Optimal addiction training for child and adolescent psychiatry (CAP) residents may differ from training received during general psychiatry residency since the pattern of child and adolescent substance abuse is significantly different from adult substance abuse. For example, adolescents undergo significant alcohol withdrawal symptoms or other symptoms of physiological dependence to alcohol much less commonly than adults (+1). The years of childhood and adolescence represent a critical time for the potential initiation of substance use. Early onset of substance use may be associated with increased severity of addiction and may have negative consequences on physical, social, and cognitive development. Substance use has been associated with injury, suicide, and homicide in young people (+2). In adolescents, substance abuse often presents comorbid with other psychiatric conditions (+3).

Thus, it is important that CAP residents learn to screen, assess, refer, and/or treat children and adolescents who have substance abuse diagnoses. In 1989, Steg et al. surveyed accredited child and adolescent psychiatry programs and indicated that there was a lack of emphasis on substance abuse training (+4). Steg et al. noted that most CAP programs had at least some addiction didactic time. However, only 59% of the training directors reported that the child and adolescent trainees were adequately trained to identify and at least initially manage a substance abusing adolescent (+4). Using a training director survey, our study sought to update information on the status of didactic and clinical addiction training opportunities among CAP programs, to examine how training in specific addiction treatment modalities relates to whether CAP residents treat patients for substance use disorders in one or both years of training, and to report preliminary qualitative data on barriers to addiction training in CAP residencies.

The authors developed survey questions relevant to addiction psychiatry didactics, supervision, and clinical experiences in CAP programs. The survey included numerical and multiple choice items, as well as the option to include comments by the training director. In July 2002, this questionnaire was sent by mail to the directors of all 113 accredited U.S. child and adolescent psychiatry programs as listed in the Graduate Medical Education Psychiatry Directory 2002—2003 (+5). A cover letter from the American Psychiatric Association (APA) Committee on Training and Education in Addiction Psychiatry accompanied the survey requesting the recipients’ cooperation with the project. The cover letter contained the statement that no individual programs would be explicitly identified, thereby assuring confidentiality. A prestamped return envelope was included. CAP training directors were asked to complete questions related to their respective child and adolescent training programs. Follow-up emails and letters were sent over the course of the ensuing 6 months to the program directors in order to elicit further responses. The data collection period was from July 2002 to May 2003. Responses to all of the questions were tabulated and are summarized in +Table 1, except for the question assessing hours of clinical supervision (see +Table 1, question #9) in which the vast majority of respondents did not provide quantitative responses.

Bivariate analyses were conducted in order to examine the relationship between specific treatment modalities for addiction and whether the programs’ CAP residents treat patients for substance use disorders in one or both years of clinical training. These analyses were conducted in order to determine whether there would be significant differences in the use of different treatment modalities in programs in which the CAP residents treat substance abuse patients in one versus both years of training.

Seventy percent (79 of 113) of the CAP directors completed and returned the survey. The represented residency programs were located in 36 states and Puerto Rico. Among the eight states with CAP programs that did not respond to the survey, there was one CAP program in each of the eight states. The remaining 26 programs that did not respond to the survey were distributed evenly among states in which other programs had responded to the survey. The survey questions and the number and percentage of the total responding residency directors are reported in +Table 1. The majority of the responding program directors indicated a high prevalence ("commonly" or "very frequently") of substance use disorders in the clinical population of patients treated by residents. The majority of programs have CAP residents treating patients for substance use disorders in the first and second years of training. However, only 29 program directors (37%) reported that their programs have a rotation for CAP residents in which the treatment is primarily dedicated to substance use disorders.

The CAP inpatient unit was the most common setting in which CAP residents treated patients specifically for substance use disorders. Other common settings included the CAP outpatient clinic, day treatment program and psychiatric emergency room. The CAP residency directors reported that their residents utilized different modalities in the treatment of substance use disorders. The most commonly reported treatment for substance use disorders was cognitive-behavioral therapy. Most programs (53 of 79) provided exposure to at least two addiction treatment modalities (mean number of SUD treatment modalities= 2.25). CAP faculty members were reported to most commonly provide substance use disorder training to the CAP residents. Lectures were the most commonly reported didactic approach for addiction training. The majority of the respondents felt that the program had "too little time" devoted to substance use disorders through didactic lectures and clinical supervision.

