CLINICAL REPORT Health and Mental Health Needs of Children in … · mental health services for active duty service members and their families as well as activated National Guard

CLINICAL REPORT

Health and Mental Health Needs of Children in USMilitary Families

abstractThe wars in Afghanistan and Iraq have been challenging for US uni-formed service families and their children. Almost 60% of US servicemembers have family responsibilities. Approximately 2.3 million activeduty, National Guard, and Reserve service members have beendeployed since the beginning of the wars in Afghanistan and Iraq(2001 and 2003, respectively), and almost half have deployed morethan once, some for up to 18 months’ duration. Up to 2 million USchildren have been exposed to a wartime deployment of a loved onein the past 10 years. Many service members have returned fromcombat deployments with symptoms of posttraumatic stress disorder,depression, anxiety, substance abuse, and traumatic brain injury. Themental health and well-being of spouses, significant others, children(and their friends), and extended family members of deployed servicemembers continues to be significantly challenged by the experiencesof wartime deployment as well as by combat mortality and morbidity.The medical system of the Department of Defense provides health andmental health services for active duty service members and theirfamilies as well as activated National Guard and Reserve servicemembers and their families. In addition to military pediatriciansand civilian pediatricians employed by military treatment facilities,nonmilitary general pediatricians care for >50% of children andfamily members before, during, and after wartime deployments. Thisclinical report is for all pediatricians, both active duty and civilian, toaid in caring for children whose loved ones have been, are, or will bedeployed. Pediatrics 2013;131:e2002–e2015

All Americans are challenged in a world changed by terrorism and war.For the past decade, the wars in Iraq (Operation Iraqi Freedom, Op-eration New Dawn) and Afghanistan (Operation Enduring Freedom)have been especially challenging for US service members and theirfamilies. Recent studies describe the physical and mental health issuesof US service members involved in wartime deployments, including thetoll on American lives.1,2 Approximately 2.3 million active duty, NationalGuard, and Reserve service members have deployed since the be-ginning of the wars (2001, 2003), and over 40% have deployed morethan once, some for up to 18 months’ duration.3 Almost 60% of USservice members have family responsibilities, resulting in 2 million USchildren exposed to at least 1 parental wartime deployment in the

Benjamin S. Siegel, MD, Beth Ellen Davis, MD, MPH, andTHE COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD ANDFAMILY HEALTH AND SECTION ON UNIFORMED SERVICES

KEY WORDSmilitary, families, children, deployment, mental health, healthmaintenance

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

The guidance in this report does not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

The views expressed in this article are those of the authors anddo not reflect the official policy of the Department of the Army,the Department of Defense, or the US Government.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-0940

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past 10 years.4 The US public and itspolicy makers are increasingly con-cerned about the health and well-being of the children and families ofuniformed service members facing pro-longed and multiple wartime deploy-ments. To this end, in January 2011,President and Mrs. Obama announcedtheir commitment to the “care andsupport of military families as a topnational security policy priority.”5

To a child, wartime deployment meansseparation from a loved one, usuallya parent; an increased sense of dan-ger; and a routine of daily uncertainty.On return of the deployed parent orrelative, there are an infinite numberof challenges for the child and familymembers. There are recent andemerging studies specifically describ-ing the effects on children of parentalwartime deployments. These studies,outlined in this report, can help informpediatricians about the needs of mili-tary children. Most commonly, childrenexperience separation as loss. Con-comitant fear and chronic anxiety havebeen shown to disrupt the developingarchitecture of the brain.6 Children, andeven adolescents, watch closely forparental cues to gauge their own de-gree of distress in a given situation.Maladaptive parental coping or dis-tress may be the single most impor-tant predictor of child biopsychosocialsymptoms during stressful situations,such as wartime deployment.7–9 Somemilitary families may be at higher riskof distress, especially if they are young,experiencing a first separation, haverecently relocated, include a foreign-born spouse, have young children,are junior enlisted (entry pay level),are single parents, or have childrenwith special needs.4,9 Service membersand families who have not anticipatedan extended wartime deployment, suchas activated National Guard and Re-serve personnel, may be especiallychallenged.10

Pediatricians and other clinicians car-ing for children are on the front line inthe medical home because they iden-tify and assess effects of wartime de-ployment in children and their familymembers. More than 50% of militarychildren receive their health andmental health care from nonmilitaryproviders, outside the gates of militaryinstallations, especially children ofactivated service members in the Na-tional Guard and Reserve.11 One civil-ian group practice outside a largemilitary treatment facility has 12% oftheir pediatric patient population en-rolled in Tricare Prime, constitutingcare for more than 22 000 childrenfrom military families (Stuart A. Cohen,personal communication, November21, 2012). Pediatricians need to beaware of common issues duringwartime deployments, assess familycoping skills, provide anticipatoryguidance for the typical cycle of de-ployment, know where to find appro-priate resources, and know when torefer for specialized services or care.For example, during well- or acute-carevisits, pediatricians can address familystress and coping in addition to indi-vidual child needs related to parental/family military service (see Appendix,General Pediatrician Resources, Home-Base, a toolkit for well-child care ofchildren in military families). This cli-nical report is intended for all pedia-tricians, both active duty and civilian,to aid in caring for military childrenwhose loved ones have been, are, orwill be deployed.

DEMOGRAPHICS OF MILITARYFAMILIES

US military demographics have changeddramatically since the dissolution ofthe draft in 1973. As the military be-came an all-volunteer force with ca-reer options, new challenges emergedfor the Department of Defense to in-clude housing; family services; over-

seas resources, including education;aging issues; and an increasing retireepopulation. The addition of more womento the uniformed services (increasingfrom 1% in 1970 to 15% in 2009) broughtwith it the need to balance mission andmotherhood in a military workplace.12

Use of the National Guard and Reserveto augment the active duty wartimedeployments has resulted in the in-volvement of even more children andfamilies.

