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The American Board of Medical Specialties, which includes the American Board of Psychiatry and Neurology, promotes standards focusing on changes in physicians' medical knowledge and skills. The authors describe the literature concerning the effectiveness of lifelong learning. They review the status of the American Board of Psychiatry and Neurology Maintenance of Certification program as an example of a model of lifelong learning, including an innovative pilot. The final sections include a discussion of new innovations to consider in continuing professional development and a reflection about the state of lifelong learning within the context of maintenance of certification in psychiatry.

Training combining the disciplines of pediatrics, psychiatry, and child and adolescent psychiatry dates back to World War II, but formal combined programs began more than 3 decades ago as the Triple Board Program and 10 years ago as the Postpediatric Portal Program (PPPP). Triple board training was rigorously examined as a pilot program and ongoing surveys suggest that it provides successful training of physicians who can pass the required board examinations and contribute to clinical, academic, and administrative/advocacy endeavors. As evidence grows showing the value of integrated care, physicians with combined training will offer a unique perspective for developing systems.

Problem-based learning (PBL) is one of the core components of medical education. To facilitate the spread and use of PBL in child and adolescent psychiatry (CAP) fellowship training, a special interest study group (SISG) was formed at the American Academy of Child and Adolescent Psychiatry (AACAP). Different approaches to the implementation of PBL between programs represented at the SISG are compared in this report. The authors distributed a survey to SISG participants after the 2015 annual AACAP meeting, which gathered information about the different approaches programs use to implement PBL in graduate medical education. Six CAP training programs responded to the survey, providing descriptions of the structure and content of PBL seminars. Programs chose to include a wide variety of topics in PBL courses and approach course organization in a number of ways. To the degree that PBL draws from identified reference texts, programs were similar in selecting definitive textbooks, practice parameters, and seminal articles. This small pilot study is intended to provide a snapshot of the state of PBL implementation in CAP fellowship programs. It reflects that programs can incorporate PBL in a variety of ways, tailored to the needs of the institution. Future directions of research include assessment of resident satisfaction with PBL, impact on resident education, and identifying successful methods of implementation of PBL.

Background Studies across a range of specialties have consistently yielded positive associations between performance on in-training examinations and board certification examinations, supporting the use of the in-training examination as a valuable formative feedback tool for residents and residency programs. That association to date, however, has not been tested in child and adolescent psychiatry residents. Objective This is the first study to explore the relationship between performance on the American College of Psychiatrists' Child Psychiatry Resident In-Training Examination (CHILD PRITE) and subsequent performance on the American Board of Psychiatry and Neurology's (ABPN) subspecialty multiple-choice examination (Part I) in child and adolescent psychiatry (CAP). Methods Pearson correlation coefficients were used to examine the relationship between performance on the CHILD PRITE and the CAP Part I examination for 342 fellows. Results Second-year CAP fellows performed significantly better on the CHILD PRITE than did the first-year fellows. The correlation between the CHILD PRITE total score and the CAP Part I examination total score was .41 (P = .01) for first-year CAP fellows; it was .52 (P = .01) for second-year CAP fellows. Conclusions The significant correlations between scores on the 2 tests show they assess the same achievement domain. This supports the use of the CHILD PRITE as a valid measure of medical knowledge and formative feedback tool in child and adolescent psychiatry.

Directing child and adolescent psychiatry (CAP) training for residents is a complex and challenging administrative task that encompasses the broad creativity of the orchestral conductor, the social and interpersonal effectiveness of the best politician, and the orientation to details of the finest accountant. This article examines these roles in detail, recognizing the leadership, administrative, and managerial achievements of the successful child and adolescent program director. Resources for optimizing the chances for success in each of these areas, and the common pitfalls to avoid, are identified and discussed. The article concludes with suggestions for CAP training directors to influence medical student education. Although challenging and sometimes frustrating, the role of the program director in CAP training is almost always exciting and rewarding.

