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i 

58–290 2010

[H.A.S.C. No. 111–155] 

IMPLEMENTATION OF THE REQUIREMENT 

TO PROVIDE A MEDICAL EXAMINATION 

BEFORE SEPARATING MEMBERS DIAGNOSED WITH POST–TRAUMATIC STRESS 

DISORDER (PTSD) OR TRAUMATIC 

BRAIN INJURY (TBI) AND THE CAPACITY OF THE DEPARTMENT OF DEFENSE 

TO PROVIDE CARE TO PTSD CASES 

HEARING 

BEFORE THE

MILITARY PERSONNEL SUBCOMMITTEE 

OF THE

COMMITTEE ON ARMED SERVICES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

SECOND SESSION 

HEARING HELD 

APRIL 20, 2010 
(II) 

MILITARY PERSONNEL SUBCOMMITTEE 

SUSAN A. DAVIS, California, Chairwoman 

VIC SNYDER, Arkansas 

LORETTA SANCHEZ, California 

MADELEINE Z. BORDALLO, Guam 

PATRICK J. MURPHY, Pennsylvania 

HANK JOHNSON, Georgia 

CAROL SHEA-PORTER, New Hampshire 

DAVID LOEBSACK, Iowa 

NIKI TSONGAS, Massachusetts 

JOE WILSON, South Carolina 

WALTER B. JONES, North Carolina 

JOHN KLINE, Minnesota 

THOMAS J. ROONEY, Florida 

MARY FALLIN, Oklahoma 

JOHN C. FLEMING, Louisiana 

MICHAEL HIGGINS, Professional Staff Member 

JEANETTE JAMES, Professional Staff Member 

JAMES WEISS, Staff Assistant 
(III) 

C O N T E N T S 

CHRONOLOGICAL LIST OF HEARINGS 

2010 

Page 

HEARING: 

Tuesday, April 20, 2010, Implementation of the Requirement To Provide 

a Medical Examination before Separating Members Diagnosed with Post– 

Traumatic Stress Disorder (PTSD) or Traumatic Brain Injury (TBI) and 

the Capacity of the Department of Defense To Provide Care to PTSD 

Cases ..................................................................................................................... 1 

APPENDIX: 

Tuesday, April 20, 2010 .......................................................................................... 21 

TUESDAY, APRIL 20, 2010 

IMPLEMENTATION OF THE REQUIREMENT TO PROVIDE A MEDICAL 

EXAMINATION BEFORE SEPARATING MEMBERS DIAGNOSED WITH 

POST–TRAUMATIC STRESS DISORDER (PTSD) OR TRAUMATIC 

BRAIN INJURY (TBI) AND THE CAPACITY OF THE DEPARTMENT OF 

DEFENSE TO PROVIDE CARE TO PTSD CASES 

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS 

Davis, Hon. Susan A., a Representative from California, Chairwoman, Military Personnel Subcommittee ............................................................................. 1 

Wilson, Hon. Joe, a Representative from South Carolina, Ranking Member, 

Military Personnel Subcommittee ...................................................................... 2 

WITNESSES 

Carr, William J., Deputy Under Secretary of Defense for Military Personnel 

Policy, Office of the Under Secretary of Defense for Personnel and Readiness ........................................................................................................................ 5 

Rice, Dr. Charles L., President, Uniformed Services University of the Health 

Sciences, Performing the Duties of the Assistant Secretary of Defense for 

Health Affairs, U.S. Department of Defense ..................................................... 3 

APPENDIX 

PREPARED STATEMENTS: 

Carr, William J., joint with Dr. Charles L. Rice ............................................ 29 

Davis, Hon. Susan A. ....................................................................................... 25 

Wilson, Hon. Joe ............................................................................................... 27 

DOCUMENTS SUBMITTED FOR THE RECORD: 

[There were no Documents submitted.] 

WITNESS RESPONSES TO QUESTIONS ASKED DURING THE HEARING: 

Mrs. Davis ......................................................................................................... 47 

Mr. Pascrell ....................................................................................................... 49 

Dr. Snyder ......................................................................................................... 48 
Page

IV 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING: 

Ms. Fallin .......................................................................................................... 53 
(1) 

IMPLEMENTATION OF THE REQUIREMENT TO PROVIDE 

A MEDICAL EXAMINATION BEFORE SEPARATING 

MEMBERS DIAGNOSED WITH POST–TRAUMATIC 

STRESS DISORDER (PTSD) OR TRAUMATIC BRAIN INJURY (TBI) AND THE CAPACITY OF THE DEPARTMENT 

OF DEFENSE TO PROVIDE CARE TO PTSD CASES 

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, MILITARY PERSONNEL SUBCOMMITTEE, Washington, DC, Tuesday, April 20, 2010. 

The subcommittee met, pursuant to call, at 5:35 p.m., in room B– 

318, Cannon House Office Building, Hon. Susan A. Davis (chairwoman of the subcommittee) presiding. 

OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM CALIFORNIA, CHAIRWOMAN, MILITARY 

PERSONNEL SUBCOMMITTEE 

Mrs. DAVIS. The hearing will come to order. 

Today the subcommittee will hear testimony about the efforts of 

the Department of Defense (DOD) to implement Section 512 of the 

National Defense Authorization Act, Fiscal Year 2010. 

The section requires the Secretaries of the military departments 

in certain cases to conduct a medical examination before administratively separating a member under less than honorable conditions if the member has been deployed overseas in support of a contingency operation. 

The purpose of the examination is to evaluate a medical diagnosis or assertion by the member that Post-Traumatic Stress Disorder, PTSD, or traumatic brain injury, TBI, might have caused 

the behavior that resulted in the commander’s decision to pursue 

separation. The subcommittee considered this legislation at the request of the gentleman from North Carolina, Mr. Jones, who, unfortunately, is not able to be here, and I want to commend Mr. 

Jones for bringing this issue before the attention of the subcommittee. 

I agree with the gentleman that it is unacceptable that the military departments were separating service members because of misconduct that was caused by a PTSD or TBI injury that occurred 

during his or her combat tour. Now that we know so much more 

about the extent of those injuries in the force, we owe every returning service member the assurance that we will not punish them for 

an injury that resulted from combat service. 

The unfortunate truth is that we have very likely already separated a number of service members where the commanders did not 

consider that the member was experiencing the consequences of 
2 

PTSD or TBI. That is why the provision we adopted last year also 

requires the Discharge Review Boards in the military departments 

to provide expedited review of cases that involve a diagnosis or assertion of the influence of PTSD or TBI. 

We intend to learn about the status of DOD efforts to implement 

this law and improve the general access to mental health care. As 

always, if the Congress needs to do more, we would like to know 

what further action is needed. 

I want to welcome our witnesses here today. We are very pleased 

that you are here joining us. Mr. Bill Carr, Deputy Under Secretary of Defense, Military Personnel Policy Officer of the Under 

Secretary of Defense for Personnel and Readiness; and Dr. Charles 

Rice, MD, Dr. Rice is performing the duties of the Assistant Secretary of Defense for Health Affairs and is president of the Uniformed Services University (USU) of Health Sciences. 

Again, we are pleased that you are here and look forward to your 

discussion. 

Mr. Wilson, do you have any comments you would like to make? 

[The prepared statement of Mrs. Davis can be found in the Appendix on page 25.] 

STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM 

SOUTH CAROLINA, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE 

Mr. WILSON. Thank you, Chairwoman Davis, for holding this 

hearing. 

I believe Congress and this nation has no greater responsibility 

than to provide the care and support needed by members of our 

armed forces, who endure the horrors of war to protect our freedom. 

I am aware of the challenges the Department of Defense and the 

Department of Veterans Affairs (VA) have in providing mental 

health care to the growing numbers of combat veterans returning 

with Post-Traumatic Stress Disorder and traumatic brain injury. I 

am also aware that the legislation Congress passed last year requiring medical examinations prior to administratively separating 

service members who may be experiencing Post-Traumatic Stress 

Disorder or traumatic brain injury may increase the burden on the 

two departments. But that does not mean we should allow one 

combat veteran to slip through the cracks and be discharged from 

the service without the proper recognition of and medical benefits 

for the mental health issues they may be facing. 

As a former president of Mid-Carolina Mental Health Association, I especially appreciate mental health care. Thankfully, the 

mental health profession now understands that Post-Traumatic 

Stress Disorder and traumatic brain injury may cause behaviors 

that previously would only be considered reasons to administratively discharge service members. 

