Stephen Cozza

Uniformed Services University of the Health Sciences | USUHS · Center for the Study of Traumatic Stress, Department of Psychiatry

Objective: The purpose of this article was to examine the accuracy of DSM-5 proposed criteria for persistent complex bereavement disorder in identifying putative cases of clinically impairing grief and in excluding nonclinical cases. Performance of criteria sets for prolonged grief disorder and complicated grief were similarly assessed. Method:...

In this issue of The Future of Children, we seek to integrate existing knowledge about the children and families of today's United States military; to identify what we know (and don't know) about their strengths and the challenges they face, as well as the programs that serve them; to specify directions for future research; and to illuminate the ev...

Since 2001, more than two million military service men and women have deployed to combat operations in Iraq and Afghanistan. They come from every military service branch, hail from every state in the country, and represent the active duty, National Guard, and Reserve components of the military. These service members are from the Army, Navy, Air For...

This study examined rates, predictors, and course of probable posttraumatic stress disorder (PTSD) and depression among seriously injured soldiers during and following hospitalization. The patients were 613 U.S. soldiers hospitalized following serious combat injury. Standardized screening instruments were administered 1, 4, and 7 months following i...

We conducted a systematic review of the medical, nursing, forensic, and social science literature describing events and processes associated with what happens after a traumatic death in the socio-cultural context of largely Western and high-income societies. These include death notification, why survivors choose to view or not view the body, forens...

LAY SUMMARY Creative arts therapists (art therapists, dance/movement therapists, and music therapists) administer assessments and interventions that support the holistic well-being of military families affected by traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). Through participation in the Creative Forces: United States Nati...

SOMMAIRE NON SCIENTIFIQUE Les thérapeutes en psychothérapie de créativité (art-thérapeutes, thérapeutes par la danse/le mouvement, musicothérapeutes) évaluent et interviennent pour favoriser le bien-être global des familles militaires touchées par un traumatisme crânien (TC) et le trouble de stress post-traumatique (TSPT). Avec une participation à...

Objective: Attachment style and social support networks (SSN) are associated with suicide ideation (SI) and suicide attempt (SA). How these two factors interact is important to understanding the mechanisms of risk for suicidal behaviors and identifying interventions. Method: Using the Army Study to Assess Risk and Resilience in Servicemembers Ne...

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 surviva...

Objective: In this report, we tested ChatGPT's ability to think abstractly and to integrate information about two seemingly disparate topics by requesting a well-articulated, intellectually stimulating essay in response to a complex and somewhat paradoxical task. Method: We asked ChatGPT to write a satirical essay comparing SpongeBob Squarepants to...

Military families have been affected by combat-related injuries, both visible (e.g., musculoskeletal injuries, amputations, burns) and invisible (e.g., posttraumatic stress disorder [PTSD], traumatic brain injury [TBI]), as well as combat-related bereavement. These profound stressors typically include short-term and long-term challenges that affect...

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 exp...

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 pos...

Objective: Among U.S. Army soldiers suicide attempts (SAs) are a significant public health concern, particularly early in service. We examined the association of attachment style with SA and suicide ideation (SI) among U.S. Army soldiers. Methods: We analyzed survey data from new soldiers who participated in the Army Study to Assess Risk and Res...

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 bereav...

For a limited time, full text of this article is available at: https://authors.elsevier.com/a/1epe89UUG-vl9H The DOI for published article: https://doi.org/10.1016/j.jaclp.2022.02.007

Background Bereavement has been associated with increases in immune/inflammatory and neuroendocrine reactions, cardiovascular events, non-specific physical symptoms, mental conditions, and healthcare utilization. However, little is known about bereavement effects in younger samples, multiple health effects within samples, or health changes from pre...

Exposure to war causes a wide range of harmful mental health effects. Those working with refugees and people directly impacted in Ukraine can protect mental health by using the following evidence-based actions and other resources. Resources include: (1) Rapid Psychological First Aid: Help for You, Family, and Friends (2) Helping Others Calm an Ac...

LAY SUMMARY Creative arts therapists (art therapists, dance/movement therapists, and music therapists) administer assessments and interventions that support the holistic well-being of military families affected by traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). Through participation in the Creative Forces: United States Natio...

Increasing rates of posttraumatic stress disorder (PTSD) in military populations during recent conflicts have sparked concerns regarding the incidence of other commonly associated problems, such as intimate partner violence (IPV). From a clinical perspective, it is important to understand patterns of PTSD symptomology that may indicate heightened r...

Objective Suicide and suicide attempts among U.S. Army soldiers are a significant concern for public health. This study examined the association of parental suicide attempt prior to age 13 of the soldier with subsequent risk of pre-enlistment suicide attempt. Method We conducted secondary analyses of survey data from new soldiers who participated...

