Exploring Traumatic Influences
farm1980
O R I G I N A L P A P E R
Parental Combat Injury and Early Child Development: A Conceptual Model for Differentiating Effects of Visible and Invisible Injuries
Lisa A. Gorman • Hiram E. Fitzgerald • Adrian J. Blow
Published online: 26 November 2009 � Springer Science+Business Media, LLC 2009
Abstract The injuries (physical and emotional) sustained by service members during combat influence all members of a family system. This review used a systemic framework
to conceptualize the direct and indirect effects of a service member’s injury on family
functioning, with a specific focus on young children. Using a meta-ethnographic approach
to synthesize the health research literature from a variety of disciplines, this review makes
relevant linkages to health care professionals working with injured veterans. Studies were
included that examined how family functioning (psychological and physical) is impacted
by parental illness; parental injury; and posttraumatic stress disorder. The synthesis of
literature led to the development of a heuristic model that illustrates both direct and
indirect effects of parental injury on family functioning and the development of young
children. It further illustrates the contextual factors or moderating variables that buffer
detrimental effects and promote family resilience. This model can be a foundation for
future research, intervention, and policy.
Keywords Parental combat injury � Trauma � Children
The Iraq and Afghan conflicts have produced an estimated 20,000 children of America’s
military force who have a parent with a combat related injury [1]. This number does not
include the effects of posttraumatic stress disorder (PTSD) or milder forms of brain injury.
PTSD, traumatic brain injury (TBI), and depression are the most common forms of
affective and cognitive impairment identified among approximately 30% of returning
veterans [2]. Hoge et al. [3] reported that 15% of service members returning from Iraq and
L. A. Gorman (&) � H. E. Fitzgerald University Outreach and Engagement, Michigan State University, 22 Kellogg Center, East Lansing, MI 4882, USA e-mail: [email protected]
H. E. Fitzgerald Department of Psychology, Michigan State University, East Lansing, MI, USA
A. J. Blow Department of Family and Child Ecology, Michigan State University, East Lansing, MI, USA
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Psychiatr Q (2010) 81:1–21 DOI 10.1007/s11126-009-9116-4
Afghanistan have suffered a mild TBI that involved either a loss of consciousness or
altered mental status. The fifth report of the Mental Health Advisory Team [4] indicates
that service members with multiple deployments are at a higher risk for PTSD and other
mental health concerns. These numbers suggest that a relatively large number of returning
veterans have either a physical or an emotional injury. Of note is that nearly half of the
active duty Army have dependent children, 27% of whom are under age three [5], meaning
that many injured service members are returning home to households that include a very
young child. In the National Guard and Reserve alone, there are 106,000 children ages
birth-three. Additionally, there are 90,000 babies born each year to active duty service
members [6]. The number of injured service members returning home to families
emphasizes the need to understand the long-term implications of parental injury on early
child development, and to identify buffers to the negative effects of these injuries.
The purpose of this article is to present a conceptual framework for studying the effects
of both visible and invisible injuries on individual and family dynamics, in order to
understand more fully the kinds of supportive services needed to reduce risk to very young
children in families traumatized by injuries. Because the early life course trajectory is
shaped ‘‘largely [by] the result of the infant’s relational world of family, community, and
life context’’ [7, p. 176] the impact of parental injury can negatively affect relationships
within the family system, including relationships that impact infants and toddlers who are
the most vulnerable members of that system. The effects of parental combat injury on early
child development continue to be understudied [8–10], despite mounting evidence for the
intergenerational transmission of trauma [11–14]. Consequently, there is a need for a
conceptual framework to guide this work; a conceptual framework that encompasses the
systemic components of the veteran’s life space including all of the factors that encompass
direct and indirect effects of parent difficulties on the child’s social, emotional, intellectual,
and physical well-being.
Theoretical Approach: A Systemic Model
The family has been described as ‘‘a unity of interacting personalities’’ [15], in short, as a
dynamic system of relationships. Thus, the relationship pathways between parents, and
parents and children, are both direct and indirect (mediated or moderated). Direct effects
include the range of direct parent-to-child interactions. For example, the nature of the
injury may affect the parent’s ability to maintain daily parenting routines like picking up,
feeding, or bathing the child. Indirect effects include those mediated through a parent, for
example, the demands of caring for the injured veteran may leave the other parent drained
and unable to be attuned to the needs of the child. Further, there are adjunctive system
impacts on the family system. The injury may cause the veteran to spend extended time
away from the child interacting with rehabilitation services influencing the parent’s ability
to develop or maintain secure attachment relationships. Hence, the system meant to support
the service member’s recovery may in this way directly undermine his or her ability to
parent if family functioning is not considered in treatment planning. Additionally, if the
culture of the military prevents the injured service member from receiving needed care for
invisible wounds [16], the cultural context has indirectly affected child outcomes by
impeding the soldier’s self-care, reintegration into the family, commitment to family well-
being, and parenting abilities. Potential pathways through which parental combat injury
might influence family functioning and early child development are illustrated in Fig. 1.
