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Children’s Social, Emotional, and Behavioral Outcomes in Military Families: A Rapid Review
Auteurs:
Jessica E. Opie, Mohajer Hameed, An Vuong, Felicity Painter, Anna T. Booth, Heng Jiang, Rowan Dowling, Jessica Boh, Natalie McLean, Jennifer E. McIntosh
In light of ongoing global military conflicts, including the Israel-Hamas war and the Russia-Ukraine war, it is imperative to study the effects of parental military service and deployment on the health and well-being of children within military families. Emerging evidence suggests that children with a parent in service appear to face unique developmental challenges associated with the military lifestyle, which differ from those experienced by civilian children. However, there is currently limited systematic research that compares the developmental outcomes of children with serving parents to their civilian peers. Therefore, the aim of this review is to synthesize existing literature on the behavioral, social, emotional, and educational functioning of children with currently serving parents in defense forces, in comparison to their civilian counterparts. This rapid systematic review was conducted in accordance with the Joanna Briggs Institute methodology framework, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, and Cochrane Rapid Review methodological recommendations The following databases were searched: Medline, PsycINFO, CINAHL, and Cochrane Central Register of Controlled Trials. Relevant online databases were searched from February 2012 to 2022 to examine the contemporary literature. Fourteen identified published quantitative studies were identified. No qualitative studies were found, and no study reported on academic outcomes. Despite considerable sample heterogeneity across studies, military children of all ages appear to be a particularly vulnerable population. Findings suggest that children in military families experience substantially higher risk for negative psychological, social, and behavioral health outcomes than their civilian counterparts, with parental deployment increasing risk across all developmental stages (i.e., early, middle, and late childhood). Among these age groups, adolescents of currently serving members showed highest risk, particularly concerning suicidal ideation and suicidal behaviors. Implications are discussed in terms of early detection, preventative interventions, and support services for families and children with a serving parent. PROSPERO registration: CRD42022313999.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
In the United States in 2023, there were 1.3 million active-duty military personnel, with approximately 13% deployed overseas in an ongoing capacity (Pew Research Centre, 2023). Globally, there are multiple ongoing conflicts, including the Israel-Hamas war and the Russia-Ukraine war. Given that military spouses and children outnumber service personnel by a ratio of 1 to 4, it is critical to understand the implications of military participation for not only the serving member, but for their familial system as well. Serving members’ family systems tend to be nested within broader military cultures; “when one person joins the military, the whole family serves” (Center for Deployment Psychology, 2023; D’Aniello Institute for Veterans and Military Families, 2023). As such, families of serving members indirectly experience military-related challenges and consequently higher levels of psychosocial stressors relative to their civilian counterparts. The health and well-being of families and children with a military serving parent is an emerging research focus (Hom et al., 2017; Ramchand et al., 2015). Initial findings indicate that one of the most prominent military-specific family stressors is the experience of frequent parent-child separations due to deployments, lone parenting, geographical separations from loved ones, and relocations (Gewirtz & Youssef, 2016). While literature has highlighted military impacts on the serving and non-serving parent (Corry et al., 2021), less research reports on service impacts on children (Cramm et al., 2019; Williamson et al., 2018; Yablonsky et al., 2019).
In terms of child developmental outcomes, there appears to be limited research comparing outcomes between children of serving parents and civilian same-aged peers (Williamson et al., 2018). Emerging evidence highlights both benefits and vulnerabilities associated with growing up in a military family. Benefits may include enhanced child resilience, the provision of a positive role model, and financial security (Blamey et al., 2019; Godier-McBard et al., 2021; McGaw et al., 2019). Conversely, children with a serving parent appear to be more vulnerable to socioemotional sequalae, such as externalizing and internalizing mental health problems relative to their nonmilitary peers (Cramm et al., 2016; Daraganova et al., 2018). Expanding such research is important considering the high global prevalence of intergenerational military participation (Campante & Yanagizawa-Drott, 2015; Pew Research Center, 2011). For example, in the United States, 39% of serving defense personnel have at least one child (National Academies of Sciences, Engineering, and Medicine, 2019), with service children twice as likely to become the next generation of serving members (Military Child Education Coalition, 2017). Therefore, it is of clinical, research, and policy interest to explore the health and well-being of children of serving parents, as well as understanding potential service needs in individual, family, military, and broader community settings.
A Developmental Perspective of Parental Military Service
It is well established that the childhood years lay the foundation for later development, signifying a period of profound biological, cognitive, and emotional maturation (Duschinsky, 2020). Parental presence is important to the developing child. Specifically, for later social adaptation and maladaptation, research emphasizes the central role of early parent-child attachment and caregiver sensitivity (McIntosh et al., 2024). Attachment is the unique relationship a parent-child dyad shares, which serves to protect the child, while caregiver sensitivity relates to the caregiver’s predictability, responsiveness, and attunement to the child, particularly in times of distress (Bowlby, 1988).
Military service, and in particular deployment, can result in prolonged separations between parent and child. Separations may introduce additional stress for the developing child, as the child may question the physical and psychological availability of their parent (Paley et al., 2013). Military children may further experience the “ambiguous loss” (Boss, 1977) of their serving parent, wherein the parent is alive and well, but not physically present. Due to the young child’s immature reasoning capacities, this may result in confusion and relational incongruence for the young child. These experiences can in turn impede the child’s capacity to engage with their environment, as attention shifts from learning and development to self-protection (Paley et al., 2013).
The child’s relationship with the nonmilitary parent may potentially serve as a buffer or further stressor in the serving parents’ absence. Parent-child attachment organization is person-specific, meaning that a child can have a secure attachment with one parent and an insecure attachment organization with another parent (Duschinsky, 2018). However, the dual-parent-child relationship is complex. Whether a parent’s involvement in the military alters the secure base of a family unit, such that the development of a child’s security is challenged, depends on the nature of the parent-child attachment relationships and how they adapt and respond to separation (Riggs & Riggs, 2011).
Previous Reviews
Several previous reviews have been published on the topic of families and children with a serving parent, yet the impact on children in military families is still not well understood. Previous systematic reviews have shown that when children are separated from their deployed parent, they may experience and present with higher levels of behavioral and emotional symptoms (Creech et al., 2014; Trautmann et al., 2015). Similarly, youth with a deployed parent are at greater risk of an array of adjustment concerns including depression, suicidal ideation, and externalizing behavior (Cunitz et al., 2019; Williamson et al., 2018). A dose-response effect has also been identified wherein cumulative parental deployment exposure is associated with increased risk of adverse child outcomes (Blamey et al., 2019). Frequent relocations due to deployments and factors associated with relocations have been found to account for the negative impact upon military children’s well-being, resulting in more pronounced emotional and behavioral problems (Blamey et al., 2019). Further, previous reviews highlight a pattern of increased risk of child maltreatment during a parent’s deployment period (Card et al., 2011; Trautmann et al., 2015). This may be due to a decline in caregiver sensitivity of the nonserving spouse who may experience additional stressors throughout deployments (Trautmann et al., 2015).
