Lifelong Learning for Professional Development in Psychiatry: Pedagogy, Innovations, and Maintenance of Certification.

The American Board of Medical Specialties, which includes the American Board of Psychiatry and Neurology, promotes standards focusing on changes in physicians' medical knowledge and skills. The authors describe the literature concerning the effectiveness of lifelong learning. They review the status of the American Board of Psychiatry and Neurology Maintenance of Certification program as an example of a model of lifelong learning, including an innovative pilot. The final sections include a discussion of new innovations to consider in continuing professional development and a reflection about the state of lifelong learning within the context of maintenance of certification in psychiatry.

Preparing Trainees for Integrated Care: Triple Board and the Postpediatric Portal Program.

Training combining the disciplines of pediatrics, psychiatry, and child and adolescent psychiatry dates back to World War II, but formal combined programs began more than 3 decades ago as the Triple Board Program and 10 years ago as the Postpediatric Portal Program (PPPP). Triple board training was rigorously examined as a pilot program and ongoing surveys suggest that it provides successful training of physicians who can pass the required board examinations and contribute to clinical, academic, and administrative/advocacy endeavors. As evidence grows showing the value of integrated care, physicians with combined training will offer a unique perspective for developing systems.

Comparing and Contrasting the Use of Problem-Based Learning in Child and Adolescent Psychiatry Programs.

OBJECTIVE: Problem-based learning (PBL) is one of the core components of medical education. To facilitate the spread and use of PBL in child and adolescent psychiatry (CAP) fellowship training, a special interest study group (SISG) was formed at the American Academy of Child and Adolescent Psychiatry (AACAP). Different approaches to the implementation of PBL between programs represented at the SISG are compared in this report. METHODS: The authors distributed a survey to SISG participants after the 2015 annual AACAP meeting, which gathered information about the different approaches programs use to implement PBL in graduate medical education. RESULTS: Six CAP training programs responded to the survey, providing descriptions of the structure and content of PBL seminars. Programs chose to include a wide variety of topics in PBL courses and approach course organization in a number of ways. To the degree that PBL draws from identified reference texts, programs were similar in selecting definitive textbooks, practice parameters, and seminal articles. CONCLUSIONS: This small pilot study is intended to provide a snapshot of the state of PBL implementation in CAP fellowship programs. It reflects that programs can incorporate PBL in a variety of ways, tailored to the needs of the institution. Future directions of research include assessment of resident satisfaction with PBL, impact on resident education, and identifying successful methods of implementation of PBL.

Practical Applications for Maintenance of Certification Products in Child and Adolescent Residency Training.

OBJECTIVE: The authors evaluated whether Maintenance of Certification (MOC) Performance-in-Practice products in training increases trainee knowledge of MOC processes and is viewed by trainees as a useful activity. METHODS: Six child and adolescent psychiatry fellowships used MOC products in continuity clinics to assess their usefulness as training tools. Two surveys assessed initial knowledge of MOC and usefulness of the activity. RESULTS: Forty-one fellows completed the initial survey. A majority of first-year fellows indicated lack of awareness of MOC in contrast to a majority of second-year fellows who indicated some awareness. Thirty-five fellows completed the second survey. A majority of first- and second-year fellows found the activity easy to execute and would change something about their practice as a result. CONCLUSIONS: Using MOC products in training appears to be a useful activity that may assist training programs in teaching the principles of self- and peer-learning.

US Medical Licensing Exam scores and performance on the Psychiatry Resident In-Training Examination.

OBJECTIVE: This study explores relationships between US Medical Licensing Examination (USMLE) and Psychiatry Resident In-Training Examination (PRITE) scores over a 10-year period at a university-affiliated program. METHODS: For all MD general psychiatry residents who matriculated from 2003 to 2012 (n = 51), we extracted three-digit first-attempt and passing USMLE Step 1 and Step 2 clinical knowledge (CK) scores and PRITE percentile scores, stratified by global psychiatry and neurology scores, for postgraduate year (PGY)-1, 2, 3, and 4. A mixed model repeated measures analysis was performed to assess the association between USMLE and PRITE scores, adjusting for age, sex, and US medical graduate versus IMG status. Multiple linear regression models of USMLE and PGY-1 PRITE scores were also constructed. RESULTS: USMLE Steps 1 and 2 CK scores were significant predictors of PRITE psychiatry and neurology scores, both in PGY-1 as well as across all years of training (p < 0.01 for each). CONCLUSION: Given that PRITE scores are a significant predictor of success on the ABPN written examination, USMLE scores may be an important quantitative predictor of performance during residency.

