1 They Also Serve: U.S. military children and our wars of the 21 st Century Gregory Toussaint, MD Wright State University Boonshoft School of Medicine.

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They Also Serve:They Also Serve:U.S. military children andU.S. military children and

our wars of the 21our wars of the 21stst Century Century

Gregory Toussaint, MDGregory Toussaint, MDWright State University Wright State University

Boonshoft School of MedicineBoonshoft School of Medicine

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Overview - children and deployment

• Scope of this issue

• Early research: Desert Storm / Gulf War 1

• The “under-5s”

• School age

• Uncomfortable issues: child and parent

• Making it real: personal vignettes

• Where is the help? What can I do?

• First, some questions…

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U.S. military today

• Terminology Active duty – 4 branches and Coast Guard Reserves – all 5 branches National Guard – Army, Air Force Mobilized – activated Reserves, Nat’l Guard

• “Deployed”

• CENTCOM OEF: Afghanistan, central Asia OIF: Iraq, Arabian peninsula Horn of Africa

www.globalsecurity.org

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U.S. military today

Personnel End Strength – FY05

FY2005 Active Mobilized Guard Reserve Civilian TOTAL

TOTAL 1,421,414 77,861 464,900 379,600 752,000 3,017,414

DOD ----- ----- ----- ----- 126,000 126,000

Army 562,400 48,331 358,200 205,000 250,000 1,375,600

Navy 324,239 10,818 ----- 65,500 199,000 588,239

Marines 203,075 2,261 ----- 39,600 ----- 242,675

Air Force 331,700 16,451 106,700 69,500 177,000 684,900

www.globalsecurity.org

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Scope of the issue

• Since 2001: > 2 million service men/women have deployed 793k have deployed more than once; many 3-4

tours Length of tours vary by service, what you do

“Ops tempo” a critical part of family life

• Active duty service members 1.2 million ‘dependents’ < 23 yrs of age 40% < 5 yrs of age

• Reservists / Nat’l Guard 660,000 dependents 20% < 5 yrs of age

JAMA 2008, 300:644

J Am Acad Child Psych 2010, 4:297

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Women in the US militaryWomen in the US military

US military Number Percent of total

Total Active Duty and Reserves 342,000 14.3% of active duty force

Deployed to Iraq or Afghanistan since 2001

165,683 48.4% of all military women

Women of minority in the military

White African-American Hispanic Asian, other

All active duty 64% 15% 15% 6%

AD women 50% 30% 6% 5%

Civilian women 70% 13% 12% 5%

US Congress Joint Economic Committee Report, May 2007

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Military moms (active duty)

• 38% all active duty women have children 44% of men

• 11% all active duty women are single parents 4% single fathers

• Higher attrition rate than men 2002 GAO report: 1/3 left due to child care

concerns

• New mothers: 6 weeks maternity leave Additional time off uses earned leave (vacation

time) If on deployment status : 4-to-6 month deferment

US Congress Joint Economic Committee Report, May 2007

What happens during ‘deployment’?

• Pre-deployment Notification of orders to go Accomplish training needed, get “spun up” Clock ticking, but for how long?

• Deployment / sustainment A send off, then time “in theater” The waiting. And waiting

• Re-deployment Reintegration into family unit

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What else happens?

• Pre-deployment Stress. On parent(s), spill-over to child Fear. Age-related understanding of what’s

coming

• Deployment Impact of parent’s absence takes effect Families adapt, or not, to range of feelings

• Reunification First reunion. Rebuild relationships, boundaries Parent back to work. Reserve/Guard may

deactivate9

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New issues for military children

• Striking number of affected children More ‘dependents’ now than military personnel Almost 40% personnel are activated Reserve, Guard

• How can combat deployments affect children? Longest sustained conflict, repeated tours

Sustained operations tempo taking a toll Army tours longer; Air Force shorter + more

frequent numbers of parents w/ physical, mental health

effects Communication technology unprecedented

Home front is on the front lines and vice versaAmbul Peds 2007, 7:1

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Early research

• 1990-1991 Desert Shield --- Desert Storm --- Gulf War 1 Air war start Jan 91, short ground campaign

followed ~ 580,000 U.S. troops in-theater

(almost 30,000 hospital beds) First 24-hour news coverage, children exposed more Relatively brief period conflict, small number

casualties Short deployments without recurrence

• 1992-1993 Operation Restore Hope (Somalia)

