caring for military children in the 21st century

SPECIAL ARTICLE - JOINING FORCES

Caring for military children in the 21st centuryHeather L. Johnson, Lt Col, USAF, NC, DNP, FNP-BC, FAANP (Assistant Professor) & Catherine G. Ling, PhD,FNP-BC (Assistant Professor)

The Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, Maryland

KeywordsMilitary; children; combat; deployment;

behavioral health; family.

CorrespondenceHeather L. Johnson, Lt Col, USAF, NC, DNP,

FNP-BC, FAANP, Graduate School of Nursing,

The Uniformed Services University of the Health

Sciences, Bethesda, MD 20814.

Tel: 301-295-1089; Fax: 301-295-1711;

E-mail: [email protected]

Received: October 2012;

accepted: November 2012

doi: : 10.1111/1745-7599.12003

The views expressed here are those of the

authors and do not necessarily represent the

views of the Department of Defense, U.S. Air

Force, U.S. Navy, or the Uniformed Services

University of the Health Sciences.

Both authors are mothers of military children

and have experienced deployments from

different perspectives. Dr. Johnson is a

Lieutenant Colonel in the Air Force and Dr. Ling

is the spouse of a career Naval officer.

Abstract

Purpose: Civilian healthcare professionals provide approximately 2/3 of thehealthcare for the 2 million U.S. military children. The President of the UnitedStates has made their care and support a top national security priority. Thepurpose of this article is to arm NPs with information necessary to care for the21st century military child by providing current data on military family life,deployments, and the impact on children and their health-seeking behaviors.Data sources: Literature collected from sources identified through searches ofPubMed, CINAHL, and PsycInfo covering the periods from 2003 to 2012.Conclusions: Military children are both resilient and vulnerable. While fre-quent moves build resilience, combat deployments increase the risk for abuse,neglect, attachment problems, and inadequate coping. The risk is highest rightafter the service member leaves for deployment and immediately upon re-turn. Children’s reactions to deployment differ by age, gender, and individualtemperament. There is an 11% increase in outpatient visits for mental or be-havioral health issues during deployment.Implications for practice: Healthcare professionals can support the physi-cal and mental health of children by normalizing expectations and using the ICARE (Identify, Correlate, Ask, Ready Resources, Encourage) strategy to facil-itate prevention and encourage early engagement with available resources.

Introduction

Civilian healthcare professionals provide approxi-mately 2/3 of the healthcare for military children(Gorman, Eide, & Hisle-Gorman, 2010). This is substan-tial given that there are 2 million U.S. military childrenwho are part of this distinct and unique culture. They arelargely geographically dislocated from extended familyand are prone to frequent and prolonged separation fromone or both parents because of military deployments. Ofsignificance, military families move every 2–4 years andwill attend 6–9 different schools before they turn 18.Most will move at least twice during their high schoolyears (National Military Family Association, 2012). Fre-quent moves disrupt the social support network, conti-nuity of care and established resources causing disorder,and the potential for family or child instability (Barker &Berry, 2009; P. Lester et al., 2010). Thus, the culture ofmilitary family life is greatly shaped by the stress and con-

stant change associated with deployments and repeatedmoves.

The President of the United States has recognized thedistinctive nature of military families and has made theircare and support a top national security priority (B.Obama, 2011). Nurse practitioners (NPs) in primary careand specialty roles are on the front lines providing thiscare and support. The purpose of this article is to armNPs with information necessary to care for the 21st cen-tury military child by providing current data on militaryfamily life, deployments, and the impact on children andtheir health-seeking behaviors. “I CARE” can guide theNP in caring for military children.

Military family life

The sheer number of military families is not incon-sequential. There are currently 2.2 million active duty,National Guard and Reserve military service members.

195Journal of the American Association of Nurse Practitioners 25 (2013) 195–202 C©2012 The Author(s)Journal compilation C©2012 American Association of Nurse Practitioners

Caring for military children in the 21st century H. L. Johnson & C. G. Ling

Over 58% of the military have family responsibilities, and40% have at least two children (Flake, Davis, Johnson, &Middleton, 2009). As noted previously, frequent reloca-tion factors greatly into the construct of military familylife. On average, military children engage five differentschool districts in their academic career. It is a commonmisconception that relocating every 2–4 years is detri-mental to military children. In actuality, frequent relo-cation (known in the military as permanent change ofstation or PCS) is associated with improved coping, re-silience, and fewer school problems (Kelley, Finkel, &Ashby, 2003; Weber & Weber, 2005).

