Overview and Design of the Child Maltreatment in Military Families Life Course Study.

OBJECTIVE: This report presents an overview of the objectives, design, and analytic strategy of the Child Maltreatment in Military Families Life Course Study, an investigation of factors associated with child maltreatment in active duty military families. METHOD: The study uses a case-control retrospective research design and discrete-time survival methodology to examine service member demographic characteristics, family characteristics, military-related characteristics, and military family life events associated with child maltreatment incidents that meet the Department of Defense definition of child abuse or neglect. The sample includes all active duty families with a first occurrence of child maltreatment anytime between Fiscal Year (FY) 2009 and FY 2018 (n = 28,684), and a representative sample of control families with children under age of 18 during the same period (n = 589,417). Analyses include child maltreatment and domestic abuse data from the Family Advocacy Program Central Registry; sponsor socio-demographic, military-related, and family data from the Active Duty Military Personnel Master and Defense Enrollment Eligibility Reporting System data files; deployment data from the Contingency Tracking System; and mental health data from the Medical Data Repository. RESULTS AND CONCLUSIONS: Study results identify risk and protective factors associated with child maltreatment in military families, subgroups at elevated risk of child maltreatment, and periods of heightened risk during the military family life course. These results are expected to improve the ability to identify families most at-risk for particular types of child maltreatment and inform prevention strategies that promote the health and safety of military families.

Latent classes of child neglect types and associated characteristics.

BACKGROUND: Children who experience neglect typically endure multiple types of neglect and abuse during a single maltreatment incident. However, research on the phenomenology and predictors of neglect types has primarily examined neglect types in isolation. OBJECTIVE: To advance understanding of neglect incidents that more accurately reflect the experiences of children who have been neglected, we examined latent classes of neglect defined by co-occurring neglect types and multiple forms of abuse. To inform efforts to identify families at-risk for particular classes of neglect, associations between child, parent, and family characteristics and latent classes were examined. PARTICIPANTS AND SETTING: 390 child neglect incidents substantiated at U.S. Army installations. METHODS: Neglect types and incident severity were coded using the Modified Maltreatment Classification System. Child, parent, and family characteristics were coded using information drawn from case records. RESULTS: Latent class analysis yielded 5 classes: exposure to violence, failure to provide, supervisory lapses, substance-related endangerment, and non-specific. The exposure to violence and substance-related endangerment classes were characterized as highly severe. High and low severity classes were associated with distinct child, parent, and family characteristics. The latent classes were also differentiated by distal outcomes, including probability of law enforcement investigation, child removal from home, and offender removal from home. CONCLUSIONS: By identifying the types of neglect and abuse that are likely to occur concomitantly as well as the child, parent, and family characteristics associated with increased risk of latent classes of neglect, results advance knowledge regarding the phenomenology of neglect types and inform prevention efforts.

The effect of war injury and combat deployment on military wives' mental health symptoms.

BACKGROUND: Although much has been learned about the physical and psychological impacts of deployment and combat injury on military service members, less is known about the effects of these experiences on military spouses. METHODS: The present study examined self-reported mental health symptoms (using the Brief Symptom Inventory [BSI]-18 and the posttraumatic stress disorder [PTSD] Checklist [PCL-C]) in wives of service members who were combat-injured (CI; n = 60); noninjured with cumulative deployment longer than 11 months (NI-High; n = 51); and noninjured with cumulativel deployment less than 11 months (NI-Low; n = 53). RESULTS: 36.7% and 11.7% of CI wives endorsed above threshold symptoms on the PCL-C and overall BSI-18, respectively. Multivariate linear regressions revealed that being a CI wife was associated with higher PCL-C, overall BSI-18, and BSI-18 anxiety subscale scores compared to NI-Low wives in models adjusted for individual and family characteristics, as well as prior trauma and childhood adversities. Compared with the NI-High group, the CI group was associated with higher overall BSI-18 scores. CONCLUSIONS: While CI wives evidenced fewer mental symptoms than expected, these findings suggest a negative impact of service member's combat injury on wives' mental health above that attributable to deployment, highlighting the need for trauma-informed interventions designed to support the needs of military wives affected by combat injury.

Bereavement during the COVID-19 Pandemic: Impact on Coping Strategies and Mental Health.

