Acad Psychiatry DOI 10.1007/s40596-015-0302-4
IN DEPTH ARTICLE: COMMENTARY
US Military Child and Adolescent Psychiatry Training Programs and Careers of Military Child Psychiatrists Christina G. Weston & Joseph G. Dougherty & Suzie C. Nelson & Matthew J. Baker & Jennifer C. Chow
Received: 15 June 2014 / Accepted: 27 January 2015 # Academic Psychiatry 2015
Abstract Military child and adolescent psychiatry (CAP) fellowship programs offer educational experiences universal to all civilian training programs in the USA. They also offer unique training opportunities not found in civilian CAP fellowships in order to prepare graduates to serve the needs of military families. Military-specific curricula and exposures prepare trainees to address various issues faced by military families, in contending with frequent military moves, parental deployments, and disrupted social ties. Curricula are also designed to provide the psychiatrist with a greater understanding of the rigors of military service. CAP training and subsequent assignments prepare military psychiatrists for diverse career paths in the military environment. CAP military careers often include duties in addition to treating patients. Administrative roles, academic teaching positions, as well as school consultation positions are all career options available to military CAP. Keywords Residents . Child and adolescent . Workforce
There are approximately 7700 child psychiatrists in the USA, or one child psychiatrist for every 40,000 people, a very small percentage of which train in military child and adolescent C. G. Weston (*) : S. C. Nelson : M. J. Baker Wright State University Boonshoft School of Medicine, Dayton, OH, USA e-mail: [email protected] J. G. Dougherty Uniformed Services University of the Health Sciences School of Medicine, Bethesda, MD, USA J. C. Chow United States Air Force, Wright-Patterson Air Force Base, Dayton, OH, USA
psychiatry fellowship programs [1]. Over the past several decades, the all-volunteer military has changed from a fighting force of single men to one of married service members with young families [2]. This has increased the need for military child and adolescent psychiatrists (CAP). Of the approximately 1.8 million children of active duty and reserve US military personnel, over 75 % are age 12 or younger [2]. Military families experience multiple unique stressors related to military service that may affect the emotional well-being of military children. Frequent military moves, disrupted social ties, parental deployments, and potential parental injuries during deployment are only a few of the challenges they face. Fellows in military CAP programs require additional training to address these problems when working with military families. Adopting a military-specific curriculum and practicing in military settings provide CAP fellows with the preparation to meet these challenges. Civilian residency programs can help prepare their graduates for work with military families by exploring the difficulties faced by this population, the effects on child development, and known helpful interventions.
Psychiatric Issues Specific to Military Children and Families Military families face distinct challenges compared to many of their civilian counterparts. They are often physically separated from non-military families by living in base housing communities and by patronizing predominantly military facilities, such as hospitals, stores, and schools. Deployments, frequent moves, and disrupted social ties are common phenomena that affect active duty parents, their spouses, as well as their children. Children of military families are particularly vulnerable as these changes occur during developmentally sensitive periods and can affect later progress. Although these stressors may provide opportunities for growth in resilient children,
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those at risk may be detrimentally affected, leading to social or school impairments that often prompt mental health referral. The increase in stressors placed upon military children in recent years has led to a great deal of scientific investigation on the subject of parental deployment as it relates to childhood behavioral and emotional problems. Research after the 1990– 1991 Persian Gulf War revealed that children whose parents had deployed experienced higher levels of self-reported depressive symptoms compared to children of non-deployed parents. However, these symptoms rarely reached pathological levels [3]. During the first several years of US involvement in the conflicts in Iraq and Afghanistan, over two million children were directly impacted by deployment of a parent [4]. Contending with parental departure may lead to a variety of difficulties depending on the age of the child. Additionally, effects on the parents, such as increased caregiver stress as well as injury or death of the deployed parent, can have deleterious effects on the child [2]. A study of 3–5-year-old children with a deployed parent indicated increased behavioral symptoms compared to same-aged peers not contending with parental deployment [4]. A 2010 study examined the effect of parental combat deployment and parental distress on behavioral and emotional problems in school-aged children. It found the children’s anxiety scores to be significantly higher than community norms, with a prevalence of 24.7 % in children with a currently deployed parent, and 31.9 % for those with a recently deployed parent. Children’s internalizing symptoms, externalizing symptoms, and depression scores appeared to be predicted by both the presence of depression in the at-home civilian parent and the presence of PTSD symptoms in the active duty parent [5]. A Washington State study published in 2011 found that parental deployment was associated with a higher likelihood of suicidal ideation among teenage girls as well as greater reports of low quality of life, depressed mood, and thoughts of suicide among adolescent boys [6]. There is also evidence that child maltreatment, such as neglect or abuse, may be 42 % higher and of increased severity among Army families of enlisted soldiers when a parent is away on combat-related deployment [7]. Studies such as these indicate the need for preventive approaches and targeted interventions to help families adapt and develop resiliency, as well as the necessity of rapid access to mental health resources when difficulties occur. Several interventions created for assisting military families are being developed and researched. The Families OverComing Under Stress (FOCUS) project for military families is one such approach, aiming to improve families coping with deployment by providing education and skills training for parents and children. Participation in the program appears to produce improvements in family functioning, decreased parental and child distress, a decrease in children’s conduct problems from 47.7 % at intake to 28.4 % post-intervention, and a decrease in children’s emotional symptoms from 40.4 %
at intake to 22.1 % post-intervention [8]. Other approaches are currently being evaluated, such as the Strong Intervention and the After Deployment: Adaptive Parenting Tools program (ADAPT), which teach stress reduction skills, parenting, and discipline and target adjustment reactions following deployment [9, 10]. Inherent to military duty is the expectation that service members and their families will relocate at various times during one’s career. Service members may be selected for assignments across the continental USA or overseas. This inevitability of military service can present multiple challenges if a child or spouse of a service member has special needs, developmental disabilities, unique educational requirements, or medical problems requiring a specialized level of care. The military’s Exceptional Family Member Program (EFMP) seeks to ensure that comprehensive medical, educational, and support services are provided to military beneficiaries faced with such challenges. The EFMP likewise seeks to prevent familial relocation to areas where necessary services may not be available. Duty assignments to particularly rural areas or foreign installations with limited regional medical services may not serve the best interests of some families or the military units to which they are assigned. Thus, such families are required to enroll in the EFMP. Effective execution of the EFMP mission requires coordination among family members, their health-care providers, and military assignment officers who determine appropriate duty station opportunities. This places the military medical provider in a position of dual agency. Enrollment in the EFMP can have positive and negative consequences for the active duty member. The program allows family members to have better access to needed educational and medical resources, but it may have a negative effect on the service member’s career progression by limiting assignment to remote areas. Familiarity with EFMP is integral to the practice of CAP in the military. As military children continue to face the above challenges, the experience gained in a military CAP fellowship is invaluable. At overseas assignments, active duty CAPs are often the only providers available. In the USA, military children may be referred to the provider network of community CAPs; however, the network may not be adequate or readily available at remote bases. In these locations, the presence of military CAPs ensures that necessary care is available for the children who require it.
