Children of Combat Veterans Army Family Readiness Advisory Council Alexandria, VA September 2007

1. Children of Combat VeteransArmy Family Readiness Advisory CouncilAlexandria, VA September 2007 Stephen J. Cozza, M.D. COL, U.S. Army (Retired) Associate Director, Center for the Study of Traumatic Stress Child and Family Programs Professor of Psychiatry Uniformed Services University of the Health Sciences

2. Center for the Study of Traumatic StressUniformed Services University Focus:Education Consultation Research TrainingTopics:Trauma Disaster Terrorism War Community Resilience www.centerforthestudyoftraumaticstress.org

3. Public Education http://www.centerforthestudyoftraumaticstress.org

4. Homer’s Odyssey andthe Military Family

5. War: A Traumatic EventTraumatic Experience vs “traumatized” Individuals Exposed Communities/ Populations Exposed Intentional War assault robbery rape Unintentional accident MVA injury Human Made War industrial acc. plane crash toxic exposure Natural hurricane earthquake tornado Like all trauma war trauma can result in powerful consequences

6. Understanding War Trauma • Children are affected by their parents’ traumatic experiences as well as their own • Little scientific information about impact of parental combat exposure on children • Equally dangerous to assume uniform resilience or uniform problems as a result of war exposure • A real accounting of the trauma and its effects is an opportunity to honor the service and sacrifice • War trauma is a primary source of difficulty for all military family members (combat experience, deployments, separations)

7. Reality About Combat • The combat environment is harsh and demanding • Fear in combat is ubiquitous • Unit members will be injured and killed • Combat impacts every soldier mentally and emotionally • Soldiers are afraid to admit that they have a mental health problem • Deployments place a tremendous strain upon families

8. Unique Challenges in Theatre

9. Unique Challenges in Theatre

10. Unique Challenges in Theatre

11. Improvised Explosive Devices IEDs in Iraq

12. IMPROVISED EXPLOSIVE DEVICE (IED) Reported 11 July 2007 source: http://www.icasualties.org/oif/ AUGUST 16, 2006: 1,666 bombs exploded in Iraq in July, “the highest monthly total of the war.” New York Times

13. U.S. Injured in Iraq U.S. Injured In Iraq U.S. Wounded Reported 11 July 2007 source: http://www.icasualties.org/oif/

15. Injured By Staten=26,528 Reported 11 July 2007 source: http://www.icasualties.org/oif/

16. U.S. and Coalition Fatalities in Iraq Reported 11 July 2007 source: http://www.icasualties.org/oif/

17. Combat Stress Reactions

18. Psychiatric and Behavioral Responses to War and Combat • Change in Sleep • Decrease in Feeling Safe • Isolation (staying at home) Distress Responses Health Risk Behaviors (changed behavior) Mental Health/ Illness • Smoking • Alcohol • Reckless driving • Anxiety • PTSD • Depression • Resilience

19. Psychiatric Sequelae to Combat Exposure Hoge CW, Castro CA and Messer SC et al: New Eng Jour of Med, 1 JUL 04 Hoge CW, Auchterlonie JL, Milliken CS: JAMA, 1 MAR 06

20. Percent of Soldiers Screening Positive • From WRAIR Land Combat Study and NEJM July 2004 Hoge, et.al.

21. Percent Screening Positive for PTSD by Number of Firefights [%] • From Hoge, et. al., NEJM July 2004

22. Resilience Variability in Trauma Response functional illness Time of trauma

23. Graduated Tiers of Intervention Pyramid of Resilience Healthy Community Support Command Actions Support services Education Self-help services At Risk Support toward Resilience Mental Health Support Clinical Treatment Psychoeducation Skill Building Communication Disequilibrium Avoid complicating factors Illness

24. Principles of Psychological First Aid a non-treatment intervention calm reassurance basic information about trauma response provide comfort and support establish and ensure safety connection with community resources

25. Service Members 43.3% n=2,284,262 Family Members 56.7% n=2,992,719 Our Military Community Health of military children and families 44% military members have children Military children are our nation’s children, a national resource Military children are our future Total N=5,276,981 1st Quadrennial Quality of Life Review DoD, 2004

26. The Recovery and Social Environment Military service member is contained within layers of support systems Transactional interplay between layers Interaction may be mutually helpful or disruptive Family is the closest social support Important to maintain function in all roles – spouse and parent Community Military Community Family/Children Service Member

27. Military Family Challenges Deployment *transient stress *modify family roles/function *temporary accommodation *reunion adjustment *military commun maintained *probable sense of growth and accomplishmt Injury *trans or perm stress *modify family roles/function *temp or perm accommodation *injury adjustment *military commun jeopardized *change must be integrated before growth Psych Illness *trans or perm stress *modify family roles/function *temp or perm accommodation *illness adjustment *military commun jeopardized *change must be integrated before growth Death *perm stress *modify family roles/function *permanent accommodation *grief adjustment *military commun jeop or lost *death must be grieved before growth S T R E S S L E V E L

