Postgraduate medical programs in general psychiatry are required by the American Council for Graduate Medical Education to provide education for trainees in ethics, socioeconomics, and the law (1). Reflecting this expectation, gradually increasing attention has been paid to instruction in ethics (2,3) and forensic psychiatry (4,5) by training programs during the past two decades. Relevant contributions to the literature on education in ethics include Michels and Kelly's (6) discussions of varied teaching approaches and curricular content for medical students and psychiatry residents, and Coverdale et al.'s (7) survey of general psychiatry training directors and chief residents, which attempted to determine pertinent subject matter (e.g., psychiatrist—patient sexual contact and confidentiality) for a residency ethics curriculum. In 1996, Academic Psychiatry devoted its entire fall issue to the education of psychiatric residents in ethics, discussing such facets as supervision, problem-based learning, and cost containment (8).
In a similar vein, Dietz (9), Ciccone (10), and Hassenfeld and Grumet (11) have outlined forensic issues to which general psychiatry residents ought to receive exposure, as they describe the interface between psychiatric practice and civil law, criminal law, and legal procedure. Furthermore, Marroco et al. (12) recently published the results of a survey of residencies in the United States and Canada that establishes current approaches to the teaching of forensic psychiatry in general psychiatry programs. Specific foci of their study included descriptions of key didactic topics, the professional backgrounds of the educators, and the settings used for forensic psychiatry rotations.
Child and adolescent psychiatric work draws, in part, on approaches and conceptualizations resembling those used in general psychiatry. However, the exact nature of child and adolescent psychiatric work demands knowledge of ethics (13) and forensic psychiatry (14) pertinent to the subspecialty's practice. Accordingly, the accreditation requirements for the training programs mandate education in these areas. Previous writings have indicated directions that the instruction might take. For example, Sondheimer and Martucci (15) propose the discussion of pertinent ethical dilemmas, in the context of case-centered child and adolescent psychiatry seminars, to convey approaches to ethical analyses that prove useful for subsequent clinical interventions. Similarly, Cohen et al. (16) describe the participation of residents in courtroom experiences to permit trainees to obtain firsthand knowledge of the intricacies of legal procedures involving domestic relations. In an effort to describe the nature of current education in ethics and forensic psychiatry provided by child and adolescent psychiatry training programs, I describe the responses to a national survey obtained from their training directors.
An initial questionnaire on the teaching of ethics was compiled in 1990 by two training directors in child and adolescent psychiatry. The items included in the instrument were derived from a review of prior literature; no prior survey was located. This questionnaire was piloted at an American Association of Directors of Psychiatric Residency Training (AADPRT) "Teaching of Ethics" workshop and completed by the training directors in attendance. Subsequently, the questionnaire was reviewed by the 1991 executive committee of AADPRT's Child and Adolescent Psychiatry Caucus. The committee suggested the enlargement of the questionnaire to encompass as well the teaching of forensic psychiatry in child and adolescent psychiatry training programs and the demographic characteristics of these programs. Items for the forensic psychiatry segment were again derived from a review of prior pertinent literature, and findings from limited national surveys were incorporated into the instrument. Following the review and final approval of this revised questionnaire by the AADPRT executive committee as well as by the chairman of the American Academy of Child and Adolescent Psychiatry (AACAP) ethics committee, the 1992 AADPRT Child and Adolescent Psychiatry Caucus survey was mailed to the training directors of the 120 accredited member programs located in the United States. Following the initial mailing in 1992, nonrespondents received two subsequent mailings, resulting in the final receipt of responses in 1994. The collected surveys were forwarded either directly to the author (AS) or to the AADPRT central office and ultimately to the author.
The instrument and study design assured participant confidentiality, though not anonymity. The study was reviewed by the Institutional Review Board for research involving human subjects by the author's institution and was found to be exempt.
The questionnaire contained 91 closed-ended items thought at the time to cover adequately a broad range of pertinent inquiry. The survey was designed to obtain information about each program's didactic coverage of specific subject matter, the nature of clinical experiences offered, the professional disciplines of the instructors, the time devoted to instruction, the presence or absence of evaluation mechanisms, and demographic characteristics of the responding training programs.
