Table Of ContentPsychological Screening of Recruits Prior to Accession in the US Military
Chapter 16
PSYCHOLOGICAL SCREENING OF
RECRUITS PRIOR TO ACCESSION IN
THE US MILITARY
ROBERT CARDONA, MD*; and ELSPETH CAMERON RITCHIE, MD, MPH†
INTRODUCTION
RECRUIT ATTRITION
HISTORY OF MILITARY PSYCHOLOGICAL AND PSYCHIATRIC SCREENING
World War I
World War II
Post-World War II
MILITARY ACCESSION PSYCHOLOGICAL SCREENING TODAY
AIR FORCE SCREENING PROGRAM
OTHER SCREENING INITIATIvES
EFFECTIvENESS OF SCREENING AND OTHER INTERvENTIONS
SUMMARY
*Captain, Medical Corps, US Army; Chief, Department of Behavioral Health, Reynolds Army Community Hospital, Fort Sill, Oklahoma 73503-6300
†Colonel, Medical Corps, US Army; Program Director, Mental Health Policy and Women’s Issues, Office of the Assistant Secretary of Defense for Health
Affairs, US Department of Defense, The Pentagon, Washington, DC 20310-6606
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INTRODUCTION
Recruit attrition prior to the end of the first term • mental health intervention levels,
of enlistment is a continuing problem. Often, military • updates on policy changes,
leaders become frustrated with the high rate of attrition • link between long-term functional outcomes
and wonder if better screening efforts would produce and medical accession standards,
fewer dropouts. It is also believed that more in-depth • mental health coding differences among the
screening methods could lead to fewer cases of psycho- military services, and
logical disability after combat. However, the history of • preventative and treatment intervention
psychological testing in the military has demonstrated assistance.
that psychological screening has limited efficiency and
success in performing these tasks. However, a central issue of concern is whether
In this chapter, screening is defined as a cursory high-risk trainees should be prevented from entering
interview and/or a pen-and-paper (or computerized) the service or given the opportunity to attempt train-
test that predicts which recruits will remain in the ing and service at the risk of unproductive cost to
military through their first assignment or otherwise the military and potential emotional or occupational
succeed while on active duty. Different, although re- damage to themselves. Thus, performance is not nec-
lated, issues are prominent in pre- and postdeployment essarily a product of intrinsic capabilities—which are
screening for psychological issues, such as suicidal measured to varying extents by screening tests—but,
behavior or posttraumatic stress disorder. more importantly, the capacity for adaptation in spe-
The Office of the Assistant Secretary of Defense cific environments. Does the military have a system
(Force Management Policy) reported on diverse is- already in place that assesses adaptive capacity? It is
sues affecting current recruit attrition, including the believed that this process occurs under stressful con-
following topics: ditions through interactions with fellow recruits and
instructors in actual military training environments.
• mental health accession standards, Therefore, basic training is considered a functional
• medical and psychological screening tools, screening measure, albeit an expensive one.
• disqualification and waiver processes, This chapter discusses the problems associated with
• existed-prior-to-service recruit mental health recruit attrition. In addition, it outlines the history of
issues, psychological testing of recruits in the US military
• definition of the recruit population, along with current practices.
RECRUIT ATTRITION
Enlisted recruit attrition has been an enduring of Defense (DoD) and Congress launched a multitude
challenge for the US military service. Over the past of new initiatives and policy developments that have
2 decades, enlisted attrition rates have consistently been subsequently integrated over the past 4 years into
averaged 30% during first-term periods. In 1997 this the National Defense Authorization Acts.
issue was reemphasized after the Subcommittee on One major area of investigation involved mental
Personnel for the US Senate Committee on Armed health effects on enlisted entry-level attrition. Accord-
Services requested the General Accounting Office ing to the director for Accession Policy in the Office
(GAO) to review 6-month attrition rates for enlisted of the Undersecretary of Defense for Personnel and
service members. Investigations were launched into Readiness, reasons for attrition can be grouped into
the increasing 6-month and 4-year attrition rates, and three areas: (1) medical disqualifications, (2) hardship
the faltering ability of some services to meet their conditions, and (3) behavioral problems or unsatisfac-
recruitment goals. tory performance. Behavioral/performance issues
A series of investigative reports by GAO were constitute 80% of separations.5
published in January 1997. These reports reflected the In 1979 the US Army sought the assistance of the
multifaceted complexity of enlisted attrition, which RAND Corporation (Santa Monica, Calif) to investigate
expanded into issues of recruitment, selection, training, why one third of its recruits dropped out during the
and retention.1-4 In 1962 expended financial and per- first term of service. First-term attrition rates ranged
sonnel resources for enlisted 6-month attrition losses from 25% to 40%, averaging 30% among all the armed
equated to approximately $390 million.2 In response to forces.1 Between fiscal years 1982 and 1993, 31.7%
GAO analysis and recommendations, the Department of all enlistees did not complete their first term, and
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Psychological Screening of Recruits Prior to Accession in the US Military
11% of all enlistees were separated during their first different separation codes used by each of the armed
6 months.6 services has hampered accurate data interpretation.
