Staff Perspective: Stigma and Military Pediatric Behavioral Health Care
In October 2021, the American Academy of Pediatrics, the Children’s Health Association, and the American Academy of Child and Adolescent Psychiatry jointly declared a “National State of Emergency in Children’s Mental Health” (American Academy of Pediatrics, 2021). The declaration highlighted rising rates of significant mental health needs amongst pediatric age ranges, exacerbated by the COVID-19 pandemic, and further noted the concern for lack of services prepared to address such substantial need. In fact, worldwide, about 60% of children and adolescents with mental health needs go untreated (Patulny, Muir, Powell, Flaxman, & Oprea, 2013), and regrettably, the Centers for Disease Control and Prevention (CDC) reported that an estimated only 20% of U.S. children and adolescents receive the behavioral health care they need (CDC, 2022).
The call for alarm would appear to include our military children and teens, but the story is a bit different regarding access to care. Regarding overall rates of mental health needs, there does not appear to be an appreciable difference between pediatric military populations and the U.S. pediatric population on the whole during non-deployed periods (Aranda, Middleton, Flake, & Davis, 2011). Further, a National Military Family Association (NMFA) 2022 survey of over 2,500 military adolescents (ages 13-19) suggested that 28% identify as having low mental well-being, but the preponderance (64%) endorsed moderate well-being and 9% reported high levels of well-being (NMFA, 2022).
Fortunately, amongst U.S. military adolescents, most who ask for help are able to get it. For example, TRICARE-covered children were more likely than commercially insured children to have coverage for mental and behavioral health (to include the first year of the COVID-19 pandemic), and to describe this type of care as having met their needs (Hero et al., 2021). Although important, only 5% of military adolescents’ parents were not successful in identifying an available behavioral health provider (NMFA, 2022), which seems to be a far cry from the large percentage of families struggling to get access to care as reported in larger media and research reports on U.S. pediatric populations. But nonetheless, about 20% of military teens who seek help do not actively receive behavioral health support (NMFA, 2022).
Why?
The primary reason military teens do not get needed behavioral health support appears to relate to barriers at the level of the individual and family and could be conceptualized as relating to stigma at a broad level. Of the military adolescents who reported needing behavioral health support, about 10% indicated they did not get connected to care because they did not feel able or willing to ask their parents for help (NMFA, 2022). Findings from similar studies have shown military adolescents can worry about parental response to reports of mental health needs and struggle to feel comfortable conversing with a parent/guardian (Becker et al., 2014). Inherently, there is fear from military adolescents that their needs will be stigmatized by others, parents included. This fear is not unfounded. Parental stigma has been well-documented as a barrier to adolescents connecting with behavioral health care (Villatoro et al., 2018). In fact, of the military adolescents who reported needing behavioral health care, 4% indicated having parents/guardians who were unwilling to connect them with care even once the adolescents did disclose their high levels of need (NMFA, 2022).
So how can we work to increase connection of military children and adolescents with behavioral health services? If we look at the data, it would seem the focus should be on reduction of stigma. Although seemingly simple, this may be a complex problem to address. Because a child/adolescent may have stigmatizing thoughts, as well as the parents/guardians who are necessary to connect the child/adolescent with care, as well as the systems in which the child/adolescent lives (to include the military), stigma around pediatric behavioral health needs and subsequent treatment is often highly complex and factors have dynamic relationships (Mukolo, Heflinger, & Wallston, 2010).
Although not yet established, it seems possible that military families and teens may share the same stigma around seeking behavioral health care as compromising other aspects associated with military identity that can be observed in broader military culture (Meyer, 2022) - particularly given the majority of military adolescents (65%) plan to serve in the U.S. military and thus may worry about potential negative impact to service if they carry a history of behavioral health disorder or treatment (NMFA, 2022). For my own work, this makes me wonder about the possibility that some military parents may perhaps model avoidance of behavioral health services out of fear for their career trajectories which in turn complicates military adolescents’ perceptions about the risk/reward of seeking care.
Fortunately, addressing stigma is a known need amongst our military and veteran behavioral health care providers. Beyond a military focus, there are many national- and international-level agencies taking on the effort to reduce stigma as a barrier to behavioral health care. Thus, although it is an issue true for our military pediatric population, it is not unique to them and we can leverage these larger efforts to extend how we support our pediatric populations, as well. What is critical, though, is to recognize the need to engage in these efforts and to not miss opportunities to broaden the aperture to dialogue about our children and adolescents as much as our adult populations.
