Caring for children and youth from Canadian military families: Special considerations

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Children and youth from Canadian military families are a unique population. Circumstances such as frequent relocations, parental deployment and separation and difficulties accessing medical and mental health services can influence the health and well-being of children and their families [1]. Paediatric care providers can support children and youth from military families by acknowledging the particular strengths and challenges they face, ensuring appropriate medical surveillance, building awareness around the services and supports available to this population and advocating for their particular health needs.

The objectives of this position statement are to present evidence on the health and epidemiology of military families, identify unique considerations regarding health care provision for children and youth from military families and outline supportive resources. Recommendations for paediatric health care providers and governments to improve the care for young people in military families are presented.

THE CONTEXT: CANADA’S MILITARY STRUCTURE AND MISSION

The Canadian Forces (CF) consists of the Regular Force and the Reserve Force. Regular Force members (Army, Navy, Air Force) are enrolled in full-time military service. Reserve Force members are ‘citizen soldiers’ (i.e., individuals holding civilian occupations and taking part in military life part-time, when not on active service). There are important differences between the Regular and Reserve Forces, especially with regard to deployment, benefits and medical services. All Regular Force personnel are covered for medical and dental benefits from the time of enrolment to the effective date of release from the CF. Reserve Force personnel are covered only during specified periods of eligibility, based on their duty status and the relatedness of their illness or injury to military service [2]. Military service is a voluntary profession in Canada, but it requires a significant personal commitment from military members and their families.

A deployment is the short-term assignment of a military member to a combat or noncombat zone. Deployments typically last from 1 to 15 months and can be routine training, planned or unexpected. Deployment is a significant stressor for military families and a defining aspect of military life. Over the past three decades, many Canadian deployments have been to hostile and unstable regions of the world, such as Afghanistan and Iraq.

Seventy per cent of Canadian military spouses have experienced the deployment of their military partner at least once, while 17% have experienced deployment more than five times [3].

DEMOGRAPHICS

Fifty-nine per cent of military members are either married or living common-law. Eighty per cent of Regular Force members have a civilian partner, while 20% are married to another CF member [3]. Most military spouses (87%) are female [3]. As of January 2014, there was a total of 14,200 women (Regular Force and Reservists) in the CF, comprising 14.8% of the CF. Seventy-five per cent of military couples have children. Canada has over 57,000 military families with over 64,000 children under the age of 18 having a military parent [4][5]. Compared with the general Canadian population, military families have a higher proportion of young parents and children.

There are 32 military bases in Canada, often located in geographically remote areas. Eighty-three per cent of Regular Force families now live in civilian communities rather than on a military base [5].

MILITARY FAMILIES ARE UNIQUE

In a 2013 report, the Canadian Department of National Defense/CF Ombudsman identified three important factors that distinguish military families from civilian families: mobility, separation and risk [1]. Military families are required to relocate frequently and at the discretion of the CF. Forced adaptations to new communities, foreign country postings and wartime deployments are common. Seventy-six per cent of spouses have relocated at least once to accommodate a partner’s military posting [3]. Relocating is challenging because it impacts so many of the elements essential to a stable family life, including access to and continuity of health care, quality child care or schooling and the establishment of social circles. Family members are often required to be away from their immediate and extended families for long periods of time, resulting in de facto single-parenting for the at-home partner, often without extended family support. The risks to safety, including the possibility of permanent injury, illness or death, are accepted as integral to the military profession. The demanding combination of high mobility, prolonged separations and acceptance of risk is inherent to family life in the CF. The absence of predictability and choice, and the difficulties of planning for the future are added key stressors.

Deployment makes military families unique, with children and youth experiencing predictable emotions and responses during each cycle. Before a parent’s deployment, a child or adolescent may become emotionally withdrawn, apathetic or exhibit regressive behaviours. Early in deployment, they can feel overwhelmed, sad or anxious, manifest more somatic complaints or develop aggressive behaviours. These emotions often diminish as children enter a readjustment phase, when new routines and supports are developed. With family reunification comes excitement, anticipation and relief, followed occasionally by emotional conflict as the service member reintegrates back into everyday family life. Three-quarters of families reported that the first 3 months after coming home was the most stressful part of the deployment cycle [1][6]. Further, unlike a decade ago, many military families communicate frequently with their deployed partner and parent, usually in real-time. While this contact might be viewed as an advantage, it can also be anxiety-provoking because the family is more privy to, and involved with, the deployed parent’s reality.

