Acad Psychiatry DOI 10.1007/s40596-015-0305-1
EMPIRICAL REPORT
Psychiatry’s Next Generation: Teaching College Students About Mental Health Jess P. Shatkin & Ursula Diamond
Received: 8 September 2014 / Accepted: 27 January 2015 # Academic Psychiatry 2015
Abstract Objective The authors describe an integrated area of study for undergraduate college students that targets an increase in knowledge of mental health issues in children, adolescents, and emerging adults; encourages mental health service utilization on college campuses; and exposes young minds to the possibilities of working with children and adolescents in the mental health field. Methods An overview of the program is provided, including the resources required to oversee and manage the program, student requirements, a description of the role that clinicians and researchers play as the program faculty, and an explanation of the tuition model. Results The program currently includes 40 courses with an annual enrollment of over 3000 students, resulting in departmental revenues that currently exceed $11 million per year. Student evaluations of the courses are very positive, and in a program survey students reported that their participation in the program had a positive impact on their life (84.2 %) and impacted their career choice (60.2 %). Conclusions The benefits of the program include a valuable outreach to college students regarding the importance of seeking help for mental health issues, a positive influence on early career decision-making, opportunities for clinical and research educators to develop their scholarly areas of interest, and a significant source of departmental discretionary revenues.
Keywords Child psychiatry . Workforce . Mental health
J. P. Shatkin (*) : U. Diamond New York University Langone Medical Center, New York, NY, USA e-mail: [email protected]
The high prevalence of mental health problems among children, adolescents, and emerging adults continues to be a cause for national concern, with more than one in four adolescents in the general population experiencing disorders that result in severe impairment [1]. The most recent data available from the National Comorbidity Survey Adolescent Supplement (NCS-A), using diagnostic criteria from DSM-IV-TR measuring a nationally representative sample ages 13–18, indicate a lifetime prevalence of 31.9 % for anxiety disorders, 19.6 % for behavior disorders, 14.3 % for mood disorders, and 11.4 % for substance use disorders [1]. Half of all lifetime cases of mental illness begin by age 14 years and three quarters by age 24 years [2]. The college years mark a major role transition accompanied by multiple, complex stressors related to increased academic, social, and financial pressures. While there is a lack of recent epidemiological data regarding mental illness on college campuses [3], there is evidence of a high prevalence of mental illness based on national survey data provided by students and counseling directors. A national survey of over 200,000 full-time, first-year students reported that incoming students are rating their emotional health at the lowest point since the survey began 25 years ago [4]. The National College Health Assessment sponsored by the American College Health Association (ACHA-NCHA) is conducted annually with more than 90,000 respondents. In the most recent survey, nearly one third of undergraduates (31.3 %) reported feeling so depressed it was difficult to function at least once in the previous year, over half reported feeling overwhelming anxiety (50.7 %), and nearly one in ten (7.1 %) reported that they had seriously considered suicide in the previous year [5]. The National Survey of Counseling Center Directors (NSCCD) has been conducted annually for 30 years, and, during this period, there has been a marked increase in student pathology [6]. In the most recent
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survey of 293 centers representing 2.7 million students, 92 % of directors reported that the number of students seeking help at their centers has been increasing, 39 % of their clients have severe psychological problems, and 24 % are on psychiatric medication [7]. Other crosssectional studies have found that one third to one half of college students met DSM-IV criteria for at least one psychiatric disorder in the preceding year, with rates of depression ranging from 11 to 15 % [8, 9]. Depression has been found to be a significant predictor of lower academic performance, lower GPA, and higher probability of dropping out of college [10]. While most college campuses provide a variety of mental health services and support, untreated mental disorders are the norm in student populations [11]. The NCS-A results indicate that the majority of adolescents with a diagnosed DSM-IV disorder do not receive any treatment, and up to 80 % of youths with anxiety disorders do not utilize any health services [12, 13]. Only one third of college students with a past-year diagnosis of a mood disorder, 16 % of students with a past-year diagnosis of an anxiety disorder, and 5 % of students with a past-year diagnosis of an alcohol or drug disorder seek mental health services [8]. One study identified that attitudes toward seeking mental health services have become increasingly negative among college students over the past 40 years [14]. Negative attitudes and beliefs, such as stigma, a lack of perceived need, and social context, are significant demand-driven barriers to help seeking among college students [15]. A critical supply-side barrier to service utilization for children, adolescents, and college students is the lack of mental health practitioners who have been trained to treat children, adolescents, and young adults. Child and adolescent psychiatry (CAP) remains among the most underserved specialties in medicine [16]. The most recent workforce review estimates that there are currently 15,000 youths under age 18 for every child and adolescent psychiatrist and that there will be a shortfall of more than 4000 child and adolescent psychiatrists to meet national demand by 2020 [17]. The number of CAP residency programs has reduced from 130 in 1980 to 123 in 2013–14 [18] due in part to decreased federal funding support for CAP residency training, decreased clinical revenue support, and CAP’s perceived lack of prestige relative to other medical subspecialties [17]. Although the number of programs has decreased over time, the number of fellows across all CAP programs had increased slightly from 534 in 2004 to 560 in 2014 [19, 20]. There are still, however, insufficient mental health practitioners for children, adolescents, and emerging adults with mental health issues. While data related to demand and supply of child and adolescent psychiatrists are limited, there are no equivalent data available for child and adolescent mental health specialists in related fields, such
as psychologists, nurses, social workers, or mental health counselors. All evidence points to a similar issue in these allied fields. These circumstances present an opportunity for academic programs that can simultaneously tackle the critical issues of untreated mental health issues on campus and the lack of mental health professionals focused on child and adolescent mental health. This paper describes an integrated area of study for undergraduate college students that targets an increase in knowledge of mental health issues in children, adolescents, and emerging adults; encourages mental health service utilization on college campuses; and exposes young minds to the possibilities of working with children and adolescents in the mental health field [21]. The Child and Adolescent Mental Health Studies (CAMS) program was introduced as a college minor in the fall of 2006 at a large urban non-profit private university in New York. An initial paper was published shortly after the CAMS program was initiated [21], and the current paper provides a summary of the program’s outcomes after 8 years of continuous operation.
