Deployment & Redeployment

The cycle continues…

Douglas Lehman, LCSW, CAC IIIDepartment of Behavioral Health

EVANS Army Community HospitalFt. Carson, CO

Views expressed in this presentation are those of the author and do not reflect the official policy of the Army, the Department of Defense or the United States Government.

Deployment & RedeploymentDeployment & Redeployment

I. Introductions

II. Research

III. Cycle of Deployment

A. Signs of Stress and Interventions

1. Adults (at home spouse)

2. Preschool

3. Elementary

4. Adolescent

IV. Talking with Children About War

V. Deceased Soldiers and Their Families

VI. Creating Successful Reunions

A. The Returning Veteran & The Family

VII. Wrap-Up

Army FamiliesArmy FamiliesAge of AD Soldiers’ SpousesAge of AD Soldiers’ Spouses

41 or older9%

26 - 30 yrs

23%

25 or younger

36%

31 - 35 yrs

19%

36 - 40 yrs

13%

41 or older26% 26 - 30

yrs19%

25 or younger

9%

31 - 35 yrs

24%

36 - 40 yrs

22%

Enlisted Officers

Army FamiliesArmy FamiliesAge of Soldiers’ ChildrenAge of Soldiers’ Children

19 yrs or older4%

15 - 18 yrs8%

4 - 7 yrs25%

3 yrs or less26%

8 - 11 yrs21%

12 - 15 yrs16%

Military FamiliesMilitary Families

Family members include spouses, children, and adult dependentsFamily members include spouses, children, and adult dependents

ArmyArmy NavyNavy Air Air ForceForce

Marine Marine CorpsCorps

TotalTotal

Service Service MembersMembers

486,483486,483 357,853357,853 349,362349,362 179,836179,836 1,373,5341,373,534

Family Family MembersMembers

712,895712,895 479,144479,144 494,654494,654 178,365178,365 1,865,3101,865,310

Ratio Ratio (FM/SM)(FM/SM)

1.471.47 1.341.34 1.421.42 0.990.99 1.361.36

Percent Percent w/Childrenw/Children

47%47% 42%42% 45%45% 31%31% 43%43%

Avg. # of Avg. # of ChildrenChildren

2.022.02 1.971.97 1.961.96 1.921.92 1.971.97

Military Family High Risk IndicatorsMilitary Family High Risk Indicators

Family History of Mental Health IssuesFamily History of Mental Health Issues

Child History of Mental Health IssuesChild History of Mental Health Issues

School History of Special Education i.e. IEPSchool History of Special Education i.e. IEP

Lower Rank Soldiers (financial considerations and Lower Rank Soldiers (financial considerations and ability to access resources)ability to access resources)

Single parent male or female and foreign spousesSingle parent male or female and foreign spouses

Has the family experienced deployments and how many Has the family experienced deployments and how many and durationand duration

Military Family High Risk IndicatorsMilitary Family High Risk Indicators

How well does the child exhibit coping skills prior to How well does the child exhibit coping skills prior to deploymentdeployment

Dual military career Dual military career

Newly MarriedNewly Married

Socially Isolated and DependentSocially Isolated and Dependent

Younger ChildrenYounger Children

Detecting the warning signsDetecting the warning signs

Persistent fear about war that interferes with a child’s regular Persistent fear about war that interferes with a child’s regular activities.activities.

Sleep changes.Sleep changes.

Changes in the way a child eats that persist beyond several days.Changes in the way a child eats that persist beyond several days.

Changes in a child’s ability to concentrate.Changes in a child’s ability to concentrate.

Prolonged increase in irritability.Prolonged increase in irritability.

Atypical behavior problems at school or at home.Atypical behavior problems at school or at home.

Declining grades and performance.Declining grades and performance.

Physical complaints with no signs of illness.Physical complaints with no signs of illness.

An increase in the child’s negative talk about himself and others.An increase in the child’s negative talk about himself and others.

Withdrawal from friends and from family.Withdrawal from friends and from family.

