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When a Parent Is Injured or Killed in Combat
VOL. 23 / NO. 2 / FALL 2013 143
Summary
When a service member is injured or dies in a combat zone, the consequences for his or her
family can be profound and long-lasting. Visible, physical battlefield injuries often require
families to adapt to long and stressful rounds of treatment and rehabilitation, and they can leave
the service member with permanent disabilities that mean new roles for everyone in the family.
Invisible injuries, both physical and psychological, including traumatic brain injury and combat-
related stress disorders, are often not diagnosed until many months after a service member
returns from war (if they are diagnosed at all—many sufferers never seek treatment). They can
alter a service member’s behavior and personality in ways that make parenting difficult and
reverberate throughout the family. And a parent’s death in combat not only brings immediate
grief but can also mean that survivors lose their very identity as a military family when they
must move away from their supportive military community.
Sifting through the evidence on both military and civilian families, Allison Holmes, Paula
Rauch, and Stephen Cozza analyze, in turn, how visible injuries, traumatic brain injuries, stress
disorders, and death affect parents’ mental health, parenting capacity, and family organization;
they also discuss the community resources that can help families in each situation. They note
that most current services focus on the needs of injured service members rather than those of
their families. Through seven concrete recommendations, they call for a greater emphasis on
family-focused care that supports resilience and positive adaptation for all members of military
families who are struggling with a service member’s injury or death.
www.futureofchildren.org
Allison K. Holmes is a developmental research psychologist at the Center for the Study of Traumatic Stress at the Uniformed Services
University of the Health Sciences. Paula K. Rauch, a child psychiatrist, is the family team program director for the Red Sox Foundation
and Massachusetts General Hospital Home Base Team and an associate professor of psychiatry at Harvard Medical School. Colonel
Stephen J. Cozza (U.S. Army, Retired) is a professor of psychiatry and associate director of the Center for the Study of Traumatic Stress at
the Uniformed Services University of the Health Sciences.
When a Parent Is Injured or Killed in Combat
Allison K. Holmes, Paula K. Rauch, and Colonel Stephen J.
Cozza (U.S. Army, Retired)
144 THE FUTURE OF CHILDREN
Allison K. Holmes, Paula K. Rauch, and Colonel Stephen J. Cozza (U.S. Army, Retired)
Since the U.S. military began
fighting in Iraq and Afghanistan
in 2002, approximately two mil-
lion military children have seen a
parent deploy into harm’s way at
least once, and many families have experi-
enced multiple deployments.1 Most deploy-
ments end with a parent’s safe return home,
but more than 50,000 service members have
been physically injured in combat, and even
more are later diagnosed with traumatic
brain injury (TBI) or posttraumatic stress
disorder (PTSD). In the worst case, deployed
parents don’t return at all. In this article, we
examine the impact on dependent children of
deployments that result in visible or physical
injuries (for example, amputations or burns);
invisible injuries, including TBI and PTSD;
and a parent’s death.
Few researchers have studied how military
children adapt to a parent’s injury or death in
the conflicts in Iraq and Afghanistan. But mil-
itary and civilian accounts describe profound
effects on parents’ mental health (including
that of injured, uninjured, and surviving
parents), parenting capacity, family organiza-
tion, and community resources. Where there
are gaps in the research, we present data
from studies of civilian parents or of service
members from previous conflicts who faced
similar challenges. These studies can help us
understand what military-connected children
are likely to experience, and what the affected
children and their families will need in the
long run. Of course, their needs will change
as they move from the initial notification of
injury or death and on to treatment, recovery,
and reintegration into civilian communities.
Clinical and nonclinical providers alike must
be aware of these evolving needs and make
a long-term commitment to the children and
families who, in serving our nation, have paid
a particularly high price.
Combat-Related Injury
Since fighting began in Iraq and Afghanistan,
more than 50,000 men and women have been
physically injured and required immediate
medical attention.2 Other combat-related
conditions, including PTSD and TBI, may
not be recognized or treated until service
members return home. Thus injuries can
be categorized as visible or invisible. The
distinction is important, because visible and
invisible injuries have different effects on
children, families, and their relationships.
Visible injuries are those easily identified by
others, such as amputations, blindness or eye
injuries, auditory damage, burns, spinal cord
injuries, and paralysis.3 TBI and PTSD are
called invisible injuries because there is often
no immediate external bodily indication of
trauma; the symptoms appear as changes in
cognition, behavior, and social functioning.4
Because service members wear body armor
that protects their vital organs, most severe
physical injuries affect the arms and legs
(54 percent) or the head and neck (29 per-
cent). Advances in medical care mean that
severely injured service members are more
likely to survive today than they were in
previous conflicts.5 Multiple physical injuries
are common, and physical and psychological
injuries often occur together.
An array of variables affects the way fami-
lies experience a service member’s combat
injury. They include the type and sever-
ity of the injury, family composition, the
children’s developmental age, individual or
family characteristics, the course of required
medical treatment, and changes that occur
as the injured parent regains function and
the family copes and adapts. The course of
recovery can be thought of as an injury recov-
ery trajectory, with four phases: acute care,
VOL. 23 / NO. 2 / FALL 2013 145
When a Parent Is Injured or Killed in Combat
medical stabilization, transition to outpatient
care, and long-term rehabilitation and recov-
er y.6 In each phase, children and families face
emotional and practical difficulties.