Methods The director of Undergraduate Studies, who is also responsible for all aspects of resident and public education within the Department of Child and Adolescent Psychiatry, oversees the program from within the School of Medicine. The current director was responsible for the inception of the program, together with many of the course ideas and designs. The program also employs a full-time administrator who is responsible for day-to-day responsibilities such as course scheduling, student advisement, and faculty support. The goals for the students of the CAMS program are to: [1] develop analytic and problem-solving skills; [2] compare and contrast normal versus pathological behavior, cognition, and emotion; [3] reduce stigma related to mental illness; and [4] encourage more undergraduates to pursue a career in the mental health field working with children and adolescents. Similar to the minimum requirement model adopted by other minors within the college where the program is housed, we require that five courses or 18–20 credits be completed to confer the minor degree. At least three of these courses must be selected from the catalog of CAMS courses, one of which much include CAMS-UA.101 Child and Adolescent Psychopathology, which itself mandates Introduction to Psychology or a 4 or 5 on the Advanced Placement examination in psychology as a prerequisite. The remaining two courses may either be CAMS courses or taken from a list of approved non-departmental courses. All CAMS courses are individually approved by the college’s Curriculum Committee and Academic Senate. The program is formally marketed to undergraduate students via a number of mechanisms,
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including the electronic registration system, the departmental website, CAMS sponsored events, student advisement, and orientation events. The CAMS program has also developed a strong “word of mouth” based on its diverse academic offerings and perceived quality of instruction. The courses are offered every fall, spring, and summer semesters on the college campus. Our CAMS faculty work full-time as child and adolescent psychiatrists (42 %), psychologists (52 %), social workers (4 %), or as experts in their field (4 %). The instructors’ experience in teaching prior to CAMS varies, but, in general, the instructors approached the CAMS director with a strong desire to participate in the program in some capacity. In a few instances, the CAMS director approached potential instructors due to their expertise in a particular field. Most courses are offered multiple semesters per year, and the teaching commitment (including preparation, grading, office hours, and travel time to campus) is approximately 6–12 h per week, depending on the size of the class. For courses with more than 50 students, instructors often decide to hire teaching assistants and/or graders to help reduce their personal time commitment. Instructors are encouraged to incorporate clinical vignettes and real-life examples into their courses. Resident fellows in CAP often engage in the development and instruction of a new CAMS course as their second-year elective. In fact, resident trainees have designed 13 of the 40 courses currently offered in the minor. Many of these fellows continue to teach their courses after they have graduated from the program. A significant portion of the tuition dollars generated by course enrollment is allocated back to the course’s sponsoring department at the end of each semester. Faculty members receive a supplemental bonus at the end of each semester for their time and effort. The faculty members are responsible for the cost of any teaching assistants or graders who provide support for those courses with larger student enrollments.
