Trends in Behavioral Health Service Use By Military-Connected Children during the Iraq and Afghanistan Wars

Background:  Frequent relocations, changes in schools and communities, parental deployment, and the challenges of post-deployment reintegration put military-connected children at risk for anxiety, depressive symptoms, and substance use. Given the demands and uncertainty of the military, these problems can persist over time and result in the need for behavioral health (BH) care. Yet, little evidence exists about BH service use by military children. We examined trends in BH diagnoses and service use by child (<18 years) Military Health System (MHS) beneficiaries from 2000-2014.

Methods:  Secondary data analysis of medical claims from South Carolina (SC) Health Care Systems with BH disorders as the primary diagnosis and the MHS as the primary/secondary payer. The sample included 2,810 child dependents of military service members from all branches of military service who visited an emergency department (ED) or inpatient (IP) facility from January 1, 2000 to December 31, 2014. BH disorders were defined by Major Diagnostic Codes (MDC) 19 (mental health diseases/disorders) and MDC 20 (alcohol/other drug disorders). Mental health and substance use disorders (SUDs) were identified within MDCs 19 and 20, respectively, using International Classification of Diseases, Ninth Revision (ICD-9) codes and algorithms for case definitions from the Armed Forces Health Surveillance Center. Prevalence of BH visits were estimated annually and categorized by years [2000-2002 (pre-war), 2003-2008 (first 6-year post-deployment period), 2009-2014 (last 6-year post-deployment period)] for any BH care and for mental health and SUDs visits to estimate prevalence before and during Iraq and Afghanistan wars. Prevalence of BH visits was also estimated by age group (0-4, 5-11, 12-17), sex (male, female), race (black, white, Hispanic, other), visit type (ED, IP), and bed-days (<=7, 8-14, >=15). 

Results:  From 2000-2014, military-connected children accounted for 19.6% (n=5,004) of all military BH visits (n=25,534), including 41 (1.5%) for preschoolers (0-4 years), 474 (16.9%) for school-aged children (5-11 years), and 2,295 (81.7%) for adolescents (12-17 years). From 2000-2002, BH service use by military children resulted in 646 visits, 1,898 visits from 2003-2008, and 2,415 visits from 2009-2014. Mental health visits accounted for the majority of utilization, which increased from 171 in 2000 and peaked at 437 in 2013. SUD visits represented a small proportion of BH visits (7.3%), and were almost exclusively for adolescents. Mental health services did not differ by gender, but about two-thirds of SUD visits were by males. Mean bed-days were 10.5 days for BH visits overall, however SUD hospitalizations resulted in a much longer stay on average (21.5 days) compared to mental health hospitalizations (10.1 days). Depressive disorder was the most prevalent diagnosis in both school-aged children and adolescents followed by bipolar, adjustment, and anxiety disorders. For adolescents, alcohol use disorder, mixed/unspecified drug abuse, and cannabis abuse accounted for the majority of SUDs visits.

Conclusions/Implications:  BH care by military-connected children increased substantially during the Iraq and Afghanistan wars. Adolescents received the majority of care and depressive disorder was the most prevalent diagnosis, but SUDs resulted in longer hospital stays. Future research should examine factors associated with depression and SUDs in military-connected adolescents.