Patient-centered care is identified by the Institute of Medicine as a key area for improvement in healthcare delivery (1). In child psychiatry, the concept of family-driven care is an approach that recognizes the partnership among patients, providers, and families; the primary decision-making role of the family; and family involvement in the broader caregiving system, including the development of related public policy (2).

In psychiatry, training in patient-centered care skills has focused on the individual relationship with the provider, such as the patient–provider interview (3) and the provision of cultural competency (4). Other key skills required of a child and adolescent psychiatrist include approaching patient-centered care/family-driven care from a systems-based perspective that involves addressing the needs of patients and families within a system-of-care, collaborating with other medical or child-serving system professionals, coordinating care across service systems, and affecting policy while including families.

To help promote the use of patient-centered care/family-driven care with a systems-based perspective, the American Academy of Child and Adolescent Psychiatry Work Group on Community-Based Systems of Care proposed the development of a toolkit for residency training. In 2006, an American Academy of Child and Adolescent Psychiatry Abramson Fund grant was awarded to the Work Group to develop the Toolkit, to pilot test the Toolkit in child and adolescent psychiatry residency programs, and to develop both educational competency outcomes and a training director/trainer network.

The Training Toolkit for Systems-Based Practice in Child and Adolescent Psychiatry was developed by use of an iterative process involving the members of the American Academy of Child and Adolescent Psychiatry Work Group, expert clinicians, family and youth served by the systems, and potential end-users of the Toolkit. End-users were identified as child and adolescent psychiatry residents, attending physician trainers, and residency training directors. Work Group members identified the topic areas, then wrote and revised modules with comments from multiple reviewers.

The Training Toolkit is organized into 13 modules of two types: Process and System modules (see Table 1). Process modules discuss important processes the child and adolescent psychiatrist should understand and consider in systems-based practice. System modules discuss the basic elements of individual child-serving systems, and the potential roles for the child and adolescent psychiatrist working with and in these systems. Each module contains learning objectives, core information in handout form, and case vignettes. The objectives for each module are categorized on the basis of the Psychiatry Residency Review Committee systems-based, practice-specific competencies. Each module has case vignettes for group discussion and a specific evaluation vignette to assess individual resident’s competency.

Fifteen child and adolescent psychiatry residency programs in the United States volunteered to participate in the pilot phase of the Toolkit implementation for the 2007–08 academic year. The pilot programs were recruited through Work Group members, the American Academy of Child and Adolescent Psychiatry training director listserve, and the 2007 annual meeting of the American Association of Directors of Psychiatry Residency Training. Each program agreed to use four process modules (systems-based practice overview; family-driven, youth-guided care; consultation; and cultural considerations in systems-based practice) and then chose specific system modules of interest. Programs were encouraged to adapt the use of the toolkit to their specific program needs. Residents completed evaluation vignettes for each module used, and focus groups were conducted with residents to provide input regarding the Toolkit content, the educational process used, and general feedback. A training director network was established, with periodic updates, scheduled meetings at the American Academy of Child and Adolescent Psychiatry annual meeting, and collection of general feedback.

Feedback was solicited from training directors and residents participating in the pilot study. The training directors emphasized that being able to implement the Toolkit in a flexible way was beneficial and practical for their individual programs. Program issues to consider include the resident classes involved, timing the use in the academic year, number and length of sessions, seminar leaders, specific presenters, and teaching methods. Participating resident classes varied, with smaller programs including both resident classes, whereas larger programs included only their second-year residents. Training directors from many small programs noted that having residents with different experience levels was helpful for the learning process. The timing in the academic year varied from a year-long weekly seminar to a multi-session seminar during a concentrated time period. Programs were able to complete the 13 modules in 1 year with use of a weekly conference, although the majority of programs completed 5 to 6 modules in the pilot year. Most programs had a seminar leader assigned, and a few programs identified interested child and adolescent psychiatry residents as the leader. Specific presenters for individual modules included attending faculty and/or child and adolescent psychiatry residents. Many programs also included families, youth, and/or system representatives during the module discussions. Teaching methods varied according to program needs. Most often, this involved a combination of self-study and didactic review of the modules, with promotion of group discussion. Residents were encouraged to identify salient points, consider the information in terms of their experiences, and discuss the case vignettes.

