Parental combat injury and early child development: a conceptual model for differentiating effects of visible and invisible injuries

Experience of children growing up with a parent who has military-related post-traumatic stress disorder: a qualitative systematic review

OBJECTIVE

The objective of this review is to describe the experiences of children growing up in military families whose parents have military-related post-traumatic stress disorder.

INTRODUCTION

Whether serving as a peacekeeper or warrior, military service is both physically and psychologically demanding, increasing exposures to potentially traumatic and morally injurious events and threats to personal safety. Those who have served in the military are at increased risk for developing post-traumatic stress disorder, which includes symptoms such as emotional numbing, withdrawal, and hyperarousal. Research has focused on the experiences of and impacts on spouses and partners of military veterans with post-traumatic stress disorder, with quantitative and synthesis studies reporting on measurable impacts on children growing up in military families where a parent is diagnosed with post-traumatic stress disorder.

INCLUSION CRITERIA

This review included children who are or have grown up in military families in domestically peaceful nations that deploy their armed forces to global locations of political instability, armed civil conflict, and/or natural disasters for the purposes of peacekeeping, humanitarian aid, or war, as well as parents living with post-traumatic stress disorder who speak specifically about the experience of their children. Situations of homeland conflict were excluded. The military families of interest are those with one or more parent having a diagnosis of post-traumatic stress disorder associated with military service. Traumatic experiences leading to post-traumatic stress disorder can be acquired prior to military service or through unrelated experiences, so it cannot be presumed that military service or even combat deployment, in and of itself, causes post-traumatic stress disorder. This review includes the experiences of children currently in childhood as well as adult children of a parent with current or previous military service.

METHODS

The following databases were first searched in August 2016 and updated in January 9, 2020: MEDLINE, Embase, Web of Science Core Collection, CINAHL, PsycINFO, AMED, ERIC, and ProQuest Dissertations and Theses Global. This review was conducted in accordance with JBI methodology for systematic reviews of qualitative evidence and with an a priori protocol published in 2018.

RESULTS

Twelve studies were included. The majority of the studies were published after 2006. The review represents the experiences of 139 children (n = 66) and adult children (n = 73) participants from military families in the United States, Canada, and Australia. There were four synthesized findings: i) Parental post-traumatic stress disorder creates a volatile and distressing climate within the family, eliciting a range of responses from children (86 findings across three categories); ii) Parental post-traumatic stress disorder ripples through the family system, disrupting interpersonal communication and relationships during childhood (57 findings over four categories); iii) Children can experience emotional and psychological difficulties well into adulthood (84 findings across five categories); and iv) Making sense of it all and moving beyond parental post-traumatic stress disorder can take significant time, energy, and support (74 findings across four categories).

CONCLUSIONS

The quality of the included studies proved to be high, giving strength to this review. Effective ways of communicating with children about the nature of both the traumatic exposure and the post-traumatic stress disorder itself must be developed. While individuals with post-traumatic stress disorder deserve appropriate interventions to alleviate symptoms and improve functioning, it is not sufficient for recovery from post-traumatic stress disorder either for the individual or for the family who has been deeply affected themselves. Prospective and longitudinal research is needed, ensuring that both the voice of the child and multiple perspectives within family systems are included and compared.

Impact of parental injury on adolescent sleep

STUDY OBJECTIVES

The aim of this study was to determine the impact of serious parental injury on adolescent sleep disorder diagnoses, outpatient care, and medication use.

METHODS

U.S. military personnel who sustained a serious injury and were parents of adolescents aged 10-18 years were identified. Included adolescents were enrolled in the Military Health System for 2 years before their parent's injury and 2 years after the injury. We used logistic regression clustered by adolescents to compare the odds of having a sleep diagnosis and negative binomial regression analysis clustered by adolescents to compare outpatient sleep disorder visits and sleep medication days before and after parental injury.

RESULTS

There were 96,318 parents seriously injured during 2004-2014 who had 117,577 children aged 10-18 years in 2002-2016. Approximately 2% of adolescents had a sleep disorder diagnosis, both before and after their parent's injury or illness. Outpatient sleep disorder visits increased 36% after a parent's injury (incidence rate ratio 1.36 [1.24-1.50]), with a twofold increase in insomnia visits (incidence rate ratio 2.35 [2.08-2.64]). Increases in sleep visits were most pronounced in adolescents of parents with traumatic brain injury, comorbid traumatic brain injury and posttraumatic stress disorder, battle injury, and those who were medically discharged from the military. The number of adolescents using sleep medications increased, but sleep medication days did not increase.

CONCLUSIONS

Adolescents in our study used more outpatient medical care for sleep disorders; sleep medication use increased after parental injury. Sleep disorders should be considered in the care of adolescents with injured parents.

Mechanisms Through Which a Family Caregiver Coaching Intervention Might Reduce Anxiety Among Children in Military Households

OBJECTIVES

Children of injured or disabled veterans and service members may be at risk for mental health and adjustment problems due to household stress. Yet, there are few widely available interventions to address the needs of this population. Reducing distress and improving coping skills of the parent who cares for the injured or disabled adult may improve child outcomes. This paper examines whether changes in caregiver psychosocial outcomes after a caregiver coaching intervention are associated with decreases in child anxiety.