Of the 60% of active duty service mem-bers who are married, 93% have femalespouses (wives), and 44% have children.On average, military parents marry andhave children at a younger age thancivilian US parents. Seventy-five percentof all military children are younger than11 years. The National Guard and Reservemembers have similar family demo-graphics as Active Duty service mem-bers, except that National Guard andReserve members and spouses areslightly older, and the greatest pro-portion of children are schoolage.12

Military families have many of the samestruggles common to all families, in-cluding child care, elder care, parentingconcerns, marital issues, educationissues, and career choices. However, inthe military, families face additionalstressors, including frequent reloca-tions, international moves, separationsother than war, and wartime deploy-ment and its consequences.

Understanding military structure isimportant when considering the ef-fects of deployment on children ofservice members. Each of the activeduty services and each of the SelectedReserves have unique qualities thatcan help pediatricians understandthe context of a child’s experience withwartime deployment. The Departmentof Defense has 4 services with anactive duty component. The largest isthe Army, with 500 000 members,followed by the Navy, Air Force, andMarine Corps. The 5 states with most

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active duty members are California,Virginia, Texas, North Carolina, andGeorgia.12 As a group, the Reserve andNational Guard are often referred toas the Selected Reserve and are madeup by the largest group, the ArmyNational Guard, followed by the ArmyReserve, the Air National Guard, andthe Reserve components from theNavy, Marine Corps, Air Force, andCoast Guard (now under HomelandSecurity). The 5 states with the larg-est Selected Reserve members areCalifornia, Texas, Pennsylvania, NewYork, and Florida. In 2005, half of thefighting forces in Iraq and Afghanistanwere from the Selected Reserve, andalthough this has decreased to 15% to20% of total deployed service mem-bers, more than 255 000 NationalGuard and Reserve service membershad deployed by 2008.13

Service members are either enlistedor officers. For every officer (averageage is 30 years, and >85% have abachelor’s degree), there are approx-imately 5 enlisted personnel (>50%are younger than 25 years, and 100%have high school diploma or generalequivalency diploma). Active dutyfamilies often live on or near a mili-tary installation, they have neighborsand friends who are also military, andcommunity resources are organizedaround military activities, includingchild care, financial and legal sup-ports, and deployments. Typically, newfamilies are “sponsored” or “hosted”by more experienced military familieswhen they move to a new area.

In contrast, the National Guard andReserve members train and are “ac-tivated,” as needed. When these mem-bers are activated, it means they havebeen called up for active duty serv-ices. Most often, Selected Reservemembers are activated for wartimedeployment, although recent naturaldisasters have also resulted in acti-vations of Selected Reserve members

to Southeast Asia and Haiti. The Na-tional Guard has state and homelandresponsibilities as well. National Guardand Reserve members’ families rarelylive near a military installation and of-ten seek health care and support fromthe community in which they live. Theseservice members have primary civil-ian jobs. Civilian employers are notrequired to pay National Guard andReserve members while they are ac-tivated and deployed. They are re-quired to vacate or hold a positionuntil return, although sometimes it isfor 12 to 15 months.

TRICARE, the health care entitlementprogram for military families, has el-igibility and benefits determined by theUS Congress and administered by theDepartment of Defense via the TRICAREManagement Authority.14 TRICARE uni-tes the direct health care resources(hospitals, clinics, and medical profes-sional services) of the military medicalsystem with networks of civilian pro-fessionals, hospitals, and agencies.TRICARE is free to all active dutymilitary service members and theirfamilies. When National Guard orReserve members are activated, theyand their families are entitled to thesame health coverage as active dutymembers.14 This includes medical careand mental health services at any postor base regardless of service type aswell as services provided by civilianproviders endorsed in the TRICAREnetwork. TRICARE mental health serv-ices (whether at a military hospital orclinic or by civilian providers) can beaccessed directly by TRICARE bene-ficiaries without a referral from aprimary care provider or previousauthorization. Many National Guardand Reserve families switch to theTRICARE health care coverage duringdeployment because it is basicallyfree, their own company does notcover them during the deployment, orthey did not have coverage before

activation. Thus, activation and de-ployment often mean changing familyhealth care providers temporarily orpermanently. There are mechanismsfor families who wish to seek carefrom a non-TRICARE network provider,but this choice requires a deductibleand copay. For pediatricians with anumber of patients with TRICARE ben-efits, it may be appropriate to considerTRICARE Preferred Provider status(www.tricare.osd.mil). TRICARE bene-fits remain up to 180 days after de-activation from duty. Dental coveragefor families is also available but isnot automatic. Eyeglasses are notcovered.

DEPLOYMENT

Deployment is a temporary (3- to 15-month) movement of an individual ormilitary unit away from his or her localwork site, resources, and family toaccomplish a task or mission. De-ployments can occur during peacetime(activated service members duringHurricane Katrina in 2005 or, morerecently, 12 000 service members toHaiti in 2010). Peacetime deployments(operations other than war) usuallymean travel to safe locations, shortduration, and interludes of rest andrecovery between absences, and mostmilitary families do well. In fact, mostmilitary families expect periodic sep-arations from their service memberfor sea tours or specialized schoolingand training. Traditionally, “unaccom-panied tours” (1-year remote assign-ments in which the family staysstateside) have not been described asdeployment. Wartime deployments, incontrast, represent hostile, dangerousactivity of usually long duration.

This is the first time in our nation’shistory that families are experiencingwar in almost real time, with the useof cell phones, instant computer vid-eos, and media coverage on the bat-tlefield. Media reporters embedded in

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combat units provide “living room” ob-servation of war activities. Video cam-eras and web messaging capabilitiespermit frequent personal contact withdeployed services members, whichfamilies say is comforting.15 However,there are also conversations of “nearmisses,” abrupt disruptions in phonecalls, and rumors of injury and death(even in the “safe zone”) before con-firmation, a few examples of a height-ened sense of fear experienced byat-home family members not stud-ied in previous wars.