Overall, military adolescents are less prone to riskysexual and substance use behaviors than their civil-ian counterparts (Hutchinson, 2006; Klein & Adelman,2008). Possible reasons for this aversion to risk-takinginclude: having access to confidential services, a phys-ical community shared by military families on and offmilitary bases, resilient peers and parents with job se-curity. Also, relocation allows children the opportunityto start over and recreate themselves while limiting theinfluence of destructive peer groups (Hutchinson, 2006;Weber & Weber, 2005).

Because military children move so frequently, they aresometimes reserved and difficult to get to know and attimes may come across as aloof or “bratty.” The “mili-tary brat” is an old adage used to describe children raisedin military families. It is actually more complicated thansimply being distant. Reductions in the size of the mil-itary have led to smaller military communities and lackof a military-based peer group. Children who are fortu-nate enough to live on or near a base are immersed inmilitary culture and have immediate access to militaryspecific support systems such as health care, family sup-port centers, and other children who are familiar withtheir unique culture. Children of National Guard and Re-servists may not have the same access.

Members of the National Guard and Reserves are the“citizen soldiers” who live and work in civilian communi-ties across the country. When the Guard or Reserve par-ent is “called up” to active duty, the children must sud-denly become “military.” They may be the only child intheir school system to have a military parent and there-fore lack an understanding support network. Their onlyexposure to the military may be what they see on tele-vision, which only serves to increase anxiety. These anx-ieties can partially be mitigated through strong commu-nity support.

Sustaining military families has become a priority inthe United States. “Joining Forces” is a White House ini-tiative to provide opportunities and support for militaryfamilies (M. Obama & Biden, 2012). Flake et al. (2009)found that most military families (82%) feel supported

overall. Sixty-four percent of families find their supportthrough military groups and organizations; 48.5% findsustenance through churches and religious organizations;25% through nonmilitary groups and organizations likeschools, boy scouts, and other civic groups; and 22%through nonlocal family (Flake et al., 2009). Numerouschildren find their family pet and/or peers to be goodsources of support (Fitzsimons & Krause-Parello, 2009).For many families, living on base offers the advantages ofaccess to sports, youth activities, a strong military com-munity, and peers who understand the military lifestyleand deployments.

Despite, or because of, frequent moves and ad-justments, the majority of military children are veryresilient. Family cohesiveness and strong mother–childrelationships are associated with adequate psychosocialadjustment and resilience (Kelley et al., 2003; Lincoln,Swift, & Shorteno-Fraser, 2008). Resilience makes mil-itary families exceptional, but they are still vulnerable.Deployments and the deployment cycle contribute to thisvulnerability.

Deployment and vulnerability

Deployment is the name given to the movement of anindividual or a military group (unit) to accomplish a taskor mission. A deployment may be for routine trainingor dangerous overseas combat. Since the onset of Opera-tion Iraqi Freedom in 2003 and Operation Enduring Free-dom in 2002, 2 million Soldiers, Marines, Sailors, and AirForce personnel have been deployed (B. Obama, 2011).In general, they are away from home anywhere from 6 to18 months. Deployments reoccur after a period of time athome depending on the service branch and job of the mil-itary member. During a deployment, communication andvisits home are limited. In addition to separation, childrencan also be anxious for their parent’s safety. That anxi-ety may be justifiable given that as of July 5, 2012, therewere 1981 fatalities and 16,024 wounded in action insupport of Operation Enduring Freedom and 4488 deathsand over 32,000 wounded in action in support of Op-eration Iraqi Freedom and Operation New Dawn in Iraq(U.S. Department of Defense, 2012).

By 5 years of age, 40% of military children have beenaffected by deployment (Flake et al., 2009). Some fam-ilies are particularly impacted by parental deployment,notably the 95,187 families with both parents in the mil-itary (dual military), 74,086 families with single parents,and 102,053 families with children with special health-care needs (CSHCNs). During the military member’s timeaway from their home base, or deployment, 30%–50% offamilies relocate to the hometown of one of the parents

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H. L. Johnson & C. G. Ling Caring for military children in the 21st century

to seek support from extended family. Those who haveschool-aged kids tend to stay put (Flake et al., 2009).