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In Fig. 1, we illustrate the mediating effect that family functioning has on early child
development. The critical interactions for infant mental health and development include
the primary caregiver [17], parental figures, grandparents, and siblings [18]. We will later
use the Process Model of Family Functioning [19] to organize and discuss family processes
which contribute to healthy family functioning. The Process Model includes seven con-
structs: task accomplishment, role performance, communication, affective expression, involvement, control, and values and norms [19, p. 192] that are reflected in the parent child relationship and contribute to development across time. We will propose that parental
combat injury has a direct and deleterious effect on dimensions of family functioning
including those aspects of family functioning that promote resilience in the face of illness
and injury.
Conceptualizing Differential Impacts of Visible and Invisible Injuries on Child Development
Injuries sustained in combat may be visible or invisible to the child. Children can more
easily understand the effects of an injury when they can visually see the bandages, loss of
limb, scarring, or prosthetic. However, injuries like TBI, PTSD, or depression remain
invisible to the child. Symptoms are both more difficult to associate with the invisible
injury and are more readily internalized by the child as they attempt to read and control
their parent’s mood. For example, the child might read the parent’s anger as a result of his/
her running through the house rather than the deficit in the parent’s attention associated
with TBI. The child might attribute experienced rejection from his/her parent to his/her
own self-worth rather than to PTSD symptoms of avoidance or emotional numbing.
Methodological Approach to the Literature Review
We used a meta-ethnographic approach [20] to synthesize the literature on parental injury
and illness. The existing body of literature demonstrating the direct impact of a service
member’s injury upon the development of his/her young child is scarce [1, 21], as is the
literature demonstrating the efficacy of inclusion of children in evidence based family
Family Functioning
Contextual Factors
Parental Combat Injury
Individual and Dyadic Factors
Early Child Development
Invisible Injury
Visible Injury
Fig. 1 A conceptual model of parental combat injury: direct and indirect effects on early child development
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treatment [22]. Therefore, the review draws upon other bodies of literature relevant to
professionals working with injured service members and their families. Studies were
included that examined the impact of parental illness on family functioning (cancer, HIV/
AIDS, affective disorders); psychological and family adjustment following a TBI; impact
on family function following other parental injury (farm injury, burns, and spinal cord
injury); and PTSD and family adjustment. Relevant studies of child development, life
course perspective, attachment theory, family process, family functioning, resilience and
posttraumatic growth were also included. Excluded were studies of sibling illness or injury
(require different family coping) and studies of parental death (grieving process for injury
is uniquely different than grieving parental death) [23]. Key phrases, ideas, and concepts
were recorded to compare how studies were related to each other. As themes began to
emerge in the synthesis, new bodies of literature emerged that added to the knowledge base
for how infant and toddler development are influenced by parental injury.
The organizational structure of the review reflects the nature of parental combat injury,
the individual and family processes following injury, and associations with early child
development. The review also considers the indirect effects on early child development by
looking at paths where injury impinges on dyadic relationships, social supports, and family
functioning, which then affects child outcomes. Finally, the review looks at extra-familial
systems, such as health care and community support that buffer the effects of parental
combat injury on family functioning and the young child’s early development.
Conceptual Model
Parental Combat Injury: Visible Versus Invisible
The nature of the injury has far-reaching implications for how the service member will
interact with all levels of systems including how he/she is received in the larger societal
system. The nature of the injury determines the course of treatment, but also patterns of
interaction in the family, family function and adjustment, the parent–child relationship, and
ultimately child development outcomes. Though injuries may be classified as visible or
invisible, the complexity involved in quantifying the biological, psychological, and social
consequences over time make it difficult to ascertain parental injury as exclusively one or
the other.
Invisible injuries are those that cannot readily be identified by non-professionals and have no obvious physical impairment. PTSD, TBI, and depression are the most common
forms of invisible injury among returning veterans [2]. PTSD is a factor of combat trauma
with a relationship to variables such as the intensity and duration of the combat experience,
an ability/inability to control one’s environment, and witnessing the death of an important
comrade [24, 25]. TBI is the loss of brain function due to an open or closed wound to the
head and subsequent biochemical events in the brain [26]. Invisible, injuries like PTSD and
TBI are associated with increased somatic symptoms, increased health care visits, and
more work absenteeism [27].
Invisible wounds can be a source of heightened stress as the injured may be unaware
how his/her personality and interactions with family have changed [28]. In addition, the
family may not be aware of the injury or they may attribute personality changes to other
factors. Invisible wounds are most difficult for children to understand [29] and can be very
draining for both the person with the injury and the family [30]. Invisible parental injury is
further complicated by the stigma associated with psychological changes and mental health
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care [16, 29]. ‘‘Disapproval of their unproductiveness’’ is an example of larger societal
values which denigrate persons with invisible injuries [30, p. 595]. Social stigma may
interfere with needed care and further isolates the family from critical social support.
