Alcoholism and Substance Abuse Teaching in Child Psychiatry Residency Programs JAMES A. STEG, M.D., LEE S. MANN, M.A., J.D., RICHARD H. SCHWARTZ, M.D., THOMAS N. WISE, M.D., AND GEORGE W. BAILEY, M.D. Abstract.
In orderto determine the needs and goals of substance abuse teaching, vis-a-vis child psychiatry training, a questionnaire was sent to the training directors at every child psychiatry program accredited by the Accreditation Council of Graduate Medical Examination. The results demonstrated that most child psychiatry programs schedule at least some didactic time specifically for substance abuse topics. However, only 59% of the training directors felt that their fellows were adequately educated to identify and at least initially manage a drug abusing adolescent. J. Am. Acad. Child Adolesc. Psychiatry, 1990,29,5:813-816. Key Words: adolescence, alcoholism, child psychiatry, graduate medical education, substance abuse.
Alcoholism and substance abuse are significant public health problems in adolescents. Although the 1987 and 1988 National Institute of Drug Abuse sponsored surveys of high school seniors demonstrate encouraging declines in drug use in many categories, the proportion of seniors reporting having used an illicit drug the prior year remains quite high at 39% (Johnston et al., 1988, 1989). Of equal concern is that substance abuse is spreading to preadolescent populations. Although the Epidemiologic Catchment Area study of specific mental disorders does not report data on children and adolescents, substance abuse disorders were found to be the most common psychiatric illness in adult populations with a 1 month prevalence of 3.8% and a calculated lifetime prevalence of 16.4% (Regier et al., 1988). In spite of the lack of specific data on the relationship between mental disorders and substance abuse, it is known that child and adolescent substance abuse carries with it significant morbidity, Adolescent abusers report twice as many distress experiences and three times as many events involving deviant behaviors as do their nonabusing peers (Brown, 1989). Adult alcoholics with an onset of alcoholism before age 20 have a much higher incidence of violence, depression, and suicide (Buydes-Branchey et al., 1989). Alcohol abuse has been shown to be a significant predictor of suicidal behavior in adolescent psychiatric inpatients (Pfeffer et al., 1988) and is a prominent factor in completed suicides among children and adolescents (Hoberman and Garfinkel, 1988). In the San Diego suicide study, over one-half of young suicides had the principal psychiatric diagnosis of substance abuse (Fowler et al., 1986). Furthermore, adolescent drug AcceptedDecember21,1989. Drs. Steg, Mann, and Wise are with the Department ofPsychiatry and Dr. Schwartz is with the Department ofPediatrics ofthe Fairfax Hospital, Falls Church, Virginia and Georgetown University School ofMedicine, Washington, DC; and Dr. Bailey is with the Children's Hospital National Medical Center, Washington, DC. A version of this paper was presented at the 36th Annual Meeting of the American Academy ofChild and Adolescent Psychiatry, New York, October 11-15,1989. Reprint requests to Dr. Steg, Fairfax Hospital, Department ofPsych iatry, 3300 Gallows Road, Falls Church, VA 22046. 0890-8567/90/2905-0813/$02.00/0© 1990 by the American Academy of Child and Adolescent Psychiatry.
involvement has been found to have a strong influence on subsequent outcome measures of performance in adulthood: employment, marriage, and continued drug involvement (Kandel et al., 1986). There is clearly a need for training child psychiatrists who can identify and treat substance abuse disorders. However, the extent to which child psychiatry fellows receive training in this area has never been assessed. Previous studies of substance abuse and alcoholism teaching in psychiatric residency training programs have focused solely on general adult psychiatry programs. In 1978, Solomon et al. surveyed psychiatric residency programs to determine the extent of training in both alcohol and substance abuse (Solomon et al., 1981). They found that 88% of responding programs reported at least some training in alcoholism and drug abuse. Diaz et al. reported the results of their survey on the extent of alcoholism training in adult psychiatric residency programs (Diaz et al., 1988). They found that 76% of respondents indicated that there was a formal educational module for alcoholism included in the residency training program. Galanter et al. (1989) reported the results of a survey of adult psychiatric residency training in alcoholism and substance abuse. Their results were similar to those of Solomon et al., with 91 % of respondents indicating the program offered a curriculum unit (defined as a formal block of teaching) in alcoholism and drug abuse. In order to determine the needs and goals of substance abuse teaching, vis-a-vis child psychiatry training, this study surveyed the training directors of all the nation's accredited child psychiatry residency training programs concerning the substance abuse curricula offered by their programs. This paper represents the results of that survey. Method A questionnaire was developed by the authors consisting of data elements found in previous studies of adult psychiatry programs. Individuals with expertise in either substance abuse education or specifically adolescent substance abuse also reviewed drafts of the instrument. Their comments were incorporated into the questionnaire; however, reliability and validity tests were not conducted. The questionnaire re813
STEG ET AL. TABLE
1. Composition ofChild Psychiatry Programs Responding to the Survey
Type of Program University hospital , Private for-profit hospital County hospital State hospital Military hospital Other
-
TABLE
%
Fellows/year
SO
Faculty
66.7 6.1 5.1 4.0 3.0 15.2
3.6 4.6 3.5 3.0 3.0 3.2
1.8 4.2 1.3 2.0
Staff psychiatrist or psychologist with specialty interest in drug/alcohol abuse Staff psychiatrist or psychologist without specialty interest in drug/alcohol abuse Child psychiatry fellow Physician who is not a psychiatrist Drug/alcohol abuse professional (nonphysician) Other
1.7
1.3
-
X = 3.7 Fellows/year; X = 2.3 SO.
