The prevalence rate of psychiatric disorders in individuals with developmental disabilities (which includes mental retardation) ranges between 10% and 60% and is greater than the prevalence in the general population (¹—⁴). In the past, the diagnosis of mental retardation has overshadowed other appropriate diagnoses. There has been some interest in applying the same principles that govern the diagnostic process in the general population to individuals with developmental disabilities (⁵). Still, the psychiatric needs of these individuals are often not met. There is difficulty recruiting psychiatrists in this area due to the lack of proper education and exposure to developmental disabilities (⁶, ⁷). Throughout their medical education and specialty training, psychiatrists receive adequate exposure to patients diagnosed with psychiatric illness, but report minimal contact with patients diagnosed with developmental disabilities. While child psychiatry training does focus on developmental disorders, mental retardation, in particular, has never been in the mainstream of psychiatric education. When there is exposure to developmentally disabled populations it is often insufficient. Residents may see these patients within their regular clinics without specialized supervision and support. This sporadic and inadequately supervised exposure does not develop competence and may create anxiety. The following summarizes our experience of the critical issues in treating patients with developmental disabilities:

The crux of the issue lies in appropriate training and exposure to patients with developmental disabilities during medical education. Research on attitudes has shown that contact with and education about people suffering from physical and developmental disabilities affects the attitudes of the general public as well as health care professionals (⁸). Moreover, evidence suggests that in order to be efficient, contact must be carefully controlled and supported by accurate information highlighting the patient’s abilities and individuality (⁹). The stereotyping of individuals with developmental disabilities as "all alike" results in a loss of individuality that leads the physician to lack appreciation of the individual’s own strengths, wishes, and needs. In addition, when there is an overemphasis on the effects of disability, normal behavior may be interpreted as abnormal. Individuals are then treated in terms of their disabilities instead of their abilities, causing an underestimation of the individual’s potential (¹⁰). Furthermore, the literature has demonstrated that positive attitude changes will occur once discomfort in social interaction is addressed (¹¹). A telepsychiatry program with specialized supervision that teaches skills and emphasizes the individual patient can address the inadequacies of training. Telepsychiatry brings the experts to patients in remote areas. This virtual subspecialty clinic of low incidence disorders would not be available from local referral alone. The Cedars Sinai Medical Center Telepsychiatry Developmental Disability Clinic founded in 1997 has a threefold mission: to treat patients with developmental disabilities and provide ongoing collaborative consultation to their primary care physicians; to teach caretakers, families, and staff to better understand and help these patients; and to train doctors with the skills and needed tools to provide exceptional care. In order to develop a successful training program we identified five clinical weaknesses seen in psychiatrists without adequate training in this area:

1. A psychiatrist who is extremely adept at assessing a verbal patient may be at a loss when confronted with a nonverbal patient, deferring or dismissing the assessment as if the patient is temporarily mute.

2. A psychiatrist may become reductionistic, attributing symptoms to retardation and dismissing other psychiatric disorders. This concept of "diagnostic overshadowing" has been used to describe the practice of physicians neglecting to diagnose comorbid axis I disorders in patients with an axis II diagnosis of mental retardation (⁴, ¹²). With mental retardation "overshadowing" other diagnoses, common disorders such as anxiety and depression are not considered or are misattributed to the developmental disability.

3. A psychiatrist who does not establish rapport with the patient tends to minimize the patient’s complaints and symptoms as though mental retardation prevents the experience of common emotions. In addition, as a result of common practice, symptoms are labeled as "behaviors" within many treatment facilities, feeding into the lack of appreciation for the individual’s feeling state.

4. A psychiatrist may develop inadequate treatment plans, reacting more to the fact that he or she cannot impact the mental retardation, instead of focusing on the axis I disorder, which he or she can impact.

5. A psychiatrist may not be able to generalize his psychiatric knowledge and skills to this population without specific clinical training.

