Impact of paternal deployment to the conflicts in Iraq and Afghanistan and paternal post-traumatic stress disorder on the children of military fathers

Health and well-being of serving and ex-serving UK Armed Forces personnel: protocol for the fourth phase of a longitudinal cohort study

INTRODUCTION

This is the fourth phase of a longitudinal cohort study (2022-2023) to investigate the health and well-being of UK serving (Regulars and Reservists) and ex-serving personnel (veterans) who served during the era of the Iraq and Afghanistan conflicts. The cohort was established in 2003 and has collected data over three previous phases including Phase 1 (2004-2006), Phase 2 (2007-2009) and Phase 3 (2014-2016).

METHODS AND ANALYSIS

Participants are eligible to take part if they completed the King's Centre for Military Health Research Health and Wellbeing Cohort Study at Phase 3 (2014-2016) and consented to be recontacted (N=7608). Participants will be recruited through email, post and text message to complete an online or paper questionnaire. Data are being collected between January 2022 and September 2023. Health and well-being measures include measures used in previous phases that assess common mental disorders, post-traumatic stress disorder (PTSD) and alcohol misuse. Other areas of interest assess employment, help-seeking and family relationships. New topics include the impact of the British withdrawal from Afghanistan in 2021, complex PTSD (C-PTSD), illicit drug use, gambling and loneliness. Analyses will describe the effect size between groups deployed to Iraq and/or Afghanistan or not deployed, and those who are currently in service versus ex-service personnel, respectively, reporting prevalences with 95% CIs, and ORs with 95% CI. Multivariable logistic and multiple linear regression analyses will be conducted to assess various health and well-being outcomes and associations with risk and protective factors.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Ministry of Defence Research Ethics Committee (Ref: 2061/MODREC/21). Participants are provided with information and agree to a series of consent statements before taking part. Findings will be disseminated to UK Armed Forces stakeholders and international research institutions through stakeholder meetings, project reports and scientific publications.

Experiences and perceptions of family members of emergency first responders with post-traumatic stress disorder: a qualitative systematic review

OBJECTIVE

The objective of this review was to examine the perceptions and experiences of family members of emergency first responders (EFRs) with post-traumatic stress disorder (PTSD).

INTRODUCTION

Research indicates that rates of PTSD in EFRs are approximately double civilian rates; however, little is known about the resultant effects on their family members. This review identifies the qualitative literature and data examining the perceptions and experiences of families with a current or former EFR family member with diagnosed or undiagnosed PTSD.

INCLUSION CRITERIA

This review included all relevant articles, books, reports, and doctoral theses in English, globally, with no time limits, examining the experiences of family members of current or former EFRs family with diagnosed or undiagnosed PTSD. All possible familial configurations and family members were considered, including nuclear, separated, and blended families, of an EFR. There were no age restrictions on EFRs or their family members, or limitations on recency of service. EFRs included police, ambulance/paramedics, firefighters, and rescue personnel.

METHODS

The databases searched included MEDLINE (PubMed), PsycINFO (Ovid), Embase, CINAHL (EBSCOhost), and Scopus. Hand-searching of relevant journals was conducted across Australian Paramedic , Australasian Journal of Paramedicine , British Paramedic Journal , International Paramedic Practice , Irish Journal of Paramedicine , Journal of Paramedic Practice , Prehospital and Disaster Medicine , and Prehospital Emergency Care . Sources of unpublished studies and gray literature, such as dissertations, were searched via PTSDpubs (ProQuest) and OpenGrey (DANS EASY Data Archive). The search was updated in October 2021. Titles, abstracts, and full texts were screened by 2 independent reviewers against the inclusion criteria, and any conflicting views were resolved by discussion. Results were critically appraised for methodological quality. Post-data extraction results were synthesized and evaluated for credibility and dependability in accordance with the a priori protocol.

RESULTS

The search yielded 1264 records and 48 were deemed eligible for full-text review. Seven studies were critically appraised, and 5 studies were agreed upon for inclusion in the synthesis. From these 5 studies, 53 findings were extracted with associated illustrations and synthesized into 9 categories. Following meta-aggregation, 4 broad synthesized findings were developed: i) Changed family member roles, spousal relationships difficulties, and family functioning when living with an EFR with PTSD; ii) Spouses of an EFR with PTSD may experience vicarious trauma, secondary trauma, and/or overburden as a consequence of protecting the family unit; iii) Children of an EFR parent with PTSD may experience secondary trauma, vicarious trauma, and/or separation anxiety; and iv) Spouses' help-seeking and support needs for their EFR partners with PTSD, their children, and themselves. The first 3 findings received a low ConQual score due to low dependability and moderate credibility. The final finding received a moderate ConQual score due to low dependability and high credibility.