TABLE
%
63.1 24.3 1.0 1.0
6.8 3.9
2. Composition of Training Sites Usedfor Clinical Exposure to Substance Abuse Problems
Training Site Regular adolescent inpatient unit Adolescent chemical dependency inpatient unit Outpatient chemical dependency program Other Does not apply
%
21.3 15.7 5.6 5.6 51.7
quested information regarding the size and demography of the training program, training sites, faculty composition, didactic and clinical experiences, as well as the extent of training in specific topics. The questionnaire was then sent to the training director of each child psychiatry program accredied by the Accreditation Council of Graduate Medical Education (ACGME) in 1989 (N = 121). A questionnaire was also sent to the child psychiatry resident listed in the American Psychiatric Association's Directory of Psychiatry Residency Training Programs as the fellow representative for the program. Repeat mailings were made to nonrespondents. The findings in this report are the results of the analysis of the data when the training directors' response rate reached 85% (N = 104). The minimum number of child psychiatry residents required for ACGME accreditation is two per year, or a total of four for the 2 year program. If the programs that either had been discontinued or had a total number of two child psychiatry residents or less within the program were excluded, 117 accredited programs remain. This yields a response rate of 89% among the accredited programs. The results of the child psychiatry residents' responses will be reported separately. Results University hospitals constitute the majority of programs surveyed (Table 1). The number of child psychiatry residents per year per program was 3.7 (SD = 2.3). Only 20.2% of the programs reported a required clinical rotation related specifically to chemical dependency. However, 46.1 % indicated that child psychiatry residents have at least some exposure (defined as 1 hour or more) to an adolescent drug/alcohol abuse treatment unit or facility . Only 18.4% of the responding programs required child psychiatry residents to attend an Alcoholics Anonymous (AA) or Narcotics
814
3. Composition ofFaculty Involved in Teaching Alcoholism and Substance Abuse
Anonymous meeting as part of their training. In41.7% of the programs, child psychiatry residents are routinely scheduled to observe group therapy for adolescents in treatment for drug abuse. The most common training site for alcohol and substance abuse is a regular adolescent inpatient unit (21.3%) (Table 2). Only 15.7% of respondents reported a clinical training experience on a dedicated adolescent chemical dependency unit. Eighty-four percent of responding programs reported that 1 or more scheduled didactic hours were specifically allotted to alcohol/drug abuse topics during the residency. In the remaining 16%, no didactic hours were allotted for this purpose. The mean number of didactic hours scheduled for these topics was 8.3 (SD = 13.0). Because there was a very wide range of responses to this item (0 to 144 hours), the median (5.0 hours) may be a more useful figure. The number of reference articles suggested by teaching staff specifically relatedtodrugabusewas7.2(SD = 5.7). In 63.1 % of responding programs, the teaching is done by a staff psychiatrist or psychologist with recognized specialty interest in drug/alcohol abuse problems, and in 24.3% the teaching is done by a staff psychiatrist or psychologist without such specialty interest (Table 3). In 6.8%, teaching is by a nonphysician drug/alcohl abuse professional. Nearly two thirds (64.4%) of the respondents indicated that there was a faculty member at their fellowship training program who had special interest or expertise in drug abuse. Table 4 outlines curriculum topics that training directors reported to be adequately taught in their programs. The topics most frequently considered well taught were: DSM-III-R criteria for drug abuse/dependence (90.2%); specific drugs of abuse mimicking mental disease (79.0%); and intervention with a drug-abusing adolescent (70.3%). The least commonly endorsed topics were: Alcoholics Anonymous and 12-step programs (41.4%); the role of the drug abuse counselor (38.4%); the impaired physician (29.3%); and the Michigan Alcohol Screening Test (MAST) (22%). Only 59.0% of the training directors felt that their child psychiatry residents were adequately educated to identify and at least initially manage a drug-abusing adolescent patient. The residency programs we partitioned into those that gave more instruction versus those that gave less instruction to their residents. (The affirmative responses on Table 4 were added and then a median split was calculated.) The programs l.Am.Acad. Child Adolesc. Psychiatry, 29:5, September 1990
