The willingness with which our young people are likely to serve in any war, no matter how justified, shall be directly proportional to how they perceive how the veterans of earlier wars were treated and appreciated by their nation.
George Washington? 1
This editorial is the second of the 2-part series on the recruitment crisis currently confronting the Army, Navy, and Air Force. Part 1 focused on rationales for the lack of interest or motivation among those potentially eligible to join the military. This column looks at individuals eager to serve who do not meet eligibility requirements. A 2022 article examining the 2020 Qualified Military Available Study found that without a waiver 77% of Americans in the prime recruiting age group 17 to 24 years would be ineligible for the military due to weight, substance use, or mental and physical health conditions. Most young adults met several ineligibility criteria.2
Obesity and substance use are the most common disqualifiers, mirroring the culture at large. Scores of other physical and mental health conditions render an applicant ineligible for military service or require a waiver. The justification of all eligibility criteria is to: (1) ensure that service members can safely and effectively deploy; and (2) reduce the attrition rate. Both are essential to the mission readiness of the military. In 2022, the military gave 1 in 6 of those seeking enlistment an accession waiver.3 About 4% of waivers issued were for mental health conditions, such as autism and attention-deficit hyperactivity disorder (ADHD). The response to the recruiting crisis resulted in the largest number of waivers granted in a decade. Military Times noted that exact numbers are hard to obtain, interfering with the transparency of public policy as well as high-quality research on waivers’ impact on recruits and the service.3
The War Horse reported that the current waiver process is riddled with procedural injustice and inequity in implementation.4 Each service sets its eligibility requirements: the rationale being that the respective branches have distinct roles necessitating distinguishing qualifications. What is far more difficult to defend is that wide variation exists in the application of the criteria. Similar cases are judged differently, depending on nonmaterial factors, such as geographic location and unwritten policies of recruiting offices. Waiver approval rates for mental health conditions range from 35% for the Army to 71% for the Marines. The prospective recruit, not the military service, bears the burden of demonstrating that their condition does not impair their fitness for duty; hence, thousands have been disqualified based on their diagnosis.4 This comes at a time when the US Department of Veterans Affairs (VA) and the US Department of Defense (DoD) have been battling a suicide epidemic for years. Current qualifying standards send a strong stigmatizing message to those who want to enlist and those already in the ranks at a time the DoD and VA are launching campaigns to persuade active-duty members and veterans to seek mental health treatment.5
The recruiting crisis brought into stark relief more fundamental questions about the clinical and ethical aspects of eligibility criteria that either disqualify outright or require a waiver process for many young Americans with mental health conditions who want to serve their country. One of the most clinically perplexing standards is that applicants with ADHD are disqualified if they have taken medications in the past 12 to 24 months, depending on the service.6 Despite this policy, the Army acknowledges that stimulant medications may improve the function of individuals with ADHD and reduce the rates of substance use and behavior disturbances, the real concerns for recruiters and commanders.7
Requirements like these place otherwise high-functioning individuals whose professional goal is to serve in the military in a double bind. The military’s studies show that recruits’ persistent nondisclosure of their diagnoses results in poorer performance and higher attrition rates of those who have enlisted, even when treated.8 If potential recruits disclose their psychiatric history, they may well be disqualified and/or denied a waiver. This is even more true for service members already in the military who may believe they have one of the conditions but fear that being diagnosed will negatively impact their career. Not disclosing their condition prevents service members from obtaining the clinical care and support they need to succeed and also limits the ability of commanders to make decisions about deployment that ensure maximal unit performance and the safety of the service member.9 However, ADHD is one of 38 diagnoses that the DoD is considering for possible removal or modification of the waiver for some subset of applicants.10
The final irony is that medicine and warfare have changed dramatically and rapidly since the initial determination that diagnoses like ADHD and autism disqualify individuals from serving. A Rand Corporation study found that individuals who are neurodivergent—the name collectively assigned to individuals with diagnoses like autism and ADHD—may have unique abilities that enable them to outperform neurotypical persons in areas like pattern recognition, attention to detail, repetitive tasks, and memory, among others. These highly technical skills are essential to intelligence analysis and cybersecurity domains that are increasingly crucial to both national defense and victory on the battlefield.11 Even congressional representatives who just a few years ago criticized waivers for mental health conditions as “lowering the standards” are now pushing for more moderate policies, especially for those who have received and responded to treatment for their mental health disorders.12
The epigraph has been widely and persistently misattributed to the country’s first commander in chief, George Washington, because it captures a salient sentiment directly bearing on the question of who is fit for duty.1 History has shown that discrimination in enlistment only weakens the fighting force, whereas diversity, including neurodiversity, in the military as in society is a source of strength. Equitable inclusion of those who have the discipline, desire, and dedication to serve their country may be the most positive response to the recruitment crisis.