U.S. Military Enlisted Accession Mental Health Screening: History and Current Practice

Transcription

1 MILITARY MEDICINE, 172, 1:31, 2007 U.S. Military Enlisted Accession Mental Health Screening: History and Current Practice Guarantor: COL Elspeth Cameron Ritchie, MC USA Contributors: Robert Andrew Cardona, MD*; COL Elspeth Cameron Ritchie, MC USA Through the stimulus of war and concerns about neuropsychiatric disability, the U.S. military developed methods to rapidly screen the mental health of World War I and II draftees. Intelligence testing and brief psychiatric screening expanded the accession physical examination and underwent revision to identify only gross mental health disability. Supplemental psychiatric evaluations and written psychological screening tools were abandoned after postwar assessments; they demonstrated poor predictive power in evaluating recruit service capacity for combat environments. Currently, only three mental health accession tools are used to screen applicants before their entrance into military service, namely, educational achievement, cognitive testing, and a cursory psychiatric evaluation. The Navy and Air Force use a fourth screening measure during entry-level training. Educational attainment with high school graduation has been the strongest predictor of finishing a service term. The purpose of this article is to provide both a historical review and a review of testing efforts. Introduction nterest in reducing attrition was renewed in the middle to late I 1990s as attrition rates reached new highs. Over the past two decades, first-term enlisted attrition rates consistently averaged 30%. By 1997, 4-year attrition rates peaked at 37%. 1 This sparked a variety of activities to investigate causation and to identify potential remedies. 2 One such activity was the Accession/Recruit Mental Health Symposium held in Chicago on September 12 to 13, The symposium was sponsored by the Office of the Assistant Secretary of Defense (Force Management Policy) and represented a tri-service working group of mental health professionals, which reviewed recruit attrition issues related to mental health. In preparation for that conference, it became clear that a recent historical review of military psychological screening did not exist. This history provides insight into the contributions and limitations of mental health screening for military attrition. This article outlines the 85-year history of accession mental health screening and current screening practices. Civilian psychological testing initially served as a template for the military, leading to the development of accession screening tools. Intelligence testing materialized in World War I, psychiatric qualification became the focus during World War II, and then a variety of personality and motivation measures were explored. There are *Community Mental Health Service, Reynolds Army Community Hospital, Fort Sill, OK Psychiatry Consultant, Office of the Surgeon General, 5109 Leesburg Pike, Suite 689, Falls Church, VA The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the U.S. government. This manuscript was received for review in April The revised manuscript was accepted for publication in June three accession tools that are currently used to screen military service applicants. The Navy and Air Force use a secondary screening measure during entry-level training. The Origins of Psychological Testing In the late 19th century, the study of individual differences led to interest in the quantification of human qualities. Francis Galton, who is ascribed as the father of psychological testing, administered the first measurement battery to thousands at the International Health Exhibit in England in In 1897, Alfred Binet began work on measuring and testing individual differences by studying children in the Paris public school system. Binet and a physician, Theodore Simon, developed the Simon-Binet test of intelligence in 1905, to select students needing remedial education. By 1908, Henry Goddard had translated the test into English for U.S. consumers. As intelligence testing increased in popularity, this test underwent multiple revisions, with Lewis Terman standardizing the test for U.S. children in It is known today as the Stanford-Binet test. In 1917, Robert Woodworth developed the Personal Data Sheet, which was briefly used to screen military recruits. This was the first group personality test and was the forerunner off the current Minnesota Multiphasic Personality Inventory. As the country headed into World War I, efficient methods of screening vast numbers of drafted men were sought to support the war effort. The war provided a major stimulus in the further development of cognitive testing and novel screening efforts. World War I and Intelligence Testing From 1909 to 1915, 83% of all military service applicants were rejected. Because of the war effort, the applicant pool was expanded with modification of a few physical requirements and reduction of the age requirement from 21 years to 18 years. World War I medical screening produced 468 defective men per 1,000. Mental health defects represented 6% of all rejections, with the majority being intelligence deficiencies. 3 Dr. Robert Yerkes, then president of the American Psychological Association, proposed blanket intelligence testing for military recruits. The Surgeon General of the Army considered his proposal, whereas the Navy turned him away. Dr. Yerkes was appointed director of the U.S. Army Psychological Testing Corps and headed a task force of psychologists. The expansion of draftee screening brought hundreds of psychologists into the service to perform testing. They processed draftees at the rate of several thousand per day through each induction station. A paper-and-pencil survey was developed and correlated with the standardized Stanford-Binet test. Testing was designed to screen for intellectual defectiveness and to 31

