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Impact of deployment on military families with young children: A systematic review
Jennifer Trautmann, PhD, FNP-BC, RN*, Jeanne Alhusen, PhD, CRNP, RN, Deborah Gross, DNSc, RN, FAAN
Johns Hopkins School of Nursing, Baltimore, MD
a r t i c l e i n f o
Article history: Received 1 April 2015 Revised 28 May 2015 Accepted 1 June 2015 Available online 12 June 2015
Keywords: Child mental health Health disparities Mental health Military families Parenting Review of literature Systematic review Veteran Young children
* Corresponding author: Jennifer Trautmann House, Room 301, Baltimore, MD 21205.
E-mail address: [email protected] (J. Trau
0029-6554/� 2015 The Authors. Published b creativecommons.org/licenses/by-nc-nd/4.0/) http://dx.doi.org/10.1016/j.outlook.2015.06.002
a b s t r a c t
Background: More than 40% of children in military families are <6 years old, a period when children are most dependent on their parents’ physical and emotional availability. Purpose: This systematic review describes the impact of deployment since 9/11 on the mental health of military families with young children, evaluates evidence- based interventions for military parents with young children, and identifies gaps in the science limiting our ability to support the needs of these families. Methods: Databases were reviewed from 2001 to 2014 using preferred reporting items for systematic reviews and meta-analyses approach; 26 studies met re- view criteria. Results: Deployment was associated with increased parent stress, child behavior problems, health care utilization, and child maltreatment. Few studies tested interventions or focused on racial/ethnic minority or veteran families. A number of methodological limitations are noted. Conclusions: More research using multiple methods, stronger designs, and more diverse samples is needed to understand and address the needs of military families with young children.
Cite this article: Trautmann, J., Alhusen, J., & Gross, D. (2015, DECEMBER). Impact of deployment on
military families with young children: A systematic review. Nursing Outlook, 63(6), 656-679. http://
dx.doi.org/10.1016/j.outlook.2015.06.002.
Introduction
Nearly two million children in the United States have at least one parent in the military (Department of Defense [DoD], 2012). After the terrorist attacks of September 11, 2001, military personnel suddenly faced long and frequent deployments to combat environ- ments in Iraq, Afghanistan, and other Middle East and Southwest Asian countries (Defense Manpower Data Center, 2014; Westat, 2010). Children experience
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stressful effects from these deployments, and military parents struggle to reestablish their connection into civilian and family life when returning home from combat (Card et al., 2011; Lester & Flake, 2013).
A recent systematic review by Creech, Hardley, & Borsari (2014) evaluated 42 studies on the effects of deployment on parenting and children and adoles- cents. The results of that review highlighted the pervasive and negative impact of deployment and reintegration on children’s mental health. Specifically, children in military families have significantly more
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mental health problems including anxiety, depression, externalizing behavior problems, suicidal ideation, and substance use (Chandra, Martin, Hawkins, & Richardson, 2010; Creech et al., 2014). However, few studies evaluated in their review focused on military families with young children, a significant gap given that more than 40% of military children are <6 years old (DoD, 2012).
Young children are most dependent on their par- ents’ physical and emotional availability for estab- lishing and maintaining a sense of safety and security and have limited ability to comprehend their military parents’ lengthy absence (Chartrand, Frank, White, & Shope, 2008). Moreover, the rapid pace of develop- ment that occurs during the first 5 years of life can make it especially difficult for deployed parents to re- engage. It is not uncommon for returning parents to reunite with a child who is not only very different from the one they left but who has no memory of their parent and no relationship from which to draw on for providing nurturance and discipline (Defense Advisory Committee on Women in the Services, 2004). Thus, military-connected families with young children may be a highly vulnerable population with different needs that those with older children (Osofsky & Chartrand, 2013).
Building on the previous literature, the purposes of this focused systematic review are to (a) describe what is known about the impact of deployment on the mental health of military families with their young children (from birth to the age of 5 years), (b) evaluate the state of the science regarding evidence-based parenting interventions for military families with young children, and (c) identify important gaps in the science that limit our ability to fully support the needs of parenting families in the military. Given evidence of mental health disparities in the military and the gen- eral population (Institute of Medicine [IOM], 2010; Saha et al., 2008; Williams & Mohammed, 2009), we also examine the extent to which there may be differences in behavioral and mental health outcomes of military parents and young children across racial/ethnic and socioeconomic groups.
Background
Although it is well understood in the general population that children’s well-being is integrally tied to the health and well-being of their parents (Deater-Deckard, 2004; Earls & Carlson, 2001), there are two important as- sumptions underlying this review. First, military fam- ilies face unique life circumstances associated with military service that place greater burdens on them than those on families in the general population. These circumstances across multiple wars and during peace- time have been well documented (Isay, 1968; Kelley, 1994; Rosen, Durand, Westhuis, & Teitelbaum, 1995). A second assumption is that compared to earlier
generations, military parents serving in Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) have grappled with heavier burdens associated with more frequent and lengthier deployments to combat zones (Baiocchi, 2013). There- fore, we focus specifically on research published since September 11, 2001. To provide context for this review, we begin with a brief overview of these wars and high- light the implications for mental health of military families with dependent children.
The Impact of OIF/OEF/OND on the Mental Health of Parents
The 9/11 terrorist attacks in New York, Washington DC, and Pennsylvania acted as the catalysts for a renewed sustained war effort and frequent, lengthy deployments to Southwest Asia for military personnel and subse- quently their families (Defense Manpower Data Center, 2014). More than 2.5 million military personnel were deployed in support of OIF or OEF comprising 3.5 million individualdeployments(DefenseManpowerDataCenter, 2014; DoD, 2012). Deployments to these hostile environ- ments are associated with increased mental health dis- orders for military parents, including posttraumatic stress disorder (PTSD; Hoge, Auchterlonie, & Milliken, 2006; Tanielian & Jaycox, 2008). Indeed, poor mental health is among the most common complaints among veterans, with more than 55% of OEF/OIF/OND veterans served within the Veterans Administration (VA) system receiving a mental health diagnosis (US Department of Veteran Affairs, 2013).
An estimated 44% of the military personnel deployed to Iraq or Afghanistan since 2001 are parents (DoD, 2010). Research supports that the longer the deployment during these wars, the more likely the military member’s family would experience a range of difficulties affecting their dependent children, such as PTSD, depression, sleep disorders, marital stress, and divorce (Negrusa, Negrusa, & Hosek, 2014; Tanielian & Jaycox, 2008). In addition, veterans from these wars struggle with accessing medical care related to their service, including mental health services and report great difficulty reintegrating into civilian and family life (Hoge et al., 2006; Tanielian & Jaycox, 2008).
Ethnic and Racial Disparities within the Military
More than one third of U.S. military personnel self- identify as an ethnic or racial minority (DoD, 2012). Compared to white, non-Hispanic military personnel, those from racial and ethnic minority backgrounds, are disproportionately represented in enlisted ranks (and thus receive lower military salaries) and often have less education (DoD, 2012). Although all military personnel have equal access to health care, ethnic and racial health disparities among U.S. military personnel have been reported (Bibb, 2001; Blow et al., 2004; Hatzfeld, LaVeist, & Gaston-Johansson, 2012). Service members who perceive racial discrimination often
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delay seeking health care (Moore, Hamilton, Pierre- Louis, & Jennings, 2013). Ethnic and racial disparities have been highlighted by the Institute of Medicine as a priority to address in military medicine (Smedley, Stith, & Nelson, 2003).
The purposes of this systematic review were to critically examine the state of the science on mental health needs of and evidence-based treatments for military-connected parents and their young children, from birth to the age of 5 years. We reviewed and synthesized the existing literature and posed the following questions:
� What is the impact of deployment on the mental health of military-connected parents and their young children (from birth to the age of 5 years)?
� What is the state of the science regarding evidence- based parenting interventions for military families with young children?
� What is known about the needs of military families with young children from racial/ethnic minority backgrounds and from lower socioeconomic backgrounds?
Methodology
The preferred reporting items for systematic reviews and meta-analyses approach was used for generating, systematically reviewing, and analyzing original pub- lished studies on military families, their children’s behaviors, and parenting interventions (Moher, Liberati, Tetzlaff, & Altman, 2009). The following key definitions and Medical Subject Headings terms were used to search for research studies: military personnel, parent, parenting, child-rearing, veteran, and parente child intervention. To be included in this review, the study needed to be original research addressing
Figure 1 e PRISMA m
parenting aspects of military families with dependent children from birth to the age of 5 years, sample U.S. military-connected parents or children impacted by deployment, and be published in an English-language peer-reviewed journal. After inclusion criteria had been determined for the review, Medical Subject Headings terms were entered into PubMed, CINAHL, Scopus, PsychInfo, Web of Science, and Embase for years 2001 to 2014, yielding more than 11,800 records. Journal articles duplicated between the databases were eliminated. Articles that did not include children’s ages, study results, and U.S. military-connected fam- ilies as participants were eliminated from further analysis. Further search within the reference lists and bibliographies of the analyzed studies and previous review articles on similar subjects revealed two addi- tional studies that were included in the final analysis. This process resulted in 26 published studies meeting study criteria. Figure 1 details the research synthesis process.