CAP Training Selection in the Army, Air Force, and Navy The military offers the following three training tracts for residency and fellowship, all of which differ somewhat from the civilian CAP training pathway: military training, “civilian-deferred” training, and “civilian-sponsored” training (see Fig. 1). Military-trained residents are members of the armed services
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who are selected for a military residency program. Civiliandeferred residents have a military service obligation and are allowed to participate in civilian residencies with funding from the civilian residency program. Civilian-sponsored residents have a military service obligation and are selected by the military to complete civilian residency programs with funding provided by the military. Selection of Army, Air Force, and Navy military residents and fellows occurs through a yearly process termed the Joint Service Graduate Medical Education Selection Board (JSGMESB), more commonly known as the “military match.” The JSGMESB meets annually in late November/early December to review applications for residency and fellowship for medical students, residents, and physicians affiliated with the military. The results are released in mid-December. This allows medical students time to participate in the civilian match if not selected for a military residency program. For residents applying for CAP fellowship, the results of the JSGMESB are released shortly before the CAP rank order list is due in December. Some residents apply to both military and civilian CAP programs to increase their chances of acceptance.
The US Army conducts CAP fellowship training for residents who are active duty officers at two medical centers: Walter Reed National Military Medical Center (WRNMMC) in Bethesda, Maryland, and Tripler Army Medical Center (TAMC) in Honolulu, Hawaii. Traditionally, the Army has supported four to five incoming CAP fellows per year, with trainees divided between the two medical centers. The US Air Force (USAF) had a combined military-civilian CAP fellowship program at Wright-Patterson Medical Center (WPMC) and Wright State University Boonshoft School of Medicine (WSUBSOM) from 1997 to 2007. The Air Force decided in 2007 that it was more cost effective to train Air Force fellows elsewhere and closed the USAF CAP fellowship program. Current USAF psychiatry residents selected for fellowship can apply to train at Army programs or request civilian deferment or sponsorship to train at civilian fellowship programs. The USAF is the only service that allows civilian fellowship training; Army and Navy psychiatrists wanting to complete CAP fellowship must do so at an active duty Army program. The US Navy supports CAP fellowship training at both Army programs. The Navy typically trains one to two fellows on a
Military CAP Training Pathway
Civil ian CAP Training Pathway
Enter E Medical School with Military Service Obligation
Medical School
UHS / HPSP / Undergraduate ROTC Serv USU vice obligation
NRMP Maatch Military Match
Psychiatry Residency
Military psych residency
Civilian psych residency
NRMP Match Active Duty General Psychiatrist
Military Match CAP Fellowship
General Psychiatrist Fellowship CAP F Not Selected NRMP Match
Civilian deferred* CAP Fellowship Training
Civilian sponsored** CAP Fellowship Training
Military CAP Fellowship Training
Active Duty y General Psychiatrisst
Active Duty Child & Adolescent Psychiatrist Fig. 1 Military and civilian CAP training pathways
Civilian Child & Adolescent Psyychiatrist
USUHS = Uniformed Ser vices University of the Health Sciences HPSP = Health Profession s Scholarship Program ROTC = Reserve Offiicer Training Core NRMP = National Reside ncy Matching Program *Salary Paid by Civilian P rogram **Salary Paid by the Military
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rotating basis with the Army. The pathways to selection for military CAP fellowship compared with civilian training pathways are seen in Fig. 1. Selection of trainees for Army fellowships typically draws from applicants in military psychiatry residency programs and Army general psychiatrists stationed at various Army installations. As such, the latter are typically experienced clinicians who may be serving in remote assignments around the world. Therefore, training directors may have to rely on phone or video teleconference interviews as well as references from others working with the individual in order to rank order available applicants. Training in a military-supported general psychiatry residency lasts four years, in accordance with program requirements dictated by the American Council of Graduate Medical Education (ACGME). Fellowship training in CAP is a twoyear process also accredited by the ACGME. In keeping with the practice of non-military CAP fellowships, the Army and Air Force allow general psychiatry residents to participate in a modified training schedule that permits completion of both general psychiatry residency and subsequent CAP fellowship in a five-year period. This approach results in successful graduates being eligible for board certification in both general psychiatry and CAP. Traditionally, the Navy has required graduates of four-year general psychiatry residencies to complete active duty assignments as general psychiatrists before pursuing fellowship training. Only after completion of a successful post-graduation assignment are Navy psychiatrists permitted to begin a CAP fellowship. Army and Air Force psychiatrists who are practicing independently at a military installation (a.k.a. “in the field”) are also permitted to apply to the JSGMESB to enter CAP fellowship.
CAP Military Curriculum All CAP fellowships that train military providers satisfy ACGME program requirements. Likewise, such fellowships offer a concurrent military-specific curriculum that focuses on systems-based practice that prepares fellows to function in the military health-care system. A unique element of participating in a military CAP fellowship is the opportunity for a provider to be an active duty military officer. Active duty officers are required to meet physical fitness standards and maintain appropriate military appearance. They also adhere to standards of decorum consistent with military professionalism in addition to the high professionalism standards inherent to medical practice. Compliance with such expectations lends to patients and families identifying with a fellow member of the armed forces. Military CAP fellowships prepare trainees to practice as effective, competent CAPs, with subject matter expertise in military psychiatry, the dynamics of military families, and the effects of deployment on military families and communities.
Upon completion of fellowship, military CAP psychiatrists contend with the same military realities their patients and families encounter: relocation, potential deployment, interaction with their own chains of command, and the uncertainties inherent to serving in a military whose missions may change with minimal advanced notice. Beyond required, structured rotations in inpatient, partial hospitalization program, substance abuse, community, consult-liaison, and outpatient settings, several CAP fellowship offerings contribute to the development of a military psychiatrist (see Table 1). A four-month course in military psychiatry is required of all fellows prior to graduation from both Army Medical Center fellowships. Instructors are senior Army and Navy psychiatrists who combine didactic instruction, subject matter expertise, and their own personal experiences (stateside, overseas, and during deployment) to educate trainees on the principles of military behavioral health. Military-specific behavioral health policies, effective education of military commanders on mental health issues potentially affecting troop readiness, the impact of deployment and training cycles on troops and their families, and fundamentals of “Psychological First Aid” for use in disaster situations are taught. Additional classes focus on the history of military psychiatry and the delivery of behavioral health services in past conflicts. Fellows with previous deployment experience as general psychiatrists are afforded the opportunity to service as guest instructors for this course. If this course was taken by a fellow during general residency, it is not repeated.