Visible injuries are defined in War Psychiatry as those disabling and disfiguring injuries which can be readily observed by others. Visible injuries include burns, eye injury or
blindness, major amputation, facial disfigurement, spinal cord injury, and paralysis [31].
According to Weinstein, the demands of multiple surgeries and painful rehabilitation are
often followed by emotional stress and worry as the service member begins to understand
the physical and social limitations of the injury. A review of the psychological effects of
severe burn injuries [32] suggests that anxiety and depression are prevalent in the first year
following injury, but may subside with time. Visible injuries also result in the service
member experiencing physical limitations, altered body image, lowered self-esteem, social
stigmatization, and changes in personal relationships [31].
Visible injuries can represent a significant change in the service member’s way of life
and employment [32, 33]. Those who sustain disabling and disfiguring injuries may also
experience psychological disorders such as PTSD, depression, anxiety, or combinations of
these and other mental health issues [32, 34, 35]. Injury severity has been strongly asso-
ciated with symptoms of PTSD and depression within the first year post injury [34].
Direct Effects of Parental Combat Injury on Early Child Development
The direct effect of parental combat injury is largely associated with physical constraints
placed on the relationship between the injured parent and the child. Relationships among
family members are social and interpersonal constructions. Whereas the developmental
processes driving the organization of social relationships (e.g., attachment) are robust, the
socially constructed contents of such relationships are fragile, particularly in the formative
stages of organization. Constructed within the general attachment motivational system
[36], relationships can be challenged by the extended separations from the parental/
attachment figure/s that come with treatments such as hospitalizations, surgeries, doctor’s
visits, and rehabilitation that involve one and often both parents. This is just one of the
ways in which the injury disrupts primary bonding leading to a loss of stable object
relations [36].
Affective expression is an important part of parent–child interactions and includes time,
intensity, and content of expressed feelings and can be positive or negative [19]. Emo-
tional/psychological injuries directly influence affective expression. For example, PTSD
symptoms include heightened reactivity and emotional numbing [12, 37], and TBI
symptoms include anger and aggression [38, 39]—all of which may interfere with the
injured service member’s ability to express positive affection to his/her child [37, 40] and
add to the fragile nature of parent–child relationship building.
Indirect Effects of Parental Combat Injury on Early Child Development
When parental combat injury alters the parent’s attunement to the child’s needs, the child’s
emotional, social, and physical development suffers. If developmental issues are not
attended to, the child is at risk for disorganized attachment, psychological distress, the
inability to regulate emotions, behavior problems, developmental delays, and poorer health
and well-being. Cumulative risk during developmental years is a significant public health
concern.
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The kind of risk associated with parental combat injury and early child development is
largely based on evidence related to the known context of parental influences on children
rather than empirical data specific to families involved in Operation Enduring Freedom
(OEF) and Operation Iraqi Freedom (OIF) combat endeavors. Developmental risk factors
associated with parental injury and illness are attachment problems [41–45]; brain
development [46]; emotion dysregulation [47–49]; cognitive, emotional, or developmental
delays [9, 28, 46]; psychological problems [50]; behavioral problems [51–56]; and health
concerns [54, 56–60].
Attachment
Optimal physiological and psychosocial development occurs in the context of a quality
attachment relationship and the development of a secure base between a child and par-
ent(s). Early attachment relationship disruption place children with an increased vulnera-
bility to the development of psychiatric difficulties [42, 45]. Secure attachments are formed
within the context of a caregiver’s availability and attentive responses to the needs of the
child [61, 62].
Parental injury can affect the child’s attachment to both parents. Parental injury is a life
event which potentially disrupts responsive parenting leaving one or both parents physi-
cally present but psychologically absent [63]. Studies show that some emotional challenges
which co-occur with parental injury such as depression, marital conflict, and economic
stress interfere with establishing a secure attachment between parent and child [41, 43, 44].
The caregiver’s availability and responsiveness to the child has an effect on the child’s
attachment style and long-term vulnerabilities. A combination of a disorganized attach-
ment style and parental psychosocial problems predict aggressive-hostile behavior in the
preschool child [50], while a hostile or anxious attachment style may make the child prone
to anxiety-related disorders [64]. If the injured parent has undergone significant psycho-
logical changes, the child may experience him/her as ‘‘alienating’’ or ‘‘abandoning’’ [28].
Alienation experiences occur for the child if the parent acts in disturbing and unfamiliar
ways; abandonment when the parent is present but unresponsive and inaccessible.
Brain Development
The National Scientific Council on the Developing Child [46] reviewed numerous studies
showing how the child’s early environment and experiences interact with genes to deter-
mine the architecture of the developing brain. Environmental impoverishment occurring
during periods of sensitive brain development leads to detrimental effects on long-term
abilities and learning. Further, ‘‘toxic stress’’ (chronic adversity) not only has detrimental
effects on brain architecture but on the chemical and physiological systems as well. The
interconnections taking place in the central nervous system are ‘‘wired’’ and become
embedded in the architecture of the brain. Delays in brain development affect the child’s
future brain functioning including emotion regulation, academic performance, behavior,
mental health, and ability to function.