This article assesses the impact of a telepsychiatry rotation on the self-assessed clinical skills and knowledge of psychiatric residents and fellows using a side-by-side supervision model. In the absence of a validated rating scale to assess the impact of training in this field, we developed a questionnaire for this purpose. The questionnaire was administered at the beginning and end of the rotation. We hypothesized that the most sophisticated trainees, the child fellows, would experience an overall greater benefit and impact compared to the residents at a lower level of training. This hypothesis was based on the supposition that the greater foundation in psychiatry would benefit the child fellows more than the junior residents.

Patients in the Cedars Sinai Medical Center Telepsychiatry Developmental Disability Clinic are referred by rural primary care physicians. All patients are clients of the California Regional Centers, whose mandate is to provide services to people with developmental disabilities. These patients live in a variety of settings: at home with parents/guardians, in group homes, in supported living settings, or in foster care. The patients range in age from 2 to 60 years. The hub site at Cedars Sinai provides regular clinics, with long distance real-time consultations, to many rural spoke sites. It uses a Polycom ViewStation 512 MP with Dual 46-inch flat screen plasma monitors. The system is capable of making calls using the ISDN network up to 512 Kbps or using the hospitals IP network up to 2 Mbps. The rural sites are located throughout California and include Bakersfield, Redding, Chico, Mammoth, Ridgecrest, and Ukiah. The program is designed to include initial 1-hour evaluations and 30-minute follow-up sessions as needed. Immediately after the patient is seen, the progress note is faxed to the rural site and then to the primary care physician. All rural clinics are staffed by a site clinic coordinator, who participates during all sessions. This key staff person ensures the optimal functioning of the clinic. Other regular rural team members vary by site and have included family physicians, a pediatrician, and a neurologist. Other participants include family members, caretakers, treatment providers, regional center caseworkers, and therapists. Individuals not able to easily attend, such as teachers, may participate by speakerphone. Key attending staff at the Cedars Sinai Medical Center hub site include a child psychiatrist and a dysmorphologist/geneticist who is present at one-third of the Cedars Sinai clinics. Three psychiatry residents and one child psychiatry fellow are usually on clinical rotation. Other trainees who may join the clinic include medical students, art therapists, social workers, psychologists, pharmacy trainees, pediatric residents, and genetics fellows. A collaborative approach to treatment is utilized. Parents and caregivers are regarded as treatment partners as much as possible. As within clinic policy, case discussions are held with the sound "on," not "muted," so that rural site participants can better understand the case by hearing the discussion and formulation of the treatment plan.

There are two major components to the training program: didactic and clinical. The didactics cover six areas: developmental disabilities, psychiatric disorders commonly seen in this population, communication and interviewing, mental status examination, special education, and genetic and other causes of mental retardation. In addition to psychiatric literature, trainees are encouraged to read literature written by parents and affected individuals. We recommend The Child Who Never Grew by Pearl Buck (¹²), Thinking in Pictures by Temple Grandin (¹³), and The Broken Cord by Michael Dorris (¹⁴). Clinical skills are taught through a specialized supervision model in which the attending and trainee work side-by-side. First, the attending models the evaluation process and formulates the case with the team. He or she can discuss his or her understanding of the patient’s issues and reactions to this individual, encouraging trainees to do the same. This facilitates the development of empathy and rapport. As a trainee begins to gain comfort with the patient interview, the attending allows the trainee to take over the interviewing role. However, the attending continues to provide active guidance, directives, and supervision within each clinical encounter to facilitate the trainee’s optimal skill development and performance.