To that end, although there may not be an immediately obvious solution, my hope is that this blog calls our collective attention to stigma as a barrier to military children and adolescents’ connection with behavioral health care. Further, I hope this information invites conversations between professionals and across systems to consider the messaging we give our service members and their families about behavioral health and what it means to address needs.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Andrea Israel, Ph.D., is a clinical psychologist serving as a Military Behavioral Health Child Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
American Academy of Pediatrics. 2021. Declaration of a national emergency in child and adolescent mental health. Retrieved 5 July 2022 from: https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/
Aranda, M. C., Middleton, L. S., Flake, E., & Davis, B. E. (2011). Psychosocial screening in children with wartime-deployed parents. Military Medicine, 176 (4), 402-407.
Becker, S. J., Swenson, R. R., Esposito-Smythers, C., Cataldo, A. M., & Spirito, A. (2014). Barriers to seeking mental health services among adolescents in military families. Professional Psychology: Research and Practice, 45(6), 504-513.
Centers for Disease Control and Prevention. (2022). Improving access to children’s mental health care. Retrieved 5 July 2022 from https://www.cdc.gov/childrensmentalhealth/access.html
Hero, J. O., Gidengil, C. A., Qureshi, N. S., Tanielian, T., & Farmer, C. M. (2021). Access to health care among TRICARE-covered children. Santa Monica, CA: RAND Corporation.
Meyer, E. G., DeSilva R. B., Hann, M. C., Aggarwai, N. K., Brim, W. L., Engel, C. C., Lu, F. G., & Lewis-Fernandez, R. (2022). Adapting the cultural formulation interview for the military. PS in Advance. Retrieved 15 May 2022.
Mukolo, A., Heflinger, C. A., & Wallston, K.A. (2010). The stigma of childhood mental disorders: a conceptual framework. Journal of the American Academy of Child & Adolescent Psychiatry, 49(2), 92-103.
National Military Family Association. (2022). The military teen experience: A snapshot of America’s military teenagers and future force. Alexandria, VA: NMFA.
Patulny, R., Muir, K., Powell, A., Flaxman, S., & Oprea, I. (2013). Are we reaching them yet? Service access patterns among attendees at the headspace youth mental health initiative. Child & Adolescent Mental Health, 18(2), 95–102.
Villatoro, A.P., DuPont-Reyes, M.J., Phelan, J.C., Painter, K., & Link, B.G. (2018). Parental recognition of preadolescent mental health problems: Does stigma matter? Social Science Medicine, 216, 88-96.
In October 2021, the American Academy of Pediatrics, the Children’s Health Association, and the American Academy of Child and Adolescent Psychiatry jointly declared a “National State of Emergency in Children’s Mental Health” (American Academy of Pediatrics, 2021). The declaration highlighted rising rates of significant mental health needs amongst pediatric age ranges, exacerbated by the COVID-19 pandemic, and further noted the concern for lack of services prepared to address such substantial need. In fact, worldwide, about 60% of children and adolescents with mental health needs go untreated (Patulny, Muir, Powell, Flaxman, & Oprea, 2013), and regrettably, the Centers for Disease Control and Prevention (CDC) reported that an estimated only 20% of U.S. children and adolescents receive the behavioral health care they need (CDC, 2022).
The call for alarm would appear to include our military children and teens, but the story is a bit different regarding access to care. Regarding overall rates of mental health needs, there does not appear to be an appreciable difference between pediatric military populations and the U.S. pediatric population on the whole during non-deployed periods (Aranda, Middleton, Flake, & Davis, 2011). Further, a National Military Family Association (NMFA) 2022 survey of over 2,500 military adolescents (ages 13-19) suggested that 28% identify as having low mental well-being, but the preponderance (64%) endorsed moderate well-being and 9% reported high levels of well-being (NMFA, 2022).
Fortunately, amongst U.S. military adolescents, most who ask for help are able to get it. For example, TRICARE-covered children were more likely than commercially insured children to have coverage for mental and behavioral health (to include the first year of the COVID-19 pandemic), and to describe this type of care as having met their needs (Hero et al., 2021). Although important, only 5% of military adolescents’ parents were not successful in identifying an available behavioral health provider (NMFA, 2022), which seems to be a far cry from the large percentage of families struggling to get access to care as reported in larger media and research reports on U.S. pediatric populations. But nonetheless, about 20% of military teens who seek help do not actively receive behavioral health support (NMFA, 2022).
Why?
