Supporting families with a parent in the military

Currently in the United States, less than 0.5% of the population serves in the uniformed armed services. This small sliver of the population has borne a large burden over the past dozen years, as the United States engaged in wars in both Iraq and Afghanistan. While those in the armed services have traditionally been quite young themselves, Operation Iraqi Freedom and Operation Enduring Freedom saw many more Army Reservists and National Guardsmen deployed.

Many of those deployed are parents, coming from civilian communities and jobs rather than from military bases. While combat operations in Iraq and Afghanistan have officially ceased, there are many families still living with the effects of a military deployment, whether deployment is ongoing or the deployed parent recently returned; the effects of deployment include post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in a returning parent, or even the death of a parent.

As many as 2 million children in the United States have lived through a parent’s deployment, with more than 800,000 living through two or more deployments. Pediatricians are in a unique position to provide useful information and support to the parents of these children, especially for those not on military bases, which have all of the built-in supports such a location may provide.

Supporting resilience in the families of our military service members can begin with a simple question, "Is someone in your family serving in the military?" Simply asking this question suggests you understand the range of risks, level of stress, and potential isolation of these "single" parents. Children with a deployed parent are at greater risk for anxiety and depression than their civilian peers are, and the risk goes up with longer or multiple deployments.

Somewhat counterintuitively, the risk can be higher for adolescents than for younger children. Adolescents have more complex needs to adjust and test their emerging identities with both parents, and they are faced with greater real-world risks given their many hours of unsupervised time, access to alcohol, and, if they are old enough, the ability to drive. It can be useful to find out if the child is functioning well at school, at home, and with peers, or if there have been any changes in function since the parent was deployed. This may be an ideal time to consider using a mental health screening instrument, such as the Pediatric Symptom Checklist (PSC) to check for functional impairment that may indicate a need for a mental health referral.

It is also important to ask the remaining parent how they are managing the deployment. The combined effect of their anxiety about their partner’s safety; sudden, single parenthood; and the financial strains that deployment can bring is often profound. Families with a deployed reservist are likely to experience some social isolation as they manage these challenges outside of the structure and organization of the military community. It can be meaningful for these parents to receive support from a pediatrician, and the suggestion that they make good use of all of their available supports, whether through the military, a faith organization, family, or community-service agencies.

On a practical level, it can be very helpful to consider how the family is managing communication around the deployment. How much should their children know about the details of the parent’s deployment? How is the child or adolescent dealing with the information? How anxious are they? What questions are they asking? Do the children feel they have enough information or would they prefer to know more? Are there certain things they don’t want to know? Do they know to ask a trusted adult if they have a specific worry or hear something worrisome at school, on television, or even at home? How is the parent himself or herself adjusting? Is she able to cope with the stress? Is he depressed or overwhelmed?

Similarly, it can be powerful for a parent to hear from their pediatrician that it is protective to preserve a child’s routines, rules, and responsibilities during a parent’s deployment. Even an adolescent will find it reassuring and organizing to have consistency in her schedule. School, extracurricular activities, homework, sports, and play dates should continue whenever possible, and parents may need to use their support network to help with this. They might focus on special rituals, such as holidays or birthdays, and document them so that they can be shared with the deployed parent, either in a care package or when they return.

While a parent’s return will be eagerly anticipated, it will also be a time of some unexpected changes and challenges. During deployment, usually 8 to 12 months, their children will have grown and changed, and the at-home parent will have adjusted to a different pace and routines. Simple questions can help the other parent anticipate and prepare for the challenge of reintegration into the home and community. What have they told their children about the return? Have they talked about what might be difficult? What has been surprising or easier during the parent’s deployment? What will be easier after that parent returns? How have they changed since their parent was deployed? What are they most curious about? What are they most worried about? Reintegration takes time, but as long as there are open lines of communication during the transition and supports to turn to in case of significant difficulties, it will be successful.

If a parent has recently returned, it is reasonable to ask if there have been any unexpected problems. While some injuries are visible, many returning soldiers will experience the "invisible wounds" of TBI or PTSD. There is ample evidence that many veterans will not seek care for PTSD, and those who do may experience significant barriers to accessing treatment. These conditions will affect a whole family, so asking a parent (and your patient) about concerning behaviors, such as anxiety, anger, avoidance, withdrawal, or substance abuse in a returned parent can be the first step to helping a family. Reminding parents that there are resources available to them, whether through the Department of Veterans Affairs, community service agencies, or even online (see below), can empower them to help the returning parent get the needed treatment and support.

