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The Children and Families of Combat-Injured Service Members

Chapter 31

THE CHILDREN AND FAMILIES OF 

COMBAT-INJURED SERVICE MEMBERS

STEPHEN J. COZZA, MD*; RYO S. CHUN, MD†; and CORINA MILLER, MSW‡

INTRODUCTION 

BACKGROUND LITERATURE

NOTIFICATION OF INJURY

Communicating With Children About the Injury

Travel to Military Medical Facilities and Family Separations

THE HOSPITALIZATION

CHILDREN IN THE HOSPITAL SETTING

SUPPORT TO COMBAT-INJURED FAMILIES WITH CHILDREN

CHILDREN’S RESPONSES TO COMBAT INJURIES

EFFECT OF THE INJURY ON THE PARENT

Principles of Caring for Combat-Injured Families

Long-Term Rehabilitation and Transitions

SUMMARY

ATTACHMENT 1: Parent Guidance Assessment–Combat Injury

attachment 2: Principles of Caring for Combat-Injured Families

and their Children

*Colonel (Retired), US Army; Associate Director, Center for the Study of Traumatic Stress, and Professor, Department of Psychiatry, Uniformed Services 

University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814; formerly, Chief, Department of Psychiatry, Walter Reed Army 

Medical Center, Washington, DC

†

Colonel (Retired), US Army; Clinical Director, Child and Adolescent Psychiatry Service, Department of Psychiatry, Walter Reed Army Medical Center, 

6900 Georgia Avenue NW, Washington, DC 20307; formerly, Chief, Child and Adolescent Psychiatry Service, Department of Psychiatry, Walter Reed 

Army Medical Center, Washington, DC 

‡

Clinical Social Worker, Department of Psychiatry, Walter Reed Army Medical Center, Building 2, Office #6317, 6900 Georgia Avenue NW, Washington, 

DC 20307-5001; formerly, Clinical Social Worker, National Naval Medical Center, Bethesda, Maryland
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Combat and Operational Behavioral Health

INTRODUCTION

As of July 2008, over 30,000 soldiers, sailors, marines, and airmen have been injured in ongoing operations in Iraq and Afghanistan.1

 A substantial number 

of these injuries have been serious, resulting in limb 

amputations, severe soft-tissue and orthopaedic injuries, traumatic brain injuries (TBIs), eye enucleations, 

and body burns.2 The effect of these severe injuries on 

families, parents, and children is not easily ascertained, 

but will likely be determined by the functional consequences of the injuries. Even when physical recovery 

is complete, families can be profoundly affected by the 

injury of a parent. Because 40% of US service members 

(SMs) have children, averaging about two children 

per parent,3 the authors estimate that approximately 

24,000 military children have been affected by serious combat-related parental injuries within that same 

time period. These numbers do not reflect the many 

other nondependent children whose siblings or other 

military family members have been injured.

Case reports have described the anecdotal experience of combat-injured families and children.4,5 The 

effects appear complex, particularly with children. 

From the initial distress to the longer-term injury adjustment challenges, children and families face difficult 

emotional and practical problems. These phenomena 

have been described and are being addressed in several clinical treatment centers and studied through 

ongoing research. However, no empirical data have 

yet been systematically collected examining the effect 

of combat injury on families. Such investigation is 

required to inform intervention and treatment planning across the injury-to-recovery timeline. In addition, no family- or parent-focused interventions have 

been uniformly implemented and no evidence-based 

treatments developed and evaluated. This chapter 

describes the clinical experience and insights of mental 

health practitioners who have been involved with the 

children and families of the combat injured at Walter 

Reed Army Medical Center (WRAMC) in Washington, 

DC, a major military medical center that has been treating injured SMs since the start of global war on terror 

combat operations.

BACKGROUND LITERATURE

Although no literature exists that systematically 

examines the effect of parental combat injury on military children, other areas of scientific literature help 

the understanding of this population. Several types of 

parental illness have been carefully studied, including 

parental cancer.6–9 In these studies, children’s emotional and functional responsiveness were affected 

by their age and gender. A recent study examined the 

influence of parental multiple sclerosis (MS) on the 

adjustment of children and adolescents as measured 

by parental report.10 The authors found that children 

of MS parents showed greater difficulty in relating 

interpersonally and in managing their lives when 

compared to non-MS children. They also evidenced 

higher levels of distress, but did not show elevated 

levels of emotional or behavioral symptoms indicative 

of psychopathology. 

Family function is central to the child’s response 

to parental illness.11–14 A family’s capacity to maintain structure, to provide emotional support, and to 

diminish distress all appear to help children adjust 

to parental illness. The level of parental disability is 

also a principal factor affecting children’s responses 

to parental illness.15–19 As with many family stresses, 

children’s responses tend to mirror the distress and 

functional capacity of the important adults in their 

lives. Whether the seriousness of the illness or resultant parental disability has a greater influence on 

child functioning and emotional response is less well 

understood. In either case, these findings highlight 

the importance of adopting intervention models that 

improve family and parental functioning when parental health problems exist, to support the health and 

well-being of children.

Sudden health-altering events, such as combat 

injury, may have more profound effects on children 

and families than parental illness. Families have very 

little time to prepare for the consequences of sudden 

injuries. The noninjured parents must often make rapid 

decisions about childcare, or may be so preoccupied 

by the needs of the injured partner that they are too 

overwhelmed to address the needs of children.

Of the few studies that have examined the effect 

of sudden medical events on families, those related 

to TBI are most instructive.20–25 TBI often has a profound effect on children and families,25 with greater 

difficulty in families with young children, those with 

lesser social or financial support, or where psychiatric 

problems are prominent. Elevated levels of emotional 

and behavioral symptoms in children of TBI patients 

correlate with compromised parenting in both the 

injured and noninjured parent, as well as depression 

in the noninjured parent, suggesting the importance 

of healthy family and parental functioning to protect 

children’s mental health.22 Strategies that support 

such outcomes appear warranted; however, no established family-focused interventions have been 

empirically studied in TBI populations. In addition, 
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The Children and Families of Combat-Injured Service Members

there has been no scientific examination of the psychological effect of parental burns, amputation, or 

motor vehicle accidents on children that would help 

in the understanding of the experiences of combatinjured families.

From the initial distress to the longer-term injury 

adjustment challenges, the children and families of 

the combat injured face difficult emotional and practical problems. It is likely that the effects of combat 

parental injury on children are more complicated and 

potentially more challenging than nonviolent and 

accident-related injuries. Often immediate information regarding the nature and severity of the injury 

is limited, and sometimes inaccurate, causing further 

anxiety. Injuries sustained in combat are likely to result 

in sudden family distress and a flurry of urgent activity, leading to disruption of family roles, sources of 

care, and instrumental support. Over time, the consequences of parental injury and required treatment also 

include changes in the child’s residential community, 

loss of military career by the parent, and changes in 

parenting capacity. The cascade of events following 

injury is graphically portrayed in Figure 31-1.

Any serious physical injury may result in the development of comorbid psychiatric symptoms,26 as 

well as physical injuries. Longitudinal data suggest 

that combat-injured SMs may develop complicating 

psychiatric problems, such as posttraumatic stress 

disorder (PTSD) and depression.27 Mental health 

symptoms may present a variable course, resolving 

or commonly worsening during the first year after 

hospitalization.2

In addition to moderate or severe TBI, researchers 

have voiced concern about the influence of milder 

forms of TBI that may not come to medical attention, 

but can result in serious dysfunction or sense of ill 

health.28 When mild TBI is comorbid with other physical injuries, families may contend with the complication of dealing with a parent with psychiatric illness, 

cognitive or personality alterations, as well as physical 

injury. When significant changes in parental ability 

result from injury, parents and children must renegotiate family relationships and integrate the reality of the 

injury, whether physical, psychological, or both, and 

its consequences. Continued scientific investigation is 

required to develop effective preventive interventions 

that address both short- and long-term effects of these 

parental injuries.

