The needs of infants and young children of parents in the military deserve special attention because the first years of life are pivotal in establishing trusting attachment relationships, which are based on the developmental expectation that parents will be reliably available and protective both physically and emotionally (Bowlby 1969/1982). For young children in military families, this expectation of parental availability and protectiveness can be strained and derailed by extended absences of mothers and/or fathers as the result of deployment abroad, recurrent separations and reunions resulting from repeated deployments, parents struggling with the emotional sequelae of their war experiences, and parental injury and death. In addition, the young child must cope with the caregiving parent’s preoccupation with the deployed military parent’s safety and the challenges of single-handedly managing a household. The field of developmental psychopathology provides a useful multitheoretical approach to understand and address the impact of these experiences on the child’s functioning by recommending a developmental and contextual framework that includes the transactional influences among the family’s cultural values and practices, socioeconomic circumstances, and emotional functioning as well as the quality of the parent(s)–child relationships and the child’s constitutional and developmental characteristics (Cichetti and Lynch 1993; Sameroff and Fiese 2000). This article focuses on three specific components of this conceptual model: the characteristics of mental health in infancy and early childhood, the developmentally expectable early anxieties that all children experience in the first years of life across cultures and circumstances, and the ways in which these normative anxieties are exacerbated by the events of deployment, reunification, and associated circumstances that are specifically relevant to young children in military families. The article also describes interventions that may be helpful in supporting military families and their children with the specific challenges they face.

A Contextual-Developmental Framework for Understanding Young Children in the Military

Parenting young children is a frequent component of service members’ family life. Figures assembled by the Zero to Three: Coming Together Around Military Families (CTAMF) project reveal that 41 % of active duty service members and 24.7 % of members in selected reserve have children in the birth-five age range (Williams and Fraga 2011). These figures highlight the centrality of young children in the lives of many military families and frame the service members’ well-being in the context of its implications for their children well-being. A large-scale survey of previously deployed veterans referred for mental health evaluation documents the significant presence of emotional difficulties among previously deployed service members, with 14 % meeting depression criteria, 14 % meeting post-traumatic stress disorder criteria, and 75 % meeting both criteria (Schell and Marshall 2008). Although these figures refer to service members seeking mental health services, a comparable rate of PTSD was found in a sample of soldiers who were screened 1 year post-deployment, with 16.6 % met the criteria for PTSD (Hoge et al. 2007). These figures are markedly higher than those for civilian populations, where the rate of PTSD is about 3.5 % and the rate of depression is 6.7 % (Williams and Mulrooney 2012). The impact of these psychiatric conditions is manifested in the high rate of suicide among military personnel even with the withdrawal from Iraq and the pullback in Afghanistan, with a steep climb over the last decade from 10.3 per 100,000 troops in 2002 (well below the comparable civilian rate) to a current rate of above 18 per 100,000 (nearly the same as the civilian rate) (The New York Times, May 16, The New York Time (Thursday, May 16 2013) and a doubling of the suicide rate between June 2012 and July 2012 (Burns 2012). For each service member affected, his or her children, partners, and spouses are affected as well because mental health problems and parental death by combat or suicide create an atmosphere of sadness, grief, tension, and fear that is absorbed to a lesser or greater degree by all members of the family. In addition, family stress associated with the soldier-parent deployment has concrete ramifications for the child’s safety. Child maltreatment was shown to significantly increase when the military parent is deployed in a combat-related mission (Gibbs et al. 2007; Rentz et al. 2007) as well as when the deployed parent returns home (Rentz et al. 2007). These figures confirm research findings from the civilian population that the parents’ stress level and emotional functioning are powerful predictors of the child’s safety as well as their emotional health (see Chu and Lieberman 2010 for a review).

At the same time, it is important to remember that military families partake of a culture with solid, sustaining values that include duty, courage, fortitude in facing adversity, optimism, love and loyalty to country, and community support (Blaisure et al. 2012; Cozza and Lieberman 2007). The strengths of its families and communities are as essential a component of the military culture as the stresses of everyday life, the trauma of injury, and the grief of war-related casualties. These protective characteristics should be incorporated in assessing the needs of young children in military families because relational and community supports may moderate the impact of adversity on development and mental health and are important component of intervention plans (Boyce et al. 1998; Lieberman and Van Horn 2008).

Defining Mental Health in Infancy and Early Childhood

Infant mental health has been described as “the young child’s capacity to experience, regulate, and express emotions, form close and secure relationships, and explore the environment and learn. All these capacities will be best accomplished within the context of a supportive caregiving environment that includes family, community, and cultural expectations for young children. Developing these capacities is synonymous with healthy social and emotional development” (Zero to Three 2001). This definition, which has gained widespread acceptance, emphasizes the centrality of relational and social contexts to support young children’s healthy development and is consistent with a multitheoretical biopsychosocial perspective such as the ecological–transactional model that informs the field of developmental psychopathology (Cichetti and Lynch 1993).

