The Accreditation Council for Graduate Medical Education requires that child and adolescent psychiatric fellows acquire skills in a range of treatment modalities. However, little is known about what models of treatment are being provided to child and adolescent psychiatry fellows in their training. This study reports on the primary treatment approaches described by fellows (N=66) in seven child and adolescent psychiatry fellowship programs.
Requirements for the Accreditation Council for Graduate Medical Education (ACGME) in Child and Adolescent Psychiatry stipulate that fellows must have “clinical experiences with children and adolescents for the development of conceptual understanding and beginning clinical skills in major treatment modalities, which include brief and long-term individual therapy, family therapy, group therapy, crisis intervention, supportive therapy, psychodynamic psychotherapy, cognitive-behavioral therapy, and pharmacotherapy” (1). Nevertheless, our knowledge about the treatment approaches currently taught in child and adolescent psychiatry training programs is limited.
Two older studies examined common treatment modalities in child psychiatry training. Stubbe (2) surveyed early career graduates of child and adolescent psychiatry fellowships and looked at their training and its relevance for their present positions in five outpatient treatment approaches: outpatient therapy, cognitive-behavioral therapy, family therapy, group therapy, and school consultation. In a sample of child and adolescent psychiatry trainees in the U.K., Smart and Cottrell (3) found systemic, biological, behavioral, cognitive-behavioral, and psychodynamic therapies to be common treatment orientations. Both of these studies considered only a subset of the educational experiences offered in most child psychiatry training programs.
Child and adolescent psychiatry fellowship programs likely select treatment emphases that are influenced by accrediting bodies, outcome research, practice guidelines, faculty interests and availability, popular clinical trends, and the preferences of training directors who shape their curricula:
Training curricula must adapt constantly to the changing face of child and adolescent psychiatry practice, incorporating new innovations while adhering to basic tenets that survive over time (4).
This brief paper addresses a current gap in our knowledge about child psychiatry training by reporting on the primary treatment approaches in a sample of child and adolescent psychiatry fellowship programs.
Training directors from nine programs affiliated with academic medical centers were contacted to participate in the study toward the end of the training year in 2008. The programs were selected for diversity, in that public, private, and geographically distributed programs were identified. Seven training directors (78%) agreed to participate (University of Washington, Stanford, UCLA, Baylor, Emory, Brown, and Cambridge Health Alliance), and fellows in their programs were invited to participate in a study of family therapy training in child psychiatry (5). After giving informed consent, fellows (N=66; 90%) completed a questionnaire assessing their family therapy training experiences and their programs’ primary models of child and adolescent treatment. This article reports on the data regarding treatment approaches.
The fellows were nearly equally divided between first-year (N=34) and second-year fellows (N=31). Their mean age was 34.19 years (SD; 4.24), and there were more women (N=40) than men (N=26). In terms of ethnicity, 49% were White (N=32), 32% Asian (N=15), 15% Black (N=10), 3% Latino (N=2), and 2% Mixed (N=1). More than half of the fellows were married (58%; N=38).
The fellows reported that their programs offered training in a wide range of treatment approaches. In fact, more than half of the fellows identified 11 different treatment orientations (see Table 1).
TABLE 1.Primary Treatment Models Reported by Fellows
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Table 1 shows that although cognitive-behavioral therapy and psychopharmacology were, by far, the most common treatment approaches identified by fellows, over three-fourths also ranked psychoeducation, psychodynamic therapy, play therapy, and family therapy as primary treatment approaches taught in their programs. In contrast, only one-quarter of the trainees viewed the wave of newer treatments—dialectical-behavior therapy, motivational interviewing, parent–child interactional therapy, and acceptance and commitment therapy—as central to their training. When asked which models they wanted to learn more about, the fellows listed play therapy, dialectical-behavior therapy, family therapy, cognitive-behavioral therapy, and behavior training at the top of their lists.
These preliminary data offer an unprecedented look at what child psychiatry trainees see as the clinical emphases in their training programs. Although fellows in this sample nearly unanimously identified cognitive-behavioral treatment and psychopharmacology as primary modalities, they also agreed that their fellowship programs offered considerable breadth in treatment approaches. At least at the level of providing exposure to the required modalities set out by ACGME, the participating training programs were successful. This study offers valuable insights into fellows’ perspectives on child psychiatry training, yet it unfortunately cannot tell us whether the fellows achieved “beginning clinical skills” in the ACGME-mandated treatment orientations.
Training directors will be interested to learn that fellows did not see the recent psychotherapies playing a primary role in their programs. However, the fellows did express a desire to learn more about play therapy, dialectical-behavior therapy, family therapy, cognitive-behavioral therapy, and behavior training. Why these particular modalities attracted special interest is unclear, although there may be practical reasons. Play therapy and behavior training are often viewed as particularly well-suited for younger children, whereas dialectical-behavior and cognitive-behavioral therapies have been tailored for working with adolescents. The appeal of family therapy may be that it serves as both a primary and adjunctive treatment for children of all ages and their families.
Limitations in this study’s methodology must also be considered. In terms of sampling, an effort was made to identify a small, but diverse, group of training programs. The a priori decision to trade off the possibility of a higher response rate in a selected number of programs rather than risk a lower response rate by surveying every fellow in every program succeeded. The fellows’ response rate within the selected programs was high, and the total number of fellows represented about 10% of child psychiatry fellows in training nationally (6). However, because the programs were not randomly selected at the outset, legitimate questions can be raised about the generalizability of the sample and these findings.
Training in child and adolescent psychiatry is an ambitious endeavor. In the limited time that we have the opportunity to work with our trainees, we cannot possibly prepare them to achieve competency in every clinical approach (6, 7). Continued study of the specific training experiences that fellows are receiving, those they would like to augment, and their level of skill in each treatment modality will enable us to better understand how well we are succeeding in our academic mission. By reframing fellowship training as an intensive introduction to an ongoing process of lifelong learning, we can offer deeper and more comprehensive educational opportunities while recognizing that there is always more to be done.