Exploring Traumatic Influences

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ParentalCombatInjuryandEarlyChildDevelopment-AConceptualModelforDifferentiatingEffectsofVisibleandInvisibleInjuries.pdf

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

Psychiatr Q (2010) 81:1–21 3

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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].

Psychiatr Q (2010) 81:1–21 7

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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.

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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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