CONCLUSIONS

The findings of the 5 qualitative studies included in the review showed significant mental health and functional impacts for family members of EFR with PTSD. Most studies focused on spouses, with some limited data on children. Two of the 5 studies focused on the 9/11 World Trade Center terrorist attacks in the United States. The findings also indicate the need for targeted psychological and social services for EFR family members. Recommendations derived from the synthesized findings of this review include the need for further qualitative research, not only to deepen the understanding about the impacts and needs of EFR with PTSD on family members, but also to inform the design and provision of support services.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020196605.

The mental health and wellbeing of spouses, partners and children of emergency responders: A systematic review

Emergency responders (ERs), often termed First Responders, such as police, fire and paramedic roles are exposed to occupational stressors including high workload, and exposure to trauma from critical incidents, both of which can affect their mental health and wellbeing. Little is known about the impact of the ER occupation on the mental health and wellbeing of their families. The aim of the current study was to investigate what mental health and wellbeing outcomes and experiences have been researched internationally in ER families, and to examine the prevalence and associated risk and protective factors of these outcomes. We conducted a systematic review in accordance with an a priori PROSPERO approved protocol (PROSPERO 2019 CRD42019134974). Forty-three studies were identified for inclusion. The majority of studies used a quantitative, cross-sectional design and were conducted in the United States; just over half assessed police/law enforcement families. Themes of topics investigated included: 1) Spousal/partner mental health and wellbeing; 2) Couple relationships; 3) Child mental health and wellbeing; 4) Family support and coping strategies; and 5) Positive outcomes. The review identified limited evidence regarding the prevalence of mental health and wellbeing outcomes. Family experiences and risk factors described were ER work-stress spillover negatively impacting spousal/partner wellbeing, couple relationships, and domestic violence. Traumatic exposure risk factors included concerns family had for the safety of their ER partner, the negative impact of an ER partners’ mental health problem on the couples’ communication and on family mental health outcomes. Protective factors included social support; however, a lack of organisational support for families was reported in some studies. Study limitations and future research needs are discussed. Progressing this area of research is important to improve knowledge of baseline needs of ER families to be able to target interventions, improve public health, and support ER’s operational effectiveness.

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.

Experiences and perceptions of family members of emergency first responders with post-traumatic stress disorder: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to understand the perceptions and experiences of family members of emergency first responders with post-traumatic stress disorder.

INTRODUCTION

Research indicates that rates of post-traumatic stress disorder in emergency first responders are approximately double civilian rates; however, little is known about the effects of post-traumatic stress disorder on family members. This review seeks to identify qualitative research on families' experiences and perceptions.

INCLUSION CRITERIA

This review will consider all studies of family members of current or former emergency first responders with diagnosed or undiagnosed post-traumatic stress disorder of any level of severity. All possible familial configurations and family members will be considered, including nuclear, separated, and blended families, of a current or former emergency first responder. There will be no age restrictions on emergency first responders or their family members, or limitations on recency of service. Emergency first responders may include police, ambulance workers, paramedics, firefighters, or rescue personnel, with no restriction on geographic location.

METHODS

The databases to be searched will include PubMed, PsycINFO, Embase, CINAHL, PTSDpubs, and Scopus, as well as handsearching of relevant journals. Unpublished studies and gray literature will be searched via PTSDpubs and OpenGrey. The search will aim to find English-language publications with no time limits. Titles and abstracts will be reviewed and then full texts, all screened by two independent reviewers against the inclusion criteria. Any conflicting views will be resolved by discussion or a third reviewer. Results will be critically appraised for methodological quality. Data extraction results will be synthesized and evaluated for credibility and dependability.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020196605.

