CEHL:

War’s Most Vulnerable Victims

Elizabeth Slater, PhD June 2010

A note from Dr. Howard King, MD, MPH, Founder of CEHL.org:
Can an editor have a favorite section in a website?

It isn’t easy since I wrote much of this web site.  Also, good friends contributed their own articles.  I think of the late Jan Hindman and her memorable article on, “Preventing Child Sexual Abuse.”

On the other hand, I have attended many pediatric meetings over the years and there isn’t much I haven’t heard at one time or another.

However, at a recent regional meeting, I had the opportunity to hear Dr. Slater present some information I have rarely heard expressed before and in a most affecting manner. It was about “War’s Most Vulnerable Victims.” These men, women, and children will be often found in our pediatric offices but they are easy to overlook unless we consciously inquire about them and somehow “tag” these families, administratively. 

But it is important we don’t ignore the painful experiences that set them apart from the other families for whom we provide care.
The impact of the recent tragic oil spill along the southern part of our country, if not upon our whole nation, will remain with us for many years.  In a similar way, as Dr. Slater painfully describes, the impact of our endless involvement in Iraq and Afghanistan will also be with us for many years to come. 

If you review her careful documentation, few of us will remain detached from the scars that this military conflict will leave with each of us as physician and as citizen for many years.  If we close our eyes and think of “the numbers,” it will be hard not to believe that we, too, could as easily have been “there.”


War’s Most Vulnerable Victims

 

Since the war in Afghanistan, Operation Enduring Freedom (OEF) began in 2002, over 2,000,000 American children have had a parent or older sibling deployed there or in the war in Iraq, Operation Iraqi Freedom (OIF).

In order to appreciate some of the potentially devastating effects on these children, it is necessary first to describe both the changes in the deployed parent and the parent remaining at home. To streamline the discussion, I’ll address husbands being deployed and wives at home.  However, there are many combinations and permutations, including a couple’s simultaneous deployment with grandparents left to manage the home front.

The Troops

First, there are financial stresses imposed by deployment.  As of March 2009, 1.7 million troops have been deployed a total of 2.2 million times.  Half of those serving are reserve or national guard troops.  For these servicemen and women, regular employment and careers are then interrupted.  Employers by law have to give jobs back post-deployment, but in fact violations occur frequently.  For the self-employed the situation is more dire, as returning veterans need to begin again from scratch.  Of all the states, New Hampshire has the highest number of self-employed troops.

Secondly, there are the casualties.  Over 4,000 men and women have lost their lives in these wars as of March 2009.  IEDs are the cause of most injuries, so that Traumatic Brain Injury (TBI) and loss of limb are most common.  A physician with a prominent position in the Department of Defense reports in a personal communication last fall that of the 60,000 troops deployed in OEF, 22,000 have been diagnosed with TBI.  Of these we have no data about whether or not TBI symptoms are transient or enduring.  Like loss of limb, symptoms of TBI, if chronic, are life altering and debilitating.  These include depression, intense rage episodes, and cognitive changes reducing pre-morbid intellectual abilities and effecting productivity.  Needless to say, the cost of such injuries for these men and women, for their families, and for society, at large, is immense.

The emotional sequelae of deployment in OIF and OEF have been prominently featured in news reports.  303,000, or 50% of reserve and national guard troops and 40% of regular military troops, have reported a diagnosable mental disturbance on discharge, particularly PTSD and depression.  Symptoms of PTSD are found in 23% of troops returning from their first deployment, a percentage that increases dramatically after the second or third deployment so common among these warfighters due to the current shortage of troops in the military. 

PTSD is associated with a wide array of other medical and behavioral problems, including cardiovascular disease, arthritis, diabetes and certain cancers.  Lifestyle and behavioral difficulties include homelessness, substance abuse, sexual risk-taking and cigarette smoking.  Additionally, an increasing rate of domestic violence is frequent, as are divorce and impaired parent-child relationships.  Lowered work productivity and the need for ongoing medical treatment again result in huge costs to one's family and society at large. 

Among active and veteran troops successful suicides and suicide attempts have increased rapidly each year.  The number of attempts in 2009 reflected a six-fold increase over the number in 2002.  The number of successful suicides in 2007 was 20% higher than in 2006, which was 15% higher than in 2005.

