Forensic education for child-and-adolescent psychiatry (CAP) residents is an essential experience that may affect trainees long after they have completed their training. Since relevant educational resources may not be immediately available in some residency programs, this article may serve as a resource to CAP training directors who wish to enhance their forensic curriculum and increase the forensic competence of their residents. Child-and-adolescent forensic psychiatry is the study of how CAP interfaces with the legal system. Major areas of child-and-adolescent forensic psychiatry include policy development (hospitalization, seclusion, restraint, consent, privilege, confidentiality, malpractice), dependency issues (child abuse, neglect, custody, adoption), and juvenile-justice mental health.
The Accreditation Council on Graduate Medical Education (ACGME) requires CAP training programs to offer a 2-year "specialty curriculum" with clinical supervision, "graduated learning," and "formal didactic instruction" (1). The CAP training program must include forensic education; however there are no specific requirements regarding the nature of that education. The challenge for CAP residency training directors is to integrate forensic training into an intricate, space-limited curriculum.
The ACGME affords training directors flexibility regarding how to achieve this goal. One approach to the problem includes offering a course in forensic child-and-adolescent psychiatry, along with legally-informed CAP rotations, throughout the residency training experience (2, 3), which introduces residents to medico-legal concepts that are conducive to safe, competent child-and-adolescent psychiatric practice. To this end, there is a growing collection of resources that may be used to educate CAP residents in salient legal topics that can serve as a springboard for forensic CAP education (Table 1). The nationwide shortage of child-and-adolescent psychiatrists, especially those with forensic training, necessitates that most forensic education of CAP residents will come from non-forensically trained child-and-adolescent psychiatrists and from professionals in related fields who work with youth who have forensic concerns. Access to a comprehensive forensic CAP training curriculum is not likely for most training directors. However, they may use the framework of the ACGME forensic CAP psychiatry requirements, locally-existing resources, and interdisciplinary networking to weave various forensic-education activities into a sound and meaningful education module for child-and-adolescent psychiatry residents.
TABLE 1.References for Sample Forensic Texts
A well-designed survey of a CAP program may identify forensically-relevant topics that are already being presented to residents during clinical rotations, seminars, lectures, and so on. Free and low-cost survey software programs and services that facilitate development and dissemination of questionnaires are currently available for professional and educational purposes.
Faculty members may be invited to identify forensic CAP topics that they feel comfortable presenting to residents. The faculty could also be encouraged to submit names of potential speakers, rotation sites, and supervisors for community-based forensic CAP training. These local resources may then be reviewed during faculty or curriculum committee meetings, or by an ad-hoc task-force comprising faculty, residents, and other interested parties. CAP residents may be queried about the quality of existing forensic experiences, as well as other forensic-education experiences that occur during their training. The results of each survey—assets, faculty, and resident—may be used to develop educational opportunities that fit into the ACGME framework for forensic CAP training. The resources and deficiencies gleaned from the forensic CAP resource and needs-assessment surveys could be used to inform development of a flexible, comprehensive, forensic CAP curriculum that will satisfy ACGME guidelines.
Educational topics are best disseminated over a 2-year period to permit residents to explore forensic material as their skills develop (1). Educators could be encouraged to use teaching aids, including vignettes, diagrams, current events, and video footage (4—6) to improve the residents' comprehension and retention of concepts. The training director should work with supervisors to incorporate forensic education goals into each clinical rotation. A CAP outpatient rotation, for example, may be used to review forensic child-psychiatry topics such as child custody, parental rights, and malpractice. Emergency rooms and consultation—liaison services are suited to educate CAP residents about risk-management, including violence and suicide prevention, exceptions to confidentiality, protecting third parties, treatment in absence of parental permission, malingering, and factitious disorder, including Munchausen by proxy.
School consultation rotations are ideal settings for discussions about school violence, risk-assessment, and education law and policy, including the Individuals with Disabilities Education Act (IDEA) and how the Families Educational Rights and Privacy Act (FERPA) differs from the Health Insurance Portability and Accountability Act (HIPAA) (7). Meetings with legal professionals are often underutilized, but can help residents understand clinical issues from a legal perspective, explain the importance of patient advocacy, and help residents feel less intimidated by the legal profession.
Another topic of importance is statutory language. Residents should receive education about statutes involving matters that are relevant to child psychiatric practice. Although IDEA, HIPAA, and FERPA are federal requirements, child abuse and neglect regulations, child custody arrangements, emancipation requirements, and the age at which a youth can consent to receive mental health care vary by state (8). Child psychiatry residents should become familiar with these requirements during training and should be encouraged to research applicable statutes if they plan to practice in a different jurisdiction after they complete child psychiatry training. Forensic seminars provide fruitful opportunities to introduce residents to concepts related to juvenile and family law, including foster care, adoption, child custody, guardianship, juvenile delinquency, rehabilitation of mentally ill juvenile offenders, transferring juvenile cases to criminal court, and consultation to juvenile-justice agencies.
