Current Training Practices and Training Gaps in Clinical Child and Adolescent Psychology: Implications for Training Guidelines

Abstract

This study aimed to inform training guidelines for Clinical Child and Adolescent Psychology (CCAP) by assessing current CCAP training practices and perceived gaps in trainee readiness at each stage of training. Training directors (TDs) of doctoral, internship, and postdoctoral programs offering training in CCAP completed an online survey regarding training experiences offered in their program and areas in which trainees could be better prepared. Responses from each training program were coded to characterize the program’s level of specialty training using the Taxonomy for Clinical Child and Adolescent Psychology. Among doctoral programs, 30.8% met criteria for Major Area of Study in CCAP, 23.1% for Emphasis, 28.2% for Experience, and 15.4% for Exposure. Most internship programs (94.3%) and all postdoctoral programs met criteria for Major Area of Study. TDs indicated that trainees could be better prepared in areas specific and central to each level of training; time management was identified as an area for improvement across levels of training. Postdoctoral TDs identified proficiency gaps among trainees nearing independent practice that are critical for competent service delivery in CCAP, including case conceptualization, assessment, and intervention. The pattern of increased specialization later in training and identified gaps particularly near the end of training have implications for specialty training and the development of training guidelines in CCAP.

Public Significance Statement

Training guidelines for CCAP offer value for program development, promoting consistency in training across programs, assisting trainees in achieving necessary experiences, and ensuring the competency of the mental health workforce. This study describes the current landscape of training and areas where trainees can be better prepared for doctoral, internship, and postdoctoral work. The results are intended to facilitate development of training guidelines for the specialty.

Clinical Child and Adolescent Psychology Specialty and Training Council

Clinical Child and Adolescent Psychology (CCAP) has been recognized as a specialty in professional psychology since 1998. A specialty is an:

“area of professional psychology practice characterized by a distinctive configuration of competent services for specified problems and populations. Practice in a specialty requires advanced knowledge and skills acquired through an organized sequence of education and training in addition to the broad and general education and core scientific and professional foundations acquired through an American Psychological Association (APA) or Canadian Psychological Association (CPA) accredited doctoral program” (APA, 2011).

The CCAP specialty is institutionalized through the existence of its own specialty council (Clinical Child Psychology Specialty Council), APA Divisions (Society of Clinical Child and Adolescent Psychology [SCCAP], Society of Pediatric Psychology [SPP]), specialty board certification (American Board of Clinical Child and Adolescent Psychology [ABCCAP]), and a specialty-specific training council (Clinical Child and Pediatric Psychology Training Council [CCaPPTC]). The CCaPPTC was established in 2016 with key objectives of 1) developing a common language, or “a training taxonomy,” for categorizing levels and extent of specialized training in CCAP offered by a program and 2) developing formal guidelines for training in CCAP.

The unique training needs of individuals seeking to provide clinical psychology services to children, youth, and families were first recognized in the late 1970s and later formalized by a task force of the APA Division of Children, Youth and Families. National conferences focused on education and training in 1985 and 1998 (Roberts et al., 1998; Spirito et al., 2003). In 1985, suggestions for training in the specialty were established at the Conference on Training Clinical Child Psychologists (Tuma, 1986) and were updated in 1998 (Roberts et al., 1998). However, these suggestions have not been updated to reflect advancements within the field of psychology and within the specialty, as well as changes in the needs, opportunities, work environments, and populations served by clinical child and adolescent psychologists. These evolving needs include the current state of children’s mental health and mental health services in the United States. As observed by the American Academy of Pediatrics (2021), we are facing a youth mental health crisis, with multiple indicators of worsening youth mental health over the last decade (Centers for Disease Control, 2023). Although several leaders, organizations, and task forces within the specialty have provided training recommendations (e.g., Spirito et al., 2003; Palermo et al., 2014) since the updated Roberts and colleagues (1998) guidelines, these writings have represented the opinions of individuals or individual organizations and have not been established as training guidelines across constituent groups in the specialty.

As the specialty-specific training council, CCaPPTC is uniquely positioned to facilitate development of CCAP training guidelines for endorsement by key constituent groups within the specialty, facilitating more widespread adoption. Toward this end, CCaPPTC, in partnership with SCCAP, SPP, and ABCCAP, sought to identify aspirational and best practices for training in CCAP in doctoral, internship, and postdoctoral programs. For this purpose, the need to better understand the current state of training in CCAP was recognized.

Taxonomy for Education and Training in Professional Psychology Health Service Specialties

Quantifying and categorizing levels of specialty training is crucial for understanding current training opportunities, but this goal has been complicated by inconsistencies in nomenclature used to describe training. Terminology has varied over the years and across specialties, professional groups, training entities, and programs (Rozensky et al., 2015). For example, among APA-accredited graduate programs, terms such as “emphasis,” “track,” and “concentration” have referred to widely varying training opportunities in coursework, practica, and research (Rozensky et al., 2015). This lack of shared terminology created challenges for prospective and current students, programs, and credentialing and licensure organizations reviewing training experiences of learners. To address this, APA’s Commission for the Recognition of Specialties and Proficiencies in Professional Psychology (CRSPPP) issued the Education and Training Guidelines: A Taxonomy for Education and Training in Professional Psychology Health Service Specialties (APA, 2012), which was updated in 2020 (APA, 2020). The taxonomy defines four graded levels of education and training: Exposure, Experience, Emphasis, and Major Area of Study. These can be pursued across four stages of training: doctoral programs, internship programs, postdoctoral programs, and post licensure education and training. Member specialties of the Council of Specialties in Professional Psychology (CoS) were tasked with creating a specialty-specific taxonomy defining experiences at each stage and level of training.

