IACAPAP Textbook of Child and Adolescent Mental Health

MISCELLANEOUS

Chapter

J.15

A global perspective on training
and education in child andadolescent psychiatry
Peter Deschamps1, Brian Jacobs2, Anna Sofie Hansen3,
Jeffrey Hunt4, Marie Aude Piot5, Paul Robertson6, Victor
Pereira-Sanchez7, Aisha Chachar8, Andrés Camilo Cardozo
Alarcón9, Helena Daniel10, Alvin Lee Lewis11, Suaad Moussa12,
Marieke van der Schaaf13, André Luiz Schuh Teixeira da Rosa14,
Tjhin Wiguna15, Sana Younus16, Hiroshi Yamashita17

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions expressed
are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks to describe the besttreatments and practices based on the scientific evidence available at the time of writing as evaluated by the authors and may change asa result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines and laws of their country ofpractice. Some medications may not be available in some countries and readers should consult the specific drug information since not all
dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked to illustrate issues or as a sourceof further information. This does not mean that authors, the Editor or IACAPAP endorse their content or recommendations, whichshould be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2019. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited and theuse is non-commercial.
Suggested citation: Deschamps P, Jacobs B, Hansen A et al. A global perspective on training and education in child and adolescent
psychiatry. In Rey JM, Martin A (eds), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International
Association for Child and Adolescent Psychiatry and Allied Professions 2022. In Rey JM, Martin A (eds), IACAPAP e-Textbook of Childand Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2019.

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IACAPAP Textbook of Child and Adolescent Mental Health

AFFILIATIONS
1. Department of Psychiatry, Utrecht University Medical Center, Utrecht, The
Netherlands; President of Board of Education UEMS-CAP
2. South London & Maudsley NHS Foundation Trust, London, UK; late Presidentof Board of Education UEMS-CAP
3. Research Unit for Child and Adolescent Psychiatry, Department of Psychiatry,
North Denmark Region, Denmark; Bureau member UEMS-CAP
4. Department of Psychiatry and Human Behavior, Alpert Medical School ofBrown University, Providence, Rhode Island USA
5. Department of Child and Adolescent Psychiatry, Academic hospital NeckerAPHP, University of Paris Cité, Paris, France.
6. Department of Psychiatry, University of Melbourne, Melbourne
7. Department of Child and Adolescent Psychiatry, NYU Grossman School of
Medicine, New York, NY, USA; Department of Psychiatry, Columbia University,
New York, NY, USA; Division of Translational Epidemiology and Mental Health
Equity, New York State Psychiatric Institute, New York, NY, USA; Department of
Psychiatry, Amoud University, Borama, Somaliland
8. Synapse, Pakistan Neuroscience Institute, MBBS, FCPS; Aga Khan University,
Pakistan
9. Servicio de Psiquiatría y Salud Mental, Hospital Universitario San
Ignacio y Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá D.C.,
Colombia
10. Department of Mental Health, Ministry of Health, Mozambique; Hospital
Psiquiátrico de Nampula, Mozambique; Federal University of Rio Grande do Sul,
Porto Alegre, Brazil.
11. Department of Psychiatry and Behavioral Sciences, Medical University ofSouth Carolina, Charleston, SC, USA
12. Emeritus Prof of Psychiatry, Kasr al Ainy Faculty of Medicine, Cairo University,
Consultant Child and Adolescent Psychiatry, Founding President of EgyptianChild & Adolescent Psychiatry Association ECAPA, Egypt.
13. Director Utrecht Centre for Research and Development of Health Professions
Education, Utrecht University, Utrecht, The Netherlands.
14. Department of Child and Adolescent Psychiatry, Hospital de Clínicas de Porto
Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
15. Child and Adolescent Psychiatry Division, Department of Psychiatry, Facultyof Medicine Universitas Indonesia-Dr. Cipto Mangunkusumo General Hospital,
Jakarta – Indonesia
16. Menninger Department of Psychiatry & Behavioral Sciences, Baylor Collegeof Medicine, TX, USA
17. Department of Child Psychiatry, Kyushu University Hospital, Japan.

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IACAPAP Textbook of Child and Adolescent Mental Health

CORRESPONDING AUTHORS
P. Deschamps p.k.h.deschamps@umcutrecht.nl
A. Hanssen uems-cap-trainers@googlegroups.com
B. Jacobs brian.jacobs@kcl.ac.uk

TABLE OF CONTENT
Summary
General Introduction
Section A - History, common ground and diversity
Section B – Personal experiences of trainees and trainers
Section C - Continuous development, wellbeing and resiliency
Section D - Exploratory roadmap to evidence based best-practices and educational
research
Section E - Resources and networks
Epilogue and reflection

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IACAPAP Textbook of Child and Adolescent Mental Health

SUMMARYT

his chapter takes a global look at training in child and adolescent psychiatry(CAP). We provide an overview of the history and current state of CAP
training internationally including common models for training that havebeen developed, noting their similarities and differences. Then, to illustrate thedifferences in CAP practice and training related to local, societal and culturaldifferences, a number of personal experiences of CAP training in various countries
are presented and a qualitative content analysis of these is provided. Stories
were contributed by trainees and trainers based on the questions: What is mostculturally and locally specific about CAP training programs in your country? What
are the major challenges and inspirational solutions? The development of a childand adolescent psychiatrist does not finish at the end of their training. Life-longmodels of learning are considered through the lenses of personal development,
continuing medical education and development of resilience; an introduction toeducational theory supporting these, is provided. Next, the chapter offers a possible
roadmap to increase the available evidence for CAP training and implement
evidence-based best practices that will allow us to guide investments in training
towards a stronger profession and improved child and adolescent mental health forour patients globally. At the end of the chapter, we provide a summary of available
materials and resources from international trainees, trainers and training relatedorganization that can be used by those seeking to start or enrich local training
programs.

GENERAL INTRODUCTION
It is stated that 10,000 hours is the time it takes for an average human being
to become expert at a certain skill. This seems to apply to arts, sports, and mostprofessional activities including becoming a CAP. This Chapter offers a perspective
on how our trainees in CAP in different parts of the world spend their first 10,000
hours. It offers an over-view of differences and similarities in CAP training andprovides links to practical resources. It attempts to describe how CAP trainees andtrainers apply knowledge and theory of how adults learn and the importance of
resilience and wellbeing to guide our trainees through personal and professional
development. The aim is to help them become good enough to respond to themental health needs of children and young people into the future.
Our aim was not to be comprehensive, rather to provide an anthology andhopefully inspiration. All sections were co-composed by a group of experienced
trainers in close cooperation with trainees. We have tried to shed light on thesimilarities and differences, local and cultural, in CAP training hoping thatinternational comparison will inspire and encourage further exchange of ideas. The
chapter begins to describe similarities and differences with respect to local history,
culture, economic circumstances and organization of mental health care.
Despite, and maybe because of this wide variety, we argue for greaterinternational collaboration in CAP training initiatives, recognizing it will help
us better face future challenges in our profession. As has happened in medical
research in the past decades, those aiming to increase their effectiveness in training

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IACAPAP Textbook of Child and Adolescent Mental Healthcan be more efficient when they cooperate, share materials and insights on what
and how we teach. As child and adolescent psychiatrists, we are already skilled
and experienced in taking a life-long developmental perspective, in putting
ourselves in the shoes of people with a different background, in cooperating withcomplex systems and in balancing autonomy and guidance. Our hope is for thedevelopment of a trusting, well-functioning collaborative international network
around CAP training, a task that may take more than 10,000 hours! We hope thischapter inspires you to join us in such an emerging global learning community ofpractice for CAP training.
As an author group, we invite you to share comments or suggestions ofchanges and additional topics after reading and we are open to any help offered for
future revisions of this Chapter.