Data entry and analysis, using the Statistical Package for the Social Sciences (17), were conducted at the New York State Psychiatric Institute. Response frequency information was obtained. The demographic variable responses of program size; geographic location; and the program's self-perception about the nature and degree of academic, ethics, and forensic psychiatry emphases were compared with the number of actual hours provided in ethics and forensic psychiatry instruction. Comparisons among three groups were followed up by comparisons between two groups by using the Yates-corrected chi-square statistic (χ2), at the 5% significance level. Data from differing but neighboring geographic areas were pooled when the number of programs were too few to analyze separately.
Responses were received from 94 of the 120 programs to which questionnaires were sent, for a response rate of 78%. Eighty-seven percent (n=82) of the 94 programs reported formal instruction for trainees in ethics, with 98% (n=92) reporting formal instruction in forensic psychiatry. Seventy percent (n=57) of 82 programs reported offering formal instruction in ethics and forensic psychiatry at separate, discrete times.
T1 describes the programs' size, as measured by trainee numbers per program (small: 0—5, medium: 6—8, large: 9—15), regional locations, and self-assessments as programs with differing degrees of clinical, research, ethical, and forensic psychiatry emphases. The majority of the responding programs are of medium size (54%, n=51), are located in the Northeast and Midwest (62%, n=59), and assess themselves as conveying strong clinical (72%, n=66) and strong forensic psychiatry (54%, n=47) emphases. A minority of the programs assessed themselves as conveying a strong emphasis on ethics (33%, n=28) and as balancing clinical and research emphases (28%, n=26).
T2 compares the training programs' self-assessments of offering excessive, adequate, or inadequate amounts of instruction in ethics with the actual number of hours provided, and pairs these assessments with the demographic variables included in T1. Sixty-one percent (n=51) of 84 programs felt that they devoted an adequate amount of time to instruction in ethics; none (0%) felt the amount of time excessive. But 39% (n=33) thought the amount of time was inadequate. Of note, the difference in the number of hours (mean ± standard deviation [SD]) devoted to instruction in ethics between the programs' self-perceptions as adequate (12.5 ± 7.6) or inadequate (9.4 ± 17.6) number of hours is nonsignificant. The programs perceiving themselves as having a strong emphasis on instruction in ethics (n=26) were significantly (P<0.05) more likely to regard themselves as giving an adequate number of hours to ethics instruction than those self-perceiving as having a minor emphasis (n=52). Significance (P<0.05) is also achieved suggesting that the majority of the medium-size programs (n=34, 72%) perceived that they provide an adequate number of hours, whereas half of the small (n=13, 50%) and a majority of the large (n=7, 64%) programs felt that they provided an inadequate amount of ethics instruction. A nonsignificant trend (P<0.08) suggests that the combined Southern and Southwestern programs view themselves as providing an adequate number of hours. Regarding self-perceived adequacy of time provision, no significant difference was noted between the programs self-described as having clinical vs. balanced clinical and research emphases.
Sixty-four percent (n=54) of 84 programs provide 2—6 hours of formal lecture/seminar instruction in ethics during the academic year (5 hours median), 27% (n=23) present 7—20 hours, and 9% (n=7) offer 0—1 hour. Seventy percent of the responding programs (n=57; N=82) devoted 2—10 hours per year (median 4 hours) to clinical conference time focusing specifically on ethical issues. The 33 programs that assessed themselves as providing inadequate time for instruction in ethics thought 12.5 ± 8.2 hours would provide adequate time to cover the material.
T3 illustrates, in descending order of frequency, the topics and methods of formal instruction in ethics that were reported by 91 programs. Other than the conference settings, lecture/discussion is the educational method used.
Responses further indicate that 89% (n=81) of the programs use child and adolescent psychiatrists as the primary ethics educators. Multidisciplinary team presentations are next at 31% (n=28). Other participants include lawyers: 23% (n=21), general psychiatrists: 21% (n=19), other mental health professionals: 21% (n=19), and ethicists/philosophers: 19% (n=17). Ten percent (n=9) of the programs use pediatricians, and 4% (n=4) use a chaplain/theologian. By contrast, of the 88 responding programs, 94% (n=83) would prefer ideally to use child and adolescent psychiatrists as their primary ethics educators, 84% (n=74) want to use an ethicist/philosopher, 72% (n=63) would choose a nonspecified multidisciplinary team, and 52% (n=46) a lawyer. Other mental health professionals, chaplains/theologians, pediatricians, and/or general psychiatrists ranked at preferences of 40% or below.
