Infusing intellectual and Developmental disability training into Medical School curriculum: a Pilot intervention

ABSTRACT

Purpose

Despite the rising prevalence of developmental disabilities (DD) in the US, there remains insufficient training for healthcare professionals to care for this medically underserved population – particularly adults. The National Inclusive Curriculum for Health Education (NICHE) aims to improve attitudes and knowledge towards people with intellectual and developmental disabilities (PWIDD); herein we describe one such intervention.

Method

The intervention integrated didactic, panel presentation and clinical skills components into a 2^nd year medical school curriculum.  The didactic session, covering  health and assessment of PWIDDs, history of IDD, stigma, etc., was co-taught by a developmental pediatrician, family medicine physician and social worker.  A panel of 3 adult self-advocates (SAs) with DD and a parent of a child with DD spoke about their lived experiences.  One week later, students practiced taking clinical histories of SAs within small group settings with adult PWIDDs, facilitated by medical school faculty. Students completed the NICHE Knowledge(49 items) and Attitudes (60 items) surveys. The evaluation analyzed pre/post intervention differences in a) knowledge and attitude scores overall and b) by student age, gender, intended medical specialty, and prior experiences with PWIDDs. Open-ended comments were analyzed with content analysis.

Results

Overall Knowledge scores increased from pre-to posttest (n = 85; 65[19] vs. 73[17], p = 0.00), while Attitudes score improved (i.e., decreased) (n = 88; 0.55 [.06] vs. 0.53 [0.06]); p = 0.00).  Higher pretest knowledge was found among female identified students (vs. others; p = 0.01) and those knowing > = 5 PWIDD (vs < 5; p = 0.02).  Students characterize their IDD training and experience prior to intervention as ‘lacking’ and described the sessions as effective.

Conclusions

A brief (4 hours total) intervention was associated with modest but significant improved knowledge and attitudes towards PWIDDs. Replication and sustainability of this and other NICHE interventions are needed to fill gaps in PWIDDs’ health care.

Introduction

The 2005 US Surgeon General’s ‘Call to Action to Improve the Health and Wellness of Persons with Disabilities,’ cited insufficient education and training for health care professionals in the needs of persons with disabilities [1]. Developmental disabilities (DDs), as used herein, are defined by Public Law 106–402 106th as any severe, chronic disability of an individual that is attributable to a mental and/or physical impairment, manifested before age 22, likely to continue indefinitely, and that results in substantial functional limitations in ≥ 3 of the following: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency [1]. Approximately 5 million people in the United States have a DD [2]. Nearly two decades since the Call to Action, medical education fails to adequately prepare physicians to meet the challenge of reducing health care disparities for these individuals [3,4]. Notably, 50% of physicians lack confidence in caring for people with disabilities [5]. Medical school education on disability often reflect an ableist perspective [6]; when offered, it is rarely integrated across all years of medical school or fully embedded into the curriculum [7].

To address the aforementioned gaps in medical education, the American Academy of Developmental Medicine and Dentistry (AADMD) created the National Curriculum Initiative in Developmental Medicine (NCIDM; renamed NICHE, for ‘National Inclusive Curriculum for Health Education’) The purpose of NICHE is to provide training to medical students in the field of developmental medicine – the care of persons with IDD across the lifespan. Our efforts were part of a multi-year partnership between AADMD and Special Olympics, with resources from a cooperative agreement funded by the Centers for Disease Control & Prevention, which funded 18 medical school curricula efforts. This paper describes one such intervention that integrated didactic, panel presentation and clinical skills components into the 2^nd year medical school curriculum and its evaluation. The aims of the evaluation were to analyze pre/post intervention differences in a) overall knowledge and attitude scores and b) scores by student demographics (e.g., age, gender, intended medical specialty, and prior experiences with PWIDDs). We also describe (qualitatively) shifts in knowledge and attitudinal sub-scale scores.

Methodology

Setting

The NCIDM (NICHE) grant was awarded by AADMD to the Rose F. Kennedy (RFK) University Center of Excellence in Developmental Disabilities (UCEDD), affiliated with Albert Einstein College of Medicine (Einstein)-Montefiore Medical Center in the Bronx, New York. Development and placement of the course’s didactic, panel, and clinical skills components were coordinated with faculty leaders and the dean for medical education. The intervention built upon the UCEDD’s longtime advocacy and intellectual and developmental disabilities (I/DD) training at Einstein, in the local community, and beyond. Curricula were developed in collaboration with adult self-advocates (SAs) with whom UCEDD Co-Director (JFS) has worked, parents of children with I/DD who receive services at the RFK UCEDD’s multidisciplinary tertiary care center along with its clinical faculty within developmental pediatrics, family and social medicine, psychiatry, dentistry, and social work.

