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research-article20172017
SGOXXX10.1177/2158244017720484SAGE OpenForan et al.
Article
Child Mental Health Symptoms Following Parental Deployment: The Impact of Parental Posttraumatic Stress Disorder Symptoms, Marital Distress, and General Aggression
SAGE Open July-September 2017: 1–10 © The Author(s) 2017 https://doi.org/10.1177/2158244017720484 DOI: 10.1177/2158244017720484 journals.sagepub.com/home/sgo
Heather M. Foran1, Rachel D. Eckford2, Robert R. Sinclair2,3, and Kathleen M. Wright2
Abstract The current study examined the impact of active duty service members’ symptoms following a combat deployment on child mental health symptoms. Soldiers from a brigade combat team (N = 974) participated in the study 2 months following return from a 15-month combat deployment to Afghanistan, of which 169 soldiers (17.3%) reported having at least one child living at home. Results supported two research hypotheses examining the interrelationship between parental posttraumatic stress disorder (PTSD) symptoms, general aggression, and marital distress on child mental health. First, the study documented a moderate association between parental PTSD symptoms and child mental health symptoms during the postdeployment reintegration period. This association was significant even after accounting for marital distress. Second, the study demonstrated that the impact of PTSD symptoms on child mental health symptoms may be explained by parental general aggression such that aggression mediated the PTSD symptoms–child mental health association. Keywords child mental health symptoms, general aggression, postdeployment, posttraumatic stress disorder, military populations Deployment separation is one of the greatest demands of the military lifestyle on military families as it includes the risk of injury or death of the service member, as well as additional responsibilities for the at-home spouse who must adjust to the role of a single parent (Wright, Riviere, Merrill, & Cabrera, 2013). Aside from Vietnam, Operation Enduring Freedom (OEF) in Afghanistan has been the longest war the U.S. military has fought to date, and Operation Iraqi Freedom (OIF) the third longest (Hosek, 2011). More than 2.1 million service members have deployed in support of these missions. Approximately 100,000 (44%) of these service members are parents, with 48% of these deployed parents having deployed more than once (Department of Defense, 2010). In this time, nearly 2 million children experienced a parent’s absence due to deployment (Flake, Davis, Johnson, & Middleton, 2009). Studies conducted with military families indicate that the psychological effects of a service member’s deployment extend to their children. For example, the Survey of Army Families (Orthner & Rose, 2005) reported that approximately 25% of school-age children were depressed because of deployment separation and 37% reported fear of harm to the deployed parent. Further evidence comes from a retrospective
cohort study that linked health care visit records of children with parents’ deployment records (Gorman, Eide, & HisleGorman, 2010), and found that for children aged 3 to 8 years old, behavioral disorders increased 19% and stress disorders increased 18% when the military parent was deployed. Other studies of child psychological adjustment and parental deployment have found that children aged 3 to 5 years with a deployed parent had significantly higher externalizing behavior scores and clinically elevated internalizing behavior when compared with same-aged peers without a deployed parent (Chartrand, Frank, White, & Shope, 2008). Children with a deployed parent also experienced more emotional and behavioral difficulties than civilian samples, and 1
Alpen-Adria-University Klagenfurt, Austria U.S. Army Medical Research Unit-Europe, Walter Reed Army Institute of Research, Sembach, Germany 3 Clemson University, South Carolina, USA 2
Corresponding Author: Heather M. Foran, Alpen-Adria-University Klagenfurt, Universitaetsstr. 65-67, 9020 Klagenfurt, Austria. Email:
[email protected]
Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 3.0 License (http://www.creativecommons.org/licenses/by/3.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
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these difficulties tended to increase with deployment length (Chandra et al., 2010). Child attachment behaviors also have been related to length of deployment and number of deployments (Barker & Berry, 2009), and cumulative length of parental deployment during the child’s lifetime predicted child depression and externalizing behaviors (White, de Burgh, Fear, & Iversen, 2011). In one of the few studies including the previously deployed service member (Lester et al., 2010), total number of months deployed and parental distress (both at-home spouse and returned soldier) independently predicted child adjustment problems. The returned soldier’s posttraumatic stress disorder (PTSD) symptoms predicted child depression as well as internalizing and externalizing behaviors. Although these studies support the relationship between child psychological adjustment and parental deployment, they do not explain the reasons why these effects occur. In addition, many studies focus on psychological effects on the family during the deployment separation time period rather than on the postdeployment reintegration period when the service member transitions back into the family. To investigate the association between mental health symptoms in returning service members and the effects on their children, a targeted assessment to determine possible pathways and mediators is needed. To this end, the current study examined the interrelationship between the active duty service member’s PTSD symptoms, general aggression, and marital distress following a combat deployment on child mental health symptoms. Two research questions were examined: Research Question 1: Can the parental PTSD–child mental health association be documented for a sample of active duty service members who had just returned from a combat deployment, and is the association significant even after accounting for a known risk factor for child mental health problems—marital distress? Research Question 2: Is the impact of PTSD symptoms in returning service members on child mental health explained by general aggression of the parent?
