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Military Youth and the Deployment Cycle: Emotional Health
Consequences and Recommendations for Intervention
Christianne Esposito-Smythers,
Dept. of Psychology, George Mason University
Jennifer Wolff, and
Dept. of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University
Keith M. Lemmon
Dept. of Pediatrics, Madigan Army Medical Center
Mary Bodzy, Rebecca R. Swenson, and Anthony Spirito
Dept. of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University
Abstract
The United States military force includes over 2.2 million volunteer service members. Three out of
five service members who are deployed or are preparing for deployment have spouses and/or
children. Stressors associated with the deployment cycle can lead to depression, anxiety, and
behavior problems in children, as well as psychological distress in the military spouse. Further, the
emotional and behavioral health of family members can affect the psychological functioning of the
military service member during the deployment and re-integration periods. Despite widespread
acknowledgement of the need for emotional and behavioral health services for youth from military
families, many professionals in a position to serve them struggle with how to best respond and
select appropriate interventions. The purpose of this paper is to provide an empirically-based and
theoretically informed review to guide service provision and the development of evidence based
treatments for military youth in particular. This review includes an overview of stressors
associated with the deployment cycle, emotional and behavioral health consequences of
deployment on youth and their caretaking parent, and existing preventative and treatment services
for youth from military families. It concludes with treatment recommendations for older children
and adolescents experiencing emotional and behavioral health symptoms associated with the
deployment cycle.
Keywords
deployment; military; child; adolescent; mental health
An ongoing issue in the lives of military families is managing the stress associated with the
deployment cycle. More than 2.2 million service members make up our all volunteer
military force (Department of Defense; DoD, 2011), with mobilization and deployment at
their highest levels since World War II. Operation Enduring Freedom in Afghanistan and
Correspondence should be addressed to Christianne Esposito-Smythers, George Mason University, Department of Psychology, MSN
3F5, 4400 University Drive, Fairfax, VA, Phone: 703-993-2039, Fax: 703-993-1359, cesposi1@gmu.edu. .
Publisher's Disclaimer: The following manuscript is the final accepted manuscript. It has not been subjected to the final copyediting,
fact-checking, and proofreading required for formal publication. It is not the definitive, publisher-authenticated version. The American
Psychological Association and its Council of Editors disclaim any responsibility or liabilities for errors or omissions of this manuscript
version, any version derived from this manuscript by NIH, or other third parties. The published version is available at
www.apa.org/pubs/journals/fam
NIH Public Access
Author Manuscript
J Fam Psychol. Author manuscript; available in PMC 2012 August 1.
Published in final edited form as:
J Fam Psychol
. 2011 August ; 25(4): 497–507. doi:10.1037/a0024534.
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Operation Iraqi Freedom (OEF and OIF) have been uniquely characterized by deployments
that are extended, repeated, and associated with relatively high rates of death and injury
(Chandra et al., 2011; Lemmon & Chartrand, 2009; Mansfield et al., 2010). With the advent
of improvised explosive devices and multiple insurgencies, all deployed service members
face the potential of combat regardless of their service role (Chandra et al., 2011). Three out
five of service members have family responsibilities (i.e. spouse and/or children) (American
Psychological Association; APA, 2007). Since the start of OEF and OIF, more than 2
million children of United States service members have been affected by wartime
deployment, including 30,000 youth subject to parental death or injury (Chartrand, Frank,
White & Shope, 2008; Lemmon & Chartrand, 2009).
Given the degree of family involvement among service members, a number of task forces
have been assembled to examine the impact of the deployment cycle on the emotional and
behavioral health of military families (APA, 2007; DoD, 2007). They concluded that
children and families of military personnel are at risk for emotional and behavioral health
consequences of war related stress and strongly advocated for the development and
application of efficacious evidence-based prevention and treatment programs for these
families. Moreover, the President of the United States has made the enhancement of the
“well-being and psychological health of the military family” a top national security policy
priority” (DoD, 2011). A recent report from Center for Military Health Policy Research
(Chandra et al., 2011) offered the following recommendations in this regard: 1) provide
support services for military families with children experiencing emotional difficulties and
longer deployments; 2) offer resources for caregiver support, particularly for the National
Guard and Reserve Components; 3) integrate family communication into support services;
4) implement programs across the deployment cycle; 5) screen for family emotional health;
and 6) require rigorous and systematic research evaluation of services that are developed for
military families.
Despite widespread acknowledgement of the need for emotional and behavioral health
services for military families, many who are in a position to serve them struggle with how to
best respond and select appropriate interventions. The purpose of this paper is to address this
gap by providing an empirically-based and theoretically informed review to guide service
provision and the development of evidence based treatments for military youth in particular.
