Deployment & Redeployment The cycle continues… Douglas Lehman, LCSW, CAC III

1. Deployment & Redeployment The cycle continues… Douglas Lehman, LCSW, CAC III Department of Behavioral Health EVANS Army Community Hospital Ft. Carson, CO

2. Views expressed in this presentation are those of the author and do not reflect the official policy of the Army, the Department of Defense or the United States Government.

3. Deployment & Redeployment I. Introductions II. Research III. Cycle of Deployment A. Signs of Stress and Interventions 1. Adults (at home spouse) 2. Preschool 3. Elementary 4. Adolescent IV. Talking with Children About War V. Deceased Soldiers and Their Families VI. Creating Successful Reunions A. The Returning Veteran & The Family VII. Wrap-Up

4. Army FamiliesAge of AD Soldiers’ Spouses Enlisted Officers

5. Army FamiliesAge of Soldiers’ Children

6. Military Families Family members include spouses, children, and adult dependents

7. Military Family High Risk Indicators Family History of Mental Health Issues Child History of Mental Health Issues School History of Special Education i.e. IEP Lower Rank Soldiers (financial considerations and ability to access resources) Single parent male or female and foreign spouses Has the family experienced deployments and how many and duration

8. Military Family High Risk Indicators How well does the child exhibit coping skills prior to deployment Dual military career Newly Married Socially Isolated and Dependent Younger Children

9. Detecting the warning signs Persistent fear about war that interferes with a child’s regular activities. Sleep changes. Changes in the way a child eats that persist beyond several days. Changes in a child’s ability to concentrate. Prolonged increase in irritability. Atypical behavior problems at school or at home. Declining grades and performance. Physical complaints with no signs of illness. An increase in the child’s negative talk about himself and others. Withdrawal from friends and from family.

10. Understanding Children’s Reactions to War Deployment Children are affected by their parents’ traumatic experiences as well as their own Little scientific information about impact of parental combat exposure on children Equally dangerous to assume uniform resilience or uniform problems as a result of war exposure A real accounting of the trauma and its effects is an opportunity to honor the service and sacrifice War trauma is a primary source of difficulty for all military family members

11. More Military Kids Seeking Mental Health Treatment • Children of U.S. military troops sought outpatient mental health care 2 million times last year, double the number at the start of the Iraq war. • From 2007 to 2008, some 20 percent more children of active duty troops were hospitalized for mental health services, the documents show. • Since the 2003 invasion of Iraq, inpatient visits among military children have increased 50 percent. • The total number of outpatient mental health visits for children of men and women on active duty doubled from 1 million in 2003 to 2 million in 2008. • During the same period, the yearly bed days for military children 14 and under increased from 35,000 to 55,000, the documents show. Kimberly Hefling, Associated Press Writer, July 7, 2009

12. Office of Family Policy and Office of Children and Youth, DOD13.June .08 A suicide prevention project in San Antonio found that nearly 35 percent of more than 200 children from local military families needed to be treated for mental health conditions, further illustrating how the stresses of militarylife can affect the entire family. Results of the one-year screening project to identify military dependents at risk of suicide were announced Tuesday at the third annual Texas Suicide Prevention Symposium, which is being held in San Antonio to increase suicide awareness in the Alamo City. Barbara A. GoodnoSenior Program Analyst

13. Prevalence of Child Maltreatment OIF/OEF Child maltreatment among non military populations before and during military options in the middle east (Rentz et al.,2006). They found that the rate of child maltreatment was relatively stable between 2000-2003 among non military families; however among military families increased at end of 2002 and increased “dramatically” during the beginning of 2003. A study of the Army Central Registry found that maltreatment occurred more frequently at home while soldiers were engaged in combat-related deployments (Gibbs et al., 2007)

14. Rand Study: Center for Military Health Policy Research “Understanding the Impact of Deployment on Children and Families.” Findings from a Pilot Study of Operation Purple Camp Participants Chandram, Burns, Tanielian, Jaycox, and Scott (April 2008)

15. Emotional Cycle Of Deployment Stage 1. Pre Deployment (varies) Stage 2. Deployment (first month) Stage 3. Sustainment (months 2 thru5) Stage 4. Redeployment (last month) Stage 5. Post-deployment (3-6 months after deployment) *based on 6, 8,12 month stable deployment Dayton Peace Accords 1995 Bosnia