Relationship between performance on child and adolescent psychiatry in-training and certification examinations.

BACKGROUND: Studies across a range of specialties have consistently yielded positive associations between performance on in-training examinations and board certification examinations, supporting the use of the in-training examination as a valuable formative feedback tool for residents and residency programs. That association to date, however, has not been tested in child and adolescent psychiatry residents. OBJECTIVE: This is the first study to explore the relationship between performance on the American College of Psychiatrists' Child Psychiatry Resident In-Training Examination (CHILD PRITE) and subsequent performance on the American Board of Psychiatry and Neurology's (ABPN) subspecialty multiple-choice examination (Part I) in child and adolescent psychiatry (CAP). METHODS: Pearson correlation coefficients were used to examine the relationship between performance on the CHILD PRITE and the CAP Part I examination for 342 fellows. RESULTS: Second-year CAP fellows performed significantly better on the CHILD PRITE than did the first-year fellows. The correlation between the CHILD PRITE total score and the CAP Part I examination total score was .41 (P  =  .01) for first-year CAP fellows; it was .52 (P  =  .01) for second-year CAP fellows. CONCLUSIONS: The significant correlations between scores on the 2 tests show they assess the same achievement domain. This supports the use of the CHILD PRITE as a valid measure of medical knowledge and formative feedback tool in child and adolescent psychiatry.

Improving child and adolescent psychiatry education for medical students: an inter-organizational collaborative action plan.

OBJECTIVE: A new Child and Adolescent Psychiatry in Medical Education (CAPME) Task Force, sponsored by the Association for Directors of Medical Student Education in Psychiatry (ADMSEP), has created an inter-organizational partnership between child and adolescent psychiatry (CAP) educators and medical student educators in psychiatry. This paper outlines the task force design and strategic plan to address the long-standing dearth of CAP training for medical students. METHOD: The CAPME ADMSEP Task Force, formed in 2010, identified common challenges to teaching CAP among ADMSEP's CAPME Task Force members, utilizing focus-group discussions and a needs-assessment survey. The Task Force was organized into five major sections, with inter-organizational action plans to address identified areas of need, such as portable modules and development of benchmark CAP competencies. RESULTS/CONCLUSION: The authors predict that all new physicians, regardless of specialty, will be better trained in CAP. Increased exposure may also improve recruitment into this underserved area.

Clinical skills verification in general psychiatry: recommendations of the ABPN Task Force on Rater Training.

OBJECTIVE: The American Board of Psychiatry and Neurology (ABPN) announced in 2007 that general psychiatry training programs must conduct clinical skills verification (CSV), consisting of observed clinical interviews and case presentations during residency, as one requirement to establish graduates' eligibility to sit for the written certification examination. To facilitate implementation of these requirements, the ABPN convened a task force to prepare training materials for faculty and programs to guide them in the CSV process. This article reviews the specific requirements for the CSV experience within general residency programs, and briefly describes the recommendations of the task force for faculty training and program implementation. METHODS: Materials prepared by the ABPN Task Force include background information on the intent of the observed interview, a literature review on assessment methods, aids to train faculty in direct observation of clinical work, directions for effective feedback, notes regarding special issues for cross-cultural trainees, clarification of performance standards, and recommendations for structuring and conducting the assessments. RESULTS: Recommendations of the task force include the use of a variety of clinical settings for CSV assessments, flexibility in the duration of CSV interviews, use of formative and summative feedback after each CSV assessment, and frequent use of the CSV across all years of training. Formal faculty training is recommended to help establish performance parameters, increase interrater reliability, and improve the quality of feedback. CONCLUSIONS: The implementation of the CSV process provides psychiatry training programs with an excellent opportunity to assess how interviewing skills are taught and evaluated. In the process, psychiatry educators have an opportunity to establish performance parameters that will guide the training of residents in patient interaction and evaluation.

Directing child and adolescent psychiatry training for residents.

Directing child and adolescent psychiatry (CAP) training for residents is a complex and challenging administrative task that encompasses the broad creativity of the orchestral conductor, the social and interpersonal effectiveness of the best politician, and the orientation to details of the finest accountant. This article examines these roles in detail, recognizing the leadership, administrative, and managerial achievements of the successful child and adolescent program director. Resources for optimizing the chances for success in each of these areas, and the common pitfalls to avoid, are identified and discussed. The article concludes with suggestions for CAP training directors to influence medical student education. Although challenging and sometimes frustrating, the role of the program director in CAP training is almost always exciting and rewarding.