We appraised each study’s purpose, design, methods, sample size, demographic composition, and results. To assure inclusion criteria were met, the au- thors reviewed all questionable studies. The studies were separated into three categories: (a) descriptive, (b) intervention, and (c) program evaluation studies. Table 1 summarizes the studies reviewed.
Results
Study Profiles
Twenty-six studies met review criteria. Seven (26.9%) were qualitative studies, 15 (57.7%) were quantitative descriptive studies, two (7.7%) used mixed methods, and two (7.7%) were randomized clinical trials. Among
ethod of review.
Table 1 e Summary of Reviewed Studies
Author(s) Purpose Methodology/Research Design Sample/Setting Results/Significant Findings
A. Descriptive studies Allen et al., 2011
Evaluated relevant sociodemographic variables (income, education, rank), prior experiences that may help couples adapt to demands of military life, connection and support, marital quality. Examined number of children and children’s behavioral problems.
Design: cross-sectional. Variables: stress, combat exposure, socioeconomic status, military experience, connection and support, marital quality, child behavior problems, perceptions of Army and mission. Measures: Combat Exposure Scale, Kansas Marital Satisfaction Scale, Child Behavior Checklist, work readiness/effectiveness scale.
N ¼ 300 married couples comprised active duty Army men deployed within last 12 months and their civilian spouses. Children ages 0e23 years. Sociodemographic indicators reported: Race/ethnicity: husbands: 70% white (non-Hispanic), 13% Hispanic, 9% African American, 7% multiracial or other minority; wives: 72% white non-Hispanic, 11% Hispanic, 9% African American, 8% multiracial or other minority; 61% couples white non-Hispanic. Education: 70.2% of husbands and 53.5% of wives reported highest degree obtained H.S. diploma/GED.
Wives reported higher levels of stress than husbands in the majority of stressors assessed. Lower income and lower rank related to greater economic strain and marital conflict and needing more support. Husband combat exposure associated with increased stress for both husbands and wives. For wives only, increased stress was associated with more child behavior problems. Education level in husbands and wives not related to stress.
Barker and Berry, 2009
Examine the impact of parent deployment (single and multiple) on young children’s behavior and attachment.
Design: mixed method longitudinal. Variables: length of deployment, child behavior, coping behavior, parent stress, and social support. Measures: investigator-developed surveys with closed and open-ended questions.
N ¼ 57 Army National Guard spouses with one young child. Child ages 0e47 months at time of deployment. Sociodemographic indicators reported: Rank: 66.6% enlisted, 29.8% officers, 3.5% not reported. Education: 35.1% reported college without degree, 22.8% with bachelor’s or graduate school, 12.3% H.S. diploma.
Per retrospective parent report, children with recently deployed parents displayed increased behavioral problems and increased “intense” attachment behaviors at reunion compared with children whose parents had not recently deployed. Increased child behavior problems was significantly associated with child’s age (i.e., older), length of deployment, number of moves, and number of parent stressors experienced. Parents choosing not to re-enlist described themselves as depressed and reported more behavioral problems in their children compared to
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Table 1 e (Continued)
Author(s) Purpose Methodology/Research Design Sample/Setting Results/Significant Findings
those parents in the re-enlisting group.
Chartrand et al., 2008
Describe the association of wartime military deployments and the behavior of young children in military families.
Design: cross-sectional. Variables: child behavior, parenting stress, depressive symptoms. Measures: Child Behavior Checklist, Parenting Stress Index-Short Form, Center for Epidemiologic Studies Depression Screen, Child Behavior ChecklisteTeacher Report Form.
N ¼ 169 Marine families. Child ages 1.5e5 years; childcare providers. Sociodemographic indicators reported: Race/ethnicity: 66% white (non-Hispanic), 16% African American, 13.5% Hispanic. Education: 45% completed some college, 42% college degree.
After controlling for parent age, depression and stress, rank, and parity, deployment associated with more externalizing behavior problems in children aged 3e5 years based on parent and childcare provider report (no association in children aged <3 years). Depressive symptoms did not differ significantly between parents with a deployed spouse and parents without a deployed spouse.
Cozza et al., 2010
Examine the early impact of combat injury on children and families.
Design: qualitative design using the Parent Guidance Assessment-Combate injured clinical evaluation; semistructured interviews of combat- injured spouses between 1 and 12 weeks postinjury. Variables: child emotional difficulty related to injury, child behavior change postinjury, preinjury deployment-related family difficulty, injury severity, disruption to child and family schedules, impact of injury on parental discipline, impact on amount of time noninjured parent spent with her children. Measures: clinician-directed semistructured interview.
N ¼ 41 female spouses of combat-injured service members. Child ages 0e16 years. No sociodemographic indicators reported.
Based on spouse report, 63% of families experience high deployment-related distress before the combat injury; 68% reported high child distress after combat injury. Families with high predeployment stress were more likely to report high child distress postinjury. Combat injury severity not associated with high child distress after adjusting for preinjury deployment- related family distress.
Dayton et al., 2014
Explore men’s experiences of their own and their young children’s regulatory processes in the context of separations and reunions
Design: qualitative design using grounded theory. Variables: demographic questionnaire, parental attributions, beliefs, and representations of their young children.
N ¼ 14 fathers deployed in last 2 years from Army NG/R units in Michigan. Child ages 0e7 years. Sociodemographic indicators reported: Race/ethnicity: 83% Caucasian.
Major themes: Raising strong and resilient children. Difficulty responding to child’s negative emotions. Conflict about building
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Table 1 e (Continued)
Author(s) Purpose Methodology/Research Design Sample/Setting Results/Significant Findings
associated with military deployments.
Measures: working model of the child interview.
Socioeconomic status: Education: 75% some college. Salary: 66% income <$50,000, 50% unemployed.
closeness and reconnection. Reliance on parenting partner to support fathere child relationship.
Eide et al., 2010
Determine whether parental deployment affected the rates at which children of military parents accessed health care within the military system.
Design: Secondary data analysis of 2007 military health system OP health care claims data. Variables: All visits and well-child visits; age, gender, marital status, and pay grade of the parent; gender, age, and birth order of the child; deployment status examined as confounders.
N ¼ 169,986 child records linked to 1,772,703 OP visits. Child ages 0e2 years. Sociodemographic indicators reported: Race/ethnicity: 64% white, 16% African American (child). Socioeconomic status: Rank: 74% junior enlisted (parent).
Children of married parents had increased rates of OP visits and well-child visits during periods of deployment, compared with periods during which the parent was not deployed. Children of single parents had decreased rates of OP visits and well-child visits during periods of deployment, compared with periods during which the parent was not deployed.
Everson et al., 2013
1. Typify the parenting features of spouses of deployed service members.
2. When controlling for racial background and mean age of children, can parenting stress and length of deployment, family coping resources, and sense of coherence predict life contentment for spouses of soldiers deployed in combat?
Design: cross-sectional design using a mailed survey to 1,000 households. Variables: length of deployment, parenting stress, level of family coping, sense of coherence, and life contentment. Measures: demographic data, Parental Stress Scale, Family Crisis Oriented Personal Evaluation Scale, Orientation to Life Scale, and Generalized Contentment Scale.
N ¼ 200 female spouses or significant others of soldiers deployed to Iraq. Child mean age ¼ 2.5 years. Sociodemographic indicators reported: Race/ethnicity: 44.5% Caucasian, 22% African American, 18.5% Hispanic, 15% multiracial, or other. Rank: 30.6% enlisted, 39.8% noncommissioned officer, 2.5% warrant officer, and 27.0% officer. Education: 12.5% some H.S., 8.0% GED, 29.0% H.S. diploma, 20.5% bachelor’s degree, 3.0% master’s degree, 1.0% doctoral degree. Salary: mean and median family incomes between $30,000 and $40,000.
Longer deployments related to greater parenting stress and lower levels of family coping, sense of coherence, and life contentment. Minority spouses experiencing longer deployments, with younger children, and greater parental stress noted lower levels of sense of coherence.
Flake et al., 2009
Describe psychosocial stress profile of military children and families experiencing wartime deployment; identify predictors of children at “high risk” for psychosocial morbidity during wartime deployment.
Design: cross-sectional. Variables: pediatric psychosocial function (internalizing, externalizing, and attention behavior), parenting stress, perceived stress. Measures: Pediatric Symptom Checklist, Parenting Stress Index-Short Form, and Perceived Stress Scale-4.
N ¼ 101 Army spouses with deployed service member and children Child ages 5e12 years. Sociodemographic indicators reported: Race/ethnicity: 65% white, 13% Hispanic, 9% African American, 9% Asian American, 4% other Rank: 23% officer, 77% enlisted
42% of spouses reported clinically significant levels of parenting stress. Spouses reported high levels of psychosocial difficulties in their children. At-home and deployed parents with less than a college education were
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Table 1 e (Continued)
Author(s) Purpose Methodology/Research Design Sample/Setting Results/Significant Findings
Education: 58% less than college degree, 42% college degree or higher.
more likely to report psychosocial difficulties in their children. The most significant predictor of child psychosocial functioning during deployment was parental stress.
