It is well established that Child and Adolescent Psychiatry (CAP) is the number one shortage specialty in all of psychiatry (1). Currently, there are approximately 7,000-8,000 practicing child and adolescent psychiatrists in the United States (2). In various reports the number of youth nationwide with significant psychopathology requiring evaluation and treatment varies from 12%–22% (3), with the best evidence reporting at least 12% showing serious disturbance (4, 5). This amounts to about 10 million youth. Clearly there are insufficient child and adolescent psychiatrists to provide care to this number of children and adolescents. To compound matters, the workforce is concentrated in urban areas, with large sections of rural and inner city youth and families highly underserved (6). Finally, while the numbers of residents going into child and adolescent psychiatry have increased about 10% over the past 10 years, the number of current CAP graduates in the United States is approximately 420 per year, far below the numbers needed to improve the workforce, particularly as the baby boomers prepare to retire.

This dire situation has no current solution. While many national organizations have been lobbying for increased entry into CAP, including creative programs like the Triple Board and Post Pediatric Portal programs, the numbers of residents in child and adolescent psychiatry have increased only modestly and have not kept up with increases in the population. Further, graduate medical education funding is in danger of being cut back by Congress, and some in national leadership positions worry that all graduate medical education positions may be reduced by 20%. At this same time there is increasing public awareness and recognition of the treatment needs of children and adolescents with mental health needs.

In light of this situation increased demands have been placed on pediatricians, family physicians, and general psychiatrists to evaluate and treat children and adolescents. While the American Academy of Pediatrics has recognized the need for pediatricians to be well versed in child mental health, they receive very limited training during residency and often feel ill equipped to address this public health need. In many pediatric practices, prescribing of any psychotropic medications is eschewed. As a result there is a national initiative to increase the comfort, skills, and knowledge of primary care physicians (see www.ncpap.org) through programs across the country, such as the Massachusetts Child Psychiatry Access Program (www.mcpap.org) and New York’s Child and Adolescent Psychiatry for Primary Care (www.cappcny.org). While primary care physicians may be looked to for mild-moderate cases, much of the burden of caring for youth under 18 and their families will increasingly fall in the laps of general psychiatrists.

General psychiatry residencies require some training in CAP in the U.S. The Review Committee of the Accreditation Council of Graduate Medical Education currently requires 2 months of CAP in all residency programs. This, of course, is quite minimal, and less than our Canadian colleagues, who have a minimum of 6 months of child psychiatry during their 5-year psychiatry programs. Despite the rather limited training, many general psychiatrists take on child cases out of necessity, interest, or professional sense of duty. Along the way many have found these cases to be rewarding, if not often challenging. In any case, greater lifelong learning in CAP is essential. Thus one purpose of this issue of FOCUS is to increase the knowledge base of general psychiatrists who will care for youth and families.

But beyond the pressure to understand children and families due to the shortage of child and adolescent psychiatrists, we feel there are additional reasons for general psychiatrists to acquire broader knowledge, skills, and attitudes in CAP. Let us consider the following reasons for expanding learning in this arena:

• Most psychiatric disorders begin in childhood or in transitional age youth (ages 14-24) (7), and treatment is often delayed for years (8). Thus, providing optimal treatment of adult disorders necessitates taking a lifespan approach and knowing about their child and adolescent history.

• Psychopathology in adulthood has a significant impact on family members, including spouses and youth. In turn, improving the functioning of adult patients in their caring for children requires the attention of providers, just as increasing performance in other areas of life includes appreciating the impact of psychopathology on job and social performance.

• Many adult patients under the care of general psychiatrists will ask for professional advice in their parenting children and adolescents, both those with and those without psychiatric disorders.

• It may be extremely helpful for general psychiatrists to have some skill in family intervention in order to understand the family’s reaction to psychiatric illness in the patient. Additionally, family members are often critical in the treatment and rehabilitation of an adult patient.

• All patients are perhaps best understood in a developmental framework. Most forms of individual, couples, family, and group psychotherapies embrace developmental principles, and the use of developmental formulations in treatment may be extraordinarily useful.

• CAP requires an understanding of the context of child patients, including the family, system of care, and public agencies in much greater depth than typical in general psychiatry. Understanding schools, courts, and social service systems is essential to child psychiatric practice. Many adults in treatment may receive needed services in the community, and the awareness of available resources may significantly improve adult patient wellbeing and provide more comprehensive care.

For all of these reasons, we believe the outstanding reviews in this issue of FOCUS will be an important educational experience for general psychiatrists. We have included a number of important topics that are seen in everyday clinical practice. Attention deficit hyperactivity disorder (ADHD), one of the most common childhood psychiatric conditions, is well known now to begin in childhood with symptoms typically continuing into adulthood. Dr. Rostain presents a comprehensive review of the etiology, course, complications, and treatment of this disorder. Another disorder starting in childhood and commonly seen in general psychiatric practice is mental retardation, now being referred to as intellectual and developmental disabilities. Dr. Barnhill covers the clinical challenges of diagnosing and treating these disorders. Dr. Ascherman provides an “Ask the Expert” case of a medical student with significant attentional and academic difficulties, highlighting the importance of recognizing specific learning disorders, which can easily go unnoticed in adult practice.

We all appreciate the dangers of substance abuse in our work. Again, most addictive disorders begin in adolescence and transitional age youth. Drs. Howlett, Williams, and Subramaniam present a comprehensive view of adolescent substance abuse.

Many of our adult patients have children and adolescents with chronic psychiatric and medical illnesses. These disorders present our adult patients with considerable challenges, including emotional distress and family, social, and economic hardships. Our appreciation of these factors is extremely valuable in the overall treatment of our adult patients. In their review, Drs. Smith and Kaye address these issues along with practical suggestions for assisting adult patients with children with chronic conditions.

It should be noted that these conditions, as well as substance abuse, ADHD, and intellectual and developmental disabilities all require a team approach. All the authors help us with the challenges of developing or working in a team to mitigate the negative consequences of these disorders.

Our digital era poses new and complicated problems for children, adolescents, and parents. Drs. Gorrindo, Fishel, and Beresin address the multifaceted problems in managing use and misuse of digital media in our children and teens, through an Eriksonian approach that considers the challenges for children at different developmental stages. By doing so, the review may help parents and clinicians understand the risks and benefits of these media in society. Not only are digital media used by youth, but adults have come to increasingly rely on digital media. Facebook, Twitter, and the Internet have become common means of our acquiring information and staying in contact with others. While many have found social media extremely valuable, it poses tremendous challenges to maintaining professionalism, boundaries, and maintaining our privacy as individuals and physicians. Dr. Stubbe complements this article in the Communication Column by providing guidelines for the professional use of electronic communications with patients.

Finally, in the Ethics Column, Drs. Goldsmith and Joshi provide an overview of the American Academy of Child and Adolescent Psychiatry’s Code of Ethics along with illustrative case examples of selected principles. They consider some of the differences and subtleties as well as possible conflicts in or work with minors as opposed to adults. These principles are important for all psychiatrists as we must understand them when we work with children, and when parents ask about advice that has ethical and possibly legal implications regarding the autonomy and rights of minors.

In addition we, together with the Editors, have selected critical articles in CAP from the past few years that will be relevant and useful to the practicing psychiatrist.

This issue is a valuable resource for general psychiatrists as well as child and adolescent psychiatrists. We hope it will prove useful for you in your work with patients of all ages, and stimulate you to seek greater clinical education and training in child and adolescent psychiatry.