Does your child want to join the military? Check their medical records first.

By seeking counseling for their two teenage daughters as their family coped with multiple moves and multiple deployments to Afghanistan, an Army major and his wife unwittingly prevented both girls from following their father, their grandfather and their great-grandfather into military service.

Rudy and Mia De La Rosa thought they were providing emotional support for daughters Juliet and Samantha.

Neither the parents nor the daughters knew there were notations like “suicidal gesture” or “self-mutilation” in their counseling files. And neither knew Army and Air Force medical providers would have access to those records — and anything else in dependent medical records — if their daughters ever enlisted.

This sets them apart from their civilian counterparts, who don’t come into the military with a previous electronic health record. It sets them apart from military dependents entering the Navy and the Marine Corps, which don’t merge dependent and service member records. And it puts the actions of the Army and Air Force in their cases, and those involving other dependents, at odds with the ethical judgement of some medical experts.

And despite multiple clean bills of health from civilian and DoD behavioral health providers, both girls have been denied waivers to enter the military.

“If I had known then what I know now, I never would have taken my kids to [Army] behavioral health,” Rudy De La Rosa, an Army major stationed in South Korea, said. “We could have taken a lot of different routes to protect their futures and get them the help and guidance they needed.”

This practice of merging dependent health records with new service member health records began in 2004 after those records were transferred into electronic formats.

Now, it’s potentially preventing thousands of military dependents who came of age during the wars in Iraq and Afghanistan, a time when everyone in the military community was encouraging all members of the military community to seek help for mental health concerns, from putting on a uniform.

For the post-9/11 generation of military children seeking to follow in their parents’ footsteps to serve as adults in the Army and Air Force, the disclosure of their once-private health records is making them feel like the military as an institution has misled them and violated their trust.

“I felt utterly and completely betrayed,” Samantha De La Rosa told Military Times in a recent interview.

“I was told that whatever I told them would be completely confidential, could never be held against me, and no one outside that room would ever find out about it. … Those were my counselor’s words to me when I was about 13.”

‘100 percent confidential’

Older daughter Juliet joined the Air Force in late 2016 at the age of 19 and was involuntarily discharged a month into basic training. The service alleged she’d enlisted fraudulently (later changed to “erroneously”) because she didn’t reveal the findings of Army dependent counselors.

Puzzled, the family requested Juliet’s medical records and discovered notations that included “suicidal gesture.” They began to clarify the record in the process of seeking a waiver for Juliet to reenter the Air Force.

And as a result of Juliet’s experience, the De La Rosas requested the medical records of younger daughter Samantha before she visited an Army recruiter.

She informed her recruiter that those records included mention of “self-mutilation” — a diagnosis she and her family reject, and one that wasn’t passed on to the family at the time it was made. She was told she couldn’t join, and that a waiver wasn’t an option.

Both suicidal gesture and self-mutilation are disqualifying for military service, by DoD regulation.

After Samantha De La Rosa visited behavioral health at age 13 because of what her father called “some minor self-harm markings we saw she had inflicted,” her military career was over before it started.

Her older sister’s admission to a primary care doctor that she’d once “almost took too many ibuprofen” before spitting the pills out led to a referral to a counselor, and to a notation in her medical records of a suicidal gesture. That should’ve prevented her enlistment, only she didn’t consider it a suicidal gesture (and wasn’t told it was one at the time).

Juliet said she answered all health questions on her processing forms honestly, and that she didn’t consider her meetings with the counselor “treatment” because “I thought I was just talking to someone after I moved from place to place.”

The Air Force saw it differently and discharged her. She and her family successfully fought fraud allegations, but when she applied for a waiver to continue service, she was denied.

“After a thorough review, which included her history of recurrent adjustment disorder that occurred over years in multiple, differing situations, in addition to a suicidal gesture, [Air Education and Training Command’s] Physical Standards Branch determined that the applicant’s history did not meet waiver criteria for military service” in accordance with DoD qualification standards, said Air Force Capt. Beau Downey, a spokesman for Air Education and Training Command.

“We wholeheartedly encourage anyone needing help to seek it. We also recognize there is sometimes an undue stigma attached to those seeking help for depression or other mental health concerns, when help-seeking behavior is actually a sign of strength,” Downey said. “However, the Air Force also requires its recruits to be truthful when seeking entry, including giving forthright answers about their psychological adaptation, because the demands of military service require high standards for all levels of fitness.”

Rudy De La Rosa, who has more than 19 years of service, said he wants to make it clear he’s not advocating putting unhealthy people in the service.

“But we’re talking about records from when they were children,” he said.

That history the service relied upon stemmed from “transcriptions captured from conversations with clinicians that my daughters were assured were 100 percent confidential and non-attributional,” he said.

Merging records

Once a dependent enters the Army or Air Force, their previous dependent medical records are merged with their new service member medical treatment record.