Figure 31-1. Child response to events resulting from combat 

injury. 

Drawing courtesy of: Center for the Study of Traumatic 

Stress, Uniformed Services University of the Health Sciences, 

Bethesda, Maryland

NOTIFICATION OF INJURY

SM families are faced with multiple challenges, 

beginning the day the SM receives notification about 

a combat deployment. These challenges continue 

through the deployment cycle and can include many 

changes within the family system resulting from the 

SM’s absence (See Chapter 30, The Impact of Deployment on Military Families and Children). When SMs are 

injured, facing the threat of permanent bodily changes 

or reductions in their physical, cognitive, or psychological functions, greater distress is unavoidable.

Family stress begins with notification of the SM’s 

injury. Although there have been improvements in 

the process of injury notification (eg, when possible, 

injured SMs may contact a spouse or other family 

member directly, relieving their loved ones of the worst 

fear of imminent death), it is not uncommon that initial 

information pertaining to an injury may be incomplete 

or inaccurate, leading to even greater worry. Occasionally, information that a member of a military unit 

has been injured is communicated through informal 

channels, causing broad confusion and anxiety on the 

home front. Only when accurate information about the 

personnel involved and the details of the injury are 

known is some relief achieved. The manner in which 

the information of the injury is related to the spouse 

and family varies significantly from spouse to spouse 

and unit to unit. Typically, the accuracy and detail of 

available information, as well as the mode of its communication, reflect the unique circumstances of the 

injury. Injury notification may be conducted either in 

person or by telephone.

Several clinical examples help to illustrate. One 

spouse of an injured SM recalled that she had been 

visited at home by two rear detachment officers 

TIME (months)

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

C

H

I

L

D

S

T

R

E

S

S

L

E

V

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fear of loss of parent change in parenting ability

move from

community

separation from noninjured parent

hospital visits

Trauma Response is a Process

Not an Event
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Combat and Operational Behavioral Health

dressed in Army combat uniforms. While the sight 

of these visitors at her door raised concern about her 

husband’s health, she also noted with great relief that 

they were not dressed in the formal Class A uniform, 

indicating that they were not part of a death notification team. Another spouse spoke about how she received telephonic notification of her husband’s injury 

while she was driving. Before relating the news of the 

injury, the caller made certain that she had pulled off 

the road, stopped the engine, and was in a safe area, 

to ensure that she was not in danger of having a motor 

vehicle accident as a result of receiving the frightening 

news. Another spouse spoke about having received 

three separate phone calls from three different offices 

that related different versions of her husband’s injury. 

Even the simplest inaccuracies can undermine a family’s confidence in the care that an SM may receive 

after an injury, and are often remembered and related 

by spouses or other family members in the hospital 

setting. Family members typically describe the most 

reassuring and trusted information coming from the 

face-to-face visits of familiar members of their injured 

SM’s unit, rather than from telephone callers who are 

unknown to them.

Communicating With Children About the Injury

Whether injury notification occurs on the phone or 

in person, children may be present when news of the 

injury is shared with adult family members. Children 

may witness the response of their non-SM parents or 

other adults, who may become extremely distressed, 

tearful, or emotionally volatile. When possible, children should be protected from viewing the raw adult 

emotional response to such news because it can be 

both confusing and overwhelming. Also, when possible, information should be shared with adults first, 

so that they can be better emotionally prepared for a 

discussion with their children that is based on accurate 

information.

Most adults understand that some information 

should be shared with children whose parents or close 

relatives have been injured in combat. It is recommended that all children should be given some explanation 

to better understand the emotions and behaviors that 

they see in the adults around them. Depending upon 

their age and psychological and cognitive abilities, 

children have different capacities to understand and 

tolerate sensitive and disturbing news. The amount 

and type of information that adults share should be 

based upon the developmental capacity of any given 

child. Older children and teens are generally capable 

of understanding and accepting more details, including the cause of the injury, the nature and degree of 

the physical wounds, the plan for treatment, and the 

likely effect on the family (eg, expected family separations, visits to the hospital, and changes in childcare 

arrangements). Adults may be more circumspect about 

the details that they share with preschoolers or early 

elementary school children. In some circumstances, 

facts may be briefly withheld from young children 

until a parent’s immediate survivability is determined. 

Although infants and toddlers are not cognitively 

capable of understanding the injury of a SM parent, 

they will quickly respond to perceived changes in the 

emotional climate of a household, changes in behavior or availability of any adult childcare providers, or 

disruptions in their daily schedules or routines. The 

most important communication to children of any 

age is that, despite the news of the injury, they will 

be cared for and that important adults will remain 

available to them.

It is not recommended that children over the age of 

5 or 6 years not be told about an injury for an extended 

period of time because they are likely to overhear adult 

conversations or recognize changes in adult behavior 

that will cause them to worry that something is wrong. 

Adults should never conduct conversations about the 

injury within the earshot of children assuming they do 

not understand. Typically, children will listen and be 

interested in everything that is discussed. When children ask questions, they should be answered matterof-factly and with the level of information that seems 

appropriate and desired by the child. Children should 

be given permission to ask questions and understand 

that those questions will be respected and answered 

truthfully, to the degree that is possible. Sometimes 

the questions that children ask do not have known 

answers, in which case adults should say that they do 

not know. Not uncommonly, children and teenagers 

may worry that their injured SM parent may die. When 

an injured SM has stabilized and is not at risk of death, 

children should be quickly reassured. In situations 

when health status is precarious, adults should be 

careful not to unrealistically reassure children. Adults 

can offer a hopeful message such as, “Dad was hurt 

very badly, but he is being given the best treatment 

possible to help him get better.”

Often non-SM parents or other adults have trouble 

gauging what to tell their children. Adults sometimes 

struggle with their own emotional reactions, which 

may make it particularly difficult for them to determine what is appropriate to pass on to children. These 

adults may need help processing and calibrating the 

amount, content, and timing of the facts that they 

share. Their description of the injury and its consequences may be based more on their own anxiety than 

on the needs of the children. Some noninjured parents 

may choose to share either too much or too little, making it difficult for children to understand the nature or 
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The Children and Families of Combat-Injured Service Members

seriousness of the injury and its realistic implications 

for the injured parent. Knowledgeable professionals 

should offer parental guidance when needed.

Some adults may choose to withhold important 

information related to serious injuries from children in 

an attempt “not to worry them.” In such circumstances, 

clinicians need to challenge the assumption that such 

“secrets” can realistically be kept from children. The 

clinician should communicate that even younger children can be given some explanation without causing 

them to become overly worried, and may help them 

understand the actions and emotions of the adults they 

see around them. Just as some parents may provide too 

little information about the injury, others share more 

than children are able to tolerate. This may frighten 

them by unnecessarily bringing up unknown future 

consequences. The foundation of the clinician’s helpful 

stance toward the families and children of the injured 

is to increase adult awareness and to help them notice 

and respond appropriately to children’s emotional 

signals.

All children require some patient adult assistance to 

better integrate their understanding of serious injuries. 

Psychologically minded adults implicitly understand 

this need and may demonstrate tremendous creativity 

and sensitivity in meeting the needs of young children. As an example, one mother made a thoughtful 

and developmentally informed decision not to bring 

her nearly 3-year-old son to visit his seriously injured 

father until he was no longer intubated, so that the 

boy could hear his father’s voice when first meeting 

him in the hospital. This sensitive decision enabled 

the young child to relate with his father in the ways 

he was accustomed to despite the seriousness of the 

father’s injuries.