METHODS

Using programmatic data collected between 2015 and 2019 from participants in a family caregiver coaching intervention (170 caregivers, 294 children), we apply linear mixed models to assess associations between changes in family caregiver well-being, including problem solving, depressive symptoms, burden, health complaints and quality of life, and changes in parent-reported child anxiety.

RESULTS

The baseline median Spence Children's Anxiety Scale-Parent score was 17; children aged 6-11 had slightly higher scores. Child anxiety scores decreased on average 2.8 points (SD 8.4) between baseline and follow-up. In adjusted models, decreases in caregiver depressive symptoms and health complaints were associated with decreases in child anxiety. Caregiver problem-solving skills, quality of life, and subjective burden were not associated with changes in child anxiety.

CONCLUSION

Family caregiver-focused interventions that decrease caregiver stress may positively affect children in the household. Few resources are directed at military children; therefore, practitioners should consider ways to leverage caregiver interventions to address child well-being, such as incorporating information on parenting strategies and addressing issues faced by military children.

Lifetime PTSD is associated with impaired emotion recognition in veterans and their offspring

PTSD is associated with emotion dysregulation. Studies have found inconsistent impaired facial emotion recognition ability (ERA) in patients with PTSD and intergenerational transmission of PTSD has been reported, although no studies exist regarding ERA. Our objective was to characterise the facial ERA of a group of traumatised war veterans with, and without lifetime PTSD, and also of their respective adult offspring. Sixty-one veterans with, and without lifetime PTSD and 73 offspring were tested for ERA of seven basic facial emotions expressions, 40 years after veterans had been exposed to war-related trauma. Veterans with lifetime PTSD showed impairment of recognition of all emotions, irrespective of the type, when compared with veterans without PTSD. This result was maintained after adjusting for potential confounders-including depressive symptoms. Offspring of veterans with lifetime PTSD also showed impaired recognition of all emotions, including after adjustment for the same variables. Offspring of veterans with lifetime PTSD also showed specific impairment in recognising the emotions of happiness and disgust. These results confirm that PTSD has negative effects with regards to emotion regulation and also on the next generation. This could result in this population being at increased risk of suffering from relationship problems and psychopathology.

Intergenerational transmission of war-related trauma assessed 40 years after exposure

BACKGROUND

The intergenerational transmission of posttraumatic stress disorder (PTSD) from parent to offspring has been suggested in the literature, but this is highly controversial. We aimed to study the association between veterans' war exposure and lifetime PTSD and the psychological characteristics of their respective offspring, 40 years after war-related trauma.

METHODS

Forty-four adult offspring of veterans with PTSD and 29 offspring of veterans without PTSD were included in the study, from a total of 46 veterans. War exposure intensity, lifetime PTSD, and the general psychopathology (with Brief Symptom Inventory-BSI) of the veterans were studied, as were childhood trauma, attachment, and the general psychopathology (with BSI) of their offspring.

RESULTS

Veterans' war exposure was associated with BSI in the offspring with regard to somatisation (β = 0.025; CI 0.001, 0.050), phobic anxiety (β = 0.014; CI: 0.000, 0.027), Global Severity Index (GSI) (β = 0.022; CI 0.005, 0.038), and Positive Symptom Distress Index (β = 0.020; CI 0.006, 0.033). The fathers' GSI mediated only 18% of the effect of the veterans' total war exposure on offspring's GSI. Fathers' war exposure was associated with offspring's physical neglect as a childhood adversity, although non-significantly (p = 0.063). None of the other variables was associated with veterans' war exposure, and veterans' lifetime PTSD was not associated with any of the variables studied.

CONCLUSIONS

The offspring of war veterans showed increased psychological suffering as a function of their fathers' war exposure intensity, but not of their fathers' lifetime PTSD. These results could be used to suggest that mental health support for veterans' offspring should consider the war exposure intensity of their fathers, and not just psychopathology. This could spare offspring's suffering if this mental health support could be delivered early on, after veterans return from war.

Parental injury and psychological health of children

OBJECTIVE

To determine how parental injury affects the psychological health and functioning of injured as well as uninjured children.

METHODS

We recruited 175 parent-child dyads treated at a regional trauma center in 4 groups: parent and child both injured in the same event, child-only injured, parent-only injured, and neither parent nor child met criteria for significant injury. The preinjury health and functioning of parents and children were assessed with follow-up at 5 and 12 months.

RESULTS

Parents who were injured themselves showed higher levels of impairment in activities of daily living, quality of life, and depression at both follow-up assessments than parents who were not injured. Children in dyads with both parent and child injured had the highest proportion of posttraumatic stress disorder (PTSD) symptoms at both 5 and 12 months. In addition, children with an injured parent but who were not injured themselves were more likely to report PTSD symptoms at 5 months.

CONCLUSIONS

There were bidirectional effects of parental and child injury on the outcomes of each other. Injuries to the parent negatively affected the health-related quality of life of the injured children, over and above the effect of the injury itself on the child. Of great concern is the effect of parental injury on risk of stress and PTSD among uninjured children in the home.