Intervention

One class section on I/DD content was integrated into each of two mandatory courses across a two-week period in November 2019, as described below. See visual description of the intervention components in Figure 1.

Figure 1.

Depiction of curriculum intervention.

Class 1: MS2 Neurology: Nervous System and Human Behavior, a 120-minute curricular intervention entitled, ‘IDD: A Neurodevelopmental Approach Across the Life Span.’ Didactic content covered two areas: 1) Health and Assessment-typical/atypical child development milestones, assessment IDD in children and adults, and; adult health care issues related to people with IDD, and; 2) Psycho-Social Determinants of Health (didactic): history of IDD, stigma and unconscious bias toward IDD, social determinants of health, and barriers to healthy living and treatment. A third component featured a panel discussion led by a faculty facilitator. Panelists included one family member/caretaker who addressed their child’s and family experiences regarding medical diagnosis, evaluations, treatment and care. Three SAs who discussed their inpatient and outpatient medical experiences.

Class 2: MS2 Introduction to Clinical Medicine (ICM) II Communication and Clinical Skills Care. This 120-minute class entitled ‘Introduction to Care of Adult Patients with Developmental Disabilities” featured in vivo instruction on how to conduct a patient history with a PWIDD. Fifteen (15) groups were held, each comprised of: 1 non-standardized patient (i.e., an adult SA), 12 MS2 students and 1–2 faculty members. All but two of the SAs (one with high functioning autism and one with spina bifida) had an ID.

The session included: student prep prior to the session (15–30 mins.), history taking and interviewing the SAs about their medical needs (~45–60 mins.) and debriefing with faculty mentors (15–30 mins.). Caretakers were included at the discretion of the faculty leader, with the non-standardized patient’s permission.

Curriculum development process

SAs, recruited from a local self-advocacy group and our center’s clinical program, participated in all phases of the curriculum. During weekly meetings with the Principal Investigator (JFS) over seven months, they discussed their issues and concerns with the health care system. Bio-psycho-social histories were developed during this period to aid faculty mentor/student clinical discussion and history taking as the basis of their interviews with the students. To reduce SA anxiety about being interviewed in the small group session with doctors and medical students, the SAs practiced telling their histories and experiences in various medical settings. Faculty group leaders and students for the ICM small group sessions familiarized themselves with each SA’s biopsychosocial sketch before the group.

Measures

Attitude Survey- the NCIDM project employed a 60-item instrument, informed by the Attitudes Toward Intellectual Disability Questionnaire’s (ATTID). The original ATTID was validated in a general population sample (Morin, 2013). Its 31 items were classified into 5 domains: 1) Discomfort (Emotional Dimension), 2) Knowledge of Capacity and Rights, 3) Interaction (Behavioral Dimension), 4) Sensitivity or Tenderness (Emotional Dimension), and 5) (Knowledge of Causes (Cognitive Dimension). The NCIDM project adapted a subsequent version of the ATTID for health professionals (unpublished). The authors then operationally defined ATTID’s 5 domains in terms of medical student education and met over several months to categorize survey items into domains, based on consensual agreement. Several items were assigned to more than one domain. Additional items were added on including: demographics (e.g., race/ethnicity, income, region of origin, etc.), intended medical specialty, and past connection to PWIDD (e.g., number known, quality of relationships). Response formats included: open text, multiple choice, or 5-item Likert scale (1=Strongly Disagree, 2=Disagree, 3=Neither Agree or Disagree, 4= Agree, 5=Strongly Agree) regarding agreement with statements.

The authors convened as a group multiple times to classify Likert-scaled Attitude items as most or least responsive/appropriate for the care of PWIDD. Scores were then standardized such that higher scores corresponded to more optimal responses.