PTSD and Child Outcomes Much of the literature that explores psychological symptoms in returned war veterans and emotional and behavior consequences for their children has focused on PTSD symptoms as exacerbating risk for children (Dekel & Goldblatt, 2008). Several studies have examined parenting behaviors that may be affected by PTSD symptoms. For example, a longitudinal study of returned National Guard soldiers and reintegration effects on the family system (Gewirtz, Polusny, DeGarmo, Khaylis, & Erbes, 2010) found that PTSD symptoms during deployment influenced couple adjustment and parenting 1 year later. Positive parenting behaviors, child discipline and supervision, and involvement and interest in the child’s
activities were affected by the soldier’s symptoms and resulted in impaired parent–child interactions. A review of the literature (Galovski & Lyons, 2004) summarizing the effects of exposure to violence during combat concluded that PTSD symptoms resulting from such exposure affected family relationships and psychological adjustment. Numbing and arousal symptoms, as well as anger, were predictive of family distress and secondary traumatization. The arousal cluster of PTSD symptoms promoted anger and hostility toward both spouses and children, and disrupted marital and parental relationships (Wadsworth, 2010). Combat exposure, PTSD symptoms, and aggressive behavior have also been related to violence and hostility in the families of veterans as well as increased aggression in their children (Glenn et al., 2002). This research was conducted with an older cohort of children of Vietnam veterans and revealed a possible continuity of risk of behavioral problems into adolescence and early adulthood. Additional support for the negative effects of PTSD on parenting comes from studies of spouses and partners of veterans (Manguno-Mire et al., 2007) who were secondarily traumatized by the service members’ PTSD, and reported negative consequences for parenting behaviors. Psychological effects have also included secondary traumatization for children (Rosenheck & Nathan, 1985) and higher risk of developing behavioral or psychiatric problems (Davidson, Smith, & Kudler, 1989). One study compared Vietnam combat veterans with and without PTSD, and found significantly more behavioral problems among those children of veterans with PTSD than among children of veterans without PTSD (Jordan et al., 1992). More specifically, research from the Veteran Center counselor survey (Matsakis, 1988) reported that the most common problems among children of veterans were low self-esteem, aggressiveness, developmental difficulties, impaired social relationships, and symptoms characteristic of secondary traumatization. These findings suggest that PTSD symptoms in the returned service member contribute to negative mental health outcomes in their children; however, the link requires further explanation. One possibility is the association between PTSD and aggression (e.g., Taft et al., 2007). As there is evidence that aggression in a parent predicts child outcomes (Jouriles, Barling, & O’Leary, 1987; Margolin & Gordis, 2000), aggression could be a mediating factor explaining the PTSD–child outcome link.