The Army’s attrition rate, in general, has been the Central issues include overlapping categories of
highest, and the Air Force‘s attrition rate has been the discharge, different utilization of codes among the
lowest. However, the overall first-term attrition rate military services, and enlisted separations (80%) hav-
in all the military services has been between 32% and ing more than one cause. Interpretation is essential in
35%. Recently, the first-term attrition rate hit an all-time clearly identifying causes of attrition, which would al-
high at 36.9%.4 The average college dropout rate is 28% low empirical guidance to address avoidable etiologies
for a comparably aged population.5 and directing appropriate policy revision.
Since 1987 the 6-month attrition rate has also The majority of attrition is attributed to adjustment
steadily increased. Among the armed services, there and behavioral issues, but the separations are coded
is a 15% attrition rate (12% for the Air Force and 16% through administrative channels. These separations
for each of the other services), which represents the represent reversible psychological or psychiatric is-
largest loss during first-term periods.7 Training costs sues that responded to earlier preventative measures
per enlistee range from $9,400 to $13,500 for recruit- or treatment.
ment and basic training, with additional training costs The three military services set goals to reduce at-
of another $6,100 to $16,300 per recruit.1 In fiscal year trition by 4% to 10%, but it was questioned whether
1998, the average cost of recruiting an enlistee was this could occur without accurate analysis of attrition
$6,732, and the average cost of training a recruit was causes.1 The DoD’s enlistment standards are not em-
an additional $28,800—a total of $35,532 per trained pirically linked to military performance, but rather
recruit.1 attrition risks are based on military experience and
Attrition is a complex issue and is closely linked to expert opinion. The 1996 formation of the Accession
retention and recruiting. Since 1997 the military has Medical Standards Analysis and Research Activity
had difficulty meeting recruitment goals, thus mak- (AMSARA) has sparked efforts to develop evidence-
ing attrition rates even more significant. In addition, based accession standards. AMSARA’s mission is the
because of annual accession requirements, building a collection and analysis of service epidemiological
recruit applicant pool in the delayed entry pool has data, which can then be linked with cost-effective-
been impaired considerably. ness analysis, medical waiver quantitative risks, and
There are many reasons for the growing recruit direct medical attrition minimization policy. Another
attrition rate.8 The military has relied on a volunteer concern has been using administrative databases for
force since 1973. After the Persian Gulf War, in the early medical purposes. There is support for revising separa-
1990s, recruiting resources were scaled down. Signifi- tion codes and in centralizing this process. Efforts are
cant losses have been linked to civilian sector competi- being made to revise all separation codes and advise
tion, specifically in the areas of information technology, uniform application among the armed services. Use of
communications, and airplane mechanics. Since 1993 recognized codes from the International Classification
greater financial investments into the system have of Diseases on all medical waivers and separations is
not translated into higher quality recruits. Additional being considered.9
contributing factors include the following: According to 1995 to 1998 data from AMSARA,7
psychological and psychiatric conditions composed
• civilian educational/employment interests one quarter of all existed prior to service first-term
and opportunities, discharges. Orthopedic causes were the most com-
• a formerly robust economy (with its low un- mon, followed by psychiatric causes and pulmonary
employment rates), (asthma) causes. From 1995 to 1998, for enlisted
• fewer veteran role models, personnel with 2 years of service, psychiatric condi-
• changes in cultural trends, tions represented 3% of Army disability discharges
• reduced stability and predictability of military and 13% of Air Force disability discharges. Musculo-
lifestyle, skeletal causes were the primary reasons for disability
• long duty hours, discharges. (Data are unavailable from the US Navy
• frequent moves, and Marine Corps.) Also unrecorded are a substantial
• extended family separations, and number of discharges that result from psychiatric
• spousal employment disruptions. causes but are cataloged under the guise of another
category (usually orthopedic). This may be done to
One of GAO’s main concerns has been to accurately protect the recruit or simply to expedite the separa-
determine the fundamental reasons for attrition. The tion process.
