8
Conclusions and Recommendations

The U.S. Department of Defense (DoD) faces both short-term and long-term challenges in selecting and recruiting an enlisted force to meet personnel requirements associated with diverse and changing missions. This report gives guidance to DoD on the physical, medical, and mental health standards used to select members of the enlisted force. This chapter recapitulates the committee’s conclusions and recommendations in these areas.

PROCEDURES, REQUIREMENTS, AND STANDARDS

Medical Standards and Screening

The committee reviewed the current medical screening process. DoD’s medical enlistment standards (DoD Instruction 6130.4, updated in 2005) form the basis for screening recruits for all Services; these standards include mental health as well as physical conditions. In addition, each Service has its own guidance and regulations for entrance and job assignment. There are several points in the enlistment process at which screening takes place. The first is at the recruiting station, where applicants complete a medical prescreening form. This form is not systematically retained or entered into a database, precluding an understanding of screening decisions made at the recruiting station. Body mass index (BMI) is also estimated at the recruiting station based on height and weight. Note that each Service has it own BMI standards. The second is at the military entrance processing stations (MEPS), where a physician takes a



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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards 8 Conclusions and Recommendations The U.S. Department of Defense (DoD) faces both short-term and long-term challenges in selecting and recruiting an enlisted force to meet personnel requirements associated with diverse and changing missions. This report gives guidance to DoD on the physical, medical, and mental health standards used to select members of the enlisted force. This chapter recapitulates the committee’s conclusions and recommendations in these areas. PROCEDURES, REQUIREMENTS, AND STANDARDS Medical Standards and Screening The committee reviewed the current medical screening process. DoD’s medical enlistment standards (DoD Instruction 6130.4, updated in 2005) form the basis for screening recruits for all Services; these standards include mental health as well as physical conditions. In addition, each Service has its own guidance and regulations for entrance and job assignment. There are several points in the enlistment process at which screening takes place. The first is at the recruiting station, where applicants complete a medical prescreening form. This form is not systematically retained or entered into a database, precluding an understanding of screening decisions made at the recruiting station. Body mass index (BMI) is also estimated at the recruiting station based on height and weight. Note that each Service has it own BMI standards. The second is at the military entrance processing stations (MEPS), where a physician takes a

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards medical history and conducts a brief examination, and where vision and hearing tests, HIV and drug testing, height and weight (BMI) measurement, and an orthopedic/neurological examination are conducted. Here candidates are classified as medically qualified, disqualified with a condition that may be considered for a waiver, or permanently disqualified with a condition viewed as nonwaivable. Third, disqualified candidates seeking a waiver apply to Service-specific waiver authorities, and a review is conducted. Finally, additional medical evaluation may be done in basic and advanced individual training, as well as in operational units. Conclusion: To adequately assess the impact of medical standards on applicant flow and disqualification rates, information about screening that takes place before the military entrance processing station physical is required. Recommendation 2-1: The Services should develop a procedure for maintaining data from the DoD Form 2807-2 (Medical Prescreening of Medical History Report) in an automated form for all applicants, including those who are disqualified at the recruiting station. Physical Fitness Standards and Screening There are no DoD-wide physical fitness standards for entry into the Services. The assumption is that a medically qualified recruit can develop the needed level of physical fitness over the course of basic combat training. There are Service-specific initiatives aimed at addressing physical fitness prior to accession. For example, the Air Force has implemented a short strength test administered at the MEPS, and the Army and the Marine Corps have programs addressing fitness while recruits are in the delayed entry program (DEP). Currently, however, fitness is viewed primarily a training issue, rather than an accession standards issue. Physical Demands of Military Service Studies show that technology is increasing the physical demands of some jobs and decreasing the demands of others. This leads to the question of whether it is feasible or advisable to set differing physical and medical standards for different military occupational specialties (MOSs). With limited exceptions, there is little research detailing the physical requirements of individual MOSs. However, the crucial feature underlying the question of setting lower standards for some MOSs than for others is the DoD policy decision that every uniformed Service member be combat-ready. This implies a common set of requirements for combat tasks regardless of one’s primary MOS. While part of the charge to the commit-