Children with parents who have returned from deployment with military-acquired health problems also may have adverse socioemotional and behavioral outcomes. When the returned parent presented with depressive symptoms, children (4–12 years) were found to have increased anxiety, fear, and behavioral problems (Veri et al., 2021). Similarly, children of all ages with a parent who recently returned from deployment with a physical injury or symptoms of Post-Traumatic Stress Disorder (PTSD) experienced adverse mental health ramifications, such as increased anxiety and depression (Cramm et al., 2019; Creech et al., 2014). These children further utilized mental healthcare services to a greater degree than their civilian peers (Cramm et al., 2019). These families also reported negative impacts on family dynamics and the non-serving parent–child relationship (Cramm et al., 2019; Creech et al., 2014).
Whilst some previous reviews have shown adverse health and well-being impact on children of serving and/or deployed parents, other studies have not found differences compared to children with non-serving parents. For instance, in a meta-analytic review conducted by Cunitz et al. (2019), no significant differences were observed in mental health problems between military children and their civilian peers., Likewise, Williamson et al. (2018) found that military youth did not have lower well-being compared to their civilian peers. Additionally, Card et al. (2011) reported that deployments had a minimal impact on child adjustment. Moreover, concerning educational outcomes, Card et al. (2011) found varying associations between parental deployment and child academic performance at different developmental stages: a small-to-medium association was observed in middle childhood, a small association in early childhood, and no association in youth.
Despite the contributions of previous reviews in shedding light on the effects of parental service and deployment on children, the research field still exhibits several limitations and gaps. Notably, due to inconsistent findings, there is a pressing need for further research to gain a more precise understanding of how military service influences child outcomes, encompassing behavioral, psycho-social, and academic aspects.
Prior reviews have primarily examined the impact of parental military deployment on child development (e.g., Card et al., 2011; Cunitz et al., 2019; Trautmann et al., 2015). However, this focus overlooks the impact of nondeployed service. These reviews have also concentrated on the longer-term consequences of parent service on child functioning, with limited research exploring concurrent implications of parental service on child outcomes. Furthermore, there is an insufficient amount of research on the academic outcomes of children with active military parents. Additionally, to the authors knowledge, comparative evidence of children’s socioemotional and educational outcomes has primarily centered on youth populations, making it challenging to generalize these findings to younger children (Williamson et al., 2018). Finally, research has predominantly emphasized the negative consequences of parental service for children, often neglecting positive outcomes that that could play a protective role in mitigating the impacts of military-specific stressors (Easterbrooks et al., 2013). A comprehensive understanding of both risk and protective factors will be valuable for informing prevention and intervention efforts.
Through a developmental framework, this systematic rapid review aims to examine contemporary published literature on the impact of concurrent parental military service (e.g., reserve, deployed, and non-deployed service) on the behavioral, emotional, social, and educational outcomes of children aged 0–18 years. We will compare these outcomes between children with currently serving military parents and those from non-serving civilian families.
Methods
A rapid systematic review was chosen as the most appropriate knowledge synthesis methodology for this study. Rapid reviews are an abbreviated form of systematic review used to synthesize and generate research evidence (King et al., 2022; Moher et al., 2015; Tricco et al., 2022). This expedited process provides timely results (Moons et al., 2021; Tricco et al., 2022), while allowing for a thorough search and evaluation of findings (Moher et al., 2015; Tricco et al., 2022). Rapid reviews offer a concise overview of the evidence, aiding evidence-driven conclusions and are commonly used by policymakers to inform decisions or advocate for further research (King et al., 2022; Moons et al., 2021; Tricco et al., 2022).
This rapid systematic review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology framework (Aromataris & Munn, 2020) and the Cochrane Rapid Review methodological recommendations (Garritty et al., 2021). Additionally, it follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Page et al., 2021; Fig. 1) guidelines. For a detailed account of the standardized reporting process, please refer to Supplementary Material 1, which contains the completed PRISMA checklist (Page et al., 2021).. The approach for this review involved the following phases: 1) deciding on the research question and appropriate search terms; 2) systematically searching the literature; 3) using inclusion and exclusion criteria to screen retrieved studies; 4) undertaking data extraction; 5) assessing the quality of the included data using the JBI Critical Appraisal Tool (Aromataris & Munn, 2020); and 6) narratively synthesizing the findings. This rapid review was registered on PROSPERO at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022313999.
Fig. 1
PRISMA flowchart of includes studies
×
Search Strategy
Online databases Medline, PsycINFO (both via the OVID interface), CINAHL (via the Ebscohost interface), and Cochrane Central Register of Controlled Trials (Central; via Cochrane Library) were searched to retrieve contemporary relevant studies, published in English, from February 2012–2022 (inclusive). All databases were selected based on relevancy to the topic and offered comprehensive coverage of the topic.
Search year parameters were included to ensure a highly contemporary review of the existing literature. Grey literature was excluded as it is outside the scope of a rapid review (Garritty et al., 2021). Search terms were based on the following concepts: 1) serving member; 2) child; 3) currently serving in a defense force; 4) child socioemotional and educational outcomes. See Supplementary Material 2 for a detailed search strategy for each database. All search terms were co-developed alongside a senior health science librarian. All records retrieved from databases were imported into Endnote and subsequently into Covidence, a program to aid with the screening process for reviews (Covidence systematic review software, 2018).
Eligibility Criteria
A priori inclusion and exclusion criteria were developed.
Inclusion and exclusion criteria
Studies were included if they reported on a primary study with child behavioral, social, emotional, and/or educational outcomes for children (aged 0–18 years) with at least one parent currently enrolled in the military (for any length of time). In terms of parental service, this could be of any type of military force (e.g., army, navy, air force), any type of military service (e.g., deployed, reserves, non-deployed active duty); however, the serving parent must have been in active service or have completed their service within eight weeks of study data collection. All family compositions were included, provided one parent or caregiver was participating in active military service and the family included at least one child 18 years or younger. Families were also included if a serving parent did not reside with them prior to their service. In addition, to warrant inclusion studies must have had a population comparison group. This could involve a comparison group of children from non-serving, civilian families, or include a discussion of study results relative to civilian population norms. Therefore, for studies that compared child outcomes for deployed versus non-deployed these were excluded, if there was not a community nonmilitary comparison included in the study. All included studies must have been published in English within the prior decade (i.e., between February 2012–2022 (inclusive)). The search strategy was limited to contemporary literature published in the last decade to ensure an up-to-date synthesis of findings, and to build (not replicate) previous relevant reviews (e.g., Card et al., 2011). Finally, included primary studies could be of any study design.
Studies were excluded if they met any of the following criteria: i) Did not include a non-military-family comparison group; ii) Data reported on veterans only (i.e., historical outcomes) that was conducted beyond eight weeks of service exit; iii) Study does not report on data that was concurrent with parents’ service or within eight weeks of parents military exit; iv) Study reports on child social, emotional, or academic outcome data that pertains to a parent completing mandatory service; v) Secondary research outputs (e.g., meta-analyses & systematic reviews); vi) Non-published outputs (e.g., grey literature & white papers); vii) Health related behavioral outcomes (e.g., smoking, substance use, & risk-taking) were beyond the scope of the present review.
If an intervention study was identified, only pre-intervention baseline data was used in the present review for both military and civilian child data. Further, information from the same sample could not be reported more than once from different publications. To account for overlapping sample data, the study with the largest sample was size included and the other study with the smaller sample size excluded.