During acute care, the injured parent
receives life-saving and life-sustaining medi-
cal interventions. When families are notified,
children may be exposed to unfiltered infor-
mation about the injury and raw emotional
responses. When families are reunited, chil-
dren may hear medical providers talk about
injuries or medical procedures, and they may
see other ill or injured people in the hospital;
they may also have to take on some caregiv-
ing responsibilities.
Medical stabilization includes surgery and
other medical care that prepare the injured
service member to leave the hospital. How
long this phase lasts depends on the severity
of the injury. Stabilization typically occurs in
a facility far from the family’s home, and the
other parent may need to travel to be near
the injured service member, with or without
the children. In a 2007 report, 33 percent
of active-duty, 22 percent of Guard and
Reserve, and 37 percent of retired service
members reported that a family member or
friend relocated temporarily to spend time
with the injured service member while he or
she was in the hospital.7 Whether children
come with their uninjured parent or are left
in the care of others, their daily routines are
disrupted. Separation from parents, exposure
to an injured parent, or exposure to an unin-
jured parent’s emotional distress may cause
children to feel sadness, anxiety, or confusion.
Younger children commonly express what
they’re feeling through behavior, such as
aggression, greater dependency, or regres-
sion to behaviors more typical of a younger
child. Older children may display the same
kinds of symptoms; they may also either
assume caregiving or household responsibili-
ties or disengage from the family.8 Children
who lack social connections, as well as those
who already suffer from a psychiatric illness,
are more likely to experience emotional and
behavioral problems.9 Research in other con-
texts has shown that children with behavioral
problems are more likely to be maltreated,
and this may be true in the families of injured
service members as well.10
Transition to outpatient care begins before
discharge from the hospital, when follow-up
care and rehabilitation are arranged. Families
prepare to meet everyday needs (such as
housing, financial planning, transportation,
child care, and schooling) as they adapt to
new medical demands (rehabilitation appoint-
ments, the service member’s daily care) that
add new emotional challenges for parent and
child alike. The responsibility for coordinat-
ing these old and new demands falls mostly
on the uninjured parent. In fact, family mem-
bers or friends often must leave their jobs to
care for the injured service member full time.
Rehabilitation and recovery is when service
members learn to adapt to their injuries and
settle into their new lives. During this phase,
Injuries can be categorized
as visible or invisible. The
distinction is important,
because visible and invisible
injuries have different effects
on children, families, and
their relationships.
146 THE FUTURE OF CHILDREN
Allison K. Holmes, Paula K. Rauch, and Colonel Stephen J. Cozza (U.S. Army, Retired)
families often move to new communities
and seek new health-care providers. New
homes, new neighborhoods, new schools,
new friends, new child-care providers, and
new daily routines add instability to chil-
dren’s lives. If schools, peers, and community
providers don’t know how to support children
of injured service members, or if they are
unfamiliar with military children in general,
the readjustment may further tax a child’s
ability to cope.11
Visible Injuries
Severe injury often requires extended
treatment, which is especially difficult for
families. Periods of medical stability may
alternate with periods of instability, when
complications occur, progress is limited,
or additional treatments (such as multiple
reconstructive surgeries) are needed.12 The
family’s living arrangements may change,
and months or years of recurring hospital-
based treatments and outpatient visits may
disrupt their connections to the community.
Moreover, when service members suffer
multiple injuries, or when visible and invis-
ible injuries occur together, treatment grows
more complex and family adjustment more
difficult.13 A long and disruptive recovery
can take its toll on children, 15 percent of
whom exhibit clinical levels of emotional and
behavioral problems several years after their
military parent’s injury.14
Parents’ Mental Health
In addition to physical changes, combat-
injured service members are at significant risk
for invisible injuries or psychiatric prob-
lems, such as PTSD and depression.15 These
problems may not appear until long after the
injury. In fact, one study found that nearly
80 percent of combat-injured service mem-
bers who screened positive for either PTSD
or depression seven months after their injury
had screened negative for both conditions six
months earlier.16 When injured service mem-
bers have poor emotional health, they may not
be able to engage fully with their children,
which affects the children’s ability to cope.
Parenting Capacity
External events can disrupt both relation-
ships between couples and the entire family
system, as well as individual wellbeing. A
family systems framework explains how a
parent’s physical injury can affect a child’s
wellbeing by disrupting the parenting of
both the injured and uninjured parent.17 For
example, among children of parents suffering
from stroke, the uninjured parents’ stress and
depression were associated with anxiety and
depression among their children.18
One critical way that combat injury can
influence an injured parent’s ability to engage
with his or her children is through changes in
physical function. Amputation, musculoskel-
etal injuries, burns, or eye injuries are likely
to produce temporary or permanent loss
of function, requiring prosthetic assistance
or rehabilitative care. Before their injuries,
many young military service members are
physically active, and, especially among
A long and disruptive
recovery can take its toll
on children, 15 percent of
whom exhibit clinical levels
of emotional and behavioral
problems several years after
their military parent’s injury.