Importantly, the military ombudsman also found that CF families could describe key skills imparted by military life, including the ability to adapt and integrate effectively into changing surroundings. Military children can be more mature, responsible and self-sufficient than their civilian peers because of the range of issues affecting their families [1]. Most military families respond to the stressors they face with remarkable resilience.

HEALTH CARE FOR MILITARY FAMILIES

Unlike the USA, the spouses and children of Canadian soldiers do not receive care from the military medical system (i.e., Canadian Forces Health Services). Instead, they use the public provincial/territorial health care system.

Supplemental insurance and benefits are provided to CF members and families through the Public Service Health Care Plan and the Canadian Forces Dental Care Plan, which are comparable to many public service health care plans.

Recently, every province and territory has agreed to waive the 90-day waiting period before relocating CF families become eligible for health insurance coverage [7].

EVIDENCE FOR HEALTH IN MILITARY FAMILIES

Most of the data on the health of military families are based on research conducted in the USA. While acknowledging that the Canadian military experience differs significantly, the influences and pressures on family life are believed to be comparable.

Health care-related visits

Studies have shown that mental and behavioural health visits increased by 11% in children 3 to 8 years of age when a military parent was deployed; behavioural disorders increased by 19% and stress disorders increased by 18%. By contrast, however, the overall outpatient rate and rates of visits for other diagnoses were found to decrease when a parent was deployed [8][9].

Deployment has been clearly associated with increased use of specialist office visits for both spouses and children, as well as increased use of antidepressant and anti-anxiety medications [10]. Children of young, single, military parents were seen less frequently for acute or well-child care when their parent was deployed [11]. Children of single parent families are often cared for by a relative or must relocate when their parent is deployed, which may result in less access to medical care.

Young children (3 to 8 years of age) of deployed and combat-injured military parents have more postdeployment visits for mental health, injury-related and child maltreatment concerns [9][12].

Adolescent military dependents were more likely to have admissions for injury, suicide attempts and mental health diagnoses than non-military teens [13]. Military children who made a geographic move within the previous year have greater odds of requiring a mental health encounter; among adolescents, this need extends to psychiatric hospitalizations and psychiatric emergency visits [14][15].

Mental health and behavioural concerns

Changes in behaviour, both externalizing and internalizing, and changes in school performance are consistently reported during parental deployments [14][27], and higher levels of mental health disorders, sadness and worry are reported for most age groups [16]–[18][21]. Depressive symptoms are reported in approximately one in every four children experiencing the deployment of a parent [26]. The gender of the deployed parent does not seem to affect children’s adaptation differently [28].

A recent, large-scale retrospective study using outpatient medical treatment data from >300,000 children with a parent in the US Army, showed an association between parental combat deployment and higher risk for a mental disorder- related visits among both boys and girls, with the greatest increase in the number of mental health cases in children whose parents were deployed for >11 months. The largest deployment-related effects were noted in relation to acute stress disorder, adjustment disorders, behavioural disorders and depression [29].

A study of preschool children (3 to 5 years of age) affected by current wartime deployments revealed higher levels of emotional reactivity, anxiousness or depression, somatic complaints, sleep difficulties and withdrawal than in children whose parents were not deployed, after controlling for caregiver stress and depressive symptoms [19].

Another study showed that older youth, and young women in particular, experienced more emotional problems (school-, family- and peer-related) during both parental deployment and parental reintegration, than their civilian counterparts. Length of parental deployment and non-deployed caregiver mental health problems were associated significantly with increasing challenges for children during both deployment and reintegration [17].

