The Journal of School Nursing

http://jsn.sagepub.com Military Children: When Parents Are Deployed Overseas

Virginia M. Fitzsimons and Cheryl A. Krause-Parello J Sch Nurs 2009; 25; 40 DOI: 10.1177/1059840508326733 The online version of this article can be found at: http://jsn.sagepub.com/cgi/content/abstract/25/1/40

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Feature Article

Military Children: When Parents Are Deployed Overseas

Virginia M. Fitzsimons, EdD, RNC, FAAN, and Cheryl A. Krause-Parello, PhD, RN Members of the Armed Services and Reserve Unit Members, both male and female, are being deployed to distant lands for long periods of time, disrupting family life and causing stressful times for the adults and children in the family. Traditionally, the mother of the military family was left to be the caregiver after the deployment of the husband/father. Today, extended family members as well as mothers or fathers are asked to serve as caregivers for dependent children of deployed servicemen and servicewomen. This article provides information about the challenges families face and the psychosocial developmental needs of children and families during the five stages of military deployment: predeployment, deployment, sustainment, redeployment, and postdeployment. School nurses can offer children and families support and link them with available resources and networks that will assist them with their needs. Keywords: military deployment; war; stress; caregiver stress; role strain

Deployment orders for military personnel prompt many challenges for families because members of the Armed Forces and Reserve Unit members are often stationed far from home. As part of the armed forces, the family unit was traditionally stationed on military bases that provided structured support, including military school systems. However, on July 1, 1973, the male draft ended, and the All-Volunteer Force began (Bush, 2003). Consequently, the percentage of women entering the military has increased dramatically. In 2004, the total number of active-duty women in the military was 212,000, and of that total, 35,100 women were officers, and 177,000 were enlisted (U.S. Census Bureau, 2006). Subsequently, in recent years deployed military personnel are both men and women, many of whom are mothers and fathers. In the United States, there are approximately 1.2 million school-age children who have one or both parents actively serving in the armed forces (Finkel, Kelley, & Ashby, 2003). According to
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Kelley and colleagues (2001), parental deployment may be finite; however, separation may also occur again and again throughout the course of military service, and the time apart may account for a considerable portion of a childs life. Due to the psychological impact of this separation, effective coping strategies are needed for both the children and their caregiver(s) (Ryan-Wenger, 2001). Military families are faced with many challenges that can cause stress that may manifest as child maltreatment. Child maltreatment in the
Virginia M. Fitzsimons, EdD, RNC, FAAN, is a professor in the College of Natural, Applied, and Health Sciences at Kean University, Union, NJ. Cheryl A. Krause-Parello, PhD, RN, is an assistant professor and coordinator of the School Nurse Program at Kean University, Union, NJ. JOSN, Vol. 25 No. 1, February 2009 40-47 DOI: 10.1177/1059840508326733 # 2009 by the National Association of School Nurses

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military is embedded in complex biopsychosocial processes and in the context of individual, family, and community dynamics (Chamberlain, 2003, p. 260). Subsequently, children of military families are at higher risk for alteration in psychosocial development compared to civilian families (RyanWenger, 2001). Ambiguity and uncertainty cause ranges of emotions associated with parental deployment (Huebner, Mancini, Wilcox, Grass, & Grass, 2007). In addition, there are special consideration needs for children with disabilities or special needs due to the parents deployment compared to children without special needs (Hebdon, 2007; OKeefe, 2005). Considerations include seeking healthy outlets under stressful situations (Elliot & Paterson, 2007) and lack of respite time for nondeployed caregivers (Hebdon, 2007). The purpose of this article is to promote understanding of the mechanism by which children of military personnel and their significant caregivers cope with the emotional cycle through the five stages of deployment: predeployment, deployment, sustainment, redeployment, and postdeployment.

