Training for child and adolescent psychiatry in the twenty-first century

Experiences in child and adolescent psychiatry training: an international qualitative study

BACKGROUND

Experiences of medical specialist trainees in psychiatry can be informative for those who seek to improve post-graduate training. This study aimed to explore the experience of child and adolescent psychiatry (CAP) trainees across different training settings and cultures worldwide to seek out similarities and differences.

METHODS

A convenience sample of CAP-trainees (n = 36) and -trainers (n = 54) was recruited internationally. All provided a narrative account on aspects of training in their region (n = 27 different countries), either first-person (trainees) or through external perception (trainers). Thematic analysis was used for inductive treatment of the data.

RESULTS

Trainees' and trainers' perspectives covered psychological security of the educational framework (including a comprehensive curriculum; social support and recognition of local context), specific skills to be acquired during training and the effects of the social-cultural dimension on mental health (training). Trainers' perspectives highlighted the importance of support and training for supervisors; an overall view to make sense of the training framework; and of looking at training through objective and subjective frameworks of thinking to understand and guide trainees' pathways.

CONCLUSIONS

Experiences from international psychiatry trainees suggest themes that may guide further development of international standards in psychiatry specialist training on a tailored and consistent supervision framework for trainees. For their trainers, a learning community may offer ongoing support, supervision skill development and help reflect on overall views on systems of care.

Target profiles for suicidality prevention with role-playing interventions in adolescence: a call-to-action protocol

This protocol invites researchers and practitioners across Europe to establish a research network and disseminate role-playing interventions for suicidality prevention among adolescents. By understanding and targeting specific adolescent profiles, the aim is to improve preventive strategies that are evidence-based and cost-effective, incorporating methodologies similar to the Youth Aware of Mental Health (YAM) program while considering current restrictions due to ownership and copyright. This initiative seeks to facilitate better developmental trajectories for young people by fostering mental health and reducing suicide rates through collaborative efforts with public services, schools, and policymakers.

The importance of genetic counselling for turner syndrome transition

The healthcare transition (HCT) is the process of planning, monitoring, and adjusting the clinical management from children's care to adult specialists. Although this practice is common for all children, it is especially crucial (and challenging) for those with chronic disorders and genetic conditions that also involve mental health issues, requiring a multidisciplinary approach. In this review, we aim to assess the current status of transition for girls and young women with Turner syndrome (TS) as a model as it is one of the most common sexual chromosomal aneuploidies. We first describe the syndrome highlighting some of the challenges regarding behavioural, neurodevelopmental, and mental health characteristics that must be addressed for a successful HCT. Finally, we emphasize the importance of genetic counselling within multidisciplinary groups for the successful implementation of HCT, especially for girls and women with TS, to facilitate their adaptation and adhesion to the transition process.

Rethinking how to deal with demand and supply in CAP: a European training perspective

Mental health care is suffering from a substantial gap between current service provision capacity and demand. For the generation of young doctors in psychiatry training programs today, this means they face substantial and potentially overwhelming challenges in their clinical practice. This situation calls for creative solutions in psychiatry training to prepare them best for these challenges. Perspectives of European trainers in child and adolescent psychiatry (CAP) were collected and analysed following an iterative procedure in three rounds using thematic analysis of focus groups. The three iterative rounds resulted in five proposed strategies for meeting the challenges of current and future demand in CAP specifically addressing implications for CAP training. Examples were provided illustrating how these strategies could be put into daily training practices. Four strategies aimed mainly at increasing capacity: efficiency (making best use of the existing CAP workforce); consultation (task-sharing); innovation (practicing differently); and wellbeing of the CAP workforce. An additional strategy focusing on prevention and early intervention was identified to decrease demand upstream. Rethinking CAP training practices through a European perspective on the balance between capacity and demand yielded strategies for aspects of training that are not yet universally applied. Implementation is partly dependent on the larger service provision system of care while training has leverage for future capacity and quality of care.

[Transition in mental health from childhood to adulthood: A scoping review]

BACKGROUND

The management of mental health conditions may deteriorate in adolescents during the transition from adolescent mental health services to adult mental health services. This study aimes to assess the impact of interventions and transition programs on treatment continuity and mental health outcomes for individuals moving between these services.

