Service members and their families have endured significant stressors over the past 19 years in support of the nation’s engagement in the wars in Iraq and Afghanistan. ‘Resilience’ is the term most commonly used to describe the military spouse and military-connected child. However, due to a paucity of research on military families, little is known about the impact of spousal/parental military service on the military family. The ability of the healthcare provider is critical to ensuring the success of the military spouse and military-connected child. Providers can support the physical and psychological health needs of military families through (1) identification of military family members in clinical practice and (2) providing culturally competent care that correlates the unique lifestyle and physical and psychological health exposures associated with spousal/parental military service. Historically, in the United States, there has been a proud legacy of generational military service in families—upwards of 80% of new recruits have a family member who has served in the military. The leading factor associated with retention of the service member on Active Duty or in the Reserve or National Guard is the satisfaction of the at-home spouse. Disenfranchising the military spouse and lack of services and support for military-connected children could create a gap in meeting recruitment goals creating a threat to national security in the United States.
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- primary care
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Resilient is the term most often used to describe military spouses and military-connected children.
The impact of 19 years of war has exposed military spouses and military-connected children to stressors that impact their physical and psychological health.
Providers should be knowledgeable regarding the impact of spousal/parental military service to ensure that the health needs of the military spouse and military-connected child are met.
Inability to meet the needs of military families could negatively impact national security.
Military spouses and military-connected children experience many positive benefits secondary to spousal/parental military service.
The United States has been at war for almost two decades, and there is an entire generation of military partners or spouses (MS) and military-connected children (MCC) who have only known their service member serving in support of the wars in Iraq and Afghanistan. Approximately 1.3 million US Active Duty and 1.04 million Reserve and National Guard service members have supported over 3.3 million individual deployments since 2001.1 2 This high operational tempo has resulted in roughly 700 000 MS and 1.68 million MCC serving on the home front while their spouse/parent is deployed away from home.2 More than 50% of Active Duty service members are married and more than 39% have family responsibilities; meaning they have at least one child and 41.5% of Reserve and National Guardsmen have families.2 In addition, there are more than 1.8 million children of veterans who have assimilated into civilian communities across the country and may or may not have any connection with the military.3
While military families experience benefits from the military lifestyle—the term ‘resilient’ is the word most often used to describe the MS and MCC—Oxford Dictionary of English defines resilience as ‘the capacity to recover quickly from difficulties; toughness’.4 While the focus of military resilience research has been on the service member, it is critically important that we expand the focus to include the entire family. In tandem with benefits are risks. There are inherent risks associated with military service that directly impact the physical and psychological health of military families. These risks can have a lasting impact on not only the health of the military family member but the security of the Nation.5 6 Military family health, resilience and risks are key factors in today’s mission readiness and tomorrow’s volunteer professional armed service.
Multigenerational military families
Military family members live with a sense of patriotism and respect for the role their spouse/parent(s) play in providing for the safety and security of the country. This is evident in the legacy of service in generations of military families dating back to the American Civil War. Supporting and ensuring the well-being and resilience of military family members are essential to ensuring the well-being, readiness and resilience of service members is. The US military comprises a subset of families for which generations of family members have served in the military, and these families bear the burden for the safety and security of the Nation. When you consider that 5% (18.6 million veterans) of the 328.2 million Americans have served, it is important to bear in mind the burden that military families experience and how, when decisions are made at the highest levels of government regarding service members and their families, lack of the lived experience coupled with the lack of cultural knowledge what military service entails can make these choices difficult on those who do serve.7 8
While economic factors such as job security, job skills, healthcare benefits and pension coupled with pride and sense of duty are the reasons most commonly cited by new recruits when asked why they chose to join the military, the strongest predictor of military service in the United States is having a family member who has or is serving. A study conducted by the Department of Defense found that 80% of new recruits across branches have a family member who has served and upwards of 35% of recruits are the child of a service member.8 9 Specifically, in 2012–2013, 86% of Air Force, 82% of Navy, 79% of Army and 77% of Marine new recruits had a close relative who had served in the military.9 This can lead to a lack of diversity in the forces and widens the military-civilian divide as well as impose a layer of isolation for a shrinking pool of military family members.9 In the United States, conscription ended in 1973, and to date and despite 19 years of war, recruiters have met recruiting goals for all four branches of the military since 11 September 2001.