HEALTH AND MENTAL HEALTHOUTCOMES OF RETURNINGSERVICE MEMBERS

In the past 5 years, researchers havedocumented a greater understandingof the effects of war on the psycho-logical well-being of soldiers, many ofwhom are parents.1,2,16,17 Complicationsrelated to war-combat stress disorder,traumatic brain injury, developmentof psychiatric illness, and increase inhealth risk behaviors can complicatefamily life for a child. After deployment,soldiers’ emotional and behavioral re-sponses can range from typical short-term distress, such as change in sleep,decreased sense of safety, or socialisolation, to the development of moreserious psychiatric conditions, such asposttraumatic stress disorder or de-pression. It is estimated that morethan 30% of returning soldiers haveexperienced posttraumatic stress dis-order, depression, and/or traumaticbrain injury.18 Comorbidities, such asaggression and alcohol misuse, areprevalent in up to half of those withimpairment.1 There has also been anincrease in the rates of suicide amongmilitary personnel. In 2007–2008, 255active duty personnel committed sui-cide (20/100 000), an 80% increasefrom 2003, the beginning of the majortroop deployments in Afghanistan andIraq. There has also been an increase

in service members seeking mentalhealth support; approximately 280 000service members sought behavioraltreatment in 2011.19

Studies of service members and theirspouses indicate deployment has aneffect on spouses’ well-being and onmarital relationships. In a 2010 reportof more than 250 000 Army wivesinterviewed between 2003 and 2006,there were 41.3 excess cases of amental health diagnosis per 1000wives attributable to 1 to 11 months ofwartime deployment. Furthermore, ifmore than 11 months of deploymentoccurred in those 3 years, 60.7 excesscases of mental health diagnosis per1000 wives were identified.20 It is notsurprising that the toll of lengthyand recurrent deployments has beenreflected in marital dissolution. Theannual divorce rate among active dutysoldiers in 2009 was 3.6%, up from3.3% in 2007.6 There is a significantbody of literature available for inform-ing pediatricians about the effects ofparental psychopathology and maritaldiscord on child well-being, distinct

from the stress of wartime deployment.Recognizing the increased vulnerabilityof children in these circumstances isa role general pediatricians alreadyassume.21–23

CYCLE OF DEPLOYMENT

In 2001, Pincus et al reinforced a modeldescribing the typical emotional re-actions of family to deployment, calledthe “emotional cycle of deployment.”24

With onset of longer and repeatedexposures, it is unclear whether a cy-cle is the correct paradigm, but itdoes provide insight into the diverseand complex nature of deployments,reflecting both the tremendous re-silience as well as vulnerability ofmilitary families. Table 1 provides guid-ance for practitioners to assess andintervene with families throughout thecycle of deployment.

Before the wars in Iraq and Afghanistan,deployment was a rare occurrencefor the vast majority of militaryforces. Most families had never ex-perienced a separation to a hostile

TABLE 1 Anticipatory Guidance for Cycle of Deployment to Assess and Intervene in the FamilySystem

Stages of Deployment Provider Assessment and Anticipatory Guidance

Predicting difficulties with deployment Assess previous history of family dysfunction, mental healthissues in parent, special needs of children, recent familyrelocation, and previous problems during a deployment.

Predeployment Discuss responsibilities and expectations of each familymember during upcoming deployment. Make plans and goalsfor family rather than “put lives on hold.” Decrease likelihoodof misperception and distortion. Prepare for communicationstrategies and expectations.

Deployment Initiate plans made during predeployment. Continue familytraditions and develop new ones. Facilitate children’sunderstanding of the finite nature of the deployment bydeveloping timelines (as age appropriate).

Sustainment Establish support systems (extended family, friends, religiousgroup, family support groups, etc). Communicate withdeployed service member via e-mail, phone, and letters. Avoidoverspending. Spend some time without the children. Askchildren how they are doing.

Postdeployment Take time to communicate and get to know each other. Spendtime talking to each other. Take time to make decisions andchanges in routine. Lower holiday expectations. Keep planssimple and flexible. Do not try to schedule too many thingsduring the first few weeks. Let absent parent “back into” thefamily circle.

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environment before 2001. Since then,however, families have experiencedprolonged and repeated wartime de-ployments. Deployments have 3 stages,each with typical dynamics: prede-ployment, deployment (including sus-tainment), and postdeployment (orredeployment).

1. The predeployment stage beginswith the unit sending orders for aservice member to deploy. Sometimesthere are months of notice and prep-aration, and sometimes only days.Often, soldiers know their next de-ployment date when they return froma previous deployment. On 1 survey,spouses indicated that the hardestthing about a deployment was hearingof subsequent deployments.15 Prede-ployment can be challenging for boththe service member and the at-homeparent. Often, the unit requires longhours and lengthy trainings in themonths leading up to deployment, re-sulting in extended absences. Deci-sions to find alternative or additionalchild care are often expensive andstressful. For the 40% to 60% of at-home parents who work outside thehome, decisions about careers, finan-cial adjustments, or excessive leave tosupport sick children result in manyspouses quitting their jobs. Legal re-quirements, such as power of attorneyand a will, bring up issues of mortality.Unresolved anxieties and expectationsfrom previous deployments interferewith preparation for new deployments.

Although the predeployment stage isstressful for parents, it can be con-fusing to children, who may not un-derstand why separation is necessaryand have no concept of the changeabout to occur. Children at variousdevelopmental ages experience exci-tement, denial, worry, fear, and anger.Emotional withdrawal is not uncom-mon immediately before deployment.Last-minute or recurrent goodbyesoften increase tension.

2. Deployment typically lasts between3 and 15 months. The deploymentstage usually begins with a tearfulceremony, despite strong feelings ofsupport, patriotism, and duty. This isoften followed by a period (usually1–6 weeks) of emptiness, loss, andabandonment. Spouses report feelingnumb, sad, and vulnerable.15 The in-tensity leading up to a goodbye can beoverwhelming, and the sense of re-lief that the deployment has actuallystarted can be confusing. After about6 weeks, most families try to establisha routine. This stage of adjustmentmay be erratic, with good days andbad days. Finding new resources andnew routines and understanding thelimits of the family’s coping abilitiesoccurs during this time.

