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Stress and Distress in Military Children Heather Johnson, Lt Col, USAF, NC, FNP-BC Acknowledgments: Diane Seibert, PhD, CRNP Lorraine Masse, CPT, USAN,

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Presentation on theme: "Stress and Distress in Military Children Heather Johnson, Lt Col, USAF, NC, FNP-BC Acknowledgments: Diane Seibert, PhD, CRNP Lorraine Masse, CPT, USAN,"— Presentation transcript:

1 Stress and Distress in Military Children Heather Johnson, Lt Col, USAF, NC, FNP-BC Acknowledgments: Diane Seibert, PhD, CRNP Lorraine Masse, CPT, USAN, BSN 1

2 Conflict of Interest I have no conflict of interest to report. 2

3 Objectives 1. Discuss factors associated with military service that impact the behavior of military children – Review the different impact of Active Duty, Guard and Reserve components 2.Identify manifestations of stress and distress in children 3.Differentiate manifestations of stress by age group 3

4 Objectives 4.Describe the positive effects of the military experience on children 5.Discuss implications for adults who work with military children 4

5 Military 101 General Concepts 5

6 Military 101 The Department of Defense – Army – Navy Marines Coast Guard and Coast Guard Reserve – Air Force – Reserves and the National Guard All volunteer force 6

7 Military 101 Active duty military – Most live on or near a military base – Immersed in military culture – Have ready and immediate access to military support systems such as health care, family support centers, and a community that is familiar with their unique culture. 7

8 Military 101 Reserve and National Guard – Our “citizen soldiers” – Live and work in civilian communities across the country – They do not have ready access to military- specific support mechanisms often do not live near military installations 8

9 Military 101 Children of the Guard/Reserve – When Reservists or Guard members are called to active duty they and their families may need to deal with changes to income, child care, and medical insurance. Children and families must become “suddenly military” when a parent is activated* *activated- called up to serve on active duty 9

10 Military 101 Children of Guard/Reserve Families May be the only children in their schools or communities who have a military parent May not have had prolonged separations before Do not have the same support resources as their active duty counterparts May not have established a sense of being a military family member 10

11 Military Terminology Deployments 11

12 Military Terminology Deployment – The short-term assignment of a military member to a combat or noncombat zone – 1 to 15 months – Can be routine, planned, or unexpected Deployment cycle – Recurrent deployment and redeployment* pattern that occurs over the career of a military service member 12 *redeployment-return from deployment

13 Military Terminology Deployment Also the name given to the movement of an individual or military unit – Either within the United States or to an overseas location to accomplish a task or mission. – May be routine (providing additional training) – May be dangerous (such as going to war) 13

14 Military Terminology Deployment Three phases of deployment – Pre-deployment Preparing to go (may take 3-6 months) – Training, preparation of the individual and the unit, packing, etc – Deployment (1 to 15 months) Actual movement to the duty location – Post-deployment Coming back from deployment – Reintegrating with family and unit, resting, recuperating, 14

15 Military Statistics 2.2 million service members in Active Duty (AD), Guard and Reserve – 32% smaller than 1990 Operation Desert Storm – ~ 1.9 million children have at least one parent in the military – 1.6 million service members have served at least 1 tour in Iraq or Afghanistan 34% served more than 1 tour (some up to 8 tours) – Operation Iraqi Freedom/Operation New Dawn/Operation Enduring Freedom 15

16 Military Terminology Statistics as of Jan 31, 2011 (since 9/11) Iraq – Deaths 4422 – Wounded in action 32,012 Afghanistan – Deaths 1437 – Wounded in action 9971 Total deaths 5859 Total wounded 41,983 16

17 The Military Family Statistics, Rank, Occupations, and Transitions 17

18 Military Family 58% of military service members have family responsibilities – 40% have 2 children By age 5- 40% of kids affected by deployment 30-50% relocate to hometowns to seek support from extended family – Those with school age kids tend to stay put 18

19 Military Family 95,000 Dual military families 74, 000 single parents 102,000 families with CSHCN (child with special health care needs) Guard/Reserve not usually co-located with a base 19