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards tee was to review evidence on the physical requirements of military jobs, we found no research detailing the fitness requirements of all of the common military tasks required for combat readiness. Conclusion: In order to understand the fitness requirements needed to perform the set of common military tasks within each service, an analysis of the requirements of each task is needed. While the requirements of a few tasks (e.g., carrying a loaded pack) have been studied, there is no systematic analysis of the entire set of common tasks in each Service. Recommendation 2-2: We recommend that research be undertaken to determine the fitness requirements (based on defining the functional requirements) of the common tasks cutting across military occupational specialties in each Service, with the goal of using this research to set fitness standards. The committee notes that each Service has some form of routine physical fitness testing for all members. While all include components measuring aerobic capacity, upper body muscle strength, and abdominal muscle strength, the components vary considerably by Service, as do the standards for passing. While the research we recommend would provide a scientific underpinning for specifying the physical requirements for combat-readiness, the current annual fitness testing standards serve as the Services’ current operational definition of the physical requirements of military service. We note that the use of different fitness measures by the Services makes it difficult to assess fitness across the Services. While acknowledging that each Service may have reason to set standards differently from the others and may have reason to implement additional Service-specific measures, the use of a common set of basic fitness measures would aid understanding of fitness across the Services. Recommendation 2-3: We recommend that an inter-Service panel develop a common core set of uniformly administered fitness measures for use across the Services in research studies on physical fitness and its policy implications for military service. This does not preclude the use of additional Service-specific measures or the setting of differing standards by each Service. FRAMEWORK FOR EVALUATING MEDICAL AND PHYSICAL STANDARDS The committee reviewed methods for examining the linkage between a medical or fitness standard and an outcome of interest (e.g., attrition,

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards performance). Methods for specifying these linkages are well established; the key need is for systematic data collection and management, thus permitting the application of these methods. Such methods are used by the Services in evaluating standards in other domains, such as cognitive ability and educational attainment. However, the committee found that empirical justification for many physical and medical standards is lacking. Conclusion: Some standards are justified on prima facie grounds, based on an incontrovertible link between the standard and fitness for service (e.g., blindness, deafness, paralysis). Many, however, are based on a presumed link between the standard and an outcome of interest. The evaluation framework linking standards to outcomes is applicable to all such physical and medical enlistment standards. Recommendation 3-1: We recommend that data be collected that would allow the study of empirical links between physical and medical characteristics and performance-based outcomes, such as attrition and injury. Establishing a correlation between a physical or medical standard and an outcome of interest means that the Services can affect the outcome of interest by changing the cutoff score on the standard (i.e., increasing or decreasing the stringency of the standard). Doing so, however, has cost implications, as setting a more stringent standard would result in higher recruiting costs. The committee examined potential applications of the accession quality cost-performance trade-off model, a computer-based optimization model used to evaluate standards in the domain of cognitive and education standards, to the evaluation of standards in the physical and medical domains. The model aids in the identification of how to obtain the highest level of the outcome of interest at the lowest cost. Conclusion: Application of the cost trade-off model requires valid data on enlistee health and fitness throughout the tour of duty, as well as the ability to link health and fitness measures to such outcomes as lost work time and attrition. This requires ready access to and linkage between health and personnel databases. Recommendation 3-2: We recommend that DoD undertake a project to develop the data and technology necessary for a cost-performance trade-off model that could be applied to setting and evaluating medical and physical standards. Recommendation 3-3: We recommend that DoD commission a review of the medical databases necessary for evaluating and assessing

