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This article originally appeared in the July 2007 volume of the Zero To Three Journal on Coping With Separation and Loss.

Copyright 2007 ZERO TO THREE. Reproduced with permission of the copyright holder. The Young Military Child: Our Modern Telemachus. Zero to Three, 27, 27-33. Further reproduction requires express permission from ZERO TO THREE (www.zerotothree.org/reprints).
 

The Young Military Child

Our Modern Telemachus

Stephen J. Cozza
Uniformed Services University of the Health Sciences

 Alicia F. Lieberman
University of California, San Francisco

Abstract
For thousands of years military children have been faced with many challenges that result from the combat deployment of their parents. These challenges are likely to be particularly burdensome to infants, toddlers, and preschoolers because of their emotional and cognitive immaturity, their reliance on magical thinking, and their dependence upon their parents for healthy development. This article outlines the challenges that modern young military children face, focusing on parental combat deployment, parental combat injury, parental postcombat health consequences, and parental death. Readers are reminded of the unique needs of young military children and the culturally informed services that are necessary for them to overcome these challenges.

 

Military Child Over 2000 years ago Homer penned The Odyssey, the story of Odysseus’ 9-year journey home to Ithaca after the lengthy Trojan War. Although the story is better known for Odysseus’s fantastic travels and adventures, The Odyssey is also the classic story of the military family and its struggle to transition through and beyond their war experience. Homer understood that war is not only a concern for the warrior, but also for the family and specifically for the military child. He described the plight of Penelope, Odysseus’ faithful wife, and their son Telemachus (whose name literally means “distant warrior”) and drew the direct connection between their fates, the integrity of their family, and Odysseus’ absence and war experience. It is the story of the “coming of age” of Telemachus, a newborn at the time of his father’s departure. Telemachus faces the difficult task of growing to adulthood while meeting the challenges that are thrust upon him in the absence of his war-deployed father. Like our modern military child, it is in this great effort that he struggles and grows.

After the attacks by terrorists on September 11, 2001, many people commented upon the lasting changes that these events would have on American life. Nowhere has that been truer than in the lives of our active duty, Reserve and National Guard service members and their families. Since 9-11 our military has been involved in ongoing combat activities in Iraq and Afghanistan. While the Global War on Terror has provided a sense of meaning and purpose to many of our U.S. service men and women, it has also brought many challenges to their families and their children.

As we examine the young military child’s experience during wartime it is wise to be cautious of assumptions. First, political viewpoints about the war are likely to color understanding of military children’s experiences. To assume either widespread trauma or uniform resilience is harmful to our efforts as concerned professionals. The truth lies somewhere between these two extremes. Second, we must distinguish psychological stress from trauma. Psychological stress is a normal part of life and is caused by the various challenges that we all face. In contrast, trauma suggests injury resulting from an overwhelming experience that leads to psychological impairment and possible psychiatric illness. Most military families are likely to experience substantial stress from the experiences with which they are faced, but only a minority of military families are likely to evidence psychiatric illness. Finally, professional interest in the military family needs to maintain a healthy respect for military culture, traditions, and values that bring a sense of purpose and meaning through difficult times. Among those are patriotism, duty, and courage, sustaining principles for our military children and families.

In the past 4 years military families have faced multiple profound stressors, some of traumatic proportion. Military war zone deployments have been continuous and many families have dealt with repeated separations that have been unexpectedly extended in time. War-related injuries have sometimes been severe and resulted in functional changes in combat veterans. Combat stress responses in war veterans have not infrequently led to psychiatric disorders that require treatment. In the most serious cases a service member parent dies in combat. All of these combat related stresses—parental deployment, injury, post-combat health consequences, and death—can have profound effects on the military family, with young military children being most vulnerable. Little specific scientific study informs our understanding of the impact of these events on military children. In most circumstances we must translate findings from other populations to understand expected consequences in military youth.

Combat Deployment
Military deployments are a universally difficult part of life for service members, their families, and their children. Every deployment experience is unique to the family who manages it. During peacetime, when service member parents deploy to safe locations for limited periods of time that include interludes of rest and recovery between absences, most military families fare well. In fact, some data suggest that military deployments offer an opportunity for children to develop independence, take additional responsibility at home, and develop self-pride in their gained maturity (Jensen, Xenakis, Wolf, Bain, 1991).