The study was given exemption status by the Institutional Review Board of the Human Research Protections Program at Cedars Sinai Medical Center. The duration of this study was 36 months, during which time all rotating residents and child psychiatry fellows were invited to participate. During this period of time, 10 child psychiatry fellows and 23 psychiatry residents rotated through the Cedars Sinai Telepsychiatry Clinic. Each participant was asked to fill out a 92-item questionnaire at the beginning and end of the training. In order to keep the questionnaires anonymous, participants and corresponding questionnaires were identified numerically. Questionnaires were scored by an individual who did not know the participant or whether the test was a pretest or a posttest. The present study included eight fellows (six second-year and two first-year). Of the 10 fellows who rotated through the clinic, two did not turn in their posttests. Of the 23 residents, seven did not turn in their posttests and one turned in a posttest that was missing a complete section and was therefore discounted. Of the 15 remaining residents, 13 were third-year and two were second-year.

Because no validated scale was available for the study purpose, we developed a questionnaire to assess the trainees’ skills and psychiatric knowledge. The questionnaire consisted of 92 multiple-choice questions that were divided into four distinct categories. The first category, self-assessment, provided the total self-assessment score. The other three categories assessed knowledge directly. The total knowledge score is a sum of the three different categories that test knowledge. The self-assessment section included 23 questions regarding self-assessed competence, confidence, and clinical skills on a 5-point Likert scale (1=limited, 5=very developed). The knowledge category included 22 multiple-choice questions assessing knowledge of intellectual and developmental disabilities; 22 questions about comorbid psychiatric disorders including 18 multiple-choice questions and four matching questions; and 25 questions about special education and IQ testing, including 15 multiple-choice questions and 10 matching questions.

Of the residents who participated, 60% (n=9) were male, 53% (n=8) were Caucasian, 20% (n=3) Asian, 6% (n=1) African American, 6% (n=1) Indian, and 13% (n=2) mixed ethnicity. The mean age was 31.33 years old (SD=3.66). The mean length of their telepsychiatry rotation was 3.5 months, and the mean number of developmentally disabled patients seen per resident was 70. The majority of fellows who participated were male (75%, n=6) and Caucasian (63%, n=5). In addition, 13% (n=1) were Asian, and 13% (n=2) were mixed ethnicity with a mean age of 34.25 years old (SD=3.20). The mean length of their rotation was 6 months and the mean number of developmentally disabled patients seen was 120. The majority of residents had no previous child psychiatry exposure in residency. The residents also reported having exposure to two or fewer patients with developmental disabilities of any age. This can be seen in their various comments and assumptions presented in Table 1 . In addition, none of these trainees had prior telemedicine experience. Results of a Wilcoxon signed-ranks test revealed that the study sample as a whole showed significant increases in self-assessment (Z=−4.35, p<0.001) as well as improvements in their knowledge base (Z=−4.32, p<0.001) over the course of their telepsychiatry rotation. In order to determine whether there was a significant difference in the degree of improvement between residents and fellows, we first calculated the difference between pre- and posttest scores for each person with regard to self-assessment and knowledge, and used the Wilcoxon Mann-Whitney test to calculate group differences. Results revealed that both residents (Z=−3.63, p<0.001) and fellows (Z=−2.39, p<0.02) exhibited significant increases in self-assessment over the course of the rotation. However, residents showed more improvement in this domain than did fellows (Z=−3.36, p<0.001) (see Figure 1 ), and by the end of the rotation, their self-assessment scores were equivalent to those of the fellows (Z=−0.21, p<0.842). Figure 1 shows that both residents (Z=−3.62, p<0.001) and fellows (Z=−2.32, p<0.02) achieved significant gains in knowledge between pre- and posttest. There was no difference in the degree of improvement across groups (Z= −1.11, p<0.29). Fellows exhibited superior levels of knowledge before (Z=−2.95, p<0.002) and after (Z=−2.28, p<0.023) completing their rotation.