Results At its inception in 2006, we anticipated that the number of CAMS offerings might increase to 12–14 courses over time. The minor currently includes 40 distinct courses on the domestic campus, three of which are also currently offered at three of the college’s international campuses. Figure 1 shows the number of CAMS courses offered and the number of students enrolled per academic year from 2006 to 2014. A full list of the syllabi for the current offerings can be found at http:// www.aboutourkids.org/education/undergraduate_minor/ cams_courses_and_syllabi. Annual enrollment in CAMS courses has grown from 54 students in 2006–07 to 3268 students in 2013–14. This growth in student enrollment has, in turn, led to a growth in discretionary revenues to the department. Annual revenues to the
70
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60
3,000
50
2,500
40
2,000
30
1,500
20
1,000
10
500
0
FY FY FY FY FY FY FY FY 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14
0
Fig. 1 CAMS courses offered and students enrolled per academic year from 2006 to 2014
department increased from $121,500 in 2006–07 to $11.4 million in 2013–14. A total of 529 undergraduate students have graduated with the CAMS minor degree as of May 2014, and a further 228 students are currently working toward it. Course evaluation data indicate students are highly satisfied with the quality of the CAMS courses, with instructors rated with a mean score of 4.5 (5=excellent, 1=poor) and courses rated with a mean score of 4.3 (5=excellent, 1=poor). In addition, 89 % of students report that they would recommend their instructor and the course to a friend. Based on a survey of almost 900 students enrolled in CAMS classes during 2011 and 2012, a demographic profile of a typical CAMS student emerged. The typical CAMS student is female (86.7 %), 20.1 years old (SD =1.6), white (61.8 %), and currently pursuing a major in one of the helping professions, such as psychology, social work, or nursing (46.2 %). In addition, 60.6 % have previously taken psychology courses, and 44.6 % of all students taking CAMS classes intend to minor in the program. Perhaps one reason why more students do not declare the minor is that a large proportion of our students are in programs (such as social work, nursing, applied psychology, and performing arts) that preclude them from having sufficient elective credits to fulfill the requirements of the minor. Many of our students are also seniors who have fewer elective credits available to fulfill the minor requirements before they graduate. In terms of the impact of the CAMS program on student behaviors and college experience, initial responses from the students are positive: 84.2 % of students agree that CAMS has had a positive impact on their life, 60.2 % believe the program impacted their career choice, 59.4 % are planning to pursue a career working with children and adolescents, and 41.4 % are planning to pursue a career working in mental health. We suspect that the most impactful courses are those that provide undergraduate students with an experiential learning opportunity. An increasing proportion of our courses feature some kind of fieldwork opportunity: the CAMS Summer Internship Program offers students a 12-week clinical or
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research internship at the Department of Child and Adolescent Psychiatry or one of its affiliates; Child and Adolescent Psychopathology includes attending and writing up of a family psychiatric evaluation; Risk & Resilience in Urban Teens is a two-semester course that features a 10-week practicum teaching CBT and stress-reduction techniques to high school students; the Advanced Seminar in Autism Spectrum Disorders includes a 3-h weekly lab practicum at an affiliated school program for children and adolescents with ASD; and the Lab in the Advanced Study of Clinical Intervention and Clinical Research includes a 5-h weekly lab practicum supervised by clinical and research faculty at the Department of Child and Adolescent Psychiatry. The program has also provided nearly 200 students with the opportunity to pursue independent study opportunities within the department. Each of these courses and numerous others provide unique opportunities for undergraduates to gain handson experience working in the field of child and adolescent mental health under the close supervision of experienced clinicians and researchers.
Discussion The continuing growth of the program demonstrates that the Departments of Child and Adolescent Psychiatry can have a positive impact on undergraduate education. Many factors, including the positive trend in course numbers and student enrollment, the positive feedback based on course evaluations and anecdotal reports, and the number of faculty interested in teaching within the program, indicate that there is a strong demand for this type of academic program at the undergraduate level. There appear to be many potential benefits to students, faculty, and the department alike. Undergraduate students are at a developmental stage when many are refining career choices and making decisions about the type of specialized training that they plan to pursue. Exposure to professionals as career role models can play a critical role in this decision-making [22]. Undergraduate students who decide to pursue a career in psychiatry or a related field are often highly influenced by perceptions that the field contains interesting and challenging subject matter [23]. A program that offers multiple diverse perspectives of child and adolescent mental health, taught by successful and engaging practitioners, is one way to encourage early interest and possibly influence career choices in medical and graduate school. College faculty members are often the only university staff who learn of a student’s mental health issues, particularly when students use these issues to justify poor academic performance [24]. There is an increasing call for college campuses to engage faculty in helping to identify students with mental health issues and actively encourage students to seek
help when necessary [3, 25]. In one survey at a large urban university, one third of faculty reported that they rarely or never felt confident when dealing with a student who has symptoms of mental illness, and one half of faculty were unfamiliar with available services on college campuses [26]. Faculty members who are experienced in mental health issues are more likely to play a critical outreach role by increasing the knowledge of their students in mental health issues and treatment options and emphasizing the importance of seeking help for students or their peers. The curricula are also more likely to be infused with clinical examples and modeling of appropriate health-seeking behaviors. The CAMS program represents a valuable outreach opportunity on campus to an estimated 20 % of the student body each year, many of whom would never consider entering the student counseling offices. A program such as CAMS provides clinician educators with an opportunity and encouragement from the department to further develop a scholarly area of interest. It also provides faculty researchers with the opportunity to investigate the benefits of teaching students applied concepts and techniques. The expansion of the program to international campuses brings a number of benefits. The program has become further ensconced into the university’s educational programming, it encourages more students to complete the minor while they are studying abroad, and it creates an environment that fosters international perspectives and faculty relationships. Interpersonal and clinical connections have already been established between CAMS teachers in the USA and at our abroad campuses. We hope to see research collaboration between sites in the future as well. CAP departments, and CAP residency programs in particular, are coming under increasing financial pressure as state and federal budgets, grant funding, and clinical reimbursements continue to decline [17, 27, 28]. In a nationwide survey of residency training programs, only 11 % of respondents believed that teaching undergraduates would be an additional source of revenue for the department, 29 % believed that it might be a source of funding, and 60 % believed teaching undergraduates would not be a source of revenue [28]. The CAMS program has demonstrated that teaching undergraduates creates an opportunity to generate a significant amount of discretionary revenue to the department, while also self-funding all the costs of running the program. While the benefits are manifold, it is worth noting a few minor drawbacks related to the way in which the program is set up and located. The program is housed within a liberal arts college, which has at times highlighted the dichotomy between the department’s desire to teach more applied concepts that we believe are vital to prevent or limit emotional distress for college students (e.g., stress reduction, organizational skills, mood management, sleep hygiene, etc.) and the more
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theoretical orientation of the college. For the most part, we have found ways to incorporate aspects of these applied concepts into our academic courses. For example, we teach students about cognitive behavior therapy for insomnia in our sleep course, but we cannot require that the students practice these concepts; nor do we have a single course built solely upon wellness practices. Although the university has a student health and wellness center, its purview is largely secondary and tertiary care. We maintain that programs like CAMS can augment university health services in part by teaching about prevention and primary care practices. The administration of the program is located off campus at the medical school (approximately 2 mi away) which somewhat isolates the program from the university administration. This drawback has been mitigated to some degree by regular attendance of the program director at administrative meetings held on campus. The distance to the campus requires faculty to incorporate a 40-min round trip commute for each class taught on campus as well as any office hours that they offer to students. It is worth noting that classes held at the medical school tend to have lower enrollment than those taught on the college campus.