Study Screening and Selection
The systematic search identified 4294 records (see Fig. 1). Following removal of duplicates in Endnote and Covidence (n = 1363), review authors (JO, AV, and FP) commenced title and abstract screening applying the inclusion and exclusion criteria. This screening resulted in 59 studies demonstrating enough relevance to have their full text retrieved and reviewed. The process of full text in-depth reviewing excluded 45 studies and included 14 studies which met all eligibility criteria and these were included in the final synthesis. These processes yielded an interrater reliability (IRR) of 98.30% (Cohen’s κ = 0.37), with conflicts resolved via conferencing. At the full-text screening level, JO screened 100% of references. One author (AV) double-screened all excluded studies, yielding an IRR of 100% (Cohen’s κ = 1.00). See Fig. 1 for a PRISMA diagram outlining the identification, screening, exclusion, and inclusion process of the examined records.
Data Extraction, Synthesis, and Quality Assessment
One author (AV) extracted all data using a pre-determined data extraction form. A second reviewer (JO) checked for data extraction correctness and completeness. A single reviewer (JO) narratively synthesized the data to grade the evidence, and a second reviewer (AV) verified these judgements. Results were narratively synthesized and presented according to developmental periods of early childhood (0–5 years), middle childhood (6–11 years), and youth (12–18 years). In terms of quality assessment, the JBI Critical Appraisal Checklist for Case Control Studies was used to assess study quality and risk of bias (Moola et al., 2020). This checklist includes 10 items scored on a four-point scale (i.e., Yes, No, Unclear, or Not Applicable). Irrespective of study quality, it was determined a priori that no study would be excluded based on quality or risk of bias (see online Supplementary Material 3 and Fig. 2 (Fig. 2 depicts the quality assessment of the 14 included studies across each criterion of the JBI)).
Fig. 2
Quality assessment graph. Note. Quality assessment graph. Reviewer judgements regarding each risk of bias item, as presented as percentages for the 14 included studies using the Joanna Briggs Institute Critical Appraisal Checklist for Case Control Studies. N/A Not assessed
×
Results
Overview of Studies
Fourteen studies were included. All studies reported on 1) a military family, and 2) a comparative civilian population or community normative data. Despite all research designs being eligible for inclusion, all included studies were quantitative. Study design was predominantly cross-sectional (n = 13), with an additional one study adopting a two-stage cluster random sampling design (Clements-Nolle et al., 2021). All included studies were conducted in North America, with the majority (n = 12; 85.71%) taking place in the USA, and the remaining two (n = 2; 14.29%) conducted in Canada. Table 1 provides a detailed description of included studies. The following sections synthesize the findings in terms of military family and child characteristics.
Table 1
Description and characteristics of included studies (N = 14)
Adolescents with family member (parent/sibling) currently serving in military
14,299 children (Con: 12,385; military-connected parent: 1305, military-connected sibling: 609)
52% (7277)
12–17 yrs
(7th, 9th, & 11th grade)
Non-military-connected youth with no serving family member or deployment experience from same school classes/ schools/communities as military-connected youth
Parents of children in current military service (deployed/not deployed during child’s life) & past military service (Deployed/not deployed during child’s life)
39,465 children (Defense NR: Con NR)
49.26%
0–17
Civilian children with no parents in military service
Families with preschooler & military father (deployed or non-deployed)
85 children (40 with non-deployed father; and 11 with deployed father, Con: 34)
Children: 49% (42)
Serving parent: 0% (51) At-home parent: 100%
3–6
49.82mos (12.76)
Military: 51.96 (14.73), Con: 46.62 (8.24)
Non-military families in community with similar characteristics (child age, child gender, language spoken at home) to military families, at low sociodemographic risk
Child: Deployed parents: 56% reported on son, 44% on a daughter; At-home parents: 54% reported on a son and 46% on daughter
3–17
9.75 (Children of deployed parents: 9.88 (3.71), Children of at-home parents: 9.61 (3.63)
Community norms based on National Health Interview Survey
BMI Body mass index, Con Control group, LOC Loss of control eating, M Mean, MM Mixed methods study, NR Not reported, Quan Quantitative, SD Standard deviation, Yrs Years
aCHAMPUS, Tricare, or CHAMPVA
bHighest rank below General or Admiral in the United States military with a monthly pay of between 7k–13k depending on years of service experience
Military Family Characteristics
Age and gender
Only one study (Crockett et al., 2020) reported on the serving military parent’s mean age (33.3 years), while two studies (Crockett et al., 2020; Lester et al., 2012) reported on the non-serving military parent’s mean age (35.66 years). The few studies which reported on parent gender indicated that serving military personnel were mostly males (mean: 94%; n = 2; Tupper et al., 2020; Wilson et al., 2014), and the non-serving parents were mostly females (mean: 98%; n = 4; Lester et al., 2012; Tupper et al., 2018; Tupper et al., 2020; Wilson et al. 2014).
Personnel and service type
In terms of military personnel and service type, approximately one third of the studies (n = 5) included military personnel from various military forces (e.g., a combination of Army, Navy, Air Force, Marine Corps, and Officers), one study exclusively focused on Army personnel (Crockett et al., 2020), and another study only involved National Guard personnel (Wilson et al., 2014). Ten studies reported details about the type of military service (e.g., deployed, non-deployed), while four studies did not provide specific information about parental military service (Clements-Nolle et al., 2021; Gilreath et al., 2016; Pressley et al., 2012; Schvey et al., 2015).
Deployment status
In terms of deployment, ten studies reported on military service type and included a deployment sample or subsample. Among these, two studies exclusively focused on children with deployed parents (Lester et al., 2012; Crockett et al., 2020), while while one study included a mixed-service personnel sample, encompassing fathers who were either deployed, away but not deployed, or working from their home military unit (Tupper et al. 2018). Additionally, four studies centered their research on military deployments within the context of the Iraq and Afghanistan wars(De Pedro et al., 2018; Lester et al., 2012; Tupper et al., 2020; Wilson et al., 2014). Only one study provided information on the total length of parental military service, reporting an of 12.2 years of service with a range of 1 to 28 years (Crockett et al., 2020). Deployment separation timing and duration were mentioned in half of the studies (n = 7). In four of these studies, deployment timing was defined by the number of overseas deployments in the past 10 years (Cederbaum et al., 2014; De Pedro et al., 2018), recent deployment within the last two years or more than two years ago (Crockett et al., 2020), or parents who were either currently deployed or who had returned from war-time duties in the last 12 months (Lester et al., 2012).
More than half of the military children had experienced two or more deployments (66.9% Cederbaum et al., 2014; 71% Lester et al., 2016; 51% Wilson et al., 2014). The average deployment length was reported as 16.6 months in one study (Lester et al., 2012). Among the 14 studies, only five reported on the association between deployment exposure (cumulative length, frequency, and recency) and child outcomes.
Children Characteristics and Outcomes
Included studies reported on children aged from 0–17 years. Eight studies reported the mean age of children, considering both military and control groups. One average, the children were 7.45 years old. Female children represented slightly over half of all children (55%; n = 10) (military and control aggregated). However, the breakdown of child sex and age by respondent type (i.e., military versus control) was infrequently reported (see Table 2).