SECTION A:
HISTORY, COMMON GROUND AND DIVERSITY
Origin of training in CAP
The origin of Child Psychiatry, and training in the discipline, is a very recent
development in the history of mental health as a medical concern (Rey et al.,2015). The first known child psychiatry clinic was established at the Heidelberg
University Clinic in Germany by August Homberger in 1876 (Jacobs et al., 2018).
Quite how knowledge was passed to doctors learning about child and adolescentmental health between then and the first textbooks in German (Homberger, 1926;
Strohmeyer, 1923), and then in English (Kanner, 1935), is unclear.

National and international training organizations emerge
Professional national organizations aiming to improve and stimulate clinicalcare, research and training and education in CAP were, for a brief period, embedded
in general psychiatry as a whole and then for child and adolescent psychiatry as aseparate discipline. Contact between child psychiatrists within Europe, suggesting
an international organization and cooperation, can be traced to 1935 and in 1937,
when IACAPAP began as The International Committee for Child Psychiatry(Schleimer, 2012). In the USA, in 1953, The American Academy of Child andAdolescent Psychiatry (AACAP) was founded, followed by national organizations
in some European countries and Australia. A crude indicator of the spread of theprofession in the past 50 years can be gained by looking at the countries in which
the biennial IACAPAP conference has taken place. For many years it occurred inEurope, USA and Canada, Israel and Australia. In 1990 it took place in Japan(Kyoto), New Delhi 2002, Turkey (Istanbul) 2008 and China (Beijing) 2010,
South Africa (Durban) 2014 and Singapore in 2020.

Some characteristics of current state of CAP training around the world
The differentiation and organization of CAP and the specialist training
associated with it in different countries across the globe varies quite significantly.

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IACAPAP Textbook of Child and Adolescent Mental HealthIn many countries it is a separate specialty from the other psychiatry professions.
In some places, this leads to a completely separated training, sometimes with little
overlap or requirement to spend time in adult psychiatry. Elsewhere, there is alimited, defined placement expected in adult psychiatry whilst in other countries
very significant time is devoted to adult psychiatry training before specializing inChild and Adolescent Psychiatry. In some places the specialist training is largely
in areas of adult psychiatry with little time spent becoming a CAP specialist. Thiscounters consensus views in several continents that specialist training in CAP
itself takes a minimum of two to three years to achieve (Hunt et al., 2020; Royal
Australian and New Zealand College of Psychiatry, 2015; UEMS-CAP & Jacobs,
2014). In some countries training experience in pediatrics and/ or neurology is arequirement. Some parts of the world still rely on informal training in CAP withpractitioners following their interest after training formally in adult psychiatry.
These differences reflect the various histories of CAP in different parts of the world,the level of child and adolescent mental health (CAMH) service development incountries and the number of CAPs for the population.
Historically, organization of CAP training in each region of the world
seems to have developed largely by a process of importing models of training into
these countries and communities by influential senior clinicians and educatorsfrom the institution and countries in which they, themselves, were trained.
Some examples of how this model leads to difference in training can be seen in
Europe, where the organization of training in France has historically been rather
dependent on a psychoanalytic model of practice across all of childhood versus in
Finland, where adolescent psychiatry is a separate specialty from child psychiatry.
Interestingly, many countries separated by language and culture seem to have coevolved similar models, for example in the UK and Sweden where the curriculums
were surprisingly similar in recent years. There are other examples where there
has probably been a convergent evolution of training curriculums, even if themodels of service delivery are different; the USA, UK and Australia/New Zealandoffer examples. In Asia, child psychiatry was recognized as a specialty in 12 of
17 Far East nations by 2014 (Lim et al., 2015) but there was a paucity of official
guidelines for training (Hirota et al., 2014). In Singapore an apprenticeship model
based on the historical UK system became much more structured in 2010 (Limet al., 2015). Indonesia had CAP specialists trained abroad at the University of
Honolulu in Hawaii during the late 1960’s and early 1970s. On the basis of this,they adapted that program for local conditions in 1976 with a 2 year fellowship
program (Wiguna et al., 2016). In Pakistan, a two year fellowship program has
been developed in collaboration between Pakistan and Yale University (Azeem etal., 2015). In Egypt, a MSc program in Psychiatry of Children & Adolescence
was established in 2009 (Kasralainy Faculty of Medicine, Cairo University). In
the Arab world a unified training program has been offered since 2009). In the
Arab world a unified training program is offered (Arab Board, 2016). In China,
there are a number of university-based trainings (He et al., 2020) but as yet, there
is no national over-view of training. Very recently, a collaborative program has
been developed between Shenzen and Harvard, USA which is now expanding tobecome a possible model for a national training program in China (Belfer et al.,2021). In South America (personal communication) there are some university
programs (e.g. at Salvador University in Argentina) but as yet, no national training
programs in CAP.

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IACAPAP Textbook of Child and Adolescent Mental HealthCountries with a more recent tradition of child and adolescent mental healthand child and adolescent psychiatry are adopting different models to train the childand adolescent psychiatrists of the future, possibly due to being unburdened withthe history of a particular training methodology. There is a complex relationshipbetween the recognition of need for specialists and the existing provision that
affects the shape and capacity to train (Sourander et al., 2018). Some have largely
adopted a corpus of knowledge and processes that are then adapted to the practiceenvironment in their countries, e.g. Japan where there was an initiative to linkto the Institute of Psychiatry, Psychology and Neuroscience, King’s College in
London to provide training seminars over several years (personal communication).
Training in Japan remains a challenge (Tateno et al., 2017). In many countries
where there has been an insufficient body of specialists, doctors who want to train
as child psychiatrists have travelled and trained abroad. For example, many fromSouth American countries have looked to universities in the USA. Malaysia andmore recently Sri Lankan CAP have migrated to Australia for such training. There
has been some cross-fertilization of training within Europe. For example, theAlicia Koplowitz Foundation Fellowship scheme (Alicia Koplowitz Foundation)
has enabled trainees from Spain to train abroad in the absence of a recognizedspecialty of CAP in their country. Other examples of such fertilization are seen ata trainee level with the efforts of the European Federation of Psychiatric Trainees
to facilitate short-term experience for trainees in different European countries(European Federation of Psychiatric Trainees, 2021).

Best-practices and quality assurance systems
Given the variety in training and education practices the question arises as
to what and how works best for whom and where. There is little research on theseissues for CAP. There is some descriptive research of patterns of training and thedegree to which training in different countries meets criteria set out in parts of theworld. For example, in Europe, there have been several such studies, some led bysenior child and adolescent psychiatrists (Barrett et al., 2020; Karabekiroglu et al.,2006) and others by trainees (Simmons et al., 2012). Perhaps unsurprisingly, they
do not always agree about what constitutes good training. There is also an Europewide model of what should constitute a national training system to attempt toensure quality, resources and probity of training(UEMS-CAP & Jacobs, 2014).
A special edition of the European Journal of Child and Adolescent Psychiatry(January 2020) included editorials and papers describing current systems of
training across the continents of the world (Deschamps et al., 2020; Deschamps& Jacobs, 2020; Dingle & Kolli, 2020; Gregoric Kumperscak et al., 2020; Huntet al., 2020; Kommu et al., 2020; Rao et al., 2020; Scivoletto et al., 2020). Thereis also research that is relevant in terms of the ways in which adults learn.
Systems of auditing the quality of training also show great variation acrossmedical training worldwide. Some progress has been made with countries acrossEurope coming together to develop common curriculums in different branchesof medicine (UEMS, 2015) including Child and Adolescent Psychiatry (UEMSCAP & Jacobs 2014; UEMS-CAP, Deschamps & Thorsten). Potentially, thismodel offers opportunities for international benchmarking within a specialty as
well as comparisons of approach between specialties.

