Stress and Distress in Military Children

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

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

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 • Identify manifestations of stress and distress in children • Differentiate manifestations of stress by age group

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

5. Military 101 General Concepts

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

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.

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

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

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

11. Military Terminology Deployments

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 *redeployment-return from deployment

13. Military TerminologyDeployment • 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)

14. Military TerminologyDeployment • 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,

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

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 http://siadapp.dmdc.osd.mil/

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

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

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

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

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

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

23. Stress, Distress and Resilience in Military Children

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

25. Recognizing stress and distress

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

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 Internalizing behaviors • Emotions that are turned inward • Withdrawn • Lonely • Anxious • Depressed • Low self-perceptions (self-esteem) • Can be in multiple domains • Shyness

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

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

30. The Military Family Vulnerable yet exceptional

31. The Military FamilyFrequent 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

32. The Military FamilyFrequent 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

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

34. Post-traumatic stress • Post-traumatic stress • Acute • Post-traumatic stress disorder • Chronic, dysfunction

35. General Findings

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%)

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

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

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

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

41. Negative Behaviors • Diminish over time

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

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

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

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

46. Changes at Home Risk in the Home

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

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

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

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