Integrated Trauma-Focused Cognitive Behavioral Therapy for Comorbid Combat-Related Posttraumatic Stress Disorder: A Case Study with a Military Veteran

Individual Trauma-focused CBT has been shown to be effective for treating posttraumatic stress disorder in military veterans. Treatment challenges are common including the presence of dissociation and comorbidities including depression, traumatic brain injury symptoms, substance misuse, and social transition difficulties. There are currently no standard psychological therapy guidelines for veterans with comorbid presentations. However, as recommended by the National Institute for Health and Care Excellence treatment guidelines, adapting existing treatments can improve the chances of successfully treating trauma cases. In line with these recommendations, the current case study describes how the existing individual trauma-focused CBT model was integrated to treat posttraumatic stress disorder with comorbid depression, persistent mild-traumatic brain injury migraine, and social transition difficulties in a 38-year-old male combat veteran. The client attended 16-sessions of trauma-focused CBT. This model integrated his comorbidities and involved his spouse and multidisciplinary discussions with his general practitioner, and neurorehabilitation team and the Veterans’ Transition Service. At the end of treatment, the client no longer met the diagnostic criteria for posttraumatic stress disorder. This case illustrates how trauma-focused CBT can be integrated to treat comorbid posttraumatic stress disorder in veterans.

Are we family? A scoping review of how military families are defined in mental health and substance use research

Introduction: While some families may experience poor mental health, substance use, and poor school performance due to service life, the usefulness and applicability of these research findings may be affected by how representative study participants are of the broader population. This article aims to examine how research on mental health and substance use defines a “military family” to understand if the current body of evidence reflects the increasing diversity of this population. Methods: A systematic search of academic articles was conducted in Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, Ebsco CINAHL and ProQuest PILOTS using database-specific subject headings and keyword searches for ‘military’, ‘family’, ‘mental health’ and ‘substance use’. Sociodemographic and military characteristics of study participants were extracted to identify who was and was not included. Results: The most commonly represented family structure was the traditional, heteronormative family comprised of a male service member married to a female civilian with whom they have children. Military couples without children, dual-serving couples, families of LGBTQ personnel, unmarried and new relationships, single parents, male spouses/partners, Veterans not seeking Veterans Affairs (VA) services, and families with additional challenges were regularly not reflected in the research due to implicit or explicit exclusion from studies. Discussion: Research on mental health and substance use among the family members of service personnel continues to reflect the traditional, heteronormative family. Future studies should consider more inclusive definitions of family and creative approaches to recruitment to ensure research in this area reflects the experiences, needs, and strengths of an increasingly diverse military community.

Psychological Stress-Induced Immune Response and Risk of Alzheimer's Disease in Veterans from Operation Enduring Freedom and Operation Iraqi Freedom

PURPOSE

Psychological stress is a significant health problem in veterans and their family members. Traumatic brain injury (TBI) and stress lead to the onset, progression, and worsening of several inflammatory and neurodegenerative diseases in veterans and civilians. Alzheimer's disease (AD) is a progressive, irreversible neuroinflammatory disease that causes problems with memory, thinking, and behavior. TBIs and chronic psychological stress cause and accelerate the pathology of neuroinflammatory diseases such as AD. However, the precise molecular and cellular mechanisms governing neuroinflammation and neurodegeneration are currently unknown, especially in veterans. The purpose of this review article was to advance the hypothesis that stress and TBI-mediated immune response substantially contribute and accelerate the pathogenesis of AD in veterans and their close family members and civilians.

METHODS

The information in this article was collected and interpreted from published articles in PubMed between 1985 and 2020 using the key words stress, psychological stress, Afghanistan war, Operation Enduring Freedom (OEF), Iraq War, Operation Iraqi Freedom (OIF), Operation New Dawn (OND), traumatic brain injury, mast cell and stress, stress and neuroimmune response, stress and Alzheimer's disease, traumatic brain injury, and Alzheimer's disease.

FINDINGS

Chronic psychological stress and brain injury induce the generation and accumulation of beta-amyloid peptide, amyloid plaques, neurofibrillary tangles, and phosphorylation of tau in the brain, thereby contributing to AD pathogenesis. Active military personnel and veterans are under enormous psychological stress due to various war-related activities, including TBIs, disabilities, fear, new environmental conditions, lack of normal life activities, insufficient communications, explosions, military-related noise, and health hazards. Brain injury, stress, mast cell, and other immune cell activation can induce headache, migraine, dementia, and upregulate neuroinflammation and neurodegeneration in veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. TBIs, posttraumatic stress disorder, psychological stress, pain, glial activation, and dementia in active military personnel, veterans, or their family members can cause AD several years later in their lives. We suggest that there are increasing numbers of veterans with TBIs and stress and that these veterans may develop AD late in life if no appropriate therapeutic intervention is available.