In 2021, the CoS approved the education and training taxonomy for CCAP (hereafter, “the CCAP taxonomy”), which provides a classification to describe depth of specialty training in CCAP, which is inclusive of pediatric psychology. At each of the four stages of training, levels of opportunity for depth of training in the specialty (i.e., Major Area of Study, Emphasis, Experience, Exposure) are defined according to requisite numbers of courses, practica, and research experiences in CCAP (See Figure 1). The CCAP taxonomy is intended to create a common nomenclature for discussing level of opportunity for specialty training without intending to convey which level of opportunity or what specific experiences should happen at each training stage. The CCAP taxonomy does not represent best practices for training or training guidelines, and given its focus on quantity of experience, it was not developed based on a competency framework and does not overlap with Standards of Accreditation provided by the APA Commission on Accreditation and the Profession-Wide Competencies. Therefore, it should not be assumed or inferred that opportunities for greater depth in specialty training are inherently more desirable, valuable, or ideal.

Figure 1. Taxonomy for Training in Clinical Child and Adolescent Psychology.

Note. The complete published taxonomy for training in Clinical Child and Adolescent Psychology can be found at https://www.cospp.org/cos-approved-specialty-e-t-taxonomies

¹Clinical Child and Adolescent Psychology is a specialty of professional psychology that is inclusive of pediatric psychology. The specialty brings together the basic tenets of clinical psychology with a thorough background in child, adolescent and family development and developmental psychopathology. Clinical child and adolescent psychologists conduct scientific research and provide psychological services to infants, toddlers, children, and adolescents. The research and practices of Clinical Child and Adolescent Psychology are focused on understanding, preventing, diagnosing, and treating psychological, cognitive, emotional, developmental, behavioral, and family problems of children. Of particular importance to clinical child and adolescent psychologists is a scientific understanding of the basic psychological needs of children and adolescents and how the family and other social contexts influence socio-emotional adjustment, cognitive development, behavioral adaptation, and health status of children and adolescents. There is an essential emphasis on a strong empirical research base recognizing the need for the documentation and further development of evidence-based assessments and treatments in clinical child and adolescent psychology. Pediatric psychology, in relation to the specialty of Clinical Child and Adolescent Psychology, addresses physical, cognitive, social, and emotional functioning and development as they relate to health and illness in children, adolescents and families. Pediatric psychologists promote the health and psychological well-being of children and youth, most often in a pediatric health setting, applying a developmental framework, and utilizing an evidence-based approach to practice, education, training, and advocacy.

²A graduate course is defined as a 3-credit hour semester long course (or equivalent quarter credit hours). For the designation at the Major Area of Study at the Doctoral stage of training, 2 of these 4 courses must be dedicated Clinical Child and Adolescent Psychology courses in the areas of developmental psychopathology, assessment, treatment, and consultation. The other 2 courses (or remaining hours) can be a combination of material from other courses that would equate to a course equivalent (e.g., half of a semester of two separate assessment courses focused on child/adolescent material that combine to a course equivalent of a full semester). For the designation at the Emphasis level, 1 of these 3 courses must be a dedicated Clinical Child and Adolescent Psychology course in the area of treatment, assessment, and/or developmental psychopathology. The other 2 courses (or remaining hours) can be a combination of material from other courses that would equate to a course equivalent (e.g., half of a semester of two separate assessment courses focused on child/adolescent material that combine to a course equivalent of a full semester). For all levels (i.e., Major Area of Study, Emphasis, Experience, Exposure), course material from a discipline-specific knowledge course (e.g., developmental requirement for accreditation standards) does not count toward any of the course requirements at any level of education or training listed above.

³Clinical Child and Adolescent Psychology Practicum is defined as a practicum experience (approximately 9 months) of supervised training, at least 8 hours per week or its equivalent (e.g., a minimum of 240 total hours) with at least 50% of clinical service delivery with a child/adolescent-focused presenting concern.

⁴For the purposes of this level of education and training, the dissertation or research project may include Clinical Child and Adolescent Psychology focused empirical research, extended case studies/small-N designs, literature reviews/analyses, or capstone projects.

⁵Supervised experience in the specialty at the Internship and Postdoctoral stages of training includes didactic activities (e.g., seminars, grand rounds) and clinical service delivery to children, adolescents, and their families (e.g., assessment, treatment, consultation) with supervision by a licensed psychologist with competencies in Clinical Child and Adolescent Psychology as demonstrated by appropriate training, credentials, and qualifications.

⁶At the Postdoctoral training level, it is recognized that the Major Area of Study is consistent with training standards for specialty accreditation in Clinical Child Psychology through the APA.

⁷Major area of study at the Post-Licensure level represents what a licensed psychologist would need to do in order to re-specialize in Clinical Child and Adolescent Psychology after initial training, the doctoral degree is received in a different specialty, and the psychologist has already obtained licensure.

⁸Continuing Education (CE) must be from an organized CE program provider approved by the American Psychological Association, or State/Provincial Psychological Association, or State/Provincial licensing board, or relevant Accredited Continuing Medical Education course, or from a professional organizational entity that maintains administrative control including responsibility for course design and contents, accountability, and record-keeping of course participation/attendance. Specialty training gained through CE workshops is supplemental to an organized program of coursework because CE offerings are not systematic in covering topics of developmental psychopathology, assessment, treatment, and consultation in Clinical Child and Adolescent Psychology.

⁹Supervised Clinical Child and Adolescent Psychology practice is defined as 100% time devoted to clinical service delivery to children, adolescents, and their families (e.g., assessment, treatment, consultation) with supervision by a licensed psychologist with competencies in Clinical Child and Adolescent Psychology as demonstrated by appropriate training, credentials, and qualifications.

Current Study

In 2018, the CCaPPTC established the Training and Education Guidelines Committee, tasked with assessing current training experiences in CCAP at the doctoral, internship, and postdoctoral levels. Further, this workgroup sought to identify current gaps in training by querying competencies and skills in which training directors (TDs) perceived trainees could be better prepared. Thus, CCaPPTC conducted a survey of TDs of programs offering CCAP-focused education and training. The present study analyzed the CCaPPTC survey data to achieve the following aims: 1) assess current levels and depth of specialty training across programs at the doctoral, internship, and postdoctoral stages by applying the CCAP taxonomy nomenclature, and 2) identify gaps in training by assessing TD perspectives on competencies and skills that could be better developed prior to entry to each training stage.