Table 1 CAP fellowship experiences oriented toward serving in the military and treating military families Military psychiatry course which covers various issues The history of military psychiatry in the US Armed Forces Department of Defense behavioral health policies and regulations Army, Navy, and Air Force specific behavioral health policies and regulations Educating military commanders on behavioral health issues that may affect service members Principles of behavioral health treatment in deployed or austere environments The impacts of deployment on service members and their families The fundamentals of “Psychological First Aid” for use in disasters The Combat Operational Stress Control (COSC) Course Consultative rotation at schools and day care centers serving children from military families Participation with school-based behavioral health program serving children from military families Education on military unique programs such as the Exceptional Family Member Program (EFMP) Individual and group therapy with children from military families Training in trauma-focused cognitive-behavioral therapy (TF-CBT)
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Complementing such lectures is a series of experiential offerings to CAP fellows that solidify the basic principles of military psychiatry and permit the application of such principles prior to graduation. Army CAP fellows are strongly encouraged to attend a five-day “Combat Operational Stress Control” course prior to graduation. This instruction prepares military behavioral health professionals of various disciplines to address behavioral health issues that may arise in a deployed or combat environment. Topics such as identifying stress responses in service members, effectively intervening to provide appropriate triage, determining the appropriate level of care based on clinical scenarios, and effectively engaging military commanders are presented. Of note, fellows with previous deployment experience do not typically attend this course given their familiarity with the curriculum. Another experiential opportunity afforded to Army and Navy fellows at WRNMMC permits them to serve as behavioral health instructors and observers during a five-day military training exercise for local military medical students. This event, entitled “Operation Bushmaster,” permits CAP fellows to teach medical students the principles of military and operational behavioral health and then assess medical student performance in simulated and adverse conditions. In addition to receiving military-specific training, CAP fellows at Army programs collaborate with unique communitybased child programs that serve military children in the immediate vicinity of the fellowships. Trainees assume a consultative role for local elementary schools where children of military families are enrolled. Use of a traditional school consultative model permits fellows to observe how children from military families fare, assess issues that may affect students in an educational environment, and provide valuable feedback to teachers and staff. Additional collaboration with regional, formal school-based behavioral health programs serving students from military families permits an additional training opportunity for some fellows. Complementing the fellowship curriculum on childhood growth and development is a series of consultative events at military installation day care facilities whose enrollees are from military families. Fellows observe children in the day care environment and with supervision offer consultative services to the day care staff. This approach may be targeted toward children whose day care providers have requested consultation (and obtained parental consent for such) or may focus on any global behavioral issues that arise in this setting. During fellows’ day care visits, trainees present on various issues to include normal child development, potential behaviors of concern in children, and behavioral management challenges, to interested parents. In the clinic setting, CAP fellows may provide individual or group-based services to children of wounded service members. This opportunity permits fellows to provide appropriate supportive and clinical interventions, and it prepares them for future assignments taking care of families contending with the
sequelae of military conflict. Clinical supervisors utilize evolving literature pertaining to military behavioral health issues to enhance supervision, and resources have been provided to fellows and staff to ensure familiarity with both clinical and systems-based issues. A particularly noteworthy resource for fellows and training faculty has been the Brookings Institution and Princeton University’s 2013 volume on Military Children and Families, readily accessible online [11]. This review provides education designed to increase familiarity with military family culture, addresses commonly seen behavioral health concerns for military children, and suggests methods of enhancing community supports for military children. As a means of connecting military CAPs with civilian community CAPs, members of the CAP teaching faculty at WRNMMC engage regional civilian CAP fellows and faculty and provide resources to several program directors pertaining to behavioral health issues affecting children of in active duty, guard, and reserve military families. As this process evolves, future engagements with regional fellowships will incorporate military CAP fellows. Like Army and Navy fellows, Air Force CAP fellows also receive training to prepare them for military service. Air Force CAP fellows frequently choose to complete their fellowship training with WSUBSOM and maintain a rotation site with the Mental Health Clinic at Wright-Patterson Medical Center (WPMC). Their continued presence at a military training site places these fellows in a unique position to assess and manage children while maintaining an understanding of how military culture directly impacts their formulations of their patients. Fellows who obtain their training through WSUBSOM/ WPMC build on a military-specific curriculum begun during their third year of residency at WPMC. This didactic instruction series is designed to educate residents on common disorders and treatments as well as the unique resources, policies, and programs for families and service members in the USAF, such as the Family Advocacy Program (similar to civilian children’s services bureaus), the EFMP, and the Military Family Life Consultant Program (problem-focused, nonmedical counseling services supporting military families). USAF CAP fellows maintain a continuity clinic at WPMC throughout the fellowship training, allowing them to build on the didactic instruction by working more closely with these programs and understanding them at an operational level. WSUBSOM/WPMC also offers opportunities for fellows to provide group psychotherapy to children and adolescents at WPMC or individual psychotherapy for military families. CAP fellows receive additional training in trauma-focused cognitivebehavioral therapy, an evidence-based treatment for childhood PTSD. The in-depth psychotherapy experience with military families allows fellows to become intimately familiar with the issues faced by children of service members, preparing them to recognize and formulate problems in military children more easily while serving as CAPs at their duty assignments.
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As is the case with many civilian CAP fellowships, military fellowships utilize the expertise and perspectives of child psychologists and child social workers to train fellows in assessing and intervening with children and families. It is common to find such multidisciplinary clinicians in military training programs who themselves previously served as behavioral health providers while on active duty. Such prior military experience lends a unique perspective in preparing fellows to enter the military health-care system.