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IACAPAP Textbook of Child and Adolescent Mental HealthA potential way to move forward in improving CAP training programs is
to integrate what is known from medical education more broadly (see later in thischapter). This has incorporated models and the evidence base drawn from what is
known about adult learning.
In summary, there is still a long way to go to develop high quality CAP
training worldwide. Whether the same goals of training and curriculum topics areappropriate for radically different societies with very varied cultures, local contexts
and needs, remains largely unexplored so far.

SECTION B: PERSONAL EXPERIENCES OF TRAINEESAND TRAINERS
Introduction
To start illustrating the rich differences in CAP practice and training related
to local, societal and cultural differences, this section presents brief vignettes of
CAP training. It is based on an online survey, sent out by the authors of this
Chapter, inviting connections in their networks to send contributions outlining
what they found most culturally and locally specific about CAP training programsin their respective region. We asked for contributions describing two different
levels of subjective experience and perspective: those of the trainee and the trainer.
The main question was to provide experience and perspective in answer to someopen-ended probe-questions (see Table 1).
Table 1. Prompt questions for vignettes• What is it like to be a trainee/trainer in your country?
• What do you enjoy and appreciate most?
• What are the challenges and things you would like to change?
• Are there features to your training that you think are speciﬁc to thecontext you are in (cultural, geographical, resource speciﬁc, etc.)?

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Twenty-six vignettes were received: thirteen from trainees and thirteen fromtrainers. Countries of participants are reported in Table 2.
Table 2. Participants’ countries of origin
Country

Trainees

CanadaTrainers
1

Colombia

1

Denmark

2

2

Egypt

2

2

Estonia1

France1

Greece1Indonesia

1

Kingdom of Bahrain

1

Spain

1

The Netherlands

2

3

UK

1

2

USA
Total

1

1
13

13

To help interpret the input provided by trainees, we used a qualitative
approach by thematic analysis (Braun & Clarke, 2006). Our aim was to perform
an initial exploration. It is not a complete description, in terms of number ofcountries and continents surveyed. We could not claim to have reached data
saturation but sufficiency, that is, we had enough data to provide a first in-depth
understanding of phenomena of interest. Table 3 and Table 4 summarize themes
and sub-themes including quotations based on the responses provided by trainees
and trainers.

Trainees’ perspective
Trainees emphasized three main themes: psychological security ofeducational framework, local and culturally specific issues, and the specific detailed
skills in CAP training compared with other medical specialties.

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IACAPAP Textbook of Child and Adolescent Mental HealthTrainee Theme 1: Psychological security of educational framework
Several factors supporting or limiting psychological security of trainees
arose as an important theme of influence for CAP training. First, a certain degreeof agreement and structure of curriculum appeared as a strong scaffolding factor
that allowed a safe involvement in training while its absence aroused feelings ofbeing overwhelmed and exhaustion in trainees that inhibited learning. Second,a benevolent and less hierarchical attitude of trainers was seen as a strong factor
supporting the ability to learn from mistakes and allow for a personal transformationfrom trainee to medical specialist. Some trainee participants highlighted thesubtlety of an appropriate mentorship, suggesting tailoring this to the trainees’
needs and progression. Third, support embedded in positive learning relationshipwith their trainee peers was mentioned. Together, trainees and trainers need toassure appropriate, available and timely support in critical situations as well as help
with personal reflection.
Fourth, the issue of certification and formative assessment was mentioned,
although only by very few trainees, suggesting this issue was less prominent andimportant in trainees’ minds during higher training. One trainee regretted theabsence of certification goals and requirements in their country. It left unrecognized
the high level of motivation and skills necessary to work with children andadolescents. Another criticized the many issues that needed justification in thecertification process and found this created feelings of ‘infantilization’. At thesame time, this participant recognized the sense and necessity of some kind ofsummative assessment and examination. The issue was also raised of a relative
surfeit of training positions are sometimes on offer compared to the number ofcandidates that are particularly qualified; this lack of applicants could influence theappraisal processes and overall quality of training.
Finally, a good work-life balance was also mentioned as an importantcondition for learning during training as well as the degree to which the educationalframework helped trainees deal with socioeconomical and political issues in theirrespective context.

Trainee Theme 2: Local and culturally specific issues
Issues and challenges related to their local context also emerged. The Egyptian
trainee pointed to the current lack of health workers that are well-trained in mental
health in their country. The role of religion limiting care access was stressed by the
Bahraini trainee. In the UK, a trainee mentioned a complex transition process
between being a trainee and becoming a medical specialist. In Spain, CAP has
only very recently been recognized as a separate specialty. There are still aspects tothe structure and content of training that are residues of trying to achieve relevant
knowledge and skills for trainees in a system not well adapted to deliver this. In
Colombia, a trainee described the gap between evidence-based practices that werementioned during training and the current situation and availability of resources
limiting their ability to apply them in healthcare.

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IACAPAP Textbook of Child and Adolescent Mental HealthTrainee Theme 3: Specificity of CAP training compared with other medical
specialties
Beyond traditional challenges associated with all higher training - a broadclinical experience incorporating a wide range of pathological presentations andcare conditions - specific interview, counselling and self-regulation skills were
stressed by trainees as essential and specific to CAP as was the need to support
them within a strong and regular supervision framework.
One participant described how the specific interview skills required to build
a therapeutic alliance with children and adolescents were rather new and how along prior medical training failed to inform or build a foundation; some aspects
of interviewing patients previously learned were unhelpful in CAP and needed
to be changed. The ability to contain a wide range of emotions was pointed as afundamental skill while psychotherapy training was recognized as essential by mosttrainee participants in countries where this has already been implemented as wellas in countries in which this was not yet developed. In-depth, regular supervision
was expected and stressed as essential by almost all trainee participants.

Table 2: Trainee themes and sub-themes
ThemesPsychological security ofeducational framework

Sub-themes

Examples of quotations

Curriculum: levelof agreement andstructure

ID1 Tre “Being a trainee in my country is
exciting because the place where I am
studying has a structured educational
curriculum.”

Attitude of trainer:
benevolent and‘horizontal’

NL2 Tre 1: “What I appreciate most is
the safe training climate (…). There is an
open atmosphere, in which contact withsupervisor/trainer is easily accessible.”

Support: availability
from trainers and peers
when needed

EE3 Tre: “Having someone to ask whenevernecessary.”
DK4 Tre: “When we are on call there is often
a feeling of being very much alone (…).”

UK5 Tre: “The right balance between
self-direction and always having seniorconsultant support.”

Certiﬁcation andsummative assessment

UK Tre: “There seem to be bureaucratic
processes that might make trainees seem‘infantilised’ - yet on reflection, there needs
to be a system of assessment - bothsummative and formative.”
DK Tre 1 “…minority of poorly qualified andmotivated candidates compared to otherspecialties”

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IACAPAP Textbook of Child and Adolescent Mental HealthWork-life balance

NL Tre 1: “Attention is also paid to work-lifebalance.”
EG6 Tre: “It was a burden on my social andfamilial life.”