20 Military Rank Rank Structure – Commissioned officers Leaders/managers Have a bachelor’s degree or higher – Noncommissioned officers (NCO) The senior enlisted managers HS diploma to Bachelor’s degree or higher – Enlisted HS diploma for entry » Generally higher education than overall civilian population 20

21 Military Occupations Military occupational specialty – Often correlates with potential for combat deployment and injury Security forces Infantry Special forces Medical *All have equal access to healthcare 21

22 Military Transitions A little more terminology – TDY or TAD- temporary duty or time away – PCS- permanent change of station (move) Military families move every 2-4 years Some children attend 8 or more different schools Affects continuity of care – Deployment – Humanitarian deployment- provide support for disaster relief (e.g. Haiti, Somalia) – Combat deployment- wartime operations 22

23 Stress, Distress and Resilience in Military Children 23

24 Definitions (Literature) – Adolescent ~12-18 – Children ~5-12 – Young children < 5 – Children with special health care needs (CSHCN) or Autism Spectrum Disorders (ASD) 24


26 Interpersonal, behavioral, physical, and developmental – Internalizing behaviors – Externalizing behaviors – Somatic signs and symptoms – Changes in academic performance 26

27 Internalizing behaviors Emotions that are turned inward – Withdrawn – Lonely – Anxious – Depressed – Low self-perceptions (self-esteem) Can be in multiple domains – Shyness 27

28 Externalizing behaviors Emotions that are turned outward Aggressive Impulsive Distractible Coercive Delinquency “Acting out” Hyperactivity Drug/alcohol use Defiant Temper tantrums 28

29 Physiologic/Somatic Signs Elevated heart rate Elevated systolic BP Appetite changes Nightmares Sleep disturbance Others may include – GI upset – Headache – Neck/back pain – Jitteriness 29

30 The Military Family Vulnerable yet exceptional 30

31 The Military Family Frequent Moves Negative – Disruption of family, social network – Students change schools – Teachers PCS or deploy Positive – Broader perspective toward people and cultures – Child can “recreate” him/herself – More moves resulted in higher participation in social activities 31

32 The Military Family Frequent Moves Repeat combat deployments Media – Coverage of wartime events challenging Resilience of the military child and family – More frequent relocation experience equals better child adjustment 32

33 Characteristics of the Military Member Military combat soldiers – Expected to be aggressive and violent when deployed – Hyper-aroused, hyper-vigilant Expected to turn those characteristics off when return 33

34 Post-traumatic stress – Acute Post-traumatic stress disorder – Chronic, dysfunction 34

35 General Findings 35

36 Support Most families/children/SM do well Most families feel supported overall (82%) – Military groups and organizations (64%) – Church (48.5%) – Nonmilitary groups and organizations (25%) Including schools – Non-local family (22%) 36

37 Child Psychosocial Functioning 1/3 of military children are at high risk for psychosocial morbidity Caregiving parent stress – Significant predictor of child psychosocial functioning – Affects perceptions of child psychosocial functioning 37

38 Child Psychosocial Functioning Feeling supported overall positively predicted child functioning – Military, family, peer, church, school and community support – Feeling supported is key to promoting healthy behavior – Non-local family was not a significant predictor 38

39 Demographic Predictors Parental level of education Age Enlisted rank Duration of marriage <5 yrs The gender of the deployed service member 39

40 Family Cohesiveness High family cohesiveness – Less aggression – Fewer issues of noncompliance – Higher self-esteem in children 40

41 Negative Behaviors Diminish over time 41

42 Cumulative Impact Impact of combat deployment on children tends to accumulate ADSM may be deployed for half of a child’s life More months of combat deployment= greater impact on child Living on base = fewer problems 42

43 Cumulative Impact High stress/distress in the family – May affect decision to re-enlist or stay in the military – Consider divorce 43

44 Cumulative Impact At home caregiver – Increased stress and anxiety – Fatigue Especially when caring for young children – Concern about spouse’s safety – Loneliness – Trouble keeping house up – Dealing with child behavior – Finances 44

45 Effect of the Media Children >3 years old – at risk of developing depressive symptoms or more prone to externalizing behaviors 45

46 Changes at Home Risk in the Home 46

47 Abuse/Neglect Onset of intensive conflict in Middle East (2002-2003) – Rates of substantiated abuse/neglect in military families doubled – Consistently higher ever since Highest rates in children < 4 yrs of age – Rates decreased with increasing age 47