IMPLICATIONS

Per these published reports, the fact that TBIs and psychological stress can accelerate the pathogenesis of AD should be recognized. Active military personnel, veterans, and their close family members should be evaluated regularly for stress symptoms to prevent the pathogenesis of neurodegenerative diseases, including AD.

Stress and its Social Determinants - A Qualitative Study Reflecting the Perceptions of a Select Small Group of the Public in Sri Lanka

BACKGROUND

Exposure to stress, especially for prolonged periods, can result in physical and mental disorders. To attribute causality to its associated disease profile, social determinants need to be identified at the population level. The objective of this study was to explore perceptions regarding stress and its probable social determinants, among a purposeful cohort of the public from Colombo district, Sri Lanka.

METHODS

A qualitative study using focus group discussions (FGDs) was conducted among adults. Purposive sampling was used to recruit 8--10 participants into homogenous groups. Data were collected until information saturation. A semistructured FGD guide was used to facilitate the discussions. Content analysis methods were used to analyze data.

RESULTS

Six FGDs consisting of 59 participants were conducted. Participants included primary healthcare workers, community members, village leaders, private and public sector employees, unemployed individuals, homemakers, self-employed persons, slum dwellers, and persons from affluent communities. Three main themes emerged: social, economic, and cultural factors. Social factors consisted of four sub-themes: social role or status, generation gap, disability, and unsafe environment. Economic factors included three related subthemes: poverty, unemployment, and job insecurity. Cultural factors included three subthemes: superstitious beliefs, religion and caste, marriage and dowry.

CONCLUSION

Elements regarding stress and its social determinants among the public in Sri Lanka seem to be an amalgam of interconnected sociocultural and economic factors. However, addressing these social determinants in isolation (at an individual level) may not be feasible, as most causes appear to be outside the scope of the individual.

'It's nice to just be you': The influence of the employment experiences of UK military spouses during accompanied postings on well-being

Repeated military relocations (accompanied postings) can have a detrimental effect on employment and well-being among the spouses and partners of military personnel. Semi-structured telephone interviews were conducted with 19 spouses of British Army/Royal Air Force personnel with recent experience of accompanied postings to explore this issue through the lens of self-determination theory; all were married women with at least one child. Participants explained how employment contributed to an independent identity, enabling social connectedness, providing a sense of self-confidence and value but limiting agency over employment decisions. Spouse employment, and therefore, well-being could be improved by the provision of better childcare access or additional support in finding employment and training opportunities.

Out of sight out of mind: an examination of mental health problems in UK military reservists and veterans

BACKGROUND

Reservists often have different experiences to regular military personnel which may impact their mental health.

AIMS

To investigate the incidence of mental health problems in both active and veteran reservists and determine how this compares to regular service personnel and ex-regular veterans.

METHOD

Five studies which included reservist and/or veteran participants, a validated assessment of mental health problems, and provided primary data were included in the synthesis. Common mental health disorders, post-traumatic stress disorder and alcohol use disorder were examined.

RESULTS

Nondeployed mobilized reservists were significantly less likely to report common mental health disorders than nondeployed regulars. There were no other significant differences between groups. Regardless deployed reservists reported more mental health problems than nondeployed reservists. Similarly, ex-regular deployed veterans were more likely to experience mental health difficulties than nondeployed ex-regular veterans. Notably, a large proportion of non-deployed reservists reported probable alcohol use disorders, indicating that problematic alcohol consumption may not be due to deployment in this group.

CONCLUSION

These results highlight the need for ongoing support for military regular, ex-regular and reservist personnel. Additional research is needed to examine potential risk and protective factors for mental health problems in both deployed and nondeployed reservists. Key points Overall, mobilized deployed reservists were more likely to experience mental health problems than non-deployed reservists. Nondeployed regulars reported significantly more common mental health problems than nondeployed mobilized reservists. Reservists and (ex-)regulars reported similar rates of PTSD. This suggests reservists are vulnerable to developing PTSD following non-combat related trauma that may not lead to PTSD in regulars and this warrants future research. Reservists were less likely to report problematic alcohol consumption compared to regular personnel and ex-regular veterans. The greatest amount of reservist problematic drinking was reported in non-deployed veteran reservists. This indicates problematic alcohol consumption is not deployment related in this group and highlights the need for ongoing formal support for alcohol use disorders in the UK Armed Forces.