There is a higher risk for mental health issues among adolescents with parents in the military; they are more likely than civilian peers to report depressive symptoms and suicidal ideation. Controlling for educational grade, gender and ethnicity, a family member’s deployment has been associated with increasing the likelihood of feeling sad or hopeless, as well as with depressive symptoms and suicidal ideation [30]. One study assessing military adolescents with and without a deployed parent found that both teens and parents reported experiencing increased stress in the deployed subgroup [20]. Research also suggests a higher risk for substance use in adolescents from deployed military families [31]. In a large normative study from California, military-connected youth had significantly greater odds of substance use (odds ratio [OR] 1.73), bringing a gun to school (OR 2.20), or being threatened with a weapon (OR 1.87) than their civilian counterparts [32].

Alternatively, some studies have highlighted the positive effects of parental deployment, including increased opportunity for individual responsibility and independence, greater participation in the functioning of the family and, particularly for adolescents, increased self-confidence [27][33].

Child maltreatment

Several US studies have described increasing rates of child maltreatment in military children, with the greatest rise in rates attributable to child neglect [34]–[36]. These studies examined substantiated cases of child maltreatment, including physical abuse, sexual abuse and emotional abuse and neglect. The incidence of child abuse in families with one parent deployed was noted to be 42% higher than for military families during non-deployment times, but both rates are higher than for civilian families [35]. Interestingly, nonmilitary caregivers perpetrated the largest number of substantiated maltreatment cases in military families. This finding further suggests that the stress of war extends beyond the soldier to the family left behind [34].

A Canadian report conducted by an independent military police service in 2008 provided an overview of the domestic violence cases across the country investigated by the military police. It found a notable increase in reported domestic violence incidents in 2007 and 2008, following Operation Athena in Afghanistan [37].

Child development

Parental deployment may be related to risk for developmental delays in children from military families. One recent study showed that children in deployed families were nearly three times more likely to fail the age-appropriate ASQ-3 (Ages and Stages Questionnaire) developmental screen than children of non-deployed parents [38]. Early childhood development depends on a healthy caregiver and can be adversely influenced by environmental stress and compromised caregiver mental health. This finding is important because the psychological and developmental burdens on affected military children may be long term.

At-home parent well-being

Research has shown repeatedly that children’s behavioural responses and emotional state during a deployment are closely connected with the well-being and mental health status of the at-home parent [16]–[18][22][23][39]. In one Canadian survey, the spouses or partners of a currently deployed CF member were found to be more depressed than those preparing for a deployment or whose spouse/partner had recently returned [40]. Approximately one-fifth of respondents had been diagnosed with depression at some point during their military partner’s career in the CF, while 12% had been diagnosed with an anxiety disorder [3].

A large survey of electronic outpatient data for female military spouses showed that use of mental health services was positively associated with the length of cumulative deployment, with the greatest increase in cases being in wives whose husbands were deployed for >11 months [41].

Spousal underemployment or unemployment is common for military partners. Only 46% of Canadian military spouses report being employed full-time [42]. Obstacles to spousal employment include frequent relocations, the lack of professional opportunities in some smaller CF communities and difficulties securing child care. The spousal employment challenge is frequently identified as a major consideration for leaving the CF [1].

Risk factors for coping difficulties

Several factors increase the risk for impaired family adaptation during deployment. They include younger parental age, having young children, having a family member with prior psychopathology, having children with special needs, having a child with pre-existing emotional or behavioural difficulties, pre- deployment marital or financial problems, being a spouse for whom English is a second language, having relocated recently and not having a firm return date for a deployment [18][21][26][41][43][44]. A 2013 Canadian study of CF personnel deployed to Afghanistan also showed that assignment to higher-threat locations, Army service and lower rank were independent risk factors associated with deployment-related mental disorders during the follow-up period [45].

