European Child & Adolescent Psychiatry https://doi.org/10.1007/s00787-019-01402-9 REVIEW Child and adolescent psychiatry training in the USA: current pathways Jeffrey Hunt1 · Jared Reichenberg1 · A. Lee Lewis2 · Sansea Jacobson3 Received: 28 May 2019 / Accepted: 3 September 2019 © Springer-Verlag GmbH Germany, part of Springer Nature 2019 Abstract This manuscript reviews contemporary training in the field of child and adolescent psychiatry in the USA. There are multiple well-defined pathways to becoming a child and adolescent psychiatrist in the USA. The Accreditation Council of Graduate Medical Education oversees child and adolescent psychiatry training programs and ensures that training programs are meeting the appropriate common and program-specific requirements. The American Board of Psychiatry and Neurology ensures that the individual child and adolescent psychiatrist is competent. There is a substantial shortage of child and adolescent psychiatrists in the US, and efforts are being made to increase the number of and accessibility of trained child and adolescent psychiatrists. Child and adolescent psychiatry training in the United Sates is constantly evolving and future directions include increased engagement of medical students and general psychiatry residents, new abbreviated pathways for training, and international collaboration between programs. Keywords Medical education · Child and adolescent psychiatry · Residency training Introduction The field of child and adolescent psychiatry (CAP) in the USA developed during the early part of the twentieth century in the context of the establishment of the juvenile court system [1]. The American Academy of Child Psychiatry was first formed in 1953 and was later renamed the American Academy of Child and Adolescent Psychiatry (AACAP) in 1986. It received its first major funding for training through the Mental Health Act of 1946, although it was not until 1959 that child psychiatry was first recognized as a This article is part of the focused issue ‘The European and Global Perspective on Training in Child and Adolescent Psychiatry. * Jeffrey Hunt Jeffrey_hunt@brown.edu 1 Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Bradley Hospital 1011 Veterans Memorial Parkway, East Providence, RI 02915, USA 2 Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Charleston, SC 29425, USA 3 Department of Psychiatry, Western Psychiatric Institute & Clinic, UPMC, 3811 O’Hara Street, E503, Pittsburg, PA 15213, USA subspecialty by the American Board of Psychiatry and Neurology (ABPN) [2]. Child and adolescent psychiatry training began as an apprentice-based model which has essentially continued through today in that all trainees are supervised by more experienced clinicians [1, 3]. Leo Kanner wrote the first textbook in child and adolescent psychiatry, Child Psychiatrist, in 1935 and efforts to define the specific training requirements beyond general psychiatry training began in 1944 in the context of the child guidance clinic movement [4]. As this movement became more and more popular, the need for specialized medical (and psychotherapeutic) practitioners developed to help lead these clinics. This led to the development of child and adolescent psychiatry training programs [4]. This article reviews the current training pathways available in the USA and also includes a discussion of accreditation, workforce shortages in the context of training, and proposals for innovations in training. Current training pathways After completing undergraduate (college) education in the USA, students who wish to pursue a career in medicine apply to a (typically 4 year) medical school program. Although medical school admission requirements vary by institution, it is highly recommended that applicants have 13 Vol.:(0123456789) European Child & Adolescent Psychiatry some form of medical experience prior to entering medical school such as working as a hospital volunteer and emergency medical technician. [5–7]. This experience may be in general psychiatry or CAP if desired. In the final year of medical school, students apply for a medical residency training program in their specialty of choice (to begin after graduation). For those who have decided on a career in CAP, there are five different pathways that one can take, all of which ultimately lead to board certification from the ABPN allowing them to practice in the field. There is no preferred method of training and alternative pathways allow for greater emphasis on pediatrics and research. Categorical track There are 139 accredited CAP training programs that are currently active according to the Association of American Medical Colleges (AAMC) [8]. Programs must have at least two fellows per year by ACGME requirement. Most programs have 4–6 fellows per year. The larger programs have 10–12 fellows per year. There must be a minimum of three faculty including the program director. Larger programs are required to have a “sufficient number of faculty to supervise” [9]. The “categorical” track is the most common training trajectory, which in most cases involves 4 years of general psychiatry training (residency) followed by 2 years of CAP training (fellowship). In order to get accepted into the traditional categorical track, medical students interested in CAP will first match into a general psychiatry program by participating in the National Residency Matching Program (NRMP) after graduating from an allopathic or osteopathic 4-year medical school [10]. After meeting the requirements of their general psychiatry training, these interested candidates again enter the NRMP (a second time) in order to match into a CAP fellowship training program. The NRMP is a private, not-for-profit organization that serves as a centralized body that manages the residency application process for all major medical specialties and uses a computerized mathematical algorithm to “match” medical school graduates into specific residency training programs by accounting for both applicant and program selection preferences [11]. It is important, however, to note that there are some instances where general psychiatry residents applying for a CAP fellowship may obtain positions outside the NRMP match process. This is most typically utilized by programs that have difficulty recruiting trainees due to geographic or other factors [12]. This process is explicitly outlined by the Gentlepersons’ Agreement among directors of American programs, which is a nonbinding agreement among US program directors to participate in the Match or accept their residents before the Match begins.