LITERATURE REVIEW

Research on the effects of deployment on children of military personnel in the school community is limited. However, research indicates that there are psychosocial factors that need to be considered when caring for a child from a military family in the school setting. These factors may include feelings of loneliness, depression, and anxiety. Huebner and colleagues (2007) conducted a study using focus groups to examine uncertainty, loss, resilience, and adjustment of children whose parents were deployed to a war zone. The children, aged 12 to 18 years, who participated in this study attended a military-sponsored camp. The researchers found the children exhibited a range of emotions, including acting out, emotional outbursts, and self-reported manifestations of depression and anxiety. The results of this study suggest that parental deployment has a profound effect on the family unit as a whole and the child in particular. Ryan-Wenger (2001) compared the children of active-duty, reserve, and civilian families perceptions of war and its psychosocial manifestations. Of the 91 children participating, 48 were from

civilian families, 25 were from reservist families, and 18 were from active-duty families. Childrens perception of war and the threat of war were measured by interview, an anxiety scale, emotional indictors, and a coping scale. The statistically significant findings indicated that children from military families are adaptive and resilient in response to the stress of war. The results suggest that military children are not overly anxious and are able to effectively cope with the negative effects of war or the threats of war. However, these findings are not generalizable and more research from the childrens perspective is needed. Kelley (1994) studied mothers of school-age children before, during, and after the military deployment of their husbands to the Persian Gulf War to determine the effects of military-induced separation on family factors, maternal separation anxiety, and child behavior. The participants included 61 mothers of children between 5 and 13 years whose husbands completed a 6- to 7-month Navy deployment. The participants completed self-report instruments on family adaptation and cohesiveness, parenting, and child behavior. The results indicated that separation is especially disruptive for families with school-age children. Families with younger children reported less family organization and self-sufficient children in the absence of supportive assistance from their husbands. The findings also suggest that family separation due to military deployment results in less nurturance and cohesiveness and more internalizing and externalizing behaviors in schoolage children. In summary, research indicates that children from military families experience an increase in emotional discord including a change in family roles and daily routines. Military children are faced with academic issues such as the need to change schools during parental deployment (Horton, 2005). Frequent school changes may cause an inner struggle for adaptation and peer acceptance. School changes may also affect school performance. According to Lemmon and Stafford (2007), school failures can be a significant cause of stress for American military families.

EMOTIONAL STAGES OF DEPLOYMENT

Children with deployed military service parents experience an emotional cycle through the five

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TABLE 1.

The Five Stages of Deployment and School Nursing Perspectives Specific Emotional Challenges for Children and Significant Caregivers

Deployment Stages 1. Predeployment: Five weeks to more than a year

School Nurse Perspectives

Anticipation of loss Long hours away for training Mental/physical disturbances Arguments Getting affairs in order

Identify potential families that will be affected by a regional deployment of the military Meet with parents and caregivers to discuss the plans for child care during the deployment period Do anticipatory guidance regarding physical, emotional, and psychological needs of all Have all care and health records of children up to date, and have medical power of attorney documents drawn up with/for the caregivers Inform all school personnel regarding the deployment of parents, and in-service those regarding needs of the children and caregivers Meet with child and assess sleep, eating and activity levels Review home and personal safety strategies with the child and caregivers Get together with caregivers to assess their adjustment and success in their ability to address the needs of the home, the children, and themselves Have the family unit identify their successes and areas to be attended to with the school nurse and other professionals Stay abreast of information regarding deployment calendars of parents Join with the child and caregivers as the range of emotions is experienced, and assess for needed emotional/psychological support Make appropriate arrangements with teachers and parents groups at school to celebrate returning parents Monitor childs attention to school work and demands of activities of daily living Assist family in reorganizing family roles and living arrangements Consider anticipatory guidance regarding changing role of caregivers and parents in the life of the child Assess family health and potential for intervention in the event of untoward adjustment difficulties (traumatic stress disorder) subsequent to service experiences

2. Deployment: Leaving home through the first month away

Mixed emotional feelings of relief, disorientation, and overwhelm Sleep difficulty Security issues

3. Sustainment: Second month to the fifth month up to a year or more

New routines established, new sources of support, feeling of being in control Independence/confidence

4. Redeployment: The month before returning

Anticipation of homecoming Excitement/apprehension

Burst of energy/nesting impulse Difficulty making decisions 5. Postdeployment: Immediate arrival home and for 6 months

Loss of independence of caregivers decision making for the child(ren)s needs and homemaking requirements Need for own space, renegotiating routines Reintegrating into family

SOURCE: Adapted from Pincus, House, Christenson, and Adler (2007).

stages of deployment: predeployment, deployment, sustainment, redeployment, and postdeployment (Pincus, House, Christenson, & Adler, 2007). Each deployment stage is characterized by

a time frame and particular emotional challenges (Table 1). Failure of the school community and family to identify and help the child cope with these emotional needs in the school setting can

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lead to conflict and risk of poor educational outcomes. Understanding the five emotional stages of deployment can help to minimize the need for crisis intervention and mental health counseling.