Programs in which CAP residents treat patients with substance use disorders in both years of clinical training were more likely to include instruction in the following treatment approaches compared with programs in which CAP residents treat patients in only 1 year: detoxification (33/59, 56% versus 4/20, 20% [χ²=7.75, df=1, p=0.005]), 12-step methods (35/59, 59% versus 6/20, 30% [χ²=5.14, df=1, p=0.023]), and cognitive-behavioral therapy (48/59, 82% versus 10/20, 50% [χ²=4.87, df=1, p=0.027]). There were no significant differences in clinical training with respect to motivational interviewing or harm reduction approaches.

Twenty-five percent (20 of 79) of the residency directors added comments regarding their CAP programs as well as the general status of addiction training. The residency directors recognized the continued need for providing addiction training but also noted many potential limitations. The high psychiatric comorbidity of addiction in adolescents, time constraints, lack of supervisors, and limited available clinical teaching settings within the individual residency programs were cited as hindrances to the provision of addiction psychiatry training. One program director noted that in the past few years several child and adolescent psychiatry residents pursued further addiction training by entering addiction fellowship programs after completing CAP residency training. Sample comments from the CAP residency directors are listed in +Appendix 1.

Findings from this study indicate that the majority of CAP residents are treating patients with substance use disorders in both years of training and in multiple treatment settings. Yet, only 37% of the programs have a rotation primarily dedicated to SUD and more than one-half (58%) of the training directors reported that there was "too little time" devoted to addiction training. In addition, exposure to specific treatment modalities was related to intensity of exposure to patient care of substance use disorders. The qualitative data provided may highlight potential obstacles to addiction training. Addressing this gap in training is valuable because earlier research suggests that even minimal increases in addiction training exposure may have an impact on the attitudes of physicians. It has been determined that even a 1 day educational conference could lead to significant changes in attitudes including increased beliefs that physicians can motivate addicted patients to obtain treatment and greater physician interest in obtaining advanced addiction training (+6). In addition, model curriculums for incorporating substance abuse education in CAP programs have been described in the past (+7). In some cases, the treatment settings of juvenile detention centers, residential facilities, and juvenile drug courts may be further staffed by CAP residents.

Potential limitations of the current study include the nature of the survey instrument for analysis. The CAP residency directors may have had different interpretations of the survey questions. Moreover, it may have been difficult for residency directors to accurately report on specific treatments for substance use disorders in adolescents because treatment may involve several comorbid conditions.

There may have been a possible bias of the CAP residency directors who returned the survey. Thirty-four program directors did not return the survey. The programs whose residency directors did not return the survey were diverse with respect to program size, urban/rural settings, and geographic region. Therefore, no trends in nonparticipation could be assessed. It is possible that CAP residency directors who were more satisfied with their programs’ addiction training may have been more likely to return the survey. On the other hand, CAP residency directors who were opposed to the further augmentation of addiction training might have been more likely to respond. The overall response rate of 70% for our survey can be considered as exceeding the typical return rate for mail survey research (+8).

Another possible limitation to the study was that the descriptions of addiction training were only from CAP residency directors and did not include feedback from the residents. The residents’ perceptions of addiction training may differ from those of their directors. In a study conducted by Steg et al. (1992), 24% of the residents reported some exposure (≥1 hour) to an adolescent drug abuse treatment facility during their training, whereas 46% of the training directors indicated that their residents had this exposure (+9).

The findings from this study raise awareness of the need for substance use disorder training in CAP residencies. The survey provides preliminary data for system-level constraints that merit additional consideration in order to potentially advance addiction training in CAP residencies. Future surveys of CAP residents in addition to the residency directors may be useful to further characterize the status of addiction training in CAP programs.

This study was supported by grants from the Scaife Family Foundation and the Bodman Foundation.

The authors thank Bea Edner and the APA Committee on Training and Education in Addiction Psychiatry for their assistance.