The experience of stress is an inherent ingredient of the human condition that begins at birth and poses a challenge to the infant’s capacity to tolerate dysregulation, conflict, and frustration while maintaining developmental momentum. An expanded definition of infant mental health that includes the child’s capacity to cope with developmentally expectable physical, emotional, and relational stresses would describe it as “the capacity to experience, regulate, and express emotions and to recover from dysregulation; form close and secure relationships and repair interpersonal conflict; and explore the environment and learn while tolerating and managing frustration.” The young child learns to negotiate and cope with expectable environmental stresses when the family is functioning reasonably well in the context of a sufficiently safe and predictable environment. When social resources and family coping are burdened by adversity and trauma, the child’s healthy developmental course is also affected. Assessing the magnitude, developmental appropriateness, and chronicity of stressors and the availability of protective factors is essential to understand individual children’s social and emotional health in the context of their relationships and their broader environment.

The magnitude and tolerability of environmental stress can be conceptualized along a stress–trauma continuum that ranges from the normative strains associated with everyday life to the extreme burdens on physiological and emotional balance resulting from catastrophic experiences (Lieberman and Van Horn 2008). Developmentally expectable, mild-to-moderate stress enables a child to develop and practice strategies to tolerate displeasure, fear, anger, and pain that are essential to recover from emotional dysregulation, repair inter-personal conflict, and tolerate and manage frustration in the course of exploration and learning. Intense, pervasive, and chronic stress can result in an allostatic load (wear and tear on the body) that is costly to the development of brain circuits and compromises physical and mental health in the long term through frequent and repeated stress responses to multiple novel stressors; failure to habituate to repeated stressors of the same kind; inability to turn off stress responses in a timely manner; and hyperactivity of other systems to compensate for inadequate stress responses (McEwen and Stellar 1993; Rifkin-Graboi et al. 2009). At the most extreme end of the continuum, traumatic stress consists of the response to an event that threatens the life or physical or emotional integrity of the child or others and leads to a collapse in the child’s age-appropriate coping strategies (Pynoos et al. 1999; Zero to Three 2005). For young children, witnessing injury to the attachment figure constitutes a traumatic event is associated with more symptoms of traumatic stress than injury to the self (Scheeringa and Zeanah 1995). Traumatic experiences have a far-reaching effect in changing expectations of danger, safety, injury, loss, and protection. In the early years, trauma exposure shatters the child’s trust in the parent’s capacity and willingness to protect, creating an enduring sense of helplessness and resulting in persistent preoccupation with existential questions about the child’s intrinsic lovability and worth (Freud 1926/1959; Pynoos et al. 1999). The immature understanding of cause–effect relations in infancy and early childhood results in a self-referential logic that Piaget described as “egocentrism” (Piaget 1959). When the parent is emotionally unavailable, punitive, injured, or absent, the young child’s immediate formulation involves the conviction that the child is responsible for this situation. Advances in the understanding of very young children’s capacity to develop a “theory of mind” that enable them to understand situations from the perspective of another have raised questions about the continuing relevance of Piaget’s original formulation of young children’s egocentrism (Thompson 2008). For example, toddlers as young as 14–18 months can demonstrate that they understand and respond to the preferences of others even when those preferences are very different from their own (Repacholi and Gopnik 1997). One explanation for the observed discrepancy between young children’s egocentrism and capacity to hold a theory of mind about others is that young children, not unlike adults, are optimally able to understand the perspective of others when their own needs are not aroused. Strong emotion clouds reason and empathy across the age range, and children resemble adults in their tendency to resort to self-referential thinking when they feel unsafe, worried, angry, or sad.