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HISTORY OF MILITARY PSYCHOLOGICAL AND PSYCHIATRIC SCREENING
World War I then president of the American Psychological Associa-
tion, proposed blanket intelligence testing for military
Psychological screening has been an integral part recruits. The US Surgeon General considered Yerkes’
of military accession practices for the past 80 years. proposal, even though the Navy refused. Subsequently,
Novel screening efforts emerged at critical time for the Yerkes was appointed director of the US Army Psy-
US military as it headed into World War I and drafted chological Testing Corps and headed a task force of
men into service. With the many scientific advance- psychologists.12
ments in intelligence testing, more efficient methods The expansion of screening needs for the draft effort
of screening have materialized. attracted hundreds of psychologists into the service to
In the late 19th century, the study of individual perform the testing. A paper-and-pencil survey, cor-
differences developed interest in the quantification of related to the standardized Stanford-Binet test, was
human qualities. In 1884 Francis Galton, the father of developed for the US military. Testing screened for
psychological testing, administered the first test bat- intellectual defectiveness and inappropriate career
tery to thousands of people at the International Health placement. In 1917 Yerkes—with the help of Lewis
Exhibit in England. James Cattell modified Galton’s Terman, David Wechsler, and others—developed the
test and introduced it to the United States, along with Army’s alpha and beta tests (alpha tests measured lit-
the term “mental tests.” In 1897 Alfred Binet measured eracy and beta tests measured illiteracy).13 This became
and tested individual differences by studying children the first group-administered and population-based
in the overcrowded Paris public school system. In 1905 usage of intelligence testing.
Binet and Theodore Simon developed the Simon-Binet Approximately 2 million draftees received the
intelligence test to accurately test the intelligence of tests. Civilian agencies, particularly universities,
schoolchildren. demonstrated interest in these screening methods and
By 1908, as intelligence testing increased in popular- adopted similar entrance procedures. A flood of tests
ity, Henry Goddard translated the test into English for imitating the Army’s tests appeared. Line officers
the American consumers. The test underwent multiple found these test ratings useful when forming training
revisions, with Lewis Terman standardizing the test groups. Also, they noted specific predictive elements of
on American children with his own 1916 revision. a draftee’s ability to make training progress at 2, 4, and
Today, this test is known as the Stanford-Binet test. In 6 months. After the war, testing remained of interest at
1917 Robert Woodworth developed the Personal Data recruit evaluation stations. There was a commitment to
Sheet. This was the first group personality test, and the continuance of military psychology in developing
it was briefly used to screen military recruits. It was further screening methods. Interest focused on simpli-
the forerunner of the current Minnesota Multiphasic fying the examining procedure to diminish reliance on
Personality Inventory. testing administration by psychologists.
From 1909 to 1915, 83% of all military service ap- Neuropsychiatric casualties were always a major
plicants were rejected from the armed forces. However, problem, accounting for approximately 10% of disabili-
because of the war, the applicant pool was expanded, ties. A large percentage of these casualties had symp-
with modification of a few physical requirements and toms present several years before service induction.
reduction of the age requirement (from 21 years to 18 Medical care and disability from the war cost $1 billion
years).10 World War I medical screening produced for more than 2.3 million World War I veterans.14
468 defective men per thousand. Defects consisted of
orthopedic causes (39%), sense organ anomalies (12%), World War II
infectious causes (11%), and mental health issues (6%).
In the last category, intelligence deficits had the largest In 1940 careful evaluation of all selectees for psycho-
percentage of applicants.11 Rejection for neuropsychiat- logical and psychiatric qualification was considered
ric reasons included more than 4% of applicants. essential to the war. Rapid testing and classification of
Intelligence testing became linked with the predic- new recruits were critical to the buildup of US forces af-
tion of future performance. It was adopted during ter Pearl Harbor. The usefulness of intelligence testing
World War I for testing military recruits. The war was was fully accepted, and the goal was to reject all men
a major stimulus in the development of cognitive who had a greater than average likelihood of having
testing, which was used in processing American men difficulty adjusting to rigorous military conditions.
through each induction station across the country at Adjustment difficulties and psychiatric conditions
the rate of several thousand a day. Dr Robert Yerkes, were rarely considered treatable, and were cause for
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exemption from military service. It was estimated that decision could not be reached in 15 minutes, further
approximately 1% to 2% of applicants had a form of observation was performed in a hospitalized setting.
