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Strengthening the Paediatricians Project 2: The effectiveness of a workshop to address the Priority Mental Health Disorders of adolescence in low-health related human resource countries

Strengthening the Paediatricians Project 2: The effectiveness of a workshop to address the... Background: Paediatricians can be empowered to address the Priority Mental Health Disorders at primary care level. To evaluate the effectiveness of a collaborative workshop in enhancing the adolescent psychiatry knowledge among paediatricians. Methods: A 3-day, 27-hours workshop was held for paediatricians from different regions of India under the auspices of the National Adolescent Paediatric Task Force of the Indian Academy of Paediatrics. A 5-item pretest- posttest questionnaire was developed and administered at the beginning and end of the workshop to evaluate the participants’ knowledge acquisition in adolescent psychiatry. Bivariate and multivariate analyses were performed on an intention-to-participate basis. Results: Forty-eight paediatricians completed the questionnaire. There was significant enhancement of the knowledge in understanding the phenomenology, identifying the psychopathology, diagnosing common mental disorder and selecting the psychotropic medication in the bivariate analysis. When the possible confounders of level of training in paediatrics and number of years spent as paediatrician were controlled, in addition to the above areas of adolescent psychiatry, the diagnostic ability involving multiple psychological concepts also gained significance. However, both in the bivariate and multivariate analyses, the ability to refer to appropriate psychotherapy remained unchanged after the workshop. Conclusions: This workshop was effective in enhancing the adolescent psychiatry knowledge of paediatricians. Such workshops could strengthen paediatricians in addressing the priority mental health disorders at the primary- care level in countries with low-human resource for health as advocated by the World Health Organization. However, it remains to be seen if this acquisition of adolescent psychiatry knowledge results in enhancing their adolescent psychiatry practice. Introduction primary-care paediatricians to use standardized diagnos- In most of the developing countries training in adoles- tic criteria to screen psychiatric disorders in their clini- cent psychiatry are largely limited to mental health spe- cal practice [3] and strengthen them to develop cialists; pediatricians, and other primary care physicians primary-care adolescent mental health services [4]. receive little training. As a result, effective diagnostic, It has been suggested that gaining practical experience treatment and prevention models that have been devel- and training in adolescent psychiatry is an effective way oped are not yet widely applied at the primary-care pae- for the paediatrician to acquire perspectives and skills diatric settings [1,2]. However, it is possible to train that is helpful in hospital or community paediatrics [5]. Many models have been suggested to acquire knowledge and clinical skills by paediatricians, which include a * Correspondence: russell@cmcvellore.ac.in 1 training module in the undergraduate medical training Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore 632 002, Southern India, India © 2010 Russell and Nair; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Russell and Nair Asia Pacific Family Medicine 2010, 9:3 Page 2 of 5 http://www.apfmj.com/content/9/1/3 and postgraduate training in paediatrics, integrating the invited by the NFLLSE facilitated each group. After the child and adolescent psychiatry training program in to pre-workshop assessment of knowledge related to ado- conferences, conducting special workshops and finally as lescent psychiatry, the two morning sessions in the first Continuing Medical Education modules [6]. day introduced the Adolescent Psychiatry as well as It is evident from the mental health burden and systems in mind with their phenomenon and related resources mismatch in developing countries that psychopathology identifiable in a mental status examina- national efforts are required to restructure paediatric tion. The two sessions in the afternoon focused on iden- mental healthcare delivery [7]. Providing training to pae- tifying the psychopathology with case vignettes and diatricians in adolescent psychiatry, whose undergradu- interviewing ‘cases’ (enacted by psychiatrists) for the ate and postgraduate training programs invariably psychopathology. The morning session of the second excludes this discipline, will help tide over the resource day translated the psychopathology noted in the mental paucity [7]. In India, National task Force on Family Life status examination of the ‘cases’ to the International and Life Skill Education (NFLLSE) of the Adolescent Classification of Diseases: Mental and Behavioral Disor- Paediatrics Chapter of the Indian Academy of Paedia- ders (Clinical Descriptions and Diagnostic Guidelines) - trics encourages training in adolescent mental health. As Tenth version (ICD-10) [8] based diagnosis of priority part of the Postgraduate Diploma in Adolescent Paedia- mental health disorders that paediatricians will encoun- trics by Child Development Centre and University of ter. The afternoon session deliberated on PHMD that Kerala a three-day workshop was conducted to address needs non-pharmacological interventions and the non- the training needs of the paediatricians in identifying pharmacological interventions. The forenoon session of and treating the PMHD among adolescents. the third day addressed