Caring for children and families with psychiatric illness is not easy. Our work draws on a dynamic developmental understanding of growth and change; the relevance of biology; the child’s environmental conditions in the hospital, school, and community; risk and resilience factors; our ability to make alliances to participate in a therapeutic process, and to use our experience and best evidence to provide care. Appreciating, studying, and considering these complexities in evaluation and treatment make our efforts as challenging as they are exciting. However, our numbers are small and the needs of society are great. With only about 350 graduates annually, we cannot keep up with the rate of retirement and the clinical need, given the high prevalence of serious emotional problems in children and adolescents. Estimates indicate that 20% of children and adolescents will develop a psychiatric disorder (1). To compound matters, correlates of the mental health needs of children and families include poverty, lack of health insurance, parental psychopathology, academic failure, and parental reports of poor access to mental health services (2).
Some have argued for increasing the number of child and adolescent psychiatrists through new pathways, and though novel approaches are underway, the numbers will continue to be small. Others have argued for sharing the burdens of care with allied health professionals such as pediatricians. And we all feel that the best efforts lie in prevention, early detection, and intervention. Regardless of our approach, the road ahead is daunting if we are to make a real difference in the health of our nation’s youth.
Recruitment of child and adolescent psychiatrists has been and remains a problem (3, 4). The approximately 6,000 child and adolescent psychiatrists are hardly capable of caring for our nation’s children (5). With the aging of our professional population, projections indicate that in the next decade there will be even fewer child and adolescent psychiatrists to meet clinical needs (6). Models for increasing recruitment, such as the triple board program, a 5-year combined general and child and adolescent psychiatric residency, and a new pediatric portal are exciting approaches (7). Yet the reduced funding for Graduate Medical Education, decreased reimbursements from managed care, and the high burden of resident debt all threaten new positions in teaching hospitals and diminish incentives for residents to take on the extra years of training. In our culture, as of 2008, most medical school graduates are burdened by debt and drawn to high salaried and “lifestyle” specialties. Additionally, faculty members have been burdened by increasing demands for service to generate their own salaries, detracting from teaching and research (8). Yet efforts are underway to foster recruitment into child and adolescent psychiatry (9, 10). We also need to consider ways of collaborating with pediatricians, school personnel, and other allied professionals to join the effort to provide early detection and care of kids (11).
Despite the gloomy picture of our clinical shortage and the need for new blood in the field, child and adolescent psychiatry has made a number of impressive strides in promoting basic and clinical research, teaching evidence-based medicine (12), developing new therapeutic methods, and creating educational models. Teaching the art and science of child and adolescent psychiatry is perhaps as difficult as delivering care. If we are to inspire our students, enrich their appreciation for the complexities of youth and families, and above all encourage them to join in our mission, our pedagogical approach must be creative, rigorous, exciting, and outcomes-based. Previous reports have focused on new ways of teaching development to medical students and residents through the use of seminal papers, chapters in textbooks, life stories, field trips, clinical interviews, and using videotapes in child and adolescent education (13–15). Similarly, models have been developed to foster the achievement of competencies in child and adolescent residencies (16, 17). Researchers have studied residents’ views of an ideal training program (18) and graduates’ assessments of training experience as preparation for practice (19).
Academic child and adolescent psychiatrists are clearly under the gun. We have to teach medical students, general psychiatry residents, pediatric house officers, parents, and teachers, among others; provide clinical services; administer educational programs; and conduct research—all with shrinking funds from academic and clinical sources. This is no small task, particularly given our small numbers. In this situation, one would surmise that we are tired, beaten down, and demoralized. Clearly at times we are! However, in my 23rd year as a child and adolescent psychiatry training director, I have never seen as much enthusiasm for our clinical and educational goals. Our work in our medical schools and teaching hospitals, in national organizations, and in collaborative research projects, and our participation in conjunction with accrediting and certification organizations, such as the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Psychiatry and Neurology (ABPN), have been nothing short of exuberant. My observation, shared by countless colleagues, generated the title of this special issue: Innovation and Inspiration in Child and Adolescent Psychiatric Education. One can only speculate on the emotional underpinnings of the excitement in our new efforts. In my view, we are a small community that has had a long tradition of mutual moral, emotional, and intellectual support and a deep devotion to training professionals to care for kids and families. Like the small number of Jedi who survived the self-interest of the Empire, we are a hearty group that loves children and our work. Further, we are boosted by the increased interest in child and adolescent psychiatry among medical students and general psychiatry residents. I think our efforts are paying off. The articles in this issue provide some level of evidence for these observations.
Our authors focus on a broad range of new educational strategies that may improve our pedagogy, recruitment, and practice. The domains, as you will see, move from undergraduate education to medical school and residency training, to helping pediatricians better understand disorders in children and adolescents. The critical issues of mentorship and educational leadership are also considered.
Shatkin and Koplowitz (20) describe the Child and Adolescent Mental Health (CAMS) undergraduate minor at New York University. The authors articulate their effort to broaden undergraduate student education that may later improve recruitment into medical school and child and adolescent psychiatry. This unique project, overcoming considerable barriers, may prove to be a model to help medical schools integrate better with other components of the university and pave the way for interdisciplinary coalitions within our academic institutions.