mental illness barring them from military service, The differing screening philosophies and tests between
which should be detected through competent screen- the dual systems of the local draft board and induction
ing processes.15 stations were finally amalgamated into one examina-
Psychiatric evaluation for service suitability was a tion standard. These changes resulted in Sullivan’s
complicated endeavor. Opinions varied on the ability resignation.20
of screening measures to perform this task adequately. Selection standards were high before the war and
Different proposals arose from diverse screening phi- during mobilization efforts. However, this uniform
losophies and included acceptance of borderline cases standard underwent several revisions throughout the
for probationary training and acceptance of psycho- duration of the war. The Navy was more rigid in its
pathic individuals for selected services under special enlistment standard and rejected more registrants than
observation. Many researchers took a moderate view, the Army psychiatrists. All men with actual psychiatric
citing the medical corps’ reasonable ability to detect disorders, character flaws, or presumed inability to
those applicants with existing neuropsychiatric dis- adapt were screened out, for an average psychiatric
abilities. However, they doubted the medical corps’ rejection rate of 10% to 15%.19
absolute capacity to detect soldiers who would break After the United States entered the war in 1942, a
down under combat conditions.16 Bowan17 cited infor- large Army was required. This resulted in the lowering
mation from World War I, indicating a 5% general psy- of stringent screening standards. Examiners shifted
chiatric illness rate in all applicants (with subsequent rigid or liberal interpretations of existing induction
review, it was found to be 3%). However, less than half standards based on manpower needs. Registrants
the disorders were detected in the selection process, were not considered fixed in one category, but were
but more could have been detected if a complete his- constantly screened and reevaluated. In April 1944, a
tory had been obtained. He recommended that local war department directive emphasized accumulating
draft boards obtain additional historical records from evidence that many individuals with minor psychiatric
hospitals, schools, courts, and social service agencies. conditions or personality flaws could be of service.19
Other researchers disagreed (including Menninger18), Those individuals who had originally been screened
believing that personal history—or even the presence out were later reconsidered and were found to be good
of significant personality abnormalities—would be performers.21
efficiently predictive of nonadaptability to military Significant emphasis was placed on obtaining his-
service. It was repeatedly shown that recruits who torical material for review when screening draftees.
were maladjusted in their premilitary life—even those This material included legal, medical, educational, and
with a history of psychiatric treatment—could and did mental health records. Screening selection methods
accommodate well to military service.19 were considered ineffective if solely based on brief
In 1941 Harry Stack Sullivan was appointed as psy- examination. The most efficient assessment occurred
chiatric consultant to the Selective Service. He directed when a longitudinal and/or functional history was
planning of the draftee psychiatric examination to aid made available. The Medical Survey Program was
medical examiners at draft boards. First, local com- developed in 1943 to set up procedures to obtain his-
munity physicians evaluated draftees for a medical torical information. For this endeavor, DSS Form 212
screening examination. Then, those individuals found (Medical and Social History) was created. Comple-
fit were advanced to an induction station (which was tion of the form depended on the activity of medical
assigned at least one Army and one Navy medical field agents, usually trained social workers, who were
officer) for final evaluation, including standardized scarce in number. The medical field agent obtained the
intelligence testing. information and forwarded it to the medical examiner
Civilian psychiatrists were used frequently, be- at the induction station. Many of the forms used by
cause of the military psychiatrist shortages, and were psychiatrists in screening potential service members
responsible for conducting 50 examinations each day. were significantly incomplete and addressed only
In practice, this consisted of about 5 hours a day and pathological histories. Even if completed, they were
equaled approximately 6 minutes per examination. In too lengthy to be useful in review.
many instances, screening only required 2 to 3 min- To partially address time efficiency concerns, a
utes per applicant (if the applicant had good school trained psychiatric social worker was placed in each
and work records). Consequently, more time was induction station to review the form and summarize
made available to consider men for whom there was the information on a face sheet. However, because of
less certainty of successful training completion. If a persistent deficits in their completion, this program
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Recruit Medicine
was scaled down and used only when the local board a poor outcome.20
had reason to suspect or knew of significant medical, Several postwar studies reviewed the overall ef-
mental, or social maladjustments. Despite the pro- forts of neuropsychological screening.21,25,26 Psychiatric
gram’s shortcomings, psychiatrists were unanimous screening failed as a primary method of preventing the
in the assessed value that an effective program could great majority of losses caused by psychiatric disor-
have in the selection process.20 ders. However, induction screening eliminated those
Because of the insufficient number of psychiatrists individuals with overt psychosis, mental retardation,
available to provide a thorough routine evaluation and severe psychoneurosis from military service.
under significant time constraints, many general Recognition of induction screening limitations led
physicians were pulled into service as psychiatric to secondary screening at initial training centers. This
examiners. To attempt greater efficiency of personnel effort expanded into preventative psychiatric inter-
resources, a group screening measure was created to ventions on individual and group levels.27,28 Mental
reduce the number of inductees undergoing psychiat- hygiene and personal adjustment lectures were stan-
ric interviews. Several induction station psychiatrists dardized and distributed. Experimental retraining
devised their own customized tests and screened for units, with the support of commanding generals, were
past and present symptoms, antisocial behavior, and created to retrain selected psychoneurotic soldiers.