Specifically, this review includes an overview of the unique stressors and risks associated
with the deployment cycle, emotional and behavioral consequences of deployment for the
non-deployed spouse and child, the relation between parental and youth emotional health,
and the current state of the field on services and interventions for youth from military
families. This review concludes with treatment recommendations for older children and
adolescents experiencing emotional and behavioral health symptoms associated with the
deployment cycle. These recommendations are based on a synthesis of the aforementioned
literatures, culturally sensitive considerations for serving military families, and evidence
based treatment techniques designed to address stress, emotional, and behavioral problems
among older children and adolescents.
Unique Stressors Associated With the Deployment Cycle
There are at least four distinct phases of deployment, including pre-deployment (period from
notification to departure), deployment (departure period), reunion (period of preparation just
prior to return), and post-deployment or re-unification (period after return) (APA, 2007).
According to Pincus (2001), each phase of deployment is associated with unique stressors
and emotions for families. For example, during the pre-deployment phase, families may
experience stress and confusion. Feelings of shock and disbelief as well as worry around the
pending departure and resulting life changes are common. During the deployment phase,
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intense feelings about deployment may begin to fade and the emotional impact of the service
members departure becomes salient. Families may struggle with feelings of loss, grief, and
fear, while also taking on new duties and routines. The re-unification phase may initially be
associated with feelings of extreme joy, but fades into mixed emotions for some families.
Family members may have trouble re-connecting and adjusting to changes in roles, routines,
and responsibilities.
Varied emotional responses expressed by children and their parents stem from a number of
unique challenges associated with the deployment cycle. During deployment, the non-
deployed spouse may have to take on sole responsibility for the household and childcare,
which may include changing employment or assuming a new job to accommodate this role.
The spouse may also face separation strain, loneliness, role overload, role shifts, financial
concerns, and changes in marital roles and feelings for their deployed partner, all of which
become more difficult with longer separation. Providing emotional support to their children
and managing child misbehavior or academic decline can also pose challenges. Other
stressors faced by the military spouse and children include the re-negotiation of boundaries
and family roles (e.g., family schedules, responsibilities, rules), lack of understanding about
deployment from community members, and less time for enjoyable activities, as well as
regular media reports which often relay incomplete information and dwell on the negative
aspects of deployment (Chandra et al., 2011; Huebner & Mancini, 2005).
Similar to deployment, there are also numerous stressors associated with re-integration.
Among others these include: 1) conflict associated with role (e.g., childcare responsibilities)
and boundary issues which require re-negotiation; 2) conflict over household management
issues (e.g., state of household, loss of the spouse’s new found independence, disagreement
over new rules); 3) conflict over new relationships that developed during the deployment; 4)
feelings of abandonment due to prolonged separation; 5) resurrection of old unresolved
problems and the development of new adjustment related problems; 6) negotiating a balance
between independence and attachment to support networks utilized during deployment; 7)
youth rejection of, apathy toward, or anxiety around the returning parent; 8) youth display of
loyalty to the parent left behind and lack of responsiveness to discipline from the returning
parent; 9) worry about the emotional/physical health of the returning service member; and
10) worry about the next deployment (Chandra et al, 2010a; 2010b; 2011; Pincus et al.,
2001).
In general, Lemmon and Chartrand (2009) suggest that the deployment cycle precipitates
normative, tolerable, and toxic stressors, which differentially impact families. They suggest
that normative stressors, which are mild-to-moderate in nature (e.g., brief and non-combat
related deployments), are typically well adapted to by families. Tolerable stressors, which
are moderate to severe in nature (e.g., longer and combat deployments, parental injury or
death), are generally successfully adapted to when adequate support is in place. However,
these tolerable stressors can become severe and toxic, and result in emotional and behavioral
consequences for children and families, when they are chronic in nature and adequate
support is unavailable.
There exists ample research to support Lemmon and Chartrand’s (2009) theory. Longer
deployments have been associated with greater separation and reintegration related
difficulties (Chandra, Burns, Tanielan, Jaycox, & Scott, 2008; 2010b; 2011; Lester et al.,
2010). Youth and caretakers who face greater deployment related stressors and less access to
support, such as older youth and those from the National Guard and Reserve components,
may also be at greater risk for negative health consequences. Specifically, older adolescents
may have to assume significant household responsibilities (e.g., more chores, care for
siblings), face increasing academic demands (e.g., homework, exams, college preparation),
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provide emotional support to others, and can appreciate the danger of deployment. Indeed,
there exists some preliminary evidence to suggest that older adolescents experience more
deployment related difficulties than younger teens (Chandra et al., 2010b; Chandra et al.,
2011).
With regard to differences in components, National Guard and Reserve families do not live
on military bases, do not have access to the same level or quality of services offered on
bases (e.g., free or low cost housing, medical and behavioral healthcare, support services,
like-minded community), and most are geographically isolated from other military families
(Mansfield et al., 2010). Moreover, given their dual civilian and military status, they do not
receive the same level of pre-deployment preparation and training for combat. Further,
despite potential legal ramifications for employers, service members from the National
Guard and Reserve components often lose their civilian jobs prior to, during, or upon return
from deployment. Therefore, it is not surprising that children and adolescents (ages 11-17)
from these families have more difficulties associated with deployment and re-integration,
and that non-deployed spouses report poorer emotional well-being, more household
challenges, and more relationship issues with their spouse, relative to active duty families
(Chandra et al., 2008; 2011).