VOL. 23 / NO. 2 / FALL 2013 147
When a Parent Is Injured or Killed in Combat
fathers, parenting activities are often physi-
cal, “hands-on,” or athletic.19 After the injury,
those activities may no longer be possible, or
they may need to be modified significantly. In
turn, injured service members must modify
their ideas of how to be a good parent at
the same time that they are mourning their
own bodily changes or loss of function. The
injured parents’ physical absence during
hospitalizations, and their emotional unavail-
ability due to physical condition or treatment
effects, can also seriously limit their ability to
effectively interact with their children.20
The uninjured parent may also find it hard to
be available for the children. For one thing,
if the injured service member can’t take part
in routine activities, the uninjured parent
(as well as the children) has to take on new
responsibilities. Similarly, the uninjured par-
ent may be less available while caring for the
injured parent. Either of these circumstances
can limit the parent’s ability to engage in
warm, nurturing interactions with children.
As multiple sources of stress spill over into
the parent-child relationship, children have
fewer resources, and their risk for maladapta-
tion increases. Thus, supporting the children
of injured service members means bolstering
the parenting relationships of both injured
and uninjured parents.
Family Organization
We know from studies of families dealing
with combat injuries, multiple sclerosis, or
stroke that when an injury or illness produces
significant changes in parenting ability, par-
ents and children alike must renegotiate fam-
ily relationships and come to terms with the
injury and its consequences. When service
members remain impaired and can’t resume
their former parental and household respon-
sibilities, uninjured parents and children are
likely to see their own roles change. In these
circumstances, children may act out if the
family becomes disorganized or dysfunc-
tional.21 Likewise, relationships between par-
ents and children, or between spouses, may
grow strained, and children may experience
emotional problems.22 If the family’s organi-
zation was poor before a combat injury, the
injury is likely to make things worse, under-
mining family members’ capacity to negotiate
the challenges they face. In one small study
of hospitalized injured service members,
children from families where the stress from
deployment was high even before the injury
suffered greater emotional distress after the
injury than did other children.23 Because
children’s wellbeing depends on how well the
family functions after a combat injury, service
providers may need to work with such at-risk
families more intensively.
A combat injury generates confusion and
fear in the family, and better communica-
tion between parents and children can help
children cope.24 Injury communication refers
to communication about injury-related topics
both within the family and with others in the
civilian and military communities.25 Effective
injury communication requires open dialogue
about the injury and its consequences among
many parties: the injured service member
and the uninjured parent; family members,
including children; friends; and medical
personnel and other community profes-
sionals and service providers. Parents need
sophisticated guidance about how to talk
with their children about medical conditions;
professionals need to know how to offer this
support to parents.26 Just as some parents
may tell their children too little about the
injury, others share more than the children
can handle, or frighten them by unnecessarily
bringing up unknown future consequences.
Thus adults may need help calibrating the
148 THE FUTURE OF CHILDREN
Allison K. Holmes, Paula K. Rauch, and Colonel Stephen J. Cozza (U.S. Army, Retired)
amount, content, and timing of the facts they
share. But even young children should be
given some explanations to help them under-
stand the actions and emotions of the adults
they see around them.
Community Resources
Families who are dealing with combat
injuries need support and services from the
community, and these needs change and
evolve as recovery from the injury progresses.
For example, families may need help finding
adequate housing, particularly when they
expect long-term visits from extended family
members. They may require assistance with
child care, family health or schooling, or help
navigating military regulations and paper-
work, transitioning to civilian medical care, or
finding a job.27 Guard and Reserve families,
who often live far from military communities
and their associated support services, may
require additional help. And when injured
service members leave the military system
and move to communities around the coun-
try, military families may find that service
providers, teachers, and others are unfamiliar
with their unique needs.
Traumatic Brain Injury
The number of service members who return
home with combat-related TBI is not entirely
clear. Estimates differ depending on the
source of information, the screening criteria,
and the threshold of diagnostic clarity, as
well as the severity of the injury (that is, mild,
moderate, or severe). The military health
system reported that more than 250,000
cases of TBI had been diagnosed in military
service members from 2000 through 2012.28
Others have estimated a significantly higher
incidence, for example, 320,000 cases among
returning Iraq and Afghanistan combat
veterans through 2007.29 Overall, 33 percent
of service members who return from combat
are reported to suffer from TBI, PTSD, or
depression, and 5 percent meet the criteria
for all three diagnoses.30 When such injuries
occur together, they are likely to have cumu-
lative effects on children and families.