[12]. Once accepted into a CAP fellowship program, trainees in the categorical track 13 complete a 2-year-long training program to become board eligible in CAP. Because of the great need for CAP-trained psychiatrists in the USA (to be discussed later), this 6-year process can be truncated into a 5-year process through a “fast track” pathway. This involves starting the CAP fellowship program after 3 years of categorical psychiatry residency training. This pathway is made possible by “double counting” some of the requirements that CAP training and adult training have in common (forensic, addiction, community mental health, outpatient, etc.) [9]. In either case, the general psychiatry residency incorporates approximately 4 months of internal medicine (or pediatrics) and 2 months of adult neurology training into the first year, as well at least 2 months of CAP training throughout the program [13]. The CAP fellowship includes at least 1–2 months of pediatric neurology training in the first or second year. Of note, there are other psychiatry sub-specialties that one may pursue after general psychiatry training such as addiction, geriatric, forensic, or consultliaison psychiatry, which typically involve 1 year of postresidency training [13]. Combined general psychiatry and CAP Combined general psychiatry and CAP programs were first implemented in the 1970s at the University of Pittsburgh, and only a few institutions have adopted this training pathway since then. This pathway is 5 years long and is similar to the categorical “fast track” pathways. The main difference between these programs and the aforementioned “fast track” is that these programs allow you to enter the NRMP match process only once (after medical school), matching into both the general and CAP training programs at the same institution (i.e., with a designated NRMP program code separate from that of the categorical program). There are numerous practical benefits of these programs, such as the fact that training is not interrupted by a second match process thus not contributing to the stress, financial costs, and time burden of interviewing outside the home institution, relocation, becoming acquainted with a brand new community, and orientation to new systems. Arguably most beneficial for CAP trainee recruitment and retention, however, is that these programs enable the resident to begin building their professional identity as specialist within CAP through more longitudinal and integrated exposure to pediatrics and CAP experiences, projects, and mentorship from the early years of training. Subsequently, by the time the trainee begins their CAP fellowship, they are better equipped to serve more senior roles as clinician-educators and peer mentors for the categorical residents. Of note, some residency training programs have less formal pathways that allow trainees who have matched into European Child & Adolescent Psychiatry a categorical psychiatry residency to declare and pursue an interest in CAP early in their training (without having a separate NRMP Program Code). The hope is that this allows those not in a formal combined program to build more child and adolescent experiences into their general training prior to starting CAP fellowship. These programs have the added benefit of allowing CAP fellowship directors to recruit candidates from within their own residency and provide guidance and targeted exploration of the field in a more individualized manner from PGY-1 onwards. Completion of general psychiatry and CAP training at the same time has been shown to enhance longitudinal interest in CAP and increase the likelihood that those trainees will indeed pursue CAP fellowship [4, 14]. Combined pediatrics, general psychiatry, and CAP (Triple Board Training Programs) Based on the identified need for enhanced CAP recruitment in the 1980s, the Combined Program in Pediatrics, Psychiatry, and Child and Adolescent Psychiatry (Triple Board) training programs were developed through a collaboration between the American Board Pediatrics (ABP) and the ABPN. This integrated curriculum was designed to encourage medical students to pursue this much needed field by condensing total training duration/requirements (5 years) versus the time it would take an interested student to become certified in all three disciplines separately (8–9 years). Six pilot programs were initially approved and started in July 1986. After the great success of these programs, this training pathway was granted permanent status by the ABP and ABPN in 1995 [1, 14]. There are currently 9 of these programs in the USA. Triple Board residents complete a total of 24 months of pediatric (medicine) training, 18 months of general psychiatry training, and 18 months of CAP training. Upon completion, Triple Board program graduates are board eligible, through the ABP and ABPN, in all three of these distinct specialties. Each program varies in how they distribute these phases of training, but