Stress and Distress in Military Children Heather Johnson, Lt Col, USAF, NC, FNP-BC Acknowledgments:...

Stress and Distress in Military Children

Heather Johnson, Lt Col, USAF, NC, FNP-BCAcknowledgments:

Diane Seibert, PhD, CRNPLorraine Masse, CPT, USAN, BSN

1

Conflict of Interest

• I have no conflict of interest to report.

2

Objectives

1. Discuss factors associated with military service that impact the behavior of military children– Review the different impact of Active Duty, Guard

and Reserve components

2. Identify manifestations of stress and distress in children

3. Differentiate manifestations of stress by age group

3

Objectives4. Describe the positive effects of the military

experience on children5. Discuss implications for adults who work

with military children

4

Military 101

General Concepts

5

Military 101

• The Department of Defense– Army– Navy

• Marines• Coast Guard and Coast Guard Reserve

– Air Force– Reserves and the National Guard

• All volunteer force

6

Military 101

• Active duty military– Most live on or near a military base– Immersed in military culture– Have ready and immediate access to military

support systems such as health care, family support centers, and a community that is familiar with their unique culture.

7

Military 101

• Reserve and National Guard– Our “citizen soldiers” – Live and work in civilian communities across

the country– They do not have ready access to military-

specific support mechanisms • often do not live near military installations

8

Military 101

• Children of the Guard/Reserve– When Reservists or Guard members are called to

active duty• they and their families may need to deal with changes

to income, child care, and medical insurance. • Children and families must become “suddenly

military” when a parent is activated*

*activated- called up to serve on active duty

9

Military 101

• Children of Guard/Reserve Families• May be the only children in their schools or

communities who have a military parent • May not have had prolonged separations before• Do not have the same support resources as their active

duty counterparts• May not have established a sense of being a military

family member

10

Military Terminology

Deployments

11

Military Terminology• Deployment

– The short-term assignment of a military member to a combat or noncombat zone

– 1 to 15 months– Can be routine, planned, or unexpected

• Deployment cycle– Recurrent deployment and redeployment*

pattern that occurs over the career of a military service member

12

*redeployment-return from deployment

Military TerminologyDeployment

• Also the name given to the movement of an individual or military unit– Either within the United States or to an overseas

location to accomplish a task or mission. – May be routine (providing additional training) – May be dangerous (such as going to war)

13

Military TerminologyDeployment

• Three phases of deployment– Pre-deployment

• Preparing to go (may take 3-6 months)– Training, preparation of the individual and the unit,

packing, etc

– Deployment (1 to 15 months)• Actual movement to the duty location

– Post-deployment• Coming back from deployment

– Reintegrating with family and unit, resting, recuperating,

14

Military Statistics

• 2.2 million service members in Active Duty (AD), Guard and Reserve– 32% smaller than 1990 Operation Desert Storm– ~ 1.9 million children have at least one parent

in the military– 1.6 million service members have served at

least 1 tour in Iraq or Afghanistan• 34% served more than 1 tour (some up to 8 tours)

– Operation Iraqi Freedom/Operation New Dawn/Operation Enduring Freedom

15

Military Terminology Statistics as of Jan 31, 2011 (since 9/11)

• Iraq– Deaths 4422– Wounded in action 32,012

• Afghanistan– Deaths 1437– Wounded in action 9971

• Total deaths 5859• Total wounded 41,983

16

http://siadapp.dmdc.osd.mil/

The Military Family

Statistics, Rank, Occupations, and Transitions

17

Military Family

• 58% of military service members have family responsibilities– 40% have 2 children

• By age 5- 40% of kids affected by deployment

• 30-50% relocate to hometowns to seek support from extended family– Those with school age kids tend to stay put

18

Military Family

• 95,000 Dual military families• 74, 000 single parents• 102,000 families with CSHCN (child with

special health care needs)• Guard/Reserve not usually co-located with

a base

19

Military Rank

• Rank Structure– Commissioned officers

• Leaders/managers• Have a bachelor’s degree or higher

– Noncommissioned officers (NCO)• The senior enlisted managers• HS diploma to Bachelor’s degree or higher