There is some evidence that invisible wounds place children at greater risk than visible
wounds. A comparison of children with medically ill, non-ill, and affective disordered
parents had the following results. Children with medically ill parents scored between
affectively disordered parents and non-ill parents in regard to academic and behavior
problems [65, 66]. Children with affective disordered parents faired considerably worse
than the other two groups in relation to academic and psychological function. Reasons for
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this are thought to be because a small child can more easily link changed behavior with
physical injuries compared to invisible injuries like PTSD where there is no apparent
tangible cause for symptoms such as reexperiencing and hyperarousal. Zeanah [67]
explains that parental triggers of trauma are not evident to the young child, and in essence,
the sources of these frightening experiences are ‘‘invisible’’ and ‘‘inaccessible’’ to the child
(p. 527).
Psychological Distress
The offspring of an injured service member may be more vulnerable to subsequent trauma
or psychological difficulty. Children growing up in homes with a depressed parent are at
increased risk for depression themselves as they become over-involved in reading and
managing the parent’s emotional state [68, 69]. Children traumatized by family violence
may themselves develop symptoms of PTSD [70, 71], as are children reared in households
with substance abusing parents, particularly when substance abuse is comorbid with other
forms of psychopathology such as antisocial behavior and aggression [72].
It is difficult to generalize a causal relationship between parental injury and psycho-
logical distress of the child in families where there are multiple stressors. For example,
Annunziato et al. [73] examined the effects of maternal chronic illness on the child’s
wellbeing, comparing both ill and non-ill single parent households. This study showed that
distress and aggravation in parenting were associated with poorer child outcomes but not
the maternal chronic illness directly. However, children with an ill parent had presented for
mental health consultation more often than children in the control group.
A parent’s injury may have an impact on the psychological health of his/her offspring
beyond the early developmental years. Solomon et al. [13] looked at combat-related PTSD
among second-generation Holocaust survivors. Among Israeli soldiers with identified
combat stress reaction, those whose parents survived the Holocaust reported higher rates of
PTSD at the 3 year follow-up suggesting consequences for mental health concerns may be
passed onto the next generation. For example, Rosenheck and Fontanna [74] showed the
offspring’s tendency toward violence was associated with parental abusive violence 10–
15 years after their father’s Vietnam experience.
Emotion Regulation
Infancy and early childhood is the time when one learns to understand, experience, and
manage emotion [75]. The security and confidence of the child in relationship with the
parent/attachment figure is a principal resource for emotion regulation [64, 76–78]. The
young child is dependent on the parent for emotional support. In one study of preschoolers
and their mothers, reciprocal emotion regulation was evident with each influencing the
other [79, 80]. This reciprocal emotional regulation is characteristic of close relationships
throughout life [81].
When the parent–child relationship is troubled, the young child is at risk for affective
dysregulation [48], which leads to behaviors such as a dampened emotional response in
relationships, a lack of curiosity or interest in his/her surroundings, gaze avoidance, anger,
and a disorganized response to separation [71]. Abuse and neglect from the caregiver may
result in psychosocial and emotional problems such as insecure attachment style and the
inability to modulate aggression [82–84]. Abusive parent–child interactions leave young
children at risk for conduct problems [85, 86] and replicating cycles of abuse [87, 88].
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Behavior Problems
The parent’s injury, including both visible and invisible wounds, can manifest in emotional
and behavioral problems for children. Parental PTSD and level of combat experience
among Vietnam veterans predicted internalizing and externalizing behavior problems in
their children [51]. Jordan et al. [53] found that children had more behavior problems if the
veteran parent had a PTSD diagnosis compared to other veterans. Hostility and violence
among children was positively associated with parental PTSD symptoms [52].
Pessar et al. [55] studied families where one parent had incurred a brain injury. Ninety
percent of families in the study reported problematic behavior change in the children
following parental injury. Physical illness and chronic pain of parents have also been
associated with poorer social skills and behavior problems in school [54, 56].
Physiological Health
The review of Armistead, Klein, and Forehand [57] tentatively proposed an association
between dimensions of parental physical illness and child functioning. The Adverse
Childhood Experiences (ACE) study looked at childhood maltreatment and family dys-
function among 17,000 participants. The ACE study showed that as the number of adverse
childhood experiences increases, so do the number of health risks later in adult life
including early death [89].
Hyatt and Allen [59] found that when the parents were unable to provide for their own
personal care, the timely immunization of their infants and toddlers was significantly
lower. Maternal depression may place the infant at risk for poorer nutrition and conse-
quently retarded growth and development [90]. Also, somatic symptoms in children have a
direct relationship with pain intensity and emotional distress of their parent [54, 56, 60]
with higher degrees of physical impairment in the parent indicative of earlier somatization
in the child [58].
