Emerging evidence continues to point to an increase in the prevalence of mental health problems among adolescents and young adults (1). Whether this increase is due to better diagnosis, an actual increase in prevalence, or both is unknown, but half of all lifetime cases of mental illness are now recognized to begin by age 14 and three-quarters begin by age 24 (2). Despite effective treatments, however, there are typically long delays—sometimes decades—between when individuals first experience clinically significant symptoms and when they first seek and receive treatment (3).
Mental health practitioners who treat children and adolescents, including social workers, psychologists, educational specialists, and psychiatrists, are in short supply. The United States’ Federal Bureau of Health Professions has named child and adolescent psychiatry as the most underserved of all medical subspecialties. The current workforce consists of approximately 6,300 child and adolescents psychiatrists (4), whereas the need has been estimated to be over 30,000 (5). Child and adolescent psychiatrists are not alone, however, as the national need for child and adolescent social workers, educational specialists, and psychologists is equally as great (1, 6, 7). In addition to the lack of skilled clinicians, there are few professionals in journalism, sociology, public health, law, politics, public policy, medicine, and social welfare who understand the biological, psychological, and social basis of child and adolescent mental health and illness. Without such an orientation, misinformation, stigma, and bias about mental illness will continue to spread unchecked, and children and adolescents with mental illness will have few advocates. An integrated area of study for college undergraduate students that would address this notable lack of knowledge and skills among future leaders would have far reaching impact.
In the summer of 2005, the Dean of the College of Arts and Science at New York University (NYU) initiated a discussion with the second author of this report (HK, the Chairman of the Department of Child and Adolescent Psychiatry at the NYU School of Medicine) in part, at least, because a series of student suicides which tragically occurred during the 2003–2004 academic year had pushed the mental health agenda on campus to the forefront. Both parties realized that a focused area of study in child and adolescent mental health, although not intended to address the suicides directly, would be a useful addition to the university’s academic offerings. The Child and Adolescent Mental Health Studies (CAMS) minor grew out of these discussions.
The NYU Child Study Center (the Department of Child and Adolescent Psychiatry) has a mission to provide community education about the need to identify and treat childhood mental illness and to battle popular stigma against mental illness. The dean of the college supported our mission from the beginning, and in this way we were highly fortunate. Our desire to develop a college minor was greeted with considerably more skepticism by the Curriculum Committee of the College of Arts and Science, however, which must approve all new academic programs and courses. Committee members were understandably concerned about a variety of issues. First, they wondered about the ability of psychiatrists and psychologists, who had spent the majority of their careers in schools of medicine teaching professionals, to teach undergraduates. They worried that our approach to teaching would be more fact- and skill-driven and less one of open inquiry. They imagined that we might spend a great deal of time, for example, teaching students the DSM-IV criteria for child and adolescent mental illness and correspondingly less time on teaching critical thinking skills and adopting a more global perspective on mental illness. Second, the Curriculum Committee was concerned about our ability to physically manage a college minor (e.g., advise students or integrate effectively with other departments), given that the medical school is situated two miles away from the undergraduate campus and that the medical school had few preexisting linkages to the undergraduate campus. Finally, they wondered about our ability to provide a broad variety of course offerings.
In the early phases of project development, the authors requested assistance from the provost’s office in identifying a few members of the Curriculum Committee who might be particularly interested in the development of a child and adolescent mental health area of study. The identification of two such key stakeholders (a vice dean and the chair of the committee) proved invaluable, as these individuals helped to shepherd the minor through the committee. Because the School of Medicine at NYU had never before been directly involved in providing undergraduate education, and given the aforementioned skepticism by at least some members of the committee, this support was paramount.
Much as a private organization would build an advisory board, throughout the winter and early spring of 2006 we built an advisory committee consisting of full-time and volunteer clinical faculty from the NYU Child Study Center, a vice provost, and various professors of sociology, neural science, and psychology at NYU. Although most members were pleased to contribute, numerous individuals were ambivalent. They felt that they would have little to contribute to an academic program emanating from the medical school and/or that the courses we offered might compete with courses from their own departments. This hurdle, however, was relatively easy to overcome, as we emphasized that the undergraduate domain was new to us and that we could very much use their assistance in designing courses in subject areas not currently being taught by their departments and in maintaining integrity within the current offerings by their departments. We were also fortunate in that the department of psychology at NYU is largely oriented toward research and cognitive neuroscience, such that our minor, which is clinical in its focus, was not perceived to be in direct competition for students or resources. To the contrary of what might be expected elsewhere, in fact, the department of psychology was highly receptive to our minor from the start.