48 Abuse/Neglect Neglect, physical, emotional or sexual abuse – US Army enlisted soldiers – 42% higher during combat deployments – Linked to departure and return – Female civilian caregiver increased, male did not – Neglect more common than abuse 48

49 Domestic Violence Deployment, reunification Domestic violence and child maltreatment Increased risk 49

50 Risk Most families cope well We need to watch for those at risk for not coping well 50

51 Effects of Combat Injuries 51

52 Nature of Military Very private May not tell you there are visible or invisible injuries And children may not want to bring attention to themselves 52

53 Effect is on the whole family Parental injury – Observable injuries – Traumatic Brain Injury (TBI) – Post Traumatic Stress Disorder (PTSD) Difficult transition for children Effect on social skills Behavior problems in school 53

54 Developmental Risk Factors (Theoretical) – Attachment problems – Brain development – Emotional dysregulation – Cognitive, emotional or developmental delays – MH or behavioral problems – Other health concerns 54

55 Effects of combat injuries TBI – Problematic behavior changes in children 55

56 Effect of Poor Family Cohesion/Coping High reported family stress/distress prior to deployment Significant disruption post injury Higher rates of family/child stress and distress post-injury 56

57 Reserve/Guard May largely deal with these problems on their own Fewer supports available than in military communities 57

58 Psychological casualties “For the first time in history, the number of psychological casualties exceeds those who die in battle or who are physically injured.” (McFarlane, 2009) 58

59 Psychological casualties Interpersonal consequences – May be reflected in injured or by their children – Social withdrawal – Emotional numbing – Lack of empathy – Irritability – High risk group 59

60 Military Children in School Literature 60

61 Study of School Personnel Schools with AD/G/R Children School personnel perceive that kids are coping well In fact, kids reported they were dealing with a range of deployment issues Affected their ability to function in school 61

62 School personnel concerns Student uncertainty about deployment length Perceived mental health issues of the non- deployed parent – Contribution to difficulties at school Children from Guard/Reserve families – Lacked the social support network within their school (peers) who understood the military experience 62

63 The Adolescent Special Populations 63

64 The Early Adolescent 11-14 Domains of development (Bright Futures) Physiological- puberty, growth, menarche Psychological- – concrete thought, questioning independence, parental controls remain strong, preoccupation with body changes, sexual identity, Social- – search for same-sex peer affiliation, good parental relationships, other adults as role models, sensitivity to differences between home culture and culture of others, transition to middle school, involvement in extracurricular activities Potential problems- – school problems, psychosomatic concerns, depression, unintended pregnancy, initiation of alcohol, tobacco or other drugs 64 Bright Futures, 2008

65 The Middle Adolescent 15-17 Domains of development (Bright Futures) Physiological- Ovulation, growth spurt Psychological – Competence in abstract and future thought, idealism, sense of invincibility or narcissism, beginning of cognitive capacity to provide legal consent, sexual identity Social – Begin emotional emancipation, increased power of peer group, conflicts over parental control, risk-taking behavior, cultural conflict between values of peers, family and culture, transition to high school, reduced involvement in extracurricular activities Potential problems – Experimentation, unintended pregnancy, conflicts with parents, poor eating or disordered eating, decreased physical activity. 65 Bright Futures, 2008

66 General Experiences By age 17, military youth have attended an average of 5 schools – Some outside of Continental U.S. (CONUS) Develops resiliency and coping skills Limits access to high-risk behavioral influences 66

67 RISK-TAKING Military Adolescent 67

68 Susceptibility to risky behaviors Multiple relocations Changes in peer groups (+ or -) Separation from peers and family Worry about loved one Loss of a loved one 68

69 Sexual activity Adolescents presenting to MTF health clinics – 30% vs 46-51% in general population – Prolonged paternal absence may increase risk for sexual activity (especially in girls) and teen pregnancy 69

70 Substance abuse rates Far below national average – Alcohol 21% vs 45% Ntl – Tobacco 5% vs 22% Ntl – Marijuana 8% vs 22.4% Ntl Except 12 th grade males 20% vs 26-30% 70