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 posttrau...

The United States has been continuously at war for nearly 2 decades, during which time some 2.7 million Americans have answered the call to arms. Such prolonged conflict is unprecedented in US history. Also unprecedented is the number of service members of the National Guard and military Reserve forces who have left their families to deploy to the...

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 conside...

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,...

Human Remains, Grief, and Posttraumatic Stress in Bereaved Family Members Fourteen Years after September 11, 2001, a forthcoming manuscript in the Journal of Traumatic Stress describes the mental health effects on 9/11-bereaved family members after being notified (often multiple times) that remains of their loved ones were identified. Although retu...

Infectious disease outbreaks, such as the novel Coronavirus (nCoV) increase fear and uncertainty. Knowing how to care for yourself and your family can reduce distress and allow people to function more effectively. These educational fact sheets provide information and recommendations for healthcare personnel, families, businesses, and communities on...

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 thro...

The death of a loved one is one of life's greatest stressors. Most bereaved individuals experience a period of acute grief that diminishes in intensity as they adapt to the changes brought about by their loss. Over the past four decades, a growing body of research has focused on a form of prolonged grief that is painful and impairing. There is a su...

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 differe...

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 poorer outcomes. No systematic research has examined these effects. Method: Using outpatient medical records...

Objectives This presentation will inform attendees about the effects of a range of adversities faced by military families and foster strategies to promote well-being in affected children. Methods This research Symposium will include 4 data-driven presentations by clinician/scientists (Ellen DeVoe, LICSW, PhD; Stephen Cozza, MD; Elizabeth Hisle-Gor...

Objectives The goal of this session is to examine longitudinal changes in the prevalence rates of mental health conditions, physical injuries, and outpatient health care visits among children of deceased active duty male service members compared with their nonbereaved peers. Methods Rates of mental health conditions, physical injuries, and outpati...

Objectives The goal of this session is to characterize the types of child neglect and their associated risk factors within the US Army community to inform effective prevention, policy, and strategy. Methods A record review of 400 randomly sampled substantiated neglect cases from 4 Army installations with the highest number of substantiated cases f...

Witnessing the terror attacks on September 11, 2001 affected practically all of us who were alive at that time. But, for some, 9/11 was a far more personal and tragic experience. On September 11, 2001, nearly 3,000 families lost a loved one who perished at the World Trade Center, at the Pentagon or in Shanksville, PA. Although nearly 18 years have...

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...

The dead affect us in many ways – in our grief and despair, by evoking memories from the past or visiting us in our dreams, in the ways we pay tribute and memorialize the deceased, or through the hope and promise of reuniting with our loved ones following our own deaths. Death impacts us most viscerally in the material form of the human corpse. In...

There are special considerations when treating depression in the children of military families, due to both unique stressors and unique access to treatment and support resources. This article provides a brief overview of the history of military family care, an understanding of ongoing efforts to provide excellent and timely care for these children,...

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 bereave...

Military service deaths result from a variety of causes but most are sudden and violent. Bereaved military family members appear to share similar outcomes to civilians who are faced with sudden and violent deaths, and a small but significant number of military family survivors suffer with persistent and impairing grief. Bereaved military families r...

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 substantiate...

Background The World Health Organization (WHO) International Classification of Disease (ICD-11) is expected to include a new diagnosis for prolonged grief disorder (ICD-11 PGD ). This study examines the validity and clinical utility of the ICD-11 PGD guideline by testing its performance in a well-characterized clinical sample and contrasting it wit...

When the US military began combat operations in Iraq and Afghanistan in 2002, little was known about how military children and families would be affected by combat-related service in an era of prolonged war. The ability of clinicians, policymakers, community service providers, commanders, and researchers to meet the needs of military children was l...

Those who serve in the military represent a distinct cultural group whose perceptions of illness and treatment are often influenced by factors specific to military service. This chapter explores the unique influences military service can have on care. These cultural and subcultural influences come from groups including active duty members from a va...

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...

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...

This study examined the relationship of on- and off-post resources to perceived residential neighborhood quality in 432 soldiers and their spouses from the four largest U.S. Army installations. Participants completed a questionnaire that measured one important element of perceived neighborhood quality (social cohesion/interrelatedness) and the exte...

Covering both natural and man-made scenarios including war and terrorism, the Textbook of Disaster Psychiatry is a vital international reference for medical professionals, community leaders and disaster responders a decade after its initial publication. Spanning a decade of advances in disaster psychiatry, this new and updated second edition brings...

Are complicated grief criteria better for diagnosing grief disorder than prolonged grief disorder criteria?—Yes.

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 n...

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 ser...

TO THE EDITOR: Smid and Boelen rightfully highlight the importance of identifying standards for diagnosing clinically impairing grief. This issue has been of clinical interest within the United States and internationally, leading to the proposed DSM-5 persistent complex bereavement disorder criteria, as well as newly defined ICD-11 criteria for a s...

