Skip to main content
Have a personal or library account? Click to login
Mental Health Among Children Living with Veterans: A Literature Mapping Cover

Mental Health Among Children Living with Veterans: A Literature Mapping

Scandinavian Journal of Military Studies
Volume 2 (2019): Issue 1
By: ,  ,   and    
Open Access
|Sep 2019
Figures & tables

Figures & Tables

Table 1

Search terms of the main search.

Descriptor terms applied in the search strategy
Family descriptorsFamily – Relative – Significant other – Spouse – Partner – Off-spring – Offspring – Child – Adolescent – Toddler – Infant – Teens – Teenager – Youngster
Veteran descriptorsWar – Deployment – Deployed – Conflict – Peace – NATO – North Atlantic Treaty Organization United Nations
Deployment descriptorsWar – Deployment – Deployed – Conflict – Peace – NATO – North Atlantic Treaty Organization United Nations
Psychosocial descriptorsPsychological health – Inter generational – Transmission trauma – At risk – Depression – Anxiety Psychological stress – Mental health – Secondary traumatization – Vulnerability – Coping – Isolation – School problem – Loneliness – Well-being – Psychosocial health – Behavior problem – Psychological adaptation – Mental or psychosocial well-being – Quality of life – Distress – Alienation – Rejection psychology – Distress – Disruption – Academic difficulty or problem – Adjustment – Emotional stress – Aggression or aggressive – Anger – Fear – Guilt – Detachment
Social connections descriptorsLeisure time – Spare time – Social involvement – Community involvement – School involvement – Social relation – Colleague – Peer – Friend – Participation – Network – Support group – Extended family
Figure 1

Flowchart for the literature search and screening of child mental health, family relationship, psychosocial well-being, and social relations.

* Notes: Included publications (n = 103) cover both child mental health, family relationship, psychosocial well-being, and social relations.

Table 2

Descriptive table of publications included in systematic literature mapping of mental health among children living with a veteran parent.

Publication characteristicsNumber of publications
Veteran post-deployment effects
    Physical–
    Psychological6
    Both–
    None–
    Not reported10
Country of deployment
    Iraq (Gulf war)2
    Iraq11
    Balkan4
    Afghanistan7
    Syria–
    Lebanon–
    Lebanon (UNIFIL)–
    Libya–
    Piracy–
Study nationality
    Canada–
    Different nationalities–
    Croatia2
    Netherlands1
    United States13
Publication type
    Peer-reviewed paper14
    Dissertation2
    Book chapter–
Method
    Quantitative14
    Qualitative–
    Mixed2
Observational vs. experimental study
    Observational study13
    Experimental study3
    Both–
Study design
    Cross-sectional7
    Longitudinal6
    RCT–
    NRS3
Outcome categories
    Internalizing16
    Externalizing11
    ADHD symptoms6
    Secondary traumatization–
    Other mental health outcomes4
Table 3a

Characteristics of participants, study type, and methods of publication included in a systematic literature mapping of mental health among children living with a veteran parent.