Table 2
Summary of outcomes, covariates, and effect sizes of reviewed studies (N = 14)
Author
Year
Country
Point of service
Indicator
variables
Outcomes
variables
Outcome measure(s)
Covariates
Relevant child outcomes with civilian comparison data
Military parent associated with decreases odds of positive child outcomes, e.g., well-being, OR(95%CI) = 0.79 (0.67–0.94), but not sadness/hopelessness OR(95%CI) = 0.88 (0.76–1.01), suicidal ideation OR(95%CI) = 1.10(0.88–1.38), or depressive symptoms, OR(95%CI) = 0.90(0.81–1.01). Compared to no deployments, increased likelihood of feeling sad for children experiencing 1 deployment (OR(95%CI) = 1.40 (1.24–1.59) and 2+ family member deployments (OR(95%CI) = 1.56 (1.34–1.83)). 2+ family member deployments associated with 34% increase odds of suicidal ideation (OR(95%CI) = 1.34; 1.12–1.60). Increased likelihood of depressive symptoms among those with 1 (OR(95%CI = 1.15(1.00–1.33) and 2+ family member deployments (OR(95%CI) = 1.41(1.26–1.58). Deployments did not predict odds of well-being (1 deployment: OR(95%CI) = 90(0.76–1.08), 2 + deployments: OR(95%CI) = 1.13(1.00–1.27)).
Relative to civilian peers, students in military families had twice odds of attempting suicide in past 12-mos (AOR = 2.16, 95% CI = 1.30, 3.61, p < 0.01). Cumulative ACEs exposure mediated relationship between military family involvement and attempted suicide (β = 0.167, p < 0.001).
Compared to civilian peers, military children had greater internalizing problems (χ2 = 4.27, p = 0.04). Fewer military children had deficits in resiliency (χ2 = 5.92, p = 0.02) such that military children had greater resiliency compared to their civilian peers. Military and civilian children did not differ on rates of externalizing problems (p = 0.10) and adaptive skills (p = 0.34). Children with recently deployed parent (≤2 yrs ago) more likely to have internalizing problems (p = 0.04) and poor adaptive skills (p = 0.01) but no differences externalizing problems (p = 0.50) and resiliency (p = 0.83), relative to those that deployed >2 yrs ago. Parent’s military rank no effect on outcomes (externalizing problems p = 0.64, internalizing p = 0.33, adaptive skills p = 0.75, resiliency p = 0.63).
1) Military connection (parent, sibling, non-military student)
2) No. of deployments in past 10 yrs
3) School climate
4) Gender
5) Race/ethnicity
1) Well-being
2) Depressive symptoms
3) Suicidal ideation
1) CHKS
1) Gender
2) Race
No differences between students with military parent, military sibling, or non-military students on relationship between military connection and well-being (χ2 = 0.052, p = 0.97). Students with military parent high depressive symptoms (7.9%), higher than students with military sibling, (6.9%) and non-military students (5.7%) (χ2 = 9.85, p < 0.05). Students with military sibling (27.6%) higher rates of suicidal ideation than students with military parent (26.2%) and non-military students (19.6%) (χ2 = 31.753, p = 0.000). Significant group differences in relationship between deployments & suicidal ideation (χ2 = 31.753, p = 0.000), but not well-being (p > 0.05) or depression (p > 0.05). Students ≥2 deployments (27.6%), reported higher suicidal thoughts (26%) than students reporting one deployment and no deployment.
1) Whether student had parent currently serving, grade, sex & race/ethnicity
1) Suicide attempts in the past 12-mos
1) CHKS
1) Grade; 2) Sex; 3) Race/ethnicity
Controlling for grade, sex, & race/ethnicity, military-connected youth at increased risk for suicidal ideation (OR(95% CI) = 1.43, 95% CI = 1.37–1.49, p < 0.001), making plan to self-harm (OR(95%CI) = 1.19 (1.06–1.34), p < 0.01), attempting suicide (OR(95% CI) = 1.67(1.43–1.95), p < 0.001), & attempting suicide requiring medical treatment (OR(95%CI) = 1.71 (1.34–2.16), p < 0.001) compared to non-military youth.
Currently serving family (deployed & non-deployed), service did not predict the odds of reporting a mental health condition for each one unit increase in number of times moved, Not deployed: OR(95%CI) = 0.96(0.63–1.46), p > 0.05; Deployed: OR(95% CI) = 0.95(0.76–1.19), p > 0.05). Children in never-serving and ex-serving military families (never-deployed) higher odds of reporting mental health condition for every one unit increase in number of times moved: Never-serving families (OR (95% CI) = 1.12(1.07–1.17), p < 0.05) and children in families where parents previously served without deployment (OR(95% CI) = 1.17(1.07–1.28), p < 0.05), previously served with deployment (OR(95% CI) = 1.03(0.90)–1.18), p > 0.05). The relationship between parent mental health and child mental health stronger for non- military families (OR (95% CI) = 0.63 (0.56–0.71), p < 0.05) where parent mental health, higher odds of reporting child mental health problem or mental health treatment. Military families (deployed & non-deployed) did not display association between parent mental health and child mental health problems (non-deployed: OR(95% CI) = 0.77(0.44–1.34), p > 0.05(deployed: OR(95%CI) = 1.11(0.42–2.9), p > 0.05).
Military children did not show elevations in depression, internalizing or externalizing symptoms relative to community norms (all p > 0.05). Girls with currently deployed parent displayed elevated externalizing symptoms, M(SD) = 48.45(11.59), relative to norms, M(SD) = 45.44(10.40); however, not significant (p = 0.09). Military child anxiety significantly greater than community norms (Boys: M(SD) = 42.06(15.83); Girls: M(SD) = 49.12(16.05) for both genders (Boys: M(SD) = 56.18(9.13); Girls: M(SD) = 54.79(9.75), p < 0.001,) in children with family with a returned deployed parent and in children with currently deployed parent (Boys: M(SD) = 56.21(8.89); Girls: M(SD) = 53.62(9.68), p < 0.001,). 31.9% vs. 24.6% of children of recently returned parent compared to currently deployed parent had clinically significant anxiety symptoms. Number of months serving parent away and deployed for predicted child depression (p < 0.05) & externalizing symptoms (p < 0.001), but not child internalizing symptoms (p > 0.05). Psychological symptoms of the civilian AHC predicted child internalizing (p < 0.001) & externalizing symptoms (p < 0.001), even after controlling for cumulative deployment months. Child depression predicted by AHC parent’s depression (p < 0.01), but not parent months away in combat (p > 0.05). After controlling for child age & gender, active-duty parent PTSD symptoms predicted child depression (p < 0.05), internalizing (p < 0.01) & externalizing symptoms (p < 0.05). Child internalizing symptoms predicted by active-duty parent’s depression & anxiety symptoms (all p < 0.01).
5) Primary caregiving parent’s prior military experience;
6) Military component (Active vs Reserve)
7) Military pay grade
Children with currently serving parents aged 3–5 yrs significantly increased general, separation, & total anxiety relative to community norms (results not shown). Higher degree of parental deployment exposure throughout child’s life associated with increased social anxiety (results not shown).
