Developmental and behavioral implications for military children with deployed caregivers

INTRODUCTION — With the United States military involved in prolonged and ongoing conflicts around the world, more children in military families experience parental or caregiver absence [1]. This absence is different than other parent-child separations because, for a military child, a deployment can mean prolonged separation, fear for that caregiver's safety, and increased uncertainty in daily routine.

This topic will provide an overview of deployment's developmental and behavioral implications for children and adolescents of parents or caregivers in the military.

EPIDEMIOLOGY — Deployment is a way of life for military families [2]. Among active-duty military members in 2019, approximately 40 percent had children <20 years of age, roughly 30 percent were married to a civilian with children, 4 percent were married to another service member, and 4 percent were single parents [3]. In 2019, approximately 1.6 million United States children had at least one parent in the military. Roughly 38 percent of children in military families were younger than 6 years, 32 percent were aged 6 to 11 years, 24 percent were 12 to 18 years, and 6 percent were 19 to 22 years [3].

DEFINITION OF TERMS

●Deployment – A deployment is the short-term assignment of a military service member to a combat or noncombat zone. A deployment can last from 1 to 18 months, with typical deployments lasting 12 to 15 months [4,5]. Deployments can be planned or unexpected. They vary according to the service member's job description and branch of service.

●Active duty – Active duty refers to military members serving full time in their military capacity. The active duty military consists of the Army, Navy, Air Force, Marines, and Coast Guard. The Army has the largest active duty force (>485,000), followed by the Navy (>347,000), Air Force (>335,000), Marines (>181,000), and Coast Guard (>41,000) [6]. Active duty military members and their families usually live on or near a military base and have access to military support services [7].

●Selected Reserve – The Reserve (Army, Navy, Air Force, Marine Corps, and Coast Guard) and National Guard (Army and Air) are military organizations with members who generally perform a minimum of 39 days of military duty per year and who augment the active duty military when necessary. The reserve components are referred to collectively as "the Selected Reserve." The composition (eg, Army, Navy, etc) of the Selected Reserve is similar to that of active duty services.

Selected Reserve members and their families often do not live on or near a military base. They may have less access to the military-specific supports and services available to their active duty counterparts [8-13]. Members of the Selected Reserve may experience stress-related long-term deployments disrupting their employment or changes in health care.

EFFECTS OF CAREGIVER DEPLOYMENT — The body of research demonstrating the impact of recent deployments on children in military families has grown substantially since 2001. Deployments in support of military operations in Iraq and Afghanistan, as well as other regional hot spots, differ in fundamental ways from historical wartime deployments [7,10,11,14]:

●Deployments can be extended and repeated; some units regularly deploy for three to six months every year

●Advancements in medical care for wounded service members have resulted in more remarkable survival but increased physical and psychological disability

●Greater involvement of the Selected Reserve (whose families may have less access to support services)

●Increased media coverage with increased intensity

●Technologic advances that permit increased instantaneous communication

●Extensive duration of ongoing military operation with a focus in the Pacific region

●Concerns regarding other future threats which influence training practices

Emotional cycle of deployment — When a military member deploys, several adjustments happen at home: household responsibilities shift, schedules change, and new routines are established. These changes are dynamic depending upon the phase of deployment.

The "emotional cycle of deployment" was developed as a model for understanding the psychosocial phases and transitions that military families go through as part of the deployment process (algorithm 1) [15]. In addition, in a qualitative study of focus groups of service members and spouses, the pattern of responses for both active and reserve families conformed to the emotional stage of deployment [16].

The emotional cycle of deployment separates into five stages: predeployment, deployment, sustainment, redeployment, and postdeployment.

●Predeployment – The phase from the time of notification of deployment to the actual departure of the service member. Emotions range from psychological denial, intense preparation, and anticipation of leaving. Service members report that deployment preparation was stressful because of training requirements, personal preparation, and family preparation [17]. Preparation for deployment requires weeks of fast-paced work and time away from the family at local training sites before the actual deployment.

●Deployment – The phase defined as the first month after deployment. The early deployment phase can be marked by emotional distress as the family tries to regain balance and routine. Families frequently choose to relocate near loved ones for the duration of the deployment.

●Sustainment – The phase that spans from the second month of deployment until one month before the service member's return. In adaptive families, a new routine occurs during this time, and available resources are employed to continue the "family business." Conversely, families that do not adapt are likely to experience emotional and behavioral distress.

●Redeployment – The phase that occurs in the month before the service member returns home. The family may feel anxious, excited, and apprehensive as they anticipate and prepare for the service member's return.

●Postdeployment – The reintegration of the service member into the family. There may be unanticipated stresses as the family roles and routines are redefined, especially if the service member has suffered physical or psychological injury. The postdeployment period may continue for months to years, and its impact compounds by additional military and life stressors.