Understanding Children’s Understanding Children’s Reactions to War DeploymentReactions to War Deployment

Children are affected by their parents’ traumatic Children are affected by their parents’ traumatic experiences as well as their ownexperiences as well as their own

Little scientific information about impact of parental Little scientific information about impact of parental combat exposure on childrencombat exposure on children

Equally dangerous to assume uniform resilience or uniform Equally dangerous to assume uniform resilience or uniform problems as a result of war exposureproblems as a result of war exposure

A real accounting of the trauma and its effects is an A real accounting of the trauma and its effects is an opportunityopportunity to honor the service and sacrifice to honor the service and sacrifice

War trauma is a primary source of difficulty for all military War trauma is a primary source of difficulty for all military family membersfamily members

More Military Kids Seeking Mental Health Treatment Children of U.S. military troops sought outpatient mental health care 2

million times last year, double the number at the start of the Iraq war.

From 2007 to 2008, some 20 percent more children of active duty troops were hospitalized for mental health services, the documents show.

Since the 2003 invasion of Iraq, inpatient visits among military children have increased 50 percent.

The total number of outpatient mental health visits for children of men and women on active duty doubled from 1 million in 2003 to 2 million in 2008.

During the same period, the yearly bed days for military children 14

and under increased from 35,000 to 55,000, the documents show. Kimberly Hefling, Associated Press Writer, July 7, 2009

Office of Family Policy andOffice of Family Policy and Office of Children and Youth, DOD Office of Children and Youth, DOD13.June .0813.June .08

A suicide prevention project in San Antonio found that nearly 35 A suicide prevention project in San Antonio found that nearly 35 percent of more than 200 children from local military families needed percent of more than 200 children from local military families needed to be treated for mental health conditions, further illustrating how the to be treated for mental health conditions, further illustrating how the stresses of militarystresses of militarylife can affect the entire family. life can affect the entire family.

Results of the one-year screening project to identify military Results of the one-year screening project to identify military dependents at risk of suicide were announced Tuesday at the third dependents at risk of suicide were announced Tuesday at the third annual Texas Suicide Prevention Symposium, which is being held in annual Texas Suicide Prevention Symposium, which is being held in San Antonio to increase suicide awareness in the Alamo City. San Antonio to increase suicide awareness in the Alamo City.

Barbara A. GoodnoBarbara A. GoodnoSenior Program Senior Program AnalystAnalyst

Prevalence of Child Maltreatment OIF/OEFPrevalence of Child Maltreatment OIF/OEF

Child maltreatment among non military populations before and during military Child maltreatment among non military populations before and during military options in the middle east (Rentz et al.,2006). They found that the rate of child options in the middle east (Rentz et al.,2006). They found that the rate of child maltreatment was relatively stable between 2000-2003 among non military maltreatment was relatively stable between 2000-2003 among non military families; however among military families increased at end of 2002 and families; however among military families increased at end of 2002 and increased “dramatically” during the beginning of 2003.increased “dramatically” during the beginning of 2003.

A study of the Army Central Registry found that maltreatment occurred more A study of the Army Central Registry found that maltreatment occurred more frequently at home while soldiers were engaged in combat-related deployments frequently at home while soldiers were engaged in combat-related deployments (Gibbs et al., 2007)(Gibbs et al., 2007)

“Understanding the Impact of Deployment on Children and Families.”

Findings from a Pilot Study of Operation Purple Camp Participants

Chandram, Burns, Tanielian, Jaycox, and Scott (April 2008)

Rand Study: Center for Military Health Policy Research

Emotional Cycle Of DeploymentEmotional Cycle Of Deployment

Stage 1. Pre Deployment (varies)

Stage 2. Deployment (first month)

Stage 3. Sustainment (months 2 thru5)

Stage 4. Redeployment (last month)

Stage 5. Post-deployment

(3-6 months after deployment)

*based on 6, 8,12 month stable deployment Dayton Peace Accords 1995 Bosnia

Remedies for Negative Consequences by Stage of DeploymentRemedies for Negative Consequences by Stage of Deployment

Pre-DeploymentPre-Deployment Discuss responsibilities and expectations of each family member during the Discuss responsibilities and expectations of each family member during the upcoming deployment. Make plans and goals for family rather then “put lives on hold.” upcoming deployment. Make plans and goals for family rather then “put lives on hold.” Decreases likelihood of misperception and distortion.Decreases likelihood of misperception and distortion.

