They Also Serve:
U.S. military children and
our wars of the 21st Century
Gregory Toussaint, MD
Wright State University
Boonshoft School of Medicine
1
Overview - children and deployment
• Scope of this issue
• Early research: Desert Storm / Gulf War 1
• The “under-5s”
• School age
• Uncomfortable issues: child and parent
• Making it real: personal vignettes
• Where is the help?
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What can I do?
• First, some questions…
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U.S. military today
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Terminology
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Active duty – 4 branches and Coast Guard
Reserves – all 5 branches
National Guard – Army, Air Force
Mobilized – activated Reserves, Nat’l Guard
• “Deployed”
• CENTCOM
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OEF: Afghanistan, central Asia
OIF: Iraq, Arabian peninsula
Horn of Africa
www.globalsecurity.org
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U.S. military today
Personnel End Strength – FY05
FY2005
Active
TOTAL
1,421,414
Mobilized
77,861
-----
Guard
464,900
-----
Reserve
752,000
3,017,414
-----
126,000
126,000
205,000
250,000
1,375,600
199,000
588,239
-----
Army
562,400
48,331
Navy
324,239
10,818
-----
65,500
Marines
203,075
2,261
-----
39,600
Air Force
331,700
16,451
106,700
TOTAL
379,600
DOD
358,200
Civilian
69,500
----177,000
242,675
684,900
www.globalsecurity.org
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Scope of the issue
• Since 2001:
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> 2 million service men/women have deployed
793k have deployed more than once; many 3-4 tours
Length of tours vary by service, what you do
 “Ops tempo” a critical part of family life
Active duty service members
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1.2 million ‘dependents’ < 23 yrs of age
40% < 5 yrs of age
• Reservists / Nat’l Guard
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660,000 dependents
20% < 5 yrs of age
JAMA 2008, 300:644
J Am Acad Child Psych 2010, 4:297
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Women in the US military
US military
Number
Percent of total
Total Active Duty and Reserves
342,000
14.3% of active duty force
Deployed to Iraq or Afghanistan
since 2001
165,683
48.4% of all military women
Women of minority in the military
White
African-American
Hispanic
Asian, other
All active duty
64%
15%
15%
6%
AD women
50%
30%
6%
5%
Civilian women
70%
13%
12%
5%
US Congress Joint Economic Committee Report, May 2007
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Military moms (active duty)
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38% all active duty women have children
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11% all active duty women are single parents
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4% single fathers
Higher attrition rate than men
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44% of men
2002 GAO report: 1/3 left due to child care concerns
New mothers: 6 weeks maternity leave
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Additional time off uses earned leave (vacation time)
If on deployment status : 4-to-6 month deferment
US Congress Joint Economic Committee Report, May 2007
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What happens during ‘deployment’?
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Pre-deployment
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Deployment / sustainment
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Notification of orders to go
Accomplish training needed, get “spun up”
Clock ticking, but for how long?
A send off, then time “in theater”
The waiting. And waiting
Re-deployment
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Reintegration into family unit
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What else happens?
• Pre-deployment
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Deployment
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Stress. On parent(s), spill-over to child
Fear. Age-related understanding of what’s coming
Impact of parent’s absence takes effect
Families adapt, or not, to range of feelings
Reunification
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First reunion. Rebuild relationships, boundaries
Parent back to work. Reserve/Guard may deactivate
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New issues for military children
• Striking number of affected children
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More ‘dependents’ now than military personnel
Almost 40% personnel are activated Reserve, Guard
How can combat deployments affect children?
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Longest sustained conflict, repeated tours
 Sustained operations tempo taking a toll
 Army tours longer; Air Force shorter + more frequent
 numbers of parents w/ physical, mental health effects
Communication technology unprecedented
 Home front is on the front lines and vice versa
Ambul Peds 2007, 7:1
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Early research
• 1990-1991
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Desert Shield --- Desert Storm --- Gulf War 1
Air war start Jan 91, short ground campaign followed
~ 580,000 U.S. troops in-theater
 (almost 30,000 hospital beds)
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First 24-hour news coverage, children exposed more
Relatively brief period conflict, small number casualties
Short deployments without recurrence
1992-1993
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Operation Restore Hope (Somalia)
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Early research
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Smaller studies, limited scope
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Increases noted in internalizing, externalizing symptoms
 Internalizing = emotional lability, anxious, depressed
 Externalizing = attention difficulties, aggression
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Children rarely required clinical attention
Mil Med 1993, 158:465
• One, a pre-Desert Storm study, did f/u work
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Increased levels of anxiety, depression
Did not reach pathologic levels, resolved quickly
Boys, younger children at higher risk
J Am Acad Child Psych 1996, 35:433
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The “under 5”s
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Remember the math?