PTSD, General Aggression, and Child Outcomes Population-based cross-sectional studies of service members have documented anger and aggression as frequently reported problems for combat veterans returning from war in Iraq and Afghanistan (Jakupcak et al., 2007; Killgore et al., 2008; Thomas et al., 2010). Studies have also identified aggressive behaviors as comorbid with PTSD (Forbes,
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Foran et al. Creamer, Hawthorne, Allen, & McHugh, 2003; Thomas et al., 2010), and found that combat experiences such as exposure to human trauma, combat violence, and killing predicted verbal and physical aggression toward others (Killgore et al., 2008). Combat veterans with PTSD symptoms, but not meeting full diagnostic criteria for PTSD, also reported significantly higher aggressive behaviors when compared with the non-PTSD group, thus increasing the potential magnitude of postcombat adjustment problems for service members returning home to their families (Jakupcak et al., 2007). A meta-analysis examined the association between anger and PTSD (Orth & Wieland, 2006). The authors found larger effect sizes in samples with military war experiences compared with samples exposed to other types of trauma, suggesting that anger may be a more likely response for those exposed to combat. Although very little research has explored the link between general aggression and child outcomes in families of returning service members, findings from the civilian literature indicate that parental aggression is a risk factor for child behavioral and emotional problems (Jouriles et al., 1987; Margolin & Gordis, 2000). Notably, general aggression may affect the child even if it is not directed at the child but at the spouse or other nonfamily members (Galovski & Lyons, 2004; Glenn et al., 2002; Hurt, Malmud, Brodsky, & Giannetta, 2001). A parent’s display of anger/aggressiveness may manifest in several ways that affect the child (e.g., verbal outbursts, marital conflicts, angry facial expressions, and other visible displays). Children who are exposed to angry interactions between their parents may become more sensitized to marital conflict and more vulnerable to its effects (Faircloth, 2012). This, in turn, may lead to the child having lower thresholds for exposure to aggression and experiencing increased arousal, distress, and fear which can affect their mental health. Anger and general aggression rather than more covert symptoms of PTSD may be important in understanding the impacts on children and families. Thus, one mechanism by which PTSD symptoms have an effect on a child’s mental health symptoms may be via increased aggression in the parent.
Marital Distress and Child Outcomes From the civilian literature, there is substantial evidence that parental marital distress and conflict can increase risk of child mental health problems (Rhoades, 2008). Consequently, the impact of marital distress on children in military families is an important consideration as marital problems have been reported as significant, negative outcomes of combat deployment. An extensive review of research on readjustment needs for service members and their families (Committee on the Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families, 2013) identified several key studies documenting the impact of deployment on marital and family quality. For example, a
population-based longitudinal study of service members returning from Iraq and Afghanistan (Milliken, Auchterlonie, & Hoge, 2007) found an increase in reported interpersonal problems (including those with family members) from the reintegration period up to 6 months later. Additional population-based assessments of family and marital problems were documented in the Army Gold Book Report (Department of the Army, 2012) where 19% of spouses were reported to be in counseling. Therefore, the consequences of marital distress and conflict should be considered in the assessment of child outcomes to determine whether parental relationship problems are the key mechanism affecting psychological adjustment in children of returning service members.
Marital Distress, General Aggression, and Child Outcomes Marital distress is a robust predictor of anger and aggressive behaviors, particularly directed at the spouse (Stith, Green, Smith, & Ward, 2008; Stith, Rosen, McCollum, & Thompson, 2004). Marital conflict also has been identified as a strong predictor of adults seeking mental health services and of poor psychological adjustment for children, with severity of aggression linked to marital functioning for the couple and to depression, delinquency, aggression, and declines in psychosocial functioning for children (Faircloth, 2012). Research conducted with a nationally representative sample (Vissing, Straus, Gelles, & Harrop, 1991) found that children who witnessed verbally aggressive conflict between their parents had higher rates of interpersonal problems, aggression, and delinquency than other children. This finding suggests that an atmosphere of anger and conflict in the family can lead to mental health problems for children. Marital distress also may increase risk of angry and aggressive behaviors toward children and aggression in general. As a result, chronic patterns of violence or an atmosphere of anger and aggression in the home may affect family relationships and the psychological adjustment of family members. For example, anger in postcombat veterans has been associated with family relationships marked by distress and emotional conflict, with the veteran’s anger directed at a variety of targets and not necessarily at their spouses and children (Galovski & Lyons, 2004). In a review of family risk and resilience in the context of war, Wadsworth (2010) reported that OIF/OEF veterans at postdeployment felt uncertain of their family roles and believed their family members were afraid of them, with many describing conflicts involving shouting, pushing, and shoving. Thus, not only abuse or aggression directed at the spouse but also other types of aggressive or angry behaviors may increase in response to marital distress. Taken as a whole, this literature suggests that parental aggression represents one of the possible causal mechanisms linking parental PTSD symptoms and marital distress to child mental health problems.