Gewirtz et al., 2010
Examine impact of change in PTSD symptoms following combat deployment on National Guard soldiers’ perceived parenting, and couple adjustment 1 year following return from Iraq.
Design: longitudinal with data collected in theater (Time 1) and 1 year following return from deployment (Time 2). Variables: perceived parenting behaviors, couples adjustment, and alcohol use. Measures: PTSD Checklist-Military Version, Alabama Parenting Questionnaire-Short Form, Dyadic Adjustment Scale, Alcohol Use Disorders Identification Test.
N ¼ 468; Army National Guard fathers Child ages 0e17 years. Sociodemographic indicators reported: Racial/ethnicity: 89% European American, 6% Hispanic American, 5% African American.
Increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges at Time 2. PTSD symptoms predicted parenting challenges independent of impact on couple adjustment. African American fathers reported higher levels of effective parenting behaviors relative to European Americans, and Hispanic Americans reported lower levels of couple adjustment.
Gewirtz et al., 2014a
Examine predeployment recent life stressors among deployed and nondeployed women, compare individual and family adjustment, maternal and child adjustment, couple adjustment, and parenting.
Design: cross-sectional secondary data analysis gathered from parent RCT. Variables: negative life events, stressful military experiences, maternal psychopathology, posttraumatic stress symptoms, couple adjustment, parenting, parental efficacy, and child psychosocial functioning. Measures: Life Events Questionnaire, Deployment Risk and Resilience Inventory, Hopkins Symptom Checklist, Difficulties in Emotion Regulation Scale, PTSD checklist, Dyadic Adjustment Scale-7, Alabama Parenting Questionnaire-9, Parental Locus of Control Scale, and Behavioral
N ¼ 181 (n ¼ 147 nondeployed mothers, n ¼ 34 deployed mothers). Child ages 4e12 years. Sociodemographic indicators reported: Racial/ethnicity: 91.2% white, 8.8% nonwhite, 3.4% Hispanic/Latina. Education: high school/GED or less 7.2%, some college/AA degree 41.4%, 4-year college degree 36.5%, graduate degree 14.9%. Salary: nondeployed mothers mean income: $72,192 (SD ¼ $33,830); median $75,000; deployed mothers mean income $69,411 (SD ¼ $35,776); median $65,000.
Deployed mothers reported more symptoms of depression and anxiety, PTSD (except avoidance subscale), and greater difficulties in emotional regulation compared with nondeployed mothers. No significant differences noted in relationship adjustment, parenting indices, or child psychosocial functioning between deployed and nondeployed mothers.
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Table 1 e (Continued)
Author(s) Purpose Methodology/Research Design Sample/Setting Results/Significant Findings
and Emotional Rating Scale, second edition.
Gibbs et al., 2007
Examine the association between combat-related deployment and rates of child maltreatment in families of enlisted soldiers in the US Army with one or more substantiated reports of maltreatment.
Design: descriptive case series design using linked data from Army Central Registry and Army human resources data from September 9, 2001 to December 31, 2004. Variables: child maltreatment (i.e., neglect, physical abuse, emotional abuse, sexual abuse) categorized as mild, moderate, or severe.
N ¼ 1,771 families of enlisted soldiers with substantiated child maltreatment (with 1,858 incidents examined). Child ages 0e18 years. Sociodemographic indicators reported: Race/ethnicity: 69.2% non-Hispanic white, 30.8% black or Hispanic Rank: 51.5% lower enlisted (E1eE4), 48.5% higher enlisted (E5eE9).
Among Army families of enlisted soldiers with at least one substantiated report of child maltreatment who experienced deployments, the rate of child maltreatment was 42% greater during deployments compared with times when soldiers were not deployed. The rate of child neglect was greater during times of deployment, whereas rates of physical abuse were less. Elevated rate of maltreatment during deployment attributed to higher (i.e., three times higher) rates of child maltreatment by civilian female spouses during deployment. There were significant increases in rates of maltreatment among children between the ages of 2 and 12 years as compared with children aged <2 years or >12e18 years. There were not significant differences by sex of child.
Gorman et al., 2010
Determine the effect of parental military deployment on the relative rate of OP visits for mental and behavioral health disorders in children aged 3e8 years.
Design: retrospective cohort study using secondary data from TRICARE Management Activity and Defense Enrollment Eligibility Reporting System. Variables: diagnoses derived from ICD-9 codes, including a category for mental and behavioral health disorders, child age and gender,
N ¼ 642,397 children of 442,722 active duty parents. Children ages 3e8 years. Sociodemographic indicators reported: Race/ethnicity: 68% white, 22% black, 10% other. Rank: 12.4% junior enlisted, 65.8% senior enlisted, 2.4% warrant officer, 7.8% junior officer, 11.6% senior officer.
Parent deployment associated with an 11% increase in the rate of OP visits for mental and behavioral health conditions despite associated decreases in visits for all other visit classifications (e.g.,
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Table 1 e (Continued)
Author(s) Purpose Methodology/Research Design Sample/Setting Results/Significant Findings
parental marital status, gender, military rank, and deployment status.
infections, respiratory, GI, injury, symptoms). Pediatric behavioral and stress disorders increased 18% and 19%, respectively, when a parent was deployed while there was an 11% decrease in all health care visits for this population during deployment.
Larson et al., 2012
Determine whether the deployment of Army active duty member is associated with changes in dependent health care utilization.
Design: Preepost nonequivalent group design comparing health care utilization change among dependents of deployed and comparison service members. Variables: Changes in dependent total utilization in the military health system, including office visit services, emergency department visits, institutional stays, or psychotropic medications.
N ¼ 137,602 children of active duty Army parent; N ¼ 55,518 nonpregnant spouses for deployed group. N ¼ 199, 520 children of active duty Army parent; N ¼ 74,853 nonpregnant spouses for comparison group. Child ages: mean 7.7 (SD ¼ 5) years for deployed and 8.9 (SD ¼ 5.1) years for comparison. Sociodemographic indicators reported: Race/ethnicity: 59.4% white, 21.1% black, 11.4% Hispanic, 4.6% Asian or Pacific Islander, 3.4% other. Rank: 80.0% enlisted, 4.9% warrant officer, 15.1% officer.
Deployment associated with small decreases for four health care utilization measures including ED use (spouses only), any institutional stay (spouses only), any generalist visit (spouses and children), and any prescription (spouses and children). Deployment associated with small increases for two health care utilization measures for spouses and children including specialist office visits, and any psychotropic prescription (i.e., antidepressant, antianxiety). Children using antidepressants and anxiolytics increased by 22% and 36%, respectively. Spouses using any psychotropic medication increased by 25%.
Lee et al., 2013
Explore fathers’ access to parenting information during the transition to parenthood and to determine methods for
Design: qualitative descriptive design, focus groups (3e8 participants). Variables: semistructured interview guide focused on topics including access to, types of general resources for parenting information,
N ¼ 39 active duty male personnel in the U.S. Air Force with at least one child. Child ages not restricted, 68% had a child aged <3 years. Sociodemographic indicators reported:
Fathers motivated to develop and maintain positive relationships with partners and children despite deployments, moving, and demanding occupation.
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Table 1 e (Continued)
Author(s) Purpose Methodology/Research Design Sample/Setting Results/Significant Findings
engaging fathers in intervention.
co-parenting and communication, developmental milestones, and discipline.
Race/ethnicity: 59% white American, 26% Hispanic American, 13% African American, 3% multiracial. Education: 17.9% some college, 46.2% associate degree, 33.3% college degree or higher. Salary: 3% <$29,999, 38.5% $30,000e$49, 999, 59% >$50,000.
Fathers eager to utilize resources and services but not aware of many available resources. Fathers would have benefited from additional resources, particularly when their children were quite young; fathers receptive to technology- based resources and interventions. Fathers rely more on informal sources of information for parenting (family, friends) than formal (pediatricians).
Louie and Cromer, 2014
Explore the deployment experiences of military families with young children and identify strategies that promote attachment during deployment.
Design: mixed methods. Variables: qualitative interviews focused on preparing children for deployment, communication during deployment, and reintegration experiences and preparation. Quantitative assessment of parental stress. Measures: Parental Stress Scale.
N ¼ 30 active duty and Air National Guard, National Guard, and Reserve military fathers deployed in the previous 2 years of study with at least one child younger than the age of 6 years. Child ages 0e6 years. Sociodemographic indicators reported: Race/ethnicity: 83.3% white, 10% black, 6.7% other. Socioeconomic status: Rank: 76.7% enlisted, 23.3% officer.
Military families without preparation strategies to maintain fatherechild attachment during deployment reported higher parenting stress after deployment and at reintegration compared with those with preparation strategies. Frequency of communication with child not significantly associated with reintegration parenting stress scores.
McCarroll et al., 2008
Update the trends in child maltreatment in the Army Central Registry, present severity data by type of maltreatment, and compare cases of maltreatment by sex of victim and sex of parent perpetrator.
Design: secondary data analysis. Variables: type of maltreatment (i.e., physical abuse, emotional abuse and neglect coded by severity: mild, moderate or severe), age and sex of child, sex of parent.