Travel to Military Medical Facilities and Family 

Separations

Once the family has been notified of the injury, a 

period of intense activity typically follows, often leading to disruptions in the family’s schedule or structure. 

Spouses usually join injured SMs being treated at 

military hospitals distant from the family home. When 

necessary, they leave their children under the supervision of other adults either at home or at the homes 

of other family members or friends in local or distant 

communities. Sometimes children are uprooted to join 

parents at the hospital. All these options are likely to 

be unsettling, particularly for young children, with 

resultant disruptions of routines and relationships. 

Recommendations cannot be broadly made about 

where children should be cared for when family 

separations are necessary. When an injury is serious, 

military spouses might fly alone to join their injured 

SMs at military medical centers. Spouses must plan 

for the care of their children and the maintenance of 

their households while they quickly arrange trips to 

distant locations, not infrequently overseas. Planning 

can be complicated as noninjured parents may not 

know how long they will be away from home. Some 

spouses make the choice to bring their children with 

them while others make interim arrangements for 

childcare with friends or neighbors, or send their 

children to stay with relatives in distant places for 

uncertain periods of time. In some cases, families must 

split the children, due to age, logistical requirements, 

or because of custody agreements (stepchildren). Siblings may stay with friends, while others move in with 

relatives. In such circumstances, children are not only 

separated from their parents, homes, and routines, 

they are also separated from their siblings, adding 

distress. Some families are fortunate enough to have 

their extended families move into their homes with 

their children, resulting in less disruption. Decisions 

about childcare and separations are never simple and 

often can result in parental confusion and guilt as they 

try to meet competing responsibilities. The following 

two vignettes provide examples of the complexity 

of military family situations and the solutions that 

families found.

Vignette 31-1: Shirlene, the mother of a seriously injured 

SM, was staying with her son at a military medical center 

across the country from her home in Washington state. She 

had been with her injured son since his admission and was 

torn between staying at the hospital or going home. Her 

younger daughter, Candace, who was living at home with 

her stepfather, had requested that Shirlene return home to 

celebrate the daughter’s birthday. Shirlene was hesitant to 

leave her son’s bedside, but was encouraged by the treatment team to visit with her daughter. During the few days 

that they visited, Candace had the opportunity to talk with 

her mother about some problems that she was having with 

friends. She didn’t want to burden Shirlene during their 

phone calls, and she didn’t feel comfortable talking with 

her stepfather about these problems. Shirlene’s decision to 

leave the hospital had been difficult, but upon her return she 

recognized the importance of this visit and was pleased that 

she had decided to make it.

Although the decision for children to stay with parents at the hospital can be a helpful way of maintaining 

the integrity and support of families, many families 

appropriately choose to have children remain at home. 

The following example describes how decisions are 

often complicated and emotionally difficult.

Vignette 31-2: John was injured in an improvised explosive device (IED) blast that resulted in multiple soft-tissue 

injuries, an upper-extremity amputation, and severe TBI. He 

and his young wife Miriam were parents of a 10-month-old 
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Combat and Operational Behavioral Health

daughter, Sarah. Miriam had made the decision for Sarah 

to stay with her parents in Oklahoma during the hospitalization. John’s initial prognosis was described as poor and he 

was not expected to walk or talk again. Miriam, his wife of 2 

years, was quite devoted to him and made the decision to 

remain with him and be there for his ongoing therapies. She 

received criticism from hospital staff and from some other 

patients’ wives for her decision to leave their young child 

with her parents. However, she knew that her daughter was 

in a stable environment with people who loved her. Miriam 

wanted to provide ongoing support to her husband, something she felt no one else was able to do. The presence of 

Sarah would have made it hard to give John the care she 

felt he deserved.

THE HOSPITALIZATION

Duration of hospitalization of combat-injured SMs 

can vary in length, based upon the type and seriousness of the injury. Critical specialty care services are 

available at most major military medical centers. 

Because many war-related injuries are extensive, the 

care of patients can be time consuming, often requiring months to years of hospital-based treatment and 

rehabilitative services. Within the hospital setting both 

formal and informal supports and services are available. Specialty care units, such as the US Army Institute 

of Surgical Research Burn Unit at Brooke Army Medical Center, San Antonio, Texas, provide specialized 

care. The course of treatment for the severely injured 

can be unpredictable, involving multiple surgeries, 

as well as other treatment procedures and intensive 

therapies. As a result, treatment plans must be fluid 

and can change, leading to disappointment in both 

patients and their families.

Injured patients cannot be effectively treated within 

the hospital setting without understanding and addressing the needs of families. Loved ones understandably want to spend time with their injured SMs, 

especially when their health status may be uncertain 

or when they are undergoing complicated or painful treatments. Some family members may choose 

to remain in hospital rooms for extended periods of 

time or even continuously. Although healthcare teams 

recognize the importance of family member involvement, and work to incorporate families into the overall 

treatment plan, their presence can also complicate 

the ability to provide effective care. Family members 

who have feelings of anger or frustration related to 

the injury may misdirect those emotions toward the 

treatment team. Families may also bring preexisting 

emotional conflicts and challenges or interpersonal 

difficulties into the hospital setting. It is essential that 

medical teams recognize and address family conflicts 

to find resolutions that support effective treatment.

Many military families are nontraditional in their 

composition. Marital separations and divorces, as well 

as the young age of many injured SMs, can lead to 

conflicts between spouses, former spouses, girlfriends, 

boyfriends, and parents, all of whom may visit the hospital. Due to the stress of the injury, conflict not uncommonly develops along these fracture lines and can lead 

to interpersonal clashes within the healthcare setting, 

making treatment more difficult. In young SMs with 

serious injuries, disagreements can develop between 

the SMs’ mothers, who respond to the regressive needs 

of their incapacitated sons or daughters, and young 

spouses who can feel like intruders to the parent–child 

relationship. Spouses may second guess their commitments to SMs who now are to be permanently altered 

by the injury. Marital dissolution and divorce are not 

rare. Sometimes parents, particularly mothers, can 

unfairly criticize spouses who they believe will abandon their injured children. Legal questions can arise 

as a result of these conflicts; for example, who in the 

family will hold medical decision-making capacity or 

who will be the recipient of insurance or government 

disability payments?

Marriages are not always healthy or functional 

prior to the combat deployment or injury. Military 

family members struggle with many of the same family challenges that all Americans face. Marital conflict, 

separation, divorce, and infidelity occur. When these 

problems are present prior to deployment, an injury 

only compounds them. The case below describes an 

example.

Case Study 31-1: Peter, a marine, was treated at a 

military medical center for a left-side below-the-knee amputation. While in Afghanistan he was called by his wife Diane 

on his birthday, 2 months before his injury. Peter was quite 

pleased until he heard a voice in the background saying, “Tell 

him you’re engaged and wearing my ring. Tell him the marriage is over.” It was in this way he learned that Diane was 

having an affair. She had also emptied their bank account 

and sold their home using the power of attorney Peter had 

provided when he began the deployment. Peter and Diane 

had a 4-year-old son and 18-month-old daughter. Peter was 

unable to get in touch with them and didn’t know whether 

they ever learned of his injury. Having been served divorce 

papers and with no place to return, Peter left the hospital to 

live on his father’s farm in Iowa. He said he would have liked 

his children to receive counseling to make sure they were 

handling their new life well but he didn’t have the physical 

ability to pursue this nor did he have the financial ability to 

fight for custody.

Complicated family situations can affect children as 

well as adults. When the injured SM is divorced and 

a child resides with a former spouse with whom the 

SM sponsor has a conflict-laden relationship, hospital 
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The Children and Families of Combat-Injured Service Members

visits or telephone calls with the injured parent become 

major events to negotiate. When the military parent 

is remarried, the discussions can become even more 

difficult because the current spouse, the divorced parent of the children, or other former in-laws may not 

get along. When families are unable to resolve these 

differences, clinicians should serve as facilitators to 

negotiate communication and visitation.