Relationship between Resident-In-Training Examination in psychiatry and subsequent certification examination performances.

OBJECTIVE: This study analyzed the relationship between performance on The American College of Psychiatrists' Psychiatry Resident-In-Training Examination (PRITE) and the ABPN Part 1 examination. METHODS: Pearson correlation coefficients were used to examine the relationship between performance on the 2002 PRITE and the 2003 Part 1 examination for 297 examinees. RESULTS: The correlation between the PRITE global psychiatry and the Part 1 psychiatry scores was 0.59, and the correlation between the PRITE global neurology and the Part 1 neurology scores was 0.39. CONCLUSION: Although the PRITE and the Part 1 examination have different purposes and are developed independently, the significant correlations between scores on the two tests support the use of PRITE results to guide preparation for the Part 1 examination. Guidelines for PRITE scores associated with poor performance on the Part 1 examination are provided.

Social support from family and friends as a buffer of low spousal support among mothers of critically ill children: A multilevel modeling approach.

OBJECTIVE: To investigate whether social support from family and friends (family/friend support) attenuated ("buffered") adverse effects of having low spouse support (spousal support) among mothers of children undergoing hematopoietic stem cell transplantation (HSCT). DESIGN: One hundred sixty-three married mothers who were their child's primary caregiver during treatment completed assessments during the child's hospitalization for HSCT and 3-, 6-, and 12-months post-HSCT. MEASURES: Family/friend support and spousal support were assessed during hospitalization. Maternal physical and mental health-related functioning (the main outcome measures) were assessed at all timepoints. RESULTS: Multilevel modeling was used to analyze trajectories of maternal functioning. Findings indicated that mothers with low spousal support and low family/friend support demonstrated the worst functioning across all timepoints. Mothers with low spousal support and high family/friend support demonstrated significantly better functioning, supporting the hypothesized buffering effect. Their functioning compared to the functioning of mothers with high spousal support. Moreover, mothers with high family/friend support demonstrated trajectories of physical health-related functioning that were more stable than the trajectories of mothers with low family/friend support. CONCLUSION: These findings have clinical implications in addition to advancing knowledge of social support processes among couples coping with the shared stressor of a child's life-threatening illness and treatment.

Models of integrated training in psychiatry and child and adolescent psychiatry.

OBJECTIVE: Previous studies indicate declining interest in child and adolescent psychiatry (CAP) as a career choice during psychiatry residency training. Programs have developed integrated training in psychiatry and CAP as a means to address the workforce shortage in CAP, but little is known about the number or nature of these training tracks. METHODS: A survey was conducted among all program directors of Accreditation Council for Graduate Medical Education (ACGME) accredited CAP residency training programs in the United States. Those reporting integrated training with their affiliated psychiatry training programs were contacted for in-depth interview. Integrated research programs were not included in this survey. RESULTS: Of the 115 ACGME accredited CAP programs at the time of the survey, 93 responded and 33 of those indicated having some form of integrated training in psychiatry and CAP. Only seven programs identified residents in integrated training in the first year of residency. CONCLUSION: There is no consensus regarding a definition of integrated psychiatry and CAP training. Even though integrated training may provide opportunities for recruitment and retention of child and adolescent psychiatrists, few programs currently offer fully integrated training. This article describes several potential models for integrated training tracks, identifying factors to consider when developing such pathways.

Blinded, multi-center validation of EEG and rating scales in identifying ADHD within a clinical sample.

Previous validation studies of attention deficit/hyperactivity disorder (ADHD) assessment by rating scales or EEG have provided Class-IV evidence per standards of the American Academy of Neurology. To investigate clinical applications, we collected Class-I evidence, namely from a blinded, prospective, multi-center study of a representative clinical sample categorized with a clinical standard. Participating males (101) and females (58) aged 6 to 18 had presented to one of four psychiatric and pediatric clinics because of the suspected presence of attention and behavior problems. DSM-IV diagnosis was performed by clinicians assisted with a semi-structured clinical interview. EEG (theta/beta ratio) and ratings scales (Conners Rating Scales-Revised and ADHD Rating Scales-IV) were collected separately in a blinded protocol. ADHD prevalence in the clinical sample was 61%, whereas the remainder had other childhood/adolescent disorders or no diagnosis. Comorbidities were observed in 66% of ADHD patients and included mood, anxiety, disruptive, and learning disorders at rates similar to previous findings. EEG identified ADHD with 87% sensitivity and 94% specificity. Rating scales provided sensitivity of 38-79% and specificity of 13-61%. While parent or teacher identification of ADHD by rating scales was reduced in accuracy when applied to a diverse clinical sample, theta/beta ratio changes remained consistent with the clinician's ADHD diagnosis. Because theta/beta ratio changes do not identify comorbidities or alternative diagnoses, the results do not support the use of EEG as a stand-alone diagnostic and should be limited to the interpretation that EEG may complement a clinical evaluation for ADHD.