Knowledge Survey- this 49-item instrument was designed for the NCIDM project by a multi-disciplinary team of IDD experts to assess 6 domains, that aligned with the project’s aims: 1) Medical Knowledge, 2) Patient Care/Compassionate Care, 3) Interpersonal/Communication Skills, 4) Professionalism, 5) Practice Based Learning: Investigate and Apply, and 6) Systems-Based Practice. Respondents are presented with case studies pertaining to medical knowledge or clinical issues (e.g., ‘Based on his diagnosis of moderate intellectual disability, which of the following is most reasonable to expect regarding Matthew’s communication skills and understanding of verbal information?’). Each question has only one correct response. Authors followed the same group consensus process as above to assign items to domains. Reliability tests were run on each of the baseline data Attitudes & Knowledge scales. These tests included Spearman’s correlations (a nonparametric measure of strength and direction) and produced Cronbach’s alphas for each scale.

Survey administration

Pre-intervention surveys were distributed via Qualtrics by the MS2 Neurology course leader seven weeks before the first class, along with two reminders. Post-intervention surveys were available to complete up to 3 weeks after the second class. The project was deemed exempt by Einstein’s Institutional Review Board (IRB # 2019–10027). Participation was voluntary. Students who completed surveys received $35.00 gift cards at both baseline and follow-up (i.e., pre/post intervention).

Data analysis

Data were analyzed in SPSS (version 28.01), after removing both personal identifiers and the least complete survey of repeat attempts (17 cases). Demographic variables were re-coded into dichotomous or trichotomous categories. We conducted paired sample t-tests of standardized mean differences in pre- vs. post-intervention total Knowledge and Attitude scores for participants with non-missing data. We also analyzed differences in students’ overall Knowledge and Attitudes scores by demographics (i.e., age, gender), intended specialty, and prior experiences with PWIDD, using either [independent sample] t-tests for dichotomous variables, or ANOVA for variables with 3+ categories (i.e., intended medical specialty). Knowledge and Attitudes scale score reliability is described using Cronbach’s α, with α ≥ 0.70representing acceptable reliability [8].

We performed a content analysis of the three open-ended questions on the Attitude pre- and post-tests. A medical anthropologist with expertise in qualitative data analysis [EN] conducted an initial analysis, which was reviewed by all authors. We report here on the primary themes.

Human subjects

This project was approved by the Institutional Review Board.

Results

Altogether n = 180 medical students were exposed to the NCIDM curriculum. Total Attitudes scores were available for n = 114 students at pre-test, n = 95 at post-test, and n = 88 at both pre- and post-test. Total Knowledge scores were available for n = 112, n = 96, and n = 85 students at pre-, post- and both pre- and posttest, respectively.

Table 1: The below sample description is based on the n = 88 students who completed the pre- and posttest Attitudes survey. Half knew or met ≥ 5 PWIDDs, and 37% (n = 33) had last been in contact with a PWIDD in the last week or month.

Table 1.

Pre-post sample description (n = 88).

		% (n)
Region	Northeast USA	67% (58)
	Other	33% (29)
Gender	Female	57% (50)
	Other	43% (38)
Intended Specialty a	Primary Care a	42% (37)
	Surgery	16% (14)
	Other/Undecided	42% (37)
Primary Language	English	81% (71)
	Other than English	19% (17)
# PWIDD: Know or met	0–4	50% (43)
	5+	50% (43)
Last Contact PWIDD	Last week or month	37% (33)
	Within 6 months	16% (14)
	Longer than 6 months	47% (41)

^aSpecialties were categorized as: a) primary care: family medicine, general medicine, ob/gyn, and internal medicine/pediatrics, b) surgery (neurological, orthopedics, vascular, plastic, urology, ENT), and c) other; remaining or undecided.

Table 2: Scale– Only the Attitudes ‘Discomfort,’ (α = 0.72) and Knowledge ‘Interpersonal/Communication Skills’ (α = 0.78) demonstrated good reliability. Pre-Post-- Given these reliability statistics, pre- to posttest scale score changes are difficult to interpret.

Table 2.

Knowledge and Attitude subscale Statistics and student scores.