Previous validation studies of attention deficit/hyperactivity disorder (ADHD) assessment by rating scales or EEG have provided Class-IV evidence per standards of the American Academy of Neurology. To investigate clinical applications, we collected Class-I evidence, namely from a blinded, prospective, multi-center study of a representative clinical sample categorized with a clinical standard. Participating males (101) and females (58) aged 6 to 18 had presented to one of four psychiatric and pediatric clinics because of the suspected presence of attention and behavior problems. DSM-IV diagnosis was performed by clinicians assisted with a semi-structured clinical interview. EEG (theta/beta ratio) and ratings scales (Conners Rating Scales-Revised and ADHD Rating Scales-IV) were collected separately in a blinded protocol. ADHD prevalence in the clinical sample was 61%, whereas the remainder had other childhood/adolescent disorders or no diagnosis. Comorbidities were observed in 66% of ADHD patients and included mood, anxiety, disruptive, and learning disorders at rates similar to previous findings. EEG identified ADHD with 87% sensitivity and 94% specificity. Rating scales provided sensitivity of 38-79% and specificity of 13-61%. While parent or teacher identification of ADHD by rating scales was reduced in accuracy when applied to a diverse clinical sample, theta/beta ratio changes remained consistent with the clinician's ADHD diagnosis. Because theta/beta ratio changes do not identify comorbidities or alternative diagnoses, the results do not support the use of EEG as a stand-alone diagnostic and should be limited to the interpretation that EEG may complement a clinical evaluation for ADHD.

Objective To assess the longitudinal health-related quality of life (HRQL) of children receiving hematopoietic stem cell transplantation (HSCT). Methods Mothers (N = 160) of HSCT recipients aged 5–20 at six US transplant centers completed the Child Health Ratings Inventories (CHRIs), the Disease Impairment Inventory (DSII)–HSCT module, and the Short Form (SF)-36 at baseline, 3, 6, and 12 months. Results HRQL domain scores at baseline varied by recipient age and program site. Longitudinal data over the first year post-HSCT revealed lowest functioning at baseline and 3 months, with largest improvement in functioning between the 3 and 6-months assessments and continued improvement from 6 to 12 months. Recipients of unrelated donor transplants had steepest declines in functioning at 3 months and great HSCT-specific issues at 3 and 6 months. Among children who survived the first year, functioning at 12 months was similar across transplant types and surpassed baseline scores. Children who did not survive the first year exhibited deterioration in HRQL in the months before death and trajectories were strikingly different than for survivors. Conclusions This study offers the first glimpse of the 12-month trajectory of HRQL following pediatric HSCT from mothers’ perspectives. This study also highlights the importance of and approaches to addressing missing data in longitudinal research.

Objective: Residency training programs in all areas of medicine are required to identify core competencies expected of all graduates and develop methods to assess and ensure attainment of these competencies. To assist with this process for residency programs in child and adolescent psychiatry, the Work Group on Training and Education of the American Academy of Child and Adolescent Psychiatry has developed several principles of the assessment process and compiled a variety of assessment methodologies for use in assessing competency. The principles of assessment include 1) residents should share responsibility for assessment; 2) assessment should be an open, ongoing and predictable process; 3) a wide range of evaluators should be utilized in the process; 4) residents should demonstrate competency in a variety of formats; 5) the goal is for 100% of residents to achieve core competencies. Methods: Sample methods of assessment are provided in the report with special attention to how the method could be used in child and adolescent psychiatry. Conclusion: A multi-method, multi-evaluator for process of assessment is recommended.

OBJECTIVE This study investigated the role of cognitive processing in maternal adjustment to a life-threatening pediatric medical procedure (bone marrow/stem cell transplantation: BMT/SCT). METHODS Ninety-one mothers participated in structured interviews about their fears, intrusions, avoidance, and distress regarding their child's BMT/SCT at two time points: during their child's hospitalization and during his/her recovery. Structural equation modeling was used to determine the role of fears, intrusions, and avoidance in mothers' distress. RESULTS Mothers' fears played a primary role in their adjustment to their child's transplantation. Intrusions mediated the relations of fears with distress at both time points. Mothers' avoidance of thoughts, feelings, and reminders of their child's illness during the child's transplantation was associated with their distress three months later. The child's risk for an unsuccessful transplantation outcome was not associated with mothers' fears or distress during the child's hospitalization, but was associated with mothers' distress during the child's posthospital course of recovery. CONCLUSIONS The results of this study indicate the critical role of mothers' fears, intrusions, avoidance, and the child's transplant risk in maternal distress and have treatment implications for reducing maternal distress during pediatric transplantation.