Effects of Parent Combat Injury on Family Functioning
Task Accomplishment
Task accomplishments are central in organizing the family in relation to parental injury
and reflect the family’s ability to adapt to the injury of the parent while continuing to meet
the developmental needs of all family members. Successful coping strategies and the
ability to maintain routines for the child are examples of how task accomplishment
mediates the effects of parental injury on early child development.
Karlovits and McColl [91] use a qualitative approach to explore how brain injured
adults reintegrate into the community; they identified two key coping strategies. First, the
perception-focused coping strategy refers to the ability to change the meaning of a stressful
event. Second, coping occurs by avoiding situations thus enabling individuals to distance
themselves from events that have a high probability of triggering or exacerbating a
problem. These kinds of coping strategies were found to be a protective factor in dyadic
adjustment following a brain injury [92]. Because individual and family growth takes place
across the family life cycle [93], successful coping is not a one time event but a process
that will develop as the family adapts to the injury. Parents can provide comfort and
security for children by establishing and maintaining routines [94]. Placing boundaries in
this way around the normal routines of the family will protect the family and will prevent
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all things related to the injury from taking over [29]. Once the family has passed the crisis
phase of the injury, boundaries and routines provide opportunities for self-care, commu-
nication, and activities that are not saturated with the injury.
Role Performance
The nature and extent of the injury determines how the service members adapt to new roles
in multiple environments: the ability to maintain their Military Occupational Specialties;
the ability to provide for their family; whether they become recipient of caregiving; and
their ability to perform valued parenting tasks. Invisible wounds like PTSD directly affect
general health risk and increase somatic symptoms resulting in more sick days, and more
days of work missed [27]. These changes all affect the service members’ functioning role
within the family.
Significant role changes often take place for other family members as well, and these
changes represent significant ‘‘caregiver burden’’ [95]. The non-injured parent balances
previous family and work responsibilities with the recovery and/or continuous care of the
injured service member [28]. Rolland [29] suggests that the demands of caring for the ill or
injured parent diminish family resources and the ability of the family to stay on task in
relation to the life cycle (p. 250). Shared responsibility for parenting should be discussed if
real limitations prevent the injured parent from participating is some parenting roles.
Addressing traditional gender roles may open new spaces for both parents to maintain
balance and contribute significantly to the development of their child/ren.
Parents and children are empowered when the injury is framed as a family issue. The
whole family shares in adapting to the psychosocial impact of the injury rather than placing
blame or responsibility on the injured [29]. Age appropriate tasks may help the child/ren
feel as though they are contributing positively to the family. This is illustrated in a case of a
six year old girl appearing to ‘‘enjoy the closeness and her ability to help her mother’’ who
had lost use of her arm [96, p. 376]. Adolescent children of disabled parents assume more
responsibility compared with children of non-disabled parents [97]. This may be viewed as
parentification or a dynamic that emerges from disorganization in family process.
Assuming that developmentally appropriate tasks are assumed by children and they are
able to maintain their childhood, an alternative view is building resilience by teaching
children how to become a team that faces challenges, uses creative problem solving, and
overcomes barriers.
Communication
Communication contributes positively to family functioning when there is mutual under-
standing among family members and the message sent is congruent with the message
received [19]. However, communication problems are common among injured service
members and their families [98, 99].
Communicating with the child is an important part of family functioning that can buffer
negative effects of parental injury. Even though the parents themselves may be struggling
with the effects of the injury, the child still needs to make sense of what the injury will
mean for his/her life. The parent may struggle with how much information to share with
the children [8, 96]. Like other factors of parental injury, communication around parental
injury is not a one time event but a process that develops over time. A central factor is
providing an emotionally safe environment where the young child knows it is acceptable to
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ask questions. The kinds of questions asked by a 3 year old at the time of injury will be
very different from the questions he/she will ask 10–15 years later.
Age appropriate acknowledgement of the parent’s injury by family members will
support the child’s intuitive sense that something is wrong. Dale and Altschuler [8]
demonstrated that children as young as three are very aware of parental illness. Rolland’s
case presentation (1999, p. 257) demonstrates how a 5 year old daughter’s well-being was
impacted by projected worry and fears associated with parental illness kept secret. Not only
should the child be told about parental injury, they should be prepared for sights, sounds
and smells when visiting their parent at the hospital [96, 100]. Rauch et al. [100] suggest
having a trusted adult (other than the spouse) available for each child. The intent is so the
child/ren can visit their parent in the hospital as little or as long as they are comfortable
without cutting short the visit of the non-injured parent.
Affective Expression
The young child also has feelings surrounding the parent’s injury. Duvdevany et al. [97]
ascertained that both positive and negative feelings exist toward parents in and experi-
mental group of school aged children of disabled parents and a control group of school
aged children with non-disabled parents. However, the children of disabled parents
expressed more positive and ambivalent feelings and fewer negative and indifferent
feelings than children of non-disabled parents [97]. Affective expression, within the
context of healthy family functioning, is an environment that provides safety for children
to express a broad range of experienced emotion. The goal is to help that young child to
articulate and regulate their emotions. A study of children with a depressed parent revealed
that emotional fluidity (the ability to express experienced emotion concerning their affectively ill parents) was an important factor in promoting resilience [101].
