The United States continues to experience a significant shortage of child and adolescent psychiatrists, with recent estimates predicting a shortfall of more than 4,000 of these specialists by the year 2020 (¹). In response, the American Academy of Child and Adolescent Psychiatry has stated that recruitment into the field should be of the highest priority. Increased exposure to child and adolescent psychiatry during medical school could spark interest among students. A literature review identified only one study that specifically addressed changes in knowledge and attitudes of medical students after taking a course in child and adolescent psychiatry (²). However, in that study pediatrics was taught in combination with child and adolescent psychiatry, which may have affected student perceptions. Also, the study did not assess student likelihood of selecting child and adolescent psychiatry as a specialty.

Martin et al. (³) showed that student attitudes can change over the course of a psychiatry clerkship, and several studies have focused on the effect of specific methods or designs of general psychiatry clerkships. Weintraub et al. (⁴) found that those students exposed to an "enriched" psychiatry curriculum, as opposed to a "regular" one, were more likely to choose psychiatry as a specialty. Other studies have noted the positive effect of offering an outpatient experience during the clerkship (⁵—⁷). The majority of medical students are not exposed to child and adolescent psychiatry during the general third-year clerkship (⁸). Kay (⁹) stressed the importance of developing approaches to teaching child and adolescent psychiatry topics as part of a medical school curriculum.

In this study, we surveyed third-year students at the Feinberg School of Medicine of Northwestern University regarding a child and adolescent psychiatry case seminar that had recently been introduced into the general psychiatry clerkship. Students were asked to complete a survey immediately following the seminar. Although giving pre- and postseminar surveys would have been preferable in order to establish true change over time, this was not feasible. We anticipated that students would report interest in and a positive regard for child and adolescent psychiatry as a result of the seminar, which would support the hypothesis that the inclusion of child and adolescent psychiatry in a third-year clerkship might encourage more future physicians to consider the field.

The case seminar was held during the final week of each 4-week general psychiatry clerkship rotation. At the start of the block, each student received a copy of Concise Guide to Child and Adolescent Psychiatry, 3rd ed. (¹⁰) and an information packet explaining how the seminar would be conducted. Students were instructed to read specified sections of the book.

The seminar began with a brief introduction by a member of the faculty (usually the child and adolescent psychiatry training director [MBL]) that included an enthusiastic but realistic presentation of child and adolescent psychiatry as a field. Training opportunities, diverse career options, and status as a shortage specialty were emphasized. Next, students participated in three consecutive 1-hour sessions. Each session was led by a different faculty member and covered a different diagnostic area (mood/anxiety disorders, disruptive behavior disorders, and psychosis/pervasive developmental disorders). The sessions were conducted using a problem-based learning-type model in which students actively discussed material in the context of realistic patient cases. Each session concluded with the generation of a formal five-axis differential diagnosis and a comprehensive multimodal treatment plan including office-based and community services. Students were given copies of the case descriptions to use during the seminar. Prior to the seminar, faculty facilitators were free to review the cases and the information packet that was given to the students. Facilitators were expected to discuss one case per hour and were encouraged to lead a participant-focused seminar rather than a formal lecture. The standardized cases were easy to follow for the facilitators, and they were used as a springboard for each faculty member to bring his or her own clinical expertise to the discussions. This also allowed students to more personally identify with potential mentors or role models.

All students participating in the seminar over a 12-month period (N=165) were asked to fill out a survey immediately afterward; however, one group of students completed the survey later on in the same week due to scheduling issues. The cover letter of the survey clearly stated that in order to protect anonymity there would be no identifying information on the survey. Also, students were not required to fill out the survey, and there was no penalty for not participating. Since the survey was completed anonymously and was not associated with medical clerkship staff or supervisors, it could have no effect on how students were graded on the rotation. The survey and overall project were approved by Institutional Review Board. Survey questions used a 5-point Likert scale. An area for comments closed the survey. Data analysis was performed using Student’s and paired t tests where applicable.

Of the 165 students, 164 completed the survey (99% response rate). Regarding prior exposure to the field, the majority of students (72%, n=118) reported learning about child and adolescent psychiatry while in the second year of medical school (see Table 1 ). Fewer students had been exposed to the field at other times. Notably, 12% (n=19) reported no prior exposure at all.

Students wanted more exposure to child and adolescent psychiatry. On a Likert scale with a "1" indicating that the seminar provided too little exposure and a "5" indicating that it provided too much, 52% marked a "1" or "2" and only 4% marked a "4" or "5." The mean score was 2.3 (SD=0.8).

