Stephen J. Cozza

Posttraumatic stress disorder and depression in battle-injured soldiers.

OBJECTIVE This study examined rates, predictors, and course of probable posttraumatic stress disorder (PTSD) and depression among seriously injured soldiers during and following hospitalization. METHOD The patients were 613 U.S. soldiers hospitalized following serious combat injury. Standardized screening instruments were administered 1, 4, and 7 months following injury; 243 soldiers completed all three assessments. Cross-sectional and longitudinal analyses of risk factors were performed. PTSD was assessed with the PTSD Checklist; depression was assessed with the Patient Health Questionnaire. Combat exposure, deployment length, and severity of physical problems were also assessed. RESULTS At 1 month, 4.2% of the soldiers had probable PTSD and 4.4% had depression; at 4 months, 12.2% had PTSD and 8.9% had depression; at 7 months, 12.0% had PTSD and 9.3% had depression. In the longitudinal cohort, 78.8% of those positive for PTSD or depression at 7 months screened negative for both conditions at 1 month. High levels of physical problems at 1 month were significantly predictive of PTSD (odds ratio=9.1) and depression at 7 months (odds ratio=5.7) when the analysis controlled for demographic variables, combat exposure, and duration of deployment. Physical problem severity at 1 month was also associated with PTSD and depression severity at 7 months after control for 1-month PTSD and depression severity, demographic variables, combat exposure, and deployment length. CONCLUSIONS Early severity of physical problems was strongly associated with later PTSD or depression. The majority of soldiers with PTSD or depression at 7 months did not meet criteria for either condition at 1 month.

Military families and children during operation Iraqi freedom.

The general public has become increasingly interested in the health and well being of the children and families of military service members as the war in Iraq continues. Observers recognize the potential stresses or traumas that this population might undergo as a result of the military deployment or the possible injury or death of military family members. While such concern is welcomed, it is sometimes misplaced. Not infrequently, conclusions that are drawn are fraught with misunderstanding and bias based upon lack of understanding of the military community or a preconceived notion of the vulnerabilities of the population. This problem is compounded by the paucity of scientific study. In this article the authors review the strengths of military families as well as the unique challenges that they face. The authors also highlight parental deployment, parental injury and parental death as unique stresses to military children and families. Available and pertinent scientific information is reviewed. Clinical observations of children and families during the ongoing war in Iraq are presented.

When a parent is injured or killed in combat

When a service member is injured or dies in a combat zone, the consequences for his or her family can be profound and long-lasting. Visible, physical battlefield injuries often require families to adapt to long and stressful rounds of treatment and rehabilitation, and they can leave the service member with permanent disabilities that mean new roles for everyone in the family. Invisible injuries, both physical and psychological, including traumatic brain injury and combat-related stress disorders, are often not diagnosed until many months after a service member returns from war (if they are diagnosed at all—many sufferers never seek treatment). They can alter a service member’s behavior and personality in ways that make parenting difficult and reverberate throughout the family. And a parent’s death in combat not only brings immediate grief but can also mean that survivors lose their very identity as a military family when they must move away from their supportive military community. Sifting through the evidence on both military and civilian families, Allison Holmes, Paula Rauch, and Stephen Cozza analyze, in turn, how visible injuries, traumatic brain injuries, stress disorders, and death affect parents’ mental health, parenting capacity, and family organization; they also discuss the community resources that can help families in each situation. They note that most current services focus on the needs of injured service members rather than those of their families. Through seven concrete recommendations, they call for a greater emphasis on family-focused care that supports resilience and positive adaptation for all members of military families who are struggling with a service member’s injury or death.

Using Multidimensional Grief Theory to Explore the Effects of Deployment, Reintegration, and Death on Military Youth and Families

To date, the US military has made major strides in acknowledging and therapeutically addressing trauma and post-traumatic stress disorder (PTSD) in service members and their families. However, given the nature of warfare and high rates of losses sustained by both military members (e.g., deaths of fellow unit members) and military families (e.g., loss of a young parent who served in the military), as well as the ongoing threat of loss that military families face during deployment, we propose that a similar focus on grief is also needed to properly understand and address many of the challenges encountered by bereaved service members, spouses, and children. In this article, we describe a newly developed theory of grief (multidimensional grief theory) and apply it to the task of exploring major features of military-related experiences during the phases of deployment, reintegration, and the aftermath of combat death—especially as they impact children. We also describe implications for designing preventive interventions during each phase and conclude with recommended avenues for future research. Primary aims are to illustrate: (1) the indispensable role of theory in guiding efforts to describe, explain, predict, prevent, and treat maladaptive grief in military service members, children, and families; (2) the relevance of multidimensional grief theory for addressing both losses due to physical death as well as losses brought about by extended physical separations to which military children and families are exposed during and after deployment; and (3) a focus on military-related grief as a much-needed complement to an already-established focus on military-related PTSD.