Deployment's emotional and behavioral effects on children — A caregiver's deployment may adversely impact a child's behavior and mental health [10,13,18-21]. Although few studies focus on young children, who comprise the majority of children with caregivers in the military, observational studies suggest that caregiver deployment can be associated with externalizing problems (eg, aggressiveness, irritability) and internalizing problems (eg, crying, sadness, depression, anxiety) [22-31]. Nonetheless, through the adversity of a deployment, children often demonstrate increased responsibility, independence, confidence, and participation in decision-making compared with their peers who have not experienced deployment [8,32].

Systematic reviews and meta-analyses of observational studies of the effects of deployment have identified associations between deployment and poor adjustment (particularly reported by parents and when compared with children with civilian parents), problem behavior independent of age (compared with children of nondeployed parents), and substance use among adolescents [20,27,33].

Individual studies conducted before or during Operation Desert Storm (1990-1991) noted increased sadness, tearfulness, demands for attention, and psychological symptoms among school-aged children during caregiver deployment [34,35]. In these and other studies, the effects were mediated by the child's baseline mental health status and the at-home caregiver's mental health status [18,34-36]. Caregiver deployment generally did not provoke pathologic levels of mental illness in otherwise healthy children.

Nevertheless, studies assessing the impact of deployment to Afghanistan or Iraq during Operations Enduring Freedom, Iraqi Freedom, New Dawn in Afghanistan, or New Dawn in Iraq have noted certain at-risk groups (more extended deployments, psychological distress of the at-home caregiver) that may manifest behavioral and psychological effects with a deployed parent, including:

●Increased levels of behavior problems among three- to five-year-old children compared with same-aged peers without a deployed parent [37]

●Increased risk for psychosocial morbidity (assessed with the Pediatric Symptom Checklist) among school-age children compared with same-age peers without a deployed parent [10]

●Increased symptoms of anxiety compared with community norms; psychological symptoms in the active duty and the at-home caregiver predicted child adjustment problems [38]

●Reports of impaired well-being, including low quality of life, depressed mood, and thoughts of suicide [39]

●Excess mental health diagnoses compared with military children whose parents did not deploy; mental health diagnoses including acute stress reaction/adjustment, depressive, and pediatric behavioral disorders that increased with total months of deployment [40]

●Increased school-, family-, and peer-related difficulties compared with national samples, exacerbated by more extended deployments and poorer mental health of at-home caregivers [41]

●Feelings of uncertainty and loss [42]

●Increased heart rates and perceived levels of stress [43]

●Negative effects on social and emotional function at school (as reported by teachers and other school personnel) [44]

●Increased visits for mental health diagnoses, injuries, and child maltreatment [29]

●Increased risk of alcohol and drug use, with increasing risk as the number of deployments increased [30,45,46]

●Increased risky sexual activity [47]

●Increased risk of suicidal thoughts [39]

Health care utilization — Parental/caregiver deployments may impact health care utilization for children of various ages [44,48,49], as illustrated below:

●In a retrospective study of outpatient health care claims data for military service members' children (n = 642,397), overall health care visits decreased by 11 percent when a military parent was deployed. Nonetheless, mental and behavioral health visits increased by 11 percent, diagnosis of behavioral disorders increased by 19 percent, and diagnosis of stress-related disorders increased by 18 percent during deployment [48]. Parental deployment was also associated with an overall increase in prescription medications for children, particularly antidepressants and antianxiety agents [50].

●In a similar study of outpatient health care claims data for military service members' children younger than two years of age (n = 169,986), children of young, single, active duty parents were seen less frequently for acute and well-child care during their parent's deployment [51].

●In a population-based study, when a parent returned from deployment with injuries, children's medical visits for stress-related conditions increased by 67 percent [29].

Opportunities for preventive screening and intervention may be lost if military children are not being brought in for routine health care maintenance. (See 'Role of the primary care provider' below.)

The National Academy of Science encourages a collaborative model of care, incorporating medical and nonmedical resources to optimize resilience in families that face stressful or traumatic experiences [52].

Child maltreatment — Data from observational studies suggest that children in military families are at risk for maltreatment during deployment [29,53-55]. Reports of child neglect during deployment were most frequent among young married couples with young children.

School performance — Parental/caregiver deployment is associated with modest effects on school performance. In observational studies, longer deployments have been associated with more significant effects [56-58]. Family relocation with transitions to a new school system can also be difficult for children in military families, especially those with special health care needs [59,60]. Teachers and administrators report increased social maladaptive behavior problems during deployments [61].

RISK AND PROTECTIVE FACTORS — As with other forms of stress, an individual child's response to deployment depends upon several factors, including the developmental age of the child and physical and emotional availability of the at-home caregiver, coping skills, and community resources [8].

