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
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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
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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
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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.
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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/Accreditation/Milestones/Research). 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].
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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
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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.
Compliance with ethical standards
Conflict of interest There are no conflicts of interest identified by any
of the authors.
Ethical approval No IRB review was required for this manuscript.
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