Military family situations can be complex even 

when relationships are not conflicted. Regulations 

governing marriage within the military are legally 

determined and therefore can lack the flexibility that 

families sometimes wish would be possible. The following case provides an example.

Case Study 31-2: Steven, a transportation driver in the 

Army, suffered a TBI in Iraq from an IED while he was driving 

in a convoy. Steven and his wife, Cathy, had divorced prior 

to his deployment but began working out their differences 

by e-mail and phone while he was in Iraq and planned to 

remarry upon his return. They had two children, ages 9 and 

12 years. After the injury, Cathy and the children joined Steven at the hospital. However, Steven was listed as “divorced” 

on all his paperwork and Cathy, unlike other married military 

spouses, had no rights and was provided no financial compensation for her stay in a hotel close to the hospital. The 

medical staff members were reluctant to speak with Cathy 

because she and Steven were divorced. Steven was given 

written instructions and would lose them. He wanted to pass 

on information to Cathy but he would forget because of his 

TBI. Consequently, there were periods of time when he was 

considered noncompliant, and uninterested and unmotivated 

in his recovery. During the hospitalization the couple remarried, allowing Cathy and the children access to housing 

and her greater involvement in the medical care. Prior to 

the remarriage a well-meaning but misguided administrator 

counseled Steven that perhaps Cathy only wanted to remarry 

him because of the money he would be getting from military 

disability. The family found this to be quite inappropriate and 

unsupportive.

The following vignette provides another example 

of a stressful military family situation.

Vignette 31-3: Beth, a divorced mother of three, was 

injured as a result of crossfire during a small arms firefight. 

She was hospitalized for sustained injuries to her chest 

and upper extremities. Beth was injured 9 months into a 

12-month deployment with a National Guard unit from the 

Midwest. Because of her medical treatment, Beth’s activation 

was extended well beyond the original 12-month period. In 

addition to two biological children, ages 10 and 12, she had 

a 13-year-old foster daughter. All three children remained 

with a caregiver in Beth’s hometown. Because Beth was the 

agency-approved foster mother, her ongoing medical care 

and extended deployment caused the foster daughter to be 

returned to the agency where another foster home had to be 

found. This loss was an additional disruption because the foster child had become an important member of the family.

The needs of a family can change dramatically during the course of hospitalization. Attendance to these 

needs can be extremely supportive to both the SM 

and family as treatment and rehabilitation progress. 

Families sometimes require help finding adequate 

housing, particularly when long-term family stays are 

required. Questions can arise and practical assistance 

may be necessary regarding childcare, family health, 

or educational needs. Familiarity with military regulations and coordination of appropriate paperwork 

to ensure financial support, adequate housing, and 

travel arrangements and support are all necessary for 

military family success during extended combat-injury 

treatments. Some families are able to demonstrate a 

tremendous amount of resourcefulness and identify 

independent ways to meet their own needs. Many 

others require help through the Family Assistance 

Center, social work services, or through active case 

management.

The Psychiatric Consultation Liaison Service (PCLS) 

at WRAMC has developed a system of care—Preventive Medical Psychiatry (PMP)—that includes ongoing 

clinical consultation to injured SMs and their families.29,30 Through PMP, all injured SMs are seen without 

the need for traditional consultation from the primary 

treatment team. Patients are told that members of the 

PCLS routinely see all those who were injured and that 

PCLS is part of the trauma team. As a result, PMP is 

met with little patient or family resistance. The major 

goals of PMP are to place psychological reactions within an appropriate context, to support and encourage 

healthy defenses, and to monitor for development of 

psychiatric disorders. Identified posttraumatic symptoms are explained as expected responses to combat 

and injury, rather than being viewed as necessarily 

pathological. In addition, PMP serves secondary and 

tertiary prevention efforts through posthospitalization 

identification and treatment of at-risk or symptomatic 

SMs. (For more information see Chapter 16, Psychiatric 

Intervention for the Battle-Injured Medical-Surgical 

Patients Following Traumatic Injuries.) 

In addition to PMP, PCLS social workers also provide family assistance. Family support services must 

be individually based, addressing the needs of any 

particular family in crisis at any given time. Many 

solutions are met through referral to resources in the 

surrounding civilian and military communities. Sometimes, effective interventions require more personal 

professional involvement using creative social work 

skills, a willingness to get personally involved, and a 

readiness to “work outside of the box.” As examples, 

WRAMC PCLS social workers have called Operation 

First Response for portable cribs and have found car 

seats for spouses who have precipitously flown into 

town without them. Social workers have arranged for 
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Combat and Operational Behavioral Health

baby items for couples with newborns who were not 

financially prepared and needed to fully equip a new 

nursery. Most families are disorganized when they first 

arrive at the hospital. They may come to the hospital 

without their automated teller machine (ATM) cards, 

other bank cards, or their military or other identification cards. Some go months before they can access 

their pay. Medical treatment centers must expect these 

problems and attend to them as they would the medical care that is afforded the SMs.

The following vignette is an example of how family 

needs can arise during hospitalizations.

Vignette 31-4: Enrico, a US Marine from California, was 

injured by sniper fire to his eye and upper extremity, resulting in eye enucleation and arm amputation. Eventually, 6 

months into the hospitalization, Enrico was able to arrange 

for his fiancée, Maria, to join him from Puerto Rico. They 

were married shortly thereafter and Maria became pregnant. 

She precipitously delivered a premature infant at 25-weeks 

gestation at a local civilian hospital after visiting their emergency room; the infant required a lengthy stay in a neonatal 

intensive care unit. Maria did not speak English fluently and, 

therefore, had difficulty communicating the complex healthcare needs of her family to civilian providers. Active military 

social work assistance was required to coordinate services 

between Enrico’s treatment and the needs of the couple’s 

newborn. Special arrangements were made for vouchers 

that allowed the couple to travel between the military medical 

center and the civilian hospital as they were unable to afford 

these costs. In addition, the social worker coordinated with 

Army Community Service to ensure that nursery equipment 

was delivered to Maria’s temporary housing unit when their 

newborn eventually left the hospital. 

Other innovative solutions have been developed 

by PCLS social workers. To help support the family 

members, a group—Girls Time Out (GTO)—has been 

meeting weekly since January 2005 at WRAMC. GTO’s 

mission is to provide a forum to support the wives, 

mothers, sisters, female friends, and fiancées of injured 

SMs. Group members meet, talk, eat, and learn from 

one another. They occasionally invite guests who present pertinent information to the group. For the past 

several years, GTO members have gotten together 

during the holiday season and made cookies using 

kitchens available in both Occupational Therapy and 

Army Community Service. This activity has allowed 

the women to make and share their favorite seasonal 

treats while getting away from the hospital setting for 

a few hours.

Finally, the importance of understanding and 

attending to family cultural differences cannot be 

overestimated. Recognizing how different races and 

ethnicities respond to trauma is quite important. For 

example, Latinos have been observed to be more 

“hands on” with their injured loved ones. Very often 

Latino family members touch injured patients and 

talk to them regardless of their seeming unresponsiveness. Family members will include the injured 

in prayers (eg, rosaries, novenas), instruct them, 

talk to them as they shave them, and give them the 

latest family news. For non-Latino healthcare providers, these cultural methods may seem foreign. 

Unfortunately, family members can inadvertently 

feel demeaned by their sense of the disapproval of 

the medical staff.

Relationships between family members and the 

healthcare team can become further complicated 

when language barriers exist. Some of the Latino family members may believe that their observations are 

not accepted because they do not speak English. It is 

as though their comments are tainted by ignorance 

simply because they are not bilingual. The following 

vignette provides an example.