Identifying the underlying mental health issues and brain injuries is often further compounded by a service member’s reluctance 

to seek help. Too often they are self-medicating, which leads to behavior problems. Simply discharging these troops without the possibility of necessary medical care is not the answer. We owe it to 

our combat veterans and their families to proper diagnose combat- 
3 

related mental health and brain injury issues and to provide the 

care, regardless of cost, to facilitate their recovery. 

I am interested in hearing from our witnesses today how the Department of Defense is providing the required medical exams before separating a service member. I am particularly interested in 

how you are accomplishing this, given the recognized shortage of 

mental health providers. I would also like to know how many previously discharged service members have been screened by the Discharge Review Board and how many have been identified with 

Post-Traumatic Stress Disorder or traumatic brain injury. Finally, 

I would like to know how we can help. 

With that, I welcome our witnesses and thank them for participating in the hearing today. I look forward to your testimony. 

[The prepared statement of Mr. Wilson can be found in the Appendix on page 27.] 

Mrs. DAVIS. Thank you, Mr. Wilson. 

I want to ask unanimous consent that Congressman Bill Pascrell 

be allowed to participate in the hearing. 

Without objection, so ordered. 

I know that you have a plan to present short opening statements, 

and without objection, your full statements will be entered into the 

record. 

Mrs. DAVIS. Do I understand, Mr. Carr, you are going to start? 

Oh, Dr. Rice. Okay, please proceed. 

STATEMENT OF CHARLES L. RICE, M.D., PRESIDENT, UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES, 

PERFORMING THE DUTIES OF THE ASSISTANT SECRETARY 

OF DEFENSE FOR HEALTH AFFAIRS, U.S. DEPARTMENT OF 

DEFENSE 

Dr. RICE. Thank you, Madam Chair and distinguished members 

of the committee, it is a pleasure to join my colleague, Mr. Carr, 

the Deputy Under Secretary For Military Personnel Policy, and 

thank you for the opportunity to discuss with you today our efforts 

to both implement the requirements for pre-separation medical examinations for service members diagnosed with Post-Traumatic 

Stress Disorder or traumatic brain injury, and to ensure that we 

have the resources to meet the demand for behavioral health services. 

DOD continues to apply the necessary resources to develop and 

improve policies and programs that address all behavioral health 

issues for our service members. Our clinical programs provide a 

continuum of care, whether through prevention, treatment, rehabilitation, reintegration, or transition. 

DOD screens all service members returning from the operational 

theater for potential traumatic brain injury. Although positive 

screens are not necessarily diagnostic of traumatic brain injury, 

they do trigger the requirement for further evaluation by a clinician. TBI screening of service members can occur at several time 

points and locations. Our Operation Enduring Freedom/Operation 

Iraqi Freedom (OEF/OIF) patients who are medically evacuated 

from the combat theaters are screened at Landstuhl Medical Center in Germany. In addition, all service members will be screened 
4 

after any deployment and upon admission to a VA health care facility. 

All service members identified as having sustained a traumatic 

brain injury, whether from deployed or non-deployed locations, are 

provided care following evidence-based clinical care guidelines to 

ensure maximum treatment benefits for any level of severity of 

their traumatic brain injury. 

Similar guidelines also exist for Post-Traumatic Stress Disorder. 

DOD providers not only have very detailed treatment guidelines 

but receive ongoing training and education on the screening, diagnoses, common symptoms, and recognized treatments for TBI and 

PTSD. 

Regarding DOD’s policy on separation examinations, service 

members scheduled for separation from active duty must have had 

a physical examination within 12 months prior to separation and 

a termination evaluation for any occupational exposure in which 

they are enrolled. Waivers to this policy are granted only when 

both the service member consents and the unit commander concurs. Service members with work limitations related to TBI or 

PTSD must be referred for a medical board to determine fitness for 

retention and may receive a disability evaluation and separated appropriately. 

The Joint Executive Council has recently directed establishment 

of a DOD VA work group to reexamine and make recommendations 

concerning our separation examination policies. 

Regarding our ability to meet the demand for behavioral health 

services, we are addressing access issues with every tool available. 

Our active duty mental health professionals are largely focused on 

serving those in uniform. We have placed an unprecedented number of these professionals into the combat theaters. We have also 

increased our capacity to leverage a combination of contracted professionals in our medical facilities and on our managed care support contractor networks in the civilian community to serve the 

needs of our families. 

Our VA partners are part of the network, and within the medical 

treatment facilities (MTFs), the services have contracted for additional mental health specialists to augment existing staff, adding 

almost 2,000 additional mental health providers to our direct care 

system. 

We have entered into a collaborative relationship with the 

United States Public Health Service (PHS) that has resulted in 

over 130 PHS officers either assigned or in the process of being assigned into DOD positions, and we are making significant progress 

in bringing those resources on board. 

TRICARE management activity monitors the adequacy of the 

TRICARE civilian network, and we work with our TRICARE contractors to find remedies for service areas that are not meeting our 

standards for access. In 2009, we established a new program within 

TRICARE in which telephone mental health services may be offered to beneficiaries, providing the opportunity to address medically underserved populations by using resources that are available 

in other communities. 

We have also established the TRICARE Assistance Program, 

called TRIAP, which permits beneficiaries to contact a counselor for 
5 

assessment and advice via the Internet. And finally, our managed 

care support contractors offer a health care finder capability for 

TRICARE prime beneficiaries to assist service members and their 

families in locating mental health providers who accept TRICARE. 

VA medical facilities also provide services for post-traumatic 

stress and other mental health problems to our beneficiaries 

through both local and national resource sharing agreements. 

While we offer patients choice in facilities, they can use these facilities and resources when they are proximate and they can provide 

timely access to care. 

Madam Chair and distinguished members of the committee, 

thank you again for inviting us here today. The Department is 

working constantly to improve and to monitor the content and performance of these examinations. We look forward to actively participating in the Joint Executive Committee Working Group focused on this important issue. We hope to gain valuable insight 

that will enhance the evidence-based guidelines we use in the process. We are intently focused on ensuring available behavioral 

health services to those we serve, to include when they are ready 

to separate and require examination. 

We are both pleased to answer to any questions you have and to 

participate in a continuing dialogue to better serve our current and 

former service members. 

[The joint prepared statement of Dr. Rice and Mr. Carr can be 

found in the Appendix on page 29.] 

Mrs. DAVIS. Thank you very much, Dr. Rice. 

And that would be your statement as well, Mr. Carr. 

STATEMENT OF WILLIAM J. CARR, DEPUTY UNDER SECRETARY OF DEFENSE FOR MILITARY PERSONNEL POLICY, 

OFFICE OF THE UNDER SECRETARY OF DEFENSE FOR PERSONNEL AND READINESS 

Mr. CARR. It would be. I would just add one thing to put in historical context. The committee’s actions on 512 were timely, and 

they are producing results. 

To put it in historical context, if we went back to the time when 

I was a company commander in the 1970s, you had a different type 

of soldier than you would have today, and you could have a motivational problem, or you could have a distressed psychological condition. And so you would, perhaps, refer the soldier to a psychiatrist, 

and a diagnosis, if it came back a personality disorder, then the 

separation would be immediate. And, therefore, it was often used. 

As we ran into 2008, the question arose, has that become a practice where we would look toward a personality disorder, which is 

an expedient separation of a problem, when it was masking, just 

as the committee did in 512, when it was masking PTSD? And we 

decided it could. And so the rule we established was that in the 

event that you ever separated someone who had been deployed in 

the past 24 months, then you had to rule out PTSD. And if you 

didn’t want to do that, then you could have an exception but the 

exception had to be sent to the surgeon general of the service, so 

it was clearly administratively something a commander would 

never do because it was simply too much. 
6 

That had the same impulse that 512 did, and that was to guard 

against PTSD and the possibility that we could do harm administratively to someone who was doing the best they could and suffered and was separated for some reason other than their disability. So those actions have taken place, and we applaud 512 to 

this day. 

[The joint prepared statement of Mr. Carr and Dr. Rice can be 

found in the Appendix on page 29.] 

Mrs. DAVIS. Thank you. I appreciate your sharing that with us 

because we know this is a somewhat different time. 

We are going to want to talk about the needs, the capacities, certainly, of the mental health community within the services and the 

general population as well, and being able to meet these requirements as well as having the numbers really to review a number of 

these cases. 