– Enlisted• HS diploma for entry

» Generally higher education than overall civilian population

20

Military Occupations

• Military occupational specialty– Often correlates with potential for combat

deployment and injury• Security forces• Infantry• Special forces• Medical

• *All have equal access to healthcare

21

Military Transitions

• A little more terminology– TDY or TAD- temporary duty or time away– PCS- permanent change of station (move)

• Military families move every 2-4 years• Some children attend 8 or more different schools• Affects continuity of care

– Deployment– Humanitarian deployment- provide support for

disaster relief (e.g. Haiti, Somalia)– Combat deployment- wartime operations

22

Stress, Distress and Resilience in Military Children

23

Definitions (Literature)

– Adolescent ~12-18– Children ~5-12– Young children < 5– Children with special health care needs (CSHCN)

or Autism Spectrum Disorders (ASD)

24

RECOGNIZING STRESS AND DISTRESS

25

Interpersonal, behavioral, physical, and developmental

– Internalizing behaviors– Externalizing behaviors– Somatic signs and symptoms– Changes in academic performance

26

Internalizing behaviors

• Emotions that are turned inward– Withdrawn– Lonely– Anxious– Depressed– Low self-perceptions (self-esteem)

• Can be in multiple domains

– Shyness

27

Externalizing behaviorsEmotions that are turned outward

• Aggressive• Impulsive• Distractible• Coercive• Delinquency

“Acting out”

• Hyperactivity• Drug/alcohol use• Defiant• Temper tantrums

28

Physiologic/Somatic Signs

• Elevated heart rate• Elevated systolic BP• Appetite changes• Nightmares

• Sleep disturbance• Others may include

– GI upset– Headache– Neck/back pain– Jitteriness

29

The Military Family

Vulnerable yet exceptional

30

The Military FamilyFrequent Moves

• Negative– Disruption of family, social network– Students change schools– Teachers PCS or deploy

• Positive– Broader perspective toward people and cultures– Child can “recreate” him/herself– More moves resulted in higher participation in

social activities

31

The Military FamilyFrequent Moves

• Repeat combat deployments• Media

– Coverage of wartime events challenging• Resilience of the military child and family

– More frequent relocation experience equals better child adjustment

32

Characteristics of the Military Member

• Military combat soldiers– Expected to be aggressive and violent when

deployed– Hyper-aroused, hyper-vigilant

• Expected to turn those characteristics off when return

33

Post-traumatic stress

• Post-traumatic stress– Acute

• Post-traumatic stress disorder– Chronic, dysfunction

34

General Findings

35

Support

• Most families/children/SM do well • Most families feel supported overall (82%)

– Military groups and organizations (64%)– Church (48.5%)– Nonmilitary groups and organizations (25%)

• Including schools

– Non-local family (22%)

36

Child Psychosocial Functioning• 1/3 of military children are at high risk for

psychosocial morbidity • Caregiving parent stress

– Significant predictor of child psychosocial functioning

– Affects perceptions of child psychosocial functioning

37

Child Psychosocial Functioning• Feeling supported overall positively

predicted child functioning– Military, family, peer, church, school and

community support – Feeling supported is key to promoting healthy

behavior– Non-local family was not a significant predictor

38

Demographic Predictors• Parental level of education• Age• Enlisted rank• Duration of marriage <5 yrs• The gender of the deployed service

member

39

Family Cohesiveness• High family cohesiveness

– Less aggression– Fewer issues of noncompliance– Higher self-esteem in children

40

Negative Behaviors

• Diminish over time

41

Cumulative Impact

• Impact of combat deployment on children tends to accumulate

• ADSM may be deployed for half of a child’s life

• More months of combat deployment= greater impact on child

• Living on base = fewer problems

42

Cumulative Impact

• High stress/distress in the family– May affect decision to re-enlist or stay in the

military– Consider divorce

43

Cumulative Impact

• At home caregiver– Increased stress and anxiety – Fatigue

• Especially when caring for young children

– Concern about spouse’s safety– Loneliness– Trouble keeping house up– Dealing with child behavior– Finances

44

Effect of the Media

• Children >3 years old– at risk of developing depressive symptoms or

more prone to externalizing behaviors

45

Changes at Home

Risk in the Home

46

Abuse/Neglect• Onset of intensive conflict in Middle East

(2002-2003)– Rates of substantiated abuse/neglect in

military families doubled – Consistently higher ever since

• Highest rates in children < 4 yrs of age– Rates decreased with increasing age

47

Abuse/Neglect• Neglect, physical, emotional or sexual

abuse– US Army enlisted soldiers– 42% higher during combat deployments– Linked to departure and return– Female civilian caregiver increased, male did

not– Neglect more common than abuse

48

Domestic Violence

• Deployment, reunification• Domestic violence and child maltreatment• Increased risk