The impact of parents’ traumatic brain inju-
ries in military families has not been well
studied. But evidence from nonmilitary
families shows that this type of parental
impairment can have profound effects on
children. Children living with a parent who
has suffered a TBI display more behav-
ioral and emotional problems, feelings of
loss and grief at the change in the injured
parent, and a sense of isolation. They also
exhibit more posttraumatic stress symp-
toms, and 46 percent meet the criteria for
PTSD.31 Interestingly, when compared with
children of parents with diabetes, children
of parents with TBI report higher levels of
posttraumatic stress but no differences in
behavioral problems, depression, or anxiety;
this suggests that a parent’s TBI may be
uniquely traumatic for children.32
Parents’ Mental Health
The symptoms of TBI and PTSD overlap,
and the prevalence of co-occurring diagnoses
among service members returning from Iraq
and Afghanistan varies depending on the
definition of TBI. When the TBI is moderate
(for example, producing loss of conscious-
ness), the incidence of co-occurring PTSD
was higher than when the TBI was mild
(for example, producing alteration of con-
sciousness) or severe (for example, an open
head wound).33 Compared with those with
TBI only and those who screened negative
for either condition, service members with
both TBI and PTSD engaged in more high-
risk behaviors like reckless driving, binge
VOL. 23 / NO. 2 / FALL 2013 149
When a Parent Is Injured or Killed in Combat
drinking, and heavy smoking.34 Because
TBIs are not always immediately identified
or treated, families may not know what is
causing the changes they see in a returning
service member. Problems related to undiag-
nosed TBI or PTSD may continue for months
or years, eroding a family’s bonds.
Parenting Capacity
TBI poses unique challenges to parenting. Its
psychiatric effects tend to be more distress-
ing to family members and more disruptive to
family functioning than those of other physi-
cal and nonneurological impairments.35 These
effects include altered personality, emotional
problems (for example, irritability, a low frus-
tration threshold, poor anger management, or
apathy), difficulty with behavioral regulation,
cognitive problems (for example, a short atten-
tion span or intolerance for overstimulation),
lack of energy, substance abuse, thrill-seeking
behavior, disrupted sleep, communication
problems, and difficulty with personal engage-
ment.36 To cope with such TBI symptoms,
injured parents may withdraw from the family
to protect children and other loved ones.
Children are likely to be confused and dis-
tressed by these behaviors and may blame
themselves for their parents’ outbursts, loss
of control, or emotional aloofness. In some
cases, children and families are left with a
troubling sense that the injured service mem-
ber bears little resemblance to the person
they knew before the injury, resulting in a
sense of sadness and loss. As one 12-year-old
girl said: “I basically just feel sad, because
he’s there physically. I suppose I’ve got a Dad,
but he’s not my Dad.”37
Uninjured parents are also likely to be
affected. They often must care for the
injured parent, and they are at high risk
for depression and anxiety, either of which
can undermine their parenting capacity.38
Compromised parenting in either the injured
or the uninjured parent, as well as depres-
sion in the uninjured parent, correlates with
higher levels of emotional and behavioral
problems in children of TBI patients.39 Thus,
visible and invisible injuries prevent injured
and noninjured parents from engaging in
the warm, nurturing relationships children
require after trauma. Supporting and inter-
vening through parenting relationships can
help children cope and adapt.
Family Organization
Unlike those of other physical injuries, the
effects of TBI on children and families may
not improve. In one study, families dis-
rupted by a TBI still needed professional
help 10–15 years after the injury, and young
families with the least financial and social
support were at the highest risk.40 The initial
severity of the TBI was not the greatest
predictor of how the uninjured parent and
children would fare; rather, it was the degree
to which the injury affected the victim’s
cognitive and interpersonal functioning. In
particular, the uninjured parent’s experience
was heavily affected by whether the couple
was still able to have a reciprocal emotional
relationship and communicate effectively.
Because TBIs are not always
immediately identified
or treated, families may
not know what is causing
the changes they see in a
returning service member.
150 THE FUTURE OF CHILDREN
Allison K. Holmes, Paula K. Rauch, and Colonel Stephen J. Cozza (U.S. Army, Retired)
For families of long-term TBI sufferers, the
study concluded, social support from friends,
family, and professionals alike was critical.
Community Resources
The common delay in diagnosing TBI, as
well as the injury’s long-term effects, can
damage job performance, earnings, and the
sufferer’s military career. Because of the long-
term effects, community providers will be
seeing more cases of TBI as injured service
members return to civilian life, and they will
need to recognize the symptoms and provide
appropriate treatment. Uninjured parents will
need support of many kinds—practical, logis-
tical, emotional—and they may also need
temporary relief from caregiving. Similarly,
the long-term impact of TBI means that
children will need expanded community sup-
port from schools, clinicians, and therapists
long after the injured parent leaves military
service. Some younger children affected by
a parent’s TBI can be expected to exhibit
disruptive behaviors, poor academic perfor-
mance, and substance abuse years later, in
middle school and high school.
Combat-Related Stress Disorders
Psychological injury is another invisible
wound that affects children’s health and well-
being. Combat-related stress disorders can
include PTSD, depression, anxiety disorder,
and substance abuse. Recent reports indi-
cate that up to one-third of service members
deployed to Iraq and Afghanistan experience
some sort of mental health disorder within
three to four months of returning home.41
PTSD is a signature injury of the post-9/11
conflicts. Since 2000, 66,935 new cases of
PTSD have been diagnosed among service
members who have deployed, as well as
21,784 new cases among service members
who have never deployed; the overall preva-
lence of PTSD among military personnel
is variously estimated to be between 6 and
25 percent.42 The disorder is associated with
a range of problems, including occupational
and social impairment, poor physical health,
neuropsychological impairment, substance
use, and risk of death.43 Any of these compli-
cations can slow service members’ recovery,
affect children and families, disrupt reinte-
gration into the community, and impair ser-
vice members’ ability to resume their former
roles at home.