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Current Study
Table 1. Participant Characteristics.
The current study examined the interrelationship between parents’ PTSD symptoms, general aggression, marital distress, and military children’s mental health. While many studies have focused on the civilian spouse during the separation period, the current study examined the impact of the active duty service member’s symptoms following a combat deployment on child mental health symptoms (hyperactivity, conduct, and emotional problems). We hypothesized that the service member’s PTSD symptoms and marital distress would both predict child mental health symptoms. However, we expected general aggression of the parent would mediate the impact of PTSD symptoms and marital distress in returning service members on child mental health.
Variable
Method Participants and Procedure Active duty soldiers from a brigade combat team (N = 1,068) were invited to participate in the study 2 months following return from a 15-month combat deployment to Afghanistan. The study was approved by the local Institutional Review Board, and informed consent was obtained for all study participants, similar to other studies with active duty soldiers (e.g., Wright, Foran, Wood, Eckford, & McGurk, 2012). Surveys were administered to large groups of soldiers and required approximately 1 hr to complete. After being briefed on the purpose and procedure of the study, 91% consented to participate (N = 974) and were administered the anonymous paper-and-pencil survey. Participants in the current study included only those who reported having at least one child between the ages of 3 and 17 living at home (n = 169; 17.3% of the full sample). This rate is expected as this was a study of soldiers who served in a heavy combat deployment of which half of the overall sample was below 24. Sample demographics are presented in Table 1.
Measures Parental PTSD symptoms. The widely used 17-item PostTraumatic Stress Disorder Checklist (PCL; Blanchard, Jones-Alexander, Buckley, & Forneris, 1996) was used to assess PTSD symptoms. This measure has been validated with active duty military personnel (Bliese et al., 2008) and shown to have high internal consistency (e.g., Cronbach’s α = .96, current sample). Participants rated symptoms in the last month using a 5-point scale from 1 = not at all to 5 = extremely. Possible scores range from 17 to 85 with scores greater than 34 indicating a positive screen for PTSD symptoms among active duty military populations (Bliese et al., 2008).
Rank Jr. enlisted NCO officers Officer/warrant officer Age (years) 20-24 25-29 30-39 40 or older Years in the military, M (SD) Multiple deployer (>1 deployment) Gender (male) Married Number of children One Two Three or more Unit type Combat arms Combat support
% 29.2 61.9 8.9 11.4 33.5 46.7 8.4 8.91 (5.43) 61.5 96.8 95.9 47.9 32.5 16.6 47.9 52.1
Child mental health symptoms. The Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) was used to assess child behavioral difficulties in children aged 3 to 17. In addition to an overall score, the SDQ includes three subscales that assessed emotional problems (five items), conduct problems (five items), and hyperactivity/inattention (five items) rated on a dichotomous scale (0 = symptom absent, 1 = symptom present). This measure has good psychometric properties (Goodman, 2001; Tobia & Marzocchi, 2017), and has previously been used to assess child mental health symptoms among military samples (Chandra et al., 2010). Participants reported on symptoms for up to six children; symptoms scores were averaged across children. In addition, scores were computed using responses for the child with the highest scores reported within the family. Results were similar, so only average scores will be presented. In the current sample, the subscale alphas were .69 for hyperactivity/inattention, .58 for conduct problems, and .64 for emotional problems. These low to moderate alphas are not surprising, given that each subscale consists only of five items that are relatively broad in symptom content (Cortina, 1993). Cronbach’s α for the 15-item total scale was .77. Marital distress. Marital distress was examined with three dichotomous items: “Are you having marital problems?” “Have you and your spouse gotten into frequent arguments or disagreements?” and the reverse-scored item, “Is your relationship strong?” This measure was developed based on item response theory analysis of commonly used marital distress items in military samples (Bliese, Wright, Adler,
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Foran et al. Table 2. Descriptive Statistics and Bivariate Correlations (n = 169). Variable 1. 2. 3. 4. 5. 6. 7. M SD
Parent PTSD symptoms Child MH–Overall Child MH–Conduct Child MH–Emotional Child MH–Hyperactivity Marital distress Parent aggression
1 .33*** .21** .25** .32*** .38*** .64*** 30.67 14.39
2
.75*** .72*** .82*** .29*** .42*** 3.66 2.55
3
.40*** .41*** .32*** .28*** 0.70 0.93
4
.32*** .21** .35*** 0.73 1.01
5
.16* .33*** 2.23 1.38
6
7
.53*** 1.39 0.41
2.06 1.00
Note. PTSD = posttraumatic stress disorder; MH = mental health. *p < .05. **p < .01. ***p < .001.