New methods of medical student education are reviewed with an eye to both better teaching and possible enhancement of recruitment. Malloy et al. (21) present a pilot instrument, the Child and Adolescent Experiences Questionnaire (CAPE-Q), to evaluate clinical experiences in child and adolescent psychiatry and future career interests. The authors use their instrument in a clerkship and seminar experience. Such an evaluative tool may be replicated in other institutions across the country. Educational models require greater measures of efficacy, and this approach contributes to this effort. Hunt et al. (22) consider how different approaches of teachers affect their influence on medical students. They present a study of teacher perspectives that positively influence medical student satisfaction. Finally, Kaplan and Lake (23) surveyed third-year medical students at the Feinberg School of Medicine at Northwestern University in response to the inclusion of a case-based seminar in child and adolescent psychiatry within the general psychiatry clerkship. Their results showed a more positive view of the field and an increased likelihood of considering child and adolescent psychiatry while in medical school. This article substantiates the view that child and adolescent psychiatry, long absent from general clerkship experiences, could be included in ways that promote fundamental learning and interest in the field.
In the context of residency training, Sexson et al. (24) present their survey of integrated training programs as opportunities for recruitment and retention of child and adolescent psychiatrists. Integrated programs may well be vehicles for more creative presentation of our seminal knowledge, skills, and attitudes within our core competencies while blending general and child psychiatry in an appealing, well-crafted, and educationally sound manner. It is well recognized that all of medicine is struggling with efforts to produce physician-researchers. Stubbe et al. (25) describe the Integrated Research Pathway in Child and Adolescent Psychiatry (IRCAP). They describe the programs at Yale and Colorado, which meet ACGME Residency Review Committee criteria for general and child psychiatry while providing a thoughtful and rigorous method for training the next generation of researcher-scientists. The challenges and limitations of replicating these two models are discussed.
Clinical teaching in residencies is described in three articles. Williams et al. (26) compared clinical assessments of children at Stanford and found that the information obtained during an initial evaluation and the number and type of services recommended were no different between attendings and clinicians-in-training. Access to care in specialized units is quite difficult for much of the population. Child and adolescent programs have generally not harnessed modern technology for evaluation and training purposes. Szeftel et al. (27) at Cedars Sinai Medial Center explored the use of their Telepsychiatry Developmental Disability Clinic to enhance supervision and training while providing expert consultation for this population. They found that on-site supervision in their clinic was effective for training both general and child and adolescent psychiatry residents. Josephson (28) reviews the history of teaching family therapy and the scientific foundation for what residents should be taught in order to best care for patients. He suggests a new paradigm that goes beyond former models of family systems therapy and offers a new teaching perspective, “family intervention,” that should replace “family therapy” and could be incorporated into general as well as child and adolescent curricula.
Leadership and mentoring in education must be considered if we are to promote faculty development and nurture future academicians. Three articles in this issue focus on these areas. Academic careers typically begin in residencies but need to be nurtured and enhanced between residency training and early career academic psychiatry. Chief residencies are traditionally designed to be geared toward leadership, administration, and teaching. However, little attention has been paid to teaching how to teach. Ivany et al. (29) describe the position of Academic Chief Fellow and present a method that aids these fellows in developing their academic skills through teaching, guiding, and supervising junior colleagues. The American Academy of Child and Adolescent Psychiatry (AACAP) created the AACAP-Harvard Macy Teaching Scholars Program (HMTSP) to develop the teaching expertise of child and adolescent academic faculty. Hunt et al. (30) present findings of participants after 2 years in the program. It is noteworthy that the graduates considerably increased their teaching and scholarly activity in their local institutions and on the national level. Mentoring has long been recognized as instrumental to the fostering of career interests in clinical, scholarly, and research sectors. However, traditional models are quite time-intensive. Martin et al. (31) present a novel brief mentoring program at two child and adolescent conferences, one national and one international. This intensive 4-day program included daily small group meetings consisting of two mentors and six participants. A quantitative questionnaire administered to participants indicated a broad positive impact for trainees, largely in feelings of connectedness. The beauty of this model is that it could easily be replicated at annual meetings. Further work is needed to see if the effects are lasting on connectedness and career development.
As noted above, child and adolescent psychiatrists increasingly must rely upon and work with other health professionals. In particular, we need a close relationship with pediatricians. The Residency Review Committee guidelines for pediatric residencies require only 2 months of developmental behavioral pediatrics, and few programs teach sufficient child and adolescent psychiatry to meet the needs of practicing pediatricians. In an effort to pilot an educational model and determine the needs of pediatricians, Kutner et al. (32) produced a DVD-based educational program intended to help practicing pediatricians and pediatric house officers recognize and respond to adolescent depression in the context of their busy ambulatory practices. The cohort studying the DVD indicated that it was not only useful but that programs such as this would be a welcome addition in a large number of areas of child and adolescent psychiatry. This type of portable curriculum is easily adoptable by many residency programs that have few child psychiatrists to teach a comprehensive curriculum and might be useful as a postgraduate update for practicing pediatricians.
The reader may now well appreciate how I came to the title of “Innovation and Inspiration” in child and adolescent psychiatry education. The work presented here is quite remarkable and demonstrates how far we can go in our transmission of new knowledge and clinical acumen, all in the context of creative programs that clearly enhance psychiatric education. Most of the articles are data-driven. Though many are pilots, they present models we should all seriously attempt to replicate in our home institutions. These wonderful projects were published to tantalize us—to fuel our enthusiasm for developing sound and tested programs which will captivate our students, residents, and colleagues. Only in this way will we generate increased recruitment in the field, form necessary and productive coalitions among professionals, and ultimately improve the needed services for youth and their families.