Lack of scaﬀolding todeal with economicaland political issues

EG Tre: “High rate of patients relative to staff
represents a difficulty.”
DK Tre: “There tends to be a focus on
production from our directors.”

BH7 Tre: “to change is the stigma associatedwith seeking professional help for mental
health difficulties, rather than relying on
religious healers, which is a common
approach by many”

Issues related to local
context

EG Tre: “in a far area due to lack of training
centers nearby my home and general (…).,
it’s exhausting (…) and it adds more physicalload and time consumption to my journey”.

Speciﬁcity of CAP training
versus other specialties

Speciﬁc interview skills

NL Tre 2: “strange position of being
experienced and inexperienced at the sametime. (…), I had to examine a 7-year-old boy
in a playroom, I did not have a clue how toapproach this. (…)””… training is a strange and invaluable time… not only about ‘learning’ in the strict sense
but about growth as well. In one case I
learned … when you’re short on time, there’s
little to win by hurrying, there is lots to win bybeing more selective.”

Ability to contain a wide
range of emotions

UK Tre: “ [that we could learn that we
could] play a role in ‘containing’ anxiety andmanaging highly anxiety provoking situations(…).”
UK Tre: “Out-of-hours on-call - … covering
very big areas in a big urban context weredifficult -... It also taught me a lot - how
to prioritize, (…) evaluating complex
information quickly (…), consult withcolleagues and seniors in a timely manner,(…) ‘containing’ anxiety, and managing
highly anxiety provoking situations (…)
creating ‘good enough’ collaboration withpatients and families (...)”

Importance of in-depth
and regular supervision

EE Tre: “There could be more (and better)supervising, guidance.”
EG Tre: “I would like to have more time to
discuss the cases with my supervisors”.

1

ID: Indonesia

6

EG: Egypt

72

NL: The Nederland

3

EE: Estonia

4

DK: Denmark

5

UK: United Kingdom

BH: Bahrain

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IACAPAP Textbook of Child and Adolescent Mental HealthTrainers’ perspective
Four main themes emerged from the trainers’ narratives: key strengths oftraining aligned with trainees’ view; support and training for supervisors; an overall
view making sense in CAP training framework; and variation and combination of
epistemic positions to understand CAP trainees’ pathway.

Trainer Theme 1: Key strengths of training aligned with trainees’ view
Trainers were all very satisfied with their role as trainer. Almost all essential
themes and concerns raised by trainees for their training were mentioned asprevalent challenges by trainers.

Trainer Theme 2: Support, training and a dedicated community ofsupervisors
One trainer participant focused on the help that may be needed to help
develop supervisory skills that are needed to fulfil the role of “trainer”; that is, anability to provide appropriate training support through experiential training oftrainees. The possession of a high level of clinical skills and abilities were considered
as insufficient. A dedicated learning community of supervisors was mentioned tosupport each other, to reflect together and improve supervision and training. A
parallel was drawn with the role of healthy team support for involvement in dailyclinical practice.

Trainer Theme 3: An overall view making sense in CAP training framework
As expected and consistent with their positions, most training organizers
presented a well-summarized overall perspective of CAP trainee pathway in theirrespective countries. They highlighted that making sense of CAP training can only
be done when taking an overall view including the organization of mental healthand public health issues. They provided examples of how resolving these issues
would influence CAP training and education.
This supports the idea that core aspects of CAP training should include thespecific professional knowledge, skills, and attitudes that CAPs need to perform at
the end of their training; that this also requires a broad perspective to ensure that
CAP professionals adapt to evolving societal needs. A historical perspective wasalso mentioned including changes in CAP training implementation. CAP training
is young; it has been developing between 0 to no more than 50 years for thecountries of our survey participants. This encouraged dynamic criticism, pointingout gaps and differing evolution alongside complex transformations of countries’socioeconomic contexts and suggesting future improvements.

Trainer Theme 4: Variation and combination of epistemic positions tounderstand CAP trainees’ pathway
Different approaches emerged throughout the several views of organizers of
training participants, to understand CAP trainees’ pathway and experience. Thismay be situated between two poles of a continuum. On the one side, CAP training

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IACAPAP Textbook of Child and Adolescent Mental Healthis perceived as having external validity with good and representative indicators to
support the development of appropriate analytical criteria. On the other side, CAP
training is seen through the lens of helping trainees develop a mindset or gestaltof a holistic, integrated approach to a discourse with their patients and the parents
that supports their shifting away from a narrow pathological way of presenting andtowards health. This can significantly influence the way training organizers design
their recruitment and their relationship with trainees.

Table 3: Trainee themes and sub-themes
Themes
Key strengthsaligned withtrainees’ viewSupport andtraining forsupervisors

Sub-themes

Examples of quotations

Importance of
psychological security ofeducational framework

NL Tra II: “As an organizer of the training I try to optimize
this process [of safe training ], to generate qualified
professionals with self-esteem.”

Well-adjusted trainer’support tailored to thetrainees’ needs

NL Tra II: “It is a balance between compassion with thetrainees and consideration of their boundaries, and on
the other hand encouragement to go beyond their limits
and drawing lines to keep them up to the demands of the
traineeship.”

Importance of work-lifebalance

NL Tra II: “Having their own children and the interaction
with them often amplify the struggle of their own emotional
processes and a new adequate work-life balance has to befound.”

Impact of heavy
contextual frameworkon training

EG Tra: “Some of the challenges we face [for CAP training] are the limited number of the trained psychologist andsocial workers, the unsatisfactory quality of the delivered
services due to workload and limited some services suchas school-based interventions, difficult families, shortageof medications and proper documentation especially digitalsystem.”Key role of supervision

GR Tra: “It is not a matter of teaching technicalskills but a true interaction that helps the therapeutic
relationship between the trainee and the patient (throughsupervision…).”

Speciﬁcity of CAP
training regarding othermedical specialties

NL Tra II: “The medical training they already received, gavethem the medical view, decisiveness and responsibility theyneed in this profession. This traineeship amplifies theseabilities; however, it adds psychotherapeutic skills and tosometimes lean back to stimulate growth and responsibilityby the patients.”

Ability to contain a wide
range of emotions

NL Tra II: “They need to develop self-awareness of their own
psychological processes, in order to be able to use theiremotions and emotional stability to let their patients grow.”

Importance of
psychotherapy training

NL Tra II: “The interaction with patients and their familysystems, stresses the own emotional stability, and thetransference and counter-transference feelings can raisehigh”

Training of supervising’s
skillsNL Tra I: “Fortunately, we do have an internal supervisor
training to work on your supervisor skills.”

GR: Greece

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IACAPAP Textbook of Child and Adolescent Mental HealthAn overall view
making sense
in CAP training
framework

Aﬃliation to acommunity ofsupervisors

NL Tra I: “[Despite the high ] workload with patients, I
believe that we have a strong association of psychiatry witha strong subsection CAP”

A well-summarized
overall perspective

UK Org I: “Though it usually takes 6 years if a trainee istraining full time (3 years for training in Core Psychiatry
and then 3 years of specialist CAP training after securing
the MRCPsych (Membership of the Royal College of
Psychiatrists) exam).”

