Current Status of Research Activity in American Child and Adolescent Psychiatry: Part I THEODORE SHAPIRO, M.D ., DAVID MRAZEK, M.D. ,
AND
HAROLD ALAN PINCUS, M.D.
Abstract. A survey of research activity of American academic child psychiatrists was completed in February , 1989. The survey demonstrated an increase in research activity since the 1983 report in the Curr ent Statu s of Child Psychiatry . A definition of a researcher was derived from a study of internists and general psychiatrist s and applied to the 488 respondents (78.5% of sample) , and it was found that males outnumber females and that researchers contribute significantly more to the literature and educat ion than nonresearchers . Early research exposure and mentoring are important influences on a research career. Recommendations by researchers for future training of researchers are presented. Periodic surveys are encouraged. J . Am . Acad. Child Adolesc. Psychiatry, 1991,30, 3:443-448. Key Words: research activity, academic survey.
The aim of this study was to assess the level and nature of research activity in American academic child and adolescent psychiatry since the 1983 publication, Child Psychiatry: Recommendations for the Future , which summarized 5 years of work on Project Future of the Academy. The objective of this inquiry was to find out how many child psychiatrists are doing research , and what was critical in their decision to choose a research career. Is there a difference between the beginning and the latter part of the 1980s, and what is the status of child psychiatry in academic centers with regard to participation in research? Do those who are investigators also show greater academic productivity in teaching and in generating new knowledge for the field so that child and adolescent psychiatry can grow and become more of a central force in American Medical Schools. Moreover , can we determine from the investigators themselves what training they pursued, what they recommend for others, and what they are investigating? This is the first of a two-part presentation of data gathered; the second paper will address the data from an age cohort vantage to determine changing trends among researchers. The project was set in motion by the Work Group on Scientific Issues of the American Academy of Child and Adolescent Psychiatry, which met in March of 1988 to plan to study the current status of child and adolescent psychiatric researchers in the United States to determine the base rate Accepted December 20 , 1990 . Dr. Shap iro is Professor of Psychiatry, Professor of Psychiatry in Pediatrics, and Director of Child and Adolescent Psych iatry , Cornell Univers ity Medical Coll ege-Payne Whitney Clini c, New York , NY . Dr .
from which new work could be encouraged. A questionnaire was developed based upon the American Psychiatric Association's adaptation of two instruments used by the Association of American Medical Colleges (AAMC) and the American Association of Professors of Internal Medicine (Beaty et al. , 1986; Levey, 1988). An earlier survey conducted in 1982 and published in 1983 (Philips et al.) revealed that in the 32 of 47 child psychiatry programs (39% return) that returned questionnaires no scientific papers had been published in the preceding year. Only two programs had more than two fulltime faculty members working more than 80% of the time on research , and four programs each reported two full time faculty members working between 40 and 80% time-eight programs had submitted only one grant proposal each and fewer submitted more than one to the National Institute of Mental Health (NIMH). Moreover, in half of the 47 training programs , there had been no submission for grant application to the NIMH or the National Science Foundation. Forty-two programs claimed no career investigator or special fellowship support for any child psychiatrist, and 32 programs had no grant support for research. Five university programs produced a disproportionate amount of scholarship in child and adolescent psychiatry, doing frontline research and carrying the knowledge base of child and adolescent psychiatry forward . At that time, intradepartmental support for child psychiatric research was meager within the universities and hospitals, and to many, the rewards of practice and administration seemed greater (Shapiro, 1989b) . This absence of a "critical mass" of investigators and a limited resource base
Mrazek is Professor of P sychiatry and Pediatrics, University of Col-
seriously undercut the status of child and adolescent psy-
orado, and Director of Pediatric Psychiatry at the National Jewish Center f or Immunology and Respiratory Medicin e. Denver, CO . Dr. Pincus is Deputy Med ical Dir ector and Director . Office of Research , American Psychiatric Associat ion. Washington, D.C . Work Group Participants were Dr. T. Shapiro . Chair; Dr . B . Garfinkel . Dr . M. Campb ell. Dr. J . Leckman, Dr . P. Tangua y , Dr . D . Mra zek , and Dr . H. Leonard. Consultants were Dr. H. A. Pincus, Dr . J . Shaw. and Dr. M. Fishman . Reprint requests to Dr . Shapiro. 525 East 68th Street . New York, NY /0021 . 0890-8567/9113003-0443$03 .00/0 © 1991by the American Academy of Child and Adolescent Psychiatry.
chiatry as an "interesting" area for new young academicians . The plan for the Coming Decades report emphasized that develop ing new knowledge was a priority. The report stated: " New knowledge is essential to psychiatric needs of children" . . . Training, clinical practice and research are inextricably linked." The conclusion of this critique stated finally, "Child psychiatry must expand its research enterprise" (p. 83). Although questions concerning the comprehensiveness of the report were raised because of the low response rate (Anders, 1982), the most active programs
l.Am.Acad. Child Adolesc. Psychiatry. 30 :3. May 1991
443
SHAPIRO ET AL.