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Early research

• Smaller studies, limited scope Increases noted in internalizing, externalizing

symptoms Internalizing = emotional lability, anxious, depressed Externalizing = attention difficulties, aggression

Children rarely required clinical attention

• One, a pre-Desert Storm study, did f/u work Increased levels of anxiety, depression Did not reach pathologic levels, resolved quickly Boys, younger children at higher risk

Mil Med 1993, 158:465

J Am Acad Child Psych 1996, 35:433

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The “under 5”s

• Remember the math? 40% active duty, 20% Reserve/Guard Total ~ 620,000 dependent children < 5 yrs age

• Time of critical developmental periods Two studies focus on behaviors Two on utilization of health care

• Concerns: Evidence suggests young not spared Huge size of group warrants closer look

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Developmental issues

• Cross-sectional study, large Marine base Arch Ped Adol Med 2008, 162:1009 Chartrand M et al.

• On-base child care centers, children 1.5-5 yrs May-Dec 2007, 169 families Child Behavior Checklist, two parental stress measures CBCL-Teacher Report form for centers’ staff

• Results Controlled for parental stress, depressive symptoms Highest behavior issues: 3-5 yr olds w/ parent gone 1.5-3 yrs age had signif lower externalizing symptoms Note: one base, organized care, short (3.9 mos) tours

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More observed behaviors

• Study of 57 Army families (Ft Knox, KY) Mil Med 2009, 174:1033 Barker L et al

Married, > 1 child 0-47 months No-, single-, and multiple-deployment groups

• Parent-reported on “observed behaviors” Not a normed assessment tool Needs attention, clingy, tantrums Prefers non-

deployed

• Results: “Children in deployment grp had parent gone > ½

life” 2/3 reported transient attachment behaviors on

reunion

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Utilization of health care?

• Study of 2007 DoD claims data (direct + Tricare) Pediatrics 2010, 126:1 Eide M et al

• Linked care visit data to parental deployment 169k+ children with 1.77M outpatient visits Well child visits = 27% Overall visits 7%, well child visits 8% ** if had young, single military parent = fewer visits ** children of married parents seen more frequently

• Conclusions Could caretakers for single parents not access care? Increased use a marker for stress?

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Utilization of mental health services• Same people, databases (direct + Tricare)

Pediatrics 2010, 126:1058 GormanG et al

• Focused on mental / behavioral health visits > 642k kids ages 3-8 yrs. > 442k active duty

parents Analyzed claims for > 611k visits

Mental health visits Mental health visits 11% when parent deployed 11% when parent deployed Behavioral disorders Behavioral disorders 19% 19% Stress disorders Stress disorders 18% 18%

Larger increases seen if: Older children, parents married, father military Older children, parents married, father military

oneone

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What about school age?

• Greater numbers total than “under 5”s

• Military children generally robust, healthy group

• Three principal areas of wartime stress Deployment of military parents Injury or illness of parents Parental death

Psych Quart 2005, 76:371

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Deployment + school age children

• Survey of parents w/ child 5-12 yrs old J Dev Behav Ped 2009, 30:271 Flake E, Davis BE, et al

Pediatric Symptom Checklist, Parenting Stress-Index form

1/3 families at “high risk” for psychosocial problems Most significant predictor = degree of parenting stress

• 171 families from Army post, Marine base J Am Acad Child Adol Psych 2010, 49:310 Lester P et al

Active duty parent deployed > once, ave 16.7 months 40% of AD parents showed signif signs distress Problems: girls more during, boys after deployment

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School age children

• Study population military children at camp Pediatrics 2010, 125:16 Chandra A et al

Phone interviews w/ 1507 children (11-17 yrs), caregivers Controlled for family, service member characteristics

• Results Children had more emotional difficulties than US norms Older youth had greater # problems during deployment Girls had more problems during reintegration Caregivers mental health correlated w/ child well-being Greater total time away = increased stressors

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Perspectives of school staff

• Qualitative study at 12 schools around U.S. J Adol Health 2010, 46:218 Chandra A et al

• Focus groups or interviews of school staff Teachers, counselors, administrators 3 schools on post, rest with 30-70% military students

• Results: Personnel see deployments affecting ability to

function Students are losing resiliency as deployments

continue Schools are becoming the stable place or sanctuary

Students’ stress also wearing on staff

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Other issues: child maltreatment

• Clear evidence for profound emotional impact Does it translate into increased maltreatment?

