System-of-care initiatives for child mental health services have become more common throughout the United States for addressing the needs of seriously emotionally disturbed youths and their families. As communities attempt to implement these initiatives, the lack of sufficiently trained staff becomes more apparent. Indeed, in order for system-of-care principles to be implemented, there needs to be a change in how services are delivered. One way to promote change is to focus on training by altering the curriculum in professional training programs.
In 1986, Stroul and Friedman (1) provided the foundation on which system-of-care principles are based. The principles of the Child and Adolescent Services System Program (CASSP) are philosophical concepts that describe the focus of a system of care as providing integrated care that is family centered, child focused, culturally competent, and community based. Once these principles were delineated, guidelines to inform their implementation in service delivery were needed.
In this column I discuss the guidelines available to address system-of-care training and describe its implementation in the training program of our university psychiatry department as an example.
The American Academy of Child and Adolescent Psychiatry (AACAP) task force on community-based systems of care has developed guidelines for residency programs to use in implementing educational experiences and promoting competencies that are needed to function in systems of care (2). This document begins by describing the characteristics of community-based systems of care, including basic principles, levels of care, and the roles of child and adolescent psychiatrists. Included are guidelines that address specific knowledge, skills, attitudes, clinical and didactic curricula, supervision and mentorship, and interdisciplinary training. The task force also made recommendations on evaluating curriculum implementation.
Another set of guidelines was developed through the Pennsylvania CASSP Training and Technical Institute (3). These guidelines specify child, family, and community core competencies that involve the basic knowledge and skills needed to use system-of-care principles in practice.
The impetus to review our training program's emphasis on systems of care came from multiple areas. First, faculty members who were interested in systems issues became involved in the emerging field of children's mental health systems of care. These faculty members and state mental health officials began working on a grant application for the newly emerging CASSP under the auspices of the Center for Mental Health Services (CMHS).
In 1994 the Pitt and Edgecombe-Nash Public Academic Liaison (PEN-PAL) Project received a grant from CMHS through the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. The objectives of the PEN-PAL project included establishing a comprehensive community-based system of care for seriously emotionally disturbed youths and their families as well as an academic liaison initiative to address the inclusion of system-of-care principles in the continuing education of professionals in practice and in university programs (4). Participants from the disciplines of marriage and family therapy, nursing, psychiatry, psychology, recreation therapy, and social work were involved in this effort. The PEN-PAL project allowed faculty colleagues from these mental health professions to work together on the issue of training. Furthermore, it promoted more interdisciplinary opportunities for interactions between child and adolescent psychiatry residents and child mental health professional students.
A review of the residency didactic and clinical curriculum was instituted. Particular attention was paid to emphasizing components of the didactic curriculum that were related to system-of-care work. As suggested by the AACAP work group (2), important topics included systems theory, social factors, cultural competence training, epidemiology, system-of-care conceptual literature, core spiritual concepts, concepts of quality assurance and total quality management, use of management information systems, health care financing and administration, and leadership principles. Most of these topics were already part of the curriculum but were augmented to have more emphasis.
The review of the clinical curriculum revealed a variety of existing clinical experiences with the potential to be organized to emphasize system-of-care principles and practice. For example, many of our clinical rotation sites were in public mental health settings, and the emphasis was on working with seriously emotionally disturbed youths and their families who were being served by multiple agencies. Furthermore, under the PEN-PAL grant there was an emphasis on working with this group of children and families in a system of care. So we began to organize the existing rotations to enable residents to work at all levels of the continuum of care in the local public mental health system, including a general child and adolescent outpatient clinic, an intensive child and adolescent outpatient clinic, an adolescent substance abuse outpatient clinic, day treatment services, and residential services.
The community-based intensive service rotations helped the residents understand the multiple strengths and needs of seriously emotionally disturbed youths and their families as well as the importance of service coordination and interdisciplinary work. In addition, independent system-of-care rotations were developed for residents to work directly with child service providers in their respective agencies (child welfare and juvenile justice) and a school mental health clinic to learn about the agency mission, function, procedures, programs, and working experiences.
As we instituted these changes, it became apparent that system-of-care training experiences should address the practice differences that are inherent in using this new philosophy. Six areas are particularly important for trainees who are learning to work in systems of care: partnering with families, attending to caregiver stress, service planning, interdisciplinary collaboration, outcomes and accountability, and supervision (5).
Partnering with families in a meaningful way has been challenging both for trainees and for professionals in the field. Under the PEN-PAL initiative—and other public academic liaison initiatives in North Carolina—the "parents in residence" concept has been used to help meet this challenge. University faculty members partner with parents of seriously emotionally disturbed youths to revise and update university curricula and co-teach classes (6). Co-teaching has provided a model of how to partner with parents, and both faculty and students have noted how this experience has positively affected their attitudes toward working with parents (7). In addition, training with parent advocates and working with youths and families in nonclinical settings have been valuable in promoting partnership with families.
One factor that has been evident over the past eight years as system-of-care concepts have been incorporated into our curriculum is that change is inevitable. As I write this column there is a wave of change in North Carolina as the mental health reform process approved by the state legislature in 2001 proceeds (8). This process will most likely change the current system of care, and we will have to respond accordingly to provide an adequate learning experience for our trainees and to advocate for the children and families we serve. I look forward to hearing how other training programs throughout the country are integrating system-of-care principles into their educational programming.
Dr. McGinty is associate professor and training director of child and adolescent psychiatry residency at the Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Greenville, North Carolina 27858 (e-mail, firstname.lastname@example.org). Charles Huffine, M.D., is editor of this column.