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

2. 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. 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. 4 U.S. military today Personnel End Strength – FY05 FY2005ActiveMobilizedGuardReserveCivilianTOTAL 1,421,41477,861464,900379,600752,0003,017,414 DOD----- 126,000 Army562,40048,331358,200205,000250,0001,375,600 Navy324,23910,818-----65,500199,000588,239 Marines203,0752,261-----39,600-----242,675 Air Force331,70016,451106,70069,500177,000684,900 www.globalsecurity.org

5. 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. 6 Women in the US military US militaryNumberPercent of total Total Active Duty and Reserves342,00014.3% of active duty force Deployed to Iraq or Afghanistan since 2001 165,68348.4% of all military women Women of minority in the military WhiteAfrican-AmericanHispanicAsian, other All active duty64%15% 6% AD women50%30%6%5% Civilian women70%13%12%5% US Congress Joint Economic Committee Report, May 2007

7. 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 8

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 9

10. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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 Total deaths# women Operation Enduring Freedom159030 Operation Iraqi Freedom / Operation New Dawn (Sep 2010) 4444110 Totals6034140 RAND Corp 2010

26. 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. 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… 28

29. 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. 30 Military OneSource www.militaryonesource.com/

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

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

33. 33 Operation Purple camp National Military Family Association Operation Purple camp www.operationpurplecampinfo.com

34. 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. 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?”