N ¼ 47,473 substantiated cases of child maltreatment victims of active duty Army personnel from 1990 to 2004. Child ages 0e18 years. No additional sociodemographic indicators reported.
Child abuse rates decreased from high (6.92/1,000) in 1990 to low (4.65/1,000) in 2000, followed by a 17% increase (5.44/1,000) from 2000 to 2004. Neglect rates declined by 28% from 1991 to 2000 but increased in 2004 to near the same level as 1991. Neglect rates were highest for children
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Table 1 e (Continued)
Author(s) Purpose Methodology/Research Design Sample/Setting Results/Significant Findings
aged <1 year and rate decreased with increase in age. Excluding sexual abuse, all types of maltreatment higher among boys.
Rentz et al., 2007
Examine the occurrence of child maltreatment in military and nonmilitary families before and during intense military operations in the Middle East.
Design: T-series secondary data analysis of monthly individual-level child maltreatment data and state-level population estimates. Variables: type of maltreatment (i.e., physical abuse, sexual abuse, emotional abuse, other abuse, neglect); gender, race/ethnicity, and age of child.
N ¼ 147,982 total children; 1,399 active duty military children and 146,583 nonmilitary children; report-child pair ¼ 164,239; 1,539 military and 162,700 nonmilitary. Child ages 0e17 years. Sociodemographic indicators reported: Race/ethnicity: 47.2% white, 52.8% other for children in military families; 37.6% white, 62.4% other for children in nonmilitary families.
Rate of occurrence of substantiated maltreatment in military families was twice as high in the period after October 2001 compared with the period before that date. Rate of child maltreatment increased by 30% for each 1% increase in the percentage of active duty personnel departing to or returning from deployment. Children in both military and nonmilitary families that were young (i.e., <4 years), and of “other” race/ethnicity had higher rates of child maltreatment than children older than 4 years and white, non-Hispanic. The rate of child maltreatment was lower among children of military families compared with children in nonmilitary families across gender, race/ethnicity, and age. Children in military families were more likely to be maltreated by home caregiver.
Scannell-Desch and Doherty, 2013
Describe the lived experience of military nurse-parents separated from their
Design: qualitative, phenomenological approach. Variables: semistructured interviews
N ¼ 20 current or former Army, Air Force, and Navy nurse-parent with children younger than the age of 21 years.
Nurses reported leaving their children was the hardest part of the military mission.
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Table 1 e (Continued)
Author(s) Purpose Methodology/Research Design Sample/Setting Results/Significant Findings
children during deployment to Iraq or Afghanistan, 2003e2010.
focused on the experience of leaving children during deployment and communication strategies.
Child ages 5 monthse21 years. Sociodemographic indicators reported: Rank: none reported, although RNs are officers in military service.
Childcare arrangements were challenging and nurses worried about the associated stress on their children. Nurses reported caring for injured children was particularly difficult.
Walsh et al., 2014
To understand the experiences of fathers parenting young children after deployment.
Design: qualitative, grounded theory approach. Variables: household composition, marital status, deployment history, ages and gender of children, family income, depression symptoms, parents’ attribution, beliefs, and representations of their children. Measures: demographic questionnaire, parent mental health, parent interview.
N ¼ 14 Army National Guard males with at least one child younger than the age of 7 years; deployed in last 2 years. Child ages 0e7 years. Sociodemographic indicators reported: Race/ethnicity: 17% nonwhite, 83.3% white. Education: 16.7% high school diploma, 75% some college, 8.3% technical certificate. Salary: 36.4% income <$30,000. 50% unemployed.
Fathers reported significant levels of parenting stress and identified specific challenges, including difficulty reconnecting with children, varied expectations from military to family life, and co-parenting. Fathers regretted missing important milestones in their children’s lives and desired to improve parenting skills. Fathers described a need for support in expressing emotions, promoting nurturing behavior, and managing tempers.
Willerton et al., 2011
Describe military fathers’ range of involvement with their children, with regards to deployment separation and reintegration.
Design: qualitative, descriptive; focus groups at 14 U.S. military installations. Variables: cognitive, affective, and behavioral domains of functioning.
N ¼ 71 military-connected males deployed in the past 6 months of 2005. Child ages 5 monthse28 years, 81% elementary school-aged children or younger. Sociodemographic indicators reported: Race/ethnicity: 54.9% white, 18.3% African American, 14.1% Hispanic.
Fathers discussed responsibilities in terms of proving for their families, being a role model/teacher/ mentor, instilling values, and being honest and consistent. Many discussed challenges in parenting responsibilities because of their frequent absences. Fathers discussed concerns about monitoring children’s behavior while deployed although some felt the military provided a “protective culture.” Fathers exhibited great
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Table 1 e (Continued)
Author(s) Purpose Methodology/Research Design Sample/Setting Results/Significant Findings
variability in their behavioral involvement, and many discussed the challenges after deployment in reestablishing a bond with their children and resuming an active parenting role.
Wilson et al., 2014
Explore whether deployed and at-home parents’ reports of family communication patterns were associated with reported child difficulties and prosocial behavior during a military parent’s deployment.
Design: quantitative cross-sectional. Variables: family communication patterns, children’s behavioral difficulties, and prosocial behavior. Measures: Revised Family Communication Patterns Measure-short form, Strengths and Difficulties Questionnaire.
N ¼ 222 Army National Guard spouse or significant other; military member deployed 30e90 days before event (102 deployed parent and 110 at home spouses/partners). Child ages 3e17 years. Sociodemographic indicators reported: Rank: 41% junior enlisted, 40% senior enlisted, 3% warrant officer, 16% officer. Education: 26% H.S./GED, 37% some college, 7% associate degree, 27% bachelor degree, 3% Masters.
Deployed parents reported conversation orientation (e.g., comfort with communication) had children with fewer reported behavioral problems and more prosocial behavior during reintegration. At-home parents’ reports of conversation orientation were not associated with their reports of child difficulties or prosocial behavior. Among service members, lower education related to more positive family communication and more prosocial behavior in their children.
B. Intervention studies Gewirtz et al., 2014b
To examine the feasibility and acceptability of the After Deployment, Adaptive Parenting Tools intervention and to examine baseline demographic factors associated with group attendance, use of online tools, home practice completion, and satisfaction.
Design: randomized control effectiveness trial. Variables: feasibility, acceptability, sociodemographics.
N ¼ 42 National Guard/Reserve member and/or spouse/partner assigned to intervention Child ages 4e12 years. Sociodemographic indicators reported: Race/ethnicity: 89% white, 92% non-Hispanic. Rank: 69% enlisted, 31% officer. Education: 56% at least bachelor degree. Salary: median income $80,000.
Preliminary data presented showing that 79% of military parents attended at least 50% of the sessions; attendance did not differ by gender, deployment status, education, or income. Completion of home practice assignments ranged from 0 to 12 (of 13 total); M ¼ 6.82,
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Table 1 e (Continued)
Author(s) Purpose Methodology/Research Design Sample/Setting Results/Significant Findings
SD ¼ 4.07. Participants’ use of online tools averaged 14.97 of 56; 55% of families accessed the online tools at least once. High parent satisfaction (M ¼ 3.39 on four-point scale), ratings did not differ by gender or other demographic variables.
Schachman et al., 2004
To test the effects of a nursing intervention (Baby Boot Camp) vs. traditional childbirth education on prenatal and postpartum maternal role adaptation among military wives.
Design: randomized clinical trial. Variables: prenatal adaptation, postpartum adaptation, external resources (social support), internal resources (inner strength). Measures: Prenatal Self-Evaluation Questionnaire, Postpartum Self-Evaluation Questionnaire, Personal Resources Questionnaire, and Resilience Scale.
N ¼ 91; active duty Air Force wives. Child ages birth to 6 weeks. Sociodemographic indicators reported: Race/ethnicity: 76% white, 14% African American, 5% Hispanic, 2% Asian. Rank: 63% junior enlisted, 20% senior enlisted, 17% officers. Education: 47.2% high school, 35.2% some college, 17.6% college graduate.
Intervention group reported greater maternal role adaptation than control group at prenatal and postnatal phases of intervention. No intervention effect on mothers’ reported internal or external resources at 6-week postpartum follow-up.
C. Program evaluation studies Kelley et al., 2006
Examine survey data on the New Parent Support Program, composed of centered-based parenting classes and home- based visits, collected at program sites Navy-wide.
Design: quantitative purposive sampling by mailed survey. Variables: participant satisfaction. Measures: program evaluation survey (satisfaction, primary objective of program, assist service members in their job, program impact on mission).
N ¼ 821 experienced program users at all New Parent Support Program sites Navy-wide; patrons that have used the program or familiar with the services including active duty, dependent of active duty, other service members and their spouses, DoD civilians and retirees. No sociodemographic indicators reported.
Most participants believed program effectively met their need for parenting education. Participants agreed the program contributed to their military readiness and quality of life. Participants perceived the program demonstrated the Navy’s concern for sailors and their families.
Ross and DeVoe, 2014
Describe a series of evidence- based strategies used to enhance engagement of military families with young children “Strong Families” for OEF/OIF/OND service members and their families.