Developmentally Expectable Anxieties

These anxieties counterbalance the child’s momentum toward competence and pleasure in the body, in relationships, and in exploration and learning, emerging in stage-like fashion in the first 5 years of life and remaining an integral component of the human experience. The field of early childhood mental health owes much to the early interest of psychoanalytic theory in the anxieties of the first 5 years of life. Freud (1926/1959) developed a model of anxiety that first gave name to these primal anxieties, labeling them fear of abandonment, loss of love, castration, and superego condemnation. Subsequent studies of infants and young children by developmental researchers and clinicians from a variety of theoretical orientations make clear that these anxieties are easily amenable to infant observation even in the absence of a psychoanalytic framework. Fear of abandonment is now widely known as separation anxiety, a reliably observed developmental milestone with a typical onset between 6 and 9 months and a gradual decline between 24 and 36 months (Crowell and Waters 1990). Young children’s fear of body damage is now understood as not being narrowly focused on the genitals. Rather, fear of body damage is an adaptive byproduct of young children’s incipient understanding of the dangers posed by their increasing mobility and sense of agency in the world in tandem with their immature mastery of gross and fine motor skills, so that being hurt by falling, bumping into things, getting cut, or receiving a burn mobilize self-protective responses to fend off perceived threat to bodily integrity. Within this perspective, two-year-olds’ vehement protests at having their nails or hair cut are understood not in the classic psychoanalytic perspective of castration anxiety but as a straightforward manifestation of young children’s difficulty grasping that nails and hair grow again and their being cut off does not constitute injury to the body. The psychoanalytic concepts of anxiety over loss of love and superego condemnation are now understood more broadly as the results of advances in intersubjective attunement and moral development. The child’s evolving sense of self and increased sense of reciprocity in interpersonal relationships go hand in hand with an increased fear of disapproval and fear of doing wrong and their attendant emotions of self-blame, guilt, and shame (Kagan 1984; Stern 1985). These internal states are anchored in the efforts at meaning-making of 2–5-year olds, who tend to believe that thoughts are equivalent to actions and that others can detect their thoughts; learn to read accurately the facial expressions of others; become increasingly aware of social standards; and respond with distress when they are unable to meet their own expectations or the expectations of others (Gopnik et al. 1999).

Separation anxiety is the best documented of young children’s normative fears. The manifestations of separation anxiety in response to brief, normative separations are well known and consist largely of the proximity-seeking and contact-maintaining behaviors that characterize attachment behavior in the first 3 years of life: crying when the child anticipates separation or after the parent leaves and clinging, reaching toward, following, and searching for the parent. When the parent has been gone for long periods of time, the classical sequence of protest, despair, and detachment outlined by Robertson and Bowlby (1952) on the basis of careful filmed documentation of children remains valid. Protest is the universal first response of young children to separation from the parent: crying, reaching toward, following, and searching for the parent. As the separation lengthens, the child may become uncharacteristically irritable, shaking the crib, throwing himself about, engaging in frequent bouts of intense crying or tantrums, refusing efforts to console him, and responding angrily to minor frustrations that previously were managed with ease. Search behavior increases: the child may insist on holding on to reminders of the parent (a piece of clothing, a photograph) and responds eagerly to any stimulus that may signal the parent’s return, such as the doorbell ringing or a door opening. Children who have acquired language repeatedly call for the parent or ask when the parent will return.

The second phase of separation anxiety, labeled despair, has its onset when the child realizes that efforts to bring the parent back have proven futile. This phase is characterized by a marked decrease in the energetic search for the parent, which is replaced by withdrawal, reduced activity, a serious or sad facial expression, and intermittent bouts of low-keyed crying. The child seems lethargic, despondent, and often responds passively to the caregiving of others, although interest in the surroundings gradually increases and the child eventually seems to recover. The continuing distress over separation becomes evident particularly in sleep disturbances and, paradoxically, when the parent returns. Reunion behavior after an emotionally difficult separation shows the child’s new ambivalence toward the parent, who often is initially rebuffed and avoided, sometimes for a day or more.

Detachment, the third phase of the separation response, may emerge when the separation continues for weeks or longer. The child may appear fully engaged with surrounding people and objects, although there often a change in the child’s demeanor that may take the form of increased fearfulness and timidity or a new controllingness that may be understood as an effort to master the feelings of helplessness and loss of love engendered by the separation. Some children show a preference for playing with objects rather than people. The distinguishing characteristic of detachment, however, occurs during reunion. The child seems not to recognize the parent, staring blankly and not showing any feelings. This is not a memory lapse because the child recognizes and relates to other people, places, or objects that s/he has not seen for similar periods of time. The lack of recognition can best be understood as a self-protective response that creates emotional distance from the pain caused by the parent’s absence. It is important to note that detachment is most often observed in young children who have endured frequent changes of unfamiliar caregivers, and is seldom observed in children who continue to have access to the other parent or another familiar and loved caregiver and who continue to have a predictable daily routine during the separation.

For young children whose parent is deployed, separation anxiety becomes a major risk to emotional well-being. There are no studies documenting whether or how the phases of protest, despair, and detachment are manifested in young children with parents participating in operation enduring freedom (OEF) and operation Iraqi freedom (OIF), which had an unprecedented high number and frequency of unit deployments (high operational tempo). It is likely that different children will respond differently to the repeated separations and reunions depending on their constitutional proclivities to distress versus resilience, whether the deployed parent has been the primary attachment figure, the impact of the repeated deployment on the parents’ relationship and family cohesiveness, the predictability of daily routines in the course of separations and reunions, and the quality of environmental supports. Some children may adjust to the repeated separations and reunions as a predictable aspect of their family life; others might become sensitized to the repeated separations and show increased generalized anxiety as the number of separations increases. Behaviors associated with the phases of protest and despair are the most likely to be observed by the caregiving parent, but detachment may occur as the separation becomes longer. Interventions designed to help the child maintain an ongoing awareness of the parent are very important to nurture the presence of the parent in the child’s mind. In addition, much care should be given to maximize the stability and predictability of surrogate caregiving during the deployed parent’s absence in order to prevent the onset of detachment.

