The optimal curriculum for teaching child psychiatry to medical students continues to be ill defined. Instruction in child psychiatry has two main purposes: exposing medical students to the discipline of child psychiatry and providing them with learning experiences considered central to the knowledge, skills, and attitudes of the subspecialty (1). Lack of consensus, manpower restrictions, and excessive service commitments contribute to the wide variability among approaches to teaching child psychiatry to medical students across the United States and abroad. In a survey of the 16 Canadian medical schools, MacLeod and Steinhauer (2) comment about the extreme ranges of exposure to clinical child psychiatry and suggest establishing priorities for general principles and for exposure to clinical material.
In order to improve educational efforts Kay (3) suggests underscoring the relevance of child psychiatry to the practice of primary-care medicine and helping the student appreciate the value of the child psychiatrist as a consultant to other physicians, as well as to schools and other community agencies. This observation was made at a time when community-based systems of care for children and adolescents were first being developed.
According to Stroul (4), "A system of care is a comprehensive spectrum of mental health and other necessary services which are organized into a coordinated network to meet the multiple and changing needs of severely emotionally disturbed children and adolescents." These systems of care are becoming the main configuration for child mental health services in many communities. Treatment providers in a system of care help build on the strengths of the child and his/her family and respond to their needs. As this process unfolds, inter-agency coordination and collaboration occurs as the family "partners" with individuals from different agencies to provide services based on CMHS-CASSP (Center for Mental Health Services Child and Adolescent Service System Project) principles (5). A system-of-care approach relies on the biopsychosocial model to conceptualize problems and provide solutions.
With more than 60% of our medical students selecting primary-care residencies, we wanted to find new ways to emphasize the importance of the role of the family in working with children and adolescents, while introducing them to the system-of-care model. Many of our students were placed at a clinical site that was one of the CASSP sites.
At this site, CASSP principles were organized to emphasize four system-of-care concepts felt to be especially relevant to medical students. These concepts included the role of the family in all aspects of evaluation and treatment, the need for the physician to form a partnership with the family to advocate for their needs, the importance of working as a member of a multidisciplinary team, and helping youth receive treatment services in the least restrictive environment. While these systems-of-care concepts were being demonstrated in the clinical setting and during child service agency visits, they were also taught in didactic seminars. This article reports on the efficacy of didactic and experiential exposure in communicating system-of-care attitudes and concepts. The hypothesis was that students experiencing clinical exposure would show a significant change in attitude toward system-of-care concepts as compared with their peers who were only presented didactic material.
The medical students surveyed were third-year students at East Carolina University School of Medicine during the 1997—98 academic year. Students completed pre- and post-clerkship questionnaires regarding system-of-care concepts. During the clerkship, all students participated in a child and adolescent psychiatry seminar series that covered the major areas of child psychopathology. The importance of family involvement and systems-of-care concepts were highlighted. The seminar series used the same curriculum for each cohort of students and was taught by two board-certified child and adolescent psychiatrists, one of whom is an author. The seminar series is a course requirement with attendance mandatory. Absences were infrequent.
During their 8-week psychiatry clerkship, each student participates in two 4-week rotations. They are assigned one inpatient psychiatry rotation (with two possible sites) and one outpatient psychiatry rotation (with four possible sites). Before the clerkship begins, students complete a rotation preference form specifying their first and second choice of rotation sites. The type of practice or educational experience is not described on this form. Then the clerkship director assigns students to the rotation sites on the basis of the students' preferences for geographic location and available slots. The clerkship director had no knowledge of student exposure or interest in system-of-care concepts and had no involvement in this assessment. Therefore, the rotation assignment process was essentially blind and unlikely to be biased.
Each 8-week clerkship group had a student cohort with 12—14 students. Four of these students spent 4 weeks at a community mental health center (for a yearly total of 24 students). One afternoon per week was dedicated to child and adolescent psychiatry evaluations. Students were exposed to faculty who emphasized the importance of including the family in the evaluation process, who helped the family identify their needs, and who used a strengths-based approach to treatment planning (6,7). There were two child and adolescent psychiatry supervisors, one of whom is an author. The two supervisors discussed the modeling of these principles. No other clinical personnel at the sites were aware of the study. Other treatment providers (therapists, case managers) interacted with the students and modeled the concept of interdisciplinary collaboration. An emphasis was placed on the partnership between families of children with severe emotional disturbances and community agency personnel. During this process, students were also taught to gather information from agency representatives (including mental health professionals, teachers, probation officers, social services personnel, and health department workers). An additional day each week was devoted to field trips to different agencies (schools, social services, juvenile justice) that emphasized each agency's unique contributions and helped the student learn to work with different types of professionals.