had responded. More importantly, a substantial body of evidence had been collected that clearly indicated the critical shortage of child psychiatric faculty committed to the pursuit of new knowledge about the field. Since Child Psychiatry: Recommendations for the Future was published, several writers have addressed the shortage of clinician investigators in psychiatry generally (Burke et al., 1986; Haviland et al., 1987) as well as in child psychiatry specifically (Haviland et al., 1988; Weisman and Bashook, 1986). The current survey provides a more comprehensive and timely picture of child psychiatric researchers. The response rate of 78.5% of academic psychiatrists (488/622) is considerably better than the 1982 effort. Both the intensity of current research efforts and new data that may lead to desirable future developments are reported. Emphasizing the need for review of the field, Rutter commented that the 1983 report served the American Academy of Child and Adolescent Psychiatry well, "raising challenges in its unambiguous and sometimes provocative recommendations on the changes needed to make child psychiatry what we all wish it to be." He noted further on, "Nevertheless, what the report succeeds well in forcing us all to reconsider our practices with respect to patterns of clinical care, training, and research" (Rutter, 1984, p. 580). It is in light of these considerations that it was deemed appropriate to take stock periodically of our disciplinary status and provide relevant data to influence plans for our professional and academic place in the American university and medical school of the future. Method
Survey
The instrument developed by the AAMC and by the Society of Professors of Internal Medicine and revised by the American Psychiatric Association was further revised to focus on issues related to the conduct of research by child and adolescent psychiatrists. The modified questionnaire was sent out in a pilot trial to 30 academicians from eight divisions represented by members of the committee. A final revision was completed based on their responses. The revised survey was then sent in October 1988 to the faculty in all 127 approved child and adolescent programs functioning at American medical colleges. Returned questionnaires were collected until February 1989. The survey had 34 items that tapped age, sex, faculty rank, residency and fellowship experience, and questions about supervised research experience in the past. Research was defined by the following statement. "For the purposes of this study, research activity is defined as: Systematic study performed which usually leads to publication and which may be the basis for funding support. Research may be in the basic or clinical areas including behavioral biological and epidemiological sciences" Percentage of effort devoted to research, external funding, and sources over the past 5 to 10 years, research space, and areas of research interest were documented. The rele-
444
TABLE
I. Overall Characteristics of Respondents (N
Age (N = 474) 30-39 40-49 >50 Sex (N = 480) Male Female Faculty rank (N = 438) Instructor/assistant professor Associate professor Full professor
=
488)
N
%
156 196 122
32.9 41.4 27.7
340 140
70.8 29.2
258 110 70
58.9 25.1 16.0
vance of specific components of research training for conducting child psychiatry investigations were elicited using a four-point scale. The length, nature, and timing of postdoctoral research training were recorded. Specific questions regarding.financial support for training and the role of mentors also were included. Finally, the nature of initial grant support and rating of potential critical factors that influenced the respondents careers were documented. It was determined that there are 622 child and adolescent psychiatrists in full-time academic positions at 127 programs by polling the directors of each division. Questionnaires were then sent to the directors of these programs who distributed them to the 622 faculty members. The survey tapped every training institution in the country but did not examine Ph.D. investigators or other M.D. investigators in child development or child psychopathology, unless they were designated as child and adolescent psychiatrists for their primary professional identity and worked in universities and not in primary governmental agencies, such as the NIMH. Thus, this survey is most narrowly concerned with what child and adolescent psychiatrist academicians do and how this academic professional group functions when compared with peers among other academic specialties in the medical and psychiatric professions. Results
Four hundred eighty-eight of the possible 622 child and adolescent psychiatry full-time faculty members receiving the questionnaire completed it, yielding a response rate of 78.5%. The response rate from the faculty of the 15 largest programs was not significantly different from the response rate of the remainder of the sample. Three hundred fortyeight (71.3%) of the total sample were males (Table 1). A preliminary analysis of these data was included in a report of the Work Group on Scientific Issues submitted on May 4, 1989, to the President of the American Academy of Child and Adolescent Psychiatry, Dr. Jerry M. Wiener, and subsequently made available to the Institute of Medicine for inclusion in their assessment of the state of child mental health research (Leckman, 1989). Statistical Methods Comparisons were primarily designed to clarify characteristics of academicians engaged in research versus those l.Am.Acad. Child Adolesc. Psychiatry, 30:3, May 1991
CURRENT STATUS OF RESEARCH ACTIVITY TABLE
2. Characteristics of Categories of Academic Child Psychiatrists Based on Level of Research Commitment Limited Commitment Researcher (N = 95)
Nonresearcher (N = 344) Age (N = 474) 30--39 40--49 > 50 Sex (N = 480) Male Female Faculty rank (N = 438) Assistant professor Associate professor Full professor Participated in research during medical school (N = 473) Received postdoctora l research training (N = 469)
Researcher (N = 49)
N
%
N
%
N
%
106 134 96
31.6 39.9 28.6
35 39 16
38.9 43.3 17.8
15 23 10
31.3 47 .9 20.8
236 102
69 .8 30.2
67 26
72.0 28.0
37 12
(75.5) (24.5)
193 68 29
64.3 22.7 13.0
46 26 19
50 .6 28.6 20.9
19 16 12
110 33
(33.2) (10.1)
46 41
(48 .9) (43 .6)
34 34
with other commitments. Categorical data were compared using Chi-square analyses , and continuous variables were contrasted using t tests. Analy sis of variance was used to compare differences among three groups.
Definition of Researcher A working definiti on of a "researcher" was developed. A 1983 survey of full-time faculty of departments of medicine defined " active researcher" as one who spent at least 33% of his or her time in research , had at least one original publication in the 2 years preceding the survey, and had external funding or assigned space for research activities " (Beaty et aI. , 1986). This was subsequently modified to include' ' persons who spent 20% or more of their time in research endeavors" in order to include principal investi gators not formerly included (Levey et al., 1988). Using these models of definitions, a number of workin g definitions were carefull y considered for compari son in order to determine if there were significant differences among the algorithms ranging from a "Limited Commitment Researcher" (LCR) to a clear commitment to resear ch by time and productivity. The definitions are as follows: "Limited Commitment Researcher"-more than 10% time , but does not reach criteri a for " Researcher." " Researcher"-25% or more effort ; external funding ;
40.4 34 .0 25.5 (p < 0 .01) (70 .8) (69.4)
with or without funds plus the Researcher category) , 72.2% were males . Included in this group was the LCR and full Researchers . The age differences of the respondents among the different groups did not differ significantl y (Table 2). The majority of full professors were Researchers or LCR s rather than nonresearchers. Thirty-nine (13%) of the 300 nonresearchers, 19 (21%) of the LCRs, and 12 (26%) of the 49 Researchers attained the rank of full professor (p = 0.05 ), and when nonresearchers are compared with LCRs, the comparison approach ed significance (p = 0.064) , but the difference between LCR and Researcher is not significant. Moreover, 71% of " Researchers" had done supervised research in medical school, which was twice the rate of nonresearcher s. Addition ally, Researchers had more postdocto ral research trainin g (Table 2). Similarly , investigators are much more likely to write and be represented in the professional literature than nonresearchers, not only as authors of original research article s, but as authors of book chapters, book reviews, commentaries, and even case reports. Seventy-eight percent (38) of the defined researchers had published more than one original research article in which they were first author as compared with 8% of the nonresearchers . Similarly, 51% (25) of Researcher s wrote more than one research article as coauthor and 57% (28) wrote more than one book chapter as com-
one or more original publications in the pr evious 2 years.
pared w ith 13 % of nonresearchers . Case reports are as likely
"Stringent Researcher"-50% or more effort; external funding , one or more original publicat ions in the previous 2 years. Reviewing variou s definitions of research showed that 95 (19 .5%) of the total sample were classified as LCRs and 49 or (10%) were identified as Researchers.
