Affects of Multiple Deployments on Military Service Members and Families during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF): Time Period 2001-2012
Gina Pagano-Briglin, MSW
University of the Incarnate Word
3 December 2012

I. Introduction Since September 11, 2001, there have been significant changes in the security measures of air travel, financial security, but one of the most significant changes is that of military operations. The United States began combat operations in Iraq and Afghanistan on October 7, 2001 in response to the September 11, 2001 terrorist attacks officially referred to as Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Since October 2001, about 1.9 million service members have been deployed to Afghanistan and Iraq (Asbury & Martin, 2011). OEF/OIF has many unique features with regard to the military forces being sent to fight oversees. The all-volunteer military has experienced multiple deployments to the combat areas, with an increased use of the National Guard and Reserve Components, higher numbers of deployed women and parents of young children, and increases in the number of service members surviving severe injuries and other side effects from combat (Shaw & Hector, 2010). Service members may be subjected to more than one deployment. Studies show that overall about 40% of current military service members have been deployed more than once, with over one quarter serving more than two tours in combat (Sheppard, Malatras, & Israel, 2010). The repeat deployments have created taxing situations for the service members and their families. Moreover, the deployments average a length of sixteen months; which includes pre-deployment training and post deployment transition (Sheppard et al., 2010). An average of 44% of these service members are parents, with an average of two million children being affected by deployments (Park, 2011). With that being said, the repercussions to not only the service members, but also their families are significant. Issues ranging from mental health to family violence were discussed in the research and will be depicted in this paper. The purpose of this literature review is to understand the impact that multiple deployments have on service members fighting in the combat zones of OEF/OIF, and the families and children left behind.
II. Deployments Since the beginning of the wars in Iraq and Afghanistan in 2001, the 1.9 million service members have been deployed in a total of three million tours of duty as part of OEF/OIF (Beardslee, 2011). OEF/OIF are fundamentally different from the first Gulf War and other previous wars due to their heavy dependence on the National Guard/Reservists, pace of deployments, duration and number of deployments, short recovery time between deployments, combat and injuries sustained, and the effects on the service members, families, and their communities (Beardslee, 2011). Out of the 1.9 million service members, over 1.3 million were active duty personnel, 304,000 were National Guard, and 235,372 were Reservists (Caska & Renshaw, 2010). The average deployment is nine to sixteen months depending on the branch of service. Historically, the Army and Marines experience longer deployments, while the Air Force and Navy experience shorter deployments (Lester & Bursch, 2011). However, there is more to the deployment preparation then the actual time deployed in combat. Many of the service members are away from their homes and families two to three months prior to deployment for various preparation and training activities (Lester & Bursch, 2011). To make it even longer, there is an average of one to two months of time away from their home upon return from deployment (Lester & Bursch, 2011). This is considered the reintegration process, which also includes various training activities. To fully understand deployment, it is also important to recognize the number of deployments for the average service member. The amount of time between deployments differs for each service member and family. There may be an extended break between deployments or the break maybe limited to a few months (Goff, Crow, & Reisbig, 2007). The average tour of duty for a service member is a minimum of two deployments. This can vary depending on if the service member is injured or released from the military which prohibits a return to war. Research indicates that there are sometimes as many as five to six deployments for each service member (Lester & Bursch, 2011). With no deployment being identical, the effects on not only the service member and/or their family are critical. In reviewing research on this topic, it was discovered that there is a significant difference between active duty service members and those deployed as National Guards/Reservists. With an active duty service member, the families left behind have access to all of the advantages of the military. These advantages include commissary use, which includes, but not limited to lower cost food, clothing, and gas. Housing is also a big advantage. Covered in the service member’s financial compensation is convenient on-base housing and school programs, to include day care for non- school age children. Additionally, located on military installations are areas known as Army Community Services (ACS) and Family Advocacy Program (FAP) (Arincorayan, Applewhite, & Robichaux, 2010). These programs offer assistance with employment readiness, financial assistance, parenting classes, stress management classes, mobilization and deployment information, and social support groups. Even more important, there are computer labs and video teleconferencing capabilities for families to have the opportunity to communicate with their deployed service member. For deployed National Guard/Reserve families, the benefits may not be the same. Many of these families reside in remote areas, not located close to a military installation, so their accesses to the benefits described above are not viable options. This is the same circumstance when it comes to housing. National Guard/Reservists are recognized as civilians, until they are activated to deploy. These service members maintain employment, homes, and families in the community. Once their tour is over, the service members go back to their homes and families, they do not remain on active duty status. Research shows that there is many times where their jobs are no longer waiting for them, health coverage has been canceled, and they are left with the side effects of deployment, and little to no assistance (Caska & Renshaw, 2011). The physical separation, especially when the deployments are to combat zones, is difficult for families. Service members are expected to work long and unpredictable hours, especially in preparation for deployment, which places additional stress on families. Moreover, when a service member returns from deployment with injuries associated with war, these problems may also contribute to the family stress (Makin, Gifford, McCutcheon, & Glynn, 2011). Most service members have been exposed to combat or imminent danger while deployed, in addition to poor living conditions and limited communications with families (Park, 2011). Sections below will go into depth on what research shows are the most common affects of deployment on military families.
