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Trauma Faced by Children of Military Families
What Every Policymaker Should Know

Authors: Fianna Sogomonyan and Janice L. Cooper
Publication Date: May 2010

Active duty military personnel and National Guard and reservists experience multiple deployments as a result of the conflicts that comprise the War on Terror. A large body of research has accumulated on the behavioral health problems faced by military personnel as a result of these conflicts. After nearly a decade of war, a growing area of research shows the negative impact on children, youth and families of U.S. military personnel. Children of military families often experience multiple stressors before and during their parent’s deployment and when they come home. Without appropriate mental health support systems, children of military personnel may be at a significant disadvantage compared with their peers in non-military families.

Who Are the Children of Military Families?

The 1.76 million children and youth in military families are:1

  • predominantly in early and middle childhood: 78 percent are under age 11 (active duty) and 80 percent are under age 15 (reserve component) compared to a national average of 66 percent and 83 percent;1
  • chiefly from families where the heads of households are married (55 percent) active duty vs. (49 percent) reserve component;3
  • mostly white (70.5 percent), for active duty and (75.6 percent) for reserve component;4 and
  • disproportionately African-American (15.5 percent) and (13.7 percent) among active duty and reserve component respectively and disproportionately American-Indian (1.4 percent) among active duty personnel compared to the general civilian population of military age.5
  • – Among active duty personnel, five percent hail from immigrant families.6

Profile of Newly Enlisted Personnel

New enlisted personnel come primarily from:7

  Active duty Reserve
Rural areas/Small towns 44% 40%
Suburban/Large towns 27% 30%
Urban areas 29% 30%

Over one-third of new active duty enlistees come from communities where the median household incomes are $42,039 or less per year (considered low-income) and almost 50 percent come from moderate-income communities with median household incomes between $42,040 and $65,000 per year.8 Among new enlistees in the reserve component, nearly 50 percent come from communities where the median household income is approximately $46,000 per year.9

Military families belong to three distinct employment categories:

  • Active duty comprised of Department of Defense (DOD) active duty (38.8 percent) and Coast Guard Active Duty (1.2 percent);
  • the Reserve Components comprised of ready reserve (31 percent), standby reserve (.6 percent) and retired reserve (5.5 percent); and
  • DOD civilian personnel (22.9 percent).

An almost equal proportion of active duty military (43.2 percent) and reserve component (41.9 percent) personnel have children.10 Similar numbers of single parents are enlisted as active duty, National Guard and Reserve personnel.11

How many children of military families experience the direct impact of nation’s wars?

  Active Duty Parents12 National Guard and Reserve Parents12
Ages 0 to 5 43% (481,103) 28% (174,401)
Ages 6 to 11 32% (368,850) 52% (327,342)
Ages 12 to 18 25% (279,319) 20% (126,284)

More than two million American children have had a parent deploy to Iraq or Afghanistan.14

  • At least 19,000 children have had a parent wounded in action.15
  • Over 2,200 children have lost a parent in Iraq or Afghanistan.16

Impact of Deployments on Children’s Mental Health

Children in military families experience high rates of mental health, trauma and related problems.

Military life can be a source of psychological stress for children. Multiple deployments, frequent moves and having a parent injured or die is a reality for many children in military families.

Wartime parental deployments can be one of the most stressful events of a child’s life.17

  • Changes reported included changes in school performance, lashing out in anger, worrying, hiding emotions, disrespecting parents and authority figures, feeling a sense of loss, and symptoms consistent with depression.18
  • High levels of sadness were seen in children in all age groups.19
  • Depression was seen in about one in four children.20
  • Academic problems occurred in one in five children.21
  • Thirty-seven percent of children with a deployed parent reported that they seriously worry about what could happen to their deployed caretaker.22
  • Parents reported that one in five children coped poorly or very poorly to deployment separation.23
  • Media coverage of the war posed a significant source of stress for children and makes it much more difficult for children to cope with a parent’s deployment.24

Length of deployment was associated with mental health problems including depression, acting out, and externalizing behaviors.25

What Service Use Data Show

Service use data also indicate high need for mental health services and supports among the offspring of military personnel.

  • Outpatient mental health visits provided to children of active duty parents doubled from one million to two million between 2003 and 2008.26
  • Total days of inpatient psychiatric care for children of active duty personnel 14 and under increased from 35,000 in 2003 to 55,000 in 2008.27
  • One-third of children with a deployed parent were at “high-risk” for psychosocial issues.28

Factors associated with the negative impact of deployment on children and youth include age, the mental health of the remaining parent, re-integration, and employment status.