The COVID-19 coronavirus has caused 5.4 million deaths worldwide, including over 800,000 deaths in the United States (as of December 2021). In addition to these staggering statistics, an even greater number of individuals have died from other causes during the COVID-19 pandemic. As a result, a large portion of the global population has faced bereavement during the COVID-19 pandemic and resulting quarantine. The often rapid and unexpected nature of COVID-19 deaths and the presence of pandemic-related stressors and living restrictions make it more difficult for individuals bereaved during the pandemic to implement effective strategies for coping with the loss compared to non-pandemic periods. Quarantine-related constraints (e.g., social distancing, availability of and access to resources) impede coping strategies that have been found to be adaptive after a loss, such as supportive (e.g., seeking emotional and instrumental support) and active (e.g., problem-focused and cognitive reframing) coping, and they augment avoidant strategies (e.g., substance use, denial, and isolation) that have been found to be maladaptive. Poorer mental health outcomes (including prolonged grief disorder; PGD) have been associated with less healthy coping. This article reviews research findings regarding bereavement during the COVID-19 pandemic, discusses the effects of pandemic-related stressors on bereavement coping strategies, and proposes how different types of coping during the pandemic may account for the poorer mental health outcomes described in recent reports. Interventions for promoting adaptive coping strategies and minimizing maladaptive coping strategies are also outlined.

Mental Health, Ill-Defined Conditions, and Health Care Utilization Following Bereavement: A Prospective Case-Control Study.

BACKGROUND: Bereavement has been associated with increases in immune/inflammatory and neuroendocrine reactions, cardiovascular events, nonspecific physical symptoms, mental conditions, and health care utilization. However, little is known about bereavement effects in younger samples, multiple health effects within samples, or prebereavement to postbereavement health changes. OBJECTIVE: To determine the effect of bereavement on the prevalence of medical conditions and utilization of health care. METHODS: This study examined the prevalence of 15 medical conditions and health care utilization before and in the first and second years after bereavement in a population of 1375 U.S. military widows and compared them to those of 1375 nonbereaved U.S. military control wives. RESULTS: Compared with controls, widows showed greater increases in prebereavement levels of prevalence of ill-defined conditions and mental health conditions in years 1 and 2 following bereavement. Health care utilization also increased for widows compared with controls. Utilization was highest for widows with comorbid ill-defined conditions and mental health conditions. CONCLUSIONS: The increased prevalence of both ill-defined conditions and mental health diagnoses following bereavement and the resultant need for increased health care utilization in this help-seeking sample suggest a need for proactive health monitoring of all military widows to identify and treat mental health conditions, as well as recognize manifestations of physical symptoms, in those who may not seek treatment.

Development of the Bereavement and Interpersonal Domains codebook.

We describe the development of an empirically-derived codebook for qualitative data concerning the impact of grief on the interpersonal relationships of bereaved individuals. Relatives (N = 39) of deceased military service members participated in focus groups concerning how grief influenced their relationships across multiple interpersonal domains, including family, friends, community, and with the deceased. Focus group transcripts were coded using a stepwise process consistent with grounded theory to identify and categorize recurrent themes. The process yielded a comprehensive codebook containing 44 nodes with definitions and examples. The codebook provides researchers with an empirically-grounded analytic tool for future studies on bereavement.

Child Maltreatment Fatality Review: Purposes, Processes, Outcomes, and Challenges.

Better understanding of the causes and circumstances of maltreatment deaths of children is needed to prevent tragedy. The purpose of this article is to facilitate understanding of child maltreatment fatality review processes and their outcomes. A literature review was conducted through searches of the databases PubMed, PsycINFO, and EMBASE and through citations in publications. Over 165 publications were reviewed and 55 were selected for inclusion. Papers were from the United States, England, Ireland, Northern Ireland, Netherlands, France, Canada, Australia, South Africa, Switzerland, Saudi Arabia, Japan, and China. These were included if they described fatality review goals, authority, procedures, and outcomes. Although we searched databases on a continual basis during the preparation of this review, we could have missed publications, particularly those in newspapers and journals that are not included in large-scale databases or cited in other articles. Improvement of fatality review requires diligence by individuals and organizations that provide information to the reviewers. Among challenges to the review process are varying criteria for review, misclassifications of the manner of death, inadequate or incomplete forensic and medical investigations, lack of information about the perpetrator, diversity of the community, concealment of the cause of death by parents or other caregivers, and disagreement among reviewers about the results of their inquiries. Institutional challenges are also present, which include the need for funding, privacy issues on obtaining information, updating reviewer training, lack of follow-up by institutional authorities on the recommendations of the reviews, and research facilitating the review of maltreatment fatalities.