Finally, the death of a parent during deployment is a subject worthy of its own column. Express your condolences while acknowledging that grief is a gradual process that is different for each individual and is especially different for children and spouses. Ask if they are taking good care of themselves and have enough personal support. You might remind a parent that some regressive behaviors, moodiness, or even seeming normalcy are all typical expressions of grief in children and require patience. Increased risk-taking behaviors in an adolescent or significant dysfunction (refusing to go to school or total withdrawal from friends and extracurricular activities) are concerning, though, and should be referred for additional evaluation and support. Assess the parent’s capacity during this difficult time, and see if the surviving parent and children have access to sufficient support or whether a referral for mental health services is needed. For a child to know that she can speak to another family member, teacher, or coach can be protective and allay guilt, as she can voice her grief or worries to an adult who is not grieving as intensely as her surviving parent. Finally, you might work with parents to locate the community resources that are available to them and their children as they manage this painful adjustment while also supporting their children’s healthiest development.

Some examples of online resources for the families of deployed or returned veterans:

• The Department of Veterans Affairs Mental Health page.

• The Veteran Parenting Toolkit.

• The Home Base Program.

Most of us are isolated from the difficulties that military families routinely face, and it is easy to forget the impact and the risks to children when parents are deployed. We should not forget their service and their needs.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is chief clinical officer at Partners HealthCare, also in Boston. E-mail Dr. Swick and Dr. Jellinek at pdnews@frontlinemedcom.com.

Currently in the United States, less than 0.5% of the population serves in the uniformed armed services. This small sliver of the population has borne a large burden over the past dozen years, as the United States engaged in wars in both Iraq and Afghanistan. While those in the armed services have traditionally been quite young themselves, Operation Iraqi Freedom and Operation Enduring Freedom saw many more Army Reservists and National Guardsmen deployed.

Many of those deployed are parents, coming from civilian communities and jobs rather than from military bases. While combat operations in Iraq and Afghanistan have officially ceased, there are many families still living with the effects of a military deployment, whether deployment is ongoing or the deployed parent recently returned; the effects of deployment include post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in a returning parent, or even the death of a parent.

As many as 2 million children in the United States have lived through a parent’s deployment, with more than 800,000 living through two or more deployments. Pediatricians are in a unique position to provide useful information and support to the parents of these children, especially for those not on military bases, which have all of the built-in supports such a location may provide.

Supporting resilience in the families of our military service members can begin with a simple question, "Is someone in your family serving in the military?" Simply asking this question suggests you understand the range of risks, level of stress, and potential isolation of these "single" parents. Children with a deployed parent are at greater risk for anxiety and depression than their civilian peers are, and the risk goes up with longer or multiple deployments.

Somewhat counterintuitively, the risk can be higher for adolescents than for younger children. Adolescents have more complex needs to adjust and test their emerging identities with both parents, and they are faced with greater real-world risks given their many hours of unsupervised time, access to alcohol, and, if they are old enough, the ability to drive. It can be useful to find out if the child is functioning well at school, at home, and with peers, or if there have been any changes in function since the parent was deployed. This may be an ideal time to consider using a mental health screening instrument, such as the Pediatric Symptom Checklist (PSC) to check for functional impairment that may indicate a need for a mental health referral.

It is also important to ask the remaining parent how they are managing the deployment. The combined effect of their anxiety about their partner’s safety; sudden, single parenthood; and the financial strains that deployment can bring is often profound. Families with a deployed reservist are likely to experience some social isolation as they manage these challenges outside of the structure and organization of the military community. It can be meaningful for these parents to receive support from a pediatrician, and the suggestion that they make good use of all of their available supports, whether through the military, a faith organization, family, or community-service agencies.

On a practical level, it can be very helpful to consider how the family is managing communication around the deployment. How much should their children know about the details of the parent’s deployment? How is the child or adolescent dealing with the information? How anxious are they? What questions are they asking? Do the children feel they have enough information or would they prefer to know more? Are there certain things they don’t want to know? Do they know to ask a trusted adult if they have a specific worry or hear something worrisome at school, on television, or even at home? How is the parent himself or herself adjusting? Is she able to cope with the stress? Is he depressed or overwhelmed?