Multiple deployments have taken their toll on militaryfamilies. Prior to 2001, the rates of substantiated abuseand neglect were lower in the military than in the civil-ian population. Since the increase in deployments andstress on the military post September 11, 2001, thoserates have doubled and, according to some studies, nowexceed the civilian population (Gibbs, Martin, Kupper, &Johnson, 2007; Lamberg, 2008; Rentz et al., 2007). Inaddition, substantiated abuse and neglect rates are 42%higher right after the service member leaves for deploy-ment and immediately after the return from combat de-ployment than at any other time (Gibbs et al., 2007).A move to a new area or military base right before orafter a deployment can compound this risk (Barker &Berry, 2009). Multiple stressors, social isolation, difficultyaccessing available resources, financial and lifestyle is-sues, and the private nature of military members andtheir families contribute to the risk for abuse, neglect,and long-term psychosocial dysfunction of some of thesechildren.

Up to 1/3 of military children are considered “high-risk” for psychosocial morbidity and 19% are “at-risk” formaltreatment (Flake et al., 2009; Ternus, 2010). Rates ofmaltreatment are highest in children less than 4 years ofage and in children with special needs, particularly dur-ing the time immediately following deployment or returnof a parent (Rentz et al., 2007). As is the case with mal-treatment in civilian communities, neglect is more com-mon than abuse (McFarlane, 2009). Predictably, a care-giving parent who is immature, has poor coping skills,or has mental illness is more likely to have a childwith psychosocial problems (Chandra, Martin, Hawkins,& Richardson, 2010; Manos, 2010; Ternus, 2010). It maybe that the child learns poor coping skills, or sees thatmom (or dad) is stressed, distressed, or distraught dur-ing the other parent’s absence and learns that this is howthey are supposed to act. Predictors of psychosocial symp-toms in children of deployed service members include

Pre-deployment (3 to 6 months)

Deployment (1 to 15 months)

Post-deployment (days to months)

Figure 1 The three-phase deployment cycle.

high parental stress, younger parent age, shorter durationof marriage, and lower socioeconomic status (Flake et al.,2009). Mitigating factors for risk of abuse and neglectduring deployment are college level education, militarysupport, community or religious support, and employ-ment of the nonactive duty parent outside of the home.Deployment carries not only psychosocial risk and chal-lenges for the military family it is also follows an emo-tional cycle.

Deployment cycle

Many sources describe five to seven phases of the emo-tional cycle of deployment (Pincus, House, Christenson,& Adler, 2012; Riggs & Riggs, 2011). For simplicity, thisarticle will distill this cycle into three phases: predeploy-ment, deployment, and postdeployment (Figure 1). Eachphase carries with it tasks or challenges that military fam-ilies must meet in order to constructively move througheach phase. The length of the overall deployment cyclevaries across the Army, Navy, Air Force, and Marines. Itis important to remember that service members are al-ways in some phase of the deployment cycle (Table 1).

Table 1 Deployment phases, time frames, and associated tasks

Deployment phase Description Time frame Tasks to accomplish

Predeployment Get ready to deploy—training, preparation, packing 3–6 months before deployment Detachment

Reorganization

Deployment (also called

sustainment or

maintenance)

Time away from home—actual movement to and

time at the duty location

1–15 months Daily living

Division of labor

Anticipation of reunion

Postdeployment (also called

redeployment,

reintegration, or reunion)

Return from deployment—reintegrating with family

and military unit, resting, recuperating to prepare

for predeployment phase

Days to months depending on branch

of service

Reunion

Reintegration

Reorganization

Sources: Pincus et al. (2012) and Riggs and Riggs (2011).

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Each of the emotional tasks associated with the de-ployment cycle centers around roles, relationships, andconstant redefinition. Each parent, whether deployed orat their home base, must adapt parenting style to re-flect daily availability (DeVoe & Ross, 2012; Willerton,Schwarz, Wadsworth, & Oglesby, 2011). Depending uponage, children also adapt their roles to reflect more adultresponsibilities. Once the deployed parent returns, rolesand responsibilities must be renegotiated and the return-ing parent reintegrated into daily family life. Failure torespond to or accomplish these tasks places the fam-ily and children at risk for poor health and relationshipoutcomes.

Age-specific concerns and the deploymentcycle

Children’s experiences during the deployment cyclediffer by age, genders of the child and deployed parent,as well as individual temperament. The manifestations ofa child’s stress during the deployment cycle are describedin terms of internalizing and externalizing behaviors, so-matic signs and symptoms, and changes in academic per-formance. Internalizing behaviors are emotions that areturned inward and manifest with symptoms such as anx-iety, depression, and being withdrawn. Externalizing be-haviors are outward behaviors such as aggression, im-pulsivity, defiance, and tantrums (Flake et al., 2009). Acomprehensive analysis of the experiences of children af-fected by deployment and combat injury is beyond thescope of this article, but a brief description of select find-ings of children in the adolescent (12–18 years), school-age child (5–12 years), and young child (<5 years) agegroups is provided.