Fear of losing the parent’s love or approval, which emerges in the second year, can be difficult to identify because toddlers do not as a rule have the linguistic tools to express such a complex emotion and because adults seldom take the time and effort to explore the inner life of very young children. The most direct examples come from children who can use language, such as the 4-year-old who told her mother, “Tell daddy I will eat my soup, tell him to come back” or the 3-year-old who whispered, “I am sorry I was bad.” Two-year-olds can be just as expressive without words, as when a toddler stopped biting his nails and visibly relaxed when his father said, “I am not mad at you, I was yelling at someone on the phone who did something wrong.” The fear of “being bad” follows closely the fear of losing love, as when a 5-year-old said sadly to his aunt, “I am so sad that my daddy left. I try to be a good boy.” Fear of body damage can become connected with fear of losing love and fear of being bad. A 2-year-old who had a painful ear infection fought off the doctor that was trying to examine his ear. A year later, when his mother informed the child that they were going to the doctor, the boy screamed, “Don’t, don’t, I’ll be good,” while covering his ears. He had interpreted the painful examination as his mother’s punishment for a transgression.

All normally developing children experience these fears/anxieties even when their environment is safe and supportive, although they may express distress with greater or lesser intensity depending on their constitutional makeup and the fluctuations of their everyday routines. External stressors reinforce these anxieties while protective responses from trusted adults moderate them. Understanding the possible developmentally based meanings that young children attribute to external events—for example, thinking that the mother is displeased with them when she looks sad, or worrying that the father left because of the child’s misbehavior—can help develop more effective interventions for young children in military families as they face major changes in their relationships with their parents and other family members resulting from the demands of military life.

Impact of Stress and Trauma on Parental Caregiving

The quality of the parent–child relationship and the quality of family relationships are important components of the ecological–transactional model of developmental psychopathology (Cichetti and Lynch 1993). There is extensive evidence that the quality of the parent–child relationship may mediate and moderate the association between child exposure to stressful and traumatic events and child functioning. These associations have been reported for normative samples (Sroufe et al. 2005) as well as with maltreated infants (Gunnar and Cheatham 2003), preschoolers exposed to community violence (Linares et al. 2001), preschoolers who witnessed domestic violence against their mothers (Lieberman et al. 2005), Israeli preschoolers whose homes were damaged by SCUD missiles during the first Gulf war (Laor et al. 2001), and infants and young children living near the Gaza Strip who were exposed to daily missiles (Feldman and Vengrober 2011). A similar conclusion was reached regarding children from military families in a 2010 report to the Senate and House Committees on Armed Services, which stated that the non-deployed parent/caregiver’s psychological health is positively associated with children’s successful coping with deployment-related stress.

Numerous studies document that the parent–child relationship, although fundamentally important in shaping the child’s social and emotional functioning, does not exist in a vacuum and is best understood in the context of how the family functions as a whole. Children exposed to marital discord, for example, are vulnerable to an array of behavioral, emotional, and coping difficulties (Cummings and Davies 2002), whereas children in cohesive families show more security and better psychological adjustment than those in disengaged or enmeshed families (Davies et al. 2004).

These findings have important implications for young children in military families.

A study of service members who were referred for mental health evaluation by their primary health provider after returning home from deployment found that 40 % reported feeling like a guest in the household; 37 % were unsure of their role in the family; 25 % perceived their children as not warm or afraid; 25 % said that their spouse or partner was afraid, and 54 % described themselves as “shouting, pushing, shoving” a family member (Sayers et al. 2009). These findings illustrate the intricate associations between emotional well-being and perceived quality of family relationships, which is particularly evident among young children because they are most dependent on their parents for physical care and emotional support. Although there is a scarcity of research on infants, toddlers, and preschoolers in military families, a study by Chartrand et al. (2008) involving children ranging in age from 1 1/2 to 5 years enrolled in child care centers in a Marine base found that children over age 3 who had a deployed parent showed higher behavioral problems than their age-mates without a deployed parent. Children younger than age 3 were not reported to manifest increased difficulties when their parents were deployed an unexpected finding that is not consistent with other studies and remains to be elucidated.

The dearth of research involving young children in the military led Zero to Three (2012) to launch an initiative titled Research and Resilience designed to identify and address the research gaps. The first step consisted of convening two 2-day meetings involving 13 experts in early childhood development, research design and implementation, military community services, and military trauma to develop research questions; share current or recent studies; discuss methodologies; address ethical issues associated with conducting research involving children in the military; explore cultural issues related to research with military families; and share resources to facilitate research. One major contribution to date of this initiative is the identification of key issues affecting young children in military families and the delineation of a comprehensive list of stressors faced by these children and their families (Zero to Three 2012, pp. 7–8; Williams and Mulrooney 2012). Attention to these issues, itemized below, should be an integral component of efforts to help young children and their families.