Methods

Participants

Participants recruited for this study were TDs of psychology doctoral, internship, and postdoctoral training programs that provide any training in CCAP, regardless of level of depth in specialty training A common database listing all graduate, internship, and postdoctoral programs with specialty training in CCAP is not available; therefore, separate processes were needed for identifying programs at each training stage. To identify doctoral programs, a list of all accredited APA Clinical Ph.D. or Psy.D. programs was obtained from the APA website (https://accreditation.apa.org/accredited-programs). Filters to select for programs offering opportunities in CCAP were not available; therefore all APA-accredited programs were included in the email distribution list for recruitment, which included over 250 programs. To identify internship programs, the APPIC Directory (https://membership.appic.org/directory/search) was searched using filters for “internship” for program type and “child/adolescent psychiatric or pediatrics” for program criteria/agency type. To identify postdoctoral programs, the APPIC Universal Psychology Postdoctoral Directory (https://www.appic.org/Postdocs/Universal-Psychology-Postdoctoral-Directory-UPPD) was searched using the “clinical child psychology” filter for specialty; the APA accredited programs website was also searched using the filter “clinical child psychology” for practice area. As of November 2023, APPIC lists 421 internship sites and 126 postdoctoral programs offering training with children. The survey was also sent through the Council of University Directors of Clinical Psychology, SCCAP, and SPP listservs.

Inclusion criteria assessed via self-report were: 1) the program had a clinical child or pediatric psychology-focused track, concentration, emphasis, practicum, specialization, or training experience (i.e., specifically clinical, not inclusive of counseling or school psychology), and 2) the survey respondent was the program’s TD. While training in child psychology also occurs in counseling and school programs, our intent was to focus on clinical programs given the CCAP taxonomy used to categorize programs and forthcoming training guidelines are both specific to clinical child psychology. In fact, counseling psychology and school psychology have separate CoS-approved taxonomies. Only TDs were asked to complete the survey to avoid having multiple informants from one program. If a respondent was not the TD, they were asked to provide contact information for the TD, who was then invited to participate.

Measures

We developed draft survey questions and then piloted and refined the questions by asking a small number of faculty to complete a draft survey based on their own programs. The final survey included questions about quantity/percentage of CCAP training experiences offered (e.g., coursework, clinical practica/rotations, research requirements), accreditation status, membership status in the CCaPPTC, and the current number of CCAP trainees and CCAP faculty in the program. TDs also reported areas they perceived trainees could be better prepared at their program’s training stage. Separate survey questions were developed for each stage of training; surveys are available upon request from the corresponding author.

Procedures

Respondents completed the survey utilizing REDCap. Following indication of consent, participants completed questions regarding inclusion criteria and training level (i.e., doctoral, internship, or postdoctoral program). Subsequent questions were tailored to level of training. If a TD oversaw multiple programs, they were asked to complete the survey separately for each program. TDs reported the name of their institution and program to confirm that no program had multiple entries. In one case where multiple entries were identified for the same program, the program was contacted and asked which of the survey responses had been submitted by the TD, and that response was retained for analyses. Subsequently, all identifying information was deleted from the database. Use of de-identified data was determined to be non-subjects research by the first author’s Institutional Review Board.

Data Analysis

Given responses were categorical, data were analyzed descriptively using frequencies. Based on their survey responses, programs were classified by the authors according to the CCAP taxonomy (Council of Specialties in Clinical Psychology, 2021; Figure 1) as offering a “Major Area of Study,” “Emphasis,” “Experience,” or “Exposure” in CCAP. Two authors independently coded all programs for taxonomy classification; percent agreement reliability was 80% for doctoral programs and 100% for internship and postdoctoral programs. Classification of the doctoral programs with discrepant initial categorization was discussed to consensus.

Results

Description of the Sample

Respondents from 91 institutions reported on 100 training programs (i.e., 42 doctoral programs, 37 internship programs, 21 postdoctoral programs). Ninety programs (i.e., 39 doctoral programs, 35 internship programs, 16 postdoctoral programs) completed the questions needed for inclusion in analyses (i.e., 10 programs reported basic program information but failed to respond to questions regarding training experiences). Most programs were accredited (n = 75; 83.3%) with 72 (80.0%) accredited by APA, three (3.3%) by CPA, and five (5.6%) by the Psychological Clinical Science Accreditation System (PCSAS). Across training stages, most programs (n = 58; 64.4%) reported that 80–100% of the training opportunities provided were child-focused. Table 1 presents additional program descriptives.

Table 1.

Program Descriptives

	All Sample Programs (n = 90)	Graduate Programs (n = 39)	Internship Programs (n = 35)	Postdoctoral Programs (n = 16)
Program Accredited
Yes	75 (83.3%)	39 (100%)	31 (88.6%)	5 (31.3%)
No	15 (16.7%)	-	4 (11.4%)	11 (68.8%)
Member of CCaPPTC
Yes	32 (35.6%)	17 (43.6%)	10 (28.6%)	5 (31.3%)
No	41 (45.6%)	16 (41.0%)	17 (48.6%)	8 (50.0%)
Unsure	17 (18.9%)	6 (15.4%)	8 (22.9%)	3 (18.8%)
Percentage of Training Opportunities Offered that are Child-Focused
0–19%	1 (1.1%)	1 (2.6%)	-	-
20–39%	8 (8.9%)	6 (15.4%)	2 (5.7%)	-
40–59%	13 (14.4%)	13 (33.3%)	-	-
60–79%	10 (11.1%)	9 (23.1%)	1 (2.9%)	-
80–100%	58 (64.4%)	10 (25.6%)	32 (91.4%)	16 (100%)
Number of Core Full-Time Faculty in the Program Providing CCAP training
1–3	23 (25.6%)	18 (46.2%)	2 (5.7%)	3 (18.8%)
4–6	34 (37.8%)	16 (41.0%)	14 (40.0%)	4 (25.0%)
7+	33 (36.7%)	5 (12.8%)	19 (54.3%)	9 (56.3%)
Number of CCAP Trainees Completing the Program in the Last 5 Years
< 10	25 (27.8%)	10 (25.6%)	6 (17.1%)	9 (56.3%)
10–19	36 (39.9%)	18 (46.2%)	13 (37.2%)	5 (31.2%)
20–29	12 (13.3%)	2 (5.2%)	10 (28.6%)	-
30–39	9 (10.0%)	4 (10.3%)	5 (14.5%)	-
40+	8 (8.8%)	5 (12.9%)	1 (2.9%)	2 (12.5%)

