The Hardt family is no rookie to the fold. Korin Hardt, 38, has seen her husband through five year-long military deployments; four of which her three children have also endured. But of the four deployments, Hardt said, the latest one has hit her 9-year-old daughter the hardest.
Hardt's husband, a career army gunner, left for his first tour to Afghanistan in August. Hardt received a call two months later from her daughter's school, saying that Abigail cut herself on the leg with a pair of scissors.
"She said she wanted to know what it felt like," Hardt said.
"Did it hurt," Hardt remembered asking her daughter.
"Not really," Abigail said.
"Did you hurt?" Hardt asked.
"I always hurt. I miss my dad," Abigail said.
And Abigail is not alone. A study released Monday in the journal Pediatrics suggested that children whose military parents have been deployed are more likely to suffer from behavioral or mental health disorders.
"Military deployment doesn't just affect the soldier, but it's the family back home. Not just the spouse but children, too," said Dr. Gregory Gorman, a military-based commander and assistant professor of pediatrics at the Uniformed Services University of the Health Sciences in Bethesda, Md., and lead author of the study.
"We hear this anecdotally, but now medical records show that it's true."
Gorman and his colleagues tracked health claim records during 2006 and 2007 of nearly 650,000 children ages 3 to 8 and found that those with a parent deployed within the two years had an 11 percent higher rate of clinic visits because of mental health or behavioral issues than military children whose parents were not deployed. Researchers also noted the rate of visits increased as the child grew older.
Previous studies have looked at emotional and behavioral changes during one point in time. This is the first study of its kind to track children of all military branches over time, Gorman said.
During her father's most recent deployment, Abigail was diagnosed with general anxiety disorder, sensory processing disorder and attention deficit hyperactive disorder, commonly known as ADHD. She is taking medication to help curb her symptoms.
But doctors have upped Abigail's prescription for Zoloft -- an antidepressant -- to 200 milligrams since August, the highest dosage for a child her age.
Deployed Dads Missed More Than Moms
"Bedtime is the worst," Hardt said, adding that Abigail worries her father won't come home. "That's the time I think when she's not busy, so she has time to think about it."
Gorman's study also suggested that children with deployed fathers were more likely to face problems than those with deployed mothers. But families where the father was deployed may have been more likely to enroll in the military health insurance program Tricare, which provided the data for the research, according to Dr. Beth Ellen Davis, retired colonel and pediatrician at Madigan Army Medical Center in Tacoma, Wash., and author of the study's accompanying editorial.
"On the basis of my clinical experience, I would have as much (if not more) concern about child MH [mental health] and behavioral problems in single AD [active duty] parent and female deployed-service-member households," Davis wrote in her editorial.
Researchers also noted that the findings may underestimate the psychological stress of military families, since they looked at records of children in all military branches -- not just the Army and Marine families who have incurred a larger number of deployments.
Most Problems Occur With Children Living 'Outside the Gates,' Study Finds
Military bases are known to provide the largest support network for families enduring a deployment. Many children share deployment experiences, and schools often provide programs, including deployment support groups. But most military families do not live on a military base.
"Right now, [Abigail] is not in a military school and I think that makes a difference," Hardt said.
Indeed, 65 percent of mental health and behavioral problems were reported by civilian physicians, not by military doctors and not on military bases, according to Gorman's study.
"This is not just an issue of importance to military policymakers. This is applicable to anyone who takes care of children," professor Gorman said. "Hopefully, this will draw attention to military children that are present in these practices and [the doctor] may not even know it."
While pediatricians and other child-care providers routinely ask children about their family dynamic, Davis said, it is now important to understand whether the child is part of a military family, and include questions specific to their parents' service.
Surviving Deployment: No One Size Fits All
"By simply asking, 'I understand your daddy-mommy is deployed. How are you feeling?' pediatricians can uncover important stressors in a military family," Davis wrote.
The problems seen in a child are often problems experienced within the family, said Dr. Oscar Bukstein, pediatric psychiatrist at Children's Memorial Hermann Hospital and director of the Division of Child and Adolescent Psychiatry at the University of Texas Medical School in Houston.
"When the spouse is away and in harm's way, it's hard to keep your feelings about it from your child," Bukstein said. "Kids have a difficult time expressing [their feelings] and it could be exacerbated by parents who show that they are also having a tough time."
The U.S. Department of Defense and other military organizations provide a wealth of program to support military personnel, spouses and children, including those who do not live on military installations.
But according to Dr. Michael Faran, director of the child adolescent family behavioral health at Madigan Army Medical Center at Joint Base Lewis-McChord in Washington, while there are plenty of resources available, some families choose not to participate.
"There's a stigma against seeking mental health and behavioral health help, and I don't think it's any different in the civilian world," said Faran.
Mental health is often viewed differently than other types of chronic medical conditions such as diabetes, according to Faran.
"Many view mental health problems as mental and something we can overcome on our own," he said.
Some families think once the deployment is over, so too will the problems, he said. But Faran said it's important for families to realize it may not be over, and they should continue to seek help. In fact, Fran said more families may be likely to accept help if mental health becomes a mainstream way to achieve overall health.
"We need to embed behavioral health into community, and get it outside of just the clinics and schools," said Faran. "I don't think that we as a culture have got to that point, but the Army is working hard to change this. There's a lot to do, and families are suffering."
Abigail attends free counseling and psychiatric sessions, a practice now common to military members and their families who have endured all or part of the near decade-long fight against international terrorism.
"I think the largest support is me trying to keep a sense of normalcy for them," Hardt said of her children.
Hardt said her network of family members, military and non-military friends, and military provided resources have always helped her children through. Abigail is a girl scout, and the family takes vacations often, she said.
Indeed, community involvement is important, study author Gorman said. Still, he added, each deployment within a family presents separate challenges. Every age brings about new experiences for a child.
"We need to tailor resources to children within different age groups," he said.
But Gorman said there's no one source that will provide the best support.
"I think it's a holistic approach," he said. "Anytime there's a medical condition for a child, the medical provider, the military command, and families have to work together.
"To treat the child you have to treat the family."