III. Mental Health With over ten years of war, returning service members have experienced significant repercussions revolving around mental health. Research shows high rates of Post Traumatic Stress Disorder (PTSD), depression, substance abuse, and suicide (Dekel & Manson, 2010). PTSD is the most common diagnosed mental health disorder in service members retuning from combat (Walker, Clark, & Sanders, 2010). PTSD can develop after a direct personal experience or witnessing an incident that poses an alleged threat of death or injury (Schneiderman, Braver, & Kang, 2008). Symptoms that distinguish PTSD arise in the aftermath of a traumatic exposure and include re-experiencing of the traumatic event through flashbacks and nightmares, isolation, avoidance of places, and situations associated with the trauma, and hyperarousal, which is also known as a heightened sense of awareness. (Schneiderman et al., 2008). Examples of research show service members deployed to Iraq earlier in the conflict were at higher risk for PTSD than those deployed to Afghanistan (Shaw & Hector, 2010). PTSD can hinder the functioning and quality of life for service members. Research by Allen, Rhoades, Stanley, and Markman (2010) show there is considerable evidence that symptoms of combat-related trauma and posttraumatic stress are associated with the relationship quality and stability of the service member. Service members with more severe PTSD symptoms were more likely to have been divorced, and service members who had reported severe symptoms years earlier had become even less satisfied with their marriages and lives (Renshaw, Rodrigues, & Jones, 2008). PSTD symptoms can also promote service members to express anger and violence toward their spouses and families (Forgery & Badger, 2006). Evidence shows that PTSD disrupts family functioning, specifically in relationships with children. Service member fathers diagnosed with PTSD have been characterized as withdrawn, irritable, and controlling (Willerton, Schwartz, Wadsworth, & Oglesby, 2011). A recent study focused on 199 military service members who served in Iraq or Afghanistan after 2001, who received referrals to mental health practitioners from his/her primary care physician (Renshaw, Allen, Rhoades, Blais, & Marksman, 2011). Results indicated that service members diagnosed with depression or PTSD were five times as likely to report problems with family readjustment as those who did not (Renshaw et al., 2011). Additionally, reports show that service members often expressed feeling like strangers in their own homes, reporting that their children acted afraid of them, and that their partners were afraid of them (Renshaw et al., 2011). Along with PTSD, depression is another familiar mood disorder, which is described as persistent feelings of sadness with other symptoms related to changes in appétit, sleeping patterns, loss of interest in activities, fatigue, inability to concentrate, hopelessness, and/or suicidal thoughts (Lester, Mogel, Saltzman, Woodward, Nash, Leskin, & Beardslee, 2011). Tanielian and Jaycox (2008) reviewed 12 studies that assessed the occurrence of depression in service members who served in OEF/OIF. None of the studies used a diagnostic instrument to determine depression, and findings were based solely on self-report. However, the results of the study indicated that depression in service members ranged from 5% to 37% (Tanielian & Jaycox, 2008). Depression is associated with a decrease in quality of life, and researchers project that depression will be the second-most common contributor to disability worldwide in 2020 (Tanielian & Jaycox, 2008). Research also indicates that service members between the ages of 18-29 are more likely to be diagnosed with depression than service members whom are older (Verdeli, Bailey, Vousoura, Belser, Singla, & Manos, 2011). Jakupak and Varra (2011) indicate that suicidal behavior is one of the most serious consequences of mental disorders. Multiple studies have assessed the relationship between combat exposure and suicide, but the results have been inconsistent (Jakupak & Varga, 2011). With the high rates of mental disorders in service members returning from OEF/OIF, there are concerns about elevated rates of suicide. According to the Mortality Surveillance Division Armed Forces Medical Examiner, the rates of suicide deaths among service members have increased. Looking at rates per 100,000 in 2001 the reports were 10.3 and in 2009 the reports were 17.5 (Guerra & Calhoun, 2010). Service members who attempt suicide often suffer from depression and other mental disorders, which pose an increased risk for attempting suicide again and resulting in successful loss of life and critical affects on families. With the increase in critical affects, repeated research indicates that there is a significant shortage of health-care professionals, specifically those who specialize in mental health for those returning from OEF/OIF and their family members. The professionals who serve the military population include psychologists, psychiatrists, and social workers report extremely high caseloads, which often time results in poor care or provider burn out (Horrelt, Holohan, & Didion 2011). Literature reports significant problems with substance abuse, particularly alcohol, among service members returning from OEF /OIF. In the United States, about 1 in 12 adults abuse or are dependent on alcohol, with problems highest among people 18–29 years old (Seal, 2010). A recent study found that one in ten of active duty service members reported binge drinking resulting in risky behavior with dangerous consequences (Seal, 2010). An additional study of OEF/OIF service members returning from combat show that 26.5% of 152 service members screened reported hazardous drinking (Mcdevitt-Murph et al., 2010). Another emerging substance-abuse issue is that many of today’s service members are more likely to be addicted to prescription medications, specifically opiates for pain control. Research indicates this can be attributed to the multiple injuries sustained while deployed in combat areas (Cohen, Gima, Bertenthal, Marmar, & Seal, 2010).