Of 92 responding programs, 54% (n=50) reported a primary reliance on individual supervision for the discussion of ethical issues, in contrast to a formal curriculum and group settings. Of 93 responding programs, 31% (n=29) said systematic mechanisms were in place to evaluate trainees' ethical knowledge, skills, and attitudes.
T4 shows the same program self-assessment pairings as in T2, this time with regard to instruction in forensic psychiatry. Eighty-three percent (n=74) of 89 programs felt the amount of time they devoted to forensic psychiatry instruction was adequate, and 17% (n=15) thought the time inadequate. A significant difference (P<0.01) is apparent between those programs (n=74) that perceived that they provided an adequate number of hours of instruction (21.4 ± 17.5) vs. those that thought they provided an inadequate number of hours (n=15, 6.7 ± 3.4 hrs). The programs that perceived themselves as having a strong forensic psychiatry emphasis significantly (P<0.01) assessed themselves as providing an adequate number of hours of instruction compared with the programs that assessed themselves as conveying a minor emphasis. The relationships between self-perceived adequacy of forensic psychiatry instruction and the variables of program size, geographic region, and self-assessment regarding distribution of clinical and research emphases were nonsignificant.
The programs, on average, provide 8 hours of formal lectures and/or reading seminars and 4 hours of clinical conference time focusing specifically on forensic psychiatry issues, per academic year. The 15 programs that assessed themselves as providing inadequate time for instruction in forensic psychiatry thought 12.3 ± 6.5 hours would provide adequate time to cover that material.
T5 illustrates, in descending order of frequency, the topics and methods of formal instruction in forensic psychiatry reported by 91 responding programs. Furthermore, 92% (n=84) of these programs report that forensic psychiatry subjects are taught primarily by a child and adolescent psychiatrist, and 58% (n=53) report the collaboration of a lawyer in this instruction. Other mental health professionals are used by 35% (n=32) of the programs and general psychiatrists by 23% (n=21). Of 88 responding programs, 96% (n=84) thought that the teaching of forensic psychiatry ideally should be provided by a child and adolescent psychiatrist, with 91% (n=80) preferring that the teaching be performed by a lawyer as well. A nonspecified multidisciplinary team was suggested by 66% (n=57); other mental health professionals were preferred by 43% (n=37); and one-quarter or fewer of the responding programs recommend ethicists/philosophers (25%, n=22), general psychiatrists (22%, n=19), pediatricians (21%, n=18), or chaplains/theologians (12%, n=10).
In contrast to individual supervision, 66% (n=61) of 92 programs rely primarily on the formal curriculum and group settings for their discussion of forensic psychiatry matters. Thirty-seven percent (n=34) of 91 programs report having systematic mechanisms in place to evaluate trainees' forensic psychiatry knowledge, skills, and attitudes.
Almost four-fifths of the child and adolescent psychiatry training programs operating during the years 1992—1994 responded to the questionnaire. Of the 91 items in the questionnaire, an average of 5 or fewer of the responding programs did not reply to most of the individual items. Thus, the findings can legitimately be considered representative of a significant majority of the training programs operating during this time period.
It is reassuring to learn that 87% of the responding programs provide formal instruction in ethics, and 98% in forensic psychiatry. The fact that so many institutions positively endorsed these items stands in contrast to earlier writings (7,18) that decried the lack of emphasis on these subjects during the prior decade. Furthermore, the majority of the responding institutions provide training in ethics and forensic psychiatry at separate and discrete times, indicating that these programs realize the importance of teaching both topics and that they realize that the subject matters are separate and discrete—though often related—and that each subject requires extensive and independent time commitment rather than loosely overlapping presentations.
Since the number of variables measured are many and some of the cell sizes small, it is not statistically sound to collapse the variables of program size, geographic location, and program self-assessments in an attempt to produce a description of the modal program responding to the survey. By using the means of the responses for the individual variables, however, a composite emerges of the modal responding training program as one of medium size (6—8 trainees), located in the Northeast or Midwest, assessing itself as possessing a strong clinical orientation, having a strong emphasis on instruction in forensic psychiatry, and having a minor emphasis on ethics instruction.
