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As U.S. military deployments continue around the world, children are experiencing separation from one or more parents in unprecedented numbers. As of 2009, the year for which the most recent data are available, the parents of nearly 2 million children were on active or reserve duty in the military.1 Since Sept. 11, 2001, more than 800,000 parents have deployed for military activity.2 More than 200,000 have deployed twice, and more than 100,000 have deployed three or more times.2
Mounting evidence points to an association between deployment-based separation and psychological and behavioral disorders in military children. Civilian providers are responsible for almost two-thirds of outpatient care for the children of military parents,3 and they may be less likely to have knowledge of the military resources available for behavioral health referral.
Effects of Stress on Children
Stress is the disruption of a normal state of well-being that results in emotional and physiologic changes.4 A certain amount of stress is normal and even necessary, since it allows children to develop skills and coping mechanisms that allow them to adapt to new situations. But when stress is significant enough to overwhelm a child's existing coping mechanisms, negative health effects can occur.
Prolonged stress and the subsequent increase in production of stress-related hormones can affect the immune system and neurologic functioning. Excessive levels of cortisol and other stress-related hormones can suppress immunologic response, resulting in increased infection risk. In addition, continued high levels of cortisol can damage structures in the hippocampus, leading to neuronal atrophy and cognitive impairment that may persist into adulthood.5,6 Childhood stress has been linked to health problems later in life, such as alcoholism, depression, heart disease and other chronic illnesses.4
Stress in the Military Child
The deployment of a parent to a war zone is a major event in the life of a child. Some child mental health experts describe it as a "catastrophic" stressor on children and families.7 In some cases, family members may experience more stress than the deployed soldiers.8
Historically, children from military families have been viewed as a particularly resilient population. Research performed during Operation Desert Storm found that children in military families often had similar if not better mental health outcomes than children from civilian families, with no increase in psychopathology.9,10 Because the U.S. military interventions in Iraq and Afghanistan have required repeated deployments, they have taken a unique toll. Children and families who were able to cope well with an initial deployment may not be able to function as optimally with subsequent deployments, since emotional and psychological resources are exhausted.11
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Research has consistently documented an increase in anxiety, depression and behavioral problems among children whose parents are deployed. In one study, approximately one-third of 5- to 12-year-olds were identified as being at high risk for psychosocial morbidity.12 A 19% increase in behavioral disorders and an 18% increase in stress disorders have been recorded among military children during deployment.3 This statistic is particularly alarming because the number of overall healthcare visits by military children decreases when a parent is deployed.3
Parental deployment can negatively affect children's academic outcomes. In addition to the reports of increased absenteeism and behavioral complaints among children with deployed parents, standardized reading and math scores are lower during periods of deployment.11
Vulnerable Populations
Table 1 outlines which military children are at increased risk for stress-related problems while a parent is deployed.12,13 Older children, particularly adolescents, tend to have more problems with deployment and reintegration during the post-deployment period. This is not surprising considering the developmental characteristics of this age group. Children in this age range have a greater tendency to worry in general, likely due to increased personal and social challenges.14 In addition, older children are typically more likely to assume a greater number of household responsibilities during a parental deployment and may experience additional stress as a result of these new roles.14
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Other demographic factors may place children at increased risk for stress-related problems. Vulnerable family structures are likely to experience proportionally greater strain and challenges during the deployment period. Children and families who are functioning less than optimally prior to deployment are likely to experience a magnification of existing problems.11 Children of single military parents may be living with extended family during a parent's deployment. These temporary guardians may not be as familiar with the child's baseline behavior, and they may over- or underreport behavioral concerns. In addition, they are less likely to be familiar with available community resources.3
The stress levels of parents and caregivers at home should not be overlooked. Studies have shown that one of the most significant predictors of stress-related symptoms in children with a deployed parent is the psychological health of the at-home parent or caregiver. In these studies, parents who report clinically significant stress were more than seven times as likely to have children identified as being at high risk for psychological or behavioral problems as parents who did not report stress.12,15
Role of the Primary Care Provider
Primary care providers play an important role in the diagnosis and treatment of behavioral health concerns. Early treatment of mild to moderate behavioral health disorders decreases the risk for long-term morbidity.16 Primary care providers are typically the first to encounter early signs and symptoms of emotional or psychological distress. Continuity of care allows for these providers to develop and maintain an ongoing relationship built on familiarity and trust.
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That said, it is important to know that psychosocial needs may be overlooked in primary care settings unless the purpose of the visit is to address a new or ongoing behavioral concern. Primary care providers report a number of obstacles to the recognition and treatment of behavioral health symptoms. Common themes include perceived lack of training on the part of the provider, the limited amount of time allotted for a typical office visit, and lack of available specialty care resources.17
One study found that the presence of somatic complaints, particularly pain, and seeing a male healthcare provider are inversely proportional to the likelihood that psychosocial issues will be addressed at a primary care visit.18 The authors concluded that multiple complex factors are associated with the discussion of psychosocial health, and that pain interferes with discussion during all types of visits, particularly those involving children with mental health symptoms. All primary care providers should obtain education and information about the signs and symptoms of stress-related behavioral disorders to facilitate early detection of mental health problems.
Presenting Signs and Symptoms
Each child responds differently to a parent's deployment. Typical responses are a reflection of the child's age, emotional and psychological maturity, and the presence of any preexisting psychological or behavioral issues. Stress-related symptoms may manifest as somatic complaints or as emotional, psychological or behavioral symptoms (Table 2).
Often, children or parents may be reluctant to verbalize concerns or may not be aware that a problem exists. One military expert recommends that healthcare providers initiate discussion with children by asking the following question: "I understand your mom or dad is deployed. How are you feeling?"19 In addition, NPs and PAs can perform a quick assessment of coping skills related to a specific complaint, such as "What do you do when you have difficulty with your math homework?" If a concern presents itself, ask questions about the presence or absence of the specific symptoms listed in Table 2.