Description of Training Experiences Offered

Based on TD-report of program offerings, 12 doctoral programs (30.8%) were categorized as meeting criteria for Major Area of Study, nine (23.1%) for Emphasis, 11 (28.2%) for Experience, and six (15.4%) for Exposure. One program was not coded due to missing data. As detailed in Table 2, doctoral programs varied in the amount of child-focused training opportunities reported.. As expected, programs categorized as offering a Major Area of Study provided the most child-focused coursework, practica, and research in terms of frequency and percentage of overall curriculum. Nearly half of responding doctoral programs (47.4%) offered 5 or more courses devoted entirely to CCAP or lifespan/development. However, programs varied in the number of CCAP courses required: one-to-two CCAP courses (23.7%), three-to-four CCAP courses (34.2%), or five-to-six CCAP courses (28.9%). Half of responding doctoral programs (50.0%) offered seven or more practicum experiences in CCAP, and students in most programs (58%) had 500–1500 CCAP clinical hours before beginning internship.

Table 2.

Training Experiences Offered by Doctoral Programs by Level of Opportunity for Training in Clinical Child and Adolescent Psychology

	Programs with Major Area of Study (n = 12)	Programs with Emphasis (n = 9)	Programs with Experience (n = 11)	Programs with Exposure (n = 6)
Clinical Child and Adolescent Psychology (CCAP) Coursework
Number of courses offered devoted entirely to CCAP or lifespan/development
0	-	-	-	1 (16.7%)
1–2	-	-	10 (90.9%)	2 (33.3%)
3–4	2 (16.7%)	4 (44.4%)	-	1 (16.7%)
5–6	9 (75.0%)	4 (44.4%)	1 (9.1%)	2 (33.3%)
7+	1 (8.3%)	1 (11.1%)	-	-
Number of CCAP or lifespan/development courses a trainee is required to take
0	-	-	1 (9.1%)	1 (16.7%)
1–2	1 (8.3%)	1 (11.1%)	5 (45.5%)	2 (33.3%)
3–4	3 (25.0%)	6 (66.7%)	2 (18.2%)	2 (33.3%)
5–6	7 (58.3%)	1 (11.1%)	2 (18.2%)	1 (16.7%)
7+	1 (8.3%)	1 (11.1%)	1 (9.1%)	-
Program has a CCAP-specific course on Psychopathology
Yes	10 (83.3%)	7 (77.8%)	3 (27.3%)	4 (66.7%)
No	2 (16.7%)	2 (22.2%)	8 (72.7%)	2 (33.3%)
Program has a CCAP-specific course on Assessment
Yes	12 (100.0%)	8 (88.9%)	6 (54.5%)	5 (83.3%)
No	-	1 (11.1%)	5 (45.5%)	1 (16.7%)
Program has a CCAP-specific course on Therapy
Yes	12 (100.0%)	9 (100.0%)	7 (63.6%)	3 (50.0%)
No	-	-	4 (36.4%)	3 (50.0%)
Clinical Child and Adolescent Psychology (CCAP) Practicum Experiences
Number of CCAP practica offered
0	-	-	-	2 (33.3%)
1–2	-	1 (11.1%)	-	-
3–4	2 (16.7%)	4 (44.4%)	2 (18.2%)	2 (33.3%)
5–6	2 (16.7%)	-	3 (27.3%)	1 (16.7%)
7+	8 (66.7%)	4 (44.4%)	6 (54.5%)	1 (16.7%)
Number of CCAP clinical hours during graduate training before beginning internship
< 500	-	-	-	3 (50.0%)
500–1500	8 (66.7%)	4 (44.4%)	8 (72.7%)	2 (33.3%)
1500–2500	2 (16.7%)	5 (55.6%)	2 (18.2%)	-
2500–3500	2 (16.7%)	-	1 (9.1%)	1 (16.7%)
How many therapy contact hours in CCAP do trainees receive during graduate training before beginning internship
< 100	-	1 (11.1%)	-	2 (33.3%)
100–500	5 (41.7%)	4 (44.4%)	10 (90.9%)	3 (50.0%)
500–1000	6 (50.0%)	2 (22.2%)	1 (9.1%)	1 (16.7%)
1000–2000	1 (8.3%)	2 (22.2%)	-	-
How many assessment contact hours in CCAP do trainees receive during graduate training before beginning internship
< 100	1 (8.3%)	3 (33.3%)	2 (18.2%)	4 (66.6%)
100–500	9 (75.0%)	4 (44.4%)	9 (81.8%)	1 (16.7%)
500–1000	2 (16.7%)	2 (22.2%)	-	1 (16.7%)
1000–2000	-	-	-	-
Students required to do a CCAP internship
Yes	6 (50.0%)	1 (11.1%)	1 (9.1%)	-
No	6 (50.0%)	8 (88.9%)	10 (90.9%)	6 (100%)
Clinical Child and Adolescent Psychology (CCAP) Research Experience
Students required to do a child-focused thesis
Yes	9 (75.0%)	1 (11.1%))	3 (27.3%)	-
No	3 (25.0%)	8 (88.9%)	8 (72.7%)	6 (100%)
Students required to do a child-focused dissertation
Yes	12 (100%)	1 (11.1%))	5 (45.5%)	-
No	-	8 (88.9%)	6 (54.5%)	6 (100%)

Note. n = 38. One graduate program was excluded due to insufficient information to code taxonomy level of training.

