Published online April 1, 2008
PEDIATRICS
Vol. 121
No. 4
April 2008, pp.
e993-e997
(doi:10.1542/peds.2007-2060)
Basic Training for the Pediatrician: How to Provide Comprehensive Anticipatory Guidance Regarding Military Service
William P. Adelman, MD, FAAP
Department of Pediatrics, Adolescent Medicine Service, Walter Reed Army Medical Center, Washington, DC
It may be laid down as a primary position, and the basis of our system, that every Citizen who enjoys the protection of a Free Government owes not only a proportion of his property, but even of his personal services, to the defense of it.
—George Washington
Effective anticipatory guidance for adolescents requires developmentally appropriate discussions of preventive health issues.1 National organizations differ in their recommendations for what topics to address, and how often to screen.1–5 The American Academy of Pediatrics recommends yearly visits to the health care provider during adolescence, with anticipatory guidance that is used to review educational performance and counseling in relation to specified risk behaviors.4,6 No national guideline or evidence-based task force recommends anticipatory guidance for a specific educational choice, vocation, or profession, such as military service. Despite this assertion, recent commentary in Pediatrics recommended that routine adolescent anticipatory guidance include "discussion of military service issues" recognizing that it will require "additional time and effort on the part of health care providers."7 This commentary recommended discussion of the selective service system in anticipation of a possible future draft, offered that an alternative to hypothetical future conscription could be conscientious objection, reviewed how to establish conscientious objector status in case of a hypothetical future draft, and recommended providing information about the health risks of combat and options for service outside the military. It included a discussion on how to avoid military recruitment. Such routine anticipatory guidance is inappropriate, because it is contrary to current national recommendations, offers physician bias in place of evidence, is less than a comprehensive review of military service, provides no proven benefit for the teenager, and is impractical to implement.
Instead, I suggest that when an adolescent or family has questions for the health care provider regarding military service, the responsible pediatrician must provide knowledgeable, balanced, and comprehensive anticipatory guidance or refer to a source that can. Anticipatory guidance regarding military service balances the numerous educational, vocational, financial, and personal benefits with an honest assessment of unique risks. It is then within the purview of the pediatrician to assist the family with assessment of the suitability of military service for the individual patient. This approach is consistent with national recommendations for adolescent health care that identify educational and vocational success as an important health supervision outcome.8
Patient-centered anticipatory guidance regarding military service combines knowledge of adolescent medicine with an understanding of military service in the United States. This commentary affords the pediatrician an initial approach to these issues in 4 major ways. First, this commentary summarizes military service in the United States by reviewing the scope of the uniformed military, the critical role adolescents serve within the military, and how military service and understanding varies across the United States. Second, this commentary reviews current best evidence regarding the risks of service and discusses the life-affirming elements of military service. Third, this commentary reviews criteria for eligibility and exclusion from service. Finally, this commentary offers 1 way to provide developmentally appropriate guidance and summarizes available resources for individual and patient reference.
 |
MILITARY BASICS FOR THE PEDIATRICIAN: UNDERSTANDING THE BIG PICTURE
|
|---|
The uniformed services are the largest US employer in general and the largest employer of adolescents and young adults in the United States in particular. Therefore, it is critical that pediatricians, who are advocates for youth, fully understand military service. There are >1 million active-duty uniformed personnel currently serving in the 4 military branches of the US Department of Defense. These personnel have nearly 2 million dependent beneficiaries.9 Hence, the US Department of Defense is the largest "company" in the world and provides comprehensive benefits to more people than any other American organization. Adolescents and young adults primarily comprise the military labor force, which is significantly younger than the civilian labor force.10 Therefore, the US military is the largest organization in the world that primarily depends on an adolescent and young adult workforce for its form and function.9–11 This fact affords the adolescent who is interested in a meaningful job with benefits and opportunity for advancement a wide expanse of occupational choices.
