FORT MEADE, Md. (May 1, 2015) -- They are strong and they are resilient. They are adaptable. They are well-travelled and fiercely patriotic. They are bright, inquisitive and eager to help out, whether that is at home or in their communities. They have advantages many kids do not: parents with jobs and steady incomes, health care, safe housing, good education systems and access to early intervention programs.

But they are also children, and they are navigating a new and strange world of school and sports, bullies and gossip, first boyfriends and girlfriends, and puberty and hormones. Growing up is hard. It is scary. It is easy for kids to lose their way. And life can become harder and scarier when kids have to move every three years or when their parents miss portions of their childhoods because they are regularly deployed. And it becomes twice as hard when those parents come home changed from post-traumatic stress or traumatic brain injuries.

While most Army kids tend to handle one or two deployments well, and as a whole are doing great, experts say the trouble can start with repeated, back-to-back deployments.

DISTRESS

"Kids often experience more anxiety," said Dr. Michael Faran, a psychiatrist, retired colonel and chief of the Child, Adolescent and Family Behavioral Health Office, or CAFBHO, at Army Medical Command, explaining that while there is not a lot of data, some studies suggest about 30 percent of children will have difficulties as a result of deployment. "There's an increase in depression and anxiety. There can be a decrease in academic performance. In some adolescents, there's an increase in use of drugs and alcohol. And there has been more gang activity reported in some teens."

There have even been reports of higher levels of suicidal ideations among children who have been through numerous parental deployments, said Dr. Stephen Cozza, a retired colonel, psychiatrist, researcher, professor and associate director of the Center for the Study of Traumatic Stress at the Uniformed Services University in Bethesda, Maryland.

"That that doesn't necessarily mean that military children are mentally ill, but that they're distressed," he said. "They express it in a variety of ways. The other thing that's important to recognize is that … the majority of children are doing well despite those challenges."

Warning signs of stress in children vary by age, but can include anything from developmental regressions such as bedwetting in very small children to a lack of interest in formerly favorite activities to anger and risk-taking behavior in teenagers.

Parents should not equate good behavior with mental health, however. Faran cautioned that parents can easily overlook children, who withdraw because they are quiet and they are not causing trouble. "They may be getting very depressed or anxious, and no one is aware of it," he said. "So these kids stop talking and they used to talk to the parents. That is a red flag."

Signs of anxiety - the most common disorder in military children - also include separation anxiety, fears for the health of the parent left at home, excessive worry, sleep problems and frequent physical complaints such as headaches or stomachaches.

Maisley Paxton, a child clinical psychologist on Fort Meade, Maryland, said that while parents should expect to see some changes in their children in the period immediately after a permanent change of station move or a deployment or even a homecoming, they should not let any pronounced differences persist for long before seeking help. Paxton also recommended that children be evaluated by their pediatricians, especially if they are experiencing those frequent aches and pains.

Any child who self harms, threatens to kill herself or says he wishes he was dead, needs immediate help.

EARLY INTERVENTION

"People always think that it's a phase," said Paxton, adding this attitude is especially common in military families. It is all too easy to blame the current duty station or the local school and teachers for a child's behavior or sudden poor grades, and just hope that things will be different after the next move. Occasionally, that is a valid belief. "However, the news that parents need to have is that the earlier they get the intervention, the earlier they get the treatment, the better the prognosis and the better the outcome."

"I think it's important for a lot of parents to recognize that kids don't always use the same words and terminology that we do," said retired Lt. Col. Patti Johnson, psychologist and Faran's deputy chief at CAFBHO. She explained that many children express their emotions differently than parents might expect - depression often manifests itself as anger in teenagers, for example. She urged parents to see their children's mental health as every bit as important as their physical health, and to readily seek care just like they would for a medical illness.

"Parents think it will go away," Faran said, "and then by the time they're teenagers, it can be a big issue." He said that the Army is rolling out the Child and Family Behavioral Health System, or CAFBHS, to better connect Family members with top-notch mental health care. It includes traditional behavioral health care, but also integrates care into primary care clinics and schools, the places issues are often first identified in children and teens.

Elements of CAFBHS are on 20 installations, and will be implemented Army wide by 2017. "The CAFBHS is a collaborative program with the Army medical homes, working with the primary care folks … to ensure that our kids are first identified if they are having problems, and then that they're getting services they need. … Once it's out there, it's going to reach more Army youth than we have in the past."

Under the umbrella of CAFBHS, the Army has also instituted the School Behavioral Health Program, embedding psychiatrists, psychologists and social workers in 46 schools on eight installations, with plans to expand it to 107 on-post schools.

Paxton, who is the program chief for Fort Meade, explained that children are referred to the program from a variety of sources: parents, teachers, school administrators and pediatricians. Poor grades and poor behavior in school are big red flags, so she said the ability to observe children in their environments is invaluable for practitioners. "It's not unusual for you to be able to see a child right there in the moment when they need you.

"We get to talk to the teachers. We get to talk to the administrators. We get to talk to the school staff and advise and counsel them. Sometimes with permission we can sit in the classroom," she said, adding that it is also easy for parents and kids to get to the appointments because they do not have to go anywhere. They miss less work and school.