Sustainment is the period during thedeployment stage (usually between 4and 13 months) when a new routinewithout the deployed parent is estab-lished. During this time, school-agechildren and adolescents can developsome positive attributes of a deploy-ment. These difficult life experiences(not dissimilar to family illness, a housefire, etc) can foster maturity, provideopportunities to acquire new skills,encourage independence, build newrelationships, and strengthen familycohesion. Deployed service membersmay come home for 2 weeks for a“midtour” or rest and recuperationleave. Many families have said that restand recuperation leave is a difficulttime for children because it often fallsduring the school year; children aredistracted by anticipation, excitement,and a short period of visitation; andthey then have to say goodbye all overagain. Despite trying to find resilienceand strength, many families describedeployment as a “surviving, not thriv-ing” time. For the month or 2 beforehomecoming, there may be worry aswell as excitement. New independenceor self-reliance may have emerged,

and family members are unsure howto reintegrate a deployed parent intoa year-older family. This can also be achallenge to the returning servicemember.

3. At postdeployment (reunion),most families start off with a “honey-moon.” The happiness of reuniting ismixed with getting reacquainted anddeciding how to share the time lost.There is a sense that problems can besolved, and, to some extent, familiescan return to “normal.” However, thenew normal may look different fromthe roles family members played whena service member left over a year be-fore. The service member is immedi-ately thrust back into a full-time familylife, which is desired but often difficultto accommodate while readjusting todaily routines. “Block leave” is 2 to 4weeks of vacation time given to thepostdeployment individual or unit butmay not coincide with family memberavailability from school or work. Duringthis time, at-home parents often wantsome much-needed respite after a pro-longed period of “full-time” parenting.

ASSESSING FAMILY’S RESPONSETO STRESS

Stress reactions represent an evolu-tionary advantage in the face of dan-ger, prompting effective adaptations tochanging conditions in the environ-ment. Such reactions are often criticaland not detrimental. How well or poorlyan individual or family responds to agiven stressor, such as wartime deploy-ment, is dependent on several factors:

� the individual’s previous experien-ces with stress;

� the meaning of this specific stress;

� the family context where the stressis experienced, including how theparent is coping; and

� the inherent, as well as external,resources available to deal withthe stress.

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“To assume either widespread pa-thology or uniform resilience to thestresses of wartime deploymentswould be superficial and harmful tochildren and their families.”25 Mostfamilies experience substantial stress,and although the risk is present,a minority of families have evidenceof being “stressed out,” such as mal-adaptive coping, mental illness, sub-stance use or abuse, or maltreatment.

Resilience appears to play a majorfactor in all phases of deployment.Overall, studies indicate protectivefactors, including family readiness,“meaning making” of the situation,receipt of community and social sup-port, acceptance of military lifestyle,ability to develop self-reliant copingskills, and adoption of flexible genderroles. Additionally, at least 5 years ofmarriage, higher parental education,and civilian spouse working outsidethe home may contribute to strongerfamily resilience9 during deployments.

EFFECT OF WARTIME DEPLOYMENTON CHILDREN

Previous Research

In the earliest research (1949) onmilitary families coping with postwarsettings, Hill studied how the familyadjusted to World War II soldiers’return. He proposed that the actualwar “time of separation” needed to beconsidered in the context of familyresources. On the basis of family in-terviews, he noted that the meaningfamilies placed on the war, and the“time of separation” predicted posi-tive versus negative adaptation onreturn of the soldier.26 Subsequently,McCubbin and Patterson studied fami-lies of Vietnam veterans and con-cluded that a “pile up” of prewar,during-war, and postwar stressors“added up” to the degree of malad-aptation and that a cumulative effectof stress was not purely the result of

wartime deployment.27 This conceptof contextual factors in a family influ-encing coping and adaptation to stressof war studied during 20th-century USmilitary conflicts may provide impor-tant insight into the first war experi-ences of the 21st century.

In 1978, LaGrone coined the term“military family syndrome” followingreview of 792 Army charts of childrenseen in psychology clinics for behav-ioral problems.28 He concluded thatmilitary families suffer greater psy-chosocial difficulties than do familiesin the general population. Later, moremethodologically rigorous research,with prospective studies of militaryversus nonmilitary children, did notfind any differences between militaryversus nonmilitary children. Interest-ingly, 1 study of Navy families, forwhom routine 6-month “sea duty”deployments were a way of life foryears, indicated that children demon-strated increased responsibility, inde-pendence, and confidence comparedwith their peers without deploymentexperiences, suggesting that childrendevelop a different and beneficialparent-child relationship with the at-home parent.29 In many nonmilitarysituations in which parents are ab-sent for periods of time but not indanger, many children demonstrateresilience and strong coping strategies.

Clearly, dangerous combat deploy-ments of parents are significantlymore distressing than are peacetimedeployments for most children. Thefirst combat deployment studies wereconducted during Operation DesertStorm (1990–1991). Children demon-strated moderate degrees of increasedinternalizing symptoms (such as de-pression and anxiety)30,31 and possiblyless family cohesion.32 At-risk groupsincluded those with preexisting psy-chosocial issues and at-home parentswith psychopathologic problems. Onestudy addressing whether gender of

deployed parents affected childrenfound no significant differences inchild adaptation between fathers ver-sus mothers who were deployed.33

An Army family study reported thatchildren who demonstrated strongcoping skills during deployment hadgreater adaptation postdeployment.34

Additional information about thehistory of military children and fam-ilies is available in a recent Pediat-rics supplement devoted to militarypediatrics.35

Current Research

Wartime deployment can be stressfulfor a child, regardless of his or herdevelopmental stage. Changes inbehavior, both externalizing and in-ternalizing, and changes in schoolperformance are reported.7–9,11,36–38

High levels of sadness and worry arereported in most age groups.7–9,39

Depressive symptoms are reportedin approximately 1 in 4 children ex-periencing deployment of a parent.39