Vignette 31-5: Geraldo was wounded by an IED in Iraq 

and was transported for further medical treatment while in 

a coma. His mother, Sonia, remained at his bedside and 

continued to talk to him and to pray out loud. There were 

times when she felt he was listening to her but was unable to 

respond. The medical staff continued to tell her not to expect 

too much and kindly explained that he could not hear her and 

had no awareness. Although Sonia did not speak English, 

she understood the looks the medical staff gave her and 

knew they did not believe her, but this did not deter her and 

she continued stimulating Geraldo throughout the day and 

late into the night. She was quite excited on the day after 

Christmas when she reported that Geraldo had whispered, 

“Feliz Navidad” on Christmas Eve, but no one believed her. 

The clinical social worker supported Sonia in her belief that 

Geraldo had spoken, despite the medical team’s skepticism, 

and encouraged her to continue what she was doing. Ultimately, Geraldo came out of the coma and told his mother 

he knew she had been with him around the clock. He told 

her that he had sensed her in his “sleep” and stated that he 

recognized and was comforted by her perfume, one that 

she had used throughout his life. Geraldo was also able to 

relate conversations that had been held in his room while 

he was in the coma.

CHILDREN IN THE HOSPITAL SETTING

Recognizing and meeting the needs of children 

within general hospital settings is complex. Most 

pediatric hospitals have developed effective ways 

of engaging children and recognizing and meeting 

them at their developmental levels. Hospitals that 

provide care to adult populations have been much 
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The Children and Families of Combat-Injured Service Members

less effective in planning for the presence of children. 

Because children are important members of military 

families, the identification of, and attention to, their 

unique developmental needs is key if engagement with 

combat-injured families is to be effective.

When the family of a combat-injured patient arrives 

at the hospital, the noninjured parent must navigate 

the medical environment and military system while 

being available to their injured military service member. Noninjured spouses often are inundated by the 

requirements they face, and thus the needs of their 

children can go unmet. When children arrive at the 

hospital, they can quickly become overwhelmed by 

the hospital’s size and complexity. Young parents may 

have little understanding of how to best prepare their 

children for the hospital setting and how to prepare 

them for the visits with their injured parents.

Family members can have a difficult time with 

children’s activity levels, leading to frustration and 

unnecessary harshness. Younger children can be loud 

and boisterous. They may get negative feedback from 

parents or hospital staff members, leaving them to feel 

that they are not wanted. Children may also be viewed 

as obstacles to care. Hospital and nursing personnel 

typically do not know how to engage younger children. They can benefit from simple recommendations 

that can make a child’s visit much more pleasant. For 

example, one 4-year-old boy was repeatedly making 

loud noises and gestures in the hospital that were 

disturbing other patients and hospital staff members. 

His parents and grandmother were embarrassed by the 

behavior and became engaged in a heated and public 

emotional exchange. After a discussion with Child 

and Adolescent Psychiatry Service (CAPS) staff, they 

were helped to recognize that the child had his own 

ways of expressing worries and needed time to play 

and unwind outside of the hospital setting.

Children’s presence within the hospital should 

be time limited and structured. Medical centers that 

provide care to injured service members should ensure 

that there are appropriate areas for family activities 

that are “child and family friendly.” Specific plans need 

to be put in place that allow children to be present and 

involved in their parent’s care, while preparing and 

protecting them from what they are likely to see in 

the hospital setting. Because of the many injured SMs 

being treated at military medical centers, children can 

not only be exposed to their own parent’s frightening 

medical condition, but also the burns, amputations, 

and serious injuries of those other SMs receiving care. 

Recommendations for healthcare treatment facilities’ 

support of families of the combat injured are outlined 

in Exhibit 31-1.

Parents can assist children to prepare for, and 

comfortably participate in, hospital visits. When possible, it is helpful for parents to settle into the hospital 

routine alone, before children arrive. If children must 

accompany parents to the hospital at the first visit, 

it is best that children remain in the hotel or other 

living quarters while the noninjured parent gets to 

know the hospital environment. Parents can help their 

children understand what they may see or be exposed 

to. In order to do this, parents must first integrate the 

experience themselves. The opportunity for parents 

to describe what the hospital looks like, where it is 

located, who are the members of the treatment team, 

the appearance of the hospital room, and the names of 

individuals with whom the injured parent may share a 

room, will all help to orient a child to this new setting. 

When possible, parents can also show children pictures 

of the hospital, the ward, the hospital room, and their 

injured SM parent to best prepare them for what they 

will see when they come.

Preparation for the meeting with the injured parent is 

a continuation of the discussion that began with injury 

notification and continues throughout the hospitalization and recovery period. Children typically want to 

know what is happening and what they can expect 

when they come to the hospital. Noninjured parents 

can best accomplish this by gauging the appropriate 

amount of injury-related information (presence of 

bandages, casts, amputations, or medical equipment) 

and mixing the discussion with descriptions of less 

anxiety-provoking topics, such as the hospital cafeteria, 

the kind of food that they can eat while in the hospital, 

or the hotel or living quarters. With proper planning 

most children will feel comfortable when the time for 

the visit arrives. It is particularly important to carefully 

prepare children when dramatic changes in a parent’s 

appearance occur, such as facial wounds or serious 

burns. The following vignette describes how one couple 

successfully met their young child’s needs.

Vignette 31-6: Teddy was a 31⁄2-year-old boy whose 

father, Bill, had been deployed to Iraq for 6 months when 

he was wounded in an IED explosion. The father sustained 

serious injuries to his face and upper extremities requiring 

unilateral facial bandaging and resulting in an inability to 

effectively use his arms and hands. On the day of Teddy’s 

first visit with his father, his mother spent several minutes 

explaining the nature of the injuries and what he was likely 

to see upon entering his father’s room, to include the presence of facial bandages, as well as his father’s hoarse and 

somewhat unrecognizable voice. Teddy became very excited 

about the prospect of seeing his father. When they entered 

the room Teddy became silent and transfixed by his father’s 

appearance. While his mother tried to reassure him, Teddy 

cautiously approached his father and carefully climbed on 

Bill’s lap when invited. Instinctively, Bill began jostling Teddy 

between his legs, a game they had played often prior to 
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Combat and Operational Behavioral Health

EXHIBIT 31-1

TREATMENT FACILITIES’ SUPPORT OF FAMILIES OF THE COMBAT INJURED

Recognize the contributions of families as part of treatment and establish appropriate boundaries for involvement

Develop child- and family-friendly treatment environments

	 •	 Welcome children and families

	 •	 Families don’t VISIT, they PARTICIPATE in care

	 •	 Develop appropriate areas for family visiting: in room, on ward, off ward, dining area, family lounge

	 •	 Develop child-appropriate environments within the hospital

	 •	 Ensure adequate available family lodging

	 •	 Consider child life worker involvement within the hospital

Protect children from unnecessary exposures

	 •	 Educate healthcare providers about child developmental issues and exposure risks

	 •	 Develop a systematic methodology to prepare children for hospital visits

	 •	 Support parents in parenting role and encourage them to speak with their children about health status

Develop family intervention strategies

•	 Watch for and address intrafamilial conflicts

	 •	 Consider multifamily or spouse group involvement

	 •	 Recognize the role of bereavement in family transition

	 •	 Actively address expected role changes within the family, especially in TBI and polytrauma victims

Monitor for “at risk” family situations

•	 Traumatic brain injury

	 •	 Polytrauma victims

	 •	 Marital or intrafamilial strife/domestic violence

	 •	 Substance use problems

	 •	 Signs of spousal or parental disengagement

Rally resources to aid

•	 Practical assistance

	 •	 Military Severely Injured Program

	 •	 Veterans Administration resources—Seamless Transition

	 •	 Military OneSource

	 •	 Military treatment facilities/TRICARE

	 •	 Self-help and other support organizations

the deployment. The familiarity of this activity eased Teddy, 

who immediately relaxed and began talking with Bill in a 

more natural and comfortable way. Recognizing the stress 

that Teddy faced, his mother limited the amount of time that 

Teddy stayed in the hospital setting and ensured that he 

spent considerable time at the hotel pool.