Similarly, it can be powerful for a parent to hear from their pediatrician that it is protective to preserve a child’s routines, rules, and responsibilities during a parent’s deployment. Even an adolescent will find it reassuring and organizing to have consistency in her schedule. School, extracurricular activities, homework, sports, and play dates should continue whenever possible, and parents may need to use their support network to help with this. They might focus on special rituals, such as holidays or birthdays, and document them so that they can be shared with the deployed parent, either in a care package or when they return.

While a parent’s return will be eagerly anticipated, it will also be a time of some unexpected changes and challenges. During deployment, usually 8 to 12 months, their children will have grown and changed, and the at-home parent will have adjusted to a different pace and routines. Simple questions can help the other parent anticipate and prepare for the challenge of reintegration into the home and community. What have they told their children about the return? Have they talked about what might be difficult? What has been surprising or easier during the parent’s deployment? What will be easier after that parent returns? How have they changed since their parent was deployed? What are they most curious about? What are they most worried about? Reintegration takes time, but as long as there are open lines of communication during the transition and supports to turn to in case of significant difficulties, it will be successful.

If a parent has recently returned, it is reasonable to ask if there have been any unexpected problems. While some injuries are visible, many returning soldiers will experience the "invisible wounds" of TBI or PTSD. There is ample evidence that many veterans will not seek care for PTSD, and those who do may experience significant barriers to accessing treatment. These conditions will affect a whole family, so asking a parent (and your patient) about concerning behaviors, such as anxiety, anger, avoidance, withdrawal, or substance abuse in a returned parent can be the first step to helping a family. Reminding parents that there are resources available to them, whether through the Department of Veterans Affairs, community service agencies, or even online (see below), can empower them to help the returning parent get the needed treatment and support.

Finally, the death of a parent during deployment is a subject worthy of its own column. Express your condolences while acknowledging that grief is a gradual process that is different for each individual and is especially different for children and spouses. Ask if they are taking good care of themselves and have enough personal support. You might remind a parent that some regressive behaviors, moodiness, or even seeming normalcy are all typical expressions of grief in children and require patience. Increased risk-taking behaviors in an adolescent or significant dysfunction (refusing to go to school or total withdrawal from friends and extracurricular activities) are concerning, though, and should be referred for additional evaluation and support. Assess the parent’s capacity during this difficult time, and see if the surviving parent and children have access to sufficient support or whether a referral for mental health services is needed. For a child to know that she can speak to another family member, teacher, or coach can be protective and allay guilt, as she can voice her grief or worries to an adult who is not grieving as intensely as her surviving parent. Finally, you might work with parents to locate the community resources that are available to them and their children as they manage this painful adjustment while also supporting their children’s healthiest development.

Some examples of online resources for the families of deployed or returned veterans:

• The Department of Veterans Affairs Mental Health page.

• The Veteran Parenting Toolkit.

• The Home Base Program.

Most of us are isolated from the difficulties that military families routinely face, and it is easy to forget the impact and the risks to children when parents are deployed. We should not forget their service and their needs.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is chief clinical officer at Partners HealthCare, also in Boston. E-mail Dr. Swick and Dr. Jellinek at pdnews@frontlinemedcom.com.

Currently in the United States, less than 0.5% of the population serves in the uniformed armed services. This small sliver of the population has borne a large burden over the past dozen years, as the United States engaged in wars in both Iraq and Afghanistan. While those in the armed services have traditionally been quite young themselves, Operation Iraqi Freedom and Operation Enduring Freedom saw many more Army Reservists and National Guardsmen deployed.

Many of those deployed are parents, coming from civilian communities and jobs rather than from military bases. While combat operations in Iraq and Afghanistan have officially ceased, there are many families still living with the effects of a military deployment, whether deployment is ongoing or the deployed parent recently returned; the effects of deployment include post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in a returning parent, or even the death of a parent.

As many as 2 million children in the United States have lived through a parent’s deployment, with more than 800,000 living through two or more deployments. Pediatricians are in a unique position to provide useful information and support to the parents of these children, especially for those not on military bases, which have all of the built-in supports such a location may provide.

Supporting resilience in the families of our military service members can begin with a simple question, "Is someone in your family serving in the military?" Simply asking this question suggests you understand the range of risks, level of stress, and potential isolation of these "single" parents. Children with a deployed parent are at greater risk for anxiety and depression than their civilian peers are, and the risk goes up with longer or multiple deployments.