49

Risk

• Most families cope well• We need to watch for those at risk for not

coping well

50

Effects of Combat Injuries

51

Nature of Military

• Very private• May not tell you there are visible or invisible

injuries• And children may not want to bring attention

to themselves

52

Effect is on the whole family

• Parental injury– Observable injuries– Traumatic Brain Injury (TBI)– Post Traumatic Stress Disorder (PTSD)

• Difficult transition for children• Effect on social skills• Behavior problems in school

53

Developmental Risk Factors (Theoretical)

– Attachment problems– Brain development– Emotional dysregulation– Cognitive, emotional or developmental delays– MH or behavioral problems– Other health concerns

54

Effects of combat injuries

• TBI– Problematic behavior changes in children

55

Effect of Poor Family Cohesion/Coping

• High reported family stress/distress prior to deployment

• Significant disruption post injury• Higher rates of family/child stress and distress

post-injury

56

Reserve/Guard

• May largely deal with these problems on their own

• Fewer supports available than in military communities

57

Psychological casualties

• “For the first time in history, the number of psychological casualties exceeds those who die in battle or who are physically injured.”(McFarlane, 2009)

58

Psychological casualties

• Interpersonal consequences – May be reflected in injured or by their children– Social withdrawal– Emotional numbing– Lack of empathy– Irritability – High risk group

59

Military Children in School

Literature

60

Study of School Personnel Schools with AD/G/R Children

• School personnel perceive that kids are coping well

• In fact, kids reported they were dealing with a range of deployment issues

• Affected their ability to function in school

61

School personnel concerns

• Student uncertainty about deployment length• Perceived mental health issues of the non-

deployed parent– Contribution to difficulties at school

• Children from Guard/Reserve families– Lacked the social support network within their

school (peers) who understood the military experience

62

The Adolescent

Special Populations

63

The Early Adolescent 11-14 Domains of development (Bright Futures)

• Physiological- puberty, growth, menarche

• Psychological- – concrete thought, questioning independence, parental controls

remain strong, preoccupation with body changes, sexual identity,

• Social- – search for same-sex peer affiliation, good parental relationships,

other adults as role models, sensitivity to differences between home culture and culture of others, transition to middle school, involvement in extracurricular activities

• Potential problems- – school problems, psychosomatic concerns, depression, unintended

pregnancy, initiation of alcohol, tobacco or other drugs

64Bright Futures, 2008

The Middle Adolescent 15-17 Domains of development (Bright Futures)

• Physiological- Ovulation, growth spurt• Psychological

– Competence in abstract and future thought, idealism, sense of invincibility or narcissism, beginning of cognitive capacity to provide legal consent, sexual identity

• Social– Begin emotional emancipation, increased power of peer group,

conflicts over parental control, risk-taking behavior, cultural conflict between values of peers, family and culture, transition to high school, reduced involvement in extracurricular activities

• Potential problems– Experimentation, unintended pregnancy, conflicts with parents,

poor eating or disordered eating, decreased physical activity.


General Experiences

• By age 17, military youth have attended an average of 5 schools– Some outside of Continental U.S. (CONUS)

• Develops resiliency and coping skills• Limits access to high-risk behavioral influences

66

RISK-TAKINGMilitary Adolescent

67

Susceptibility to risky behaviors

• Multiple relocations• Changes in peer groups (+ or -)• Separation from peers and family• Worry about loved one• Loss of a loved one

68

Sexual activity

• Adolescents presenting to MTF health clinics– 30% vs 46-51% in general population– Prolonged paternal absence may increase risk for

sexual activity (especially in girls) and teen pregnancy

69

Substance abuse rates

• Far below national average– Alcohol 21% vs 45% Ntl– Tobacco 5% vs 22% Ntl– Marijuana 8% vs 22.4% Ntl

• Except 12th grade males 20% vs 26-30%

70

Difference is more than demographic

• Military adolescents averse to risk-taking– Access to confidential services– Environment shared by military families