ALCOHOL AND SUBSTANCE ABUSE TEACHING TABLE 4. Percentage ofTraining Directors Indicating Fellows Received Adequate Illstruction in Various Substallce Abuse Topics
Topic
%
DSM-III-R criteria for drug abuse/dependency Specific drugs of abuse mimicking mental disease Intervention with a drug abusing adolescent "Carving" (self-harm) vs. suicide Community resources for teenage drug abuser Pharmacology of specific drugs of abuse AIDS and mental symptoms Stages of progressive chemical dependency Adult children of alcoholics Emergency management of toxic reactions to PCP Management of withdrawal from benzodiazepines Laboratory tests for drugs of abuse : pitfalls in interpretation Alcoholics Anonymous and 12-step programs The role of the drug abuse counselor The impaired physician The Michigan Alcohol Screening Test
70.3 69.3 64.7 61.0 61.6 58.6 57.6 54.0 55.0 45.0 41.4 38.4
Are the fellows adequately educated to identify and initially manage a drug-abusing adolescent patient?
59.0
90.2 79.0
29 .3 22.0
that gave more instruction (with eight or more affirmative responses) had a required clinical rotation related specifically to chemical dependency (X2 = 4.6, I df, p < 0.05) and indicated they had a faculty member with special expertise in drug abuse (X2 = 5.0, 1 df, p < 0.05). These programs required residents to spend at least an hour in an adolescent drug abuse treatment unit (X2 = 4.6, 1 df, p < 0.05), to be involved in actual clinical interventions (X2 = 17.5, 1 df, p < 0.001) , and to observe group therapy for adolescents in treatment for drug abuse (X2 = 3.8, 1 df, p < 0.05) . The programs had more printed reference materials that were related to drug abuse (9.3 6.2 versus 5.0 4.4) (t = 3.2, 66 df, p < 0.01) and believed that their residents were adequately educated to identify and manage a drug abusing adolescent (X2 = 15.1, 1 df, p < 0.001). Discussion Previous studies have demonstrated that adult psychiatry residents receive considerably more teaching in alcoholism and substance abuse (Solomon et aI., 1981; Diaz et aI., 1988; Galanter et aI., 1989) than do residents in family medicine, internal medicine, and pediatrics (Davis et al., 1988). However, there seems to be a lack of emphasis on alcoholism and substance abuse teaching in child psychiatry training programs. In a recent survey, child psychiatry program directors ranked experience with drug dependencies 20th in importance among 26 various training experiences (Schowalter, 1989). The present study reaffirms this lack of emphasis in child psychiatry training. Only one-fifth of responding programs reported having a required clinical rotation specifically related to chemical dependency and less than one-half reported that their trainees have even minimal exposure (at least 1 hour) to an adolescent drug/alcohol abuse treatment unit. Furthermore, only 59% of the training directors felt that their child psychiatry residents were adequately educated to identify and initially manage a drug-abusing adolescent. This is lamentable in view of the fact that child psychiatrists have J. Am . Acad. Child Adolesc. Psychiatry, 29:5 , September 1990
significant clinical exposure to substance abusing youth and are in a unique position to intervene with this population. This study indicates that most programs schedule at least 1 hour of didactic time specifically for substance abuse topics, with a median of 5 hours. Sixteen percent, however, offer none. Most often (60%), a faculty member with recognized specialty interest in substance abuse gives the lectures. These figures indicate, however, that a large proportion of child psychiatry residents may be receiving less than optimal teaching in substance abuse (or in the case of 16%, no teaching). At the same time, the figures highlight the problem of faculty recruitment, in particular, faculty with specialized expertise, which faces child psychiatry training programs today (Beresin and Borus, 1989). Substance abuse topics that were