DeploymentDeployment Initiate plans made during pre-deployment> Continue family traditions and develop Initiate plans made during pre-deployment> Continue family traditions and develop new ones. Facilitate children’s understanding of the finite nature of the deployment by new ones. Facilitate children’s understanding of the finite nature of the deployment by developing timelines (as age appropriate)developing timelines (as age appropriate)

SustainmentSustainment Establish support system (extended family, friends, religious groups, family support Establish support system (extended family, friends, religious groups, family support groups, etc.). Communicate with deployed service member via email, phone, letters. Avoid groups, etc.). Communicate with deployed service member via email, phone, letters. Avoid overspending ,Spend sometime without children. overspending ,Spend sometime without children.

Re-DeploymentRe-Deployment Maintain routines. Make plans for homecoming but develop alternate plans in the Maintain routines. Make plans for homecoming but develop alternate plans in the case of changes of return time. Maintain realistic expectations of homecoming., try to dispel case of changes of return time. Maintain realistic expectations of homecoming., try to dispel high expectationshigh expectations

Post-DeploymentPost-Deployment Take time to communicate and get to know each other. Spend time talking to Take time to communicate and get to know each other. Spend time talking to each other . Take time to make decisions and changes in routines. Lower expectations Keep each other . Take time to make decisions and changes in routines. Lower expectations Keep plans simple and flexible. Don’t try to schedule too many things during first few weeks. plans simple and flexible. Don’t try to schedule too many things during first few weeks.

Adopted from Pincus et, al 2007 (Rand report 2008)Adopted from Pincus et, al 2007 (Rand report 2008)

Deployment Group Curriculum GoalsDeployment Group Curriculum Goals

Goal 1: To take the extreme emotional and behavioral responses about Goal 1: To take the extreme emotional and behavioral responses about deployment and mitigate these responses.deployment and mitigate these responses.

Goal 2: To change unhealthy coping to healthier responses.Goal 2: To change unhealthy coping to healthier responses.

Goal 3: To have participants understand that feelings about Goal 3: To have participants understand that feelings about deployment are understandable and normal. deployment are understandable and normal.

Goal 4: Focus on stay at home caregiver/parent is also part of the Goal 4: Focus on stay at home caregiver/parent is also part of the deployment cycle. deployment cycle.

Deployment Group Curriculum – 12 SessionsDeployment Group Curriculum – 12 Sessions

Session 1: Introduction and Deployment Session 1: Introduction and Deployment Session 2: Tell us about your deployed parent.Session 2: Tell us about your deployed parent. Session 3: Stress Session 3: Stress Session 4: DepressionSession 4: Depression Session 5: FearSession 5: Fear Session 6: Anger Session 6: Anger Session 7: Growing up in a military family Session 7: Growing up in a military family Session 8: What changes when dad/mother is deployed? Session 8: What changes when dad/mother is deployed? Session 9: Corresponding with deployed parent Session 9: Corresponding with deployed parent Session 10: Self-awareness/Self-expression Session 10: Self-awareness/Self-expression Session 11: Celebration of being an Army Brat Session 11: Celebration of being an Army Brat Session 12: Wrap upSession 12: Wrap up

Spouse Stressors During Spouse Stressors During Deployment PhaseDeployment Phase

Loneliness Loneliness reported by more than 85% of spousesreported by more than 85% of spouses Miss companionship and intimacyMiss companionship and intimacy Regret that the deployed service member misses Regret that the deployed service member misses

important eventsimportant events Two-thirds describe it as stressfulTwo-thirds describe it as stressful

0

10

20

30

40

50

20 months or more 10 - 19 months 9 months or less

Percent handlingloneliness“well” or “very well”

2008 Survey of Active Duty Spouses (ADSS 2008) and the 2008 Survey of Reserve Component Spouses (RCSS 2008)

Both surveys were paper-and-pencil and Web-basedADSS 2008 fielded March 21 – August 4, 200849K spouses of active duty members surveyed, weighted response rate of 28%RCSS 2008 fielded December 10, 2007 – March 26, 200854K spouses of Reserve component members surveyed, weighted response rate of 30%

Loneliness (90%)Safety of spouse during deployment (84%)Feelings of anxiety or depression (83%)Difficulty sleeping (79%)Household repairs, yard work, or car maintenance (75%)

ADSS: Effect Of Deployments On Spouses 2008 Summary Top 5 most common problems during spouse’s most recent deployment were:

Increase in stress level (94%)Loneliness (92%)Feelings of anxiety or depression (89%)Household repairs, yard work, or car maintenance (88%)Difficulty sleeping (86%)

RCSS: Effect Of Deployments On Spouses 2008 Summary Top 5 most common problems during spouse’s most recent deployment were:

Cycle of the At-Home Spouse

Pre-Deployment

Deployment

Post-Deployment

•Confusion

•Denial

•Resentment

•Planning

•Arguing

• Busier than usual

• Crying, loss of sleep/appetite

• Self-growth, independence

• Less angry, but lonely

• Apprehension

• Cleaning

• Dieting

• Excitement

• Worry

Children’s Reactions to DeploymentChildren’s Reactions to Deployment

Percent reported with “Moderate” to “Very serious” problems

0 5 10 15 20 25 30 35 40

Beh. Prob in school

Academic prob.