Conclusion While the program has performed well both academically and financially, we only have anecdotal evidence that participation in the CAMS program has a positive effect on career choices related to working in the field of child and adolescent mental health, although our survey data strongly suggest that this is the case. For this reason, in fall 2011, we started collecting data as part of a 5-year IRB-approved longitudinal study to determine the extent to which the program positively impacts the career choices of CAMS students. We are also conducting a series of research studies that attempt to evaluate the effectiveness of individual courses on student mental health and well-being. The first paper on Risk and Resilience in Urban Teens is currently under review and demonstrates that students who participated in that course, when compared to students in another CAMS course, experienced reduced perceived stress, better coping skills, and lower scores on a dysfunctional attitudes scale after the fall semester (under review). Further studies are at various stages of planning and design. More than 109,000 students graduate with a degree in psychology every year [29], but very few of them go to medical school. We believe this program provides an opportunity to encourage students whose natural interest is in medicine, psychology, or another helping profession to consider entering the field. We strongly believe in the value of this program and welcome the opportunity to work with other departments
and divisions of Child and Adolescent Psychiatry to start or expand a program of their own. Implications for Educators • Academic medical centers have the opportunity to design and teach undergraduate college courses at affiliated universities and colleges. • Designing a college education program from within an academic medical center’s psychiatry department can result in beneficial research and scholarly opportunities for faculty members and residents. • The design of such a program can also provide much needed financial support for departments of psychiatry. • Department of psychiatry-driven college education programs are likely to steer more college students toward a career in psychiatry and psychology. • Having clinical psychologists and psychiatrists teaching undergraduate students on a college campus will help to increase awareness of mental health issues on campus and may improve students’ mental health.
Disclosure The authors have no conflicts of interest to disclose.
References 1. Merikangas KR, He J-p, Burstein M, Swanson SA, Avenevoli S, Cui L. Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatr. 2010;49(10):980–9. 2. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. AGP. 2005;62(6):593–602. 3. Mowbray CT, Megivern D, Mandiberg JM, Strauss S, Stein CH, Collins K, et al. Campus mental health services: Recommendations for change. AJO. 2006. 4. Pryor JH, Hurtado S, DeAngelo L, Palucki Blake L, Tran S. The American freshman: national norms fall 2010. Los Angeles: Higher Education Research Institute, UCLA; 2010. 5. ACHA. American College Health Association-National College Health Assessment II: undergraduate reference group executive summary spring 2012. Hanover: American College Health Association; 2012. 6. Gallagher RP. Thirty years of the National Survey of Counseling Center Directors: a personal account. J Coll Stud Psychother. 2012;26(3):172–84. 7. Gallagher RP. National survey of counseling center directors. Alexandria: International Association of Counseling Services; 2012. 8. Blanco C, Okuda M, Wright C, Hasin DS, Grant BF, Liu S-M, et al. Mental health of college students and their non-college-attending peers: results from the national epidemiologic study on alcohol and related conditions. AGP. 2008;65(12):1429–37. 9. Zivin K, Eisenberg D, Gollust SE, Golberstein E. Persistence of mental health problems and needs in a college student population. J Affect Disord. 2009;117(3):180–5. 10. Eisenberg D, Golberstein E, Hunt JB. Mental health and academic success in college. The BE J Econ Anal Policy. 2009; 9(1).
Acad Psychiatry 11. Hunt J, Eisenberg D. Mental health problems and help-seeking behavior among college students. J Adolesc Health. 2010;46(1):3–10. 12. Merikangas KR, He J-p, Burstein M, Swendsen J, Avenevoli S, Case B. Service utilization for lifetime mental disorders in US adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatr. 2011;50(1):32–45. 13. Merikangas KR, He J-P, Brody D, Fisher PW, Bourdon K, Koretz DS. Prevalence and treatment of mental disorders among US children in the 2001–2004 NHANES. Pediatrics. 2010;125(1):75–81. 14. Mackenzie CS, Erickson J, Deane FP, Wright M. Changes in attitudes toward seeking mental health services: a 40-year cross-temporal meta-analysis. Clin Psychol Rev. 2014;34(2):99–106. 15. Eisenberg D, Hunt J, Speer N. Help seeking for mental health on college campuses: review of evidence and next steps for research and practice. Harvard Rev Psychiatr. 2012;20(4):222–32. 16. Fox GS, Stock S, Briscoe GW, Beck GL, Horton R, Hunt JI, et al. Improving child and adolescent psychiatry education for medical students: an inter-organizational collaborative action plan. Acad Psychiatr. 2012;36(6):461–4. 17. Kim WJ. Child and adolescent psychiatry workforce: a critical shortage and national challenge. Acad Psychiatr. 2003;27(4):277–82. 18. ACGME. List of ACGME accredited programs and sponsoring institutions 2014 [cited 2014 July 1]. Available from: https:/http:// www.acgme.org. 19. NRMP. National resident matching program results and data: specialties matching service. Washington, DC: NRMP; 2008. 20. NRMP. National resident matching program results and data: specialties matching service. Washington, DC: NRMP; 2014.