But I wanted to focus initially on the commanders in the field 

and talk about how we are educating them and the role that you 

think they are actually playing in trying to assess the severity or 

the possibility that someone could be suffering with PTSD or TBI. 

One of the things we know is how difficult it is to diagnose and certainly in a subjective fashion to be able to get that information, but 

yet the commander plays a pretty significant role. What are we 

doing, and what is the status of that? How do you think we are 

doing in trying to move that area forward? 

Mr. CARR. The first is for the commanders. We use the term 

PTSD, but what does it mean? How do you spot it? What does it 

mean in concrete terms? If you can express it in a way that they 

comprehend, then the likelihood of their uniting that circumstance 

with medical help is that much greater. The Army and the Marine 

Corps have active programs and training where they instruct the 

field in the terms. 

For example, for PTSD, my point before this was that commanders have guides that allow them to take a situation that presents and make some more rational and informed judgment as to 

whether or not the symptoms they are seeing represent PTSD. And 

for example, some of the instruction presents to them that if the 

person reports disturbing memories and disturbing dreams, reliving and so forth, those are things we would all say, yes, I recognize 

that now as PTSD. 

But unless we actively say it to the chain of command, then they 

will hear it, and they won’t understand the medical significance of 

what they have just heard. So the education and training programs 

of the Army and the Marine Corps and making sure commanders 

know that. 

Mrs. DAVIS. Can you be more specific in helping us understand? 

I think in the testimony there was some notion of how much time 

is spent, but what does that look like in terms of that training? 

Mr. CARR. It would take the form of about one hour training, and 

I am going to have to, I am sorry, I will have to confirm back to 

you exactly how it would play out for a unit at let’s say Fort Bragg, 

what specifically do they experience? I would be glad to provide 

that back. There are a number of references on the Web that are 

available to those who go look for them, and they are easily found. 

But I think the question from the Chair is, what do we present so 
7 

it is deliberately placed before the chain of command so that these 

terms are described? And I am sorry, I can’t define that now, but 

I will provide that. 

[The information referred to can be found in the Appendix on 

page 47.] 

Mrs. DAVIS. Dr. Rice. 

Dr. RICE. Yes, ma’am. 

Madam Chair, I think it is important to emphasize that the emphasis on this comes from the very top. General Chiarelli, the Vice 

Chief of Staff of the Army; General Amos, the Assistant Commandant of the Marine Corps, have talked about this over and over 

and over again with their commanders. Once a month, for example, 

General Chiarelli has a video teleconference with all of his commanders where a suicide has occurred, and the general officer at 

that particular post or station is there to report on what were the 

specific circumstances that led up to the suicide. 

Obviously, we don’t want to be tumbling to this problem after a 

suicide has been completed, but I think it does bring to bear the 

fact that the emphasis from the Vice Chair, Vice Chief and from 

the Assistant Commandant is continuous; it is important, and they 

are very emphatic about making sure that it gets disseminated 

down the chain of command. 

I think the other, in addition to the point that Mr. Carr made, 

the other place that it is really important is at the senior noncommissioned officer level, because those are the people who are 

really in day-to-day contact with the troops. Education in this area 

has been incorporated into the sergeant major course, for example. 

All of the senior noncommissioned officer (NCO) leaders are taught 

about how to recognize various aspects, and the details and content 

of those courses are something, like Mr. Carr, I would have to get 

back to you on. 

[The information referred to can be found in the Appendix on 

page 47.] 

Mrs. DAVIS. Thank you very much, because I think we all know 

how long it takes the medical professional to be able to describe 

and understand, and I think there is a great deal for our commanders to be doing, and certainly the officers. And it is difficult 

to even find some of the time for that. But I think that, while we 

had a great deal of emphasis early in the last few years and had 

to focus a great deal on suicide in the units, I think that we want 

to be sure that we are spending enough time doing that, because 

in many ways, they really are the critical factor in this. 

Dr. RICE. Yes, ma’am, I think that is exactly right. I think the 

most important thing that the commander or the senior NCO does 

is to convey to a member of his unit it is okay to go ask for help. 

It takes a strong person to do that. 

Mrs. DAVIS. Mr. Wilson. 

Mr. WILSON. Thank you, again, for both of you being here. 

Mr. Carr, how has DOD reached out to former military members 

who are administratively discharged, separated, to inform them of 

the opportunity to request a review of their separation through the 

Discharge Review Board (DRB)? And to date, how many individuals have requested such a review? 
8 

Mr. CARR. The outreach was through media principally to ensure 

that it reached cities and towns. And to date, the number is relatively low, 129 Army have applied to the Discharge Review Board. 

So it was a media effort. 

Mr. WILSON. A media effort. And also, I am sure for persons discharged, you all send—I have seen them—periodic newsletters to 

the discharged personnel, and it would have been in that publication, too, wouldn’t it? 

Mr. CARR. I am almost sure it was in those publications as well. 

Mr. WILSON. Inadvertently, one of my sons who served a year in 

Iraq, I kept getting his mail, and it was really very enlightening 

and very encouraging to me how helpful the information that was 

provided, and of course, I would get it to him right away. And then 

they got his correct address. 

What is your plan for providing additional mental health assets 

required for the pre-separation exams and the Discharge Review 

Boards, how many additional personnel do you anticipate needing? 

Additionally, I am very grateful, I work with a volunteer organization called Hidden Wounds of Columbia, South Carolina, which is 

serving as a back-up for discharged personnel. They are actively 

promoting mental health assistance, and so it is DOD, VA, and 

then volunteer organizations, but how many more personnel do we 

need? 

Mr. CARR. For the Discharge Review Board function, as long as 

the criteria are kept broad, for example, we don’t stipulate a grade 

and whether active or reserve and are not overly restrictive in the 

academic disciplines, my understanding is that the manning requirements will be met for the DRBs, that that wouldn’t impose 

the restraint on the flow of applications. 

Mr. WILSON. And it is encouraging to me, I went to a pancake 

breakfast to raise money for Hidden Wounds, and the VA had a 

table set up there with personnel from the VA hospital. I could see 

it was a really positive interaction between volunteer organizations 

and DOD and personnel and VA personnel. 

Mr. CARR. Yes, sir. 

Mr. WILSON. It is my understanding the same neuro-cognitive assessment test used for pre-deployment assessment is not authorized for post-deployment assessment of our returning soldiers in 

the Army. Do you feel this is a violation of the law in the fiscal 

year 2008 National Defense Authorization Act aimed to create a 

comprehensive approach to address the mental health of our soldiers? If not, why not? 

Dr. RICE. I think our understanding of what an appropriate instrument is for a pre-deployment screening for psychological condition and for post-deployment is evolving. And so the Army, I know, 

has been reevaluating the use of an instrument called the automated neurological assessment metric (ANAM) at the point of predeployment. There has been some professional disagreement within 

the community about whether or not the ANAM is an appropriate 

post-deployment instrument. 

I think this is all evolving. I think the important point to make 

is that there is screening going on. Exactly how we are going to ultimately get to a point where we are satisfied that we have a comparable instrument that was used before deployment and post-de-
9 

ployment, I don’t think we are quite there yet, but certainly, we are 

working hard at it. 

Mr. WILSON. Well, again, I appreciate your working with our 

troops. As a parent of two sons who have served in Iraq and another in Egypt and another one who may be on the way as an engineer, I appreciate, on behalf of my constituents and my family, 

what you are doing. Thank you. 

Dr. RICE. I can’t help but point out that one of your sons is a 

USU graduate. 

Mr. WILSON. We have a USU graduate in the family, so Dr. Rice 

has been very helpful. I am very proud of his Navy service. But I 

see Army people in the back, and I want to verify that the other 

three are Army National Guard. 

Mrs. DAVIS. Thank you. 

Mr. Pascrell. 

Mr. Loebsack, I am sorry, I was thinking of our joint—— 

Mr. LOEBSACK. Actually, I wouldn’t mind, as long as I can have 

my five minutes, I wouldn’t mind letting my colleague, Mr. Pascrell, go before me if that works for the committee. 

Mrs. DAVIS. I would need to let Dr. Snyder go first, and then, 

since Mr. Pascrell is not on the committee, the rules say he would 

have to go last. 

Mr. LOEBSACK. Thank you, Madam Chair. 

I do want to thank both witnesses for being here today, and also 

thank the chairwoman and the ranking member for holding this 

hearing. This subcommittee has looked into some really critical 

issues this year, and I appreciate your leadership, Madam Chair 

and Ranking Member, in taking a critical look at some of the really 

tough issues facing our services, the troops and their families. 