• TX study of child maltreatment rates Am J Epidemiol 2007, 165:1199 Rentz E et al

Jan 2000-Jun 2003 study period All substantiated cases in TX, civilian and military Majority of perpetrators parents Military rates 37% < civilian until Oct 02 Rate after Oct 02 double that prior and 22% > Rate after Oct 02 double that prior and 22% >

civiliancivilian Rates for civilian families remained stable

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Child maltreatment

• Study of 1771 families of Army enlisted JAMA 2007, 298:528 Gibbs D et al

40-month study period Child maltreatment rate

42% higher during combat deployment times Greatest increase in neglect cases Physical, emotional abuse rates much lower Rates for neglect by female civilian parent 4x

• Rates for physical abuse 2x No change in rates by male civilian parent

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Returning parents…

• Injured parents Dramatic increase in numbers of severely wounded Spillover is in number of children w/ disabled parent “No such thing as injured service member. We

should be thinking injured family.”

• Parental suicide Review article from Dept Veterans’ Affairs

Am J Epidemiol 2009, 19:757 Kang H, Bulliman T

Published studies do not prove increased rate in vets

Rates are increasing among active duty personnel

Stephen Cozza, MDUSU Center for Traumatic StressJAMA 2010, 300:644

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And those who didn’t

• Combat + non-hostile deaths as of 31 May 2011:

• Est 12,000 children have had a parent die

• When active duty member dies, families will move Lose on-base housing, may return to hometown New community may not appreciate experiences,

needs

siadapp.dmdc.osd.mil

Total deaths # women

Operation Enduring Freedom 1590 30

Operation Iraqi Freedom /Operation New Dawn (Sep 2010)

4444 110

Totals 6034 140

RAND Corp 2010

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Making it personal

• Vignettes from people I deployed with or know

• What did I learn? Speed of communication has forever changed

things Home events have ripple effect in combat zone Pre-deployment planning yields huge benefits Stability of non-deployed parent (or figure), home

critical If you’ve got it, you can do anything

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Brave new world of communication • Time warp (Mr. Peabody’s Wayback machine)

• Feb 2002 One 10 min phone call per week, full e-mail

• Jan 2003 “Location masked” base, all special ops units No phone/e-mail x 6 wks, no mailing address x 2

months

• Sep 2004 COMSEC rules, full e-mail except…, AT&T phone bank

• May 2011 Official e-mail, phones in quarters, contract internet

service No COMSEC, full internet access including Skype

“Too much” connectivity?

• Physician father (adult type ) deployed for 6 months 3 children – ages 4 + 2 yrs and 6 months (left at 6

wks age)

Well established location, e-mail, phone, internet “Skypes” regularly with family

• Infant develops bad conjunctivitis Mother holds infant up to laptop camera Father…

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Where is the help?

• Early on (2001-2003) – not much Units built their own support structure Deactivated Reserve, Guard often on their own

• Gradual response, now a proactive effort DoD internal efforts

Family support centers, pre / post-deployment events

Enhanced social work, mental health services Military family organizations Academic institutions’ research efforts Private corporations

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Military OneSource

www.militaryonesource.com/

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Sesame Street help! www.sesameworkshop.org

ADM Mullen, then CJCSonline.wsj.com

New in Apr 2010,traveling USO showsStarring Katie!

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Purdue Military Family Research Institute

www.mfri.purdue.edu/

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National Military Family Association

Operation Purple campOperation Purple camp

www.operationpurplecampinfo.com

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What should I remember?

• These children are also “serving” Not just ”base kids” – they’re in all our

communities Stress affects both sides of equation (and ocean) Effects on children vary with developmental stage

U-5s different than school age and teensU-5s different than school age and teens Resources improving for children and families

• Military families are resilient Resilience waning for those called again, again

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What can I do?

• Play the same role you always have Advocate for the child Educate, support family

• Be willing to ask your patients’ families: ““Have you or has anyone you know been Have you or has anyone you know been

involved in the war effort in Iraq or involved in the war effort in Iraq or Afghanistan?”Afghanistan?”