21. Shatkin JP, Koplewicz HS. The child and adolescent mental health studies (CAMS) minor at New York University. Acad Psychiatr. 2008;32(5):438–45. 22. Krous T, Nauta MM. Values, motivations, and learning experiences of future professionals: who wants to serve underserved populations? Prof Psychol Res Practice. 2005;36(6):688. 23. Malhi GS, Coulston CM, Parker GB, Cashman E, Walter G, Lampe LA, et al. Who picks psychiatry? Perceptions, preferences and personality of medical students. Aust N Z J Psychiatry. 2011;45(10): 861–70. 24. Nolan SA, Pace KA, Iannelli RJ, Palma TV, Pakalns GP. A simple and effective program to increase faculty knowledge of and referrals to counseling centers. J Coll Couns. 2006;9(2):167–70. 25. Mitchell SL, Darrow SA, Haggerty M, Neill T, Carvalho A, Uschold C. Curriculum infusion as college student mental health promotion strategy. J Coll Stud Psychother. 2012;26(1):22–38. 26. Becker M, Martin L, Wajeeh E, Ward J, Shern D. Students with mental illnesses in a university setting: faculty and student attitudes, beliefs, knowledge, and experiences. Psychiatr Rehab J. 2002;25(4):359. 27. Schlozman SC, Beresin EV. Frustration and opportunity: teaching child and adolescent psychiatry throughout medical education. Acad Psychiatr. 2010;34:172–4. 28. Braslow KJ, Feeney DJ, Elliott GR, Matthews KL, Bush AC. Improving recruitment and funding in psychiatry by teaching college undergraduates. Acad Psychiatr. 2005;29(5):459–63. 29. Digest of education statistics: 2012 [Internet]. Institute of Education Sciences. 2012. Available from: http://nces.ed.gov/programs/digest/ d12/index.asp.
EMPIRICAL REPORT
Psychiatry’s Next Generation: Teaching College Students About Mental Health Jess P. Shatkin & Ursula Diamond
Received: 8 September 2014 / Accepted: 27 January 2015 # Academic Psychiatry 2015
Abstract Objective The authors describe an integrated area of study for undergraduate college students that targets an increase in knowledge of mental health issues in children, adolescents, and emerging adults; encourages mental health service utilization on college campuses; and exposes young minds to the possibilities of working with children and adolescents in the mental health field. Methods An overview of the program is provided, including the resources required to oversee and manage the program, student requirements, a description of the role that clinicians and researchers play as the program faculty, and an explanation of the tuition model. Results The program currently includes 40 courses with an annual enrollment of over 3000 students, resulting in departmental revenues that currently exceed $11 million per year. Student evaluations of the courses are very positive, and in a program survey students reported that their participation in the program had a positive impact on their life (84.2 %) and impacted their career choice (60.2 %). Conclusions The benefits of the program include a valuable outreach to college students regarding the importance of seeking help for mental health issues, a positive influence on early career decision-making, opportunities for clinical and research educators to develop their scholarly areas of interest, and a significant source of departmental discretionary revenues.
