Deployment, Stress, and Crisis

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Deployment, Stress, and Crisis

• Caring for Our Children
• Role of the Health Care Provider

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Elisabeth M Stafford, MD, FAAPCOL, MC, USA

• San Antonio Military Pediatric Center
• elisabeth.stafford_at_amedd.army.mil

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Goals and Objectives

• Overview of the military community
• Challenges of the military life
• Impact of deployment on children
• Counseling Support needs with deployment
• Support programs and resources

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Community Pediatrics

• American Academy of Pediatrics Policy Statement
• June 1999

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The Military Community

• An Overview

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Waiting, Worrying, and..Grieving

• Inherent danger of military operations
• Terrorist attacks9/11 aftermath
• Armed Forces service members-targets
• Intermittent, ongoing geo-political volatility
• Dramatic, graphic television coverage

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Challenges of the Military life.

• Frequency of moves
• Relocation issues and starting over again
• Intermittent separation from parents
• Safety concerns for military parent/family
• Increased challenge if family member has special
  needs.

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Some of the numbers

• 1.2 million active duty service members
• 700,000 spouses
• 1.2 million children
• 40 birth to 5
• 32 6 to 11
• 24 12 to 18
• 4 19 to 23

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States with greatest numbers of military personnel

• California
• Virginia
• TEXAS
• North Carolina
• Georgia

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States with greatest numbers of military
reservists

• California
• TEXAS
• Pennsylvania
• New York
• Florida

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Responses to mental health related questions in
the 2002 DoD Survey of Health Related Behaviors
in the Military indicate that family separation
is a common life stressor for the active duty
service member (m-18.7, f-21.2).
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Combat Duty and Mental Health

• Hoge CW et NEJM, July 2004
• 15-17 with significant mental health issues
  post-deployment to Iraq, esp. PTSD
• Only 23-40 had sought mental health care
• Concern for stigma of seeking mental health care,
  other barriers
• Family members presenting for care can be
  screened for post-deployment adjustment issues of
  the returning service member within a family
  context

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Overview of Deployment
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Emotional Cycle of Deployment

• Pattern of emotional response within family when
  military member deploys
• Emotional cycle plays out through phases of
  pre-deployment, deployment, and reunion
• Emotional Cycle of Deployment 1987 U.S. Naval
  Institute Proceedings-Logan, KL
• Concepts generalized to describe impact on entire
  family

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Stages of Deployment

• Pre-deployment (varies in length)
• Deployment ( 1st month)
• Sustainment (months 2 through ?)
• Re-deployment (last month)
• Post-deployment (3-6 months after return)

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Stage 1 Pre-deployment

• Anticipation of loss vs. denial
• Train-up/long hours away
• Getting affairs in order
• Mental/physical distancing
• Arguments

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Stage 2 Deployment

• Mixed emotions/relief
• Disoriented/overwhelmed
• Numb, sad, alone
• Sleep difficulty
• Security issues

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Stage 3 Sustainment

• New routines established
• New sources of support
• Feel more in control
• Independence
• Confidence ( I can do this)

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Stage 4 Re-deployment

• Anticipation of homecoming
• Excitement
• Apprehension
• Burst of energy/ nesting
• Difficulty making decisions

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Stage 5 Post-deployment

• Honeymoon period
• Loss of independence
• Need for own space
• Renegotiating routines
• Reintegration of the family

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Predicting Difficulties with Deployment

• Preceding family dysfunction
• Mental health issues
• Special needs children
• Particular closeness to the deployed parent
• Recent family relocation with limited support
  systems in place

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Deployments Impact on Children
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Infants.

• Irritability
• Difficulties with comforting by caregiver
• Difficulties with self-comforting
• Sleep difficulties
• Eating disturbances

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Dad brings in 7 month old baby

• Just doesnt know how to handle the baby crying
  all the time, feeding difficulties

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Rest of the story .

• Mom has deployed in the past month
• Dad has never had to fully care for the baby
  alone, past psychiatric history
• Mom is the glue that held everything together
• Sometimes dad feels like he could lose it when
  baby cries
• Emergent SWS consultation to assess babys safety
  in the home

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Preschool and Kindergarten

• Clinging to people or favorite toy or blanket
• Unexplained crying or tearfulness
• Choosing adults over same-age friends
• Increased violence toward people or things
• Shrinking away from people, more quiet
• Eating, sleep difficulties
• Regression in behaviorsbedwetting

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Mom brings in 3 year old for

• New onset biting other children in the CDC, they
  are threatening to kick him out

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Rest of the story.

• Daddy has just deployed in past month
• Seems anxious, irritable at home
• Hitting little sister
• Clinging, leaving him at the CDC requires extra
  time to reassure him that he will be o.k.
• Mobilize support from CDC staff

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School-aged Children

• Any of the signs noted previously
• Rise in complaints of stomach aches, head aches,
  or other illness
• More irritable or crabby
• Increase in school problems-drop in grades,
  school avoidance, fights
• Other changes in behavior

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Mom brings in 7 year old female..

• For new onset stomach aches with increased school
  absence

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Rest of the story.

• Patient lives on post
• Recent tragedy in dads unit
• Several service members injured/killed
• Everyone is talking about it
• The little girl hears her mother and friends
  talking
• Will her daddy be o.k.what if something happens
  while she is at school?

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Adolescents

• Any of the signs noted previously
• Acting out behaviors (getting into trouble at
  school, at home, or with the law)
• Low self-esteem and self-criticism
• Misdirected anger (lots of anger over small
  incidents)
• Depression, anxiety

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Mom brings in 16 year old son

• Worried because he seems down, not concentrating
  at school, not engaged in his usual activities

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Rest of the story.