Emotional Health Consequences of the Deployment Cycle on the Non-
Deployed Spouse
As suggested above, stress associated with the deployment cycle can compromise the
emotional health of the non-deployed spouse. In a sample of 180 spouses of deployed
service members, some common emotional reactions to deployment reported included:
loneliness (78%), worry (74%), sadness (65%), anxiety (56%), anger (37%), headaches
(43%), eating problems (22%-44%), insomnia (48%), nervousness (47%), and concentration
problems (38%) (Wexler & McGrath, 1991). In a sample of 250,626 Army wives, those
with a deployed spouse reported higher rates of depressive (18-24%), anxiety (25-29%),
sleep (21-40%), and acute stress reaction/adjustment (23-39%) disorders than those without
a deployed spouse, with higher rates associated with longer deployments (greater than 11
months). Further, rates of mental health service use were 19% (1-11 month deployment) to
27% (11+ month deployment) higher among wives with a deployed spouse (Mansfield et al.,
2010).
Research conducted with youth from military families and their teachers also suggests that
non-deployed spouses may experience poor emotional functioning. In a focus group study
conducted with adolescents who have a deployed father, consistent themes emerged when
asked “Do you see changes in your at-home parent when the other is deployed?” Many teens
reported that their mothers were more emotional, slept more often, had problems with
concentration, and were more irritable. The majority of teens also reported that their mothers
were stressed out due to increased responsibilities, worry about their spouse, and concerns
over finances (Huebner & Mancini, 2005). In a second focus group study, adolescents
reported strained relationships with the caretaking parent due to parental worry, somatic
illness, and anger (Mmari, Roche, Sudhinaraset, & Blum, 2009). In a study conducted with
school staff, a number of focus groups (42%) and interviewees (63%) perceived that many
youth with a deployed parent had a depressed caretaking parent (Chandra, Martin, Hawkins,
& Richardson, 2010a).
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Emotional and Behavioral Health Consequences of the Deployment Cycle
on Youth
Recent studies have found heightened emotional and behavioral difficulties around the
deployment cycle for youth of all ages, across multiple informants (i.e., parent, youth,
teachers), and using multiple methods (i.e., quantitative, qualitative). For example, Gorman,
Eide, & Hisle-Gorman (2010) found that behavioral and stress disorders increased by 18%
to19% in children (ages 3-8) when a parent deployed, with a concurrent 11% increase in
outpatient visits for youth emotional and behavioral health care. Similarly, Flake, Davis,
Johnson, and Middleton (2009) found that 39% of children (ages 5-12) with a deployed
parent were at significant risk for internalizing symptoms, 29% for externalizing symptoms,
56% had trouble sleeping, and 14% had school related problems.
Qualitative studies have yielded similar results. Huebner and Mancini (2005) conducted
focus groups with 107 adolescents (ages 12-18) attending summer camps for military youth.
Teens were asked to respond to the question “Has your behavior changed since your parent
has been deployed?”. Emotionally, many teens reported a loss of interest in activities, social
withdrawal, changes in sleeping and eating, sadness, crying, and worry about their deployed
parent’s safety. Behaviorally, many teens reported increased irritability and disrespectful
behavior at home and school. Academically, teens reported a decline in grades due to
concentration problems, less time for homework, and less supervision.
Adolescent reports are consistent with observations by school staff. Chandra et al. (2010a)
conducted interviews and focus groups with 148 school staff from elementary, middle, and
high schools who serve children from Army families. More than half of the focus groups/
staff interviewed felt that parental deployments led to anger and sadness for many youth,
which negatively impacted classroom performance and peer relationships. Further, in about
one-third of the middle and high school focus groups, school staff expressed concern about
students engaging in heightened risky behavior (e.g., cutting, promiscuous sexual behavior).
Data from these studies correspond with findings from similar work (e.g., Chandra et al.,
2008; Chartrand et al., 2008; Houston et al., 2009; Lester et al., 2010; Mmari et al., 2009).