to have been written by LCRs but not as likely to have been written by nonresearchers who are full-tim e facult y in medical schools. Reviews and commentaries similarly command the attention of Researchers, with 35% (17) producing more than one as comp ared with 23% of LCRs and 5% of nonresearchers. These data hold up also with respect to the authorship of books as a vehicle to communicate ideas and investigi tive results (Table 3) . Two other areas differenti ate investigators and nonin vestigators at a highly significant level. They concern partie-
Differences among Categories of "R esearcher" Among the 144 respondents who claimed to do some research (those spending 10% or more time in investigation l .Am.Acad. Child Adolesc .Psychiatry, 30:3 , May 1991
445
SHAPIRO ET AL. TABLE
3. Publication History in the Two Years Preceding the Survey of Child Psychiatrists of Varying Levels of Research Commitment Limited Commitment Researcher (N = 95)
Nonresearcher (N = 344) Original research articles First author None One More than one Coauthor None One More than one Reviews/commentaries None One More than one Book chapters None One More than one
N
%
N
%
N
291 26 27
85 7 8
55 9 31
58 9 33
11
38
0 22 78
277 33 34
81 9
44
10
19 32
46 20 34
17 7 25
35 14 51
300 26 18
87 8 5
61 12 22
64 13 23
21 17
43 22 35
286 14
83 4 13
59
62
10
11
26
27
18 3 28
37 6 57
44
ipation as a faculty member involved in training programs or serving as a research mentor. Seventy-six percent of the research cohort are heavily occupied in mentoring as compared with 20% of the nonresearchers (p = 0.001) . Fortysix percent of the "LCRs" participated as mentors and had postdoctoral training, thus falling intermediately between the two poles.
Characteristics of Researcher Respondents who were involved in research were asked to categorize their research interests in terms of both clinical problem or issue (i.e., pervasive developmental disorder (PDD), mental retardation, attention deficit hyperactivity disorder (ADHD), etc.) or overall approach (i.e., diagnosis and nosology, basic biology, epidemiology , etc.) The areas of investigation appeared somewhat narrow considering the breadth of the field (Table 4) . No responding investigator defined by the study 's definition reported an interest in mental retardation. Clinical psychobiology, defined as studying the biological characteristics of patient sample, and the study of developmental and cognitive factors were reported most frequently. Interest in diagnosis and nosology , psychopharmacology, and psychosocial treatment were also identified as areas for investigation . Among the lowest areas claimed (16-20%) are mental health services, epidemiology , and basic neuroscience . Focusing on diagnostic categories, researchers are most occupied studying affective disorders (35%), ADHD (20%), PDD (16%) , anxiety disorders, and normal development (12% each) . Disorders of infancy and Tourette's syndrome also occupy 10% each of investigations (Table 5). Essential positive influences on research career development included an outstanding mentor , undergraduate, and medical school experience, with residency graduate school 446
Researcher (N = 49)
0
II
%
and family designated as exerting lesser influence (Table 6).
Researchers were asked to register their recommendations for the education of future investigators (Table 7) . Research design and statistics (83%), relationship to a mentor (69%), clinical investigation (57%), patient care (43%) led the list. Just below these were instruction in computer use (39%), medical and technical writing (38%), basic developmental science (35%), and ethics (31%). Almost equal enthusiasm was registered for psychometric assessment techniques (29%) and multidisciplinary group participation (28%), with social science and epidemiological experience (23%), training in administration (21%), and administrative work (21%) following. Overall, the enthusiasm for a relationship with a mentor along with a study of experimental design , statistics, and clinical investigation made a package of the most positive responses in preparation for research by all. Eightyseven to 100% of respondents recommended 2 or more years of specific research preparation.
The "Stringently Defined Researcher" and the Role of Major Research Training Centers Using the most stringent criteria of more than 50% time, external funding, and first authorship as criteria for a Researcher, it was found that the original 49 faculty who were identified as Researchers drops to 26 or 5.4% of the total group of respondents. A large percentage of these individuals are in their 30s. Again the sex ratio was 20 males to 6 females (80%), and 20 (74%) of those doing research at this level had supervised research in medical school years. This group again shows a propensity to be working in clinical psychobiology and affective disorders, with behavioral, developmental , and cognitive issues, and ADHD occupying the next rank in popularity . Close behind those are diagnosis J .Am. Acad. Child Adolesc. Psychiatry, 30 :3, May 1991
CURRENT STATUS OF RESEARCH ACTI VITY TABLE
4. Areas of Research Interest of Researchers (N
N Clinical psychobiology (biological characteristics of patient populations) Behavioral, developmental, cognitive, or social services Diagnosis/nosology Psychopharmacology or other somatic treatments Psychosocial treatment Health/mental services research Epidemiology Basic biological science including neuroscience and pharmacology
= 49) %
21
43
19
39 22
11
7
20 20 16.3 14
6
12
10 10 8
and noso logy , psyc hopharmacology, and eating disorders that interest this more stringently defined gro up . These investiga tors are also avid contributors to the literature and serve seriously as mentors to others doing research, with 19 of 26 or 70.37 % of the group functioning in this capacity. Again, 88. 89% received postdoctoral training for 24 or more months. Interestingly , 14 of these were in additiona l training for more than 36 months. A wide array of training centers provide opportunities for child psyc hiatric research training . However , a relatively small numb er of institutions produ ce a disprop ortionately large number of researchers . A subsample of 108 indiv iduals designated that they had received "research training. " Of these 108, forty-s ix received their research training at one of seven centers . Ten trained in some program withi n the National Institute s of Health or NIMH . Yale , Universi ty of California at Los Angeles, Stanford , and New York University each trained seve n. Both the University of Pittsburgh and Columbia were designated as a research training site by four respondents. No other training site was cited more than three times. The subsam ple of ind ividuals who trained at these seven centers (N = 46) was subsequently com pared with those responden ts who had rece ived their resea rch training at other cen ters (N = 62) . Interestingly, the age distribution, faculty rank , and training of these two gro ups were quite similar. However , they differed significantly in two areas . Firs t, those from the seve n cent ers were more likely to have publi shed extensively. Thi s was true of being the first author on two or more research papers (p = 0 .039), a coauthor on two or more research papers (p = 0.028) , the first author on two or more book chapters (p = 0 .004) , and a coa uthor on two or more book chapters (p = 0.038). Regarding areas of rese arch interest, they were more likely to be concerne d with diagnosis and nosology (p = 0 .001) . However , training at one of the seven centers was not associate d with being classified as a Researcher or Stringent Researcher when this grou p was compared with others who had received research training elsew here .