Assessment in child and adolescent psychiatry is a complex process that involves developmental, environmental, and experiential perspectives. Recently, there has been interest in including spiritual and religious assessment in the psychiatric assessment of children, but no well-recognized guidelines for such an assessment have been established. This article proposes an approach to spiritual assessment of children and adolescents that begins with developing an understanding of the family's spiritual and religious life, followed by a developmentally informed method of observing and talking with children and adolescents about their spiritual and religious beliefs. The article concludes with a discussion of ethical issues involved when the psychiatrist addresses issues of spirituality and religion with child and adolescent patients and their families.

Objective To evaluate the role of maternal coping strategies in depressive symptoms experienced by mothers of children undergoing bone marrow transplantation (BMT). Method A total of 207 mothers completed measures of coping and depressive symptoms at the time of the child's BMT, 3 and 6 months post-BMT. The sample was collected between 1998 and 2002. The acceptance rate was 73%. The contribution of demographic, illness and treatment parameters, and mothers' concerns about the child were also evaluated. Growth curve modeling was used to evaluate the role of coping in the course of depressive symptoms. Both main effects and interactions of coping strategies with time of assessment were evaluated. Results Acceptance and humor were associated with reductions in maternal depressive symptoms, and planning and alcohol/substance use were associated with increases in maternal depressive symptoms. Positive reframing, use of emotional support, and use of religion were associated with the course of depressive symptoms, but the magnitude of associations differed depending on the use of the coping strategies at the time of transplantation. Mothers' fears about the child also predicted depressive symptoms. Conclusions Acceptance and humor may be targets for behavioral interventions to reduce mothers' depressive symptoms during and after pediatric BMT hospitalization.

The authors evaluated whether Maintenance of Certification (MOC) Performance-in-Practice products in training increases trainee knowledge of MOC processes and is viewed by trainees as a useful activity.Six child and adolescent psychiatry fellowships used MOC products in continuity clinics to assess their usefulness as training tools. Two surveys assessed initial knowledge of MOC and usefulness of the activity.Forty-one fellows completed the initial survey. A majority of first-year fellows indicated lack of awareness of MOC in contrast to a majority of second-year fellows who indicated some awareness. Thirty-five fellows completed the second survey. A majority of first- and second-year fellows found the activity easy to execute and would change something about their practice as a result.Using MOC products in training appears to be a useful activity that may assist training programs in teaching the principles of self- and peer-learning.

This article begins with a discussion of attachment theory and childhood depression and the link between the two. Emphasis is placed both on pediatric and parental depression and their associations with attachment difficulties throughout the developmental periods, from infancy through adolescence. This information provides a backdrop for a discussion of family-oriented interventions for depressed young people and their parents that targets the enhancement of attachment relationships in an effort to address the problem of depression. Specific modifications of developmentally informed interventions that address attachment issues within the context of various constellations of family members are presented. These interventions include infant-parent psychotherapy, toddler-parent psychotherapy, other parent-child interaction therapies, variations of the use of play in family therapy, and modifications of interpersonal psychotherapies to be used with adolescents within a family context.

This study examined anxiety and depressive symptoms among 115 mothers of children undergoing bone marrow transplant and evaluated the ability of the Beck Anxiety Inventory (BA1; A. T. Beck, N. Epstein, et al., 1988) and the Beck Depression Inventory (BDI; A. T. Beck, 1978) to serve as screening tools for assessing generalized anxiety disorder (GAD), panic disorder (PD), and major depressive disorder (MDD). Mothers with BAI or BDI scores greater than or equal to 14 were administered a structured clinical interview. An additional 20% was randomly selected for interview to determine whether the scale cutoff was an accurate screening method. Among the 64 mothers interviewed, 20% received at least 1 of the 3 diagnoses. Although the BAI did not demonstrate predictive accuracy in assessing GAD and PD, the BDI did in assessing MDD. The results suggest that a subset of mothers may have an anxiety or depressive disorder and that investigators should use caution before using the BAI as a screening instrument for anxiety disorder.