& Thomas, 2004; Ployhart, 2004). Items were rated on a scale from 1 to 2, with higher scores indicating more marital distress. These items have been used in other studies with military samples (Foran, Wright, & Wood, 2013). Internal consistency was .81. General aggression. General aggression was assessed with eight items developed by the Walter Reed Army Institute of Research based on longer anger and aggression scales (Kulka et al., 1990; Spector & Jex, 1998; Spielberger, 1999) and used in previous studies with military populations (Cabrera, Bliese, Hoge, Castro, & Messer, 2010; Wilk et al., 2013). The items asked about angry feelings and aggressive behaviors during the past month (e.g., “threaten someone with physical violence,” “get into a fight with someone and hit the person,” “get angry at someone and yell or shout at them,” “boil inside with anger,” “feel like smashing something,” “get angry with someone and kick or smash something,” “slam the door,” and “punch the wall”). The items were rated on a 5-point Likert-type scale from 1 = never to 5 = five or more times. The internal consistency of the scale was .89. The aggressive behaviors may have been directed at the spouse, child, or nonfamily member. The scale was not meant to assess a specific type of aggression (i.e., spouse aggression) but rather aggression in general, which is a common presenting problem among combat veterans seeking mental health services (e.g., Taft et al., 2009). As expected, this measure was significantly but not perfectly correlated with a two-item measure of spouse aggression (r = .56, p < .001).
Results Sample Descriptives and Bivariate Correlations Almost one third of the sample reported PTSD symptoms above the cutoff of 34 or higher (31%). This high rate of PTSD symptoms is expected, given that there was a high level of combat exposure during the deployment. For example, 64% of the sample reported being attacked or ambushed,
79% reported that an improvised explosive device (IED) or booby trap exploding near them, and 51% reported a member of their own unit was killed in action. In terms of child mental health symptoms, 50.9% of participants reported at least three hyperactivity symptoms for one of their children, 11.8% reported at least three emotional symptoms, and 9.3% reported at least three conduct symptoms. As shown in Table 2, parental PTSD symptoms, child mental health, marital quality, and general aggression of the parent were all significantly correlated as hypothesized.
Model of Parental PTSD Symptoms, Marital Distress, and Child Mental Health Structural equation modeling was used to test the multivariate model of parental PTSD symptoms, marital distress, and child mental health. Mplus 7.1 statistical software was used to conduct the analyses (Mplus, 2010). Model fit was evaluated with a variety of fit indices, including comparative fit index (CFI) > .95, Tucker– Lewis Index (TLI) > .95, root mean square error of approximation (RMSEA) < .08, and standardized root mean square residuals (SRMR) < .08 (Browne & Cudeck, 1993; Hu & Bentler, 1999). First, we tested a model in which PTSD symptoms and marital distress predicted latent child mental health to determine whether they both accounted for unique variance in the context of each other. Because child mental health symptoms were strongly correlated, we analyzed them as a single latent construct in the model, treating each dimension as a separate indicator in the model. For latent child mental health, the factor variance was fixed to 1.0 and factor loadings were freely estimated. Analyses were conducted with full-maximumlikelihood estimation with robust statistics to adjust for potential bias due to multivariate nonnormality (Asparouhov & Muthén, 2005); notably, missing data on the various measures were minimal (