			Student Scores
	Scale Statistics (n= 114)		Mean (SD)		Median
Attitudes a lower = better	Range (# items)	Cronbach’s α	Pretest	Posttest	Pretest	Posttest
Discomfort	0–40 a (8)	0.72	0.42 a (0.10)	0.43 a (0.11)	16 a	17.5 a
Knowledge of Capacity and Rights	0–65 (13)	0.40	0.60 (0.05)	0.56 (0.05)	39	37
Interaction	0–10 (13)	0.55	0.67 (0.14)	0.69 (0.14)	7	7
Sensitivity or Tenderness	0–10 (2)	0.04	0.51 (0.12)	0.46 (0.12)	5	5
Medical Knowledge	0–75 (15)	0.43	0.53 (0.06)	0.49 (0.06)	39	37
			Student Scores
	Scale Statistics (n= 112)		Mean (SD)		Median
Knowledge	Range (# items)	Cronbach’s α	Pretest	Posttest	Pretest	Posttest
Medical Knowledge	0–16b (16)	0.50	0.54 (0.16)	0.63 (0.17)	n/a	n/a
Patient Care/Compassionate Care	0–11 (11)	0.64	0.66 (0.20)	0.69 (0.21)	n/a	n/a
Interpersonal/Communication Skills	0–7 (7)	0.78	0.70 (0.22)	0.72 (0.24)	n/a	n/a
Professionalism	0–10 (10)	0.68	0.70 (0.21)	0.75 (0.22)	n/a	n/a
Practice Based Learning: Investigate & Apply	0–11 (11)	0.63	0.19 (0.07)	0.20 (0.07)	n/a	n/a

^aAttitude Likert scale responses were coded 1–5 (1: most optimal, 5: least optimal, 0: no response). Lower = better.

^bKnowledge responses were coded as either 0 (no response/incorrect) or 1 (correct)..

Table 3. The overall Attitudes score improved (i.e., decreased) from pre- to post-test (0.55 [.06] vs. 0.53 [0.06]); p = 0.00). There were not demographic differences in Attitudes at pre- or post-test.

Table 3.

Attitudes scores Pre/Post-intervention and by student characteristics.

	Attitudes Pretest: Mean (SD)	p-value (Attitudes pre v. post)	Attitudes Posttest: Mean (SD)	p-value
Total Score (n= 88)	0.55 (0.06)	p=0.00*	0.53 (0.06)	—
Gender: Pretest			Gender: Posttest
Else	0.54 (0.05)	p=0.89	0.52 (0.06)	p=0.52
Female	0.55 (0.06)		0.53 (0.06)
Region of Origin: Pretest			Region of Origin: Posttest
Else	0.55 (0.06)	p=0.54	0.52 (0.06)	p=0.38
Northeast	0.54 (0.06)		0.53 (0.06)
Intended Specialty: Pretest			Intended Specialty: Posttest
Primary Care	0.55 (0.05)	p=0.99	0.54 (0.07)	p=0.39
Surgery	0.54 (0.05)		0.51 (0.07)
Other/Undecided	0.55 (0.06)		0.52 (0.06)
Language: Pretest			Language: Posttest
English	0.55 (0.06)	p=0.83	0.53 (0.07)	p=0.58
Else	0.54 (0.06)		0.52 (0.05)
# PWIDDs Know/Met: Pretest			# Persons Known with IDD: Pretest
0–4	0.54 (0.05)	p=0.91	0.52 (0.06)	p=0.62
5+	0.55 (0.06)		0.53 (0.07)
Last Contact with Person with IDD: Pretest			Last Contact with Person with IDD: Posttest
Past Week/Month	0.55 (0.06)	p=0.45	0.53 (0.08)	p=0.53
Past 6 Months	0.53 (0.04)		0.51 (0.05)
Beyond 6 Months	0.54 (0.05)		0.53 (0.05)

Table 4. The overall Knowledge score increased from pre-to posttest (65[19] vs. 73[17], p = 0.00). At baseline, female identified students had higher scores than others (71 [13] vs. 63 [16]; p = 0.01), as did students who knew ≥ 5 PWIDD vs. those knowing < 5 PWIDD (72 [12] vs. 63 [16]; p = 0.02). These demographic differences did not persist to follow-up.

Table 4.

Knowledge scores pre/Post-intervention and by student characteristics.

	Knowledge Pretest: Mean% Correct (SD)	p-value (Knowledge pre v. post)	Knowledge Posttest: Mean % Correct (SD)	p-value
Total Score (n= 85)	65 (19)	p=0.00*	73 (17)	n/a
Knowledge Scores x Student Demographics
Gender: Pretest			Gender: Posttest
Else	63 (16)	p=0.01*	72 (17)	p=0.18
Female	71 (13)		76 (17)
Region of Origin: Pretest			Region of Origin: Posttest
Northeast	68 (14)	p=0.42	70 (22)	p=0.25
Else	67 (15)		76 (14)
Specialty of Interest: Pretest			Specialty of Interest: Pretest
Primary Care	64 (17)	p=0.25	65 (19)	p=0.22
Surgical Specialty	74 (9)		80 (10)
Other/Undecided	69 (12)		75 (16)
Language: Pretest			Language: Posttest
English	69 (14)	p=0.24	75 (18)	p=0.73
Else	61 (17)		71 (15)
# Persons Known with IDD: Pretest			# Persons Known with IDD: Posttest
0–4	63 (16)	p=0.02*	72 (14)	p=0.24
≥5	72 (12)		77 (19)
Last Contact with Person with IDD: Pretest			Last Contact with Person with IDD: Posttest
Past week or month	65 (18)	p=0.82	74 (17)	p=0.15
Past 6 months	72 (8)		81 (10)
6 months	68 (13)		72 (19)