IV. Deployments and Children The conflicts in OEF/OIF have taken a toll on the children of service members who have been deployed. Since 2001, there have been an estimated 1.2 million children who have experienced parental deployment (Esposito, Wolfe, Lemmon, Bodzy, Swenson, & Spirito, 2011). The majority of these children are under the age of 10 years old, with an average of 40% younger than 5 years (Lester & Bursch, 20110). The deployment cycle also has an effect on military children of all ages. The cycle includes three phrases – pre-deployment, deployment, and post deployment (Berry, 2009). Pre-deployment is the preparation phase. Families are preparing to continue on with family life without the service member parent. With the deployment phase, this is where the children must cope with the physical and emotional separation. This phase is where many of the problems associated with deployment surface. Last is post deployment, which is typically a joyous occasion, but also has some challenges as both the families and the service members’ fight to adjust to a new routine (Barker & Berry, 2009). During these three phrases is when military children experience parental separation, redistribution of household roles, fear and anxiety of the dangers of war for their service member parent, and other family stressors. Military children experience a variety of stress to include but not limited to psychological, academic, and socio-emotional (Park, 2011). Children of service members deployed to OEF/OIF reportedly sought outpatient mental health services 2 million times in 2008 with inpatient visits by military children increasing by 50% since 2003 (Sheppard et al., 2010). Higher rates of anxiety, depression, substance abuse, and risky sexual behavior have proven to be an issue for children of service members who are deployed compared to children who have not been exposed to multiple deployments (Esposito et al., 2011). Much of the research around military children and deployment has focused on the psychological aspect and little on the academic. However, research that has been conducted indicates that deployment related parental absentees and relocations have a detrimental effect on military children in the academic setting (Saltzman, Lester, Beardslee, Layne, Nash, & Woodward, 2011). Research shows that children’s scores on academic achievement tests dropped as a result of parental deployment (Tunac et al., 2011). Another study of adolescents found that those with deployed parents reported more reactions to stress and loss than those who had nondeployed or civilian parents (Tunac et al., 2011). More recently, a study by Chandra et al., (2010) found that children in military families reported higher levels of emotional challenges than children in the general population. Chandra et al., (2010) also found that length of deployment was associated with an increased level of adjustment difficulties. This includes academic and anxiety in children both during deployment and the reintegration process. Thus far, the findings from the current war are consistent with those of earlier research. Another recent analysis of the psychosocial effects of deployment on military children found that families experiencing deployment identified one-third of children at high risk for psychosocial diagnosis and that parenting stress was the most significant predictor of children’s psychosocial functioning (Tunac et al., 2011). Available data, although limited, indicate that bereaved children are at increased risk for psychiatric disorders, behavioral or emotional problems (Hardin, Hayes, Cheever, & Addy, 2003). Moreover, Harden et al., (2003) confirmed injured service member parents might have reduced capacity to respond with sensitivity to their children. Family roles may become confusing and unstable as the result of serious injury and long recovery process. Researchers believe that little guidance is available to help children to understand and acclimate to the death or life-altering injury of a parent (Harden, et al., 2003). Although there is considerable agreement among researchers that some children are more vulnerable than others to the challenges of deployment, the findings have been mixed. Several studies suggest that boys and younger children may be more vulnerable than girls and older children, but older girls are at greater risk for sexual abuse (Wong & Gerras, 2010). Researchers have come to a general consensus that children who experience multiple deployments have experienced a greater psychological weight. However, more longitudinal studies are needed to fully understand the impact on the multiple deployments and the effects on military children (Wong & Gerras, 2010).
V. Deployment and Military Spouses The challenges of deployment are different for each spouse left behind. There have been some studies suggesting that spouses face similar levels of distress and may develop mental health issues such as depression, anxiety or trauma as a result of experiences during the service member’s deployment (Asbury & Martin 2011). Research showed that military spouses were more likely than service members to seek care and less worried about the stigma that may follow for those who seek help (Faulk, Gloria, Carce, & Steinhardt, 2010). Additionally, studies now suggest that service member’s deployments are linked with increased stress during pregnancy and increased risk of postpartum depression (Faulk et al., 2012). A survey of pregnant military and civilian patients at Camp Lejeune, North Carolina, indicated that deployment, active-duty status, and having more than one child at home were associated with higher levels of stress (Haas & Pazdernik, 2007). In an older study, Vormbrock (1993) reviewed the literature on military spouses’ and their reactions to deployment in relation to attachment theory, predicting that adults would show the same detachment pattern as children in response to separation. Data did suggest that sadness was prominent with anger not being too far behind. Vormbrock also predicted emotional detachment, anger, and anxiety at upon the return of the deployed service member. Researchers predicted and found that separation length was positively related to distress, detachment, and damage to the marital relationship. During deployment, service members can develop strong support relationships with fellow service members, whereas the families left behind rely on members of the community, other families experiencing deployment, and children. Upon return, service members and their spouses may both find it challenging to reorient themselves to each other and find comfortable ways to process their deployment experiences with other support networks. Even though there is less attention focused on the spouses/partners of returning service members, growing research indicates an increased risk for psychological issues. Gerwitz, Erbes, Polusny, & DeGarmo (2011) found that service member deployment to OEF/OIF had a connection to increased rates of depression, sleep and anxiety disorders, acute stress reaction, and adjustment disorders in the spouses left behind.