Recent increases in the use of mental health services are also evident among youth facing
the potential deployment and re-integration of a parent. Pentagon documents show that
“since the 2003 invasion of Iraq, inpatient visits among military children have increased
50%. The total number of outpatient emotional and behavioral health visits for children of
men and women on active duty doubled from 1 million in 2003 to 2 million in 2008. During
the same period, the yearly bed days for military children 14 and under increased from
35,000 to 55,000. From 2007 to 2008, some 20% more children of active duty troops were
hospitalized for emotional and behavioral health services”
(www.msnbc.msn.com/id/31784856/ns/us_news-military)
Relation Between Parental and Youth Emotional and Behavioral Health
There exists ample evidence to suggest that parental functioning affects youth emotional and
behavioral health (Chandra et al., 2011; Lester et al., 2010). Both attachment theory
(Bowlby, 1969) and family systems theories (see Chabot, 2011 for a review) may be helpful
in explaining why adequate parental emotional health and support during stressful
experiences, such as the deployment and re-integration of a parent, is important to youth
emotional well-being. According to attachment theory, children instinctively form a bond to
their primary caregiver based on their need for survival and security. Children become
securely attached to caregivers who provide consistent care and who are both sensitive and
responsive to their child’s needs. Sensitive caregiver responses also further healthy internal
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working models, or mental representations, of social relationships. In this manner, a secure
attachment bond sets the stage for healthy socio-emotional development. Various stressors
associated with the deployment cycle, such as repeated and prolonged parental absence,
poor parental emotional health, fear of parental loss, and financial trouble, can negatively
impact the attachment bond by interfering with the quality of parental care and threatening
the child’s sense of security. Over time, repeated disruptions in sensitive care-giving can
negatively impact youth psychosocial adjustment and place them at increased risk for
emotional and behavioral problems (Bretherton,1992; Chandra et al., 2011; Mmari,
Bradshaw, Sudhinaraset, & Blum, 2010; Morris & Age, 2009; Stroufe, 2005).
In support of attachment theory, research suggests that prolonged separation from a parent
figure and poor parental emotional health can negatively affect youth adjustment to the
deployment cycle and quality of parental care. As noted earlier, greater cumulative length of
deployment has been associated with greater youth separation and re-integration related
difficulties (Chandra, Burns, Tanielan, Jaycox, & Scott, 2008; 2010b; 2011). Moreover,
parental emotional health problems, such as depression and post-traumatic stress disorder,
have been shown to negatively affect parenting quality and parent-child relationships
(Jordan et al., 1992; Gewirtz, Polusny, DeGarmo, Khaylis, & Erbes, 2010; Restifo &
Bogels, 2009; Ruscio, Weathers, King, & King, 2002). For example, depressed mothers
often display negative affect which can impede effective parent-child communication
(Beardslee, Versage, & Gladstone, 1998), consistent with observations shared by
adolescents in military focus group research (Huebner & Mancini, 2005; Mmari et al.,
2009). Parental depression has also been perceived by school staff to negatively impact
parental engagement in school related activities (e.g., attendance at activities, missed teacher
meetings, homework monitoring)(Chandra et al., 2010a). Similarly, post-traumatic stress
disorder symptoms of emotional numbing among returning service members may lead to
decreased involvement in family activities, poor communication with children, and lower
parenting satisfaction (Gewirtz et al., 2010; Ruscio et al., 2002; Sampler, Taft, King, &
King, 2004), which may in turn compromise quality of parental care and the parent-child
bond.
Numerous studies have also found a direct association between parental and youth
emotional health. Chandra et al (2010b; 2011) found that poorer emotional health of the
non-deployed caretaker was associated with greater youth emotional difficulties as well as
poorer academic engagement and social (peer and family) functioning, during deployment
and re-integration. Moreover, if caretaker emotional problems persisted or increased, youth
difficulties remained higher. Kelley (1994) found maternal depressive symptoms and child
internalizing behavior to be positively correlated at the mid-deployment and upon re-
integration. Lester et al. (2010) found that poorer emotional health of the non-deployed
caretaker (depression and anxiety symptoms) as well as the active-duty service member
(depression and post-traumatic stress disorder symptoms) was associated with youth
internalizing and/or externalizing symptoms, even after controlling for length of combat
related deployments. Others studies with military families have yielded similar results
(Medway, Davis, Cafferty, Chappel, & O’Hearn, 1995; Jordan et al., 1992; Kelley et al.,
2001).
It is also important to note that the relation between parental and youth emotional health is
likely reciprocal in nature. Consistent with family systems theories (see Chabot, 2011 for
review), families function as a relational system. Though symptoms may present as residing
within an individual, they often stem from problems within the family (e.g., organization,
structure, boundaries, functional attachment, emotional processes, differentiation) which
may negatively affect all individual members. Moreover, the emotions and behaviors of
each family member effects other members, as well as the relational system as a whole.
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Indeed, youth in poor emotional and behavioral health also precipitate stressful events and
circumstances within the family system (Rudolph et al., 2000). This process can further
dysfunctional family processes, particularly when a parent’s ability to manage heightening
parenting stress is compromised by poor emotional health. For example, Birmaher et al.