This study analyzed the relationship between performance on The American College of Psychiatrists’ Psychiatry Resident-In-Training Examination (PRITE) and the ABPN Part 1 examination. Pearson correlation coefficients were used to examine the relationship between performance on the 2002 PRITE and the 2003 Part 1 examination for 297 examinees. The correlation between the PRITE global psychiatry and the Part 1 psychiatry scores was 0.59, and the correlation between the PRITE global neurology and the Part 1 neurology scores was 0.39. Although the PRITE and the Part 1 examination have different purposes and are developed independently, the significant correlations between scores on the two tests support the use of PRITE results to guide preparation for the Part 1 examination. Guidelines for PRITE scores associated with poor performance on the Part 1 examination are provided.

Successful school functioning for children with chronic medical illnesses is a dynamic, ongoing process that requires continuous cooperation and commitment among the home, the medical team, and the school. Having an adequate knowledge of potential illness and treatment effects on academic performance, an appropriately skeptical attitude toward attributing all of the child’s problems to the direct medical effects of the illness, and a willingness to serve as the coordinator among the family, school, and health care team permits the child psychiatrist to play an important role in maximizing the child’s success in school and ultimately their positive adaptation to life in general. This article discusses the effects of chronic medical illnesses or their treatments on children’s academic adaptation both as a primary effect through neurocognitive changes or as a secondary effect related to school absences, illness-induced stress, constraints on physical and social activities, or decreased expectations from family, school, and the health care team.

Selecting a psychiatry program is a seminal event. There is often not enough guidance about this process. The American Association of Directors of Psychiatric Residency Training (AADPRT) recognized that this was a high-stakes process and that there was the opportunity to provide input about the process and promoting fairness and consistency, which could help provide the best opportunity for applicants to select where they will train and for programs to accept trainees who are well qualified for what a program offers and will best fit into the learning environment. A workgroup created guidelines included herein for the application process to begin general psychiatry training and to transition from one program to another, including transfer from one General Psychiatry program into another and entry into Child and Adolescent Psychiatry Residencies as well as subspecialty fellowships in psychiatry.

Adolescent cancer survivors were compared with nondiseased control subjects on measures of adaptation, coping, body image, sexual adjustment, psychopathology, and family functioning. Cancer survivors reported no major difficulties in social competence, overall coping, and family communication. Although their school teachers reported no symptoms of psychopathology, the cancer survivors did report body image disturbances and adjustment difficulties. Further, the surviving adolescents were eager to present themselves favorably. Compared with nondiseased control families, families of survivors were characterized as somewhat inflexible. Implications for clinical practice include the careful monitoring of youth who have survived cancer as well as sensitivity to underlying concerns that the survivors and their families may avoid.

This study examined coping and family adaptation in siblings of cancer patients, their ill brothers or sisters, and a control group consisting of nonclinical children who have healthy siblings. Assessments included children's self-report measures of coping and family adaptation. Variables of individual differences, including gender and age of the sibling, and family constellation factors, including birth order and number of siblings in the family, were examined to determine effects on coping. Better adaptation was found in larger families, while decreased family involvement was found among older siblings. Recommendations for future research include elucidating the process by which children adjust to having a chronically ill sibling in their family.

Chronic illness affects up to 20% of children in the school-age population, 10% of whom are severely compromised. Reintegrating these children is a growing problem for schools, children and their families, and health care professionals, as it has become apparent that school adjustment is highly significant in the children's overall adjustment. This article focuses on the issues of reintegrating the chronically ill child into the school setting, the types of school problems encountered, the process of school reentry, with illustrative case material, and the implications for the school and family of returning the chronically ill child to school.

Iatrogenic cognitive impairments have been reported for survivors of childhood leukemia after prophylactic central nervous system therapy with craniospinal radiation. To determine whether chemotherapy alone might be a source of central nervous system damage, we assessed in a cross-sectional design the cognitive and academic functioning of 48 children with acute lymphocytic leukemia who were at various stages in their treatment or who had completed treatment. The off-therapy patients who had completed a 3-year course of chemotherapy were more impaired in tasks of higher-order cognitive functioning than were those children whose leukemia had been newly diagnosed and those children whose diagnoses had been 1 years earlier. Off-therapy patients also had concomitant diagnosable learning disabilities in mathematics. We recommend appropriate liaison and special education placements, as well as continued evaluation of cognitive and learning functioning of children treated for moderate-risk acute lymphocytic leukemia who receive chemotherapy alone.