VI. Family Violence Multiple deployments not only affect families on the emotions side, but there are also physical repercussions. Multiple deployments affect the rates of child maltreatment (Moon, 2007). Although rates in general appear to be no higher than those in the civilian population, child maltreatment by the military spouse appears to rise during deployment (Moon, 2007). A recent analysis of deployment and child maltreatment in military and nonmilitary families after September 2001 found that the rate of substantiated maltreatment of children of military families doubled, whereas the rates in nonmilitary families were not affected. In military families that experienced deployment and child maltreatment in 2001–2004, results found an increase of 200% in physical abuse, 300% in maltreatment, and 400% increase in neglect. (Arincorayan et al., 2010). Reintegration can be a dangerous period for military families. Some studies have shown positive relations between length of deployment and rates of intimate-partner violence, especially if service members are suffering from combat-related trauma (Forgery, et al., 2006). The increases in rates of child maltreatment observed as service members left for deployment also occurred when they returned. A recent study of over 1,700 military families (Gibbs, Martin, Kupper, & Johnson, 2007) found that the overall rate of child maltreatment was higher when the service member parents were deployed than when not. The demographics of the deployed service members are males, 18-24 who have limited experiences with relationships and parenthood. Because of this, the number of children who have been affected by these conflicts is clearly larger than in past (Gibbs et al. 2007). Additionally, research shows that the rate of intimate partner violence is higher in military couples than in civilian couples. Jones (2011) reported that spouses of service members reported significantly higher rates of violence than wives of civilian holding the same demographic. Although reports indicate that intimate partner violence has declined over the last few years, intimate partner violence still affects 20% of military couples in which the service member has been deployed for at least six months (Klostermann, Mignore, Kelley, & Mussan, 2012). Arincorayan et al., (2010) research indicates that multiple deployments among service members were more likely to commit severe aggression towards their spouses/partners and the longer the deployment the worse the aggression. Intimate partner violence also increases as the rates of PTSD increase with returning service members (Arincorayan et al., (2010). Research shows that there is a connection between post deployment psychological diagnosis and family violence at a rate of 17% (Klostermann et al., 2012). Reviewing literature on the statistics of intimate partner violence associated with military service members, the rates across military populations range from 13.5-58% depending on the studies and population areas (Marshall, Panuzio, & Taft, 2005). Violence can be described as moderate with examples of being hit, slapped, kicked, bitten to severe being beat up, choked, and threatened with a weapon or worst case scenario death (Marshall et al., 2005). Research studies show that from the time period of 2001-2011 there has been an 85% increase in intimate partner violence, with 54% being violence related to alcohol abuse, showing a possible correlation of multiple deployments and increased family violence (Jones, 2011).
VII. Marriage Satisfaction As expected, exposure to combat appears to threaten the quality of marriage. A report by Allen et al., (2010) found evidence that deployed service members were more likely to have marital problems upon return from deployment. Several studies have examined the effect of deployments on marital status. As a result of the current conflict in OEF/OIF, there is evidence that symptoms of combat-related trauma are related to marital distress for both partners (Renshaw, 2011). Military spouses were more troubled when they experienced symptoms that their service member spouses failed to acknowledge which resulted in marital discord (Renshaw et al., 2008). Since 2003, family separation has consistently been among the top concerns of service members deployed in OEF/OIF. Length of deployment appears to be positively correlated with the percentage of deployed service members who indicate that they plan to obtain a divorce or to separate after their return from combat (Karney & Crown, 2007). Contrary to the view that longer deployments lead to a higher risk of marital dissolution, Karney & Crown (2007) found in a study of personnel records of over 560,000 service members who married in 2002–2005 that the longer a service member was deployed, the lower the risk of divorce or separation, especially if they were male, were younger, or had children. This suggestion differs from an alternate explanation which suggests that the stress of deployment undermines otherwise healthy marriages. Karney & Crown (2007) findings are preliminary and focus only on relatively recent marriages followed for a relatively short period. There was very limited research and views on this topic, which presented a challenge in obtaining an accurate view of what the real situation is regarding marriage satisfaction of families experiencing multiple deployments.