considered adequately covered, such as diagnostic criteria and pharmacological aspects, most often tended to be descriptive in nature. Least widely covered topics, such as use of the MAST orthe 12-step program of AA, tended to be operational aspects of working with substance abusers. This may reflect the lack of direct clinical exposure to substance-abusing populations. Although 84% of responding programs reported having one or more didactic hours devoted to substance abuse topics, clinical exposure is lacking. The findings reported here indicate a lack of comprehensive alcoholism and substance abuse teaching in child psychiatry training programs . The most common explanation for this gap, as noted on the survey instrument by some respondents, was that since substance abuse training was offered in the adult training program, there was no need to repeat it in the child psychiatry program. This is flawed reasoning. First, substance-abusing youth are a unique population with a unique set of psychosocial problems. The appropriateness of using adult diagnostic criteria for substance abuse and adult treatment models for youthful abusers has been questioned (Bailey, 1989). Second, patterns of youthful abuse may differ from those of adults . Third, the developmental stage requires special consideration. Susceptibility to peer group pressures, the capacity for impulse control, the capacity to form a therapeutic alliance , and coping skills are considerably different for the 13-year-old abuser and the 22-year-old abuser. Given the high prevalence and morbidity of substance abuse among adolescents, it is of concern that the extent of child psychiatry training in this disorder does not match the magnitude of the problem. References Bailey, G. W. (1989), Current perspectives on substance abuse in youth. J. Am. Acad. ChildAdo/esc. Psychiatry , 28: 151-162 . Beresin , E. V. & Borus , J. F. (1989), Child psychiatry fellowship training : a eri sis in recruitment and manpower. Am . J . Psychiatry,
146:759-763. Brown , S. A. (1989), Life events of adolescents in relation to personal and parental substance abuse. Am . J. Psychiatry, 146:484-489. Buydes-Branchey, L., Branchey , M . H. & Noumair, D. (1989), Age of alcoholism onset : I. relationship to psychopathology . Arch . Gen Psychiatry , 46:225-230. Davis, A. K. , Coller, F. & Czechowicz , D. (1988), Substance abuse units taught by four specialties in medical schools and residency programs . J. Med. Educ., 63:739-746. Diaz, M. A., Mann, L. S. & Wise, T. N. (1988), Alcoholism curriculum survey of psychiatric residency training programs. Journal ofPsychi atric Education , 5: 107-121.
815
STEG ET AL.
Fowler, R. C. , Rich, C. L. & Young, D. (1986), San Diego suicide study: II. substance abuse in young cases. Arch. Gen. Psychiatry, 43:962965. Galanter, M., Kaufman, E., Taintor, Z. et a!. (1989), The current status of psychiatric education in alcoholism and drug abuse. Am. J. Psychiatry, 146:35-39. Hoberman, H. M. & Garfinkel, B. D. (1988), Completed suicide in children and adolescents. J. Am. Acad. C hildAdolesc .Psychiatry, 27: 689-695. Johnston, L. D., O'Malley, P. M. & Bachman, J. G. (1988),lllicitdrug use, smoking, and drinking byAmerica's high school students, college students, and young adults, 1975-1987. (DHHS Publication No. ADM 89-1602), Washington, DC: U.S. GovermentPrintingOffice. - - - - - - (1989), Drug use, drinking and smoking: national survey results from high school, college, and young adult populations, 1975-1988. (DHHS Publication No. ADM 89-1638), Washington, DC: U.S. Government Printing Office.
Kandel, D. B., Davies, M., Karns, D. eta!' (1986), The consequences in young adulthood of adolescent drug involvement. Arch. Gen. Psychiatry, 27:746-754. Pfeffer, C. R., Newcom, J., Kaplan, G. eta!. (1988), Suicidal behavior in adolescent psychiatry inpatients. J. Am. Acad. Child Adolesc. Psychiatry, 27:357-361. Regier, D. A., Boyd, J. H., Burke, J. D. et a!. (1988), One-month prevalence of mental disorders, in the United States. Arch. Gen. Psychiatry, 45:977-986. Schowalter, J. E. (1989), Child psychiatry program directors' ratings of residency experiences. J. Am. Acad. Child Adolesc. Psychiatry, 28:124-129. Solomon, J., Pokorny, A. & Zimberg, S. (1981), Alcoholism and drug abuse training during psychiatric residency. Journal of Psychiatric Education, 5:108-121.