Serving in the military does not necessarily mean fighting in combat. In fact, most military occupations are not directly related to combat, and some occupations are specifically noncombatant. For example, the Army offers training in 200 different occupational specialties, only 24 of which are specific to combat arms.12 Therefore, adolescents are not faced with a dichotomous choice of military service or conscientious objection but, rather, may choose 1 of a multitude of career paths on the basis of individual interest and aptitude. Military jobs range from administrative specialist to vehicle mechanic and from neonatologist to geriatrician.13
The Military Selective Service Act (50 U.S.C. App. 451 et seq.) is the federal law that mandates selective service registration in case the President, if authorized by Congress, institutes a draft. However, since 1973, the United States has employed an all-volunteer military. Hence, this largest professional American workforce directly competes with civilian labor pools for employees, which is to the benefit of the armed forces. The all-volunteer military is more educated, more married, more female, and more racially diverse than the draft-era military.9,14,15 Financial incentives, increased roles for women, and comprehensive family benefits, including universal health care, provide a unique opportunity for personnel with dependents, and approximately one-half of all active-duty personnel are married. Cities with a large military presence are among the least racially segregated residential and employment areas in the United States.9,16 In this way, military communities serve as an example for the rest of the country.
|
SERVICE AND UNDERSTANDING OF THE MILITARY VARIES BY GEOGRAPHY AND CLASS
|
|---|
Exposure to, and understanding of, military service varies considerably across the United States. Military communities are not evenly distributed throughout the United States. For example, New England, the North Central states, and Alaska have relatively small military populations. In contrast, the Southern states have large military populations. More than 40% of all new personnel that were enlisted or commissioned in 2002 came from the South, where only 
36% of the total US population aged 18 to 24 years lives.17 Americans who have infrequent exposure to the military are less likely to understand, appreciate, and emulate the values inherent in military service. This fact perpetuates the under representation of military personnel from the Northeast and North Central states and overrepresentation of military personnel from the Southern states.
Since the Vietnam War, there has been a widening gap between those who serve in the military and the cultural and intellectual elite in the United States who are much less likely to serve.18,19 Before the Vietnam era, upper-class Americans viewed military service as a natural part of good citizenship, and they routinely served. After the Vietnam era, it has increasingly become the case in the United States that the people who create, support, or protest military policy have no military experience. America's elected officials reflect a growing lack of expertise in military affairs. In 1969, 70% of those in Congress had previous military experience. In 2004, only 25% of those in Congress claimed personal military experience.20
Desire and expectation of service are the most powerful predictors of who will serve in the military.21 As the desire and expectation of service wanes according to geography and class, those who are the most privileged and may be afforded the best education, particularly in the Northeast and North central states, with arguably much to offer our military, increasingly become the least likely to serve and least likely to expect to serve. As a result, the gap grows between those who choose to serve and the wealthiest Americans; between those who serve and those who are elected to represent the nation; between those who understand the military and those who do not, but feel empowered to speak out against the professional military. This fact causes mistrust, resentment, and misunderstanding to grow between the civilian and military communities.19 For these reasons in particular, pediatricians must take an evidence-based approach to the military to effectively and comprehensively discuss military service with their patients of all socioeconomic classes and geographic backgrounds.
|
IS MILITARY SERVICE A HEALTH RISK?