SUPPORT TO COMBAT-INJURED FAMILIES WITH CHILDREN

To better meet the needs of the families and children 

of injured SMs, the CAPS at WRAMC has established 

a system of care in which clinicians actively engage 

families of combat-injured SMs. CAPS staff members 

are informed of the pending arrival of the families of 

injured SMs by official notification. Clinicians provide 

an informational briefing to incoming families during 

their orientation at the Family Assistance Center, at 

which time they are given general information about 

CAPS services and how they can access care for identified problems. Families are also notified that they will 

be contacted by CAPS providers within the immediate 

future. This contact is typically made within 1 week of 

arrival at WRAMC.

Available CAPS services include anticipatory parental guidance to the injured SM and spouse, assistance 

in preparing children for their visit to the hospital (to 

include how and what they should be told in anticipation of seeing their wounded parent for the first time), 

supportive reassurance, anxiety relief, and connec-
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The Children and Families of Combat-Injured Service Members

tion to appropriate resources when required. CAPS 

staff members work collaboratively with WRAMC 

PCLS at the hospital bedside. CAPS staff members 

also provide therapeutic activities to the children 

living at the Fisher and Malone Houses, where families reside during SM treatment, and at the Military 

Advanced Training Center, where wounded SMs and 

their families participate in outpatient occupational 

and physical rehabilitation. Services are offered in an 

outreach or “preclinical” format to support healthy 

family recovery. The goals of the intervention are to 

assist the reunion of the injured SM family, to promote 

children’s mastery of the complex and stressful injury 

experience, and to facilitate and promote the rehabilitation process of the injured parent by acknowledging 

the integral and essential role of parenting in the SM’s 

life. By interacting with families from early in their 

arrival and developing trusting relationships, CAPS 

strives to assist families to avert potential difficulties 

and support their comfort in accepting additional 

services when indicated. When deemed appropriate, 

children and families requiring clinical assessment or 

treatment are referred to the outpatient mental health 

clinic for formal assessment.

At WRAMC and Brooke Army Medical Center, 

mental health clinicians have begun using the Parent 

Guidance Assessment–Combat Injured (PGA–CI) 

instrument as a mechanism to assist in conducting 

discussions with injured SMs and their spouses 

about the needs of their families (especially their 

children) in response to the combat injury. A copy 

of the PGA-CI is included in Attachment 1. This 

semistructured clinical interview is designed to assess family demographics, deployment experience, 

nature of the combat injury, intrafamilial communication about the injury, and the effect of the event 

on family members, and to initiate discussion about 

family expectations and future plans. Often, the 

PGA-CI interview is the spouses’ first opportunity to 

talk about their personal experiences and to describe 

the effect of this powerful event on the family. The 

PGA-CI affords the time to think about their children and to ask questions about how best to meet 

their children’s needs. Ultimately, the PGA-CI was 

designed to assist healthcare professionals in the 

formulation of family assistance strategies and plans, 

with specific interest and emphasis on the positive 

growth of children.

CHILDREN’S RESPONSES TO COMBAT INJURIES

It is expected that all family members are likely to 

show some level of distress because of the sudden 

injury of a military family member. Clinicians have 

anecdotally observed that although most children do 

not initially demonstrate symptoms consistent with 

actual psychiatric disorder, many appear anxious, 

saddened, or troubled by the news. Parents do not 

always accurately recognize the emotional effect of 

the parent’s injury on children. Prior studies have 

shown that parent reports alone are not reliable in 

the determination of child behavioral and emotional 

problems and that cross-informant input from others, 

to include children, is required for accurate assessment.31 Children who have been exposed to trauma 

similarly report different and much higher levels of 

clinical symptoms than their parents, highlighting 

the importance of direct child assessment for accurate evaluation.32 No scientific investigation has yet 

systematically and directly measured the responses of 

children to parental combat injury. This section provides anecdotal descriptions of children with whom 

the authors have engaged.

When children first meet their injured parent, their 

understanding of the injury and the implication of the 

injuries can be limited. They may experience a broad 

range of emotional responses that can be confusing 

both to themselves and to the important adults in their 

lives. Some children become hesitant and afraid of 

what they see. They are often distressed and unable to 

show affection to the injured parent. As a result, some 

injured SMs express feelings of hurt or disappointment 

by these reluctant responses. When this occurs, the 

uninjured parent or another relative may be overly 

forceful in pushing children, especially young children, 

to show affection for the injured.

When parents deploy, children are usually told that 

their parents will safely return home. After the injury, 

children realize that parents cannot always keep promises that they make. A few children have expressed 

confusion and anger toward authority, as if they have 

been wronged. Frequently this anger may be directed 

toward the caregiver or other adults. Alternatively, 

children may verbalize fear and ambivalence. They 

may look to blame others for their parents’ injuries or 

may feel guilty as if somehow they are responsible. 

After the immediate emotional response, children report feelings of relief and gratitude that the SM parent 

is alive and safe. However, emotions can fluctuate in 

character and intensity.

A developmental perspective is helpful when the 

expected responses of children to parental injury are 

considered. For example, although infants and toddlers 

(0–2 years) may be assumed to have little cognitive 

capacity to appreciate their parents’ injuries, they will 

respond based upon changes in the schedules and 

routines of their lives, and the physical and emotional 
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Combat and Operational Behavioral Health

availability of important adults, as well as any changes 

in the emotional tenor (anxiety, interpersonal abruptness, irritability) of these individuals.

Young children (3–6 years) have greater awareness 

of the actual nature of the injury. However, this understanding is likely to be undeveloped and fragile. 

Young children use “magical thinking,” an immature 

cognitive process characterized by egocentric thinking, 

which can lead them to inaccurately take responsibility 

for events that occur. Young children’s cognitive processes become even less reality based at times of high 

anxiety, as occurs after a parent’s injury. For example, 

one 4-year-old son of an injured SM told his grandparent that he was responsible for his father’s injury 

because he did not remind his dad to be careful when 

the SM was deploying. The young child needed to be 

reassured that he did not cause his father’s injury.

The immature cognition capacity of young children 

can lead to an inability to gauge an accurate sense of 

time. For example, a 3-year-old boy, whose father had 

multiple injuries and was prescribed extensive bed rest 

after an amputation, gave his father’s wound a kiss and 

said, “It’s all better now, Dad. Let’s play.” He became 

confused and frustrated when repeatedly told that his 

father could not yet play with him. The staff worked 

with the boy and his parents to establish more circumscribed ways of playing that allowed the father and 

son to enjoy their time together. Because many serious 

injuries can result in months, if not years, of medical 

treatment and rehabilitative services, the patience of 

young children can rapidly dissipate. Professional 

intervention that assists parents in understanding the 

developmental limitations of children and in creating 

new means of interaction can be invaluable for the 

future success of the family.

The clinician must recognize how young children 

perceive and integrate the nature of their parents’ 

injuries. Not uncommonly, young children who see 

their seriously injured parents become disorganized 

and extremely anxious. They may wonder “if this 

powerful and important person in my life can be hurt 

in this way, what could potentially happen to me?” For 

example, the mother of two young sons of a seriously 

injured marine asked to talk with a WRAMC CAPS 

clinician about their behavior. The boys were becoming 

increasingly aggressive, impulsive, and active, especially when their father’s injury was discussed. While 

in the room visiting their father, the boys sat quietly 

and were immobilized, carefully watching him. After 

leaving the room, they became aggressive with each 

other and oppositional to their mother.

