They Also Serve: U.S. military children and our wars of the 21 st Century

1. They Also Serve:U.S. military children andour wars of the 21st Century Gregory Toussaint, MD Wright State University Boonshoft School of Medicine

2. 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? • What can I do? • First, some questions…

3. U.S. military today • Terminology • Active duty – 4 branches and Coast Guard • Reserves – all 5 branches • National Guard – Army, Air Force • Mobilized – activated Reserves, Nat’l Guard • “Deployed” • CENTCOM • OEF: Afghanistan, central Asia • OIF: Iraq, Arabian peninsula • Horn of Africa www.globalsecurity.org

4. U.S. military today www.globalsecurity.org

5. Scope of the issue • Since 2001: • > 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 • 1.2 million ‘dependents’ < 23 yrs of age • 40% < 5 yrs of age • Reservists / Nat’l Guard • 660,000 dependents • 20% < 5 yrs of age JAMA 2008, 300:644 J Am Acad Child Psych 2010, 4:297

6. Women in the US military Women of minority in the military US Congress Joint Economic Committee Report, May 2007

7. Military moms (active duty) • 38% all active duty women have children • 44% of men • 11% all active duty women are single parents • 4% single fathers • Higher attrition rate than men • 2002 GAO report: 1/3 left due to child care concerns • New mothers: 6 weeks maternity leave • 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

8. What happens during ‘deployment’? • Pre-deployment • Notification of orders to go • Accomplish training needed, get “spun up” • Clock ticking, but for how long? • Deployment / sustainment • A send off, then time “in theater” • The waiting. And waiting • Re-deployment • Reintegration into family unit

9. What else happens? • Pre-deployment • Stress. On parent(s), spill-over to child • Fear. Age-related understanding of what’s coming • Deployment • Impact of parent’s absence takes effect • Families adapt, or not, to range of feelings • Reunification • First reunion. Rebuild relationships, boundaries • Parent back to work. Reserve/Guard may deactivate

10. New issues for military children • Striking number of affected children • More ‘dependents’ now than military personnel • Almost 40% personnel are activated Reserve, Guard • How can combat deployments affect children? • 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

11. Early research • 1990-1991 • 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) • First 24-hour news coverage, children exposed more • Relatively brief period conflict, small number casualties • Short deployments without recurrence • 1992-1993 • Operation Restore Hope (Somalia)

12. Early research • Smaller studies, limited scope • Increases noted in internalizing, externalizing symptoms • Internalizing = emotional lability, anxious, depressed • Externalizing = attention difficulties, aggression • Children rarely required clinical attention • One, a pre-Desert Storm study, did f/u work • Increased levels of anxiety, depression • Did not reach pathologic levels, resolved quickly • Boys, younger children at higher risk Mil Med 1993, 158:465 J Am Acad Child Psych 1996, 35:433

13. The “under 5”s • Remember the math? • 40% active duty, 20% Reserve/Guard • Total ~ 620,000 dependent children < 5 yrs age • Time of critical developmental periods • Two studies focus on behaviors • Two on utilization of health care • Concerns: • Evidence suggests young not spared • Huge size of group warrants closer look

14. Developmental issues • Cross-sectional study, large Marine base • Arch Ped Adol Med 2008, 162:1009 Chartrand M et al. • On-base child care centers, children 1.5-5 yrs • May-Dec 2007, 169 families • Child Behavior Checklist, two parental stress measures • CBCL-Teacher Report form for centers’ staff • Results • 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

15. More observed behaviors • Study of 57 Army families (Ft Knox, KY) • Mil Med 2009, 174:1033 Barker L et al • Married, > 1 child 0-47 months • No-, single-, and multiple-deployment groups • Parent-reported on “observed behaviors” • Not a normed assessment tool • Needs attention, clingy, tantrums Prefers non-deployed • Results: • “Children in deployment grp had parent gone > ½ life” • 2/3 reported transient attachment behaviors on reunion

16. 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 • 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 • Could caretakers for single parents not access care? • Increased use a marker for stress?

17. Utilization of mental health services • Same people, databases (direct + Tricare) • Pediatrics 2010, 126:1058 GormanG et al • Focused on mental / behavioral health visits • > 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

18. What about school age? • Greater numbers total than “under 5”s • Military children generally robust, healthy group • Three principal areas of wartime stress • Deployment of military parents • Injury or illness of parents • Parental death • Psych Quart 2005, 76:371

19. Deployment + school age children • Survey of parents w/ child 5-12 yrs old • J Dev Behav Ped 2009, 30:271 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 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

20. School age children • Study population military children at camp • Pediatrics 2010, 125:16 Chandra A et al • Phone interviews w/ 1507 children (11-17 yrs), caregivers • Controlled for family, service member characteristics • Results • 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

21. Perspectives of school staff • Qualitative study at 12 schools around U.S. • J Adol Health 2010, 46:218 Chandra A et al • Focus groups or interviews of school staff • Teachers, counselors, administrators • 3 schools on post, rest with 30-70% military students • Results: • 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

22. Other issues: child maltreatment • Clear evidence for profound emotional impact • Does it translate into increased maltreatment? • TX study of child maltreatment rates • Am J Epidemiol 2007, 165:1199 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

23. Child maltreatment • Study of 1771 families of Army enlisted • JAMA 2007, 298:528 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

24. Returning parents… • Injured parents • 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.” • Parental suicide • Review article from Dept Veterans’ Affairs • Am J Epidemiol 2009, 19:757 Kang H, Bulliman T • Published studies do not prove increased rate in vets • Rates are increasing among active duty personnel Stephen Cozza, MD USU Center for Traumatic Stress JAMA 2010, 300:644

25. And those who didn’t • Combat + non-hostile deaths as of 31 May 2011: • Est 12,000 children have had a parent die • When active duty member dies, families will move • Lose on-base housing, may return to hometown • New community may not appreciate experiences, needs siadapp.dmdc.osd.mil RAND Corp 2010

26. Making it personal • Vignettes from people I deployed with or know • What did I learn? • 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

27. Brave new world of communication • Time warp(Mr. Peabody’s Wayback machine) • Feb 2002 • One 10 min phone call per week, full e-mail • Jan 2003 • “Location masked” base, all special ops units • No phone/e-mail x 6 wks, no mailing address x 2 months • Sep 2004 • COMSEC rules, full e-mail except…, AT&T phone bank • May 2011 • Official e-mail, phones in quarters, contract internet service • No COMSEC, full internet access including Skype

28. “Too much” connectivity? • Physician father (adult type ) deployed for 6 months • 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 • Mother holds infant up to laptop camera • Father…

29. Where is the help? • Early on (2001-2003) – not much • Units built their own support structure • Deactivated Reserve, Guard often on their own • Gradual response, now a proactive effort • 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

30. Military OneSource www.militaryonesource.com/

31. Sesame Street help! www.sesameworkshop.org ADM Mullen, then CJCS online.wsj.com New in Apr 2010, traveling USO shows Starring Katie!

32. Purdue Military Family Research Institute www.mfri.purdue.edu/

33. National Military Family AssociationOperation Purple camp www.operationpurplecampinfo.com

34. What should I remember? • These children are also “serving” • 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 • Resilience waning for those called again, again

35. What can I do? • Play the same role you always have • Advocate for the child • Educate, support family • Be willing to ask your patients’ families: • “Have you or has anyone you know been involved in the war effort in Iraq or Afghanistan?”