28. Military Deployments

29. Corrosive Impact of Stress • Disruption of family equilibrium • Distraction of responsible parties • many contingencies to address • manage anxiety and personal stress • potential impairment of role functioning • Disruption of relationships, interpersonal strife, loss of attachments • Most dependent are most vulnerable in the process • Reduction of Parental Efficacy – the availability and effectiveness of the service member and spouse • Target Parental Efficacy as key to child health

30. Child Maltreatment and Deployment • Rentz ED, Marshall SW, Loomis D, et al., Am J Epidem 2007 • Gibbs DA, Martin SL, Kupper LL, et al., J Amer Med Assoc 2007 • McCarroll JE, Fan Z, Newby JH, et al., Child Abuse Rev, in press • Elevated rates of child maltreatment during combat deployment periods • Greatest rise in maltreatment appears to be attributed to child neglect • Rates of child neglect appear highest in junior enlisted population

31. Army Neglect Data (FY 2006) Percent of Neglect Cases by Sponsor Rank

32. IMPACT OF PARENTAL PSYCHIATRIC ILLNESS ON MILITARY CHILDREN • Parental psychiatric illness • disrupts parental role • modifies parental behavior • disrupts child development • child confusion and cognitive distortion • increases risk behaviors • possible domestic violence • substance misuse • Avoidance – withdrawal of parental availability

33. Parent Guidance Assessment Post Combat Injury

34. Background Information and Demographics Deployment Data Nature of Injury Notification Process Cascade of Events Communication Parental Emotional Responses Child Emotional and Behavioral Responses Hospital Visits Future Plans Domains of Interest

35. Impact of the Injury on the Child • The meaning of the injury to the child • Child’s developmental limitations of understanding • Time of parental distraction and preoccupation with injury • Child must modify the internal image of his injured parent • Health requires developing an integrated and reality based acceptance of parental changes

36. Impact of the Injury on the Family • remember there is no such thing as an injured service member: think injured service member FAMILY • Disruptions in family structure • change in domicile, family constellation, neighborhoods, schools and peer/social groups • Possible loss of AD military status and/or military community benefits • Disruptions in parenting • change in disciplinary style, emotional support or availability • change in personality or cognitive ability • Psychological First Aid Intervention • Monitor for longitudinal changes in functional status of all parties

37. C H I L D S T R E S S L E V E L 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 T I M E (months) Trauma Response is a Process Not an Event Change in parent/family change in parenting ability fear of loss of parent Change in home/community separation from non-injured parent Fear of parental death move from community Separation anxiety hospital visits Health facility exposure

38. Impact of the Injury on the Parenting Process • Need for mourning related to body change and/or functional loss • Self concept of “idealized parent image” is challenged • Must develop an integrated sense of “new self” • Parental attention must be drawn to child’s developmental needs • Explore new mutually directed activities and play (transitional space) that allows parent and child to “try on” new ways of relating

39. Parental Death in Military Families • Family and child grieving • Potential loss of military community support • Probable family relocation • Change of schools • Services typically shift to the civilian community • Early parental death is a known contributor to compromised child outcomes • Consider traumatic grief

40. Resilience • The ability to function effectively and growin the face of adversity or challenge • NOT the lack of discomfort • NOT returning to “the way I/we used to be” but Living in the New Normal™. • May be applied to individual, family, or community functioning

41. National Community Resilience a recovery and social environment that would lend opportunities for the military family to re-equilibrate after redeployment or trauma event an environment that acknowledged the multiple stresses that military families have experienced without minimizing nor pathologizing a recovery environment that meets the broad basic support needs of all service members and families ranging in intensity from no-risk to high risk

42. Strategies for Health Promotion Knowledge Attitudes SMs Families Children Communities Behaviors

43. Tasks for Military Children when Parents Return from War • Develop an age-appropriate understanding of what the parent went through and the reasons why • Accept that they did not create the problems they now see in their families • Learn to deal with the sadness, grief and anxiety related to parental injury, illness or death • Accept that the parent who went to war may be “different” than the person who returned – but is still their parent • Adjust to the “new family” situation by: • staying hopeful • having fun • being positive about life • maintaining goals for the future

44. Civilian Community Family Military Community Children SM Schools Health Care A Coordinated Effort Military Population In Flux Change of station between communities Transition to civilian life National Guard and Reserve units Medical and psychiatric discharges Know your role Think about function across organizations

45. Military Child Resiliency Building ModelA Community Effort School Valued Role Medical care Parental Efficacy Command Family Sense of Meaning Military community

46. Coming Together

47. scozza@usuhs.mil