More than one-third of children re-port excessive worry about theirparent’s deployment.38,39 A parentsurvey noted 1 in 5 school-age chil-dren cope poorly,9,38,39 and a similarnumber have academic problems.Length of deployment was associatedwith significant behavioral healthproblems.7 Children and their familieswere ambivalent about access to awartime parent, on the one handcomforted by talking to parent oncomputer15 and on the other handidentifying media coverage as asource of stress.39 In addition, a re-cent population-based study reportedincreased use of mental-behavioralhealth services in children whose par-ents were deployed.11 Finally, a largepopulation study of 307 520 children ofparents in the nonretired active dutymilitary, children 5 to 17 years of age(2003–2006) noted a greater numberof mental health diagnoses and more

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diagnoses correlating with the totaltime of deployment.40

Children of All Ages Are Affected byWartime Deployments

Infants and Toddlers

In a survey of almost 4000 militaryspouses with and without deployedpartners, researchers investigating de-pressive symptoms during pregnancynoted that twice as many women withdeployed partners reported depressivesymptoms before and after deliverycompared with those whose partnerswere at home.41 In 2008, the first studyof preschool-age children affected bycurrent wartime deployments revealedhigher emotional reactivity, anxious-ness/depression, somatic complaints,and withdrawal than did childrenwhose parents were not deployed.37 Asubsequent study of 57 families withyoung children found similar findingsduring deployments.42

School Age

The degree of at-home parental stresswas the most significant predictor ofthe child’s psychosocial functioningduring a wartime deployment. School-age children whose parents wereyounger, had been married for ashorter period of time, and were ju-nior enlisted rank were at higher riskof having psychosocial problems.Parents who had a college education,a sense of military support, and com-munity support had less parentalstress and reported fewer psycho-social problems in their children. Us-ing the Pediatric Symptom Checklistduring parental deployment, school-agechildren scored “high-risk” for emo-tional and behavioral problems 2.5times more frequently than nationalnorms. Sleep problems were notedin a majority (56%) of the children.9

Lester et al found combat deploymentshad a cumulative negative psychoso-cial effect on a sample of school-age

children that persisted despite thereturn of the deployed parent.7 Mans-field accessed electronic medical re-cords for outpatient care on more than300 000 school-age children and founda similar “dose-response” pattern be-tween deployment and increased men-tal health diagnoses.40

Adolescents

In a focus group of adolescents whoseparents were deployed to Iraq (Oper-ation Iraqi Freedom, Operation NewDawn) and Afghanistan (Operation En-during Freedom), there were reportedchanges in relationship with the de-ployed parent, concern and anxietyabout the deployed parent’s well-being, and worse performance inschool, yet increases in responsibilityand maturity in caring for youngersiblings.38 In a telephone survey of1500 military youth and their at-homeparent, Chandra reported increasedemotional difficulties associated withlonger deployment times and empha-sized the importance of positive cop-ing and mental health of the at-homeparent.8 The effects of war can havelife-threatening consequences formilitary children and their familiesfar removed from the battlefields. Astudy in Texas demonstrated the rateof child maltreatment in the militaryincreased significantly since 2001and was associated with increasedrates of deployment. For militarypersonnel with at least 1 dependent,the rate of child maltreatment in-creased by approximately 30% forevery 1% increase in service mem-bers who left for or returned fromcombat.43 In another study, froma confidential registry of substan-tiated cases in the Army, child mal-treatment was found to be 42%higher in families of US enlisted sol-diers during combat deploymentversus nondeployed status and ex-ceeded the comparative civilian rates

of maltreatment, which remainedsteady during the same time frame.Overall, child maltreatment was 3times higher during times of de-ployment, with neglect being 4 timeshigher and physical abuse being 2times higher. This study reported thehighest increase in maltreatment tobe attributed to the at-home care-giver while the service member wasdeployed.44

SUGGESTIONS FOR PEDIATRICIANS

All pediatricians should be preparedto address parental (and other rela-tionships that may be meaningful tothe child) wartime deployment issues.This includes recognition of service-specific characteristics of the de-ployed service member, stage ofdeployment, and whether there havebeen previous deployment experi-ences. The role of the pediatrician is toassess the level of family and childstress that occurs whenever there isa family change, like wartime de-ployment, and to use the principlesof anticipatory guidance, psycho-education, and continued surveillanceand screening as families are seenover time. Asking “How are you doingwith this deployment?” may be thesingle most important family assess-ment question. Another question is,“Has anyone in your family or closecommunity been involved with war-time experiences?” If yes, the follow-up is “How are your family memberscoping with this experience?” Thereare specific situations that warrantadditional probing such as, during thepostpartum period, when new moth-ers with a deployed partner may be atheightened risk of depression. Addi-tional guidance during perinatal andpostpartum period can be found inthis article’s Appendix. Another situa-tion to plan for includes speakingconfidentially with adolescents, whichmay help to ensure they are not

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downplaying their fears and worry.Because of the increased risk of childmaltreatment during deployments, childabuse screening and mental healthscreening of child caregivers arealso important elements of the clini-cal encounter.

Next, the pediatrician should deter-mine the developmental age of thechild and assess his or her under-standing of deployment (see earliersection, “Cycle of Deployment”). Fam-ilies need reassurance that children’sreactions to a deployed parent arecommon reactions (see Table 2) andthat, for the most part, children adaptto the experience with effective copingskills. Adolescents self-report prob-lems with a similar prevalence astheir parents and may have morevalid reporting than their parents oftheir own internalizing symptoms.38

Common Child and AdolescentReactions to Deployment

� Preschool: children at this agehave difficulty with change and willnot have a full understanding ofwhy a parent is leaving or for howlong, compared with the older childand adolescent. Before deployment,they will understand that there hasbeen a change in the family behav-ior but will not understand the fullextent until the parent is absent.Children need reassurance thatthey will be cared for and keptsafe and they did not cause thedeployment.

� School-age: children at this agehave a greater understanding ofwhy a parent is being deployed,but there still may be confusion.They may hear from other friendsand see stories about the war ontelevision and may have height-ened worries about the safety oftheir loved one. It is reasonablefor the remaining parent to shelterchildren from the day-to-day details

of news about the war. Sometimeschildren feel responsible for theparent being deployed, especiallyif there has been unresolved ten-sion between the deployed parentand the child. The parent shouldexplain the child’s situation to aschoolteacher. It is important tomonitor thoughts and feelingsabout a spouse or partner in frontof the child. At this age, childrenneed a trusted adult, either theremaining parent or another adult,with whom they can talk and sharetheir feelings. They need to feel safeand secure.