• Atmosphere of change and community

– Resilient peer group– Parents with job security– Relocation away from destructive peer groups– Parental deployments and risk association

71

Effect of age on risk-taking behavior

• As age increased– More difficulties in academic engagement– Fighting and drinking – More problems with reintegration

• BUT– Peer functioning improved– Anxiety decreased

72

PEER RELATIONSHIPSMilitary Adolescent

73

Peer relationships

• Difficulty in peer relationships– Results in low self-esteem– Higher fear of negative evaluation by peers– Social avoidance and distress– Loneliness

• Longer time at the current address– Better peer relationships– Less loneliness

74

General issues

• Difficult forging new relationships on PCS• Academic issues• Emotional/behavioral adjustment• Differing family roles and responsibilities

75

IMPACT OF DEPLOYMENTMilitary Adolescent

76

Pre-deployment

• Fear that caregivers won’t be able to adequately care for them

• Ineffective coping– Crying, temper tantrums

77

Deployment• Mixed emotions• Angry, sad, numb, alone• Sleep difficulties, anxiety, ineffective coping• Poor diet• Lack of exercise• Changes in academic performance

78

Deployment

• Interaction with peers• Somatic complaints • Added roles and responsibility• Uncertainty, loss, boundary ambiguity• Relationship conflict

79

Redeployment (Reintegration)

• Intense anticipation• Excitement, bursts of energy, difficulty making

decisions• Fear of homecoming due to changes in routine

or expectations • Fear loss of independence

80

Post-deployment

• Reunion can be difficult for both parent and child– Hard to respond to discipline from returning

parent– Fear of changes to routine – Re-establishing old models of discipline and

caretaking

81

Experience of the Adolescent Caregiver

• Deployment – Anxiety, strain, tension during deployment– Excessive stress interferes with caregiver-child

relationship• Return from deployment

– Resentment as returning parent begins to “reengage” with the family

82

Risk Factors/Predictors

• Psychosocial vulnerability is not inevitable• Family cohesiveness and mother-child

relationships– Critical to psychosocial adjustment of child– Strong relationships= Better resilience– Ineffective coping skills of adolescent and

caregiving parent= Poor functioning

83


• Deployed mother leads to significant increase in risk-taking behavior

• Pre-existing emotional problems in caregiving parent or child leads to poor psychosocial functioning

• Parents with poorer mental health reported more child difficulties during deployment

84

Support

• Pets • Strong coping skills• Reservists

– Family support groups• Help with boundary ambiguity

– Tend to re-stabilize once parent home and back at work

• Living in base housing (support)• Parental employment outside the home

85

Children

Ages 5-12

86

Problem behaviors

• Often lower between the ages of 2-12 – Modulated by

• Level of adult supervision• Self-exploration during development

• Increase during adolescence

87

Middle Childhood (5-12)

• Development – Self– Family– Friends– School– Community

88

Bright Futures, 2008

Self

• Self-esteem– Experiences of success– Reasonable risk-taking behavior– Resilience and ability to handle failure– Supportive family and peer relationships

• Self-image– Body image– Physical changes associate with development


Family

• What matters at home:– Consistent expectations and limit setting– Family time together

• Family meals

– Communication– Family responsibilities– Family transitions– Sibling and caregiver relationships


Friends

• Making friends• Family support of friendships


School

• Consistent expectations for school performance• Homework• Building relationships with teachers

– Managing conflict• Parent-teacher communication• Addressing cultural needs in the school• Negative Impact

– Aggression, bullying, and victimization– Absenteeism


Community

• Community organizations• Religious groups• Cultural groups


Potential High-Risk Behaviors

• Substance use• Unsafe friendships• Unsafe community environments

94

Anxiety

• 1/3 clinically significant anxiety– Regardless of deployment status – 32% exceed cutoff for “high risk” anxiety levels

• 2.5 times the national norm

• Cumulative length of parental deployment and parental distress– Correlate with child depression and

externalizing behaviors

95

Children (5-12 years)