The Status of Research Child psychiatry in this country evolved out of the direct needs of parents and other adults responsible for children. It developed in community clinics which were called upon to deal with the great number of our antisocial, maladapted, and unhappy children. Although serious clinicians, as, for instance, Healy and Bronner, structured records at the Judge Baker Clinic so that they could be broken down into components that could be statistically handled, most of the clinical material was recorded in a somewhat hit-or-miss fashion which lent itself poorly to research. The statistical data, also, had serious limitations. Scientific study remained incidental to the pressure of social demands. The fact that the only textbook in our field, for years, was written by Leo Kanner, one of the few child psychiatrists who worked in a university-hospital setting, is indicative of the absence of systematic formulation that generally prevailed. JAACP, Vo!. I, No. I January, 1962
816
J. Am. Acad. Child Adolesc. Psychiatry, 29:5, September 1990
In orderto determine the needs and goals of substance abuse teaching, vis-a-vis child psychiatry training, a questionnaire was sent to the training directors at every child psychiatry program accredited by the Accreditation Council of Graduate Medical Examination. The results demonstrated that most child psychiatry programs schedule at least some didactic time specifically for substance abuse topics. However, only 59% of the training directors felt that their fellows were adequately educated to identify and at least initially manage a drug abusing adolescent. J. Am. Acad. Child Adolesc. Psychiatry, 1990,29,5:813-816. Key Words: adolescence, alcoholism, child psychiatry, graduate medical education, substance abuse.
Alcoholism and substance abuse are significant public health problems in adolescents. Although the 1987 and 1988 National Institute of Drug Abuse sponsored surveys of high school seniors demonstrate encouraging declines in drug use in many categories, the proportion of seniors reporting having used an illicit drug the prior year remains quite high at 39% (Johnston et al., 1988, 1989). Of equal concern is that substance abuse is spreading to preadolescent populations. Although the Epidemiologic Catchment Area study of specific mental disorders does not report data on children and adolescents, substance abuse disorders were found to be the most common psychiatric illness in adult populations with a 1 month prevalence of 3.8% and a calculated lifetime prevalence of 16.4% (Regier et al., 1988). In spite of the lack of specific data on the relationship between mental disorders and substance abuse, it is known that child and adolescent substance abuse carries with it significant morbidity, Adolescent abusers report twice as many distress experiences and three times as many events involving deviant behaviors as do their nonabusing peers (Brown, 1989). Adult alcoholics with an onset of alcoholism before age 20 have a much higher incidence of violence, depression, and suicide (Buydes-Branchey et al., 1989). Alcohol abuse has been shown to be a significant predictor of suicidal behavior in adolescent psychiatric inpatients (Pfeffer et al., 1988) and is a prominent factor in completed suicides among children and adolescents (Hoberman and Garfinkel, 1988). In the San Diego suicide study, over one-half of young suicides had the principal psychiatric diagnosis of substance abuse (Fowler et al., 1986). Furthermore, adolescent drug AcceptedDecember21,1989. Drs. Steg, Mann, and Wise are with the Department ofPsychiatry and Dr. Schwartz is with the Department ofPediatrics ofthe Fairfax Hospital, Falls Church, Virginia and Georgetown University School ofMedicine, Washington, DC; and Dr. Bailey is with the Children's Hospital National Medical Center, Washington, DC. A version of this paper was presented at the 36th Annual Meeting of the American Academy ofChild and Adolescent Psychiatry, New York, October 11-15,1989. Reprint requests to Dr. Steg, Fairfax Hospital, Department ofPsych iatry, 3300 Gallows Road, Falls Church, VA 22046. 0890-8567/90/2905-0813/$02.00/0© 1990 by the American Academy of Child and Adolescent Psychiatry.
involvement has been found to have a strong influence on subsequent outcome measures of performance in adulthood: employment, marriage, and continued drug involvement (Kandel et al., 1986). There is clearly a need for training child psychiatrists who can identify and treat substance abuse disorders. However, the extent to which child psychiatry fellows receive training in this area has never been assessed. Previous studies of substance abuse and alcoholism teaching in psychiatric residency training programs have focused solely on general adult psychiatry programs. In 1978, Solomon et al. surveyed psychiatric residency programs to determine the extent of training in both alcohol and substance abuse (Solomon et al., 1981). They found that 88% of responding programs reported at least some training in alcoholism and drug abuse. Diaz et al. reported the results of their survey on the extent of alcoholism training in adult psychiatric residency programs (Diaz et al., 1988). They found that 76% of respondents indicated that there was a formal educational module for alcoholism included in the residency training program. Galanter et al. (1989) reported the results of a survey of adult psychiatric residency training in alcoholism and substance abuse. Their results were similar to those of Solomon et al., with 91 % of respondents indicating the program offered a curriculum unit (defined as a formal block of teaching) in alcoholism and drug abuse. In order to determine the needs and goals of substance abuse teaching, vis-a-vis child psychiatry training, this study surveyed the training directors of all the nation's accredited child psychiatry residency training programs concerning the substance abuse curricula offered by their programs. This paper represents the results of that survey. Method A questionnaire was developed by the authors consisting of data elements found in previous studies of adult psychiatry programs. Individuals with expertise in either substance abuse education or specifically adolescent substance abuse also reviewed drafts of the instrument. Their comments were incorporated into the questionnaire; however, reliability and validity tests were not conducted. The questionnaire re813
STEG ET AL. TABLE
1. Composition ofChild Psychiatry Programs Responding to the Survey
Type of Program University hospital , Private for-profit hospital County hospital State hospital Military hospital Other
-
TABLE
%
Fellows/year
SO
Faculty
66.7 6.1 5.1 4.0 3.0 15.2
3.6 4.6 3.5 3.0 3.0 3.2
1.8 4.2 1.3 2.0
Staff psychiatrist or psychologist with specialty interest in drug/alcohol abuse Staff psychiatrist or psychologist without specialty interest in drug/alcohol abuse Child psychiatry fellow Physician who is not a psychiatrist Drug/alcohol abuse professional (nonphysician) Other
1.7
1.3
-
X = 3.7 Fellows/year; X = 2.3 SO.