2 32 Accession Mental Health Screening assist in appropriate career placement, where a recruit could render maximal military service. 4 In 1917, Dr. Yerkes, with the help of Lewis Terman, David Wechsler, and others, developed the Army Alpha and Beta tests (Alpha for those who were literate and Beta for those who illiterate). Approximately 2 million draftees were administered the tests. Line officers found the ratings useful in the formation of training groups and noted a predictive element regarding the draftee s capacity to make training progress at 2, 4, and 6 months. The civilian sector, particularly universities, demonstrated interest in adopting similar entrance screening procedures. After the war, interest persisted in the development of cognitive testing at recruit evaluation stations. The military committed to expanding the role of psychological testing, with the expectation of further developing screening methods. Despite this interest, minimal research occurred during the 1920s and 1930s. A significant lesson from World War I included the recognition that war elicited a significant number of neuropsychiatric casualties. Although only 10% of all disabilities were attributed to neuropsychiatric conditions, it was noted that a large percentage of these casualties had preexisting symptoms. 3 Questions were raised about whether additional screening efforts could assist in minimizing future neuropsychiatric casualties. Costs of medical care and disability from the war reached 1 billion dollars for the 2.3 million World War I veterans. 5 Interest in reducing economic and personnel expenditures became the focus of mental health screening as the United States headed into World War II. World War II and Psychiatric Qualification Screening Goal Rapid testing and classification of new recruits were critical to the rapid build-up of U.S. forces after the attack on Pearl Harbor. The usefulness of intelligence testing was fully accepted, and attention turned toward issues of mental health fitness through psychiatric qualification. Selection standards were high before the declaration of war. All men with actual psychiatric disorders or character flaws were screened out, creating a psychiatric rejection rate of 10 to 15%. 6 To minimize neuropsychiatric casualties, the goal was to reject all men who had a greater than average likelihood of having difficulty adjusting to military conditions. It was thought that adjustment difficulties and psychiatric conditions were rarely treatable and patients should be exempted from military service. A Divergence of Opinion Opinions varied regarding the ability of psychiatric screening measures to adequately qualify draftees for service. Many took a moderate view, citing the reasonable ability to detect applicants with existing neuropsychiatric disabilities but doubting the capacity to identify soldiers who would break down under combat conditions. 7 Different screening proposals arose from diverse philosophies, including acceptance of borderline cases for probationary training and acceptance of antisocial applicants for specific service assignments. Bowan 8 cited information from World War I indicating a 5% general psychiatric rate (with subsequent review, it was found to be 3%), but less than one-half of cases were detected in the selection process. That author was convinced that more could have been detected if a complete history had been obtained. He recommended that local draft boards obtain additional historical records from hospitals, schools, courts, and social service agencies. Others disagreed that personal history, or even the presence of significant personality abnormalities, would be efficiently predictive of nonadaptability to military service. 9 It was repeatedly cited that recruits who were maladjusted in their premilitary life, and even those with a history of psychiatric treatment, could and did accommodate well to military service. 10 Harry Stack Sullivan was appointed as psychiatric consultant to the Selective Service in He directed the planning of draftee psychiatric examinations to aid medical examiners at draft boards. Local community physicians first evaluated draftees in a screening medical examination. Those found to be fit were advanced to an induction station for final evaluation, including standardized intelligence testing. Civilian psychiatrists were frequently used, because of military psychiatrist shortages, and conducted up to 50 examinations each day. Screening in many instances required only 2 to 3 minutes per applicant, in the setting of good school and work records. Consequently, more time was made available for consideration of men for whom there was less certainty, with an average examination time of 6 minutes. If a decision could not be reached in 15 minutes, then further observation was performed in a hospital setting. Screening philosophies and testing differences emerged in the dual systems of the local draft board and induction stations. Ultimately, they were amalgamated into one examination standard, which underwent several revisions throughout the duration of the war. Sliding Accession Screening Standards After the United States entered the war in 1942, a large Army was required, resulting in the lowering of stringent screening standards. Examiners shifted rigid or liberal interpretations of existing induction standards to reflect manpower needs. The Navy tended to be more rigid in its enlistment standards and was prone to reject more than the Army psychiatrists. Registrants were not considered fixed in one category but were constantly reevaluated. In April 1944, a War Department directive emphasized accumulating evidence that many individuals with minor psychiatric conditions or personality flaws could be of service. 