Psychiatric Quarterly, Vol. 76, No. 4, Winter 2005 (C ?2005)
MILITARY FAMILIES AND CHILDREN
DURING OPERATION IRAQI FREEDOM
COL Stephen J. Cozza, M.D., COL Ryo S. Chun, M.D.,
and COL James A. Polo, M.D.
The general public has become increasingly interested in the health and well
being of the children and families of military service members as the war in
Iraq continues. Observers recognize the potential stresses or traumas that this
population might undergo as a result of the military deployment or the possible
injury or death of military family members. While such concern is welcomed,
it is sometimes misplaced. Not infrequently, conclusions that are drawn are
fraught with misunderstanding and bias based upon lack of understanding of
the military community or a preconceived notion of the vulnerabilities of the
population. This problem is compounded by the paucity of scientific study. In
this article the authors review the strengths of military families as well as the
unique challenges that they face. The authors also highlight parental deploy-
ment, parental injury and parental death as unique stresses to military chil-
dren and families. Available and pertinent scientific information is reviewed.
Address correspondence to COL Stephen J. Cozza, M.D., Department of Psychiatry,
Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307-
5001; e-mail: email@example.com.
0033-2720/05/1200-0371/0 C ?2005 Springer Science+Business Media, Inc.
Clinical observations of children and families during the ongoing war in Iraq
KEY WORDS: military family; military child; military deployment; combat injury;
MILITARY AND NON-MILITARY CHILDREN
Depending upon the social and political climate of the country, military
children and families are often portrayed as stereotyped groups, rather
than the complex and heterogeneous populations that they are. As an
example, in the 1970’s Lagrone (1978) coined the term “military family
syndrome.” He used this term to describe a set of traits presumably
resulting from the noxious influence on children of growing up within
autocratic military families and communities (1). Much more likely the
result of post-Vietnam anti-military sentiment, this formulation was
not based on valid empirical support. More recently, Ryan-Wenger re-
ported findings that compared the children of active duty members,
reservists and civilians, and found no difference among the groups in
measures of anxiety or other psychopathology (2). An earlier study by
Jensen et al. actually reported fewer behavioral and emotional symp-
toms in the military child population they examined, when compared to
civilian counterparts (3). In many ways military children and families
appear to be a robust and healthy group. However, this is not to say that
they are invulnerable to the stresses that war or trauma may bring.
Current concerns related to military children, as a result of the war
in Iraq, focus on three principal areas of wartime stress: deployment
of military parents; injury or illness of military parents; or parental
deaths. Increasing interest and concern is being raised about the im-
pact of the war on military families and potential pathological sequelae.
It would be destructive to assume either widespread pathology or uni-
form resilience as a result of these wartime experiences. Drawing such
conclusions without supporting data would indicate again the intru-
sion of inappropriate social and political agendas on scientific process.
The war in Iraq provides an unprecedented opportunity to study these
Separation of military members from their families during peacetime
has been an increasingly common experience for military families,
particularly for active duty families. With the onset of the war in Iraq,
STEPHEN J. COZZA, RYO S. CHUN, AND JAMES A. POLO373
reserve and National Guard families have had increasing experience
with deployments, as well.
A number of studies have looked at the impact of parental deploy-
ment on military children during both peacetime and wartime. One
study examining the impact of father absence on children during non-
wartime deployment described increases in anxiety and depression in
the study group children when compared to non-deployed controls (4).
Pathological responses were more directly related to the effect of mater-
nal psychopathology or other family stressors as mediating variables.
Most wartime deployment studies were conducted during Operation
Desert Storm (ODS), a conflict that was relatively short lived and re-
sulted in fewer casualties and deaths in comparison to the current war
in Iraq. In at least two of these studies, moderate increases in internal-
were deployed to combat areas (4,5). Of note, Rosen reported that those
children who actually demonstrated increases in symptoms rarely re-
quired clinical attention and those that did were more likely to have a
past history of mental health treatment (4). Kelly further found that
families of those deployed to combat areas demonstrated less cohesive-
ness than the control families of service members who were deployed
to non-combat areas (5).
At the outbreak of ODS Jensen took the opportunity to compare data
in a population of children that were involved in an ongoing study (7).