It is fascinating to note that a minority of the programs self-perceived as having a strong emphasis on ethics, which largely tended to consider themselves as providing an adequate number of hours of ethics instruction, in fact did not differ significantly in the number of hours provided from the majority of the programs self-assessed as having a minor emphasis on ethics and providing an inadequate number of hours. Why these programs assess themselves differently, despite providing similar hourly amounts of instruction, is not clear. In addition, the medium-size programs and the combined Southern and Southwestern programs tended to view the number of hours they provided as adequate, compared with the programs of other sizes and locations, though the basis for this self-perception is also unclear.
Eighty percent or more of the responding programs cover ethical issues related to advocacy, consent, conflicting rights, agentry, excessive familiarity, and practitioner's responsibilities and also present representative cases for the purpose of focusing on ethical issues. About two-thirds of the programs discuss ethical concerns about payment sources, disseminate AACAP's Code of Ethics to the trainees, and review the relationship of ethics to forensic psychiatry as well as ethical considerations in child-centered research. Furthermore, a majority of the programs describe the ethical reasoning process and discuss, as well as disseminate, the AACAP Code of Ethics. One-third or fewer of the programs conduct case conferences focusing on ethical issues. This distribution appears to indicate the relative importance to the responding programs of these topics and educational approaches. The fact that these varied issues are addressed by the overwhelming majority of the programs suggests the importance training programs as a group ascribe to education in ethical matters.
The law is a systematic, written set of regulations that derives much of its codifications from previously considered ethical concerns (19). Some programs promote that understanding more comprehensively than others. Thus, while only a minority of programs provide a discussion of the history of ethics, fully two-thirds describe the relationship between ethics and forensic psychiatry. Moreover, three-fifths of the programs report discussing ethical systems and the ethical reasoning process. This is an impressive number, as that body of knowledge and the process are largely theoretical, though the material serves to provide the underpinnings for resolutions of clinical ethical dilemmas. By contrast, as noted earlier, one-third or fewer programs feel the need, or have the capacity, for instruction in ethics via case conferences devoted specifically to that topic. Rather, most programs (80%) attempt to portray clinical ethical dilemmas via the use of representative case vignettes.
The vast majority of the programs reported that a child and adolescent psychiatrist is the primary educator for ethical issues related to the subspecialty, with less than one-third reporting the additional presence of a professional from another discipline. Interestingly, a large number of the programs (84%) ideally would have an ethicist/philosopher participate in these discussions. This discrepancy in numbers suggests the possibility that access to these professionals is not easily achieved by many programs, but that these professionals' potential presence remains desirable. Possibly, the self-perception of some programs as inadequate in ethics instruction may stem from their lack of nonmental health professional (NMHP) expertise, but such a statistical comparison was not performed. This speculation on the absence of NMHP expertise is further fueled by the finding that the majority of the programs reported that their instruction in ethics relied on individual child psychiatric supervision, in contrast to education via a formal curriculum.
The programs perceiving themselves as offering an adequate number of hours of forensic psychiatry instruction in fact provide three times the number of hours provided by the programs self-assessing as inadequate. Similarly, the programs self-assessing as having a strong forensic psychiatry emphasis accurately perceive themselves as providing a significantly greater number of hours of forensics psychiatry instruction than the programs with a self-perceived weak forensic psychiatry emphasis. The number of hours offered was unrelated to program size, geographic location, and the presence or lack of research emphasis.
The fact that the programs generally perceived themselves accurately with regard to provision of hours of forensic psychiatry instruction might be explained in part by the degree of use by the programs of the services of an attorney during instruction, though such a statistical comparison was not performed. The responses do reflect the perception that forensic psychiatry is best taught jointly by representatives of both child and adolescent psychiatry and the legal profession, likely reflecting the complementary expertise that each discipline brings to the subject matter when presented in collaboration. That only a minority of the programs reported using individual supervision as the primary means of instruction in forensic psychiatry matters also suggests that the presence of lawyers enhanced the provision of comprehensive forensic psychiatry education.
Almost all programs report the provision of formal training in forensic psychiatry, three-quarters or more discuss state laws relevant to child and adolescent psychiatric practice and to the juvenile justice system, and two-thirds require trainees to perform forensic psychiatry evaluations and provide them with the opportunity for court attendance. More than half of the programs provide opportunities for psychiatric work at a court-related site. All the forensic psychiatry subjects itemized in the questionnaire were addressed by the vast majority of the programs, with the specific child-related matters of abuse, divorce, civil commitment, delinquency, competence, and guardianship achieving greatest prominence. It appears that these approaches represent training programs' informal consensus of a necessary core of training experiences and knowledge, with participation in mock trials and/or law school seminars deemed a relative luxury, that is, they are approaches used by less than 25% of the programs.
