Worries of Military Parents: Understanding and Supporting Children during Deployment

1. G.W.O.T. Moms and Dads(Global Worries of Today) Scott Uithol, MD & Dawn Uithol, MD USAFP, 2005

2. Objectives • Be able to list common worries of today’s military parents • To discuss normal from abnormal child behavior • Be able to provide guidance and reassurance to worried parents

3. The Emotional Cycle of Deployment • Desert Storm  Bosnia/Kosovo  Afghanistan  Iraq • Growing body of experience regarding the impact of extended deployment on military families • 2/3 soldiers married • Emotional cycle of an extended deployment can be divided into 5 stages

4. The Five Stages • Characterized by time frame and emotional challenges • Pre-deployment • Deployment • Sustainment • Re-deployment • Post-deployment

5. 1. Pre-deployment • Anticipation of loss vs. denial • Do you really have to go? • Train-up/long hours away • Psychologically deployed • Getting affairs in order • Honey-do lists • Mental/physical distance • “best” holiday, “perfect” vacation, “most” romantic date • Arguments • Ebb-and-flow of marriage vs catastrophic event

6. 1. Pre-deployment • Discuss in detail their expectations of each other during deployment • Without this: misperception, distortion and hurt later on in the deployment

7. 2. Deployment(first month away) • Mixed emotions/relief • Disoriented/overwhelmed • Numb, sad, alone • Sleep difficulty • Security issues

8. 3. Sustainment • New routines established • New sources of support • Feel more in control • Independence • Confidence – “I can do this!”

9. 3. Sustainment • Communication vulnerable to distortion or misperception • No face to face • Long distances • Unidirectional communication • Email – freeing and filter • Rumors

10. Children during deployment • Response individualized but depends on developmental stage • It is reasonable to assume that a sudden negative change in a child’s behavior or mood is a predictable response to the stress of having a deployed parent

11. Infants • < 1 year • Must be held and actively nurtured in order to thrive • Behaviors: refuse to eat, listless • Early intervention becomes critical • Remedy: Support for parent • SWS, ACS, counseling

12. Toddlers • 1-3 years • Generally take their cue from the primary caregiver • Behaviors: cries, tantrums, irritable, sad • Remedy: increased attention, holding, hugs • Parent time important

13. Preschoolers • 3-6 years • May regress in their skills • Potty training, “baby talk”, thumb sucking, sleep • Behaviors: potty accidents, clingy, irritable, sad, aggressive, somatic • Remedy: increased attention, holding, hugs, avoid changing routines

14. School Age Children • 6-12 years • Behaviors: whines, body aches, become aggressive, “act out” their feelings • Remedy: spend time, maintain routines • Expectations regarding school performance may need to be lowered

15. Teenagers • 13-18 years • Behaviors: isolates, irritable, rebellious, fight, attention-getting behaviors • Increased risk for promiscuity, EtOH, drugs • Remedy: patience, stay engaged, limit-setting, counseling • Additional responsibility in the family can help them feel important and needed

16. When should parents seek help: • If they are unable to return to at least some part of their normal routine • If they display serious problems over several weeks • Children of deployed parents are more vulnerable to psych hospitalization

17. Pitfalls during deployment • Over-interpreting arguments • Hot topics/long distances • Rumors/loss of trust • Investment in date of return • Not accepting changes in marriage • Children can cue off of the parent

18. Helpful Hints during deployment • Establish a base of support • Make plan to break up the time • E-mail/phone calls/letters • Avoid overspending/alcohol • “Single” parents need time without kids

19. Re-Deployment(month prior to soldier’s return) • Anticipation of homecoming • Conflicting Emotions • Excitement and apprehension • Burst of energy/”nesting” • Difficulty making decision • High expectations

20. Post-deployment(begins with soldier’s return) • Honeymoon period • Reunite physically but not necessarily emotionally • Loss of independence • Need for “own” space • Renegotiating routines • Reintegrating into family

21. Children in post-deployment • Infants – may not know the soldier and cry when held • Toddlers – may be slow to warm up • Pre-schoolers – may feel guilty and scared over the separation • School age children – may want a lot of attention • Teenagers – may be moody and appear not to care

22. Post deployment keys(avoiding the cat and mouse game) • Patient communication • Going slow • Children’s pace • Lowering expectations • Taking the time to get to know each other again

23. Deployment Effects on Medical Assets • Parents and children feel the effects • Somatization • Emotional problems • Regression • Family Support Groups • Extended family help • Then there’s the Family Medicine Doc!

24. Challenges for Primary Care • Screening • Anticipation, Listening for • Determining the severity • Developmental variation • Behavioral problems • Behavioral disorders • Treat or refer • Provider practice/skill, “Go-to” colleagues

25. Consequences of Missing the Problem • Worsening condition • ADHD, school impairment • ODD, peer impairment • Conduct Disorder, negative identity formation • Antisocial Personality, societal impact • More costly/intensive treatment

26. Barriers to Identification • Limited appointment times • Limited educational training • Inadequate access to Mental Health, others • Reimbursement problems (civilians)

27. Behavioral Assessment Model • Environment-Behavior relationship • Family has the problem, not the child • Identifies areas for change • Parents better able to ID objective data • In contrast to psychometric testing • WARNING: Do not attempt during one appt

28. ABC Model • Antecedent (stimulus) • Behavior (response) • Consequence (parent’s response) • Parents assigned homework ABC log

29. Behavioral Consultation Model • Variant of ABC model • More time involvement – 3-4 appts? • Consults will contain more helpful info • Involvement of other professionals • With experience, process will quicken

30. Behavioral Consultation Model • Problem identification • ABC model • Problem analysis • Positive reinforcement • Negative reinforcement • Plan implementation • Treatment evaluation

31. An Example: Non-compliance • Can be considered developmentally appropriate • Adolescents and pre-schoolers • Examples: whining, yelling, tantrums, failure to complete tasks • Common cause: parental inconsistency

32. Failure to Make Bed • Problem identification • Antecedent: Child is told to make his bed before leaving for school • Behavior: Child fails to make his bed properly • Consequence: Parent returns from work and notices after dinner, argument ensues, parent lectures, and child goes to bed ultimately without making his bed

33. Failure to Make Bed • Problem Analysis • Positive reinforcement: Gets parent’s otherwise limited weeknight attention • Negative reinforcement: Child does not have to make bed • Plan Implementation • Parent initially makes bed with child before work • Praises and (re)teaches the “how-to’s”

34. Failure to Make Bed • Treatment evaluation • # of times bed made right per week • # of “special times” per week • Other areas of non-compliance • Other behaviors that require change • Eating behaviors- 25-35% prevalence • Sleep behaviors- 25% prevalence

35. Other Helpful Tools • Look child in the eye when assigning tasks • One task assignment at a time • Get a back-brief to ensure understanding • Use “Do” statements vs. “Don’t” • Catch them while they are good

36. What do you think?

37. Picky Eaters • Development stage • Less caloric need • Parent’s role • Child’s role • Influences www.cdc.gov: “Bright Futures”

38. Toilet Training • “Child-Oriented” Approach (Brazelton) • Socially acceptable • Little supportive evidence • Intensive approach (Azrin and Foxx) • Unknown acceptability • Good empiric support

39. Temper Tantrums • 18mos to 4 yrs • Window to emotions • Crying to breath-holding, head banging, to spectacular displays of dysregulation in “normal” children • Anger and Distress

40. QUESTIONS OR COMMENTS?