Among internship programs, most programs were categorized as offering a Major Area of Study (94.3%; n = 33) based on TD-reported training opportunities, with the remaining offering an Emphasis in CCAP (5.7%; n = 2). Most internship programs (62.9%; n = 22) reported that their training experiences included both clinical child and pediatric psychology. Programs provided a range of training settings (percentages non-exclusive): hospital/medical center (71.4%; n = 25), community mental health center (25.7%; n = 9), academic teaching (20.0%; n = 7), school district/system (11.4%; n = 4), psychiatric facility (11.4%; n = 4), consortium (5.7%; n = 2), health maintenance organization (5.7%; n = 2), independent practice (2.9%; n = 1), correctional institute (2.9%; n = 1), and residential treatment/partial hospitalization (2.9%; n = 1). Most (62.9%; n = 22) internship programs had 100% CCAP-focused hours for trainees. All responding internship programs (n = 35) offered formalized child-focused didactics and nearly all offered training in supervision (88.6%; n = 31). Table 3 reports information regarding child-focused internship rotations by length and activity.

Table 3.

Frequency and Percentage of Rotations in CCAP Offered by Internship Programs

Descriptor	n (%)
Number of CCAP Rotations Lasting > 6 Months Offered
1–3	21 (60.0%)
4–6	9 (25.7%)
6–8	1 (2.9%)
8–10	2 (5.7%)
10+	2 (5.7%)
Number of CCAP Rotations Lasting < 6 Months Offered
1–3	23 (65.7%)
4–6	4 (11.4%)
6–8	3 (8.6%)
8–10	4 (11.4%)
10+	3 (8.1%)
Missing	1 (2.9%)
Number of Assessment Rotations Offered
0–2	16 (45.8%)
3–4	14 (40.0%)
6–9	4 (11.5%)
Other	1 (2.9%)
What Percentage of the Total Training Experience is Assessment?
1–25%	12 (34.3%)
25–50%	17 (48.6%)
50–75%	6 (17.1%)
Number of Consultation/Liaison Rotations Offered
0–2	21 (60.0%)
3–4	9 (25.8%)
6–13	5 (14.3%)
What Percentage of the Total Training Experience is Consultation?
1–25%	21 (60.0%)
25–50%	13 (37.1%)
75–99%	1 (2.9%)
Number of Therapy Rotations Offered
0–2	14 (40.1%)
3–5	13 (37.1%)
6–10	7 (20.1%)
Other	1 (2.9%)
What Percentage of the Total Training Experience is Therapy?
1–25%	1 (2.9%)
25–50%	21 (60.0%)
50–75%	9 (25.7%)
75–99%	3 (8.6%)
100%	1 (2.9%)

All postdoctoral programs (n = 16) were categorized as offering a Major Area of Study in CCAP per TD-report of training offered. Most postdoctoral programs reported most training occurring in clinical care (75.0%; n = 12). Nearly all programs offered training in clinical child psychology (93.8%; n = 15) and most offered training in pediatric psychology (68.8%; n = 11); a notable number of programs offered training in developmental disabilities (43.8%; n = 7). Training settings (percentages non-exclusive) included hospital/medical centers (100%; n = 16), academic teaching (18.8%; n = 3), school district or system (18.8%; n = 3), consortium (12.5%; n = 2), health maintenance organization (12.5%; n = 2), community mental health center (12.5%; n = 2), independent practice (6.3%; n = 1), and child welfare (6.3%; n = 1). Postdoctoral training included child-focused didactics (93.8%; n = 15), clinical training (100%; n = 16), and research training (75.0%; n = 12). Average total clinical hours in CCAP varied: 500–1000 hours (12.5%; n = 2), 1000–1500 hours (37.5%; n = 6), 1500–2000 hours (25.0%; n = 4), or more than 2000 hours (25.0%; n = 4). Most postdoctoral programs (87.5%; n = 14) reported that CCAP trainees completed all postdoctoral training hours in CCAP. Details regarding training opportunities within postdoctoral programs are provided in Table 4.

Table 4.

Clinical Rotations/Experiences in CCAP Described by Postdoctoral Programs

Descriptor	n (%)
Total Number of CCAP Rotations/Experiences
1–3	4 (25.0%)
4–6	6 (37.5%)
7–9	1 (6.3%)
10+	5 (31.3%)
Number of Rotations/Experiences in CCAP Assessment
1–3	9 (56.3%)
4–5	4 (25.1%)
10–12+	2 (12.6%)
Other	1 (6.3%)
Number of Rotations/Experiences in CCAP Consultation
1–3	9 (56.3%)
4–6	3 (18.9%)
10–12+	3 (18.9%)
Variable	1 (6.3%)
Number of Rotations/Experiences in CCAP Therapy
1–4	8 (50.0%)
5–10	6 (37.5%)
10+	1 (6.3%)
Variable	1 (6.3%)

Perceptions of Gaps in Current Trainee Competencies and Skills

Doctoral program TDs most frequently endorsed the following areas in which entering students could be better trained before starting graduate school: scientific writing (69.2%; n = 27), time management (66.7%; n = 26), and research methodology (e.g., data collection, recruitment; 61.5%; n = 24). Internship program TDs perceived trainees could be better prepared in implementation of therapeutic interventions (74.3%; n = 26), implementation of psychological assessment (68.6%; n = 24), knowledge of child development (65.7%; n = 23), knowledge of psychological assessment (62.9%; n = 22), and time management (62.9%; n = 22). TDs of postdoctoral programs endorsed time management (87.5%; n = 14), working on interdisciplinary or collaborative teams (81.3%; n = 13), openness to feedback (68.8%; n = 11), knowledge of psychological assessment (62.5%; n = 10), implementation of psychological assessment (62.5%; n = 10), and case conceptualization (62.5%; n = 10) as areas for improved preparation. Gaps in current skills for recognizing and working with cultural and individual differences were also noted across doctoral (46.2%, n = 18), internship (45.7%, n = 16), and postdoctoral training (56.3%, n = 9). A full list of endorsement rates by training level can be found in Table 5.