Military Child Psychiatrist Careers The US Army has approximately 125 active duty general psychiatrists assigned to duty stations across the USA and overseas, to include Germany, Italy, and South Korea. Approximately 25 % of the Army’s general psychiatrists have completed a CAP fellowship at some point in their careers (personal communication with Child and Adolescent Psychiatry Consultant to the Office of the Surgeon General of the US Army, Sept 4, 2014). The majority of Army psychiatrists are assigned to Army installations or posts, where they see predominantly active duty patients. The USAF has 98 active duty general psychiatrists assigned to duty stations in the USA and abroad, including Germany, England, and Japan. Approximately 15 % of Air Force general psychiatrists have completed a CAP fellowship at some point in their careers (personal communication with the Air Force Psychiatry Consultant to the office of the Air Force Surgeon General, Sept 3, 2014). The US Navy has approximately 110 active duty general psychiatrists, with approximately 10 % having completed a CAP fellowship at some point in their careers (personal communication with Navy Psychiatry Specialty Leader June 11, 2014). For all three services, fellowship training does not guarantee placement in a dedicated CAP staff assignment immediately after training. For example, the majority of Navy psychiatrists work with adult patients, typically sailors and Marines, at major Naval or Marine Corps installations in the USA and abroad, to include Spain, Italy, Guam, and Japan. They often have the ability to work with a small number of children to maintain their skills, and they serve as consultants for children presenting in crisis to pediatrics or military emergency services. Quite often, the majority of the active duty population are young enlisted members who are young adults with issues similar to civilians who have recently graduated from high school. The developmental perspective gained in CAP fellowship is valuable in working with these younger active duty members. Military units are very similar to families; the additional understanding of family dynamics acquired in CAP fellowship can be useful to understanding the interrelations of members of military units. Military commanders often spend a great deal of time addressing the family crises of their
troops. Timely consultation with a CAP can allow for a quick resolution of the crisis and return to the military mission. The majority of active duty CAPs have more administrative and academic opportunities following training than their civilian counterparts. CAPs that remain in the USA are often stationed at large facilities with academic training programs. At these assignments, military CAPs may supervise residents of various disciplines. These initial experiences may spark interest for early career psychiatrists to pursue academic careers. Many elect to serve as program directors in graduate medical education, and this exposure to academic psychiatry may make them more inclined to seek civilian academic positions following military service. CAPs may assume military command positions of clinics or medical centers, serve as senior medical leaders in military units, or choose a career in health-care administration as they advance their careers. A unique and rewarding opportunity exists in overseas military communities for CAPs. The Department of Defense (DoD) provides a kindergarten through 12th grade education for children of service members living overseas. The Educational and Developmental Intervention Services program fulfills the requirements of a free and appropriate education for all children at DoD schools on overseas military bases. The opportunity to work in DoD schools is available at locations including Japan, Korea, Italy, England, Germany, and others. Some of these bases retain the services of CAPs to evaluate children for an individualized education plan. Observation of children in the classroom setting allows the psychiatrist to consult and recommend interventions and accommodations to teachers and staff. The CAP works closely in a team with developmental pediatricians, speech therapists, occupational and physical therapists, audiologists, social workers, and psychologists for each evaluation. The ability to work with so many specialists and school staff affords a broad picture of the child’s behaviors and emotions difficult to achieve in office-based settings. While military children display typical diagnoses such as attention deficit hyperactivity disorder, depression, and anxiety, they have the distinct stressors discussed previously, including long separations from caregivers due to deployments, frequent changes of schools and homes, and the challenges inherent to living overseas in an environment culturally different than their country of origin. Each of the three military branches has a slightly different path to becoming a military CAP. As the largest branch of the military, the Army is able to support two CAP fellowship programs, while the Air Force and the Navy are smaller service branches that instead fund CAP fellows to train with the Army programs or in civilian fellowship programs. CAP training that occurs in military facilities provides future CAPs with the skill sets required to be competent clinicians prepared for a military career. Such training, combined with subsequent military experience, prepares the military CAP to be a subject matter expert on military families and the behavioral health
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issues they may encounter. Military CAPs, with their unique clinical, academic, and leadership opportunities at military bases both in the USA and overseas, are poised to support this dynamic population by fostering resilience and facing challenges inherent to a commitment of service for military members and their families. Implications for Educators • Civilian CAP training programs should educate residents on unique issues faced by military families and related behavioral health implications to allow for improved treatment of military families by civilian providers. • Military CAP fellows are selected by the military match, some for active duty programs with the Army and Navy; Air Force fellows are allowed to train in civilian CAP programs with funding as available. • CAP active duty military fellows complete a military-specific curriculum which helps physicians understand the stresses inherent to military service and how these affect families, as well as provide familiarity with programs designed to help military children and families. • Clinical training in a variety of settings with military families allow CAP fellows to see how issues related to separation from parents, injury of parents, and frequent military moves affect childhood development. Implications for Academic Leaders • Military CAPs often leave military service with academic and administrative experience, making them ideal candidates for recruitment into civilian CAP careers in academia or health-care administration. • Experiences with advocating for the mental health of children in a military family environment require military CAPs to consult directly with military leaders, at both command levels and medical agency levels, which prepare them for future roles in shaping mental health policy.
Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest. The views expressed in this article are
those of the authors and do not reflect the official policy or position of the Department of the Army, Navy, Air Force, Defense, or the US Government.