First authorAndresMaršanićFranićHerzogKelley*LesterLetamendiMedwayPfefferbaum*ReedWilson
Publication year20112014201220091994a/1994b2010201220132012199520112012201320112011
Nationality of study populationNetherlandsCroatiaCroatiaUSAUSAUSAUSAUSAUSAUSAUSAUSAUSA
N109 mothers reporting on 221 children244 adolescents695 children54 couples (mother + father) reporting on their child28 mothers reporting on their child272 children, 228 parents representing 171 families461 parents of 493 children representing 331 families280 parents reporting on 505 children21 father-child dyads100 mothers reporting on any of their children18 children/10 mothers representing 10 families13 children/9 mothers representing 9 families11 children/9 mothers repre-senting 9 families10,606 adolescents77 parents & children
Response rateN/A100%N/A5.3%100% of sub-sample92%67.8%N/AN/AApprox. 25%N/A61.1%8th grade: 77%, 10th grade: 60%, 12th grade: 50%N/A
Range in years of children, mean age (SD)0–28, m:9.59 (7.45)12–18, m:15.0 (3.49)11, m:12.2 (0.33)2–17, m:9.38 (N/A)5–13, m:N/A for sub-sample6–12, m:8.53 (2.0)3–18, m:N/A3–17, m:7.44 (3.5)6–17, m:9.8 (SD:N/A)1st child: N/A, m:11 (6.0), 2nd child: N/A, m:9 (5.0)6–17, m:N/A6–18, m:N/A8–15, m:10.91 (2.51)Age N/A. 8th, 10th, and 12th grade3–17, m:9.13 (4.13)
Veteran post-deployment effectsN/APsychN/APsychN/APsychPsychPsychPsychN/AN/AN/AN/A
Country of deploymentBos & AfgCroaCroaIraqIraq (Gulf war)Iraq & AfgIraq & AfgIraq & AfgIraq & AfgIraqIraqIraq & AfgIraq, Afg, Bos, & other
Further sample informationChildren of Dutch veterans having experienced a deploymentChildren of veterans referred to an outpatient psychiatric clinicChildren in 6th grade with parental Homeland war involve- mentChildren of National Guard veteran fathersChildren of veteran fathers with Navy deploymentChildren of active duty Army or Marine Corps parentChildren of Navy and Marine veterans participating in the FOCUS interventionChildren of fathers with 1+ deploymentChildren of Reserve or National Guard veteranChildren of National Guard veteransChildren of National Guard veteransChildren of National Guard veteransChildren with parental deployment within the last 6 yearsChildren of National Guard veteran participating in the PTS intervention
ComparisonNo comparisonChildrenwith/without veteran fathers with PTSDChildrenwith/without parents partici-pating in theHomeland war of CroatiaChildren of fathers with elevated PTSD symptoms compared to community normsaChildren of fathers with peace-time vs. wartime deploymentChildren of recently returned veterans vs. currently deployed soldiers and com- munity normsPre-posttestAssocia-tions within sample of fathers with combat exposureChange fromdeployment to postdeploymentPreposttest and associations within samplePre- posttest and associa- tions within samplePre- posttest and associa- tions within sampleChildren with parents with combat zone deployment within the last 6 years vs. non-veteran parentsChildren of veter- ans vs. children in a national- ly repre- sentative study
Study designLong.Cross.Cross.Cross.Long.Cross.NRSNRSCross.Cross.Long.Cross.NRS
MethodMixedQuant.Quant.Quant.Quant.Quant.Quant.Quant.Quant.Quant.Quant.MixedQuant.

[i] * Same study with >1 publication included; a See Table 4 for further descriptions of comparisons. N/A = not available; SD = Standard deviation; Bos = Bosnia; Afg = Afghanistan; Croa = Homeland war in Croatia; Psych = Psychological; Cross. = Cross-sectional; Long. = Longitudinal; NRS = Non-randomized study design; PTS = Passport Toward Success, FOCUS = Families OverComing Under Stress Resilience Training

Table 3b

Outcome measurements in publications included in systematic literature mapping of mental health among children living with a veteran parent.

First authorAndresMaršanićFranićHerzogKelley*LesterLetamendiMedwayPfefferbaum*ReedWilson
Publication year20112014201220091994a/1994b2010201220132012199520112012201320112011
InternalizingSeparation anxiety (1 item)Intern. (YSR)b; Anxious/Depressed (YSR)bDepression (CDI)bIntern. (CBCL)aIntern.(CBCL)aIntern. (CBCL)a, Depression (CDI)b, Anxiety (MASC)bEmotional symptoms (SDQ)aEmotional symptoms (SDQ)aIntern. (CBCL)a, Anxious/Depressed (CBCL)a, Withdrawn/Depressed (CBCL)a, Somatic complaints (CBCL)a, Depression (CDI)b, Anxiety (MASC)bAnxiety (1 item)aIntern. (BASC-2)a, b, Emotional symptoms (BASC-2)bIntern. (BASC-2)a, bIntern. (BASC-2)b,Emotional symptoms- (BASC-2)bDepression (1 item)bEmotional symptoms (SDQ)a
ExternalizingExtern. (YSR)b,Aggressive behavior (YSR)b,Delinquent behavior (YSR)bExtern. (CBCL)aExtern.(CBCL)aExtern. (CBCL)aConduct problems (SDQ)aConduct problems (SDQ)aExtern. (CBCL)aExtern. (BASC-2)aConduct problems (SDQ)a
ADHDAttention problems (YSR)bHyperactivity/Inattention (SDQ)aInattention/hyperactivity (BASC-2)bHyperactivity (SDQ)a
Other mental health outcomesSuicide attempt (3 items)bChild distress (overall SDQ)aPTSD (UPID)bSuicide thoughts (2 items)b