the PMHD that requires medi- Adolescent Psychiatry training in such special work- cation and pharmacotherapy of these disorders. In the shops may require evidence of their effectiveness, and post-lunch session, the post-workshop assessment was this type of data has been difficult to obtain. In an ear- conducted. lier paper we have studied the need, content and process The process facilitation included didactic teaching of Strengthening the Paediatrician Project, a collabora- using audio-visual materials, interacting with the child tive workshop for paediatricians on adolescent psychia- psychiatrist to clarify their queries, small group case- try with psychiatrists. Here we focus on the effectiveness work up with case vignettes, presenting the case by a of the workshop in enhancing adolescent psychiatry participant from each group supported by the respec- knowledge among paediatricians. tive group member, identifying the psychopathology and diagnosing the PMHD using role plays, conducting Methods diagnostic interviews of the ‘cases’ based on ICD-10 We review only the relevant aspects of our methods diagnosis. Finally of the analysing of the video record- here; an extensive description of the workshop has been ing of the interviews by the members of each group presented in the accompanying paper [6] and details are and then along with their facilitators as well as the reported using the Consolidated criteria for Reporting child psychiatrist for interviewing skills, mental status Qualitative Research (COREQ) guidelines. examination and diagnostic formulation was conducted. Setting and participants Data used in the present analyses are from the Strength- Measure ening the Paediatrician Project (SAPP), a seminal adoles- A brief questionnaire to assess the acquisition of adoles- cent psychiatry workshop to explore the need, content, cent psychiatry knowledge by pediatricians was specifi- process and effectiveness of a workshop for paediatri- cally developed and used. It had five multiple choice cians in collaboration with psychiatrists. The workshop items and each correct endorsement was given a score was conducted at the Child Development Centre, Thiru- of one and thus a score range of 0-5 was possible. Each th st vananthapuram from the 19 to 21 of June 2006 of the five items was intended to evaluate one of the under the auspices of the NFLLSE of the Indian Acad- five areas namely: (1) understanding of the phenomenol- emy of Paediatrics was for 27 hours and spread over ogy, (2) identification of the psychopathology, (3) diag- three days. nosis of the PMHD, (4) selection of the appropriate psychotropic medication and (5) non-pharmacological Interventional Workshop interventions for which appropriate referrals will have to In brief, the content facilitation was done by psychia- be made. The same multiple-choice questions were trists (facilitators) who were proficient in the theory and completed at the beginning of Day 1 before the first ses- practice of psychiatry. The participants were divided in sion began and during the last session of Day 3 before to five groups of about 8-10 each and five psychiatrists the focused group discussion. Russell and Nair Asia Pacific Family Medicine 2010, 9:3 Page 3 of 5 http://www.apfmj.com/content/9/1/3 Data analysis psychopathology, diagnosing the PMHD and selecting The descriptive data was presented in percentages and the psychotropic remained significant as in the bivariate the acquisition of knowledge was analysed using Wil- analysis (Table 1). However, the ability to diagnose dis- coxon Matched-Pairs Signed-Ranks test. Multivariate orders involving multiple psychological concepts gained linear regression was done to adjust for the confounding significance, as the years of experience also significantly effect of the level of paediatric training, and years of confounded the ability to diagnose disorders with multi- experience in paediatric care. To account for the 14.6% ple psychological concepts (P = 0.05). The years of of the participants who left the workshop immediately experience the paediatrician had also significantly con- prior to the closing session to catch commuter and founded the ability to understand phenomenology (P = intercity trains we did an intention- to- participate ana- 0.006). The level of paediatric training did not signifi- lysis where the pretest scores brought forward as the cantly confound any area in the acquisition of knowl- posttest scores for analysis. Significance was set at P < edge among the participants. Despite controlling for the 0.05 (two tailed) and data was analysed using SPSS 11.5. confounders the ability to refer the adolescents for appropriate psychotherapy did not show any significance Results improvement. The participant characteristics are described in the accompanying paper [6]. Discussions We are not aware of any study documenting the effec- Acquisition of knowledge tiveness of an inter-disciplinary collaborative workshop In the bivariate analysis, the overall knowledge of the to enhance the acquisition of adolescent psychiatry paediatricians statistically significantly improved after knowledge among academic and practicing paediatri- the workshop. The maximum gain was in the areas of cians using multimodal training techniques. However, understanding the phenomenology, identifying the psy- the findings from our study are consistent with that of chopathology and diagnosis of common mental disorder other studies found in the pharmacy, nursing and medi- as well as selecting the psychotropic medication. The cal education literature. areas that did not show statistically significant gains were making diagnoses that involved multiple