References 1. Center for workforce studies. Physician data specialty book Washington, DC. Washington, DC: Association of American Medical Colleges; 2012. 2. Report on the Impact of Deployment of Members of the Armed Forces and Their Dependent Children. Department of Defense. 2010. http://www.militaryonesource.mil/12038/MOS/Reports/ Report_to_Congress_on_Impact_of_Deployment_on_Military_ Children.pdf. Accessed 15 May 2014. 3. Jensen et al. Children’s response to parental separation during operation desert storm. JAACAP. 1996;35:433–44. 4. Chartrand et al. Effect of parents’ wartime deployment on the behavior of young children in military families. Arch Pediatr Adolesc Med. 2008;162(11):1009–14. 5. Lester et al. The long war and parental combat deployment: effects on military children and at-home spouses. JAACAP. 2010;49:310–20. 6. Reed et al. Adolescent well-being in Washington State military families. Am J Public Health. 2011;101:1676–82. 7. Gibbs et al. Child maltreatment in enlisted soldiers’ families during combat-related deployments. JAMA. 2007;298: 528–35. 8. Lester et al. Evaluation of a family-centered prevention intervention for military children and families facing wartime deployments. Am J Public Health. 2012;102:S48–54. 9. Rosenblum KL, Muzik M. Strong intervention for military families with young children. Psychiatr Serv. 2014;65:399. 10. Gewirtz et al. Helping military families through the deployment process: strategies to support parenting. Prof Psychol Res Pract. 2011;42: 56–62. 11. Military Children and Families. The Future of Children. PrincetonBrookings Fall 2013; 23 (2). (Accessible at: http://futureofchildren. org/futureofchildren/publications/journals/journal_details/index. xml?journalid=80)
IN DEPTH ARTICLE: COMMENTARY
US Military Child and Adolescent Psychiatry Training Programs and Careers of Military Child Psychiatrists Christina G. Weston & Joseph G. Dougherty & Suzie C. Nelson & Matthew J. Baker & Jennifer C. Chow
Received: 15 June 2014 / Accepted: 27 January 2015 # Academic Psychiatry 2015
Abstract Military child and adolescent psychiatry (CAP) fellowship programs offer educational experiences universal to all civilian training programs in the USA. They also offer unique training opportunities not found in civilian CAP fellowships in order to prepare graduates to serve the needs of military families. Military-specific curricula and exposures prepare trainees to address various issues faced by military families, in contending with frequent military moves, parental deployments, and disrupted social ties. Curricula are also designed to provide the psychiatrist with a greater understanding of the rigors of military service. CAP training and subsequent assignments prepare military psychiatrists for diverse career paths in the military environment. CAP military careers often include duties in addition to treating patients. Administrative roles, academic teaching positions, as well as school consultation positions are all career options available to military CAP. Keywords Residents . Child and adolescent . Workforce
There are approximately 7700 child psychiatrists in the USA, or one child psychiatrist for every 40,000 people, a very small percentage of which train in military child and adolescent C. G. Weston (*) : S. C. Nelson : M. J. Baker Wright State University Boonshoft School of Medicine, Dayton, OH, USA e-mail: [email protected] J. G. Dougherty Uniformed Services University of the Health Sciences School of Medicine, Bethesda, MD, USA J. C. Chow United States Air Force, Wright-Patterson Air Force Base, Dayton, OH, USA
psychiatry fellowship programs [1]. Over the past several decades, the all-volunteer military has changed from a fighting force of single men to one of married service members with young families [2]. This has increased the need for military child and adolescent psychiatrists (CAP). Of the approximately 1.8 million children of active duty and reserve US military personnel, over 75 % are age 12 or younger [2]. Military families experience multiple unique stressors related to military service that may affect the emotional well-being of military children. Frequent military moves, disrupted social ties, parental deployments, and potential parental injuries during deployment are only a few of the challenges they face. Fellows in military CAP programs require additional training to address these problems when working with military families. Adopting a military-specific curriculum and practicing in military settings provide CAP fellows with the preparation to meet these challenges. Civilian residency programs can help prepare their graduates for work with military families by exploring the difficulties faced by this population, the effects on child development, and known helpful interventions.
Psychiatric Issues Specific to Military Children and Families Military families face distinct challenges compared to many of their civilian counterparts. They are often physically separated from non-military families by living in base housing communities and by patronizing predominantly military facilities, such as hospitals, stores, and schools. Deployments, frequent moves, and disrupted social ties are common phenomena that affect active duty parents, their spouses, as well as their children. Children of military families are particularly vulnerable as these changes occur during developmentally sensitive periods and can affect later progress. Although these stressors may provide opportunities for growth in resilient children,
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those at risk may be detrimentally affected, leading to social or school impairments that often prompt mental health referral. The increase in stressors placed upon military children in recent years has led to a great deal of scientific investigation on the subject of parental deployment as it relates to childhood behavioral and emotional problems. Research after the 1990– 1991 Persian Gulf War revealed that children whose parents had deployed experienced higher levels of self-reported depressive symptoms compared to children of non-deployed parents. However, these symptoms rarely reached pathological levels [3]. During the first several years of US involvement in the conflicts in Iraq and Afghanistan, over two million children were directly impacted by deployment of a parent [4]. Contending with parental departure may lead to a variety of difficulties depending on the age of the child. Additionally, effects on the parents, such as increased caregiver stress as well as injury or death of the deployed parent, can have deleterious effects on the child [2]. A study of 3–5-year-old children with a deployed parent indicated increased behavioral symptoms compared to same-aged peers not contending with parental deployment [4]. A 2010 study examined the effect of parental combat deployment and parental distress on behavioral and emotional problems in school-aged children. It found the children’s anxiety scores to be significantly higher than community norms, with a prevalence of 24.7 % in children with a currently deployed parent, and 31.9 % for those with a recently deployed parent. Children’s internalizing symptoms, externalizing symptoms, and depression scores appeared to be predicted by both the presence of depression in the at-home civilian parent and the presence of PTSD symptoms in the active duty parent [5]. A Washington State study published in 2011 found that parental deployment was associated with a higher likelihood of suicidal ideation among teenage girls as well as greater reports of low quality of life, depressed mood, and thoughts of suicide among adolescent boys [6]. There is also evidence that child maltreatment, such as neglect or abuse, may be 42 % higher and of increased severity among Army families of enlisted soldiers when a parent is away on combat-related deployment [7]. Studies such as these indicate the need for preventive approaches and targeted interventions to help families adapt and develop resiliency, as well as the necessity of rapid access to mental health resources when difficulties occur. Several interventions created for assisting military families are being developed and researched. The Families OverComing Under Stress (FOCUS) project for military families is one such approach, aiming to improve families coping with deployment by providing education and skills training for parents and children. Participation in the program appears to produce improvements in family functioning, decreased parental and child distress, a decrease in children’s conduct problems from 47.7 % at intake to 28.4 % post-intervention, and a decrease in children’s emotional symptoms from 40.4 %
at intake to 22.1 % post-intervention [8]. Other approaches are currently being evaluated, such as the Strong Intervention and the After Deployment: Adaptive Parenting Tools program (ADAPT), which teach stress reduction skills, parenting, and discipline and target adjustment reactions following deployment [9, 10]. Inherent to military duty is the expectation that service members and their families will relocate at various times during one’s career. Service members may be selected for assignments across the continental USA or overseas. This inevitability of military service can present multiple challenges if a child or spouse of a service member has special needs, developmental disabilities, unique educational requirements, or medical problems requiring a specialized level of care. The military’s Exceptional Family Member Program (EFMP) seeks to ensure that comprehensive medical, educational, and support services are provided to military beneficiaries faced with such challenges. The EFMP likewise seeks to prevent familial relocation to areas where necessary services may not be available. Duty assignments to particularly rural areas or foreign installations with limited regional medical services may not serve the best interests of some families or the military units to which they are assigned. Thus, such families are required to enroll in the EFMP. Effective execution of the EFMP mission requires coordination among family members, their health-care providers, and military assignment officers who determine appropriate duty station opportunities. This places the military medical provider in a position of dual agency. Enrollment in the EFMP can have positive and negative consequences for the active duty member. The program allows family members to have better access to needed educational and medical resources, but it may have a negative effect on the service member’s career progression by limiting assignment to remote areas. Familiarity with EFMP is integral to the practice of CAP in the military. As military children continue to face the above challenges, the experience gained in a military CAP fellowship is invaluable. At overseas assignments, active duty CAPs are often the only providers available. In the USA, military children may be referred to the provider network of community CAPs; however, the network may not be adequate or readily available at remote bases. In these locations, the presence of military CAPs ensures that necessary care is available for the children who require it.