(2004) found that mother-child interactions in families with a depressed youth relative to
families with at-risk or symptom free children, were characterized by poorer quality and
depth of communication, less warmth, and greater tension. Continued maladaptive social
interactions between parent and child may also increase risk for physical violence,
particularly when families are under significant stress. In a review of the literature,
Campbell, Brown, and Okwara (2011), concluded that rates of child maltreatment may be
more common during deployment and re-integration. Overall, these findings highlight the
need for interventions tailored for military youth who experience emotional and behavioral
health symptoms in response to the unique and complex stressors associated with the
deployment cycle.
Existing Services For Youth From Military Families
Over the past several years, there has been substantial growth in the number of services
offered to support military families. There have also been Centers of Excellence funded to
facilitate program development and the provision of technical assistance to military youth
serving professionals of all disciplines (e.g., Child, Adolescent, and Family Behavioral
Health Proponency). Below we review existing prevention and treatment services for youth
from military families, including prevention (psychoeducation, outreach, peer based
programs, family based programs) and treatment services, and conclude with a brief
evaluation of services.
Prevention Oriented Psychoeducation
Numerous psychoeducational websites and materials exist to facilitate youth adjustment to
the deployment cycle and prevent emotional and behavioral health consequences. Examples
of online resources include Military HOMEFRONT (www.militaryhomefront.dod.mil), the
Military Child Initiative (www.jhsph.edu/mci), Military One Source
(www.militaryonesource.com), and the Military Child Educational Coalition
(www.militarychild.org). Psychoeducational video series have also been developed to help
youth cope with deployment. For example, Maj. (Dr.) Keith Lemmon, an active duty US
Army Pediatrician and Adolescent Medicine Specialist, developed the Military Youth
Deployment Support Video Program
(www.aap.org/sections/uniformedservices/deployment/videos.html). This program was
funded by the US Army Medical Command. It includes one video designed to help youth
prepare for and cope with deployment (Military Youth Coping With Separation: When
Family Members Deploy) and a second with re-integration (Mr. Poe and Friends Discuss
Family Reunion After Deployment). Over 200,000 copies of each video have been
distributed to professionals worldwide through MilitaryOneSource. These videos have been
officially endorsed by the American Academy of Pediatrics Committee on Psychosocial
Aspects of Child and Family. This program was designed to support the healthy emotional
and behavioral development of military youth during potentially stressful times in their
lives. It employs testimonials from youth in military families and cartoon portrayals to
convey information designed to normalize common experiences and feelings surrounding
deployment and re-integration, decrease feelings of stigma and isolation, correct
misperceptions, and reduce anxiety and fear surrounding the deployment cycle. The program
also conveys information about evidence based coping strategies, warning signs for
significant emotional and behavioral health consequences, and how to access help from
adults and professionals when needed.
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Prevention Oriented Outreach Services For Youth
Operation: Military Kids is a collaborative outreach program between the U.S Army and
community agencies (over 43 national, state, and local organizations) to support children
and youth with a deployed parent from all branches of the service, both active duty and
reservists. The goal of Operation: Military Kids is to connect military youth with local
resources in an effort to facilitate a sense of community support and enhance their well-
being. Through community partnerships (i.e., Boys and Girls Club of America, 4-H,
Military Child and Youth Services), youth can participate in local recreational, social, and
educational activities and programs (e.g., Hero Pack initiative, clubs, scholarship programs,
sporting events). Another function is to educate school personnel and the community about
the unique needs of military youth and the impact of deployment on families. Similarly, the
Joint Family Support Assistance Program, whose mission is to coordinate or provide family
readiness services and support to military families from all services and components, also
connects youth coping with deployment and re-integration to community based activities
and programs.
Prevention Programs for Youth – Peer Based
A number of peer-based prevention programs have been developed for school and summer
camp settings. School based services typically include resiliency based support groups,
facilitated by school counselors, open to youth with a deployed parent. They are provided on
a school-by-school basis in areas with a heavy constituent of military youth (APA, 2007).
Summer camps are offered by Operation: Military Kids and the National Military Family
Association that are open to youth (ages 11-17) from military families of all ranks and
service. They are designed to help youth from military families, facing all phases of the
deployment cycle, to connect with one another and cope with the stress of war. Operation:
Military Kids offers numerous themed camps focused on fun (e.g., fun and friendly boot
camp, fishing) and resilience (e.g., life skills, deployment training) building activities. The
National Military Family Association offers one general camp for youth (Operation Purple
Camp). Satisfaction surveys completed by youth who participated in Operation Purple Camp
and their parents were quite favorable (Chandra et al., 2008).
Prevention Programs for Youth –Family Based
The Families OverComing Under Stress (FOCUS) project (www.focusproject.org) is a
family-centered resiliency training program for active duty families that is offered at 18
military installations across the United States. It is open to families coping with all phases of
deployment. This program was developed by integrating evidence-based preventive
interventions and adapting them to the needs of military families facing all phases of
wartime deployments. The core intervention components include psychoeducation as well as
emotional regulation, goal setting, problem-solving, traumatic stress reminder management,
and family communication skills. This is a selective prevention program and thus is not
designed to treat youth or family members with diagnosed mental health problems (Lester et
al., 2011).