71 Difference is more than demographic Military adolescents averse to risk-taking – Access to confidential services – Environment shared by military families Atmosphere of change and community – Resilient peer group – Parents with job security – Relocation away from destructive peer groups – Parental deployments and risk association 71

72 Effect of age on risk-taking behavior As age increased – More difficulties in academic engagement – Fighting and drinking – More problems with reintegration BUT – Peer functioning improved – Anxiety decreased 72

73 PEER RELATIONSHIPS Military Adolescent 73

74 Peer relationships Difficulty in peer relationships – Results in low self-esteem – Higher fear of negative evaluation by peers – Social avoidance and distress – Loneliness Longer time at the current address – Better peer relationships – Less loneliness 74

75 General issues Difficult forging new relationships on PCS Academic issues Emotional/behavioral adjustment Differing family roles and responsibilities 75

76 IMPACT OF DEPLOYMENT Military Adolescent 76

77 Pre-deployment Fear that caregivers won’t be able to adequately care for them Ineffective coping – Crying, temper tantrums 77

78 Deployment Mixed emotions Angry, sad, numb, alone Sleep difficulties, anxiety, ineffective coping Poor diet Lack of exercise Changes in academic performance 78

79 Deployment Interaction with peers Somatic complaints Added roles and responsibility Uncertainty, loss, boundary ambiguity Relationship conflict 79

80 Redeployment (Reintegration) Intense anticipation Excitement, bursts of energy, difficulty making decisions Fear of homecoming due to changes in routine or expectations Fear loss of independence 80

81 Post-deployment Reunion can be difficult for both parent and child – Hard to respond to discipline from returning parent – Fear of changes to routine – Re-establishing old models of discipline and caretaking 81

82 Experience of the Adolescent Caregiver Deployment – Anxiety, strain, tension during deployment – Excessive stress interferes with caregiver-child relationship Return from deployment – Resentment as returning parent begins to “reengage” with the family 82

83 Risk Factors/Predictors Psychosocial vulnerability is not inevitable Family cohesiveness and mother-child relationships – Critical to psychosocial adjustment of child – Strong relationships= Better resilience – Ineffective coping skills of adolescent and caregiving parent= Poor functioning 83

84 Risk Factors/Predictors Deployed mother leads to significant increase in risk-taking behavior Pre-existing emotional problems in caregiving parent or child leads to poor psychosocial functioning Parents with poorer mental health reported more child difficulties during deployment 84

85 Support Pets Strong coping skills Reservists – Family support groups Help with boundary ambiguity – Tend to re-stabilize once parent home and back at work Living in base housing (support) Parental employment outside the home 85

86 Children Ages 5-12 86

87 Problem behaviors Often lower between the ages of 2-12 – Modulated by Level of adult supervision Self-exploration during development Increase during adolescence 87

88 Middle Childhood (5-12) Development – Self – Family – Friends – School – Community 88 Bright Futures, 2008

89 Self Self-esteem – Experiences of success – Reasonable risk-taking behavior – Resilience and ability to handle failure – Supportive family and peer relationships Self-image – Body image – Physical changes associate with development 89 Bright Futures, 2008

90 Family What matters at home: – Consistent expectations and limit setting – Family time together Family meals – Communication – Family responsibilities – Family transitions – Sibling and caregiver relationships 90 Bright Futures, 2008

91 Friends Making friends Family support of friendships 91 Bright Futures, 2008

92 School Consistent expectations for school performance Homework Building relationships with teachers – Managing conflict Parent-teacher communication Addressing cultural needs in the school Negative Impact – Aggression, bullying, and victimization – Absenteeism 92 Bright Futures, 2008

93 Community Community organizations Religious groups Cultural groups 93 Bright Futures, 2008

94 Potential High-Risk Behaviors Substance use Unsafe friendships Unsafe community environments 94

95 Anxiety 1/3 clinically significant anxiety – Regardless of deployment status – 32% exceed cutoff for “high risk” anxiety levels 2.5 times the national norm Cumulative length of parental deployment and parental distress – Correlate with child depression and externalizing behaviors 95

96 Children (5-12 years) – Difficulty sleeping- 56% – Attention concerns- 13% – School related- 14% Dropping grades Decreased interest in school Teacher conflict 96