Mental health care of our armed forces is an issue that I know 

we all take extraordinarily seriously, and I have a personal interest 

in this as well. I have had a number of family members affected 

by mental illness, so this is kind of a personal concern of mine, I 

have to admit. 

And given the shortage of civilian mental health professionals in 

the country, I think the challenges facing the Department in recruiting these specialists is understandably difficult, and that is 

mentioned in your testimony as well. 

But I have an ongoing concern about access to mental health 

services for members of the reserve components, not unlike Mr. 

Wilson, and their families, those components and their families, especially those living in rural areas. I am from Iowa, and there are 

a number of us, obviously, in this Congress who represent rural 

areas. 

In your testimony, on page 40, you mention a telehealth initiative that the Department has undertaken. Can you go into the status of that program, how you are making service members and 

their families aware of it, and how service members who are determined and need in-person care through a telehealth session are in 

fact receiving that treatment? 

Dr. RICE. Yes, sir. Thank you. 

The telehealth program was developed specifically to address 

those in more remote areas, especially among the guard and reserve, who frequently had difficulty accessing qualified behavioral 
10 

health specialists. Through a variety of media on post and in camps 

and stations, we make the web site known. People can access this 

over the Internet and communicate directly. There are educational 

materials provided on the web site, and there is the ability for 

someone to self-refer if they require further evaluation, or screening, or consultation. 

The ability for someone, particularly in a rural area, to seek consultation with a qualified behavioral health provider who understands the context of the experience that that guard or reserve 

member has been through has been a challenge. 

Mr. Young, several years ago, in collaboration with the American 

Psychological Association, asked us to develop a program, the Center for Deployment Psychology. This is based at the Uniformed 

Services University. This program offers a one- and two-week 

training course for civilian psychologists, usually not near a military base, but who are likely to see guardsmen or reservists returning from deployment, and educates them about the kinds of experiences these guardsmen and reservists have been through during 

their deployment. 

So far, I think we have offered, and I forget the exact numbers, 

but approximately 50 courses of the two-week type and a similar 

number of the one-week type and have reached several hundred, if 

not a thousand, civilian practitioners. 

Mr. LOEBSACK. I will keep following up with you folks on that 

particular issue as we move forward and as a member of this committee and someone who does represent, as I said, rural America 

in many ways, so I really appreciate that. I think this is going to 

be a huge issue, there is no doubt about it, especially as more and 

more of these folks—and in Iowa, I am talking about the guard in 

particular—as they continue to deploy and do multiple deployments 

and all of the problems that get presented. I will continue to follow 

up on that. 

I do have one other question. Can you walk me through the steps 

that are taken if a member of the reserve components is determined to be suffering from PTSD or TBI due to a combat deployment after they have already been taken off title 10 active duty? 

What sort of treatment do they get? Who provides the treatment? 

And while undergoing treatment, are they put back on title 10? 

Dr. RICE. Medical treatment for someone who is already separated, they would likely be referred to the VA. And they are, of 

course, eligible for care at the VA for anything, for any combat-related problem. 

Mr. CARR. For the reservist, let’s say national guard, I have been 

on active duty, I have been on deployment, I am now back in Iowa, 

and I have been there for eight months. And I believe I have PTSD. 

I am going to probably proceed with my physician on my own medical program to discuss it. 

Or I could, as Dr. Rice said, take it up with the VA on the expectation that in short order, when I address this with the VA, they 

will administratively determine it to be a consequence of combat, 

therefore combat-related, therefore something that must be addressed by the VA. 

So that is the exchange with the VA, where you have a logical 

talk about, I believe I have this, and if I do, it could, I believe, only 
11 

have come from there; the potential is so high that I will be rated 

by the VA, that I would like to pursue this conversation with you 

because I don’t have health insurance. Then it would be the VA. 

Mr. LOEBSACK. Sometimes those ratings are problematic, and 

that is why I raise the issue. 

Thank you so much for your time. 

Mrs. DAVIS. Thank you. 

Dr. Snyder. 

Dr. SNYDER. Thank you, Madam Chair. 

Last week, Mrs. Davis held a hearing on the Centers of Excellence, which I thought was a good discussion of what has been described and was described by our witnesses last week as the signature issue of these wars, which is the blast injury. And this discussion today is a continuation of that discussion in many ways. 

I have been having some discussion with our colleague Dr. Tim 

Murphy, a Ph.D. psychologist from Pennsylvania, about this issue 

of traumatic brain injury. The question I want to ask is this: We 

are aware that the unfortunate circumstance of war is every injury 

you can imagine has occurred in war or will occur. Some are minor, 

and some are absolutely devastating and lead to death. And then 

we have all the spectrum in between. 

So when we think about traumatic brain injury, and that is what 

I want to ask about, TBI, pretty much isolated from the psychological aspects of it, so we are familiar with the devastating injuries in which our brave men and women end up as a total care individual. And then we have been talking a lot today about people 

who may have mild TBI, may have PTSD, but they are at home. 

They need some mental health counseling, but they are working 

and performing at home. 

What I want to ask you about is the folks that have recovered 

from their wounds, I think this falls under, Dr. Rice, in your statement about the separation policy. You talk about the people that 

you conclude, the military concludes, are not fully capable of performing their tasks, so they are going to be released from the military. The segment of the population I want to ask about are those 

who, if you saw them walking down the street, you would not even 

notice anything different about them. But if you were a family 

member or their caretaker, you would realize in their own way this 

person is also going to need some kind of 24-hour care. Perhaps 

they can walk into town. Perhaps they can be dropped off in town. 

But they are going to need, in the olden days we called it a domiciliary, or some kind of a residential care facility. Tell me where 

that fits into the discussions you are having. 

Clearly, this is probably going to be a veterans’ health care part 

of things, but your separation policy, people need to get separated, 

not just released, but they need to end up immediately on the right 

perch. Would you discuss that segment of the population, and do 

you have any idea of what the numbers might be for the person 

I am describing? 

Dr. RICE. No, sir, I don’t have a sense of the numbers off the top 

of my head. We will certainly take it for the record. 

[The information referred to can be found in the Appendix on 

page 48.] 
12 

Dr. SNYDER. Do you share my concern about those types of injuries? 

Dr. RICE. Yes, sir, I do. And as you know very well, there is no 

gold standard diagnostic study for traumatic brain injury. We are 

working very hard on a program in collaboration with the National 

Institutes of Health to pursue that, to see whether there are either 

biomarkers or there are sophisticated neuro-imaging techniques 

that may shed some light on both a sensitive and a specific diagnostic test for traumatic brain injury. 

With respect to the question of people who are not functional any 

more or are having challenges in functioning, if they are still on active duty, they would undoubtedly be referred to a Medical Evaluation Board to determine whether or not they are fit for duty. If they 

are found not fit for duty, they would go through the Disability 

Evaluation System. 

Dr. SNYDER. And I assume that that process would occur at the 

point the medical team determined this person has probably recovered as much as they are going to recover? 

Mr. CARR. If they have the potential of being unfit, and if that 

is the case, then it will go to the Medical Review Board to decide 

if we have that condition before us, or is this something easily remediable? But if it is long term and likely to be chronic unfit, then 

it would be evaluated for disability evaluation and either severance 

or retirement. 

Dr. SNYDER. The people I am talking about would clearly fit into 

that category. But I am concerned about what happens to them 

afterwards. So, at the time of separation, how do we make sure 

they have the continuity of care so that they end up in the right 

place and not be lost, to their detriment, for maybe a matter of 

hours, days or weeks? 

Dr. RICE. That is a discussion that we are having on a regular 

basis with the Department of Veterans Affairs to make sure that 

if somebody is medically retired with a disability rating of greater 

than 30 percent, they are medically retired from the armed services 

and are eligible for care, either in the military system or in the VA, 

if they are separated with less than that, then they are eligible for 

care in the VA. 

The VA rating system is different. That is a whole other discussion. But they are eligible for care in the VA, and the VA is very 

sophisticated in providing that kind of continuing and long-term 

care for people with those injuries. 

Mr. CARR. Another way we can go at this is just to follow on 

through that I was on active duty. I spotted this person in Roanoke, and they don’t seem to be able to care for themselves. So, 

first, how did they get there? Were they recognized and disability 

processed? 