The Home Front

Deployment entails all the usual concomitants of separation and emotional abandonment along with ongoing and relentless anxiety about the safety of one's loved one.  Sadness, anger and fear arise in the context of diminished family cohesion and structure.  As one wife put it, "Every night you go to bed and you say am I going to get a phone-call tonight...or a knock on the door; that's how we live every day."  Modern technology is a mixed blessing for family at home as daily partners and children are preoccupied with the question of whether they will receive a phone call or e-mail and what it might mean if they don't receive precious communication.  Emotional distance begins to develop as warfighters censor the danger they are in to protect spouses at home, while those spouses in turn don't want to burden their loved one on the front with the mundane aspects of life at home, the water in the basement, the beehive in the rafters or a child’s trouble at school or difficulty sleeping.

New roles are foisted on family members at home.  Wives face the stresses of learning and managing unfamiliar tasks such as household repairs or finances.  Many have to enter or re-enter the workforce.  Spouses at home suffer high rates of anxiety and depression, and there are indications that the suicide rate is climbing for them as well.  Anger follows feeling abandoned and invisible.  Military wives often feel the sacrifices they make on the home front that allow their husbands to serve, but for them go unacknowledged.

Nowhere is the stress greater than in parenting.  The parents remaining at home become SSMs – Suddenly Single Mothers – dealing with the myriad issues of child-rearing in general and the special circumstances of a child dealing with parental absence, solo.  There is no one with whom to share everyday decision-making or discipline for previously sunny children who often become anxious, moody or develop behavior problems. Younger children tend to develop sleep problems and anxiety, while older children and girls of all ages demonstrate more school, family and peer-related problems, all of which intensify with the length of deployment.  Overall the rate of child abuse and neglect increases 40% during the deployment of a parent, and the highest rate of physical abuse occurs when it is the father who is away.  The implication is that these mothers feel overwhelmed in circumstances beyond their control.
A child’s resilience and well-being is directly related to the mental health and coping skills of the remaining parent.

In Massachusetts almost all of our servicemen and women are in the reserves and the guard, their families sprinkled among us and largely invisible and unknown to us.  We may not know that a parent is deployed, that a mother is struggling alone, a child is bed-wetting or developing behavior problems at school, or that with her husband’s return the family is in crisis. Teachers and other students may speak out against the wars, not knowing a teenager’s father or older brother is in combat.  A four-year-old runs away repeatedly to bring his daddy home from Iraq.  A high school student says he wants to bring down the government, is seen as a potential terrorist threat, only to find out he wants his father safe at home when he is brought before a judge.  A junior in high school becomes depressed and lonely as her mother returns to work, her older brother begins college and her father serves in Iraq.  She won’t talk about it to her mother because she doesn’t want to burden her even more.

Reintegration

The joy of reunion is coupled with the challenges of family relationships in flux.  Vets return home profoundly changed but not always able or willing to share their stories.  As one wife put it, “No one returns safe and sound.  Our loved ones who left do not come back.”  In turn, home life has changed. There are new babies and children have transitioned from one stage of childhood to the next.  They have also gotten used to life without the absent parent and may have trouble allowing them to reassert parental authority.  As one mother put it, “They don’t know what the kids eat, what their bedtime is. You adjust to their being gone and suddenly it’s, “Honey, I’m home.”   

Wives have developed new independence and confidence as well, potentially threatening a returnee’s place.  One said,” … I guess predicting and knowing what it will be like the second time isn’t any easier…I must say both times were totally different…They are fighting a war in Iraq.  We have our own war over here…When we all get face to face we are all so proud of them…Yet they don’t see what we did…”  Another wife said, “You get a soldier home first, a husband later.” 

Returning warfighters have two families – the one at home and the family they fought along side.  The family at home has waited so anxiously and long for reunion, and they are hurt, confused and angry when their returning vet withdraws from them only to seek out fellow veterans for comraderie.  Intense loyalty remains with their outfits, and there is guilt with the safe return home while buddies remain in harm’s way in the field.  Moreover, many returning vets feel oddly at sea and out of sync without the compelling adrenalin rush accompanying combat: another reason many return for second and third deployments.  These additional absences in turn create further distancing and feelings of loss among spouses and children at home.  No statistics about the divorce rate are available, but it is significant, as is infidelity during deployment.