1) Parent deployment (timing and duration; recent long deployment lasting ≥30 days in past 3mnths, and percentage of the child’s life that the parent had
been deployed)
1) Child socio-emotional development
2) Child anxiety
3) Child emotional/ behavioral issues
1) ASQ:SE
2) PAS
3) SDQ
1) Child age;
2) Child; gender
3) Race/ethnicity;
4) No. of children in family;
5) Family structure
6) Military component (Active vs. Reserve/Guard
7) Military branch (Army, Marine, Air Force, Navy)
8) Military pay grade
Percentage of children (0–5 years) at risk of socio-emotional difficulties not different to at-risk community (12.63% vs. 16.14%, p < 0.28). Compared to community norms, children aged 3–5 with serving parent higher general anxiety (2.71 vs. 2.15, p < 0.001), separation anxiety (3.87 vs. 2.73, p < 0.001), total anxiety (19.72 vs. 17.28, p < 0.001) & lower social anxiety (4.11 vs. 4.66, p < 0.01). In those aged 8–10, boys had higher total difficulties (9.13 vs. 7.90, p < 0.001), emotional difficulties (2.00 vs. 1.50, p < 0.001), & peer problems (1.71 vs. 1.50, p < 0.001) vs. age-specific norms. Girls higher total difficulties (7.18 vs. 6.40, p < 0.01), emotional difficulties (2.00 vs. 1.50, p < 0.001), & prosocial behaviors (, 9.13 vs. 9.00, p < 0.01) vs. age-specific norms, & significantly lower peer problems vs. girls in national sample (1.27 vs. 1.40, p < 0.05). No association between deployment & problematic social & emotional development in children 0–5 yrs (deployed at birth: OR(SE) = 1.371(1.074), p > 0.05; Recent long deployment: OR(SE) = 1.492, p > 0.05; Percentage deployed: OR(SE) = 1.009(0.019), p > 0.05), but for each 1mnth increase in child age, risk of problematic development increased by about 3% OR(SE) = 1.028 (0.016), p < 0.05). Experiencing a recent long deployment associated with higher generalized anxiety (IRR(SE) = 1.427(0.261), p < 0.05) in children aged 3–5 yrs, & total % of life exposed to deployment was associated with elevated social anxiety (IRR(SE) = 1.008 (0.005), p < 0.05). For older children (6–10 yrs), having parent deployed at birth associated with more total (IRR(SE) = 1.261 (0.176), p < 0.05) & peer problems (IRR(SE) = 1.630 (0.316), p < 0.01), & recent long deployment with more emotional problems (IRR(SE) = 1.395 (0.233), p < 0.01).
1) Mental Health Diagnoses & Mechanisms and Intent of Injury Classifications
1) ICD-9-CM
1) Age
2) Gender
Military dependents higher hospital admissions for attempted suicide compared with non-military dependents (3.8% vs. 1.6%, p = 0.0001). Suicide attempts per 1,000 injury-related hospitalizations higher in military dependents compared with non-military (χ2 = 28.4 (p < 0.0001)). Age- and sex-adjusted odds higher in both age groups 10–14 & 15–17 yrs for suicide (p = 0.0001). Black military dependents more likely admitted for suicide attempts vs. black non-military dependents (p = 0.019). In all age groups (0–4; 5–9; 10–14 & 15–17 yrs), military children more likely to have mental health diagnosis. Age- and sex-adjusted odds of history of mental health diagnosis at time of hospitalization 40% higher in military compared with non-military children. Anxiety disorder diagnoses 71% higher in military children of all ages than nonmilitary. Affective disorder diagnoses higher in all age groups: Diagnoses of behavioral disorders higher in youngest and oldest age groups. Compared with non-military teens, military teens 15–17 yrs 104% higher rate of history of mental illness, 34% higher rate of alcohol abuse, 15% higher rate of substance abuse.
Accounting for child age, race, and weight, military-dependents reported more objective binge-episodes over the past 3 months compared to civilians (F = 7.93, p = 0.006; η2 = 0.05). Groups did not differ regarding number of subjective binge-episodes (F = 0.47, p > 0.05), and overeating-episodes (F = 0.01, p > 0.05). More military-dependents (17%) met criteria for Binge Eating Disorder compared to civilians (2%) (χ2 = 10.13, Fisher’s p = 0.01, Cramer’s V = 0.28). Compared to civilians, military dependents reported greater eating- (F = 10.14, p = 0.001), shape-(F = 12.74, p < 0.001), and weight- (F = 8.74, p = 0.001) concern, and global score (F = 12.44, p < 0.001). Groups did not differ on eating restraint (F = 1.07, p = 0.30). Military-dependents greater depressive symptoms (F = 4.17, p = 0.044; η2 = 0.03), after controlling for weight, race, and age. Military-dependents did not differ from civilians on school (F = 1.43, p > 0.05) or family functioning (F = 0.59, p > 0.05). Military children marginally worse functioning on friendships (F = 3.64, p = 0.059).
More insecure attachment in deployed group compared to general population norms, p = 0.001. Deployment status distinguished secure from insecure child attachment χ2 = 9.4, p < 0.01, Cohen’s d = 0.80. Only deployment condition reliably predicted child attachment, χ2 = 4.60, p = 0.03, Cohen’s d = 0.54. Away condition not significant predictor of child attachment, χ2 = 1.75, p = 0.14, Cohen’s d = 0.33. An odds ratio of 4.22, 95%CI [1.13, 15.73], for deployed condition suggests child is >4 times to be classified insecure attachment when partner deployed. Association between deployment and child attachment security not mediated through maternal depressive symptoms or parent stress.
Deployment predicted higher internalizing (R² = 0.08, F = 5.39, p = 0.006) and conduct problems (R² = 0.06, F = 2.70, p = 0.07) beyond contributions of attachment organization (R² = 0.11, F = 5.30, p = 0.007) and stress (R² = 0.18, F = 10.56, p < 0.001). Deployed group greater insecure mother-child attachment, than non-deployed and control dyads (χ²= 6.87, p = 0.032). Deployed group greater internalizing problems than control (F = 5.06, p = 0.009, ηp2 = 0.115). Deployed group higher internalizing problems compared to control, p = 0.019. Non-deployed group higher internalizing than control, p = 0.076. Children with deployed parent greater conduct problems, relative to children with military non-deployed and control child with no military affiliation, F = 4.15, p = 0.019, ηp2 = 0.092. Child–mother attachment insecurity (95%CI = 0.07–0.67, p = 0.016) and maternal parenting stress (95% CI = 0.09–0.31, p = 0.001) predicted higher child internalizing. Maternal stress (95%CI = 0.05–0.28, p = 0.006) but not child–mother attachment insecurity (p > 0.05), predicted higher child conduct issues.
1) Respondent type (deployed vs. non-deployed at-home parent)
1) Behavior problems
2) Prosocial behavior
1) SDQ
1) Child age;
2) Child gender;
3) Service member education;
4) Child participation in reintegration program
Children whose parent recently returned from deployment greater behavioral difficulties compared to USA norms during deployment and at reunion: At-home parents report: Deployment vs. Norms: t = 6.6, p < 0.01; At-home parents reports: Reunion vs. Norms: t = 5.4, p < 0.01; Deployed Parents reports: Reunion vs. Norms: t = 4.3, p < 0.012). Children whose parent recently returned from deployment displayed less prosocial behaviors compared to norms: At-home parents reports: Deployment vs. Norms: t = −3.1, p < 0.01; At-home parents reports: Reunion vs. Norms: t = −2.0, p < 0.05; Deployed Parents reports: Reunion vs. Norms: t = −2.5, p < 0.05. Deployed parents’ reports of conversation orientation continued to predict less child behavioral difficulty (β = −0.43, p < 0.01), and greater prosocial behavior (β = 0.36, p < 0.01).