In these days of fiscal strain in academia, it was perhaps paradoxical that financing the college minor was one of the easier issues to resolve. When a department teaches an undergraduate course at NYU, a portion of the student’s tuition, a per academic credit amount, is passed onto that department. In the case of the CAMS minor, the College of Arts and Science and the Child Study Center agreed upon a 70% share of the per credit fee going to the Child Study Center, resulting, by current tuition fees, in a $630.00 per credit per student reimbursement to the Child Study Center (Table 1
). This fee is paid to the teaching department as discretionary funding.
As required by all undergraduate teaching departments, a director of undergraduate studies was appointed to provide leadership and administrative oversight in the development and maintenance of the CAMS minor. The first author of this report (JS) was hired by the NYU Child Study Center in December of 2005 as the first Director of Education and Training for the Center and the entire development of the CAMS minor was under his purview as the Director of Undergraduate Studies.
Supreme among our beliefs in the development of the CAMS minor is that the most renowned experts do not always make the best teachers. In fact, as many of us deeply involved with medical education have known for years, teaching requires an entirely different set of skills from those necessary to be a scientific investigator, clinician, or administrator. Consequently, we decided early that courses would be taught by the most qualified instructor or team of instructors available for a given topic, which in some cases would be a successful researcher or clinician in these areas, but sometimes would not. Instructors are invited to teach in the minor based not only on their interest in CAMS, but also their teaching reputations in the Department of Child and Adolescent Psychiatry and the teaching evaluations they have received by child and adolescent psychiatry residents and psychology interns in the past. Undergraduate classes about child mental health must be approached differently from resident education, but we believe that good teachers will adjust their methods appropriately and many steps are taken to ensure that the instructors meet the goals of the program. For example, the Director of Undergraduate Studies spends extensive time sculpting new courses and editing new course syllabi with potential instructors, visiting ongoing courses, providing feedback to instructors, and reviewing course evaluations with instructors. Furthermore, we require our instructors to be proficient at teaching didactics, not simply to be good clinical instructors, which requires a different set of skills (e.g., apprenticeship teaching). We encourage them to pepper classes generously with clinical vignettes and audiovisual clinical examples to make the material come alive.
We have made great efforts to pair instructors whenever possible so as to bring a diverse body of experience and perspective to the course being taught, such that psychologists are paired with psychiatrists and educational specialists are paired with clinicians. We have also begun to hire outside consultants to develop courses in areas in which we require additional expertise, such as incorporating a lawyer to assist in developing a course on divorce and its effects on children and families and a children’s book critic to help develop a course on children’s literature. In all cases, the focus of each course remains on child and adolescent mental health, and each course must adequately address the goals of the CAMS minor. The goals are as follows:
Students will explore the relationship between human behavior and its biological and environmental bases
Students will increase their intellectual curiosity and build analytic and problem-solving skills
Students will be challenged to think critically about the concepts of “normal” or “typical” versus “abnormal” behavior and engage in a meta-level analysis of the social, historical, and cultural context of mental health, illness, and diagnosis
We will encourage those students with a natural interest and inclination toward careers in social work, education and special education, psychology, law, medicine, sociology, nursing, public health, scientific journalism, and psychiatry to consider focusing their future career in some significant capacity on children and adolescents.
The goals of the CAMS minor were established at the outset. In addition to helping students develop analytic and problem-solving skills we want them to contrast “normal” versus pathological behavior, cognition, and emotion and to understand that mental illness is a unique entity which is truly different from mental wellness. The need to concretely address this point was made even more apparent to us during the development of the minor, as some members of the curriculum committee spoke with great skepticism about the validity of childhood mental illnesses such as attention-deficit/hyperactivity disorder. Finally, although we do not necessarily expect that large numbers of undergraduates will decide to become child psychiatrists based on their experience with our courses, we do believe that some eventually will and that we can have a positive and lasting impact on students who later enter a range of other careers such as social work, psychology, nursing, law, public health, journalism, and medicine. Most importantly, we hope that all students will consider the importance of child and adolescent mental health and illness in whatever career they ultimately pursue.
Following the model of other minors within the College of Arts and Science at NYU, we require that five courses or 20 credits be completed to confer the minor degree. At least three of these courses must be from within the CAMS minor, and two can be from other select departments within the College of Arts and Science and/or the Steinhardt School of Culture, Education, and Human Development. A thorough search for relevant courses throughout the university revealed a number which are directly relevant to the CAMS minor (Table 2
). Subsequent discussions with the instructors of each of these courses and a review of each course syllabus, to evaluate for relevance and to check for content duplication, resulted in an agreement to classify these courses as eligible nondepartmental offerings which would contribute to the 20-credit minor requirement. Finally, we require that courses taken for the CAMS minor not be applied to another major or minor without prior approval from the directors of Undergraduate Studies of each department (e.g., no “double-dipping”), as is typically required by other minors within the University.