Coping Strategies and Considering the Possibility of Death in Those Bereaved by Sudden and Violent Deaths: Grief Severity, Depression, and Posttraumatic Growth.

BACKGROUND: Bereavement by sudden and violent deaths can lead to increased grief severity, depression, and reduced posttraumatic growth compared to those bereaved by natural causes. These outcomes can be affected by coping strategies and whether a survivor had been "prepared" for the death. The present study examined the effect of coping and considering the possibility of death on grief severity, depression, and posttraumatic growth in those bereaved by sudden deaths. METHODS: Participants bereaved by suicide, accident, or combat deaths completed an online survey about demographics (including the cause of death), coping, grief severity, depression, and posttraumatic growth. A factor analysis of the coping measure yielded factors representing three coping strategies: avoidant coping, supportive coping, and active coping. These three strategies, the causes of death and considering the possibility of death were used as predictors of either grief severity, depression, or posttraumatic growth in multivariate linear regression models. RESULTS: Each coping strategy and cause of death was differentially associated with grief severity, depression, and posttraumatic growth. Specifically, supportive coping and active coping were each only associated with higher posttraumatic growth. In contrast, avoidant coping was associated with all outcomes (higher grief severity and depression and lower posttraumatic growth). In addition, accidents and suicides (compared to combat deaths) had independent effects on grief severity and posttraumatic growth. Considering the possibility of death interacted with avoidant coping and also with supportive coping to predict grief severity in combat-loss survivors. DISCUSSION: Findings highlight the differential contributions of coping strategies and their complex relationships with cause of death in contributing to grief severity, depression, and posttraumatic growth. Avoidant coping contributed to negative outcomes and inhibited posttraumatic growth, suggesting its importance as a target for therapeutic intervention. Although supportive and active coping facilitated posttraumatic growth, they had less of a role in mitigating grief severity or depression in this study. Although considering the possibility of death appeared to mitigate negative outcomes among survivors of combat death, avoidance of that possibility is likely protective for the majority of family members whose loved ones return home safely.

Human Remains Identification, Grief, and Posttraumatic Stress in Bereaved Family Members 14 Years After the September 11, 2001, Terrorist Attacks.

Returning human remains to family members after a loved one's death is thought to support grief adaptation. However, no known research has examined the effects that notifications of fragmented remains have on bereaved family members. We examined the number of notifications received, continuing questions about the death, grief severity, and posttraumatic stress (PTS) in family members bereaved by the September 11, 2001 attacks (N = 454). One notification was associated with fewer continuing questions compared to zero notifications, p = .037, or two or more notifications, p = .009. A model using notifications and continuing questions to predict grief severity showed there was no difference between receiving one and zero notifications, p = .244; however, receipt of two or more notifications was associated with higher grief severity compared to zero notifications, p = .032. A similar model demonstrated that receipt of any notifications was associated with PTS, ɳp 2 = .026, p = .006. Having continuing questions was associated with grief severity, ɳp 2 = .170, p < .001; and PTS, ɳp 2 = .086, p < .001. Additionally, participants who received one notification and chose not to receive more had fewer continuing questions compared to all other participants, and participants who received two or more notifications and chose no future notifications had higher PTS levels compared to all other participants. The results indicate that human remains notification is not associated with reduced grief severity but is associated with PTS. These findings should inform notification policy and guide families' notification choice after traumatic deaths.

Effect of comorbid anxiety and depression in complicated grief on perceived cognitive failures.

