EDITORIAL Meeting the Intervention Needs of Military Children and Families Stephen J. Cozza,
S
ince 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, involving 3, 4, or even 5 or more family separations and reunifications. Others have struggled with combat-related psychiatric disorders, such as posttraumatic stress disorder (PTSD) and physical injuries, including traumatic brain injury (TBI), which can affect children and families for years. Primary care and mental health clinicians in the United States know little about military children or the costs imposed on their health and functioning owing to their parents’ military service. Military and veteran families live in communities across the country, often far from military installations, where they obtain their health care from clinicians who might not understand their unique experiences, strengths, or challenges. After departing the military, veteran families often reintegrate into civilian communities, bringing their military identities and experiences with them. Active duty and selective reserve military children are young, with nearly 40% of these children younger than 6 years and two thirds younger than 12 years.1 There is a paucity of scientific study of these youth, but what exists describes their strengths,2 as well as elevated levels of distress and psychosocial problems associated with parental combat deployments,3-5 with cumulative parental deployment time associated with poorer outcomes.3,4,6 Child maltreatment, child neglect in particular, also has been associated with combat deployments to Iraq and Afghanistan.7-9 The article by Hisle-Gorman et al.10 in this issue of the Journal is an important addition to our knowledge about military children that can inform policy and practice. The study reports risks faced by young children (3–8 years old) and the differential effects of parental deployment and combat injury, both physical and psychological, on their health care usage in the 1-year period after deployment. Increases in child mental health visits and child injury- and maltreatmentrelated health care visits in deployed families in this study strengthen the association of child health and wellness burdens with parental combat-related military duty. In addition, the investigators found significant differences and escalating risk of these outcomes among no deployment, deployment without combat injury, and deployment with combat injury conditions, respectively. These findings provide greater clarity on the varying impact of combat-related experiences on child health and mental health, which likely require different types and levels of support and intervention. JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 4 APRIL 2015
MD
What remains unclear, based on the brief 1-year period examined in this study, is the degree to which risk continues or changes over time. Does risk decrease after deployment or do the stresses and strains of combat deployment and reunification continue to negatively reverberate within a family over time? We might expect that the effects of deployments on children in families not impacted by physical or psychological injury would resolve more readily, whereas effects resulting from PTSD or chronic physical conditions such as TBI would parallel the commonly extended courses of these parental conditions. Future longitudinal scientific studies should address these questions, delineating risk pathways and informing effective intervention strategies. The results reported in this study should be interpreted with some caution. For example, the investigators used procedural codes that clinicians employ for insurance and other nonclinical purposes. Data on health care utilization are not necessarily indications of the health care requirements of the population. In addition, greater use of mental health services should not be equated with greater levels of mental illness. Although some military children develop mental disorders, they are a minority. Higher levels of child mental health utilization found by Hisle-Gorman et al. may be best understood as greater help-seeking by highly distressed children and families impacted by combat deployments or resultant parental injuries. Similarly, increased injury- and maltreatment-related health appointments likely reflect heightened parental and family distress, disorganization, and dysfunction resulting from these same challenges. Distress is not an illness, but it can profoundly affect individuals, families, and communities. In addition to the emotional anguish it causes, distress can undermine individual, family, and parental functioning. Researchers universally recognize that children’s health is related to the health and well-being of their parents, and this also has been found true for military children.3,4 The lives of military children are intertwined with their parents’ lives, and their health risks reflect their families’ risks. Not surprisingly, family-centered approaches to care, those that target parenting and family processes, have been found promising in supporting military child and family health.11,12 In 1994, the Institute of Medicine outlined a spectrum of activities that promote and sustain health in variably affected at-risk populations.13 It places prevention strategies along a spectrum of intensity: universal (helpful to all), selective (useful to those at higher risk), and indicated (targeted to those who exhibit symptoms of a disorder). Beyond prevention, the Institute of Medicine intervention spectrum includes interventions such as case (i.e., illness) identification, traditional treatment, and health maintenance
www.jaacap.org
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COZZA
activities. Such a model, incorporating trauma-informed approaches, provides an excellent foundation to sustain the health of military children and families within a spectrum of risk. Universal prevention in military communities can support the readiness of military children and families and should be studied further to determine its effect on enhancing strength and limiting negative outcomes. Such prevention is best achieved by programs that ensure social support and make resources readily available to help adults, children, and families develop resilience-enhancing skills— communicating, connecting with others, being flexible, taking on new and appropriate challenges, solving problems, resolving conflicts, and building a core sense of individual and family capacity and wellness. Such programs should be available in the settings where service members, veterans, and their children and families are likely to be found— schools, child-care programs, youth services, faith-based organizations, and health care systems, all of which have the capacity to promote health and wellness. More intensive selective or indicated prevention programs that address the greater needs of those families with post-deployment distress or dysfunction or those that struggle with PTSD or physical injury must be further developed and implemented. My colleagues and I14 described recommendations to support children in the highest-risk military and veteran families facing chronic PTSD and TBI. For example, it is important to stabilize the family environment by ensuring access to basic needs, such as housing, education, health care, child care, and jobs throughout injury recovery and adjustment; to identify and promote services that support family organization, communication, coping, and resilience; to provide specific information to all family members (including children) so they better understand the negative impact that diagnoses such as PTSD and TBI can have on children and families; to teach parenting tools specific to injury-related challenges; to provide family problem solving and conflict-resolution strategies; and to sustain systems of support for these families who might need help for many years.
