Behavioral Health Service Use by Military Children During Afghanistan and Iraq Wars

  • Nikki R. WootenEmail author
  • Jordan A. Brittingham
  • Nahid S. Sumi
  • Ronald O. Pitner
  • Kendall D. Moore


Medical claims were analyzed from 2810 military children who visited a civilian emergency department (ED) or hospital from 2000 to 2014 with behavioral health as the primary diagnosis and TRICARE as the primary/secondary payer. Visit prevalence was estimated annually and categorized: 2000–2002 (pre-deployment), 2003–2008 (first post-deployment), 2009–2014 (second post-deployment). Age was categorized: preschoolers (0–4 years), school-aged (5–11 years), adolescents (12–17 years). During Afghanistan and Iraq wars, 2562 military children received 4607 behavioral health visits. School-aged children’s mental health visits increased from 61 to 246 from pre-deployment to the second post-deployment period. Adolescents’ substance use disorder (SUD) visits increased almost 5-fold from pre-deployment to the first post-deployment period. Mental disorders had increased odds (OR = 2.93, 95% CI 1.86–4.61) of being treated during hospitalizations than in EDs. Adolescents had increased odds of SUD treatment in EDs (OR = 2.92, 95% CI 1.85–4.60) compared to hospitalizations. Implications for integrated behavioral health and school behavioral health interventions are discussed.


Military children Behavioral health care Military health system beneficiaries Military medicine Mixed effects model Afghanistan and Iraq wars 



Data are from the records of the South Carolina Revenue and Fiscal Affairs Office (SC RFA), Health and Demographics, whose authorization to release these data does not imply endorsement of this study or its findings by either the Division of Research and Statistics or the Data Oversight Council. The authors acknowledge programming assistance from Mr. Chris Finney, SC RFA, Health and Demographics Division, in creating the data extract used in this study and research assistance from Tamara L. Grimm, MSW.

Funding Information

This study was funded by the National Institute on Drug Abuse (NIDA #K01DA037412, PI: Nikki R. Wooten, PhD).

Compliance with Ethical Standards

Conflict of Interest

Dr. Wooten is a lieutenant colonel in the U.S. Army Reserves and Mr. Moore is a lieutenant junior grade in the U.S. Naval Reserves, but neither conducted this study as a part of their official military duties. All other authors report no conflicts of interest. The opinions and assertions herein are those of the authors and do not necessarily reflect the official views of the Department of Defense, SC RFA, NIDA, or the National Institutes of Health.

Presentation Information

This study was presented as an oral presentation at the annual meeting of the Society for Social Work and Research, New Orleans, LA, January 14–17, 2017.

Supplementary material

11414_2018_9646_MOESM1_ESM.docx (13 kb)
ESM 1 (DOCX 13.1 kb)
11414_2018_9646_MOESM2_ESM.docx (40 kb)
ESM 2 (DOCX 39.9 kb)