ACEs Adverse Childhood Experiences, ASQ:SE Ages and Stages Questionnaire: Social–Emotional, ADD Attention-deficit disorder, ADHD attention-deficit hyperactivity disorder, BDI Beck Depression Inventory, BACS-2 Behavior Assessment System for Children-Second Edition, BED Binge eating disorder, BMI-z Body mass index z-score, CHKS California Healthy Kids Survey, CDC-YRBS Centers for Disease Control and Prevention Youth Risk Behavior Survey, CHKS California Healthy Kids Survey, CDI Children’s Depression Inventory, CBCL Child Behavior Checklist, EDE The Eating Disorder Examination, IBQ Infant Behavior Questionnaire, Infant SSP Infant Strange Situation for children ≤2½yrs, ICD-9-CM International Classification of Diseases V9th Rev. Clinical Modification, MMPI Minnesota Multiphasic Personality Inventory, MASC Multidimensional Anxiety Scale for Children, NSCH National Survey of Children’s Health, NR Not reported, Ns Non-significant, Observations, PACS MacArthur Preschool Attachment Coding System, PANAS-X Positive and Negative Affect Schedule-Expanded Form, OBE Objective Binge-Episodes, OO Overeating-episodes, Preschool SSP Preschool Separation-Reunion for Children ≥2½yrs, SAS Social Adjustment Scale-Self-Report, PAS Spence Preschool Anxiety Scale, SDQ Strengths and Difficulties Questionnaire, SBE Subjective Binge-Episodes, vs. Versus
Six studies covered a broad age range of children, including multiple developmental periods. They examined and combined results for children spanning early childhood to middle childhood (0–10 years, n = 2; Lester et al., 2016; Mustillo et al., 2016; 2–11 years, n = 1; Crockett et al., 2020), birth to youth (0–17 years, n = 2; Hinojosa et al., 2021; Pressley et al., 2012), and early childhood to youth (3–17 years, n = 1; Wilson et al., 2014). In contrast, the remaining studies focused on narrower child age ranges: children in the early childhood period (0–6, n = 2; Tupper et al., 2018; Tupper et al., 2020), middle childhood aged children (6–12, n = 1; Lester et al., 2012), and youth (12–17, n = 5).
While none of the studies reported on academic outcomes, all 14 studies examined the impact of concurrent parental military affiliation on child behavioral and/or socioemotional outcomes (Table 2). Child health and well-being outcomes included emotional and behavioral issues (n = 6), parent-child attachment (n = 2), and child mental health concerns & diagnosis (n = 2). More specifically, studies assessed suicidal behaviors (n = 3), anxiety (n = 3), depression or depressive symptoms (n = 4), as well as overall well-being (n = 2).
In terms of measurements, the included studies used a variety of data collection tools to assess child behavioral and socioemotional outcomes. For example, 12 studies employed self-report assessments completed by either the serving or non-serving parent (n = 7) or the child (n = 5). Additionally, two studies included laboratory-based observation sessions (Tupper et al., 2018; Tupper et al., 2020), and one study utilized both parent- and child-report measures (Lester et al., 2012). One study collected data from external databases (Pressley et al., 2012). Commonly used self-report instruments to assess children’s behavioral and socioemotional outcomes included the Strengths and Difficulties Questionnaire (n = 4), the California Healthy Kids Survey (n = 2), Preschool Anxiety Scale (n = 2), and the Ages and Stages Questionnaire: Social-Emotional (n = 2). See Table 2 for additional measure details. The following section synthesizes the findings across the early (0–5 years) and middle childhood (6–11 years), as well as the youth developmental period (12–18 years).
Comparative data between military and civilian child outcomes
Table 3 summarizes the key differences between military children and civilian comparison child data. Overall, military children, especially those with deployed parents, consistently showed higher adverse socioemotional outcomes compared to their civilian peers. For significant findings, refer to Table 3.
Table 3
Summary of significant findings when comparing military children to civilian comparison data (N = 14)
Author (year)
Country
Socioemotional outcomes
Comparative significant outcomes (a) between military children and civilian peers
BED Binge eating disorder, NS Non-significant, OBE Objective Binge-Episodes, OO Overeating-episodes, SBE Subjective Binge-Episodes, USA Unites States of America
aSignificant outcomes when comparing military children to a comparison group
Early childhood (0–5 years)
The findings indicate that children with deployed fathers, compared to civilian controls, tend to present with higher internalizing concerns (e.g., Tupper et al., 2020, p = 0.019). Mustillo et al. (2016) found that preschooler children (3–5 years) with a serving parent reported significantly higher anxiety scores compared to USA community samples and norms, including general anxiety (2.71 versus 2.15, p < 0.001), separation anxiety (3.87 versus 2.73, p < 0.001), and total anxiety (19.72 versus 17.28, p < 0.001). The findings indicate that children with deployed fathers tend to present with higher internalizing concerns (e.g., Tupper et al., 2020, p = 0.019).In terms of externalizing concerns, Tupper et al. (2020) found that children with a deployed father experienced more pronounced conduct problems than non-deployed (p = 0.039) and civilian controls (p = 0.018).
In terms of parent-child attachment classifications, Tupper et al. (2018) observed no differences in the prevalence of children classified with ‘secure attachment’ in the overall military sample (57% and 65%, respectively, p = 0.21). However, significant differences persisted for children classified as ‘insecure’ in the deployed military sample compared to the general population (73% and 35%, respectively, p = 0.001). Subsequent research examining these associations compared to a demographically similar civilian control group found that children with a deployed father experienced significantly higher rates of insecure mother-child attachment (z = 2.6) and lower rates of secure attachment (z = −2.6) (Tupper et al., 2020).Regarding mental health concerns and diagnoses, Pressley et al. (2012) found that children aged 0–4 years with a serving parent were 43% more likely to receive a mental health diagnosis than their non-military same-aged peers. Within this age group, military children were 67% more likely to have an anxiety disorder diagnosis, 72% more likely to have an affective disorder diagnosis, and more likely to have a behavioral disorder diagnosis compared to their non-military peers.
Middle childhood (6–11 years)
Comparing with community norms, Mustillo et al. (2016) found that both military-connected boys and girls aged 6–10 presented with higher mean scores for peer problems (boys: 9.13 versus 7.90, p < 0.001; girls: 7.18 versus 6.40, p < 0.01) and emotional difficulties (boys: 2.00 versus 1.50, p < 0.001; girls: 2.00 versus 1.50, p < 0.001). Additionally, military boys had significantly higher peer problems (1.71 versus 1.50, p < 0.001) than boys in national samples. Mustillo et al. (2016) also found that relative to military-connected children aged 6–10 who were born while one parent was deployed experienced greater emotional, hyperactivity/inattention, and peer social problems compared to those not born during a deployment.
While these children generally experience more pronounced emotional problems when a parent has recently had a long deployment (i.e., 30 days or longer within the past 3 months), there are exceptions. For example, girls with a serving parent (deployed and non-deployed), compared to gender-specific norms 8–10 years olds, demonstrated significantly fewer peer problems (1.27 versus 1.40, p < 0.05), and significantly more prosocial behaviors (9.13 versus 9.00, p < 0.01; e.g., helping, sharing, donating, cooperating, volunteering; Mustillo et al., 2016).
Lester et al. (2012) found that child behavioral adjustment and levels of depression symptoms did not significantly differ from community normative data when compared to both currently deployed (p > 0.05) and recently returned parents (p > 0.05). However, rates of child anxiety, for both boys and girls, were significantly higher for children with both a currently deployed (p < 0.001) and recently returned parent (primarily fathers) (p < 0.001) compared to community normative data. Additionally, Pressley et al. (2012) found that military children (5–9 years) admitted to hospital were 31% more likely to recieve a mental health diagnosis compared to non-military children,. Specifically, they were 113% more likely to receive an anxiety diagnosis and 93% more likely to receive an affective disorder diagnosis during this developmental period.