Somewhat counterintuitively, the risk can be higher for adolescents than for younger children. Adolescents have more complex needs to adjust and test their emerging identities with both parents, and they are faced with greater real-world risks given their many hours of unsupervised time, access to alcohol, and, if they are old enough, the ability to drive. It can be useful to find out if the child is functioning well at school, at home, and with peers, or if there have been any changes in function since the parent was deployed. This may be an ideal time to consider using a mental health screening instrument, such as the Pediatric Symptom Checklist (PSC) to check for functional impairment that may indicate a need for a mental health referral.

It is also important to ask the remaining parent how they are managing the deployment. The combined effect of their anxiety about their partner’s safety; sudden, single parenthood; and the financial strains that deployment can bring is often profound. Families with a deployed reservist are likely to experience some social isolation as they manage these challenges outside of the structure and organization of the military community. It can be meaningful for these parents to receive support from a pediatrician, and the suggestion that they make good use of all of their available supports, whether through the military, a faith organization, family, or community-service agencies.

On a practical level, it can be very helpful to consider how the family is managing communication around the deployment. How much should their children know about the details of the parent’s deployment? How is the child or adolescent dealing with the information? How anxious are they? What questions are they asking? Do the children feel they have enough information or would they prefer to know more? Are there certain things they don’t want to know? Do they know to ask a trusted adult if they have a specific worry or hear something worrisome at school, on television, or even at home? How is the parent himself or herself adjusting? Is she able to cope with the stress? Is he depressed or overwhelmed?

Similarly, it can be powerful for a parent to hear from their pediatrician that it is protective to preserve a child’s routines, rules, and responsibilities during a parent’s deployment. Even an adolescent will find it reassuring and organizing to have consistency in her schedule. School, extracurricular activities, homework, sports, and play dates should continue whenever possible, and parents may need to use their support network to help with this. They might focus on special rituals, such as holidays or birthdays, and document them so that they can be shared with the deployed parent, either in a care package or when they return.

While a parent’s return will be eagerly anticipated, it will also be a time of some unexpected changes and challenges. During deployment, usually 8 to 12 months, their children will have grown and changed, and the at-home parent will have adjusted to a different pace and routines. Simple questions can help the other parent anticipate and prepare for the challenge of reintegration into the home and community. What have they told their children about the return? Have they talked about what might be difficult? What has been surprising or easier during the parent’s deployment? What will be easier after that parent returns? How have they changed since their parent was deployed? What are they most curious about? What are they most worried about? Reintegration takes time, but as long as there are open lines of communication during the transition and supports to turn to in case of significant difficulties, it will be successful.

If a parent has recently returned, it is reasonable to ask if there have been any unexpected problems. While some injuries are visible, many returning soldiers will experience the "invisible wounds" of TBI or PTSD. There is ample evidence that many veterans will not seek care for PTSD, and those who do may experience significant barriers to accessing treatment. These conditions will affect a whole family, so asking a parent (and your patient) about concerning behaviors, such as anxiety, anger, avoidance, withdrawal, or substance abuse in a returned parent can be the first step to helping a family. Reminding parents that there are resources available to them, whether through the Department of Veterans Affairs, community service agencies, or even online (see below), can empower them to help the returning parent get the needed treatment and support.

Finally, the death of a parent during deployment is a subject worthy of its own column. Express your condolences while acknowledging that grief is a gradual process that is different for each individual and is especially different for children and spouses. Ask if they are taking good care of themselves and have enough personal support. You might remind a parent that some regressive behaviors, moodiness, or even seeming normalcy are all typical expressions of grief in children and require patience. Increased risk-taking behaviors in an adolescent or significant dysfunction (refusing to go to school or total withdrawal from friends and extracurricular activities) are concerning, though, and should be referred for additional evaluation and support. Assess the parent’s capacity during this difficult time, and see if the surviving parent and children have access to sufficient support or whether a referral for mental health services is needed. For a child to know that she can speak to another family member, teacher, or coach can be protective and allay guilt, as she can voice her grief or worries to an adult who is not grieving as intensely as her surviving parent. Finally, you might work with parents to locate the community resources that are available to them and their children as they manage this painful adjustment while also supporting their children’s healthiest development.

Some examples of online resources for the families of deployed or returned veterans:

• The Department of Veterans Affairs Mental Health page.

• The Veteran Parenting Toolkit.

• The Home Base Program.

Most of us are isolated from the difficulties that military families routinely face, and it is easy to forget the impact and the risks to children when parents are deployed. We should not forget their service and their needs.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is chief clinical officer at Partners HealthCare, also in Boston. E-mail Dr. Swick and Dr. Jellinek at pdnews@frontlinemedcom.com.