Childhood Adversity, Trauma and Psychiatric Disorders: Developmental Outcomes and Effective Interventions Stephen J. Cozza, M.D. Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, stephen.cozza@usuhs.edu Objective: To review articles chosen by the Work Group on Lifelong Learning addressing current co...

Military children and families possess many strengths and generally enjoy health, wellness, and a capacity for resilience. However, they have also faced unprecedented war-related challenges since 2001, including combat-related parental injury, illness, and death. This chapter describes the distress faced by military children and families due to the...

Military combat operations result in a number of outcomes that can adversely impact families and children (Cozza, Chun, & Polo, 2005). Of these, post-traumatic stress disorder (PTSD) has been reported in 15 to 20% of combat exposed military service members (Hoge, et al., 2004; RAND Center for Military Health Policy Research, 2008). PTSD is known to...

Background: Neglect has been linked to short-term and long-term deleterious outcomes in children, but has received little attention in the research literature. Objective: Identify types, subtypes, and severity of child neglect in a sample of substantiated cases at 4 U.S. Army installations. Describe demographic correlates of victims and offender...

-Understanding features of community strength both on and off the military installation will help identify and address the needs of military families. This study introduced a measure to identify adequacy of community resources for military families. Using confirmatory factor analysis with data from 717 service users (M age = 37.3 yr., SD = 10.6) re...

Since 2001, the United States has seen the largest sustained deployment of military service members in the history of the all-volunteer force. More than 2 million military children have been separated from service member parents because of combat deployments. Most families have experienced at least 1 deployment, and many have undergone multiple, in...

Military children are our nation’s children and military families are our nation’s families. They serve courageously and their commitment and sense of duty is comparable to their military service family members’, worthy of national interest, and most worthy of national commitment, support, and sustainment.

This Social Policy Report summarizes what is currently known about our nation's military children and families and presents ideas and proposals pertinent to the formulation of new programs and the policies that would create and sustain these initiatives. We emphasize the need for future rigorous developmental research about military children and fa...

Background Self-directed multimedia resources that provide psycho-educational information to selected populations have been supported in child health related areas including parenting skills in adults and literacy in children. Comparable programs for use with bereaved children and families have not been adequately developed or empirically examined....

When a service member is injured or dies in a combat zone, the consequences for his or her family can be profound and long-lasting. Visible, physical battlefield injuries often require families to adapt to long and stressful rounds of treatment and rehabilitation, and they can leave the service member with permanent disabilities that mean new roles...

In this issue of The Future of Children, we seek to integrate existing knowledge about the children and families of today’s United States military; to identify what we know (and don’t know) about their strengths and the challenges they face, as well as the programs that serve them; to specify directions for future research; and to illuminate the ev...

The US military community includes a population 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...

To date, the US military has made major strides in acknowledging and therapeutically addressing trauma and post-traumatic stress disorder (PTSD) in service members and their families. However, given the nature of warfare and high rates of losses sustained by both military members (e.g., deaths of fellow unit members) and military families (e.g., lo...

Although current research recognizes robust interdependence among family members, it is not yet evident that such principles have fully integrated into existing systems of care for military and veteran families. Such gaps can create disadvantages in delivering effective support, prevention, and treatment, while including families may yield signific...

Deployment and its possible consequences, including a service member's injury, psychological trauma, or death, put considerable strain on military children and families. Most of them are resilient in the face of this adversity. Still, the psychological distress they experience can reverberate through the family, impairing the healthy functioning of...

This study examined potential changes in perceptions of therapeutic ("working") alliance during a child's initial diagnostic interview from the parent's perspective. The major study objective was to determine whether parental perceptions of alliance vary by group (video teleconferencing [VTC], face-to-face [FTF]) over time (Pre, Post intake). It wa...

Military families include 2.9 million people, with approximately 40% of all service members having at least one child. Rates of child neglect in this population have increased in recent years, but little is known about the characteristics of the neglect. To better identify targets for intervention, it is necessary that we refine our understanding o...

It was once said that if the military wanted service members to have spouses and children, they would have been issued to them. This attitude reflected a different era, a time when the force was largely made up of young men who were drafted into military service and when commanders were required to give permission to junior enlisted members to marr...

Although most mental health clinicians receive some training in child and adolescent mental health, few have a clear understanding of the needs of children in the unique circumstances that accompany the combat exposure and deployment experiences of military parents. Children are often the unseen and unheard individuals in the family, and their emot...

Combat injury can profoundly affect the children and families of service members. The range of experiences for these families varies depending the specific injury type, severity, and recovery trajectory; composition of the family; developmental age of the children; preexisting parent, child, or family characteristics; as well as the longer-term fun...