psycholo- Effectiveness of the workshop gical constructs (like the levels of psychological conflict, Our findings suggest that this collaborative, multimodal topography of mind required to differentiate malinger- training approach to teaching is enjoyable and effective ing disorder, factitious disorder and dissociative disor- in the acquisition of theory and clinical skills related to der) and ability to refer for appropriate psychotherapy adolescent psychiatry. The authors speculate that pae- (Table 1). diatricians possibly displayed a positive attitude to learn In the multivariate regression analysis when the possi- adolescent psychiatry even before attending the training ble confounders namely the level of training in paedia- workshop. However, they acquired adolescent psychiatry trics and the number of years of experience in treating knowledge and skill significantly after the workshop. A children were adjusted, the acquisition in overall knowl- statistically significant increase in questionnaire edge, understanding of phenomenology, identifying responseswas observed in 4ofthe 5ofthe questions Table 1 The change in child and adolescent psychiatry knowledge of paediatricians following the three day workshop. Item Pre Post Unadjusted P Adjusted P workshop workshop difference Value difference Value Mean (sd) Mean (sd) Z value b(SE) value 1. When an adolescent says that he has been hearing people talk bad 0.40(0.49) 0.57(0.50) -2.5 0.01 1.0(0.27) 0.001 things about him when no one is talking about him, when he is fully awake and conscious. What is this phenomenology? 2. When an adolescent complaints to you about racing of thoughts, what 0.37(0.49) 0.53(0.50) -2.9 0.004 1.6(0.32) 0.001 psychiatric disorder is this psychopathology suggestive of? 3. What is your medication of choice for depression among adolescents? 0.28(0.45) 0.52(0.50) -3.5 0.001 1.4(0.28) 0.001 4. When an adolescent girl comes to you with weakness of her right hand 0.10(0.30) 0.20(0.40) -1.7 0.08 1.3(0.29) 0.001 and all the lab investigations are normal and has significant stressful life events, what is her possible psychiatric diagnosis? 5. What form of psychotherapy is cognitive therapy? 0.18(0.39) 0.22(0.41) -5.3 0.5 0.17(0.32) 0.5 Total score 1.33(1.44) 2.0(1.7) -4.0 0.001 1.7(0.36) 0.001 = adjusted for level of training in paediatrics and number of years spent as paediatrician Russell and Nair Asia Pacific Family Medicine 2010, 9:3 Page 4 of 5 http://www.apfmj.com/content/9/1/3 and therefore, it can be concluded that there was a rela- impact of the entire multi-element workshop, no con- tionship between the training intervention and the clusions could be drawn for the individual elements of increase in knowledge for all but one area. the intervention such as the didactic sessions, case-vign- When the mental illnesses addressed in the workshop ettes, simulated case workups, or video feedbacks. were viewed from a biopsychosocial perspective, the sig- Which of these intervention elements had the most nificant increase in knowledge of phenomenology, diag- impact on increasing the knowledge is conjectural. The nosis and pharmacological management (medical study should also be extended to other teaching settings constructs of mental illnesses) and insignificant (like conference and CME programs) and the teaching improvement of knowledge in psychological manage- elements themselves could then be modified to include ment and referral for psychotherapy (psychosocial con- other methods designed to specifically address these set- structs of mental illnesses) suggest that the workshop tings (real cases in CME programs). In the future, based was more successful at increasing ‘medical constructs’ on the positive response, this multimodal training with a and less successful at changing ‘psychosocial constructs’ collaborative approach will be continued in the Post- of the paediatricians relevant to adolescent psychiatry. graduate Diploma in Adolescent Paediatric health train- ing program at Child Development Centre. The next Recommendations to paediatric education learning experience will occur in our Postgraduate Research on the outcomes of educational improvement Diploma in Developmental Neurology program in which interventions can be utilized to strengthen the theoretical neurologistwilllearn basictheoryand practiceofado- basis for required regulatory training as well as to validate lescent psychiatry. interventions for health-care education. This knowledge and skill acquisition suggests that when this adolescent Limitations psychiatry module is added in the various training pro- The main caveats of this study are the specific nature of cesses like postgraduate training or CME successfully the training subject and the nature of the population. increase the knowledge towards the identification of psy- Firstly, the study assumed that the choice of data gath- chopathology, a classificatory system based diagnosis of ering instruments was appropriate for the task at hand. disorders, psychopharmacological management and feasi- While the present study utilized a specific set of knowl- ble psychological interventions or referrals as recom- edge evaluation questions that concentrated on what the mended by World Health Organization [7]. Also, interdisciplinary team believed represented appropriate continual assessment of participants’ knowledge with such concerns of paediatricians facing adolescent mental learning experience will occur so that we can incorporate health issues at the primary care level, all of the specific this into appropriate areas of the paediatric training. Other needs of the paediatricians at different practice settings potential