Summar y and Conclusion This survey indicates that child psyc hiatry has moved rather rapidly into the 1990s in taki ng its place as a resea rch discipline in terms of research activity. These data suggest l.Am .Acad. Chil d Adolesc. Psychiatry, 30 :3, May 1991
TABLE
5. Designated Diagnostic Categories of Research Interest of Researchers (N = 49)
Affective disorders ADDH Pervasive developmental disorders Anxiety disorders Conduct disorders Normal development Disorders of infancy Tourette's syndrome Schizophrenia Eating disorder Physical (nonpsychiatric disability) Learning disorders Mental retardation
N
%
17 10
35 20 16 14 12 12 10
8
7 6 6 5 5 4 4 4
10 8 8 8
3 0
6 0
that a researc h base is beginning to be cultivated in ch ild and adolescent psychiatry. The 4 ,000 members of the American Academy of Child and Adolescen t Psych iatry represent bare ly 10% of Ame rican psychiatry and about 10% of the American pediatric work force. On the othe r hand , at this juncture, using the criteria of 25 or more hour s in sequestered research time with externa l funding and one publicatio n or more as first author, 49 investigators or 10% of those respondi ng to the questionnaire have been identified . These data suggest an increase in research ranks from the status in 1982 insofar as it can be judged from the ear lier reports, inade quate as they are. At that time , the report suggests that by informal count, there were barely 30 investigators and most of them were not funded . It is also noted that there is a strong assoc iation bet ween being a Researcher and previous research traini ng experience as an undergraduate and medical student. Pathways to research have changed , and planning for the next generation should include postdoctoral research training and careful mentoring if we are to beco me compe titive with those areas in academic medicine where new know ledge is generated. The re are important areas that are critically underpopu lated by chi ld psyc hiatry researchers , i.e ., psychopharmacology research, research on behavioral and psychosocial treatments, mental retardation, learning disabilities, etc. The former interest in autism is diminishing, while psychoph armacology , psychotherapy, mental retardation, learning disabilities, and behavio ral psychopathology remain significant pursuits without a large following. Newer areas in biological investigation seem to be interesting the work force as well, and me ntors sho uld be available to ,begin to defi ne the areas where such investigation is needed, as based on clini cal needs and newer developmental propositions. Sufficient mentoring along with the study of research design and statistics was strongly endorsed as an important elemen t of research training by curre nt child psyc hiatry researchers. Researchers, defi ned by the criteria used for this study , also tend to write in scholarly jo urna ls , author boo k chapters and books, and communicate the findings of their work in scientific jo urna ls, providing new knowledge releva nt to the diag nosis and treatment of children. Women
447
SHAPIRO ET AL. TABLE 6. Designated Factors of Most Infl uence in Pursuing a Research Career among Researchers (N = 49) Outstanding professor/mentor Undergraduate experience Medical school experience Residency Family influence Graduate school
TABLE 7. Important Areas of a Research Training Program as Identified by Researchers in Child Psychiatry (N = 48)
N
%
13
38 12 12 12 3 6
4
4 4 2 1
are beginni ng to enter the field of research and academics but still represent somewhat less than a fourth of the research force as compared with their larger and increasing number s in psychiatry and medical school classes as well as child psychiatry faculty generally . There is a concentration of investigators in seven major centers and a need for a critical mass of worker s to interlock their child specific activities with those investigators workin g in basic biology and in general psychiatry. This survey suggests that more child and adolescent psychiatrists are doing research . However, the number of child and adolesce nt psychiatry investigators, their overall level of productivity, and funding are still insufficient. These data support the need for urgent attention to the suggestions made by Haviland et al. (1987, 1988) to increase recruitment into child psychiatry research careers (Tuma et aI., 1987). These data can be used for future periodic comparisons to monitor the status and evaluation of academic child psychiatry discipline.
Experimental design and statistics Relationship with mentor Clinical investigation Patient care Instruction in the use of computers Medical and technical writing Basic developmental and behavioral science course work Ethical issues in research Psychometric and assessment techniques Participation in a multidisciplinary group Basic social science and epidemiological experience of techniques Training in administration including grants Basic biological science course work Basic biological laboratory experience or technique
Very Important
Moderately Important
Less Important
%
%
%
83 69 57 43
15 27 30 26
2 4 13 31
39 38
24 38
37 24
35 31
35 38
30 31
29
50
21
28
53
19
23
42
35
21
33
46
15
36
49
II
18
71
References Anders, T . F. (1982), The child psychiatrist and research. Editorial. J. Am. Acad . Child Psychiatry . 2 1:570-571. Beaty. H. N., Babbott, D., Higgins, E. J. , Jolly, P. & Levey, G. S. (1986). Research activities of faculty in academic departments of medicine. Ann. Intern. Med.• 104:90-97. Boyle, M. H. , Offord, D. R. , Hofmann, H. G. et al. (1986), The clinician-researcher in psychiatry. Am . J . Psychiatry. 143:968-974 . Haviland, M. G ., Pincus, H. A. & Dial, T. H. (1987) . Career , research involvement, and research fellowship plans of potential psychiatrists. J. Am . Acad. Child Adolesc. Psychiatry. 26:493-496 . - - Dial, T. H. & Pincus, H. A. (1988), Characteristics of senior medical students planning to subspecialize in child psychiatry . J . Am . Acad . Child Adolesc. Psychiatry. 27:404-407 . Leckman, J. (1989), Research on children and adolescents with mental. behavioral disorders: mobilizing a national initiative. Report of a Study by a Committee of the Institute of Medicine Division of Mental Health and Behavioral Medicine. Washington , D.C .: National Academy Press. Levey. G. S. , Sherman, C. R. , Gentile, N.D . , Hough. L. J., Dial, T. H. & Jolly, P. (1988), Postdoctoral research training of full-time
448
faculty in academic departments of medicine. Ann. Intern . Med .• 109:414-41 8. Philips, I. , Cohen, R. & Enzer, N. (1983), Child psychiatry: a plan for the coming decades. A Project of the American Academy of Child Psychiatry. Washington , D.C. : American Academy of Child Psychiatry. Rutter, M. (1984) , " Project Future" : The way forward for child psychiatry? J . Am . Acad. Child Psychiatry. 23:577- :58 1. Shapiro, T. (1989a) Report of the work group on scientific issues . Washington, D.C.: American Academy of Child & Adolescent Psychiatry. - - (I 989b), Child and adolescent psychiatry research and academic promise. Acad. Psychiatry, 2 19--226. Tuma, A. H. , Mitchell, W . & Brunstetter, R. W . (1987), Toward a manpower base for research in child psychiatry: report of three National Institute of Mental Health workshops . J. Am . Acad. Child Adolesc. Psychiatry . 26:281-285. Weissman, S. H. & Bashook, P. G. (1986), A view of the prospective child psychiatrist. Am . J . Psychiatry, 143:722-727.