in all cases this unique program structure offers multiple benefits including earlier exposure to CAP, pediatric medicine exposure throughout training, and a foundational emphasis on integrated care. Accreditation by the ACGME (The Accreditation Council of Graduate Medical Education) of a Triple Board program requires that the three parent programs in pediatrics, general psychiatry, and CAP be in good standing and not on probation due to noncompliance with common and specialtyspecific program requirements. The combined programs are reviewed separately [14]. The majority of graduates from these programs (72% in one follow-up study) go on to pursue academic careers in CAP; however, a substantial minority also go on to focus on pediatrics (25%) medicine or adult psychiatry (8%) [14, 15]. Most graduates of these combined programs who have academic focus also have substantial clinical roles in addition to research careers [14, 15]. Post‑pediatric portal The creation of the Post-Pediatric Portal program represents another effort to address the shortage of child and adolescent psychiatrists in the US [15–17]. This program allows physicians who have completed a pediatric medicine residency (and who have been certified by the American Board of Pediatrics) to complete general psychiatry/CAP training. Typical applicants have either recently completed their pediatric training or are later in their careers and looking to shift to psychiatry. This pathway, initiated within the ACGME but now overseen by the ABPN, involves 3 years of combined training in general psychiatry and CAP (similar to the triple-board programs). Graduates then become certified in general psychiatry and CAP. Due to a scarcity of funding, there are very few of these programs. Currently there are four programs that are active in the USA [18]. Integrated research pathway in child and adolescent psychiatry (IRPCAP) Collaboration between the National Institute of Mental Health (NIMH), National Psychiatry Training Council (NPTC) Models Program Task Force, and AACAP Task Force on curricular reform in research training of child and adolescent psychiatrists resulted in the creation of the IRPCAP. This program is designed to integrate clinical and research training in both general psychiatry and CAP over a 6-year period [14]. There are three programs in the USA: University of Colorado, University of Vermont, and Yale University. Many of the graduates of these programs have been successful in developing research careers [17]. The integrated research track does not provide participants with a PhD; however, some of the residents who choose this track already have a PhD from previous training. The length of the residency is 6 years with prescribed clinical and research training integrated throughout. The integrated training programs are designed to address the relative lack of CAP researchers in the field and it provides the clinical experiences essential for developing pertinent scientific questions. Residents in these programs receive assistance in preparing for and applying for post-graduate research awards through the NIMH and other funding sources. 13 European Child & Adolescent Psychiatry CAP training program oversight It is the responsibility of the ACGME to ensure that each program is meeting the core program requirements. They do this through an oversight group known as the Psychiatry Residency Review Committee (RRC). Since 2015, programs have been required to record the specific milestones within each sub-competency of the six core competencies reflecting each fellow’s current performance and attributes [19]. The Milestones provide a structured framework for the assessment of the development of the resident physician in key elements of physician competency in CAP. They neither represent the entirety of the dimensions of the six domains of physician competency nor are they designed to be relevant in any other content. The competencies include patient care, medical knowledge, professionalism, system-based practice, practicebased learning and improvement, and interpersonal and communication skills. For each reporting period, faculty select milestone levels that best describe each fellow’s current performance and attributes. Milestones are arranged into numbered levels. Tracking from Level 1 to 5 is synonymous with moving from novice to expert in the subspecialty. These levels do not correspond to post-graduate year of education [19]. Each individual program’s educational leadership reviews and reports the Milestones for each resident every 6 months. These levels do not necessarily correspond to postgraduate year of education, but are anchored in very specific training level descriptors. These milestones provide a framework by which supervisors can assess the development of a resident physician in the essential dimensions needed for being a competent psychiatrist. Also, these milestones provide important data on what elements of training each program is excelling in, and what elements of education the program may need to improve in a given specialty or subspecialty. The ACGME plans to collect several years of milestone data prior to developing benchmarks for use in review of programs (See milestone research trends at https​://www.acgme​.org/ What-We-Do/Accre​ditat​ion/Miles​tones​/Resea​rch). After this process becomes validated, the goal for the Milestone project is that the ACGME Psychiatry RC should eventually be able to examine milestone performance data for each program’s fellows and know that the programs are providing competent training for future CAP clinicians [4]. 