10 Many who had been screened out earlier were later reconsidered and placed into service. They were found to provide the war effort with good performance. 11 Medical Survey Program and Longitudinal Functioning Significant emphasis was placed on obtaining historical and functionally based material for review when screening a draftee. This material included legal, medical, educational, and mental health records. Screening selection methods would be considered ineffective if based solely on a brief examination. The Medical Survey Program was developed in 1943 to set procedures for obtaining historical information. For this endeavor, Department of Selective Service Form 212 (Medical and Social History) was created. 6 Completion of the form depended on the activity

3 Accession Mental Health Screening 33 of social workers, who were limited in number. Information was obtained and forwarded to the induction station medical examiner. Many of the forms used by psychiatrists in screening potential service members were incomplete and addressed only pathological histories. Even if fully completed, they were too lengthy to be useful. To improve efficiency, a trained psychiatric social worker was placed in each induction station to review the forms and to summarize information on a face sheet. However, because of persistent deficits in completion of the forms, this program was downscaled and used only when the local board had reason to suspect significant deficits. Despite the program s shortcomings, psychiatrists were unanimous regarding the potential effectiveness of such a program in the selection process. 6 Because of insufficient numbers of psychiatrists to provide thorough routine evaluations, many general practitioners were pulled into service as psychiatric examiners. A group screening measure was contemplated, to reduce the number of inductees to undergo the psychiatric interview and to improve personnel utilization. Several induction station psychiatrists devised their own homemade tests and screened for past and present symptoms, antisocial behavior, and psychosomatic manifestations. 6 Neuropsychiatric Screening Adjunct Dr. John Appel, chief of preventative psychiatry in the neuropsychiatry consultants division of the Office of the Surgeon General, made an effort to validate a single screening device. A 15-item screening test was developed for the most common psychiatric problems. Eight questions were added to screen for psychosis and antisocial dispositions. Those with poor scores underwent individual psychiatric examination. The uniform measure was named the neuropsychiatric screening adjunct (NSA) and was adopted for use at all induction stations by the end of The NSA never replaced the psychiatric interview and was administered to augment this process. NSA scores successfully selected 80% of those diagnosed as psychiatrically impaired in interviews. 13 The authors of the test concluded that the screen could have served an important role in selection efficiency, but they acknowledged the need for better standardization. A follow-up study evaluated the effectiveness of the selection process by reviewing hospitalization rates. For neuropsychiatric disorders, 53% had the diagnosis of psychoneurosis. A large percentage of these had worksheets at the induction station with evidence of deficiencies or had undergone more-extensive examination at the time of induction. Those with a diagnosis of schizophrenia or bipolar disorder were consistently free of this evidence. 14 Many of the service members who manifested disciplinary problems were administratively discharged and were not included in the review. An investigation was made by the Office of the Surgeon General to evaluate the predictive power of the NSA for neuropsychiatric disabilities. A poor association was noted. 6 Department of Defense Review of Neuropsychiatric Screening Several postwar studies reviewed the overall efforts of neuropsychiatric screening. Psychiatric screening was considered inefficient and failed as a primary method of preventing the great majority of losses caused by neuropsychiatric disorders. 11,15 However, induction screening did serve a useful purpose in eliminating from service those with overt psychosis, mental retardation, or severe psychoneurosis. 16 World War II accession standards were recognized as excessive and resulted in unnecessary loss of potential service members. The mental health criteria used in determining suitability were seen as being inadequate for predicting service performance. 6 Screening processes were unable to evaluate the most important factors influencing the adjustment of a soldier, including the leadership he would receive, his degree of motivation, the type of position and unit assigned, and the degree of external stress to which he would be exposed. It was advocated that greater proficiency of evaluating service suitability would be accomplished by evaluating recruits under military conditions, rather than by using extensive induction screening procedures. Recognition of induction screening limitations led to secondary screening efforts at initial training centers under military conditions. This effort expanded into individual and group preventative psychiatric interventions. 