Changes and alterations in behavior include a change in academic performance, interaction with peers, and somatic complaints. The reaction of children to extended parental deployment is highly individualized due to the stage of psychosocial development (Pincus et al., 2007).
Redeployment

Failure of the school community and family to identify and help the child cope with these emotional needs in the school setting can lead to conflict and risk of poor educational outcomes.

Predeployment

The predeployment time frame varies and begins with a notice of deployment. During this time, families may experience stress that may affect the activities of daily living for both the parents and children. This stress can increase childrens fears that parents or caregivers are not well equipped to care for them or that the deployed parent may not return home safely. In response, children may display symptoms of ineffective coping such as an increase in crying, temper tantrums, and other maladaptive behaviors (Pincus et al., 2007).

The redeployment stage occurs the month before deployed military personnel are scheduled to arrive home. During this stage, there may be intense waves of emotion in anticipation of the homecoming for caregivers and children (Pincus et al., 2007). Emotions may include anticipation, excitement, a burst of energy, and difficulty making decisions.
Postdeployment

Deployment

The deployment stage occurs from the time of actual deployment through the first month away. This stage presents a mixture of emotions for both caregivers and children. Some feel angry, sad, numb, abandoned, and alone. Others may experience alteration in sleeping patterns due to anxiety and ineffective coping measures. During this time, the child may also have a sudden change in appetite. Therefore, it is important to assess sleeping, eating, and activity levels during parental deployment (Pincus et al., 2007).

The postdeployment stage occurs when the deployed parent arrives home. During this time, the parent-child reunion can be difficult. Depending on the childs stage of psychosocial development, the reaction to the homecoming can vary (Table 2). It may be difficult for children to obey and respond to discipline from the returning military parent. Children may also feel frightened of their parents homecoming due to changes in family routines or expectations. During this time, children need time to adjust to the parents presence in the family to ensure a successful reunion (Pincus et al., 2007).
STAGES OF PSYCHOSOCIAL DEVELOPMENT AND DEPLOYMENT

Sustainment

The sustainment stage occurs during the first month of deployment through the fifth (penultimate) month of deployment. During sustainment, new routines and sources of supportive networks are developing. Stress can cause changes and alterations in a childs affect and behavior.

Across the life span there are stages of psychosocial development (Erikson, 1950), and parental deployment risks the appropriate transition of these stages. These developmental stages represent a psychosocial crisis and conflict that must be resolved for children to progress emotionally and socially. The resolution integrates maturation and physical and social demands. Therefore, responses of children to the expected or actual deployment of a parent are highly individualized and vary according to their developmental stage (Pincus et al., 2007). Subsequently, an unexpected alteration in a childs behavior may be a reaction

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TABLE 2. Age

Possible Reactions to Parental Deployment Reaction Crying Slow to warm up to parent Feel guilty and scared about the separation Want attention Moody and may not appear to care

Babies (< 1 year old) Toddlers (1-3 years) Preschoolers (3-6 years) School-age children (6-12 years) Teenagers (13-18 years)

SOURCE: Adapted from Pincus, House, Christenson, and Adler (2007).

of physical, social, and school skills. If there is an unsuccessful resolution of crisis, the child may exhibit a sense of inferiority and have difficulty learning. The school-age child might focus on the deployed parent missing a key event, such as a ball game or birthday, that may cause acting-out behaviors (arguing, crying, talking back to authority figures) or depressive symptoms (sleep disturbances, neglecting school work, decreased or increased appetite, avoiding interactions with friends), which may be overt indicators of unexpressed feelings of grief and loss (Pincus et al., 2007).
Adolescence

to the anxiety of having a parent or parents deployed (Pincus et al., 2007). In this section, three stages of childhood psychosocial development put forth by Erikson (1950) are discussed in relation to parental deployment.
Preschool

According to Erikson (1950), the psychosocial crisis that occurs in preschool children (3 to 6 years of age) is initiative versus guilt. During this stage the family relationship is a fundamental source of inquiry. The resolution of this developmental task is to have a sense of purpose and initiate ones own activities. If there is an unsuccessful resolution of the crisis, the child may have a sense of inadequacy, guilt, and an aggression-fear conflict. Children coping with parental deployment may regress in their cognitive development and psychomotor skills as exhibited by difficulty with toilet training, thumb sucking, refusing to sleep alone, and seeming more emotionally attached. During this psychosocial stage, it is common to see irritability and depression with a likelihood of somatic complaints and fear of being abandoned during parental deployment (Pincus et al., 2007).
School Age