Unfortunately, only half of returning service
members who meet the criteria for PTSD or
depression seek treatment. Many are worried
about job security; for example, they fear that
they could lose a security clearance, or that
their coworkers will lose trust in them. They
may also fear the treatment itself.44 Even
among those who seek treatment, half receive
only minimally adequate care. The chil-
dren of these service members are affected
as well. In studies from the Vietnam War
and the second Iraq War alike, children of
soldiers with PTSD showed higher levels of
anxiety, depression, and posttraumatic symp-
toms themselves.45 The children’s symptoms
may best be accounted for by disruptions
in the parenting relationship and repeated
exposure to the symptoms that the affected
parent displays.46
As with visible injury, the way a parent’s
PTSD affects children depends on a child’s
age, developmental level, temperament, and
preexisting conditions. Because their cogni-
tive and emotional skills are less developed,
PTSD is a signature injury of
the post-9/11 conflicts.
VOL. 23 / NO. 2 / FALL 2013 151
When a Parent Is Injured or Killed in Combat
younger children may struggle more than
older children to cope and adapt to changes
in a parent’s behaviors and the parenting
relationship. Very young children may have
an especially hard time coping with the
disorganized parental behavior that can result
from PTSD, such as overreaction or disen-
gagement. These inappropriate responses can
lead to an emotional disconnection between
parents and very young children, resulting in
a nonnurturing parent-child relationship that
can mimic the dysfunctional relationships
seen in early childhood abuse.47 Definitive
mental health treatment, mental health
education for parents and children, develop-
mental guidance, and supportive therapeutic
assistance, such as parent-child interpersonal
therapy, may all be tremendously useful in
such situations, both on return from deploy-
ment and throughout the recovery.
Parents’ Mental Health
Invisible stress-related injuries can harm the
spouse’s mental health along with the injured
service member’s. In studies from several
conflicts, spouses of soldiers with PTSD were
more likely than others to show traumatic
stress symptoms themselves and to experi-
ence general distress.48 Moreover, a spouse’s
mental health problems were more likely
to harm children’s functioning than were
a service member’s own, making spouses’
mental health a critical target for treatment.49
Clearly, attention to the mental health needs
of both parents is essential to the health of
their children.
Parenting Capacity
Studies of how parents’ combat-related PTSD
affects children and families come largely
from work with American, Australian, and
New Zealander Vietnam War veterans and
their families. Within these populations,
PTSD has been associated with poor intimate
relationships, impaired family functioning,
greater family distress, higher levels of family
violence, and disrupted parenting and parent-
child relationships.50 The complex interaction
of risk behaviors and psychological symptoms
that characterize PTSD—including emotional
numbing, avoidance, and anger—make it dif-
ficult for those who suffer from the disorder
to engage with their families. Ayelet Meron
Ruscio and colleagues, writing about male
victims of PTSD, say that “the disinterest,
detachment, and emotional unavailability that
characterize emotional numbing may dimin-
ish a father’s ability and willingness to seek
out, engage in, and enjoy interactions with his
children, leading to poorer relationship qual-
it y.” 51 In turn, spouses may see service mem-
bers with PTSD as unreliable and inadequate
caregivers, further alienating them from their
children. The way that spouses’ emotional
health affects children’s wellbeing suggests
that the traditional approach to treating a vet-
eran’s PTSD—individually, without providing
primary mental health support to spouses and
children—is inadequate.
Family Organization
Through their effects on marital and par-
enting relationships, combat-related stress
disorders make it harder for families to
readjust after deployment. Up to 75 percent
of service members who screen positive for
postdeployment mental health disorders
report marital conflict, and service mem-
bers with PTSD symptoms show higher
rates of conflict with spouses and children,
as well as more difficulty with parenting.52
Spouses and children often struggle to avoid
triggering negative or explosive responses
from affected service members. As PTSD
symptoms become more severe, rates of
interpersonal violence rise and the burden
152 THE FUTURE OF CHILDREN
Allison K. Holmes, Paula K. Rauch, and Colonel Stephen J. Cozza (U.S. Army, Retired)
on caregivers increases.53 When families
experience stress and conflict, the poten-
tial for child abuse is higher.54 But military
families and children have great capacity for
resilience, and targeted individual and family
treatments can harness these skills.55
Community Resources
Given the prevalence of combat-related
stress disorders and their far-reaching effects
on children and families, service members,
spouses, children, and families need several
levels of support. Moreover, services must
be available in both military and civilian
communities.
Identifying and treating stress disorders early
can prevent long-term family exposure and
reduce family stress. Unfortunately, lack of
understanding, concern for career, and stigma
regarding treatment prevent many service
members from seeking diagnosis and help.56
Thus we should encourage and train people to
identify children affected by combat-related
stress disorders in schools, community organi-
zations, sports teams, and religious groups, as
well as during pediatric visits.