Systematic mechanisms to evaluate the extent of trainees' ethical and forensic psychiatry knowledge are reported by only a minority of programs. The survey did not request descriptions of these mechanisms. It would be useful to identify various pertinent approaches to evaluate trainees' knowledge of both ethical and legal matters, particularly those that would extend beyond the use of a consultation vignette on an oral examination.
The results of this study are limited by a lack of additional data that were not obtained during the course of the survey or subsequent data analysis. While close to 80% of the training programs responded to this survey, both the demographic profiles of the nonresponding programs as well as the nature of their provision of instruction in ethics and forensic psychiatry are unknown. Thus, it is not known if the nonresponding programs' profiles and responses would resemble or differ from the respondent-derived findings. Second, the reasons individual programs did or did not offer specific ethical and forensic psychiatry topics or rotations were not identified. Relatedly, statistical comparisons of self-perceived adequacy of instruction and the use of NMHP expertise were not performed, and the term "multidisciplinary team" was not defined. Thus, while one may speculate about the potential meanings of some findings, it is difficult or impossible to determine the accuracy of these speculations. Finally, while one-third or fewer of the programs reported mechanisms in place to evaluate trainees' assimilation of instruction in ethics and forensic psychiatry, the survey instrument unfortunately did not request descriptions of those mechanisms.
Within these limitations, the survey results give rise to several reasoned speculations. It is possible that the programs self-assessing as inadequate with respect to time devoted to ethics instruction were responding to their difficulties in obtaining the services of professionals with expertise and/or distinct interest in that subject matter. Furthermore, this particular difficulty might hold most true for small programs (i.e., those with fewer available personnel). Medium-size programs might more readily access personnel with relevant knowledge, and large programs might experience their trainees as spread too thinly to provide them simultaneously with adequate instruction. It might also be the case that programs dependent on individual supervision for ethics instruction found that that dependence did not have sufficient impact. In addition, given that many more programs assessed themselves as adequate with respect to provision of time for forensic psychiatry than for ethics education, these findings may reflect the majority of programs' relatively readier access to lawyers and forensically knowledgeable psychiatrists than to individuals with expertise in psychiatric ethics. It is also possible that programs self-assessing their provision of ethics instruction as inadequate may reflect their experience with ethically unsophisticated—or frankly problematic—behaviors of trainees (20,21) or faculty (22).
It is probably reasonable to suppose that the very few programs not offering formal instruction in ethics or forensic psychiatry do so informally, that is, via individual supervision, if only to conform to training program accreditation requirements. Furthermore, two specific foci of ethical concerns not addressed by one-third of the programs also deserve comment. First, one might speculate that the avoidance of the discussion of ethical concerns surrounding sources of payment is a consequence of the discomfort some educators have with the discussion of fiscally related practical considerations, and/or these matters may not, at the time of the survey, have impinged to a great extent upon the program's consciousness. However one might view prior ignorance of fiscal factors by training programs, changing approaches to the funding of mental health care now and for the foreseeable future dictate the necessity for instruction in related ethical matters (23—25). Second, the diminished emphasis on research in some programs might possibly account for the relatively reduced number of programs discussing research-related ethical issues. Nevertheless, disclosure of risks/benefits and other concerns associated with the performance of research involving minors should likewise be discussed, whether or not there exists much in the way of a research emphasis in the program.
Finally, it is noteworthy that while two-thirds of the programs disseminate the AACAP's Code of Ethics, only half (52%) actually discuss details of the code, either as a freestanding document or in the context of case discussion. Perhaps these findings suggest that some programs find discussion of the code to be demanding or tiresome, and others might only be aware subliminally of the code's existence.
Based on the aggregate results, it is clear that a considerable majority of training programs are very cognizant of the need for teaching in the areas in both ethics and forensic psychiatry. They consequently attempt to provide a relevant education, even when individual programs do not view themselves as placing strong emphasis on the subject matter. Furthermore, a consensus suggests topics that appear to represent majority choices for a core curriculum, presented via a combination of formal didactic and conference/seminar-style instruction.