A systemic approach

ID Org: “The long way but it is totally valuable. Indonesia isa huge country with more than 250 million population, and
40% of its population consist of children and adolescents.
By 2045, more than 70% of our total population will be in the
productive age (15-64 years old).”

A direction anchoredin “Entrustable
Professional Activities”
adjusted with societal
needs

ID Org: “They need to be trained not only as a CAP clinician(…), but also being an advocator that advocate the stakeholder, case manager and collaborator with other mental
health professionals to provide a better CA mental healthsystems.”

A reference to history
basing distance andtrails for improvements

DK Org 1: “Training in CAP has (…) been starved (…) as
a consequence of increasing referral numbers and politicaldemands of short waiting times without adding resources.
(…)
5-10 years ago, trainees were to a much higher extend
trained in CAP by being paired with more experiences staff.
“

Variation of
epistemic
positions tounderstand
CAP trainees’
pathway

Perceptions throughexternal and analytical
criteria

UK Org: ““This has been especially popular with 100%
recruitment into the pilot (providing the certainty of training
throughout in one geographical training scheme). We havealso noted a significant national improvement in recruitment
in higher training in CAP since the pilot started .”Perceptions throughholistic and subjective
criteria

NL Org: “Tomorrow I have an appointment with one of mytrainees. I know what she is going to ask me: whether she
may postpone her scientific case report for the next week.
She was having a patient in crisis and a sick child at home,so had no time to prepare this teaching moment. This
question indicates the multiple tasks a CAP trainee must
fulfil.”Inﬂuence on recruitment
and position toward
CAP trainees

NL Org: “We are looking for candidates able to connect
emotionally with other people, who can reflect on their own
emotions, who are able to work in stressful situations and tocollaborate with a wide range of professionals.”

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IACAPAP Textbook of Child and Adolescent Mental Health

Conclusions
Despite its exploratory nature, the results from this collection of vignettes
and analysis of them using a qualitative approach triggers reflections about CAP
training in each context while raising opportunities to inform international
best-practices in this area. Among other efforts, this could help building future
cornerstones to reduce inequalities while respecting each cultural context. We hope
this section will also inspire further qualitative exploration about the relationshipand the perceptions of CAP trainers and trainees. It might also include the viewsof their patients and carers about CAP training and services.
Based on our experience, such an effort would seem feasible using online
questionnaires, but it should allow for enough time and rigor to obtain data
saturation, apply some degree of interactivity and sending back results to at least a
sub-sample of participants to get their feedback and ensure the results align with
their view.
These first results stress the importance of adjusted, enhanced and consistentsupervision being available for trainees. It also suggests the benefit of focusedsupervision skills training and a supervisor community supporting continuing
professional development as a trainer. Reflection on the epistemological models
that underly trainers’ perception of trainees’ training could ultimately enhance anddiversify the quality of support provided to trainees.

Section C: Continuous development, wellbeing
and resiliency
The development of medical professionals does not end with completion oftraining. Increasing attention is given to continuous medical education and lifelong
learning models based on educational theory. In this continuous professional
development, post-graduate training takes an important role, but modesty andsustainability require those concerned with CAP training and education to start
thinking about and integrating lifelong development attitudes and skills early on
during training and even in medical school. It includes the related aspect of resilienceand personal wellbeing. The latter is crucial for CAP training as our core activities
include working with vulnerable patients at different stages of development. We
also need to safeguard and respect our patients’ increasing autonomy as we aim
to help them to develop into mature adults who will flourish or at least manage
despite the difficulties that have brought them to our attention. For a broader
overview of wellbeing and resilience in CAP professionals we refer to Chapter J.12
on this topic “Wellbeing: identification and prevention of burn-out, depression
and suicide among child mental health clinicians”.

Lifelong learning in CAP: continuous medical education
There is an ongoing effort to improve quality of care through increased
physician accountability, improved patient safety, and greater consistency inthe delivery of care. Nevertheless, substantial inconsistencies in the delivery ofevidenced based health care exist worldwide (Deschamps & Jacobs, 2020; Institute

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IACAPAP Textbook of Child and Adolescent Mental Healthof Medicine (US) Committee on Quality of Health Care in America, 2000).
Ensuring and improving physicians’ lifelong learning is considered an importantpart of the response to these challenges and should already be considered during
training. However, it remains a challenge to best design and implement continuing
education for physicians so that we positively affect the health of our patients andthe public.
Historically, physicians typically choose passive types of CME along with
topics that appeal to them, not necessarily topics where they have a gap in theirknowledge (Bower et al., 2008). Studies have demonstrated little relationshipbetween self and external assessments (Davis et al., 2006). A more concerning
finding is that the largest inaccuracy in self-assessment occurs most prominently
among the demonstrably least skilled, yet most confident, physicians (Davis etal., 2006). A systematic review by the Cochrane Collaboration concluded thatworkshops using interactive formats lead to moderately large changes in physician
practice (Thomson O’Brien et al., 2001). Training programs need to anticipate
this pattern.
The following 5 steps have been identified as key to help trainees become
successful self-directed adult learners (Moore Donald, 2008) - 1) recognizing an
opportunity for learning; 2) searching for the resources for learning; 3) engaging
in learning to address an opportunity for improvement; 4) trying out what waslearned in practice; and 5) incorporating what was learned in new situations.

Adult learning theory as guidanceLife-long learning of child and adolescent psychiatrists can be situated in
the field of “adult learning theory” in line with the descriptions of Knowles & al.
(2005) on how adult can best learn and focus on their attitude toward learning(Knowles et al., 2014). Adult learning has features different from the ways children
learn (Taylor & Hamdy, 2013):(1) The need to know (Why do I need to know this?)(2) The learners’ self-concept (I am responsible for my own decisions)(3) The role of the learners’ experiences (I have experiences which I value,
and you should respect)(4) Readiness to learn (I need to learn because my circumstances arechanging)(5) Orientation to learning (Learning will help me deal with the situationin which I find myself )(6) Motivation (I learn because I want to)This approach to adult learning emerged in the context of wide social,
psychological, educational and philosophical development during the twentiethcentury: from behaviorism and cognitivism to the essential role of “communities ofpractice in guiding and encouraging the learner” (Taylor & Hamdy, 2013; Wenger,
1998). In particular, self-determination theory highlighted the essential role of“intrinsic motivation” for learning, sustained by three basic needs: autonomy,competence and feeling of belonging (Ryan & Deci, 2000). Moreover, the aim