97 Impact on Girls 5-12 AD parent deployed – Increase in externalizing behaviors And not internalizing behaviors – Resolves on return of parent – Problems with reintegration – Girls more likely to have problems with the deployment than boys 97

98 Impact on Boys 5-12 Increase in externalizing behaviors when AD parent returns Man of the house 98

99 Single study result Fort Lewis and Camp Pendleton – No elevations in depression, internalizing or externalizing behaviors compared to community norms – Limitation: very few E1 to E4 outcomes 99

100 Caregiver experiences Anxiety – ¼ of parents with a deployed spouse – Decreased on reintegration Care-giving parent distress – 42% had high levels of stress significantly higher than national norm – Correlates with child symptoms Employment and higher education – Correlated with significantly less parenting stress 100

101 Caregiver experiences As the number of combat months deployed increased – stress and distress of at-home caregiver increased 101

102 Impact of parent-child relationship If parent perceived their child as “difficult” – Reported more dysfunctional interactions 19% exceeded “at risk” 102

103 Impact of parent-child relationship If parent perceived their child as “difficult” – Reported more dysfunctional interactions 19% exceeded “at risk” for maltreatment Neglect and maltreatment – 55% exceeded at risk on at least 1 of 3 measures – 10% on all 3 measures – Only 6% would be considered “high risk” for neglect and maltreatment 103

104 Children of parents with PTS Exhibit externalizing (but not internalizing) behaviors 104

105 Risk Factors/Predictors Mental health and coping of parents – Correlates with adjustment of child 105

106 Incidence of Mental and Behavioral Health Issues There is an 11% increase in outpatient visits for mental and behavioral health issues during a parent’s deployment – Despite overall 11% decrease in outpatient visits during deployment – 18-19% increase in behavioral and stress disorders – Stressed parents must prioritize which conditions warrant an outpatient visit 106

107 Incidence of Mental and Behavioral Health Issues – Older children and children of married parents had more outpatient mental and behavioral health visits 107

108 The gender of the deployed member makes a difference – Male member deployed Increased outpatient visits – Female member deployed Decreased outpatient visits – Combination of factors Gender-specific differences in the behavioral response of children to deployment – Recognition of child issues during deployment – Difficulty in bringing issues to professional attention 108

109 Children 109

110 Young Children <5 110

111 Special Populations Young Children (<5 years) Growth and Development – Based on developmental milestones – Gross motor – Fine motor – Cognitive, linguistic, and communication – Social-emotional 111 Bright Futures, 2008

112 Child Case Study 112

113 Behavior Changes No single, simple effect Increased behavior problems usually begin at deployment – Behavior changes increase by number of deployments number of months deployed Attachment problems occurred at reunion – Worsened with each successive deployment 113

114 Behavior Changes Associated with individual child factors – Temperament “Anxious”, “difficult “ had more problems – Pre-deployment attachment – Pre-deployment behavior – Age of the child 114

115 Age Differences and Deployment Infants have fewer behavioral changes than older toddlers and pre-schoolers Children age 3-5 tend to have more externalizing behaviors 115

116 Frequent Relocations In young children, frequent relocations increases behavior problems – Disrupts parent and child routine, social relationships – Worse if relocate right before or right after a deployment 116

117 During deployment – Need lots of attention – Clingy – Increase in temper tantrums – Asks lots of questions about the deployed parent – Attempts to control things – Defiant, disobedient, argumentative – Appetite changes – Prolonged crying – Sleeping problems/nightmares 117

118 Reunion/reintegration – Won’t sleep in their own bed – Prefers non-deployed parent or caregiver – Doesn’t want returning parent to leave the house – Ignores returning parent – Won’t let returning parent comfort him/her 118

119 Risk Factors/Predictors Child – Personality- flexible, cooperative – Disposition – Positive mood – Parent support- warmth and family cohesion – Community support- strengthens coping, provides role models 119

120 Parent Perception as a Predictor Parents who report being stressed – Report that their children are stressed – Report more attachment problems in their children on reintegration 120

121 Children with Special Health Care Needs (CSHCN) 121

122 CSHCN Developmental issues CSHCN – Have same developmental goals and milestones as other children – Additional issues in achieving those goals 122