While military families significantly contribute to stability of an all-volunteer armed service, military spouses are a significant contributor to the stability and longevity of partnered service members and families. The term military spouse refers to a committed partner of a military service member. While women comprise 92% of spouses, the number of male spouses is increasing.2 Implications of the increasing number of male spouses are yet to be determined.10 These partners can be a key element to a successful military career and a healthy transition to civilian life. Contemporary military partners support frequent moves, establish home routines and then maintain them during deployments. Spouses also contribute to the economic well-being of the military family.
However, the support of a partner’s military career often comes with a cost. Frequent relocation, restarting a career in a new city or region, and geographic separation from family, friends and partners can create isolation and economic hardship. Maintaining a career is extremely challenging as opportunities that match education and experience may not be available in the new duty station.11 Military spouses suffer unemployment rates that are consistently four times the national average and make 25% less than their civilian counterparts despite the fact that they are equally or more educated.12 Some families opt to ‘geo-bach’ to maintain the economic or social stability of the family and spouse. Geo-baching refers to being a geographic bachelor—the service member goes to the new assignment location while the family stays at an established home. While this arrangement alleviates some stressors, it creates others through separation and additional living expenses associated with maintaining two homes. A new stressor on the horizon is the Department of Defense’s policy to remove spouses and children from military treatment facilities. This move will require that family members will have to re-establish healthcare with each move in a community where access to providers who accept military health insurance may be limited. Limited providers taking insurance payments limits access to care. Additionally, if the health literacy and advocacy of the spouse are limited, engagement in a complex or fractured healthcare system may also be truncated leading to increased emergency room costs, late diagnoses and lack of participation in preventative care. 13 14
Despite the myriad of stressors, military spouse are a pillar of stability within the military family. They establish routines and activities for children and maintain the home during deployments. Research has found that a military spouse with socioeconomic supports like employment and sense of community who is exhibiting positive coping strongly influences the well-being of any children, a sense control within a dynamic environment and the readiness of the service member to meet the mission.11 15 16 The last 19 years of combat has shown an inverse relationship between number and length of deployments and spousal well-being.17 18 During a deployment, spouses take on the majority of the adult home duties while working with the service member to facilitate a transition to and from deployment while maintaining the service member’s presence at home.19 Examples of that presence maintenance are setting times for video calls, creating care packages and countdown to return calendars. While the return of the service member can be joyful, it is also a challenge to be navigated. Roles and authority need to be renegotiated. During this reintegration period, spouses are at higher risk for negative communication and interaction.17–19 For example, the aggregated prevalence of intimate partner violence (IPV) in military populations is 21% for men and 13% for women.20 Military spouses are at higher risk for IPV post-deployment with alcohol use, pre-deployment aggression, post-traumatic stress disorder (PTSD) and age being mitigating factors.21 Military divorce rate is 3%.22 Risk for divorce post-deployment is associated with length of deployment, communication and service member injury.23–25 Additional challenges arise if the service member has been injured and the spouse assumes a caretaker role.25
All of these stressors can impact the service member’s career decisions. The preference to continue military service or to separate is heavily influenced by the spouse.12 Additionally, if the spouse has difficulty coping with frequent separations, infrequent communication and lack of predictable scheduling, the service member can be pulled between the needs of the military and the needs of the family. The military acknowledges spouses as a key element in personnel retention. Initiatives to improve work portability and licensure, support caregiving and educational opportunities have all been rolled out over the last decade. Military spouses now qualify for unemployment benefits and licensure cost supports as part of an ordered move. However, spouses and children are still called ‘dependents’ in the military system. Given the role that spouses play in building and maintaining healthy military families, these partners are anything but dependent.
Like military spouses, the children of Active Duty service members live, work and play in a unique and distinct culture, their role members of the military family have an occupational and cultural context that can have a real and lasting impact on their health.6 The military culture and lifestyle provide for many amazing opportunities and experiences such as travel and living in diverse countries and cultures. With every move, MCC have the opportunity to reinvent themselves and quickly learn how to make new friends and adapt to new environments. On average, military children attend six to nine different school systems from kindergarten through 12th grade.26 Active Duty military families tend to be financially stable, in that they receive a steady paycheck in addition to numerous support systems, resources and healthcare coverage. However, due to the constant moves and relocations, many MCC experience disruptions in social support networks and established resources that can affect continuity of care.27–29 Most Active Duty MCC are geographically separated from extended family such as grandparents, so other military families living on military installation or in surrounding civilian communities become their ‘military family’. They often assume many of the same roles and responsibilities as the traditional extended family. Military families tend to have close bonds because their parents and siblings are the one constant in the many changes is their lives.