J. Am .Acad. Ch ild Ado /esc . Psychiatry , 30:3, May 1991
AND
HAROLD ALAN PINCUS, M.D.
Abstract. A survey of research activity of American academic child psychiatrists was completed in February , 1989. The survey demonstrated an increase in research activity since the 1983 report in the Curr ent Statu s of Child Psychiatry . A definition of a researcher was derived from a study of internists and general psychiatrist s and applied to the 488 respondents (78.5% of sample) , and it was found that males outnumber females and that researchers contribute significantly more to the literature and educat ion than nonresearchers . Early research exposure and mentoring are important influences on a research career. Recommendations by researchers for future training of researchers are presented. Periodic surveys are encouraged. J . Am . Acad. Child Adolesc. Psychiatry, 1991,30, 3:443-448. Key Words: research activity, academic survey.
The aim of this study was to assess the level and nature of research activity in American academic child and adolescent psychiatry since the 1983 publication, Child Psychiatry: Recommendations for the Future , which summarized 5 years of work on Project Future of the Academy. The objective of this inquiry was to find out how many child psychiatrists are doing research , and what was critical in their decision to choose a research career. Is there a difference between the beginning and the latter part of the 1980s, and what is the status of child psychiatry in academic centers with regard to participation in research? Do those who are investigators also show greater academic productivity in teaching and in generating new knowledge for the field so that child and adolescent psychiatry can grow and become more of a central force in American Medical Schools. Moreover , can we determine from the investigators themselves what training they pursued, what they recommend for others, and what they are investigating? This is the first of a two-part presentation of data gathered; the second paper will address the data from an age cohort vantage to determine changing trends among researchers. The project was set in motion by the Work Group on Scientific Issues of the American Academy of Child and Adolescent Psychiatry, which met in March of 1988 to plan to study the current status of child and adolescent psychiatric researchers in the United States to determine the base rate Accepted December 20 , 1990 . Dr. Shap iro is Professor of Psychiatry, Professor of Psychiatry in Pediatrics, and Director of Child and Adolescent Psych iatry , Cornell Univers ity Medical Coll ege-Payne Whitney Clini c, New York , NY . Dr .
from which new work could be encouraged. A questionnaire was developed based upon the American Psychiatric Association's adaptation of two instruments used by the Association of American Medical Colleges (AAMC) and the American Association of Professors of Internal Medicine (Beaty et al. , 1986; Levey, 1988). An earlier survey conducted in 1982 and published in 1983 (Philips et al.) revealed that in the 32 of 47 child psychiatry programs (39% return) that returned questionnaires no scientific papers had been published in the preceding year. Only two programs had more than two fulltime faculty members working more than 80% of the time on research , and four programs each reported two full time faculty members working between 40 and 80% time-eight programs had submitted only one grant proposal each and fewer submitted more than one to the National Institute of Mental Health (NIMH). Moreover, in half of the 47 training programs , there had been no submission for grant application to the NIMH or the National Science Foundation. Forty-two programs claimed no career investigator or special fellowship support for any child psychiatrist, and 32 programs had no grant support for research. Five university programs produced a disproportionate amount of scholarship in child and adolescent psychiatry, doing frontline research and carrying the knowledge base of child and adolescent psychiatry forward . At that time, intradepartmental support for child psychiatric research was meager within the universities and hospitals, and to many, the rewards of practice and administration seemed greater (Shapiro, 1989b) . This absence of a "critical mass" of investigators and a limited resource base
Mrazek is Professor of P sychiatry and Pediatrics, University of Col-
seriously undercut the status of child and adolescent psy-
orado, and Director of Pediatric Psychiatry at the National Jewish Center f or Immunology and Respiratory Medicin e. Denver, CO . Dr. Pincus is Deputy Med ical Dir ector and Director . Office of Research , American Psychiatric Associat ion. Washington, D.C . Work Group Participants were Dr. T. Shapiro . Chair; Dr . B . Garfinkel . Dr . M. Campb ell. Dr. J . Leckman, Dr . P. Tangua y , Dr . D . Mra zek , and Dr . H. Leonard. Consultants were Dr. H. A. Pincus, Dr . J . Shaw. and Dr. M. Fishman . Reprint requests to Dr . Shapiro. 525 East 68th Street . New York, NY /0021 . 0890-8567/9113003-0443$03 .00/0 © 1991by the American Academy of Child and Adolescent Psychiatry.
chiatry as an "interesting" area for new young academicians . The plan for the Coming Decades report emphasized that develop ing new knowledge was a priority. The report stated: " New knowledge is essential to psychiatric needs of children" . . . Training, clinical practice and research are inextricably linked." The conclusion of this critique stated finally, "Child psychiatry must expand its research enterprise" (p. 83). Although questions concerning the comprehensiveness of the report were raised because of the low response rate (Anders, 1982), the most active programs
l.Am.Acad. Child Adolesc. Psychiatry. 30 :3. May 1991
443
SHAPIRO ET AL.