[i] * Same study with >1 publication included; a Parent reported; b Child reported; c Teacher reported; YSR = Youth Self-Report; SDQ = Strength and Difficulties Questionnaire; CBCL = Child Behavior Checklist; CDI = Children’s Depression Inventory; MASC = Multi-dimensional Anxiety Scale; UPID = The UCLA PTSD Reaction Index for DSM_IV; BASC-2 = Behavior Assessment System for Children.

Table 4

Main findings and summary of limitations in publications included in systematic literature mapping of mental health among children living with a veteran parent.

First author & publication yearInternalizingExternalizingADHDOther mental health outcomesLimitations
Andres 2011Separation anxiety: 40% of children were afraid their fathers would leave again (mainly children <10 years).

  1. No information for judging representativeness

  2. Attrition/difficulty in obtaining follow-up data

  3. Possible reporting bias; parent-reported separation anxiety

  4. No information on veteran post-deployment effects

  5. No examination of possible predictors for separation anxiety; only prevalence was presented

  6. Non-validated and single item measure (separation anxiety)

Maršanić 2014Adolescents of veterans with PTSD had sig. higher OR for overall internalizing above borderline-clinical cutoffs OR: 1.92 (CI: 1.11–3.33) compared to adolescents of veterans without PTSD.
Sig. higher OR for anxiety/depressed symptoms OR: 1.71 (CI: 1.00–2.89) among adolescents of veterans with PTSD compared to adolescents of veterans without PTSD.		Adolescents of veterans with PTSD had sig. higher OR for overall externalizing above borderline-clinical cutoffs. OR 2.16 (CI 1.22–3.81), compared to adolescents of veterans without PTSD.
Aggressive behavior: OR 2.40 (CI 1.36–4.22).
Delinquent behavior: OR 2.30 (CI 1.29–4.11).		Adolescents of veterans with PTSD had sig. higher OR for Attention problems above borderline-clinical cutoffs, OR 1.96 (CI: 1.10–3.50).

  1. Clinical sample. Sample may not be representative for Croatian veteran children or children referred to psychiatric clinics (symptoms may be more severe compared to other clinics)

  2. No information on deployment length or number of deployment

  3. Cross-sectional study design

Franić 2012Mean depressive symptoms: NS difference in mean between boys with and without a veteran parent. Borderline sig. difference among girls: 8.66 (SD 9.97) vs. 6.82 (SD 7.11), p = 0.052.Suicidal thoughts/attempts. Boys of veterans sig. higher odds of suicide thoughts OR: 5.06 (CI: 1.72–14.89) compared to non-veteran boys. Girls: NS difference.

  1. Convenience sample

  2. Risk of reporting bias risk; child self-reported data on parental war involvement. Child depression based on self-report (no clinical assessment)

  3. No information on post deployment effects, intensity of combat, and deployment length

  4. Cross-sectional study design

  5. Non-validated outcome measure used to assess suicidal ideation

Herzog 2009Overall child internalizing sig. correlated with soldier PTSD (p = 0.008) and spouse secondary traumatization (p < 0.001). Spouse secondary trauma symptoms mediated the association between soldier’s PTSD symptoms and child internalizing symptoms. Children of fathers with elevated PTSD symptom level (PCL ≥ 48) averaged the 72.8 percentile in internalizing symptoms compared to norms.Overall child externalization NS correlated with soldier PTSD and spouse secondary traumatization. Children of fathers with elevated PTSD symptom level (PCL ≥ 48) averaged the 69 percentile in externalizing symptoms compared to norms.