Design: descriptive study of engagement during a RCT in progress. Variables: completion, engagement, and retention rates.
N ¼ 115 NG/R families; military member returned from deployment in past 12 months. Child ages 0e5 years. No sociodemographic indicators reported.
93% (n ¼ 53) of families completed seven of eight modules, and 89.5% (n ¼ 51) completed all modules.
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N u r s
O u t l o o k
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6 6 9
T a b le
1 e
(C o n ti n u ed
)
A u th
o r( s )
P u rp
o s e
M e th
o d o lo g y /R
e s e a rc h D e s ig n
S a m
p le /S e tt in g
R e s u lt s /S ig n ifi c a n t
F in d in g s
W il s o n e t a l. ,
2 0 1 1
E v a lu a te s P a s s p o rt
T o w a rd
S u c c e s s , d e s c ri b e s p ro
g ra m
’ s th
e o re ti c a l b a c k g ro
u n d ,
a n d p re s e n ts
fi n d in g s fr o m
a n e v a lu a ti o n s tu
d y
a s s e s s in g a n in it ia l v e rs io n
o f P a s s p o rt
T o w a rd
S u c c e s s ,
a p ro
g ra m
d e s ig n e d to
h e lp
c h il d re n a n d fa m
il ie s
re c o n n e c t fo ll o w in g a
p a re n t’ s d e p lo y m
e n t.
D e s ig n : q u a n ti ta ti v e s u rv e y m e th
o d s
u s e d in
a p re p ro
g ra m
b a s e li n e
m e a s u re .
V a ri a b le s : p re p ro
g ra m
d e m o g ra p h ic s
q u e s ti o n n a ir e a n d d e p lo y m
e n t
in fo rm
a ti o n , p ro
g ra m
fi d e li ty
fo r
e a c h “i s la n d ” fe e li n g s , re la x a ti o n
a n d c o m m
u n ic a ti o n .
M e a s u re s : re v is e d fa m
il y
c o m m u n ic a ti o n p a tt e rn
s a n d
S tr e n g th
s a n d D if fi c u lt ie s
Q u e s ti o n n a ir e .
N ¼
1 6 1 c h il d re n fr o m
8 8 fa m
il ie s o f
N a ti o n a l G u a rd
s p o u s e s o r s ig n ifi c a n t
o th
e r.
m il it a ry
m e m
b e r d e p lo y e d
3 0 e 9 0 d a y s b e fo re
e v e n t.
S o c io d e m o g ra p h ic
in d ic a to rs
re p o rt e d :
R a n k : 8 2 .6 %
e n li s te d ; 5 .8 6 %
o ffi
c e r.
S a la ry : m
e d ia n in c o m
e $ 5 0 ,0 0 0 -$ 5 9 ,0 0 0 .
P a re n ts
o f c h il d re n in
m il it a ry
fa m
il ie s re p o rt e d
g re a te r b e h a v io ra l
d if fi c u lt ie s th
a n d id
p a re n ts
o f c h il d re n in
c iv il ia n p o p u la ti o n .
P ro
g ra m
fi d e li ty
w a s
h ig h e r in
s e s s io n s w it h
7 - to
1 1 -y e a r- o ld
c h il d re n
th a n s e ss io n s w it h
3 - to
6 -y e a r- o ld
c h il d re n .
A A , A s s o c ia te
in A rt s ; D o D , D e p a rt m
e n t o f D e fe n s e ; E , e n li s te d ; E D , e m
e rg e n c y d e p a rt m
e n t; H .S ., H ig h
S c h o o l; IC
D , In te rn
a ti o n a l C la s s ifi c a ti o n
o f D is e a s e s ; N G /R
, N a ti o n a l
G u a rd
/R e s e rv e ; O E F , O p e ra ti o n
E n d u ri n g F re e d o m
; O IF , O p e ra ti o n
Ir a q i F re e d o m
; O N D , O p e ra ti o n
N e w
D a w n ; O P , o u tp
a ti e n t;
P T S D , p o s tt ra u m
a ti c s tr e s s d is o rd
e r;
R C T ,
R a n d o m iz e d C o n tr o l T ri a l; R N , re g is te re d n u rs e ; S D , s ta n d a rd
d e v ia ti o n .
M il it a ry -c o n n e c te d : b ra n c h , o r s ta tu
s o f m
il it a ry
m e m
b e r n o t re p o rt e d o r e a s il y id e n ti fi e d .
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the qualitative studies, all used individual or focus group interviews to gather data; none used ethno- graphic or observational methods (Cozza et al., 2010; Dayton, Walsh, Muzik, Erwin, & Rosenblum, 2014; Lee et al., 2013; Louie & Cromer, 2014; Scannell- Desch & Doherty, 2013; Walsh et al., 2014; Willerton, Schwarz, Wadsworth, & Oglesby, 2011). Among the quantitative descriptive studies, eight used cross- sectional survey designs of parent-reported data (Allen, Rhoades, Stanley, & Markman, 2011; Chartrand et al., 2008; Everson, Darling, & Herzog, 2013; Flake, Davis, Johnson, & Middleton, 2009; Gewirtz, McMorris, Hanson, & Davis, 2014a; Kelley, Schwerin, Farrar, & Lane, 2006; Wilson, Wilkum, Chernichky, MacDermid Wadsworth, & Broniarczyk, 2011; Wilson, Chernichky, Wilkum, & Owlett, 2014). Six studies were secondary analyses of military fam- ily health care utilization records (Eide, Gorman, & Hisle-Gorman, 2010; Gorman, Eide, & Hisle-Gorman, 2010; Larson et al., 2012) or child maltreatment re- cords (Gibbs, Martin, Kupper, & Johnson, 2007; McCarroll, Fan, Newby, & Ursano, 2008; Rentz et al., 2007). Two studies collected longitudinal data exam- ining change associated with deployment (Barker & Berry, 2009; Gewirtz, Polusny, DeGarmo, Khaylis, & Erbes, 2010). In sum, almost all of the studies in this review (92.3%) are descriptive in nature.
Target study populations were recruited from a range of U.S. military sources including the Army, Navy, Air Force, Marines, and Army and Air Force National Guard and Reserve. In all cases, the service member had been deployed for combat. None focused on veteran households, although one study did include responses from retirees (Kelley et al., 2006). Six study samples recruited only the military service member of the family (Dayton et al., 2014; Gewirtz et al., 2010; Lee et al., 2013; Scannell-Desch & Doh- erty, 2013; Walsh et al., 2014; Willerton et al., 2011). With the exception of one qualitative study of 20 military nurses, 75% of whom were women (Scannell- Desch & Doherty, 2013), the respondents in these studies were men. Five study samples collected data only from the service member’s spouse or partner (Barker & Berry, 2009; Chartrand et al., 2008; Cozza et al., 2010; Flake et al., 2009; Schachman, Lee, & Lederman, 2004), and most of the respondents in these studies were women. Six studies included both service members and their spouses or partners (Allen et al., 2011; Gewirtz et al., 2010; Kelley et al., 2006; Ross & DeVoe, 2014; Wilson et al., 2011, 2014). One study (Gewirtz et al., 2014a) compared family adjustment among military mothers, 19% of whom were also service members who had been deployed. In sum, there was diversity in the military branches repre- sented among the families studied, but overall, there was limited gender diversity within the adult family member groups being studied (i.e., service members were predominantly fathers; spouses and partners were predominantly mothers).
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All studies examined parent mental health or chil- dren’s behavioral health in the context of military deployment (we use the term “behavioral health” to describe child outcomes because all the studies sampled assessed a broad range of child behavior and not specifically their mental health). Across studies, deployment was generally defined as the service members’ departure from home to engage in combat or other activities related to the OEF/OIF/OND campaigns. One study (Larson et al., 2012) offered specific inclusion criteria for defining deployment (i.e., deployment pe- riods of 6 months or longer), although most did not. Some studies also examined the periods surrounding the deployment (i.e., pre- and post-deployment) although inclusion criteria for defining these periods were not typically reported. For example, Barker and Berry (2009) instructed parents to recall their chil- dren’s behavior “before deployment,” although the length of time preceding deployment was not specified in their instructions (in contrast, the comparison group of nondeployed families was asked to recall the prior 3 months). Other studies examined the postdeploy- ment phase, periods referred to as “reunion” (Barker & Berry, 2009), “reintegration” (Louie & Cromer, 2014; Willerton et al., 2011), and “reunification” (Flake et al., 2009; Walsh et al., 2014). However, with the exception of Gewirtz et al. (2010) who included a time frame of 1 year after deployment, “postdeployment period” was not operationalized. Although the data suggest that the periods before, during, and after deployment are salient ones for the health and well-being of young children and their parents, the lack of consistency or detail on the most relevant time frames for defining these periods makes it difficult to compare results across studies or identify potentially “sensitive” pe- riods for initiating intervention.