psychosomatic manifestations.20 Seventy percent of the selected soldiers were made
Dr John Appel, Chief of Preventative Psychiatry in available for assignment, and the rest were separated
the Neuropsychiatry Consultants Division of the Sur- from service.14
geon General’s Office, attempted to validate a single World War II accession standards were recognized
screening device. The research branch of the Army’s as excessive and resulted in substantial and unneces-
information and education division constructed a 15- sary loss of potential service members. The mental
item screen for the most common psychiatric problems health criteria used in determining suitability were
in World War II, primarily psychoneurosis. Eight ques- seen as being inadequate for predicting service perfor-
tions were added to screen for psychosis and antisocial mance.20 Screening processes were unable to evaluate
dispositions. Those who passed were not required to the most important factors influencing a soldier’s
undergo individual psychiatric examination. The Neu- adjustment: leadership, degree of motivation, type of
ropsychiatric Screening Adjunct (NSA) was adopted job and unit assigned, and exposure to external stress.
for use at all induction stations by the end of 1944.22 Greater proficiency could be accomplished by evalu-
The NSA never replaced the psychiatric interview ating suitability for service under military conditions
and was administered as a data collection tool in as- rather than strictly by screening procedures.
sociation with the interview. NSA scores successfully Experience accumulated in training centers and
selected 80% of those recruits to be diagnosed as psy- line commands caused a change in philosophy about
choneurotic, with a miss rate of about 20%. The authors the ability of individuals to withstand war stress. As
of the test concluded that the screening could have manpower needs liberalized some of the induction
served an important role in selection efficiency, but they psychiatric standards, it became evident that individu-
acknowledged the need for better standardization.23 als with minor symptoms were still able to serve the
A follow-up study to determine the effectiveness war mission effectively. Emphasis was placed on the
of the selection process was conducted by reviewing importance of longitudinal information in establishing
hospitalization rates. For neuropsychiatric disorders, the suitability of applicants, and only those individuals
53% were diagnosed as psychoneurotic. A large per- with clear evidence of incapacitating dysfunction were
centage of those applicants who were discharged with disqualified from military service.19,20 Unsuitability
a diagnosis of psychoneurosis had work sheets at the rested on clear evidence of disability, and openness to
induction station that had evidence of psychoneurotic trial service was supported. Liaison with classification
tendency or had been examined more extensively by and assignment sections placed inductees where they
two or more psychiatrists. Those individuals with a were best suited and also placed those individuals
diagnosis of schizophrenia or bipolar disorder were into service who might otherwise have been rejected
consistently free of this evidence.24 during entry screening. These findings appeared in
Many of the service members who manifested the War Department’s Technical Bulletin 33. Thus,
disciplinary problems were discharged under admin- many induction stations reexamined their applicants
istrative actions, and their records were not available and found that more than 50% were acceptable; these
for review. An investigation was conducted by the US were subsequently inducted. One study investigated
Surgeon General’s Office to evaluate NSA’s predictive attrition of these soldiers and found that, after 1 year,
power in neuropsychiatric disabilities, but resulted in 80% of them remained in military service.20 In addition,
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Psychological Screening of Recruits Prior to Accession in the US Military
many of these soldiers were capable of satisfactory per- ability to achieve emotional growth within the military
formance for prolonged periods of time.29 By the end environment, the fleet’s ability to use specific services
of the war attitudes about psychiatric screening had of marginal enlistees, and the fleet’s initial transient
changed. For the first time, mild mental deficiencies training difficulties.
were considered acceptable, with historical evidence Lachar et al,36 in 1974, used two testing measures:
supporting the capacity to adjust and render good (1) the Psychological Screening Inventory and (2) the
military service. History, Opinion, and Interest form on approximately
15,000 male Air Force recruits. They identified a high-
Post-World War II risk group with an adaptation index that demonstrated
a 50% accuracy in identifying recruits who did not
After the war, psychiatric screening procedures were complete basic training. Lachar promoted a tiered
modified. Psychiatric evaluation was integrated into approach to screening and utilization of screening
the general medical examination with the intention of not only for unsuitability but also for identification
identifying and disqualifying only gross psychiatric of potential recruits who would respond to training
disabilities. Supplemental psychiatric screening aids modalities that integrated behavioral modification
were discontinued. If there was a question concern- and group dynamics.
ing an applicant’s suitability, a consultation for a full In 1975 the Air Force used the History, Opinion, and
psychiatric evaluation was warranted for final military Interest form as part of a research-screening program
service determination. Any applicant who was not conducted over the course of a year. The result was the
incapacitated by personality flaws in civilian life and Air Force Medical Evaluation Test Program (AFMET),
who otherwise demonstrated stability was acceptable which involved a three-phase screening program. Ad-
for service. In the 1950s, as a result of further policy ditional modifications produced the AFMET that is
development in accordance with field findings, the used in the Air Force today.