Keywords Child psychiatry . Workforce . Mental health
J. P. Shatkin (*) : U. Diamond New York University Langone Medical Center, New York, NY, USA e-mail: [email protected]
The high prevalence of mental health problems among children, adolescents, and emerging adults continues to be a cause for national concern, with more than one in four adolescents in the general population experiencing disorders that result in severe impairment [1]. The most recent data available from the National Comorbidity Survey Adolescent Supplement (NCS-A), using diagnostic criteria from DSM-IV-TR measuring a nationally representative sample ages 13–18, indicate a lifetime prevalence of 31.9 % for anxiety disorders, 19.6 % for behavior disorders, 14.3 % for mood disorders, and 11.4 % for substance use disorders [1]. Half of all lifetime cases of mental illness begin by age 14 years and three quarters by age 24 years [2]. The college years mark a major role transition accompanied by multiple, complex stressors related to increased academic, social, and financial pressures. While there is a lack of recent epidemiological data regarding mental illness on college campuses [3], there is evidence of a high prevalence of mental illness based on national survey data provided by students and counseling directors. A national survey of over 200,000 full-time, first-year students reported that incoming students are rating their emotional health at the lowest point since the survey began 25 years ago [4]. The National College Health Assessment sponsored by the American College Health Association (ACHA-NCHA) is conducted annually with more than 90,000 respondents. In the most recent survey, nearly one third of undergraduates (31.3 %) reported feeling so depressed it was difficult to function at least once in the previous year, over half reported feeling overwhelming anxiety (50.7 %), and nearly one in ten (7.1 %) reported that they had seriously considered suicide in the previous year [5]. The National Survey of Counseling Center Directors (NSCCD) has been conducted annually for 30 years, and, during this period, there has been a marked increase in student pathology [6]. In the most recent
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survey of 293 centers representing 2.7 million students, 92 % of directors reported that the number of students seeking help at their centers has been increasing, 39 % of their clients have severe psychological problems, and 24 % are on psychiatric medication [7]. Other crosssectional studies have found that one third to one half of college students met DSM-IV criteria for at least one psychiatric disorder in the preceding year, with rates of depression ranging from 11 to 15 % [8, 9]. Depression has been found to be a significant predictor of lower academic performance, lower GPA, and higher probability of dropping out of college [10]. While most college campuses provide a variety of mental health services and support, untreated mental disorders are the norm in student populations [11]. The NCS-A results indicate that the majority of adolescents with a diagnosed DSM-IV disorder do not receive any treatment, and up to 80 % of youths with anxiety disorders do not utilize any health services [12, 13]. Only one third of college students with a past-year diagnosis of a mood disorder, 16 % of students with a past-year diagnosis of an anxiety disorder, and 5 % of students with a past-year diagnosis of an alcohol or drug disorder seek mental health services [8]. One study identified that attitudes toward seeking mental health services have become increasingly negative among college students over the past 40 years [14]. Negative attitudes and beliefs, such as stigma, a lack of perceived need, and social context, are significant demand-driven barriers to help seeking among college students [15]. A critical supply-side barrier to service utilization for children, adolescents, and college students is the lack of mental health practitioners who have been trained to treat children, adolescents, and young adults. Child and adolescent psychiatry (CAP) remains among the most underserved specialties in medicine [16]. The most recent workforce review estimates that there are currently 15,000 youths under age 18 for every child and adolescent psychiatrist and that there will be a shortfall of more than 4000 child and adolescent psychiatrists to meet national demand by 2020 [17]. The number of CAP residency programs has reduced from 130 in 1980 to 123 in 2013–14 [18] due in part to decreased federal funding support for CAP residency training, decreased clinical revenue support, and CAP’s perceived lack of prestige relative to other medical subspecialties [17]. Although the number of programs has decreased over time, the number of fellows across all CAP programs had increased slightly from 534 in 2004 to 560 in 2014 [19, 20]. There are still, however, insufficient mental health practitioners for children, adolescents, and emerging adults with mental health issues. While data related to demand and supply of child and adolescent psychiatrists are limited, there are no equivalent data available for child and adolescent mental health specialists in related fields, such
as psychologists, nurses, social workers, or mental health counselors. All evidence points to a similar issue in these allied fields. These circumstances present an opportunity for academic programs that can simultaneously tackle the critical issues of untreated mental health issues on campus and the lack of mental health professionals focused on child and adolescent mental health. This paper describes an integrated area of study for undergraduate college students that targets an increase in knowledge of mental health issues in children, adolescents, and emerging adults; encourages mental health service utilization on college campuses; and exposes young minds to the possibilities of working with children and adolescents in the mental health field [21]. The Child and Adolescent Mental Health Studies (CAMS) program was introduced as a college minor in the fall of 2006 at a large urban non-profit private university in New York. An initial paper was published shortly after the CAMS program was initiated [21], and the current paper provides a summary of the program’s outcomes after 8 years of continuous operation.
Methods The director of Undergraduate Studies, who is also responsible for all aspects of resident and public education within the Department of Child and Adolescent Psychiatry, oversees the program from within the School of Medicine. The current director was responsible for the inception of the program, together with many of the course ideas and designs. The program also employs a full-time administrator who is responsible for day-to-day responsibilities such as course scheduling, student advisement, and faculty support. The goals for the students of the CAMS program are to: [1] develop analytic and problem-solving skills; [2] compare and contrast normal versus pathological behavior, cognition, and emotion; [3] reduce stigma related to mental illness; and [4] encourage more undergraduates to pursue a career in the mental health field working with children and adolescents. Similar to the minimum requirement model adopted by other minors within the college where the program is housed, we require that five courses or 18–20 credits be completed to confer the minor degree. At least three of these courses must be selected from the catalog of CAMS courses, one of which much include CAMS-UA.101 Child and Adolescent Psychopathology, which itself mandates Introduction to Psychology or a 4 or 5 on the Advanced Placement examination in psychology as a prerequisite. The remaining two courses may either be CAMS courses or taken from a list of approved non-departmental courses. All CAMS courses are individually approved by the college’s Curriculum Committee and Academic Senate. The program is formally marketed to undergraduate students via a number of mechanisms,
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including the electronic registration system, the departmental website, CAMS sponsored events, student advisement, and orientation events. The CAMS program has also developed a strong “word of mouth” based on its diverse academic offerings and perceived quality of instruction. The courses are offered every fall, spring, and summer semesters on the college campus. Our CAMS faculty work full-time as child and adolescent psychiatrists (42 %), psychologists (52 %), social workers (4 %), or as experts in their field (4 %). The instructors’ experience in teaching prior to CAMS varies, but, in general, the instructors approached the CAMS director with a strong desire to participate in the program in some capacity. In a few instances, the CAMS director approached potential instructors due to their expertise in a particular field. Most courses are offered multiple semesters per year, and the teaching commitment (including preparation, grading, office hours, and travel time to campus) is approximately 6–12 h per week, depending on the size of the class. For courses with more than 50 students, instructors often decide to hire teaching assistants and/or graders to help reduce their personal time commitment. Instructors are encouraged to incorporate clinical vignettes and real-life examples into their courses. Resident fellows in CAP often engage in the development and instruction of a new CAMS course as their second-year elective. In fact, resident trainees have designed 13 of the 40 courses currently offered in the minor. Many of these fellows continue to teach their courses after they have graduated from the program. A significant portion of the tuition dollars generated by course enrollment is allocated back to the course’s sponsoring department at the end of each semester. Faculty members receive a supplemental bonus at the end of each semester for their time and effort. The faculty members are responsible for the cost of any teaching assistants or graders who provide support for those courses with larger student enrollments.