Table 5.

Areas Child/Pediatric Psychology Students Could be Better Prepared for as Endorsed by Doctoral, Internship, and Postdoctoral Directors

	Doctoral	Internship	Postdoctoral
Scientific writing	27 (69.2%)	1 (2.9%)	3 (18.8%)
Time management	26 (66.7%)	22 (62.9%)	14 (87.5%)
Research methodology (e.g., data collection, recruitment)	24 (61.5%)	1 (2.9%)	3 (18.8%)
Critical thinking	22 (56.4%)	16 (45.7%)	6 (37.5%)
Prepared for the intensive coursework and training environment	22 (56.4%)	8 (22.9%)	5 (31.3%)
Openness to feedback	21 (53.8%)	13 (37.1%)	11 (68.8%)
Research design (e.g., developing research studies)	20 (51.3%)	2 (5.7%)	3 (18.8%)
Knowledge of child development	18 (46.2%)	23 (65.7%)	7 (43.8%)
Professionalism	18 (46.2%)	11 (31.4%)	8 (50.0%)
Considering cultural and individual differences	18 (46.2%)	16 (45.7%)	9 (56.3%)
Experience working with children, parents, and families	17 (43.6%)	18 (51.4%)	0 (0.0%)
Problem solving	17 (43.6%)	10 (28.6%)	5 (31.3%)
Working on interdisciplinary or collaborative teams	9 (23.1%)	20 (57.1%)	13 (81.3%)
Understanding of psychological theory	9 (23.1%)	11 (31.4%)	3 (18.8%)
Experience working with child-serving systems (e.g., schools)	9 (23.1%)	13 (37.1%)	0 (0.0%)
Knowledge of therapeutic interventions	5 (12.8%)	21 (60.0%)	9 (56.3%)
Implementation of therapeutic interventions	4 (10.3%)	26 (74.3%)	9 (56.3%)
Knowledge of psychological assessment	3 (7.7%)	22 (62.9%)	10 (62.5%)
Implementation of psychological assessment	3 (7.7%)	24 (68.6%)	10 (62.5%)
Experience working in clinical settings	9 (23.1%)	n/a	n/a
Experience working in medical settings	5 (12.8%)	n/a	n/a
Case conceptualization	n/a	20 (57.1%)	10 (62.5%)
Developing treatment plans	n/a	13 (37.1%)	7 (43.8%)
Knowledge of ethical and legal standards	n/a	8 (22.9%)	7 (43.8%)
Role in the supervisory relationship as a supervisee	n/a	8 (22.9%)	3 (18.8%)
Knowledge of supervision models	n/a	5 (14.3%)	3 (18.8%)
Skill and knowledge for delivery of supervision as a supervisor	n/a	5 (14.3%)	7 (43.8%)

Note: n/a = response option was not provided for level of training

Discussion

This study described the training opportunities of nearly 100 programs that offer training in CCAP and the perspectives of TDs regarding areas in which trainees could be better prepared. Our goal was to inform the development of training guidelines within CCAP. Broader training and greater variability in specialty training opportunities were observed among doctoral programs, with greater specialization during internship and postdoctoral training. Areas such as considering cultural and individual differences, understanding of child development, and knowledge and implementation of psychological assessment and intervention were noted as areas where trainees could be better prepared, including at later training stages. These results have implications for the development of training guidelines and advancing the field at large.

Reporting doctoral programs offered highly variable depth of training in CCAP, ranging from a Major Area of Study to an Exposure, while nearly all internship and all postdoctoral programs offered training consistent with a Major Area of Study. This finding reflects that postdoctoral programs are already aligned with the CCAP taxonomy’s exclusion of the Emphasis and Experience categorizations at the postdoctoral level. These results are not surprising given the time-limited nature of internship training, the ability of internship and postdoctoral sites to focus services exclusively for children and adolescents, recruitment methods for this study, and longstanding APA support for generalist training at the doctoral level and specialized training at the postdoctoral and sometimes internship level. In fact, some have suggested that broad training is preferable at the doctoral level (Katell & Adler, 2013), allowing students to develop wide-ranging competencies before moving toward specialization. However, there have been recent trends towards increased specialization at earlier stages (e.g., Ham et al., 2022), which may be even more pronounced in the CCAP specialty and warrant further examination. One significant gap in our current understanding of specialty training is empirical study of whether specialization at earlier or later stages of training results in differences in trainee outcomes, skills, preparation for entry and practice within the profession, or ability/propensity to transition across settings or populations over the course of a career. To our knowledge, there is currently no empirical literature examining the relation between trajectory of specialization or level of specialization at each stage of training and these outcomes. Future research examining trainee outcomes based on when specialization occurs is long overdue, and future work in this area should also examine whether there are differences in effectiveness of services delivered by psychologists based on training trajectory and pathway. If research were to identify these varied pathways as related to differential outcomes, there would be significant implications for CCAP training practices.

In the current context of heterogenous depth of training in CCAP at the doctoral level, we identified areas for improvement in trainee skills and competencies. This current model of varied generalist and specialty opportunities in doctoral programs may contribute to outcomes such as the high percentage of internship and postdoctoral program TDs noting trainees could have a better understanding of child development. While exposure to CCAP in doctoral training was reported across programs, this level of depth was not sufficient for optimal readiness in areas such as implementation of therapeutic interventions and psychological assessment in a CCAP internship. High variability in specialization in CCAP at the graduate level results in some trainees entering internship with significant prior experience and knowledge in CCAP, while other trainees enter internship with much less specialization. This heterogeneity puts internships in a complex situation of developing training to meet the needs of incoming trainees at varying degrees of preparation and specialization and likely requires individually tailored learning opportunities that consider the prior experiences and current competencies of each trainee.