METHODS

A scoping review was conducted using the descriptors "Child Psychiatry", "Adolescent Psychiatry", "Transition to Adult Care", "Mental Health Services", and "Continuity of Patient Care" in Medline, Web of Science, Scopus, CINAHL, Cochrane Library, LILACS, and CUIDEN, from October to December 2023. Studies of any design published in English and Spanish were included, with no time restrictions. The quality of the studies was assessed using Joanna Briggs Institute tools.

RESULTS

Eight studies were included (two reviews, four qualitative studies, and two cohort studies), with quality ratings ranging from moderate to excellent. Only 23.5% of young people experienced a successful transition, with many facing delays and reduced long-term follow-up. Key factors for a successful transition included the transfer of information, parallel care, and the involvement of patients and family, while voluntary discharge and prior drug use before hospitalization hindered the transition process.

CONCLUSIONS

To optimize the continuity of care during the transition from child/adolescent to adult mental health services, key strategies include the transfer of information, parallel care, and active participation. Implementing coordinated measures that address barriers, reduce delays, and enhance follow-up is essential. A proactive, individualized, and collaborative approach involving patients, families, and professionals is necessary to ensure comprehensive and effective care.

How Do Psychiatry Residents View Their Training in Spain? A Mixed-Method Survey

BACKGROUND

Efforts to improve psychiatry training must incorporate residents' assessment of their training. This study sought to collect the opinion of residents about the program that has been in force in Spain since 2008, until the current transition to a new plan.

METHODS

The authors conducted an online survey of psychiatry residents in Spain, asking about their formative and working conditions. Based on previous research and the national training programme, it was distributed electronically to resident representatives of the National Board of Psychiatry. This descriptive, cross-sectional study used a mixed-methods (quantitative and qualitative) approach, following standard procedures for data analysis.

RESULTS

A total of 109 residents from 67 training units responded to the survey. The average score for satisfaction with their training was 6.84 (standard deviation (SE) = 2.4; the maximum possible score was 10). Psychotherapy was considered the area with the greatest need for improvement, while the rotations that participants would most like to be extended were child psychiatry and addictions. It was reported that rotation durations established by the national programme were not fulfilled in 38.5% of cases, while the required direct supervision for first-year residents was not fulfilled in 77.1% of cases. Regarding working conditions, 47.7% of the residents reported that they exceeded the maximum working time established by European law.

CONCLUSIONS

Psychiatry residents in Spain perceive certain areas of their training as deficient, especially those related to psychotherapy and clinical supervision, and they consider that their working time is excessive. The approval of the new training programme opens up an interesting opportunity for improvement.

Exploring the experiences of resident doctors in child and adolescent psychiatry with virtual reality-based simulation training: a qualitative study

BACKGROUND

The use of virtual reality simulation for the training of non-technical skills among healthcare professionals may improve professional development as well as the quality of care. This study aims to explore the experiences of resident doctors in child and adolescent psychiatry with the use of virtual reality-based simulation for the training of non-technical skills.

METHODS

The study had an exploratory qualitative design. Data were collected through observations of thirteen resident doctors in child and adolescent psychiatry during their participation in three virtual reality-based simulation sessions, followed by two focus groups. Data were analyzed using reflective thematic analysis.

RESULTS

The analysis revealed the following three themes: 1) The importance of pedagogical principles, 2) Playful and motionally affected learning, and 3) Observational learning contributing to lifelong learning.

CONCLUSIONS

Virtual reality-based simulation was felt to be an appropriate method of training non-technical skills for resident doctors in child and adolescent psychiatry. In particular, the intervention met resident doctors' desires and needs regarding learning through observation and peer discussions. However, some challenges related to technical issues and the content of the scenarios were highlighted. This method may not only increase the resident doctors' self-efficacy and competence, but also contribute to their lifelong learning.

Living on Site While Renovating; Flexible Instructional Design of Post-Graduate Medical Training

Background

Developing theoretical courses for post-graduate medical training that are aligned to current workplace-based learning practices and adaptive to change in the field is challenging, especially in (sub) specialties where time for re-design is limited and needs to be performed while education continues.

Approach

An instructional design method was applied based on flexible co-design to improve post-graduate theoretical courses in child and adolescent psychiatry (CAP) in the Netherlands. In four phases over a period of three years, courses were re-designed at a national level.

