Ask About Family Military Service

Children in military families face unique challenges and stressors related to deployment and frequent relocation. However, these children also have access to an array of services of which civilian pediatricians and other care providers may be unaware.

New guidance from the American Academy of Pediatrics’ Section on Uniformed Services details needs, challenges, and opportunities for military-connected children and points clinicians to resources for these families.

For clinicians who care for military-connected children, key suggestions outlined in the report include attainment of cultural competency; this begins with simply asking about the military status of families, wrote Cmdr. Chadley R. Huebner, MD, MPH, the lead author of the report published in Pediatrics.

A Veteran’s Affairs Community Provider Toolkit gives good grounding in military culture, he added.

The behavioral and emotional screening recommended by the AAP as part of routine pediatric practice also will provide clinicians with valuable information to help guide care of military-connected children; asking about prior or current parental military service and deployment also will help guide care.

Up to half of children in military families receive care in civilian settings, according to Dr. Huebner. “Many children in military families live in settings remote from a military community, and civilian health providers are faced with caring for military children in their practices.”

Dr. Huebner, an active duty commander in the U.S. Navy, led the revision of a 2013 report on the health and mental health needs of children in U.S. military families.

The broad category of military-connected children includes not just the estimated 1.3 million children of active duty service members, but also children of 818,000 National Guard and Reserve members and more than 2 million military retirees. All told, about 4 million children are in military-connected families, with about a third of these aged 5 years or younger.

Even in young children aged 8 years and under, mental and behavioral health visits increase during deployment; older children experience more psychosocial morbidity as parental stress increases, an effect that can be mitigated by military support systems. Much existing research focuses on “the immediate effects of wartime deployment, and more longitudinal studies are needed to assess the long-term effects,” he wrote.

Still, neglect and child maltreatment increase in military families that have experienced deployment, with the risk increasing at the time of redeployment.

In addition to the known family stresses of deployment, children in military families face frequent relocation, with transitions occurring every 2-4 years and an average of nine schools attended by high school graduation, according to government data cited by Dr. Huebner.

Relocation within the past year is associated with increased use of mental health services, and adolescents in this group saw more psychiatric hospitalizations and ED visits. However, increased resilience among children in military families has been seen in some studies, with frequent relocation associated with fewer problems in school and a positive attitude about the changes associated with moves.

And families turn to each other for support with frequent moves. “Because families often move away from extended family support, they often refer to the military community as a surrogate family that provides a support network,” wrote Dr. Huebner.

Reservists don’t relocate as frequently as active duty service members but are more likely to live in areas without military resources, and their children’s peers, teachers, and caregivers may not be aware of the special challenges of military life. Similar isolation may occur when veterans make the transition to civilian life, with changes in eligibility for and access to military services and benefits.

Military programs can help

Military families, their children, and care providers and educators can turn to the military for help in many areas, whether families are receiving mental and physical health care through the military or from civilian facilities.A key resource for neglect and abuse prevention is the military’s Family Advocacy Program (FAP), which engages families by means of workshops and other support programs. When child maltreatment is alleged, FAP also conducts its own investigation, so health care professionals should include the local FAP office in the reporting process when there are concerns.

For new parents, home visits and other support programs are available through the New Parent Support program, which will connect families to resources within the community and the Department of Defense (DOD).

Families living near or on military facilities may access DOD-sponsored infant and preschool child development programs, as well as school-aged care programs; subsidies for civilian childcare are also available. Although these programs constitute the country’s largest employer-sponsored childcare program, they serve just a small minority of military families, noted Dr. Huebner, citing a 2008 study by RAND.

DOD schools are attended by 72,000 students, but DOD resources stretch into civilian schools: School liaison offices assist civilian schools and military families located near military installations, and grant funding helps the DOD partner with civilian schools serving military-connected children.

Turning to health care, the military health system provides care globally to service members, retirees, and their families. Tricare is a single-payer, government-managed insurance program that is managed through regional contracts; some care is also delivered through the centralized Military Health System.

Whether Tricare participants receive care at military facilities or from civilian network providers, they generally do not have out-of-pocket costs unless they enroll in the Tricare Select program, a fee-for-service plan that involved cost sharing with deductibles. A link to information about how to connect patients to a Tricare provider or how to become on is available in the full report in Pediatrics.

About 20% of military-connected children have special health care needs and may receive specialty care through civilian providers. To help these families navigate multiple systems of care, the DOD provides a publication called Special Needs Tool Kit: Birth to 18. This toolkit guides families through early intervention and special education, and also provides military-specific information about relocation, Tricare benefits, and military support services.

A program available to all family members with special education or chronic medical needs is the Exceptional Family Members Program (EFMP). Children with autism spectrum disorders and ADHD, for example, are eligible for EFMP enrollment.

Additional supplemental benefits, with rank-adjusted sliding fees, are available for children with serious developmental and physical problems; children with autism spectrum disorders are eligible for additional therapy through an autism care demonstration program.

Forms to document chronic medical conditions (DD Form 2792) and special educational needs, if needed (DD Form 2791-1), are required for EFMP enrollment, which is mandatory for children of active duty personnel. Guidance for completing the forms can be found at

When overseas posts are imminent, clinicians should know that certain medical conditions may disqualify children from accompanying their service member parent. Overseas screening coordinators within the military medical system serve as the point of contact for the family and pediatrician in such circumstances, and clinicians can help families by providing appropriate documentation early in the process.

In addition to attaining military cultural competence, being aware of resources available to military families, and working closely with school personnel to support military-connected children, local and national advocacy efforts can make a difference, noted Dr. Huebner. And in all cases, “health care professional, schools, and communities should proactively reach out to military families.”

Dr. Huebner reported no conflicts of interest and no outside sources of funding. The full report contains hyperlinks to all resources named.

SOURCE: Huebner CR. Pediatrics. 2019;143(1):e20183258