Three published studies reported evaluations of programs designed to support military families. These included the New Parent Support Program (Kelley et al., 2006), the Strong Families Program (Ross & DeVoe, 2014), and Passport Toward Success (Wilson et al., 2011). All three programs evidenced high user satis- faction and acceptability. However, there was limited information on the content and fidelity in the delivery of these programs and how many parents accessed and actively participated in different components of each program. In addition, none included systematic data on the impact of the programs for improving parent mental health or child behavioral health or on program cost. These data suggest that military families will participate in programs designed to support their parenting; however, program fidelity, cost, and impact on mental health are not yet known.
Sample sizes varied widely, depending on the study design. Only one of the quantitative studies (Schachman et al., 2004) reported results of a power analysis to determine an appropriate sample size. More than half of the studies used relatively small sample sizes (n � 200) making it difficult to conduct valid subgroup analyses that might highlight more specific
risk factors (e.g., sociodemographic factors, child age and gender). With the exception of the six secondary analyses of administrative data, all studies relied entirely on parent self-report for assessing parents’ mental health. Of the seven studies that assessed children’s behavioral health, six relied solely on par- ents’ reports of child behavior. One also collected measures of military-connected children’s mental health from their childcare provider (Chartrand et al., 2008). None of the studies used observational methods to assess parent and child behavior or clinical assessments to determine parent or child mental health.
What is the impact of deployment on the mental health of military-connected parents and their young children (from birth to the age of 5 years)?
Parent Mental Health
Nine studies examined the associations between deployment and indicators of parent distress, family functioning, and spouses’ health care utilization (Allen et al., 2011; Chartrand et al., 2008; Cozza et al., 2010; Everson et al., 2013; Flake et al., 2009; Gewirtz et al., 2010, 2014a; Larson et al., 2012; Wilson et al., 2014). Overall, more frequent and lengthier deployments appear to be associated with greater levels of parent stress and depressive symptoms (Barker & Berry, 2009; Chartrand et al., 2008; Gewirtz et al., 2014a), poorer family or couple functioning (Allen et al., 2011; Cozza et al., 2010; Gewirtz et al., 2010), poorer general well- being (Eide et al., 2010; Everson et al., 2013), and greater use of mental health services for the military spouse (Larson et al., 2012). Mental health problems were particularly high among military spouses raising young children alone during deployment periods (Barker & Berry, 2009).
Deployed parents also experienced high levels of distress associated with parenting. Six studies exam- ined service members’ parenting concerns associated with their deployment (Dayton et al., 2014; Lee et al., 2013; Louie & Cromer, 2014; Scannell-Desch & Doh- erty, 2013; Walsh et al., 2014; Willerton et al., 2011). Several described parents’ fears that their children would forget them while deployed, their distress when children worried for their safety, and apprehension about childcare arrangements during deployment (Everson et al., 2013; Scannell-Desch & Doherty, 2013; Willerton et al., 2011). Five studies examined parenting challenges faced by military fathers’ postdeployment (Dayton et al., 2014; Lee et al., 2013; Louie & Cromer, 2014; Walsh et al., 2014; Willerton et al., 2011). Reinte- gration concerns raised by these fathers included discomfort asking for parenting advice from their spouse or partner, difficulties reconnecting emotion- ally with their children after deployment, reticence to discipline their children, and struggling to communi- cate positively with their spouse and children (Dayton et al., 2014; Lee et al., 2013; Louie & Cromer, 2014; Walsh
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et al., 2014; Willerton et al., 2011). Among military fa- thers who returned from deployment injured or with PTSD, parenting stress associated with reintegration was particularly high as these men were also strug- gling with their own recoveries (Allen et al., 2011; Cozza et al., 2010; Gewirtz et al., 2010).
Across samples and methods, results converged on the common theme that deployments were linked to greater mental health problems and parenting con- cerns. However, several important methodological limitations were noted. First, all the studies assessing parent mental health symptoms relied on parents’ self- report. Although parents’ perceptions are important, the potential for method bias affects interpretation of the data (e.g., negative reporting bias on measures of family functioning that might occur due to re- spondent’s depressive symptoms). In addition, con- cerns about stigma might lead respondents to underreport their mental health symptoms. Second, only seven studies employed standardized measures with clinical cut points for estimating mental health problems (Allen et al., 2011; Chartrand et al., 2008; Everson et al., 2013; Flake et al., 2009; Gewirtz et al., 2010, 2014a; Louie & Cromer, 2014). Using population norms to identify proportions of the sample with mental health symptoms in the “clinical range” can indicate whether these family members may require treatment from a mental health provider or if their symptoms could be more cost-effectively addressed through psychoeducation and support. Finally, there was wide variation in the types of mental health in- dicators examined including couple functioning (Allen et al., 2011; Gewirtz et al., 2010, 2014a), family func- tioning (Everson et al., 2013), parenting stress (Chartrand et al., 2008; Flake et al., 2009; Louie & Cromer, 2014), psychotropic medication use (Larson et al., 2012), “life contentment” and “sense of coher- ence” (Everson et al., 2013), parenting concerns (Everson et al., 2013; Gewirtz et al., 2014a), marital concerns (Allen et al., 2011; Gewirtz et al., 2010, 2014a), and depressive symptoms (Chartrand et al., 2008), thus making it difficult to directly compare results across studies.
Child Behavioral Health
Eleven studies tested the associations between deployment and indicators of young children’s behavioral health (Barker & Berry, 2009; Chartrand et al., 2008; Cozza et al., 2010; Flake et al., 2009; Gewirtz et al., 2014a), pediatric health care utilization (Eide et al., 2010; Gorman et al., 2010; Larson et al., 2012), or rates of child maltreatment (Gibbs et al., 2007; McCarroll et al., 2008; Rentz et al., 2007). Results indicate that young children separated from a deployed parent experience more emotional and behavioral problems than children not exposed to parental deployment separations (Barker & Berry, 2009; Chartrand et al., 2008; Flake et al., 2009; Gewirtz et al., 2014a). Behavior problems appear to be higher among
3- to 5-year-old children of deployed parents than those among younger children and higher among children who experience more frequent and longer separations due to deployments (Flake et al., 2009). Children aged younger than 3 years experienced adverse effects from their parents’ deployment although, consistent with this developmental period, their symptoms centered on greater attachment diffi- culties, particularly during periods of reintegration (Barker & Berry, 2009).
It should be noted that one study of military mothers (Gewirtz et al., 2014a) reported no differences in young children’s psychosocial functioning based on whether the mother was the deployed service member or the civilian spouse of a deployed service member. Divergent findings may be due to differences in target population (this was the only study that analyzed deployed mothers), the behavioral health variable measured (this study measured children’s emotional and behavioral strengths whereas the other studies examined behavioral difficulties), combat exposures experienced by deployed mothers versus deployed fa- thers, and supports extended to children during deployment (i.e., deployed mothers may receive more extended family and friend support than mothers who remain home although the fathers are deployed).
Three studies linked parental deployment to increased pediatric health care utilization. Gorman et al. (2010) reported that children incurred more behavioral health and mental health visits during deployment than those during nondeployed periods. Another study noted an increased use of psychotropic medications by spouses and children during the mili- tary member’s deployment (Larson et al., 2012). Eide et al. (2010) found that deployments were associated with fewer acute and well-child visits among children in single-parent military families than those among children of two-parent military families. Given that pediatric mental health care often begins with the well-child encounter, it is possible that young children in single-parent military families may have more mental health needs than is identified by health care utilization records (Eide et al., 2010).
Three studies reviewed child maltreatment and neglect cases of military families, and all found higher rates of substantiated maltreatment cases among military families during deployment periods (Gibbs et al., 2007; McCarroll et al., 2008; Rentz et al., 2007). Children aged <4 years were at greater risk for maltreatment than were older children (Rentz et al., 2007). McCarroll et al. (2008) reported child maltreat- ment cases among U.S. Army families were twice as high 1 year after 9/11 than those during the previous year. Rentz et al. (2007) found that reported rates of substantiated child maltreatment cases among mili- tary families in Texas were twice as high during pe- riods of deployment. For every 1% increase in percentage of military personnel departing to or returning from combat, there was a 30% rise in child maltreatment rate, suggesting that the periods before
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and after deployment are most stressful (Rentz et al., 2007). Similarly, Gibbs et al. (2007) reported that child maltreatment rates among families of enlisted military personnel were 42% greater during military deploy- ment. Of note, child neglect rates by military spouses were four times greater during deployment than those during nondeployment periods (Gibbs et al., 2007). These studies provide consistent evidence that mili- tary deployment and the periods surrounding the deployment have significant negative effects on parenting and young children’s well-being.
Taken together, the data show that children in military families experience a range of adverse effects from their parents’ service that could have long-term implications for their mental health and well-being. However, there are a number of important methodo- logical issues that limit our ability to use this data for building an effective mental health care response. First, none of the studies used clinician-based as- sessments of children’s mental health; all relied on screening and Likert-type scales completed by parents to estimate indicators of children’s behavioral health. Given the high rate of stress and depression in this population of adults, reporting biases may have affected the child data obtained. Assessments based on clinical interview of parents and child observation could provide more accurate and fine-grained evalu- ations of children’s mental health status. Second, none of the studies used parentechild observations, a more rigorous method for understanding child behavior in the context of family functioning and parenting behavior. Finally, the studies examine different aspects of children’s behavioral health (i.e., parent reports of attachment behavior, coping behavior, internalizing and externalizing behavior, and strengths) making it difficult to compare results across studies.