16. Remedies for Negative Consequences by Stage of Deployment Pre-DeploymentDiscuss responsibilities and expectations of each family member during the upcoming deployment. Make plans and goals for family rather then “put lives on hold.” Decreases likelihood of misperception and distortion. Deployment Initiate plans made during pre-deployment> Continue family traditions and develop new ones. Facilitate children’s understanding of the finite nature of the deployment by developing timelines (as age appropriate) Sustainment Establish support system (extended family, friends, religious groups, family support groups, etc.). Communicate with deployed service member via email, phone, letters. Avoid overspending ,Spend sometime without children. Re-Deployment Maintain routines. Make plans for homecoming but develop alternate plans in the case of changes of return time. Maintain realistic expectations of homecoming., try to dispel high expectations Post-Deployment Take time to communicate and get to know each other. Spend time talking to each other . Take time to make decisions and changes in routines. Lower expectations Keep plans simple and flexible. Don’t try to schedule too many things during first few weeks. Adopted from Pincus et, al 2007 (Rand report 2008)

17. Deployment Group Curriculum Goals Goal 1: To take the extreme emotional and behavioral responses about deployment and mitigate these responses. Goal 2: To change unhealthy coping to healthier responses. Goal 3: To have participants understand that feelings about deployment are understandable and normal. Goal 4: Focus on stay at home caregiver/parent is also part of the deployment cycle.

18. Deployment Group Curriculum – 12 Sessions Session 1: Introduction and Deployment Session 2: Tell us about your deployed parent. Session 3: Stress Session 4: Depression Session 5: Fear Session 6: Anger Session 7: Growing up in a military family Session 8: What changes when dad/mother is deployed? Session 9: Corresponding with deployed parent Session 10: Self-awareness/Self-expression Session 11: Celebration of being an Army Brat Session 12: Wrap up

20. Spouse Stressors During Deployment Phase Loneliness reported by more than 85% of spouses Miss companionship and intimacy Regret that the deployed service member misses important events Two-thirds describe it as stressful Percent handling loneliness “well” or “very well”

21. 2008 Survey of Active Duty Spouses (ADSS 2008) and the 2008 Survey of Reserve Component Spouses (RCSS 2008) Both surveys were paper-and-pencil and Web-based ADSS 2008 fielded March 21 – August 4, 2008 49K spouses of active duty members surveyed, weighted response rate of 28% RCSS 2008 fielded December 10, 2007 – March 26, 2008 54K spouses of Reserve component members surveyed, weighted response rate of 30%

22. ADSS: Effect Of Deployments On Spouses 2008 Summary Top 5 most common problems during spouse’s most recent deployment were: Loneliness (90%) Safety of spouse during deployment (84%) Feelings of anxiety or depression (83%) Difficulty sleeping (79%) Household repairs, yard work, or car maintenance (75%) RCSS: Effect Of Deployments On Spouses 2008 Summary Top 5 most common problems during spouse’s most recent deployment were: Increase in stress level (94%) Loneliness (92%) Feelings of anxiety or depression (89%) Household repairs, yard work, or car maintenance (88%) Difficulty sleeping (86%)

23. Cycle of the At-Home Spouse • Confusion • Denial • Resentment • Planning • Arguing • Apprehension • Cleaning • Dieting • Excitement • Worry • Busier than usual • Crying, loss of sleep/appetite • Self-growth, independence • Less angry, but lonely

24. Children’s Reactions to Deployment Percent reported with “Moderate” to “Very serious” problems Source: 2004/2005 Survey of Army Families, U.S Army Community and Family Support Center (CFSC)

25. ADSS: EFFECT OF DEPLOYMENTS ON CHILDRENSummary of Findings66% of spouses reported they had at least one child ages 18 or under living withthem either part-time or full-time during their spouse’s most recent deployment 27% of spouses reported they had one child 39% reported they had more than one child Average age of child most impacted by deployment was 6.1 years old Most impacted child’s positive emotional/behavioral changes in response to deployment were increased: Closeness to family members (48%) Degree of pride in having a military parent (39%) Level of responsibility (36%) Level of independence (33%) Closeness to friends (31%) Most impacted child’s negative emotional/behavioral changes in response to deployment were increased: Fear/anxiety (64%) Problem behavior at home (57%) Level of anger about my spouse’s military requirements (46%) Level of distress over discussions of the war (42%) Problem behavior at school (37%)