Family-Centered Care for Military and Veteran Families Affected by Combat Injury

The US military community includes a population of mostly young families that reside in every state and the District of Columbia. Many reside on or near military installations, while other National Guard, Reserve, and Veteran families live in civilian communities and receive care from clinicians with limited experience in the treatment of military families. Though all military families may have vulnerabilities based upon their exposure to deployment-related experiences, those affected by combat injury have unique additional risks that must be understood and effectively managed by military, Veterans Affairs, and civilian practitioners. Combat injury can weaken interpersonal relationships, disrupt day-to-day schedules and activities, undermine the parental and interpersonal functions that support children’s health and well-being, and disconnect families from military resources. Treatment of combat-injured service members must therefore include a family-centered strategy that lessens risk by promoting positive family adaptation to ongoing stressors. This article reviews the nature and epidemiology of combat injury, the known impact of injury and illness on military and civilian families, and effective strategies for maintaining family health while dealing with illness and injury.

Psychiatric Interventions with Returning Soldiers at Walter Reed

War is a malefic force and results in many psychiatric and medical casualties. Psychiatrys involvement with soldiers experiencing psychological stress resulting from combat experience has been reported for many years (Zajtchuk, 1995). It has been demonstrated that a myriad of diagnosis to include depression, anxiety, somatoform, adjustment disorders and psychotic behaviors also emerge (Wain et al., 1996, 2005a). Nearly all survivors exposed to traumatic events briefly exhibit one or more stress related symptoms (Morgan et al., 2003). In many instances these symptoms dissipate within a reasonable amount of time. However, symptoms persisting for a prolonged period following a traumatic event increase the probability of developing stress-related psychiatric disorders.

Supporting America's Military Children and Families

Military children are our nation’s children and military families are our nation’s families. They serve courageously and their commitment and sense of duty is comparable to their military service family members’, worthy of national interest, and most worthy of national commitment, support, and sustainment. Military children’s involvement in national service is one that they do not choose, but they take on because of the occupation of their parents. It was once said that if the military wanted enlisted service members and officers to have spouses and children, they would have been issued to them. This attitude is from a different time and era, when the force was mostly made up of young men who were drafted into military service, and when there were far fewer family members. Today, there are about two million children and adolescents who are the sons and daughters of America’s active duty, reserve, or National Guard military members. In addition, there are approximately four million youth who are the sons or daughters of veterans who have served since 9/11. Before the start of the all-volunteer force, spouses and children were fewer in number and, when present, were typically those of officers or senior enlisted members. Today, according to a recent U.S. Department of Defense Demographics Report (DoD, 2010), military family members outnumber service members: 57% of the active force are married and 44% of active duty members have children. Of these 1.2 million children of active duty members, almost three-quarters are 11 years of age or younger and 42% of all children are under the age of 6 years. Approximately 43% of selected reserve members (including both Reserve and National Guard components) have children, and nearly 60% of these children are younger than 12 years. The U.S. military community includes a population of mostly young families living throughout the continental United States, Hawaii, Alaska, and at overseas locations. While many live on or near military installations, many others also reside in geographically remote areas. They live in the communities where all of us live, but we do not always identify them for who they are or their connections to military life or challenges. Not until their recent media attention have military children and families come to the broader attention of the public and scientists around the country. As a result, the experiences and developmental life course of military children have largely gone unstudied. Who are these children and what can we learn from the strength they possess and the challenges that they face? They are as different from each other as they are alike, and reflect the broad socioeconomic, racial, cultural, and ethnic dimensions of the United States. In contrast to their diverse demographics, they share common values and experiences that come with their parents’ military-related duty. These characteristics include a sense of meaning and purpose, military community connectedness, and servicerelated pride, in addition to shared experiences such as frequent residential moves, combat and non-combat related deployments, and possible parental combat related sequelae. Combat deployment impact has been profound for military families. Since 2001, over two million military service men and women have deployed to combat operations in Iraq and Afghanistan. They come from every military service branch, hail from every state in the country, and represent the active duty, National Guard, and reserve components of the military. Many families have faced repeated deployments, some as many as five or more. Since the start of combat operations over 6,000 service members have died in combat theater, tens of thousands have suffered combat injuries, and hundreds of thousands continue to suffer with traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) of varying severity. This article not subject to U.S. copyright law. Stephen J. Cozza’s views expressed herein do not necessarily reflect those of the Uniformed Services University of the Health Sciences or the Department of Defense. Address correspondence to Stephen J. Cozza, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. E-mail: stephen.cozza@ usuhs.edu GUEST EDITORIAL