Age as a Risk Factor

Current research shows that a child’s response to a parent’s deployment varies by age, phase of deployment, gender, as well as other family factors. The research is mixed: but the stress of war affects children even prior to their birth.

  • Wives of deployed personnel experience more stress, a factor known to increase risk for medical complications of pregnancy.29
  • Children ages 3 to 5 with a deployed parent exhibited greater behavioral symptoms than did peers without a deployed parent.30
  • Children of military families ages 11 to 17 were found to have a higher prevalence of emotional and behavioral difficulties than children in the general population.31
  • Parental deployment places school-age children and adolescents at higher risk for a range of adverse mood and behavioral changes: anger, apathy, anxiety, depression, withdrawal, decline in school performance, loss of interest in normal activities, and social isolation.32

Mental Health of Remaining, At-home Parent or Caregiver

The mental health status of the at-home parent or caregiver during a deployment impacts the mental health of children under their care. Children whose at-home parents or caregivers had better self-reported mental health were better able to cope with the deployment experience during and after the deployment.

  • Caregivers with poorer mental health reported more child-related difficulties during deployment.33
  • Caregiver mental health is also linked to child well-being, emotional difficulties, peer and family function and academic engagement.34
  • Recent research builds on earlier work that suggests the mental health of the remaining parent plays a large role in determining the how well the child adjusts to the deployment.35
  • High parent stress is associated with high child risk for poor functioning. One of the strongest predictors of a child functioning during a war deployment was parental stress.36
  • Parents who described their families as strong were more likely to also report that their child coped well with deployment.37
  • Parents who coped well are twice as likely as those who coped poorly to believe their children coped well.38

Increased Rates of Child Maltreatment

Research indicates that phases of deployment (pre-deployment, deployment and re-integration) are important and effect children’s well-being. Both departures to, and returns from, combat deployment cause stress in families that can lead to increased rates of child maltreatment.

  • Prior to October 2002, maltreatment rates were slightly higher among non-military families than among military families. Rates of maltreatment in military families far outpaced the rates among non-military families after the U.S. started sending larger numbers of troops to Afghanistan and Iraq in 2003.39
  • Among families of enlisted U.S. Army personnel with substantiated reports of child maltreatment (physical, emotional or sexual abuse), rates of maltreatment are greater when the soldiers are on combat-related deployments. In fact, the rate of child maltreatment in families of enlisted Army soldiers was 42 percent higher during combat deployment than during non-deployment.40
  • For military personnel with at least one dependent, the rate of child maltreatment increases by approximately 30 percent for every one percent increase in the number of active duty soldiers who depart or return from combat deployment.41

Post-Traumatic Stress Disorder (PTSD) and Other Psychological Injuries

Even if the remaining parent or caretaker has fared well during a deployment, family dynamics may change significantly upon the service-member’s return. The stress on family interaction is exacerbated by pervasive rates of trauma and other mental health conditions among military personnel.

High levels of PTSD, depression, traumatic brain injury (TBI) and other mental health conditions are prevalent among returning veterans.

According to the Department of Veterans Affairs, 269,331 veterans were receiving compensation for PTSD as of 2006. One in five Iraq and Afghanistan veterans, roughly 300,000 individuals, suffer from PTSD or major depression.42

An estimated 320,000 service members may have experienced a (TBI).43 Eighty-five percent of veterans with TBI also had at least one psychiatric diagnosis. Most prevalent were PTSD, depression and substance use disorder.44

Children in families with high levels of deployment-related stress prior to a combat-related injury were more likely to experience distress that would lead to poor child outcomes when a family member was injured.45

Stress on Families, and Domestic Violence

Spouses of veterans with PTSD have higher levels of emotional distress than the general population.46 Partners of PTSD-diagnosed veterans experience more caregiver burden and had poorer psychological adjustment than did partners of veterans without PTSD.47

Spouses of active duty and reserve component personnel show increases in marital problems (44 percent and 39 percent respectively) due to deployment related stress.48

Recent literature hasn’t yet fully investigated how PTSD affects the children and spouses of troops returning from the nation’s current conflicts, though certain aspects of PTSD were found to be related to poorer parent-child relationships.49 According to the Veteran’s Administration, partners of the veterans with PTSD reported lower levels of happiness, less satisfaction in their lives with about half reporting having felt “on the verge of a nervous breakdown.”50