As initial ratings had been completed prior to ODS deployment, the
investigators were able to prospectively evaluate the impact of wartime
deployment by comparing follow-up ratings between a wartime de-
ployed group and the children of those who did not deploy. Similar to
previous studies the authors measured increased levels of depression
and anxiety in the children of the deployed group. These symptoms did
not reach pathological levels, however. The authors also highlighted
the important finding that boys and younger children appeared to be
at higher risk for complication.
Peebles-Kleiger and Kleiger argued that deployment during wartime
should be considered a “catastrophic” stressor to children and families,
suggesting that wartime deployment would be traumatic in most or
all circumstances (8). While these conclusions may be overstated, the
troubling than routine, non-combat deployments is realistic.
INJURIES AND PSYCHIATRIC ILLNESS OF PARENTS
There are few objective data that help us in our understanding of the
impact on children of injury to military parents during wartime. The
374 PSYCHIATRIC QUARTERLY
authors’ experiences during the current war in Iraq suggest that the
impact is likely to be considerable in certain cases, although risk factors
for vulnerability can only be postulated.
Scientific interest begins with the process of family notification of in-
jury. While there have been improvements in this system of notification
(e.g. often the injured service member is the individual who contacts a
spouse or other family member), it is not uncommon that initial infor-
to greater anxiety. Once notification has been made, intense activity
typically follows. Such activity may lead to disruption of the family
schedule or structure. Spouses often join the injured service members
who are likely receiving treatment at military hospitals distant from
the family home. This may require that children either be left under
the supervision of other adults (either at home or at the home of other
family members or friends) or be uprooted to join parents at the hospi-
tal. Either option is likely to be unsettling, resulting in disruptions of
schedules and relationships, as well as potential alterations in parental
empathy, structure or discipline. Children who travel to hospitals will
miss school and may move into treatment environments that are not
prepared to meet the needs of younger family members. Of the utmost
importance is that children be properly prepared before visiting the
hospital to handle whatever clinical situation that they will face when
visiting an injured parent. This is crucial when the injury is disfiguring
or is of significant severity, such as amputation.
The nature of the information that parents share with children may
or may not be developmentally appropriate and may be based more
on the anxieties of parents, rather than the needs of the children. Not
infrequently parents may choose to share either too much or too little
information with children, making it difficult for them to understand
the nature or seriousness of the injury and its realistic implications for
the injured parent. The following clinical vignette provides an example.
that occurred while he was driving in Iraq. He has two sons ages 7 and 8 who live
with a former spouse. SGT R says that since the injuries were not sustained in
battle he could not share the news of his injury with his sons for fear that he might
disappoint them. SGT R stated that his boys continue to view him as a “war hero”
so he chose to share no information about this non-combat caused injury.
This example shows how the meaning of an injury may keep a par-
ent from sharing appropriate amounts of information related to the
injury with a child. In the experience of the authors, several soldiers or
their spouses have made the decision to withhold information related
STEPHEN J. COZZA, RYO S. CHUN, AND JAMES A. POLO375
to serious injuries from their children. This can be due to a variety
of reasons, often related to a desire “not to worry them.” Sometimes
these uninformed children have been as old as 12 or 13 years and have
demonstrated a full capacity to rationally understand the injury. In
such circumstances clinicians have challenged assumptions that such
“secrets” could be adequately kept, emphasizing that older youngsters
must also work with parents to help them understand how the with-
holding of information may likely negatively impact on the relationship
“what else are they not telling me about,” resulting in greater long term
As some parents may provide too little information about the injury,
others feel the need to share more than is necessary or force children
to see an injury in a particular kind of way. In rare situations, a par-
ent may actually demand that a child look at the injury site to fully
appreciate the nature of injury sustained. When the injury is one of
considerable trauma, is physically disfiguring, or results in amputa-
tion graphic exposure can lead to pointless and problematic anxiety.