Distress over war rumors

Depression

Distress over media

Aggression

Concentration prob

Adjustment to one parent

Sadness

Fear about deployed parent

Source: 2004/2005 Survey of Army Families, U.S Army Community and Family Support Center (CFSC)

ADSS: EFFECT OF DEPLOYMENTS ON CHILDRENSummary of Findings66% of spouses reported they had at least one child ages 18 or under living withthem either part-time or full-time during their spouse’s most recent deployment

27% of spouses reported they had one child39% reported they had more than one childAverage age of child most impacted by deployment was 6.1 years old

Most impacted child’s positive emotional/behavioral changes in response todeployment were increased:Closeness to family members (48%)Degree of pride in having a military parent (39%)Level of responsibility (36%)Level of independence (33%)Closeness to friends (31%)

Most impacted child’s negative emotional/behavioral changes in response todeployment were increased:Fear/anxiety (64%)Problem behavior at home (57%)Level of anger about my spouse’s military requirements (46%)Level of distress over discussions of the war (42%)Problem behavior at school (37%)

RCSS: EFFECT OF DEPLOYMENTS ON CHILDRENSummary of Findings70% of spouses reported they had at least one child ages 18 or under living withthem either part-time or full-time during their spouse’s most recent deployment24% of spouses reported they had one child45% reported they had more than one child76% of spouses indicated their need for child care increased as a result of theirspouse’s deploymentAverage age of the child most impacted by deployment was 8.1 years old

Most impacted child’s positive emotional/behavioral changes in response to deployment were increased:Pride in having a military parent (66%)Closeness to family members (54%)Level of responsibility (37%)Closeness to friends (33%)Level of independence (31%)

Most impacted child’s negative emotional/behavioral changes in response to deployment were increased:Fear/anxiety (67%)Distress over discussions of the war (56%)Problem behavior at home (50%)Level of anger about my spouse’s military requirements (44%)Problem behavior at school (34%)

Children Coping Children Coping with Deploymentwith Deployment

0

20

40

60

80

100

Very well/Well Neutral Poorly/Very poorly

Source: 2004/2005 Survey of Army Families, U.S Army Community and Family Support Center (CFSC)

Infants & Toddlers

What are you going to see in the babies?

What are you going to do?

Behavioral Results

Inconsolable CryingWithdrawal from daily activitiesSleeplessnessLack of appetiteAnxietyPoor weight gainAggressive behavior in older

toddlers

Cycle for Preschoolers

Post-Deployment

Deployment

Pre-Deployment

• Confusion

• Sadness

• Surprise

• Guilt

• Behavior

problems

• Separation anxiety

• Feelings of abandonment

•“Father Hunger”

• Attempt to care for parent

• Afraid of parent

• Wants attention

• Clingy

• Anger

• Needs reassurance

Draw your family(Don’t forget the pets).

Draw your house.

Draw your bedroom.

Draw anything you know how.

Draw what you remember from the memorial or funeral.

Preschool Interventions

PredictabilityMedia ExposurePhysical & Emotional ComfortCommunicationOutside PlayTactile Experiences

Cycle for Elementary Ages

Pre-Deployment

Deployment

Post-Deployment

• Regression

• Guilt

• Angry outbursts

• Sadness

• Loneliness

• School problems

• Over-responsible to irresponsible

• Mom’s companion/Man of the house

• Toileting accidents

• Attempt to split parents

• Desires recognition

• Joy

• Anger

• Excitement

Common QuestionsCommon Questions

What is war?What is war? Do innocent people die?Do innocent people die? Will the terrorist attack our country?Will the terrorist attack our country? Who’s protecting Ft. Carson?Who’s protecting Ft. Carson? What is friendly fire?What is friendly fire? What is it like to be a soldier?What is it like to be a soldier? When is my parent coming back?When is my parent coming back? Who will take care of me if my parent dies?Who will take care of me if my parent dies?