Veterans with PTSD commit acts of domestic violence at rates greater than veterans without PTSD, and at rates greater than the general population.51

Few studies have explored the impact of parental (TBI) on children. The findings of this research suggest effects on both parenting and child and parent behaviors. Parent-related behaviors included depression, impatience, liberal or lax disciplinary practices, and less engagement.52 Child-related behaviors included depression, and other emotional and behavioral problems and a sense of feeling ineffective. Problems with parent-child relationships posed significant challenges. These studies have not included military families and the added dimension of combat-related TBI.53 However, depression is a leading psychiatric diagnosis associated with TBI and research on parental depression. It can impact a parent’s ability to parent appropriately, resulting in harsh, indifferent, inconsistent parenting and management difficulties.54

Role of Employment Status on Child Outcomes

Nearly two-fifths (38.3 percent) of deployed services personnel are not full-time military.55 Many of the nearly 1.1 million individuals in the National Guard and Reserve components experience combat-related duty.56 Reserve and Guard troops represent a significant sub-population within the military, and face specific challenges that impact their families.

Research shows that living on base is linked to reduced difficulties both during and after deployment.57

Reservists and their families have less experience dealing with deployment and re-integration and less support than active duty soldiers and families.58

Reservist families are less likely to be integrated into a military social support network, are less familiar with how to access military benefits and less likely to use installation-based services.59

Reserve component soldiers were nearly one and a half times more likely to report mental health problems and over three times more likely to be referred for services than active duty personnel three to six months after their return.60 These higher levels of referrals were attributed to differential health benefits and supports for these individuals compared to active duty personnel.61

Less than one-half of National Guard and Reserve families surveyed reported a consistent level of support during the pre-deployment, deployment and post-deployment phases. Seventeen percent reported no support.62

Resilience and Importance of Support Systems

Emerging evidence indicates that most children are resilient to the effects of a parental deployment and that children in military families have shown themselves to be adaptive and resilient despite the challenges of parental deployments.63

Family supports can mitigate the children’s negative experiences with a parental deployment. Support systems also have the ability to support the remaining parent’s mental well-being, thus improving outcomes for children.

Many children report that through family support services they had friends to talk to, and children who felt supported showed increased resiliency.64

Enhanced family resources, including family support, represents an important factor in reducing the likelihood that families will leave the military due to long separations experienced as a result of long or multiple deployments.65

Overall, research indicates that families who get or feel supported by their communities, the military or religious organizations experience less deployment-related stress.66

Military and Civilian Mental Health Systems Inadequate to Address the Problems Children and Families of Military Personnel Experience

  • There is a severe shortage of military and civilian mental health providers with expertise working with military families who are available to serve children and youth in military families. A 2007 report by American Psychological Association (APA) estimated that approximately 40 percent of active duty licensed clinical psychologists positions are vacant. There is also a shortage of other specialties including social work and psychiatry.67
  • Currently military and community mental health providers available to military families face high burn-out and attrition rates. The number of active duty mental health professionals dropped 20 percent in the Air Force from 2003 to 2007; a drop of 15 percent in the Navy for the years 2003 to 2006; and the Army saw an eight percent decline from 2005 to 2005.68 Additionally, the DOD and APA reports noted that military provider deployment and turnover resulted in lack of continuity of care for patients, even as deployment-related stress increases family need for services. There is currently no data related to the attrition rate of community mental health providers who work with military populations.
  • TRICARE, the military managed care provider organization faces many challenges. Poor provider capacity is reflected in the organization’s panel of providers. A range of administrative hurdles further intensifies the gap in mental health services. TRICARE beneficiaries report that they have access to fewer providers than appear on TRICARE’s provider lists because many do not accept new patients. Providers report that low TRICARE reimbursement and burdensome certification requirements deter them from accepting additional TRICARE patients.69
  • Inconsistent policies on access to on-base mental health services for other than full-time military personnel impacts the ability to receive care for National Guard and Reserve families. There is currently no consistent, system-wide policy on whether the reserve component personnel and their families can receive services on active-duty installations. Some installations will provide services to all service members and their families; however, some offer services to only active duty members.70
  • National Guard and Reserve face personnel difficulties in gaining easy access to TRICARE providers. When activated to duty, 72 percent of reserve component personnel and 61 percent of their families use TRICARE coverage exclusively. Following active duty, reservists coverage drops to 28 percent and 38 percent for their families respectively. Forty-one percent of service-members and 31 percent of their family members cite easier access to providers via their civilian health coverage as the main reason why they chose to drop TRICARE coverage.71

The Department of Defense, the Veterans Administration and other agencies have made considerable efforts to improve the mental healthcare systems for military families and children. However, some areas remain in need of consideration and action.