For our first semester (fall of 2006), we offered an introductory course in Child and Adolescent Psychopathology. This course is the primary prerequisite for the minor upon which all other courses will build. In an effort to expose as many students as possible to the content of the CAMS minor, however, many courses will eventually be open to the general student body and will not require prerequisites. Those requiring prerequisites include: Child and Adolescent Psychopathology, the core course for the minor, which requires students to have taken Introduction to Psychology; Research Methods and Evidence-Based Treatment in Child and Adolescent Mental Health, which requires students to have taken both Introduction to Psychology and Child and Adolescent Psychopathology; and Behavioral Interventions for Children with Disruptive Behavior Disorders: Practicum, which requires students to have taken Introduction to Psychology and Child and Adolescent Psychopathology. Prerequisites for future anticipated courses (Table 3
) will be determined by instructors and the Director of Undergraduate Studies.
As each course must be separately approved by the Curriculum Committee, we anticipate adding two or three courses each year to the CAMS minor. As of this writing, we have had five courses approved by the Curriculum Committee along with a program for Independent Study. Six additional courses are in various stages of development. Although there is no limit to the number of courses we can offer, we plan to ultimately have approximately 12–14 courses from which students can select their three required CAMS courses.
In addition to the usual course catalog and syllabus listings, we have alerted students to the presence of the CAMS minor through a number of other avenues. Along with the College of Arts and Science, we have developed a brochure on the CAMS minor for general distribution. We regularly send fliers to the new student orientation programs and post these fliers on campus bulletin boards. We maintain an e-mail list of all students who inquire about or take our courses, providing regular updates, and we post information on the NYU Child Study Center website, which receives over one million unique visitors annually.
To date, we have taught three courses in the CAMS program and had six additional students complete an independent study. Our first class, Child and Adolescent Psychopathology, enrolled 25 students. Subsequent courses, including Research Methods and Evidence-Based Treatment in Child and Adolescent Mental Health, and Behavioral Interventions for Children with Disruptive Behavior Disorders: Practicum enrolled very few students as they were approved by the Curriculum Committee only weeks before the beginning of the terms. Given the small number of students enrolled in these later courses, totaling only 10 students between the two of them, we have chosen to present only student evaluation data from our first course, Child and Adolescent Psychopathology.
Of the 25 students enrolled in our first course, Child and Adolescent Psychopathology, 24 completed confidential course evaluations. Two evaluations were completed by each student. The first evaluation was of our own creation and was designed to help us improve the course based on student enjoyment and interest in the material. The second evaluation was provided by the university and was designed to assess course objectives, quality of instruction, level of difficulty, grading, and organization. The results of these evaluations are found in Table 4
and Table 5
From our internal evaluation, 22 students reported that they “strongly agree” to recommend this course to others, and 100% of students reported on the university’s evaluation form that they would recommend both the class and the instructor to a friend. Perhaps the feature that students most frequently reported enjoying about the course was its “real life…clinical” relevance. As the course was taught by two practicing clinicians, the students greatly appreciated the inclusion of clinical material, examples, and anecdotes, which resonated with their own life experiences and career interests. On the internal evaluation form, students rated each topic taught on a 10-point scale with 10=“extremely interesting and enjoyable” and 1=“not particularly interesting or enjoyable.” With the exception of two students who rated every topic a “10,” the remaining 22 students showed some individual variability in their scoring, but virtually all students gave high rankings. On the university’s evaluation form, the vast majority of rankings, including overall course rating, clarity of objectives, interest in the material, organization, and grading, fell within the “excellent” or “good” categories.
A number of students volunteered that this course was their favorite to date at NYU. Perhaps the greatest testament to the success of the first course is that over half of the students who enrolled in our second course, Research Methods and Evidence-Based Treatments in Child and Adolescent Mental Health, had taken the first course. Furthermore, an additional six students, five of whom took our first course, have completed an independent study with us to date, and over a dozen students have already signed up to complete the entire CAMS minor. Finally, one student has requested that the first author act as her primary adviser in a self-designed major focusing on child mental health.
The income generated from teaching in the undergraduate programs at NYU is substantial, as noted in Table 1
. Based upon the 25 students who took our first course in fall, we received a total revenue of $63,000. We estimate that as our program grows, we will teach at least 200 students a year in one of our courses. At that minimum, the CAMS minor should generate $504,000 annually in discretionary funding paid directly to the NYU Child Study Center.
The ultimate impact of the CAMS minor is impossible to assess at this time. Based on the students’ response to the first course and initial subsequent offerings, however, the program is clearly popular among a segment of students and addresses a subject area not covered elsewhere in their college curriculum.