Involvement
Injury to the service member may result in psychological changes which have a direct
impact on patterns of interaction and involvement within the family. Emotional and social
alienation, depression, and anxiety are common in the course of chronic and severe PTSD
suffering veterans [102]. The caregiver (often the non-injured parent) may even begin to
experience PTSD-like symptoms or secondary traumatization [95]. The burden of caring
for a spouse with PTSD [103, 104], TBI [105], and depression [106] negatively impacts the
caregiver’s psychological well-being leaving both parents less responsive and emotionally
involved with their child/ren.
Involvement following parental injury requires the maintenance of the parent–child
relationships with the injured and non-injured parent. The literature consistently supports
the need for children to maintain a relationship with both parents. The parent–child rela-
tionship may take on new meaning as well as functional and relational changes. This is an
important protective factor for long-term development of the children regardless of the
changing dynamics of the family. Because combat injury is associated with marital dis-
ruption (and in some cases dissolution), the divorce and remarriage literature may be
especially useful. Following divorce, child outcomes are better when the child is able to
maintain a relationship with both parents [107–110]. Even when a parent has perpetrated
violence against the child or the other parent, the child does not simply forget their
existence because they are no longer living together [88]. As long as protective measures
are taken to prevent further revictimization of the child [111], conjoint parent–child
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therapy can focus on attachment issues, planning for a nonviolent future, managing con-
flict, and adjusting to new family configurations [88].
Control
Control is the family process that allows the family to maintain their environment and have
influence over one another [19]. The combat injury may have caused some unexpected and
unwanted behaviors as seen with behavior control among TBI patients [28]. Further, the
severity of aggressive behavior among injured veterans has been associated with severity
of PTSD symptoms [112].
Values and Norms
Values and norms reflect priorities that are important to the family within a larger societal
framework [19]. Values and norms shape the ‘‘family schema’’ which in turn influences
how families may interpret combat injury and attempt to deal with it [113, 114]. Hence, the
family beliefs, values, goals, and perceptions of themselves in the context of their com-
munity may influence whether the family views the injury as manageable.
Stebbins and Pakenharm [115] studied the beliefs of spouses and parents who were
caretakers of a brain injured individual. They found cognitive interpretation of the injury to
play a major role in their own psychological readjustment, suggesting irrational schemas
contribute to poorer outcomes for the caretaker. Stebbins and Pakenharm [115] found
worrying explained the greatest variance in adjustment of the caretaker. Problem avoidance
or pretending that the injury did not happen is also related to lower psychological health of
the caregiver [115, 116].
A consistent theme in family adaptation is the family’s ability to make sense of their
experience [94]. Meaning reconstruction around the injury, role changes, and loss of
personal and familial dreams is central in the process of healing [117]. The family has to
mourn the loss of the person before the injury in order to accept subsequent limitations post
injury [30]. Kosciulek [113] observed that ‘‘positive reappraisal’’ or redefining the meaning
of the stressful event of brain injury, leads to successful family adaptation.
Studies of posttraumatic growth [118, 119] show positive individual changes among
individuals following a traumatic experience. The stressful event provides the individual
with an opportunity to evaluate, reorder priorities, and live with a deepened appreciation of
life. Change may provide the emergence of new opportunities, spiritual growth, closer
personal relationships, the ability to face future challenges, and a greater capacity to show
compassion to others.
Dyadic Factors Moderating the Effects of a Combat Injury on Family Functioning
and Child Development
The child’s development takes place in relationship with his/her parents. Figure 1 illus-
trates dyadic factors as moderating variables. Since the dyadic relationship has a direct
effect on family functioning, parental injury affecting dyadic adjustment indirectly affects
child development. The dyadic relationship can either buffer or exasperate the deleterious
effects of parental injury on family functioning and early child development. This section
summarizes the known effects of parental injury on dyadic adjustment.
Psychiatr Q (2010) 81:1–21 11
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Marital Adjustment and Divorce
The literature suggests poorer outcomes for the couple relationship compared to non-
injured veterans. A number of studies show a significant association between PTSD and
couple relationship problems [53, 98, 120]. The strain of invisible injuries like PTSD and
TBI cause various levels of relationship disintegration. Marital disruption and divorce is
higher among couples where one partner suffers from PTSD and TBI compared to similar
cohorts without a diagnosis [28, 53, 120–122]. Divorced service members returning from
Iraq and Afghanistan reported higher levels of depression [123] which is often comorbid
with PTSD, TBI, chronic pain associated with physical injury, and caregiver burden.
Kessler et al. [124] show an association between depressive symptoms and risk for divorce.
Veterans with a combat injury are at increased risk for divorce, and even when the family
remains intact, subsequent family stress may cause the children to live in fear of family
disintegration [23].
