The DSM-5: An Opportunity to Affirm “The Whole Child” Concept in Child and Adolescent Psychiatric Residency Training
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- Dingle, A.D. Acad Psychiatry (2014) 38: 64. doi:10.1007/s40596-013-0007-5
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This article summarizes a 2013 American Psychiatric Association annual meeting presentation on the incorporation of the DSM-5 into child and adolescent psychiatric residency training with focus on the potential benefits of the DSM-5 for medical education.
KeywordsMedical educationChild psychiatryAssessmentLifelong learning
This article summarizes a 2013 American Psychiatric Association annual meeting presentation on the incorporation of the DSM-5 into child and adolescent psychiatric (CAP) residency training. This talk focused on the potential benefits of the DSM-5 arguing that learning, implementing, and teaching a revised diagnostic classification of psychiatric illnesses provides an opportunity for training programs and faculty to revise and enhance teaching on the evaluation and care of children and adolescents and demonstrate the practices and skills of physician lifelong learning.
Teaching residents about the psychiatric care of youth is challenging. Due to multiple pressures, often related to finances, resources, and time, clinical assessment often focuses on psychiatric symptoms with less attention paid to the narrative of individuals’ lives. Having to use a new DSM means that some assessment content has to change; this alteration offers a chance to revisit the format and approach to caring for youth. The enhanced developmental focus of the DSM-5 supports a renewed emphasis on using diagnostic criteria in conjunction with information on development and context to assess “the whole child” and gather the story of the child’s life from patient and family interviews and use this information on an ongoing basis during treatment.
Additionally, the implementation of the DSM-5 provides a framework to demonstrate and reinforce the tenets and practices of physician lifelong learning. Given the significance of the DSM to psychiatric practice, its implementation will require psychiatrists to revise their concepts of various disorders, and this will impact their diagnostic and treatment practices. Faculty must be able to demonstrate approaches and strategies to learning a significant amount of new information and assimilating it into the existing body of knowledge and skills. Whereas the new DSM has made some significant modifications in the classification system and obviously will impact psychiatric practice, being able to learn and teach phenomena that enhance our understanding of youth and psychiatric illness is an essential aspect of practice. For example, over the last few decades, the field of child and adolescent psychiatry has incorporated major changes in basic perspectives on children (e.g., children’s rights) and how treatment is provided (e.g., increased effective psychopharmacology and expanded evidence based treatments) to improve practice. Developing an effective, adaptable strategy to incorporate and disseminate new information and skills while maintaining core knowledge and abilities is an essential proficiency for effective practitioners.
Accurate psychiatric diagnoses in children and adolescents can be quite challenging. At younger ages, children have limited modes of expression, particularly about internal psychological and cognitive states. Often, developmental and environmental influences have significant impact. A DSM diagnosis may capture the child’s emotions, thoughts, and behavior but not convey the context. It can be difficult to fit a particular child’s problem into one diagnosis, which sometimes leads to multiple diagnoses simultaneously or over time.
Psychiatric assessments should result in coherent, integrated overviews that describe individuals, their current lives, personal histories, and circumstances; detail psychopathology, including the relevant biological, psychological, and social factors that are producing, perpetuating, and mitigating symptoms; address factors related to resilience; and describe current and possible levels of functioning. Children and adolescents require particular attention to environmental factors, circumstances, and relationships because of their developmental and legal status vulnerabilities. In conjunction with an evaluation of developmental and environmental characteristics, the DSM-5 classification provides a framework to describe and conceptualize the emotional and behavioral issues of children and adolescents that can inform and guide treatment.
Because training programs and faculty will have to modify educational experiences to include the content and application of the DSM-5, it is an ideal opportunity to reconsider other aspects of the patient evaluation process. For example, there is more to assessment than diagnosis, diagnostic certainty is rarely possible quickly, children and adolescents cannot be evaluated out of context, and interviewing and assessment skills require practice over time. Often spending more time initially to learn about the patient, family, and circumstances and focus the assessment on the appropriate priorities saves time in the long run and also provides better care. Educators can take the occasion of a new diagnostic scheme to ensure that clinical models and structures emphasize that assessment is not a one size fits all activity. Some assessment goals vary depending on clinical setting though all require considerations of diagnosis, treatment needs, and relevant psychosocial and environmental factors. For example, evaluations in an emergency situation require a different focus than those to determine the best ongoing outpatient treatment, but all necessitate a good understanding of the youth’s life and circumstances.
Another key aspect of evaluation and treatment is developing rapport with the individuals being seen. Engaging the youth, family, and relevant others effectively can be challenging due to differing developmental levels, desire to participate, perspectives on the problems, and goals for the intervention. Medical educators have developed an effective understanding of how to analyze, teach, and assess engagement skills. However, the evolution of the DSM and other changes in the practice of medicine have led to an increasing tendency to focus on obtaining signs and symptoms of psychopathology as the objective rather than collecting information to understand psychiatric difficulties as one aspect of an individual’s life and functioning. Knowledge from clinical literature and consensus support the idea that individuals and their families are more likely to be engaged and develop effective therapeutic relationships when they believe that the clinician views and understands them as people with lives. The DSM-5 has an increased emphasis on the impact of factors such as gender, culture, and society on diagnosis. This awareness could be utilized by programs and faculty to retool clinical teaching and practice; data on psychiatric symptomatology and functioning could be consistently acquired as one of several components of functioning. For example, one approach would be obtaining personal and psychosocial information before asking about psychiatric symptoms [1, 2].