The present study reports data from a cross-sectional investigation of the psychiatric and psychosocial functioning of 55 children diagnosed with acute lymphocytic leukemia and their families at three points in time: diagnosis (newly diagnosed), 1 year postdiagnosis, and 1 year after the completion of chemotherapy (off-therapy). Results reveal minimal psychopathology in these children and their parents based on self-and informant-reports and structured diagnostic interviews. These families appear to be functioning adequately and report more family cohesiveness and marital satisfaction after chemotherapy was completed. Coping strategies commonly used by children and their parents include problem-solving, a positive outlook, and good communication. Implications for psychiatric consultation are presented.

Treatment-related cognitive impairments have been reported for survivors of childhood leukemia following prophylactic central nervous system (CNS) treatment with craniospinal radiation. We examined the neurocognitive status of 46 children with acute lymphocytic leukemia (ALL) to assess the impact of a regimen consisting of systemic chemotherapy and prophylactic CNS chemotherapy. By comparing three groups of ALL children (i.e., patients whose diagnosis was recent, patients 1 year postdiagnosis currently receiving CNS prophylactic chemotherapy, and offtherapy patients who had been treated with chemotherapy for 3 years) and their healthy siblings on measures of sequential and simultaneous processing, we were able to examine the effects of CNS prophylactic and systemic chemotherapy at various points during treatment. Results indicate that the children who had received a 3-year course of chemotherapy (off-therapy patients) were more impaired on tasks involving right-hemisphere simultaneous processing than were sibling controls or ALL children whose diagnosis was recent and whose treatment had just begun. Age at diagnosis did not interact with the effects of chemotherapy. These findings support the need for continued evaluation of cognitive functioning in ALL, children receiving CNS prophylactic chemotherapy to identify potential harmful neurocognitive sequelae of treatment.

The growing literature regarding the development of medical-psychiatric units to facilitate diagnosis and treatment of patients with combined medical and psychiatric disorders is primarily limited to adult populations. Almost no published information is available concerning combined pediatric medical-psychiatric units. This article, the first in a two-part series, outlines the organization and development of a child and adolescent medical-psychiatric unit within a pediatric hospital. Various academic, administrative, political, financial, and clinical issues that must be considered during the developmental process are delineated and discussed. The second part of the series will address clinical management issues.

Objective To investigate whether social support from family and friends (family/friend support) attenuated ("buffered") adverse effects of having low spouse support (spousal support) among mothers of children undergoing hematopoietic stem cell transplantation (HSCT). Design One hundred sixty-three married mothers who were their child's primary caregiver during treatment completed assessments during the child's hospitalization for HSCT and 3-, 6-, and 12-months post-HSCT. Measures Family/friend support and spousal support were assessed during hospitalization. Maternal physical and mental health-related functioning (the main outcome measures) were assessed at all timepoints. Results Multilevel modeling was used to analyze trajectories of maternal functioning. Findings indicated that mothers with low spousal support and low family/friend support demonstrated the worst functioning across all timepoints. Mothers with low spousal support and high family/friend support demonstrated significantly better functioning, supporting the hypothesized buffering effect. Their functioning compared to the functioning of mothers with high spousal support. Moreover, mothers with high family/friend support demonstrated trajectories of physical health-related functioning that were more stable than the trajectories of mothers with low family/friend support. Conclusion These findings have clinical implications in addition to advancing knowledge of social support processes among couples coping with the shared stressor of a child's life-threatening illness and treatment.

Over the past 30 years, institutional ethics committees have become the standard vehicle for addressing ethical issues in health care institutions. Early in this development, general psychiatrists became integrally involved; however, child and adolescent psychiatry roles on institutional ethics committees have been delineated less clearly. This article provides an overview of the functioning of institutional ethics committees, including composition and a definition of the roles across education, policy development, and case consultation. Within the context of the various roles of the institutional ethics committee, the potential contributions of a child and adolescent psychiatrist are defined and specific areas of expertise are delineated. Case examples are cited to demonstrate the unique contributions in the areas of developmental understanding, enhanced understanding of communication styles and failures, as well as an understanding of specific psychiatric factors and cultural issues that a child and adolescent psychiatrist may bring to the institutional ethics committee.