uses for this multimodal training tool are in were notassessedduring thisstudy.Anexpandedand assessing participants’ communication skills, either with validated knowledge evaluation instrument could be the patient, family members or other health care profes- beneficial in identifying real knowledge acquisition. Sec- sionals. Also, this workshop may provide continuing edu- ondly, this study teases out the adolescent psychiatry cation opportunities for senior paediatric faculty component of a multicomponent workshop for mea- responding to policy needs in institutional settings. surement and therefore lack of a comprehensive mea- sure inclusive of the various components of the Recommendations for paediatric practice workshop could have negatively affected the perfor- The workshop elements focused strongly on cognitive mance of the participant in answering the questionnaire. knowledge, with the assumption that an increase in Finally, as this study utilized voluntary participation knowledge would result in a concomitant improvement rather than specific random sampling, extensions of of attitudes, and practicing skills. It may be possible to these conclusions to other paediatricians are under- develop an additional training element that specifically standably weakened as possibly paediatricians motivated addresses underlying assumptions and fears that can to learn the discipline of adolescent psychiatry only compromise the clinical skills that should emerge from responded. the knowledge gained. Such a training workshop might In conclusion, this model of inter-disciplinary colla- utilize open discussions or hands-on approaches. The borative, multimodal educational workshop is effective addition of a clinical psychologist to the multidisciplin- in enhancing the adolescent psychiatry knowledge ary training team may improve the outcome. among paediatricians. However, it remains to be seen if the paediatricians are able to retain the acquired knowl- Recommendations for future research edge of adolescent psychiatry and apply in their clinical Further research is needed to focus on the specific com- practice as well. If such information retention and appli- ponents of the workshop. While this study evaluated the cation follows, this model of strengthening the Russell and Nair Asia Pacific Family Medicine 2010, 9:3 Page 5 of 5 http://www.apfmj.com/content/9/1/3 paediatricians can partly help reinforce the efforts of doi:10.1186/1447-056X-9-3 WHO in addressing the Priority Mental Health Disor- Cite this article as: Russell and Nair: Strengthening the Paediatricians ders among the adolescents. Further studies to explore Project 2: The effectiveness of a workshop to address the Priority Mental Health if the acquired adolescent psychiatry knowledge is Disorders of adolescence in low-health related human resource applied and thus integrated in clinical practice are countries. Asia Pacific Family Medicine 2010 9:3. required. List of abbreviations CME: Continuing the Medical Education; ICD-10: Inter- national Classification of Diseases: Mental and Beha- vioral Disorders (Clinical Descriptions and Diagnostic Guidelines) - Tenth version; NFLLSE: National task Force on Family Life and Life Skill Education; PMHD: Priority Mental Health Disorders; SAPP: Strengthening the Paediatrician Project. Author details Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore 632 002, Southern India, India. Child Development Centre, Thiruvananthapuram Medical College, Thiruvananthapuram 695 011, Southern India, India. Authors’ contributions PSSR was involved in the conception, designing, data analysis and interpretation, drafting and approving the final version. NMKC was involved in the conception, drafting and revising the final draft. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 23 July 2008 Accepted: 18 February 2010 Published: 18 February 2010 References 1. Coyle JT, Pine DS, Charney DS, Lewis L, Nemeroff CB, Carlson GA, Joshi PT, Reiss D, Todd RD, Hellander M: Depression and Bipolar Support Alliance Consensus Development Panel. Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents. J Am Acad Child Adolesc Psychiatry 2003, 42:1494-1503. 2. Gardner W, Kelleher KJ, Pajer KA, Campo JV: Primary care clinicians’ use of standardized psychiatric diagnoses. Child Care Health Dev 2004, 30:401-412. 3. Weitzman CC, Leventhal JM: Screening for behavioral health problems in primary care. Curr Opin Pediatr 2006, 18:641-648. 4. Ani C, Garralda E: Developing primary mental healthcare for children and adolescents. Curr Opin Psychiatry 2005, 18:440-444. 5. Whitehouse W: Child psychiatry and the paediatrician in training. Child Care Health Dev 1990, 16:197-203. 6. Nair MK, Russell PS: Strengthening the Paediatricians Project 1: The need, content and process of a workshop to address the priority mental Submit your next manuscript to BioMed Central health disorders of adolescence in low-human resource countries. Hum and take full advantage of: Resour Health 2007. 7. Caring for children and adolescents with mental disorders. Setting WHO directions. World Health Organization, Geneva 2003. • Convenient online submission 8. World Health Organization: The International Classification of Disease • Thorough peer review (ICD-10): Classification of Mental and Behavioral Disorders. Clinical • No space constraints or color figure charges Descriptions and Diagnostic Guidelines. Geneva, World Health Organization 1992. • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Strengthening the Paediatricians Project 2: The effectiveness of a workshop to address the Priority Mental Health Disorders of adolescence in low-health related human resource countries