TABLE
%
63.1 24.3 1.0 1.0
6.8 3.9
2. Composition of Training Sites Usedfor Clinical Exposure to Substance Abuse Problems
Training Site Regular adolescent inpatient unit Adolescent chemical dependency inpatient unit Outpatient chemical dependency program Other Does not apply
%
21.3 15.7 5.6 5.6 51.7
quested information regarding the size and demography of the training program, training sites, faculty composition, didactic and clinical experiences, as well as the extent of training in specific topics. The questionnaire was then sent to the training director of each child psychiatry program accredied by the Accreditation Council of Graduate Medical Education (ACGME) in 1989 (N = 121). A questionnaire was also sent to the child psychiatry resident listed in the American Psychiatric Association's Directory of Psychiatry Residency Training Programs as the fellow representative for the program. Repeat mailings were made to nonrespondents. The findings in this report are the results of the analysis of the data when the training directors' response rate reached 85% (N = 104). The minimum number of child psychiatry residents required for ACGME accreditation is two per year, or a total of four for the 2 year program. If the programs that either had been discontinued or had a total number of two child psychiatry residents or less within the program were excluded, 117 accredited programs remain. This yields a response rate of 89% among the accredited programs. The results of the child psychiatry residents' responses will be reported separately. Results University hospitals constitute the majority of programs surveyed (Table 1). The number of child psychiatry residents per year per program was 3.7 (SD = 2.3). Only 20.2% of the programs reported a required clinical rotation related specifically to chemical dependency. However, 46.1 % indicated that child psychiatry residents have at least some exposure (defined as 1 hour or more) to an adolescent drug/alcohol abuse treatment unit or facility . Only 18.4% of the responding programs required child psychiatry residents to attend an Alcoholics Anonymous (AA) or Narcotics
814
3. Composition ofFaculty Involved in Teaching Alcoholism and Substance Abuse
Anonymous meeting as part of their training. In41.7% of the programs, child psychiatry residents are routinely scheduled to observe group therapy for adolescents in treatment for drug abuse. The most common training site for alcohol and substance abuse is a regular adolescent inpatient unit (21.3%) (Table 2). Only 15.7% of respondents reported a clinical training experience on a dedicated adolescent chemical dependency unit. Eighty-four percent of responding programs reported that 1 or more scheduled didactic hours were specifically allotted to alcohol/drug abuse topics during the residency. In the remaining 16%, no didactic hours were allotted for this purpose. The mean number of didactic hours scheduled for these topics was 8.3 (SD = 13.0). Because there was a very wide range of responses to this item (0 to 144 hours), the median (5.0 hours) may be a more useful figure. The number of reference articles suggested by teaching staff specifically relatedtodrugabusewas7.2(SD = 5.7). In 63.1 % of responding programs, the teaching is done by a staff psychiatrist or psychologist with recognized specialty interest in drug/alcohol abuse problems, and in 24.3% the teaching is done by a staff psychiatrist or psychologist without such specialty interest (Table 3). In 6.8%, teaching is by a nonphysician drug/alcohl abuse professional. Nearly two thirds (64.4%) of the respondents indicated that there was a faculty member at their fellowship training program who had special interest or expertise in drug abuse. Table 4 outlines curriculum topics that training directors reported to be adequately taught in their programs. The topics most frequently considered well taught were: DSM-III-R criteria for drug abuse/dependence (90.2%); specific drugs of abuse mimicking mental disease (79.0%); and intervention with a drug-abusing adolescent (70.3%). The least commonly endorsed topics were: Alcoholics Anonymous and 12-step programs (41.4%); the role of the drug abuse counselor (38.4%); the impaired physician (29.3%); and the Michigan Alcohol Screening Test (MAST) (22%). Only 59.0% of the training directors felt that their child psychiatry residents were adequately educated to identify and at least initially manage a drug-abusing adolescent patient. The residency programs we partitioned into those that gave more instruction versus those that gave less instruction to their residents. (The affirmative responses on Table 4 were added and then a median split was calculated.) The programs l.Am.Acad. Child Adolesc. Psychiatry, 29:5, September 1990
ALCOHOL AND SUBSTANCE ABUSE TEACHING TABLE 4. Percentage ofTraining Directors Indicating Fellows Received Adequate Illstruction in Various Substallce Abuse Topics
Topic
%
DSM-III-R criteria for drug abuse/dependency Specific drugs of abuse mimicking mental disease Intervention with a drug abusing adolescent "Carving" (self-harm) vs. suicide Community resources for teenage drug abuser Pharmacology of specific drugs of abuse AIDS and mental symptoms Stages of progressive chemical dependency Adult children of alcoholics Emergency management of toxic reactions to PCP Management of withdrawal from benzodiazepines Laboratory tests for drugs of abuse : pitfalls in interpretation Alcoholics Anonymous and 12-step programs The role of the drug abuse counselor The impaired physician The Michigan Alcohol Screening Test
70.3 69.3 64.7 61.0 61.6 58.6 57.6 54.0 55.0 45.0 41.4 38.4
Are the fellows adequately educated to identify and initially manage a drug-abusing adolescent patient?