Results At its inception in 2006, we anticipated that the number of CAMS offerings might increase to 12–14 courses over time. The minor currently includes 40 distinct courses on the domestic campus, three of which are also currently offered at three of the college’s international campuses. Figure 1 shows the number of CAMS courses offered and the number of students enrolled per academic year from 2006 to 2014. A full list of the syllabi for the current offerings can be found at http:// www.aboutourkids.org/education/undergraduate_minor/ cams_courses_and_syllabi. Annual enrollment in CAMS courses has grown from 54 students in 2006–07 to 3268 students in 2013–14. This growth in student enrollment has, in turn, led to a growth in discretionary revenues to the department. Annual revenues to the
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Fig. 1 CAMS courses offered and students enrolled per academic year from 2006 to 2014
department increased from $121,500 in 2006–07 to $11.4 million in 2013–14. A total of 529 undergraduate students have graduated with the CAMS minor degree as of May 2014, and a further 228 students are currently working toward it. Course evaluation data indicate students are highly satisfied with the quality of the CAMS courses, with instructors rated with a mean score of 4.5 (5=excellent, 1=poor) and courses rated with a mean score of 4.3 (5=excellent, 1=poor). In addition, 89 % of students report that they would recommend their instructor and the course to a friend. Based on a survey of almost 900 students enrolled in CAMS classes during 2011 and 2012, a demographic profile of a typical CAMS student emerged. The typical CAMS student is female (86.7 %), 20.1 years old (SD =1.6), white (61.8 %), and currently pursuing a major in one of the helping professions, such as psychology, social work, or nursing (46.2 %). In addition, 60.6 % have previously taken psychology courses, and 44.6 % of all students taking CAMS classes intend to minor in the program. Perhaps one reason why more students do not declare the minor is that a large proportion of our students are in programs (such as social work, nursing, applied psychology, and performing arts) that preclude them from having sufficient elective credits to fulfill the requirements of the minor. Many of our students are also seniors who have fewer elective credits available to fulfill the minor requirements before they graduate. In terms of the impact of the CAMS program on student behaviors and college experience, initial responses from the students are positive: 84.2 % of students agree that CAMS has had a positive impact on their life, 60.2 % believe the program impacted their career choice, 59.4 % are planning to pursue a career working with children and adolescents, and 41.4 % are planning to pursue a career working in mental health. We suspect that the most impactful courses are those that provide undergraduate students with an experiential learning opportunity. An increasing proportion of our courses feature some kind of fieldwork opportunity: the CAMS Summer Internship Program offers students a 12-week clinical or
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research internship at the Department of Child and Adolescent Psychiatry or one of its affiliates; Child and Adolescent Psychopathology includes attending and writing up of a family psychiatric evaluation; Risk & Resilience in Urban Teens is a two-semester course that features a 10-week practicum teaching CBT and stress-reduction techniques to high school students; the Advanced Seminar in Autism Spectrum Disorders includes a 3-h weekly lab practicum at an affiliated school program for children and adolescents with ASD; and the Lab in the Advanced Study of Clinical Intervention and Clinical Research includes a 5-h weekly lab practicum supervised by clinical and research faculty at the Department of Child and Adolescent Psychiatry. The program has also provided nearly 200 students with the opportunity to pursue independent study opportunities within the department. Each of these courses and numerous others provide unique opportunities for undergraduates to gain handson experience working in the field of child and adolescent mental health under the close supervision of experienced clinicians and researchers.