|
|---|
Overall and age-adjusted mortality rates in the American military are lower than the general population, because military personnel are younger and healthier than the average American. Except in the case of war (a unique military service health risk) combat-related deaths are rare. From 1980 to 2002, <1% of annual military deaths were attributable to hostile action or terrorist attacks, except in 1983, when a Marine barracks in Beirut was bombed, in 1991, during the Persian Gulf War, and in 2001, when the Pentagon was attacked. In fact, military personnel usually die from the same causes as their age-matched civilian peers.9,22 Annually, one-half to two-thirds of all military fatalities are from accidents; primarily motor vehicle and training accidents. There is considerable annual variation in suicide in the military, with a possible increase during Operation Iraqi Freedom, but suicides represent a similar percentage of deaths in the military as among American civilians aged 20 to 34 years.23–25 Homicides in the military are low, and blacks face a significantly lower risk of homicide in the military than in civilian life. On average, 18% of fatalities that occur during active duty each year are attributable to illness, and they occur more commonly in older military personnel.9
|
WAR IS HELL
|
|---|
Military deaths increase during war, vary according to the particular war, and are more likely to be combat-related during modern wars. For example, during major combat operations in Operation Iraqi Freedom from March 19, 2003, to April 30, 2003, there were 109 hostile and 30 nonhostile American deaths, respectively. During postcombat operations, hostile military deaths continue to outnumber nonhostile military deaths.26 However, possibly because of a combination of improvements in technology, combat casualty care training, and evacuation and treatment through the military medical care system, the combat fatality rate is at an all-time low. Combined case fatality rates in Afghanistan and Iraq are approximately one-half as from the Vietnam War and one-third as from World War II.27,28 Because of survivability from wounds that before this conflict would have been fatal, there exist new morbidities for which the long-term outcomes are unknown. Most wounds sustained in hostile attacks are extremity injuries, 53% of which are penetrating soft-tissue injury and 26% are fractures. Four percent are major limb amputations (600 to date, at a rate that is consistent with previous wars).29
Cross-sectional and retrospective data identify additional traumatic and mental health morbidities from current conflicts to include traumatic brain injury, posttraumatic stress disorder, anxiety, and depression.30–32 Currently, the lack of prospective data precludes understanding of the long-term effects, recovery rates, and treatment effectiveness for these entities. Prospective research will delineate the natural history of these war-related mental health morbidities within the military and civilian health care systems, and allow for meaningful interpretation of these risks within the context of military service and in comparison to alternate occupations. Clearly, there is a significant psychiatric cost of war, but mental health professionals caution against drawing early or long-term conclusions on the basis of a relative paucity of scientific study.33,34 War is the most feared and wrenching situation our adolescents face while serving their country in the military. As advocates for youth, we must anticipate the growing health needs of this population, and ensure the optimal continued health care of these individuals within both the military and civilian communities.
|
MILITARY SERVICE IS LIFE AFFIRMING
|
|---|
In times of war, with a media focus on casualty counts, pediatricians without military expertise may not recognize military service as life-affirming. Yet, most military members see their service as enriching. Ninety-five percent of all members of the military are proud to serve in America's armed forces, and a "sense of purpose" or similar sentiment is the most common reason for extending service obligations.18,19,35 As with medicine and other professions, the military has a service focus, an expert knowledge, a professional ethos, and a unique culture. Military leaders describe military culture as disciplined, loyal, hardworking, and honest, with members who value self-sacrifice, courage, and physical rigor.18,36
One example of the life-affirming nature of our military is that before current US operations in Afghanistan and Iraq, the most common reason for military mobilization was a host of worldly humanitarian missions collectively referred to as "noncombat operations." Because the United States military has the greatest logistic capabilities on earth, with assets in >120 countries, they are most often relied upon for humanitarian assistance by foreign governments, nongovernmental organizations, and charities around the globe. Even during the current conflicts in Afghanistan and Iraq, the US military mobilized for security and humanitarian assistance. These missions included Hurricane Katrina assistance in the United States, support of Indonesia, Sri Lanka, and Thailand after the Indian Ocean Tsunami in 2004, and assistance to the Philippines after the 2006 mudslides. Thousands of missions were flown into Pakistan to rescue earthquake victims in 2005 where a "Combat" surgical hospital was established. Most recently, in June 2007, the Navy launched a 4-month humanitarian mission in the Pacific to provide medical, dental, construction, and other humanitarian assistance programs (both ashore and afloat) in the Philippines, Vietnam, Papua New Guinea, the Solomon Islands, and the Marshall Islands.