VIII. Combat Related Injuries/Death Throughout OEF/OIF many service members have experienced injuries. The diversity between the injuries is vast, as explosive devices have become the most used weapon of war. Traumatic Brain Injury (TBI) is the most common injury among those wounded in OEF/OIF (Jones, Fear, & Wessley, 2007). Research varies as some studies have found that about 10–20% of service members returning from OEF/OIF have TBI, accounting for up to one-third of all combat injuries (Elder & Cristian, 2009). Although brain injuries are easily identified, TBI is more common and can go unnoticed. A concern for service members and their families are the long-term effects associated with TBI (Giranda et al., 2009). In some cases TBI can go unnoticed until the service member returns home and can no longer function as he or she did before deployment. This can result in frustration and problems for both service member and their families. Research identified several outcomes that can persist even after mild TBI, including unprovoked seizures, depression, aggression, and symptoms, such as memory problems, dizziness, and irritability (Theeler & Erickson, 2009). TBI can cause life-long impairments, and recovery might take years. One common complication of TBI is pain, specifically headaches, and there is growing evidence that it can be a long-term problem (Nampiaparampil, 2008). A study of OEF/OIF service members diagnosed with TBI found that those with TBI were more likely to have migraine-like headache, severe pain, and frequent headache than service members without TBI (Nampiaparampil, 2008). Similarly, a recent study found an association between a history of mild head trauma, usually caused by blast exposure, and onset or worsening of headache in service members (Zeiter & Brooks, 2008). TBI can also lead to disruptions in functions of everyday life, including social relationships, independent living, and employment (Jones et al., 2007). As noted earlier, OEF/OIF service members are experiencing higher survival rates than in previous wars. The overall survival rate among wounded service members is about 90% (Zeider & Brooks, 2008). Increased survival rates are attributed to the widespread use of body armor and improved battlefield procedures and faster medical evacuation. However, the protection offered by body armor may have resulted in more service members surviving injuries that in past conflicts would have led to possible death, which now result in amputations (Clark, Bair, Buckenmaier, Gironda, & Walker, 2007). As reported by the Army Office of the Surgeon General, from September 2001 to January 12, 2009, there were 1,184 amputations performed on personnel deployed to OEF/OIF, with nearly three-quarters of which were major amputations, with explosive devices causing 55% of the 1,184 amputations (Clark et al., 2007). Ebrahimzadeh & Hariri (2009) reported that 54% of amputees having persistent functional, social, and psychiatric problems, yet only 26% of patients were receiving psychologic treatment. Another common problem reported by returning service members is chronic pain (Clark et al., 2007). In a study of 100 OEF/OIF service members, about 47% reported mild pain, and 28% reported moderate to severe pain; and 25% of service members reporting chronic pain conditions (Gironda et al., 2006). Moreover, pain is known to be associated with a high prevalence of mental health disorders, including PTSD (Otis, Keane, Kerns, Monson, & Sciolo, 2009). A more recent study of 429 OEF/OIF service members Helmer et al., (2009) found that severe chronic pain, PTSD, and depression affected the service member’s ability to perform daily activities, which made readjustment for the veterans and their family members more difficult.
IX. Implications for Future Research In reading the research it was consistently reported by researchers that there are many limitations when looking into this area. Researchers indicated that many of the studies were qualitative in nature with smaller sample sizes. With this there was not a clear depiction of the effects of multiple deployments with military families. From the research, one was able to gain an understanding that there may be a growing problem, but the research does not reach all military service members and at military locations. Additionally, the research does not reach all of the service members that are no longer serving as a result of injuries or time served. More longitudinal studies need to be conducted on deploying service members and their families. In addition, separate research on service members, military children, and military spouses needs to be conducted. There have been many types of studies conducted on OEF/OIF personnel. Over 90 peer reviewed journal articles were reviewed for this literature review. These studies include but are not limited to cross sectional, telephone surveys, anonymous samples, small and large convenient samples, and just recently longitudinal samples. Some research indicated an issue with the accuracy of self-reports, asking where the evidence is. On the other hand, there are many researchers who say that future research should focus on self-report surveys. Researchers do agree that a focus needs to be placed on family experiences and not solely on the experiences of the service member.