disqualification rate for psychiatric causes dropped Efforts were made to supplement or replace the
from 5.5 to 1.9 per 1,000 applicants.30 reliance on education credentials for service determi-
In 1954 psychiatric disorders were less than half nation in the 1980s. Biographical and temperament
the rate of 1950, primarily as a result of the Korean indications were increasingly favored. The Army de-
War. These decreases occurred mainly among affec- veloped a self-reporting instrument called the Assess-
tive disorders, personality disorders, and behavioral ment of Background and Life Experiences. It screened
disorders. However, the admission rate for psychotic motivational factors and was correlated with first-term
disorders remained the same. An increasing empha- attrition and performance. This instrument produced
sis was placed on both preventative and therapeutic false negatives and was never used as a pilot program.
psychiatry in outpatient settings.31 With further development, a 30-minute self-report
Danielson and Clark32 designed a screening tool model called the Assessment of Individual Motivation
in 1954, the Fort Ord Inventory, to detect affective was created.37 This model measured dependability,
disturbances that would impair military service. adjustment, dominance, achievement orientation,
They tested 15,000 Army recruits, finding four scales agreeableness, and physical condition. Recruits who
that were valid in differentiating between those with scored low were considered higher failure risks. Find-
poor adjustment qualities and those with leadership ings showed little overlap with the Armed Services
potential. In 1961, Jensen33 used an 82-item question- Vocational Aptitude Battery or history of education.
naire with more than 9,000 male Air Force recruits and In 1988 a study of approximately 340 enlisted air-
found areas relating to training failure. men referred for command-directed evaluation was
In 1962 Plag34 published results from a 195-item reported by McCraw and Bearden.38 They emphasized
questionnaire administered to 20,000 Navy recruits, the need for early identification and separation of
finding several variables linked to training. In 1965 unsuitable recruits to minimize increasing technical
Plag and Arthur35 published another study in which training costs. These airmen were described as un-
134 Navy recruits, believed to be mentally unsuit- motivated for continued service and unresponsive to
able for military service, were specifically retained, therapeutic interventions. Early indications of reduced
trained, and then placed in the fleet. Seventy-two adaptability were present in mental health evaluations
percent of that group remained functional in active while in basic training.
duty at 2 years’ follow-up, compared with 86% for a Each branch of the military manages its own be-
control group matched for age, aptitude, and educa- havioral research program and is involved in evolu-
tion level. Plag and Arthur believed the capacity for tional revisions of accession standards and induction
successful duty for this group was related to their screening.
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Recruit Medicine
MILITARY ACCESSION PSYCHOLOGICAL SCREENING TODAY
To sustain the current military force, an annual re- with high school graduation has been the strongest
cruitment of approximately 200,000 enlisted personnel predictor of finishing a service term, followed by an
is necessary. There are two components of psychologi- AFQT score in the upper 50%.39
cal screening used in considering accession of these High-quality recruits have a high school diploma
military applicants. The first component involves as- and score in the top 50% on the AFQT. Since 1973,
sessing aptitude using the Armed Services Vocational accessions for high-quality recruits have increased
Aptitude Battery. Four of the 10 Armed Services Vo- from 30% to 60% across services to 60% to 80%. In
cational Aptitude Battery subtests are combined into 1994 those recruits with a high school diploma and
the Armed Forces Qualification Test (AFQT) score, a 50% AFQT score were 68% of all recruits accessed
which is a cognitive measure estimating a recruit’s (96% had a high school diploma and 72% had an
intelligence capacity. AFQT score of more than 50%).40 Comparatively,
The second component involves determining edu- in 1997, 75% of all youth aged 18 to 23 were high
cational achievement, specifically high school gradua- school graduates. Historical evidence indicates that,
tion or an equivalent achievement level. Congress sets if DoD did not target these higher quality recruits,
accession quality standards, based on a DoD attrition attrition rates would almost certainly be higher and
mathematical model, that link educational attainment, would result in an overall lower level of service
aptitude, and recruiting resources to job performance performance.39
within a particular cost setting. This model is based There are no specific testing measures used to
on performance using a standard obtained by the 1990 further assess personality and other psychological
enlisted recruit cohort during the last national engage- dimensions in screening processes before accession
ment in large-scale combat. Educational attainment into any military service.
AIR FORCE SCREENING PROGRAM
Approximately 30,000 recruits per year enter the to phase III, which includes additional psychological
US Air Force for a 6-week basic training course. The testing using the Minnesota Multiphasic Personality
AFMET is used in further screening trainees for ser- Inventory, and undergo clinical evaluation by a psy-
vice suitability. Phase I of the AFMET uses a revised chologist or psychiatrist.42 One third of those evaluated
History, Opinion, and Interest form—the Biographical in phase III are separated from military service because
Evaluation and Screening of Troops (formally named of sufficient evidence of impairment.