The clinical case below provides an example of a parent who forced his
young son to integrate the injury in a way that was more reflective of
his own needs than his son’s.
service member was concerned that his 3 year old son Jim would be scared of his
injury site and was relieved when, after a visit, Jim showed no concern regarding
the stump. When Jim visited he was a curious boy who engaged his father actively
and physically. At one point during the observation SPC S asked his son “where is
Daddy’s foot?” Jim pointed to his father’s stump and SPC S replied “no, no, that’s
not it.” When asked again where his father’s foot was Jim, this time, went over
and touched his father’s stump. At this point SPC S became somewhat irritated
and scolded “that is Daddy’s foot” as he pointed to his prosthesis. When asked a
third time where his father’s foot was Jim hesitantly pointed to the stump again
and walked away from his father.
In this example, the service member father’s own sense of grief and
loss related to his recent amputation likely played out within the con-
text of the relationship with his son. While Jim appeared to be respond-
lar way were forced on the child. While this particular incident may not
be representative of a typical interaction between this father and child,
376 PSYCHIATRIC QUARTERLY
it encapsulates how an injury can interfere with the normal availabil-
ity a parent may have for a child as the child develops. In the clinical
example that follows, an injured service member mother poignantly
describes her anxiety about the impact of the injury on her ability to
effectively parent her child.
to include loss of right arm functioning. While she described that she was doing
well, she was concerned about how her husband and daughter would respond to
her when they visited, worrying that they might perceive her as ugly, mutilated or
incapable of functioning. During the visit, SGT T reported that her daughter was
gentle, loving and helpful. The fact, however, that she required her daughter’s aid
in some activities that she would have previously done on her own left her feeling
sad and withdrawn. This was true despite the fact that her 6 year old appeared to
enjoy the closeness and her ability to help her mother.
Physical injuries are not the only medical problems with which re-
turning soldiers contend. Data indicate that many returning service
members may suffer from unrecognized psychiatric illness, including
post traumatic stress disorder (PTSD), depression, substance use dis-
and children is unclear, but is likely to be significant. The multigener-
ational transmission of traumatic sequelae resulting from a variety of
different exposures has been recognized and reported (10). Rosenheck
and colleagues have described the negative impact of PTSD in Vietnam
impact of PTSD (reduced family cohesion, decreased interpersonal ex-
pressiveness, greater interpersonal conflict, and reduced problem solv-
ing ability) in the families of Vietnam veterans with PTSD (13–15).
Clinicians must strive to identify and treat these disorders that oth-
erwise are likely to negatively impact on the children and families of
returning Iraq War veterans.
DEATH OF SERVICE MEMBER PARENTS
As of January 2005, over 1400 service members have been killed in
Operation Iraqi Freedom, resulting in over 900 children losing their
parents. The impact of parental death on military children has also not
been broadly examined. Studies that have more generally looked at the
impact of any parental death on children identify that these youngsters
are at higher risk for developing psychiatric disorders or other behav-
ioral or emotional problems (16). No data report the specific impact on
STEPHEN J. COZZA, RYO S. CHUN, AND JAMES A. POLO377
children of war related parental deaths. It would not be unreasonable
to conclude that given the likely intentional and aggressive nature of
these deaths the psychological consequences would probably be more
complicated and possible more problematic.
It is the impression of the authors that the media (particularly tele-
vision) serves as military children’s most significant source of stress
related to potential parental death. Interviews with children suggest
that they have a disproportion fear of the risk for possible death to their
members has been killed. Children who live on military installations
are exposed to more immediate knowledge of the death of a soldier due
to informal communications, community activities, military news or
memorial services. Knowledge of the death of a service member is typi-
cally followed by a pervasive sense of fear, until confirmation is received
that the service member is not a particular child’s parent. It is the ex-
perience of the authors that in situations where a parent has actually
been killed, children are much more likely to experience pathological
communities may provide a helpful holding environment for stricken
families that sustain family functioning and emotional health.
Similar to parental injury, the aftermath of parental death is likely
to lead to even greater family disruption. As military families are typ-
ically assigned at a distance from their extended families, many may
choose to relocate back to their homes of origin, leaving a supportive
military community behind. The benefit or detriment of such relocation
is unclear and may be case-dependent. Families typically lose access to
government housing and, if they move to a site that is not close to a
military installation, may lose access to military commissary, Post Ex-
change and health care facilities.
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