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards medical and physical enlistment standards and create a mechanism for integrating or linking the medical databases with existing personnel databases at the Defense Manpower Data Center, subject to all legal requirements. PHYSICAL FITNESS AND MUSCULOSKELETAL INJURY Physical Characteristics of Military Basic Training Basic combat training is designed to be an intense program that orients and indoctrinates new recruits to their Service. One essential component of it is physical fitness training. In order to graduate from basic training, recruits must have demonstrated that they are capable of passing Service-specific routine physical fitness tests. In this respect, basic training performs an (expensive) screening function for the Services. The selection process for enlisted personnel does not include any measurement of physical fitness. Thus, the basic training system must be capable of providing effective physical fitness training to individuals who vary widely in the levels of fitness they bring to the system. Individual Factors, Training Demands, and Injury and Attrition Musculoskeletal Injury Research has identified several risk factors for musculoskeletal injury, including individual characteristics, physical demands, and psychosocial demands. Individual characteristics include age, gender, race, physical structure, previous injury, previous physical activity, and physical fitness. Physical demands are physical stressors, such as running, marching, lifting, carrying, and jumping imposed by the training and work environment. Psychosocial demands include pressure to perform and requirements to conform to a particular social or organizational structure. Because the causal pathways to musculoskeletal injury include a consideration of all these factors, it is important to consider their interactions. Musculoskeletal injuries resulting from basic and advanced individual training pose the single most significant medical impediment to military readiness. In 1994 and 1995, these types of injuries were the leading cause of disability in all Services and were the leading cause of hospitalizations for the Army, the Navy, and the Marine Corps. High incidence rates of musculoskeletal injuries result in enormous monetary costs, lost work and training time, and recruit attrition. The injury rate for women is about twice as high as that for men.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Fitness, Injury, and Attrition The scientific literature points strongly toward the conclusion that low physical fitness is causally linked to increased risk of orthopedic injury during basic military training and attrition from military service prior to completion of the first term of enlistment. Female recruits are more likely than their male counterparts to experience orthopedic injuries during military training, but statistical adjustment for the gender difference in physical fitness largely eliminates the male vs. female differences in injury rates. Furthermore, some experimental studies examining modified training methods reinforce the view that physical fitness is an important determinant of injury and attrition outcomes in military recruits. Findings suggest that modification of training programs to consider individual fitness and moderation of exposure to running exercises early in training can reduce injury rates. There are extensive bodies of knowledge on measurement of physical fitness and on exercise training for the enhancement of physical fitness. These bodies of knowledge, if applied carefully in identifying modified approaches to screening and training military recruits, would seem to hold out considerable promise for reducing negative outcomes during basic military training. Several types of modified protocols, whether used individually or in combination, appear likely to reduce injuries and attrition during first-term military service. Fundamentally, it is possible to conceive of changes in the characteristics of the recruit population (e.g., physical fitness screening procedures at the preenlistment or induction stages), changes in preinduction preparation protocols (e.g., preinduction physical training programs), and changes in basic training protocols (e.g., modification of physical training during basic military training) that would provide important benefits. Psychosocial Factors and Injury Psychosocial factors, such as pressure to perform, the organization of tasks, and social context, may also contribute to musculoskeletal injuries and attrition among military recruits. Studies show that there is a strong interaction among physical requirements of the task, the psychosocial environment, and the personality profile of the person. The personality characteristics of the individual can interact strongly with the psychosocial environment and lead to increased coactivation of the musculoskeletal system. This coactivation typically increases joint loading and may lead to increases in cumulative tissue degeneration and increased risk of musculoskeletal disorders.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Although very few studies in the military have focused on psychosocial factors and how they might impact musculoskeletal injury, the combination of high physical training, preparing for combat, and intense operational tempo is bound to place psychological stress on military recruits. Military studies have linked decision authority, experienced responsibility for work, increased time pressure, and greater cognitive processing demands to musculoskeletal pain intensity and symptom reporting. The psychosocial environment thus merits consideration in designing interventions aimed at reducing musculoskeletal injury. Gender and Musculoskeletal Injury Since the injury rates of female recruits in basic training are higher than those for male recruits, time lost from training for these injuries is also higher, and attrition rates are higher, consideration should be given to designing different training regimens for women. In the context of integrated training, it may still be possible to separate some of the physical training by gender. Currently, the standards recognize a difference between physical abilities of men and women but the training does not adequately take these into account. All of these findings lead to a series of interrelated conclusions and recommendations as to areas showing considerable promise for reduction of injury and attrition, without harm to the resulting levels of attained fitness. Conclusion: Currently, none of the Services systematically conducts comprehensive standardized physical fitness testing at the time of recruitment. Standardized physical fitness testing prior to basic training would permit the identification of recruits at higher risk of injury and attrition. Individuals classified as not meeting a designated physical fitness standard could be assigned to remedial physical training prior to basic training (preship intervention), or to a modified basic training regime, or to both. There is a range of options for a physical fitness test (or tests) that would be valid, reliable, feasible to implement, and likely to be cost-effective. Recommendation 4-1: A standardized physical fitness test should be selected and routinely implemented at some point prior to the initiation of basic military training. Conclusion: Preship interventions aimed at improved physical fitness merit consideration. There is clear evidence that such programs would increase physical fitness in most recruits with low fitness, but evidence