|
THE MILITARY IS NOT FOR EVERYONE
|
|---|
Less than 1% of the US population serves in the military. For the vast majority of patients who present to the vast majority of pediatricians, military service is not a relevant topic for anticipatory guidance, because adolescents choose an alternate life path. The all-volunteer, professional military of the United States relies on individuals within a democracy who choose to serve their country. Those who wish to serve in the military must first meet specific physical and mental requirements before induction or commissioning, after which they have access to the largest health care delivery system in the world. Previous medical diagnoses may be disqualifying, but medical waivers are available for conditions that are no longer active or do not interfere with specific military function. Height and weight standards vary according to service but, in general, individuals must be between 60 (58 if female) and 80 inches tall, not be overweight, and be in good physical condition. Currently, openly homosexual individuals may not serve. The pediatrician may not clear for military service a motivated young adult who does not meet entrance criteria.
|
HOW SHOULD THE PEDIATRICIAN PROVIDE ANTICIPATORY GUIDANCE?
|
|---|
One method for military guidance includes 4 steps: (1) educate, (2) articulate, (3) navigate, and (4) matriculate. First, I recommend that patients educate themselves about the military, with information from multiple sources. Most adolescents choose to do their military research on the Internet (see Table 1), through discussion with current or previous service members, and through a recruiter. Ideally, the adolescent should speak to trusted friends or relatives with military experience. Second, the late adolescent should articulate what the military offers, and what the military expects in return, and then be able to complete the sentence "I plan to join the military because..." or "I decided against the military because..." A typical adolescent recruit chooses the military as a short-term means to an end; financial incentive and benefits for future education, technical training in a desired field, leadership training, pride in service or, simply, a chance to live away from home and gain valuable life experience. The typical adolescent who decides against military service goes through the same process and recognizes that the military does not meet individual needs. Third, the interested adolescent should navigate the path that seems best: enlisted person or officer, active or reserve, before or after college, Army, or other service branch. I recommend that adolescents who enter the military for specific occupational training take the Armed Services vocational aptitude battery tests before signing an enlistment contract. In this way, they know if they have a good chance of being accepted into their preferred specialty. Finally, the adolescent should matriculate only after discussion with his or her family, and the adolescent and family should review options with a service branch-specific recruiter who can facilitate the administrative and logistic elements of joining. Adolescents continue their development within the military and require comprehensive and unique health care.37–39 Pediatricians without military expertise may wish to further their own education before providing guidance on this topic, or refer adolescents to those who are more qualified to discuss such issues.
|
WHAT RESOURCES ARE AVAILABLE FOR THE PEDIATRICIAN?
|
|---|
Table 1 lists Internet resources that are available to the adolescent and the pediatrician to learn more about the military. The American Academy of Pediatrics Uniformed Services Section (www.aap.org/sections/unifserv/default.htm) is a valuable source of information about the military and military pediatrics, and contains specific resources to assist children, adolescents, and families of deployed service members. The American Academy of Pediatrics Uniformed Services Pediatric Seminar Annual Conference (www.aap.org/sections/unifserv/usps.htm) is an additional source of military information and continuing medical education. Although these secondary resources provide much military information that will benefit the pediatrician, the most comprehensive understanding of the military occurs with active service. Pediatricians have a storied history within the United States military,40 serve in current conflicts where they are often the only pediatricians available, and are in short supply.41 Pediatricians who are interested in military service can receive more information through the Army Medical Department (see Table 1) or at www.goarmy.com. A full understanding of military service allows pediatricians to effectively counsel their patients on individual military benefits and risks.
|
CONCLUSION
|
|---|
There is no organization in America that employs more adolescents and young adults, offers adolescents more comprehensive services and benefits, teaches more unique skills to adolescents, provides more opportunities for career and class advancement, and is less racially biased, than the United States military. Military service, as with nearly all choices within the workforce in America, offers unique benefits and risks to adolescents, young adults, and older adults who choose to serve. Although the military is not for everyone, for those who participate, the military can be a positive, life-affirming, and rewarding career choice. The role of the pediatrician is not to choose a career for the adolescent. The role of the pediatrician is to comprehensively address military service issues when they arise, and assist the patient, family, and community in deciding when military service is an appropriate match for the adolescent.
|
ACKNOWLEDGMENTS
|
|---|
I thank Mark Thompson, MD, Russell Moores, MD, and Kevin Creamer, MD, for their assistance with review of this article.
|
FOOTNOTES
|
|---|
Accepted Sep 14, 2007.