However it works, if that which is the physical problem resulted 

from military service, then either the military, because we catch it 

while they are on active duty and we see these things and we classify them and we rate them as a disability; or we don’t spot it, no 

one takes note of it, somehow it escaped undetected, and then it 

emerges later. In that latter case, they were not separated for medical disability, and in that instance, the most likely course of action 
13 

is they would come in contact with some veterans group and probably be advised to go to the board. There are various ways. 

The likely way, go to the Board For the Correction of Military 

Records and assert that I separated. I felt these things, but I never 

expressed them. I ended up in Roanoke, and I am even more confused, and these are the events which have progressed. I assert, 

therefore, that I had this condition while in the military, and my 

record should be reflected to show my current diagnosis, which by 

my symptoms is 50 percent disability. 

Then, at that point, that adjustment would be made. If it were 

made and it were accepted, you would be a medically retired member of the military. Or it could be caught in a different way later, 

and you would be entirely managed by the VA. 

But it would come down to, what is it that is your impairment? 

How would that rate as a disability? And when the rating is high, 

who is responsible? Somebody is, assuming it was led to their military service. Was it the military that was responsible for solving 

that and missed it? Even in good faith, it was never mentioned. Or 

was it instead something that was dormant and manifest years 

later and reasonably was not at the fault, if you will, of the military, in which case I would take that up with the VA? 

So I trust that that person is going to come in touch with social 

network, and that social network is probably going to guide them 

to a veterans’ support and that will lead them on the path. That 

is the scenario I would sort of see for the case we described to 

make it right under either of the two systems, as if it had been 

caught if it should have been caught. 

Mrs. DAVIS. Mr. Pascrell. 

Mr. PASCRELL. Thank you, Madam Chair and Ranking Member 

Wilson, for allowing me to sit on the committee today. I appreciate 

that. 

As the co-chair of the Brain Injury Task Force in the Congress, 

I have been committed to bringing awareness of the prevalence of 

TBI since 2001. As everyone here knows, and I want to thank Dr. 

Rice and Mr. Carr for their service to our country, I take this very 

seriously. And I know you do, too. 

This has been dubbed the major injury of the wars in Iraq and 

Afghanistan. It is estimated that 360,000 Iraq and Afghanistan 

veterans, or nearly 20 percent of those deployed, may have suffered 

brain injury. We are talking about over 70,000 of our bravest. The 

best way to determine the health of returning service members, because that is what this hearing is about, is to provide for a baseline 

neurological test. 

And finally, in the fiscal year 2008 National Defense Authorization Act, and I want to refer to the exact words of the act: Public 

Law 110–181, the National Defense Authorization Act, Fiscal Year 

2008, Title 16, Section 1618, the two sections, 6 and 9, one is assessment and one is managing and monitoring. The words are very 

clear. I won’t read the whole thing. I won’t suffer you through that. 

But it says, including a system of pre-deployment and post-deployment screenings of cognitive ability in members for the detection 

of cognitive impairment. It also says that at the end of the section 

on management, on managing and monitoring, including the monitoring and assessment of treatment and outcomes. 
14 

Why have a baseline if you are not going to follow it up with a 

comparative test in separating yourself from the service? You need 

a consistent test. You need a consistent metric. And, therefore, 

what we are using is absolutely inadequate. 

I read through this several times. It didn’t just happen the other 

day. This is not the baseline. It has nothing to do with the baseline, and no comparison can be made. No comparison can be made 

in terms of what tests are given to that brave soldier when he goes 

or she goes before the front line, before they go to the front line. 

So we are not doing neuropsychological testing afterwards, which 

is what the language says we must do. 

I wrote a letter, on April 19, which several my colleagues have 

signed onto to Mr. Gates, the Secretary of Defense, and John 

McHugh, Secretary of the Army. And I said in the letter, in the 

second paragraph, We were reassured that the Department of Defense had implemented pre-deployment neurocognitive assessments 

across all services. Unfortunately, we recently learned that the use 

of the same neurocognitive assessment instrument is specifically 

not authorized for post-deployment assessment of our returning soldiers. Not only is this approach ineffective at identifying brain injuries, we believe that it violates the intent, if not the letter of the 

law certainly, and I believe it is the intent of the law, the spirit 

of that law. 

One of these provisions here was the language that required— 

and the language is specific about this—that the Department of 

Defense provide pre- and post-deployment. And as I said, you cannot do this unless you have established a baseline and then follow 

it up with something where you can make a specific comparison. 

The only effective way to identify traumatic brain injury is to use 

the same neuropsychological testing, both pre- and post-incident, in 

order to produce a consistent metric. 

In late March 2010, we learned that the Army has been using 

an automated neuropsychologic metric—I just raised it to you, I 

just showed you—for pre-deployment assessment. The U.S. Army 

Medical Command had also issued a memo stating that ANAM was 

specifically not authorized for post-deployment assessment for our 

service members. Instead, only concussion-related questions have 

been added to the post-deployment questionnaire. Read pre-deployment, you will see that questionnaire, but they also are giving the 

baseline test. Service members fill this out themselves. This postdeployment health assessment is filled out by the soldier himself 

or herself, and yet we are making the comparison to a test that is 

given, a baseline test, which is given. It does not make scientific 

sense. 

So I don’t believe that the DOD is conducting neurocognitive assessments in a uniform manner, and our troops are suffering because of that. Common sense would suggest that the same 

neurocognitive assessment tool should be used throughout the term 

of service to properly identify and manage long-term changes in 

cognitive ability. The DOD has failed, and I have worked closely 

with the DOD. I have worked closely with General Sutton and I 

have worked closely with Colonel Jaffee and I have worked closely 

with my brother who is no longer with us, Congressman Murtha. 
15 

We worked in the past four or five years; we have accomplished, 

all of us together, quite a bit. 

Why has the Department of Defense selected two incompatible 

neurocognitive assessments for pre-deployment and post-deployment, specifically using a automated baseline neurocognitive assessment for pre-deployment and symptom survey for post deployment? Are you just trying to follow the letter of the law while ignoring the actual intent of it? Either one of you. 

Dr. RICE. I think that, certainly, you are absolutely right that 

you cannot compare two different instruments before and after and 

expect to get consistent results. 

I think the challenge has been validating the instrument to be 

used to make sure that it is both sensitive and specific for what 

we are trying to detect. And as I understand it—I am a trauma 

surgeon, not a neurologist or a psychiatrist—but as I understand 

it, there has been disagreement among the experts in the field 

about the extent to which the ANAM is an accurate representation 

of cognitive ability. 

It is my understanding that that was the motivation behind looking for a test that was perceived to be more accurate, more sensitive and more specific. I would be happy to look further into that 

issue and get back to you. 

[The information referred to can be found in the Appendix on 

page 49.] 

Mr. PASCRELL. So you believe the instrument in the pretest is 

valid? 

Dr. RICE. I am not certain. And again, this is not my area of expertise, but I am not certain that there is general agreement 

among the experts in the field that the ANAM is a valid test. 

Mr. PASCRELL. So you don’t—you can’t state for the record that 

the baseline neurocognitive assessment is valid? 

Dr. RICE. I believe there is disagreement among experts in the 

field about its validity. 

Mr. PASCRELL. So are you telling us today that the test we are 

using before someone goes on the battlefield may not be valid; is 

that what you are saying? 

Dr. RICE. I am not sure that it is. That is right. 

Mr. PASCRELL. Well, that says something, doesn’t it? 

Mr. Carr, what would you say to that? What is your response? 

Mr. CARR. I think this is more a matter of judgment on the medical validity, the scientific validity of this baseline against that 

later measurement, and that is, unfortunately, not my policy province or my area of expertise. 

Mr. PASCRELL. Madam Chair, if I may, in conclusion, the law, 

the words right in front of me are very, very specific. I would contend that they are not being followed, that we are breaking the 

law, and we are not doing service to our bravest. 

I don’t think the gentlemen on that side of the table want that, 

and certainly I know the people on the panel who are sensitive to 

this issue don’t want that. I would suspect that there needs to be 

a sense of urgency on this issue, otherwise we are not doing justice, 

and we are just doing empty words. And we have had enough of 

that. 

Thank you, Madam Chair. 
16 

Mrs. DAVIS. Thank you for joining us today and raising that. I 

know it was raised earlier. 

And I think, Dr. Rice, if I am not mistaken, you basically said 

that they were working on it, in terms of a post-deployment assessment and an instrument that is working. But I think we have had 

some other concerns that there is no way to align that if in fact 

the earlier instrument is not giving us the kind of information that 

is really important to be able to do that. 