13 Monitoring of individual practitioner competencies The American Board of Psychiatry and Neurology (ABPN) provides board certification for individuals after their graduation from an accredited program. At the end of training, trainees complete an ABPN certification exam (American Board of Psychiatry and Neurology test). All practicing clinicians who obtained initial certification after 1994 are required to take this examination every 10 years to maintain certification while those certified before 1994 are exempt. Questions are based on the recent articles of the past 5 years as well as general knowledge sources such as IACAPAP textbook and practice parameters. A current initiative seems to move towards an annual test that is based on a list of recent articles that will be made available to those who participate in the exam. Please note that these tests are not obligatory and CAPs are allowed to practice if they are not "board-certified". However, it seems to be an additional marker of quality and some health insurance companies might decide to only reimburse CAPs who are board certified. However, given the current shortage in CAP, currently that is not the case. Before a fellow’s completion, program directors must pre-certify in an online system that the graduate met specific training requirements. This allows the fellow to be able to take the board certification examination [20] Recruitment/workforce issues Numerous national studies substantiate the magnitude of emotional, behavioral, and developmental disorders in children and adolescents in the USA. Historically, Child and Adolescent Psychiatry had its beginnings as a discipline in the mid to late 1800s as important and influential developmental theorists began to influence society into the knowledge that childhood was its own, distinct, period of human development and growth. These fundamental changes in the concept of childhood led to the development of the “Child Guidance Movement” in the early 1900s, which led to the need for specialized medical (and psychotherapeutic) practitioners developed to help lead these clinics. The lack of enough child and adolescent psychiatrists has long been recognized but it was only in the last two decades of the twentieth century that public attention has focused on the child and adolescent psychiatry workforce. Generally, 20% of the population of youth have some emotional disturbance and 5–9% have “extreme functional impairment” [21]. Currently, there are approximately 8000 practicing child and adolescent psychiatrists European Child & Adolescent Psychiatry in the USA and over 15 million children and adolescents in need of the special expertise of a child and adolescent psychiatrist. The US Bureau of Health Professions estimates the need for more than 12,600 child and adolescent psychiatrists by 2020 to meet the growing demand for children’s mental health care, but there is an expected workforce shortfall of 4300 which equates to less than 70% of the estimated need [21]. Sponsoring institutions with existing general psychiatry programs can apply for a new CAP fellowship through the ACGME. There is an extensive application process whereby the program documents how it will meet all the common and specialty-specific program requirements including having adequate financial resources to ensure stability of the program. The Psychiatry Residency Review Committee approves the program after reviewing the application. Given these critical shortages, AACAP has been working to increase the child and adolescent psychiatry workforce. Recruitment of medical students into CAP has been at the forefront of efforts to increase workforce by offering the previously mentioned traditional and integrated tracks, but thus far these concerted efforts have not led to the increases needed to make up the projected shortfall. There have been a few proposed options that have been proposed to help combat the projected shortfall of CAP needs. One option being explored, that has already showed some success, is attempting to synergize CAP consultation and expertise within the work of Pediatricians and other healthcare professionals. The model suggests that by offering in-depth consultation (on site or training) by a CAP, other health professionals can develop the skills and confidence needed to treat a more substantial portion of mental health issues that present to their primary care clinics. Some CAP fellowships in the US already offer “collaborative care” rotations during their training, and this movement was even the target of the AACAP Presidential Initiative in 2017. Another proposed option is the expansion of the role of telemedicine in CAP care. In fact, a large number of CAP fellowships have telemedicine training rotations currently and there is a movement to more formalize the training standards across psychiatric education in the near future. The expansion of telemedicine would allow CAP providers in more densely populated areas to provide specialized care to those who do not have access to these centers themselves. Lastly, due to immense need there are examinations currently into the possibility of shortening CAP training into possibly a 3-year option (like general pediatrics) or a 4-year option (with less time devoted to General Psychiatry training, but may also make residency candidates NOT eligible for general psychiatry board certification) moving forward. While information gathering is currently underway, the conceptualization of this idea is that many current trainees are anxious to get to practice due to considerable debt accrual in the US system of education and also that medical students may be choosing general pediatrics over CAP due to the allure of training for only 3 years (and all with children and families) rather than 5 years (with at least 3 years spent in the training of treating adult populations). There has been some noted success already with the first two