Screening and identification of risk
Primary care and mental health clinicians should be attuned to common responses of children to deployment and reintegration stress. Symptoms or dysfunction in any family member should serve as an indicator of risk across the entire family. A proactive approach is recommended, with a focus on early identification and prevention as well as treatment.
Parents may notice a change in their distressed infant, such as changes in eating patterns, increased or decreased activity, impaired sleep, and/or increased crying or irritability. Separation anxiety may be exacerbated among those experiencing deployment cycle stress. Parents of distressed toddlers may notice increases in clinging behavior, changes in eating patterns, increased or decreased activity and social behavior, impaired sleep, and/or increased crying or irritability.
Young children may have confusing assumptions and misunderstandings about the deployment experience. For example, preschoolers may believe they “caused” the parent to leave but may not talk about this with anyone. Consequently, they may feel responsible and guilty without anyone knowing. In dealing with other stressors, preschool-aged children may exhibit self-soothing behaviors or distress signals that they previously used as infants or toddlers (such as thumb sucking, bed-wetting, or sleep problems). Stress-related somatic symptoms, such as functional abdominal pain, may be present. Research with preschool-aged children found that those with a deployed parent had higher levels of both internalizing and externalizing behaviors than same-aged children without a deployed parent.17
School-aged children may exhibit deployment stress symptoms in the school setting (such as attention, academic, or behavior problems) that may be misattributed to mental health problems.6,18 Like younger children, school-aged children may develop difficulties with sleep routines and may express increased worries around bedtime separations. Boys may feel a sense of responsibility for being the “man in the family” during paternal deployments.
A recent study with Army and Marine Corps families affected by wartime deployments found that about one-third of these military children had anxiety symptoms; this is significantly higher than the rate in community samples. Notably, the increased prevalence of anxiety was present both for the children currently separated from a combat-deployed parent and for those whose parents had returned from combat in the past year.5 This study also found cumulative deployment separation over the child’s lifetime to be a risk factor for greater psychological distress in school-aged children. Psychological distress among both active duty and non–active duty parents, including depression and PTSD symptoms, also correlated with the child’s symptoms.
Similar to younger school-aged children, adolescents with deployed parents may exhibit anger, defiance, or aloofness.6 Like their younger counterparts, teens had greater psychological stress when the caregiving parent had greater cumulative deployment separation and psychological distress.4 Teens with strong coping skills may derive meaning and satisfaction from assuming additional family responsibilities and providing support to others. Teens with less effective coping skills may isolate themselves and/or become resentful of the additional burdens associated with parental deployment. Positive family communication appears to buffer distress in military teens and their families.7
Mental health strategy for clinicians
The level of exposure to sustained sacrifice and stress, and the scope of the population affected by the wars in Afghanistan and Iraq, indicate the need for a public mental health response for our military families that includes a tiered approach to early identification, prevention, and treatment services. The objective of preventive interventions is the reduction of disease or disorder by using programs designed for those who may be at greatest risk.
Preventive mental health strategies provided within a strength-based framework of psychological resiliency are consistent with military culture and training. Such interventions promote psychological health and reduce distress by building on family strengths and encouraging the regular use of adaptive coping behaviors to reach desired goals. An example of this type of program is FOCUS (Families OverComing Under Stress), which was developed at the University of California, Los Angeles, and Harvard University for military families facing wartime deployments.