The health of returning service members

The emotional and behavioural responses of soldiers following deployment can range from short-term distress (e.g., changed sleep patterns, a lower sense of safety or greater social isolation), to more serious psychiatric conditions, such as post-traumatic stress disorder (PTSD), substance abuse or depression [26][45]–[47]. Recent studies suggest that 20% to 30% of soldiers have some symptoms of PTSD in the first 6 months following deployment. This proportion is believed to underestimate the true burden of illness [41]. In the 2013 Canadian Forces Mental Health Survey, the rate of PTSD nearly doubled between 2002 and 2013, with 16.5% of CF members surveyed reporting either depression, PTSD, generalized anxiety disorder, panic disorder or alcohol use or dependence [44]. This survey also found that nearly half of Regular Forces members (48.4%) met criteria for one of five mental or alcohol-related disorders at some point in their lives, with alcohol abuse (24.1%) and depression (15.7%) being the most common. The 12-month rates for PTSD and panic disorder were twice as high among Regular Forces members who served in Afghanistan, compared with those who did not [45].

Over a median follow-up of 3.7 years, 13.5% of CF personnel deployed to Afghanistan had a DSM-IV-diagnosed mental disorder that was attributed to their deployment, with PTSD being the most common diagnosis (8.0%). A considerable proportion of this study population (29.6%) also reported using CF mental health services during the study period [48].

PTSD in parents has been linked to increased rates of child internalizing and externalizing behaviours, impaired parent–child bonding, general behaviour problems and increased child neglect [49]. Complications of a parent’s combat-related stress disorder, traumatic brain injury, development of a psychiatric illness or health risk behaviours can further complicate family life for a child or youth.

SPECIAL CONSIDERATIONS FOR PROVIDING HEALTH CARE TO CHILDREN AND YOUTH FROM MILITARY FAMILIES

Problems with access and continuity of care

As a result of frequent relocations and living in more isolated, underserviced communities, Canadian military families are four times less likely to have a family physician than civilian families. The health care professionals who serve such communities are more likely to be transient or to work on a consultative basis. Therefore, military families often access medical care through emergency departments and walk-in clinics [1]. Unfortunately, this practice does not adequately address routine health prevention and maintenance.

Children, youth and other non-service military family members are cared for by civilian physicians, who may be less familiar with the unique considerations and stresses faced by military families or with the resources available to this population. Further, a family physician who cares for the whole family, including the serving member, would be much better positioned to appreciate their situation and provide optimal care.

Many Canadian military families report travelling great distances to a previous posting to consult a former physician, because they have not yet secured a doctor in their current community—a telling indicator that accessing appropriate medical care is a persistent challenge [1].

Family members requiring mental health services sometimes directly compete with their own partners or other serving members for care and treatment. The CF must often outsource mental health care to offset overwhelmed military mental health care providers. The wait times for non-serving partners to consult with a social worker or psychologist can be even longer than for civilians, particularly in small centres.

Frequent relocations and difficulties with timely transfer of medical records can further disrupt continuity and quality of health care. Such problems put children with a chronic illness, developmental disorder, learning problem or complex medical need at particularly high risk. Subsequent diagnostic delays, particularly for developmental or school-related concerns, along with other interruptions in care, entail starting ‘at the beginning’ with each new health care provider and a greater likelihood of being lost to follow-up. Many CF communities also lack access to specialists (e.g., developmental paediatricians), as well as certain diagnostic tests or treatments that are more readily available for civilians in larger urban centres.

Disruptions in care also cause problems with maintaining routine paediatric practices, such as growth measurements and immunizations. A recent US study of the records of 3421 military children 19 to 35 months of age showed that 28% were not up-to-date for their vaccinations, compared with 21.1% of other children. Military children were also more likely to be incompletely vaccinated. The study authors concluded that the high mobility rate of military families, the lack of a military-wide childhood immunization registration system and incomplete vaccine records contributed to lower vaccination rates in this population [50].

Continuity of care is especially important for medically complex children. Of the Canadian Regular Forces families with children surveyed in 2008 to 2009, 8.2% had one or more children with special needs [40]. Each province and territory has distinct programs for financial assistance and support for children with disabilities, which requires families to reapply for coverage with each interprovincial relocation.

