Version July 2025
INTRODUCTION —
Military children and families frequently encounter parental or caregiver absence [1]. This absence is different from other parent-child separations because for a military child, a deployment can mean prolonged separation, fear for that parent's/caregiver's safety, and increased uncertainty in daily routine. In addition, when not deployed, each service member must be ready for deployment, and thus often required to move or be separated from their families due to training requirements.
This topic will provide an overview of deployment, its resultant family separation, and the developmental and behavioral implications for children and adolescents of parents/caregivers in the military.
EPIDEMIOLOGY —
Deployment is a way of life for military families [2]. In 2022, there were over 1.5 million active duty family members in the United States, of whom over 920,000 were children [3]. Among active duty military members, approximately 35 percent had children, 29 percent were married to a civilian with children, 2.5 percent had children and were married to another service member, and 4 percent were single with children [3]. Approximately 41 percent of children in military families were younger than 6 years, 33 percent were 6 to 11 years, 23 percent were 12 to 18 years, and four percent were 19 to 22 years of age [3].
TERMINOLOGY
●Deployment – A deployment is the short-term assignment of a military service member to a combat or noncombat zone. A deployment can last from 1 to 18 months, with typical deployments lasting 12 to 15 months [4,5]. Deployments can be planned or unexpected. They vary according to the service member's job description and branch of service.
●Active duty – Active duty refers to military members serving full time in their military capacity. The active duty military consists of the Army, Navy, Air Force, Marines, and Coast Guard. The Army has the largest active duty force (>485,000), followed by the Navy (>347,000), Air Force (>335,000), Marines (>181,000), and Coast Guard (>41,000) [6]. Active duty military members and their families usually live on or near a military base and have access to military support services [7].
●Selected Reserve – The Reserve (Army, Navy, Air Force, Marine Corps, and Coast Guard) and National Guard (Army and Air) are military organizations with members who generally perform a minimum of 39 days of military duty per year and who augment the active duty military when necessary. The reserve components are referred to collectively as "the Selected Reserve." The military branch (eg, Army, Navy, etc) of the Selected Reserve is similar to that of active duty services. There are approximately 770,000 United States selected reserve members across all military branches [8].
Selected Reserve members and their families often do not live on or near a military base. They may have less access to the military-specific supports and services available to their active duty counterparts [9-14]. Members of the Selected Reserve may experience stress-related long-term deployments disrupting their employment or changes in health care.
EFFECTS OF CAREGIVER DEPLOYMENT
Characteristics of modern versus historic deployment — The body of research demonstrating the impact of recent deployments on children in military families has grown substantially in recent decades. Deployments in support of military operations in Iraq and Afghanistan, as well as other regional hot spots, differ in fundamental ways from historical wartime deployments in the following ways [7,11,12,15]:
●Deployments can be extended and repeated; some units regularly deploy for three to six months every year.
●Advancements in medical care for wounded service members have resulted in higher survival but increased physical and psychological disability.
●The Selected Reserve is more commonly deployed; these families may have less access to support services.
●Media coverage is more intense.
●Technologic advances enable increased use of instantaneous communication.
●Extensive duration and expansion of ongoing military operations.
●Concerns regarding new future threats influence training practices.
Moreover, although the coronavirus disease 2019 (COVID-19) pandemic significantly impacted all families, some studies highlight its unique effects on military families, who experienced the stressors of a pandemic in addition to the challenges of deployment. Despite their resilience, military children had increased mental health concerns and behavioral changes during the pandemic, and pre-existing parental/caregiver stress and internalizing symptoms in youth were also found to be predictive of pandemic related stress [16,17].
Emotional cycle of deployment — The "emotional cycle of deployment" was developed as a model for understanding the psychosocial phases and transitions that military families go through as part of the deployment process (algorithm 1) [18]. It has been validated in both active and reserve families [19].
When a military member deploys, several adjustments happen at home: household responsibilities shift, schedules change, and new routines are established. These changes are dynamic depending upon the phase of deployment and can be categorized by five stages:
●Predeployment – The time of notification of deployment to the actual departure of the service member. Emotions range from psychological denial, intense preparation, and anticipation of leaving. Service members report that deployment preparation was stressful because of training requirements, personal preparation, and family preparation [20]. Preparation for deployment requires weeks of fast-paced work and time away from the family at local training sites before the actual deployment.
●Deployment – The first month after deployment. The early deployment phase can be marked by emotional distress as the family tries to regain balance and routine. Families frequently choose to relocate near loved ones for the duration of the deployment.
●Sustainment – The second month of deployment until one month before the service member's return. In adaptive families, a new routine occurs during this time, and available resources are employed to continue the "family business." Conversely, families that do not adapt are likely to experience emotional and behavioral distress.