26. RCSS: EFFECT OF DEPLOYMENTS ON CHILDRENSummary of Findings70% of spouses reported they had at least one child ages 18 or under living withthem either part-time or full-time during their spouse’s most recent deployment24% of spouses reported they had one child45% reported they had more than one child76% of spouses indicated their need for child care increased as a result of theirspouse’s deploymentAverage age of the child most impacted by deployment was 8.1 years old Most impacted child’s positive emotional/behavioral changes in response to deployment were increased: Pride in having a military parent (66%) Closeness to family members (54%) Level of responsibility (37%) Closeness to friends (33%) Level of independence (31%) Most impacted child’s negative emotional/behavioral changes in response to deployment were increased: Fear/anxiety (67%) Distress over discussions of the war (56%) Problem behavior at home (50%) Level of anger about my spouse’s military requirements (44%) Problem behavior at school (34%)

27. Children Coping with Deployment Source: 2004/2005 Survey of Army Families, U.S Army Community and Family Support Center (CFSC)

28. Infants & Toddlers • What are you going to see in the babies? • What are you going to do?

29. Behavioral Results • Inconsolable Crying • Withdrawal from daily activities • Sleeplessness • Lack of appetite • Anxiety • Poor weight gain • Aggressive behavior in older toddlers

30. Cycle for Preschoolers • Confusion • Sadness • Surprise • Guilt • Behavior • problems • Afraid of parent • Wants attention • Clingy • Anger • Needs reassurance • Separation anxiety • Feelings of abandonment • “Father Hunger” • Attempt to care for parent

31. Draw your family • (Don’t forget the pets). • Draw your house. • Draw your bedroom. • Draw anything you know how. • Draw what you remember from the memorial or funeral.

32. Preschool Interventions • Predictability • Media Exposure • Physical & Emotional Comfort • Communication • Outside Play • Tactile Experiences

34. Cycle for Elementary Ages • Attempt to split parents • Desires recognition • Joy • Anger • Excitement • Regression • Guilt • Angry outbursts • Sadness • Loneliness • School problems • Over-responsible to irresponsible • Mom’s companion/Man of the house • Toileting accidents

35. Common Questions What is war? Do innocent people die? Will the terrorist attack our country? Who’s protecting Ft. Carson? What is friendly fire? What is it like to be a soldier? When is my parent coming back? Who will take care of me if my parent dies?

36. What is war?

37. Answering Questions Ways to talk Assure them they are safe now Brief, honest answers Focus on helping others • What to consider • What they already know • Maturity level • Their need for continual reassurance

38. Elementary Interventions • Letter Writing • Drawing • Pick your child up on time everyday • Limit media exposure • Share your feelings • Listen to feelings

40. Cycle for Adolescents • School problems • Behavior problems • Relief • Defiance • Resentment • “I don’t care” • Fear rejection • Denial of feelings • Anger • Higher value on friends • Independence • Behavior changes • Socially withdrawn • Sadness/Anger

41. Kelso: Therapy Dog

42. Narrative Story Telling : Princess Rachael

43. Adolescent Interventions • Decrease the violence in their world • Model appropriate anger management skills • Encourage an active role • Be available • Separate people from events

44. Reactions to Death and Trauma Lehman, D.H., Cozza, S.J., M.D. Deceased Military Members and the Families of the Fallen In: Ritchie EC, ed. Combat and Operational Behavioral Health. In: Lenhart MK, ed. Textbooks of Military Medicine. Washington, DC: Department of the Army, Office of the Surgeon General, Borden Institute; in press.

45. Developmental Concepts of Death 2-4 years - death seen as abandonment - seen as reversible - aware of altered pattern of care 4-7 years - concerns of guilt - feels responsible because of thoughts - violent or symbolic play 7-11 years - beginning to see death as final - see death as punishment - concerned with others - suicidal thoughts

46. Why a military death is different Military Culture and a lack of understanding by others Absence of deployed parent Death notification The loved one’s remains Military funerals Media attention and political protesters Isolation from military community Return of dads unit/ unit of friends Tension between pride and emotions of grief/ heroes.

47. The results of war…OIF/OEF/GWOT Self Inflicted Wounds Sexual Assault Suicide Handling dead bodies and body parts Combat Stress/ PTSD Physically being injured/Traumatic Brain Injury Multi-causality incidents (IED, ambush, sniper) Death of Children and Women Mass Graves Witness death /injury of a close friend Feeling trapped /unable to defend or counterattack Multiple deployments increase odds of exposure to traumatic events

48. Combat Stress Reactions Numbing of emotional responses Reduced awareness of one’s environment Derealization Depersonalization Dissociative amnesia Intrusive thoughts Avoidance behaviors Insomnia Concentration deficits Irritability Automatic arousal

50. Wrap Up • Questions