Faculty and residents were pleased with the quality of the module contents and the attention to specific roles for child and adolescent psychiatrists. They found the modules easy to use and discuss. The case vignettes were described as a useful educational tool to promote discussion of family-driven care and important system issues. Moreover, residents indicated that the use of the Toolkit helped focus their efforts on family-driven, youth-guided care, including helping to guide the family in their interactions with the various systems. The inclusion of specific roles for the child and adolescent psychiatrist also encouraged residents to think more broadly. Residents in the focus groups noted this was the only opportunity to learn about systems-based practice in an organized fashion in their programs and that using the Toolkit while reflecting on their clinical experiences led to better integration of the material, with a more holistic perspective. Likewise, faculty were pleased to have a tangible, practical resource to address issues related to systems-based practice, with additional benefit coming from the related focus on patient-centered care and family-driven care.

Residents and faculty noted that additional training experiences for residents helped augment the learning process. Many programs included families, youth, and/or system representatives during specific module discussions. For example, three programs described including parents and/or youth in the training regarding family-driven, youth-guided care, providing residents with the opportunity to interact with parents and youth as teachers who can inform the residents of “best practices” and “worst practices” from the perspective of the consumers. This was noted by residents and faculty as a unique learning opportunity for residents to speak with youth and parents in a different way. Some programs included field trips to child-service agencies to meet experts and learn more about the systems firsthand. Also, many of the pilot programs have system-based rotations wherein the residents spend time in a specific child-service agency, with the education and community mental health systems the most common. Other types of systems-based rotations included juvenile justice settings (detention, training schools), child welfare settings (residential facilities), primary-care settings (general pediatric clinics), developmental disabilities settings (developmental evaluation centers, allied health clinics, day treatment), substance abuse treatment services settings (residential facilities, day treatment, intensive outpatient services), and early-childhood services settings (early intervention, day treatment).

The resident focus groups recommended that modules be introduced early in residency training in order to maximize the educational potential for the resident. Suggestions for Toolkit improvement included having different levels of complexity in case vignettes and developing written guides for the resident and training director/trainers that include a section addressing frequently-asked questions.

On the basis of results from the pilot study and focus groups, the Work Group members completed revisions of the modules and vignettes. Guides for the residents and training directors were developed as suggested. The revised Toolkit and pilot study results were presented in October 2009 to the American Academy of Child and Adolescent Psychiatry Council, which offered positive feedback and approved the Toolkit for posting on the American Academy of Child and Adolescent Psychiatry website as an educational product (5).

There are additional American Academy of Child and Adolescent Psychiatry online products that can complement the use of the Toolkit. For example, resources about general systems of care and specific systems are available. In particular, there is a series of webinars presented by a senior child and adolescent psychiatrist with expertise in specific child-service systems. In these webinars, the child and adolescent psychiatrist discusses his or her role within the system, offers personal stories of how he/she became involved in the system, and identifies career opportunities for early- and midcareer child and adolescent psychiatrists (6–8). There are currently three webinars available to view on the American Academy of Child and Adolescent Psychiatry website, with more in development. Other products are currently being developed that involve youth as collaborators that could also help promote patient-centered care.

The Training Toolkit for Systems-Based Practice in Child and Adolescent Psychiatry was developed to address an existing training gap regarding patient-centered care/family-driven care and systems-based practice. The Toolkit emphasizes the importance of collaboration with the youth and family, as well as systems coordination. There is a particular focus on roles of child and adolescent psychiatrists in various child-service systems, and on opportunities to empower youth and families. Use of the Toolkit has been well received by residents and training directors and shows promise in improving knowledge of patient-centered care.