Family camps are available through Operation: Military Kids and the National Military
Family Association that focus on adjustment to re-integration (e.g., Operation Purple Family
Retreats) and the physical or emotional injury of a family member in war (e.g., Operation
Purple Healing Adventures). Some camps integrate outdoor with evidence-based skill
building activities. For example, the Operation Purple Family Retreat includes evidence-
based family resilience activities developed by the FOCUS Program to facilitate family
connections and closeness through communication activities.
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MilitaryOneSource is a DoD sponsored program that offers short-term, non-medical
counseling via on-line education, 24-hour phone consultation, and in-person sessions (up to
12) to service members from all components and their families. The Joint Family Support
Assistance Program offers similar services including: information/referrals for community
services and support; brief non-medical solution focused counseling and education to youth,
adults, families, and groups; financial education and counseling; and support for deployment
related events. The nature of the counseling services provided through both programs is
time-limited prevention/early intervention focused and addresses stressors associated with
deployment and re-integration.
Treatment Services for Youth
Youth experiencing longer-term emotional or behavioral health problems are typically
referred to behavioral health providers within military treatment facilities or civilian
providers who accept TriCare (military health system community based insurance carrier).
TriCare providers are not comparably trained in military family behavioral health as
providers in military treatment facilities, and their availability is often limited (APA, 2007).
Summary and Evaluation of Existing Services
Figure 1 includes a diagram that links potential youth emotional and behavioral
consequences associated with each phase of the deployment cycle (Chandra et al., 2008;
2010; 2011; Pincus, 1991; Huebner & Mancini, 2005) to the aforementioned services
designed to address them. The figure also depicts the degree of intervention (preventative vs.
treatment) offered through each service and mention of whether the service has received any
empirical evaluation (denoted by *). As is evident, though numerous services exist to help
youth from military families cope with the deployment cycle, particularly the deployment
and re-integration phases, the large majority focus on the prevention of clinically significant
emotional and behavior symptoms among youth. To our knowledge, the only service
available to youth with clinically significant emotional or behavioral health symptoms is
psychotherapy offered in a traditional professional treatment setting. Moreover, though
some services may include the use of evidence based skill building techniques (i.e., videos,
school-based programs, camps, FOCUS project, psychotherapy via some individual
providers), there has been no systematic or published empirical evaluation of the impact of
these services on youth emotional or behavioral health outcomes, or their appropriateness
for military families (APA, 2007; Chandra et al., 2011). Only Operation Purple Camp has
been subject to any empirical investigation but it was limited to satisfaction surveys (APA,
2007; Chandra et al., 2008).
Recommendations for Treatment With Youth From Military Families
As suggested above, programs delivered within the military community tend to focus on
prevention and early intervention, and have not been rigorously and systematically evaluated
(APA, 2007; Chandra et al., 2011). Empirically-supported treatment programs have not been
developed and evaluated for youth with clinically significant emotional and behavioral
health difficulties associated with the military deployment cycle. Below we offer
recommendations for the development and delivery of evidence based treatments for youth
experiencing emotional or behavioral consequences of the deployment and re-integration of
a parent.
According to the cognitive theory of stress and coping (Lazarus & Folkman, 1984),
cognitive appraisals of a stressor mediate the effects of stress and influence choice of coping
strategies. If youth lack confidence in their ability to cope with stress and perceive parental
support to be unsatisfactory, stressors such as those associated with the deployment cycle
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may be appraised as harmful to their well-being, and emotional and behavioral health
problems may result. Therefore, efficacious interventions will need to include the youth and
their non-deployed parent to foster perceptions of support as well as adaptive coping skills
and parenting skills.
Based on the cognitive theory of stress and coping, the first recommendation is to consider
the use of an evidence based treatment approach that incorporates skill building techniques.
Along these lines, cognitive-behavioral therapy (CBT) may offer a particularly promising
approach for youth experiencing emotional and behavioral health problems associated with
deployment related distress. CBT has been shown to be efficacious in facilitating youth
adjustment to stressors that involve parental separation (e.g., divorce) (Stathakos & Roehrle,
2003) as well as addressing symptoms of depression, anxiety, and disruptive behavior (see
David-Ferdon & Kaslow, 2008; Eyeberg, Nelson, & Boggs, 2008; Silverman, Pina, &
Viswesvaran, 2008 for reviews). CBT is designed to alter cognitive distortions and poor
coping skills often found to underlie emotional and behavioral health problems (Crick &
Dodge, 1996; Bogels & Zigterman, 2000; Garber, Weiss, & Stanley, 1993; Joffe, Dobson,
Fine, Marriage, & Haley, 1990). Further, CBT delivered in individual, parent training, and
group formats has demonstrated efficacy with youth (see David-Ferdon & Kaslow, 2008;
Eyeberg et al., 2008; Silverman et al., 2008 for reviews).