  • Range of stressors: These events include repeated and extended deployments; additional separations as the result of temporary assignments; deployment-related physical injury, psychological problems, or death; increased operational tempo; relocations; and military mobilization to meet national and international disasters.

  • Multiple and varied transitions: These transitions include moving from military to civilian status and from reserve to active duty status, which involve changes in resources available for the child and the family.

  • Unique National Guard and Reserve challenges, involving less access to resources and support due to distance from military installations and resulting changes in health insurance, housing, employment, and other concrete supports due to changes in activation status.

  • Deployment-related injury and its consequences for changes in self-perception, role in the family, and parenting role.

  • Family roles and structure in relation to deployment, such as grandparents stepping in as caregivers; dual military couples reconciling their respective deployment schedules; and stresses of co-parenting.

  • Financial strain, including high unemployment rates and their implications for families considering transitioning out of service and the erosion of federal funding and government work.

  • Single parents and the unique stresses of developing a deployment care plan in these circumstances.

  • Maternal depression, which has been reported informally for both female spouses and service members, and may complicate both family dynamics and quality of caregiving.

  • Developmental and relational effects on young children both directly and as the result of the secondary adversities associated with these stresses.

The section below outlines the different stresses experienced by the child as the family goes through the unfolding of the different phases of the military parent’s deployment, from preparing for the parent’s absence to his/her return.

When a Parent Goes to War

Pre-deployment Phase

Anticipating deployment is a period of stress and uncertainty, which affects the young child and each of the parents in different ways for the service member must prepare psychologically and physically for the enormous challenges and the danger ahead, while the non-deployed parent faces the very different challenges of preparing to manage the household and the children alone while worrying about the deployed spouse’s safety. Practical matters and the hassles of everyday may take priority in the weeks and days preceding the deployment, draining the adults’ energy away from communicating about feelings, and preparing emotionally for the impending separation. Childcare arrangements may change, with parents resorting to more frequent use of surrogate caregiving to give themselves the time and focus of attention they need to prepare for the deployment. In general, the parents may become so absorbed in their own immediate needs that they may overlook their young children’s efforts to understand what is happening. Infants, toddlers, and preschoolers, who closely monitor their parents’ emotional state and are adept at reading facial expressions and interpreting tones of voice, can be left without a reliable translator for their observations, without knowing what to feel about the changed atmosphere in the home. In these circumstances, babies may feel their parents’ stress at the bodily level, and respond with increased irritability, difficulty with transitions, more frequent bouts of crying, and night waking. Toddlers and preschoolers may become more defiant and easily frustrated; they may alternate between resorting to younger patterns of behavior and becoming controlling and demanding. Parents, in turn, may respond with anger or impatience while also engaging in self-blame or mutual blame for not being able to be emotionally and physically available to their child at a time of heightened need because of the many demands on their time and energy.

Helping the child to anticipate separation and to say good-bye is the first order of business in preparing the child for a parent’s deployment. Carving time to be together as a family helps to create memories that will serve as an antidote to despair and detachment after the parent’s departure. The non-deployed parent can remind the child of those moments at times of sadness to build a hopeful expectation for their happening again after the service member returns. The moments of quiet togetherness offer an opportunity to tell the child what will happen using words that the young child can understand: “Daddy has to go far away because it is part of my job.”; “Mommy will take care of you until I come back”; “I love you and I will miss you”; “I will think of you always.” These words help not only the child but the parent as well. The taboo of silence is broken, and the parents may find that internal states become more manageable when feelings are expressed simply and directly. Describing the impending separation in the form of a story that includes what each family member will do until the deployed parent returns and includes a reunion scene can help children form pictures in their minds that give concrete expression to the departure and give them tools to anticipate and cope with it. Bridges of connection can be built by making drawings, creating a family movie, taking photos of happy moments, and recording stories and songs that can be used at nighttime or when the child is particularly sad to bring the deployed parent closer. Very helpful materials are available to help parents support their young children during this period, such as children’s books and booklets for parents published by Zero to Three (zerotothree.org).

Some adults may argue that these preparatory steps will only hasten the child’s sadness and that the child is too young to notice the preparations for the deployment. Young children always notice, although they may dutifully hide what they observe in order to comply with the adults’ perceived wishes, in what Bowlby (1988) called, “knowing what you are not supposed to know and feeling what you are not supposed to feel.” In clinical work with young children, the act of telling a difficult truth is the first step toward healing: children often respond with a noticeable increase in energy and connectedness and decrease in symptoms of aggression and anxiety when they hear a trusted adult tell them that what they know or suspect is indeed real (Lieberman and Van Horn 2008).