Military childWartime deployments bring added challenges and can be particularly tough on families with young children.The most informative wartime deployment studies were conducted during Operation Desert Storm (ODS); a conflict that was relatively short-lived, January 16 to February 28, 1991, and resulted in far fewer casualties and deaths when compared to the current war in Iraq. In at least two of these studies, moderate increases in internalizing and externalizing symptoms were noted in children whose parents were deployed to combat areas (Kelley 1994; Rosen, Teitelbaum, & Westhuis, 1993). Rosen and colleagues reported that those children who actually demonstrated increases in symptoms rarely required clinical attention and those that did need treatment were more likely to have a past history of mental health problems. Kelley found that families of those deployed to combat areas demonstrated less cohesiveness than the control families of service members who were deployed to noncombat areas. These findings highlight the unique challenges that combat places on a family’s coping strategies as family members attempt to manage their anxiety about the safety and well-being of the combatant.

At the outbreak of ODS one group of researchers took the opportunity to compare data from an ongoing study of military children (Jensen, Martin, & Watanabe, 1996). As initial ratings had been completed prior to ODS deployment, the investigators were able to prospectively evaluate the impact of wartime deployment by comparing follow-up parental ratings of the children of a wartime-deployed group with parental ratings for the children of those who did not deploy. As in previous studies, the findings showed increased levels of depression and anxiety in the children of the deployed group, although not to pathological levels. Jensen and his colleagues did find that two sub-groups were at higher risk for mental health difficulties: younger children and boys. Other at-risk groups included children with pre-existing emotional or behavioral problems or children whose nondeployed parent evidences psychopathology (Jensen, Grogan, Xenakis, & Bain, 1989).

For young children, the challenges can be magnified because of their cognitive immaturity and emotional reliance on their parents for a sense of safety and well-being. Most available information about deployment does not address the more complicated nature of current family experiences: multiple or extended deployments, fear of injury and fear of death, as well as the actual occurrence of severe and incapacitating injury and death and the secondary adversities that are often associated with these family tragedies. Frequent or lengthy parental absences, particularly during the early years of child development, are more likely to contribute to disruptions in parental attachment, elevation in early childhood anxiety, or both. Families are likely to be affected by worries within the community about injuries or deaths, concern that can filter down to the youngest children in the family.Some recent reports (McCarroll, Fan, Newby, & Ursano, in press; Rentz et al., 2007) suggest that the increased deployment and operational tempo may be contributing to rising child maltreatment rates in military families. Child neglect in younger children of lower enlisted rank appears to be the greatest contributor to these elevated rates of maltreatment.

Post Combat Health Consequences
Beyond the separation of deployment, even greater challenges can occur when a service member parent returns home. Complications related to the war—combat stress disorders, development of psychiatric illness, or increase in health risk behaviors—all can complicate the family life of a young child. Understanding the unique challenges that military parents face while in the combat environment informs our awareness of their mindsets when they return home to their families.

Combat is a powerful and formative experience leading to neurobehavioral and psychological changes that do not immediately dissipate upon returning home. Military service members are encouraged and expected to be aggressive and physically forceful in combat if they are to survive. The combat environment is an ever-dangerous setting where constant hypervigilance is necessary for survival. Warfare often requires split-second decisions be made in uncertain circumstances. Service member parents may return home questioning their actions and may be unsure with whom they can speak about these confusing and troubling experiences. In combination, these predictable responses can lead to complicated transitions back to peacetime lives requiring varying amounts of time to regulate. A combat mindset or what has been referred to as Battlemind can lead to misdirected irritability or aggression that can impact on small children. Irritability, emotional rage, jumpiness, hypervigilance, or overreactivity can all lead to family conflict and misunderstanding on the part of the young child. Social withdrawal or reduced communication because of anxiety about sharing upsetting war-related experiences may cause further withdrawal from family members and lead to a child’s confusion about the meaning of such parental nonavailability.

Postdeployment emotional and behavioral responses can range from more typical short-term distress responses, such as change in sleep, decreased sense of safety, or social isolation, to the development of more serious psychiatric conditions, such as post traumatic stress disorder (PTSD) or depression. Studies conducted by Hoge and colleagues (Hoge et al., 2004; Hoge, Auchterlonie, & Milliken, 2005) at the Walter Reed Army Institute of Research have demonstrated significant postdeployment distress in populations of combat exposed soldiers and marines returning from Iraq. When screened 12 months after return from combat deployment, nearly 20% of service members endorsed symptoms consistent with a mental disorder, most often PTSD or depression.