Adolescents have unique stressors related to the de-ployment cycle. In the predeployment period, teens fearthat the remaining caregiver may be inadequately pre-pared to care for them and express this through ineffec-tive coping, crying, and temper tantrums (Fitzsimons &Krause-Parello, 2009). Mixed emotions, anger, sadness,and loneliness accompanied by changes in diet, exercise,and school performance punctuate parental deployment.Many adolescents have added roles and responsibilities,boundary ambiguity, and a new level of autonomy. Riskybehavior increases as much as 75% when mom is de-ployed and sexual activity and teen pregnancy may in-crease when dad is deployed (Klein & Adelman, 2008;Ternus, 2010). The end of the deployment is a time ofintense anticipation during which the adolescent is ex-cited but anxious about the homecoming because of thepossible changes in routine, expectations, and loss of in-dependence. Post deployment is a very difficult time forthe parent and adolescent. Adolescents have difficulty re-

sponding to discipline from the returning parent. Return-ing parents often have difficulty adjusting to changes inthe home and want to return to old styles of disciplineand caretaking, leading to resentment (Chandra et al.,2010; Fitzsimons & Krause-Parello, 2009).

School-age children portray statistically significant ratesof internalizing (29%) and externalizing (39%) symp-toms during deployment, though symptoms differ bygender (Flake et al., 2009). Parents report concerns aboutattention (13%) and trouble sleeping (56%). School re-lated trouble is described by 14% of parents includingdropped grades, decreased school interest, and teacherconflict (Flake et al., 2009). Girls are more likely todemonstrate problems during the deployment, whileboys, who may have been the “man of the house” duringthe deployment, show more problems during reintegra-tion of the family (P. Lester et al., 2010). Duration of de-ployment correlates highly with caregiving parent stressand high caregiver stress is associated with an increase inchild symptoms. Therefore, the longer the deployment,the more caregiver stress and child symptoms are exhib-ited (P. Lester et al., 2010). Children who are perceivedto be “difficult” by their caregiver tend to have more dys-functional interactions (Flake et al., 2009).

Unlike with adolescent or school-age cohorts, youngerchildren exhibit no single, simple effect. In this group,the temperament of the child is the best predictor of psy-chosocial functioning. Behavioral issues tend to begin atthe time of deployment and increase by the number ofdeployments and number of months of deployment, withinfants experiencing fewer behavioral changes (Barker& Berry, 2009). Attachment problems occur at reunionand worsen with each subsequent deployment (Gormanet al., 2010). Dysfunctional family relationships can havea significant impact on reattachment, especially if thechild was shuffled from caregiver to caregiver while theparent was away. In the period following return, youngerchildren will have mixed reactions. One moment thechild may act like they do not care if the parent is home,the next they may have a tantrum because they do notwant the parent to leave the house at all. This is a verydifficult time for both parents and children. Some chil-dren have said, “Daddy (or Mommy), please don’t leaveme, I’ll be good” to a returning parent in anticipation ofmom or dad leaving the home for even an hour.

No matter the age of the child, each phase of thedeployment cycle poses challenges. When viewing thiscycle over a service member’s career, it should be remem-bered that the impact of combat deployments on chil-dren tends to accumulate (Manos, 2010). More monthsof combat deployment equals greater impact on thechild. How profound might this impact be given thatsome service members may be deployed for half of a

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Table 2 The I CARE support strategy

Acronym Associated task

I Identify

� Military children in your practice

� The military-specific resources at the immediate disposal of the family (active duty, Guard and Reserve)

� Where the family is in the deployment cycle

� When the family last moved/anticipates moving again

� Risk factors and mitigating factors for abuse, neglect, and inadequate coping

� Coping patterns of the child and caregiver in previous deployments

C Correlate

� Healthcare factors (developmental stage, complaints, treatments) in the context of each individual child

� And provide routine health care prior to the deployment to prevent unnecessary trips

� Family and teacher concerns about the child. Take all concerns seriously as we tend to underestimate how well the child is coping.

A Ask

� About coping and roles/responsibilities at each visit. Military families are very private. They may only divulge information about poor

coping if asked. Open the door for the family to contact you should the need arise.

