Today's military is faced with an increasing number of mission requirements including combat, peacekeeping activities, humanitarian relief, and disaster response, as well as the new requirements for homeland defense. This presents significant challenges for military families as they adjust to repeated and often lengthy periods of family separation. The 9/1 1 attacks on the Pentagon and the World Trade Center have also brought about heightened concerns for personal security at home and abroad for military families. This article provides an overview of the challenges that military families face, especially with service member deployment.
Deployment can be defined as the assignment of military personnel to temporary, unaccompanied duty away from the permanent duty station. There are predictable emotional responses that family members may experience with the expected or unexpected deployment of a military parent. For children, these responses vary with age and developmental stage. The knowledgeable clinician is in a position to provide anticipatory guidance regarding coping with the stresses of military deployments, to screen for maladaptive coping, and to make referrals to military family support services in place within all the uniformed services, as well as to local community services as needed.
Both military and civilian clinicians provide health care to children of military families, whether active-duty or National Guard and reserves. There are more than 1.2 million active duty service members serving in our armed forces at this time, with approximately 700 000 spouses and 1 .2 million children of active duty members. Of these children, 39% are newborn and preschool age, 34% are ages 6 to 11 years, 24% are 12 to 18 years, and 4% are 19 years or older. The top 10 states where active duty members are stationed are California, Virginia, Texas, North Carolina, Georgia, Florida, Washington, South Carolina, Hawaii, and Kentucky. Military families move 2 to 3 times more frequently than their civilian counterparts. In addition, there are 1.3 million reserve component members and their families. The top 10 states where reservists are located are California, Texas, Pennsylvania, New York, Florida, Ohio, Illinois, Georgia, Alabama, and Virginia.1 Most children in military families will have attended several different schools before they graduate from high school, often in different states and different countries as well.
Those who care for military children must be prepared to support our military families in times of crisis and routine deployments. This requires clinicians to be educated and knowledgeable about the challenges facing military families. Intermittent single parenting characterizes life in the military family, with repeated and often lengthy deployments of the service member. The nature of the deployment may put the service member in danger. Waiting family members, both spouse and children, must cope with worries about the safety of the service member. Media coverage that is real-time and often quite graphic reinforces and may intensify concerns for safety of the absent parent. With frequent moves, often every 2 to 3 years, the traditional community support systems of extended family, close-knit neighborhoods, and long-term relationships with a school or religious community may not be available fully to the family as it copes with service member deployment. An understanding of these struggles provides an impetus to use clinical encounters with military families to determine if there are deployment issues to address.
There are predictable patterns of emotional response that a service member, spouse, and children may exhibit with deployment, which can be characterized as the emotional cycle of deployment. The original construct for the emotional cycle of deployment is traced to Kathleen V. Logan's thesis, "Deployment Adjustment Model for Navy Wives."2 This model was expanded upon by Pincus et al.3 This cycle is divided into five distinct stages closely corresponding to the service member's experience of deployment: predeployment, deployment, sustainment, redeployment, and postdeployment.3 The onset of the predeployment phase begins with the warning order or notification of impending deployment. This period is variable and may encompass days to months in advance. The deployment phase covers the period from the service member's departure from the family through the first month. The sustainment phase covers the subsequent months until the beginning of the last month of deployment. The redeployment phase covers the month prior to return of the service member, and postdeployment phase covers approximately a 3 to 6 month period of readjustment on return.
Deployment factors that can lead to increased stress include sudden deployment, longer deployment, combat environment, and perceived nonlegitimacy of a deployment by the family. Family factors that may negatively impact on coping with deployment include history of poor adaptability, family conflict and dysfunction, and poor communication. High risk factors for spouses include young age, first time away from home, foreign bom, and tenuous financial status.4
The emotions that children either internalize or exhibit are based on many factors. The age, personality, special needs, and external environment impacts how a child reacts to deployment-related family separations. Toddlers may exhibit extremes of behaviors such as temper tantrums, sullenness, or difficulty with sleep patterns. However, it is often how the primary caregiver reacts and exhibits coping to the deployment that is the critical indicator of the reactions of the toddler. Preschoolers may regress to earlier mastered behaviors and may be clingy, afraid to sleep alone, or afraid of being left alone. School-aged children may complain excessively, become aggressive, or place significance on missed events (eg, birthdays). Teenagers may exhibit irritability, attention-seeking behaviors, or other types of negative behaviors. As with all of these age groups, the key factor is not to recognize each and every possible reaction to a prolonged separation but to identify that most likely the child will be impacted to some degree and offer guidance and support.