Asia Pacific Family Medicine , Volume 9 (1) – Feb 18, 2010

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Copyright © 2010 by Russell and Nair; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/1447-056X-9-3
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20167069
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Abstract

Background: Paediatricians can be empowered to address the Priority Mental Health Disorders at primary care level. To evaluate the effectiveness of a collaborative workshop in enhancing the adolescent psychiatry knowledge among paediatricians. Methods: A 3-day, 27-hours workshop was held for paediatricians from different regions of India under the auspices of the National Adolescent Paediatric Task Force of the Indian Academy of Paediatrics. A 5-item pretest- posttest questionnaire was developed and administered at the beginning and end of the workshop to evaluate the participants’ knowledge acquisition in adolescent psychiatry. Bivariate and multivariate analyses were performed on an intention-to-participate basis. Results: Forty-eight paediatricians completed the questionnaire. There was significant enhancement of the knowledge in understanding the phenomenology, identifying the psychopathology, diagnosing common mental disorder and selecting the psychotropic medication in the bivariate analysis. When the possible confounders of level of training in paediatrics and number of years spent as paediatrician were controlled, in addition to the above areas of adolescent psychiatry, the diagnostic ability involving multiple psychological concepts also gained significance. However, both in the bivariate and multivariate analyses, the ability to refer to appropriate psychotherapy remained unchanged after the workshop. Conclusions: This workshop was effective in enhancing the adolescent psychiatry knowledge of paediatricians. Such workshops could strengthen paediatricians in addressing the priority mental health disorders at the primary- care level in countries with low-human resource for health as advocated by the World Health Organization. However, it remains to be seen if this acquisition of adolescent psychiatry knowledge results in enhancing their adolescent psychiatry practice. Introduction primary-care paediatricians to use standardized diagnos- In most of the developing countries training in adoles- tic criteria to screen psychiatric disorders in their clini- cent psychiatry are largely limited to mental health spe- cal practice [3] and strengthen them to develop cialists; pediatricians, and other primary care physicians primary-care adolescent mental health services [4]. receive little training. As a result, effective diagnostic, It has been suggested that gaining practical experience treatment and prevention models that have been devel- and training in adolescent psychiatry is an effective way oped are not yet widely applied at the primary-care pae- for the paediatrician to acquire perspectives and skills diatric settings [1,2]. However, it is possible to train that is helpful in hospital or community paediatrics [5]. Many models have been suggested to acquire knowledge and clinical skills by paediatricians, which include a * Correspondence: russell@cmcvellore.ac.in 1 training module in the undergraduate medical training Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore 632 002, Southern India, India © 2010 Russell and Nair; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Russell and Nair Asia Pacific Family Medicine 2010, 9:3 Page 2 of 5 http://www.apfmj.com/content/9/1/3 and postgraduate training in paediatrics, integrating the invited by the NFLLSE facilitated each group. After the child and adolescent psychiatry training program in to pre-workshop assessment of knowledge related to ado- conferences, conducting special workshops and finally as lescent psychiatry, the two morning sessions in the first Continuing Medical Education modules [6]. day introduced the Adolescent Psychiatry as well as It is evident from the mental health burden and systems in mind with their phenomenon and related resources mismatch in developing countries that psychopathology identifiable in a mental status examina- national efforts are required to restructure paediatric tion. The two sessions in the afternoon focused on iden- mental healthcare delivery [7]. Providing training to pae- tifying the psychopathology with case vignettes and diatricians in adolescent psychiatry, whose undergradu- interviewing ‘cases’ (enacted by psychiatrists) for the ate and postgraduate training programs invariably psychopathology. The morning session of the second excludes this discipline, will help tide over the resource day translated the psychopathology noted in the mental paucity [7]. In India, National task Force on Family Life status examination of the ‘cases’ to the International and Life Skill Education (NFLLSE) of the Adolescent Classification of Diseases: Mental and Behavioral Disor- Paediatrics Chapter of the Indian Academy of Paedia- ders (Clinical Descriptions and Diagnostic Guidelines) - trics encourages training in adolescent mental health. As Tenth version (ICD-10) [8] based diagnosis of priority part of the Postgraduate Diploma in Adolescent Paedia- mental health disorders that paediatricians will encoun- trics by Child Development Centre and University of ter. The afternoon session deliberated on PHMD that Kerala a three-day workshop was conducted to address needs non-pharmacological interventions and the non- the training needs of the paediatricians in identifying pharmacological interventions. The forenoon session of and treating the PMHD among adolescents. the third day