Primary care settings front line in battle against military children's psychosocial issues

LAS VEGAS — Military children cope with a unique mix of stressors, and warning signs of underlying pyschosocial issues are frequently missed by teachers and neighbors. Primary care clinicians should be on the lookout for signs and symptoms of these problems as more troops come home from the wars in Iraq and Afghanistan, according to a researcher at the American Academy of Nurse Practitioners 26th Annual NP meeting.

Since Operation Desert Storm in 1990, the military has shrunk in size to nearly one-third of what it was, U.S. Air Force Lt Col. Heather L. Johnson, FNP-BC, of the Uniformed Services University in Bethesda, Md., told audiences here.

This downsizing and two prolonged wars  have translated to longer and more frequent deployments for military parents. More than 1.6 million U.S. military personnel have been deployed for at least one tour of duty since 2002, but many have been deployed as many as eight times.

“For the first time in the history of war, the number of psychological injuries has exceeded physical wounds,” Johnson said.

And this number includes children of military parents. One third of military children are at high risk for psychosocial morbidity and 19% are at high risk of maltreatment, according to Johnson.

“We want to identify those that are at risk before they need services: before their parents are deployed,” she said.

Military life involves periodic disruptions of social support networks, and military children rarely live near extended family, Johnson said. Military families tend to move more frequently than civilians — every two years, on average. 

For many children moving can have positive effects, Johnson suggested, like limited influence from “high-risk” peers.

But for others boys and girls, it can be isolating and may disrupt medical and psychological care.

“Moves disrupt social support networks and the continuity of care,” she said. “Some children have attended eight different schools by the time they are 18 and on average, have been in five different school systems. When you move it's difficult to find new psychologists, clinicians and even Scouting groups.”

Deployment can add disruption of family structure and cohesion to the mix, eroding children's sense of security. 

Parents' deployments – and returns from deployment – can be significant sources of emotional and even physical stress and maladjustment, Johnson said. Although military adolescents tend to be more risk-averse than civilian teens, military girls are more likely to become sexually active or pregnant during a father's prolonged deployment, Johnson said.

Deployments can affect a child's attachment to a parent, as well. “There's a cumulative impact; with each redeployment, it's much harder for the children to re-attach,” Johnson noted.

And some military parents are bringing the war home with them, putting children at risk for neglect or abuse.

“Members are expected to be aggressive, violent, hyperaroused and hypervigilant during deployment,” Johnson said. “Then they come home and are expected to turn it off like flipping a switch. The tension of readjustment can have significant effects on a family. It can put a family at risk if the parent cannot adjust effectively.”

Traumatic brain injuries and post-traumatic stress disorder (PTSD) complicate those adjustment issues even more.

One of Johnson's patients — a sailor who had served with a unit of Marines in Iraq — was diagnosed with adjustment disorder only after a physical overreaction to his child spilling milk at the dinner table, Johnson said.

“He overreacted significantly,” Johnson said. “He didn't know until he saw a counselor that it was a sign of hyperarousal and adjustment disorder. This happened six months after he came back. Six months is a very long time for a child to walk on egg shells.”

Prior to the wars in Iraq and Afghanistan, military rates of child maltreatment were lower than those seen in civilian populations, but rates have since doubled, Johnson said.

“There is some indication they're higher than civilian rates now,” she said. “During deployment and reintegration, it's 42% higher than at other times.”

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