CAP Training Selection in the Army, Air Force, and Navy The military offers the following three training tracts for residency and fellowship, all of which differ somewhat from the civilian CAP training pathway: military training, “civilian-deferred” training, and “civilian-sponsored” training (see Fig. 1). Military-trained residents are members of the armed services
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who are selected for a military residency program. Civiliandeferred residents have a military service obligation and are allowed to participate in civilian residencies with funding from the civilian residency program. Civilian-sponsored residents have a military service obligation and are selected by the military to complete civilian residency programs with funding provided by the military. Selection of Army, Air Force, and Navy military residents and fellows occurs through a yearly process termed the Joint Service Graduate Medical Education Selection Board (JSGMESB), more commonly known as the “military match.” The JSGMESB meets annually in late November/early December to review applications for residency and fellowship for medical students, residents, and physicians affiliated with the military. The results are released in mid-December. This allows medical students time to participate in the civilian match if not selected for a military residency program. For residents applying for CAP fellowship, the results of the JSGMESB are released shortly before the CAP rank order list is due in December. Some residents apply to both military and civilian CAP programs to increase their chances of acceptance.
The US Army conducts CAP fellowship training for residents who are active duty officers at two medical centers: Walter Reed National Military Medical Center (WRNMMC) in Bethesda, Maryland, and Tripler Army Medical Center (TAMC) in Honolulu, Hawaii. Traditionally, the Army has supported four to five incoming CAP fellows per year, with trainees divided between the two medical centers. The US Air Force (USAF) had a combined military-civilian CAP fellowship program at Wright-Patterson Medical Center (WPMC) and Wright State University Boonshoft School of Medicine (WSUBSOM) from 1997 to 2007. The Air Force decided in 2007 that it was more cost effective to train Air Force fellows elsewhere and closed the USAF CAP fellowship program. Current USAF psychiatry residents selected for fellowship can apply to train at Army programs or request civilian deferment or sponsorship to train at civilian fellowship programs. The USAF is the only service that allows civilian fellowship training; Army and Navy psychiatrists wanting to complete CAP fellowship must do so at an active duty Army program. The US Navy supports CAP fellowship training at both Army programs. The Navy typically trains one to two fellows on a
Military CAP Training Pathway
Civil ian CAP Training Pathway
Enter E Medical School with Military Service Obligation
Medical School
UHS / HPSP / Undergraduate ROTC Serv USU vice obligation
NRMP Maatch Military Match
Psychiatry Residency
Military psych residency
Civilian psych residency
NRMP Match Active Duty General Psychiatrist
Military Match CAP Fellowship
General Psychiatrist Fellowship CAP F Not Selected NRMP Match
Civilian deferred* CAP Fellowship Training
Civilian sponsored** CAP Fellowship Training
Military CAP Fellowship Training
Active Duty y General Psychiatrisst
Active Duty Child & Adolescent Psychiatrist Fig. 1 Military and civilian CAP training pathways
Civilian Child & Adolescent Psyychiatrist
USUHS = Uniformed Ser vices University of the Health Sciences HPSP = Health Profession s Scholarship Program ROTC = Reserve Offiicer Training Core NRMP = National Reside ncy Matching Program *Salary Paid by Civilian P rogram **Salary Paid by the Military
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rotating basis with the Army. The pathways to selection for military CAP fellowship compared with civilian training pathways are seen in Fig. 1. Selection of trainees for Army fellowships typically draws from applicants in military psychiatry residency programs and Army general psychiatrists stationed at various Army installations. As such, the latter are typically experienced clinicians who may be serving in remote assignments around the world. Therefore, training directors may have to rely on phone or video teleconference interviews as well as references from others working with the individual in order to rank order available applicants. Training in a military-supported general psychiatry residency lasts four years, in accordance with program requirements dictated by the American Council of Graduate Medical Education (ACGME). Fellowship training in CAP is a twoyear process also accredited by the ACGME. In keeping with the practice of non-military CAP fellowships, the Army and Air Force allow general psychiatry residents to participate in a modified training schedule that permits completion of both general psychiatry residency and subsequent CAP fellowship in a five-year period. This approach results in successful graduates being eligible for board certification in both general psychiatry and CAP. Traditionally, the Navy has required graduates of four-year general psychiatry residencies to complete active duty assignments as general psychiatrists before pursuing fellowship training. Only after completion of a successful post-graduation assignment are Navy psychiatrists permitted to begin a CAP fellowship. Army and Air Force psychiatrists who are practicing independently at a military installation (a.k.a. “in the field”) are also permitted to apply to the JSGMESB to enter CAP fellowship.
CAP Military Curriculum All CAP fellowships that train military providers satisfy ACGME program requirements. Likewise, such fellowships offer a concurrent military-specific curriculum that focuses on systems-based practice that prepares fellows to function in the military health-care system. A unique element of participating in a military CAP fellowship is the opportunity for a provider to be an active duty military officer. Active duty officers are required to meet physical fitness standards and maintain appropriate military appearance. They also adhere to standards of decorum consistent with military professionalism in addition to the high professionalism standards inherent to medical practice. Compliance with such expectations lends to patients and families identifying with a fellow member of the armed forces. Military CAP fellowships prepare trainees to practice as effective, competent CAPs, with subject matter expertise in military psychiatry, the dynamics of military families, and the effects of deployment on military families and communities.
Upon completion of fellowship, military CAP psychiatrists contend with the same military realities their patients and families encounter: relocation, potential deployment, interaction with their own chains of command, and the uncertainties inherent to serving in a military whose missions may change with minimal advanced notice. Beyond required, structured rotations in inpatient, partial hospitalization program, substance abuse, community, consult-liaison, and outpatient settings, several CAP fellowship offerings contribute to the development of a military psychiatrist (see Table 1). A four-month course in military psychiatry is required of all fellows prior to graduation from both Army Medical Center fellowships. Instructors are senior Army and Navy psychiatrists who combine didactic instruction, subject matter expertise, and their own personal experiences (stateside, overseas, and during deployment) to educate trainees on the principles of military behavioral health. Military-specific behavioral health policies, effective education of military commanders on mental health issues potentially affecting troop readiness, the impact of deployment and training cycles on troops and their families, and fundamentals of “Psychological First Aid” for use in disaster situations are taught. Additional classes focus on the history of military psychiatry and the delivery of behavioral health services in past conflicts. Fellows with previous deployment experience as general psychiatrists are afforded the opportunity to service as guest instructors for this course. If this course was taken by a fellow during general residency, it is not repeated.