Effective Public Policies Can Improve Mental Health Outcomes for Children of Military Families

To improve service capacity, access and quality, the federal government, the Department of Defense (DOD) and state and local mental health officials should:

  • increase training in and of the use of evidence-based or empirically supported practices in clinical settings for children of military families. A DOD Task Force on Mental Health developed a plan to increase the use of evidence-based practices, and to increase provider training on evidence-based practices to treat PTSD. However, children do not always experience PTSD as a result of a parental deployment. Other evidence-based methods including Parent-Child Interactive Therapy and Trauma-Focused Cognitive Behavioral Therapy should be integrated for use with children of military families who experience trauma, distress, or other psychosocial symptoms;72
  • expand programs at DOD schools, and community-based schools. Train key personnel such as teachers, nurses, school social workers, administrators and other school personnel to be aware of and identify children of military personnel who at risk of, or having, difficulties. Non-profit organizations such as the Military Child Education Coalition and the Military Child Coalition have developed such initiatives. Implementing these programs formally and more broadly would enable school personnel to identify children having difficulties and thus serve as a powerful first-line of prevention and early detection;
  • enhance research opportunities that focus on implementation of evidence-based and empirically-supported practice, specifically for children and youth including their families in the military. Research suggests that the challenges of implementation of evidence- based practices serve as a barrier to uptake of these practices in community-based settings;73 and
  • develop specific effective and targeted intervention strategies for sub-groups of military families, paying attention to the developmental span, reserve component status and diverse ethnic and cultural groups. Interventions tailored to the unique needs of certain populations enhance the likelihood that these practices will be adopted and supported.74

To address poor provider capacity and retain providers with expertise in working with military personnel and their families, the federal government, the DOD, state, and local mental health officials should:

  • increase the pool and range of providers, especially in child and adolescent mental health, by providing more funding for pre-service and in-service training;
  • train military and community mental health providers in self-care to reduce burn-out and attrition. The military has seen increasing rates of attrition on mental health providers. Currently, data measuring burn-out of community mental health providers who work with the military population does not exist. However, published data indicate that participation in alternative medicine self-care training results in sustained behavioral changes and improved psychological outcomes among healthcare workers;75
  • provide training to the range of non-clinical personnel who currently work with children, youth and their families in the military;
  • develop and provide funding for support programs for parents and youth designed to ensure they know what to expect as a result of deployment and deployment-related stress, that connects them with their peers, and, that helps parents identify the signs of deployment-related stress and link their children to necessary services and supports.76 Social supports for military spouses and their families were associated with reduced stress, and increased ability to manage deployment-related challenges;77
  • augment the capacity of community-based providers to work effectively with children and youth from military families;
  • ensure equity in access to family support to active duty and reserve component personnel and address the differential need for services and supports experienced by families from reserve components of the military; and
  • attend to the need to build resilience among children and youth in military families. Intentional intervention strategies designed to foster resilience in children and youth can mitigate the negative outcomes that might result from deployment.78

Endnotes

1. Department of Defense. 2007. Demographics 2007: Profile of the Military Community, from militaryonesource.com/MOS/ServiceProviders/2007DemographicsProfileoftheMilitaryCommuni.aspx.

2. National Center for Children in Poverty. 2009. National Center for Children in Poverty Analysis Based on the U.S. Current Population Survey. New York City: National Center for Children in Poverty.

3. See Endnote 1.

4. CNA. 2008. FY 2008 Population Representation in the Military Services: Department of Defense.

5. Ibid.

6. Batalova, Jeanne. 2008 Immigrants in the US Armed Forces. Washington, DC: Migration Policy Institute.

7. See Endnote 4.

8. CNA. 2007. FY 2007 Population Representation in the Military Services: Department of Defense.

9. See Endnote 4.

10. See Endnote 1.

11. Ibid.

12. Ibid.

13. Ibid.

14. Chartrand, Molinda M.; Frank, Deborah A.; White, Laura F.; Shope, Timothy R. 2008. Effect of Parents’ Wartime Deployment on the Behavior of Young Children in Military Families. Archives of Pediatric & Adolescent Medicine, 162(11), 1009-1014.