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards that these programs would reduce the incidence of injury or attrition in basic training is limited. Recommendation 4-2: Research should be conducted to examine the relationship between physical training programs prior to basic training and the incidence of injury or attrition during basic training, focusing on recruits who would fall below a designated physical fitness standard at the start of basic training. Conclusion: Although training outcomes are the result of several interrelated factors, preliminary, direct evidence suggests that imposing limited physical demands at entry to military training and increasing physical training demands as fitness levels increase could produce comparable levels of physical fitness to current training regimes, with markedly reduced injury rates. This approach should be considered when redesigning basic training. Recommendation 4-3: Basic training’s physical and psychological demands should be tailored to broad categories of initial fitness levels and gradually increased over the duration of the training (in accordance with exercise prescription science and injury prevention principles) so that optimal fitness is achieved with minimal risk of musculoskeletal disorders, traumatic injury, and attrition. Conclusion: The literature supports the notion that, due to biomechanical and physical fitness differences, men and women have different risks of musculoskeletal disorders, traumatic injury, and attrition as a function of basic military training. In addition, these differences can impact the path to optimal fitness. Therefore, male and female training protocols should ideally be tailored differently. Female recruits have lower average levels of physical fitness and conditioning, at the initiation of basic training, than male recruits. However, it is currently unclear whether the higher risk of injury during basic training observed in women is entirely a function of their lower (on average) physical fitness, or whether it is also partly driven by the other numerous musculoskeletal, biomechanical, and neuromuscular differences between women and men. It is therefore unknown whether tailoring the demands of basic training to an individual’s fitness level (as per Recommendation 4-3) will fully address the problem of the higher risks of injury and attrition observed in female recruits. Recommendation 4-4: Research should be undertaken to address the causes of the increased risk of injury and attrition in women. This research should address differences between men and women in physical fitness and should also address musculoskeletal, biomechanical, and neuromuscular factors.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards MEDICAL STANDARDS The committee focused on two medical issues for which medical waivers from disqualification are commonly sought: BMI/body fat and diseases of the lungs. Body Composition and Body Fat The percentage of children and adults who are overweight or obese is a growing problem in the United States. Widely endorsed definitions categorize a BMI between 25 and 29.9 as overweight and 30 or greater as obese. Among adolescents, the BMI level that identified the highest 5 percent of the population in 1963 is now exceeded by 15.5 percent. The prevalence of obesity is greater for Mexican American and black children than for their white counterparts. Standards for BMI and body fat are determined by each Service. Current standards could temporarily disqualify 15 to 25 percent of the male and 25 to 50 percent of the female youth population. It is important to note that the BMI standard for remaining in the military is often different from the entry standard. For men, the retention standard is generally more stringent than the entry standard; 25 to 40 percent of the youth population would not meet the retention standard. For women, some Services impose a modestly more stringent retention standard and some a modestly less stringent standard. One argument for a BMI/body fat standard is the research linking overweight to long-term health outcomes. We note, however, that the vast majority of enlistees serve a single tour of duty, while the negative health outcomes of being overweight tend to emerge much later in life. Thus the committee focused on consequences of being overweight for outcomes during military service. A second argument is that BMI/body fat is a proxy for physical fitness and is an indicator of risk for injury. The committee reviewed research examining the relationship between BMI and a direct fitness measure and injuries. Although there is a systematic relationship between fitness and injury for both men and women, there is virtually no relationship between BMI and injury rates for men, and the small relationship observed for women reflects a slightly higher injury rate for low BMI (i.e., very lean) women. The committee conducted a series of simulations to project the change in injury rates should the Services increase the number of high BMI individuals enlisted; our findings show that injury rates would change minimally. Another potential argument is that BMI/body fat is a predictor of attrition. The committee reviewed research examining the relationship

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards between BMI and attrition in basic training, and conducted simulations examining the effect of an increase in the number of high BMI individuals enlisted. As with the injury analyses, a shift in the distribution of BMI toward heavier recruits had very little effect on attrition risk in men. For women, however, there was a higher risk of attrition in the higher BMI groups. Attrition of women is already nearly twice as high as attrition of men, and to further increase this gender differential is a concern. However, the committee’s projections show that increasing the proportion of high (25 to 34) BMI women from the current 23.6 to 40 percent would result in only a 1 point increase in the attrition rate. There could thus be access to an expanded recruit pool if the Services were willing to accept such an increase in the attrition rate. Conclusion: Committee projections based on data provided by the Army suggest that a shift toward a higher BMI force would be unlikely to adversely impact injury and attrition risk in men, but might slightly increase the attrition risk in women. It is important to note that this conclusion is based on data from individuals who qualified under the current standard. Recommendation 5-1: As BMI is less predictive of injury and attrition than aerobic fitness, we recommend that it not be used as a proxy measure for fitness in the military population. Recommendation 5-2: As a BMI standard is not justified on the basis of links to injury or attrition, we recommend that such links not be used as the basis for any use of BMI. One final potential rationale for the use of BMI/body fat is as a proxy for appearance and military bearing. Conclusion: Standards for appearance and bearing are issues of military values and thus are outside the committee’s charge. The fact that some Services have a more stringent BMI standard for retention than for entry led the committee to review research on the likelihood that individuals will be able to lose weight and maintain that weight reduction over time. That research is generally pessimistic about the prospects for long-term weight reduction. Although a relatively small number of individuals with high motivation and high self-control can lose weight and retain that weight loss through diet and high levels of physical activity, such results are not the norm, and research has not identified programs that have a high likelihood of success for achieving long-term substantial, sustainable weight loss. Given the evidence re-

