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Professional News
War Injuries Often Disrupt Parent-Child Relationships
Psychiatric News
Volume 42 Number 9 page 4-4

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 family."

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 children.

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.

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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 on families.

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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 Cozza.

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 needs.

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>.

How to Join TRICARE

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>.

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