Prenatal programming of stress responsiveness and behaviours: Progress and perspectives

Parental exposure to stress or glucocorticoids either before or during pregnancy can have profound influences on neurodevelopment, neuroendocrine function and behaviours in offspring. Specific outcomes are dependent on the nature, intensity and timing of the exposure, as well as species, sex and age of the subject. Most recently, it has become evident that outcomes are not confined to first-generation offspring and that there may be intergenerational and transgenerational transmission of effects. There has been intense focus on the mechanisms by which such early exposure leads to long-term and potential transgenerational outcomes, and there is strong emerging evidence that epigenetic processes (histone modifications, DNA methylation, and small non-coding RNAs) are involved. New knowledge in this area may allow the development of interventions that can prevent, ameliorate or reverse the long-term negative outcomes associated with exposure to early adversity. This review will focus on the latest research, bridging human and pre-clinical studies, and will highlight some of the limitations, challenges and gaps that exist in the field.

Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward

Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and veteran populations. Considerable research and clinical opinion has been focused on understanding the relationship between PTSD and military service and the implications for prevention, treatment, and management. This paper examines factors associated with the development of PTSD in this population, considers issues relating to engagement in treatment, and discusses the empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treatments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medicine approaches, advancing functional outcomes, family intervention and support, and attention to physical health.

Mental health outcomes and alcohol consumption among UK military spouses/partners: a comparison with women in the general population

Background: Military families can experience unique stressors that may contribute towards poorer well-being among the spouses/partners of Service personnel. However, there is little UK research regarding mental health or alcohol consumption among this population. Objective: This study examined mental health outcomes (probable depression and post-traumatic stress disorder (PTSD)) and alcohol consumption among UK military spouses/partners compared to women in the general population. Associations with military and socio-demographic characteristics were examined. Method: Survey data from 405 female spouses/partners of current and former UK Service personnel participating in a study of military-connected children (2010-2012) was analysed. Comparisons to women in the general population were made using the 2007 Adult Psychiatric Morbidity Survey (n = 1594). Results: Compared to women from the general population, military spouses/partners were significantly more likely to meet criteria for probable depression (adj. OR 2.50 (95% CI 1.52-4.11)). There was no significant difference regarding probable PTSD. Spouses/partners were significantly more likely to meet criteria for hazardous alcohol consumption (adj. OR 2.55 (95% CI 1.87-3.47)) and more likely to report episodes of weekly, daily or almost daily binge-drinking (adj. OR 2.15 (95% CI 1.28-3.61)) than women in the general population. Binge-drinking was significantly higher among spouses/partners of Service personnel reporting family separations of more than 2 months in the last 2 years compared to those reporting no, or shorter, separations (adj. OR 1.88 (95% CI 1.08-3.27)). Conclusion: This is the first study to examine mental health and alcohol consumption among UK military spouses/partners. The significantly higher prevalence of probable depression, hazardous alcohol consumption, and binge-drinking compared to women in the general population suggests further research is needed into the drivers of poor mental health and alcohol consumption among this population and in identifying or developing prevention campaigns to reduce alcohol use and support their well-being.

A systematic review of wellbeing in children: a comparison of military and civilian families

BACKGROUND

Children in military families have uniquely different childhood experiences compared to their civilian peers, including a parent in employment and a stable familial income, frequent relocations, indirect exposure to and awareness of conflict, and extended separation from parents or siblings due to deployment. However, whether children from military families have poorer wellbeing than non-military connected children is not well understood.

METHOD

We conducted a systematic review to explore the relationship between military family membership (e.g. parent or sibling in the military) and child wellbeing compared to non-military connected controls. Searches for this review were conducted in September 2016 and then updated in February 2018.

RESULTS

Nine studies were identified, eight were cross-sectional. All studies utilised self-report measures administered in US school settings. On the whole, military connected youth were not found to have poorer wellbeing than civilian children, although those with deployed parents and older military connected children were at greater risk of some adjustment difficulties (e.g. substance use, externalising behaviour). Although only assessed in two studies, having a sibling in the military and experiencing sibling deployment was statistically significantly associated with substance use and depressive symptoms.

CONCLUSIONS

This study is unique in its direct comparison of military and non-military connected youth. Our results highlight the need to examine the impact of military service in siblings and other close relatives on child wellbeing. Given the adverse impact of poor mental health on child functioning, additional research is needed ensure appropriate, evidence-based interventions are available for youth in military families.