The First Month Apart

The weeks following the deployed parent’s departure involve a roller-coaster of emotions for each family member. Sadness, worry, and irritability may alternate with extreme fatigue, emotional numbness, and a wish not to think or feel. Everyone in the family may have difficulty sleeping. Night waking is one of the most frequent manifestations of distress among young children, whose fears are activated by the combination of darkness and being alone. Separation anxiety is heightened for young children, who engage in a mental equation: “If my daddy left, will my mommy leave me too?” Even when the reason for the deployment has been clearly stated to the child on many occasions, the fear that the parent’s absence equates losing the parent’s love can become a secret concern for the child. A study of 57 Army families with children under 4 years of age showed that problem behaviors increased after the parent’s deployment but disappeared within 3 weeks; however, 31 % of children continued to experience difficulties (Barker and Berry 2009). Making use of the materials prepared during pre-deployment—a video or DVD of parent and child together, an audiotape of the parent singing to the child, telling stories or reading a favorite book—can be a source of great comfort to the child. A father who was deployed when his son was 8 months old left behind several unwashed T-shirts that his wife put on the child’s crib. The father continued sending home worn T-shirts that his wife exchanged for freshly laundered ones while continuing to give the worn ones to the child and showing the child videos and photos of his father. When the father returned 10 months later, the child instantly recognized him and reached out to him. Loving links can work wonders in bridging the painful separations of deployment.

Deployment

The acute distress of the initial weeks becomes chronic stress as the deployment continues. A study of medical records of more than 640,000 children aged 3–8 of active duty personnel showed an 11 % increase in outpatient medical visits during a parent’s deployment, with an 18 % increase in diagnoses of behavioral disorders and a 19 % increase in diagnoses of stress disorders while the parent was deployed (Gorman et al. 2010). The child’s heightened behavioral and emotional difficulties can represent an added stress to vulnerable caregiving parents who are struggling simultaneously with their own responses and with the increased demands of their child. The typical separation responses, which often include refusing the ministrations of someone other than the absent parent, may be taken as a personal rejection by the remaining parent, who may feel that s/he is not “measuring up.” The finding that child maltreatment rates increase during deployment is a sobering indication of the potential risk to the child’s safety as well as emotional well-being of this period (Gibbs et al. 2007; Rentz et al. 2007).

These considerations highlight the importance of supporting children by supporting their families. Programs such as FOCUS (families overcoming under stress) bring families together with the goal of enhancing emotional regulation (identifying and understanding emotions, communication, problem solving, goal setting, and coping with reminders of deployment and combat stress) through talking, playing, and finding ways of making the long period of deployment more manageable through concrete tools such as using calendars to divide time into concrete portions that are more emotionally manageable than one amorphous and unmeasurable chunk (Lester et al. 2011). One example described by Lester (2012, p. 70) involves a little boy who liked to wear his deployed father’s boot. The family made an outline of the father’s boots and a map that showed both their home and Iraq. Each month the little boy put down the outline of the father’s boots on the path linking Iraq with home, as a concrete way of grasping that time was moving slowly but steadily toward the father’s return. Bedtime rituals are also a helpful way of connecting with the absent parent. The mother of a 2-year-old girl changed the lyrics of the nightly lullaby she sang to her daughter to include a reference to the father's love for his daughter. The mother of a 3-year-old him that his deployed dad was going to sleep at the same time as the child did, and the mother and child would say “nighty-night” to the father. The father of a 4-year-old enacted a nighttime ritual where the child and the father “told” the deployed mother what they had done during the day.

These symbolic ways of connecting are important adjuncts to modern technology in keeping an emotional link between the deployed parent and the child. Although long-distance communication boosts the sense of proximity, many obstacles may interfere, ranging from bad connections to unexpected developments in either the war front or the home front that derail with plans to speak. Creating symbolic forms of nurturing the loving bond with the parent enables the child to develop internal resources and sturdy coping mechanisms to manage sadness and fear.

Preschoolers are learning about death as a normative stage of their development, and their proximity to talk of war, injury, and death heightens their concern about this topic. Children aged 4 and 5 with a deployed parent often ask, “Will my (mom or dad) die”? The caregiving parent is then confronted with the dilemma of how to answer. Many parents find it helpful to describe all the measures that the deployed parent and the military community are taking to keep the parent safe. For young children, these descriptions are the equivalent of a reassuring answer that diminishes anxiety.

The importance of continuity and predictability of daily routines and enforcing behavioral expectations cannot be overstated. The caregiving parents may be too fatigued or feel so much sorrow for the child’s distress that they may relax their expectations for age-appropriate social behavior. This is a disservice for the child, who must receive continuous guidance toward socialization to maintain a healthy developmental course. Cultivating sources of practical and emotional support, both by maintaining connections with familiar resources and by seeking satisfying new activities, is a core component of maintaining emotional balance during the deployment of a family member.