●Redeployment – The month before the service member returns home. The family may feel anxious, excited, and apprehensive as they anticipate and prepare for the service member's return.
●Postdeployment – The reintegration of the service member into the family. There may be unanticipated stresses as the family roles and routines are redefined, especially if the service member has suffered physical or psychological injury. The postdeployment period may continue for months to years, and its impact compounds by additional military and life stressors.
This model may be generalized to nonmilitary families who experience frequent and prolonged separation from a parent/caregiver. Similarly to military families, they experience initial denial and intense preparation, followed by early distress, and then challenges of establishing new routines and maintaining stability. As the separation continues, some families succeed while others struggle and have ongoing distress. The anticipation and preparation for the parent's/caregiver's return bring a mix of excitement and anxiety, culminating in the complex process of reintegration and redefinition of roles and routines. Thus, prolonged separation and subsequent reintegration, whether due to military deployment or other circumstances, impose significant emotional and practical challenges and require resilience and adaptability from all family members [21].
Emotional and behavioral effects on children — Through the adversity of a deployment, children often demonstrate increased responsibility, independence, confidence, and participation in decision-making compared with their peers who have not experienced deployment [9,22]. However, children with deployed parents/caregivers and older military-connected youth are at increased risk for adverse behavioral and mental health effects [11,14,23-27].
Systematic reviews and meta-analyses of observational studies have identified poor adjustment (reported by parents/caregivers), problem behavior independent of age, substance use, and externalizing behaviors (eg, aggressive behavior) in children and adolescents of deployed parents/caregivers compared with those of nondeployed parents/caregivers [25,28,29]. Although few studies focus on young children, who comprise the majority of children with parents/caregivers in the military, observational studies suggest that caregiver deployment can be associated with externalizing (eg, aggressiveness, irritability) and internalizing problems (eg, crying, sadness, depression, anxiety) [28,30-38].
Studies assessing the impact of parent/caregiver deployment on school-aged children and adolescents during Operation Desert Storm (1990-1991) and subsequent operations in Afghanistan and Iraq have identified specific behavioral and psychological effects, which are mediated by risk factors such as more extended deployments and psychological distress of the at-home parent/caregiver. These include:
●Increased levels of behavior problems among three- to five-year-old children and risk for psychosocial morbidity (assessed with the Pediatric Symptom Checklist) among school-age children compared with same-aged peers without a deployed parent [11,39]
●Increased sadness, tearfulness, demands for attention, and psychological symptoms among school-aged children with deployed parents/caregivers [40,41]. These effects were mediated by the child's baseline mental health status and the at-home caregiver's mental health status, although caregiver deployment did not provoke pathologic levels of mental illness in otherwise healthy children [23,40-42].
●Increased anxiety and other psychological symptoms in the active duty and at-home parent/caregiver, which predict child adjustment problems [43]
●Reports of impaired well-being in adolescents and youth with deployed family members, including increased heart rates and perceived levels of stress [44]; feelings of uncertainty and loss [45]; low quality of life, depressed mood, and thoughts of suicide [46,47]. Mental health diagnoses (eg, acute stress reaction, depression, behavioral disorders) increased with increased duration (in months) of employment [48].
●Increased school-, family-, and peer-related difficulties as reported by teachers and other school personnel [49]and compared with national samples, which were exacerbated by more extended deployments and poorer mental health of at-home parents/caregivers [50].
●Increased risky sexual activity [51] and increased risk of substance use associated with increasing number of deployments [37,52,53].
Long-term health effects — Parental/caregiver deployments may impact health care utilization for children of various ages [49,54,55], as illustrated below:
●In a retrospective study of outpatient health care claims data for military service members' children (n = 642,397), overall health care visits decreased by 11 percent when a military parent was deployed. Nonetheless, mental and behavioral health visits increased by 11 percent, diagnosis of behavioral disorders increased by 19 percent, and diagnosis of stress-related disorders increased by 18 percent during deployment [54]. Parental deployment was also associated with an overall increase in prescription medications for children, particularly antidepressants and antianxiety agents [56].
●In a similar study of outpatient health care claims data for military service members' children younger than two years of age (n = 169,986), children of young, single, active duty parents were seen less frequently for acute and well-child care during their parent's deployment [57].
●In a population-based study of nearly 500,000 children aged three to eight years, those with deployed and combat injured parents/caregivers had increased medical visits for mental health diagnoses, injuries, and child maltreatment; visits for stress-related conditions increased by 67 percent [36].
Opportunities for preventive screening and intervention may be lost if military children are not being brought in for routine health care maintenance. The National Academy of Science encourages a collaborative model of care, incorporating medical and nonmedical resources to optimize resilience in families that face stressful or traumatic experiences [58]. (See 'Role of the primary care clinician' below.)