We also must ensure that service members and veterans, in addition to their spouses and children, have ready access to trauma-informed, evidence-based treatments close to where they live when mental illness is present and formal treatment is indicated. Because many disorders for which combat veterans are treated are chronic (e.g., PTSD, substance use, depression, and TBI), programs that support veterans’ functioning and minimize clinical deterioration are essential to the health and well-being of their children and families. Given the stigma associated with mental disorders and hesitation in seeking help for family problems, military service members and family members might not seek treatment or assistance, highlighting the need for enhanced outreach and engagement strategies. Military children are our nation’s children. Like their military parents, they serve our country and deserve the country’s support in meeting the challenges that come with military family life. It is important to remember that military children reflect their families, which are a population of diversity and complexity, varying in strength and wellness. Clinicians need to understand military families’ unique and varying needs—and be prepared to assist them with a range of interventions that best serves their children. Additional research is required to better inform these decisions. & Accepted January 28, 2015. Dr. Cozza is with Uniformed Services University of the Health Sciences, Bethesda, MD. Dr. Cozza’s views expressed herein do not necessarily reflect those of the Uniformed Services University of the Health Sciences or the Department of Defense. Disclosure: Dr. Cozza has received funding from the Congressionally Directed Medical Research Program to conduct scientific research with military children and families. Correspondence to Stephen J. Cozza, MD, Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814; e-mail: [email protected] 0890-8567/$36.00/Published by Elsevier Inc. on behalf of the American Academy of Child and Adolescent Psychiatry. http://dx.doi.org/10.1016/j.jaac.2015.01.012
REFERENCES 1. Department of Defense. 2013 Demographics: Profile of the Military Community. Washington, DC: Department of Defense; 2014. 2. Easterbrooks MA, Ginsburg K, Lerner RM. Resilience among military youth. Future Child. 2013;23:99-120. 3. Lester P, Peterson K, Reeves J, et al. The long war and parental combat deployment: effects on military children and at-home spouses. J Am Acad Child Adolesc Psychiatry. 2010;49:310-320. 4. Chandra A, Lara-Cinisomo S, Jaycox LH, et al. Children on the homefront: the experience of children from military families. Pediatrics. 2010;125:16-25. 5. Chartrand MM, Frank DA, White LF, Shope TR. Effect of parents’ wartime deployment on the behavior of young children in military families. Arch Pediatr Adolesc Med. 2008;162:1009-1014. 6. Mansfield AJ, Kaufman JS, Engel CC, Gaynes BN. Deployment and mental health diagnoses among children of US Army personnel. Arch Pediatr Adolesc Med. 2011;165:999-1005. 7. Gibbs DA, Martin SL, Kupper LL, Johnson RE. Child maltreatment in enlisted soldiers’ families during combat-related deployments. JAMA. 2007;298:528-535. 8. Rentz ED, Marshall SW, Loomis D, Casteel C, Martin SL, Gibbs DA. Effect of deployment on the occurrence of child maltreatment in
248
www.jaacap.org
9.
10.
11.
12.
13.
14.
military and nonmilitary families. Am J Epidemiol. 2007;165: 1199-1206. McCarroll JE, Fan Z, Newby JH, Ursano RJ. Trends in US Army child maltreatment reports: 1990-2004. Child Abuse Rev. 2008;17: 108-118. Hisle-Gorman E, Harrington D, Nylund CM, Tercyak KP, Anthony BJ, Gorman GH. Impact of parents’ wartime military deployment and injury on young children’s safety and mental health. J Am Acad Child Adolesc Psychiatry. 2015;54:294-301. Lester P, Stein JA, Saltzman W, et al. Psychological health of military children: longitudinal evaluation of a family-centered prevention program to enhance family resilience. Mil Med. 2013;178:838-845. Gewirtz AH, Pinna KL, Hanson SK, Brockberg D. Promoting parenting to support reintegrating military families: after deployment, adaptive parenting tools. Psychol Serv. 2014;11:31-40. Mrazek PJ, Haggerty RJ, eds. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: National Academy Press; 1994. Holmes AK, Rauch RK, Cozza SJ. When a parent is injured or killed in combat. Future Child. 2013;23:143-162.