had responded. More importantly, a substantial body of evidence had been collected that clearly indicated the critical shortage of child psychiatric faculty committed to the pursuit of new knowledge about the field. Since Child Psychiatry: Recommendations for the Future was published, several writers have addressed the shortage of clinician investigators in psychiatry generally (Burke et al., 1986; Haviland et al., 1987) as well as in child psychiatry specifically (Haviland et al., 1988; Weisman and Bashook, 1986). The current survey provides a more comprehensive and timely picture of child psychiatric researchers. The response rate of 78.5% of academic psychiatrists (488/622) is considerably better than the 1982 effort. Both the intensity of current research efforts and new data that may lead to desirable future developments are reported. Emphasizing the need for review of the field, Rutter commented that the 1983 report served the American Academy of Child and Adolescent Psychiatry well, "raising challenges in its unambiguous and sometimes provocative recommendations on the changes needed to make child psychiatry what we all wish it to be." He noted further on, "Nevertheless, what the report succeeds well in forcing us all to reconsider our practices with respect to patterns of clinical care, training, and research" (Rutter, 1984, p. 580). It is in light of these considerations that it was deemed appropriate to take stock periodically of our disciplinary status and provide relevant data to influence plans for our professional and academic place in the American university and medical school of the future. Method
Survey
The instrument developed by the AAMC and by the Society of Professors of Internal Medicine and revised by the American Psychiatric Association was further revised to focus on issues related to the conduct of research by child and adolescent psychiatrists. The modified questionnaire was sent out in a pilot trial to 30 academicians from eight divisions represented by members of the committee. A final revision was completed based on their responses. The revised survey was then sent in October 1988 to the faculty in all 127 approved child and adolescent programs functioning at American medical colleges. Returned questionnaires were collected until February 1989. The survey had 34 items that tapped age, sex, faculty rank, residency and fellowship experience, and questions about supervised research experience in the past. Research was defined by the following statement. "For the purposes of this study, research activity is defined as: Systematic study performed which usually leads to publication and which may be the basis for funding support. Research may be in the basic or clinical areas including behavioral biological and epidemiological sciences" Percentage of effort devoted to research, external funding, and sources over the past 5 to 10 years, research space, and areas of research interest were documented. The rele-
444
TABLE
I. Overall Characteristics of Respondents (N
Age (N = 474) 30-39 40-49 >50 Sex (N = 480) Male Female Faculty rank (N = 438) Instructor/assistant professor Associate professor Full professor
=
488)
N
%
156 196 122
32.9 41.4 27.7
340 140
70.8 29.2
258 110 70
58.9 25.1 16.0
vance of specific components of research training for conducting child psychiatry investigations were elicited using a four-point scale. The length, nature, and timing of postdoctoral research training were recorded. Specific questions regarding.financial support for training and the role of mentors also were included. Finally, the nature of initial grant support and rating of potential critical factors that influenced the respondents careers were documented. It was determined that there are 622 child and adolescent psychiatrists in full-time academic positions at 127 programs by polling the directors of each division. Questionnaires were then sent to the directors of these programs who distributed them to the 622 faculty members. The survey tapped every training institution in the country but did not examine Ph.D. investigators or other M.D. investigators in child development or child psychopathology, unless they were designated as child and adolescent psychiatrists for their primary professional identity and worked in universities and not in primary governmental agencies, such as the NIMH. Thus, this survey is most narrowly concerned with what child and adolescent psychiatrist academicians do and how this academic professional group functions when compared with peers among other academic specialties in the medical and psychiatric professions. Results
Four hundred eighty-eight of the possible 622 child and adolescent psychiatry full-time faculty members receiving the questionnaire completed it, yielding a response rate of 78.5%. The response rate from the faculty of the 15 largest programs was not significantly different from the response rate of the remainder of the sample. Three hundred fortyeight (71.3%) of the total sample were males (Table 1). A preliminary analysis of these data was included in a report of the Work Group on Scientific Issues submitted on May 4, 1989, to the President of the American Academy of Child and Adolescent Psychiatry, Dr. Jerry M. Wiener, and subsequently made available to the Institute of Medicine for inclusion in their assessment of the state of child mental health research (Leckman, 1989). Statistical Methods Comparisons were primarily designed to clarify characteristics of academicians engaged in research versus those l.Am.Acad. Child Adolesc. Psychiatry, 30:3, May 1991
CURRENT STATUS OF RESEARCH ACTIVITY TABLE
2. Characteristics of Categories of Academic Child Psychiatrists Based on Level of Research Commitment Limited Commitment Researcher (N = 95)
Nonresearcher (N = 344) Age (N = 474) 30--39 40--49 > 50 Sex (N = 480) Male Female Faculty rank (N = 438) Assistant professor Associate professor Full professor Participated in research during medical school (N = 473) Received postdoctora l research training (N = 469)
Researcher (N = 49)
N
%
N
%
N
%
106 134 96
31.6 39.9 28.6
35 39 16
38.9 43.3 17.8
15 23 10
31.3 47 .9 20.8
236 102
69 .8 30.2
67 26
72.0 28.0
37 12
(75.5) (24.5)
193 68 29
64.3 22.7 13.0
46 26 19
50 .6 28.6 20.9
19 16 12
110 33
(33.2) (10.1)
46 41
(48 .9) (43 .6)
34 34
with other commitments. Categorical data were compared using Chi-square analyses , and continuous variables were contrasted using t tests. Analy sis of variance was used to compare differences among three groups.
Definition of Researcher A working definiti on of a "researcher" was developed. A 1983 survey of full-time faculty of departments of medicine defined " active researcher" as one who spent at least 33% of his or her time in research , had at least one original publication in the 2 years preceding the survey, and had external funding or assigned space for research activities " (Beaty et aI. , 1986). This was subsequently modified to include' ' persons who spent 20% or more of their time in research endeavors" in order to include principal investi gators not formerly included (Levey et al., 1988). Using these models of definitions, a number of workin g definitions were carefull y considered for compari son in order to determine if there were significant differences among the algorithms ranging from a "Limited Commitment Researcher" (LCR) to a clear commitment to resear ch by time and productivity. The definitions are as follows: "Limited Commitment Researcher"-more than 10% time , but does not reach criteri a for " Researcher." " Researcher"-25% or more effort ; external funding ;
40.4 34 .0 25.5 (p < 0 .01) (70 .8) (69.4)
with or without funds plus the Researcher category) , 72.2% were males . Included in this group was the LCR and full Researchers . The age differences of the respondents among the different groups did not differ significantl y (Table 2). The majority of full professors were Researchers or LCR s rather than nonresearchers. Thirty-nine (13%) of the 300 nonresearchers, 19 (21%) of the LCRs, and 12 (26%) of the 49 Researchers attained the rank of full professor (p = 0.05 ), and when nonresearchers are compared with LCRs, the comparison approach ed significance (p = 0.064) , but the difference between LCR and Researcher is not significant. Moreover, 71% of " Researchers" had done supervised research in medical school, which was twice the rate of nonresearcher s. Addition ally, Researchers had more postdocto ral research trainin g (Table 2). Similarly , investigators are much more likely to write and be represented in the professional literature than nonresearchers, not only as authors of original research article s, but as authors of book chapters, book reviews, commentaries, and even case reports. Seventy-eight percent (38) of the defined researchers had published more than one original research article in which they were first author as compared with 8% of the nonresearchers . Similarly, 51% (25) of Researcher s wrote more than one research article as coauthor and 57% (28) wrote more than one book chapter as com-
one or more original publications in the pr evious 2 years.
pared w ith 13 % of nonresearchers . Case reports are as likely
"Stringent Researcher"-50% or more effort; external funding , one or more original publicat ions in the previous 2 years. Reviewing variou s definitions of research showed that 95 (19 .5%) of the total sample were classified as LCRs and 49 or (10%) were identified as Researchers.