Address correspondence to William P. Adelman, MD, FAAP, Department of Pediatrics, Adolescent Medicine Service, Walter Reed Army Medical Center, 6900 Georgia Ave NW, Washington, DC 20708. E-mail: william.adelman{at}us.army.mil
The opinions expressed herein are those of Dr Adelman and do not represent the official policy or position of the Department of the Army, the United States Military, the Department of Defense, or the United States Government. Dr Adelman is an employee of the United States Government.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
The author has indicated he has no financial relationships relevant to this article to disclose.
|
REFERENCES
|
|---|
- Adelman W, Ellen J. Adolescence. In: Rudolph AM, Kamei R, Overby KJ, eds.
Rudolph's Fundamentals of Pediatrics. 3rd ed. New York, NY: McGraw-Hill; 2002:70
–109
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Adolescent and School Health; Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Adolescent Health; National Adolescent Health Information Center, University of California, San Francisco.
Improving the Health of Adolescents & Young Adults: A Guide for States and Communities. Atlanta, GA: Centers for Disease Control and Prevention; 2004
- American Medical Association. Guidelines for Adolescent Preventive Services (GAPS). 1997; Chicago, IL. Available at: www.ama-assn.org/ama/pub/category/1980.html. Accessed January 22, 2008
- American Academy of Pediatrics. Recommendations for preventive pediatric health care.
Pediatrics. 2000;105
(3):645
–646[Free Full Text]
- US Preventive Services Task Force.
Guide to Clinical Preventive Services. 2nd ed. Baltimore, MD: Williams and Wilkins; 1996
- American Academy of Pediatrics.
Guidelines for Health Supervision III. Elk Grove, IL: American Academy of Pediatrics; 2002
- Stafstrom CE. Counseling youth about military service options and selective service registration: an integral part of anticipatory guidance of adolescents.
Pediatrics. 2007;119
(6):1199
–1203[Free Full Text]
- Maternal and Child Health Bureau, US Public Health Services.
Bright Futures: Guidelines for Health Care Supervision of Infants, Children, and Adolescents. Available at: www.brightfutures.org. Accessed January 22, 2008
- Segal DR, Segal MW. America's military population.
Popul Bull. 2004;59(4)
:1
–40
- Binkin M, Kyriakopoulis I. Youth or experience? Manning the modern military. Brookings Institution, Washington, DC: 1979
- The Department of the Army. Field Manual 1. US Army; 2005. Available at: www.army.mil/fm1/. Accessed January 22, 2008
- www.goarmy.com.
Full Career Listing. Available at: www.goarmy.com/JobCatList.do?redirect=true&fw=careerindex&bl=. Accessed September 4, 2007
- Bureau of Labor Statistics, US Department of Labor.
Occupational Outlook Handbook, 2006–07 Edition. Available at: www.bls.gov/oco/ocos249.htm. Accessed September 4, 2007
- Cohen J, Warner RL, Segal DR. Military service and educational attainment in the all-volunteer force.
Soc Sci Q. 1995;76
(1):88
–104[ISI]
- Segal MW. Women's military roles cross-nationally: past, present, and future.
Gend Soc. 1995;9
(6):757
–775[Abstract]
- Farley R, Frey WH. Changes in the segregation of whites from blacks during the 1980s: small steps toward a more integrated society.
Am Sociol Rev. 1994;59
(1):23
–45[CrossRef][ISI]
- Defense Manpower Data Center. US Military Entrance Processing Command (USMEPCOM) Edit Files, October 2001–September 2002. Available at: www.dmdc.osd.mil/. Accessed January 22, 2008
- Roth-Douquet K, Schaeffer F.