In the predeployment phase (the variable period prior to deployment), children may feel anticipation of the loss of a parent and show fear, resentment, and hurt. Detachment and withdrawal can be coping mechanisms to shield the child from feelings of separation. Extreme emotions related to a sense of abandonment may surface. Children may feel that the deployed parent is going away because of their perceived misbehavior.
In the first month of the deployment, feelings of loss, disorganization, and anxiety may occur. Younger children may worry about their basic needs not being met, such as food and shelter. Older children may worry about the safety and well being of the deployed parent, and some adolescents begin to take on the role of the absent parent. During the period of sustainment, the family strives and works toward a state of equilibrium among the remaining family members. The acclimation to the service member's absence and the family process of onward movement may yield a new sense of adjustment and stabilization. In the month prior to the return of the service member, there is anticipation of return; however, a range of emotions from excitement to apprehension is common. Following the return of the service member, all family members begin the process of renegotiation of relationships and family roles.3
Clearly, clinicians who are aware of deployment-related separation issues when caring for a child in a military family can play an important supportive role (see Principles in Providing Support to Children in Times of Deployment, page 114). They can inquire about children's reactions and coping mechanisms during the deployment of the military parent. If difficulties are identified, brief behavioral health interventions that focus on adjustment to separation can help the family system acclimate to the absence of the military member. For example, an Air Force pediatric clinic may be staffed with a behavioral health consultant who provides consultation on behavioral health issues, including coping with deployment. The Air Force Medical Operations Agency has recognized the need to address behavioral health issues, including coping with deployment, in primary care clinics. Because deployment-related reactions should not be viewed initially as psychiatric or pathologic mental health issues, the primary care clinic is a perfect area to provide short-term assessments, recommendations, and brief interventions for the child and family. Most often, children and adolescents are displaying anticipated, predictable behaviors associated with separation from the military parent, and helpful guidance regarding strategies to meet the child's needs can be provided for the parent or caretaker. Very often one or two 30-minute interventions to educate and provide recommendations that help to restore the family to the predeployment level of functioning is all that is necessary. If mental health or more significant adjustment issues are identified, appropriate recommendations are made to the pediatrician and family by the behavioral health consultant.
Children with underlying mental health problems or other special needs may have greater difficulties adjusting to the absence of a parent. In a study focused on the impact of mothers' military deployment during Operation Desert Shield/Desert Storm, "Children whose mothers were deployed did not, as a group, demonstrate more symptoms or stress than children whose mothers were not deployed." However, during the deployment it was found that children experienced more distress when mothers had difficulties arranging for their care, older children exhibited more symptoms of stress, stress was greater the longer the mother was away, and children of reserve and guard members demonstrated greater stress, especially with mother in the combat zone.5 In a study of the impact of maternal deployment on Navy children, those whose mothers were deployed were no more likely to experience pathology than children of nondeployed mothers.6 An analysis of psychiatric hospitalizations of Navy children concluded that, in vulnerable families, deployment of the father could precipitate children's decompensation.7 Such studies can inform us regarding subsets of children and their families who may need additional support during deployment.
Clinicians can provide anticipatory guidance to parents and designated caretakers, outlining healthy coping strategies for the parent to care for themselves and their children better during deployments. It is helpful for the military providers to be aware of unit missions on the installation and of impending unit deployments to provide timely and targeted family support. The civilian pediatric professional providing care to military families may keep abreast of military installation activities and impending deployments through military installation and other community newspapers. If a child has a parent in the military, inquiry can be made about deployments during clinical encounters with brief assessment of how the family is coping while the service member is deployed.
Pediatricians have a mandate in the family support arena, as outlined in a recent position paper from the American Academy of Pediatrics. Thus they should be familiar with military community resources that are available routinely to support the needs of military families.8 In the 1960s, the Army was in the vanguard of the military family support movement with the creation of the Army Community Service organization, with the Air Force and Navy following suit.9 At the Department of Defense level, the Office of Family Policy was established and over time has crafted directives on family policy providing guidance to all branches of the service on responsibilities, standards, and procedures for implementing effective family support programs and policies worldwide.