During the evaluation, each child was asked to 

“draw a person.” They were given no additional directions and were not specifically requested to draw their 

father. The younger child produced the drawing shown 

in Figure 31-2. He initiated the drawing as one would 

expect, completing the face first, but then proceeded 

to scribble erratically over and around the face. When 

asked what the picture represented, the young boy 

stated, “This is a man in an explosion.” After completing the drawing, the boy shifted to aggressive play 

with toy dinosaurs and jungle animals.

The older 5-year-old brother was also asked to produce a drawing of a person. His drawing is shown in 

Figure 31-3. Unlike his younger brother, he completed 

the drawing in a very careful and methodical fashion. 

However, different from his younger brother and the 

typical approach of other children, the boy started by 

drawing the figure’s feet, which were large and sturdy. 

He then added extended sections of leg bilaterally. 

After adding three sections of leg to the drawing, the 

5-year-old drew a brace between the two legs to hold 

them together. The brace was later erased and is not 

present in the final drawing. This addition betrayed 

the older son’s anxiety about the body’s perceived instability that needed to be supported by an armature. 

He completed the drawing by adding arms, powerful 

shoulder muscles and a small head. There is no apparent torso and the body is joined at the shoulders.

The children’s drawings that appear in these figures 

give some view into their interior psychological worlds 

and their drive to process what they had seen and 

experienced. Their immediate choice to draw injured 

bodies indicated the psychological challenge that each 

faced. The younger son was clearly struggling to make 

Figure 31-2. Drawing of 3-year-old son of severely injured 

service member. Image courtesy of Stephen J Cozza, MD.
515

The Children and Families of Combat-Injured Service Members

Figure 31-3. Drawing of 5-year-old son of severely injured 

service member. Image courtesy of Stephen J Cozza, MD.

sense of his father’s injury, but was finding difficulty 

in doing this in any organized way. In comparison, 

his older brother, while equally preoccupied with his 

father’s injury, demonstrated greater capacity to organize his own thoughts and anxieties and develop his 

own solutions (as evidenced by the added brace). This 

greater ability probably indicates the older brother’s 

greater psychological and cognitive capacities. The 

drawings are not presented as examples of psychopathology, but rather to highlight the challenges that face 

the young children of combat-injured SMs.

Older children have more mature developmental 

capacity to meet the stresses of parental injury, both 

cognitively and emotionally. Nonetheless, the schoolaged child may still harbor similar anxieties to those 

of younger children. Fear, in combination with a 

sense of guilt and a desire to take responsible action, 

can complicate the school-aged child’s response, as 

the following two examples illustrate. An 8-year-old 

boy, whose father had multiple severe injuries and 

was unconscious as a result of an IED explosion, expressed his reaction to a 4th of July celebration that 

occurred while he was visiting the hospital. During 

the celebration he was frightened by both the fireworks and low-flying helicopters. He worried that 

his family was being targeted by missile attacks from 

“the bad guys.” He imagined another 9/11 terrorist

attack near the hospital. He was able to talk with the 

staff concerning his frequent worries about his and 

his family’s safety. One 10-year-old girl confided 

that she was sad and missed her two cats that were 

given to a friend and was sure that she would never 

see them again. CAPS staff helped her raise these 

concerns with her parents, who were unaware of the 

impact of this loss.

Not surprisingly, children can be confused about 

expectations related to their responses to the injured 

parent. They may not understand what is or is not appropriate and may feel uneasy bringing up questions. 

One injured SM expressed concern that her children 

were reluctant to have physical contact with her. As 

they had always been affectionate, she could not understand why they no longer wished to be hugged. 

The mother’s apprehension prompted a discussion 

in which the children described the fear that if they 

touched her, they might inadvertently add to her 

ongoing pain. This new understanding allowed the 

mother to reassure the children and to help them find 

ways to express their love and care without fear of 

increasing her pain.

Based upon their developmental stage, teenagers 

are faced with unique challenges related to parental 

injury. At a time when they are normally expected to 

become more independent and less reliant on family, 

they can be confused by a sudden need to once again 

be close to, and intensely involved with, their parents 

and families. Given their near-adult capacity, teenagers may also be asked to shoulder some of the greater 

demands that result from parental injury, including 

increased chores, care for younger children, or assistance in the care of the injured parent. Teenagers may 

be ambivalent and may voice wishes to be with their 

friends, rather than spend time with their families or 

injured parent. When visiting the hospital, adolescents have been observed playing electronic games or 

spending time on computers away from their parents. 

An adolescent’s apparent lack of interest should not 

be construed as apathy. Clinicians should encourage 

parents to discuss their teenagers’ fears about the injury and their ambivalence about the changed family. 

Parents may need to be reminded of the importance of 

remaining involved in their teenagers’ lives, especially 

because this age group is at high risk for engaging in 

dangerous behaviors. Parents should be encouraged to 

be clear about their expectations, set appropriate limits 

on behavior, and consistently administer discipline, 

when appropriate. 

Children and teens can also become activated in 

healthy ways in response to parental injury. One 

injured amputee parent proudly shared that his son 
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Combat and Operational Behavioral Health

started a blood drive for a local hospital in appreciation 

of the care that his father had received. Clearly, this 

boy was able to redirect the unfortunate experience 

of his father’s injury into altruism and leadership that 

supported his father’s healing. Other children have 

channeled their energy and desire to help in positive 

ways within the hospital setting. For example, two 

preteenage children came to visit their single father 

who had serious upper extremity injuries as a result 

of an IED blast. These children cared for their father by 

bringing food and water and assisting him with some 

simple and age-appropriate activities of daily living. 

As a result, the children felt that they were part of their 

father’s treatment and made important contributions 

to his progress. The clinical staff encouraged the father to include his children in these activities as they 

requested, while setting limits where developmentally 

appropriate.

Children whose situations must be closely evaluated are those with preexisting emotional, behavioral, 

developmental, or medical conditions of their own. For 

these potentially more vulnerable children, clinicians 

can expect that the stresses associated with parental 

injury may lead to greater distress or worsening of their 

underlying conditions. Healthcare providers should 

maintain a lower threshold for referral to appropriate 

clinical resources. At times, families that have children 

with preexisting conditions may move from their 

homes to live in the vicinity of the military hospital 

where the parent is being treated. These parents need 

to facilitate continuity of care from earlier treatment 

providers to newly identified clinicians at the military hospital site. Given a family’s preoccupation in 

addressing the medical needs of the injured parent, 

children’s healthcare or educational needs can go 

EXHIBIT 31-2

GOALS FOR CHILDREN OF INJURED SERVICE MEMBER PARENTS 

Develop an age-appropriate understanding of 

what happened to the parent.

Develop an age-appropriate understanding of 

the injury and required medical care that can 

result in

	 •	 family separations,

	 •	 lengthy hospitalizations,

	 •	 multiple procedures, and

	 •	 change in family structure/routine.

Accept that they did not create the problems they 

may now see in their families.

Learn to deal with the sadness, grief, and anxiety 

related to parental injury.

Accept that the parent who went to war may be 

“different” than the person who returned, but is 

still their parent.

Adjust to the “new family” situation by

	 •	 staying hopeful,

	 •	 having fun,

	 •	 being positive about life, and

	 •	 maintaining goals for the future.

unaddressed or inappropriately delayed. Ultimately, 

children must integrate the realities of the parent’s 

illness over time and adjust to the changes that they 

face. Exhibit 31-2 highlights the goals of recovery for 

the children of combat-injured SMs.