• Patient very close to dad
• Dad has been deployed to New York City post 9/11
• Sudden, unexpected, not clear how long
• Patient worried about dad
• Acute adjustment reaction
• Brief intervention with Social Worker in clinic

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15 year-old female comes in for physical..

• On filling out school physical form, she angrily
  replies that she doesnt know which school she
  will be going to, doesnt know if she will be
  playing sports .

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Rest of the story..

• Father was severely injured in Iraq
• He is hospitalized in San Antonio
• Family has just moved here to be close to him
• Teens life has been turned up side down
• Support services immediately mobilized

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Anticipatory Guidance for Parents and Caregivers
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Preparing Children for Separation

• Talk with child about separation
• Share feelings about the separation
• Discuss ways to keep in touch
• Plan special activity before the separation
• Swap important personal belongings with the child
  to keep during separation
• Take family pictures, tape a favorite story

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How Parents can support children during deployment

• Maintain routines, discipline
• Monitor television viewing
• Listen
• Discuss your feelings
• Answer questions honestly and dispel rumors give
  age-appropriate explanations
• Encourage communication, let child talk

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How parents can support children during deployment

• Be reassuring
• Show on a map where the parent is
• Have child communicate with deployed parent
• Have deployed parent send separate letters to
  each child
• Help child find ways to handle stress

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Adolescents..

• May downplay their worries
• Encourage discussion
• Discuss impact of TV viewing
• Social supports important, friends, schools
• Encourage activities
• Involve adolescents in helping, support
  activities in family, community.

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Television Viewing Challenges

• TV and internet sites reporting 24 hrs/day
• Broadcasting live as events unfold
• Reporting details in peoples private lives,
  showing grief and loss
• Pressure to get the news to public first
• Detailed and repetitive visual cover of violent
  acts and disasters

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TV viewing Tips for Parents

• Monitor amount of time child watches news
• Time and quiet place to talk about news
• Watch news with child
• Ask about what child has heard, questions
• Reassure that you are there to keep them safe
• Look for signs of anxiety and fear

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Tips for Parents on Coping during Separation

• Understanding likely reactions-denial, anger,
  depression, anxiety
• Expression of feelings
• Staying in touch
• Opportunities for growth, skill development
• Stay connected, get involved, volunteer
• Stay healthy-physically and mentally

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Preparing for Reunion Some Cautions

• Children have grown and changed
• Spouse may have changed
• Awkwardness in reestablishing relationships
• Family roles may have to be redefined

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Family Support and the Role of the
Pediatrician

• American Academy of Pediatrics Policy Statement
• January 2001

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Military Family Support Resources
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Sources of Help and Support

• Family Centers
• Family Support Groups
• Legal Assistance Office
• Chaplains Office
• Pediatric Clinic (primary care clinics)
• Mental Health Clinic
• Social Work Services

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Military Family Centers

• Army Community Service Centers (ACS)
• Family Service Center (FSC)-Navy, Marines, Coast
  Guard
• Family Support Center (FSC)-Air Force

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Family Support Groups Unit level

• Keep family informed during deployments
• Place to get accurate information on unit
• Give families opportunity build community
• Newsletters provide helpful information
• Help in emergencies
• Family support, similar circumstances

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Healthy Parenting Initiative

• DoD Office of Family Policy Initiative
• Military-focused Parenting Tool Box
• Parent/Teen Project to support healthy
  parent-teen relationships
• Command Education briefings to educate on
  critical military family issues

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Role of the Pediatrician

• Anticipatory guidance on reactions of children to
  separation
• Guidance to parents on helping children to cope
• Knowledge of community support services
• Evaluation and support of children, families in
  distress during deployment, relocation, crisis
• Military and medical community education

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Helpful Websites for Military Families

• http//www.militarystudent.dod.mil
• http//www.militarychild.org
• www.militaryhomefront.dod.mil
• http//www.pdhealth.mil/main.asp
• www.militarylifestyle.com
• www.militaryonesource.com
• http//deploymentlink.osd.mil
• http//www.hooah4health.com

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Other resources for families.

• www.aap.org (American Academy of Pediatrics)
• www.aacap.org (American Academy of Child and
  Adolescent Psychiatry)
• www.zerotothree.org (Zero to Three)
• www.nctsnet.org (The National Child Traumatic
  Stress Network)

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In these anxious, unsettled times..Ask military
families about

• Deployment of a military family member or
  relatives
• Assess coping mechanisms in the family
• Direct to resources on the military
  installation, in the community, internet
• Anticipate families/patients that may have
  difficulties during deployment

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Anticipatory Guidance for Teachers
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General Tips for Teachers..

• Greet each child warmly each day
• Spend time with each child every day
• Eliminate stress from classroom/routines
• Room arrangement simple, easy to move in
• Separate activity areas, noisy and quiet
• Stick to predictable routine
• Communicate concerns to parents

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Needs of Preschoolers.

• Regressive behaviors as sign of distress
• Bedwetting, thumb-sucking, baby talk, fear of
  sleeping alone, separation from parent
• Reassure pre-schoolers that theyre safe
• Extra comfort, contact
• Encourage child to draw pictures about a
  situation
• Encourage play, physical activity for relief

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School Age Children..

• False reassurance doesnt help this age group
• Monitor TV viewing
• Allow expression through drawing, play
• Dont be afraid to say I dont know

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Talking about War and Terrorism

• Children watch how adults respond to situations
  and listen to what they talk about
• Let children know your feelings, but dont
  overburden
• Children who are preoccupied or very stressed by
  events need added support-seek help

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Talking to Children about War and Terrorism

• In words child can understand
• Honest information
• Repeat conversations
• Acknowledge childs feelings, ideas as important
• Be consistent, reassuring
• Avoid stereotyping groups of people