Psychiatric research clearly demonstrates the negative effect of parental psychiatric illness on child development. Studies have demonstrated that the children of parents with depression (Beardslee, Versage, & Gladstone, 1998) evidence significant problems in a wide range of functional areas. Children of Vietnam veterans with PTSD are more likely to evidence symptoms similar to those of their combat-exposed fathers (Rosenheck & Nathan, 1985; Rosenheck & Thompson, 1986). Such findings suggest the importance of family intervention when parental psychiatric illness results from combat exposure. Military children, including toddlers and preschoolers, can be distressed and confused about perceived changes in combat veteran parents.Information should be made available at developmentally appropriate levels so that children can better understand the changes in their parents. Preventive programs that focus on parental illness psychoeducation, family communication, healthy cognitive reframing, and child, parent, and family skill building have been shown effective (Beardslee, Gladstone, Wright, & Cooper, 2003).

Combat veterans sometimes initiate or increase the frequency of risk behaviors that compromise their health and the health and safety of those around them. Military families and communities need to identify and address these problems when they occur. Examples include cigarette smoking, which often starts or increases in the combat zone or upon return home. Alcohol, while not allowed during deployment, is available and has been used by some service members in the combat theater. Upon return, excessive alcohol use may develop as a misguided attempt to reduce stress. Some returning veterans may continue reckless or aggressive driving that was learned in the combat theater, which can put children and families at risk. Stress and alcohol are other factors that can worsen and contribute to risky driving. When irritability or anger turns into violence, there is risk for all family members. Mixing anger with alcohol can be particularly troublesome because the individual loses the ability to understand his or her behavior or its consequences. Violent behavior can result from physical (e.g. traumatic brain injury, TBI) or emotional problems for which service members are urged to seek treatment.

Combat Injury
At the present time, over 24,000 soldiers, sailors, marines and airman have been injured in the Iraq war. A substantial portion of these injuries have been profound, resulting in limb amputations, TBI, serious eye injuries, and body burns (Grieger et al., 2006). In addition to moderate or severe TBI, some scientists have voiced concern about the impact of milder forms of TBI that may not come to medical attention, but can result in serious dysfunction or sense of ill-health. Because 40% of U.S. service members have children, averaging approximately two children per parent, it is estimated that close to 20,000 military children have been affected by combat related parental injuries.

Military ChildOf the few studies that have examined the impact of sudden parental medical events on nonmilitary families, those related to TBI are most instructive to our topic (Pessar, Coad, Linn, & Willer, 1993; Urbach, 1989; Urbach & Culbert, 1991; Verhaeghe, Defloor, & Grypdonck, 2005). TBI often results in profound impact on the child and the family, with greater difficulty in families with young children, those with lesser social or financial support, and in families where psychiatric problems are prominent (Verhaghe, et al. 2005). Elevated levels of emotional and behavioral difficulties in children of TBI patients correlate with compromised parenting in both the injured and noninjured parent as well as depression in the noninjured parent, suggesting the importance of family and parental interventions for child mental health protection (Pessar et al., 1993).

Anecdotal case reports describe the impact of parental combat injury on military children (Cohen et al. 2006; Cozza, Chun, & Miller, in press; Cozza, Chun, & Polo, 2005). Preliminary findings identify the complex nature of the effect of these injuries from initial distress to longer term injury adjustment challenges. It is possible that the effects of combat parental injury on children are more complex and potentially more challenging than nonviolent and accident-related injuries.

The potential for deleterious effects begins with the process of the family notification of injury. While there have been improvements in this system of notification (e.g., often the injured service member contacts a spouse or other family member directly), it is not uncommon that initial information pertaining to an injury may be incomplete or inaccurate, leading to even greater anxiety. Once notification has been made, intense activity typically follows along with the disruption of the family schedule or structure. Spouses often join injured service members, who are likely receiving treatment at military hospitals distant from the family home, leaving children under the supervision of other adults (either at home or at the home of other family members or friends in local or distant communities). Occasionally, children are uprooted to join parents at the hospital. All these options are likely to be unsettling, particularly for young children, because of disruptions of schedules and relationships as well as potential alterations in parental empathy, structure, or discipline. Children who travel to hospitals will miss school or other activities and may move into treatment environments that are unprepared to recognize the needs of younger family members. Before visiting the injured parent in the hospital, children must be properly prepared to handle whatever clinical situation they will face when visiting. This careful preparation becomes crucial when the injury is disfiguring or is of significant severity, such as amputation, or leads to significant changes in personality or cognitive function (as in TBI).