Our results identified key knowledge and skill areas where trainees could be better prepared, suggesting specific areas to be addressed within future CCAP training guidelines. The areas endorsed tended to correspond with key training activities inherent in each training level; for example, doctoral programs voiced interest in entering students being better prepared in scientific writing and research methodology, while these areas were less frequently endorsed at the clinically-focused internship level. Information regarding gaps in trainee knowledge and skills upon entry to doctoral programs may be useful to undergraduate psychology programs and students regarding necessary experience in preparation for doctoral study. Relatedly, internship program TDs identified interest in improved trainee preparation in child-specific intervention and assessment knowledge and skills, likely reflective of internship’s emphasis on health service delivery and the variability among doctoral programs in child-focused education and training. Areas emphasized by postdoctoral program TDs differed from those reported at earlier training levels in ways that may arguably be related to the settings in which clinically-focused postdoctoral training tends to occur (e.g., interprofessional relationships), or related to the expectation (by both supervisors and postdoctoral trainees) for more advanced and independent functioning at the postdoctoral level (e.g., time management, openness to feedback). Of note, improved knowledge and skill in psychological assessment was of frequent interest to both internship and postdoctoral TDs. While research a few decades ago suggested reductions in assessment training, more recent studies have found most training programs have either maintained or increased the level of assessment training (Wright et al., 2021). The APA Board of Educational Affairs and Society for Personality Assessment recently spearheaded development of training guidelines for psychological assessment in health service psychology (Wright et al., 2021) and use of these guidelines to structure training may impact trainee competency development and better prepare trainees for the skills required at the next level of training. As competencies that differentiate doctoral-level psychologists from those trained at the master’s level continue to be delineated in the coming years, assessment may emerge as an even more central competency to ensure at the doctoral level.

The identified gaps in trainee skills are of particular importance given the current state of mental health care in the United States and the unmet need at a time of mental health crisis for youth and families. A robust and competent stream of professionals who are prepared to effectively address youth mental health needs with evidence-based and culturally competent care is sorely needed. This includes ensuring that training is modified to address these areas where trainees could further improve their knowledge and skills. To address these unmet needs, the CCAP specialty must emphasize increasing diversity among practicing psychologists, starting by expanding access to doctoral training for systemically marginalized groups. Developed training guidelines in CCAP should be equitable, accessible, and inclusive. The specialty needs to ensure that training guidelines do not create additional barriers to access to the profession by prescribing selective training experiences that may not be available and accessible.

Interestingly, postdoctoral program TDs indicated that trainees also had room to improve in critical skills when entering their final year or two of formative training. These gaps included knowledge and implementation of psychological assessment and therapeutic interventions, considering cultural and individual factors, and skill and knowledge for delivery of supervision. These competencies are central to the profession’s ability to address unmet mental health needs in our communities. This consideration is particularly critical in the context of current trends in the field of psychology to de-emphasize postdoctoral training (e.g., 18 states no longer require postdoctoral training hours for licensure). Our data suggest that trainees still have knowledge and skill areas in need of refinement at the end internship, and this appears to justify the need for postdoctoral training in the profession.

To ensure feasibility of implementation, guidelines need to be developed within the context of existing training opportunities, while also encouraging additions and modifications to address areas where students could be better prepared. We identified that specialized CCAP training is available throughout stages of training, even with programs with less depth in CCAP training opportunities. This indicates that, in our sample, programs at all stages of training had the infrastructure and expertise to provide specialty experiences to at least some extent. Training guidelines should be developed that bolster training in areas identified as needing stronger preparation for the subsequent training level. For example, given the identified desire for entering interns to be more knowledgeable about child development, doctoral programs may need to provide additional coursework in child development and developmental psychopathology to provide enhanced education on developmental milestones, child behavior, and psychopathology across the developmental spectrum.

Many areas for improvement in trainees’ skills were not specialty specific, including time management, openness to feedback, and professionalism. It is instructive to examine areas of commonality and of differentiation across levels of training. Training guidelines should include didactics on concrete time management strategies or focus on mentoring in this area as a matter of routine, rather than solely when identified problems arise. Interestingly, postdoctoral TDs had the highest percentage of observed need for improving this skill, along with improving fellow openness to feedback, which did not appear as frequently for other training levels. Both skill areas may be related to the expectation for postdoctoral fellows to manage professional responsibilities that approximate a faculty-level role and workload with greater independence.

Limitations

Findings should be considered in the context of possible selection biases among TDs who chose to respond to the survey. Programs offering training at the Exposure or Emphasis level may have been less likely to respond to a survey about CCAP training, which could account for the large proportion of TDs reporting training offerings consistent with a Major Area of Study in CCAP. We were also unable to verify that all qualifying programs were contacted to invite participation. Additionally, there may be bias in TD reporting of data. Advising programs of the intent to assess training program offerings, or collecting data in a prospective fashion, may reduce this in the future, although such an approach could also lead to observation bias and programs altering their training offerings. Additionally, given there is no singular database cataloging all graduate, internship, and postdoctoral programs offering training in CCAP and differences in available databases across stages of training, the methods for recruiting TDs at each stage of training differed substantially. Further, data only represent a description of training at a singular period of time; some programs may have changed their training experiences after data collection, and new programs may have become available. Our data are only descriptive and cannot speak to the utility or impact of specific training experiences or specialization pathways on the development of competencies in CCAP. Additionally, some questions were worded in ways that may limit the utility of the data and should be revised for future work; for example, questions regarding clinical work inquired about direct and indirect hours separately instead of total hours, a metric more commonly used for training and licensure requirements.

Future Directions and Implications

Findings of the current study should be used to inform development of training guidelines in CCAP. Clear description of recommended specialty-specific training experiences is currently lacking. While several leaders, task forces, and organizations within the specialty have provided recommendations (e.g., Palermo et al., 2014; Spirito et al., 2003), the field has since evolved, and these have represented the opinions of those individuals or individual organizations and have not been established as training guidelines across CCAP specialty constituent groups (i.e., SCCAP, SPP, ABCCAP, CCaPPTC). To address this need, the CCaPPTC, in partnership with SCCAP, SPP, and ABCCAP, has established the Steering Committee for Training Guidelines in CCAP, which is overseeing development of training guidelines by the Training Guidelines Development Task Force with a goal of establishing guidelines in 2024 (see: https://www.ccapptc.org/training-guidelines-introduction). The Training Guidelines Development Task Force is encouraged to utilize current study findings in development of training recommendations. Numerous areas where trainees could be better prepared for doctoral, internship, and postdoctoral positions were identified, which conveys a need for modification to current training experiences. Training guidelines in CCAP that provide recommendations for development in these needed areas would be valuable.