EFFECT OF THE INJURY ON THE PARENT

In addition to the direct effect of the injury on children, it is important to consider the psychological effect 

of these injuries on SMs and on their various family 

roles. Depending upon the nature of the injury, SMs 

may have resultant physical, psychological, or cognitive changes that affect their abilities to function in 

virtually all areas of their lives, including parenting. 

Injuries can alter an SM’s capacity to feel comfortable 

in intimate relationships, may create distance with 

those to whom they are married or emotionally close, 

and may undermine their sense of sexual capacity. 

Because the vast majority of injured SMs are young 

men, it is important to recognize the potential for 

narcissistic trauma that negatively affects their sense 

of competence as men, with resulting effect on spouses 

and children.

Injured SMs were likely physically active individuals who incorporated these traits in their parenting 

activities prior to the injury. Physical activities (hiking, 

backpacking, and camping), hands-on activities (playful wrestling), and athletic activities (ball throwing, 

skiing, and golfing) were all likely modes of interaction for young military parents with their children. 

Depending upon the nature of the injury, those modes 

of interaction either may no longer be possible or 

may require significant modification to their previous form. In such cases, injured SMs will need to alter 

their former idealized sense of themselves as parents, 

mourning any related body change or functional loss. 

Clinicians should encourage children and parents to 

explore innovative, mutually developed activities and 

play that allow parents and children to “try on” fresh 

ways of relating. The capacity for the parent–child 

dyad to reestablish enjoyable modes of interaction is 
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The Children and Families of Combat-Injured Service Members

critical to future health and happiness. Candid parental 

discussions can allow injured SM parents to reframe 

their situations, develop new skills, and achieve greater 

strength in parenting. Within the hospital setting, occupational therapy and physical therapy services have 

incorporated children into therapeutic activities with 

parents in novel and creative ways.

Principles of Caring for Combat-Injured Families

Recognizing that parental combat injury is a lifechanging event for SMs, their families, and their 

children, the Center for the Study of Traumatic Stress 

at the Uniformed Services University of the Health 

Sciences convened the Workgroup on Intervention 

With Combat-Injured Families. This workgroup 

included expert military and civilian clinicians and 

academicians from around the country, focusing on 

the unique needs of this special population. As a result 

of workgroup meetings, the Center published a fact 

sheet titled “Principles of Caring for Combat-Injured 

Families and Their Children” (Attachment 2). These 

10 principles can be used by hospital- and communitybased professionals in military and civilian settings 

to support the healthy growth and recovery of this 

unique population. The principles of caring are summarized in Exhibit 31-3. 

Long-Term Rehabilitation and Transitions

Although most of this chapter has addressed the 

experiences and needs of the families and children of 

the combat injured during the immediate aftermath of 

injury, their long-term requirements can vary tremendously and must be planned for. Some data suggest 

that injured SMs may develop vulnerabilities as they 

transition back to their homes and communities.1

When families leave the hospital setting they no longer have the intensive resources that were available. 

They can lose connection with the families of other 

injured SMs with whom they may have developed a 

EXHIBIT 31-3

PRINCIPLES OF CARING FOR FAMILIES 

AND CHILDREN OF THE COMBAT 

INJURED 

	 •	 Principles of psychological first aid are

primary to supporting families of combatinjured service members.

	 •	 Medical care for the combat injured must be

family focused.

	 •	 Service providers should anticipate a range

of responses to combat injury.

	 •	 Injury communication is an essential component of care of the families of injured service 

members.

	 •	 Programs to assist the families of combatinjured service members must be developmentally sensitive and age appropriate.

	 •	 Care of the family of injured service members

is longitudinal, extending beyond immediate 

hospitalization.

	 •	 Effective family care requires an interconnected community of care.

	 •	 Care must be culturally competent.

	 •	 Communities of care should address any

barriers to service.

	 •	 Families, communities, and service providers

must be knowledgeable.

EXHIBIT 31-4

Resources 

1. Resources for Recovery—The Combat Injured 

Family: Guidelines for Care. Bethesda, Md: 

Center for the Study of Traumatic Stress, 

Uniformed Services University of the Health 

Sciences. Available at: http://www.centerforthestudyoftraumaticstress.org. Accessed 

October 14, 2009.

2. Sesame Workshop Talk, Listen, Connect: 

Deployments, Homecomings, Changes–

DVD and print materials. Available through 

Military OneSource at: http://www.militaryonesource.com, and by online streamed 

video at: http://www.sesameworkshop.

org/tlc. Accessed October 14, 2009.

3. Lee M, Ingram L. That’s My Hope: Featuring 

a Gallery of Multigenerational Artwork. Early 

Light Press, LLC. 2008. Available at: http://

www.earlylightpress.com. Accessed September 2, 2009. 

4. McCue K, Bonn R. How to Help Children 

Through a Parent’s Serious Illness. New York, 

NY: St. Martin’s Press; 1994.

5. Rauch PK, Muriel AC. Raising an Emotionally 

Healthy Child When a Parent is Sick. New York, 

NY: McGraw-Hill; 2006.

6. Beardslee WR. Out of the Darkened Room: 

When a Parent is Depressed. New York, NY: 

Little, Brown and Company; 2002.

7. Woodruff L, Woodruff B. In an Instant: A Family’s Journey of Love and Healing. New York, 

NY: Random House; 2007.
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sense of fellowship and camaraderie. Families may 

struggle with the realities of being home, having to 

face responsibilities and routines that no longer seem 

manageable. Often injured SMs require continuing 

medical or rehabilitative care. Access to needed services can be problematic or may require the scheduling of appointments at treatment facilities that are 

at great distance from home, adding more stress to 

family routines.

With the return of the injured SM, children may 

expect a return to the lives they remember. They may 

become disappointed with changes that they experience in the family. Older children and teenagers may 

have to pick up additional household responsibilities 

that the injured parent is no longer able to perform. 

When children are placed in a care-provider role to 

the injured SM, emotional challenges can be even 

greater. Teens may be asked to assist with wound 

care, self-care, or other activities of daily living that 

require intimate contact with the parent. This contact 

can be confusing, emotionally upsetting, and lead to 

resentment and frustration. Such activities should be 

minimized.

Finally, longer-term consequences of severe combat injury can result in medical retirement from the 

military service, the loss of a cherished military career, 

and movement from homes in military communities to 

other locations or back to families of origin. Although 

such transitions may increase access to available 

resources, particularly when the extended family is 

supportive, these changes are likely to be stressful for 

both adults and children. Moves from known communities likely mean loss of friends, changes in schools, 

and possible elimination of enjoyable extracurricular 

activities. Moves also can cause relocations to communities that have little understanding or appreciation of military culture and the unique challenges that 

the family has faced. (See Exhibit 31-4 for additional 

resources available to help families of combat-injured 

service members.)

SUMMARY

Combat injury can profoundly affect the lives of 

service members, their families, and their children. 

Upon injury notification, a cascade of events takes 

place that can result in distress and interpersonal turmoil for children and adults in the families of the combat injured. Disruptions in parental functioning and 

family structure are common. The effect on children 

of serious injury to a parent is likely to be profound, 

particularly when it leads to long-term or permanent 

changes in parents, or deterioration in their functioning. Immediately after the injury, noninjured parents 

are focused on the medical well-being of the injured 

SMs and may have difficulty recognizing and meeting 

the needs of their children. Children’s developmental 

and emotional capacities determine their abilities to 

understand and integrate the experience of parental 

injury. Parents and healthcare providers benefit from 

developmentally informed guidance to help children 

accept the injury, manage their distress, prepare for 

hospital visits, reengage the injured parent, and effectively communicate their needs. Family and child 

reactions to combat injury must be understood as a 

longitudinal process beginning with injury notification and continuing through longer-term rehabilitation and potential transitions to new lives and new 

communities.

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