JOURNAL
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 4 APRIL 2015
S
ince 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, involving 3, 4, or even 5 or more family separations and reunifications. Others have struggled with combat-related psychiatric disorders, such as posttraumatic stress disorder (PTSD) and physical injuries, including traumatic brain injury (TBI), which can affect children and families for years. Primary care and mental health clinicians in the United States know little about military children or the costs imposed on their health and functioning owing to their parents’ military service. Military and veteran families live in communities across the country, often far from military installations, where they obtain their health care from clinicians who might not understand their unique experiences, strengths, or challenges. After departing the military, veteran families often reintegrate into civilian communities, bringing their military identities and experiences with them. Active duty and selective reserve military children are young, with nearly 40% of these children younger than 6 years and two thirds younger than 12 years.1 There is a paucity of scientific study of these youth, but what exists describes their strengths,2 as well as elevated levels of distress and psychosocial problems associated with parental combat deployments,3-5 with cumulative parental deployment time associated with poorer outcomes.3,4,6 Child maltreatment, child neglect in particular, also has been associated with combat deployments to Iraq and Afghanistan.7-9 The article by Hisle-Gorman et al.10 in this issue of the Journal is an important addition to our knowledge about military children that can inform policy and practice. The study reports risks faced by young children (3–8 years old) and the differential effects of parental deployment and combat injury, both physical and psychological, on their health care usage in the 1-year period after deployment. Increases in child mental health visits and child injury- and maltreatmentrelated health care visits in deployed families in this study strengthen the association of child health and wellness burdens with parental combat-related military duty. In addition, the investigators found significant differences and escalating risk of these outcomes among no deployment, deployment without combat injury, and deployment with combat injury conditions, respectively. These findings provide greater clarity on the varying impact of combat-related experiences on child health and mental health, which likely require different types and levels of support and intervention. JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 4 APRIL 2015
MD
What remains unclear, based on the brief 1-year period examined in this study, is the degree to which risk continues or changes over time. Does risk decrease after deployment or do the stresses and strains of combat deployment and reunification continue to negatively reverberate within a family over time? We might expect that the effects of deployments on children in families not impacted by physical or psychological injury would resolve more readily, whereas effects resulting from PTSD or chronic physical conditions such as TBI would parallel the commonly extended courses of these parental conditions. Future longitudinal scientific studies should address these questions, delineating risk pathways and informing effective intervention strategies. The results reported in this study should be interpreted with some caution. For example, the investigators used procedural codes that clinicians employ for insurance and other nonclinical purposes. Data on health care utilization are not necessarily indications of the health care requirements of the population. In addition, greater use of mental health services should not be equated with greater levels of mental illness. Although some military children develop mental disorders, they are a minority. Higher levels of child mental health utilization found by Hisle-Gorman et al. may be best understood as greater help-seeking by highly distressed children and families impacted by combat deployments or resultant parental injuries. Similarly, increased injury- and maltreatment-related health appointments likely reflect heightened parental and family distress, disorganization, and dysfunction resulting from these same challenges. Distress is not an illness, but it can profoundly affect individuals, families, and communities. In addition to the emotional anguish it causes, distress can undermine individual, family, and parental functioning. Researchers universally recognize that children’s health is related to the health and well-being of their parents, and this also has been found true for military children.3,4 The lives of military children are intertwined with their parents’ lives, and their health risks reflect their families’ risks. Not surprisingly, family-centered approaches to care, those that target parenting and family processes, have been found promising in supporting military child and family health.11,12 In 1994, the Institute of Medicine outlined a spectrum of activities that promote and sustain health in variably affected at-risk populations.13 It places prevention strategies along a spectrum of intensity: universal (helpful to all), selective (useful to those at higher risk), and indicated (targeted to those who exhibit symptoms of a disorder). Beyond prevention, the Institute of Medicine intervention spectrum includes interventions such as case (i.e., illness) identification, traditional treatment, and health maintenance
www.jaacap.org
247
COZZA
activities. Such a model, incorporating trauma-informed approaches, provides an excellent foundation to sustain the health of military children and families within a spectrum of risk. Universal prevention in military communities can support the readiness of military children and families and should be studied further to determine its effect on enhancing strength and limiting negative outcomes. Such prevention is best achieved by programs that ensure social support and make resources readily available to help adults, children, and families develop resilience-enhancing skills— communicating, connecting with others, being flexible, taking on new and appropriate challenges, solving problems, resolving conflicts, and building a core sense of individual and family capacity and wellness. Such programs should be available in the settings where service members, veterans, and their children and families are likely to be found— schools, child-care programs, youth services, faith-based organizations, and health care systems, all of which have the capacity to promote health and wellness. More intensive selective or indicated prevention programs that address the greater needs of those families with post-deployment distress or dysfunction or those that struggle with PTSD or physical injury must be further developed and implemented. My colleagues and I14 described recommendations to support children in the highest-risk military and veteran families facing chronic PTSD and TBI. For example, it is important to stabilize the family environment by ensuring access to basic needs, such as housing, education, health care, child care, and jobs throughout injury recovery and adjustment; to identify and promote services that support family organization, communication, coping, and resilience; to provide specific information to all family members (including children) so they better understand the negative impact that diagnoses such as PTSD and TBI can have on children and families; to teach parenting tools specific to injury-related challenges; to provide family problem solving and conflict-resolution strategies; and to sustain systems of support for these families who might need help for many years.