Intimate Partner Violence
Studies reveal some association between invisible combat injury and intimate partner
violence. Aggressive behavior among individuals with PTSD along with loss of impulse
control associated with TBI place injured service members at risk for perpetrating violence
against their intimate partners [38, 39, 53, 125, 126]. Marsh and Martinovich [127] found
that among men receiving treatment for intimate-partner violence, the rate of TBI is higher
than in the general population. Further, there is some association between violence and
more caregiver burden [128].
The known effects of family violence on child development underscore the importance
of the dyadic relationship as a moderating variable. Parental combat injury that precipitates
intimate partner violence has a deleterious effect on early child development. The fol-
lowing risk factors are present when the child is exposed to family violence, either as a
victim of physical abuse or in witnessing physical violence perpetrated from one parent
onto the other: psychosomatic disorders, anxiety, fears, sleep disruption, excessive crying,
and school problems [129–132]. Dutton [87] contends that experiencing violence, shaming,
and insecure attachment contribute to intergenerational patterns of abuse.
Dyadic factors are important moderators when considering the effects of parental injury
on family functioning and early child development. Though parental divorce will certainly
have an effect on the youngest family member, contextual factors must be considered
before determining the causal relationship and developmental outcomes. Marital disruption
drains the emotional and physical resources of already stressed families leaving little
energy for attunement to the needs of the developing child. Infants and toddlers are
especially vulnerable to parental divorce and family disruption [133, 134]. In the general
population, studies show that parental divorce is the source of vulnerability for some
children and resilience for others [133–139]. In cases when intimate partner violence is
present within the dyadic relationship, divorce has the potential to protect the young child
from witnessing violence and further trauma.
Contextual Factors Moderating the Effects on Family Functioning and Child
Development
Contextual factors moderate the effects of parental combat injury on family functioning
and early child development (Fig. 1). Contextual factors including community supports,
12 Psychiatr Q (2010) 81:1–21
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the health care system, and societal values and norms all can buffer the impact of parental
injury on family functioning and early child development.
Social Support
Social support is fundamental for buffering deleterious effects of parental injury on family
functioning and early child development. The injured can easily become socially isolated
without targeted activities to facilitate reintegration into social and community life. The
development of self-esteem and feelings of having important contributions to society are
associated with social support for survivors of invisible [30] and visible injuries [32].
Social support not only predicts better adjustment for the injured, but it has a buffering
effect for the family [32] with direct effects on family functioning. Social support and the
perception of social support received are associated with less emotional distress among
caregivers [116, 140].
Social support that improves quality of life for the injured, the caregiver, and family
functioning indirectly supports early child development. Intimacy between partners and
general social support from friends and relatives are protective factors for parental stress
during the first three years of a child’s life [141]. Mothers who perceive fewer stressors
have supportive networks and are more likely to demonstrate positive interactions with
their infants [142]. Also, supportive groups of parents ‘‘who are facing or have overcome
commensurate challenges may provide a normative reference base that helps to reduce
parenting stress’’ [141, p. 954]. Social support includes both formal and informal networks
contributing to adaptation.
Continuum of Care
From critical care through rehabilitation, the service provided by the physicians and
professionals to the injured service member and his/her family make up a continuum of
care. Supportive relationships and communication between the health care professional and
the family are foundational throughout the continuum. Positive relationships are formed by
recognizing the experiences of the family, establishing trust, listening to the family, and
allowing oneself to be influenced by their story [30]. Lefebvre and associates [30] provide
a thick description in their qualitative study with TBI patients, family members, and their
health care professional. ‘‘Families appreciate being listened to by physicians and pro-
fessionals…the family is the expert on its situation of every day life…’’ [30, p. 592]. In one study, family representatives’ emotional stress, appraisal of the extent to which
their needs were being met, interpersonal appraisal of nurses and primary physician, and
the interrelationship among these variables were explored at a level one trauma center
[143]. The notification of an injury results in elevated levels of distress, symptoms char-
acteristic of acute stress disorder, and anxiety in family members [144]. During the initial
crisis, health professionals have an enormous influence over a family’s sense of compe-
tence [29, 143]. Rolland [29] describes the initial diagnosis as a ‘‘framing event’’ (p. 247).
Every interaction by the health professional, what persons are included in the conversation
as well as what is said, may be interpreted by the family as having significant meaning.
Family perception of needs met, affiliation with both physicians and bedside nurses, and
high levels of optimism among family members may be protective factors for lower levels
of emotional distress following the patient’s discharge [143]. Family members were
reassured when they felt support from physicians and professionals [30]. In contrast,
Psychiatr Q (2010) 81:1–21 13
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families viewed the professional relationships negatively when they were not recognized
for their contributions or supported in their process of adaptation [30].
Communication is a critical component in the continuum of care. Understandable and
honest information about patient medical condition builds trust and mutually respectful
relationships that help the family [29, 30]. Not only does the health care team have an
important role in communicating clear and factual information to all members of the
family in developmentally appropriate ways [94], they also have an important role in
communicating clearly as a team. Communication, intentionality, and a common purpose
contribute to teamwork among professionals [30]. Communication and continuity within
and between establishment are protective factors for the TBI patient and their family
members’ adaptation [30].