17,18 Mental hygiene and life skill lectures were standardized. Experimental retraining units were created for selected soldiers and were supported by commanding generals. Approximately 70% successfully transitioned into military service, and the rest were separated. 5 By the end of the war in 1945, experience accumulated from training centers and line commands that fundamentally changed the views regarding the ability of individuals to withstand war stress. As manpower needs liberalized some of the induction standards, it became evident that individuals with minor psychiatric symptoms were able to provide effective service in a war setting. Emphasis was placed on the importance of longitudinal information in establishing the suitability of applicants. Unsuitability needed to rest on clear evidence of sustained and incapacitating dysfunction, supporting the openness to trial service. 6,10 Liaison with classification sections afforded the opportunity to place inductees in assignments for which they were best suited. This also provided the capacity to place those into service who might otherwise have been rejected during entry screening. Upon receipt of ongoing screening findings in War Department Technical Bulletin 33, many induction stations reexamined their applicants and found that 50% were acceptable and subsequently inducted. One study investigated attrition of these reconsidered soldiers and found that 80% remained in service after 1 year. 6 Many were found to serve for long periods with satisfactory performance. 19 Post-World War II Screening Policy From these postwar assessments, screening procedures were modified. Psychiatric evaluation was integrated into the general medical examination, with the intention of identifying and disqualifying only gross psychiatric disability. Supplemental psychiatric screening aids were discontinued. If there was a question regarding an applicant s suitability, then a full psychiatric evaluation was sought through consultation, for final service determination. Similarly, any personality flaws that had not incapacitated an applicant in civilian life were acceptable for service. As a result of further developing policy in accordance with field findings, the disqualification rate for psychiatric

4 34 Accession Mental Health Screening causes decreased from 5.5 cases per 1,000 applicants to 1.9 cases per 1,000 applicants in the 1950s. 20 Post-Korean War Screening Efforts After the Korean War, efforts resumed in further developing and improving accession screening measures. Cognitive and general psychiatric screening had been fully accepted and integrated into the accession process. The focus turned to developing measures that identified personality characteristics that were predictive of satisfactory military service. Examples of these efforts follow. Danielson and Clark 21 designed a screening tool in 1954, the Fort Ord Inventory. They tested 15,000 Army recruits, finding four scales that differentiated between those with poor adjustment qualities and those with leadership potential. In 1961, Jenson 22 used a 82-item questionnaire with 9,000 male Air Force recruits and also found areas related to training failure. In 1962, Plag 23 published testing results with a 195-item questionnaire for 20,000 Navy recruits and found several variables linked to successful training. In 1965, Plag 24 published another study in which 134 Navy recruits who were thought to be mentally unsuitable for military service were specifically retained, trained, and then placed in the fleet. Approximately 70% of that group remained functional on active duty at the 2-year follow-up assessment, compared with 86% for a control group matched with respect to age, intellect, and educational experience. The author thought that the capacity for successful duty for this group was related to their achieving emotional growth within the military environment, with the fleet being able to match specific services with skills of marginal enlistees, and that initial training difficulties tended to be transient. In 1974, Lachar et al. 25 used two testing measures, the Psychological Screening Inventory and the History, Opinion, and Interest Form, for 15,000 male Air Force recruits. They identified a high-risk group with the adaptation index, which demonstrated 50% accuracy in identifying recruits who did not complete basic training. Those authors promoted a tiered approach in screening and used screening not only to determine unsuitability but also to identify potential recruits who would respond to training modalities that integrated behavioral modification and group dynamics. In 1975, the Air Force used the History, Opinion, and Interest Form as part of a research screening program conducted over the course of 1 year. The product was the Air Force Medical Evaluation Test Program (AFMET), which involved a threephase screening program. Additional modifications produced the AFMET used in the Air Force and Navy secondary screening programs today. During the same time, educational selection was integrated into general accession screening procedures. The AFMET and educational selection processes are discussed below. In 1988, a study of 340 enlisted airmen referred for command-directed evaluation was reported by McGraw and Bearden. 