Youth (12–18 years)
One study (Schvey et al., 2015) found that military-affiliated youth did not differ significantly from civilians in terms of psychosocial functioning in the family (F = 3.64, p = 0.059) or school (F = 1.43, p > 0.05) context. However, they did encounter challenges in the friendship domain, affecting their satisfaction and functioning with friends (F = 0.59, p > 0.05). Nevertheless, other studies, such as De Pedro et al. (2018) and Schvey et al. (2015), indicated that military youth (12–17 years) were more likely to report depressive symptoms compared to their same-age civilian peers (χ2 = 9.85, p < 0.05 and F = 4.17, p = 0.044, respectively). De Pedro et al. (2018) found that experiencing two or more parent deployments was predictive of depressive symptoms in youth (OR(95%CI) = 1.31 (1.03, 1.69), p < 0.05), in contrasted to youth who had not experienced any deployments.
One study (Cederbaum et al., 2014) reported symptoms of depression, specifically sadness and hopelessness. In comparison to youth who had never experienced a parent’s deployment, youth aged 12–17 years who had a family member undergo one deployment (OR (95%CI) = 1.40 (1.24–1.59), p < 0.05) and those who had a family member undergo two or more deployments (OR (95%CI) = 1.56 (1.34–1.83), p < 0.05) had increased odds of experiencing feelings of sadness and hopelessness (Cederbaum et al., 2014).
Furthermore, military youth aged 15–17 years were 59% more likely to receive a mental health diagnosis during an injury-related hospital admission, relative to their non-military counterparts (Pressley et al., 2012). Specifically, military youth were 65% more likely to be diagnosed with an anxiety disorder and 84% more likely to be diagnosed with an affective disorder. Military youth also reported a 104% higher history of mental illness compared to non-military youth (Pressley et al., 2012). For younger military youth aged 10–14 years, the likelihood of receiving a mental health diagnosis during injury-related hospital admission was 34% higher than that of controls.
In terms of eating-related concerns, one study (Schvey et al., 2015) found that military youth were at a higher risk of experiencing concerns relating to eating (F = 10.14, p = 0.001), body weight (F = 8.74, p = 0.001), and body shape (F = 12.74, p < 0.001) compared to civilian youth. Additionally, military youth displayed greater eating-related pathology, specifically in relation to binge eating disorder (χ2 = 10.13, Fisher’s p = 0.01, Cramer’s V = 0.28). However, there were not significant differences in objective binge-episodes (F = 7.93, p = 0.006; η2 = 0.05), subjective binge-episodes (F = 0.47, p > 0.05), overeating-episodes (F = 0.01, p > 0.05), or eating restraint (F = 1.07, p = 0.30) between the two groups.
Four studies reported on youth suicide, with results pertaining to suicidal ideation, suicide attempts, and suicide associated hospitalizations. Overall, findings highlight military youth experience higher rates of suicidal behaviors, relative to their non-military peers. For instance, De Pedro et al. (2018) found a significant difference in suicidal ideation rates between youth within a military family member (26.2%) relative to a non-military affiliated youth (19.6%; χ2 = 31.753, df = 2, p < 0.05). This is consistent with Gilreath et al. (2016), who reported military-connected youth were at significantly increased risk for suicidal ideation (OR (95%CI) = 1.43 (1.37–1.49), p < 0.0001) and making a plan to end their life (OR (95%CI) = 1.19 (1.06–1.34), p < 0.001), relative to non-military connected youth. More recently, Clements-Nolle et al., 2021 demonstrated higher exposure to adverse childhood experiences (ACEs) and twice the odds of recent attempted suicide in military connected youth comparative to their non-military peers (AOR (95%CI) = 2.16(1.30, 3.61), p < 0.01), with the risk association between military family involvement and suicide entirely mediated by cumulative exposure to ACEs.
Child outcomes across all age groups (0–17 years)
Overall, the results highlight that compared to non-military children, military children of all ages (0–17 years) experienced significantly higher mental health concerns and diagnoses (15.5% versus 13.2%, p < 0.0001; Pressley et al., 2012). However, other studies (e.g., Hinojosa et al., 2021) reported that military families are less likely to report child (2–17 years) mental health concerns, relative to civilians and prior military families. In terms of internalizing and/or externalizing concerns, military children (2–11 years) experienced more internalizing problems (χ2 = 5.92, p = 0.02), with children whose parent had recently deployed more likely to have internalizing problems (p = 0.04) and poor adaptive skills (p = 0.34, Crockett et al., 2020), compared to children whose parent had deployed over two years ago. However, Crockett et al. (2020) also identified these military children to be more resilient (χ2 = 5.92, p = 0.02) and to experience similar rates of externalizing problems (p = 0.10) and adaptive skills (p = 0.34) to their civilian peers.
Discussion
This rapid review identified 14 studies that explored military children’s behavioral and psychosocial outcomes in comparison to civilian children. No identified studies reported on child academic outcomes. The overall pattern of findings indicates that military children, compared to their civilian counterparts, are more likely to experience psychosocial and behavioral symptoms and have a higher prevalence of mental health diagnoses during early, middle, and late childhood. Military-affiliated youth showed the highest risk, which is of particular concern due to its association with suicidal behaviors.
Consistent with previous reviews, our findings emphasize that negative outcomes for military children are frequently observed throughout early, middle, and late stages of their childhood development (e.g., Card et al., 2011; Creech et al., 2014; Cunitz et al., 2019; Williamson et al., 2018). Across all childhood developmental periods, having a deployed parent is more likely to increase children’s internalizing and externalizing concerns (e.g., Lester et al., 2016; Mustillo et al., 2016; Tupper et al., 2020). We further observed a deployment dose-response effect on adverse childhood outcomes, similar to that observed in a prior review (Blamey et al., 2019), wherein children of deployed parents appeared to present with accumulating difficulties associated with accruing deployment length and number. For example, military youths’ rates of suicidal ideation and depressive symptoms worsened with an increased number of family deployments (e.g., De Pedro et al., 2018; Cederbaum et al., 2014).
Explanations for the association between deployment and adverse child outcomes likely include the physical absence of the deployed parent and the worry about their significant danger, as well as the potential impact on the responsiveness of the non-deployed at-home parent. Difficulties related to parental reintegration following their return are also likely contributors. It is worth noting that, in the present review, children with non-deployed serving parents did not exhibit such differences compared to their civilian counterparts. Nevertheless, from a risk perspective, further study is necessary to consider the specific impacts of various factors on child outcomes, including the unique attachment patterns with both the deployed parent and the non-deployed parent.
In terms of parent-child attachment, the findings of this review suggest that parent-child separation due to military service may impact the attachment organization of young children. Among children aged 1–6 years, military children with a deployed parent appear to experience higher rates of insecure attachment compared to civilians or military children without an actively deployed parent (Tupper et al., 2018; Tupper et al., 2020). It appears that deployment may represent a large relational rupture and loss for the developing child, with them questioning their predictability of care. The younger child’s immature logic and magical thinking may also contribute to attachment and trust concerns, as they may mistakenly attribute their parent’s absence and changes in caregiving by the non-deployed parent to themselves. Consequently, the child likely internalize these relational representations, seeing themselves as ‘unlovable,’ feeling unworthy of protection and care, and doubting the reliability and trustworthiness of those around them (Cicchetti et al., 1995; Duschinsky, 2018).