  1. Convenience sample

  2. Small sample

  3. Non-representative sample (low response rate) – only National Guard troops

  4. Sample possibly biased; innovative reunion programming in the included National Guard unit

  5. Reporting bias risk; parent reported data of internalizing and externalizing symptoms

  6. Unadjusted analyses

  7. Cross-sectional study design

Kelley 1994a + 1994b*Association between deployment and internalizing symptoms sig. (p < 0.05) modified by deployment type. Constant symptom level (approx. 52.5) pre-, during and post-deployment among children of parent with wartime deployment. Significant decrease (p < 0.01) in symptom level among children of parent with peacetime deployment.Association between deployment and externalizing symptoms sig. (p < 0.05) modified by deployment type. Constant symptom level pre-, during and post-deployment among children of parent with wartime deployment. Significant decrease (p < 0.001) in symptom level among children of parent with peacetime deployment

  1. Convenience sample

  2. Small sample

  3. Non-representative sample

  4. No information for judging attrition/difficulty in obtaining follow-up data

  5. Reporting bias risk; parent-reported data on internalizing and externalizing symptoms

  6. No information on post deployment effects

  7. Possible confounding/baseline imbalance not addressed

Lester 2010Overall child internalizing symptoms among children of recently returned veterans (RRV) not sig. different compared to community norms. NS difference in internalizing symptoms compared to offspring of currently deployed soldiers (CDS) after adj. for child gender and age. Child internalizing scores sig. associated with veteran depression, anxiety and symptom severity (p < 0.01).
Anxiety symptoms sig. above community norms for both boys and girls for both RRS and CDS children. 31.9% with RRV and 24.7% of CDS parent had clinically sig. anxiety symptoms. NS difference in anxiety symptoms compared to offspring of CDS after adj. for child gender and age.
Depression symptoms: NS difference in scores compared to community norms. Sig. (p < 0.05) association with symptom severity of recently returned veteran		NS difference in overall child externalizing symptom scores among children of recently returned veterans (RRV) compared to community norms
NS difference in overall child externalizing symptom score compared to offspring of currently deployed soldiers (CDS) after adj. for child gender and age when adj. for child gender and age. Externalizing behavior sig. associated with veteran PTSD, depression and symptom severity (p < 0.05).

  1. Convenience sample

  2. Proportion of officers in the sample not representative of the country’s military (Army and Marine) population

  3. Reporting bias risk; patient reported data on internalizing and externalizing symptoms

  4. Cross-sectional study design

Lester 2012Emotional symptoms sig. (p < 0.001) reduced from 40.9% at intervention start to 22.1% post-intervention.Conduct problems sig. (p < 0.001) reduced from 47.7% at intervention start to 28.4% post intervention.

  1. No information for judging representativeness

  2. Attrition problems – Completers more likely to be self-referred, less distressed on the Brief Symptom Inventory (BSI) and McMaster Family Assessment Device (FAD)

  3. Reporting bias risk; parent-reported data on emotional symptoms and conduct problems (SDQ)

  4. No information on deployment type or length

  5. Non-randomized study design with no control group

Lester 2013Emotional symptoms reduced from pre- to post-intervention (mean dif 1.11 (SD 2.34)).Conduct problems reduced from pre- to post-intervention (mean difference: 1.07 (SD 2.02))Mean hyperactivity/inattention problems reduced from pre- to post-intervention, (mean difference: 0.85 (SD 2.27)).Higher overall child distress pre-intervention than in the general child population. Family adjustment improved and predicted reduced distress among children.
Caretaker distress predicted child distress.