123 CSHCN Additional Developmental Issues Making friends and friendships with peers with and without special needs Family support to have typical friendship activities Parent-teacher communication Addressing cultural needs in the school Aggression, bullying, and victimization Absenteeism 123

124 CSHCN Developmental issues Available community organizations Risk-taking behaviors Easily victimized 124

125 Incidence 23% of families report having a child with a health need that will last at least 1 yr – 9% need Rx (asthma, diabetes, epilepsy) – 14% need services (medical, mental health, or educational services; special therapies; or treatment or counseling) – 11% require special medical, mental health, or educational services – 5.5% have functional limitations 125

126 Healthcare Needs – 5x’s as many admissions – 10x’s as many total days in the hospital – 2x’s as many outpatient visits Average 19 visits per year – Many visits are related services (MH, Speech, OT, PT) 126

127 Children with Special Health Care Needs (CSHCN) Autism in general population 1:110 – In military 1:88 * Why the higher rates of CSHCN in the military? – Partially due to insurance recognition and coverage for services 127 * Exact number not known

128 Children with Special Health Care Needs (CSHCN) In general population – Elevated incident of abuse and neglect – Divorce rates >2x that of typical children Disruption in family cohesiveness Inadequate coping skills 128

129 Children with Special Health Care Needs (CSHCN) Some AD members are concerned about the stigma of having a CSHCN – Particularly those with severe MH problems – Concern about effect of limited duty options (EFMP) – Ability to stay in military 129

130 Coordination of Care Opportunities for improvement – Coordinating moves for military families of CSHCN – EFMP looks to see if services are available in community May not be covered by TRICARE 130

131 Parental Stressors Find providers who accept insurance Get on waiting lists for services – Referrals for specialty services lapse Getting the child in the right school Uncover benefits, providers and services ECHO and other insurance benefits Specialty services (e.g. dentists who work with children with Autism) 131

132 CSHCN Many typical military children have trouble when a parent deploys for a long period of time – it may be even harder for a child who cannot communicate his or her feelings or just doesn’t understand where his or her parent went. – every child reacts differently to differences in family dynamics – may see significant developmental regression – Catch 22 132

133 What can school nurses do? Predeployment Identify potential units/families approaching deployment Discuss with family plans for the child during deployment Anticipatory guidance- emotional, physical and psychological needs – Local/base/community/religious resources – Peer groups Ensure health records of child up to date 133

134 What can school nurses do? Deployment Inform applicable school personnel of parental deployment In-service regarding needs of children/caregivers Follow-up on support resources Discuss home and personal safety strategies for child and caregivers Monitor child and caregiver during deployment 134

135 What can school nurses do? Re-deployment Anticipate homecoming Monitor child and caregiver emotions – Assess need for emotional/psychological support Notify applicable personnel of impending return – Help family celebrate the return Monitor child’s attention to school work, ADLs 135

136 What can school nurses do? Postdeployment/reintegration Assist family in transition – Anticipatory guidance- potential changes in roles/responsibilities/discipline – Direct to resources that can assist during transition – Reorganization of family roles and living arrangements Monitor coping – Assess family health/risk – Need for intervention 136

137 Family Support Most support needed during transitions – Deployment and upon reintegration – Targeted support – Before and after PCS Increases vulnerability, worsens peer functioning (KFA) Support for families with traumatic injuries Highly stressed families have a hard time participating in organized interventions 137

138 School Environment A strong school environment provides established routine and structure – Minimizes child stress – A positive school climate improves academic performance – Influences emotions and student behavior Identify and intervene in families at risk 138

139 Role of the School Provide support for military families – Emotional and social support Staff training to recognize problems Give children a forum to discuss deployment related issues and stressors Put children/families in touch with resources and a peer support network 139

140 References Barker LH, Berry KD. Developmental issues impacting military families with young children during single and multiple deployments. Mil Med 2009;174:1033-40. Chandra, A., Lara-Cinisomo, S., Jaycox, L. H., Tanielian, T., Burns, R. M., Ruder, T., et al. (2010). Children on the homefront: the experience of children from military families. Pediatrics, 125(1), 16-25. Chandra A, Martin LT, Hawkins SA, Richardson A. The impact of parental deployment on child social and emotional functioning: perspectives of school staff. J Adolesc Health 2010;46:218-23. 140