The other 55 students spent 4 weeks at other outpatient sites (University and community mental health center sites) where they did not receive supervision by child and adolescent psychiatrists and had limited exposure to child and adolescent psychiatric patients. System-of-care principles were not role-modeled at these clinical sites.
The authors designed a brief questionnaire based on a review of the literature about system-of-care concepts (including CASSP principles). Four relevant concepts were identified, and questions were developed to assess the learner's orientation toward these concepts. The four concepts included 1) the physician's role in working with the patient and family; 2)the importance of the family's participation in the process; 3) the importance of interdisciplinary collaboration; and 4) use of the least restrictive treatment setting. Seven fixed-choice items were developed and rated on a 5-point Likert scale (1=Strongly Disagree to 5=Strongly Agree); these are listed in t1.
The questions were asked of two groups of third-year medical students both at the start of their clerkship during the orientation and at the end of their clerkship. One group included the students who would be exposed to the clinical concepts and didactic lectures (Clinical Experience group), whereas the other group included the students who would only be exposed to the didactic lectures (Didactic-Only group). In all, 79 pre- and post-clerkship questionnaires were distributed to the two groups, and 74 were returned, yielding a response rate of 94% for both groups. The non-respondents were all members of the Didactic-Only group.
The questionnaires were scored and provided a total pre- and post-score for each respondent. All questions were scored so that a lower number (score) reflected a greater endorsement of the concept. This necessitated reversing the score for Question 6. To ensure that the groups did not differ at the outset, a ttest for independent samples compared groups on the totaled "pre-" test scores. The concept scores came directly from scores on the questionnaire. The concept score for Physician's Role was the average of the scores from Questions 2 and 7, and the score for Family Participation was the average of the scores from Questions 1, 4, and 6. Interdisciplinary Collaboration was the score from Question 3. Least Restrictive Setting was the score from Question 5. To test the initial hypothesis that students with clinical exposure to a system-of-care curriculum would show a greater endorsement of these concepts, an independent-samples t-test compared the two groups by totaled post-test scores. Another independent-samples t-test compared the two groups by post-test scores for each concept. In order to determine whether the didactic sessions alone may have provided an additive effect to the clinical exposure, a paired-samples t-test on each group compared pre- and post-scores for each concept. All t-tests were two-tailed.
The statistical results for each group are presented in t2. The overall pre-test scores from both groups were virtually identical. This was also true for each individual concept, suggesting that any bias that may exist between groups was not apparent at the outset and that the groups are probably equivalent. On the post-test score analysis comparing the two groups, the Clinical Experience group had significantly lower scores than the Didactic-Only group (t=4.5; P<0.01) indicating a higher rate of endorsement of system-of-care principles. The Physician's Role concept (t=2.7; P<0.01) and the Family Participation concept (t=5.3; P<0.01) were significantly more endorsed by the Clinical Experience group.
However, both groups showed significantly more endorsement of these two concepts when comparing their pre- test to post-test scores (Didactic-Only group: Physician's Role concept t=2.1, P<0.05; Family Participation concept t=2.4, P<0.05; Clinical Experience group: Physician's Role concept t=4.6, P<0.01; Family Participation concept t=8.7, P<0.01). These findings suggests that clinical exposure provided an additive effect to the didactic experience in shaping attitudes toward these concepts. The Least Restrictive Setting and Interdisciplinary Collaboration Concept scores did not differ between groups.
The third-year medical students who were exposed to the system-of-care concepts during their clerkship through didactic seminars, clinical training, and child service agency visits showed a significantly greater change in their attitudes compared with their peers who received only didactic instruction. Many authors have emphasized the need for "hands-on" patient contact in the integration of learning child psychiatry (2,8). Indeed, Kay (8) emphasized in a model curriculum that a significant portion of the curriculum must allow the student to translate the attitudes and knowledge received in didactic courses into the skills of patient care. Incorporating experiential interactive learning into training curricula for child mental health case managers and personnel (9) has shown similar positive results.
The students observed and participated in evaluations and in ongoing patient care as part of learning how to work in partnership with a family. The child-centered, family-oriented approach used at the clinical site was driven by the individual needs of the child while the clinician also understands the impact on the family. This process required a new attitude, which is different from simply "telling the patient what to do." As the clinician validated the child and family as part of the treatment team, the students were given the opportunity to observe collaboration and discuss possible beneficial effects on treatment. An important component of this collaboration process is learning to avoid blaming the families for their child's behavioral problems. Indeed, it has been suggested that the effectiveness of professional interventions on behalf of children, especially the professional's skill in collaborating with parents, is likely to be influenced by the professional's beliefs and attitudes about parents (10). Furthermore, Johnson and Renaud (10) note that changes in attitudes or beliefs might be helpful in facilitating collaborative work with parents. Future studies could consider whether observation of the collaborative process is responsible for the changes in attitude about partnering with families in the treatment process.