Risk factors for greater difficulty during parental/caregiver deployment include:

●Young age (of the child) [37,62]

●Increased burden of stress for the at-home caregiver [34,37,38,63,64]

●Lower socioeconomic status [35,63]

●Young parents [63]

●Increased duration of deployment or multiple deployments [38,41]

●Preexisting emotional or behavioral problems [35]

●Lack of predictable return date of the service member [65]

●Special health care or educational needs [66]

Children remain at risk after the service member returns. Children of combat veterans with posttraumatic stress disorder (PTSD) are at increased risk for depression and anxiety compared with children of noncombat veterans. Children of veterans with PTSD may develop symptoms of PTSD in response to the caregiver's PTSD-related behaviors [67].

Adverse effects can be mitigated by dependable and supportive adults who create safe environments to help children cope and recover from adverse events [7]. Factors associated with better coping and resilience in children and adolescents include [8,20,68-70]:

●Parents' preparation and readiness for deployment, including preparation of the child

●"Meaning making" of the situation (ie, constructing an account of an experience that helps to make sense of it)

●Supportive community, school, and social network

●Ability of the at-home caregiver to develop self-reliant coping skills

●Positive communication skills and during-deployment communication plans

●Flexibility regarding household and childcare responsibilities and roles

OUTCOME — Large, longitudinal, multiservice outcome studies addressing the impact of parental/caregiver deployment on children are lacking, though research is ongoing.

Preliminary reports from The Deployment Life Study indicate that military families have different experiences and stressors but emphasize that military families are resilient [71]. Nonetheless, deployment and military stressors impact the social-emotional health and well-being of a percentage of military children [72]. In a meta-analysis of observational studies, parental military deployment was associated with mental health problems in children and adolescents compared with civilian/normative samples [33]. The association was greatest for overall mental health problems, symptoms of anxiety and depression, and aggressive behavior. Within the military, children of deployed parents had more problem behavior than those of nondeployed parents. Understanding why certain families are more resilient than others may help shape policy and programming for families who struggle with military life [71,72]. The Millennial Cohort Study published 20 years of longitudinal research findings, highlighting that more than 50 percent of service members have deployed and that sleep quality and lack of healthy behaviors impact the service members' wellness, which in turn affects their children [73].

ROLE OF THE PRIMARY CARE PROVIDER — Many children in military families receive their primary care from civilian providers [13,48]. It is crucial for health care providers to have some familiarity with military systems, culture, benefits, and resources [8,13,74]. It is also important for health care providers to understand the unique stressors and characteristics of military youth during deployment and reintegration (table 1) and to acknowledge their personal service and sacrifice (independent of their parent's contributions). Health care providers can follow the three R's of care:

●Recognize military-connected families

●Respond when they are experiencing stressors

●Refer at times for additional support

Furthermore, when caring for children with parents in the military, it is important for health care providers to [7,9,10,13,74-76]:

●Communicate openly and develop trust with the family

●Ask patients/families how each family member is affected by preparing to deploy, deployment, or reintegration; ask specifically if the caregiver has any concerns about the child's behavior related to the deployment cycle

●Provide anticipatory guidance for common reactions to the deployment cycle (eg, sadness, tearfulness, anxiety) and suggest strategies to prevent or manage stress, such as maintenance of daily routines and activities (table 2)

●Help family members to recognize and build on their strengths

●Assess stress and coping skills (for the child and family)

●Monitor children and adolescents for emotional and behavioral effects (eg, somatization, acting out, sleep disturbances, depression, suicidal ideation, anxiety, poor school performance, poor interpersonal relationships, or loss of developmental milestones) by using standardized screens (eg, the caregiver-completed Pediatric Symptom Checklist [PSC] or the youth self-report PSC [Y-PSC] for adolescents ages 11 and up, available through Bright Futures)

●Refer children and family members to mental health providers as indicated (eg, depression, anxiety, help with coping skills, etc)

●Screen for and counsel against risky behaviors such as alcohol and drug use/abuse and early sexual activity

●Pay special attention to and support children and adolescents whose deployed parents have been seriously injured or killed in combat [77]

●Encourage parents to seek regular medical care and seek mental health care support as needed

●Provide information about resources that may be helpful (table 3)

Few studies evaluate civilian and military intervention programs to support military children and families during deployment and reintegration. However, in randomized controlled trials, targeted interventions to strengthen parent-child relationships, promote effective parenting practices, and increase family understanding in other challenging circumstances (eg, caregiver depression, caregiver medical illness) have demonstrated positive outcomes in child development and psychological health [78-81].