Table 1 CAP fellowship experiences oriented toward serving in the military and treating military families Military psychiatry course which covers various issues The history of military psychiatry in the US Armed Forces Department of Defense behavioral health policies and regulations Army, Navy, and Air Force specific behavioral health policies and regulations Educating military commanders on behavioral health issues that may affect service members Principles of behavioral health treatment in deployed or austere environments The impacts of deployment on service members and their families The fundamentals of “Psychological First Aid” for use in disasters The Combat Operational Stress Control (COSC) Course Consultative rotation at schools and day care centers serving children from military families Participation with school-based behavioral health program serving children from military families Education on military unique programs such as the Exceptional Family Member Program (EFMP) Individual and group therapy with children from military families Training in trauma-focused cognitive-behavioral therapy (TF-CBT)
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Complementing such lectures is a series of experiential offerings to CAP fellows that solidify the basic principles of military psychiatry and permit the application of such principles prior to graduation. Army CAP fellows are strongly encouraged to attend a five-day “Combat Operational Stress Control” course prior to graduation. This instruction prepares military behavioral health professionals of various disciplines to address behavioral health issues that may arise in a deployed or combat environment. Topics such as identifying stress responses in service members, effectively intervening to provide appropriate triage, determining the appropriate level of care based on clinical scenarios, and effectively engaging military commanders are presented. Of note, fellows with previous deployment experience do not typically attend this course given their familiarity with the curriculum. Another experiential opportunity afforded to Army and Navy fellows at WRNMMC permits them to serve as behavioral health instructors and observers during a five-day military training exercise for local military medical students. This event, entitled “Operation Bushmaster,” permits CAP fellows to teach medical students the principles of military and operational behavioral health and then assess medical student performance in simulated and adverse conditions. In addition to receiving military-specific training, CAP fellows at Army programs collaborate with unique communitybased child programs that serve military children in the immediate vicinity of the fellowships. Trainees assume a consultative role for local elementary schools where children of military families are enrolled. Use of a traditional school consultative model permits fellows to observe how children from military families fare, assess issues that may affect students in an educational environment, and provide valuable feedback to teachers and staff. Additional collaboration with regional, formal school-based behavioral health programs serving students from military families permits an additional training opportunity for some fellows. Complementing the fellowship curriculum on childhood growth and development is a series of consultative events at military installation day care facilities whose enrollees are from military families. Fellows observe children in the day care environment and with supervision offer consultative services to the day care staff. This approach may be targeted toward children whose day care providers have requested consultation (and obtained parental consent for such) or may focus on any global behavioral issues that arise in this setting. During fellows’ day care visits, trainees present on various issues to include normal child development, potential behaviors of concern in children, and behavioral management challenges, to interested parents. In the clinic setting, CAP fellows may provide individual or group-based services to children of wounded service members. This opportunity permits fellows to provide appropriate supportive and clinical interventions, and it prepares them for future assignments taking care of families contending with the
sequelae of military conflict. Clinical supervisors utilize evolving literature pertaining to military behavioral health issues to enhance supervision, and resources have been provided to fellows and staff to ensure familiarity with both clinical and systems-based issues. A particularly noteworthy resource for fellows and training faculty has been the Brookings Institution and Princeton University’s 2013 volume on Military Children and Families, readily accessible online [11]. This review provides education designed to increase familiarity with military family culture, addresses commonly seen behavioral health concerns for military children, and suggests methods of enhancing community supports for military children. As a means of connecting military CAPs with civilian community CAPs, members of the CAP teaching faculty at WRNMMC engage regional civilian CAP fellows and faculty and provide resources to several program directors pertaining to behavioral health issues affecting children of in active duty, guard, and reserve military families. As this process evolves, future engagements with regional fellowships will incorporate military CAP fellows. Like Army and Navy fellows, Air Force CAP fellows also receive training to prepare them for military service. Air Force CAP fellows frequently choose to complete their fellowship training with WSUBSOM and maintain a rotation site with the Mental Health Clinic at Wright-Patterson Medical Center (WPMC). Their continued presence at a military training site places these fellows in a unique position to assess and manage children while maintaining an understanding of how military culture directly impacts their formulations of their patients. Fellows who obtain their training through WSUBSOM/ WPMC build on a military-specific curriculum begun during their third year of residency at WPMC. This didactic instruction series is designed to educate residents on common disorders and treatments as well as the unique resources, policies, and programs for families and service members in the USAF, such as the Family Advocacy Program (similar to civilian children’s services bureaus), the EFMP, and the Military Family Life Consultant Program (problem-focused, nonmedical counseling services supporting military families). USAF CAP fellows maintain a continuity clinic at WPMC throughout the fellowship training, allowing them to build on the didactic instruction by working more closely with these programs and understanding them at an operational level. WSUBSOM/WPMC also offers opportunities for fellows to provide group psychotherapy to children and adolescents at WPMC or individual psychotherapy for military families. CAP fellows receive additional training in trauma-focused cognitivebehavioral therapy, an evidence-based treatment for childhood PTSD. The in-depth psychotherapy experience with military families allows fellows to become intimately familiar with the issues faced by children of service members, preparing them to recognize and formulate problems in military children more easily while serving as CAPs at their duty assignments.
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As is the case with many civilian CAP fellowships, military fellowships utilize the expertise and perspectives of child psychologists and child social workers to train fellows in assessing and intervening with children and families. It is common to find such multidisciplinary clinicians in military training programs who themselves previously served as behavioral health providers while on active duty. Such prior military experience lends a unique perspective in preparing fellows to enter the military health-care system.