Although preliminary, the present findings add to the limited literature regarding educational applications of tele-psychiatry. There have only been a handful of studies showing that telemedicine may be effective as a mechanism for providing both long distance education and supervision (¹⁵—²¹). However, to the best of our knowledge, this is the first study to show its unique contribution using a side-by-side supervision model. With the availability of increasingly sophisticated technology, telepsychiatry’s applications for education and supervision are continuously growing. Studies have shown that two-way real-time TV enhances the continuing education of health professionals in rural areas by allowing them to access classes, Grand Rounds, and lectures and to learn from other specialty health professionals (¹¹, ¹⁵, ¹⁷, ²²—²⁹). Moreover, telepsychiatry has enabled trainees to effectively work in areas far from their home institution, attend lectures, and consult with their supervisors via real-time two-way TV (¹⁷, ²⁷—³⁷).

The present study is the first to show the effectiveness of using telepsychiatry for "side-by-side" supervision. There is no other known documented program that provides this type of training, but in our experience, the benefits are numerous. Providing feedback midstream allows the trainee to improve and develop skills within each clinical encounter. The supervisor’s comments direct the trainee to make immediate changes in interviewing questions or style and critique the trainee’s mental status exams and assessments. This unique type of supervision can only occur when the patient is seen using teleconferencing in a virtual telepsychiatry clinic.

As a result of this experience, residents and fellows showed significant improvement in their knowledge and self-assessed skills with this patient population. Contrary to our hypothesis, and despite the fellows having a longer rotation (6 months versus 3 months) and seeing a greater number of patients with developmental disabilities (120 patients versus 70 patients), psychiatry residents demonstrated greater improvement than the child psychiatry fellows in terms of self-assessed skills. Although it is possible that this is reflective of greater gains among the residents, it is also possible that this finding may be due to a ceiling effect. In other words, it may be that trainees, in general, did not feel comfortable rating themselves in the uppermost end of the scale (i.e., "mastery"), given their level of experience. Thus, it may be that a scale with finer distinctions in the upper end would have revealed equivalent rates of improvement among residents and fellows. Nonetheless, it is notable that both groups made significant gains. This is best captured by the statement of one resident, who proclaimed, "After this I do not think I will be scared the next time I see a patient with autism in the emergency room." Even if the ceiling effect was in operation, it is clear that trainees left their rotation with more confidence in treating patients with developmental disabilities. In terms of future directions, we plan to build on the present findings by assessing competencies across a broader and more fine-tuned range of domains and adding a comparison group. This group would include trainees rotating in a local developmental disabilities clinic, or a group that is only receiving the didactics portion of the rotation. Moreover, we hope to begin to explore factors that may impact whether or not a trainee responds to training. We are also interested in identifying which particular skills are developed during this rotation, and which would endure over time. Will this rotation ultimately affect the clinical practice of doctors who have trained at Cedars Sinai Medical Center? What is the optimal length of rotation? Does the degree of benefit vary as a function of year of residency? Also, given that we found improvements among our residents, we are curious to see if medical students would also benefit. Exposure earlier in the training years may encourage trainees to "cast a large net" from the start and learn to apply their clinical skills to include people with developmental disorders from the beginning of training. Exposure in the first "introduction to clinical medicine" course in the first or second year of medical school may help expand the patient population with whom future doctors learn to feel comfortable.

Given the limited research regarding the impact of training experiences on self-assessed skills and knowledge in developmental disabilities, we created our own measurement instrument, for which we have not yet conducted reliability and validity studies. Another limitation is that we did not include a control group. In addition, the sample size was small, which limits the conclusions that may be drawn. However, the fact that the results were significant is perhaps a testament to the strength of our findings. Additionally, we did not include an objective measure of clinical skill, and it would have been informative to know if self-reported improvements in clinical skills were associated with actual improvements in the quality of care provided. Finally, it is possible that those trainees who did not complete a posttest were those who found the rotation less valuable.

Telepsychiatry, a novel but increasingly common method, appears to have some training benefit using a side-by-side supervision model. In this study, we found that trainees at various stages in their clinical training were able to gain significant knowledge and self-assessed clinical skills following a rotation in a telepsychiatry clinic specializing in the diagnosis and treatment of developmental disabilities.

1=limited; 5=very developed