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IACAPAP Textbook of Child and Adolescent Mental Healthis to train “reflexive practitioners” (Schon, 1984); that is, training practitioners
able to ensure continuing reflection in action. By this we mean an encounter withsomething new, such as a patient or a lecture, which triggers comparison between
what the learner already knows and that which is different; this allows new concept
creation to bridge the gap, and which will subsequently be tested in ongoingpractice. As well as reflecting on action, the learner reflects on the appropriatenessand rigor of their learning process.
Related to CAP training, the above raises the question as to how trainers
should create conditions to support learners develop a reflective stance as wellas sustain trainees’ intrinsic motivation to promote lifelong learning (Ausubel etal., 1968). The concept of ‘scaffolding’ has developed; that is, structural things
that trainers do to guide learners through the “sheer volume and complexity ofknowledge to be acquired (which) often leaves the learner standing on the threshold(in a state of liminality), rather than stepping into the world of learning” (Taylor& Hamdy, 2013).
The shift in medical education from a ‘teaching paradigm’ to a ‘learning
paradigm’ has implications for both training processes and assessment (Huba& Freed, 2000; Jouquan et al., 2013) and offers a way of thinking well suited
to CAP. Trainer-trainee relationships become less hierarchical and knowledge is
co-constructed. Trainers adopt a position of ‘facilitator’ tailored to the trainee’s
current level and needs, to support their reflectivity and learning, while providing
a role model. Assessment is better incorporated in the training instead of heavily,
separated summative, standardized tests.
Traditional medical curriculum structures were based on a ‘time-basedmodel’, implying a fixed time needed to be spent in training. Yet, contemporary
shifts promoted a ‘competency-based model’, focused on acquisition of identifiedcompetencies through entrustable professional activities (Park et al., 2016). From
this perspective we can see lifelong learning aligns better with this contemporarycompetency-based model. It better ensures that professionals are able to adapt tocomplex and rapidly changing systems across their careers, through continuous
cycles of learning. For a competency-based model to work well it is importantthat the learner moves from a “can show” to a “does” practice (Miller, 1990), in aconsidered manner mode of action i.e. that they have not only learned a skill but
also learned when and how to apply it and its limitations. In doing this, they aredeveloping a reflective, iterative learning style, that they can apply across futurelearning during their career.
Let us look at these developments using the US CAP training frameworkas an exemplar. The skills and attitudes for the development of lifelong learning
in US CAP training are described in the Accreditation Council of Graduate
Medical Education (ACGME) subsumed under the Practice-based Learning and
Improvement competency: “Residents and fellows must demonstrate the ability toinvestigate and evaluate their care of patients, to appraise and assimilate scientificevidence, and to continuously improve patient care based on constant selfevaluation and lifelong learning.”. The aim of the competency is to help residents
and fellows develop the habits necessary required to continuously pursue quality
improvement, well past the completion of fellowship (ACGME, 2020a).

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IACAPAP Textbook of Child and Adolescent Mental Health

The key aspects of this core competency are consistent across specialties;
though programs may differ in how they present the knowledge and which skills
they choose to focus on when training physicians (https://knowledgeplus.nejm.
org/blog/practice-based-learning-and-improvement/). The first step requires
demonstration of an ability to investigate and evaluate a patient by gathering andanalyzing patient information. This includes firstly identifying the limits of theirknowledge and skill in the understanding and treatment of a patient and throughself-reflection and then, perhaps with a trainer, identify their educational needto move beyond those limits to greater knowledge and skill. Next the trainees
must be able to access and review scientific information, identify its relevance andapply this information to their patient’s needs. The third and final element forthe core competency is for trainees to demonstrate skills in and a commitment toimproving their practice of child and adolescent psychiatry. By employing quality
improvement methods to systematically evaluate their own practice, child andadolescent psychiatrists can ensure continuous improvement of their practice.
CAP trainees must be open to constructive feedback from teachers, their patients,
as well as other members of the health care team that allows for the incorporationof outside information into their daily medical practice to enhance the quality ofpatient care.
Once qualified, a continuing ability and willingness to learn reflectively
from their patients, their colleagues and from the literature are core componentsof lifelong-learning.

Wellbeing and resilience
Physicians and other allied health professionals are experiencing very highrates of burnout. According to many sources 21-67% of mental health workers
in Europe and the US, spanning multiple disciplines—nurses, occupational
therapists, social workers, psychologists, and psychiatrists—have been reported
to have high levels of burnout (Javier et al., 2019). Nearly 40% of practicing
psychiatrists as well as 45-60% of medical students and residents have experienced
substantial symptoms of burnout (American Psychiatric Association). Burnout is
described as having a high degree of emotional fatigue, including irritability andcynicism, and a low sense of professional engagement (Maslach & Leiter, 2016;
Morse et al., 2012; Rotenstein et al., 2018; Shanafelt et al., 2012). The impact ofburnout and the possible strategies to mitigate are highlighted in the Javier et al.,2019 IACAPAP e-textbook (Javier et al., 2019).
The Accreditation Council for Graduate Medical Education (ACGME) in
the United States has begun to address burnout and wellbeing within all training
programs. This accreditation body has added an entire section (Section VI.C) of
its Common Program Requirements for all residency and fellowship programs
regardless of specialty, to address well-being more directly and comprehensively(ACGME, 2020b). The requirements emphasize that psychological, emotional,
and physical well-being are critical in the development of the competent, caring,and resilient physician. These specific requirements emphasize the importance ofinstitutional oversight of duty hours, fatigue management, and well-being. The
training programs are required to develop systems that encourage residents, fellows
and faculty members to report their concerns when they or their colleagues displays

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IACAPAP Textbook of Child and Adolescent Mental Healthsigns of depression, burnout, substance use disorder, and/or suicidal ideation
conditions, so that the program director or other designated personnel, such as thedepartment chair, may assess the situation and intervene as necessary to facilitate
access to appropriate care. The ACGME monitors these requirements throughannual resident and faculty surveys and emphasizes the important role of facultymodeling in implementing systems that support physician well-being. In addition
to monitoring well-being programs also must teach components of self-care andemphasize that these skills can be learned and nurtured throughout training.
Recent studies have described attempts by residency programs to implement
well-being initiatives. These have included well-being groups, exercise classes,
classes related to mental health and sleep, teaching meditation skills, cognitive
behavior therapy, and positive perspective taking and others (Benson et al., 2018;
Chaukos et al., 2018; Guille et al., 2015; Runyan et al., 2016). Busireddy andcolleagues (2017) systematically reviewed and analyzed 19 studies enrolling 2030
residents and found that one intervention, limiting resident hours, was consistently
found to reduce burnout (Busireddy et al., 2017). All of the other interventions
were limited by small sample size of enrolled residents and that they describedinterventions from a single residency program. Javier and colleagues (2019)
describe interventions with some level of success in non-resident groups including
physicians and allied health professionals from international settings (Javier et al.,2019). There is no doubt that further research is needed to assess efforts to improveresidents’ wellbeing including strategies to improve resilience and effectively
identify and mitigate burnout. Support from national and international residency
oversight organizations should be increased to ensure the implementation ofevidenced based strategies.

Section D: An exploratory roadmap to evidence based bestpractices in training and educational research
Introduction: relevance of research on teaching and education
Best practices in medical education help us train and educate medical
professionals in the most effective and efficient way to deliver the outcome of good
doctors providing high quality care. To support innovation in learning and training
in CAP, research into the education of CAPs is needed. As a result, training can bebased on what approach works for whom and under what circumstances. This canensure evidence-informed decision-making in policy, planning and educational
practice that promotes CAP’s learning and practice.
So far, educational research in CAP is modest, apart from small-scaleinitiatives and several surveys that are largely descriptive. The questions for thissection are: What type of educational research is desirable, on what issues andthemes, and what are the next steps to develop an educational research framework
for CAP training? The breath of the matter makes it hard to decide where to startbuilding a framework. First, we need to recognize that the training and education
process of a CAP takes years and consists of multiple elements. In terms of study
designs and drawing a parallel to medical intervention research, the preferredapproach would be comparison studies comparing different approaches throughTraining and Education J.15

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IACAPAP Textbook of Child and Adolescent Mental Healthlong-term follow-up. Secondly, the outcome measures for a successfully trained
CAP require a clear definition of what is a good doctor and CAP. It needs torecognize that good CAP practice is based on complex interpersonal skills amongst
other competencies. Third, in terms of generalizability of findings, CAP training
occurs in a wide variety of practice contexts and cultural circumstances: what works
best in one context may be less effective in another part of the world. Lastly, how
CAP provide care of their patients is confounded by factors other than training
practices, such as talent, life experience and service systems they work in to namesome.
Despite these challenges, here we offer a suggestion for a CAP training
and education research framework. In establishing such a framework, we argue
experience and knowledge drawn from the established research fields of adulteducation and medical education literature is needed, that but is yet to be
substantially brought to the training of CAP.