BACKGROUND: Bereavement is associated with cognitive difficulties, but it is unclear whether these difficulties are associated with normative and/or complicated grief (CG) and how comorbid depression and anxiety contribute to them. Self-reported "minor errors in thinking" (i.e., cognitive failures) may manifest following bereavement and be differentially affected by CG, anxiety, and depression. METHODS: Associations between perceived cognitive failures and CG, anxiety, and depression were investigated in 581 bereaved participants. To examine both single and comorbid conditions across the spectrum of bereaved participants, these relationships were examined using both linear regressions and group comparisons. RESULTS: Continuous measures of depression, anxiety, and grief each independently predicted perceived cognitive failures. Group comparisons indicated that the group with three comorbid conditions had the highest frequency of perceived cognitive failures and the group with no conditions had the lowest. In addition, groups with threshold depression levels (both alone and comorbid with another condition) had higher frequencies of perceived cognitive failures than other groups, suggesting that depression was more strongly associated with perceived cognitive failures than CG or anxiety. CONCLUSIONS: Future research about cognition following bereavement should address how multiple mental health symptoms or conditions combine to affect perceived and actual cognitive capacity.

Optimizing the clinical utility of four proposed criteria for a persistent and impairing grief disorder by emphasizing core, rather than associated symptoms.

BACKGROUND: Distinguishing a disorder of persistent and impairing grief from normative grief allows clinicians to identify this often undetected and disabling condition. As four diagnostic criteria sets for a grief disorder have been proposed, their similarities and differences need to be elucidated. METHODS: Participants were family members bereaved by US military service death (N = 1732). We conducted analyses to assess the accuracy of each criteria set in identifying threshold cases (participants who endorsed baseline Inventory of Complicated Grief ⩾30 and Work and Social Adjustment Scale ⩾20) and excluding those below this threshold. We also calculated agreement among criteria sets by varying numbers of required associated symptoms. RESULTS: All four criteria sets accurately excluded participants below our identified clinical threshold (i.e. correctly excluding 86-96% of those subthreshold), but they varied in identification of threshold cases (i.e. correctly identifying 47-82%). When the number of associated symptoms was held constant, criteria sets performed similarly. Accurate case identification was optimized when one or two associated symptoms were required. When employing optimized symptom numbers, pairwise agreements among criteria became correspondingly 'very good' (κ = 0.86-0.96). CONCLUSIONS: The four proposed criteria sets describe a similar condition of persistent and impairing grief, but differ primarily in criteria restrictiveness. Diagnostic guidance for prolonged grief disorder in International Classification of Diseases, 11th Edition (ICD-11) functions well, whereas the criteria put forth in Section III of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are unnecessarily restrictive.

Mental health conditions in bereaved military service widows: A prospective, case-controlled, and longitudinal study.

BACKGROUND/OBJECTIVES: Bereavement is associated with increases in prevalence of mental health conditions and in healthcare utilization. Due to younger age and bereavement by sudden and violent deaths, military widows may be vulnerable to poor outcomes. No systematic research has examined these effects. METHOD: Using outpatient medical records from wives of active-duty military service members (SMs), we compared the prevalence of mental health conditions and mental healthcare visits among case widows (n = 1,375) to matched (on age, baseline healthcare utilization, SM deployment, and rank) nonbereaved control military wives (n = 1,375), from 1 year prior (Yr-1) to 2 years following (Yr+1 and Yr+2) SM death. Prevalence risk ratios and confidence intervals were compared to determine prevalence rates of mental health conditions and outpatient mental healthcare visits over time. RESULTS: The prevalence of any mental health condition, as well as a distinct loss- and stress-related mental health conditions, significantly increased from Yr-1 to Yr+1 and Yr+2 for cases as did mental healthcare utilization. Widows with persistent disorders (from Yr+1 to Yr+2) exhibited more mental conditions and mental healthcare utilization than widows whose conditions remitted. CONCLUSION: Bereavement among military widows was associated with a two- to fivefold increase in the prevalence of depression, posttraumatic stress disorder, and adjustment disorder postdeath, as well as an increase in mental healthcare utilization. An increase in the prevalence of loss- and stress-related conditions beyond 1 year after death indicates persistent loss-related morbidity. Findings indicate the need for access to healthcare services that can properly identify and treat these loss-related conditions.

Extreme-groups designs in studies of dimensional phenomena: Advantages, caveats, and recommendations.