26 They underscored the need for early identification and separation of unsuitable recruits, to minimize increasing technical training costs. These airmen were described as being unmotivated for continued service and refractory to therapeutic interventions. Early indications of reduced adaptability were present in mental health evaluations during basic training. Efforts were made to supplement or to replace reliance on education credentials for service determination in the 1980s. Biographical and temperament indications increasingly became favored. The Army developed a self-reporting instrument named the Assessment of Background and Life Experiences. It screened motivational factors and was reported to correlate with first-term attrition and performance. It tended to produce falsenegative results and was never put into pilot implementation. With further development, a fake-resistant 30-minute selfreport model called the Assessment of Individual Motivation (AIM) was created. 27 It was reported that findings showed little overlap with the Armed Services Vocational Aptitude Battery (ASVAB) or educational achievement. The Army implemented it as a pilot program and successfully demonstrated that if a recruit scored high on the AIM, despite lower educational achievement or ASVAB scoring, attrition risk remained stable during the first year of service. Its development provides an inclusionary screening instrument, consistent with historical lessons against screening out potential recruits capable of providing good military service. The implementation of AIM is currently being expanded and further examined for longer-term outcome data. Current Accession Mental Health Screening To sustain today s military force, an annual recruitment of 200,000 enlisted recruits occurs. Currently, there are three components of mental health screening used in the accession of military applicants. The first involves assessing aptitude with the ASVAB, which was put into place in Four of the 10 ASVAB subtests are grouped into the Armed Forces Qualification Test (AFQT) score, which estimates a recruit s intelligence capacity. Scores are also used to place applicants in work assignments where they are most likely to succeed. The second screening measure is the determination of educational achievement, specifically high school graduation or an equivalent achievement level. The U.S. Congress sets accession quality standards, based on a Department of Defense attrition mathematical model that links educational attainment, aptitude, and recruiting resources to job performance within a cost setting. This model is based on performance, using a standard obtained for the 1990 enlisted recruit cohort during the last national engagement in large-scale combat. Educational attainment with high school graduation has been the strongest predictor of finishing a service term, followed by an AFQT score in the upper 50%. 30 High-quality recruits are defined as having a high school diploma and scoring in the top 50% on the AFQT. Since 1973, accessions for high-quality recruits have increased from 30 to 60% across services to 60 to 80%. In 1994, those with a high school diploma and 50% AFQT score were 68% of all recruits accessed. 32 Historical evidence indicates that, if the Department of Defense did not target these higher-quality recruits, then attrition rates would be higher, resulting in an overall lower level of service performance. 30 The third screening measure consists of a review of medical screening forms and a general psychiatric evaluation, which is integrated into the entrance physical examination at military entrance processing stations. Beyond these three screening measures, there are no specific tools used in assessing person-

5 Accession Mental Health Screening 35 ality or other psychological dimensions before accession into any military service. The Air Force and Navy conduct secondary psychological screening of recruits upon arrival at entry-level training sites, as mentioned above. Special Forces applicants also undergo specialized accession screening. Conclusions Military accession screening expanded to respond to the war effort needs of World War I and World War II. Intelligence testing was developed from civilian advancements in cognitive testing. Supplemental psychiatric evaluations and written screening tools were abandoned after postwar assessments. These assessments demonstrated their poor predictive power in evaluating the service capacity of recruits for a combat environment. Psychiatric screening was integrated into the induction physical examination, to identify only gross mental health deficits. Longitudinal functional histories and assessment of capacity under realistic military conditions were considered more reliable. Current accession screening continues to reflect these principles by identifying only gross mental health disability and assessing functional capacity as educational achievement. In the past few decades, efforts have again focused on evaluating personality characteristics and psychiatric symptoms by using written screening tools. The U.S. Navy and Air Force use a secondary psychological screening measure during entry-level training. The U.S. Army does not use secondary screening tools, because of their historical failure to reduce neuropsychiatric casualties and to predict combat military performance. References 1. Cekala S, Smith E, Schladt B, et al: Military Attrition: DoD Could Save Millions by Better Screening Enlisted Personnel. 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