X. Conclusion Studies of service members deployed to combat zones have used self-report screening instruments rather than structured diagnostic interviews conducted by mental health professionals. (Meis, Erbes, Kaler, & Arbisi, 2011). Most studies also used convenience samples, which may not be representative of the total population deployed to combat zones. (Meis et al., 2011). The proportion of service members who have been killed or wounded in OEF/OIF has been lower than that in past conflicts. As of November 9, 2012, 6,631 service members have died and 50,159 had been wounded (Fischer, 2012). Consequently, more service members survive to return home with severe combat-related injuries that require additional care by their spouse, children and/or outside caregivers and medical professionals. Research on family members of OEF/OIF service member suggests service members subjected to multiple deployments return home and is diagnosed with PTSD. However, PTSD is not the only affect of deployments. Depression is also found in returning service members. An increase in excessive drinking, drug use and suicidal ideations/attempts are also indicated in research. Since 2001 service members have also experienced, TBI, amputations, and self inflicted injuries at astounding rates (Fischer, 2012). With that being said, research has shown that there has been a significant negative impact on military service members and their families as a result of multiple deployments during OEF/OIF. Research has also looked at what is being done in terms of support. Department of Veterans Affairs has reported that from the time period of 2002-2009, one million service members have returned home and have received eligibility for health care services. Out of this one million, 46% have taken advantage of the services provided. Services include mental health, substance abuse, marital and family counseling, employment assistance, and aftercare for those who returned with significant injuries, to include loss of limbs or TBI (Fischer, 2012). Dr. Jaine Darwin participated in a military symposium in 2008 with the idea that if every Army Soldier has 7 close family members, to include spouse, children, parents, and siblings, which averages out to over 11.5 million individuals affected by deployments during OEF/OIF and presents an interesting calculation. Keep in mind this only depicts the Army, not the other branches of service. If you add in the extended family, aunts, uncles, grandparents the number increases to 70 million. Even though the research has limitations, it is clear to those who study this issue that the war in OEF/OIF over the past 12 years has significantly affected our countries service members and their families. Based on this literature review additional research of a broader nature, that captures more quantitative data from active and inactive service members and their families is required in order to obtain a greater understanding of the effects of multiply deployments on military families.

References
Allen, E. S., Rhoades, G. K., Stanley, S. M., & Markman, H. J. (2010). Hitting Home: Relationship Between Recent Deployment, Post Traumatic Stress Symptoms, and Marital Functioning for Army Couples. Journal of Family Psychology, 24, 280-288.
Arincorayan, D., Applewhite, L., & Robichaux, R. (2010). Family Advocacy: A Program to Support an Expeditionary Army. U.S. Army Medical Department Journal, 37.
Asbury, E. T., & Martin, D. (2011). Military Deployment and the Spouse Left Behind. The Family Journal, 20, 45-50.
Barker, L. H., & Berry, K. D. (2011). Developmental Issues Impacting Military Families with Young Children during Single and Multiple Deployments. Military Medicine, 174, 1033.
Beardslee, W. (2011). Families Overcoming Under Stress: Implementing Family-Centered Prevention for Military Families Facing Wartime Deployments and Combat Operational Stress. Military Medicine, 176, 19-25.
Berry, K. D. (2009). Developmental Issues Impacting Military Families with Young Children during Single and Multiple Deployments. Military Medicine, 174, 1033-1040.
Chandra, A. S., Lara-Cinisomo, L. H, Jaycox, T., Tanielian, R. M., Burns, T., Ruder, & Han, B. (2010). Children on the Home front: The Experience of Children from Military Families. Journal of Pediatrics 125, 16-25.
Clark, M. E., Bair, M. D., Buckenmaier, C. C., Gironda, R. J., & Walker, R. L. (2007). Pain and Combat Injuries in Soldiers Returning From Operation Enduring Freedom and Iraqi Freedom: Implications for Research and Practice. Journal of Rehabilitation Research and Development 44, 179-194.
Cohen, B. E., Gima, K., Bertenthal, D., Kims, S., Marmar, C. R., & Seal, K. (2010). Mental Health Diagnosis and Utilization of VA Non-Mental Health Medical Services Among Returning Iraq and Afghanistan Veterans. Journal of General Internal medicine 25, 18-24.
Tunac, K. M., De Pedro, R. A., Astor, A., Benbenishty, R. A., Smith, G. R., & Estrada, J. (2011). The Children of Military Service Members. Review of Educational Research, 81, 566-618.
Dekel, R., & Monson, C. M. (2010). Military-Related Post-Traumatic Stress Disorder and Family Relations: Current Knowledge and Future Directions. Journal of Aggression and Violent Behavior, 15, 303-309.
Ebrahimzadeh, M. H., & Hariri, S. (2009). Long term Outcomes of patients Undergoing Transtibal Amputations. Journal of Military Medicine 174, 593-597.
Elder, G. A., & Cristian A. (2009). Blast Related Mild Traumatic Brain Injury: Mechanisms of Injury and Impact on Clinical Care. Mount Sinai Journal of Medicine, 291-307.
Esposito-Smythers, C., Wolff, J., Lemmon, K. M., Bodzy, M., Swenson, R. R., & Spirito, A. (2011). Military Youth and the Deployment Cycle: Emotional Health Consequences and Recommendations for Intervention. Journal of Family Psychology, 25, 497-507.
Faulk, K. E., Gloria, C. T., Cance, J. D., & Steinhardt, M. A. (2012). Depressive Symptoms Among US Military Spouses During Deployment. Armed Forces & Society, 38, 373-390.
Fischer, H. (2012). U.S. Military Casualty Statistics: Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom. CRS Report for Congress. Retrievd from http://www.crs.org (accessed 15 November 2012).