In addition to promoting mental health
and family resilience, programs that work
with families affected by stress disorders
must consider their practical needs, such as
employment, finances, and housing. Help
with meeting basic needs can diminish stress,
particularly for spouses who bear the bur-
den of running the family. Comprehensive
support promotes overall family health and
increases the likelihood that mental health
treatment will succeed.
Combat-Related Death
We define combat-related deaths as deaths
that occur during combat deployment, as
well as suicides that occur in combat zones
or after return from combat deployment.
Since 9/11, more than 16,000 uniformed
service members have died on active duty.
Approximately one-third of these deaths
occurred in combat; more than 97 percent
of those killed have been male.57 Another
14 percent of all service members’ deaths are
self-inflicted. Though we know a great deal
about how a parent’s death affects children
in the civilian population, little empirical
research has been done on how a parent’s
death, especially a parent’s death in combat,
affects children in the military.
We hypothesize that a parent’s death in
combat has a more immediate impact on
military children than do visible or invis-
ible injuries. However, death during combat
deployment is not wholly unanticipated.
Military families, as well as families in other
line-of-duty professions (law enforcement,
firefighting), do not necessarily focus on the
ultimate sacrifice.58 But these high-risk ser-
vice professions carry mechanisms, such as a
professional culture and a sense of mission,
that may help children who are coping with
loss.59 For example, one study showed that
Israeli children with a relative who died in
combat reported fewer psychiatric symptoms
and greater general wellbeing than children
with a relative who died in a motor vehicle
accident.60 However, military deaths may
be experienced differently in Israel, where
nearly all adults serve in the armed forces.
Nonetheless, the military culture and its
support systems can bolster families as they
grieve and adjust. Critical to understand-
ing any family’s response to combat death is
their perspective on the death (for example,
whether they see it as meaningful or mean-
ingless), the events that surround the death,
and their experience following the death of
family and community cohesion and support.
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When a Parent Is Injured or Killed in Combat
Parents’ Mental Health
Evidence from civilian families shows that a
spouse’s death can affect the surviving spouse
in a variety of ways: increased vulnerability
to physical and psychological illness, reduced
happiness, and feelings of social isolation
and meaninglessness.61 While spouses grieve,
children of all ages may display a variety of
healthy, developmentally appropriate grief
responses: playing, talking, questioning, and
observing. Many children feel sad, cry, or
become more withdrawn; others express their
emotions through reverting to earlier behav-
iors. When the surviving parent was already
struggling with depression, anxiety, or sleep
or health problems before the death, chil-
dren are less likely to adjust well, and young
children are more vulnerable as well.62 Some
children develop childhood traumatic grief,
which is marked by trauma-related symptoms
(for example, hyperarousal, psychological dis-
tress, and avoidance) that can make it harder
for them to mourn appropriately.63 No studies
have examined the incidence of childhood
traumatic grief in bereaved military children,
but combat death shares many of the charac-
teristics (such as sudden loss) that contribute
to its development in other populations.
Parenting Capacity
A child’s response to a parent’s death is
related to the surviving parent’s response.
According to George Tremblay and Allen
Israel, “Children appear to be at risk for
concurrent and later difficulties primarily
to the extent that they suffer a higher prob-
ability of inadequate parental functioning or
other environmental support before, as well
as after, the loss of a parent.”64 Therefore,
the parenting relationship can support or
undermine a child’s adjustment after a par-
ent’s death. A warm, nurturing, and effec-
tive relationship with the surviving parent
promotes positive coping and interactions.65
Lax control (for example, inconsistent disci-
pline practices), which is more common after
one parent dies, as well as children’s fear of
abandonment, can increase problem behav-
iors, depression, and anxiety in children.66
Family Organization
Research has shown repeatedly that the
surviving parent’s competence helps ensure
the bereaved child’s positive adjustment,
as does family cohesiveness.67 The relation-
ship between family cohesion and positive
adjustment is significant, given that many
military family members describe tension
and alienation within the family after a
service member’s death.68 If the death pro-
duces a large number of additional stresses
and changes to routine, children are likely
to show lower self-esteem and feel less in
control of their lives.
For spouses, the death of a service member
leads to a series of compounding losses. In
addition to losing a husband or wife, bereaved
military spouses may lose their identity as
a “military spouse” and their way of life as
a “military family.” They may lose on-base
housing and friends, as well as the feeling
of being connected to the greater military
community. Spouses may blame the military
and the government for the death and for the
A warm, nurturing, and
effective relationship
with the surviving parent
promotes positive coping and
interactions.
154 THE FUTURE OF CHILDREN
Allison K. Holmes, Paula K. Rauch, and Colonel Stephen J. Cozza (U.S. Army, Retired)
negative consequences that they and their
families face, particularly if they have trouble
navigating the bureaucracy. Thus, although
the military culture and its support systems
can provide avenues to resilience, they can
also become painful reminders of a life lost,
or a source of stress.
