Task Sharing and Upskilling through Boston Children’s Hospital Global Partnerships in Psychiatry Observership

Nine out of 10 of the world's children live in low- and middle-income countries (LMICs), and children constitute nearly half of the populations of these countries. About 50% of all mental disorders begin before the age of 14 years.  Worldwide prevalence rates for child and adolescent mental disorders are around 20% across cultures. There is a dearth of mental health services with less than one psychiatrist per million in most LMICs.  

The World Health Organization (WHO) Atlas on Child and Adolescent Mental Health Resources was a groundbreaking study by thought leaders, Drs. Myron Belfer and Shekhar Saxena in 2006. It mapped the worldwide availability of Child and Adolescent mental Health (CAMH) resources and identified the gaps1. The Child Atlas project was a collaboration between the WHO, the World Psychiatric Association Presidential Global Program on Child Mental Health, and the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP). It surveyed 66 of 192 countries in the world. Major gaps in CAMH resources were identified in the domains of policy, training, and direct services. Although pediatricians had to provide mental health care in 56% (37 of 66) of the countries, only 15% (10 of 66) of the countries reported that more than 25% of pediatricians receiving mental health training. Given the global shortage of CAMH providers, they proposed the training of primary healthcare professionals and supplemental training of adult psychiatrists, as a resource for CAMH services. These observations served as a gem of an idea that spawned solutions. 

Some strategies to increase CAMH services are capacity building, alternative models of care delivery based on task shifting and sharing such that specialists manage severe complex illnesses and mild-moderate presentations are managed by non-specialists (lay health workers, teachers, midwives, nurses and primary care providers) and finally innovation in curricula, systems of care and funding mechanisms. 

An innovative international mental health educational initiative of the Boston Children’s Hospital (BCH) is the Global Partnerships in Psychiatry observership program (2). This BCH cross-disciplinary educational program is designed for child facing health professionals, physicians (e.g., pediatricians, general psychiatrists) and psychologists outside the US who have an interest in CAMH. 

The program’s goal is to provide exposure to CAMH within a tertiary academic medical center so that the observers can contribute to the development of child mental health policy, clinical programming, and advocacy in their respective countries of origin. Dr. Belfer and Ibeziako pioneered this observership program in 2009. Before its inception, the focus of global mental health initiatives in the United States (US) had been domestic programs preparing US health professionals for careers abroad in global mental health.  

The program screens applicants to select candidates who are proficient in English, a requirement for US clinical training programs, and will return to serve their home countries. The program is not intended for those seeking further graduate training or practice opportunities in the US. A core 1–3 month curriculum tailored to the needs and experience level of the candidate is designed to provide exposure to contemporary care that would be relevant to their future career. For example, the psychiatric consultation service highlights communication between different specialties and the therapeutic approach to physical illness with comorbid emotional and behavioral issues. The observers learn from clinical bedside observation and discussions during rounds and didactic seminars. Cross-cultural issues are emphasized, as there is a diverse patient population given that BCH is an international tertiary referral center. 

On the Inpatient Psychiatry Service, the emphasis is on the evaluation and team-based management of severe psychiatric illnesses in a restrictive setting. Family psychoeducation, intervention, and collaboration with schools and other systems of care are a part of comprehensive care-management. 

On the Community and Outpatient Psychiatry Service rotation, there is exposure to school and primary health center-based CAMH services, outpatient mental health clinics, and specialty clinics (e.g., substance abuse, developmental disorders) based on the interests of the observer. The rotation highlights the impact of collaborative and consultative mental health services delivered in the under-resourced settings. 

Throughout the observership a weekly integration seminar facilities discussion of subjective experiences of observers and also their areas of special interest for future career development e.g., ethics, policy, advocacy and program development. All observers receive an educational resource package consisting of seminal CAMH articles on a flash drive.  

Hitherto, all the initially selected observers served in academic or government institutions in their home countries and 70% were early career health professionals (within 10 years of training) (2). Notably, although 80% of the observers worked with children in their clinical practice, 60% had not received formal CAMH training. The feedback from the observers reported improved skills in critical thinking and problem solving that could be applied for developing CAMH training and systems of care in their home countries. All the observers returned to their home countries after completion of the program and many have become national and international CAMH leaders (3). The observership resulted in a bidirectional learning experience for US faculty and trainees and fostered ongoing professional collaborations on projects, presentations and publications.  

The Boston Children’s Hospital Global Partnerships in Psychiatry observership program has thus been exemplary in innovative task sharing and upskilling opportunities for countries desiring to build CAMH resources. After a hiatus during the pandemic, the program is poised to resume under the leadership of co-directors Kevin Tsang PsyD, Hesham Hamoda MD and Deepika Shaligram MD. Some of the new features will include exposure to telepsychiatry, collaborative care and potential for a future reciprocal exchange program to deepen US clinicians’ understanding of cross-cultural global CAMH issues and alternative models of treatment. 

To learn more about the program or for interested candidates, please contact: observership.program@childrens.harvard.edu.
 

Applications are available at 
Observership Program - Boston Children's Hospital (childrenshospital.org)
 

References 

1. Belfer ML, Saxena S. WHO Child Atlas project. Lancet. 2006 Feb 18;367(9510):551-2.
2. Ibeziako PI, Belfer ML, Demaso DR. Implementing a global child mental health observership program in a children's hospital: lessons learned. Acad Psychiatry. 2012 Jul 1;36(4):330-4.
3. Ibeziako P, Barrett C, Ribeiro M, Tsang K. Impact of a Global Child Mental Health Observership Program: Participant Evaluation, Perceptions, and Outcomes. Acad Psychiatry. 2021 Jun;45(3):345-349.  
    

Note from the Editor: Due to a conflict of interests pertaining to Dr. Hesham Hamoda who is part of the program described above, the editorial process was handled by Deputy Editor Dr. Maite Ferrin. 

IACAPAP Bulletin, Issue 73