What do you think the next step should be? We are in a quandary, then, in terms of how we really can represent to anyone who 

is in a situation of having been—this hearing, of course, is about 

separation and the appeals and how we move forward, but clearly 

that is something that we need to do. Where do you think we 

should be? 

Dr. RICE. Well, I think, I believe I am correct in saying this, that 

the Army, that all three of the services, actually, have engaged 

their experts in a very intense discussion of what the right psychometric evaluation should be and what the best available tools to deploy are, remembering that we are administering this to a very 

large number of people and therefore to make sure that we capture, in the most effective and efficient—— 

Mrs. DAVIS. What I am trying to determine is, are the tools out 

there to do that? Is it that we still have research to do to determine 

that? I know that a lot of money, even through the Centers of Excellence, have been focusing on some of these issues. Is there a 

problem just administratively to get this together and to focus appropriately? 

Dr. RICE. No ma’am, I don’t think it is an administrative problem, I think it is a conceptual problem of, what do we measure? If 

we take a screening test, what do we measure it against that we 

accept as a yardstick that is valid? I think that is where the disagreement among the experts has been. 

Mrs. DAVIS. How do we move that forward then? 

Dr. RICE. We are pushing on that very hard. There is a keen 

sense that, as Mr. Pascrell indicated, that this is an important 

need. We are concerned about people who have repetitive exposure 

to mild blast injuries, and we are not sure what the cumulative effect of that repeated exposure is. So determining what somebody’s 

baseline cognitive functioning is so we can compare it to what we 

assess after such an exposure is very important. 

Mrs. DAVIS. It seems, though, that there are a lot of reasons to 

have good instruments, and the one that we are focusing on today, 

it seems somewhat simple, in terms of being able to determine the 

extent to which someone’s behavior, that the contributions to that 

have been as a result of a blast injury in some way and that that 

would be demonstrated. It seems to me there is some clarity there. 

There may not be for some other purposes, but there may be some 

clarity there. Am I missing something in terms of how we, the 

whole appeal process? 

Mr. CARR. It gets linkage to the appeal process. 

Mrs. DAVIS. Sure, whether of not—the purpose that we are looking at right now is the appeal process and the extent to which a 

person has been rightly or wrongly separated and that they can 
17 

continue with either their military career or at least have the 

honor of being separated—— 

Mr. CARR. I would say, no, and the reason I would say it is because comparing the condition that presents against something 

independent of this at the moment, the standard we would look at 

for any bodily function is, what represents a disability in my elbow 

or in my PTSD? I compare the condition to that. For example, usually PTSD is, I can’t do my occupation. And depending on how severely I can’t do my occupation, the percentage of disability would 

rise. So that judgment is made in contrast to me against doing my 

work quite independent of this. 

So, no, it wouldn’t affect the capacity to correctly and properly 

dispose of the disability, to rate it, and to pay it. I think, instead, 

it was a matter of classifying the change, but that change, even if 

it were classified, hadn’t made its way into the disability rating 

system. So that, this is—it is important for all of the reasons the 

congressman pointed out. But as far as a direct deleterious effect 

on an incapacitated soldier, that judgment is made against the circumstances that present, against the description of, in this case, 

being able to do my occupation. 

Mrs. DAVIS. I know Mr. Wilson earlier asked a question about 

the number of individuals and the appeals, and I think you said 

128. Is that correct? 

Mr. CARR. 129, yes, ma’am, in the Discharge Review Board. But 

I would like to distinguish, the Discharge Review Board is, I got 

a discharge that was not an honorable; I would like another look. 

That has been for decades. 

The more recent items have been the Physical Disability Review 

Board established by the Defense Authorization in 2008, on which 

the committee played a key part. And that board said if you went 

out for less than 30 percent, because 30 percent is military retirement, it is valuable to the member, as opposed to 20 or 10 percent, 

if you went out for less than 30 percent and you think you were 

wronged, you may apply to the Physical Disability Review Board. 

It started in 2008, and it really got moving, its first full year was 

2009, and 690 applications came in. Most, about 58 percent, were 

Army, and about 61 percent of them were upheld. By that I mean, 

I now have an assertion from Bill Carr that you got it wrong. I am 

comparing the evidence that existed on me at the time of my separation, not new stuff, against the standard in making a determination. And in 61 percent of the cases, it is being adjusted upward 

for those 690 that are through so far. There are more to come, to 

be sure. 

I also should mention that, of those that come in, it is not PTSD 

or TBI or what we might have suspected going in. It is 80 percent 

orthopedic, so it is arthritis and joints and back; and 22 percent is 

PTSD. So there certainly are some where we missed, according to 

the Board’s recent conclusions, its newest conclusions, it looked at 

this, and it said that there was more than half in error. But the 

vast majority had to do with orthopedic as opposed to PTSD, and 

that is a little understood fact. 

Mrs. DAVIS. Thank you. 

My conclusion from this is some folks may say, in some ways, it 

is a premature hearing to try to get at these issues because there 
18 

are some things that I understand are definitely in progress. On 

the other hand, I think, it may be too late. 

So what I would like to do is to have some time and to come back 

in a few months and really take a look at this again, because it 

may be that we may want to strengthen some language in the authorization bill. We want to take a look at where we were. And 

whether we can put additional urgency on this I am not certain 

with the language, but it is clear that we have a problem, and we 

need to be addressing it. I know there is a lot of seriousness about 

it, but we need to put some real focus and try to understand better 

where we are. So if we can do that in a few months, that would 

be very helpful. Do you think that there is—what would be your 

timeline? What would you suggest that would be a good time to 

come back and really be sure that we are moving ahead with the 

instruments that are needed to align them properly? 

Dr. RICE. A couple of things occur to me. Obviously, as someone 

here who is not an expert in the cognitive evaluation of large numbers of people, either before or after deployment, so it is entirely 

possible that there is a great deal more sophistication that could 

be brought to bear immediately on that to better answer your question. 

Absent that, however, I would think that an opportunity for us 

to see what the current state of thinking among our experts is 

about the various tools that are available to assess cognitive ability 

is something that we could do within a relatively short period of 

time and be able to get back to you within six weeks, six to eight 

weeks. 

Mrs. DAVIS. Okay. 

Mr. Carr, did you have anything to add. 

Mr. CARR. Only that as we—section 512, which was an important 

section that we are implementing, the committee directed, the Congress directed that 240 days afterwards there be a report, and that 

will be the 25th of June. And our report will lay out how it is we 

are going to do that which 512 directs, which essentially means 

publishing a policy that integrates health, disability, and Board For 

Correction of Records all in one. Much of it is already completed 

in draft. But what we will deliver to the committee at the deadline 

is the report. In other words, at that point, the system will exist. 

People will not have been through it. A couple of months later, as 

people go through it, call that implementation, then we will provide 

another update to the committee. 

So June 25, we will meet, and that is, how are we going to do 

that which was directed by 512 exactly? Are there any shortages? 

What are the qualifications of the people, the physicians that will 

be involved, and the earlier question? Provide that report on June 

25, and then implement shortly thereafter and update the committee on how the numbers are working. Are there any bottlenecks, 

and are the skill sets proper and so forth? 

Mrs. DAVIS. So you are saying that the committee would have 

that report by the 25th? 

Mr. CARR. Yes, the 25th of June. 

Mrs. DAVIS. Okay. 

Again, you have seen some of that report. Do you think it answers the kinds of questions that we are after? 
19 

Mr. CARR. I think it does. It addresses the concern, which was, 

be certain that we haven’t disadvantaged someone who can’t take 

care of themselves by misclassifying or rushing to judgment that 

which could be a subtle injury or disease. In that case, yes, we will 

have reported how exactly it is that we will allow for success 

against that standard, exactly what the protocol, the procedure, 

and the flow will be, and what the manning of it will be to make 

for a successful implementation. 

Mrs. DAVIS. Wouldn’t that be dependent on having instruments 

that can properly make those assessments? 

Mr. CARR. No. Because, for now, we are operating on whether or 

not there is a disabling condition quite apart from—so there is a 

standard that says if you can’t perform your occupation and so 

forth. Now quite apart from that, for these signature diseases, can 

science tell us in more cogent terms an expression that is better 

than he can’t do his occupation? For example, if it can show a shift 

of a certain quantity, and that is a cogent correlation to not being 

able to do my occupation, that makes it more empirically reliable. 