59.0
90.2 79.0
29 .3 22.0
that gave more instruction (with eight or more affirmative responses) had a required clinical rotation related specifically to chemical dependency (X2 = 4.6, I df, p < 0.05) and indicated they had a faculty member with special expertise in drug abuse (X2 = 5.0, 1 df, p < 0.05). These programs required residents to spend at least an hour in an adolescent drug abuse treatment unit (X2 = 4.6, 1 df, p < 0.05), to be involved in actual clinical interventions (X2 = 17.5, 1 df, p < 0.001) , and to observe group therapy for adolescents in treatment for drug abuse (X2 = 3.8, 1 df, p < 0.05) . The programs had more printed reference materials that were related to drug abuse (9.3 6.2 versus 5.0 4.4) (t = 3.2, 66 df, p < 0.01) and believed that their residents were adequately educated to identify and manage a drug abusing adolescent (X2 = 15.1, 1 df, p < 0.001). Discussion Previous studies have demonstrated that adult psychiatry residents receive considerably more teaching in alcoholism and substance abuse (Solomon et aI., 1981; Diaz et aI., 1988; Galanter et aI., 1989) than do residents in family medicine, internal medicine, and pediatrics (Davis et al., 1988). However, there seems to be a lack of emphasis on alcoholism and substance abuse teaching in child psychiatry training programs. In a recent survey, child psychiatry program directors ranked experience with drug dependencies 20th in importance among 26 various training experiences (Schowalter, 1989). The present study reaffirms this lack of emphasis in child psychiatry training. Only one-fifth of responding programs reported having a required clinical rotation specifically related to chemical dependency and less than one-half reported that their trainees have even minimal exposure (at least 1 hour) to an adolescent drug/alcohol abuse treatment unit. Furthermore, only 59% of the training directors felt that their child psychiatry residents were adequately educated to identify and initially manage a drug-abusing adolescent. This is lamentable in view of the fact that child psychiatrists have J. Am . Acad. Child Adolesc. Psychiatry, 29:5 , September 1990
significant clinical exposure to substance abusing youth and are in a unique position to intervene with this population. This study indicates that most programs schedule at least 1 hour of didactic time specifically for substance abuse topics, with a median of 5 hours. Sixteen percent, however, offer none. Most often (60%), a faculty member with recognized specialty interest in substance abuse gives the lectures. These figures indicate, however, that a large proportion of child psychiatry residents may be receiving less than optimal teaching in substance abuse (or in the case of 16%, no teaching). At the same time, the figures highlight the problem of faculty recruitment, in particular, faculty with specialized expertise, which faces child psychiatry training programs today (Beresin and Borus, 1989). Substance abuse topics that were considered adequately covered, such as diagnostic criteria and pharmacological aspects, most often tended to be descriptive in nature. Least widely covered topics, such as use of the MAST orthe 12-step program of AA, tended to be operational aspects of working with substance abusers. This may reflect the lack of direct clinical exposure to substance-abusing populations. Although 84% of responding programs reported having one or more didactic hours devoted to substance abuse topics, clinical exposure is lacking. The findings reported here indicate a lack of comprehensive alcoholism and substance abuse teaching in child psychiatry training programs . The most common explanation for this gap, as noted on the survey instrument by some respondents, was that since substance abuse training was offered in the adult training program, there was no need to repeat it in the child psychiatry program. This is flawed reasoning. First, substance-abusing youth are a unique population with a unique set of psychosocial problems. The appropriateness of using adult diagnostic criteria for substance abuse and adult treatment models for youthful abusers has been questioned (Bailey, 1989). Second, patterns of youthful abuse