The Navy doesn’t merge medical records of dependents with new medical records of sailors or Marines, according to a spokeswoman.

Neither recruiters nor officials at the military entrance processing stations, or MEPS, have automatic access to medical records of any recruits, including prior dependents.

Recruits are asked at the stations about medical issues that could disqualify them from service; if they indicate any, they’re asked to provide an explanation, along with doctor and/or hospital names. Recruits sign authorizations specifying access to those records.

If a recruit from a civilian family mistakenly or knowingly fails to disclose something potentially disqualifying, the military might never find out about it.

Not so for military dependents. The Health Insurance Portability and Accountability Act, or HIPAA, which protects the privacy of medical records, doesn’t prevent the merging of records of prior military dependents for treatment purposes, Downey said, because the records are housed by the same provider: the Military Health System.

Army spokesman Michael Brady explained that the Army’s followed the same practice as the Air Force since 2004, when a new electronic records system allowed a former military dependent’s record to be merged into that individual’s service record.

The Navy Bureau of Medicine, which handles Navy and Marine Corps medical records, doesn’t merge the records, spokeswoman Mariah Felipe said.

“The [Military Health System] adheres to the principle a person has one complete health record, although it may have both active duty and non-active duty components,” said Kevin Dwyer, a spokesman for the Defense Health Agency.

It’s DoD policy that a health record be “created, used, maintained, shared, stored and dispositioned to ensure the maintenance of a complete and accurate health record for all beneficiaries,” he said.

“There is no reason under the Health Insurance Portability and Accountability Act (HIPAA), or any other policy, [that] a clinician or administrator with access to a person’s health record should not have access to the whole record. This means when a former beneficiary joins a uniformed service, clinicians may have access to the [non-active duty] components pre-dating the period of active service.”

He said the practice of combining the dependent medical record with the service member treatment record has been in effect since DoD began using the electronic records system in 2004, but the policy was put into place in 2010.

However the records line up, a number of health experts took issue with the spirit of the interpretation of the law, if not the letter.

“I think technically that’s accurate: There is one health care system. But ethically I don’t think it is accurate,” said Dr. Elspeth Cameron Ritchie, a retired Army colonel who is a forensic psychiatrist with expertise in military and veteran issues. “You’re using health care information to determine someone’s fitness for duty when they haven’t agreed to provide you that health care information for that purpose.

“If I, as a 13-year-old, go in and know that if I say anything that can be used to disqualify me from the military, that’s one thing. But it’s another thing if I’m just seeking treatment because I’m in distress and my parents are trying to do the right thing for me, and then later on that’s used to disqualify me without me knowing, and without me being told at the MEPS station,” she said.

Treatment for attention deficit hyperactivity disorder or depression are common examples, she said.

Barbara Van Dahlen, a licensed clinical psychologist, questioned why these records are automatically merged, and why military youth are treated differently.

“What’s the justification? It seems to be counterproductive to recruitment if the policy is not the same for kids outside the military family and inside. Doesn’t that create an unnecessary and an unhelpful vulnerability or difference for kids?” said Van Dahlen, who in 2005 founded Give An Hour, an organization that has developed national networks of volunteer professionals providing free and confidential mental health care to military members, veterans and their families.

“In this case, this young woman just happens to come from a military family, which we should be supporting and honoring and recognizing the value of that generation to generation, … and here she’s being penalized.”

Ritchie and Van Dahlen have not clinically evaluated the De La Rosa daughters, and spoke from their general years of experience treating military families and knowledge about the community.

No warning

The military medical system doesn’t provide parents disclaimers detailing how behavioral health visits could affect their child’s future military service, Dwyer said.

In most cases, before a child’s 18th birthday, parents can request their child’s medical records, but those “do not include psychotherapy notes kept separate,” he said, nor other HIPAA-protected information.

The De La Rosas never requested such records. So it was a shock in 2016 when Juliet was asked by a medical evaluator at Joint Base San Antonio-Lackland, Texas, about juvenile medical records pulled during a routine screening because of her projected assignment in air traffic control.

“Never once were we or Juliet told that she was being diagnosed with disorders. Never once was Juliet medicated,” Rudy De La Rosa said, nor was she hospitalized.

He and Juliet contend these notations about a “suicidal gesture” were inaccurate.

Juliet saw a social worker from late 2011 to July 2013. According to her medical record, the social worker discharged her after successful therapy sessions. A 2017 follow-up letter from the social worker chalked up her “working diagnosis” of depression, in part, to “just being a teen.”

The De La Rosas provided medical records and other documentation for Military Times to review.

Her primary-care doctor from the time said it was never her intention for her documentation on that day’s visit in 2014 to prevent Juliet from serving in the military. Civilian and military psychologists who tested her in 2017 gave her a clean bill of health.