– Difficulty sleeping- 56%– Attention concerns- 13%– School related- 14%

• Dropping grades• Decreased interest in school • Teacher conflict

96

Impact on Girls 5-12

• AD parent deployed– Increase in externalizing behaviors

• And not internalizing behaviors

– Resolves on return of parent – Problems with reintegration– Girls more likely to have problems with the

deployment than boys

97

Impact on Boys 5-12

• Increase in externalizing behaviors when AD parent returns

• Man of the house

98

Single study result

• Fort Lewis and Camp Pendleton– No elevations in depression, internalizing or

externalizing behaviors compared to community norms

– Limitation: very few E1 to E4 outcomes

99

Caregiver experiences

• Anxiety– ¼ of parents with a deployed spouse– Decreased on reintegration

• Care-giving parent distress– 42% had high levels of stress

• significantly higher than national norm

– Correlates with child symptoms • Employment and higher education

– Correlated with significantly less parenting stress 100

Caregiver experiences

• As the number of combat months deployed increased– stress and distress of at-home caregiver increased

101

Impact of parent-child relationship

• If parent perceived their child as “difficult”– Reported more dysfunctional interactions

• 19% exceeded “at risk”

102

Impact of parent-child relationship

• If parent perceived their child as “difficult”– Reported more dysfunctional interactions

• 19% exceeded “at risk” for maltreatment• Neglect and maltreatment

– 55% exceeded at risk on at least 1 of 3 measures– 10% on all 3 measures– Only 6% would be considered “high risk” for

neglect and maltreatment

103

Children of parents with PTS

• Exhibit externalizing (but not internalizing) behaviors

104


• Mental health and coping of parents– Correlates with adjustment of child

105

Incidence of Mental and Behavioral Health Issues

• There is an 11% increase in outpatient visits for mental and behavioral health issues during a parent’s deployment – Despite overall 11% decrease in outpatient visits

during deployment – 18-19% increase in behavioral and stress disorders– Stressed parents must prioritize which conditions

warrant an outpatient visit

106

Incidence of Mental and Behavioral Health Issues

– Older children and children of married parents had more outpatient mental and behavioral health visits

107

The gender of the deployed member makes a difference

– Male member deployed• Increased outpatient visits

– Female member deployed• Decreased outpatient visits

– Combination of factors• Gender-specific differences in the behavioral

response of children to deployment – Recognition of child issues during deployment– Difficulty in bringing issues to professional attention

108

Children

109

Young Children <5

110

Special PopulationsYoung Children (<5 years)

• Growth and Development – Based on developmental milestones– Gross motor– Fine motor– Cognitive, linguistic, and communication– Social-emotional


Child Case Study

112

Behavior Changes

• No single, simple effect• Increased behavior problems usually begin at

deployment– Behavior changes

• increase by number of deployments • number of months deployed

• Attachment problems occurred at reunion– Worsened with each successive deployment

113

Behavior Changes

• Associated with individual child factors– Temperament

• “Anxious”, “difficult “ had more problems

– Pre-deployment attachment– Pre-deployment behavior– Age of the child

114

Age Differences and Deployment

• Infants have fewer behavioral changes than older toddlers and pre-schoolers

• Children age 3-5 tend to have more externalizing behaviors

115

Frequent Relocations

• In young children, frequent relocations increases behavior problems– Disrupts parent and child routine, social

relationships– Worse if relocate right before or right after a

deployment

116

During deployment

– Need lots of attention– Clingy– Increase in temper tantrums– Asks lots of questions about the deployed parent– Attempts to control things– Defiant, disobedient, argumentative– Appetite changes– Prolonged crying– Sleeping problems/nightmares

117

Reunion/reintegration

– Won’t sleep in their own bed– Prefers non-deployed parent or caregiver– Doesn’t want returning parent to leave the house– Ignores returning parent– Won’t let returning parent comfort him/her

118


• Child– Personality- flexible, cooperative– Disposition– Positive mood– Parent support- warmth and family cohesion– Community support- strengthens coping, provides

role models

119

Parent Perception as a Predictor

• Parents who report being stressed– Report that their children are stressed– Report more attachment problems in their

children on reintegration

120

Children with Special Health Care Needs (CSHCN)

121

CSHCNDevelopmental issues

• CSHCN– Have same developmental goals and milestones as

other children– Additional issues in achieving those goals

122

CSHCN Additional Developmental Issues

• Making friends and friendships with peers with and without special needs

• Family support to have typical friendship activities

• Parent-teacher communication• Addressing cultural needs in the school• Aggression, bullying, and victimization• Absenteeism