Community Resources
Following a service member’s death, families
must immediately make arrangements. Some
of these are familiar to all families—for
example, the funeral. Others are specific to
the military, such as determining financial
benefits and entitlements. Later, military
families may have to make decisions about
housing: qualifying military dependents may
remain in on-base housing for one year after
a service member’s death, but after that they
must leave. Each military service branch
has created a casualty assistance program to
aid families from the time they learn of the
death, helping them get through military
administrative processes and connecting
them with survivor services.69
Importantly, providing practical and emo-
tional support to surviving families both
immediately and over time produces the
best outcomes. A service member’s combat
death is likely to bring a cascade of events
that can undermine the family’s connection
to practical support, communities of care,
and military culture. Though many fami-
lies remain close to military communities,
where they can continue to access military
services, others move great distances to be
closer to extended family or friends. Like
bereaved military families in the Guard and
Reserve, these families may find themselves
in communities that lack an understanding
of their experience or sacrifice, leading to a
sense of isolation or disconnection. National
community support services such as the
Tragedy Assistance Program for Survivors
(TAPS), Gold Star Wives, Gold Star
Mothers, and the Army Survivor Outreach
Services (Army SOS), among others, can
help provide continuity across communities
to ensure that families stay connected and
effectively engaged.
For children, schools can play an important
role. For one thing, children who do well in
school are likely to have fewer behavioral
problems.70 Moreover, self-esteem plays a key
role in how children experience and respond
to stressful events. Self-esteem also promotes
academic success. Thus educators can pro-
mote resilience by fostering self-esteem and
academic competence.
Conclusions and Recommendations
For the post-9/11 conflicts in Iraq and
Afghanistan, we do not have enough scientific
evidence documenting how visible and invis-
ible injuries or bereavement have affected
military children. But the long-term effects
are likely to be substantial in this high-risk
population. Certainly, we need more research
both to guide policy for future wars and to
more effectively serve the current population.
In this review, we have extrapolated from
studies of the civilian population and of fami-
lies from past wars. We know that the effects
of combat injury and death are not limited to
children’s emotional, psychological, behav-
ioral, or academic functioning at the time of
the incident. We do not know how today’s
military children will evolve over time, nor
how or whether this evolution will differ from
that of civilian children, but we do know that
families will be affected for years to come.
Clearly, the family’s structure and function
are critical to individual and familial health.
VOL. 23 / NO. 2 / FALL 2013 155
When a Parent Is Injured or Killed in Combat
Injured, uninjured, and bereaved parents
affect children directly and indirectly through
their own mental health, their parenting
abilities, the family’s organization, and their
place in the community; all of these factors
can be sources of either risk or resilience.71
Most current services emphasize the needs of
the injured service member. But deployments
that result in injury or death profoundly influ-
ence all members of the family and increase
the risk for maladaptation both immediately
and in the long term. Supporting parents’
physical and mental health, bolstering their
parenting capacity, and enhancing family
organization can help children cope and
thrive. Throughout the family’s recovery, the
most effective community support services
and resources are those that emphasize
family-focused care and resilience.
Based on our review of the evidence, we offer
seven recommendations for service providers
and policy makers.
1. Stabilize the family environment through-
out recovery by ensuring access to basic
needs, such as housing, education, health
care, child care, and jobs. Families need basic
resources, not only as they make immediate
adjustments to a service member’s injury or
death, but also as they transition later to new
communities. Many families must profoundly
alter their lives. They move, changing schools
and doctors and jobs. Their income may
fall, and they may lose access to community
resources such as child care, youth activities,
and sports programs. To succeed, families
need support both inside and outside the
military system as injuries heal, stress disor-
ders are identified and treated, and bereaved
spouses and children adjust and reorganize.
Some families are likely to be more affected,
for example, younger families, families who
have trouble making ends meet, and families
in which a parent has a disability that impairs
parenting capacity. Even families who live on
military installations or obtain treatment in
the military or VA health-care systems will
eventually transition to civilian communities,
where understanding of military culture and
expertise in working with military families
is likely to be limited. Programs and services
that foster a secure and stable environment
for families of service members who are
injured or killed are more likely to meet their
multiple needs and, in turn, promote their
children’s wellbeing.
2. Identify and promote services that sup-
port family organization, communication,
coping, and resilience. A parent’s injury,
illness, or death can powerfully disorganize
families, contributing to distress and dysfunc-
tion. Families must effectively reorganize
and rethink their activities and goals if they
are to successfully overcome the challenges
they face. Such family growth requires par-
ents to exhibit strong leadership, fortitude,
and patience, modeling positive adaptation
and coping for their children. Professional
assistance should support families in reaching
these goals.
Another critical component of healthy family
functioning is communication, particularly
to help children understand the nature of an
injured parent’s condition at an age-appropri-
ate level. Communication is also necessary
for problem-solving and planning. Families
must cope with real and perceived losses in
all family members, and they must accept
various emotional responses from everyone,
including children. Conditions such as TBI or
PTSD may complicate this process through
heightened conflict, family disorganization,
emotional problems, or interpersonal isola-
tion. People who work with military families
affected by these conditions need careful
156 THE FUTURE OF CHILDREN
Allison K. Holmes, Paula K. Rauch, and Colonel Stephen J. Cozza (U.S. Army, Retired)
strategies to support better understanding
among family members, encourage parents
and children to build their skills, and help
families come to terms with perceived losses
to recover meaning and hope. This article
has used two-parent families as illustrations,
but family-centered care should also recog-
nize and incorporate the needs of blended
families and single-parent families, as well as
families that include the younger siblings of
service members.