addressed the PMHD that requires medi- Adolescent Psychiatry training in such special work- cation and pharmacotherapy of these disorders. In the shops may require evidence of their effectiveness, and post-lunch session, the post-workshop assessment was this type of data has been difficult to obtain. In an ear- conducted. lier paper we have studied the need, content and process The process facilitation included didactic teaching of Strengthening the Paediatrician Project, a collabora- using audio-visual materials, interacting with the child tive workshop for paediatricians on adolescent psychia- psychiatrist to clarify their queries, small group case- try with psychiatrists. Here we focus on the effectiveness work up with case vignettes, presenting the case by a of the workshop in enhancing adolescent psychiatry participant from each group supported by the respec- knowledge among paediatricians. tive group member, identifying the psychopathology and diagnosing the PMHD using role plays, conducting Methods diagnostic interviews of the ‘cases’ based on ICD-10 We review only the relevant aspects of our methods diagnosis. Finally of the analysing of the video record- here; an extensive description of the workshop has been ing of the interviews by the members of each group presented in the accompanying paper [6] and details are and then along with their facilitators as well as the reported using the Consolidated criteria for Reporting child psychiatrist for interviewing skills, mental status Qualitative Research (COREQ) guidelines. examination and diagnostic formulation was conducted. Setting and participants Data used in the present analyses are from the Strength- Measure ening the Paediatrician Project (SAPP), a seminal adoles- A brief questionnaire to assess the acquisition of adoles- cent psychiatry workshop to explore the need, content, cent psychiatry knowledge by pediatricians was specifi- process and effectiveness of a workshop for paediatri- cally developed and used. It had five multiple choice cians in collaboration with psychiatrists. The workshop items and each correct endorsement was given a score was conducted at the Child Development Centre, Thiru- of one and thus a score range of 0-5 was possible. Each th st vananthapuram from the 19 to 21 of June 2006 of the five items was intended to evaluate one of the under the auspices of the NFLLSE of the Indian Acad- five areas namely: (1) understanding of the phenomenol- emy of Paediatrics was for 27 hours and spread over ogy, (2) identification of the psychopathology, (3) diag- three days. nosis of the PMHD, (4) selection of the appropriate psychotropic medication and (5) non-pharmacological Interventional Workshop interventions for which appropriate referrals will have to In brief, the content facilitation was done by psychia- be made. The same multiple-choice questions were trists (facilitators) who were proficient in the theory and completed at the beginning of Day 1 before the first ses- practice of psychiatry. The participants were divided in sion began and during the last session of Day 3 before to five groups of about 8-10 each and five psychiatrists the focused group discussion. Russell and Nair Asia Pacific Family Medicine 2010, 9:3 Page 3 of 5 http://www.apfmj.com/content/9/1/3 Data analysis psychopathology, diagnosing the PMHD and selecting The descriptive data was presented in percentages and the psychotropic remained significant as in the bivariate the acquisition of knowledge was analysed using Wil- analysis (Table 1). However, the ability to diagnose dis- coxon Matched-Pairs Signed-Ranks test. Multivariate orders involving multiple psychological concepts gained linear regression was done to adjust for the confounding significance, as the years of experience also significantly effect of the level of paediatric training, and years of confounded the ability to diagnose disorders with multi- experience in paediatric care. To account for the 14.6% ple psychological concepts (P = 0.05). The years of of the participants who left the workshop immediately experience the paediatrician had also significantly con- prior to the closing session to catch commuter and founded the ability to understand phenomenology (P = intercity trains we did an intention- to- participate ana- 0.006). The level of paediatric training did not signifi- lysis where the pretest scores brought forward as the cantly confound any area in the acquisition of knowl- posttest scores for analysis. Significance was set at P < edge among the participants. Despite controlling for the 0.05 (two tailed) and data was analysed using SPSS 11.5. confounders the ability to refer the adolescents for appropriate psychotherapy did not show any significance Results improvement. The participant characteristics are described in the accompanying paper [6]. Discussions We are not aware of any study documenting the effec- Acquisition of knowledge tiveness of an inter-disciplinary collaborative workshop In the bivariate analysis, the overall knowledge of the to enhance the acquisition of adolescent psychiatry paediatricians statistically significantly improved after knowledge among academic and practicing paediatri- the workshop. The maximum gain was in the areas of cians using multimodal training techniques. However, understanding the phenomenology, identifying the psy- the findings from our study are consistent with that of chopathology and diagnosis of common mental disorder other studies found in the pharmacy, nursing and medi- as well as selecting the psychotropic medication. The cal education literature. areas that did not show statistically significant gains were making diagnoses that involved