In addition, The Millennium Cohort Study, a 20-year report of longitudinal research findings, reported that more than 50 percent of service members have deployed, and that military related experiences adversely affect the long-term health of service members (eg, sleep quality and lack of healthy behaviors), which in turn affects their children [59].
Child maltreatment — Data from observational studies suggest that children in military families are at risk for maltreatment during deployment [36,60-62]. Reports of child neglect during deployment were most frequent among young married couples with young children.
School performance — Parental/caregiver deployment is associated with modest effects on school performance. In observational studies, longer deployments have been associated with more significant effects [63-65]. Family relocation with transitions to a new school system can also be difficult for children in military families, especially those with special health care needs [66,67]. Teachers and administrators report increased social maladaptive behavior problems during deployments [68].
RISK AND PROTECTIVE FACTORS —
As with other forms of stress, an individual child's response to deployment depends upon several factors, including the developmental age of the child and physical and emotional availability of the at-home caregiver, coping skills, and community resources [9].
Risk factors for experiencing greater difficulty during parental/caregiver deployment include:
●Younger age of the child [39,69] and parents [70]
●Increased burden of stress for the at-home caregiver [39,40,43,70,71]
●Lower socioeconomic status [41,70]
●Increased duration of deployment or multiple deployments [43,50]
●Preexisting emotional or behavioral problems [41]
●Lack of predictable return date of the service member [72]
●Special health care or educational needs (of the child) [73]
Children remain at risk after the service member returns. For example, children of combat veterans with posttraumatic stress disorder (PTSD) are at increased risk for depression and anxiety compared with children of noncombat veterans. Children of veterans with PTSD may develop symptoms of PTSD in response to the parent's/caregiver's PTSD-related behaviors [74].
Adverse effects can be mitigated by dependable and supportive adults who create safe environments to help children cope and recover from adverse events [7]. Factors associated with better coping and resilience in children and adolescents include [9,25,75-77]:
●Parents' preparation and readiness for deployment, including preparation of the child
●"Meaning making" of the situation (ie, constructing an account of an experience that helps to make sense of it)
●Supportive community, school, and social network
●Ability of the at-home caregiver to develop self-reliant coping skills
●Positive communication skills and during-deployment communication plans
●Flexibility regarding household and childcare responsibilities and roles
The overall impact of these factors is difficult to determine, and research is limited. Nonetheless, reports from The Deployment Life Study emphasize that military families are resilient [78]. Understanding why certain families are more resilient than others may help shape policy and programming for families who struggle with military life [27,78]. The Community Assessment of Military Perceived Support is a promising tool developed to help quantify and qualify the impact of support on military families [79].
ROLE OF THE PRIMARY CARE CLINICIAN —
Many children in military families receive their primary care from civilian clinicians [14,54]. It is important for these clinicians to have familiarity with military systems, culture, available benefits, and resources [9,14,80].
Clinicians can follow the "three R's" of care:
●Recognize military-connected families
●Respond when they are experiencing stressors
●Refer for additional support as indicated
When caring for children with parents/caregivers in the military, it is important for clinicians to [7,10,11,14,80-82]:
●Communicate openly and develop trust with the family.
●Elicit relevant history regarding how each family member is affected by preparing to deploy, deployment, and reintegration. Specifically, clinicians should ask whether the parent/caregiver has any concerns about the child's behavior related to the deployment cycle. (See 'Emotional cycle of deployment' above.)
●Assess the child's and family's stressors and coping skills and help family members recognize and build on their strengths. This includes understand the unique stressors and characteristics of military youth during deployment and reintegration (table 1) and acknowledging their personal service and sacrifice (independent of their parent's/caregiver's contributions).
In particular, clinicians should pay special attention to and support children and adolescents whose deployed parents have been seriously injured or killed in combat [83].
●Monitor children and adolescents for emotional and behavioral effects (eg, loss of developmental milestones, somatization, sleep disturbances, behavioral outbursts, poor school performance interpersonal relationships, anxiety, depression, suicidal ideation, substance use, early sexual activity) by using standardized screens such as the Pediatric Symptom Checklist (PSC) and the youth self-report PSC (Y-PSC) for adolescents 11 years and older (available through the American Academy of Pediatrics (AAP) Bright Futures).
●Provide anticipatory guidance for common reactions to the deployment cycle (eg, sadness, tearfulness, anxiety) and suggest strategies to prevent or manage stress, such as maintenance of daily routines and activities (table 2).
●Counsel against risky behaviors (eg, substance use/abuse, sexual activity).
●Counsel parents/caregivers about seeking regular medical care and mental health support for themselves and their child as needed.
●Provide referrals to mental health services (eg, depression, anxiety, help with coping skills, etc) and resources as indicated (table 3).