� How the family will ensure a smooth deployment and reintegration

� What has changed since mom/dad has returned

R Ready Resources

�Maintain a list of local and national resources, including the closest military medical treatment facility and family support center. These

resources provide a range of services for active duty, Guard and Reserve members, and their families ranging from specialty care,

financial advice, stress management classes and groups, and referral services.

� Encourage families to engage local support services and schools, religious organizations, civic associations, youth groups, boy

scouts, girl scouts, etc., prior to deployment. They may not have the time or wherewithal to do so once a deployment occurs.

� Ready resources that can be investigated or accessed through

• Military One Source www.MilitaryOneSource.mila an officially sanctioned web site, which offers resources for every phase of military

life from parenting, finance, tax, recreation, and childcare to health information. They offer behavioral health screening and 8–12

visits with a behavioral health provider without a referral and a host of other online supports, financial benefit information,

educational resources, moving guides, and links to other helpful resources.

• The Military Child Education Coalition www.militarychild.orga a not-for-profit organization dedicated to providing quality educational

opportunities and resources for military connected children. They offer peer-based support programs in schools and online.

• The National Military Family Association www.militaryfamily.orga a not-for-profit organization dedicated to supporting and

strengthening military families.

E Encourage

� Prevention strategies

� Strong families and healthy problem solving

� Early involvement in local and national support services

� Healthy expectations during and after deployment

aThese are only a few of the online resources available. Providers should investigate the resources that would be most useful to their population. The

authors are not responsible for the content of these web sites.

child’s life or longer? The cumulative effect is also seenin attachment patterns on reintegration. Each succes-sive deployment worsens reattachment (Barker & Berry,2009).

Health and health-seeking behavior duringdeployment

Deployments not only change household dynamics, italso impacts a child’s health. Somatic symptoms are ex-pressed in response to stress and distress during deploy-ment. Evidence suggests that elevated heart rate andsystolic BP, appetite changes, nightmares, and sleepdisturbance occur in clinically and statistically signif-

icant numbers in military children who are stressed(Fitzsimons & Krause-Parello, 2009; Lemmon & Char-trand, 2009). Symptoms that could present, but were notdescribed in these studies, include frequent complaintsof upset stomachs, headaches, neck and back pain, andjitteriness.

Health-seeking behavior for military children changesduring deployment. There is an 11% increase in outpa-tient visits for mental and behavioral health issues duringa parent’s deployment, despite an overall 11% decreasein outpatient visits during the same phase (Gorman et al.,2010). Behavioral and stress disorders are coded 18%–19% more frequently during parental deployments. Mostof these visits are to primary care clinics. Because

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Table 3 Anticipatory guidance: Normalizing expectations for reintegration

1. No matter how stressed or exhausted the caregiving parent is, it is unrealistic to expect the returning parent to be able to “take over.” The returning

parent needs time to adjust to:

� Changes in themselves

� Changes in the home

� Child’s growth and development

� Role changes

� Child independence

� Attachment issues

� Reaction to attempts at discipline

2. The family needs time to adjust to changes in the returning parent. Military members must be hypervigilant and hyperaroused when they are

deployed or they put themselves and their unit at risk. It is impossible to simply turn off this reaction. It takes time and adjustment. The returning

parent and their family should be encouraged to seek help if they have difficulty adjusting to life at home.

3. In order to set realistic expectations for reintegration, the returning parent should be made aware in advance of changes in the home that have

worked (Esposito-Smythers et al., 2011).

4. To avoid unnecessary risk and vulnerability, generally, the returning parent should avoid disciplining the children until the family has successfully

reintegrated and adapted.

5. Both parents should expect their children to be especially clingy or seemingly aloof on the return of the parent. Patience and a certain amount of

tolerance to this behavior should be encouraged during this transition.

6. Critically, the home front parent should communicate that the deployed parent was missed and is still needed, especially if the household ran

smoothly while they were away.

Sources: FOCUS (n.d.) and Esposito-Smythers et al. (2011).

caregivers must prioritize which issues warrant a visit toa healthcare provider, it is imperative that health con-cerns by caregivers and teachers during this time periodbe taken very seriously.