options and an active debate in the CAP community about what the third may mean for the training and competency of the discipline moving forward [16]. Even though general psychiatry and CAP training positions (including trainee stipends) are primarily funded by the US federal government through the Medicare system [22], trainees often have burdensome student loan debt from having to fund their undergraduate and medical school education in the current US system [23]. This often motivates individuals to pursue more lucrative medical specialties and/or specialties with a shorter total training duration [23]. Thus, there have been efforts to increase the number of training positions in CAP (which are limited in part by the amount of Medicare funding allotted) and to promote loan forgiveness and related incentives for trainees [1, 16]. Innovations in training In addition to the above efforts to increase recruitment and retention in CAP, there have been proposals for further innovations in training. For example, there have been efforts to increase the presence of CAP education and community involvement at the medical school level [1, 17]. There are programs designed to support early exposure and mentorship that may help with increased recruitment [24]. AACAP has sponsored a group of its members through a competitive process to participate in advanced education and leadership courses to enhance the educational quality of faculty presenting to medical students during their pre-clinical and clinical years [25]. The long-term outcome of this project has been positive. Some institutions have formal mentoring programs that encourage medical student involvement in CAP clinical and research activities [26, 27]. Furthermore, multiple novel models of integrated training have been proposed to help increase interest (and retention) in CAP amongst general psychiatry residents [5]. There have also been considerations to create additional portals into CAP training from other fields besides pediatrics, such as from family medicine [1]. It is clear that workforce issues cannot be solved by simply recruiting more physicians into the field, but instead we must leverage professionals within other fields to have increased competency in screening youth mental health issues and promoting skills of resiliency in our nation’s youth. The clinician–educators and advocates within the field are pioneers in these efforts and would benefit from additional support from government and community leadership. The field has been 13 European Child & Adolescent Psychiatry working towards increased collaboration and integration between training programs at the international level which will potentially be beneficial for curriculum development, cultural competency, research efforts, and so forth as we work towards keeping up with our ever-changing knowledge and understanding of child and adolescent mental health [4]. A prime example of such collaboration is the utilization of the European Union of Medical Specialists (EUMS) [4] as means of promoting collaboration between programs in different European countries, which could potentially serve as a model for expanded collaboration between the US and other countries. The US has already begun to make efforts in this regard though initiatives such as AACAP International to promote collaboration via sharing of clinical and educational resources, communication between international CAP organizations, participation in international events/conferences, and so forth [28]. Other targets of ongoing innovation include optimizing curricula for teaching the core competencies and new methodologies for trainee (and program) evaluation and remediation [1]. Telehealth initiatives and integrated care curricula are also being expanded to address workforce shortages [17]. Lastly, from a well-being perspective, when the culture of an organization aligns with altruistic values and allows flexibility of how and when care is delivered, there is the potential for improved engagement, meaning and satisfaction in the work place [29]. Thus, it is imperative that we empower leaders and create innovative systems that not only meet the needs of our nation’s vulnerable youth, but also assure that the physicians involved are adequately supported in the specialized work that they do. Summary • The field of child and adolescent psychiatry in the US began in the mid-twentieth century in the context of the development of juvenile court system and the child guidance clinic movement. • There are multiple pathways to becoming a child and adolescent psychiatrist in the US, some of which are truncated compared to the traditional categorical track and some that integrate training in pediatric medicine. • The Accreditation Council of Graduate Medical Education (ACGME) oversees that CAP training programs are meeting the common and specialty specific program requirements and collecting data on individual fellows for relating to the core competencies (Milestones) for their profession. • American Board of Psychiatry and Neurology (ABPN) provides assurance that each individual child and adolescent psychiatrist is competent through board certification and maintenance of competence after completion of training. 13 • There is a substantial shortage of child and adolescent psychiatrists in the US, and strong efforts are being made to increase the number of and accessibility to CAP providers. • CAP training is constantly evolving and future directions include increased engagement of medical students and general psychiatry residents, faculty/educator development, new pathways for abbreviated training, telehealth and integrated care initiatives, and international collaboration between programs. 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