Screening tools can be administered to the at-risk child in the clinic setting. Researchers and clinicians working with children in military families have used these tools to assist in detecting stress-related disorders in primary care settings. Such tools include the Pediatric Symptom Checklist, the Child Behavior Checklist and the Screen for Child Anxiety-Related Emotional Disorders.
Treatment Options
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For children whose symptoms are mild, family self-help measures can be effective (Table 3). These interventions focus on minimizing the impact of the separation and encouraging the development of healthy coping strategies. While it is important to provide a supportive environment, it is crucial for parents to provide the child with an opportunity to problem solve and to develop a degree of resiliency.20
Encourage parents to seek help for any emotional difficulties they experience, since children are directly affected by their parents' mental health status.14 For children who do not respond to family self-help measures, counseling may be necessary. This is typically available without charge through the military healthcare system. Children who meet clinical criteria for depression, anxiety or another mental health disorder may require referral to a mental health professional if treatment of these disorders is beyond the scope or comfort level of the primary care provider.
Support Resources for Military Families
Research has shown that parents who use military and community family support resources report significantly less psychosocial problems with their children.12 Behavioral health resources are available for free through the military healthcare system and from other entities.
Military OneSource provides links to professional, nonmedical counseling services designed to provide problem-solving strategies and help with short-term issues such as adjustment to situational stressors, stress management, etc. Patients who require ongoing care are referred to the closest military treatment facility. http://http//www.militaryonesource.com/MOS/About/CounselingServices.aspx
The TriWest behavioral health web portal provides access to evidence-based educational materials, a video library, references and community resources for both providers and families. The provider link enables healthcare providers to access referral criteria and paperwork, and allows providers and families to locate mental health professionals and behavioral health community resources in the area.
Providers: http://http//triwest.com/en/provider/behavioral-health/
Beneficiaries: http://triwest.com/en/beneficiary/behavioral-healthhttp://
The American Academy of Pediatrics maintains a web page designed to provide support for military children and adolescents. http://http//www.aap.org/sections/uniformedservices/deployment/index.html
The Army Strong website provides links to resources specifically designed to assist children in coping with deployment. Most items are available free of charge to eligible families. http://http//www.armystrongfamily.org/children2.html
References
1. Department of Defense. Demographics 2009: Profile of the Military Community. http://http://www.militaryhomefront.dod.mil/12038/Project%20Documents/MilitaryHOMEFRONT/QOL%20Resources/Reports/2009_Demographics_Report.pdf. Accessed Nov. 28, 2011.
2. Glod M. Coping with their parents' war. Washington Post. July 17, 2008. http://http://www.washingtonpost.com/wp-dyn/content/article/2008/07/16/AR2008071602878.html. Accessed Nov. 28, 2011.
3. Gorman GH, et al. Wartime military deployment and increased pediatric mental and behavioral health complaints. Pediatrics. 2010;126(6):1058-1066.
4. Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2008.
5. National Scientific Council on the Developing Child. Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper No. 3. Cambridge, MA: National Scientific Council on the Developing Child; 2005. http://http://developingchild.harvard.edu/index.php/resources/reports_and_working_papers/working_papers/wp3/. Accessed Nov. 28, 2011.
6. McEwen BS. Stressed or stressed out: what is the difference? J Psychiatry Neurosci. 2005;30(5):315-318.
7. Cozza SJ, et al. Military families and children during Operation Iraqi Freedom. Psychiatr Q. 2005;76(4):371-378.
8. Zeff KN, et al. Military family adaptation to United Nations operations in Somalia. Mil Med. 1997;162(6):384-387.
9. Jensen PS, et al. The "military family syndrome" revisited: "by the numbers." J Nerv Ment Dis. 1991;179(2):102-107.
10. Jensen PS, et al. Prevalence of mental disorder in military children and adolescents: findings from a two-stage community survey. J Am Acad Child Adolesc Psychiatry. 1995;34(11):1514-1524.
11. Chandra A, et al. The impact of parental deployment on child social and emotional functioning: perspectives of school staff. J Adolesc Health. 2010;46(3):218-223.
12. Flake EM, et al. The psychosocial effects of deployment on military children. J Dev Behav Pediatr. 2009;30(4):271-278.
13. Chandra A, et al. Children on the homefront: the experience of children from military families. Pediatrics. 2010;125(1):16-25.
14. Brown SL, et al. Gender, age, and behavior differences in early adolescent worry. J Sch Health. 2006;76(8):430-437.
15. Chartrand MM, et al. Effect of parents' wartime deployment on the behavior of young children in military families. Arch Pediatr Adolesc Med. 2008;162(11):1009-1014.
16. Williams J, et al. Diagnosis and treatment of behavioral health disorders in pediatric practice. Pediatrics. 2004;114(3):601-606.
17. Bitar GW, et al. Barriers and facilitators of adolescent behavioral health in primary care: perceptions of primary care providers. Fam Syst Health. 2009;27(4):346-361.
18. Brown JD, et al. Physician and patient characteristics associated with discussion of psychosocial health during pediatric primary care visits. Clin Pediatr (Phila). 2007;46(9):812-820.
19. Davis BE. Parental wartime deployment and the use of mental health services among young military children. Pediatrics. 2010;126(6):1215-1216.
20. Power TG. Stress and coping in childhood: the parents' role. Parent Sci Pract. 2004;4(4):271-317.
Elizabeth H. Hopewell is a family nurse practitioner at Ballston Family Medicine in Arlington, Va. She has completed a disclosure statement and reports no relationships related to this article.
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