Being difficult, inconvenient, expensive, and unpredictable is not the same as being pathologic, and appreciating the spectrum of abilities and behaviors that are considered to be developmentally typical is an essential skill for a practicing child and adolescent psychiatrist. Distinguishing between developmental phenomena and psychiatric illness can be challenging, especially in young children. Children and adolescents often exhibit behavior that is difficult to manage, immature developmentally in certain areas, and a mismatch with environmental expectations. However, they may still be within the range of typical development. Whether a child or adolescent with emotional or behavioral problems has a psychiatric disorder or is developing typically but with certain characteristics (e.g., socially awkward) may be unclear.
Unfortunately, in many situations, individuals must be diagnosed with a psychiatric disorder to receive intervention. Those involved with children and adolescents tend to be biased towards intervening at any level of impairment with the aim of getting the child or adolescent to function optimally. For example, should all socially inept youth have educational modifications and enhancements to improve their school and social experiences? Most practitioners think that children and adolescents should be supported so that they can “live up to their potential,” and a misunderstanding of developmental factors may lead youth to be misdiagnosed or mislabeled as psychiatrically ill .
The DSM-5 emphasizes development in the organization of the manual, categorization of the disorders, and the description of diagnostic criteria. Additionally, the manual’s discussion of the dimensional aspects of psychopathology more closely matches how development is conceptualized and understood, making it easier to apply both in clinical situations. Implementing the DSM-5 provides an opportunity to examine and support strategies to teach and include development as a key element in CAP education and practice. For example, a true understanding of development and its interface with psychopathology requires exposure to and interaction with typical children and adolescents in their usual environments, such as daycare, schools, and recreational programs to understand individual and group behavior as well as societal and cultural expectations for youth. The DSM has the potential to be a strong justification for providing these types of activities in CAP residency training .
Medicine has traditionally held its practitioners to a standard, which involves participation in ongoing education to maintain and enhance their clinical knowledge and skills. Over the last decade, this aspect of practice has been more rigorously defined with clearer expectations, procedures, and oversight. Teaching residents how to develop and incorporate these skills as a routine part of practice is essential. Often, faculty members are in the position of teaching residents about this expectation but not modeling it because faculty members tend to be perceived as experts. Yet, our faculty members will have to learn and use the DSM-5 along with the trainees, demonstrating lifelong learning.
Clinical teachers must simultaneously foster high-quality patient care while assessing learner clinical skills and reasoning and promoting learner progress towards independence in the clinical setting. They must diagnose the patient’s clinical problems as well as the learner’s ability and skill and provide interventions to help both reach their goals. The implementation of the DSM-5 brings up the issue of how to teach something one is simultaneously learning. Possible approaches include learning with trainees and modeling personal learning strategies. Faculty members can explain and demonstrate the process by which they modify existing diagnostic frameworks when new information is available and how to be effective and competent even when having to look up information. Clinical educators can practice with and without patients as well as practice with and without trainees. They can systematically review the changes in DSM-5 and the impact on practice. Using peer supervision and collaboration remains an effective strategy to learn and teach [5–7].
Incorporating the DSM-5 into CAP training is an exciting opportunity to refine and inform several aspects of education, specifically assessment, development, and lifelong learning. This diagnostic classification is best used for clinical care and education as one component of an assessment framework that includes clinician skills, interviewing abilities, and information integration and formulation. It can also be used to understand and teach about a youth’s development, psychosocial context, environment, problems, and functioning, as well as the interaction between development and psychopathology. The introduction of the DSM-5 is an opportunity to formally discuss how diagnostic classification systems are conceptualized and developed, their strengths and weaknesses, and how these systems reflect and influence our concepts of psychiatric illnesses and their care. It also can help trainees enhance and refine their knowledge and skills, as well as develop and maintain the ability to be flexible, problem solve, and prioritize in clinical situations. Finally, residency programs can use the DSM-5 as an impetus to encourage faculty to openly demonstrate learning new knowledge and applying it in clinical situations.
The author would like to thank Mary Beth Lake, MD; Elisabeth Guthrie, MD; and Tami Benton, MD, who were instrumental in an earlier version of this talk.
Implications for Academic Leaders
• To review and revise the structure, content, and support of faculty development in teaching and lifelong learning
• To assess and improve models of clinical care that involve faculty and trainees
Implications for Educators
• To emphasize the importance of development and the “whole child”
• To review and revise the structure and content of teaching, particularly in the areas of psychopathology and assessment
• For the faculty to be role models, demonstrating the importance and practice of lifelong learning