  1. No information for judging representativeness

  2. Number of non-participants not available

  3. No report on attrition or difficulties in obtaining follow-up data for participants

  4. Reporting bias risk; parent-reported data

  5. No information on deployment length or number of deployments.

  6. Non-randomized study design with no control group

Letamendi 2012Overall child internalizing symptoms sig. associated with fathers’ combat exposure, battle aftermath, and parental PTSD (all p = 0.003).
Child depression: Not associated with deployment factors.
Anxiety symptoms sig. associated with battle aftermath, parental combat exposure, post-deployment stressors (all p < 0.04).
NS association with parental PTSD, perceived threat during deployment, post-deployment social support.
Anxiety/depressive symptoms Scale sig. associated with parental combat exposure, battle aftermath, and post-deployment stressors (all p = 0.001).
Withdrawal/depression symptoms: NS association with parental combat exposure, battle aftermath, or post-deployment stressors.
Somatic symptoms: NS association with parental combat exposure, battle aftermath or post-deployment stressors.		Overall child externalizing symptoms: Sig. associated with fathers combat exposure, battle aftermath and post-deployment stressors (all p = 0.006). NS association with parental PTSD, perceived stress, post-deployment social support.Child PTSD symptoms: Sig. associated with fathers combat exposure post-deployment (p = 0.003) when measured with CBCL DSM-Oriented Scale of PTSD. Measured with UCLA PTSD Index for DSM-IV (UPID) no association was found. NS association with parental PTSD, perceived stress, reports of battle aftermath, post-deployment social support, and post-deployment stress.

  1. Convenience sample

  2. Very small sample

  3. Non-representative sample

  4. Sample may be biased due to recruitment method (advertisements in community or referral from VA medical providers): Fathers enrolled in the study may have been those who were undergoing therapy or have a history of utilizing mental health services

  5. Reporting bias risk; parent-reported child internalizing and externalizing behaviors

  6. Unadjusted analyses

  7. Possible selection bias: If more than one child in the family, the parents could choose which child to include in the study

  8. Cross sectional study design

Medway 1995Mean anxiety problems sig. reduced from 2.00 (SD 0.72) during deployment to 1.29 (SD 0.56) during reunion (p < 0.001).

  1. Convenience sample

  2. Non-representative sample

  3. Low response rate

  4. Reporting bias risk; mothers’ retrospective assessment of child anxiety during separation

  5. No information on deployment length and possible veteran post deployment effects

  6. Cross-sectional study design

  7. Non-validated one-item measure of child anxiety

Pfefferbaum 2011*No sig. difference in internalizing problems at post-deployment compared to pre- and during deployment. Child reported internalization post-deployment sig. correlated with worrying about the non-deployed parent during deployment and to worrying about the deployed parent readjusting to being home (p < 0.05). Parent reported internalization sig. correlated to children’s reports of how safe the world was (p < 0.05).
Mean child-reported emotional symptoms sig. lower post-deployment compared to during deployment (48.78 (SD 7.57) vs. 45.44 (SD 7.41), p < 0.05).		Parent-reported mean externalization decreased sig. from deployment to post-deployment (51.38 (SD 9.54) vs. 47.75 (SD 10.0), p < 0.05). Externalization sig. higher if children had experienced >1 deployment. Post-deployment parent-reported externalizing sig. correlated to worrying about the non-deployed parent during deployment (p < 0.05).No sig. difference in mean inattention/hyperactivity symptoms post-deployment (56.77 (SD 9.45)) compared to pre- and during deployment. Child-reported inattention/hyperactivity symptoms post-deployment sig. correlated with worrying about the deployed parents safety while deployed (p < 0.01)

  1. Convenience sample

  2. Very small sample

  3. Non-representative sample

  4. No information on number of non-participants

  5. Reporting bias risk; parent-reported child externalization and internalization

  6. No information on veteran post-deployment effects or information on deployment length

  7. Unadjusted analyses

  8. Other biases; pre-deployment measures reported after separation. Several sibling pairs in an already small sample

Pfefferbaum 2012*Child-reported internalizing problems post-deployment sig. correlated with how hard it was to help during deployment (r = 0.51, p < 0.05) and how often children felt they should do more to help at-home parents (p < 0.05).
Parent-reported child internalizing problems post-deployment sig. correlated with frequency of helping parents (p < 0.05).		Parent-reported externalizing problems post-deployment sig correlation with difficulties in knowing how to help at-home parents (p < 0.01).Child-reported inattention/hyperactivity symptoms sig. correlated with difficulty knowing how to help parents (p < 0.05).