The psychosocial crisis that accompanies adolescence (12 to 20 years of age) is identity versus role confusion (Erikson, 1950). During this psychosocial stage, the relationship with peers is prominent. The resolution for this crisis is the development of a sense of identity. If there is an unsuccessful resolution of this crisis, adolescents may be confused about who they are, and their identity may be submerged in peer relationships, group memberships, and separation from family. Adolescents in this developmental stage who are coping with parental deployment can be particularly irritable, bully others, or demonstrate other attention-seeking behaviors. These children may show lack of interest in school or extracurricular activities, shun peers, and avoid favorite past hangouts. In addition, there is heightened risk of sexual promiscuity and alcohol and drug use (Pincus et al., 2007).

CAREGIVERS

The psychosocial crisis that challenges schoolage children (6 to 12 years of age) is industry versus inferiority (Erikson, 1950). During this stage, relationships with friends, classmates, and teachers are foremost. The resolution of this crisis is a sense of competence and ability to learn, which may be accomplished through the development

Preparing a child for being taken care of by a caregiver other than his or her parent(s) or guardian(s) may be challenging when both parents are deployed or the child is from a single-parent family and the custodial parent is deployed. Caregivers may include grandparents, aunts, uncles, cousins, extended family members, close family friends, or significant others. The literature suggests that nondeployed parents experience periods of anxiety, strain, and tension during military deployment (Gibbs, Martin, Kupper, & Johnson, 2007). There is evidence that excessive stress can

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interfere with the caregiver-child relationship. This stress may lead to ineffective coping and adversely affect a childs overall health and well-being (Davis & Stafford, 2007). Gibbs and colleagues (2007) reported that during periods of increased stress, enhanced support services may be needed for military families. Therefore, it is imperative that caregivers know where and how to access coping resources, strategies, and social support services to assist them during times of stress.

childs secrets and private thoughts. Children in grade school and high school who have relationships with pets have an easier time establishing and maintaining relationships with peers (Vivo, 2008). Therefore, it is suggested that pets may be an alternate and easily accessible coping mechanism for children experiencing separation from their deployed parent(s).

COPING STRATEGIES

IMPLICATIONS FOR SCHOOL NURSING PRACTICE

According to DeRanieri, Clements, Clark, Kuhn, and Manno (2004), children develop a range of emotions during times of uncertainty that may have a significant affect on a childs wellbeing. Uncertainty for the American military child is subject to change. Changes can be capricious when new orders or time of deployment is received. This affects the entire family. During times of uncertainty, children may see the environment as unstable and they may be less confident, may hesitate in making choices, or may be vague. During times of uncertainty, coping mechanisms are immobilized and the emotional health of children requires assistance. Evidence of a childs failure to cope may be seen in emotional and somatic symptoms. Military children may feel emotional symptoms of stress such as loneliness, depression, and anxiety (Huebner et al., 2007). Feelings such as loneliness may be lessened through the use of coping strategies, which can include the presence of and relationships with friends and other significant attachment figures as these relationships are important to a childs social development (Krause-Parello, 2008). Pets also can be important attachment figures for children. Recently, the American Academy of Child and Adolescent Psychiatry (AACAP; 2008) explained that children who develop positive feelings about pets have increased self-esteem and confidence. Furthermore, pets can help children develop trusting relationships with others and fulfill emotional needs such as comfort, contact, love, loyalty, and affection. At times, children of deployed military personnel may feel that they have no one to talk to, and according to the AACAP (2008), pets can be safe recipients of a

Adaptation to stress might not be possible for all children of deployed military personnel. Some children may have difficulty coping with the loss and change in family routines or school change. Uncertainty is experienced in a number of realms. Military parents may or may not return home, and current perspectives of soldiers returning from the military may include serious physical, cognitive, and mental issues. In response to physical, emotional, and mental health disorders, soldiers may need short- or long-term rehabilitation and mental health counseling. Soldiers, both men and women, may return home and struggle with posttraumatic stress disorder. According to Hoge, Auchterlonie, and Milliken (2006), there is a positive relationship between combat duty and mental health disorders after military deployment to Iraq and Afghanistan. Recently, in the news media there has been considerable concern and discussion about violence, suicide, and murder among returning servicemen and servicewomen possibly caused by past stressful events. School nurses should be mindful of these mental health issues and provide appropriate referrals to military parents so that they may receive the adequate resources and mental health services needed to meet their mental health needs. School nurses must also be abreast of how these postdeployment consequences may affect military children in the school setting. Children in the school setting who are or have experienced these parental issues may present behaviors such as bullying, physical fighting, cheating, and skipping classes as a method to attract the attention of school personnel. Prompt counseling and referrals by the school nurse are essential to help students