Child Neglect in Army Families: A Public Health Perspective

Military families include 2.9 million people, with approximately 40% of all service members having at least one child. Rates of child neglect in this population have increased in recent years, but little is known about the characteristics of the neglect. To better identify targets for intervention, it is necessary that we refine our understanding of child neglect in the military. In this review, we examine definitions of child neglect and the specific definitions used by the U.S. Army. We identify domains of neglect and caregiver behaviors and affiliated. We suggest that this approach can inform prevention efforts within the Institute of Medicines framework for preventive interventions. Understanding risk and protective factors in the military family are important to interventions for child neglect in military families.

Characteristics, Classification, and Prevention of Child Maltreatment Fatalities

BACKGROUND Preventing child maltreatment fatalities is a critical goal of the U.S. society and the military services. Fatality review boards further this goal through the analysis of circumstances of child deaths, making recommendations for improvements in practices and policies, and promoting increased cooperation among the many systems that serve families. The purpose of this article is to review types of child maltreatment death, proposed classification models, risk and protective factors, and prevention strategies. METHODS This review is based on scientific and medical literature, national reports and surveys, and reports of fatality review boards. FINDINGS Children can be killed soon after birth or when older through a variety of circumstances, such as with the suicide of the perpetrator, or when the perpetrator kills the entire family. Death through child neglect may be the most difficult type of maltreatment death to identify as neglect can be a matter of opinion or societal convention. These deaths can occur as a result of infant abandonment, starvation, medical neglect, drowning, home fires, being left alone in cars, and firearms. Models of classification for child maltreatment deaths can permit definition and understanding of child fatalities by providing reference points that facilitate research and enhance clinical prediction. Two separate approaches have been proposed: the motives of the perpetrator and the circumstances of death of the child victim. The latter approach is broader and is founded on an ecological model focused on the nature and circumstances of death, child victim characteristics, perpetrator characteristics, family and environmental circumstances, and service provision and need. Many risk factors for maternal and paternal filicide have been found, but most often included are young maternal age, no prenatal care, low education level, mental health problems, family violence, and substance abuse. Many protective factors can be specified at the individual, family, and community level. Early interventions for children and families are facilitated by the increased awareness of service providers who understand the risk and protective factors for intentional and unintentional child death. DISCUSSION/IMPACT/RECOMMENDATIONS There is currently no roadmap for the prevention of child maltreatment death, but increased awareness and improved fatality review are essential to improving policies and practices. Prevention strategies include improving fatality review recommendations, using psychological autopsies, serious case reviews, and conducting research. We recommend a public health approach to prevention, which includes a high level of collaboration between agencies, particularly between the military and civilian. The adoption of a public health model can promote better prevention strategies at individual, family, community, and societal levels to address and improve practices, policies, and public attitudes and beliefs about child maltreatment. The process of making recommendations on the basis of fatality review is important in terms of whether they will be taken seriously. Recommendations that are too numerous, impractical, expensive, lack relevance, and are out of step with social norms are unlikely to be implemented. They can be helpful if they are limited, focused, lead to definitive action, and include ways of measuring compliance.

Lessons Learned and Future Recommendations for Conducting Research with Military Children and Families

When the US military began combat operations in Iraq and Afghanistan in 2002, little was known about how military children and families would be affected by combat-related service in an era of prolonged war. The ability of clinicians, policymakers, community service providers, commanders, and researchers to meet the needs of military children was limited by outdated research, inappropriate comparison groups, uneven systems of care, and a lack of evidence-based practices to guide intervention. Fortunately, strategic partnerships grew out of the collaborative efforts of academics, practitioners, and military leadership united in a common mission to support military children and families. This chapter describes the historical context of research on military children and families, identifying challenges to conducting high-quality research, and delineating best practices for scholarship. The following research-related lessons learned are highlighted: understanding and respecting military family culture, building trust within the community, fostering lasting relationships within the community, building collaborative multidisciplinary academic research teams, and sustaining a scientific military family program of research. Recommendations and future directions for researchers, military leaders, policymakers, and funders are also discussed.