We also must ensure that service members and veterans, in addition to their spouses and children, have ready access to trauma-informed, evidence-based treatments close to where they live when mental illness is present and formal treatment is indicated. Because many disorders for which combat veterans are treated are chronic (e.g., PTSD, substance use, depression, and TBI), programs that support veterans’ functioning and minimize clinical deterioration are essential to the health and well-being of their children and families. Given the stigma associated with mental disorders and hesitation in seeking help for family problems, military service members and family members might not seek treatment or assistance, highlighting the need for enhanced outreach and engagement strategies. Military children are our nation’s children. Like their military parents, they serve our country and deserve the country’s support in meeting the challenges that come with military family life. It is important to remember that military children reflect their families, which are a population of diversity and complexity, varying in strength and wellness. Clinicians need to understand military families’ unique and varying needs—and be prepared to assist them with a range of interventions that best serves their children. Additional research is required to better inform these decisions. & Accepted January 28, 2015. Dr. Cozza is with Uniformed Services University of the Health Sciences, Bethesda, MD. Dr. Cozza’s views expressed herein do not necessarily reflect those of the Uniformed Services University of the Health Sciences or the Department of Defense. Disclosure: Dr. Cozza has received funding from the Congressionally Directed Medical Research Program to conduct scientific research with military children and families. Correspondence to Stephen J. Cozza, MD, Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814; e-mail: [email protected] 0890-8567/$36.00/Published by Elsevier Inc. on behalf of the American Academy of Child and Adolescent Psychiatry. http://dx.doi.org/10.1016/j.jaac.2015.01.012
REFERENCES 1. Department of Defense. 2013 Demographics: Profile of the Military Community. Washington, DC: Department of Defense; 2014. 2. Easterbrooks MA, Ginsburg K, Lerner RM. Resilience among military youth. Future Child. 2013;23:99-120. 3. Lester P, Peterson K, Reeves J, et al. The long war and parental combat deployment: effects on military children and at-home spouses. J Am Acad Child Adolesc Psychiatry. 2010;49:310-320. 4. Chandra A, Lara-Cinisomo S, Jaycox LH, et al. Children on the homefront: the experience of children from military families. Pediatrics. 2010;125:16-25. 5. Chartrand MM, Frank DA, White LF, Shope TR. Effect of parents’ wartime deployment on the behavior of young children in military families. Arch Pediatr Adolesc Med. 2008;162:1009-1014. 6. Mansfield AJ, Kaufman JS, Engel CC, Gaynes BN. Deployment and mental health diagnoses among children of US Army personnel. Arch Pediatr Adolesc Med. 2011;165:999-1005. 7. Gibbs DA, Martin SL, Kupper LL, Johnson RE. Child maltreatment in enlisted soldiers’ families during combat-related deployments. JAMA. 2007;298:528-535. 8. Rentz ED, Marshall SW, Loomis D, Casteel C, Martin SL, Gibbs DA. Effect of deployment on the occurrence of child maltreatment in
248
www.jaacap.org
9.
10.
11.
12.
13.
14.
military and nonmilitary families. Am J Epidemiol. 2007;165: 1199-1206. McCarroll JE, Fan Z, Newby JH, Ursano RJ. Trends in US Army child maltreatment reports: 1990-2004. Child Abuse Rev. 2008;17: 108-118. Hisle-Gorman E, Harrington D, Nylund CM, Tercyak KP, Anthony BJ, Gorman GH. Impact of parents’ wartime military deployment and injury on young children’s safety and mental health. J Am Acad Child Adolesc Psychiatry. 2015;54:294-301. Lester P, Stein JA, Saltzman W, et al. Psychological health of military children: longitudinal evaluation of a family-centered prevention program to enhance family resilience. Mil Med. 2013;178:838-845. Gewirtz AH, Pinna KL, Hanson SK, Brockberg D. Promoting parenting to support reintegrating military families: after deployment, adaptive parenting tools. Psychol Serv. 2014;11:31-40. Mrazek PJ, Haggerty RJ, eds. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: National Academy Press; 1994. Holmes AK, Rauch RK, Cozza SJ. When a parent is injured or killed in combat. Future Child. 2013;23:143-162.
JOURNAL
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 4 APRIL 2015