Demographic characteristics influence health-seekingbehavior during deployment. Older children and childrenof married parents have more outpatient mental and be-havioral health visits. When a male parent is deployed,frequency of outpatient visits increases. The opposite ef-fect is seen when the deployed member is female. Thiscould be from a combination of factors including gender-specific differences in the behavioral response of childrento deployment, increased recognition of child issues dur-ing deployment, or the difficulty in bringing issues to pro-fessional attention. Among the most common mental andbehavioral health disorders coded in military children areattention deficit-hyperactivity disorder (ADHD), adjust-ment disorder, autistic disorder, and speech and languagedisorders (Gorman et al., 2010). The challenges posed bythe military lifestyle, deployments, and phases of the de-ployment cycle present a unique opportunity for health-care providers to support the physical and mental well-being of military children.

I CARE about military children

Healthcare professionals can support the unique needsof military children and their families using the acronym ICARE (Table 2). The acronym I CARE stands for Identify,Correlate, Ask, Ready Resources, and Encourage. Each ofthese elements is foundational in creating a supportive

network throughout the deployment cycle. This supportshould focus on prevention strategies as well as treatment(Esposito-Smythers et al., 2011).

To properly support military children, providers mustfirst Identify military children in their practice and wherethey are in relation to deployment and moving. Remem-ber that children of National Guard and Reservists are in-termittently “military” and may not have the benefit of amilitary community. Recognizing children who are at riskfor neglect, abuse, and inadequate coping, as well as pre-vious patterns of coping and potentially mitigating factorsis integral to the Identify step.

The second step is to Correlate. Correlate refers to con-sidering the developmental stage, presenting complaints,and treatments in the current holistic context of the mil-itary family. Providing routine health care prior to de-ployment and taking all concerns about the child veryseriously are key aspects to Correlate.

Ask is the third component of the strategy. Providersshould not assume that any part of a military child’slife is static. Ask the child and caregiver about changesin household composition and coping at each visit.Providers can also use scales, like the Pediatric SymptomChecklist, that have been used with military families toidentify those children who are at risk for psychosocialdysfunction (Aranda, Middleton, Flake, & Davis, 2011).Finally, it is important to inquire about plans for a smoothdeployment, reunion, and reintegration.

Healthcare providers should Ready Resources througha variety of local and national services in the fourth step.Local resources, including Military Medical Treatment

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Facilities (MTF) and family support centers, provide a va-riety of services that vary by location. These centers serveActive Duty, Guard and Reserve members, and theirfamilies. Many resources are not limited by geographiclocation (Esposito-Smythers et al., 2011). Nationalresources accessible through the worldwide web includeassociations such as: Military One Source, the MilitaryChild Education Coalition, and the Military FamilyAssociation. Benefits include referrals for mental healthcounseling, childcare, summer camps, financial, and ed-ucational resources. Some programs are service specific,for example, the FOCUS project provides family-centeredresilience training for Sailors, Marines, and their families(FOCUS, n.d.; P. E. Lester, 2012). Religious and non-military organizations, youth groups, schools, and othercivic organizations are also helpful in supporting militaryfamilies.

The final means of providing support for military chil-dren and families is to Encourage. Encourage strong fami-lies and healthy problem solving through a variety of pre-vention strategies and early involvement with local andnational support services. In addition, it is crucial to en-courage and normalize expectations of the entire familythrough the deployment cycle. Table 3 contains antici-patory guidance aimed at normalizing expectations andmitigating risk and vulnerability before and during rein-tegration. These items should be reviewed with the ser-vice member and the family before the service memberleaves their deployed area to return home. The capac-ity to address the tasks of the deployment cycle is dy-namic and changes for all members of the family bothchronologically and developmentally. A continuous cycleof Identify, Correlate, Ask, Ready Resources, and Encour-age provides a support base focused on prevention andearly intervention.

Conclusion

Military children are part of a unique culture that isboth resilient and vulnerable. While frequent moves canbuild resilience, combat deployments increase the riskfor abuse, neglect, attachment problems, and inadequatecoping. The risk for abuse and neglect is highest right af-ter the service member leaves for deployment and imme-diately upon return from deployment. A move in closeproximity to a deployment compounds this risk. Chil-dren’s reactions to deployment differ by age, gender, andindividual temperament. There is an 11% increase in out-patient visits for mental or behavioral health issues dur-ing deployment. Healthcare professionals can support thephysical and mental health of children by normalizingexpectations and using the I CARE strategy to facilitateprevention and encourage early engagement with avail-

able resources. Risk and vulnerability during reintegra-tion can be somewhat mitigated by reviewing anticipa-tory guidance in advance of the return of the deployedservice member.

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