Military Child Psychiatrist Careers The US Army has approximately 125 active duty general psychiatrists assigned to duty stations across the USA and overseas, to include Germany, Italy, and South Korea. Approximately 25 % of the Army’s general psychiatrists have completed a CAP fellowship at some point in their careers (personal communication with Child and Adolescent Psychiatry Consultant to the Office of the Surgeon General of the US Army, Sept 4, 2014). The majority of Army psychiatrists are assigned to Army installations or posts, where they see predominantly active duty patients. The USAF has 98 active duty general psychiatrists assigned to duty stations in the USA and abroad, including Germany, England, and Japan. Approximately 15 % of Air Force general psychiatrists have completed a CAP fellowship at some point in their careers (personal communication with the Air Force Psychiatry Consultant to the office of the Air Force Surgeon General, Sept 3, 2014). The US Navy has approximately 110 active duty general psychiatrists, with approximately 10 % having completed a CAP fellowship at some point in their careers (personal communication with Navy Psychiatry Specialty Leader June 11, 2014). For all three services, fellowship training does not guarantee placement in a dedicated CAP staff assignment immediately after training. For example, the majority of Navy psychiatrists work with adult patients, typically sailors and Marines, at major Naval or Marine Corps installations in the USA and abroad, to include Spain, Italy, Guam, and Japan. They often have the ability to work with a small number of children to maintain their skills, and they serve as consultants for children presenting in crisis to pediatrics or military emergency services. Quite often, the majority of the active duty population are young enlisted members who are young adults with issues similar to civilians who have recently graduated from high school. The developmental perspective gained in CAP fellowship is valuable in working with these younger active duty members. Military units are very similar to families; the additional understanding of family dynamics acquired in CAP fellowship can be useful to understanding the interrelations of members of military units. Military commanders often spend a great deal of time addressing the family crises of their
troops. Timely consultation with a CAP can allow for a quick resolution of the crisis and return to the military mission. The majority of active duty CAPs have more administrative and academic opportunities following training than their civilian counterparts. CAPs that remain in the USA are often stationed at large facilities with academic training programs. At these assignments, military CAPs may supervise residents of various disciplines. These initial experiences may spark interest for early career psychiatrists to pursue academic careers. Many elect to serve as program directors in graduate medical education, and this exposure to academic psychiatry may make them more inclined to seek civilian academic positions following military service. CAPs may assume military command positions of clinics or medical centers, serve as senior medical leaders in military units, or choose a career in health-care administration as they advance their careers. A unique and rewarding opportunity exists in overseas military communities for CAPs. The Department of Defense (DoD) provides a kindergarten through 12th grade education for children of service members living overseas. The Educational and Developmental Intervention Services program fulfills the requirements of a free and appropriate education for all children at DoD schools on overseas military bases. The opportunity to work in DoD schools is available at locations including Japan, Korea, Italy, England, Germany, and others. Some of these bases retain the services of CAPs to evaluate children for an individualized education plan. Observation of children in the classroom setting allows the psychiatrist to consult and recommend interventions and accommodations to teachers and staff. The CAP works closely in a team with developmental pediatricians, speech therapists, occupational and physical therapists, audiologists, social workers, and psychologists for each evaluation. The ability to work with so many specialists and school staff affords a broad picture of the child’s behaviors and emotions difficult to achieve in office-based settings. While military children display typical diagnoses such as attention deficit hyperactivity disorder, depression, and anxiety, they have the distinct stressors discussed previously, including long separations from caregivers due to deployments, frequent changes of schools and homes, and the challenges inherent to living overseas in an environment culturally different than their country of origin. Each of the three military branches has a slightly different path to becoming a military CAP. As the largest branch of the military, the Army is able to support two CAP fellowship programs, while the Air Force and the Navy are smaller service branches that instead fund CAP fellows to train with the Army programs or in civilian fellowship programs. CAP training that occurs in military facilities provides future CAPs with the skill sets required to be competent clinicians prepared for a military career. Such training, combined with subsequent military experience, prepares the military CAP to be a subject matter expert on military families and the behavioral health
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issues they may encounter. Military CAPs, with their unique clinical, academic, and leadership opportunities at military bases both in the USA and overseas, are poised to support this dynamic population by fostering resilience and facing challenges inherent to a commitment of service for military members and their families. Implications for Educators • Civilian CAP training programs should educate residents on unique issues faced by military families and related behavioral health implications to allow for improved treatment of military families by civilian providers. • Military CAP fellows are selected by the military match, some for active duty programs with the Army and Navy; Air Force fellows are allowed to train in civilian CAP programs with funding as available. • CAP active duty military fellows complete a military-specific curriculum which helps physicians understand the stresses inherent to military service and how these affect families, as well as provide familiarity with programs designed to help military children and families. • Clinical training in a variety of settings with military families allow CAP fellows to see how issues related to separation from parents, injury of parents, and frequent military moves affect childhood development. Implications for Academic Leaders • Military CAPs often leave military service with academic and administrative experience, making them ideal candidates for recruitment into civilian CAP careers in academia or health-care administration. • Experiences with advocating for the mental health of children in a military family environment require military CAPs to consult directly with military leaders, at both command levels and medical agency levels, which prepare them for future roles in shaping mental health policy.
Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest. The views expressed in this article are
those of the authors and do not reflect the official policy or position of the Department of the Army, Navy, Air Force, Defense, or the US Government.
References 1. Center for workforce studies. Physician data specialty book Washington, DC. Washington, DC: Association of American Medical Colleges; 2012. 2. Report on the Impact of Deployment of Members of the Armed Forces and Their Dependent Children. Department of Defense. 2010. http://www.militaryonesource.mil/12038/MOS/Reports/ Report_to_Congress_on_Impact_of_Deployment_on_Military_ Children.pdf. Accessed 15 May 2014. 3. Jensen et al. Children’s response to parental separation during operation desert storm. JAACAP. 1996;35:433–44. 4. Chartrand et al. Effect of parents’ wartime deployment on the behavior of young children in military families. Arch Pediatr Adolesc Med. 2008;162(11):1009–14. 5. Lester et al. The long war and parental combat deployment: effects on military children and at-home spouses. JAACAP. 2010;49:310–20. 6. Reed et al. Adolescent well-being in Washington State military families. Am J Public Health. 2011;101:1676–82. 7. Gibbs et al. Child maltreatment in enlisted soldiers’ families during combat-related deployments. JAMA. 2007;298: 528–35. 8. Lester et al. Evaluation of a family-centered prevention intervention for military children and families facing wartime deployments. Am J Public Health. 2012;102:S48–54. 9. Rosenblum KL, Muzik M. Strong intervention for military families with young children. Psychiatr Serv. 2014;65:399. 10. Gewirtz et al. Helping military families through the deployment process: strategies to support parenting. Prof Psychol Res Pract. 2011;42: 56–62. 11. Military Children and Families. The Future of Children. PrincetonBrookings Fall 2013; 23 (2). (Accessible at: http://futureofchildren. org/futureofchildren/publications/journals/journal_details/index. xml?journalid=80)