What is war?

Answering QuestionsAnswering Questions

Ways to talk Ways to talk Assure them they are safe Assure them they are safe nownow

Brief, honest answersBrief, honest answers Focus on helping othersFocus on helping others

What to considerWhat to consider What they already knowWhat they already know Maturity levelMaturity level Their need for continual Their need for continual

reassurancereassurance

Elementary Interventions

•Letter Writing

•Drawing

•Pick your child up on time everyday

•Limit media exposure

•Share your feelings

•Listen to feelings

Cycle for Adolescents

Pre-Deployment

Deployment

Post-Deployment

• “I don’t care”

• Fear rejection

• Denial of feelings

• Anger

• Higher value on friends

• Independence

• Behavior changes

• Socially withdrawn

• Sadness/Anger

• School problems

• Behavior problems

• Relief

• Defiance

• Resentment

Kelso: Therapy Dog

Narrative Story Telling : Princess RachaelNarrative Story Telling : Princess Rachael

Adolescent Interventions

• Decrease the violence in their world

• Model appropriate anger management skills

• Encourage an active role

• Be available

• Separate people from events

Lehman, D.H., Cozza, S.J., M.D. Deceased Military Members and the Families of the Fallen In: Ritchie EC, ed. Combat and Operational Behavioral Health. In: Lenhart MK, ed. Textbooks of Military Medicine. Washington, DC: Department of the Army, Office of the Surgeon General, Borden Institute; in press.

Reactions to Death and Trauma

Developmental Concepts of DeathDevelopmental Concepts of Death

2-4 years2-4 years - death seen as abandonment- death seen as abandonment

- seen as reversible- seen as reversible

- aware of altered pattern of care- aware of altered pattern of care

4-7 years4-7 years - concerns of guilt- concerns of guilt

- feels responsible because of - feels responsible because of thoughtsthoughts

- violent or symbolic play- violent or symbolic play

7-11 years 7-11 years - beginning to see death as final- beginning to see death as final

- see death as punishment- see death as punishment

- concerned with others- concerned with others

- suicidal thoughts- suicidal thoughts

Why a military death is differentWhy a military death is different

Military Culture and a lack of understanding by othersMilitary Culture and a lack of understanding by others Absence of deployed parentAbsence of deployed parent Death notification Death notification The loved one’s remainsThe loved one’s remains Military funeralsMilitary funerals Media attention and political protestersMedia attention and political protesters Isolation from military communityIsolation from military community Return of dads unit/ unit of friendsReturn of dads unit/ unit of friends Tension between pride and emotions of grief/ heroes. Tension between pride and emotions of grief/ heroes.

The results of war…OIF/OEF/GWOTThe results of war…OIF/OEF/GWOT

Self Inflicted WoundsSelf Inflicted Wounds Sexual Assault Sexual Assault SuicideSuicide Handling dead bodies and body partsHandling dead bodies and body parts Combat Stress/ PTSDCombat Stress/ PTSD Physically being injured/Traumatic Brain InjuryPhysically being injured/Traumatic Brain Injury Multi-causality incidents (IED, ambush, sniper)Multi-causality incidents (IED, ambush, sniper) Death of Children and WomenDeath of Children and Women Mass GravesMass Graves Witness death /injury of a close friendWitness death /injury of a close friend Feeling trapped /unable to defend or counterattackFeeling trapped /unable to defend or counterattack Multiple deployments increase odds of exposure to Multiple deployments increase odds of exposure to

traumatic eventstraumatic events

Combat Stress ReactionsCombat Stress Reactions

Numbing of emotional responsesNumbing of emotional responses Reduced awareness of one’s environmentReduced awareness of one’s environment DerealizationDerealization DepersonalizationDepersonalization Dissociative amnesiaDissociative amnesia Intrusive thoughtsIntrusive thoughts Avoidance behaviorsAvoidance behaviors InsomniaInsomnia Concentration deficitsConcentration deficits IrritabilityIrritability Automatic arousalAutomatic arousal

Wrap Up

Questions

Contact information:

Doug Lehman, LCSW, CAC IIIDepartment of Behavioral HealthSocial Work Service, Ft. Carson, CO 719-526-4585Douglas.Lehman@amedd.army.mil