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards garding the difficulties of maintaining weight loss, the committee thinks that it is unrealistic for retention standards to be more stringent than accession standards. Recommendation 5-3: Any BMI standard used for retention should not be more stringent than a standard used for accession. Asthma Asthma is ubiquitous in the general population, affecting about 8 percent of the population, with higher prevalence noted among blacks compared with others and women compared with men. An appreciable number of potential military recruits can therefore be expected to have asthma. Currently, asthma at any level of severity precludes participation in the military without a waiver. Available data indicate little difference after basic training between military personnel with and without asthma. A reasonable question is whether or not having asthma should make an individual ineligible for service. As reflected in the current waiver system, it is likely that individuals without symptoms for a prolonged period of time or even those with mild and infrequent symptoms could carry out their service requirements, especially if they received optimal medical therapy and self-management education. However, there are costs associated with ensuring timely access of personnel to needed medical therapies and making self-management education available. Furthermore, existing data are not informative regarding whether the conduct of certain military operations are more conducive to problems for those with asthma than others, for example, whether environmental conditions or specific tasks may trigger exacerbations. Nonetheless, in general, available data do not suggest a different service trajectory after initial training for individuals with asthma compared with those without. Basic training appears to provide a natural screening process for individuals with asthma, as the greatest attrition occurs during this phase of service. Individuals with asthma leave at a higher rate in basic training. Basic training is a costly facet of military activity and a careful cost-benefit analysis would be needed to determine whether or not the Services should enlist individuals with asthma knowing that a number are sure to drop out during training. It is important to note, however, that much of the research on asthma and attrition in basic training focuses on individuals whose asthma is diagnosed after enlistment. As recruiting decisions can be made only on the basis of information known prior to enlistment, information on the attrition of individuals whose condition is known or