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adjust and cope with the stresses that may be occurring at home. The media may also exacerbate childrens fear of the dangers associated with war, including the visual footage of war zones. School nurses can offer information in anticipation about what to expect, especially for the caregivers and children who have not experienced a previous separation. School nurses should work with caregivers and encourage them to keep family routines and schedules. A familiar schedule for meal, bath, and bedtime is reassuring for school-age children in times of disruption. Any questions the child might have for the caregivers or the school nurse regarding deployment should be answered briefly and to the point. This approach may help to contain the anxiety of a childs overactive imagination or potential reality. School nurses can encourage children to participate in sports, social activities, and after-school clubs as they offer a familiar framework to the school week. In addition, school-age children and their caregivers may need to establish new forms of social support. In the school setting, school nurses should be alert for symptoms of maladaptive coping by children of deployed military. These may include excessive absenteeism and frequent visits to the health office with somatic complaints. School nurses are in the position to implement primary prevention measures such as incorporating a psychosocial assessment. In addition to hearing, vision, and other health screenings, it is suggested that during the childs visit to the health office, school nurses should incorporate an assessment for behavioral and emotional problems. Reliable and valid psychometric instruments such as the Pediatric Symptoms Checklist (Jellinek & Murphy, 2003) are available to assist in this screening process. However, school nurses need to receive parental/guardian consent and assent prior to administering a stress screening tool to school-age children under 18 years of age. If the school nurse determines through subjective and objective measures that the child has an increased level of stress, he or she can suggest the child develop a personalized wellness plan that includes strategies for coping with stress and anger (Huebner et al., 2007). Consequently, a counselor or support group may be indicated for some children as some may feel overly anxious, lonely, and disconnected in the school setting.

TABLE 3.

Resources for Military Families

 Sesame Workshop and Wal-Mart Stores, Inc., have developed a kit, Talk, Listen, Connect: Helping Families During Military Deployment. This is a multimedia outreach kit for children aged 3 to 5 years designed to help children cope with the challenges and concerns experienced during various phases of parental deployment. The kit is available for military personnel at http://www.militaryonesource.com  The producers of Sesame Street, with funding from the Corporation for Public Broadcasting, developed a prime-time special titled When Parents Are Deployed. This program focuses on the courage and vulnerability of both parents and children. It is available to view free online at http://www.sesameworkshop. com/wpad  The Strategic Outreach to Families of All Reservists (SOFAR) project provides flexible and diverse ranges of psychological services. Program components include prevention, intervention, and educational materials (Darwin & Reich, 2006). These are free resources to help military personnel and their families. School nurses can access program components at http:// www.sofausa.org  The U.S. Department of Education has developed a guide for educators working with military families during deployment. This booklet is intended to help educators build coping mechanisms in students during and after a military deployment. The guidebook is available at http://www.ed.gov/about/ offices/list/os/homefront/homefront.pdf

In the school setting, school nurses should be alert for symptoms of maladaptive coping by children of deployed military.

Finally, school nurses can assist lonely students with developing new relationships or strengthening existing ones by discussing ways to improve social relationships and increase school connectedness (Krause-Parello, 2008). Lemmon and Stafford (2007) suggest that military families seek connections in their community, such as in their school or religious affiliation, to build and create strong social skills and bonds. There are practical strategies that can be used to combat military childhood stress. School nurses can advocate for enhanced support services such as school counseling, the identification of resources for military families, and the development of support groups for children and their parents or caregivers. School nurses can provide a list of resources that are available and easily accessible to all military families (Table 3).

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CONCLUSION

Anticipating challenges that children may experience is important to minimize the emotional trauma caused by parental deployment (Logan, 1987; Peeble-Klieger & Klieger, 1994; Pincus et al., 2007). There are designated stages of deployment and specific emotional challenges for children that need to be considered. As various challenges are met and overcome, feelings of confidence emerge and coping improves. School nurses are in an ideal position to assist children in coping with the five stages of deployment and to provide the necessary resources and referrals to support the child and military family during times of uncertainty.
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