Extreme-groups designs (EGDs) are common in psychopathology research, often using diagnostic category as an independent variable. Continuous-variable analysis strategies drawing from a general linear model framework can be applied to such designs. The growing emphasis on dimensional examinations of psychological constructs, encouraged by the National Institute of Mental Health Research Domain Criteria framework, encourages continuous-variable analytic strategies. However, the interpretative implications of applying these strategies to various types of populations and sample score distributions, including those used in EGDs, are not always recognized. Appropriateness and utility of EGDs depend in part on whether the goal is to determine whether a relationship exists between 2 variables or to determine its strength. Whereas the literature investigating EGDs has emphasized symmetrical thresholds for defining extreme groups (e.g., bottom 10% vs. top 10%), psychopathologists often employ asymmetric thresholds (e.g., above a diagnostic threshold vs. a broader range of scores in a healthy comparison group). The present article selectively reviews literature on EGDs and extends it with simulations of symmetric and asymmetric selection criteria. Results indicate that including a wide range of scores in EGDs substantially mitigates problems (e.g., inflation of effect size) that arise when using statistical methods classically employed for continuous variables. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Patterns of Comorbidity Among Bereaved Family Members 14 Years after the September 11th, 2001, Terrorist Attacks.

Studies of terrorism-related deaths are few and mostly focus on short-term effects. To characterize long-term bereavement outcomes, including resilience/recovery and patterns of comorbidity, following the September 11, 2001 (9/11), terrorist attacks, we report mental health conditions and grief-related impairment in 454 9/11 bereaved family members. In addition, the contribution of non-9/11 lifetime traumas, pre-9/11 mental health conditions, post-9/11 interim life events, grief services, income adequacy, and social support were examined. Latent class analyses yielded three groups: healthy, comorbid without PTSD (comorbid/noPTSD), and comorbid with PTSD and impaired (comorbid/PTSD+I). Participants in the healthy group (66.1%) were least likely to meet thresholds for mental conditions, whereas those in the comorbid/noPTSD (21.3%) and comorbid/PTSD+I (12.6%) groups had higher probabilities of meeting depression, grief, and anxiety thresholds. These groups also endorsed more negatively valenced post-9/11 interim life events than the healthy group: comorbid/noPTSD vs. healthy, odds ratio (OR) = 0.84, 95% CI [0.76, 0.94]; comorbid/PTSD+I vs. healthy, OR = 0.85, 95% CI [0.76, 0.96]. Comorbid/PTSD+I was the only group with elevated probabilities of meeting clinical thresholds for PTSD (.64) and grief-related impairment (.94). This group was also more likely to include bereaved parents: comorbid/PTSD+I vs. healthy, OR = 12.96, 95% CI [1.97, 85.41]; comorbid/PTSD+I vs. comorbid/noPTSD, OR = 15.55, 95% CI [1.63, 148.41]); and to experience more non-9/11 lifetime traumas: comorbid/PTSD+I vs. healthy, OR = 4.34, 95% CI [1.28, 14.70]; comorbid/PTSD+I vs. comorbid/noPTSD, OR = 6.54, 95% CI [1.53, 27.95]. Clinical and community programs should target this high-risk group to identify individuals in need of services.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Los patrones de comorbilidad entre los familiares de los fallecidos catorce años después de los ataques terroristas del 11 de septiembre PATRONES DE COMORBILIDAD ENTRE PERSONAS EN DUELO DEL 9/11 Los estudios sobre las muertes relacionadas con el terrorismo son pocos y se centran principalmente en los efectos a corto plazo. Para caracterizar los efectos del duelo a largo plazo, incluida la resiliencia/recuperación y los patrones de comorbilidad, después de los ataques terroristas del 11 de septiembre de 2001 (9/11), reportamos las condiciones de salud mental y el deterioro relacionado con el duelo en 454 individuos en duelo por familiares fallecidos el 9/11. Además, se examinaron los traumas a lo largo de la vida que no se relacionan con el 9/11, las condiciones de salud mental anteriores al 9/11, los eventos vitales posteriores al 9/11, las atenciones por duelo, la suficiencia de ingresos, y el apoyo social. Los análisis de clases latentes dieron tres grupos: sano, comórbido sin TEPT(comórbido/noTEPT), y comórbido con TEPT y deterioro (comórbido/TEPT+I). Los participantes en el grupo sano (66.1%) tenían menos probabilidades de alcanzar los umbrales para las condiciones mentales, mientras que los grupos comórbido/noTEPT (21.3%) y comórbido/TEPT+I (12.6%) tenían mayores probabilidades de alcanzar umbrales de depresión, duelo, y ansiedad. Estos grupos también acreditaron eventos de vida post-9/11 con una valencia más negativa que el grupo sano: Comórbido/noTEPT vs. sano, razón de probabilidades (OR) = 0.84, IC del 95% [0.76, 0.94]; comórbido/TEPT+I vs. sano, OR = 0,85, IC del 95% [0,76, 0,96]. Comórbido+TEPT/I fue el único grupo con probabilidades elevadas de alcanzar umbrales clínicos para el TEPT (.64) y el deterioro relacionado con el duelo (.94). También fue más probable que este grupo incluyera padres con duelo: Comórbido+TEPT/I vs. sano, OR = 12.96, IC del 95% [1.97, 85.41]; comórbido/TEPT+I vs. comórbido/noTEPT, OR = 15.55, IC del 95% [1.63, 148.41]); y experimentar más traumas a lo largo de la vida no relacionados al 9/11: Comórbido/TEPT+ I vs. sano, OR = 4.34, IC del 95% [1.28, 14.70]; comórbido/TEPT+I vs. comórbido/noTEPT, OR = 6.54, IC del 95% [1.53, 27.95]. Los programas clínicos y comunitarios deben dirigirse a este grupo de alto riesgo para identificar a las personas que necesitan atención.