Bringing focus: potential topics for future research
Educational research can be classified at different levels (De Corte, 2000)
that describe how individual trainees learn best, how formal and informal
contexts of work and education influence learning, how local and (inter)nationalorganizations can assist in setting curricula and how we can develop an educationaland health care system that assures patient, carer and trainee involvement in an
iterative process of feedback and improvement. All these perspectives ultimately
contribute to lifelong learning and development of CAP professionals and ensuring
they deliver the best care for their patients. Using these different viewpoints a CAP
training research framework would include:

1. Learning processes in the individual trainee
Starting at the level of an individual trainee, it is helpful to understand thelearning processes in his/her mind using learning-centred adult education concepts(Tennant, 2019).
Topics include e.g.:• self-regulatory skills;• resilience and the effects of personal well-being on learning;• trainees’ metacognition to improve their learning strategies;• scaffoldings provided by trainers to promote trainee metacognition andlearning;• the development of an inquiring-oriented attitude that enables continuous
professional development.

2. The learning context and work environment
Both the learning and clinical work environment in which CAP training
occurs can be studied.

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IACAPAP Textbook of Child and Adolescent Mental Health

Topics may include e.g.:• interprofessional learning, with multi- and interdisciplinary learning
environments teams (Tielemans et al., 2021);• learning from and with patients and their carers, based on the ‘nothing
about me without me’ principle that applies from bedside and classrooms
training to patient and career participation in curriculum development andeducational research;• impact of digitalization, including attitude and behavior with technology
in patients, carers and professional lives, digital communication withpatients, carers and colleagues as well as technologies to enable training(e.g., gamification, simulation training, e-consultation education, virtual
reality (L. Wissow et al., 2011; L. S. Wissow et al., 2008);• communities of practice that offer an effective and sustainable approachfor co-creating, sharing and implementing best practices (Wenger, 1998).

3. The curriculum
Study of local and (inter) national comparisons exploring similarities anddifferences in curriculum content, including knowledge, skills and attitudes that
equip future CAP to reflect on their practice and theoretical frameworks andcontinually adjust to evolving patients, community and societal needs.
Topics include e.g.:• flexible, modular teaching and learning programs in formal teaching andpractical learning in clinical work environments (Zitter et al., 2016);• translational medicine on how to translate CAP innovations in clinicalpractice into training;• the need for curriculums to support lifelong learning development
including how CAP create their own future learning pathways;• teaching staff development including understanding how supervisors andteachers develop educational competencies and are trained.

4. The organization of an educational and health care system
This level covers how to organize and create health care systems andorganizations where training and clinical practice takes place that allows an open
and safe learning culture that is inclusive and supports diversity.
Topics include e.g.:• the ‘hidden’ curriculum (implicitly taught norms) including how to shapea learning system that resonates with the values of patients and their carers(Beckett & Hager, 2002; Hager & Halliday, 2007);• supporting organizational and cultural change to allow supervisors andteachers to provide training well;• ensuring inclusiveness and diversity in training that promotes belonging

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IACAPAP Textbook of Child and Adolescent Mental Healthand prevents exclusion of patients, carers, trainees and staff members. This
involves selection and examining policies, measures, programs and training
approaches.

Facilitating evidence informed best practice in training and educational
research in CAP
In the broader scope and perspective, it is obvious that international
collaboration can help to create and strengthen communities of practices to support
CAP education research and its implementation. In medical science we have seenthat international organization and collaboration has improved research about
patient care. As this Chapter demonstrates, along with stronger organization at
national and regional levels, we see a rise of international collaboration around CAP
training. Given current technological developments that facilitate communicationand collaboration, we argue that the time is right to build international communities
of practice to research and facilitate the implementation of best practices in the
training of CAP.
Going forward a facilitating role will be played by blended learning (Müller
& Mildenberger, 2021). Blended learning is traditionally defined as a combinationof face-to-face learning and online learning. Today, blended learning also describes
a combination of campus education and e-learning. In addition to this ‘blend’
there is a second ‘blend’ that has to do with a combination of learning in an
educational setting and learning in the workplace. Combining both descriptions
we see it is possible to ‘work’ in an education setting in an electronically simulated
workplace. This is called double blended learning (Van Merriënboer & Kirschner,2017), reflecting a combination of online and face-to-face training both at school
and in the workplace. The digital component of such blended learning approaches
holds the promise of efficient data collection for greater support of educational
research than ever before.
As educational research in CAP develops and matures, it may include
large-scale quantitative studies, both cross sectional and longitudinal studies; andintervention studies comparing the impact of new innovative education strategies
to usual practice. By bringing the concept of “proof ” from EBM (Evidencebased Medicine) to medical education, the development of EBE (Evidence-Basededucation) constitutes huge progress in the field of medical education (KnutAspegren, 1999) and great promise to CAP education in particular. Some authorsin educational research today assume the need to combine several epistemologies –and methodological tools to try to grasp the complexity of teaching and education
phenomena(Pelaccia, 2013). The concept of EBE and proof is based on a ‘positivist’
approach that implies there is one ‘real truth’ or ‘reality’ that can be understoodby breaking down complex matters into simple components. The field of healthprofessions education can also be understood from a view of ‘constructivism’ where
reality can be subjective and experienced and constructed differently by individuals(Nestel & Bearman, 2015). This allows us to recognize and appreciate thedifferent views of students, trainers, patients, carers, health practitioners, faculty
members, service administrators, funders, politicians, and ultimately, society.
Accordingly, qualitative research methods could provide important insight within
a comprehensive perspective and complementing quantitative methods in future

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IACAPAP Textbook of Child and Adolescent Mental Healthstudies (Malterud, 2001; Mays & Pope, 2000).
The next steps are in the hands of the many and various stakeholders.
Academic positions and career pathways allowing CAPs to develop as researchersand clinical educators with a background in educational research are needed tofacilitate such a vision. On a smaller scale, practice-oriented research can flourish
from partnerships between academia and workplaces with the right support.
Structural inclusion of educational research in medical research funding rounds
will be helpful. The value of education research as part of the academic medical
culture will be stimulated by the development of traineeships, lectureships,
teaching scholarship and clinician educators having protected time for research ineducation.

Conclusion
It is obvious that increasing available evidence for teaching and educationin CAP will be a long-term investment. Historically CAP training has evolved
from a small-scale master-apprentice model to currently a more professional andinternationally benchmarked educational system. Explicit integration of results
emerging from educational research into the training and education of CAP
can start a cycle that integrates educational best practices and research into the
backbone of CAP as a scientific endeavor. Finally, there will be a cascade of benefits
for clinical care as patients, carers and health care providers work together in acontinuous cycle of learning in their quest to improve child and adolescent mental
health.