15. Stone, Andrea. June 21, 2007. At Camp, Military Kids Bear Scars on Their Own. Retrieved February 4, 2010, from dyingwarriors.blogspot.com/2007/06/military-kids-bear-their-own-scars.html

16. Ibid.

17. Lincoln, Alan.; Swift, Erika.; Shorteno-Fraser, Mia. 2008. Psychological Adjustment and Treatment of Children and Families with Parents Deployed in Military Combat. Journal of Clinical Psychology 64(8), 984-992.

18. Huebner, Angela; Mancini, Jay; Wilcox, Ryan; Grass, Saralyn; Grass, Gabriel. 2007. Parental Deployment and Youth in Military Families: Exploring Uncertainty and Ambiguous Loss. Family Relations 56(2), 112-122.

19. Orthner, Dennis K.; Rose, Roderick 2005. SAF V Survey Report: Adjustment of Army Children to Deployment Separations (Survey Report). Chapel Hill, NC: The University of North Carolina at Chapel Hill.

20. Ibid.

21. Ibid.

22. Ibid.

23. Ibid.

24. Ibid.

See Endnote 17.

25. Lester, Patricia ; Peterson, Kris; Reeves, James; Knauss, Larry; Glover, Dorie; Mogil, Catherine; Duan, Naihua; Saltzman, William; Pynoos, Robert; Wilt, Katherine; Beardslee, William. 2010. The Long War and Parental Combat Deployment: Effects on Military Children and at-Home Spouses. Journal of the American Academy of Child and Adolescent Psychiatry 49(4): 310-320.

26. Hefling, Kimberly. 2009. More Military Children Seeking Mental Care, Marine Corps Times. Springfield, VA: Army Times Publishing Company.

27. Ibid.

28. Flake, Eric; Davis, Beth Ellen; Johnson, Patti L.; Middleton, Laura S. 2009. The Psychosocial Effects of Deployment on Military Children. Journal of Developmental & Behavioral Pediatrics 30(4): 271-278 210.1097/DBP.1090b1013e3181aac1096e1094.

29. Haas, David; Pazdernik, Lisa. 2007. Partner Deployment and Stress in Pregnant Women. The Journal of Reproductive Medicine 52(10): 901-906.

30. See Endnote 14.

31. Chandra, Anita.; Lara-Cinisomo, S.; Jaycox, Lisa. H.; Tanielian, T.; Burns, R. M.; Ruder, T.; Han, B. 2010. Children on the Homefront: The Experience of Children from Military Families. Pediatrics 125(1): 16-25.

32. American Psychological Association Presidential Task Force on Military Deployment Services for Youth Families and Service Members. 2007. The Psychological Needs of U.S. Military Service Members and Their Families: A Preliminary Report. Washington, DC.

33. See Endnote 26.

34. Ibid.

35. Jensen, Peter.; Martin, David; Watanabe, Henry. 1996. Children’s Response to Parental Separation During Operation Desert Storm. Journal of American Academy of Child & Adolescent Psychiatry 35(4),:433-441.

36. See EndNote 26.

37. Wong, Leonard.; Gerras, Stephen. 2010. The Effects of Multiple Deployments on Army Adolescents (Monograph). Carlisle, PA: Strategic Studies Institute.

38. See Endnote 19.

39. See Endnote 32.

40. Gibbs, Deborah. A.; Martin, Sandra. L.; Kupper, Lawrence. L.; Johnson, Ruby. E. 2007. Child Maltreatment in Enlisted Soldiers’ Families During Combat-Related Deployments. Journal of the American Medical Association 298(5): 528-535.

41. Rentz, E. D.; Marshall, S.; Loomis, D.; Casteel, C.; Martin, S.; Gibbs, D. 2007. Effect of Deployment on the Occurrence of Child Maltreatment in Military and Nonmilitary Families. American Journal of Epidemiology 165(10): 1199-1206.

42. Chandra, Anita; Burns, Rachel M.; Tanilelian, Terri ; Jaycox, Lisa H.; Scott, Molly M. 2008. Understanding the Impact of Deployment on Children and Families: Findings from a Pilot Study of Operation Purple Camp Participants (Working Paper No. WR-566): Center for Military Health Policy Research.