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards knowable prior to enlistment is needed for the application of cost-benefit analysis. Conclusion: In light of current data, the existing standard and waiver process regarding asthma is appropriate. Research on the cost-benefit consequences of enlisting individuals with more severe asthma would be needed prior to recommending any change in enlistment policy regarding asthma. MENTAL HEALTH Psychological adaptation to military service is critical for successful completion of a tour of duty. Stressors associated with transition from civilian to military life include changes in living arrangements, geographic locations, peer relationships, support systems, schedules, priorities and control over one’s life, separation from family and friends, difficulties in communication with home, and loss of privacy. Soldiers in wartime missions must deal effectively with the stress and anxiety associated with potential loss of their lives and their fellow soldiers. Stressors associated with peacekeeping missions include isolation, a sense of powerlessness, boredom, coping with unpredictability of the mission, dealing with shifting rules of engagement, struggling with conflicting personal views, being unable to identify a clear enemy, and questioning the lasting impact of the mission. All of these features highlight the importance of mental health. Lifetime prevalence rates of mental disorders for the total active duty U.S. Army population were projected at 37.5 percent for any mental disorder, 5.8 percent for depressive disorders, 16.6 percent for anxiety disorders, 8.3 percent for antisocial personality disorders, and 1.1 percent for schizophrenia. Those hospitalized for a mental disorder have a higher subsequent rate of attrition (45 percent) than those hospitalized for other reasons (11 percent). Mental Health Enlistment Standards DoD has recently revised the mental health disorders that are causes for rejection for enlistment into the military service. For learning disorders and attention deficit hyperactivity disorder, the criteria have been changed to allow eligibility for individuals who can demonstrate passing academic performance without the use of academic and/or work accommodations or medications in the previous 12 months. An age cutoff (the 13th birthday) is used for some standards, including those for enuresis, encopresis, sleepwalking, and eating disorders.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards There is increased recognition of depression in children and a concomitant increase in the use of mental health treatment for this disorder in youth. The typical duration of treatment is approximately one year for a single episode of depression. The current DoD fitness standards exclude any individual who has a history of a mood disorder, including depression, who received outpatient treatment for longer than six months from a physician or mental health professional. The committee’s determination of a reasonable cutoff was based on clinical evidence from the civilian youth population. For an adolescent, it takes one to two years to recover from an episode of major depression. Following discontinuation of medication, the period of relapse is greatest during the first year of medication withdrawal. Because relapse rates are high in adolescents, a medication-free period of two years (e.g., ages 16-17) would allow time to assess the clinical response. A cutoff for disqualification of the 13th birthday is a conservative stance designed to decrease the likelihood of a recurrent episode of depression during combat duty. A similar clinical logic applies to anxiety disorders. Conclusion: Consideration should be given to altering the disqualifying criterion for depression because (1) there will be increasing numbers of applicants who have received treatment for depressive disorders and (2) there is no evidence base to support exclusion of individuals who have received outpatient care for longer than six months. As is the case for depression, there is increased recognition of the early age of onset of anxiety disorders. DoD fitness standards exclude any individuals who have a history of anxiety disorders. Conclusion: Given the high prevalence of anxiety disorders in youth and the lack of scientific rationale for the exclusion of an individual with a history of anxiety disorders, consideration should be given to altering this disqualifying criterion. Recommendation 6-1: We recommend that disqualification for mood and anxiety disorders should occur only if disorders occur after the applicant’s 13th birthday. We recognize that the imprecision with which age cutoffs can accurately predict the likelihood of performance problems due to mental illness suggests that waivers may be commonly requested, and frequently granted, for illness occurring after age 13. However, using the 13th birthday as a cutoff allows sufficient time for clinical follow-up of a diagnosed mood or anxiety disorder to identify potential recruits with a risk of recurrence.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Mental Health Screening There is a single item on the self-report medical prescreen form completed at the recruiting station that is related to psychiatric disorders. Applicants are asked whether they have “seen a psychiatrist, psychologist, counselor or other professional for any reason (inpatient or outpatient) including counseling or treatment for school, adjustment, family, marriage or any other problem to include depression, or treatment for alcohol, drug or substance abuse.” Applicants responding “yes” are requested to explain the affirmative response, and all documentation relating to an affirmative response is to be sent directly from the treating clinician or hospital to the MEPS chief medical officer. Conclusion: The single item (2.a.(16), DD Form 2807-2) addressing psychiatric disorders on the medical prescreen form does not contain sufficient specificity for research and evaluation purposes. Recommendation 6-2: Specific mental health disorders should be included on the medical prescreen report form. Recommended items include depression after the age of 13, bipolar disorder (manic depressive illness) after the age of 13, anxiety disorders after the age of 13, exposure to trauma, attention deficit hyperactivity disorder with medication treatment in the past year, schizophrenia and psychotic disorders, and hospitalization for mental illness care. A positive response to this screening question would require open-ended amplification regarding the specific diagnosis. At the MEPS, recruits complete a medical history questionnaire. The available information about the history of treatment for a mental condition depends solely on this self-report. Although recruits undergo a medical evaluation at the MEPS, there is no formal psychiatric assessment. Conclusion: The history questionnaire can usefully be augmented with a short set of questions regarding current symptoms and a brief standardized mental status examination that addresses mood, anxiety, psychotic symptoms, and suicide. This would be important to include as a routine component of the medical evaluation. Recommendation 6-3: A brief self-report questionnaire regarding current symptoms of mental health conditions should be administrated at the military entrance processing station. Recommendation 6-4: A brief mental status examination should be conducted by the medical officer at the MEPS.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards There is minimal systematic data collected by the Services regarding individuals with mental health conditions. The prevalence and impact of specific mental health conditions on military performance or attrition rates require further careful study. Mental illness is often coded in vague terms (e.g., adjustment disorder) or is handled administratively without attaching a diagnostic category. Conclusion: Some elements of a complete database describing the impact of mental illness on military personnel exist, and the committee has reason to think that other data elements could be developed through appropriate linkage of existing databases. Recommendation 6-5: Data about mental health disorders from recruitment through active duty should be collected and maintained so that informed decisions can be made regarding recruitment and retention of applicants with mental illness. These data should be obtained for all Services and should create an accurate picture of the impact of mental illness on military personnel from recruitment through separation, with a particular focus on the outcome of recruits who request and receive mental illness waivers for specific diagnoses, as well as the rates and diagnoses leading to attrition during training and active duty. Further studies using complete data sets should be designed to determine whether there are any differences in retention and performance between recruits with and without a history of psychiatric disorders, such as depression and anxiety disorders. SUBSTANCE ABUSE AND TOBACCO USE Alcohol and Drug Abuse The general DoD requirements relating to moral character are quite general, stating only that individuals should be disqualified “who have exhibited antisocial behavior or other traits of character that would render them unfit to associate with military personnel.” Military leaders generally agree that individual performance and unit morale would suffer greatly if individuals were allowed to be drunk or be high on drugs while on duty. The specific standards for alcohol and drug abuse are set by each Service, although there are some broad similarities across them. Generally, a history of more severe types of alcohol and drug abuse or dependence is disqualifying, while limited “recreational” use of marijuana does not now require a waiver. Alcohol use does not require a waiver unless the recruit tests positive at the physical. Between these two extremes, the