� Adolescents: teenagers understandthe reasons deployment is occur-ring and the full ramifications ofthe deployment process. Theymay feel angry and sad and oftenget support from their peers out-side the family. They may not wishto share their thoughts and feel-

ings with family members. Theymay not want their parent to in-form school of parental deploy-ment. The at-home parent shouldaccept and understand this copingmechanism while monitoring howtheir teenager is doing in schooland with friends.

Helping Children Cope and FosterResilience During Deployment

Preschool and Elementary SchoolChildren (3–9 Years)

To help the child feel connected to thedeployed family member, caregiversshould do the following:

1. Continue the discussion aboutthe deployed parent on a regularbasis.

2. Communicate to the deployed par-ent frequently and regularly: writeletters, draw pictures, put together“goodie” packages.

TABLE 2 Common Reactions to Deployment45

Feelings Behaviors

PreschoolConfusion Clinging, demands for attentionAnger Problems separating from the remaining parentGuilt Irritability and aggression

Regression (thumb sucking, bedwetting)Sleep disturbancesFeeding issues (more picky)Easy frustration and more difficult to comfort

School-ageSame feelings as preschool plus: New behavior problems or in intensification of

already existing problemsIncreased sadness (lack of family

normalcy and loss of deployed parent)Regression

Worry about deployed parent Rapid mood swingsFear that remaining parent might leave or die Changes in eating and sleepingAnger at parent for missing important events Anger at both parents for disrupting normalcy

Changes in behavior at school and with friends(anger, aggression)

Need to be and do “normal” things (eg, parties)Somatic complaints

AdolescentAnger Misdirected or acting-out behavior toward others

or themselvesSadness School problemsDepression Apathy, loss of interest, noncommunication,

and denial of feelingsAnxiety Increased importance of friends to the detriment

of reasonable family lifeFear Trying to take charge of the family

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3. Keep a calendar for each child sohe or she can see when thedeployed family member is com-ing home.

4. Have a picture of the deployedparent with the children or withthe family. Pictures can be hungup or put in prominent places.This is especially important forthe preschool-age child.

5. Protect younger children fromseeing or hearing about the wareffort or violence on television orin the newspapers.

6. Have deployed parent audio orvideo record a favorite bedtimestory before leaving, especially ifreading was a normal routine be-fore leaving.

7. Seek support from extended fam-ily or a trusted adult (mentor, forschool-age child) who can beavailable for the children.

8. Ask family and friends not to talkabout the painful or scary aspectsof deployment.

9. Keep up the family routine.

10. Try to spend extra time with thechild or children, if possible andrespond empathically to theneeds for more attention.

11. Encourage ways for children toexpress their feelings. For youn-ger children, it may be drawingor playing with dolls, and forolder children, it may be tellingstories or keeping a journal andpossibly sharing the journal, es-pecially at bedtime.

12. Appreciate that young childrenwill act out scary and fearful feel-ings through play. Support andunderstand this process andmonitor the behaviors and feel-ings during times of family orschool activities.

13. Request the free Sesame Streetvideo Talk, Listen, Connect (www.

militaryonesource.com). Requestfree Military Child or Youth vid-eos, Mr. Poe and Friends DiscussReunion After Deployment (www.aap.org/sections/uniformedservices/deployment/videos.html) for youn-ger children.

14. Communicate to teachers aboutthe deployment and continue tocheck in on their school perfor-mance and behaviors.

15. Develop a scrapbook of children’sactivities and accomplishments tobe shared when there is reunion.This will allow the child to “showand tell.”

Middle School and Adolescence (10–18 Years)

1. Encourage conversations aboutdeployment and war (“I know thisis tough for you and I am here foryou. Feel free to talk with me atany time.”).

2. Help children maintain regularcontact with the deployed parent.

3. Monitor excessive exposure or con-tact with media coverage of thewar.

4. Maintain routines.

5. Do not expect teenagers to act ascoparents. They should maintainregular activities and responsi-bilities.

6. Do not change any of the disci-pline rules or their consequences.

7. Appreciate the needs of teenagersto be with peers and provide spe-cial time with the teenager doingspecial activities.

8. Be patient and calm in the face ofincreased anger irritability andwithdrawal. Extra support or phys-ical affection can help.

9. Encourage teenagers to get ap-propriate nutrition, rest, and ex-ercise and monitor for changesin sleep patterns, changes in

school, and activities of dailyliving.

10. Encourage middle-school-age chil-dren and teenagers to keep a di-ary and respect the need forprivacy if they wish not to share.

11. Order a free copy of the video Mil-itary Youth Coping With Separation:When Family Members Deploy (seeAppendix for Resources).

12. Encourage children and teen-agers to continue extracurricularand community activities.

13. Consider attending “Operation Pur-ple” camp (www.militaryfamily.org)activities or summer camps forstudents with a deployed parent.

When Should a Primary CarePediatrician Refer for AdditionalHelp?

If a family is struggling with deploy-ment, the pediatrician can help themcontact their “rear detachment chap-lain,” the “family readiness group,” aTRICARE case coordinator, Military OneSource, or the local Exceptional FamilyMember Program; seek deployment-related respite or child care servicesor offer school-age children “OperationPurple” camp.

The pediatrician may consider a re-ferral to a mental health professional

1. if reassurance and helping the par-ent cope using a psychoeducationalintervention or generally support-ive counseling is not working after2 visits or if there is significantstress at the first visit.

2. if the pediatrician is unsure of hisor her counseling and psychoedu-cational skills and the family issignificantly stressed (learn moreabout motivational interviewing46).

3. if the child’s behaviors have becomemore extreme or continue for up to3 months after the deployed parenthas returned home.47

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4. if there is a significant change inbehavior or a drop in grades atschool.

5. if there is increased and sustainednegativity and reassurance andsupport does not help.

6. if the teenager is continually awayfrom home and does not check inwith the at-home parent.