multiple psycholo- Effectiveness of the workshop gical constructs (like the levels of psychological conflict, Our findings suggest that this collaborative, multimodal topography of mind required to differentiate malinger- training approach to teaching is enjoyable and effective ing disorder, factitious disorder and dissociative disor- in the acquisition of theory and clinical skills related to der) and ability to refer for appropriate psychotherapy adolescent psychiatry. The authors speculate that pae- (Table 1). diatricians possibly displayed a positive attitude to learn In the multivariate regression analysis when the possi- adolescent psychiatry even before attending the training ble confounders namely the level of training in paedia- workshop. However, they acquired adolescent psychiatry trics and the number of years of experience in treating knowledge and skill significantly after the workshop. A children were adjusted, the acquisition in overall knowl- statistically significant increase in questionnaire edge, understanding of phenomenology, identifying responseswas observed in 4ofthe 5ofthe questions Table 1 The change in child and adolescent psychiatry knowledge of paediatricians following the three day workshop. Item Pre Post Unadjusted P Adjusted P workshop workshop difference Value difference Value Mean (sd) Mean (sd) Z value b(SE) value 1. When an adolescent says that he has been hearing people talk bad 0.40(0.49) 0.57(0.50) -2.5 0.01 1.0(0.27) 0.001 things about him when no one is talking about him, when he is fully awake and conscious. What is this phenomenology? 2. When an adolescent complaints to you about racing of thoughts, what 0.37(0.49) 0.53(0.50) -2.9 0.004 1.6(0.32) 0.001 psychiatric disorder is this psychopathology suggestive of? 3. What is your medication of choice for depression among adolescents? 0.28(0.45) 0.52(0.50) -3.5 0.001 1.4(0.28) 0.001 4. When an adolescent girl comes to you with weakness of her right hand 0.10(0.30) 0.20(0.40) -1.7 0.08 1.3(0.29) 0.001 and all the lab investigations are normal and has significant stressful life events, what is her possible psychiatric diagnosis? 5. What form of psychotherapy is cognitive therapy? 0.18(0.39) 0.22(0.41) -5.3 0.5 0.17(0.32) 0.5 Total score 1.33(1.44) 2.0(1.7) -4.0 0.001 1.7(0.36) 0.001 = adjusted for level of training in paediatrics and number of years spent as paediatrician Russell and Nair Asia Pacific Family Medicine 2010, 9:3 Page 4 of 5 http://www.apfmj.com/content/9/1/3 and therefore, it can be concluded that there was a rela- impact of the entire multi-element workshop, no con- tionship between the training intervention and the clusions could be drawn for the individual elements of increase in knowledge for all but one area. the intervention such as the didactic sessions, case-vign- When the mental illnesses addressed in the workshop ettes, simulated case workups, or video feedbacks. were viewed from a biopsychosocial perspective, the sig- Which of these intervention elements had the most nificant increase in knowledge of phenomenology, diag- impact on increasing the knowledge is conjectural. The nosis and pharmacological management (medical study should also be extended to other teaching settings constructs of mental illnesses) and insignificant (like conference and CME programs) and the teaching improvement of knowledge in psychological manage- elements themselves could then be modified to include ment and referral for psychotherapy (psychosocial con- other methods designed to specifically address these set- structs of mental illnesses) suggest that the workshop tings (real cases in CME programs). In the future, based was more successful at increasing ‘medical constructs’ on the positive response, this multimodal training with a and less successful at changing ‘psychosocial constructs’ collaborative approach will be continued in the Post- of the paediatricians relevant to adolescent psychiatry. graduate Diploma in Adolescent Paediatric health train- ing program at Child Development Centre. The next Recommendations to paediatric education learning experience will occur in our Postgraduate Research on the outcomes of educational improvement Diploma in Developmental Neurology program in which interventions can be utilized to strengthen the theoretical neurologistwilllearn basictheoryand practiceofado- basis for required regulatory training as well as to validate lescent psychiatry. interventions for health-care education. This knowledge and skill acquisition suggests that when this adolescent Limitations psychiatry module is added in the various training pro- The main caveats of this study are the specific nature of cesses like postgraduate training or CME successfully the training subject and the nature of the population. increase the knowledge towards the identification of psy- Firstly, the study assumed that the choice of data gath- chopathology, a classificatory system based diagnosis of ering instruments was appropriate for the task at hand. disorders, psychopharmacological management and feasi- While the present study utilized a specific set of knowl- ble psychological interventions or referrals as recom- edge evaluation questions that concentrated on what the mended by World Health Organization [7]. Also, interdisciplinary team believed represented appropriate continual assessment of participants’ knowledge with such concerns of paediatricians facing adolescent mental learning experience will occur so that we can incorporate health issues at the primary care level, all of the specific this into appropriate areas of the paediatric training. Other needs of the paediatricians at different practice settings