The second recommendation is to provide skills training to help youth better cope with the
deployment and re-integration of a parent, and the many associated changes in their
lifestyle. In this regard, youth sessions may comprise of psychoeducation around the
deployment cycle to help normalize feelings, identification of deployment cycle related
triggers for emotional and behavioral health symptoms (i.e., depression, anxiety, anger), and
the introduction and practice of skills (e.g., problem-solving, cognitive restructuring, affect
regulation, relaxation, building social support, communication training) to help youths better
manage the identified stressors. Communication skills should be practiced with peers in
session as well as with parents. According to attachment and family systems theories, family
communication work may be particularly important to help strengthen family relationships
and improve perceptions of caregiver support and security. Moreover, given that emotional
and behavioral health problems place youth at risk for substance abuse, it may also be useful
to devote time to substance abuse prevention work.
The third recommendation is to include skills training for the non-deployed parent in the
intervention. Parent training will likely be needed to assist the non-deployed military spouse
in providing optimal monitoring, guidance, and support to his/her children. During parent
sessions, an ongoing emphasis on ways in which parents can enhance their child’s
adjustment to the deployment cycle using psychoeducation around the effects of the
deployment cycle on youth functioning, and skills training (e.g., problem-solving on how to
approach youth difficulties, cognitive restructuring around irrational parenting beliefs, affect
regulation around parenting, attending to youth positive behaviors, monitoring for youth
negative behavior, behavioral contracting, parent-child communication skills), may be most
helpful. It may also be useful to incorporate psychoeducation and training around how
parents can help prevent youth substance abuse. As many youth dealing with deployment
related stressors experience a decline in grades, instruction in how to best communicate with
school staff and obtain educational resources (e.g., 504 plan, individualized education plan,
special education law) may also be needed. It will also be helpful to provide parents with
guidance on how to help themselves and their teens cope with the potential injury or loss of
the family member.
The fourth recommendation is the provide parents with basic instruction in stress
management techniques as well as clinical referrals as needed. During parent sessions, it
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may be helpful to discuss how to identify and address problems with their own emotional
and physical health. Time devoted to personal stress management skills and self-care skills
may be needed as well as referrals for individual treatment if indicated. This work may help
improve their parenting ability and decrease youth worry and concern over parental health
and support.
The fifth recommendation is to help the non-deployed parent prepare for and/or adjust to the
re-integration of the service member. Psycho-education and skill building around adjustment
to re-integration of the service member may prove useful. The caretaking parent should be
provided with psychoeducation around possible emotional, behavioral, and medical
consequences of deployment on service members (e.g., communication and social
difficulties, anger, post-traumatic stress disorder, substance abuse, suicide, traumatic brain
injury) as well as skills to help their family cope with these changes. This information may
help facilitate a healthy transition for all family members and ease potential relationship
concerns. Information on when and how to access individual behavioral health and medical
services for the service member should also be provided. Family work that includes the
service member upon return home may also be indicated for some families. This need may
be most prominent when the service member participated in combat during war and/or
developed post-traumatic stress disorder , given that these factors have been associated with
more behavior problems in youth as well as poorer parenting skills, family adjustment/
functioning, and marital/relationship problems (Gewirtz, Polusny, DeGarmo, Khaylis, &
Erbes, 2010; Jordan et al., 1992; MacDonald, Chamberlain, & Long, & Flett, 1999).
The sixth recommendation is to consider a group based delivery format when possible.
Research suggests that military teens feel most comfortable sharing with other military peers
who understand these unique stressors as well as military culture (Houston et al., 2009;
Mmari et al., 2009). A group format also allows opportunities for observation, learning,
modeling, and the sharing of skills and experiences. It may also help reduce feelings of
isolation and improve perceptions of peer support. Peer support is particularly important
given that youth from military families may face peer ridicule, rejection, bullying, and attack
by antiwar individuals (Mmari et al., 2009). Optimally youth and parent sessions can be held
concurrently to decrease burden on families. This format will also allow the youth and
parent groups to merge so that each youth and parent can practice skills they have learned
with one another (e.g., communication training).
The seventh recommendation is to ensure that the intervention is sensitive to the military
culture. Providers should be well versed in military culture (e.g., history, core values,
mission, organizational structure, service branches, operations, services, components) and
language. The intervention approach should take into account how various aspects of the
military culture, including unique stressors and resources, impact family behaviors and
perspectives. Military families may also prefer treatments that offer structure and an
authoritarian style, such as the structured and directive approach employed in CBT
(Campbell et al., 2011). Concerns about confidentiality (e.g., fears of stigma and negative
career impact; Campbell et al., 2011) must also be addressed. If a group intervention is
employed, it will be very important to introduce strict rules around confidentiality and
address concerns up front. Guidance for delivering culturally sensitive intervention is
available through readings (e.g., Lemmon & Chartrand, 2009; Whaley & Davis, 2007) as
well as consultation and training with professionals and organizations with expertise in
treating military families (e.g., Uniformed Services Chapters of the American Academy of
Pediatrics and the DoD sponsored Center for Deployment Psychology).
