Child and adolescent psychiatry (CAP) remains among the most underserved specialties in medicine, as highlighted in multiple white-paper and policy statements from the Centers for Disease Control (CDC), the American Psychiatric Association (APA), the World Health Organization (WHO), the American Academy of Pediatrics, the U.S. Surgeon General, and others (1, 2). An entire 2008 issue of Academic Psychiatry was dedicated to strategies to improve CAP pedagogy and recruitment (3).

There remains a frustrating gap between the call-to-action versus implementation. Despite ongoing efforts to address CAP workforce issues (4), the number of applicants remains insufficient. From 2006 to 2011, 35% of CAP programs and 16% of positions were not filled in the Match (5). Partly because of the CAP shortage, most children receive mental health treatment from primary-care providers or general psychiatrists (6). This reality makes it imperative that all medical students receive a foundation in CAP, regardless of specialty choice. Unfortunately, CAP exposure in most medical school curricula is limited (7). Integrating CAP topics into an increasingly packed 4-year medical school curriculum is challenging.

A key overlooked fact is that most psychiatric educators are not themselves child psychiatrists. We propose that this discrepancy is partly responsible for the dearth of CAP representation in the medical school curriculum, and contributes to difficulties with recruitment into the field. New alliances need to be forged to truly address the problem.

In order to effect changes in medical school CAP curricula, collaboration between medical-student educators and CAP educators is needed. However, these two key groups of educators rarely interact at a national level. At the ADMSEP Annual Meeting, CAP presentations have been few in number and sparsely attended. In June 2009, only 14 of 163 ADMSEP members had CAP training. Many psychiatric educators report limited access to local CAP faculty resources.

In a parallel problem, the majority of CAP educators are primarily focused on CAP fellowship or general-psychiatry residency training. CAP training directors convene at the American Academy of Child and Adolescent Psychiatry (AACAP) Annual Meeting and at the American Association of Directors of Psychiatry Residency Training (AADPRT) meeting. Although problems with CAP recruitment are perennially bemoaned in these settings, efforts to improve curricula have remained primarily focused on residency and fellowship.

Another contributing factor is that the priorities of the various organizations are significantly different. ADMSEP’s primary mission is to provide excellent psychiatric education to all medical students, regardless of their future specialty. Since roughly 95% of medical students do not choose psychiatry, educators must ensure that the fundamentals of psychiatry are learned by every future physician. Recruitment into psychiatry is secondary to this goal (8). Therefore, medical-student educators in psychiatry actively resist the tendency of their Chairs to gauge success by the percentage of the graduating class selecting psychiatry. Instead, they rightly emphasize the primacy of providing excellent general psychiatric education to 100% of medical students (9). In contrast, both AACAP and AADPRT expend significant energy on recruitment and workforce issues. Job performance of general and CAP training directors is in part judged by their ability to recruit excellent candidates.

In our opinion, these organizational factors, combined with the shortage of academic child psychiatrists, have conspired to create obstacles to improving CAP education for medical students. The educators who are passionate about medical student education as their primary mission are usually general psychiatrists, whereas the CAP education experts are usually focused on postgraduate training. Given the limited opportunities for interaction and collaboration for these educators, it is not surprising that CAP offerings in the average medical school curriculum leave significant room for improvement.

If this formulation is correct, then the solution is to increase collaboration between CAP educators and medical-student educators in psychiatry. Full inter-organizational collaboration should lead to significant improvements in CAP education for medical students.

In 2010, the ADMSEP Task Force on Child and Adolescent Psychiatry in Medical Education (CAPME) was created. Importantly, participants included both CAP and non-CAP psychiatric educators. In order to identify areas of need and potential solutions, the group conducted an ADMSEP meeting brainstorming session, an ADMSEP listserve electronic survey, and focus groups with medical educators. Overall, many participants noted that they had limited resources for teaching CAP. The majority of participants were interested in seeing benchmark competencies in CAP developed for medical students. The competencies suggested were wide-ranging and often very basic, such as recognizing when a child needs further mental health assessment, knowing how to obtain a CAP history, knowing the criteria for major CAP disorders (including attention-deficit hyperactivity disorder [ADHD] and autism) and familiarity with medications for common disorders such as ADHD. Requested resources included mixed-media portable teaching modules, on-line self-study resources, problem-based or team-based learning cases, small-group activities, and lectures. Requested curriculum areas included human development, psychopathology, mental status exams, child and adolescent assessment, neuroscience, and defense mechanisms.

We developed a strategic plan to address identified areas of need. The ADMSEP CAPME Task Force was organized into five sections, each comprising ADMSEP members and CAP educators. Section leaders without CAP training were partnered with CAP educators as co-leaders. Educators from multiple organizations (ADMSEP, AACAP, AADPRT, AAP, PsychSIGN, and APA) volunteered to contribute as section members. Administrative support is provided by both ADMSEP and AACAP.