Reunification

Coming home from deployment is a joyful event, eagerly anticipated by all the members of the family. Reintegration, however, poses unique stresses as the returning veteran makes the demanding transition from combat to civilian life. Efforts to occupy the customary family role can be fraught with upheavals and misunderstandings as the spouses reacquaint themselves with each other and re-negotiate their roles vis-à-vis the other and as parents. At the same time, the children must learn to know their returning parent in new and sometimes unexpected ways, and the returning parent must update his or her customary perceptions of the children and catch up with the growth and development that took place during the deployment. For young children, the moment of reunion may become a source of confusion and disappointment if detachment has taken place and the child does not seem to recognize the parent, particularly because the burdens of war might have changed the parent’s appearance. The self-referential logic of young children predisposes them to attribute to their own thoughts or behaviors the reason for the parent’s moods or conflict between the parents. Barker and Berry (2009) found that 31 % of children under 4 reported difficulties upon reunion, such as not wanting comfort from the returning parent, not wanting the returning parent to leave the home, or preferring the other parent or caregiver instead of the returning parent.

Parents need encouragement to be patient with themselves, each other, and their children by being reminded of how young children think. Explaining young children’s sometimes puzzling behavior as manifestations of fear of losing love, self-protection against fear of abandonment, and anger at the parent for having left can help build or restore the parent’s perspective on the child’s inner experience.

Parental Injury

Combat-related injuries, both physical and psychological, greatly complicate the reunification process for all involved, and young children are no exception. At the most visceral level, the parent’s injury evokes and exacerbates the young child’s normative anxiety about body damage. The parent’s injury gives concrete manifestation to the child’s fear so that it moves from the realm of imagination to the realm of reality. No large-scale studies exist showing how young children adapt to combat-related parental injury, but the ecological-transactional model (Cichetti and Lynch 1993) is supported by findings that children closely monitor their parents’ response and are greatly influenced by how they perceive their parents’ reactions, moods, and interactions and by the course of recovery (Cozza et al. 2005). The trajectory of recovery can be extremely complex due to a variety of factors, including the type and severity of the injury; the types of medical treatment required, which can range from short-term interventions to months or years of rehabilitation and reconstructive work; logistical concerns, including proximity to medical facilities; financial considerations; family conflict versus consensus about medical care decisions; availability of appropriate surrogate care for the children; and type and quality of family support (Cozza and Guimond 2011). A very high proportion (about 67 %) of young children with a combat-injured parent live away from their parents during the parent’s hospitalization, leading to significant family disruptions and separation from the parents that are associated with parental reports of moderate to severe emotional difficulties in the child (Cozza et al. 2010). There are interventions that can help to reduce the child’s stress responses to the parent’s injury and related adversities, such as Psychological First Aid (Brymer et al. 2006), an evidence-based approach to reduce symptoms of stress and assist in healthy recovery after a traumatic event. Parental guidance and consultation in the hospital setting can be helpful in providing guidelines for parental decisions about the complexities of telling the child about the parent’s injury and preparing the child for visits to the injured or maimed parent (Cozza and Feerick 2011).

The ambiguity of what the future might bring poses an emotional burden both for the injured parent and the caregiver as they strive to answer young children’s questions. In the face of uncertainty and worry, young children may regress in developmental milestones, become afraid they will also become injured, and engage in magical thinking (“If I am good my daddy will get better”). When parents can explain in simple terms what the physical injury consists of and the implications of the injury for daily activities, children will be appropriately sad and disappointed at the loss of cherished activities with the parent, but they will be less likely to engage in unrealistic or self-blaming fantasies about their role (“Daddy got hurt because I hurt him too hard when we wrestled”).

Protective factors for children whose deployed parent was injured include the previously established patterns of family routines and the supportive availability of family and friends (Cozza and Guimond 2011). Models of family support are also available for young children and their families. Zero to Three has established an interdisciplinary, collaborative initiative named CTAMF to address the needs of babies and toddlers affected by deployment-related stress and trauma. The initiative includes materials to help the parent engage the child in story telling, such as posters, flyers, magnets, camera-ready articles, and children’s books, as well as a kit box of different materials that can be used by home visitors, therapists, pediatricians, and other service providers; and a professional guide offering a description of the materials and suggestions for their use (www.zerotothree.org). To address parental injury and death, the scope of the work was expanded to include trainings of service providers through a comprehensive training set of modules labeled Duty to Care: Supporting our Babies and Toddlers During Challenging Times. The content of the trainings is designed to meet the needs of a multidisciplinary audience with a range of roles and levels of knowledge about early childhood development. An additional training program, Honoring the Healer, was developed in response to the impact on caregivers of exposure to their clients’ traumatic experiences (Williams and Fraga 2011).