Salient matters such as the disproportionate representation of minority youth involved with the juvenile-justice system and access to mental health care for at-risk youth are important considerations for CAP residents who train in the United States, Australia, the United Kingdom, and other countries. CAP residents also could have opportunities to assess and treat youth from various cultures, countries, and traditions in juvenile-justice facilities, community settings, and hospitals. Unlike the United Kingdom, the United States does not have a network of forensic inpatient hospital services for youths. Therefore, it is important to train child-psychiatry residents working on psychiatric wards to be cognizant of possible staff and patient responses to youth from juvenile-justice facilities who receive inpatient care in non-forensic, child-psychiatry hospital units. Residency training directors who have access to child-and-adolescent forensic inpatient facilities could consider using them to educate residents about the complex, but necessary, interactions involving mentally ill minors and the juvenile-justice system.
A medical record is a clinical report that can have substantial legal implications. Forensic CAP education should help residents appreciate the importance of using a systematic approach to gathering and analyzing data that they enter into the medical record. Residents should be trained to give appropriate attribution to clinical data and to base their conclusions on clinical evidence. A resident who produces clear, concise clinical reports facilitates future patient care by making it easier for subsequent clinicians to understand how treatment decisions were made. This approach to documentation will also be used by psychiatrists who prepare reports for judges and attorneys.
A forensic report-writing exercise that involves rewriting parts or all of a psychiatric report and formulating an opinion about a legal question would help residents appreciate the importance of communicating clearly in medical records and other documents. The process of formulating sound ethical opinions to a reasonable degree of medical certainty can be an interesting educational activity for CAP residents.
Testifying in court can be intimidating to an inexperienced resident; as such, it is important to desensitize CAP residents to challenges associated with proffering testimony in court. When possible, CAP residents could observe a supervisor testifying. In some states, CAP residents may be permitted to testify in court with a forensic or clinical supervisor present. The resident could receive constructive guidance regarding courtroom decorum, effective communication of medical information to legal professionals, responding to subpoenas, how law influences clinical practice, objectivity versus advocacy, stress-management, and related topics. Supervised courtroom experiences afford residents invaluable opportunities to prepare for, analyze, and learn about courtroom testimony and preparation before they attend court as practicing child psychiatrists. Some jurisdictions do not permit CAP residents to testify in court. Alternatives include using videotaped testimony to stimulate discussion about courtroom proceedings, including the roles of fact and expert witnesses. Mock trials may be conducted with supervisors, with local attorneys, or through collaborative programs with law school court clinics. For example, a law-school professor may organize a mock trial for his or her students, with a CAP resident serving as an expert witness. The mock hearing, and the remarks that follow, may provide invaluable educational opportunities for residents (and law students).
CAP residents could be introduced to socio-cultural concerns, including community and domestic violence issues, during their training. Residents who take trauma histories, draft reports, and initiate treatment of affected youth begin to understand how violence affects the phenomenology and course of mental disorders in children and adolescents, and how it affects their physical health, their families, and their domiciles. Residents would have knowledge of the statutory requirements for charges of child abuse and neglect, including how cases are generally processed.
The skill-set that a CAP resident, under clinical supervision, brings to the policy-development process is substantial. Policymakers may seek developmental and clinical perspectives regarding institutional or community-based rehabilitative care of youths, including: safety, pharmacotherapy, behavior-management, care plans, and parental involvement (9). A resident who makes clinically-informed contributions to youth-care protocols and policies may affect the rehabilitation of countless children and their families, while informing the actions of professionals that are responsible for the well-being of young people.
Residents who are interested in learning more about forensic CAP may consider working in a setting that fosters an appreciation of legally-informed child-psychiatric care. There may be opportunities for residents to audit law school courses, such as juvenile law or family law (10). Residents may also be able to arrange elective rotations in forensic settings, including juvenile-justice facilities, adoption clinics, clinics that specialize in treating traumatized youth, victims' advocacy programs, etc. These interdisciplinary experiences help residents appreciate how legislation informs agency policy-development and affects minors and their caretakers. Residents who are interested in a career in forensic CAP may apply to forensic-psychiatry residency programs. Although these programs tend to emphasize forensic issues in general psychiatry, a few forensic-psychiatry training programs allow forensic residents to carve out time to train in venues that address child-and-adolescent forensic issues. Many forensic child psychiatrists have obtained certification credentials in either CAP, forensic psychiatry, or both.
Forensic education for CAP residents is a required component of CAP residency training that may be challenging for training directors to implement. The intention of this article is to stimulate creative development of meaningful education experiences that introduce residents to an exciting and rapidly-evolving field of study.