The primary reason military teens do not get needed behavioral health support appears to relate to barriers at the level of the individual and family and could be conceptualized as relating to stigma at a broad level. Of the military adolescents who reported needing behavioral health support, about 10% indicated they did not get connected to care because they did not feel able or willing to ask their parents for help (NMFA, 2022). Findings from similar studies have shown military adolescents can worry about parental response to reports of mental health needs and struggle to feel comfortable conversing with a parent/guardian (Becker et al., 2014). Inherently, there is fear from military adolescents that their needs will be stigmatized by others, parents included. This fear is not unfounded. Parental stigma has been well-documented as a barrier to adolescents connecting with behavioral health care (Villatoro et al., 2018). In fact, of the military adolescents who reported needing behavioral health care, 4% indicated having parents/guardians who were unwilling to connect them with care even once the adolescents did disclose their high levels of need (NMFA, 2022).
So how can we work to increase connection of military children and adolescents with behavioral health services? If we look at the data, it would seem the focus should be on reduction of stigma. Although seemingly simple, this may be a complex problem to address. Because a child/adolescent may have stigmatizing thoughts, as well as the parents/guardians who are necessary to connect the child/adolescent with care, as well as the systems in which the child/adolescent lives (to include the military), stigma around pediatric behavioral health needs and subsequent treatment is often highly complex and factors have dynamic relationships (Mukolo, Heflinger, & Wallston, 2010).
Although not yet established, it seems possible that military families and teens may share the same stigma around seeking behavioral health care as compromising other aspects associated with military identity that can be observed in broader military culture (Meyer, 2022) - particularly given the majority of military adolescents (65%) plan to serve in the U.S. military and thus may worry about potential negative impact to service if they carry a history of behavioral health disorder or treatment (NMFA, 2022). For my own work, this makes me wonder about the possibility that some military parents may perhaps model avoidance of behavioral health services out of fear for their career trajectories which in turn complicates military adolescents’ perceptions about the risk/reward of seeking care.
Fortunately, addressing stigma is a known need amongst our military and veteran behavioral health care providers. Beyond a military focus, there are many national- and international-level agencies taking on the effort to reduce stigma as a barrier to behavioral health care. Thus, although it is an issue true for our military pediatric population, it is not unique to them and we can leverage these larger efforts to extend how we support our pediatric populations, as well. What is critical, though, is to recognize the need to engage in these efforts and to not miss opportunities to broaden the aperture to dialogue about our children and adolescents as much as our adult populations.
To that end, although there may not be an immediately obvious solution, my hope is that this blog calls our collective attention to stigma as a barrier to military children and adolescents’ connection with behavioral health care. Further, I hope this information invites conversations between professionals and across systems to consider the messaging we give our service members and their families about behavioral health and what it means to address needs.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Andrea Israel, Ph.D., is a clinical psychologist serving as a Military Behavioral Health Child Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
American Academy of Pediatrics. 2021. Declaration of a national emergency in child and adolescent mental health. Retrieved 5 July 2022 from: https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/
Aranda, M. C., Middleton, L. S., Flake, E., & Davis, B. E. (2011). Psychosocial screening in children with wartime-deployed parents. Military Medicine, 176 (4), 402-407.
Becker, S. J., Swenson, R. R., Esposito-Smythers, C., Cataldo, A. M., & Spirito, A. (2014). Barriers to seeking mental health services among adolescents in military families. Professional Psychology: Research and Practice, 45(6), 504-513.
Centers for Disease Control and Prevention. (2022). Improving access to children’s mental health care. Retrieved 5 July 2022 from https://www.cdc.gov/childrensmentalhealth/access.html
Hero, J. O., Gidengil, C. A., Qureshi, N. S., Tanielian, T., & Farmer, C. M. (2021). Access to health care among TRICARE-covered children. Santa Monica, CA: RAND Corporation.
Meyer, E. G., DeSilva R. B., Hann, M. C., Aggarwai, N. K., Brim, W. L., Engel, C. C., Lu, F. G., & Lewis-Fernandez, R. (2022). Adapting the cultural formulation interview for the military. PS in Advance. Retrieved 15 May 2022.
Mukolo, A., Heflinger, C. A., & Wallston, K.A. (2010). The stigma of childhood mental disorders: a conceptual framework. Journal of the American Academy of Child & Adolescent Psychiatry, 49(2), 92-103.
National Military Family Association. (2022). The military teen experience: A snapshot of America’s military teenagers and future force. Alexandria, VA: NMFA.
Patulny, R., Muir, K., Powell, A., Flaxman, S., & Oprea, I. (2013). Are we reaching them yet? Service access patterns among attendees at the headspace youth mental health initiative. Child & Adolescent Mental Health, 18(2), 95–102.
Villatoro, A.P., DuPont-Reyes, M.J., Phelan, J.C., Painter, K., & Link, B.G. (2018). Parental recognition of preadolescent mental health problems: Does stigma matter? Social Science Medicine, 216, 88-96.