to have been written by LCRs but not as likely to have been written by nonresearchers who are full-tim e facult y in medical schools. Reviews and commentaries similarly command the attention of Researchers, with 35% (17) producing more than one as comp ared with 23% of LCRs and 5% of nonresearchers. These data hold up also with respect to the authorship of books as a vehicle to communicate ideas and investigi tive results (Table 3) . Two other areas differenti ate investigators and nonin vestigators at a highly significant level. They concern partie-
Differences among Categories of "R esearcher" Among the 144 respondents who claimed to do some research (those spending 10% or more time in investigation l .Am.Acad. Child Adolesc .Psychiatry, 30:3 , May 1991
445
SHAPIRO ET AL. TABLE
3. Publication History in the Two Years Preceding the Survey of Child Psychiatrists of Varying Levels of Research Commitment Limited Commitment Researcher (N = 95)
Nonresearcher (N = 344) Original research articles First author None One More than one Coauthor None One More than one Reviews/commentaries None One More than one Book chapters None One More than one
N
%
N
%
N
291 26 27
85 7 8
55 9 31
58 9 33
11
38
0 22 78
277 33 34
81 9
44
10
19 32
46 20 34
17 7 25
35 14 51
300 26 18
87 8 5
61 12 22
64 13 23
21 17
43 22 35
286 14
83 4 13
59
62
10
11
26
27
18 3 28
37 6 57
44
ipation as a faculty member involved in training programs or serving as a research mentor. Seventy-six percent of the research cohort are heavily occupied in mentoring as compared with 20% of the nonresearchers (p = 0.001) . Fortysix percent of the "LCRs" participated as mentors and had postdoctoral training, thus falling intermediately between the two poles.
Characteristics of Researcher Respondents who were involved in research were asked to categorize their research interests in terms of both clinical problem or issue (i.e., pervasive developmental disorder (PDD), mental retardation, attention deficit hyperactivity disorder (ADHD), etc.) or overall approach (i.e., diagnosis and nosology, basic biology, epidemiology , etc.) The areas of investigation appeared somewhat narrow considering the breadth of the field (Table 4) . No responding investigator defined by the study 's definition reported an interest in mental retardation. Clinical psychobiology, defined as studying the biological characteristics of patient sample, and the study of developmental and cognitive factors were reported most frequently. Interest in diagnosis and nosology , psychopharmacology, and psychosocial treatment were also identified as areas for investigation . Among the lowest areas claimed (16-20%) are mental health services, epidemiology , and basic neuroscience . Focusing on diagnostic categories, researchers are most occupied studying affective disorders (35%), ADHD (20%), PDD (16%) , anxiety disorders, and normal development (12% each) . Disorders of infancy and Tourette's syndrome also occupy 10% each of investigations (Table 5). Essential positive influences on research career development included an outstanding mentor , undergraduate, and medical school experience, with residency graduate school 446
Researcher (N = 49)
0
II
%
and family designated as exerting lesser influence (Table 6).
Researchers were asked to register their recommendations for the education of future investigators (Table 7) . Research design and statistics (83%), relationship to a mentor (69%), clinical investigation (57%), patient care (43%) led the list. Just below these were instruction in computer use (39%), medical and technical writing (38%), basic developmental science (35%), and ethics (31%). Almost equal enthusiasm was registered for psychometric assessment techniques (29%) and multidisciplinary group participation (28%), with social science and epidemiological experience (23%), training in administration (21%), and administrative work (21%) following. Overall, the enthusiasm for a relationship with a mentor along with a study of experimental design , statistics, and clinical investigation made a package of the most positive responses in preparation for research by all. Eightyseven to 100% of respondents recommended 2 or more years of specific research preparation.
The "Stringently Defined Researcher" and the Role of Major Research Training Centers Using the most stringent criteria of more than 50% time, external funding, and first authorship as criteria for a Researcher, it was found that the original 49 faculty who were identified as Researchers drops to 26 or 5.4% of the total group of respondents. A large percentage of these individuals are in their 30s. Again the sex ratio was 20 males to 6 females (80%), and 20 (74%) of those doing research at this level had supervised research in medical school years. This group again shows a propensity to be working in clinical psychobiology and affective disorders, with behavioral, developmental , and cognitive issues, and ADHD occupying the next rank in popularity . Close behind those are diagnosis J .Am. Acad. Child Adolesc. Psychiatry, 30 :3, May 1991
CURRENT STATUS OF RESEARCH ACTI VITY TABLE
4. Areas of Research Interest of Researchers (N
N Clinical psychobiology (biological characteristics of patient populations) Behavioral, developmental, cognitive, or social services Diagnosis/nosology Psychopharmacology or other somatic treatments Psychosocial treatment Health/mental services research Epidemiology Basic biological science including neuroscience and pharmacology
= 49) %
21
43
19
39 22
11
7
20 20 16.3 14
6
12
10 10 8
and noso logy , psyc hopharmacology, and eating disorders that interest this more stringently defined gro up . These investiga tors are also avid contributors to the literature and serve seriously as mentors to others doing research, with 19 of 26 or 70.37 % of the group functioning in this capacity. Again, 88. 89% received postdoctoral training for 24 or more months. Interestingly , 14 of these were in additiona l training for more than 36 months. A wide array of training centers provide opportunities for child psyc hiatric research training . However , a relatively small numb er of institutions produ ce a disprop ortionately large number of researchers . A subsample of 108 indiv iduals designated that they had received "research training. " Of these 108, forty-s ix received their research training at one of seven centers . Ten trained in some program withi n the National Institute s of Health or NIMH . Yale , Universi ty of California at Los Angeles, Stanford , and New York University each trained seve n. Both the University of Pittsburgh and Columbia were designated as a research training site by four respondents. No other training site was cited more than three times. The subsam ple of ind ividuals who trained at these seven centers (N = 46) was subsequently com pared with those responden ts who had rece ived their resea rch training at other cen ters (N = 62) . Interestingly, the age distribution, faculty rank , and training of these two gro ups were quite similar. However , they differed significantly in two areas . Firs t, those from the seve n cent ers were more likely to have publi shed extensively. Thi s was true of being the first author on two or more research papers (p = 0 .039), a coauthor on two or more research papers (p = 0.028) , the first author on two or more book chapters (p = 0 .004) , and a coa uthor on two or more book chapters (p = 0.038). Regarding areas of rese arch interest, they were more likely to be concerne d with diagnosis and nosology (p = 0 .001) . However , training at one of the seven centers was not associate d with being classified as a Researcher or Stringent Researcher when this grou p was compared with others who had received research training elsew here .