The nature of the information that parents share with children may or may not be developmentally appropriate. For parents who are struggling with their own emotional responses, it may be particularly difficult to evaluate what information their children are able to process and to calibrate the amount, content, and timing of the information they provide. As a result, the parents’ description of the injury and its consequences may be based more on their own anxieties rather than the needs of the children. Parents may choose to offer either too much or too little information, making it difficult for the child to understand the nature or seriousness of the injury and its realistic implications for the injured parent.

Occasionally, parents choose to withhold important information related to serious injuries from children in an attempt “not to worry them.” In such circumstances, clinicians need to challenge the assumption that such “secrets” can realistically be kept from the child. The clinician must strive to communicate to the parents that even younger children should be given some explanation for the dramatic changes that they are witnessing and attempting to understand. Just as some parents may provide too little information about the injury, others feel the need to share more than the child is able to tolerate, including forcing children to look at an injury site even when this is frightening. Helping the parent to notice and respond to the child’s emotional signals is the foundation of the clinician’s helpful stance toward the child and the family, leading to beneficial repercussions beyond the present moment and increasing the parent’s awareness of the child’s experience.

Ultimately, young children require patient parental assistance in digesting the knowledge, awareness, and emotional response related to serious injuries. Psychologically minded parents often implicitly understand this need and may demonstrate tremendous creativity and sensitivity in meeting the needs of their young children. As an example, one mother made a thoughtful and developmentally informed decision not to bring her 3-year-old son to visit his seriously injured father in the hospital until his tracheostomy tube had been removed, so that the boy could hear his father’s voice when first meeting him at the hospital. This sensitive decision enabled the young child to communicate with his father in the ways he was accustomed to during the hospital visit in spite of the other disabilities that interfered with the father’s mobility.

Longitudinal data suggest that combat-injured service members may develop complicating psychiatric problems such as PTSD and depression that do not immediately resolve and commonly worsen during the course of the first year after hospitalization (Grieger et al., 2006). In such circumstances families contend with the complication of dealing with a parent with psychiatric illness as well as physical injury. Possible longer-term consequences of parental injury and treatment also include changes in the child’s residential community, loss of military career by the injured parent, and changes in parental functional capacity. When significant changes in parental ability result from injury, both parent and child must renegotiate their relationship and integrate the reality of the injury and its consequences. Although these phenomena have been described and addressed in clinical treatment centers, continued scientific investigation is required to draw firm conclusions about both short-and long-term traumatic impact and the effectiveness of preventive interventions (Cozza et al., in press).

Parental Death
As of this writing, over 3200 service members have been killed in combat-related activities in Operation Iraqi Freedom. This number reflects an estimated population of over 2,500 children whose parents have died in combat as well as an inestimable number of siblings, nieces, nephews, and cousins whose service member relative has died in the line of duty. The impact of parental death on military children has not been broadly examined. Studies that have more generally looked at the impact of any parental death on children identify that these youngsters are at higher risk for developing psychiatric disorders or other behavioral or emotional problems (Cerel, Fristad, Verducci, Weller, & Weller, 2006; Dowdney, 2000). No data are available on the specific impact of war-related parental death on children. It would not be unreasonable to conclude that given the intentional, aggressive, and sudden nature of these deaths, the psychological consequences might be more complicated and possibly more problematic.

The media, especially television, serves as military children’s most significant source of stress related to potential parental death. Interviews with military children suggest that they have a disproportionate fear of the risk for possible death to their parent, given the reality that less than 1% of deployed service members have been killed (Cozza, et al., 2005). Children who live on military installations are exposed to more immediate knowledge of the death of a service member due to informal communication, community activities, military news, or memorial services. Knowledge of the death of an unnamed service member is typically followed by a pervasive sense of fear that persists until confirmation is received that the service member is not a particular child’s parent. Children may be much more likely to experience pathological emotional responses if the surviving parent is so emotionally distraught that he or she is unavailable to care for the children. Supportive military communities may provide a helpful holding environment for stricken families that sustain family function and emotional health.