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Services distinguish several degrees of severity of drug and alcohol abuse, and there are some important differences among the branches. Alcohol consumption dropped significantly between 1980 and 1993, from a high of over 70 percent to a low of about 50 percent. It has fluctuated only slightly since that time and stood at about 47 percent in 2003. For both males and females, white youth have the highest rates of alcohol consumption and black youth the lowest. Hispanic youth are in between but are closer to whites than blacks in their consumption rates. Marijuana usage also shows a steep drop between 1978 and 1992, from a maximum of 37 percent to a low of 12 percent. The rate began rising again in the early 1990s and reached a more recent maximum of just under 25 percent in 1997, and it has remained at about that level since that time. The use of other illicit drugs is about half the level of marijuana, and it shows a similar pattern but with somewhat less pronounced swings. Total illicit drug use among men differs very little by race; however, differences are found by gender. Black women have rates that are consistently 10 points below white women. Substance Abuse and Military Performance The primary outcome for evaluating moral character standards is attrition. Serious substance abusers are ineligible for enlistment in the first place (e.g., chronic alcoholism, illicit drug dependence), and very few waivers are granted for those who test positive at the MEPS for alcohol or illicit drugs other than marijuana. The main question therefore concerns waivers granted for positive tests for marijuana. Since a history of occasional use of marijuana no longer requires a waiver, we were restricted to evaluating attrition of enlistees who enter with a waiver for marijuana. Such waivers range from 2,000 to 3,000 per year, which is about 1.5 percent of total accessions. At 12 months, attrition is elevated for marijuana waivers by only 3 percent; female rates are more elevated, but very few women receive these waivers. Attrition rates at 24 months are more elevated (6 to 9 percent), but even this difference is modest. Finally, 36-month attrition is elevated by 10 percentage points. On one hand, it is not clear whether these elevated rates would justify changes in the waiver policy; the longer persons stay in the Service past 12 months (the maximum length of most training periods), the more likely they are to repay the initial training investment. On the other hand, there are relatively few of these waivers, which means excluding them would not have much impact on recruiting costs. A formal cost-performance trade-off analysis would be required to test whether stricter standards for marijuana waivers would be cost-effective.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Conclusion: Few persons enter the military with serious substance abuse, but about 1.5 percent of accessions enter with a marijuana waiver. Attrition is not significantly elevated at 12 months of military service for those with marijuana waivers, but it is modestly elevated at 24 and 36 months of service. It is unclear at this point whether a cost-performance analysis would suggest any changes to the current standard, since the savings from reduced training costs may or may not exceed the additional costs of recruiting. Recommendation 7-1: We recommend that DoD undertake a formal cost-performance trade-off analysis to determine whether a stricter standard for marijuana waivers would be justified on cost-effectiveness grounds. Tobacco Use Results from the DoD Survey of Health-Related Behaviors conducted in 2002 suggest that cigarette smoking is widespread in all branches of the military. This particular survey also indicates that nearly one-third of the military’s smokers brought the habit with them when they joined. Not surprisingly, then, cigarette smoking was found to be most prevalent among members in the junior pay grades, ranging from a rate of nearly 50 percent for junior enlisted personnel (E-1 to E-3), to 24 percent for senior enlisted personnel (E-7 to E-9), to just over 10 percent for junior officers (O-1 to O-3). One of the most interesting recent discoveries of research on the first-term attrition of new recruits relates to preservice smoking behavior. A series of studies over the past six years produced a variety of interesting findings. An initial Navy study found that attrition from Navy boot camp was nearly twice as high for smokers (15 percent) than for nonsmokers (8 percent). A follow-up study found that differences in attrition between preservice smokers and nonsmokers continued beyond boot camp through the first year of service, leading to the conclusion that the ban on smoking in boot camp was not the primary factor in explaining the higher rates of attrition among smokers. Additional research found that recruits who required some form of enlistment waiver were approximately 1.5 times more likely than their counterparts without a waiver to have smoked before entering military service. A subsequent Air Force study found that preservice smokers were approximately 1.8 times more likely to be discharged during the first year of service than were nonsmokers. A large-scale Army study found that the odds of attrition for soldiers who smoked prior to entering the delayed entry program were 1.54 times those of nonsmokers.