But the fact that you don’t have that empirically reliable document at the moment doesn’t stop you from doing what we have 

done for decades, and that is to take the standard as it is written 

and apply it fairly to the patient and reach a determination as to 

what the disability percent should be. 

Mr. PASCRELL. Madam Chair? 

Mrs. DAVIS. Yes, Mr. Pascrell. 

Mr. PASCRELL. I think that is preposterous, and I will tell you 

why. 

To a layman, and I am a layman, how can you prescribe care unless you have something to go on? We have taken the protocol and 

moved it into the area of sports, and I don’t want to compare sports 

to what these brave men and women have endured on the battlefield, but we are now using protocol to protect our children in middle school, high school, and college, in terms of prevention, in terms 

of what happens when there is a concussion on the field in gals 

basketball or guys football; it doesn’t matter. In fact, there is more 

injury in women’s sports than male sports. How do you prevent 

this from happening? And then, if there is a concussion, what do 

you do? So now they are testing them before they go on the field, 

aren’t they, Mr. Carr? 

Mr. CARR. They are. 

Mr. PASCRELL. In order to do that and the reason why they do 

that is to have a baseline. And then they are testing them after 

they get a concussion in order to make the comparison. 

Mr. CARR. Yes, sir. 

Mr. PASCRELL. You are not going to be able to prescribe care unless there is a comparative baseline, unless you use the same kind 

of test, whatever those tests are. 

Mr. CARR. You are right. 

Madam Chair’s question was, are we blocked from proceeding 

with the business of handling a disability absent that? And the answer is, no, we are not. We will continue to dispose of cases with 

the tools at hand. 
20 

The congressman is entirely correct, that our empirical base, so 

that we can reach—so that we can quickly and decisively and accurately and cogently know that this shift has occurred. 

Mrs. DAVIS. Mr. Carr, I am afraid we are going to have to stop. 

But I can assure you that we will continue to discuss these issues 

and perhaps bring in additional individuals who will be helpful in 

the discussion. I think it is a very important one, as you know and 

appreciate, and Dr. Rice, I know as well, to our troops and to their 

families and to their futures. And so we will want to continue to 

try and understand it better. 

I appreciate my colleague being here and Mr. Wilson, and we will 

continue. Thank you very much. 

[Whereupon, at 6:44 p.m., the subcommittee was adjourned.] 
A P P E N D I X 

APRIL 20, 2010 

PREPARED STATEMENTS SUBMITTED FOR THE RECORD 

APRIL 20, 2010 

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WITNESS RESPONSES TO QUESTIONS ASKED DURING 

THE HEARING 

APRIL 20, 2010 

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RESPONSES TO QUESTIONS SUBMITTED BY MRS. DAVIS 

Dr. RICE. The Army implemented Mild TBI (mTBI) Chain Teaching in the Fall 

of 2007, for all Soldiers in the Active and Reserve Components, to address symptoms of mTBI, Soldier and leader actions, and resources for assistance. The chain 

teaching, with video illustrations, is taught by a facilitator and takes about 30 minutes. Newly assigned Soldiers receive this training within 30 days of assignment. 

In fall 2009, an ‘‘Educate, Train, Treat & Track’’ campaign plan was implemented 

to facilitate line and clinical collaboration for acute concussion identification and 

management in conjunction with the new mTBI/concussive injury management 

strategy. This protocol directs that any Soldier who sustains a direct blow to the 

head or witnessed loss of consciousness; is within 50 meters of a blast (inside or 

outside); is in a vehicle damaged by a blast event, collision or rollover; or is command directed, must undergo a medical evaluation. Appropriate treatment includes 

assessment, a mandatory 24-hour downtime, followed by medical clearance before 

returning to duty. Comprehensive medical evaluations are mandatory for anyone 

sustaining three concussions within 12 months. The Vice Chief of Staff of the Army 

(VCSA) has addressed deploying units at Ft Campbell, JRTC, NTC, and Ft Stewart 

about the TBI protocol ‘‘Educate, Train, Treat & Track’’ via VTC since Dec 2009. 

The VCSA spent up to 90 minutes at each session. These training sessions are ongoing. 

The Marine Corps provides training on Operational Stress Control to leaders and 

Marines at all levels. This training focuses on developing the observational skills to 

detect when a Marine is ‘‘not acting quite right.’’ The Marine leader’s responsibility 

is to notice a change and engage appropriate help and resources. The curriculum 

includes six hours of training for approx 50 Marines per battalion or equivalent 

command. 

All Air Force Airmen receive basic instruction on Traumatic Brain Injury (TBI), 

Post Traumatic Stress Disorder (PTSD), and suicide awareness. Commanders and 

Supervisors are provided approximately 60 minutes of additional training on recognition and mitigation of these problems in their subordinates. Instruction is a 

combination of didactic lectures, on-line instruction, publications, and interactive 

classes. It is incorporated into pre-deployment training for all deployers, including 

commanders and Senior Non Commissioned Officers. 

The Navy is planning a programmed release of the formal Operational Stress 

Control (OSC) curriculum in all accession and leadership schools—recruit training 

and ‘‘A’’ school, petty officer and chief petty officer indoctrination and officer candidate school, to name a few—in the very near future. In addition, specific pre- and 

post-deployment OSC training is being delivered at all Navy Mobilization Processing 

sites and Returning Warrior Weekends. The extensive OSC training continuum, 

while not specific to PTSD, provides training to commanders and the chain-of-command, along with Sailors and families, to help them recognize and address the 

symptoms of many different stress reactions and injuries. [See page 7.] 

Mr. CARR. The Army implemented Mild TBI (mTBI) Chain Teaching in the Fall 

of 2007, for all Soldiers in the Active and Reserve Components, to address symptoms of mTBI, Soldier and leader actions, and resources for assistance. In fall 2009, 

an ‘‘Educate, Train, Treat & Track’’ campaign plan was implemented to facilitate 

line and clinical collaboration for acute concussion identification and management 

in conjunction with the new mTBI/concussive injury management strategy. The 

Army’s Proponency Office for Rehabilitation & Reintegration (PR&R) developed the 

following courses, which are being uploaded to Military Health System (MHS) Learn 

for training for health care providers. The TBI 101 module will also be available 

on Army Knowledge Online (AKO) for viewing by all Soldiers. 

(1) TBI 101: TBI Foundation: (All Audiences) This course describes TBI in nonclinical terms: core TBI message of early detection and recognition of symptoms; correlation between sports concussion and (mTBI); the magnitude of how TBI affects 

the military; and discusses the military’s plan to address TBI from in-theater to 

home. 

(2) TBI 201: TBI Overview for Healthcare Personnel (All healthcare personnel 

(Stateside and Deployed)) This course addresses TBI definition and discussion on 
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levels of severity; mechanisms of Injury/Pathophysiology, and identification, assessment, and management of common symptoms. 

(3) TBI 301: First Responder Training: Battlefield Management for mTBI (Deployed Healthcare Personnel) This course addresses Field management guidelines; 

MACE: Military Acute Concussion Evaluation tool—test administration process; 

emergency care techniques; pre-hospital treatment; triage and transport; and documentation and coding. 

(4) TBI 401: mTBI Symptom Management Guideline. This course addresses Primary Care Providers and TBI healthcare team (Non-deployed) Section 1: Assessment techniques, clinical algorithms, medication awareness, duty restrictions, and 

DOD/VA Clinical Practice Guidelines; Section 2: Clinical interviewing, evaluation 

techniques with patient and Families, TBI management including profile writing, 

and documentation and coding; Section 3: Principles of TBI identification, TBI 

screening process, resources, and tools for diagnosis. 

The Marine Corps provides training on Operational Stress Control to leaders and 

Marines at all levels. The Marine leader’s responsibility is to notice a change and 

engage appropriate help and resources. The curriculum includes six hours of training for approximately 50 Marines per battalion or equivalent command. Trains XOs, 

senior enlisted, junior leaders, medical and religious ministry personnel to provide, 

prevent and manage many stress problems tools, strategies, and resources (Causes 

of Stress Continuum [COSC], Five Core Leader Functions, COSC Decision Flowchart, listening skills and referrals) for preventing and managing stress problems. 

Senior Marines discuss advanced COSC issues and tools, COSC risk management, 

training for resiliency, stress mitigation strategies, psychological fitness to deploy, 

health assessments & confidentiality. Junior Marines role play scenarios to apply 

new skills and tools. 