Section E: Resources and Networks
Introduction
Training in child and adolescent psychiatry, as in other medical specialist
training programs, has evolved from a master-apprentice model to a professional
training. Multiple international organizations were founded over the years withthe aim to improve training and teaching in CAP, sometimes combined withother goals including research academies, medical associations defending therights of doctors as well as advocacy from patient perspective. These internationalorganizations have already started to explore the wide variation and similarities byexchanging national and international training curriculum frameworks, teachingcontent and methodologies.
In this section we provide information about a wide selection of suchinternational associations and networks, as well as links to their websites. Firstly,
are featured organizations that focus on trainees and early-career psychiatrists.
We encourage readers to find more information and updates about them on theoriginating websites.

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IACAPAP Textbook of Child and Adolescent Mental HealthEuropean Federation of Psychiatric Trainees (EFPT)
https://efpt.eu/
EFPT was established in 1993 and constitutes an umbrella organization of
psychiatry trainees’ associations across Europe. It counts on a Child and Adolescent
Psychiatry (CAP) Working Group and a CAP Secretary on its Executive Board. In
terms of CAP, EFPT represents the interests of existing national CAP trainees’
associations, hosts research and advocacy activities regarding CAP training inEurope, holds an annual CAP symposium during the EFPT’s Annual Meeting,and has an Exchange Program which includes some CAP placements in different
hospitals and cities of the continent. EFPT also works closely with the European
Union of Medical Specialties (UEMS), and EFPT’s CAP Secretary meets annuallywith UEMS’ Section of Child and Adolescent Psychiatry to discuss the state of
CAP training across Europe(Gnanavel et al., 2020; Simmons et al., 2012). EFPT’s
CAP Secretary & Working Group Chair can be contacted at capsecretary@efpt.eu.

World Network of Psychiatric Trainees (WNPT)
http://worldtrainees.org
WNPT, established in 2018, is a global web-based network connecting
individual training psychiatrists across the world, with a majority of members
based in low- and middle-income countries. WNPT’s membership comprises
trainees from different psychiatric specialties, with around 10% being CAP
trainees. WNPT constitutes a source of professional networking, research, andadvocacy, and organizes periodic virtual fora with contents relevant to psychiatrictrainees(Pereira-Sanches & Virani, 2021).

World Psychiatric Association and its Early Career Psychiatrists’ Section(WPA-ECPS)
https://www.wpanet.org/early-career-psychiatrists
WPA is an umbrella organization for national psychiatric associations acrossthe world. Its ECPS was established in 2015 to represent the interests of the youngest
members of the profession worldwide, namely psychiatric trainees and graduatedpsychiatrists with up to 7 years of practice. This Section has recently (2021) opened
a world exchange program (https://worldpsychiatryexchangeprogram.wordpress.
com/), some of which placements are related to CAP(Pinto da Costa, 2020).

European Union Association of Medical Specialists, Child and Adolescent
Psychiatry Section (UEMS-CAP)
http://www.uemscap.eu
UEMS is an umbrella organization for European national associations of
medical specialists and provides international representation and collaboration
among medical specialists and harmonization of quality training programs acrosscountries. Its CAP Section, working closely with trainees through EFPT, works
towards the establishment of a European Union Curriculum Framework for CAP

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IACAPAP Textbook of Child and Adolescent Mental Healthtraining, the organization of educational events for trainees, trainers and training
program directors, harmonization of national evaluation of training outcomesthrough standard examinations, standardizing training in transition services from
CAP to adult psychiatry healthcare across CAP and general adult psychiatry
training programs and the integration of quality psychotherapy training in CAP
programs and advocacy in child and adolescent mental health, and holds the aimof building an international network of CAP education(Deschamps et al., 2020,2021).

European Society for Child and Adolescent Psychiatry (ESCAP)
https://www.escap.eu/
ESCAP aims to promote the mental health and wellbeing of children,
adolescents and their families in Europe through fostering knowledge and skills
in child psychiatry, international collaboration in CAP across the continent andresearch and education in the area. It comprises three divisions: academic, clinicaland policy. The role of the academic division is to act as a forum for exchange ofscientific research and to promote education and training, especially in research, inthe field of child and adolescent psychiatry and mental health.
ESCAP provides educational opportunities for trainees and early-career childand adolescent psychiatrists, being the organizer of annual Research Academies
and Residential Courses on Assessment and Treatment of Psychiatric Disorders inChildren and Adolescents(Barrett et al., 2020).

European College of Neuropsychopharmacology (ECNP)
https://www.ecnp.eu/
ECNP is an association promoting research and collaboration in clinicalneuroscience. It offers research skills training and mentorship for early-career
professionals, and organizes the annual ECNP School of Child and Adolescent
Neuropsychopharmacology.

International Association of Child and Adolescent Psychiatrists andAllied Professions (IACAPAP)
https://iacapap.org/
IACAPAP is a worldwide professional association for specialists in the area ofchild and adolescent psychiatry and mental health. Its work includes international
collaboration, educational activities through conferences, massively online open
courses and opportunities for early-career professionals, advocacy activities andpublications. Notably, IACAPAP is the publisher of the live global, open-accessmanual of CAP this chapter is a part of.

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IACAPAP Textbook of Child and Adolescent Mental HealthIn the area of CAP education for early-career professionals, IACAPAP
offers the Donald Cohen Fellowship to foster professional development throughmentorship and international collaboration and the Helmut Remschmidt Research
Seminars to promote research skills. The establishment of an early-career groupwithin IACAPAP is underway.

Other associations and networks
The organizations featured above in more detail were selected based on
their notable availability of information about its role in CAP education and thespecific opportunities for CAP trainees and early-career psychiatrists they offer.
Notably, they have a European or global extent, and there is still less information
or opportunities regarding CAP training in vast areas of the world. We recommend
readers to consult the websites of psychiatric associations in other areas of theworld for updates regarding CAP training: the Royal Australian & New ZealandCollege of Psychiatrists (https://www.ranzcp.org/), the Latin American Psychiatric
Association (https://www.webapal.org/), the Pacific Rim College of Psychiatrists(https://www.prcp.org/), the Asian Federation of Psychiatric Associations (www.
afpa.asia/en/), the African Association of Child and Adolescent Mental Health(https://aacamh.org/) and others.
Readers are encouraged to find further information about local andnational associations and networks related to CAP (including national psychiatricassociations, national CAP associations, and national psychiatric trainees’
associations) in their respective websites. Due to its size and international impact,
we will only be providing here more information about the American Academy ofChild and Adolescent Psychiatry (AACAP) and its Medical Students and Residents
Committee (AACAP-MSR) [https://www.aacap.org]. AACAP is the largest
professional association for CAP specialists in the United States. Its mission is topromote the healthy development of children, adolescents, and families throughadvocacy, education, and research, and to meet the professional needs of child andadolescent psychiatrists throughout their careers. The AACAP website contains
resources for members, families, practice parameters, mental health advocates anda special section for students, residents and early career psychiatrists. AACAP hosts
a Medical Students and Residents Committee (AACAP-MSR) [https://www.aacap.
org/AACAP/Medical_Students_and_Residents/Home.aspx?hkey=2d57e659d566-4d70-9f68-bf8f58ff3245)]. This committee, which is connected to AACAP’s
Training and Education Committee, brings to AACAP’s leadership the voices oftrainee members, and harnesses AACAP’s resources to support medical students,
psychiatry residents, and CAP fellows in and from the United States in their clinical,
research, and advocacy work in child and adolescent mental health. AACAP-MSR
includes regular open meetings, sponsorship of trainee-focused activities during
AACAP’s annual meeting, a periodic newsletter and a peer-mentorship program.
Additionally, AACAP offers several opportunities for trainees, including annual
research colloquia for early-career investigators, awards and training and research
fellowships.

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