Accession Standards for Attention-Deficit/Hyperactivity Disorder: A Survival Analysis of Military Recruits, 1995-2000

Military Medicine, Feb 2006 by Krauss, Margot R, Russell, Robert K, Powers, Timothy E, Li, Yuanzhang

A retrospective cohort study was conducted to evaluate the Department of Defense practice of allowing some individuals with a history of attention-deficit/hyperactivity disorder (ADHD) to enter military service (waiving for ADHD). Enlisted recruits who entered active duty with a waiver for academic problems related to ADHD were compared with control subjects who did not reveal health problems before entry, in terms of retention, promotion, and mental health-related outcomes. A total of 539 recruits with a history of ADHD were retained at the same rate as 1,617 control subjects, with no differences in promotion rates, comorbid diagnoses, or mental health-related discharges. On the basis of these findings, the Department of Defense medical accession standards have been changed to allow applicants who reveal a history of ADHD but did not require medication to finish high school or to hold a job for at least 1 year the opportunity to enter active duty without going through the current waiver process.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder of childhood, estimated to affect 3% to 5% of all school-age children.' Prevalence estimates as high as 10% have been reported, in part because of different inclusion of subtypes, different methods, and the fact that the definition of the disorder has changed in various editions of the Diagnostic and Statistical Manual of Mental Disorders.2 The increasing number of children diagnosed as having ADHD and the recognition that this disorder persists into adulthood make it a disease of importance to the military, whose recruit population is largely adolescent.3-5 The diagnosis of ADHD is currently disqualifying for military service if the ADHD interfered with school or work after age 12.6

Annually, >300 recruits disqualified for revealing a history of ADHD during their induction physical examination apply for a waiver to allow them to serve on active duty. A physician from the service to which they are applying (i.e., Army, Air Force, or Navy/Marines) reviews submitted medical records and may recommend a waiver for ADHD on an individual basis. In general, waivers are granted for recruits who have demonstrated academic achievement (high school graduation) or stable employment (>6 months) without therapeutic medication for at least 1 year.

Since 1997, the Department of Defense (DoD) has been working toward establishing an evidence-based, medical accession policy through epidemiological analysis of existing databases.7 This study was undertaken as part of this process, to evaluate the DoD practice of allowing some individuals with a history of ADHD to enter military service (waiving for ADHD).

Methods

We conducted a retrospective cohort study of individuals entering active duty from January 1, 1995 through December 31, 2000, as verified through accession data from the Defense Manpower Data Center (Monterey, California). case subjects were enlisted recruit applicants disqualified in the initial medical examination who, based on individual service wavier authority data, obtained a waiver for ADHD and entered active duty during the study period. Control subjects (selected from those entering active duty who did not require a waiver) were matched with case subjects 3:1 with respect to age (within 1 year), service (Army, Air Force, Navy, or Marines), gender, race (African American, Caucasian, or other), and month of starting basic training. Both populations were monitored from entry to active service through December 31, 2002.

Kaplan-Meier survival analyses were performed to evaluate the probability of staying on active duty and remaining free of a mental health-related discharge or hospitalization. The first endpoint was defined as premature discharge from the service for any reason, including nonmedical conditions. The second endpoint was any mental health-related outcome, including discharge for a mental health condition, discharge for a behavioral problem (such as trouble with the law), any mental health hospitalization (International Classification of Diseases-9 codes 295-316), or mental health-related disability discharge. Those lost because of non-mental health conditions were treated as censored data in the second analysis.

All waiver requests for a history of ADHD submitted to the Navy and Marines in 1997 and 1998 were reviewed to gauge the diagnostic validity of the initial diagnosis and the apparent criteria for granting a waiver. The diagnosis was considered valid if it was confirmed by a psychiatrist or documentation of multiple years of therapeutic medication use that improved behavior and/or performance in school was provided. The initial diagnosis was considered "questionable" when stimulant use was

Occupational "success" in the military was defined as retention in the military and the ability to be promoted at the same rate as peers. The majority of recruits enter at the lowest rank (El), although those entering with any education above the level of high school generally start at a higher rank (E2 or E3).

Logarithmic-linear analysis was used to consider all matched sets with available entry and final ranks with regard to promotion. Demographic characteristics of case subjects were compared with those of the general recruit population by using the binomial test. Significance for survival curve comparisons was based on log rank, Wilcoxon, and log likelihood ratio tests. All analyses were performed using SAS software, version 8.2 (SAS Institute, Gary, North Carolina). The study was approved by the Walter Reed Army Institute of Research institutional review board.