Within the realm of ethics, the issues of advocacy, confidentiality, informed/proxy consent/assent, conflicting rights, agentry, and excessive familiarity seem the most pressing. Practitioner responsibilities and the impacts of compensation source similarly ought to be addressed, despite a less strongly felt need to do so by the respondents. Discussions should use case examples, describe a reasoning process, and use the AACAP principles cited in the Code of Ethics, thus ideally making the latter a living and operational document, rather than a folder simply to be filed and forgotten. Instruction ought to be conveyed by a child and adolescent psychiatrist, with the presence of an ethicist considered a desirable addition. Increased use of the case conference setting, to raise and explore ethical dilemmas, would be advantageous, as the multiplicity of inputs available during this format can most clearly illustrate the relevant application of ethical theory and reasoning to clinical practice.
With respect to forensic psychiatry, the following topics should form a core for instruction in child and adolescent psychiatry: abuse, divorce, commitment, juvenile justice, testimony, competence, and guardianship. Though discussed by slightly fewer programs, the legal aspects of physician obligations and responsibilities certainly deserve review as well. Lectures/discussions of the aforementioned subjects, awareness of pertinent state laws, and participation in court procedure via performance of court-related psychiatric evaluations should provide a basic forensic psychiatry competence for the trainee. Teaching should be provided by the child and adolescent psychiatrist, very preferably in concert with a lawyer conversant with relevant law.
Occasionally, educators question whether instruction in ethics has an impact on trainees' subsequent behavior. While attempts to carefully study this question present many difficulties, several controlled studies do indicate the benefits to school-age and high school students (26) and to medical students (27) of exposure to structured education in ethics, suggesting that a similar impact could occur as well at still higher levels of training. Moreover, Moffic et al. (28) present an example of the measurement of changes in knowledge and attitudes, as determined by written responses to pre- and postseminar questionnaires, following a course in ethics for general psychiatry trainees. Useful related work includes Mitchell et al.'s (29) and Singer et al.'s (30) assessments of clinical ethical competence among, respectively, medical students and residents in internal medicine. The overall degree of the impact of education currently offered in both ethics and forensic psychiatry during child and adolescent psychiatry training, however, remains unclear. The need for a compilation of current approaches to evaluation, the possible creation of new ones, and investigations of their utility would be desirable.
Two other future directions are also suggested by this study's data. While the overwhelming majority of the programs reported that a child and adolescent psychiatrist primarily provides instruction in relevant forensic psychiatry, and a small majority indicate that a lawyer participates as well, the perceived need for the legal presence during instruction in forensic psychiatry is indicated by the very large number of the programs that optimally would have a lawyer participate. A similar number of programs would like to use an ethicist/philosopher for teaching psychiatric ethics, but less than one-third of programs actually do so. These responses indicate that most programs believe the presence of a child and adolescent psychiatrist is imperative for the discussion of both ethical and forensic psychiatry issues. Furthermore, the desire to learn from multiple ethical and forensic psychiatry viewpoints, as could be expressed by representatives of these two professional disciplines, is palpable. This approach should be encouraged, and programs are urged to pursue efforts to identify those individuals with relevant interest and expertise for participation in the education of the trainees.
Second, trainees with combined interests in child and adolescent psychiatry and the law could consider specialty training in both fields. Benedek (18) indicates that the converging nationwide need for more child and adolescent psychiatrists and the needs of juvenile justice systems should act in confluence to spur combined training. In addition, Dietz (31) argues forcefully for narrow, in contrast to general, forensic psychiatry expertise, isolating and identifying forensic child psychiatry as one branch requiring maximum knowledge and experience. While trainees with combined interests should seek to gain advanced residency experience in both areas, programs must continue to educate the vast majority of child and adolescent psychiatry trainees about the basics of relevant ethics and forensic psychiatry, as outlined by the results of this survey.
The author thanks Ian Canino, M.D., and John Sargent, M.D., for collaboration in the creation of the survey instrument and the review of an initial manuscript; Mark Davies, Ph.D., for the supervision of data entry and performance of data analysis; Eugene Beresin, M.D., Martin Drell, M.D., and Mina Dulcan, M.D., for the review of an early survey version; and Ms. Theresa Allely for manuscript preparation and secretarial support.