What is the state of the science regarding evidence- based parenting interventions for military-connected par- ents and their young children?
Only two (7.7%) of the studies reviewed were ran- domized trials of adapted interventions targeting military parents with young children. Schachman et al. (2004) used a randomized controlled design to test a 4-week childbirth education program, Baby Boot Camp, for primigravid military Air Force wives. Compared with a control group of military wives receiving traditional childbirth education program, mothers in the experimental condition reported greater postpartum adaptation and an initial increase in internal and external resources that was not sus- tained at 6 weeks postpartum. There were a number of strengths to this study including the design, a sample size justified by power analysis, and an intervention guided by a theoretical framework. However, several important study limitations are also noted (i.e., small homogenous sample, possible sharing of information among mothers across
conditions, sole reliance on parent self-report for measuring outcomes).
Gewirtz, Pinna, Hanson, and Brockberg (2014b) published a preliminary report of the acceptability of a 14-week evidence-based parenting intervention adapted for military families of children aged 4 to 12 years, After Deployment, Adaptive Parenting Tools. This intervention is designed to teach positive parenting practices, strategies for developing and maintaining a “united parenting front” so they can effectively parent together, and strategies for man- aging the stress of reintegration following deployment. To address participation barriers unique to military families, the group-based intervention also included Web-based tools that could be accessed from a dis- tance and mindfulness exercises that could be down- loaded to a cell phone or MP3 player. Gewirtz et al. (2014b) report recruitment, retention, and accept- ability of the intervention on the first 42 families enrolled. Seventy-nine percent of the families attended at least 50% of face-to-face group sessions, and parent satisfaction was high (M ¼ 3.5/4.0). However, less than one third accessed the Web-based tools, and only 19% accessed the mindfulness exercises. Strengths of this study are the use of a randomized experimental design and a plan to recruit 240 military families. However, given the preliminary nature of this study, it is too early to discern whether this parenting program has a sig- nificant positive effect on parenting and children’s behavioral health.
What is known about the needs of military-connected parents of young children from racial/ethnic minority backgrounds and from lower socioeconomic backgrounds?
Eight of the articles reviewed did not report the racial or ethnic backgrounds of the samples studied (Barker & Berry, 2009; Cozza et al., 2010; Kelley et al., 2006; McCarroll et al., 2008; Ross & DeVoe, 2014; Scannell-Desch & Doherty, 2013; Wilson et al., 2011, 2014). Of the 18 studies that did report the racial/ethnic composition of their samples, 16 of those samples were comprised mostly of non-Hispanic white respondents. The two studies that did report a majority of re- spondents from racial/ethnic minority backgrounds dichotomized the variable for analysis as “white” or “other” (Rentz et al., 2007) and “Caucasian” or “non- Caucasian” (Everson et al., 2013).
Four studies examined mental health and parenting outcomes by race/ethnicity. Everson et al. (2013) found that non-Caucasian U.S. Army spouses scored higher on parenting stress and lower on measures of coping and contentment than Caucasian spouses. However, non-Caucasian parents were also more likely to have younger children, so these results might be a function of parenting young children alone during deployment periods. Gewirtz et al. (2010) reported that African American fathers in the Army National Guard felt more effective as parents relative to white non-Hispanic fa- thers, whereas Hispanic fathers experienced lower
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levels of couple adjustment. However, the authors note that <6% of their sample was African American or Hispanic limiting the generalizability of these results. In contrast, Flake et al. (2009) found no differences in parenting stress or child behavior problems between “white” (non-Hispanic) and “nonwhite” (Hispanic, Black Asian, other) military parents. A fourth study (Gewirtz et al., 2014b) examined the acceptability of a parenting intervention and found no racial/ethnic differences.
Two studies analyzed child maltreatment rates by race/ethnicity, although neither study analyzed rates within minority racial/ethnic groups. Rentz et al. (2007) reported higher rates of maltreatment among military children from minority backgrounds (6.08; 95% confi- dence interval [CI] [5.65, 6.53]) than those among mili- tary children identified as non-Hispanic white (4.95; 95% CI [4.58, 5.34]). However, this maltreatment rate among military children from minority backgrounds was lower than the rate found among minority families in the general population (7.76; 95% CI [7.71, 7.81]). Overall, rates of child maltreatment were lower for children in military families as compared to children in nonmilitary families across gender, race/ethnicity, and age (Rentz et al., 2007). Gibbs et al. (2007) examined child maltreatment rates among Army families during deployment and found that rates were higher among non-Hispanic white spouses than those among spou- ses from ethnic minority backgrounds, although elevated rates of maltreatment were found across both racial/ethnic groups during deployment periods. These results suggest that being in the military may be pro- tective for children from racial/ethnic minority back- grounds but a risk factor for non-Hispanic white children.
Overall, very few studies in our sample analyzed parent, family, or child behavior and well-being by race/ethnicity. Of those that did, there were few points of consensus, which is needed to build the science related to parenting and mental health among military families with young children. The one exception was the consistent finding that maltreatment rates are higher among non-Hispanic white families during deployment. However, the tendency to merge all ethnic minority groups into a single category makes any results related to this demographic variable diffi- cult to interpret or generalize.
We used three proxy variables to assess the socio- economic diversity of study samples. These include rank (enlisted vs. officer), education, and reported salary. Seven of the studies reported none of these variables (Cozza et al., 2010; Gewirtz et al., 2010; McCarroll et al., 2008; Rentz et al., 2007; Ross & DeVoe, 2014; Willerton et al., 2011). Education was re- ported in 12 studies, and there was wide variation in the educational attainments of the respondents ranging from 75% with a high school diploma (Allen et al., 2011) to 56% with college or graduate degrees (Gewirtz et al., 2014b). Thirteen studies described the military family members’ rank, and 11 of these
samples were comprised mostly enlisted service members (Barker & Berry, 2009; Eide et al., 2010; Flake et al., 2009; Gewirtz et al., 2014b; Gibbs et al., 2007; Gorman et al., 2010; Larson et al., 2012; Louie & Cromer, 2014; Schachman et al., 2004; Wilson et al., 2011, 2014). Seven studies reported the salaries of the service members, and these data also ranged widely across studies, even within military branch. For example, 66% of the Army National Guard fathers participating in the study by Dayton et al. (2014) earned less than $50,000, and 50% were unemployed. In contrast, the median reported income of Army Na- tional Guard families participating in the study by Gewirtz et al. (2014b) was $80,000. In sum, although most studies focused on enlisted services members’ families, there was substantial diversity across study samples in educational levels and income. This eco- nomic diversity was particularly true among those in the Army National Guard who often hold multiple jobs.
Four studies examined mental health differences by educational level (Allen et al., 2011; Flake et al., 2009; Gewirtz et al., 2014b; Wilson et al., 2014), rank (Allen et al., 2011), or salary (Allen et al., 2011). Among these four studies, the most common findings were that lower education, rank, or salary were associated with more marital conflict (Allen et al., 2011), poorer child behavioral health (Flake et al., 2009; Wilson et al., 2014), poorer family communication (Wilson et al., 2014), and accessing fewer components of a parenting interven- tion (Gewirtz et al., 2014b). One study found no asso- ciation between educational level in military husbands or wives and parenting stress (Everson et al., 2013). In general, these data suggest that socioeconomic disad- vantage among military families with young children may increase the likelihood of experiencing more mental health problems and more limited use of in- terventions designed to support their parenting, but given the small number of studies, its true impact in this population is unclear.
Discussion
This review presents results from 26 studies designed to describe or prevent mental health problems in mil- itary families with young children (aged 0e5 years). We focused specifically on military families with young children because the attachment relationships neces- sary for children’s social and emotional well-being are first formed during this period (Bowlby, 1960; Waters, Merrick, Treboux, Crowell, & Albersheim, 2000). Secure attachment relationships occur in the context of consistent, responsive, and nurturing environments and provide young children with a sense of safety and trust. When parents are physically unavailable, due to lengthy or frequent deployments, or emotionally un- available, secondary to the other parents’ stress and depression, children’s early development may suffer (Cassidy, Jones, & Shaver, 2013).
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The results of the studies reviewed provide pre- liminary evidence that deployment is associated with more stress and mental health problems in parents and young children, increased use of mental health care by spouses/partners and children, and greater likelihood of child maltreatment. Some risks vary by child age. For example, during deployment, infants appear to be at greater risk for neglect than preschool children (McCarroll et al., 2008), and preschool children appear to be at greater risk for physical abuse than are infants and older children (Gibbs et al., 2007). These data suggest that the heightened stress of deployment on civilian spouses left to care for their children can have significant and potentially long-lasting adverse effects on young children’s well-being. The post- deployment period is also a stressful one as service members struggle to reconnect with their spouse and a young child who may not remember them and with whom the child has not formed an attachment rela- tionship. If the service member is also recovering from physical or emotional combat injuries, the attachment and reintegration process may be particular stressful for the family.