43. Ibid.

44. Carlson, Kathleen F.; Nelson, David; Orazem, Robert J.; Nugent, Sean; Cifu, David X.; Sayer, Nina A. 2010. Psychiatric Diagnoses Among Iraq and Afghanistan War Veterans Screened for Deployment-Related Traumatic Brain Injury. Journal of Traumatic Stress 23(1): 17-24.

45. Cozza, Stephen J.; Guimond, Jennifer M.; McKibben, Jodi B.A.; Chun, Ryo S.; Arata-Maiers, Teresa L.; Schneider, Brett; Maiers, Alan; Fullerton, Carol S.; Ursano, Robert J. 2010. Combat-injured Service Members and Their Families: The Relationship of Child Distress and Spouse-perceived Family Distress and Disruption. Journal of Traumatic Stress 23(1): 112-115.

46. Dekel, Rachel; Goldblatt, Hadass; Keidar, Michael; Solomon, Zahava; Polliack, Michael. 2005. Being a Wife of a Veteran with Posttraumatic Stress Disorder. Family Relations 54(1): 24-36.

47. Calhoun, P. S.; Beckham, J. C.; Bosworth, H. B. 2002. Caregiver Burden and Psychological Distress in Partners of Veterans with Chronic Posttraumatic Stress Disorder. Journal of Traumatic Stress 15(3): 205-212.

48. Booth, Bradford; Segal, Mady Wechsler; Place, Nick. 2009. National Leadership Summit on Military Families Final Report. Hyattsville: The United States Department of Defense, The United States Department of Agriculture, and The University of Maryland.

49. Ruscio, A. M.; Weathers, F. W.; King, L. A.; King, D. W. 2002. Male War-Zone Veterans’ Perceived Relationships with Their Children: The Importance of Emotional Numbing. Journal of Traumatic Stress 15(5): 351-357.

50. Kulka, R. A.; Schlenger, W. E.; Fairbanks, J. A.; Hough, R.L.; Jordan, B. K.; Marmar, C. R.; Weiss, D. S.; Grady, D. A. 1990. Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study (1st Edition ed.). New York: Brunner Mazel Publishers.

Jordan, B. K.; Marmar, C. R.; Fairbank, J. A.; Schlenger, W. E.; Kulka, R. A.; Hough, R. L.; Weiss, D. S. 1992. Problems in Families of Male Vietnam Veterans with Posttraumatic Stress Disorder. Journal of Consulting and Clinical Psychology 60(6): 916-926.

51. Sherman, M. D.; Sautter, F.; Jackson, H.; Lyons, J.; Han, X. 2006. Domestic Violence in Veterans with Posttraumatic Stress Disorder Who Seek Couples Therapy. Journal of Marital and Family Therapy 32(4): 479-490.

Byrne, C. A.; Riggs, D. S. 1996. The Cycle of Trauma; Relationship Aggression in Male Vietnam Veterans with Symptoms of Posttraumatic Stress Disorder. Violence and Victims 11(3): 213-225.

52. Pessar, Linda F.; Coad, Mary Lou; Linn, Richard T.; Willer, Barry S. 1993. The Effects of Parental Traumatic Brain Injury on the Behaviour of Parents and Children. Brain Injury 7(3): 231-240.

53. Carlson, Kathleen F. ; Nelson, David ; Orazem, Robert J.; Nugent, Sean; Cifu, David X.; Sayer, Nina A. 2010. Psychiatric Diagnoses Among Iraq and Afghanistan War Veterans Screened for Deployment-Related Traumatic Brain Injury. Journal of Traumatic Stress 23(1): 17-24.

54. National Research Council and Institute of Medicine of the National Academies. 2009. Treatment of Depression in Parents. In England, M. J.; Sim, L. (Eds.), Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention (pp. 205-280). Washington, DC: The National Academies Press.

55. See Endnote 1

O’Bryant, JoAnne; Waterhouse, Michael; Group, Knowledge Services. 2008. National Guard Personnel and Deployments: Fact Sheet (No. RS22449). Washington, D.C.

56. Ibid.

57. See Endnote 31.

58. Faber, A. J.; Willerton, E.; Clymer, S. R.; MacDermid, S. M.; Weiss, H. M. 2008. Ambiguous Absence, Ambiguous Presence: A Qualitative Study of Military Reserve Families in Wartime. Journal of Family Psychology 22(2): 222-230.