Objectives The purpose of this study was to explore the association of meaning-making with psychological adjustment to bereavement among mothers of children who had undergone haematopoietic stem cell transplantation (HSCT). Design A prospective research design was used. Regression analyses were conducted to determine the relations between pre-bereavement variables (distress, searching for meaning, and finding meaning) and distress post-bereavement. Methods Thirty-five mothers of children who had undergone HSCT were interviewed at the time of their child's HSCT and 3 months post-bereavement. Results Mothers who reported searching for meaning at HSCT reported greater post-bereavement distress, and mothers who reported finding meaning at HSCT reported less post-bereavement distress. Distress at HSCT and the number of days between the time of death and the post-bereavement time point were also found to be significant predictors of post-bereavement distress. Conclusions This study provides partial support for the role of meaning in adjustment to loss.

Although mothers' fear appraisals about their child's future health and well-being affect their own psychological adjustment to their child's hematopoietic stem cell transplantation (HSCT), little is known about antecedents of maternal fear appraisals. This longitudinal study investigated several potential antecedents of these fear appraisals: maternal optimism, recent negative life events, lifetime history of traumatic events, and medical characteristics of the child's disease and HSCT course. One hundred-forty mothers were interviewed during their child's hospitalization for HSCT and at 3-and 6-months post-HSCT. Structural equation modeling was used to test a model of hypothesized relations. Consistent with predictions, lower optimism and a greater number of negative life events were independently associated with greater maternal fear appraisals. Contrary to expectations, lifetime history of trauma was not associated with maternal fear appraisals. Mothers' fear appraisals during their child's hospitalization were, in turn, associated with their fear appraisals up to 6 months later. These data identify a subset of mothers who may be particularly in need of an intervention to increase optimistic coping strategies, improve coping with negative life events, and reduce fear appraisals to improve their adjustment following their child's HSCT.

This article provides a summary of the history of the development of the subspecialty of child and adolescent psychiatry and the concomitant development of training in the field. The historical perspective provides a context for the discussion of an overview of child and adolescent psychiatry training in the twenty-first century. Four challenges are identified: recruitment, funding, curriculum, and assessment and remediation, each of which is discussed in some depth. The article concludes with a perspective that focuses efforts in training more on basic core competencies rather than the rapidly expanding and changing medical knowledge and specific clinical interventions relevant to the field.

This longitudinal study examined the relation between life stress and basic beliefs about self-worth and the benevolence and meaningfulness of the world among mothers of children undergoing bone marrow transplantation (BMT). One hundred mothers completed study measures during the child's hospitalization for BMT and 1 year later. Prior trauma and recent negative events were associated with basic beliefs during hospitalization and also with changes in basic beliefs in the subsequent year, with distress mediating some of these relations. Findings also demonstrated relations between basic beliefs and physical and mental functioning. However, each basic belief exhibited different relations with study variables, suggesting the need to investigate them separately.

Background: This longitudinal study investigated the course and predictors of benefit finding among 144 mothers of children undergoing hematopoietic stem cell transplantation (HSCT), a severely stressful and life-threatening medical procedure.Purpose: Children’s medical risk and mothers’ dispositional optimism and sociodemographic resources were examined as predictors of benefit finding. The association between benefit finding and mothers’ psychosocial adaptation was also investigated.Methods: Assessments occurred during hospitalization for HSCT (Time 1 [T1]) and 6 months later (Time 2 [T2]).Results: Hierarchical multiple regression analyses revealed that predictors of benefit finding differed systematically across assessments, with optimism and medical risk predicting benefit finding at both time points but sociodemographic resources predicting only T2 benefit finding. Benefit finding did not predict psychosocial adaptation until optimism was considered as a moderator of their relation: T1 benefit finding was positively associated with T2 adaptation only for mothers high in optimism.Conclusions: The need for longitudinal research on posttrauma adaptation and the utility of considering the natural history of the trauma are discussed.