  1. 1.
    U.S. Department of Defense. Report on the impact of deployment of members of the Armed Forces on their dependent children. Washington, DC: Author; 2010.Google Scholar
  2. 2.
    Sogomonyan F, Cooper J. Trauma faced by children in military families: What every policymaker should know. New York, NY: Columbia University;2010.Google Scholar
  3. 3.
    De Pedro KMT, Astor RA, Benbenishty R, et al. The children of military service members. Review of Educational Research. 2011;81(4):566–618.CrossRefGoogle Scholar
  4. 4.
    Gorman GH, Eide M, Hisle-Gorman E. Wartime military deployment and increased pediatric mental and behavioral health complaints. Pediatrics. 2010:1058–1066.Google Scholar
  5. 5.
    White CJ, de Burgh HT, Fear NT, et al. The impact of deployment to Iraq or Afghanistan on military children: A review of the literature. International Review of Psychiatry. 2011;23(2):210–217.CrossRefGoogle Scholar
  6. 6.
    Sullivan K, Capp G, Gilreath T, et al. Substance abuse and other adverse outcomes for military-connected youth in California: Results from a large-scale normative population survey. JAMA Pediatrics. 2015;169(10):922–928.CrossRefGoogle Scholar
  7. 7.
    Gorman GH, Eide M, Hisle-Gorman E. Wartime military deployment and increased pediatric mental and behavioral health complaints. Pediatrics. 2010;126(6):1058–1066.CrossRefGoogle Scholar
  8. 8.
    Flake EM, Davis BE, Johnson PL, et al. The psychosocial effects of deployment on military children. Journal of Developmental & Behavioral Pediatrics. 2009;30(4):271–278 Scholar
  9. 9.
    Cederbaum JA, Gilreath TD, Benbenishty R, et al. Well-being and suicidal ideation of secondary school students from military families. Journal of Adolescent Health. 2014;54(6):672–677.CrossRefGoogle Scholar
  10. 10.
    Gilreath TD, Cederbaum JA, Astor RA, et al. Substance use among military-connected youth: The California healthy kids survey. American Journal of Preventive Medicine. 2013;44(2):150–153.CrossRefGoogle Scholar
  11. 11.
    Chartrand MM, Frank DA, White LF, et al. Effect of parents’ wartime deployment on the behavior of young children in military families. Archives of Pediatric & Adolescent Medicine. 2008;162(11):1009–1014.CrossRefGoogle Scholar
  12. 12.
    Kelley ML. The effects of military-induced separation on family factors and child behavior. American journal of Orthopsychiatry. 1994;64(1):103–111.CrossRefGoogle Scholar
  13. 13.
    Aranda MC, Middleton LS, Flake E, et al. Psychosocial screening in children with wartime-deployed parents. Military Medicine. 2011;176(4):402–407.CrossRefGoogle Scholar
  14. 14.
    Astor R, De Pedro K, Gilreath T, et al. The promotional role of school and community contexts for military students. Clinical Child Family Psychological Review. 2013;16(3):233–244.CrossRefGoogle Scholar
  15. 15.
    Flake EM, Davis BE, Johnson PL, et al. The psychosocial effects of deployment on military children. Journal of Developmental & Behavioral Pediatrics. 2009;30(4):271–278.CrossRefGoogle Scholar
  16. 16.
    Gilreath TD, Astor RA, Cederbaum JA, et al. Prevalence and correlates of victimization and weapon carrying among military-and nonmilitary-connected youth in Southern California. Preventive medicine. 2014;60:21–26.CrossRefGoogle Scholar
  17. 17.
    Reed SC, Bell JF, Edwards TC. Weapon carrying, physical fighting and gang membership among youth in Washington state military families. Maternal and Child Health Journal. 2014.Google Scholar
  18. 18.
    Chandra A, Martin LT, Hawkins SA, et al. The impact of parental deployment on child social and emotional functioning: Perspectives of school staff. Journal of Adolescent Health. 2010;46(3):218–223.CrossRefGoogle Scholar
  19. 19.
    Mansfield AJ, Kaufman JS, Marshall SW, et al. Deployment and the use of mental health services among U.S. Army wives. New England Journal of Medicine. 2010;362(2):101–109.CrossRefGoogle Scholar
  20. 20.
    Larson M, Mohr BA, Lorenz L, et al. General and specialist health care utilization in military children of Army service members who are deployed. In: MacDermid Wadsworth S, Riggs DS, eds. Military deployment and its consequences for families. New York, NY: Springer; 2014:87–110.CrossRefGoogle Scholar
  21. 21.
    Larson M, Mohr BA, Adams RS, et al. Association of military deployment of a parent or spouse and changes in dependent use of health care services. Medical Care. 2012;50:821–828.CrossRefGoogle Scholar
  22. 22.
    Eide M, Gorman G, Hisle-Gorman E. Effects of parental military deployment on pediatric outpatient and well-child visit rates. Pediatrics. 2010;126(1):22.CrossRefGoogle Scholar
  23. 23.
    Hisle-Gorman E, Eide M, Coll EJ, et al. Attention deficit hyperactivity disorder and medication use by children during parental military deployments. Military Medicine. 2014;179(5):573–578.CrossRefGoogle Scholar
  24. 24.
    U.S. Department of Defense. Military health system review. Washington, DC: Author; 2014.Google Scholar
  25. 25.
    Wooten NR, Brittingham JA, Pitner RO, et al. Purchased behavioral health care received by military health system beneficiaries in civilian medical facilities, 2000–2014. Military Medicine. 2018;183(7–8):e278-e290.CrossRefGoogle Scholar
  26. 26.
    Defense Health Agency. Evaluation of the TRICARE program: Access, cost, and quality (Fiscal Year 2015 report to Congress). Washington, DC 2015.Google Scholar