141 References Chartrand, M. M., D. A. Frank, et al. (2008). "Effect of parents' wartime deployment on the behavior of young children in military families." Arch Pediatr Adolesc Med 162(11): 1009-1014. Cozza, S. J., J. M. Guimond, et al. (2010). "Combat- injured service members and their families: the relationship of child distress and spouse-perceived family distress and disruption." J Trauma Stress 23(1): 112-115. Fitzsimons VM, Krause-Parello CA. Military children: when parents are deployed overseas. J Sch Nurs 2009;25:40-7. 141

142 References Flake EM, Davis BE, Johnson PL, Middleton LS. The psychosocial effects of deployment on military children. J Dev Behav Pediatr 2009;30:271-8. Gibbs, D. A., S. L. Martin, et al. (2007). "Child maltreatment in enlisted soldiers' families during combat-related deployments." JAMA : the journal of the American Medical Association 298(5): 528-535. Gorman, G. H., M. Eide, et al. (2010). "Wartime military deployment and increased pediatric mental and behavioral health complaints." Pediatrics 126(6): 1058-1066. 142

143 References Gorman LA, Fitzgerald HE, Blow AJ. Parental combat injury and early child development: a conceptual model for differentiating effects of visible and invisible injuries. Psychiatr Q 2010;81:1-21. Hagan JF, Shaw JS, Duncan PM. Bright futures : guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008. Hartley, S. L., Barker, E. T., Seltzer, M. M., Floyd, F., Greenberg, J., Orsmond, G., et al. (2010). The relative risk and timing of divorce in families of children with an autism spectrum disorder. Journal of family psychology, 24(4), 449-457. 143

144 References Hutchinson, J. W. (2006). Evaluating risk-taking behaviors of youth in military families. J Adolesc Health, 39(6), 927-928. Kelley, M. L., Finkel, L. B., & Ashby, J. (2003). Geographic mobility, family, and maternal variables as related to the psychosocial adjustment of military children. Mil Med, 168(12), 1019-1024. Kelley, M. L., E. Hock, et al. (2001). "Internalizing and externalizing behavior of children with enlisted Navy mothers experiencing military-induced separation." Journal of the American Academy of Child and Adolescent Psychiatry 40(4): 464-471. 144

145 References Klein DA, Adelman WP. Adolescent pregnancy in the U.S. military: what we know and what we need to know. Mil Med 2008;173:658-65. Lamberg L. Redeployments strain military families. JAMA 2008;300:644. Lemmon KM, Chartrand MM. Caring for America's children: military youth in time of war. Pediatr Rev 2009;30:e42-8. 145

146 References Lester P, Peterson K, Reeves J, et al. The long war and parental combat deployment: effects on military children and at-home spouses. J Am Acad Child Adolesc Psychiatry 2010;49:310-20. Lincoln A, Swift E, Shorteno-Fraser M. Psychological adjustment and treatment of children and families with parents deployed in military combat. J Clin Psychol 2008;64:984-92. Manos GH. War and the military family. J Am Acad Child Adolesc Psychiatry 2010;49:297-9. 146

147 References McFarlane AC. Military deployment: the impact on children and family adjustment and the need for care. Curr Opin Psychiatry 2009;22:369-73. Newton A.W., & Vandeven A.M. (2010). Update on child abuse and neglect: A worldwide concern. Current Opinions in Pediatrics, 22(2), 226-233. Rentz, E. D., S. W. Marshall, et al. (2007). "Effect of deployment on the occurrence of child maltreatment in military and nonmilitary families." Am J Epidemiol 165(10): 1199-1206. 147

148 References Sansone, R. A., G. Matheson, et al. (2008). "Concerns about career stigma by military parents of children with psychiatric illness." Mil Med 173(2): 134-137. Ternus MP. Support for adolescents who experience parental military deployment. J Adolesc Health 2010;46:203-6. Weber EG, Weber DK. Geographic relocation frequency, resilience, and military adolescent behavior. Mil Med 2005;170:638-42.EGrelocad 2005;170:638-42. 148

149 References Williams, T. V., E. M. Schone, et al. (2004). "A national assessment of children with special health care needs: prevalence of special needs and use of health care services among children in the military health system." Pediatrics 114(2): 384-393. 149

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