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40% active duty, 20% Reserve/Guard
Total ~ 620,000 dependent children < 5 yrs age
• Time of critical developmental periods
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Two studies focus on behaviors
Two on utilization of health care
Concerns:
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Evidence suggests young not spared
Huge size of group warrants closer look
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Developmental issues
• Cross-sectional study, large Marine base
 Arch Ped Adol Med 2008, 162:1009
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On-base child care centers, children 1.5-5 yrs
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Chartrand M et al.
May-Dec 2007, 169 families
Child Behavior Checklist, two parental stress measures
CBCL-Teacher Report form for centers’ staff
Results
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Controlled for parental stress, depressive symptoms
Highest behavior issues: 3-5 yr olds w/ parent gone
1.5-3 yrs age had signif lower externalizing symptoms
Note: one base, organized care, short (3.9 mos) tours
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More observed behaviors
• Study of 57 Army families (Ft Knox, KY)
 Mil Med 2009, 174:1033
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Barker L et al
Married, > 1 child 0-47 months
No-, single-, and multiple-deployment groups
• Parent-reported on “observed behaviors”
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Not a normed assessment tool
Needs attention, clingy, tantrums Prefers non-deployed
Results:
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“Children in deployment grp had parent gone > ½ life”
2/3 reported transient attachment behaviors on reunion
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Utilization of health care?
• Study of 2007 DoD claims data (direct + Tricare)
 Pediatrics 2010, 126:1
•
Eide M et al
Linked care visit data to parental deployment
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169k+ children with 1.77M outpatient visits
Well child visits = 27%
Overall visits  7%, well child visits  8%
** if had young, single military parent = fewer visits
** children of married parents seen more frequently
• Conclusions
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Could caretakers for single parents not access care?
Increased use a marker for stress?
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Utilization of mental health services
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Same people, databases (direct + Tricare)
 Pediatrics 2010, 126:1058
GormanG et al
• Focused on mental / behavioral health visits
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> 642k kids ages 3-8 yrs. > 442k active duty parents
Analyzed claims for > 611k visits
 Mental health visits  11% when parent deployed
 Behavioral disorders  19%
 Stress disorders  18%
Larger increases seen if:
 Older children, parents married, father military one
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What about school age?
• Greater numbers total than “under 5”s
• Military children generally robust, healthy group
• Three principal areas of wartime stress
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Deployment of military parents
Injury or illness of parents
Parental death
Psych Quart 2005, 76:371
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Deployment + school age children
• Survey of parents w/ child 5-12 yrs old
 J Dev Behav Ped 2009, 30:271
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Flake E, Davis BE, et al
Pediatric Symptom Checklist, Parenting Stress-Index form
1/3 families at “high risk” for psychosocial problems
Most significant predictor = degree of parenting stress
171 families from Army post, Marine base
 J Am Acad Child Adol Psych 2010, 49:310
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Lester P et al
Active duty parent deployed > once, ave 16.7 months
40% of AD parents showed signif signs distress
Problems: girls more during, boys after deployment
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School age children
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Study population military children at camp
 Pediatrics 2010, 125:16
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Chandra A et al
Phone interviews w/ 1507 children (11-17 yrs), caregivers
Controlled for family, service member characteristics
Results
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Children had more emotional difficulties than US norms
Older youth had greater # problems during deployment
Girls had more problems during reintegration
Caregivers mental health correlated w/ child well-being
Greater total time away = increased stressors
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Perspectives of school staff
• Qualitative study at 12 schools around U.S.
 J Adol Health 2010, 46:218
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Focus groups or interviews of school staff
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Chandra A et al
Teachers, counselors, administrators
3 schools on post, rest with 30-70% military students
Results:
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Personnel see deployments affecting ability to function
Students are losing resiliency as deployments continue
Schools are becoming the stable place or sanctuary
 Students’ stress also wearing on staff
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Other issues: child maltreatment
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Clear evidence for profound emotional impact
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Does it translate into increased maltreatment?