Summar y and Conclusion This survey indicates that child psyc hiatry has moved rather rapidly into the 1990s in taki ng its place as a resea rch discipline in terms of research activity. These data suggest l.Am .Acad. Chil d Adolesc. Psychiatry, 30 :3, May 1991
TABLE
5. Designated Diagnostic Categories of Research Interest of Researchers (N = 49)
Affective disorders ADDH Pervasive developmental disorders Anxiety disorders Conduct disorders Normal development Disorders of infancy Tourette's syndrome Schizophrenia Eating disorder Physical (nonpsychiatric disability) Learning disorders Mental retardation
N
%
17 10
35 20 16 14 12 12 10
8
7 6 6 5 5 4 4 4
10 8 8 8
3 0
6 0
that a researc h base is beginning to be cultivated in ch ild and adolescent psychiatry. The 4 ,000 members of the American Academy of Child and Adolescen t Psych iatry represent bare ly 10% of Ame rican psychiatry and about 10% of the American pediatric work force. On the othe r hand , at this juncture, using the criteria of 25 or more hour s in sequestered research time with externa l funding and one publicatio n or more as first author, 49 investigators or 10% of those respondi ng to the questionnaire have been identified . These data suggest an increase in research ranks from the status in 1982 insofar as it can be judged from the ear lier reports, inade quate as they are. At that time , the report suggests that by informal count, there were barely 30 investigators and most of them were not funded . It is also noted that there is a strong assoc iation bet ween being a Researcher and previous research traini ng experience as an undergraduate and medical student. Pathways to research have changed , and planning for the next generation should include postdoctoral research training and careful mentoring if we are to beco me compe titive with those areas in academic medicine where new know ledge is generated. The re are important areas that are critically underpopu lated by chi ld psyc hiatry researchers , i.e ., psychopharmacology research, research on behavioral and psychosocial treatments, mental retardation, learning disabilities, etc. The former interest in autism is diminishing, while psychoph armacology , psychotherapy, mental retardation, learning disabilities, and behavio ral psychopathology remain significant pursuits without a large following. Newer areas in biological investigation seem to be interesting the work force as well, and me ntors sho uld be available to ,begin to defi ne the areas where such investigation is needed, as based on clini cal needs and newer developmental propositions. Sufficient mentoring along with the study of research design and statistics was strongly endorsed as an important elemen t of research training by curre nt child psyc hiatry researchers. Researchers, defi ned by the criteria used for this study , also tend to write in scholarly jo urna ls , author boo k chapters and books, and communicate the findings of their work in scientific jo urna ls, providing new knowledge releva nt to the diag nosis and treatment of children. Women
447
SHAPIRO ET AL. TABLE 6. Designated Factors of Most Infl uence in Pursuing a Research Career among Researchers (N = 49) Outstanding professor/mentor Undergraduate experience Medical school experience Residency Family influence Graduate school
TABLE 7. Important Areas of a Research Training Program as Identified by Researchers in Child Psychiatry (N = 48)
N
%
13
38 12 12 12 3 6
4
4 4 2 1
are beginni ng to enter the field of research and academics but still represent somewhat less than a fourth of the research force as compared with their larger and increasing number s in psychiatry and medical school classes as well as child psychiatry faculty generally . There is a concentration of investigators in seven major centers and a need for a critical mass of worker s to interlock their child specific activities with those investigators workin g in basic biology and in general psychiatry. This survey suggests that more child and adolescent psychiatrists are doing research . However, the number of child and adolesce nt psychiatry investigators, their overall level of productivity, and funding are still insufficient. These data support the need for urgent attention to the suggestions made by Haviland et al. (1987, 1988) to increase recruitment into child psychiatry research careers (Tuma et aI., 1987). These data can be used for future periodic comparisons to monitor the status and evaluation of academic child psychiatry discipline.
Experimental design and statistics Relationship with mentor Clinical investigation Patient care Instruction in the use of computers Medical and technical writing Basic developmental and behavioral science course work Ethical issues in research Psychometric and assessment techniques Participation in a multidisciplinary group Basic social science and epidemiological experience of techniques Training in administration including grants Basic biological science course work Basic biological laboratory experience or technique
Very Important
Moderately Important
Less Important
%
%
%
83 69 57 43
15 27 30 26
2 4 13 31
39 38
24 38
37 24
35 31
35 38
30 31
29
50
21
28
53
19
23
42
35
21
33
46
15
36
49
II
18
71
References Anders, T . F. (1982), The child psychiatrist and research. Editorial. J. Am. Acad . Child Psychiatry . 2 1:570-571. Beaty. H. N., Babbott, D., Higgins, E. J. , Jolly, P. & Levey, G. S. (1986). Research activities of faculty in academic departments of medicine. Ann. Intern. Med.• 104:90-97. Boyle, M. H. , Offord, D. R. , Hofmann, H. G. et al. (1986), The clinician-researcher in psychiatry. Am . J . Psychiatry. 143:968-974 . Haviland, M. G ., Pincus, H. A. & Dial, T. H. (1987) . Career , research involvement, and research fellowship plans of potential psychiatrists. J. Am . Acad. Child Adolesc. Psychiatry. 26:493-496 . - - Dial, T. H. & Pincus, H. A. (1988), Characteristics of senior medical students planning to subspecialize in child psychiatry . J . Am . Acad . Child Adolesc. Psychiatry. 27:404-407 . Leckman, J. (1989), Research on children and adolescents with mental. behavioral disorders: mobilizing a national initiative. Report of a Study by a Committee of the Institute of Medicine Division of Mental Health and Behavioral Medicine. Washington , D.C .: National Academy Press. Levey. G. S. , Sherman, C. R. , Gentile, N.D . , Hough. L. J., Dial, T. H. & Jolly, P. (1988), Postdoctoral research training of full-time
448
faculty in academic departments of medicine. Ann. Intern . Med .• 109:414-41 8. Philips, I. , Cohen, R. & Enzer, N. (1983), Child psychiatry: a plan for the coming decades. A Project of the American Academy of Child Psychiatry. Washington , D.C. : American Academy of Child Psychiatry. Rutter, M. (1984) , " Project Future" : The way forward for child psychiatry? J . Am . Acad. Child Psychiatry. 23:577- :58 1. Shapiro, T. (1989a) Report of the work group on scientific issues . Washington, D.C.: American Academy of Child & Adolescent Psychiatry. - - (I 989b), Child and adolescent psychiatry research and academic promise. Acad. Psychiatry, 2 19--226. Tuma, A. H. , Mitchell, W . & Brunstetter, R. W . (1987), Toward a manpower base for research in child psychiatry: report of three National Institute of Mental Health workshops . J. Am . Acad. Child Adolesc. Psychiatry . 26:281-285. Weissman, S. H. & Bashook, P. G. (1986), A view of the prospective child psychiatrist. Am . J . Psychiatry, 143:722-727.
J. Am .Acad. Ch ild Ado /esc . Psychiatry , 30:3, May 1991