The role of the child and adolescent psychiatrist on health care institutional ethics committees.

Over the past 30 years, institutional ethics committees have become the standard vehicle for addressing ethical issues in health care institutions. Early in this development, general psychiatrists became integrally involved; however, child and adolescent psychiatry roles on institutional ethics committees have been delineated less clearly. This article provides an overview of the functioning of institutional ethics committees, including composition and a definition of the roles across education, policy development, and case consultation. Within the context of the various roles of the institutional ethics committee, the potential contributions of a child and adolescent psychiatrist are defined and specific areas of expertise are delineated. Case examples are cited to demonstrate the unique contributions in the areas of developmental understanding, enhanced understanding of communication styles and failures, as well as an understanding of specific psychiatric factors and cultural issues that a child and adolescent psychiatrist may bring to the institutional ethics committee.

Pre-bereavement meaning and post-bereavement distress in mothers of children who underwent haematopoietic stem cell transplantation.

OBJECTIVES: The purpose of this study was to explore the association of meaning-making with psychological adjustment to bereavement among mothers of children who had undergone haematopoietic stem cell transplantation (HSCT). DESIGN: A prospective research design was used. Regression analyses were conducted to determine the relations between pre-bereavement variables (distress, searching for meaning, and finding meaning) and distress post-bereavement. METHODS: Thirty-five mothers of children who had undergone HSCT were interviewed at the time of their child's HSCT and 3 months post-bereavement. RESULTS: Mothers who reported searching for meaning at HSCT reported greater post-bereavement distress, and mothers who reported finding meaning at HSCT reported less post-bereavement distress. Distress at HSCT and the number of days between the time of death and the post-bereavement time point were also found to be significant predictors of post-bereavement distress. CONCLUSIONS: This study provides partial support for the role of meaning in adjustment to loss.

A practical approach to implementing the core competencies in a child and adolescent psychiatry residency program.

OBJECTIVE: The authors describe the development and implementation of the Accreditation Council for Graduate Medical Education's core competencies in a child and adolescent psychiatry residency program. METHOD: The authors identify the program's organizational approach and participants and detail various strategies and methods of defining, describing, and utilizing the core competencies, with an emphasis on using practical, easily employed techniques within existing systems and structures. RESULTS: Using this approach to developing and implementing the core competencies was effective and accepted well by the participants. CONCLUSIONS: Existing program structures and systems can be used successfully to develop and implement the core competencies in a residency program.

Optimism and life events as predictors of fear appraisals in mothers of children undergoing hematopoietic stem cell transplantation.

Although mothers' fear appraisals about their child's future health and well-being affect their own psychological adjustment to their child's hematopoietic stem cell transplantation (HSCT), little is known about antecedents of maternal fear appraisals. This longitudinal study investigated several potential antecedents of these fear appraisals: maternal optimism, recent negative life events, lifetime history of traumatic events, and medical characteristics of the child's disease and HSCT course. One hundred-forty mothers were interviewed during their child's hospitalization for HSCT and at 3-and 6-months post-HSCT. Structural equation modeling was used to test a model of hypothesized relations. Consistent with predictions, lower optimism and a greater number of negative life events were independently associated with greater maternal fear appraisals. Contrary to expectations, lifetime history of trauma was not associated with maternal fear appraisals. Mothers' fear appraisals during their child's hospitalization were, in turn, associated with their fear appraisals up to 6 months later. These data identify a subset of mothers who may be particularly in need of an intervention to increase optimistic coping strategies, improve coping with negative life events, and reduce fear appraisals to improve their adjustment following their child's HSCT.

Overview of training in the twenty-first century.

This article provides a summary of the history of the development of the subspecialty of child and adolescent psychiatry and the concomitant development of training in the field. The historical perspective provides a context for the discussion of an overview of child and adolescent psychiatry training in the twenty-first century. Four challenges are identified: recruitment, funding, curriculum, and assessment and remediation, each of which is discussed in some depth. The article concludes with a perspective that focuses efforts in training more on basic core competencies rather than the rapidly expanding and changing medical knowledge and specific clinical interventions relevant to the field.