Associations Between Family Risk Factors and Child Neglect Types in U.S. Army Communities.

Recent theory and empirical research suggest that child neglect is a heterogeneous phenomenon characterized by various types. This study examined family risk factors associated with five neglect types including failure to provide physical needs, lack of supervision, emotional neglect, moral-legal neglect, and educational neglect in 390 substantiated cases of neglect in four U.S. Army communities. Family factors associated with elevated risk of each neglect type relative to other types were identified using multivariate regression. Relatively distinct sets of family risk factors were differentially associated with the neglect types. Family mental health problems and larger family size were associated with risk of failure to provide physical needs, childcare problems and larger family size were associated with risk of supervisory neglect, and family disagreements were associated with risk of emotional neglect. None of the family factors were associated with elevated risk of moral-legal or educational neglect. Results can inform the development of indicated and relapse prevention strategies for families affected by different neglect types.

Deployment Status and Child Neglect Types in the U.S. Army.

Increases in combat deployments have been associated with rises in rates of child neglect in U.S. military families. Although various types of child neglect have been described in military families, it is unknown whether deployment status is associated with specific types of child neglect and whether other factors, such as substance misuse, play a role. To determine the contribution of service member deployment status to the risk of specific child neglect types, data were collected from 390 substantiated U.S. Army child neglect case files. The contributions of deployment status at the time of the neglect incident and parental alcohol or drug-related misuse to risk of neglect types were examined controlling for military family rank and child age. Compared to never deployed families, families with a service member concurrently deployed at the time of the neglect incident were at higher risk for failure to provide physical needs, lack of supervision, and educational neglect, but at lower risk for emotional neglect. Being previously deployed incurred risk for moral-legal neglect. Substance misuse added risk for moral-legal and educational neglect. Findings indicate the need for tailored prevention strategies to target different periods within the deployment cycle.

Examination of factor structure of the inventory of complicated grief (ICG) in a sample of bereaved military family members with persistent and elevated grief.

Knowledge about the effect of a US service member's death on surviving family members is limited. In order to identify their grief-related health care needs, a first step is to identify the characteristics of persistent and elevated grief in a military family sample. The present study identified military family members (n = 232) bereaved more than six months who endorsed an elevated level of grief. A confirmatory factor analysis and test of measurement invariance of factor structure were used to compare the factor structure of their Inventory of Complicated Grief (ICG) responses to that of a bereaved non-military-related clinical research sample with similar grief levels. Results confirmed an equivalent five-factor structure of the ICG in both the military family sample and the clinical research sample. The similarity in factor structure was present despite differences in demographic characteristics and bereavement experiences between samples. Thus, the ICG reliably measures persistent and elevated grief in military family samples and provides grief symptom profiles that facilitates better understanding of their grief-related needs.