the Navy-Air Force Medical Evaluation Test)—on According to AMSARA data, the Air Force’s attri-
the second day of basic training and measures seven tion rate is lower by 4% to 5%; the Air Force also has the
historical areas: (1) family, (2) school, (3) alcohol, (4) lowest medical and psychiatric waiver approvals and
legal, (5) antisocial behaviors, (6) depression, and the highest proportion of psychiatric hospitalizations
(7) mental health treatment. Approximately 93% of and comparable 2-year psychiatric disability discharg-
the recruits are at low risk for mental health issues.41 es.7 However, currently available data lack uniformity
The remaining recruits are evaluated in phase II us- and make interservice comparisons difficult.
ing additional testing and a mental health interview The Air Force program applies the principles of psy-
performed by a mental health technician. Of the total chological casualties within its testing rationale with
number of referrals for phase II evaluation, only 20% the principles of proximity, immediacy, and expec-
are from the AFMET screening process. The majority tancy in personnel management. Testing is matched
of these referrals come from medical providers (33%), with interventions to normalize the stress reactions in
military chaplains (24%), job counselors (14%), and training and to prevent identification with the patient
command (9%).42 Issues addressed during phase II role. One third of all Air Force mental health-related
include emotional stability, social aptitude, persever- discharges occur during the first 6 weeks of duty. A
ance, responsibility, suicidality, anger, and childhood conservative cost analysis of the Air Force trainee
abuse. Additionally, the previously identified historical screening process by the Behavioral Analysis Service
dimensions from phase I are explored in greater depth. reported a savings of a quarter of a million dollars, but
Then, a clinical psychologist reviews the testing and did not integrate cost assessments projected beyond
interview report. Of those tested at phase II, 65% are basic training. The most common diagnostic categories
identified as low risk and continue training.41,42 for those separated are depressive conditions (31%),
Approximately 1% to 2% of all trainees are forwarded adjustment disorder (20%), posttraumatic stress
304
Psychological Screening of Recruits Prior to Accession in the US Military
disorder (19%), and alcohol abuse/dependence (8%).42 to childhood abuses. The increased likelihood of male
Female recruit representation in separations exceeds recruits being administratively separated for legal and
by 25% what would be expected, compared with the performance issues may also offer an explanation. The
population. This may reflect higher prevalence of the majority of those recommended for return to duty
most common diagnostic condition separations, which were diagnosed with adjustment disorder (63%) or
include depressive disorders and increased exposure no code (34%).42
OTHER SCREENING INITIATIvES
A preimplementation pilot program was launched by This will assist them in making more informed quali-
the US Army Research Institute from September 1998 fication determinations. Two new medical screening
to May 1999, which tested more than 25,000 regular forms—DD Form 2807-1 (Report of Medical History)
Army soldiers and an Air Force sample with the Assess- and DD Form 2807-2 (Medical Prescreen of Medical
ment of Individual Motivation test.37 This showed that History Report)—were created to replace DD Form 2246
trainee attrition rates of those who scored in the lowest (Medical Prescreen Form), and they were approved in
10% were three times greater (22% vs 6%). The false- August 2000. This updates medical screening for the
negative rate remains a concern. A new experimental pi- most common types of medical separations for recruits
lot program for expanding the recruitment market was in accordance with Public Law No. 105-85, Div. A, Title
initiated in February 2000 at selected military entrance V, S532. These forms have several original inclusions,
processing stations using high Assessment of Individual namely a warning statement for falsifying information,
Motivation scores as a replacement for lack of a high a request for information about and consent to contact
school diploma. Those selected trainees will be placed previous medical providers/insurers, and the require-
in the GED Plus Program, an educational intervention ment of a recruiter signature. Furthermore, these forms
program that enables applicants who currently do not expand questioning about mental health treatment.
possess a high school diploma or high school equiva- GAO has recommended updating the high perfor-
lency certificate to be sponsored by a service branch to mance predictor profile model for relating recruit num-
obtain a GED for enlistment purposes. The program ran bers to costs, quality, and attrition. AMSARA is creating
through September 2003. more attrition models to predict attrition and improve
In 1999 the Navy Personnel Research, Studies, and the monitoring capacity of any applied interventions
Technology Department launched a new screening designed to reduce attrition. Measuring long-term out-
model known as the High Performance Predictor comes ensures that actual attrition reduction occurs and
Profile. This model screened for low-attrition charac- is not delayed into later periods of service.
teristics of applicants who did not graduate from high The Presidential Review Directive (from November
school. Those selected trainees were tracked during 1998) established a Recruit Assessment Program to de-
their initial 4 years of service. velop and maintain health and risk factor information
There has been interest expressed in improving on all recruit and officer accessions.43 Collected data are
disclosure and overall flow of historical information to used to evaluate predisposing factors that identified
medical officers at military entrance processing stations. later development of disease and injury.