may differ from those of adults . Third, the developmental stage requires special consideration. Susceptibility to peer group pressures, the capacity for impulse control, the capacity to form a therapeutic alliance , and coping skills are considerably different for the 13-year-old abuser and the 22-year-old abuser. Given the high prevalence and morbidity of substance abuse among adolescents, it is of concern that the extent of child psychiatry training in this disorder does not match the magnitude of the problem. References Bailey, G. W. (1989), Current perspectives on substance abuse in youth. J. Am. Acad. ChildAdo/esc. Psychiatry , 28: 151-162 . Beresin , E. V. & Borus , J. F. (1989), Child psychiatry fellowship training : a eri sis in recruitment and manpower. Am . J . Psychiatry,
146:759-763. Brown , S. A. (1989), Life events of adolescents in relation to personal and parental substance abuse. Am . J. Psychiatry, 146:484-489. Buydes-Branchey, L., Branchey , M . H. & Noumair, D. (1989), Age of alcoholism onset : I. relationship to psychopathology . Arch . Gen Psychiatry , 46:225-230. Davis, A. K. , Coller, F. & Czechowicz , D. (1988), Substance abuse units taught by four specialties in medical schools and residency programs . J. Med. Educ., 63:739-746. Diaz, M. A., Mann, L. S. & Wise, T. N. (1988), Alcoholism curriculum survey of psychiatric residency training programs. Journal ofPsychi atric Education , 5: 107-121.
815
STEG ET AL.
Fowler, R. C. , Rich, C. L. & Young, D. (1986), San Diego suicide study: II. substance abuse in young cases. Arch. Gen. Psychiatry, 43:962965. Galanter, M., Kaufman, E., Taintor, Z. et a!. (1989), The current status of psychiatric education in alcoholism and drug abuse. Am. J. Psychiatry, 146:35-39. Hoberman, H. M. & Garfinkel, B. D. (1988), Completed suicide in children and adolescents. J. Am. Acad. C hildAdolesc .Psychiatry, 27: 689-695. Johnston, L. D., O'Malley, P. M. & Bachman, J. G. (1988),lllicitdrug use, smoking, and drinking byAmerica's high school students, college students, and young adults, 1975-1987. (DHHS Publication No. ADM 89-1602), Washington, DC: U.S. GovermentPrintingOffice. - - - - - - (1989), Drug use, drinking and smoking: national survey results from high school, college, and young adult populations, 1975-1988. (DHHS Publication No. ADM 89-1638), Washington, DC: U.S. Government Printing Office.
Kandel, D. B., Davies, M., Karns, D. eta!' (1986), The consequences in young adulthood of adolescent drug involvement. Arch. Gen. Psychiatry, 27:746-754. Pfeffer, C. R., Newcom, J., Kaplan, G. eta!. (1988), Suicidal behavior in adolescent psychiatry inpatients. J. Am. Acad. Child Adolesc. Psychiatry, 27:357-361. Regier, D. A., Boyd, J. H., Burke, J. D. et a!. (1988), One-month prevalence of mental disorders, in the United States. Arch. Gen. Psychiatry, 45:977-986. Schowalter, J. E. (1989), Child psychiatry program directors' ratings of residency experiences. J. Am. Acad. Child Adolesc. Psychiatry, 28:124-129. Solomon, J., Pokorny, A. & Zimberg, S. (1981), Alcoholism and drug abuse training during psychiatric residency. Journal of Psychiatric Education, 5:108-121.
The Status of Research Child psychiatry in this country evolved out of the direct needs of parents and other adults responsible for children. It developed in community clinics which were called upon to deal with the great number of our antisocial, maladapted, and unhappy children. Although serious clinicians, as, for instance, Healy and Bronner, structured records at the Judge Baker Clinic so that they could be broken down into components that could be statistically handled, most of the clinical material was recorded in a somewhat hit-or-miss fashion which lent itself poorly to research. The statistical data, also, had serious limitations. Scientific study remained incidental to the pressure of social demands. The fact that the only textbook in our field, for years, was written by Leo Kanner, one of the few child psychiatrists who worked in a university-hospital setting, is indicative of the absence of systematic formulation that generally prevailed. JAACP, Vo!. I, No. I January, 1962
816
J. Am. Acad. Child Adolesc. Psychiatry, 29:5, September 1990