123

CSHCNDevelopmental issues

• Available community organizations• Risk-taking behaviors• Easily victimized

124

Incidence

• 23% of families report having a child with a health need that will last at least 1 yr– 9% need Rx (asthma, diabetes, epilepsy)– 14% need services (medical, mental health, or

educational services; special therapies; or treatment or counseling)

– 11% require special medical, mental health, or educational services

– 5.5% have functional limitations125

Healthcare Needs

– 5x’s as many admissions– 10x’s as many total days in the hospital– 2x’s as many outpatient visits

• Average 19 visits per year– Many visits are related services (MH, Speech, OT, PT)

126


• Autism in general population 1:110– In military 1:88 *

• Why the higher rates of CSHCN in the military?– Partially due to insurance recognition and

coverage for services

127* Exact number not known


• In general population– Elevated incident of abuse and neglect– Divorce rates >2x that of typical children

• Disruption in family cohesiveness• Inadequate coping skills

128


• Some AD members are concerned about the stigma of having a CSHCN– Particularly those with severe MH problems– Concern about effect of limited duty options

(EFMP)– Ability to stay in military

129

Coordination of Care• Opportunities for improvement

– Coordinating moves for military families of CSHCN

– EFMP looks to see if services are available in community

• May not be covered by TRICARE

130

Parental Stressors• Find providers who accept insurance• Get on waiting lists for services

– Referrals for specialty services lapse• Getting the child in the right school• Uncover benefits, providers and services

• ECHO and other insurance benefits• Specialty services (e.g. dentists who work with

children with Autism)

131

CSHCN

• Many typical military children have trouble when a parent deploys for a long period of time– it may be even harder for a child who cannot

communicate his or her feelings or just doesn’t understand where his or her parent went.

– every child reacts differently to differences in family dynamics

– may see significant developmental regression– Catch 22

132

What can school nurses do?Predeployment

• Identify potential units/families approaching deployment

• Discuss with family plans for the child during deployment

• Anticipatory guidance- emotional, physical and psychological needs– Local/base/community/religious resources– Peer groups

• Ensure health records of child up to date133

What can school nurses do?Deployment

• Inform applicable school personnel of parental deployment

• In-service regarding needs of children/caregivers

• Follow-up on support resources• Discuss home and personal safety strategies for

child and caregivers• Monitor child and caregiver during deployment

134

What can school nurses do?Re-deployment

• Anticipate homecoming• Monitor child and caregiver emotions

– Assess need for emotional/psychological support• Notify applicable personnel of impending

return– Help family celebrate the return

• Monitor child’s attention to school work, ADLs

135

What can school nurses do?Postdeployment/reintegration

• Assist family in transition– Anticipatory guidance- potential changes in

roles/responsibilities/discipline– Direct to resources that can assist during transition– Reorganization of family roles and living

arrangements• Monitor coping

– Assess family health/risk– Need for intervention

136

Family Support

• Most support needed during transitions– Deployment and upon reintegration– Targeted support– Before and after PCS

• Increases vulnerability, worsens peer functioning (KFA)

• Support for families with traumatic injuries• Highly stressed families have a hard time

participating in organized interventions

137

School Environment

• A strong school environment provides established routine and structure– Minimizes child stress– A positive school climate improves academic

performance– Influences emotions and student behavior

• Identify and intervene in families at risk

138

Role of the School

• Provide support for military families– Emotional and social support

• Staff training to recognize problems• Give children a forum to discuss deployment

related issues and stressors• Put children/families in touch with resources

and a peer support network

139

References

• Barker LH, Berry KD. Developmental issues impacting military families with young children during single and multiple deployments. Mil Med 2009;174:1033-40.

• Chandra, A., Lara-Cinisomo, S., Jaycox, L. H., Tanielian, T., Burns, R. M., Ruder, T., et al. (2010). Children on the homefront: the experience of children from military families. Pediatrics, 125(1), 16-25.

• Chandra A, Martin LT, Hawkins SA, Richardson A. The impact of parental deployment on child social and emotional functioning: perspectives of school staff. J Adolesc Health 2010;46:218-23.

140

References• Chartrand, M. M., D. A. Frank, et al. (2008). "Effect of

parents' wartime deployment on the behavior of young children in military families." Arch Pediatr Adolesc Med 162(11): 1009-1014.