More than 90% of the studies reviewed were descriptive in nature. Descriptive studies are useful for determining risk and protective factors and guiding intervention content, timing, and target populations. However, a number of methodological weaknesses were identified that limit the extent to which the study findings can guide intervention. These include limita- tions related to having small racially and ethnically homogenous samples, relying almost exclusively on parent report for measuring study outcomes, lack of specificity on what constitutes the “deployment” and “postdeployment” periods, employing cross-sectional and retrospective designs that do not allow for causal inference, merging all minority racial and ethnic groups into a single “nonwhite” category, and no research on veteran parents of young children. Although a number of studies examined interventions designed to prevent mental health problems in military families, only two tested those interventions using rigorous experimental designs. These limitations make it difficult to know, among military families with young children, “who needs what and when?” The following are six recommendations for strengthening the science related to understanding and addressing the needs of military families with young children.
Expand Sample Sizes and Sample Diversity
It is important to understand whether the socio- demographic variables associated with poor mental health outcomes in the general population have the same effect in the military population. This means that military study samples need to be expanded to include (a) more racial/ethnic diversity, (b) more socioeco- nomic diversity, and (c) larger sample sizes that allow for subgroup analyses by racial and ethnic group and income levels within ranks to determine which
military families are experiencing the greatest risk for poor mental health and child maltreatment. Power analyses should be conducted to ensure that sample sizes are sufficient to conduct subgroup analyses on racial and ethnic groups and indicators of socioeco- nomic status (i.e., education, income, rank).
Conduct Studies Examining the Mental Health Needs of Veteran Families with Young Children
Two thirds of the veterans from OEF/OIF/OND conflicts are younger than the age of 30 years (Seal et al., 2009), and more than 330,000 veterans of these wars receive VA health care for physical or psychological injuries related to their service (Kang, 2008; Westat, 2010). However, few VA programs provide treatment for spouses and young children (Makin-Byrd, Gifford, McCutcheon, & Glynn, 2011; Pemberton, Kramer, Borrego, & Owen, 2013) and, unlike active duty ser- vice members, veterans do not have access to the more extensive services provided through military facilities. National Guard and Reserve veterans from small towns are likely to have even fewer opportunities to access mental health care for their spouses and young chil- dren (IOM, 2010). Given the high rate of mental health problems known to exist among OEF/OIF/OND veter- ans and the likelihood that these young veterans will also have young children, it is concerning that we found no studies on the mental health needs of these families (Pemberton et al., 2013; Sayers, Farrow, Ross, & Oslin, 2009). More research on the mental health needs of the growing population of veteran families with their young children is needed.
Examine the Mental Health Needs of Deployed Mothers
Approximately 16,000 active duty military women give birth annually (Nguyen et al., 2013; Rychnovsky & Beck, 2006), so it is surprising that we found so few studies on the impact of deployment on the mental health of military mothers and their young children. More studies on military mothers of young children and how their needs may differ from those of military fathers are needed. It is possible that mothers and their young children have unique needs requiring different in- terventions from those of deployed fathers with young children. These studies should also examine the needs of active duty single mothers of young children, including whether the children have access to other attachment figures who can effectively buffer the adverse effects of separation for deployment.
Use Multiple Methods for Assessing Parent and Child Mental Health
Most studies relied solely on parent report to assess mental and behavioral health outcomes. Future studies should include multiple methods and normed surveys for assessing parent and child mental health.
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For example, direct observations of parentechild in- teractions would provide greater understanding of the extent to which the child’s behavior is outside the norms for their developmental age and whether those behaviors are an effort to engage (or avoid) a distressed and emotionally preoccupied parent. Direct observa- tion is also the strongest method for assessing chil- dren’s attachment security (Patterson, 1977; Wahler, House, & Stambaugh, 1976), which would provide important data on the extent to which deployments may be affecting the development of secure attach- ments. Clinician assessments would be useful for determining the extent to which parents and children are experiencing mental health disorders requiring treatment from a qualified mental health provider or whether their distress could more effectively be addressed using psychoeducation and instrumental support. Finally, when using parent self-report mea- sures, researchers should employ measures with pop- ulation norms to better understand how the mental health problems reported in military families compare with those in the general population.
Conduct Prospective, Longitudinal Studies to Capture the Evolution of Mental Health Issues as They Occur across Multiple Transitions Spanning Predeployment to Postdeployment Periods
Longitudinal studies could highlight important tem- poral factors associated with mental health fluctua- tions in military families with young children. For example, longitudinal studies might uncover the most “sensitive” periods for families when prevention or mental health treatments are most likely to have the greatest impact. They might also provide important data on how parents’ mental health and family func- tioning before deployment affects family members’ mental health postdeployment, particularly when service members sustain combat injuries requiring treatment and rehabilitation. Finally, longitudinal studies might reveal predeployment strategies that strengthen parentechild relationships and reduce mental health symptoms postdeployment (Louie & Cromer, 2014). Given the heightened risk of neglect during infancy (McCarroll et al., 2008), longitudinal studies should be initiated when military spouses or partners become pregnant.
Although there are currently two large longitudinal military population studies underway, neither will focus on mental health of military family members with young children. The Deployment Life Study measures military families’ emotional, psychological, and physical health over a 3-year period, including measures before and after a deployment (Tanielian, Karney, Chandra, & Meadows, 2014). However, only military children aged 11 years and older were recruited for this study. A second study undertaken by the Department of Defense, the Millennium Family Cohort Study, modeled after the Millennium Cohort Study for military members, is examining the impact of
deployment on long-term health outcomes among military service members and their spouses (Crum- Cianflone, Fairbank, Marmar, & Schlenger, 2014; Smith & Millennium Cohort Study Team, 2009). Although the Millennium Family Cohort Study in- vestigates child behavioral health and well-being by parent report, neither longitudinal study specifically addresses the mental health needs of young children.
Use Experimental Designs to Rigorously Test the Effect of Interventions on Parent and Child Mental Health
We found only two intervention studies of military families with young children that used randomized experimental designs (Gewirtz et al., 2014b; Schachman et al., 2004). Both adapted existing evidence-based programs used in the general popula- tion for use in military families. However, the study by Gewirtz et al. (2014b) presented only preliminary data on intervention feasibility and acceptability, and the findings presented by Schachman et al. (2004) suggest that the mental health gains initially found in the experimental group were not sustained 6 weeks later. Three other studies evaluated population-based pro- grams for military families with young children (Kelley et al., 2006; Ross & DeVoe, 2014; Wilson et al., 2011), although none were tested against a control condition and outcomes primarily focused on parent satisfac- tion. As a result, we were unable to find any evidence- based interventions shown to improve parent and child mental health during the early years.
Limitations
Several limitations of this review should be noted. First, we did not systematically retrieve book chapters or dissertations, and therefore all studies included in this review were accessed from journals. However, because all the reviewed articles came from refereed journals, we think that methodologically stronger studies were synthesized. Second, publication biases favoring positive findings may have led to identifying more mental health and behavioral symptoms in this military population, although several studies showing null effects are also reported in this review. Finally, a number of studies on mental health in military fam- ilies were not included in this review because the au- thors did not report children’s ages or associations with deployment. Therefore, it is possible that other relevant studies were not included in this review.
Implications for Policy
The American Academy of Nursing strongly advocates for policies that prevent or treat the physical and
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emotional stressors associated with military service (Collins, Wilmoth, & Schwartz, 2013). For military and veteran families, best practice must be built on a strong scientific base. The findings of this systematic review suggest that, to date, we still know too little about the mental health needs of families with infants and young children and how best to support them. There is abundant evidence in the general population that exposure to the loss of attachment figures, parental mental illness, maltreatment, and other forms of adverse events in early childhood can have enduring negative consequences on health and well-being (Felitti et al., 1998; National Scientific Council on the Developing Child, 2008). We also know that inter- vening early can be highly cost-effective if those in- terventions are evidence based, relevant to the populations being targeted, and capable of being scaled with fidelity (Heckman, 2006). How best to apply this knowledge to this vulnerable population of families who serve their country remains unclear. More research funds are needed to support larger, method- ologically sound studies to better understand and address the mental health needs of military families with young children.
Acknowledgments
The authors would like to acknowledge the Morton K. and Jane Blaustein Foundation for their generous sup- port of the research for this article.
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- Impact of deployment on military families with young children: A systematic review
- Introduction
- Background
- The Impact of OIF/OEF/OND on the Mental Health of Parents
- Ethnic and Racial Disparities within the Military
- Methodology
- Results
- Study Profiles
- Parent Mental Health
- Child Behavioral Health
- Discussion
- Expand Sample Sizes and Sample Diversity
- Conduct Studies Examining the Mental Health Needs of Veteran Families with Young Children
- Examine the Mental Health Needs of Deployed Mothers
- Use Multiple Methods for Assessing Parent and Child Mental Health
- Conduct Prospective, Longitudinal Studies to Capture the Evolution of Mental Health Issues as They Occur across Multiple Tr ...
- Use Experimental Designs to Rigorously Test the Effect of Interventions on Parent and Child Mental Health
- Limitations
- Implications for Policy
- Acknowledgments
- References