  1. Convenience sample

  2. Very small sample

  3. Non-representative sample

  4. No information on number of non-participants

  5. Reporting bias risk; parent-reported child externalization and internalization

  6. No information on veteran post-deployment effects or information on deployment length

  7. Unadjusted analyses

  8. Other biases; pre-deployment measures reported after separation. Several sibling pairs in an already small sample

Pfefferbaum 2013*No sig. difference in mean internalizing symptoms post-deployment compared to pre- and, during deployment.
Mean emotional symptoms decreased sig. more post- than during deployment (45.44 (SD 7.41) vs. 48.78 (SD 7.57), p < 0.05).
NS correlation between neither age nor gender and symptoms.		NS changes in mean inattention/hyperactivity symptoms compared to pre- and during deployment.

  1. Convenience sample

  2. Very small sample

  3. Non-representative sample

  4. No information on deployment length and veteran post-deployment effects

  5. Other biases; pre-deployment measures on child mental health reported after separation

Reed 2011Depressed mood: Sig. higher OR (OR 1.50 (CI 1.02–2.20)) for depressed mood among 10th-/12th-grade boys with a parent deployed to combat zone during the last six years compared to boys with non-veteran parents. NS difference in 10th-/12th-grade girls and among 8th grade children.Suicide thoughts: Sig. higher OR among 8th-grade children (girls: OR 1.66 (CI 1.19–2.32); boys: OR 1.75 (CI 1.15–2.67)) and among 10th-/12th- grade boys (OR 1.64 (CI 1.13–2.38)) with a parent deployed to combat zone during the last six years compared to adolescents with non-veteran parents. NS association among 10th-/12th-grade girls.

  1. Reporting bias risk; retrospectively child-reported parental combat zone status.

  2. No information on number of deployments, deployment length, veteran post-deployment effects.

  3. Confounding risk; timing, duration, and frequency of deployment, family structure during deployment, survival of the parent, type of deployment, and parental mental health not examined

  4. Cross-sectional study design

  5. Non-validated measure (suicide thoughts). Depressed mood measured by a one-item proxy measure only.

Wilson 2011Mean emotional symptom score during reunion (2.71 (SD 2.07)) sig. higher than children from a nationally representative sample (NHIS) (p < 0.001).Mean conduct problem score during reunion (2.35 (SD 1.97)) sig. higher than children from a nationally representative sample (NHIS) (p < 0.001).Mean hyperactivity score during reunion (4.69 (SD 2.89)) sig. higher than children from a nationally representative sample (NHIS) (p < 0.001).

  1. Small sample size (for this mapping we used the SDQ-results)

  2. Sample bias risk; families who brought a child to a program aimed at helping families and children reconnect after parental deployment

  3. No information for judging response rate

  4. Reporting bias risk; parent reported on child symptoms (differed when reported by the previously deployed parent and the at-home parent, respectively).

  5. No information on veteran post-deployment effects.

  6. No adjustment for potential confounders.

[i] OR = odds ratio; CI = 95% confidence interval; SD = standard deviation; NS = not significant; Sig. = significant/significantly; Corr. = correlated/correlation; Adj. = adjusted/adjusting; NHISCS = the National Health Interview Survey Civilian Sample. *Multiple publications based on same study.

DOI: https://doi.org/10.31374/sjms.8 | Journal eISSN: 2596-3856
Journal RSS Feed
Language: English
Page range: 122 - 147
Submitted on: Aug 10, 2018
Accepted on: Apr 23, 2019
Published on: Sep 5, 2019
Published by: Scandinavian Military Studies
In partnership with: Paradigm Publishing Services
Publication frequency: 1 issue per year
Keywords:
Children,
mental health,
military family,
post-deployment effects,
systematic mapping,
veterans

© 2019 Signe Boe Rayce, Søren Bo Andersen, Anne-Marie Klint Jørgensen, Anni Brit Sternhagen Nielsen, published by Scandinavian Military Studies
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 2 (2019): Issue 1
Previous article
Next article