Parental death is likely to lead to an aftermath of major family disruption. Young children often are asked to participate in the memorial services honoring their deceased parent. This task may be met with confusion and discomfort. The military enlists many important traditions and rituals in honoring its fallen. However, funeral processions, precision drill exercises, flag ceremonies, and gun salutes may be variably intriguing, reassuring, confusing, or frightening to young children whose family members may be overly preoccupied to notice this response.

Infants, toddlers, and preschoolers do not have a cognitive understanding of the permanence of death. And children who lost a parent to death are confronted with the overwhelming challenge of learning about the reality of death while coping with the loss of the parent and with the grief and emotional turmoil of the surviving family members (Lieberman, Compton, Van Horn, & Ippen, 2003). The difficulty of accepting that the dead parent will never come back is compounded for children in military families by the fact that the parent may have been separated from the family for a long period of time but was expected to eventually return. Due to the sudden and violent nature of combat deaths, there is significant possibility of resultant traumatic grief because young children may be overwhelmed by witnessing or remembering sights related to the death: television footage of wartime carnage associated with the death, the visitation of the uniformed notification team who comes to the home, or the emotional breakdown of the parent upon hearing the news. All of this can lead to confusion, emotional distress, behavioral problems, traumatic reminders, or nightmares that require competent clinical attention.

Conclusion
Young children require special services that address their distinct needs. Limited cognitive capacity, reliance on magical thinking, greater dependence upon parental support and involvement, as well as emotional immaturity require that young children receive unique assistance in accommodating to parental combat exposures. While parents work on modulating behaviors, treating physical and combat stress related problems, and reinvesting in newly defined parental roles, young children need to be assisted in coping with the cognitive and emotional challenges in ways that support healthy adaptation. With the caring support of an adult who is aware of the developmental needs and individual characteristics of the child, young children can master the following cognitive, psychological, and interpersonal tasks:

(a) Develop a developmentally appropriate and reality-based understanding of the parental combat-related experience and consequences;
(b) Experience relief from the burden of feelings of responsibility for parent or family problems;
(c) Develop coping strategies to manage the sadness, sorrow, and anxiety related to parental physical injury or combat stress related illness;
(d) Integrate and accept permanent parental changes when present; and
(e) Develop a hopeful, future-oriented attitude that allows interpersonal enjoyment and newfound pleasurable activities.

Many programs have been developed that focus on the unique needs of young military children. The Department of Defense is focusing on young military children during times of war through military community and partnership programs (see the Learn More box below). Community support is fundamental to the wartime recovery of service members, their families, and their children. In The Odyssey, Telemachus is aided by the support and guidance of Mentor, his father’s trusted friend and sage. In fact, Homer so valued the responsibility of this nonmilitary community protector of the warrior’s child that he deified the role: Mentor is actually the goddess Athena in disguise. This message is timeless. Military children require the support and interest of those both within and beyond their own military communities, a sacred responsibility that falls on all of us. Interest in military children must be informed and respectful of the unique strengths, challenges, and culture of the military family. Resources dedicated to their cause should reflect the national obligation that these youngsters deserve.

Author information
Stephen J. Cozza, MD, Col. (Ret) U. S. Army, is professor of psychiatry at the Uniformed Services University where he serves as associate director, Center for the Study of Traumatic Stress. He retired from the U.S. Army as chair, department of psychiatry, Walter Reed Army Medical Center in 2006 after 25 years of military service. Dr. Cozza's professional interests have included clinical and community response to trauma, and the impact of deployment, combat injury, illness, and death on military service members, their families, and their children. Dr. Cozza serves as a scientific advisor to several national organizations that focus on the needs of military children and families, including ZERO TO THREE.

Alicia F. Lieberman, PhD, is the Irving B. Harris Endowed Chair in Infant Mental Health and vice chair for academic affairs at the University of CaliforniaSan Francisco department of psychiatry, and director of the Child Trauma Research Project at San Francisco General Hospital. She is a clinical consultant with the San Francisco Human Services Agency and works with the court system in San Francisco to inform and train potential foster parents of babies and toddlers. Dr. Lieberman is president of ZERO TO THREE's Board of Directors.

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