All Air Force Airmen receive basic instruction on Traumatic Brain Injury (TBI), 

Post Traumatic Stress Disorder (PTSD), and suicide awareness. Commanders and 

supervisors are provided approximately 60 minutes of additional training on recognition and mitigation of these problems in their subordinates. It is incorporated 

into pre-deployment training for all deployers, including commanders and Senior 

Non Commissioned Officers. All Airmen now receive TBI and Post Traumatic Stress 

(PTS) computer based training (CBT), which takes about 30 minutes to complete, 

when they complete the Self Aid and Buddy Care (SABC) CBT housed on the Advanced Distributed Learning System. A Leaders Guide to Managing Personnel in 

Distress is published guidance on how to handle PTSD and other ‘‘distress’’ conditions. Frontline Supervisor Training, Assisting Airmen in Distress, is targeted at 

lower-level supervisors who work side-by-side with their Airmen. This in-depth 

training course enhances supervisors’ abilities to recognize and effectively intervene 

with personnel suffering from emotional distress due to a variety of life problems, 

build on skills first learned during annual suicide prevention training and various 

professional military education (PME) activities. 

The Navy is planning a programmed release of the formal Operational Stress 

Control (OSC) curriculum in all accession and leadership schools—recruit training 

and ‘‘A’’ school, petty officer and chief petty officer indoctrination and officer candidate school, to name a few—in the very near future. In addition, specific pre- and 

post-deployment OSC training is being delivered at all Navy Mobilization Processing 

sites and Returning Warrior Weekends. The extensive OSC training continuum, 

while not specific to PTSD, provides training to commanders and the chain-of-command, along with Sailors and families, to help them recognize and address the 

symptoms of many different stress reactions and injuries. [See page 7.] 

RESPONSE TO QUESTION SUBMITTED BY DR. SNYDER 

Dr. RICE. There is a continuum of TBI severity ranging from mild TBI (otherwise 

known as concussion) to severe and penetrating. For mild TBI, assisting living programs are rarely required. Most concussed patients do not require a caregiver nor 

are they unable to take care of themselves from a supervision and assistance standpoint. These individuals can usually be managed with outpatient care and services. 

For more severe TBI patients, the assisted living pilot program is available for Service members who are unable to function independently without supervision or assistance. The numbers of patients who require these services appear to be low at 

this time. 

Currently, there are seven Service members enrolled in the Veterans Health Administration (VHA) assisted living pilot program with two more anticipated by July 

1, 2010. The VHA anticipates that by the end of Fiscal Year 2010, there will be 12– 
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15 patients enrolled. Should more information be needed, the Department of Veterans Affairs could provide more details. [See page 11.] 

RESPONSE TO QUESTION SUBMITTED BY MR. PASCRELL 

Dr. RICE. For clarity, there are three programs, each with different intent and 

purpose. These include the 

1) Pre-Deployment Health Assessment Program, 2) Neuro-Cognitive Assessment 

Tool, and 3) Post-Deployment Health Assessment Program. 

The Pre-Deployment Health Assessment Program serves to identify conditions 

that may impair performance during an upcoming deployment and to get a Service 

member to care if these conditions warrant. In addition to the Pre-Deployment 

Health Assessment, the Department implemented a Pre-Deployment Neurocognitive 

Assessment tool, using the Automated Neuropsychological Assessment Metrics 

(ANAM), to serve as a baseline for comparison if a Service member is injured while 

deployed. In this case, retaking the ANAM test will help inform a return-to-duty determination in theater following concussion. It also is used for post-deployment concussion management to help further elucidate cognitive symptoms and complaints. 

The third program, the Post-Deployment Health Assessment, enables health care 

providers to identify and refer for treatment those Service members who have physical or mental symptoms from their deployments due to a variety of conditions, one 

of which may be concussion. 

The Department has based its neurocognitive testing programs on injury platforms, that is, the primary purpose of pre deployment neurocognitive baselining is 

to better inform a return to duty determination. We understand Congress wants the 

Department to base the neurocognitive programs on evaluating cognitive function 

before a Service member goes into war and when they come out of war to see if 

there are any differences. If there are differences, then theoretically, the clinical 

teams can evaluate these Service members and treat them, thus not allowing any 

Service member to ‘‘fall through the cracks.’’ 

While the Department understands the Congressional intent, the inherent problem with this wider based platform (all Service member vice injured Service member) is that the evidence does not support this concept for two reasons: 1) we have 

completed two studies with military populations, one at Ft Bragg and one at Ft 

Campbell that both showed that population based cognitive testing was not effective 

for screening or diagnosing concussion and 2) we do not know what ‘‘new cognitive 

normal’’ is after a theater experience. We have no normative data that would suggest what retesting these cognitive domains should look like after war. Therefore, 

any difference between pre-deployment and post deployment assessment cannot be 

attributed to any specific factors. [See page 15.] 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING 

APRIL 20, 2010 

(53) 

QUESTIONS SUBMITTED BY MS. FALLIN 

Ms. FALLIN. The FY2008 NDAA included language mandating pre- and post-deployment neurocognitive assessments. The idea behind this being that a pre-deployment assessment would provide a baseline, to which a post-deployment assessment 

could be compared to. This was well understood by OSD Health Affairs at the time. 

Recent copies of orders that I’ve received from Army Medical Command have prohibited post-deployment neurocognitive assessments. Additionally, it’s been brought 

to my attention that DOD considers itself to be complying with the law if paper and 

pencil evaluation is administered overseas before deployment back to the home station. Is it true that pre- and post-deployment neurocognitive assessments are not 

administered using the same test? What is the purpose of a pre-deployment baseline, if different methods of testing are used post-deployment? It is my understanding that DOD maintains a database of all data regarding pre-deployment assessments. Is this database accessible by the VA? Are the results in this database 

linked to each soldier, sailor, airman’s health care file? May an individual serviceman or woman access the information related to their pre-deployment assessment? 

Finally, how does what DOD considers to be the post deployment assessment permit 

‘‘differential diagnosis of traumatic brain injury in members returning from deployment in a combat zone’’? 

Dr. RICE and Mr. CARR. 1 & 2) No, DOD currently uses the same pre-deployment 

cognitive assessment tool (Automated Neuropsychological Assessment Metrics 

(ANAM)) to perform post-deployment cognitive assessments for returning Service 

members who have sustained a concussion. The Department does maintain a database of pre-deployment assessments as part of the Pre-Deployment Neurocognitive 

Program to serve as a baseline for comparison if a Service member is injured while 

deployed and to help better inform an injured Service member’s return-to-duty determinations. 

3) DOD maintains a database with pre deployment neurocognitive baselines of deploying Service members. These baselines will be available to the VA by December 

2010. Milestone 4.2.A.3 in the VA/DOD Joint Executive Committee (JEC) Strategic 

Plan for FY 2010–2012 states ‘‘VA will begin implementing technical solution to enable VA providers to view DOD neuropsychological assessment data by June 30, 

2011.’’ 

4) The results from the pre deployment neurocognitive baseline tests are not currently linked to a Service member’s electronic health record. 

5) The results are housed in a centralized repository so they may be retrieved if 

necessary post injury for comparison. Service members may access these results, 

when requested. 

6) The population-based Traumatic Brain Injury assessment (versus cognitive 

screen) that occurs is the Post-Deployment Health Assessment (PDHA), is done by 

a health care provider. This assessment evaluates the entire spectrum of symptoms 

that may be associated with concussion. These include physical symptoms, i.e. headache; behavioral symptoms, i.e. irritability and cognitive symptoms, i.e. memory 

problems. Multiple diagnoses may result from these symptoms, to include but not 

limited to, posttraumatic stress disorder, high blood pressure, obstructive sleep 

apnea, or toxic chemical exposure. Thus, the presence of these symptoms does not 

diagnose a concussion or any other disorder, but they indicate the need for further 

clinical evaluation by a trained provider. 

The TBI screening questions that have been on the Post-deployment Health Assessment form (DD 2796) since January 2008, are survey-type questions that ask 

about an injury event, alteration in consciousness while sustaining that injury 

event, symptoms reported immediately after the injury event, as well as current 

symptoms experienced. These questions have been endorsed by the Institute of Medicine and have gone through validation studies as the questions to ask to ascertain 

whether a Service member may have sustained a concussion. However, diagnosis is 

not made until a clinician evaluates and examines the Service member to determine 

whether a concussion has occurred. The assessment process is the first tier ap-
54 

proach to cast a wide net for those who possibly have sustained a concussion. It is 

not expected to be a process that has high specificity but rather high sensitivity. 

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