The current study was the first to use the CCAP taxonomy to classify the level of specialty training provided by programs. The intent of the CCAP taxonomy is to provide a consistent nomenclature for describing training experiences, and this has the potential to be helpful for trainees as they look to identify training opportunities fitting with their interests and needs. Adoption of use of taxonomy language to describe training programs in public program descriptions and accuracy in program classification is important. Future studies should examine the extent to which public program descriptions correspond to the training taxonomy nomenclature. An independent review of program descriptions listed by APA (https://www.apa.org/pubs/databases/gradstudy) or on programs’ websites could be compared with the programs’ respective course and training curricula to determine if the language used is consistent with the CCAP taxonomy. Inter-rater reliability of classifications and accuracy of self-reported classification could also be examined, which may be particularly relevant at the doctoral level where in our experience variation in classification occurred. Future studies should also examine any merits or pitfalls of timeframe of specialization, particularly in considering specialized doctoral programs versus generalist programs. The issue of timing of specialization may also relate to current trends regarding postdoctoral training. If shifts away from postdoctoral training continue (e.g., some states no longer requiring postdoctoral clinical hours for licensure), but a structure of generalist doctoral training followed by more specialized training in internship and postdoctoral study remains, this may result in a limited timeframe of opportunity for specialty training to occur. Research examining whether early specialization during graduate training relates to professional outcomes or development of competencies compared to trainees who specialize at later stages in training would be valuable to the field.

Conclusions

The current study provides important data regarding current CCAP training practices using the standardized nomenclature in the CCAP taxonomy and areas for further improvement in trainee knowledge and skills. The resulting description of current training programs across stages of training is essential for understanding pathways to the specialty and opportunities for better preparing psychologists for work with youth and their families.

Biographies

Cathleen Odar Stough, PhD is an Associate Professor in the Department of Psychology at the University of Cincinnati where she is Director of the Healthy Bearcat Families Lab and a faculty member in the Clinical Psychology doctoral program. She received her doctorate from the Clinical Child Psychology Program at the University of Kansas and completed her clinical internship and a T32 fellowship at Cincinnati Children’s Hospital Medical Center. Her research and professional interests are within pediatric obesity, specifically early feeding and eating behaviors, infant obesity prevention programs, addressing health disparities, and family-based health behavior interventions.

Kendra R. Parris, PhD is an Associate Member in the Department of Psychology and Biobehavioral Sciences at St. Jude Children’s Research Hospital, where she serves as the Director of Clinical Training. She received her doctorate in Clinical Psychology from Florida State University and completed a clinical internship at Children’s Hospitals and Clinics of Minnesota, followed by a postdoctoral fellowship at St. Jude Children’s Research Hospital. Her research and professional interests include the psychological adjustment of patients undergoing bone marrow transplantation, coping and adjustment of parents, and training in pediatric psychology.

Bridget K. Biggs, PhD, LP, ABPP is associate professor of psychology at Mayo Clinic in Rochester, Minnesota, USA, where she provides clinical services, supervises postdoctoral psychology fellows, and conducts clinically focused research. She served as training director of the clinical child/pediatric psychology track of the Mayo Clinic Medical Psychology Fellowship 2017–2020 and taught undergraduate and doctoral students in clinical child psychology while on faculty at the University of Kansas 2006–2009. Her research and professional interests focus on development and evaluation of behavioral interventions in clinical and community settings, interpersonal and motivational influences on health behaviors, and treatment of childhood anxiety disorders.

Angela Combs, MA is a doctoral candidate in Clinical Psychology at the University of Cincinnati, specializing in child health. She received her master’s degree in psychology at the University of Cincinnati in 2021. Her research and professional interests focus on pediatric psychology and health behaviors, specifically pediatric obesity, medication adherence, and self-management of chronic illness across the lifespan.

Mariella M. Self, PhD, ABPP is an Associate Professor of Pediatrics at Baylor College of Medicine and Texas Children’s Hospital, where she serves as Training Director of the Pediatric/Clinical Child Psychology Fellowship Program, delivers services as a pediatric psychologist, and contributes to NIH-funded reseach related to pediatric functional gastrointestinal disorders. She earned her doctorate in Clinical Psychology from Texas A&M University and completed internship and fellowship at Baylor College of Medicine/Texas Children’s Hospital. Her research and professional interests include adaptation and self-management in pediatric chronic illness, treatment of functional symptoms, pediatric bioethics, and ethical/professional issues in psychology education and training.

Mary Louise Cashel, PhD is an Associate Professor in the School of Psychological and Behavioral Sciences at Southern Illinois University, where she serves as the Training Director for the doctoral program in Clinical Psychology. Her research and professional interests focus on Brenda A. Wiens, PhD is clinical associate professor in the Department of Clinical and Health Psychology at University of Florida where she trains graduate students, predoctoral interns, and postdoctoral fellows in assessment and therapy with youth; teaches; and is a co-investigator on two longitudinal studies of brain development (ABCD, HBCD). She received her doctorate from Southern Illinois University at Carbondale and completed a clinical internship in the Department of Clinical and Health Psychology at University of Florida. Her professional interests include assessment of neurodevelopmental disorders in youth, training, and provision of services to youth in rural areas.

Martha C. Tompson, PhD is associate professor of psychology at Boston University, where she directs the Masters in Psychology program, teaches undergraduate and graduate courses, and conducts ongoing research. She received her doctorate from the University of California Los Angeles (UCLA) and completed a clinical internship in the UCLA Department of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine. Her research and professional interests include family functioning and family-based interventions for adults and youth with mood and anxiety disorders.