EDUCATION

Along with the challenges of socialization when adapting to a new school, children must adapt to new curriculums and expectations. Educational services for children with special learning needs vary considerably across the country. The life experiences of children and youth from military families may not be well understood by peers and educators. Difficulties with children’s schooling are consistently identified as a main reason for leaving the CF [1]. Military parents also note that academic performance is impacted by the prevalence of extended deployments. This factor is corroborated by research showing that military children with a deployed parent test substantially lower than their civilian counterparts in a range of subjects [27][51].

RECOMMENDATIONS

For the paediatric health care professional

By taking the following steps, health care professionals can improve the care of children and youth from military families:

• Identify military families in the community or practice setting and acknowledge their unique needs, especially related to relocations, prolonged separations and assumptions of risk.
• Build awareness around mental health: for the child or youth, the serving caregiver and the parent at home. Screen for anxiety, depression, behavioural problems, academic difficulties, peer relational problems or high-risk behaviours (e.g., substance use) and respond to treatment needs in a timely, sensitive manner.
• Anticipate common age-specific issues and reactions during deployments and counsel parents accordingly.
• Provide anticipatory guidance around the stresses of the whole deployment cycle, assess family stress and build on each family’s distinct coping skills.
• Ensure that each family’s medical transitions are as thorough and timely as possible. Carefully review and ensure routine primary care surveillance (e.g., growth charts, development and immunizations).
• Be aware of supportive resources and review with military families as needed.

For government

• Officially recognize children and youth from military families as a paediatric population with unique strengths and challenges and deserving special attention within the health care system.
• Increase access to medical and mental health services for this population, with engagement at provincial/territorial and national levels.
• Ensure access to appropriate primary health care and paediatric consultative services for this population, particularly in remote locations.
• Support electronic medical records for CF family members to assist with patient history, health surveillance, continuity of care and ease of transition in the event of relocation.
• Collect Canadian data related to the health of military families (specifically health care utilization and mental health issues) through Statistics Canada, the Department of National Defense, Health Canada, the Canadian Institute for Health Information and the Canadian Institute for Military and Veterans Health Research.
• Rigorously assess the effectiveness of support programs and services delivered to military families.
• Involve the school system in military communities with offering supportive services to children and youth.
• Work collaboratively with federal departments involved in the care of military families (specifically the Department of National Defense and Health Canada), national organizations (such as the Vanier Institute for the Family), local programs (e.g., Military Family Resource Centres and community programs) and research institutions (notably the Canadian Institute for Military and Veterans Health Research).

SELECTED SUPPORTIVE RESOURCES

Military Family Resource Centres (MFRCs) play a central role in delivering support and services for military families in each CF community [1]. Services include orientation, employment and educational assistance, emergency respite and casual child care, parent education, separation support and crisis intervention. MFRCs are independent organizations that are responsive to but not under the jurisdiction of CF authorities. For more information, visit www.familyforce.ca/sites/AllLocations/EN/About%20Us/Pages/CMFRCs.aspx.

Their Family Information Line provides 24-hour access to confidential trained counsellors for CF members and their families.

The American Academy of Pediatrics Uniformed Services Section and Chapter (www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-Uniformed-Services/Pages/default.aspx) includes a well-child screening tool kit for children: web.jhu.edu/pedmentalhealth/images/NNCPAP%20files/Military%20Children%20Dec%2015%20USE.pdf.

For more AAP resources, visit www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Pages/Deployment-and-Military.aspx.

Acknowledgements

This position statement has been reviewed by the Adolescent Health Committee and the Mental Health and Developmental Disabilities Committee of the Canadian Paediatric Society. Special thanks to Brigadier General Hugh Colin MacKay, Surgeon General/Commander CF Human Services Group and Colonel Dan Harris, Military Family Services, for their review and input.

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CPS COMMUNITY PAEDIATRICS COMMITTEE

Members: Umberto Cellupica MD (Board Representative), Tara Chobotuk MD, Carl Cummings MD (Chair), Sarah Gander MD (past member), Alisa Lipson MD, Julia Orkin MD, Larry Pancer MD, Anne Rowan-Legg MD (past member)
Liaison: Krista Baerg MD, CPS Community Paediatrics Section
Principal author: Anne Rowan-Legg MD

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.