EFFECTIvENESS OF SCREENING AND OTHER INTERvENTIONS
Individualized screening tools are self-reported a greater proportion of recruits with a high school
instruments, and they are vulnerable to faking and diploma reflect relevant personal capacities, academic
coached testing flaws. These tools are generally weak abilities, and social skills. Accomplishment measures
predictors and have limited efficiency in identifying of integrated individual functions are predictive of
recruits at induction who will demonstrate poor per- long-term performance. Replicating this functional
formance in the military. assessment with psychological testing is difficult to
There is an illusion of objectivity—when symp- do in a cost-effective manner.
toms and individual characteristics are identified and DoD studies have repeatedly confirmed that screen-
displaced from individual contexts—that determines ing for high school diplomas or 2 years of college is
overall functioning capacity. Military history has the best predictor of attrition and service performance,
demonstrated limited success in predicting draftee followed by AFQT scores.7,44 The GED identifies people
performance by estimating independent personal who have, on average, similar basic cognitive skills to
qualities. The established requirements of inducting high school graduates. It does not reflect noncognitive
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Recruit Medicine
characteristics that are related to performance and thus Test to identify individuals unsuitable for military
effectively duplicates what the AFQT measures. service after induction. Yet the vast majority (80%) of
Efforts are being made by military behavioral sci- individuals are referred for psychiatric evaluation by
ence research programs to develop additional screen- a variety of individual contact sources during their
ing instruments, including measures that supplement performance in a military training environment. From
the predictive power of the high school diploma and all referrals, only one third of 1% to 2% undergo more
AFQT score. Such endeavors might result in small extensive psychological or psychiatric evaluation
gains to expand the recruitment pool and reduce attri- and are ultimately separated from military service.
tion. Even with increased quotients of those who have Arguably psychological testing would not contribute
graduated from high school and who had appropriate significantly to the general service provided by each
AFQT scores, first-term attrition remains more than behavioral clinic in each of the service’s training cen-
30%. Does this attrition rate reflect recruiting and ters, which function essentially similarly to phases II
screening issues or practices that impact retention? and III of the AFMET. Just as the high school diploma
Expanding screening measures will not adequately and AFQT score stand alone as the best predictors of
address recruit attrition concerns. Furthermore, to add reduced attrition risk, basic training serves as its own
measures to select service members when the numbers screening instrument to identify recruits unsuitable for
of an applicant pool are limited will exclude a poten- military service or who may benefit from additional
tial group still capable of satisfactory performance, as training interventions.
demonstrated throughout US military history. Rather To define why some recruits do well and others
than screening and separating out individuals, efforts do poorly, a model of individual behavioral health is
to reduce attrition and improve retention would be necessary to explain and predict resiliency or the lack
better served in developing interventions to improve of it. What screening tools can provide is a quick source
adaptability and retention of high-risk trainees. of relevant psychological information for identifying
New recruits face novel social and occupational envi- recruits at higher risk of impaired adaptability and
ronments, with emphasis on physical demands and so- attrition, which can then be coupled with training
cial conformity. The prevalence of adjustment disorders interventions. Just as the military identifies physical
in the stressful environment of basic training is high. A defects that need remediation, why not identify milder
variety of reactions that can lead to separation occur psychological defects and deficits that can be identi-
with adjustments. Evaluation of whether an adjustment fied and potentially remediated with preventative or
reaction or disorder is indicative of unsuitability for treatment interventions? If larger scale preventative
further military duty is dependent on a wide variety of and treatment interventions were used, it would be
individual factors,42 including the following: imperative to follow their outcomes and integrate
empirical evidence into accession standards through
• mental health history, AMSARA and similar service agencies.
• family history, We advocate not changing military standards, but
• trauma history, rather applying principles of primary and secondary
• adaptation skills, preventative psychological interventions and the les-
• personality composition, sons learned from military history. Creating interven-
• severity of symptoms, tions and integrating specific types of psychological
• presence of other psychosocial stressors, training (designed as adjuncts to military training)
• motivation for continued service, and could facilitate adaptation and inoculate against
• safety factors. stress. These initiatives might include simple cognitive
training, stress management, group process, as well
Using induction screening measures to evaluate these as identifying potential vulnerabilities and develop-
relevant factors outside of specific individual contexts ing individualized plans. This may produce a greater
will limit prediction. Evaluation must occur in realistic benefit with the personnel and financial resources cur-
military environments. rently available. Focusing on environmental risk and
The Air Force uses mass screening of all recruits protective factors in adaptation may produce better
with the Biographical Evaluation Screening of Troops training outcomes and foster retention.
SUMMARY
There is not an inexpensive screening tool with military training and service. The best predictor of suc-
adequate predictive validity and reliability to identify cess in the military is still a high school diploma or 2 or
individuals at high-risk of attrition before they enter more years of college. Shifting efforts and resources to
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