All aspects of the seminar were rated as influencing students’ views of child and adolescent psychiatry in a positive way (see Table 2 ). In pairwise comparisons, the faculty facilitators, case examples, and faculty introduction (which were not statistically distinguishable from each other at p<0.05) were viewed as significantly more positive components (p<0.05) than the administrative process (i.e., obtaining schedule and instructions, receiving the appropriate reading material beforehand, faculty promptness) or than the Concise Guide readings (not statistically distinguishable from each other at p<0.05).

When asked after the course about their attitudes before and after the seminar, students reported regarding child and adolescent psychiatry more highly (see Table 2 ) and being more likely to consider a career in child and adolescent psychiatry after they had completed the seminar. Overall, 37% of students (n=61) reported being more likely to consider child and adolescent psychiatry. Student comments fell into three groups. The first group reported positive reactions to the format of the seminar ("Case study rather [than] lecture is a good way to teach and for us to learn"; "I think that this was a great course that covered a lot of material in an efficient format"). A second group of comments reported increased understanding of child and adolescent psychiatry ("My regard for child and adolescent psych was enlightened [by] this experience. Importance of child psychiatry was made clear to me"; "Before the course, I did not realize that pervasive developmental disorder…[was] under the domain of child psychiatry"). Finally, many comments focused on the desire for more exposure, especially to actual patients ("It would be nice if students had an option of spending a day on one child psych unit"; "It would be nice if we had at least one chance to be exposed to outpatient work in the clinics").

Based on the students’ retrospective reports, our data indicate that the child and adolescent case study seminar had an impact on the attitudes of the participants. Students indicated that it led to a more positive regard for child and adolescent psychiatry and that it fostered more interest in entering the field. Results may have been enhanced by the lack of prior exposure to the specialty. Many learned about child and adolescent psychiatry only during the second year of medical school, which included a series of pathophysiology lectures focused on general psychiatry with limited formal didactics in child and adolescent psychiatry. This type of exposure may not allow students to see the material in a clinical context and it does not provide an opportunity to integrate concepts in a way that helps students appreciate unique aspects of the specialty.

Because information is not generally shared regarding how each medical school incorporates child and adolescent psychiatry into its curriculum, no "best practices" have been established. Third-year clerkships vary, with some including no opportunities for child and adolescent psychiatry exposure, some including didactic elements, and some allowing some or all students to work with child and adolescent patients. This seminar could easily be adapted by any medical school either as part of a clerkship or as a stand-alone seminar in another context (e.g., psychiatry interest group, pediatrics rotation, child development course, psychiatric subinternship). It requires little preparation, is brief yet well-received, and is logistically simple. While clinical contact with children and adolescents is desirable (and many of the students asked for it), it is unfortunately often impractical given the constraints of academic institutions, rotation schedules, and overextended faculty. If patient exposure were incorporated into the rotation, in the form of live or videotaped patient interactions, it would supplement a seminar such as this one. At the Feinberg School of Medicine, students may elect a 4-week clinical experience in child and adolescent psychiatry during their fourth year. If the seminar sparks interest among students, they may also choose to pursue a senior elective clerkship, mentoring, research, or volunteer opportunities in the field, possibly leading to further interest.

As a follow-up to this study, one could implement the seminar at another medical school and examine whether an increased number of students would ultimately choose to pursue general psychiatry and child and adolescent psychiatry residencies, as well as whether those students felt that the seminar had affected their decision in any way. This would help to address the longitudinal component that is missing from this study. Further limitations, such as the single class sample size, that future interest and knowledge among those students choosing a different career were not addressed, and that the survey was given only after the seminar rather than both before and after (which would have allowed for the measurement of true change) should be addressed in future studies.

Given the continuing deficit of child and adolescent psychiatrists, it is critical to expose medical students to the field. Waiting until the general psychiatry residency is not ideal, as the opportunity to attract students who have entered other fields would be lost. Incorporating a case-based seminar into the third-year clerkship need not be time-consuming or onerous for those involved, but it does require a commitment by medical schools and faculty to increase exposure to and enthusiasm for the field in the hope that there will be enough psychiatrists to meet the needs of future children and adolescents.

The authors wish to thank Mina Dulcan, M.D., and Angela Nuzzarello, M.D., for their suggestions during the development of this study.