Discussion The continuing growth of the program demonstrates that the Departments of Child and Adolescent Psychiatry can have a positive impact on undergraduate education. Many factors, including the positive trend in course numbers and student enrollment, the positive feedback based on course evaluations and anecdotal reports, and the number of faculty interested in teaching within the program, indicate that there is a strong demand for this type of academic program at the undergraduate level. There appear to be many potential benefits to students, faculty, and the department alike. Undergraduate students are at a developmental stage when many are refining career choices and making decisions about the type of specialized training that they plan to pursue. Exposure to professionals as career role models can play a critical role in this decision-making [22]. Undergraduate students who decide to pursue a career in psychiatry or a related field are often highly influenced by perceptions that the field contains interesting and challenging subject matter [23]. A program that offers multiple diverse perspectives of child and adolescent mental health, taught by successful and engaging practitioners, is one way to encourage early interest and possibly influence career choices in medical and graduate school. College faculty members are often the only university staff who learn of a student’s mental health issues, particularly when students use these issues to justify poor academic performance [24]. There is an increasing call for college campuses to engage faculty in helping to identify students with mental health issues and actively encourage students to seek
help when necessary [3, 25]. In one survey at a large urban university, one third of faculty reported that they rarely or never felt confident when dealing with a student who has symptoms of mental illness, and one half of faculty were unfamiliar with available services on college campuses [26]. Faculty members who are experienced in mental health issues are more likely to play a critical outreach role by increasing the knowledge of their students in mental health issues and treatment options and emphasizing the importance of seeking help for students or their peers. The curricula are also more likely to be infused with clinical examples and modeling of appropriate health-seeking behaviors. The CAMS program represents a valuable outreach opportunity on campus to an estimated 20 % of the student body each year, many of whom would never consider entering the student counseling offices. A program such as CAMS provides clinician educators with an opportunity and encouragement from the department to further develop a scholarly area of interest. It also provides faculty researchers with the opportunity to investigate the benefits of teaching students applied concepts and techniques. The expansion of the program to international campuses brings a number of benefits. The program has become further ensconced into the university’s educational programming, it encourages more students to complete the minor while they are studying abroad, and it creates an environment that fosters international perspectives and faculty relationships. Interpersonal and clinical connections have already been established between CAMS teachers in the USA and at our abroad campuses. We hope to see research collaboration between sites in the future as well. CAP departments, and CAP residency programs in particular, are coming under increasing financial pressure as state and federal budgets, grant funding, and clinical reimbursements continue to decline [17, 27, 28]. In a nationwide survey of residency training programs, only 11 % of respondents believed that teaching undergraduates would be an additional source of revenue for the department, 29 % believed that it might be a source of funding, and 60 % believed teaching undergraduates would not be a source of revenue [28]. The CAMS program has demonstrated that teaching undergraduates creates an opportunity to generate a significant amount of discretionary revenue to the department, while also self-funding all the costs of running the program. While the benefits are manifold, it is worth noting a few minor drawbacks related to the way in which the program is set up and located. The program is housed within a liberal arts college, which has at times highlighted the dichotomy between the department’s desire to teach more applied concepts that we believe are vital to prevent or limit emotional distress for college students (e.g., stress reduction, organizational skills, mood management, sleep hygiene, etc.) and the more
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theoretical orientation of the college. For the most part, we have found ways to incorporate aspects of these applied concepts into our academic courses. For example, we teach students about cognitive behavior therapy for insomnia in our sleep course, but we cannot require that the students practice these concepts; nor do we have a single course built solely upon wellness practices. Although the university has a student health and wellness center, its purview is largely secondary and tertiary care. We maintain that programs like CAMS can augment university health services in part by teaching about prevention and primary care practices. The administration of the program is located off campus at the medical school (approximately 2 mi away) which somewhat isolates the program from the university administration. This drawback has been mitigated to some degree by regular attendance of the program director at administrative meetings held on campus. The distance to the campus requires faculty to incorporate a 40-min round trip commute for each class taught on campus as well as any office hours that they offer to students. It is worth noting that classes held at the medical school tend to have lower enrollment than those taught on the college campus.
Conclusion While the program has performed well both academically and financially, we only have anecdotal evidence that participation in the CAMS program has a positive effect on career choices related to working in the field of child and adolescent mental health, although our survey data strongly suggest that this is the case. For this reason, in fall 2011, we started collecting data as part of a 5-year IRB-approved longitudinal study to determine the extent to which the program positively impacts the career choices of CAMS students. We are also conducting a series of research studies that attempt to evaluate the effectiveness of individual courses on student mental health and well-being. The first paper on Risk and Resilience in Urban Teens is currently under review and demonstrates that students who participated in that course, when compared to students in another CAMS course, experienced reduced perceived stress, better coping skills, and lower scores on a dysfunctional attitudes scale after the fall semester (under review). Further studies are at various stages of planning and design. More than 109,000 students graduate with a degree in psychology every year [29], but very few of them go to medical school. We believe this program provides an opportunity to encourage students whose natural interest is in medicine, psychology, or another helping profession to consider entering the field. We strongly believe in the value of this program and welcome the opportunity to work with other departments
and divisions of Child and Adolescent Psychiatry to start or expand a program of their own. Implications for Educators • Academic medical centers have the opportunity to design and teach undergraduate college courses at affiliated universities and colleges. • Designing a college education program from within an academic medical center’s psychiatry department can result in beneficial research and scholarly opportunities for faculty members and residents. • The design of such a program can also provide much needed financial support for departments of psychiatry. • Department of psychiatry-driven college education programs are likely to steer more college students toward a career in psychiatry and psychology. • Having clinical psychologists and psychiatrists teaching undergraduate students on a college campus will help to increase awareness of mental health issues on campus and may improve students’ mental health.
Disclosure The authors have no conflicts of interest to disclose.
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