Task Force Chair: Geraldine Fox, ADMSEP-AACAP Liaison

• Section 1: Benchmark CAP Learning Objectives: Saundra Stock, Sandra Sexson

• Section 2: Regional CAP Curriculum Consultants: Rita Horton, Dorothy Stubbe, Margaret Stuber

• Section 3: CAP Portable Multimedia Modules: Howard Liu

• Section 4: On-Line CAP Resources for Educators: Jeffrey Hunt, Gregory Briscoe

• Section 5: CAP Opportunities for Medical Students: Steven Schlozman, Anita Chu, Myo Myint, Marika Wrzosek

Administrative Coordinators: Gary Beck, Ashley Partner Rutter

A national task force requiring full collaboration between educators who may never meet each other poses unique logistical challenges (and many conference calls). The primary CAPME Task Force meeting occurs at the ADMSEP meeting. The CAPME Task Force action plan is a Standing Agenda Item at the AACAP Training and Education Committee, as well as the Program Directors’ Luncheon at the AACAP Annual Meeting. Seven section leaders are AADPRT members. At the AADPRT CAP Caucus, a major agenda item is to actively involve CAP educators in the CAPME action plan. Also, CAPME Task Force members who are attending AAP, PsychSIGN, and APA meetings may arrange to meet there, as well. This higher visibility may be one reason that the number of medical students joining AACAP has more than doubled in the past year. AACAP now has 562 medical student members (in 2012), as compared with 206 in 2011.

The five CAPME Task Force sections’ objectives and action plans are detailed below:

Section 1: Benchmark CAP learning objectives

Section 1 members reviewed NBME and USMLE content areas, the AAMC clinical skills curricula (10), existing ADMSEP end-of-clerkship competencies, and competencies for medical students from other disciplines. A consensus list of benchmark competencies, with potential assessment measures, was outlined for all students to achieve by the end of medical school. This was endorsed by the CAPME Task Force, the AACAP Training and Education Committee, and the ADMSEP Council and was sent to the Alliance for Clinical Education for review.

Section 2: Regional CAP Curriculum Consultants

This section offers individualized CAP curriculum consultation and mentoring to the nation’s 135 medical schools. A coordinator has been designated for each of the four AAMC regions. A regional CAP consultant is available to offer individualized support, to help each ADMSEP member utilize the resources compiled by the CAPME Task Force. The consultant is available to help problem-solve local challenges to implementing CAP benchmarks in the undergraduate curriculum. This will be an iterative process, with local concerns brought back for discussion by the Task Force.

Section 3: CAP Portable Multimedia Modules

This section is integrated with ADMSEP’s Clinical Simulation Initiative (CSI) Task Force. CSI is designing portable web modules to illustrate core psychiatric disorders across all diagnostic categories. The first CAP web module prototype, “Adolescent Depression,” can be viewed at http://www.unmc.edu/bhecn/221.htm. This module was designed by the Section 3 leader with an inter-professional team, embedding video clips, voiceover narration, teaching animations, and self-learning quizzes into an interactive webinar. Currently, CSI is gathering data from psychiatry clerkships across several medical schools to analyze the module’s effectiveness. Future goals will be to develop at least one module in each of the following CAP diagnostic categories: eating disorders, attention-deficit/hyperactivity disorder, pervasive developmental disorders, and pediatric anxiety disorders. The CSI Task Force is recruiting programmers and forming an editorial board to develop a peer-review process for modules.

Section 4: On-Line CAP Resources for Educators

Medical-student educators in psychiatry expressed concern that available resources for CAP education on the web were scattered and not easily accessed. However, many disparate groups within AACAP, AADPRT, and AAP have educational products that may be of interest to medical-student educators. Section 4 leadership is coordinating with the AADPRT Model Curricula Project, various AACAP Committees, and others, to organize current resources. We determined that the most effective means of dissemination to medical-student educators in psychiatry was to host these resources on the AACAP website. Many of materials are downloadable so that educators can easily adapt them for teaching. Organization webmasters will collaborate to ensure that available CAP resources are easily located through members-only links on the ADMSEP, AACAP, and AADPRT websites. Although not searchable by the general public, the link will also be made available to non-member educators by e-mailing Ms. Rutter or Dr. Fox.

Section 5: CAP Opportunities for Medical Students

Fundamentally, medical students learn best through personal experiences with an involved mentor. This section’s objective is to increase medical students’ exposure to CAP through direct interactions and connections at the ground level. Active collaboration with PsychSIGN will publicize suggestions for CAP speakers or activities and information about CAP opportunities (e.g., AACAP medical student fellowships, and mentoring programs). This section also plans to raise awareness of CAP for students interested in other fields by working with medical student organizations such as AMSA, AAMC, and SAMSA.

Since psychiatric services for children are often delivered via primary-care providers, CAP education must be an essential part of the medical school curriculum. Furthermore, basic skills, such as interviewing an adolescent, are endorsed by the AAMC Clinical Skills curricula. Therefore, all components of the CAPME Task Force share the goal of medical students’ learning core CAP competencies as part of basic medical education.

Given the limited interaction between CAP educators and medical-student educators in psychiatry, the ADMSEP CAPME Task Force may provide the strategic key to bridging the gap and forging new alliances to create productive educational outcomes.

The process of recruiting volunteers for the Task Force sections has recently put medical student education on the agenda for discussion in multiple forums. An additional benefit of this increased visibility may be that CAP educators, regardless of whether or not they volunteer for the Task Force, now have medical-student education “on their radar,” and may make it a higher priority at their home institutions. Similarly, medical-student educators now have CAP on their radar, as well. This higher visibility may be one reason that the number of medical students joining AACAP has more than doubled in the past year.

The authors are optimistic that full inter-organizational collaboration will lead to significant improvements in CAP education for all medical students. Outcome studies are needed to assess the long-term effect of this endeavor on future physicians’ knowledge, attitudes, and interest in CAP.