: Impact on

family members. Brain Injury, 23, 535–547.

Kreutzer, J. S., Stejskal, T. M., Ketchum, J. M., Marwitz, J. H.,

Taylor, L. A., & Menzel, J. C. (2009b). A preliminary

investigation of the brain injury family intervention: Impact on

family members. Brain Injury, 23(6), 535–547.

LeClere, F. B., & Kowalewski, B. M. (1994). Disability in the family:

The effects on children’s wellbeing. Journal of Marriage and

Family, 56, 457–468.

Lester, P., Mogil, C., Saltzman, W., Woodward, K., Nash, W., Leskin,

G., et al. (2011). Families overcoming under stress: Implement-

ing family-centered prevention for military families facing

wartime deployments and combat operational stress. Military

Medicine, 176(1), 19.

MacDermid Wadsworth, S., Lester, P., Marini, C., Cozza, S. J.,

Sornborger, J., Strouse, T., et al. (2013). Approaching family-

focused systems of care for military and veteran families.

Military Behavioral Health, 1, 1–10.

MacGregor, A. J., Corson, K. S., Larson, G. E., & Shaffer, R. A.

(2009). Injury-specific predictors of posttraumatic stress disor-

der. Injury, 40, 1004–1010.

Owens, B. D., Kragh, J. F., Wenkos, J. D., Macaitis, J., Wade, C. E.,

& Holcomb, J. B. (2008). Combat wounds in operation Iraqi

freedom and operation enduring freedom. Journal of Trauma-

Injury Infection and Critical Care, 64, 295–299.

Pessar, L. F., Coad, M. L., Linn, R. T., & Willer, B. S. (1993). The

effects of parental traumatic brain injury on the behaviour of

parents and children. Brain Injury, 7, 231–240.

Peters, L. W., & Esses, L. M. (1985). Family environment as

perceived by children with a chronically ill parent. Journal of

Chronic Diseases, 38, 301–308.

Ponsford, J., Olver, J., Ponsford, M., & Nelms, R. (2003). Long-term

adjustment of families following traumatic brain injury where

comprehensive rehabilitation has been provided. Brain Injury,

17, 453–468.

Power, P. W. (1979). The chronically ill husband and father: His role

in the family. Family Coordinator, 28, 616–621.

President’s Commission on Care for America’s Returning Wounded

Warriors. (2007). Serve, support, simplify: Report of the

President’s Commission on Care for America’s Returning

Wounded Warriors. Washington, DC.

RAND Center for Military Health Policy Research. (2008). Invisible

wounds: Mental health and cognitive care needs of America’s

returning veterans. Arlington, VA: RAND Corporation.

Reiber, G. E., McFarland, L. V., Hubbard, S., Maynard, C., Blough,

D. K., Gambel, J. M., et al. (2010). Service members and

veterans with major traumatic limb loss from Vietnam war and

OIF/OEF conflicts: Survey methods, participants, and summary

findings. Journal of Rehabilitation Research and Development,

47(4), 275–298.

Resnik, L. J., & Allen, S. M. (2007). Using international classification

of functioning, disability and health to understand challenges in

community reintegration of injured veterans. Journal of Reha-

bilitation Research and Development, 44, 991–1006.

320 Clin Child Fam Psychol Rev (2013) 16:311–321

123

Ritenour, A. E., Wickley, A., Ritenour, J. S., Kriete, B. R.,

Blackbourne, L. H., Holcomb, J. B., et al. (2008). Tympanic

membrane perforation and hearing loss from blast overpressure

in operation enduring freedom and operation Iraqi freedom

wounded. Journal of Trauma, 64(2 Suppl), S174–S178.

Rutter, M., & Quinton, D. (1984). Parental psychiatric disorder:

Effects on children. Psychological Medicine, 14(4), 853–880.

Saltzman, W. R., Lester, P., Beardslee, W. R., Layne, C. M.,

Woodward, K., & Nash, W. P. (2011). Mechanisms of risk and

resilience in military families: Theoretical and empirical basis of

a family-focused resilience enhancement program. Clinical

Child and Family Psychological Review, 14, 213–230.

Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott,

M. N., et al. (2003). A mental health intervention for school-

children exposed to violence. JAMA: The Journal of the

American Medical Association, 290(5), 603–611.

Tanielian, T., & Jaycox, L. H. (2008). Invisible wounds of war:

Psychological and cognitive injuries, their consequences, and

services to assist recovery. Arlington, VA: RAND Corporation.

Urbach, J. R., & Culbert, J. P. (1991). Head-injured parents and their

children: Psychosocial consequences of a traumatic syndrome.

Psychosomatics, 32, 24–33.

Verhaeghe, S., Defloor, T., & Grypdonck, M. (2005). Stress and

coping among families of patients with traumatic brain injury: A

review of the literature. Journal of Clinical Nursing, 14,

1004–1012.

Visser-Meily, A., Post, M., Meijer, A. M., Maas, C., Ketelaar, M., &

Lindeman, E. (2005). Children’s adjustment to a parent’s stroke:

Determinants of health status and psychological problems, and

the role of support from the rehabilitation team. Stroke, 36(11),

2436–2440.

Walsh, F. (2006). Strengthening family resilience (2nd ed.). New

York: Guilford Press.

Weaver, F. M., Burns, S. P., Evans, E. T., Rapacki, L. M., Goldstein,

B., & Hammond, M. D. (2009). Provider perspectives on soldiers

with new spinal cord injuries returning from Iraq and Afghan-

istan. Archives of Physical Medicine and Rehabilitation, 90,

517–521.

Weinstein, E. A., Andres, A., Salazar, M., & Franklin, D. J. (1995).

Behavioral consequences of traumatic brain injury. In F.

D. Jones, L. R. Sparacino, V. L. Wilcox, J. M. Rothberg, & J.

W. Stokes (Eds.), War psychiatry (pp. 353–381). Washington,

DC: Office of the Surgeon General, 319-51.

Zatzick, D. J., Roy-Byrne, P., Russo, J., Rivara, F., Droesch, R.,

Wagner, A., et al. (2004). A randomized effectiveness trial of

stepped collaborative care for acutely injured trauma survivors.

Archives of General Psychiatry, 61, 498–506.

Zatzick, D. J., Roy-Byrne, P., Russo, J. E., Rivara, F. P., Koike, A.,

Jurkovich, G. J., et al. (2001). Collaborative interventions for

physically injured trauma survivors: A pilot randomized effec-

tiveness trial. General Hospital Psychiatry, 23, 114–123.

Clin Child Fam Psychol Rev (2013) 16:311–321 321

123

Copyright of Clinical Child & Family Psychology Review is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.