In her waiver request, Juliet contended that the statements in her medical records are only “vague mentions of disorders,” and the last time she had talked with behavioral health was in March 2014.

The appeal was denied.

Her departure wasn’t unique: In the five fiscal years from 2012 through 2016, behavioral health history accounted for 13 percent of all attrition from Air Force basic training, said Marilyn Holliday, spokeswoman for the Air Education and Training Command.

The service doesn’t track whether separated trainees are prior dependents, but an Air Force sampling of 120 behavioral health-related dismissal cases over that period showed 19 were.

Holliday said “fraudulent” is the third most frequent reason for attrition from basic training over the last decade, and these cases are comprised almost entirely of undisclosed behavioral health history.

Options for dependent counseling exist outside the military health infrastructure. Military OneSource counselors can provide short-term, free, nonmedical services covering multiple issues, including deployment stress.

Give an Hour connects service members, veterans and families with mental health providers who have volunteered to provide confidential, direct services.

“But pushing people outside the system — is that really the right thing to do? I don’t think it is, necessarily,” said Kathy Beasley, a retired Navy captain who is director of government relations (health affairs) for the Military Officers Association of America. “The system needs to be cognizant of this and needs to be supportive. They need to understand it’s an issue.”

Learning the hard way

A report last fall that the Army would lift a ban on waivers for recruits with certain past mental health disorders and substance abuse gave Samantha De La Rosa hope, but the Army later clarified that officials weren’t lowering standards; they were simply moving waiver approval authority back down to the commander in charge of Army accessions. That’s where the authority is for the other services.

In a statement to reporters in November, Lt. Gen. Thomas Seamands, the Army’s deputy chief of staff for personnel, said waivers are and have been considered for a variety of behavioral health issues.

“It’s also important to note that the conditions themselves have been unfairly characterized,” he said. “For example, a child who received behavioral counseling at age 10 would be forever banned from military service were it not for the ability to make a waiver request.”

During a Nov. 15 news conference with Army leaders about the issue, Sergeant Major of the Army Dan Dailey used an example of a one-time cutting incident in explaining waivers.

“If a young man or woman was taken to a hospital because they cut themselves, and a doctor said that was some form of self-mutilation, and it never happened again — then we’ll look at that case, and we’ll make a determination with medical professionals, with behavioral health professionals, and, ultimately, command,” he said. “To be automatically exclusionary … to the American public, on certain conditions, is unfair.”

But considering a waiver request is not the same as granting a waiver, officials said.

When the Army denied Samantha’s request for a waiver, Army Recruiting Command’s explanation was straightforward: “Self-mutilation is considered disqualifying. Army G1 policy does not permit medical waiver for self-mutilation/injury.”

Samantha said it doesn’t make sense that recent assessments mean nothing.

“It just blew my mind that something I did when I was 13 is stopping me when I’m an entirely different person,” said Samantha, who is now a senior in high school in South Korea. “My current character and who I am right now is a completely separate human being from when I was an underdeveloped, tempestuous little neurotic 12-year-old who had no idea what I was talking about.”

The one-time incidents that have barred Samantha and Juliet from military service should be put into context, Van Dahlen said.

“To think these young ladies are somehow different than the other applicants who didn’t report what they did as teens, who didn’t get help, is just so wrong,” she said.

‘A sign of strength’

One reason many military dependents may get help for such issues where civilians won’t: DoD and the services say they should.

“DoD encourages anyone who needs help to seek it as soon as possible,” Dwyer said, “and emphasizes that seeking help for depression or other mental health concerns is actually a sign of strength.”

While DoD and Army program officials constantly say soldiers and families won’t be stigmatized or punished for seeking help, Rudy De La Rosa said, “our children are not protected. We are not told that DoD clinicians are building their permanent military health record that will follow them their whole lives.

“A new generation of Post-9/11 military kids are now coming of age who can’t join the military, because they were left out of the stigma-ending equation.”

He contends that DoD should implement a policy that protects dependents by ensuring their medical records are carefully examined for accuracy, and by granting them waivers or exceptions to join the military as long as they are highly qualified at the time they apply.

Ritchie, the forensic psychiatrist, said she doesn’t think most doctors know that what they’re writing in the records could be future disqualifiers for military children who want to join the service.

“In some cases, you’ll say, it doesn’t matter, treat the person anyway. But in other cases, it might be, ‘Hey, this is a decision let’s discuss together, because if I give you this diagnosis or this medication, it absolutely will disqualify you from military service,’ ” she said.

Senior reporter Meghann Myers contributed to this report.

Karen has covered military families, quality of life and consumer issues for Military Times for more than 30 years, and is co-author of a chapter on media coverage of military families in the book "A Battle Plan for Supporting Military Families." She previously worked for newspapers in Guam, Norfolk, Jacksonville, Fla., and Athens, Ga.

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