Flake, E. M., Davis, B. E., Johnson, P. L., & Middleton, L. S. (2009). The Psychological Effects of Deployment on Military Children. Journal of Development and Behavioral Pediatrics 30, 271-278.
Forgey, M., & Badger, L. (2006). Patterns of Intimate Partner Violence among Married Women in the Military: Type, Level, Directionality, and Consequences. Journal of Family Violence, 21, 369-380.
Gewirtz, A. H., Erbes, C. R., Polusny, M. A., Forgatch, M. S., & DeGarmo, D. S. (2011). Helping Military Families through the Deployment Process. Professional Psychology: Research and Practice, 42, 56-62.
Gibbs, D. A., Martin, S.L., Kupper, L. L., & Johnson, R. E. (2007). Child Maltreatment in Enlisted Soldiers Families during Combat Related Deployments. Journal of American Medical Association 298, 528-535.
Gironda, R. J., Clark, M. E., Ruff, R. L., Chait, S., Craine, M., Walker, R., & Scholten, J. (2009). Traumatic Brain Injury, Polytrauma, and Pain: Challenges and Treatment Strategies for the Polytrauma Rehabilitation. Journal of Rehabilitation Psychology 54, 247-258.
Goff, B. S., Crow, J. R., Reisbig, M. J., & Hamilton, S. (2007). The Impact of Individual Trauma Symptoms of Deployed Soldiers on Relationship Satisfaction. Journal of Family Psychology, 21, 344-353.
Guerra, V. S. & Calhoun, P. S. (2010). Examining the Relation between Post Traumatic Stress Disorder and Suicidal Ideation in OEF/OIF Veterans. Journal of Anxiety Disorders 25, 12-18.
Hardin, S. B., Hayes, E., Cheever, K. H., & Addy, C. (2003). Impact of War on American Adolescents. Journal of Child and Adolescent Psychiatric Nursing, 16, 81.
Hass, D. M & Pazdernik, L. A. (2007). Partner Development and Stress in Pregnant Women. Journal of Reproductive Medicine 52, 901-906.
Helmer, D. A., Chandler, K. S., Quigley, K. S., Blatt, M., Teichman, R., & Lange, G. (2009). Chronic Widespread Pain, Mental Health and Physical Role Function in OEF/OIF Veterans. Journal of Pain Medicine 10, 1174-1182.
Horrell, S. C., Holohan, D. R., & Didion, L. M. (2011). Treating Traumatized OEF/OIF Veterans: How Does Trauma Treatment Affect the Clinician. Journal of Professional Psychology Research and Practice 42, 79-86.
Jakupcak, M. & Varra, E. M. (2011). Treating Iraq and Afghanistan War Veterans with PTSD who at High Risk for Suicide. Journal of Cognitive and behavioral Practice 18, 85-97.
Jones, E., Fear, N. T., & Wessely, S. (2007). Shell Shock and Mild Traumatic Brain Injury: A Historical Review. American Journal of Psychiatry 164, 1641-1645.
Jones, A. D. (2011). Intimate Partner Violence in Military Couples: A Review of the Literature. Journal of Aggression and Violent Behavior, 17, 147-157.
Karney, B. R., and Crown J.S. (2007). Families under Stress: An Assessment of Data, Theory, and Research on Marriage and Divorce in the Military. Santa Monica, CA: RAND Corporation. Retrieved from http://www.rand.org/pubs (accessed 25 October 2012).
Ketz, A. K. (2008). Pain Management in the Traumatic Amputee. Critical Care Nursing Clinics of North America 20, 51-57.
Klostermann, K., Mignone, T., Kelley, M. L., & Musson, S. (2012). Intimate Partner Violence in the Military: Treatment Considerations. Journal of Aggression and Violent Behavior, 17, 53.
Knobloch, L. K., & Theiss, J. A. (2012). Experiences of U.S. Military Couples During the Post-Deployment Transition. Journal of Social and Personal Relationships, 29, 423-450.
Lester, P., Mogil, C., Saltzman, W., Woodward, K., Nash, W., Leskin, G., Bursch, B., Green, S., Rynoos, R., & Beardslee, W. (2011). Families Overcoming Under Stress: Implementing Family-Centered Prevention for Military Families Facing Wartime Deployments and Combat Operational Stress. Journal of Military Medicine, 176, 19.
Lester, P., & Bursch, B. (2011). The Long War Comes Home: Mitigating Risk and Promoting Resilience in Military Children and Families. Psychiatric Times, 28, 26.
Makin-Byrd, K., Gifford, E., McCutcheon, S., & Glynn, S. (2011). Family and Couples Treatment for Newly Returning Veterans. Professional Psychology: Journal of Research and Practice, 42, 47-55.
Marshall, A. D., Panuzio, J., & Taft, C. T. (2005). Intimate Partner Violence Among Military Veterans and Active Duty Servicemen. Clinical Psychology Review, 862-876.