There is particular concern in the mental health community about spread effects of PTSD among other family members, especially children.  Symptoms of PTSD include hypervigilance and distrust, jumpiness, vivid nightmares and flashbacks of battle scenes, social withdrawal and isolation, as well as substance abuse.  Small triggers, for example a car backfiring, can set off deeply embedded and automatic violent reactions necessary in the field of combat, and thus there is often increased conflict and aggression at home expressed towards both spouse and children.  The rate of domestic violence is three times more likely in the families of veterans diagnosed with PTSD than in other military families.  Veterans with PTSD perceive imagined threats where none exist, becoming overly controlling with other members of the family in turn.  They may be neglectful about the real needs and concerns of their families because he is so preoccupied internally. 

Children respond with fear and feelings of helplessness, never knowing when his/her returning parent will act irrationally and aggressively.  There is a normative period of transient PTSD in returning vets 60-90 days post-deployment.  However, when these circumstances are prolonged, they may lead to secondary trauma, or what we call the intergenerational transmission of trauma.  There is exposure to Toxic Stress or an atmosphere of danger in which customary feelings of safety and parental protection at home is absent.  A child in this situation is likely to endure chronic anxieties in an environment felt to be chaotic and out of control.  His or her efforts may be focused on appeasing a parent, leaving little energy or internal resources available for the ordinary developmental hurdles of childhood and identity development. 

There may be concomitant physiological changes resulting in damaging and permanent changes.  These include a heightened state of arousal internally and a corollary dulling of responsiveness to others.  Basic trust in primary objects of attachment is diminished or lost.  Permanent right hemisphere changes may result and are seen in altered levels of neurotransmitters related to mood and behavior which can become permanent.  These alterations are manifest behaviorally in hyperarousal, heightened aggression, impulsivity and hyperactivity, hypervigilance and chronic worry, impaired focus and attention, concealment, sleep disorders and somatic complaints such as headaches and stomachaches – in short, many of the same symptoms of PTSD.

Summary and Recommendations

The psychological burdens imposed by OIF and OEF on those serving and their families are profound in terms of the magnitude in numbers of those suffering, the severity of emotional disturbances suffered, and their potentially lasting effects.  Military families are proud and trained for toughness.  Seeking help is often abhorrent, though the Department of Defense has mounted impressive ad campaigns to de-stigmatize mental health problems because of their current significance.

As first line responders, those in the pediatric community have a vital role to play in helping promote better outcomes for these children.   SOFAR, an organization providing pro bono mental health services to family members and psycho-education and consulting programs to the community, recommends first identifying those children in your practices who may be affected simply by highlighting a space for it on your registration/demographic information forms.  Once done, reach out to mothers and children so identified.  Appreciate their sacrifice and ask about their experiences.  Let them know these are normative, if extremely trying, and that there is support available.  Reach out beyond annual check-ups with a phone call to them or to a school guidance counselor about a child potentially at risk. 

These small efforts can have a powerful and wide-ranging, positive impact for these children and their families. 


 

Dr. Elizabeth Slater earned her Ph.D. from Adelphi University’s Derner Institute of Advanced Psychological Studies in 1981 and completed a postdoctoral certificate program in Psychoanalysis and Psychotherapy in 1987 also  from the Derner Institute.  Dr. Slater relocated to Wayland, MA in 1994, where she is in private practice working with adults and adolescents.  She has had extensive experience with the high-risk issues so many teenagers face, including adolescent depression, eating disorders, and acting out behaviors and has taught adolescent development for many years.  She has teaching and supervisory responsibilities at the Mass. Institute for Psychoanalysis, the Boston Institute for Psychotherapy, and Psychoanalytic Couple and Family Institute of New England.   

Dr. Slater also has had a strong interest in pro bono work in the community especially since 9/11 and is a member of the Executive Committee of SOFAR (Strategic Outreach to Families of All Reservists).   She meets regularly with the families of military deployed in Iraq and Afghanistan, and has lectured on the effects of service on soldiers and their families to professional groups as well.


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I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center,  and the families of my medical practice. 

I hope you find this site useful and encourage any comments.


- Dr. Howard King, M.D.