When a roadside bomb goes off in Iraq or a firefight erupts in the
mountains of Afghanistan, the wounds of war that result inevitably rebound in
the family lives of injured service personnel.
Besides the medical and psychological consequences, injuries to troops can
disrupt family structure and dynamics, Stephen Cozza, M.D., told a conference
on the mental health of returning veterans and their families. The conference
was held in Columbia, Mo., in March and sponsored by the International Medical
and Educational Trust. This organization was founded by conference chair S.
Arshad Husain, M.D., a professor and chief of the Division of Child and
Adolescent Psychiatry at the University of Missouri.
"There is no such thing as an injured service member alone,"
said Cozza, a professor of psychiatry at the Uniformed Services University of
the Health Sciences and associate director of the Center for the Study of
Traumatic Stress. "You have to think about the injured-service-member
Today, 40 percent of troops deployed to the two war zones are parents,
according to the Department of Defense. Military families are also young.
About 72 percent of children with parents on active duty are under age 12.
Simply having a parent serving in a far-away war zone can take its toll on
While a parent is deployed, many children experience feelings of anxiety,
fear, and concern about the safety of their loved one, according to Jean
Silvernail, Ed.D., chief of the military child in transition and deployment
program in the State Liaison Office of the Office of the Undersecretary of
Defense for Personnel and Readiness. Awareness of the war is increased by the
immediacy of television coverage and, paradoxically, by the easy access to
direct telephone or Internet communication with family members overseas. That
combination of absence and awareness may lead to behavioral changes, decreased
concentration or attention, somatic complaints, altered sleep patterns, or
school problems. Boys have a greater risk of acting out, while girls are more
likely to present with internalizing problems.
However, said Cozza, a parent's deployment should not be seen as inevitably
pathological for those left behind. The stress of separation can also
strengthen children. They may mature and grow in their parent's absence and
develop greater resilience and adaptability.
Despite the high percentage of parents in the U.S. armed forces, there is
no medical literature studying the effects on children of injuries to parents
during war, Cozza said. Results of analogous studies on parental traumatic
brain or spinal-cord injury or chronic illness may be extrapolated to the
children of wounded military veterans, he said.
Depending on their nature and severity, combat-related injuries are likely
to have effects in many domains. Children react to the injuries themselves and
to the changes they see and feel in the wounded parent.
While military children are as healthy and resilient as their peers in the
population at large, the effects of a parent's war injuries on children are
often underappreciated, said Cozza. For instance, parents used to engaging in
physical play with their children may no longer be able to run around with
them or throw a ball back and forth. Dealing with their injuries may mean that
parents are less available to children at a time when their engagement is most
needed. Their disciplinary styles may change. Physical or behavioral changes
in the injured parent—anger or depression, for example—may induce
disruptive behavior or discipline problems.
Furthermore, the entire universe of family life may change as a result of
the injury. The family may move away from the base that had served as home for
years, leading to a loss of friends for both children and parents. Military
bases also provide a kind of supra-familial support group for their residents,
one that may be left behind just when it is needed most. If discharged from
active service, troops may lose some pay and benefits, placing further strains
Those strains are felt first by the spouse or other adult relatives of the
injured parent. They have to convey the bad news and prepare the child for the
first visit to mom or dad in the hospital. That can be a frightening
experience for small children if developmental considerations limit how well a
child understands a parent's injury. One mother delayed her child's initial
visit until doctors removed the tracheal tube from her husband's throat, Cozza
reported. Another child took the first visit to the hospital with equanimity,
but wondered the next day why daddy wasn't back home already.
"The child must learn that the injury isn't temporary," said
Spouses also serve as advocates for their injured mates and thus are
important go-betweens connecting medical staff with families.
"Spouses are the key," said Cozza. "If we don't have a
good relationship with them, we're in trouble."
Both parents must adjust to a new reality in the parenting process, he
said. Major injury challenges one's idealized self-image as a parent and
requires development of an integrated sense of a new self, while
simultaneously demanding parental attention to the child's developmental
Providers must assist the reunion of the injured service member's family,
said Cozza. "We must help rehabilitate the injured parent by
acknowledging the essential role of parenting in his or her life."
Civilian medical pract itioners are already involved in military or
veterans' health care and will have a greater role in the future, he
suggested. Most active-duty troops and their families are covered by the
Department of Defense health system (called TRICARE), and civilian
practitioners are being encouraged to accept TRICARE payments, as they do
other insurance programs (see information at the end of this article).
However, the major role of National Guard and Reserve personnel in the current
fighting means there will be many troops who have served in the war zones and
families who live beyond convenient access to VA medical centers or who will
revert to private insurance programs once they return to civilian jobs.
The Department of Defense's Military OneSource provides information
to support troops and their families. The information is posted at<www.militaryonesource.com/skins/MOS/home.aspx>.▪
TRICARE is the Department of Defense's worldwide health care program for
uniformed services members and their families, both active duty and retired.
The system actively looks for civilian medical professionals to add to its
network of providers, especially in areas not readily served by existing
military medical facilities.
To attract providers, TRICARE cites "a large, stable pool of patients
[including] 9.1 million beneficiaries," "payment
timeliness," and flexible arrangements in connecting to the system."
Providers can join the network or accept assignment on a case-by-case
basis," according to TRICARE's Web site.
Three regional contractors administer TRICARE services in the United States
Each contractor sets terms and conditions for credentialing and certifying
providers at whatever participation level each provider chooses.
Information on becoming a TRICARE provider is posted at<www.tricare.mil/provider/provider_cert.cfm>.