In randomized trials, targeted interventions to strengthen parent-child relationships, promote effective parenting practices, and increase family understanding in other challenging circumstances (eg, parental/caregiver depression or medical illness) have demonstrated positive outcomes in child development and psychological health [84-86]. However, few studies have evaluated civilian and military based intervention programs to support children and families during deployment and reintegration [87-89].
In a preliminary study, military children participating in Families OverComing Stress, a program designed to improve family psychological health by enhancing resiliency, had improved scores on psychological adjustment and coping compared with intake measures [87]. During the coronavirus disease 2019 (COVID-19) pandemic, the FOCUS intervention model demonstrated the feasibility and benefit of virtual home visits [89]. Additional studies are needed to determine evidence-based interventions specifically for children and adolescents with deployed parents/caregivers.
A review of the various interventions and their efficacy for military families is found at the Clearinghouse For Military Family Readiness provides a review of the various interventions and their efficacy for military families. Summaries of research reports on military children and families can be accessed through the The Military Reach Project.
RESOURCES —
Several resources are available for clinicians and families to learn more about issues facing children affected by parental/caregiver deployments. These include listings of services and written materials that are available for download, as per the table (table 3).
●The American Academy of Pediatrics provides resources for military families and professionals caring for military families; the Uniformed Services Section has published a clinical report on the health and mental health needs of children in United States military families [14].
●The Military Child Education Coalition is a nonprofit organization that identifies the challenges facing military children, increases awareness of these challenges in military and educational communities, and initiates and implements programs to meet these challenges.
●Military Kids Connect provides resources to prepare children for an upcoming move [90].
●Our Military Kids is a nonprofit organization that offers extracurricular grants and resources to children and adolescents of deployed National Guard, Reserve, or 9/11 Veterans.
●Military One Source (telephone: 1-800-342-9647) is provided by the Department of Defense at no cost to active duty, Guard, and Reserve Component members and their families. Highly qualified, master's degree-prepared consultants provide various services, including help with childcare, personal finances, and emotional support during deployments; relocation information; and other types of resources in particular circumstances. Services are available by phone, online, and face-to-face through private counseling sessions in the local community.
●The National Guard Family Services provides links to resources for National Guard families living away from military installations.
●The National Military Family Association Operation Purple Program provides free summer camps for children and adolescents experiencing parental deployment. These camps offer a support network of peers and help military children and adolescents develop coping skills to manage ups and downs.
●Sesame Street Workshop: Talk, listen, connect is a multimedia outreach program designed to help support military families with young children experiencing deployments, multiple deployments, combat-related injury, or death.
●The Tragedy Assistance Program for Survivors provides assistance to families who are grieving the death of a military service member.
●Zero to Three Coming Together Around Military Families is a program aimed at strengthening the resilience of young children and families experiencing deployment and separation.
●Blue Star Families is a nonprofit organization founded by military spouses that increases awareness and provides resources and family programming services to military families.
SUMMARY AND RECOMMENDATIONS
●Epidemiology – There are over 1.5 million active-duty family members in the United States, of whom over 920,000 are children. (See 'Epidemiology' above.)
●Terminology – Active duty refers to military members serving full time in their military capacity. A deployment is assignment of a military service member to a combat or noncombat zone and can be planned or unexpected. They vary according to the service member's job description and branch of service. (See 'Terminology' above.)
●Effects of caregiver deployment – Parental/caregiver deployment has five stages (algorithm 1) and can lead to increased emotional and behavioral problems, increased risk of child maltreatment, and effects on long-term health and school performance in young children and older youth. Deployment also affects long-term health in service members, which also impacts their children. (See 'Effects of caregiver deployment' above.)
●Risk and protective factors – Risk factors for experiencing greater difficulty during parental deployment include young age (of the child and parents/caregivers), lower socioeconomic status, preexisting emotional or behavioral problems, increased burden of stress for the at-home parent/caregiver, increased duration of or multiple deployments, and lack of a predictable date of return. Adverse effects may be mitigated by dependable and supportive adults who create safe environments to help children cope and recover from adverse events. (See 'Risk and protective factors' above.)
●Role of the primary care clinician – When caring for children with caregivers in the military, it is important for pediatric health care providers to communicate openly, elicit relevant history, assess for risk and protective factors (table 1), monitor for adverse effects, and provide anticipatory guidance and counseling (table 2). Specifically, clinicians can help family members recognize and build on their strengths, suggest strategies to prevent or manage stress, and offer referrals and resources (table 3), particularly when risk factors or adverse effects are identified. (See 'Role of the primary care clinician' above.)
ACKNOWLEDGMENT —
The UpToDate editorial staff acknowledges Molinda Chartrand, MD, who contributed to an earlier version of this topic review.