Implications for Intervention and Policy
A consistent attachment figure in the environment is a critical protective factor for young
children following parental combat injury. Urbach [28] identified quality of earlier
attachment and the availability of the other parent and supports as mediating factors
associated with parental TBI. Even when faced with abuse, children are more resilient
when they receive emotional support from another adult in their lives [145, 146].
A multisystemic, resilience-oriented approach [94] is needed to strengthen family and
community resources rather than focus on individual deficits. Considering parental
combat injury, interventions should respect individual, family, military, and community
differences. Distress experienced by families of an injured service member can be
contextualized so that family members understand their experience as normal and similar
to others with similar losses [94]. The service member should have the opportunity for
continued participation in unit debriefings so as to maintain connectedness and support
from his/her military family [147]. Challenging beliefs within society that promote
shame, blame, or guilt is a shared responsibility of family, military, and community
members [94, 148].
Further, professionals are more apt to include the family in their system of care when
they feel supported and competent in doing so. A national survey of TBI rehabilitation
staff practices revealed that 19% of participants had worked with a child relative in the
past month [149]. The staff’s perception of their ability to work with the child relative
was a significant predictor of involving children in rehabilitation. Training, resources,
and support structures to include children in rehabilitation increase the likelihood for
staff interaction with youngest members of the patient support network. The antithesis to
quality care is lack of professional resources, overload, and exhaustion among profes-
sionals [30].
Implications for Future Research
In summary, the studies available for review did not meet the conditions to make valid
causal inferences [75]. Any attempts to describe the effects of parental injury sustained during combat upon their infant or toddler offspring is tenuous at best. Without rigorous
scientific study, it is not possible to make strong causal inferences regarding risk factors for
young children of war-injured parents. The ultimate research question to guide future
research should be ‘‘How does parental combat injury affect the offspring’s development
14 Psychiatr Q (2010) 81:1–21
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and life course trajectory?’’ Some stepwise questions that might lead us to a better
understanding include: Is there an association between parental combat injury and child
development? Do different types of injuries, visible and invisible wounds, have differing or
similar effects on child development? What are the critical dimensions of the injury that
influence parent–child interactions and family functioning? What other mechanisms within
individual, parental, familial, or societal systems are negatively influencing child
development?
The known parental impact on the child’s social, emotional, intellectual, and physical
well being suggests the need for systemic interventions. While research is needed that
will provide detailed observations of child development, it may be more plausible to
conduct experiments in program evaluation rather than developmental sciences [75].
Figure 1 can be used as a model for developing systemic interventions and designing
program evaluations to meet the immediate needs of wounded warriors and their
offspring.
Conclusion
The review of literature underscores the complexity of challenges faced when a parent
is injured in combat. The service member must adapt to physical and emotional
changes, and the entire system must adapt to meet the changing needs of all family
members. Because early child development is dependent upon the parent–child rela-
tionship and family functioning, targeted efforts must be made to ensure that commu-
nities of support are aware of both risk and protective factors associated with parental
combat injury.
The nature of the invisible injury may have a direct negative impact on family func-
tioning and the quality of parent–child relationships necessary for promotion of optimal
child development. While all types of parental combat injury influence various components
of family functioning, there is some evidence that families are more resilient in relation to
visible wounds (cite) and struggle more with changes related to invisible aspects of injury,
such as irritability, rapid mood swings, emotional numbing, memory loss, and behavior
control [28, 150].
The Department of Defense (DOD) can support intervention and research inclusive of
family support systems and even the youngest family members. There is also need for the
DOD to continue efforts to reduce stigma associated with invisible injuries. Further, biases
about mental health care and pathologizing labels must be challenged in all communities.
Civilian communities must be educated on the military and combat experiences and evi-
denced-based practices that promote healing, growth, and development. The local com-
munities must be ready to receive and attend to the invisible injures, the family’s
readjustment, strengthening parent–child relationships, and the early developmental needs
of the very young. Coming Together Around Military Families (CTAMF) says: ‘‘So much
for…Oh, she’s too young to remember—she won’t be affected by what’s happening. On the contrary, she may be affected without even knowing she’s been affected’’ (Building
Healthy Minds, Zero to Three, 2007, slide 22) [151]. The injured service member has
demonstrated their commitment to others. The legacy of our country can be affected
positively by demonstrated commitment to veterans, their health care, their family func-
tioning, and their offspring.
Psychiatr Q (2010) 81:1–21 15
123
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Author Biographies
Lisa A. Gorman, PhD Research Associate, University Outreach and Engagement, Michigan State University.
Hiram E. Fitzgerald, PhD Associate Provost for University Outreach and Engagement, University Distinguished Professor, Department of Psychology, Michigan State University.
Adrian J. Blow, PhD Assistant Professor, Department of Family and Child Ecology, Michigan State University.
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