Evaluation

Once common vision and learning goals were agreed upon and the prototype was developed (phases 1 and 2), the first courses could be tested in daily practice (phase 3). Phase 4 refined these courses in brief iterative cycles and allowed for designing additional courses building on and adding to previous experiences in brief iterative cycles. The resulting national theoretical courses re-allocated resources previously spent on a local level using easily accessible online tools. This allowed trainees to align content with their clinical rotations, personal preferences and training schedules.

Reflection

The development of theoretical courses for post-graduate medical training in smaller medical (sub-)specialties with limited resources may profit from a flexible instructional design method. We consider the potential merit of such a method to other medical specialties and other (inter-)national efforts to develop theoretical teaching courses. A longer-term implementation evaluation is needed to show to what extent the investment made in the re-design proves to be future-proof and enables rapid adaptation to changes in the field.

The making of child and adolescent psychiatrists in Australia and New Zealand

Child and adolescent psychiatry has an opportunity to adapt alongside the advancements in medical knowledge, post-graduate training, epidemiological realities and clinical service models. Here, we are guided by the mental health needs of our community's young and their families in our review of child and adolescent psychiatry training in Australia and New Zealand. We recognise that training must respond to clinical demand and service reform while ensuring a range of clinical and educational experiences to deliver expectable competencies in order to produce child and adolescent psychiatrists that meet the communities' needs now and in the future. We argue that training programmes be subject to rigorous evaluation by embedding continuing cycles of improvement including regular review and international bench marking.

The transition from adolescence to adulthood in patients with schizophrenia: Challenges, opportunities and recommendations

Schizophrenia is a severely debilitating neurodevelopmental disorder that requires continuous multidisciplinary treatment. Early onset schizophrenia (EOS, onset before 18) is associated with poorer outcomes than the adult-onset type. The transition from adolescent to adult mental healthcare services (AMHS) poses various challenges for maintaining continuity of care. The heterogeneous availability of specialized mental health services and resources for people with schizophrenia across Europe and the inadequacy of training programs in creating a shared culture and knowledge base between child and adult mental health professionals are major challenges at the policy level. More flexible and individualized transition timing is also needed. While changes in the relationship between patients, caregivers and mental health professionals at a time when young people should acquire full responsibility for their own care are challenges common to all mental health disorders, these are particularly relevant to the care of schizophrenia because of the severe associated disability. This Expert Opinion Paper examines the main aspects of transitioning of care in schizophrenia with the aim of identifying the challenges and the potential approaches that could enhance continuity of care.

Experiences of French medical students during their clerkship in adolescent psychiatry: a qualitative study

The epidemiology of adolescent psychiatric disorders and the relational complexity of their management make exposure to adolescent psychiatry essential during medical school. However, some clinical particularities can complicate the students' learning experiences. Our work aimed to explore the experience of being a medical student during clerkships in adolescent psychiatry. Following the Interpretative Phenomenological Analysis qualitative approach, 20 semi-structured face-to-face interviews were conducted with medical students at the end of their clerkship in adolescent psychiatry. Three super-ordered themes emerged to describe their experience: in-depth self-exploration calling on emotions, thoughts and experiences; changes in the view of adolescent mental health; better understanding of the role and meaning of adolescent psychiatric care and how to approach it. Identification between students and patients could result from time-related factors (the end of adolescent brain remodeling, long, demanding studies, and financial and material dependence). In addition, the predominant use of non-analytical clinical reasoning processes-less valued in the rest of the graduate curriculum-poses a challenge for students. Indeed, for a student to find his or her place in adolescent psychiatry requires the student to reinvent him or herself, because the codes are different (no gown, less well-defined tasks, etc.). Finally, the excess prevalence of mental disorders among medical students requires increased vigilance on the part of tutors. For all these reasons, close, attentive tutoring seems essential to support students, while these clerkships afford a real opportunity for students to broaden their interpersonal skills.

ESCAP CovCAP survey of heads of academic departments to assess the perceived initial (April/May 2020) impact of the COVID-19 pandemic on child and adolescent psychiatry services