Military pre-schoolers also reported higher anxiety symptoms compared to community norms (Mustillo et al., 2016; Lester et al., 2016). Compared to early childhood and youth, internalizing and externalizing differences in middle childhood were less overt relative to civilian controls. However, results all trended in the negative direction with strong (and significant) evidence that parental deployment at the time of birth as well as recent/current deployments adversely impact internalizing and externalizing outcomes.
Across the childhood developmental spectrum, military youth appear to be at greatest risk of adverse outcomes, such as depressive symptoms (De Pedro et al., 2018; Schvey et al., 2015); suicidal ideation and attempts (De Pedro et al., 2018; Gilreath 2016); and eating-related concerns (Schvey et al., 2015). Compared to non-military children, military youth also experienced more adverse childhood experiences (ACEs; Clements-Nolle et al., 2021), a likely contributor to these adverse socioemotional presentations.
We observed heterogeneity in study findings, as identified in past reviews (e.g., Card et al., 2011; Cramm et al., 2019). While most studies consistently reported on the detrimental outcomes associated with military children, some studies identified no adverse outcomes and reported military affiliation to have a buffering and protective effect for the child (Hinojosa et al., 2021; Mustillo et al., 2016). For instance, studies on mental health in military children showed mixed results. Pressley et al. (2012) found a higher prevalence of concerns, while Hinojosa et al. (2021) reported fewer instances of mental health issues or treatments. Inconsistencies in results were primarily observed when comparing military children of non-deployed military personnel to civilian children. However, when the comparison involved children of deployed military personnel, the outcomes were consistently negative (e.g., Tupper et al., 2020; Mustillo et al., 2016). It should be emphasized that these results are not inherently contradictory. Although the observed trends are in alignment with prior studies, they did not achieve the requisite level of statistical significance. Such an outcome may be attributed to limitations such as a limited sample size.
Disparities between military and non-military children were explained by mediating and moderating factors, such as the degree of social support available to the military child and the non-deployed parent (Moeller et al., 2015; Wadsworth et al., 2017), deployment length, and number of relocations (Moeller et al., 2015). However, it should be noted that the specific parent’s military occupation (e.g., soldier, engineer, information technology professional, or aviator) may introduce variability in these outcomes. Distinct military appointments have shown to be associated with varying degrees of risk (e.g., exposure to conflict scenarios) and protective factors (e.g., socioeconomic status; Tupper et al., 2020). Child outcomes appeared to be dependent upon the number of residential moves (Hinojosa et al., 2021), parental sensitivity (Lester et al., 2016; Tupper 2020), school environment (De Pedro et al., 2018), number of ACEs (Clements-Nolle et al., 2021), recency of deployment (Crockett et al., 2020; Mustillo et al., 2016), and family structure (Mustillo et al., 2016). However, covariates were generally not examined at the comparative level making it difficult to understand their impact and the underlying factors behind differences between military and non-military children. Despite these methodological limitations, military children displayed greater resilience in certain domains. For example, school-aged girls aged 8–10 years with parents in military service exhibited fewer peer issues, reduced social anxiety, and displayed more positive social behaviors compared to the average civilian child of the same age range (e.g., Mustillo et al., 2016).
Limitations
This rapid review emphasized certain psychosocial effects and challenges faced by children with a parent in service; however, there remains a pressing need to delve deeper into unaddressed areas and limitations. First, in this review, we observed a degree of data heterogeneity across the included studies. For example, some studies included all types of military service, whilst other studies compared the data with normative and/or civilian samples. Second, this paper included a broad age range (0–18 years), which obscured an in-depth examination of any one specific developmental period. Third, only contemporary published studies, restricted to English language, and published between 2012–2022 were included. Therefore, older papers and those that were unpublished were excluded. Notably, unpublished literature, also known as ‘grey literature’, was excluded as it falls outside the parameters of a rapid review methodology (Moons et al., 2021; Tricco et al., 2015). Fourth, the majority of the data were self-reported, which could elevate the risk of response bias. Fifth, this review provides a short-term analysis of military children to non-military child, thus long-term ramifications of parental service may not be captured. Additionally, consistent with prior contemporary reviews in this field (Jiang et al., 2022; McIntosh et al., 2023), as all identified data was exclusively from North America which raises generalizability concerns. As we assessed a broad array of outcomes, drawing comparisons was challenging due to outcome variability and breadth.
Future Research
This review emphasized that there is limited research on the educational and academic outcomes of military children. Given current findings that military children experience elevated rates of poor social, emotional, and behavioral outcomes, this may in turn negatively impact on related outcomes such as educational attainment and future employment prospects. This warrants substantial investment in development, implementation, and evaluation of early support services for families with a serving parent to mitigate the possibility of developmental effects with far-reaching lifespan consequences.
Given that most studies reported on negative child outcomes of having a serving military parent, we strongly suggest a need to focus not only on the contextual risk factors but contextual buffers to further understand resilience and strengths in military children. There is also a need for further comparative synthesis of the research literature to explore the mediating and moderating variables that contribute and strengthen the knowledge base pertaining to differences between the military and non-military child. Such additional research will allow us to better address the mental health needs of this vulnerable population and to guide the development of policies and programs.
An example of an online program that may enhance psychosocial and attachment outcomes in this population is MERTIL for Parents (My Early Relational Trust-Informed Learning; Opie et al., 2023). MERTIL for Parents is a brief, universal, self-directed parenting program about enhancing relational trust and preventing relational trauma. Future research may also consider exploring factors such as socioeconomic status, that possibly contribute to military service rank and participation (e.g., deployment type and length). This may provide opportunities to tailor the development, implementation, and evaluation of support services and/or preventative interventions with parents and children who may present with higher risk and vulnerabilities.
Implications, Translation, and Conclusion
Given their unique context, military children of all ages appear to be a particularly vulnerable population. Findings suggest that children in military families experience substantially higher risk for negative social and mental health outcomes than their civilian counterparts, with parental deployment increasing risk across all developmental stages. Military children may benefit from monitoring of their social and emotional well-being, and support as indicated. Findings confirm similar impacts for pre-deployed service children relative to civilian children. Evidence of risk factors, together with growing knowledge of protective factors will usefully inform prevention and intervention efforts. Based on these findings, and to mitigate risk, attention to targeted screening and ongoing monitoring across childhood may ameliorate adverse outcomes, including the high priority area identified in this review of youth suicidal ideation and behaviors.
We thank Natalie Pearce for assistance with search term development and conducting the systematic search.
Author Contributions
Conception or design of the work: J.M., J.O., N.M. Conducting systematic search: N.P. Screening: A.V., F.P., J.O. Data collection and extraction: A.V., J.O. Evaluated literature quality: J.O., A.V. Performed data analyses: J.O., A.V., F.P. Manuscript drafting: J.O., M.H., A.V., F.P., A.B. Revising manuscript and final version approval: All authors.
Funding
This review is funded by the Australian Government Department of Defence (SON3352211). Open Access funding enabled and organized by CAUL and its Member Institutions.
Compliance with Ethical Standards
Conflict of Interest
The authors declare no competing interests.
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