We believe that we are currently meeting our first three program goals, which are integral to the concept of the minor and the content of the courses. It will take a number of years to determine if our final goal is met. In the meantime, we intend to periodically follow the students who take our courses and assess whether or not their experience in the CAMS minor influences future undergraduate course choices or decisions about their college major and graduate and professional school. Encouraging students to focus their future careers on children and adolescents is a lofty objective and one that will take years to reach fruition if at all. There is no doubt that the students who take a child and adolescent psychopathology or research methods course are self-selected and likely to have already decided to build a career in this direction, thereby introducing bias into the final program goal. It is precisely because of this concern, in fact, that we have decided to add a number of courses to the CAMS minor that we hope will have popular appeal, such as the courses on divorce, media, literature, and drug abuse (Table 3
). Perhaps somewhat paradoxically, these courses may be the key to exciting future generations about the field of child and adolescent mental health and encouraging them to enter the field.
Statistically, as many as 20% of college-age students have suffered from a diagnosable mental illness at some point in their young lives (1), and we suspect that college students all over the country are thirsty for knowledge about mental illnesses that affect their demographic. The scores in Table 4
may substantiate this suspicion, as we note a clear trend upward in the students’ enjoyment of the course material when it is disease driven. The first few topics covered (e.g., the course introduction, normal child development review, diagnosis and nosology, and neuropsychological testing) were clearly less popular than the later illness specific material. We believe that these later scores, which are each 6%–18% higher than the scores on the first four topics, are not reflective of teaching style or instructor, as both instructors shared the teaching of the entire class and were present at, and contributed to, each class meeting. There are numerous other possible explanations for this trend, however, including the fact that students were required to have previously taken an introduction to psychology course where some of the material (e.g., normal child development and neuropsychological testing) would have been already covered. It may also be that the disease driven topics were more liked because students rarely have an opportunity to learn clinical material in college.
Although we are the first university of which we are aware that has invited an academic department from within the School of Medicine to develop, teach, and administer a college minor, others in psychiatry have clearly considered the idea in at least some form. Braslow et al. (8) recently published an article in which psychiatry residency training directors and academic department chairs were surveyed about their attitudes regarding the utility of teaching college undergraduates in order to improve recruitment into psychiatry and to generate funding. Eighty-two percent of those responding reported that teaching undergraduates might or would lead to increased recruitment, and those few departments that currently offer courses agreed that teaching undergraduates generates revenue. Given the funding challenges facing academic departments, for whom graduate medical education funding for postgraduate year-5 (PGY-5) and above child psychiatry residents is approximately half that of PGY-1–4 residents, revenue from undergraduate courses could be used to offset the financial losses of training programs. The course Advanced Topics in Child and Adolescent Mental Health (Independent Study) offers particular advantages in this regard to both the students and department researchers in that now we are able to recruit research assistants who can receive academic credit in lieu of payment. The balance is entirely shifted by virtue of the students’ tuition payment as the department is now paid to provide the students with an independent research study opportunity.
Braslow et al. (8) also make a number of other good points which substantiate the potential utility of teaching college undergraduates. Citing a study of 93 Chicago area psychologists that found that 46% had contemplated entering psychiatry (9), it is not hard to imagine that more college students would pursue medical school and psychiatry were they to have exposure to psychiatrists early in their education. Instead, fearing the premedical course work and having little contact with and no mentorship from psychiatrists, they may be more likely to choose allied fields such as psychology and social work. Braslow et al. (8) also point out that more than 70,000 bachelor’s degrees are conferred annually in psychology in the United States, suggesting that if even a small minority of these individuals were to consider psychiatry as a career, we could see substantial increases in our ranks.
Some of the most frequent comments in the course evaluations from our first class last fall (Child and Adolescent Psychopathology) were that the instructors were “approachable…interactive” and had a “relaxed way of teaching.” It is precisely this type of exposure to practicing psychiatrists, from whom they enjoy learning, which may influence undergraduates to consider a career in the field. On the contrary, if students are never taught by psychiatrists, their only teaching role models in mental health will be psychologists and social workers. This point is not novel, however, as a 1981 report to the National Institute of Mental Health suggested that if college students interested in mental health were not taught courses by psychiatrists, they will likely enter psychology and related fields (10).
We believe that we have developed a model which should be considered for implementation at other universities with an affiliated school of medicine. The model we have established may not apply directly to other universities, and there may be differences in reimbursement for teaching and in the general receptivity of the undergraduate campus. However, based on our informal review of university curricula nationwide, there are relatively few courses focused on the mental health of children and adolescents, even within departments of psychology, and students are very interested in this information. For example, in the fall of 2007 we had 57 students enrolled in our Child and Adolescent Psychopathology course and 25 enrolled in our new Developmental Theory and Human Motivation course. The CAMS minor represents an opportunity to attract and excite students about our field early in their academic careers. If we do not take advantage of this and similar prospects, we stand little chance of expanding our ranks.