59. Segal, M. W.; Segal, D. R. 2003. Implications for Military Families of Changes in the Armed Forces of the United States. In Caforio, G. (Ed.), Handbook of the Sociology of the Military. New York: Kluwer Academic/Plenum.

60. Milliken, C.S.; Auchterlonie, J.L.; Hoge, C.W. 2007. Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning from the Iraq War. Journal of American Medical Association 298(18): 2141-2148.

61. Ibid.

62. National Military Family Association. 2005. Report on the Cycles of Deployment. Alexandria, VA: National Military Family Association.

63. Huebner, A. J.; Mancini, J. A. 2005. Adjustments Among Adolescents in Military Families When a Parent Is Deployed. Perdue University: Military Family Research Institute.

See Endnote 17.

See Endnote 19.

64. Huebner, A. J.; Mancini, J. A. 2005. Adjustments among Adolescents in Military Families When a Parent Is Deployed. Perdue University: Military Family Research Institute.

Houston, J. B.; Pfefferbaum, B.; Sherman, M. D.; Melson, A. G.; Jeon-Slaughter, H.; Brand, M. W.; Jarman, Y. August 2009. Children of Deployed National Guard Troops: Perceptions of Parental Deployment to Operation Iraqi Freedom. Psychiatric Annals 39(8): 805-811.

See Endnote 29.

65. Behnke, Andrew O.; MacDermid, Shelley M.; Anderson, James C.; Weiss, Howard M. 2010. Ethnic Variations in the Connection between Work-Induced Family Separation and Turnover Intent. Journal of Family Issues 31(5): 626-655.

66 . See Endnote 19.

See Endnote 28.

67. See Endnote 32.

68. See Endnote 1.

69. Ibid.

70. Ibid.

71. Ibid.

72. Cooper, J.; Masi, R.; Dababnah, S.; Aratani, Y.; Knitzer, J. 2007. Unclaimed Children Revisited Working Paper No. 2: Strengthening Policies to Support Children, Youth, and Families Who Experience Trauma.: National Center for Children in Poverty.

73. Schoenwald, Sonja K. ; Sheidow, Ashli J. ; Letourneau, Elizabeth J. ; Liao, Jason G. . 2003. Transportability of Multisystemic Therapy: Evidence for Multilevel Influences. Mental Health Services Research 5(4): 223.

Proctor, Enla K.; Knudsen, Kraig J.; Fedoravicius, Nicole; Hovmand, Peter; Rosen, Aaron; Perron, Brian. 2007. Implementation of Evidence-Based Practice in Community Behavioral Health: Agency Director Perspectives. Administration and Policy in Mental Health and Mental Health Services Research 34(5): 479.

74. Whaley, A.L.; Davis, K. E. 2007. Cultural Competence and Evidence-Based Practices in Mental Health Services: A Complementary Perspective. American Psychologist 62(6): 563-574.

Lau, Anna S. 2006. Making the Case for Selective and Directed Cultural Adaptations of Evidence-Based Treatments: Examples from Parent Training. Clinical Psychology: Science and Practice 13(4): 295-310.

75. Staples, J. K.; Gordon, J. S. 2005. Effectiveness of a Mind-Body Skills Training Program for Healthcare Professionals. Alternative Therapies in Health and Medicine 11(4): 36-41.

Finkelstein, A. 2007. The Aggregate Effects of Health Insurance: Evidence From the Introduction of Medicare. Quarterly Journal of Economics, 122(3), 1-37.

Saunders, P. A.; Tractenberg, R. E.; Chaterji, R.; Amri, H.; Harazduk, N.; Gordon, J. S.; Lumpkin, M.; Haramati, A. 2007. Promoting Self-awareness and Reflection Through an Experiential Mind-Body Skills Course for First Year Medical Students. Medical Teacher, 29(8), 778-784.

76. Huebner, Angela J.; Mancini, Jay A. 2008. Supporting Youth During Parental Deployment: Strategies for Professionals and Families. The Prevention Researcher 15(5): 10-13.

77. Booth, Bradford; Segal, Mady Wechsler; Place, Nick. 2009. National Leadership Summit on Military Families Final Report. Hyattsville: The United States Department of Defense, The United States Department of Agriculture, and The University of Maryland.

78. MacDermid, Shelley M. ; Samper, Rita; Schwarz, Rona; Nishida, Jacob; Nyaronga, Dan. 2008. Understanding and Promoting Resilience in Military Families. West Lafayette: Military Family Research Institute, Purdue University.