Parental Death

The impact of the parent’s death on a young child is so lastingly life-altering that the first response is often to recoil from a full awareness of the enormous tragedy that it entails. As Furman (1974) stated, “There are no peaceful deaths for parents of young children. Whenever we merely say, ‘His parent died’, we leave out the inevitable horror and tragedy that such a death entails” (p. 102). Losing a parent to death is a catastrophic violation of the young child’s expectation that the parent will be reliably available as a source of help and protection, causing major injury to the integrity and continuity of the child’s sense of self (Bowlby 1980; Pynoos et al. 1999).

Young children encounter an even greater challenge than older children in processing the meaning of the parent’s death because they do not yet grasp the finality of death and because the efforts to understand why the parent died are inextricably linked with questions about the child’s role in this terrible occurrence. Whether or not the child is able to articulate them, the fears of loss, losing love, body damage, and being bad take center stage, simultaneously or in quick succession, as the child grapples with enormous questions: “Will other people I love leave me too?”; “Will I die also?”; “Who will take care of me?”; “Did I cause the death?” For many children, the longing for the parent is manifested in the wish for a reunion: “I want to die too so I can be with (daddy or mommy)” (Lieberman et al. 2003).

Manifestations of grief and mourning in young children closely resemble the stages of protest, despair, and detachment that follow prolonged separation. Whereas separation always holds the expectation of an eventual reunion, young children must be taught from the beginning that the parent’s death means that he or she can never come back. Explaining to young children, the finality of death is perhaps the most difficult task facing a loving adult. When a child, after many explanations about the parent’s death, continues to speaks in ways that show a continued anticipation of reunion, such as “I will show my daddy how I learned to swim,” it can feel cruel to respond, “You wish so much that your daddy were still alive; it is so sad to remember that he died.” But to encourage a hopeful expectation of the parent’s return subjects, the child to an endless wait and repeated bouts of anticipation followed by disappointment that can lead the child to mistrust adults’ reliability as informers and as sources of trust. This is illustrated by a 4-year-old boy who asked his mother, “Will my daddy come to my birthday party?” and was told,

“Maybe he will” because the mother could not tolerate telling him that his father’s death meant that he could not come. At the end of the party, after all the guests left, the child screamed at his mother: “He did not come! You lied to me!”, Building, moment by moment, a concrete acceptance of death helps to protect the child from creating an imaginary world where the child will find temporary but illusory refuge instead of being helped to tolerate a painful reality through loving support. Although the wish to avoid thinking about the parent’s death is understandable, a study involving older children whose parents have died showed that avoidance is associated with functional impairment (Melhem et al. 2007). In our clinical experience with young children, we have found significant symptom improvement when the child is helped to understand and process the finality of the parent’s death, often using dolls to demonstrate the concrete ways in which the body stops moving and staging a funeral to help the child visualize that the parent’s body is buried in the ground. The family’s spiritual and religious beliefs need to be incorporated into the narrative of the parent’s death, but the child is helped by a clear differentiation between what happens to the body and what happens to the soul (Lieberman et al. 2003). This process cannot be hurried. Young children can tolerate only brief periods of intense sadness, and this “short sadness span” (Wolfenstein 1966) needs to be respected as the child moves from sadness to exploration and play. Reminding children, in the depth of their despair, that they will not always be sad and that they will find things that make them happy is a powerful tool to maintain hope as the child struggles with overwhelming feelings of loss.

Parents and service providers often need resources to help them organize their responses to the child’s experience of a parent’s death. The National Child Traumatic Stress Network (NCTSN) (www.nctsn.org) has developed materials that are available online for parents, community members, and professionals to assist military families and their children and to bereaved young children and their families. The Early Trauma Treatment Network is an NCTSN center that specializes in providing child–parent psychotherapy (CPP) as an evidence-based treatment for traumatized children in the birth-five age range and their families (Lieberman and Van Horn 2008). CPP has been adapted for the specific needs of children in military families, with specific focus on grief and bereavement (Lieberman et al. 2003), clinical work with traumatized children (Osofsky 2011), and creating partnerships with Zero to Three Coming Together Around Military Families, Sesame Street, the Wounded Warriors Project, and the Military Family Advocacy Program as well as other programs working with military families to provide training to professionals and paraprofessionals and direct service to young children and their families.

Conclusion

Young children in military families are profoundly affected by their parents’ experiences of war and the family disruptions that follow as the result of deployment, the physical and emotional sequelae of combat for service members and their spouses, and the traumatic impact of injury and death. The developmentally expectable anxieties of the first years of life—separation anxiety, fear of losing love and approval, fear of body damage, and fear of being bad—become confirmed in the child’s mind by external events that interfere with the parents’ physical and emotional availability. Addressing the emotional needs of young children should become a standard component of best practice in providing support and services to families in the military both for the children’s sake and because the well-being of young children is a barometer for how well the family is coping with the adversities of deployment and its sequelae.