Open-Ended Items: Three items at the end of the Attitudes survey at both pre- and post-test elicited responses to the following questions:

This survey asked you to respond to a number of items related to the health issues experienced by people with IDD using a predetermined scale. If you would like to elaborate on any of your responses or offer additional thoughts about these issues, please do so below:

Relatively few students provided comments on PWIDD health issues or survey questions at pre-test (n = 16) or post-test-(n = 3). Several reported insufficient knowledge about PWIDDs to respond accurately. Others noted that IDD is a broad category, so answering questions about generic questions about PWIDD was a challenge, and perhaps inappropriate: ‘People with IDD vary significantly! It is hard to give one answer that reflects my experiences/expectations of all people with IDD.’ One comment reflected the need to acknowledge discomfort: ‘I think it is acceptable and normal to feel uncomfortable around people who are different from us, and that does not necessarily mean it is a bad thing to feel.’

Do you have any thoughts or concerns about your school’s efforts to incorporate information about health issues experienced by people with IDD into the medical school curriculum?

School’s Efforts to Incorporate Curriculum About PWIDD. This item generated 42 pretest comments and 17 at post-test. Pre-intervention, many students affirmed that IDD training was ‘lacking’ and would be a barrier to caring for PWIDD. Several stated their anticipation of caring for PWIDDs – if they hadn’t already. Students (n = 7) suggested introducing IDD content into the first-year Introduction to Clinical Medicine course. The intervention sessions were described as effective: ‘Hearing from a panel of patients who live their daily lives with IDDs was very helpful and aided in my understanding of how to best meet the needs of a patient with an IDD.’

What barriers exist for you in implementing the best care for patients with IDD? If any, please describe them below.

Barriers to Implementing Best Care for PWIDD. Among the pre- and post-test comments (39 and 15, respectively), ‘lack of’ experience or training was a focal concern. Students also noted barriers related to their lack of experience, knowledge, and bias against PWIDD. One student noted insightfully: ‘Me, feeling comfortable. I am the barrier.’

Discussion

There is increased recognition of health disparities experienced by people with disabilities [9–11], especially PWIDDs– [12–14] as recently seen during COVID-19 [15]. The estimated prevalence of diagnosed DDs in the US is increasing for children [16,17] and adults [14,18–22]. Yet, despite calls for medical education and training about disabilities, research on medical students knowledge and attitudes regarding PWIDDs remains scant. We implemented didactic, panel, and clinical skills curricula intervention to address this gap. We analyzed pre/post intervention changes in overall knowledge and attitudes, along with medical student demographics, intended specialty, and experience with PWIDDs. Post-intervention, overall knowledge and attitudes improved (by 7% and 2%, respectively). Pre-test knowledge scores were higher among female-identified (vs. other genders) students and those knowing ≥ 5 PWIDDs (vs. <5). No other overall knowledge or attitudes changes, or student demographics differed between pre- and post-tests.

Healthcare providers demonstrate negative biases (e.g., preference toward patients with less complex medical needs) when treating persons with disabilities in both clinical [5,23] and research settings [24,25]. Thus, the intervention’s association with improved overall knowledge – which can impact attitudes – along with attitudes is a positive finding. In the general population, positive attitudes towards PWD are higher among female-identified students (vs. male-identified). Knowledge, frequency and quality of contact are positively associated with attitudes towards PWDs [26–28]. Our findings are consistent with this prior work. At baseline, women and those knowing ≥ 5 people with IDD had higher overall scores than men and students knowing fewer people with IDD, respectively. The intervention may have reduced the effects of gender and prior exposure to PWIDDs, as such differences were no longer significant at follow-up.