potential uses for this multimodal training tool are in were notassessedduring thisstudy.Anexpandedand assessing participants’ communication skills, either with validated knowledge evaluation instrument could be the patient, family members or other health care profes- beneficial in identifying real knowledge acquisition. Sec- sionals. Also, this workshop may provide continuing edu- ondly, this study teases out the adolescent psychiatry cation opportunities for senior paediatric faculty component of a multicomponent workshop for mea- responding to policy needs in institutional settings. surement and therefore lack of a comprehensive mea- sure inclusive of the various components of the Recommendations for paediatric practice workshop could have negatively affected the perfor- The workshop elements focused strongly on cognitive mance of the participant in answering the questionnaire. knowledge, with the assumption that an increase in Finally, as this study utilized voluntary participation knowledge would result in a concomitant improvement rather than specific random sampling, extensions of of attitudes, and practicing skills. It may be possible to these conclusions to other paediatricians are under- develop an additional training element that specifically standably weakened as possibly paediatricians motivated addresses underlying assumptions and fears that can to learn the discipline of adolescent psychiatry only compromise the clinical skills that should emerge from responded. the knowledge gained. Such a training workshop might In conclusion, this model of inter-disciplinary colla- utilize open discussions or hands-on approaches. The borative, multimodal educational workshop is effective addition of a clinical psychologist to the multidisciplin- in enhancing the adolescent psychiatry knowledge ary training team may improve the outcome. among paediatricians. However, it remains to be seen if the paediatricians are able to retain the acquired knowl- Recommendations for future research edge of adolescent psychiatry and apply in their clinical Further research is needed to focus on the specific com- practice as well. If such information retention and appli- ponents of the workshop. While this study evaluated the cation follows, this model of strengthening the Russell and Nair Asia Pacific Family Medicine 2010, 9:3 Page 5 of 5 http://www.apfmj.com/content/9/1/3 paediatricians can partly help reinforce the efforts of doi:10.1186/1447-056X-9-3 WHO in addressing the Priority Mental Health Disor- Cite this article as: Russell and Nair: Strengthening the Paediatricians ders among the adolescents. Further studies to explore Project 2: The effectiveness of a workshop to address the Priority Mental Health if the acquired adolescent psychiatry knowledge is Disorders of adolescence in low-health related human resource applied and thus integrated in clinical practice are countries. Asia Pacific Family Medicine 2010 9:3. required. List of abbreviations CME: Continuing the Medical Education; ICD-10: Inter- national Classification of Diseases: Mental and Beha- vioral Disorders (Clinical Descriptions and Diagnostic Guidelines) - Tenth version; NFLLSE: National task Force on Family Life and Life Skill Education; PMHD: Priority Mental Health Disorders; SAPP: Strengthening the Paediatrician Project. Author details Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore 632 002, Southern India, India. Child Development Centre, Thiruvananthapuram Medical College, Thiruvananthapuram 695 011, Southern India, India. Authors’ contributions PSSR was involved in the conception, designing, data analysis and interpretation, drafting and approving the final version. NMKC was involved in the conception, drafting and revising the final draft. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 23 July 2008 Accepted: 18 February 2010 Published: 18 February 2010 References 1. Coyle JT, Pine DS, Charney DS, Lewis L, Nemeroff CB, Carlson GA, Joshi PT, Reiss D, Todd RD, Hellander M: Depression and Bipolar Support Alliance Consensus Development Panel. Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents. J Am Acad Child Adolesc Psychiatry 2003, 42:1494-1503. 2. Gardner W, Kelleher KJ, Pajer KA, Campo JV: Primary care clinicians’ use of standardized psychiatric diagnoses. Child Care Health Dev 2004, 30:401-412. 3. Weitzman CC, Leventhal JM: Screening for behavioral health problems in primary care. Curr Opin Pediatr 2006, 18:641-648. 4. Ani C, Garralda E: Developing primary mental healthcare for children and adolescents. Curr Opin Psychiatry 2005, 18:440-444. 5. Whitehouse W: Child psychiatry and the paediatrician in training. Child Care Health Dev 1990, 16:197-203. 6. Nair MK, Russell PS: Strengthening the Paediatricians Project 1: The need, content and process of a workshop to address the priority mental Submit your next manuscript to BioMed Central health disorders of adolescence in low-human resource countries. Hum and take full advantage of: Resour Health 2007. 7. Caring for children and adolescents with mental disorders. Setting WHO directions. World Health Organization, Geneva 2003. • Convenient online submission 8. World Health Organization: The International Classification of Disease • Thorough peer review (ICD-10): Classification of Mental and Behavioral Disorders. Clinical • No space constraints or color figure charges Descriptions and Diagnostic Guidelines. Geneva, World Health Organization 1992. • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

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Asia Pacific Family MedicineSpringer Journals

Published: Feb 18, 2010

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