7. if the at-home parent is not able tocope; is excessively worried, anx-ious, or simply overwhelmed; andcannot respond to the child’s emo-tional needs.

8. if there is injury of a parent and ifother resources provided are noteffective (discussed next section).

9. If there is death of a parent andother support programs providedfor bereaved families are not effec-tive (see next section).

Injury or Death of a Parent

From October 1, 2001, through Febru-ary 6, 2012, there were 6351 Americancasualties in Operation Iraqi Freedom,Operation New Dawn, and OperationEnduring Freedom and 47 545 woundedin action.48 Although the majority ofcombat casualties have been activeduty soldiers, 11.5% have been servicemembers from the National Guard and7% have been service members fromthe Reserve.47 The combat death orsignificant injury of a parent is anunexpected and devastating experi-ence for all families.48,49 The type ofinjury and degree of disability will de-termine the way family members copeand adapt. Many families of NationalGuard and Reserve service membersdo not have the same communitysupports as those on active duty. Themilitary medical system and the Officeof Veterans Affairs will carry out re-habilitation and medical care of theinjured service member. The pediatri-cian should be available to monitor thesocial-emotional impact of such an

event on the children and the spouseand refer when appropriate. In thissetting, the pediatrician should becomefamiliar with and/or contact the Centerfor the Study of Traumatic Stress (www.centerforthestudyoftraumaticstress.org),which has expertise and resourcesspecific to combat-injured families.50

The death of a parent or significantparenting figure during war is a cata-strophically disorganizing event fora child, the surviving parent, and thefamily. It is one of the unspoken fearsthat family members endure duringwartime deployment. Helping childrenunderstand parental death requiresa developmentally unique sensitivity,and universal preventive counseling inthe face of such a devastating stressshould be encouraged.51,52 The pe-diatrician should assess the social-emotional reaction of the child inrelationship to his or her develop-mental stage, follow the child overtime, and support the remaining par-ent or life partner. Important policystatements and reports have beenprovided for pediatricians who desireadditional guidance in these skills(see Appendix). When a family is no-tified of the death of an active dutyservice member, they are assigned toa Casualty Assistance Representative(CAR), whose sole purpose is to helpthe family through the military’s uniqueentitlement process and find neededresources. For example, families whoreside in government housing (or havea housing allowance) are allowed toremain at their current location (bothhousing and schooling) for up to 6months as they determine next steps.Because of the devastating nature ofthis event, some parents or partnersmay need referral for social-emotionalassessment and therapy, as appropri-ate. A specific resource for militaryfamilies is Tragedy Assistance Programfor Survivors (www.TAPS.org).53 Thepediatrician can encourage parents

to seek out additional military sup-port through Decedent Affairs, Chap-lains’ Office, or Commanders of themilitary unit. This support is usuallymade available at the time that thespouse or partner is notified of thedeath of their loved one.

Supporting the Parent

Above all, to have the strength to helpchildren, the nondeployed parentneeds to feel in control and havesomeone to help him or her. The pe-diatrician can encourage each primarycaregiver to stay healthy and con-nected, including someone with whomto share experiences and opportuni-ties for personal growth, respite, andspiritual wellness. The pediatrician cansupport and help the parent find amental health professional so that theparent may be better able to care forhis or her children.54 A resource for allmilitary spouses to access adult men-tal health services, regardless of loca-tion, is www.MilitaryOneSource.com. Inthe setting of a medical home, pedia-tricians should be familiar with thisWeb site to help family caregivers withtheir own emotional needs. Manydeployment-specific resources avail-able to active duty families can beaccessed on this Web site for activatedNational Guard and Reserve families,including military family life consul-tants, chaplains, legal assistance, so-cial work services, and new parentsupport programs. Recently the De-partment of Defense, under the aus-pices of the United States Bureau ofNavy, Medicine and Surgery, initiateda demonstration project titled FamilyOvercoming Under Stress (FOCUS). Thisproject began in 2008 and as of 2010included 14 military institutions. Thegoal of the project was to investigatethe impact of a family-centered pro-gram on military families, addressingstress and mental health, using a“trauma informed, skill based, family

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centered prevention intervention de-signed to mitigate the sequelae ofhighly stressful deployment-relatedevents on children and parents.” The8-session resiliency psychoeducationprogram for parents and children useda trained “Resiliency Trainer.” Resultsdemonstrated a decrease in parentalposttraumatic stress, depression, andanxiety as well as a decrease in child-hood conduct problems, emotionalsymptoms, and total childhood diffi-culties. In addition, there was signifi-cant improvement in “child pro-socialfunctioning and increases in children’suse of positive coping strategies.”55–58

In addition to direct contact witha case manager or mental health lo-cator, at-home parents can requestfree parenting and support booksfrom the online library and can findlocal support groups.

The American Academy of PediatricsCommittee on Psychosocial Aspects ofChild and Family Health has previouslyreleased a report titled “PsychosocialImplications of Disaster or Terrorismon Children: A Guide for the Pediatri-cian.”47 The report discusses the di-agnostic aspects of posttraumaticstress disorder and acute stress dis-order, which may be helpful if a childor adolescent is demonstrating ex-cessive or prolonged symptoms as-sociated with parental deployment orreunion, especially in the circumstanceof parental injury. Additional military-unique resources for the pediatriciancan be found on the Section on Uni-formed Services Web site (www.aap.org/sections/unifserv/deployment/index.htm), which includes additional militaryWeb sites, recent research publications,videos for children and adolescents, andinformation about summer camp ex-periences, such as Operation Purplecamps.

The vast majority of military familiescan and do cope and adapt to servicemember deployments. Pediatricians

need to recognize when deployment isaffecting the emotional and social well-being of children and their parentsand relatives and be particularlysensitive to the unique needs of Na-tional Guard and Reserve servicemember families. They need to gatherdeployment-specific information toassess and monitor the social-emotional reaction of children andfamily members and refer to mentalhealth professionals or deployment-specific specialists for more extensivediagnostic and therapeutic interven-tions, as appropriate. By understandingthe military family and the experiencesof parental wartime deployments, allpediatricians and other health careproviders serving children can be the“front line” for the health and well-being of US military children and theirfamily members, especially in time ofwar.