Our integrated didactic, panel and clinical skills intervention possessed certain strengths. Prior work has generally not focused on IDD, compared to general ‘disability’ (‘functional impairment’). A review of IDD curricula in post-graduate medical education found just 16 studies since the 1980s. Most focused on medical/clinical knowledge (n = 13), fewer on perspective/awareness/comfort (n = 6), and fewer still included patients, parents or caregivers as instructors (n = 2) [29]. In a systematic review of interventions (n = 77) to teach medical students about disability, just half (47%; n = 27) provided outcomes data for all attitudes, knowledge, and/or skills objectives. Further, just 8% (n = 6) included longitudinal (i.e., ≥ 2 day post-intervention) data [30]. Using NIH’s 12-point checklist for quality of pre-post studies without controls, we estimate having met ~ 6–8 of listed evaluation strengths, including: clear study question, pre-specified eligibility, sample representativeness, pre-specified outcomes and statistical analysis of pre-post change [31]. Further, partnering with PWIDDs in the design and implementation of our multi-modal curriculum aligns with recommendations from reviews of prior curricula [7,32].

Our study also has several weaknesses. As a single-site intervention, generalizability to other settings – i.e., with different course instructors, faculty group leaders, non-standardized SAs and family members – is limited. Per the above-cited NIH checklist, weaknesses included: lack of masked outcomes assessment (i.e., knowledge of data as pre- vs. post-test), loss to follow-up ≥ 80% and lack of multiple follow-up points [31]. Further, both the Attitudes and Knowledge surveys exhibited poor scale reliability. Instrument validation using data from all 18 medical schools involved with the NCIDM initiative will be an important area for future research. Lastly, reliance on explicit attitudinal bias measures may underestimate negative attitudes towards PWIDD [23], due to social desirability bias.

The Einstein NCIDM project was a complex initiative, requiring a commitment of medical school administration and faculty as well as SAs, family and outside agencies. In addition, within medical education, there were many competing demands for medical school student time. The administration’s positive acknowledgement of the importance of inclusion and diversity of PWIDD, particularly adults with IDD as an underserved growing population, was an asset to this effort. Future sustainability of the use of SAs as non-standardized patients may be difficult to maintain. Incorporation of 15 SAs involved numerous hours of preparation in order for SAs to feel comfortable within the small group setting interview. In addition, changes to medical school curriculum with the introduction of early clerkship experiences may impede additional time required for such as effort. Also, COVID-19 pre-empted in-person clinical skills experience in AY 2020 & 2021 years. Subsequently, conversion of the small group sessions were made to include a reframing of the second student contact to an interdisciplinary diagnostic and treatment panel along with a SAs and family member panel.

The experience of the NCIDM IDD inclusion curriculum into the medical school has been extremely positive and has led to a number of alternative opportunities for students to engage in extra-curricular community activities with people with IDD, including the formation of a medical student chapter of AADMD in which students participate in organizing medical lectures related to IDD, providing nutritional and cooking classes to local self-advocacy groups as well as participating in Special Olympics New York – health screening activities. These activities have provided students opportunities to engage with an underserved population and begin to discuss barriers and stereotypes that are impediments to treatment.

This IDD curriculum effort was an attempt to reach future physicians early in their academic studies to provide an opportunity to experience the unique issues related to treating PWIDD, whom they may likely encounter during their careers. Because of competing time constraints, testing requirements and student demands, the sustainability of this type of IDD curriculum effort is dependent on commitment from the highest level of medical school administration, faculty and course leaders who envision a more experiential hands-on approach toward learning that includes non-standardized patients who are able and willing to share unique personal experiences in medical settings. For practicing physicians, Continuing Education is needed to provide enhanced interactions with patients who have disabilities. However, past attempts to reach the general practitioner through this mechanism have not proved successful. For this reason, the focus of this effort was on future clinical practitioners within the medical school setting.

Future Implications

Currently 10% of US medical schools have adopted NICHE curricula (https://www.aadmd.org/niche). While Einstein was the first of NICHE-funded school to analyze its data, the authors are in the process of evaluating data from all 18 schools. This will permit analysis of the effectiveness of heterogeneous curricula, using the same (Knowledge and Attitudes) assessment tool. We anticipate that the rising prevalence of disability [33]/DDs [16] in the US, and rising emphasis on disability by institutions such as the National Institutes of Health [34], will grow the need for evidence-based curricula throughout medical training.

Funding Statement

The work was supported by the Centers for Disease Control and Prevention and Special Olympics International, National Curriculum Initiative in Developmental Medicine to the American Academy of Developmental Medicine and Dentistry.

Disclosure statement

No potential conflict of interest was reported by the author(s).