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Recruits who smoked were considerably more likely than nonsmokers to have had behavioral problems before enlistment, including high school misbehavior, criminal offenses, drug use, psychological difficulties, and trouble in dealing with authority. Thus preservice smoking is linked with some psychological factor or behavioral predisposition that raises the risk of being discharged early from the military. Interestingly, these smoking effects are independent of education, which has long been recognized as having a strong link to attrition. Conclusion: Smoking in the military is no more commonplace than in civilian populations of comparable ages. Smoking before entry is associated with injury during basic training, probably arising from its adverse effects on numerous physiological characteristics. Studies across the Services show elevated attrition rates for smokers, although the degree of elevation differs appreciably among the Services, perhaps due to different definitions of the frequency and quantity of smoking. It is clear that screening out all smokers or even frequent smokers would not be feasible simply because of their prevalence. Since smoking is correlated with other recruit characteristics related to lower performance outcomes, further research might identify subgroups of recruits with a set of behavioral characteristics that justify higher priority on entry than other subgroups. Recommendation 7-2: Further research is needed on the relationship between preservice smoking and military performance, including attrition and other indicators. The research should be conducted across the Services using the same definitions of frequency and quantity of smoking, and the correlates of smoking with other recruit characteristics should be studied. Studies should include the costs and benefits of policy and force management options for dealing with the issue of preservice smoking. RECOMMENDATIONS AND POLICY OPTIONS This volume has examined a wide variety of aspects of military recruitment, including issues of physical fitness, body mass and obesity, medical conditions, mental health, and drug and tobacco use. The results of the committee’s work led to five broad categories of conclusions and recommendations: reducing injuries and attrition, increasing the pool of eligible youth, developing databases and procedures needed to study the relationship between standards and outcomes, identifying standards that need further investigation, and identifying standards that should be retained.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Injuries and Attrition Two recommendations concern reducing injury and attrition: (1) develop a standardized fitness test for use in the recruiting process and (2) tailor the demands of basic training to the fitness levels of recruits. Recommendations aimed primarily at reducing attrition involve obtaining better information about recruits’ mental health status via the use of a brief self-report of mental symptoms at the military entrance processing station, accompanied by a brief mental status exam by a physician. Increasing the Pool of Eligible Youth Three recommendations concern increasing the proportion of the youth population eligible for entry into military service: (1) do not use BMI as a proxy for fitness, (2) do not use a BMI standard for retention that is more stringent than a BMI standard for entry, and (3) do not require documentation or further medical reviews for self-reported mood and anxiety disorders that occur before the 13th birthday. Developing Databases and Procedures Five recommendations concern developing databases and administrative procedures to permit a broader and more probing inquiry into the relationship between standards and outcomes than is possible in light of data available today: (1) maintain data from the medical history form completed by recruits at the recruiting station, (2) develop a common core of physical strength and fitness measures across the Services, (3) collect data permitting the linkage between medical standards and outcomes, (4) increase the specificity of the single mental health item on the medical history prescreen administered at the military entrance processing station, and (5) collect and retain mental health data from recruitment through length of service. Identifying Needed Research Six recommendations concern substantive research studies needed prior to recommending changes in a current standard or in implementing a new one: (1) analyze the physical requirements of the set of common military tasks across military occupational specialties to obtain a clearer picture of the physical demands of these tasks, (2) study prebasic training fitness interventions to determine whether they are a viable and cost-effective route to reduced injury and attrition, (3) examine the causes of increased injury and attrition in women, (4) compare attrition rates of

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards enlistees with and without mental health conditions existing prior to service, (5) conduct a cost-benefit analysis regarding the effects of increasing the stringency of the current marijuana waiver policy, and (6) conduct further research on the relationship between smoking and attrition, with particular attention to the behavioral factors driving the observed relationship. Standard Retention One issue concerns retaining a current standard. Due to the prevalence of asthma, the committee carefully reviewed the literature on the relationship between asthma and outcomes of interest to the Services and concluded that the current standard and waiver process are appropriate. The committee concluded its earlier study of the role of youth attitudes toward the military and of aptitude and educational standards by noting that recruiting is a complex process, with no single route toward achieving recruiting goals. We end here with the same conclusion. We think, however, that we have been able to highlight a variety of important issues meriting attention as efforts to improve the effectiveness of the recruiting process continue.