Appendix

GENERAL INFORMATIONRESOURCES FOR PEDIATRICIANSAND PARENTS

General Pediatric Resources

1. The American Academy of Pediat-rics, Section on Uniformed ServicesWeb site. Available at: www.aap.org/sections/unifserv/deployment/index.htm. Learn about what primarycare providers are doing to takecare of military children andteens. Order copies of free mili-tary child and youth support vid-eos, including the DVD MilitaryYouth Coping With Separation.

2. Ginsburg KR. Building Resiliencein Children and Teens: Giving KidsRoots and Wings. 2nd ed. ElkGrove Village, IL: American Acad-emy of Pediatrics; 2011.

3. Massachusetts Child PsychiatryAccess Project toolkit. Availableonline for assessing military chil-dren at well child visits: www.

homebaseprogram.org/community-education/∼/media/DDA3707B-C4A648E89F1A7C619C48FC28.pdf.

4. Hooah 4 Health. Available at: www.hooah4health.com. Checklists thatpediatricians can help families workthrough for each stage of deploy-ment, understand reactions postde-ployment, and find resources.

5. Center for the Study of TraumaticStress. Available at: www.center-forthestudyoftraumaticstress.org.Resources and research for healthcare providers, service members,and their families.

6. American Academy of Pediatrics,Committee on Psychosocial Aspectsof Child and Family Health. The pedi-atrician and childhood bereavement.Pediatrics. 2000;105(2):445–447.

7. Bonanno GA, Mancini AD. The hu-man capacity to thrive in the faceof potential trauma. Pediatrics.2008;121(2):369–375.

8. Levetown M; American Academy ofPediatrics Committee on Bioeth-ics. Communicating with childrenand families: from everyday inter-actions to skill in conveying dis-tressing information. Pediatrics.2008;121(5):e1441–e1460.

9. Madrid PA, Grant R, Reilly MJ,Redlener NB. Challenges in meet-ing immediate emotional needs:short-term impact of a majordisaster on children’s mentalhealth: building resiliency in the af-termath of Hurricane Katrina. Pedi-atrics. 2006;117(5 pt 3):S448–S453.

10. Hagan JF Jr; American Academyof Pediatrics Committee on Psy-chosocial Aspects of Child andFamily Health; Task Force on Ter-rorism. Psychosocial implicationsof disaster or terrorism on chil-dren: a guide for the pediatrician.Pediatrics. 2005;116(3):787–795.

11. Earls MF; Committee on Psychoso-cial Aspects of Child and Family

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Health American Academy of Pedi-atrics. Clinical Report. Incorporat-ing recognition and managementof perinatal and postpartum de-pression into pediatric practice.Pediatrics. 2010;126(5):1032–1039.Available at: http://pediatrics.aappublications.org/content/early/2010/10/25/peds.2010-2348.full.pdf+html.

12. Cox JL, Holden JM, Sagovsky R.Detection of postnatal depression.Development of the 10-item Edin-burgh Postnatal Depression Scale.Br J Psychiatry. 1987;150:782–786

Parent Resources

1. Sesame Street Talk. Listen, Connect.Preschool-aged deployment supportvideo program. Learn about the pro-gram and order free copies at:www.sesameworkshop.org/tlc.

2. Operation Purple Camps: www.nmfa.org/site/PageServer?pagename=op_default. The goal of these freesummer camps is to bring togetheryouth who are experiencing somestage of a deployment and thestress that goes along with it. Oper-ation Purple camps give kids thecoping skills and support networksof peers to better handle life’s upsand downs.

3. Military One Source. (800) 342-9647or www.militaryonesource.com. Mil-itary support solutions for families.The single best resource for anyfamily in any branch of service.

4. Ginsberg KR. A Parent’s Guide toBuilding Resilience in Childrenand Teens: Giving Your Child Rootsand Wings, 2nd ed. Elk Grove Vil-lage, IL: American Academy of Pedi-atrics; 2011.

5. Military Home Front: www.military-homefront.dod.mil.

6. Military Child Education Coalition:www.militarychild.org.7. MilitaryTeens on the Move: www.dod.mil/mtom/index_t.htm.

7. Tragedy Assistance Program forSurvivors: www.taps.org.

8. Zero to Three—Coming TogetherAround Military Families: www.zerotothree.org/about-us/funded-projects/military-families.

LEAD AUTHORSBenjamin S. Siegel, MDCOL (ret) Beth Ellen Davis, MD, MPH

COMMITTEE ON PSYCHOSOCIALASPECTS OF CHILD AND FAMILYHEALTH, 2011–2012Benjamin S. Siegel, MD, ChairpersonMary I. Dobbins, MDAndrew S. Garner, MD, PhD

Laura J. McGuinn, MDJohn M. Pascoe, MD, MPHDavid L. Wood, MD, MPHMichael Yogman, MD

LIAISONSRonald T. Brown, PhD – Society of PediatricPsychologyTerry Carmichael, MSW – National Associationof Social WorkersMary Jo Kupst, PhD – Society of PediatricPsychologyD. Richard Martini, MD – American Academy ofChild and Adolescent PsychiatryMary Sheppard, MS, RN, PNP, BC – National As-sociation of Pediatric Nurse Practitioners

CONSULTANTGeorge J. Cohen, MD

STAFFStephanie Domain

SECTION ON UNIFORMED SERVICESEXECUTIVE COMMITTEE, 2011–2012LT COL Michael Rajnik, MD, ChairpersonCOL (ret) Beth Ellen Davis, MD, MPH, ImmediatePast ChairpersonCAPT Wanda Denise Barfield, MD, MPHCAPT Jerri Curtis, MDCDR Tony Delgado, MDLTC Thomas G. Eccles, MDCDR Christine Leigh Johnson, MDLTC Catherine Anne Kimball-Eayrs, MD, IBCLCCOL Richard KynionLT COL Thomas Charles Newton, MDCOL Laura Place, MD

STAFFJackie Burke

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