Each branch of service has programs designed to maximize families' ability to cope with the unique aspects of military family life, including deployments. Military installations have Family Support Centers (Air Force), Family Service Centers (Navy and Marine), or Army Community Service Centers where a family can find a wide array of services. These include financial counsel and assistance, employment information for military spouses, emergency assistance, and guidance regarding other installation support services (eg, child development and family care centers, youth centers). Educational programs to introduce spouses to military culture and strategies for meeting the challenges of military family life, including deployments, are also offered. Examples of such programs include the Army Family Team Building and Operation READY (Resources for Educating About Deployment and You). Family readiness or support groups within the service member's work unit are also sources of information and support. Internet family support information resources have been developed for all the uniformed services and examples are listed at the end of this article. Carol Vandesteeg's When Duty Calls summarizes the various services available during a deployment to families of all branches of the military and their reserve components, as well as the Air National Guard and the Army National Guard.10 The Military Family, A Practice Guide for Human Service Providers, is another valuable reference text for pediatricians, with specific chapters addressing family support during deployment.11
Every service member's military unit has a command structure. Pediatric health care professionals can always recommend that a family member contact the service member's command for guidance and direction to appropriate family support services and agencies. Facilitating full family support is a command responsibility, and commanders receive ongoing education regarding military family needs and available services. Chaplains are another resource for spiritual and life skills counseling. Military medical treatment facilities are also avenues to seek and request direction for family support during deployments.
Although separation can be an emotionally challenging time for children in military families, there are positive aspects that should be noted. Military children have the opportunity to experience and grow within a diverse and culturally rich environment, especially for those who live outside of the United States. These experiences add to opportunities for growth and maturation as children learn how to function and master their perception of the world. Independence and flexibility are important to healthy adjustment to military life; children's development of these attributes will help build resilience and strong coping skills as they continue to meet the challenges of military family life. Deployment-related family separations can be transformed into family and personal growth-promoting experiences when military families know what to expect, understand the inevitable phases of emotional response, are educated about effective coping strategies, and are well supported as specific needs arise. In this setting, children have an opportunity to acquire new life skills, to feel a sense of pride in the contributions they make to the family, and to gain a sense of increased self-efficacy. Military pediatricians and their civilian counterparts who care for military families, active duty, reserve, and guard have a critical role to play in facilitating and supporting families as they meet these challenges.
Clinicians, both military and civilian, must be prepared to mobilize and intensify family support measures outlined above at the earliest signs of an unfolding large-scale crisis rather than waiting until multiple families are crippled by distress. This same paradigm applies to the family members of nonmilitary emergency responders as well, including police, firefighters, paramedics, and other disaster response personnel called to a crisis situation. Remember the impact of timely, proactive support of families on the ability of these military and emergency service providers to carry out critical missions at hand.
1. Military Family Resource Center. Profile of the Military Community: 2000 Demographics. Available at: http: / / mfrc.calib.com / WordFiles/ Exec_ Summ_Intro.doc.
2. Logan KL. The emotional cycle of deployment. US Naval Institute Proceedings. 1987;113:43-47.
3. Pincus SH, House R, Christenson J, Adler LE. The emotional cycle of deployment: a military family perspective. Journal of the Army Medical Department. April-June 2001;PB 8-01-4/5/6:15-23.
4. Blount BW, Curry A Jr, Lubin GI. Family separations in the military. Mil Med. 1992;157:76-80.
5. Pierce PF, Buck CL. Wartime separations of mothers and children: lessons from Operations Desert Shield & Desert Storm, military family issues. The Research Digest. 1998;2:1-4.
6. Kelley ML, Hock E, Smith KM, Jarvis MS, Bonney JF, Gaffney MA. Internalizing and externalizing behavior children with enlisted Navy mothers experiencing military-induced separation. / Am Acad Child Adolesc Psychiatry. 2001;40:464-471.
7. Levai M, Kaplan S, Ackermann R, Hammock M. The effect of father absence on the psychiatric hospitalization of Navy children. Mil Med. 1995;160(3):104-106.
8. The Pediatrician's Role in Family Support Programs. Pediatrics. 2001;107:195.
9. Albano S. Military recognition of family concern: Revolutionary War to 1993. Armed Forces and Soaety. 1994;20:283-302.
10. Vandesteeg C. When Duty Calls: A Guide to Equip Active Duty, Guard, and Reserve Personnel and Their Loved Ones for Military Separations. Enumclaw, Wash: Winepress; 2001.
11. Martin JA, Rosen LN, Sparacino LR. The Military Family: A Practice Guide for Human Service Providers. Westport, CT: Praeger Publishers; 2000.