3. Incorporate family-centered care mod-
els into clinical and community practice to
provide basic parenting intervention and
education about the challenges of a service
member’s visible or invisible injuries, or a
surviving parent’s bereavement. A family-
centered care perspective supports the physi-
cal and mental health of all family members,
especially children, by acknowledging and
ameliorating how combat-related injuries
affect parenting. A service member’s physical
limitations, changes in cognitive ability, and
psychological or emotional distress may affect
parenting capacity; an uninjured or bereaved
parent may be affected as well. Impaired par-
enting capacity may be the immediate result
of a combat injury, or it may occur later as
adversities accumulate in the injury’s wake.
Comprehensive family-centered care helps
family members understand the broad impact
of combat-related conditions on everyone in
the family, and it suggests parenting strate-
gies that can effectively promote children’s
wellbeing during the recovery. There is
an urgent need to develop and evaluate
evidence-based programs that reduce the
impact of deployment stress, PTSD, and TBI
on the extended family system.
4. Identify and treat mental health prob-
lems—including depression, anxiety, and
PTSD—in uninjured parents and children.
Clinicians who work with combat-injured
service members or veterans can help their
patients’ families and children in simple ways.
Clinicians can learn about the members of a
patient’s family and how the patient relates to
the uninjured parent and children by asking
how the illness or injury affects the mar-
riage and parenting. For example, irritability,
avoidance, or loss of interpersonal connect-
edness can decrease marital satisfaction
and parental engagement. Clinicians should
listen to uninjured parents and children for
signs of distress and, when appropriate, get
help for them. Uninjured parents and chil-
dren who had psychiatric or developmental
problems before the combat injury are at risk
for greater problems. Clinicians who identify
problems in the family can request a patient’s
permission to invite other family members
to a clinical session to discuss the nature of
family relationships and to assess the impact
of combat-related injuries or illnesses. Such
proactive attention to the clinical needs of all
family members will boost the family’s resil-
ience, both together and individually.
5. Tailor services to families’ individual
risks and strengths. Children and families
who were already functioning well may need
only shorter-term support. On the other
hand, children and families who had medi-
cal or mental health problems even before a
combat injury or death can be expected to
need more help. But in either case, strength-
based approaches are more effective than
deficit models. We can promote families’
resilience by 1) reducing their distress,
2) educating them, 3) helping them plan
for future needs, 4) linking them to outside
resources, and 5) creating a sense of hope.
Recognizing the variability among recover-
ing families and adapting to their needs to
promote resilience will help create cost-
effective programs and services.
VOL. 23 / NO. 2 / FALL 2013 157
When a Parent Is Injured or Killed in Combat
6. Educate clinical and community service
providers about the unique needs of families
of service members who have been injured or
killed in combat. Children and families who
face combat injury and death should be able
to get competent and well-informed medi-
cal, mental health, social, and educational
care in any community in the nation, even
and perhaps especially when they live far
from military installations or in rural areas.
Thus we need national programs to teach
clinicians and community service providers
about the unique needs of military children
and families; the White House’s Joining
Forces campaign, for example, helps com-
munities, businesses, clinicians, and schools
learn about military families’ needs. We also
must evaluate such programs to make certain
they deliver essential care efficiently and
cos t-ef fect ively.
Building broad access to health care and
community support programs is likely to be
challenging, however. Professionals need
incentives to participate in these pro-
grams. Because military children may need
extensive and complex help after a parent’s
injury, illness, or death, children may be
underserved. Or they may receive duplicate
services or inappropriate treatments in over-
lapping systems. Policy must target efficient
and formal coordination of care across mul-
tiple systems—education, health care, mental
health, youth services—to facilitate recov-
ery and to minimize the burden on already
stressed families.
7. Commit to sustaining systems of sup-
port for these families, who may need help
for decades. Policies and programs should
recognize that a family’s recovery after
combat-related injury, illness, or death is likely
to be prolonged, and families will have dif-
ferent needs at different times. Services from
military, VA, and civilian providers should be
supplemented, integrated, and coordinated to
meet families’ needs during their many years
of recovery and healing. Increasing the use of
web-based models of care may be a promising
way to do this.
Ultimately, we need to do more research,
evaluate the effectiveness of existing pro-
grams, and disseminate the findings so that
we can expand resilience-based family pro-
grams to providers in the communities where
families live and receive care. In the absence
of strong, evidence-based programs to sup-
port these high-risk families, however, both
contemporary practice and future research
hypotheses should be grounded in sound
clinical judgment.
Clinicians should listen
to uninjured parents and
children for signs of distress
and, when appropriate, get
help for them.
158 THE FUTURE OF CHILDREN
Allison K. Holmes, Paula K. Rauch, and Colonel Stephen J. Cozza (U.S. Army, Retired)
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