McDevitt-Murphy, M. E., Williams, J. L., Bracken, K. L., Fieds, J. A., Monahan, C. J., & Murphy, J. G. (2010). PTSD Symptoms, Hazardous Drinking and Health Functioning among US OEF/OIF Veterans Presenting for Care. Journal of Trauma and Stress 23, 108-111.
Meis, L. A., Erbes, C. R., Kaler, M. E., Arbisi, P. A., & Polusny, M. A. (2011). The Structure of PTSD Among Two Cohorts of Returning Soldiers. Journal of Abnormal Psychology, 120, 807-818.
Merrill, L. L., Crouch, J. L., Thomsen, C. J., Guimond, J., & Milner, J. S. (2005). Perpetration of Severe Intimate Partner Violence: Premilitary and Second Year of Service Rates. Journal of Military Medicine 170, 705.
Moon, M. A. (2007). Army Families' Child Abuse Rate Rises with Deployment. Journal of Clinical Psychiatry News35, 10-10.
Nampiaparampil, D. E. (2008). Prevalence of Chronic Pain after Traumatic Brain Injury: A Systematic Review. Journal of the American Medical Association 300, 711-719.*
Otis, J. D., Keane, T. M., Kerns, R. D., Monson, C. & Sciolo, E. (2009). The Development of an Integrated Treatment for Veterans With Co-morbid Chronic Pain and Posttraumatic Stress Disorder. Journal of Pain Medicine 10, 1300-1311.
Park, N. (2011). Military Children and Families: Strengths and Challenges During Peace and War. American Psychologist, 66(1), 65-72.
Renshaw, K. D., Rodrigues, C.S., & Jones, D. H. (2008). Psychological Symptoms and Martial Satisfaction in Spouses of Operation Iraqi Freedom Veterans: Relationship with Spouses Perceptions of Veterans experiences and Symptoms. Journal of Family Psychology 22, 586-594.
Renshaw, K. D., Allen, E. S., Rhoades, G. K., Blais, R. K., & Markman, H. J. (2011). Distress in Spouses of Service Members with Symptoms of Combat-Related PTSD. Journal of Family Psychology 25, 461-469.
Ruger, W., Wilson, S. E., & Waddoups, S. L. (2002). Warfare and Welfare: Military Service, Combat and Marital Dissolutions. Armed Forces Society 29, 85-107.
Saltzman, W. R., Lester, P., Beardslee, W. R., Layne, C. M., Nash, W.P., & Woodward, K. (2011). Mechanisms of Risk and Resilience in Military Families: Theoretical and Empirical Basis of a Family-Focused Resilience Enhancement Program. Clinical Child and Family Psychology Review, 14, 213-230.
Schneiderman, A. I., Braver, E. R., & Kang, H. K. (2008). Understanding Sequelae of Injury Mechanisms and Mild Traumatic Brain Injury Incurred during the Conflicts in Iraq and Afghanistan: persistent Post-concussive Symptoms and Post Traumatic Stress Disorder. American Journal of Epidemiology 167, 1446-1452.
Shaw, M. E., & Hector, M. A. (2010). Listening to Military Members Returning From Iraq and/or Afghanistan: A Phenomlogical Investigation. Professional Psychology: Research and Practice, 41, 128-134.
Sheppard, S. C., Malatras, J. W., & Israel, A. C. (2010). The Impact of Deployment on U.S. Military Families. Journal of American Psychology, 65, 599-609.
Tanielian, T. & Jaycox, L. H. (2008). Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. RAND Corporation. Retrieved from http://www.rand.org/pubs (accessed 15 November 2012).
Theeler, B. J., & Erickson, J. C. (2009). Mild Head Trauma and Chronic Headaches in Returning US Solders. Journal of Neurology 49, 529-534.
Verdeli, H., Baily, C., Vousoura, E., Belser, A., Singla, D., & Manos, G. (2011). The Case for Treating Depression in Military Spouses. Journal of Family Psychology, 25, 488-496.
Vormbrock, J. (1993). Attachment Theory as Applied to Wartime and Martial Separation. Psychological Bulletin 114, 122-144.
Walker, R. L., Clark, M. E., & Sanders, S. H. (2010). The “Post Deployment Multi-Symptom Disorder” An Emerging Syndrome in Need of a New Treatment Paradigm. Journal of Psychological Services, 7, 136-147.
Wong, L. & Gerras S. J. (2010). The Effects of Multiple Deployments on Army Adolescents. Carlisle, PA : Strategic Studies Institute, U.S. Army War College. Retrieved from http://www.strategicstudiesinstitute.army.mil (accessed on 28 October 2012).
Willerton, E., Schwarz, R. L., MacDermid Wadsworth, S. M., & Oglesby, M. S. (2011). Military Fathers' Perspectives on Involvement. Journal of Family Psychology, 25, 521-530.
Zeitzer, M. B., & Brooks, J. M. (2008). In the Line of Fire: Traumatic Brain Injury Among Iraq War Veterans. Journal of the American Association of Occupational Health Nurses (AAOHN) 56, 347-353.