TX study of child maltreatment rates
 Am J Epidemiol 2007, 165:1199
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Rentz E et al
Jan 2000-Jun 2003 study period
All substantiated cases in TX, civilian and military
Majority of perpetrators parents
Military rates 37% < civilian until Oct 02
Rate after Oct 02 double that prior and 22% > civilian
Rates for civilian families remained stable
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Child maltreatment
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Study of 1771 families of Army enlisted
 JAMA 2007, 298:528
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Gibbs D et al
40-month study period
Child maltreatment rate
 42% higher during combat deployment times
 Greatest increase in neglect cases
 Physical, emotional abuse rates much lower
 Rates for neglect by female civilian parent  4x
• Rates for physical abuse  2x
 No change in rates by male civilian parent
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Returning parents…
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Injured parents
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Dramatic increase in numbers of severely wounded
Spillover is in number of children w/ disabled parent
“No such thing as injured service member. We should
be thinking injured family.” Stephen Cozza, MD
• Parental suicide
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Review article from Dept Veterans’ Affairs
 Am J Epidemiol 2009, 19:757
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USU Center for Traumatic Stress
JAMA 2010, 300:644
Kang H, Bulliman T
Published studies do not prove increased rate in vets
Rates are increasing among active duty personnel
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And those who didn’t
• Combat + non-hostile deaths as of 31 May 2011:
Total deaths
# women
Operation Enduring Freedom
1590
30
Operation Iraqi Freedom /
Operation New Dawn (Sep 2010)
4444
110
Totals
6034
140
siadapp.dmdc.osd.mil
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Est 12,000 children have had a parent die
RAND Corp 2010
When active duty member dies, families will move
 Lose on-base housing, may return to hometown
 New community may not appreciate experiences, needs
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Making it personal
• Vignettes from people I deployed with or know
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What did I learn?
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Speed of communication has forever changed things
Home events have ripple effect in combat zone
Pre-deployment planning yields huge benefits
Stability of non-deployed parent (or figure), home critical
 If you’ve got it, you can do anything
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Brave new world of communication
• Time warp
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Feb 2002
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“Location masked” base, all special ops units
No phone/e-mail x 6 wks, no mailing address x 2 months
Sep 2004
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One 10 min phone call per week, full e-mail
Jan 2003
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(Mr. Peabody’s Wayback machine)
COMSEC rules, full e-mail except…, AT&T phone bank
May 2011
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Official e-mail, phones in quarters, contract internet service
No COMSEC, full internet access including Skype
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“Too much” connectivity?
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Physician father (adult type ) deployed for 6 months
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3 children – ages 4 + 2 yrs and 6 months (left at 6 wks age)
Well established location, e-mail, phone, internet
“Skypes” regularly with family
Infant develops bad conjunctivitis
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Mother holds infant up to laptop camera
Father…
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Where is the help?
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Early on (2001-2003) – not much
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Units built their own support structure
Deactivated Reserve, Guard often on their own
Gradual response, now a proactive effort
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DoD internal efforts
 Family support centers, pre / post-deployment events
 Enhanced social work, mental health services
Military family organizations
Academic institutions’ research efforts
Private corporations
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Military OneSource
www.militaryonesource.com/
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Sesame Street help!
www.sesameworkshop.org
ADM Mullen, then CJCS
online.wsj.com
New in Apr 2010,
traveling USO shows
Starring Katie!
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Purdue Military Family Research Institute
www.mfri.purdue.edu/
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National Military Family Association
Operation Purple camp
www.operationpurplecampinfo.com
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What should I remember?
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These children are also “serving”
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Not just ”base kids” – they’re in all our communities
Stress affects both sides of equation (and ocean)
Effects on children vary with developmental stage
 U-5s different than school age and teens
Resources improving for children and families
Military families are resilient
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Resilience waning for those called again, again
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What can I do?
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Play the same role you always have
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Advocate for the child
Educate, support family
Be willing to ask your patients’ families:
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“Have you or has anyone you know been involved
in the war effort in Iraq or Afghanistan?”
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