Studies are necessary to determine evidence-based interventions specifically for children and adolescents affected by parental deployment and reintegration [82,83]. For example, after participating in a strength-based resiliency program designed to enhance family psychological health (Families OverComing Under Stress), military children had improved scores on psychological adjustment and coping compared with intake measures [82]. During the coronavirus disease 2019 (COVID-19) pandemic, the FOCUS intervention model further demonstrated the feasibility and benefit of virtual home visiting [84]. A review of the various interventions for military families is found at the Clearinghouse For Military Family Readiness.

RESOURCES — Several resources are available for providers and families to learn more about issues facing children affected by parental/caregiver deployments. These include service listings and written materials for download and distribution (table 3).

●The American Academy of Pediatrics provides resources for military families and professionals caring for military families; the Uniformed Services Section has published a clinical report on the health and mental health needs of children in United States military families [13].

●The Military Child Education Coalition is a nonprofit organization that identifies the challenges facing military children, increases awareness of these challenges in military and educational communities, and initiates and implements programs to meet these challenges.

●Military Kids Connect provides resources to prepare children for an upcoming move [85].

●Military One Source (telephone: 1-800-342-9647) is provided by the Department of Defense at no cost to active duty, Guard, and Reserve Component members and their families. Highly qualified, master's degree-prepared consultants provide various services, including help with childcare, personal finances, and emotional support during deployments; relocation information; and other types of resources in particular circumstances. Services are available by phone, online, and face-to-face through private counseling sessions in the local community.

●The National Guard Family Services provides links to resources for National Guard families living away from military installations.

●The National Military Family Association Operation Purple Program provides free summer camps for children and adolescents experiencing parental deployment. These camps offer a support network of peers and help military children and adolescents develop coping skills to manage ups and downs.

●Sesame Street Workshop: Talk, listen, connect is a multimedia outreach program designed to help support military families with young children experiencing deployments, multiple deployments, combat-related injury, or death.

●The Tragedy Assistance Program for Survivors provides assistance to families who are grieving the death of a military service member.

●Zero to Three Coming Together Around Military Families is a program aimed at strengthening the resilience of young children and families experiencing deployment and separation.

SUMMARY

●Over two million children in United States military families have been affected by a service member deployment since military involvement in Iraq and Afghanistan. (See 'Epidemiology' above.)

●Longitudinal studies suggest that most military children who feel supported during a temporary separation from their parent or caregiver, deployment is a time of growth and development for the at-home child and family; however, some children and family have pre-existing risk factors for difficulty during parental deployment. (See 'Deployment's emotional and behavioral effects on children' above and 'Risk and protective factors' above.)

●Parental deployment can contribute to increased emotional and behavioral problems in children and adolescents, changes in health care utilization, and increased risk of child maltreatment. (See 'Deployment's emotional and behavioral effects on children' above and 'Health care utilization' above and 'Child maltreatment' above.)

●Risk factors for greater difficulty during parental deployment include young age (of the child), increased burden of stress for the at-home caregiver, lower socioeconomic status, young parents, increased duration of deployment or multiple deployments, preexisting emotional or behavioral problems, and lack of a predictable date of return. Adverse effects may be mitigated by dependable and supportive adults who create safe environments to help children cope and recover from adverse events. Healthy caregivers more often yield healthy children. (See 'Risk and protective factors' above.)

●Although most military families are resilient, deployment and military stressors impact the social-emotional health and well-being of a percentage of military children. In observational studies, parental deployment has been associated with mental health problems in children and adolescents compared with civilian/normative samples. Within the military, children of deployed parents had more problem behavior than children of nondeployed parents. (See 'Outcome' above.)

●When caring for children with caregivers in the military, it is important for pediatric health care providers to (see 'Role of the primary care provider' above):

•Communicate openly and develop trust with the family

•Ask patients/families how they are affected by preparing to deploy, deployment, or reintegration and specifically if they have any concerns about the child's behavior related to the deployment cycle and suggest strategies to prevent or manage stress (table 2)

•Provide anticipatory guidance for common reactions to the deployment cycle (eg, sadness, tearfulness, anxiety)

•Help family members to recognize and build on their strengths

•Assess stress and coping skills (for the child and family)

•Monitor children and adolescents for emotional and behavioral effects (eg, by using validated screening tests, such as the Pediatric Symptom Checklist, available through Bright Futures)

•Refer children and family members to mental health providers as indicated (eg, for depression, anxiety, help with coping skills, etc)

•Screen for and counsel against risky behaviors such as alcohol and drug use/abuse and early sexual activity

•Pay special attention to and support children and adolescents whose deployed parents have been seriously injured or killed in combat

•Provide information about resources that may be helpful (table 3)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Molinda Chartrand, MD, who contributed to an earlier version of this topic review.