Bereaved Military Dependent Spouses and Children: Those Left Behind in a Decade of War (2001-2011).

BACKGROUND: U.S. military service members die from a variety of causes (i.e., accidents, combat, illnesses, homicide, suicide, and terrorism) while on duty and in greater numbers during times of war, leaving behind bereaved dependent family members. Identifying characteristics of these dependent families improves our understanding of their unique needs, helps educate service providers who offer assistance to these surviving family members, and better informs policy addressing their health and well-being. This study describes deceased U.S. military service members (DSMs) who died on active duty between September 11, 2001 and September 11, 2011 and their surviving dependent spouses and children. METHODS: Characteristics of DSMs (service branch, rank, and cause of death) and characteristics of spouse-with-children and spouse-only families (ages of dependents, time since loss, and distance from a military installation) were examined. RESULTS: 15,938 DSMs died from a variety of causes (e.g., accidents, combat, and illnesses). 55% of DSMs had dependent spouses and 56% of those spouses had children. Most surviving dependent spouses and children were young (mean ages = 32.8, 10.3 years; SD = 9.3, 7.3 years, respectively) at the time of DSM death. Many of these young dependents were related to a DSM who experienced a sudden and violent death. 60% of spouse-with-children families and 58% of spouse-only families lived farther than 60 miles from a military installation. Time since loss (range = 1.3-11.3 years) did not predict distance to installation. CONCLUSIONS: Findings characterize surviving spouses and their children, suggest potential risk for problematic grief outcomes, and underscore the importance of educating service providers about how to support military survivor family health and resilience.

Characteristics, Classification, and Prevention of Child Maltreatment Fatalities.

BACKGROUND: Preventing child maltreatment fatalities is a critical goal of the U.S. society and the military services. Fatality review boards further this goal through the analysis of circumstances of child deaths, making recommendations for improvements in practices and policies, and promoting increased cooperation among the many systems that serve families. The purpose of this article is to review types of child maltreatment death, proposed classification models, risk and protective factors, and prevention strategies. METHODS: This review is based on scientific and medical literature, national reports and surveys, and reports of fatality review boards. FINDINGS: Children can be killed soon after birth or when older through a variety of circumstances, such as with the suicide of the perpetrator, or when the perpetrator kills the entire family. Death through child neglect may be the most difficult type of maltreatment death to identify as neglect can be a matter of opinion or societal convention. These deaths can occur as a result of infant abandonment, starvation, medical neglect, drowning, home fires, being left alone in cars, and firearms. Models of classification for child maltreatment deaths can permit definition and understanding of child fatalities by providing reference points that facilitate research and enhance clinical prediction. Two separate approaches have been proposed: the motives of the perpetrator and the circumstances of death of the child victim. The latter approach is broader and is founded on an ecological model focused on the nature and circumstances of death, child victim characteristics, perpetrator characteristics, family and environmental circumstances, and service provision and need. Many risk factors for maternal and paternal filicide have been found, but most often included are young maternal age, no prenatal care, low education level, mental health problems, family violence, and substance abuse. Many protective factors can be specified at the individual, family, and community level. Early interventions for children and families are facilitated by the increased awareness of service providers who understand the risk and protective factors for intentional and unintentional child death. DISCUSSION/IMPACT/RECOMMENDATIONS: There is currently no roadmap for the prevention of child maltreatment death, but increased awareness and improved fatality review are essential to improving policies and practices. Prevention strategies include improving fatality review recommendations, using psychological autopsies, serious case reviews, and conducting research. We recommend a public health approach to prevention, which includes a high level of collaboration between agencies, particularly between the military and civilian. The adoption of a public health model can promote better prevention strategies at individual, family, community, and societal levels to address and improve practices, policies, and public attitudes and beliefs about child maltreatment. The process of making recommendations on the basis of fatality review is important in terms of whether they will be taken seriously. Recommendations that are too numerous, impractical, expensive, lack relevance, and are out of step with social norms are unlikely to be implemented. They can be helpful if they are limited, focused, lead to definitive action, and include ways of measuring compliance.