AWOL: The Unexcused Absence of America's Upper Classes From Military Service–and How it Hurts our Country. New York, NY: Harper Collins; 2006
- Henderson K. Their war.
Washington Post Magazine. July 22, 2007:10
–15, 22–26
- Zillman DN. Where have all the soldiers gone II: military veterans in congress and the state of civil-military relations.
Maine Law Rev. 2006;58
(1):135
–156
- Bachman JG, Segal DR, Freedman-Doan P, O'Malley PM. Who chooses military service? correlates of propensity and enlistment in the U.S. Armed Forces.
Mil Psychol. 2000;12
(1):1
–30[CrossRef][ISI]
- US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.
Child Health USA 2004. Rockville, MD: US Department of Health and Human Services; 2004
- Rothberg JM, Jones FD. Suicide in the US Army: epidemiological and periodic aspects.
Suicide Life Threat Behav. 1987;17
(2):199
–132
- Rothberg JM. Stress and suicide in the US Army: effects of relocation on service members' mental health.
Armed Forces Soc. 1991;17
(3):449
–458[Abstract]
- Martinez M. Army's suicide rate has outside experts alarmed.
Baltimore Sun, Dec. 20, 2003;1
- Operation Iraqi Freedom/Operation Enduring Freedom. US casualty status. Available at: www.defenselink.mil/news/casualty.pdf. Accessed September 4, 2007
- Gawande A. Casualties of war: military care for the wounded from Iraq and Afghanistan.
N Engl J Med. 2004;351
(24):2471
–2475[Free Full Text]
- Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy R. Understanding combat casualty care statistics.
J Trauma. 2006;60
(2):397
–401[ISI][Medline]
- Owens BD, Kragh JF, Macaitis J, Svoboda SJ, Wenke JC. Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom.
J Orthop Trauma. 2007;21
(4):254
–257[CrossRef][ISI][Medline]
- Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.
N Engl J Med. 2004;351
(1):13
–22[Abstract/Free Full Text]
- Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq and Afghanistan.
JAMA. 2006;295
(9):1023
–1032[Abstract/Free Full Text]
- Grieger TA, Cozza SJ, Ursano RJ, et al. Posttraumatic stress disorder and depression in battle-injured soldiers.
Am J Psychiatry. 2006;163
(10):1777
–1783[Abstract/Free Full Text]
- Friedman MJ. Acknowledging the psychiatric cost of war.
N Engl J Med. 2004;351
(1):75
–77[Free Full Text]
- Cozza SJ, Chun RS, Polo JA. Military families and children during operation Iraqi freedom.
Psychiatr Q. 2005;76
(4):371
–378[CrossRef][ISI][Medline]
- Moniz D. Soldiers reenlist beyond US goal.
USA Today, July 17, 2005;1
- Center for Strategic and International Studies.
American Military Culture in the Twenty-first Century: A Report of the CSIS International Security Program. Washington, DC: Center for Strategic and International Studies; 2000
- Hardoff D. and Halevy A. Health perspectives regarding adolescents in military service.
Curr Opin Pediatr. 2006;18
(4):371
–375[ISI][Medline]
- Suttle DE. The military and the adolescent. In: Friedman SB, Fisher M, Schonberg SK, eds.
Comprehensive Adolescent HealthCare. St Louis, MO: Quality Medical Publishing; 1992:685
–687
- Adelman WP. Who sees the young women? a resource sharing model for providing comprehensive adolescent women's health care.
Mil Med. 2004;169
(11):877
–879[Medline]
- Callahan CW, Bass JW, Person DA, Shira JE. History of military pediatrics: fifty years of training and deploying uniformed pediatricians.
Pediatrics. 1999;103
(6 Pt 1):1298
–1303[Free Full Text]
- Heller DR. The role of a paediatrician in a war zone.
Curr Paediatr. 2006;16
(7):512
–516[CrossRef]
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
TOP
MILITARY BASICS FOR THE...
SERVICE AND UNDERSTANDING OF...