In April 2020, the European Society for Child and Adolescent Psychiatry (ESCAP) Research Academy and the ESCAP Board launched the first of three scheduled surveys to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on child and adolescent psychiatry (CAP) services in Europe and to assess the abilities of CAP centers to meet the new challenges brought on by the crisis. The survey was a self-report questionnaire, using a multistage process, which was sent to 168 heads of academic CAP services in 24 European countries. Eighty-two responses (56 complete) from 20 countries, representing the subjective judgement of heads of CAP centers, were received between mid-April and mid-May 2020. Most respondents judged the impact of the crisis on the mental health of their patients as medium (52%) or strong (33%). A large majority of CAP services reported no COVID-19 positive cases among their inpatients and most respondents declared no or limited sick leaves in their team due to COVID-19. Outpatient, daycare, and inpatient units experienced closures or reductions in the number of treated patients throughout Europe. In addition, a lower referral rate was observed in most countries. Respondents considered that they were well equipped to handle COVID-19 patients despite a lack of protective equipment. Telemedicine was adopted by almost every team despite its sparse use prior to the crisis. Overall, these first results were surprisingly homogeneous, showing a substantially reduced patient load and a moderate effect of the COVID-19 crisis on psychopathology. The effect on the organization of CAP services appears profound. COVID-19 crisis has accelerated the adoption of new technologies, including telepsychiatry.

Debate: Putting psychiatric hospitalization for children and adolescents in its place: it is time to create a system of care that works

Inpatient psychiatric care is the most expensive resource within the pediatric mental health system and is too often justified based on the lack of more appropriate and effective services. Rates of readmission are high, and data regarding long-term benefits are lacking. The continuum of care needs to be realigned to meet the needs of children and families, with investments in intensive community-based services and evidence-based training while limiting the use of acute inpatient care to those patients whose clinical presentations require and benefit from that level of service.

Editorial: Do we need inpatient units?

There is probably a consensus that psychiatric hospitalization for children and adolescents should be part of a continuum of care, but that given its expense and unnatural nature (children should be with families in a community), as noted by Kyriakopoulos in this issue, it should be used sparingly. Child psychiatrists in both the United States (McClellan) and the United Kingdom (Cotgrove and Northover) rue the fact that resources spent on inpatient units would be better spent on preventing hospitalization or providing better aftercare. It is certainly easy to see that the significant financial cost of a child's inpatient stay might well pay for his or her psychiatric treatment in the community for a year - assuming there were enough well-trained clinicians and resources to provide it. As we describe below, that is the rate-limiting step to providing alternatives and may account for why treatment is centralized rather than kept in communities. Hamdani et al eloquently describe the situation in low- and middle-income countries where there is a dearth of both inpatient and community resources; requiring urgent attention to the provision of holistic care for young people with mental health problems from preventive services upwards. The approach they describe is what our other authors are calling for, due to an historical over-reliance on inpatient beds in higher income countries.

Career Choice and Attractiveness of Child and Adolescent Psychiatry as a Medical Specialty: A National French Questionnaire Survey

Context: The shortage of child and adolescent psychiatrists in France affects access to early interventions and mental health services and impacts therapeutic practices and prescribing trends. This study aimed to describe factors associated with choosing child and adolescent psychiatry (CAP) as a career specialty and with assessing the level of attractiveness of this discipline and its predictors. Methods: We generated a self-report questionnaire using a modified two-step Delphi approach. The survey was conducted from January 13 to February 16, 2020, and targeted French child and adolescent psychiatrists or psychiatrists, mainly working with children and/or adolescents. We used a logistic regression model to assess the factors associated with the perception of CAP as attractive. A thematic qualitative analysis of the free comments section of the questionnaire was performed. Results: Of 863 doctors contacted by email, the response rate was 77.4% (668 respondents). Two-thirds of respondents were female and had an official specialization in CAP. One-third were aged between 31 and 40 years. The main reasons for choosing to specialize in CAP were interest in working with children (64.2%), interest in psychotherapy (52.8%), and influence of an internship in CAP during medical studies (46.0%), although only one-third of respondents actually did an internship. Over half of respondents (57.3%) identified personal factors as implicated in their choice of CAP, mainly personal psychotherapy (22.2%) and personal trauma (14.4%). Although only 58.4% of respondents perceived CAP as attractive, 97.8% had no regret about their choice, and 83.5% would make the same career choice today. A positive perception by respondents' surroundings for choosing CAP at the time of the choice was associated with a perception of CAP as currently attractive by respondents (odds ratio: 1.82; 95% confidence interval: 1.27-2.60; p = 0.001). Conclusion: CAP is in crisis and faces many challenges in France, with an urgent need to redress its demographics. Many child and adolescent psychiatrists do not regret their choice and would choose the same specialty today. To increase its attractiveness, better visibility during medical school, enhanced academic recognition, and increased remuneration seem promising.