  27. 27.
    South Carolina Education Oversight Committee. Educational performance of military-connected children. Columbia, SC: Author; 2015.Google Scholar
  28. 28.
    Torreon B. U.S. periods of war and dates of recent conflicts. Washington, DC: Congressional Research Service; 2015.Google Scholar
  29. 29.
    Belasco A. The cost of Iraq, Afghanistan, and other Global War on Terror Operations since 9/11. Washington, DC: Congresional Research Service; 2014.Google Scholar
  30. 30.
    Armed Forces Health Surveillance Center [AFHSC]. AFHSC surveillance case definitions. Silver Spring, MD: Armed Forces Health Surveillance Branch; 2012.Google Scholar
  31. 31.
    Bates D, Mächler M, Bolker B, et al. Fitting linear mixed-effects models using lme4. arXiv preprint arXiv:14065823. 2014.Google Scholar
  32. 32.
    Seiffge-Krenke I. Stress, coping, and relationships in adolescence. Psychology Press; 2013.Google Scholar
  33. 33.
    Lincoln A, Swift E, Shorteno-Fraser M. Psychological adjustment and treatment of children and families with parents deployed in military combat. Journal of Clinical Psychology. 2008;64(8):984–992.CrossRefGoogle Scholar
  34. 34.
    Mmari KN, Roche KM, Sudhinaraset M, et al. When a parent goes off to war: Exploring the issues faced by adolescents and their families. Youth & Society. 2008;40(4):455–475.CrossRefGoogle Scholar
  35. 35.
    Mmari K, Bradshaw C, Sudhinaraset M, et al. Exploring the role of social connectedness among military youth: Perceptions from youth, parents, and school personnel. Child and Youth Care Forum. 2010;39(5):351–366.CrossRefGoogle Scholar
  36. 36.
    Huebner AJ, Mancini JA. Adjustments among adolescents in military families when a parent is deployed: A final report submitted to the Military Family Research Institute and the Department of Defense Quality of Life Office. Falls Church, VA: Virginia Tech, Department of Human Development;2005.Google Scholar
  37. 37.
    Bradshaw CP, Sudhinaraset M, Mmari K, et al. School transitions among military adolescents: A qualitative study of stress and coping. School Psychology Review. 2010;39(1):84.Google Scholar
  38. 38.
    Barnes VA, Davis H, Treiber FA. Perceived stress, heart rate, and blood pressure among adolescents with family members deployed in Operation Iraqi Freedom. Military Medicine. 2007;172(1):40.CrossRefGoogle Scholar
  39. 39.
    Substance Abuse and Mental Health Services Administration [SAMHSA]. Behavioral health barometer: South Carolina, 2015. Rockville, MD: SAMHSA; 2015.Google Scholar
  40. 40.
    Substance Abuse and Mental Health Services Administration [SAMHSA]. Behavioral health barometer: United States, 2015. Rockville, MD: SAMHSA;2015.Google Scholar
  41. 41.
    Naeger S. Emergency department visits involving underage alcohol use: 2010 to 2013. Rockville, MD: Health Statistics and Quality, Substance Abuse and Mental Health Services Administration;2016.Google Scholar
  42. 42.
    Davis BE. Parental wartime deployment and the use of mental health services among young military children. Pediatrics. 2010:peds. 2010–2543.Google Scholar
  43. 43.
    National Center for Veterans Analysis and Statistics. 2015 Profile of unique veteran users. 2016. Available at; accessed 15 March 2016.
  44. 44.
    Resnick A, Jacobson M, Kadiyala S, et al. How deployments affect the capacity and utilization of Army treatment facilities. Santa Monica, CA 2014.Google Scholar
  45. 45.
    U.S. Government Accountability Office. Army needs to improve oversight of Warrior Transition Units. Washington, DC: GAO; 2016.Google Scholar
  46. 46.
    Capp G, Benbenishty R, Moore H, et al. Partners at learning: A service-learning approach to serving public school students from military families. Military Behavioral Health. 2017:1–10.Google Scholar
  47. 47.
    Faran ME, Johnson PL, Ban P, et al. The evolution of a school behavioral health model in the US Army. Child and Adolescent Psychiatric Clinics of North America. 2015;24(2):415–428.CrossRefGoogle Scholar
  48. 48.
    Lester P, Liang L-J, Milburn N, et al. Evaluation of a family-centered preventive intervention for military families: Parent and child longitudinal outcomes. Journal of the American Academy of Child & Adolescent Psychiatry. 2016;55(1):14–24.CrossRefGoogle Scholar
  49. 49.
    Moore KD, Fairchild AJ, Wooten NR, et al. Evaluating behavioral health interventions for military-connected youth: A systematic review. Military Medicine. 2017;182(11–12):e1836-e1845.CrossRefGoogle Scholar
  50. 50.
    Wooten N, Tavakoli AS, Al-Barwani MB, et al. Comparing behavioral health models for reducing risky drinking among older male veterans. The American Journal of Drug and Alcohol Abuse. 2017;43(5):545–555.CrossRefGoogle Scholar
  51. 51.
    Krahn D, Bartels S, Coakley E, et al. PRISM-E: Comparison of integrated care and enhanced specialty referral models in depression outcomes. Psychiatric Services. 2006;57(7):946–953.CrossRefGoogle Scholar

Copyright information

© National Council for Behavioral Health 2019

Authors and Affiliations

  1. 1.College of Social Work, Hamilton CollegeUniversity of South CarolinaColumbiaUSA
  2. 2.Arnold School of Public HealthUniversity of South CarolinaColumbiaUSA
  3. 3.Department of PsychologyUniversity of South CarolinaColumbiaUSA

Personalised recommendations