In this study, we also addressed the attitude toward the role of the physician in working with the child and family. There is empirical evidence supporting the benefits of medical interviews that focus on patients' needs. This type of interview allows patients to express concerns; it seeks their requests, elicits their explanations, facilitates expression of feelings, and provides information. Moreover, it also involves patients in the development of treatment plans (11). This type of patient-centered care has not always been modeled to medical students. Collins and Collins (12) postulated that the process of socializing professionals-in-training to professional culture has compounded attitude problems by emphasizing professional rather than patient expertise. In an effort to re-emphasize "patient expertise" in this study, the students in the Clinical Experience group were shown how to help identify the strengths and needs of the child and family, while being responsive to cultural, racial, and ethnic differences. This is a common-sense approach to involving the child and parent in the treatment process. Indeed, Donabedian (13) described the significance of such collaboration between patient and physician as an important component of quality of care. Our data suggest that the combined didactic and clinical educational experience may be more likely to help students understand and adopt these approaches. Because there was an additive effect for clinical exposure, further study would be needed to understand the relative contributions of each component.
The importance of the treatment team and the role of various service providers was presented to the students during the clinical rotation. Solid collaborative relationships among service teams and families have been shown to facilitate the ability of the child psychiatrist to participate in the identification of strengths, needs, and solutions (2). Interestingly, the two groups of students did not differ significantly on their endorsement of this concept. Although there was a trend toward greater endorsement of this concept by both groups, the differences did not reach significance. A better understanding of this issue would require more items addressing the Interdisciplinary Collaboration concept as well as knowledge of other exposure that could influence attitude before we draw any conclusions about attitudes toward interdisciplinary collaboration.
Staying in their own communities for evaluation and treatment is a primary concern for many children and their families. A system of care is designed to provide comprehensive, community-based care so that children can receive treatment services in the least restrictive setting possible. There was no significant difference between groups on scores endorsing the Least Restrictive Setting concept. However, both groups showed a trend toward an improved attitude about this concept when comparing pre- to post-test scores. It may be that a better appreciation of this concept requires exposure to crisis situations where children are at imminent risk of alternative placements. This appreciation may require a longer clinical rotation so that students experience more patient clinical crises.
This study represents a pilot assessment of attitudes toward system-of-care concepts in medical students. There were several limitations. The survey had no previous validation as an evaluative instrument. There were only seven questions, and the small sample size did not provide a high level of statistical power to find group differences. It may appear that the students in the Clinical Experience group had more opportunity to adopt positive attitudes toward the concepts, but all of the students were exposed to the classroom sessions where system-of-care concepts were emphasized.
Although not funded by the CMHS project, one of the authors did serve as a clinical supervisor for the study cohort, which may have led to increased zeal in modeling system-of-care concepts. However, that same author also served as a seminar leader for the didactic portion of the course. Any effects of increased zeal in presenting the system-of-care philosophy would have been expected to influence all of the students from the seminar as well as those experiencing the system-of-care modeling. It is therefore unlikely that the systematic differences came from only one group experiencing an enthusiastic presentation of "system of care."
Only the Clinical Experience group had regular exposure to child and adolescent psychiatric patients. It is possible that this exposure alone was sufficient to produce the additional change in attitude. A further study would need to determine whether it is exposure to the system-of-care principles or just exposure to child psychiatry patients that is responsible for the change in attitudes.
This approach to teaching child and adolescent psychiatry to medical students has several implications for psychiatric education. First, it is a practical method to introduce biopsychosocial concepts. In the current era of managed care, it can become easy to reduce the role of the psychiatrist to the realm of psychopharmacology. These students observed a child psychiatrist working well beyond the role of a psychopharmacologist, with a renewed emphasis on also understanding the psychosocial realm and its role in developmental psychopathology. Furthermore, the experience was not limited to the "luxuries" of the academic setting, but occurred in a community setting, with real-life pressures of patient volume and time limitations. Finally, our results suggest relevance for clinical exposure in promoting different attitudes toward patient care.
The authors thank Kevin F. O'Brien, Ph.D., for his statistical consultation and Richard M. Bloch, Ph.D., for his help with manuscript preparation.
This work was supported in part by CMHS grant SM15396-05-3.