• Cozza, S. J., J. M. Guimond, et al. (2010). "Combat-injured service members and their families: the relationship of child distress and spouse-perceived family distress and disruption." J Trauma Stress 23(1): 112-115.

• Fitzsimons VM, Krause-Parello CA. Military children: when parents are deployed overseas. J Sch Nurs 2009;25:40-7.

141

References

• Flake EM, Davis BE, Johnson PL, Middleton LS. The psychosocial effects of deployment on military children. J Dev Behav Pediatr 2009;30:271-8.

• Gibbs, D. A., S. L. Martin, et al. (2007). "Child maltreatment in enlisted soldiers' families during combat-related deployments." JAMA : the journal of the American Medical Association 298(5): 528-535.

• Gorman, G. H., M. Eide, et al. (2010). "Wartime military deployment and increased pediatric mental and behavioral health complaints." Pediatrics 126(6): 1058-1066.

142

References• Gorman LA, Fitzgerald HE, Blow AJ. Parental combat injury

and early child development: a conceptual model for differentiating effects of visible and invisible injuries. Psychiatr Q 2010;81:1-21.

• Hagan JF, Shaw JS, Duncan PM. Bright futures : guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

• Hartley, S. L., Barker, E. T., Seltzer, M. M., Floyd, F., Greenberg, J., Orsmond, G., et al. (2010). The relative risk and timing of divorce in families of children with an autism spectrum disorder. Journal of family psychology, 24(4), 449-457.

143

References• Hutchinson, J. W. (2006). Evaluating risk-taking behaviors

of youth in military families. J Adolesc Health, 39(6), 927-928.

• Kelley, M. L., Finkel, L. B., & Ashby, J. (2003). Geographic mobility, family, and maternal variables as related to the psychosocial adjustment of military children. Mil Med, 168(12), 1019-1024.

• Kelley, M. L., E. Hock, et al. (2001). "Internalizing and externalizing behavior of children with enlisted Navy mothers experiencing military-induced separation." Journal of the American Academy of Child and Adolescent Psychiatry 40(4): 464-471.

144

References

• Klein DA, Adelman WP. Adolescent pregnancy in the U.S. military: what we know and what we need to know. Mil Med 2008;173:658-65.

• Lamberg L. Redeployments strain military families. JAMA 2008;300:644.

• Lemmon KM, Chartrand MM. Caring for America's children: military youth in time of war. Pediatr Rev 2009;30:e42-8.

145

References

• Lester P, Peterson K, Reeves J, et al. The long war and parental combat deployment: effects on military children and at-home spouses. J Am Acad Child Adolesc Psychiatry 2010;49:310-20.

• Lincoln A, Swift E, Shorteno-Fraser M. Psychological adjustment and treatment of children and families with parents deployed in military combat. J Clin Psychol 2008;64:984-92.

• Manos GH. War and the military family. J Am Acad Child Adolesc Psychiatry 2010;49:297-9.

146

References

• McFarlane AC. Military deployment: the impact on children and family adjustment and the need for care. Curr Opin Psychiatry 2009;22:369-73.

• Newton A.W., & Vandeven A.M. (2010). Update on child abuse and neglect: A worldwide concern. Current Opinions in Pediatrics, 22(2), 226-233.

• Rentz, E. D., S. W. Marshall, et al. (2007). "Effect of deployment on the occurrence of child maltreatment in military and nonmilitary families." Am J Epidemiol 165(10): 1199-1206.

147

References

• Sansone, R. A., G. Matheson, et al. (2008). "Concerns about career stigma by military parents of children with psychiatric illness." Mil Med 173(2): 134-137.

• Ternus MP. Support for adolescents who experience parental military deployment. J Adolesc Health 2010;46:203-6.

• Weber EG, Weber DK. Geographic relocation frequency, resilience, and military adolescent behavior. Mil Med 2005;170:638-42.EGrelocad 2005;170:638-42.

148

References

• Williams, T. V., E. M. Schone, et al. (2004). "A national assessment of children with special health care needs: prevalence of special needs and use of health care services among children in the military health system." Pediatrics 114(2): 384-393.

149

Stress and Distress in Military Children Heather Johnson, Lt Col, USAF, NC, FNP-BC Acknowledgments:...

Documents

Transcript of Stress and Distress in Military Children Heather Johnson, Lt Col, USAF, NC, FNP-BC Acknowledgments:...