The eighth recommendation is to employ evidence based techniques that can address the
multiple types of emotional and behavioral problems that accompany deployment related
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stress among youth. Use of separate protocols or techniques for the treatment of depressive,
anxiety, and disruptive behavior symptoms can be costly, confusing, require significant
training, decrease the chance that youth will receive treatment for all co-occurring
conditions, and may decrease the likelihood of dissemination (Moses & Barlow, 2006). A
unified treatment approach for emotional disorders has been espoused by Barlow and
colleagues (Moses & Barlow, 2006). Such an approach goes beyond a specific symptom
focus to address broad based problems with common underlying antecedents, such as the
cognitive distortions and poor coping skills that may underlie poor adjustment to
deployment related stressors. As suggested above, CBT in particular, is designed to target
core cognitions and skill deficits that underlie emotional and behavioral health problems
among youth.
The last recommendation is to consider the sustainability and accessibility of developed
services. For sustainability, services must be accessible and reimbursable. They will need to
be endorsed by the military and offered at military treatment facilities. Moreover, to reach
those families who live in civilian settings, TriCare providers will need to be incentivized to
receive training and supervision in these evidence based services as well as reimbursed for
them. Offering evidence based treatment programs in camp and school settings may also
increase accessibility. Engaging primary care providers in the referral and treatment
development process may also be helpful. Given the unprecedented rates of injury among
service members deployed during OEF and OIF, primary care providers are in a unique
position to identify and refer “at risk” military families for intervention services. Last,
accessibility must be balanced with the need to maintain confidentially as military families
access these services.
Conclusions
Military youth are generally resilient and are able to successfully adjust to and cope with
deployment related stressors. However, when stressors become chronic and adequate
support is unavailable, stressors associated with the deployment cycle can lead to youth
emotional and behavioral problems. The majority of programs and services in place to help
youth facing the deployment cycle are prevention or early-intervention focused. Though
some employ evidence-based techniques, few have received any empirical evaluation and
those that have are limited to satisfaction surveys. To our knowledge, no evidence based
treatment programs have been developed and evaluated for youth from military families
experiencing diagnosable emotional or behavioral health problems associated with
deployment related stress. Therefore, rigorous and systematic evaluation of current
programs is needed as well as the development of treatment programs targeted for youth
with clinical levels of emotional and behavioral difficulties (APA, 2007; Chandra et al.,
2011). Youth who face longer deployments and those from National Guard and Reserve
families may be in greatest need of intervention services. Given the difficultly that civilians
often face obtaining approval to work with military families, treatment evaluation and
development may be facilitated through collaboration between civilian and military
personnel with expertise in treatment development, delivery, and dissemination work with
youth and their families, similar to the FOCUS project (Lester et al., 2011).
CBT may offer a particularly effective treatment approach for youth experiencing clinical
symptoms associated with deployment related stress. Substantial empirical support exists for
the use of CBT in treating emotional and behavioral health problems associated with other
stressors involving parental separation (e.g., divorce) as well as youth depressive, anxiety,
and disruptive behavior disorders. It can also be delivered successfully across individual,
parent training, and group formats. A CBT protocol that is sensitive to the culture of the
military, addresses the full range of youth internalizing and externalizing symptoms as they
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relate to the unique stressors associated with the deployment cycle, and includes both the
youth and his/her non-deployed parent may offer a promising approach for youth coping
with all phases of the deployment cycle.
Efficacious evidence-based prevention and treatment programs may not only reduce distress
experienced by the child and military spouse during the deployment and reintegration
phases, but also the service member. Many children and spouses have frequent but
inconsistent contact via e-mail or phone with their deployed family member (Huebner &
Mancini, 2005; Sheppard, Weil, Maltras, & Israel, 2010). Thus, deployed service members
are often aware of the condition of their family back home. Soldiers’ family problems have
been associated with poorer duty and combat performance, greater risk of going AWOL, and
retention difficulties (see Jensen et al., 1986 for a review). Moreover, the service members’
perception of family cohesion and support upon return from deployment has been associated
with future development of post-traumatic stress disorder symptoms (Benotsch et al., 2000;
King, Foy, Keane, & Fairbank, 1999). Therefore, treatments targeted for youth with
deployment related emotional and behavioral problems hold the potential to improve the
service members’ performance and safety during deployment, and emotional and behavioral
health upon re-integration, as well as improve military retention rates.
Acknowledgments
This research was supported by a grant from the National Institute of Mental Health (R34MH082164) awarded to
the first and sixth authors.
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Figure 1.
Potential Youth Emotional/Behavioral Health Symptoms and Associated Services
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