Conversely, Reserve and National Guard children tend to be more geographically stable but may reside in communities that lack knowledge of the requirements and demands of military service.6 Reservists and National Guardsmen juggle their military and civilian professions as well as all the education, training and certifications that go with those jobs. The Reservist or National Guardsman may live close to their assigned unit but may have to travel long distances to their unit, reducing the number of support systems associated with military service. The children of Reserve and National Guard troops may live in communities that lack knowledge of military life—these MCC may be the only child in their neighbourhood or the only child in the classroom with a parent serving in the military. Neighbours and school officials may lack knowledge and understanding of military life and the related stresses on children. Children of Reserve and National Guard service members are not eligible to access many services provided to the children of Active Duty troops such as healthcare, childcare and recreational programmes even when the Reserve or National Guard parent is called to Active Duty for a deployment. Finally, there could be a shift in financial status, which may decrease overall family income and impacting financial stability, healthcare benefits and access to care.
While there is a paucity of research on the MCC, there is evidence that suggests that risks for MCC can significantly impact their well-being and resilience. After 19 years of war, MCC have been exposed to a large number of stressors and uncertainties that put them at a higher risk for physical, psychological and behavioural health issues.6 27–29 The literature is beginning to show that MCC are at a higher risk for abuse and neglect, substance use and suicide compared with non-MCC primarily during parental deployments and family relocations.28–30 MCC endure many deployments and separations—upwards of 10–12 parental deployments during childhood and adolescence is not uncommon. Blue Star Children, the children of service members serving in combat, experience stress and depression related to parental deployment risks or parental post-deployment physical and psychological injuries.5 Many service members return to families with both the visible wounds of war such as amputations and burns and the invisible wounds such as PTSD, traumatic brain injury and military sexual trauma.25 MS and MCC are taking on caregiving responsibilities and an increased burden of care while caring for their wounded warrior—the toll and impact on these family members are highly underestimated and under-researched.25 These stressors may result in changes in behaviour and/or academic issues secondary to emotional distress related to parental stressors.27 30 Others may experience anxiety that can lead to changes in appetite, disrupted sleep patterns and impaired immune response, which can impact overall physical and psychological health.27 30 Finally, a number of MCC, known as Gold Star Children, have experienced the death of a parent.
National security impact
Dissatisfaction with the military lifestyle, lack of services and care for the Active Duty/Reserve/National Guard parent, and stress of parental military service resulting in physical, psychological and behavioural health issues could create barriers where MCC may decide not to serve like generations of family members before them.31 MCC may be disqualified for service due to a health-related issue that may have occurred as a result of stress associated with their parent’s military service. Additionally, the perception of a lack of consideration or dissatisfaction with the military lifestyle may hinder recruiting, leading to deficient numbers of recruits. This coupled with the report from over 120 retired generals and admirals concerned about more than 70% of young adults in the general population aged 18–24 years who are ineligible for service due to obesity, physical and psychological health issues, and incarceration to name a few, places the nation at a deficit in meeting recruiting quotas, thereby impacting the security needs of the country at risk.32
The military family is a key partner in maintaining a ready professional force and they need partners and advocates in the healthcare community. Identifying military-connected spouses and children in practice areas is the first step in providing appropriate and tailored care. Tailored care needs to include purposefully addressing sustainability and continuity of care along with aligning resources to match their needs in ways that may not be available within the military healthcare system. For example, behavioural and mental health services are available at most military treatment facilities but are restricted only to service members. This requires family members to attempt to access these services in the civilian sector, where they may be put on a protracted waiting list or have difficulty accessing the most appropriate type of provider (ie, an adolescent mood disorder therapist for a teenager vs the adult-focused therapist that is available within the referral).
Identifying military families in the practice setting and then providing necessary screenings and supports contribute to well-being and resilience.33 34 Abraham Lincoln in his second inaugural address in 1865 spoke to the obligation to care for military families when he stated that the nation must ‘… care for him who shall have borne the battle and for his widow, and his orphan’.
Data availability statement
No data are available. N/A.
Patient consent for publication
Contributors All authors were equal contributors in the planning, development and writing of this manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.