Many of the issues practitioners see in military kids - attention deficit hyperactivity disorder, depression, mood disorders and personality issues - may have little or nothing to do with their military upbringings, the experts stressed. Most of the time, the same kids would have the same issues in the civilian world. With a little professional help, the majority will be fine.

PARENTS WITH INVISIBLE WOUNDS

It is the children of parents, who return from war with their own wounds, with PTSD, with depression, with TBIs, who most concern experts because "those kinds of incidents tend to be highly disruptive to families," Cozza said. "There's less structure. There's more chaos. There are more immediate needs. … There's a lot of upheaval in families. Parents may be preoccupied in dealing with the injury so we need to help them draw their attention back to their children.

"Those disorders specifically change parents in ways that can be confusing or complicating for both spouses and children," he said. "It changes a parent's personality or makes them more gruff or less engaged, more avoidant, more reactive, getting angry or impulsive. Those can be changes that can be really difficult for kids to understand. First of all, they may not be as physically apparent to a child. They've been referred to as invisible injuries, so children can be confused as to why a parent could be acting so differently. They may draw their own conclusions about what it is that I did to cause this or why my dad doesn't like me anymore … or I've disappointed him."

Kids might develop their own anger issues and act out, Faran said. Again, they might experience depression and anxiety. Their grades might fall. But however confusing and disruptive it is for children, whose parents have a diagnosis, at least they have a name for it. Parents can explain it in age-appropriate ways. It is far, far worse for children whose parents have not gotten help and are, say, uncontrollably angry and drinking all the time.

Sometimes, Paxton said, she sees children, who startle or shake in fear simply at the sounds of their parents' voices. No one wants that, so it is doubly important that these families get help - not just the Soldiers, the Families. Paxton, Faran and Johnson encourage the Service members they see to bring their Families in for counseling as well, although Cozza does not believe this happens enough.

He said the benchmarks of successful PTSD treatment should not only be whether flashbacks and nightmares have decreased, "but we also probably want to ask them other questions related to the impact of treatment, like 'How is the treatment helping you with your relationship with your kids? Are you being less reactive with them? Are you finding ways of being calmer with them? Are you finding ways of communicating with your spouse about how to manage problems around the house?' All of those are also kind of important targets for treatment that may not be traditional, but … have the capacity to powerfully impact the Family."

HELPING KIDS

Experts agree that when it comes to stressors, be it the mental health of parents, deployments or a PCS move, kids tend to handle things as well as their parents do. "Parents, who are managing those transitions well, typically help their children do well," Cozza said, "so recognizing that as a Family, 'We can manage this,' giving children their own jobs … and addressing those transitions can be really helpful. … You want to try to help parents help their children recognize that their lives are predictable, so they want to be able to talk with them about if in fact there's going to be a change, giving them an appropriate amount of time … to get ready."

Even if parents try to fake it, acting like they are OK when they are really stressed or worried or overwhelmed, Paxton said, kids will pick up on it. "They're like antennas. … Parents don't have to say anything. They can pick up body language. They can pick up tone of voice. They can pick up eye gaze. … So even if the mom has a stiff upper lip, and says 'Everything's great,' she needs to come in (and get help) and say she's crying in the shower at night. It's OK to have other people say that it's not unusual and to just talk about it. … I always tell parents … regardless of whether you feel damaged or hurt or broken … you are the most important thing in that child's life."

Routines and rituals are crucial when it comes to getting children through these challenges. During a deployment, for example, it is important to keep bedtime routines as close to the same as possible. After a move, maintain the same traditions for pizza night or Family game night. Get kids involved in the same sorts of after school sports or activities. Start new rituals that encourage parent-child bonding. That last one is especially important when parents have PTSD and might want to isolate themselves, Paxton said. And let children be children, Cozza said. Find time to let them hang out with friends or participate in extracurricular activities, even if the Family is reeling and in chaos.

THE FUTURE

As a whole, their future is bright, and driven by their parents' examples of selfless service, many Army kids are already doing impressive things in their communities. However, experts are a little concerned that no one forgets them now that more than a decade of combat is winding down. "I think military Families are very resilient," Johnson said. "One concern is just to continue monitoring these kids over time, because we don't really know yet the impact of parental psychological issues related to the war and TBIs, for example. … I think there may be a misperception that now that the war is over, we don't have to worry about them so much. I think we still need to continue to be aware that the effects of that war will potentially continue for some time."

Cozza agreed and said he thinks about the kids whose parents are getting out of the military and who will no longer have easy access to a supportive community, and, in some cases, health care or even jobs for their parents. "We really need to be thinking as a nation: What are the programs, whether it be in health care systems or community services, that are most likely to engage the Service members, veterans and their Families in order to provide them with the support that they need?

"I'm most hopeful when I talk with these Families, who have had these incredible experiences and they still are moving on with their lives successfully. They find solutions for themselves. They seek out help and support. They mentor those who come behind them in similar circumstances. There's a tremendous amount of … resilience in this community. People do face challenges and not only overcome them, they become great examples of how to do it in a way that allows them to move on with their lives."

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Editor's Note: For more information about the mental health of military children, Cozza recommends reading a special Future of Children journal issue about military children and families, filled with articles written by both military and civilian experts. For expert tips on some of the warning signs to look for in children who are struggling read "Common warning signs of kids in distress."