J. Russell Ramsay, Ph.D.
Associate Professor of Clinical Psychology
University of Pennsylvania, Perelman School of Medicine
For a long time, at least for this writer, knowledge about the relationship of ADHD and the military was based on a lot of hearsay, rumor, and second- and third-hand accounts. However, a recent peer-reviewed article provides data on estimated prevalence rates of ADHD in the United States Army using the Adult ADHD Symptom Self-Report Scale Screener (ASRS-S)1. The ASRS-S was administered to over 21,000 active duty soldiers as part of the Army Study to Assess Risk and Resilience in Servicemembers (Army STAARS). The larger STAARS assessment battery included experiential and psychological measures and included the 6-item ASRS-S.
There were two scoring methods used for the ASRS-S to establish prevalence estimates. The first was the composite obtained from the sum of the numeric ratings provided by respondents to each of the six items (scored on a 0-4 Likert scale), with a score > 14 being considered positive for ADHD. The second scoring method was the item-response, which identified the number of specific items rated at or above the threshold considered positive for ADHD, with > 4 items considered positive for ADHD.
The sample was predominantly male and under the age of 30 years-old. The results indicated that 7.6% of the servicemembers screened positive for ADHD using the composite score and 9.0% screened positive using the item-response score. Native American/Alaskan Native respondents endorsed significantly higher rates – about 1.5 times greater – than White respondents (who were used as the reference group) on both the composite and item-response scores. Although there were no age differences on the composite score, the 25-29 and 30-39 year-old groups had a significantly higher risk for screening positive for ADHD than the 18-19 year-old group, which served as the reference group, again both older groups at around 1.5 times greater risk. There were no follow-up evaluations reported to confirm a full diagnosis of ADHD, so the findings reflect servicemembers who screened positive.
As informative as these findings are, another benefit of this article was obtaining some accurate information about ADHD and the US Army regulations (and reportedly Army regulations on ADHD are similar to other branches within the Department of Defense). According to Army regulations cited in the article, a diagnosis of ADHD is a medical disqualifier for service unless individuals demonstrate passing academic performance and have not taken any medications in the past 12 months. Thus, soldiers are permitted to have ADHD as long as they have not taken any medication in the past year (presumably medications for ADHD, but this was not made clear).
Assuming that a more comprehensive evaluation would result in a full diagnosis of ADHD for at least of percentage of those screening positive, the paradox noted by the authors is that a servicemember can have ADHD but may not take advantage of evidence-based pharmacologic treatment for it. There may be some rationale for these regulations from a military standpoint, but from a clinical standpoint it would seem that there are many military personnel in active duty who may have and are not being treated for ADHD. The incidence of any co-existing conditions (and whether these conditions are being treated) for those who screened positive for ADHD was not noted, nor was it mentioned whether the same regulations cited for ADHD would apply to common ADHD comorbidities, such as depression and anxiety. Apart from addressing the potential need for follow-up diagnostic evaluations for active duty personnel who screened positive for ADHD and any subsequent treatment needs, many of these servicemembers (and the ones who have served before them) will require appropriate assessment and treatment as they reintegrate into civilian life and their roles outside the military.
1Kok, B. C., Reed II, D. E., Wickham, R. E., & Brown, L. M. (2016). Adult ADHD symptomatology in active duty army personnel: Results from the Army Study to Assess Risk and Resilience in Servicemembers. Journal of Attention Disorders, online ahead of print. doi: 10.1177/1087054716673451