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The WHO Independent High-Level Commission on noncommunicable diseases  emphasized critical need for prevention and treatment of mental disorders in recent years. This as an integral part of measures related to the so-called noncommunicable diseases (NCDs). Mental disorders are significant part of socially important diseases. Depression alone as a leading cause of disability globally affects more than 264 million people worldwide . Importantly, about a quarter of the world's population are children and adolescents under 15 years old, and about 40% are young people under 25 years old . According to the WHO data, 10 — 20% of the world's child population suffers from mental disorders. Recent European studies revealed these diseases in 14–23% of people depending on age and gender . It is believed that about half of all mental illnesses first appear until 14 years old , and three quarters until 20 years old . Mental disorders are highly likely to be transformed into more severe registers of mental diseases without adequate treatment . The above-mentioned data, as well as obvious preventive trend of modern medicine bring to the fore those objectives of physical and mental health protection which are primarily related to pediatrics and child psychiatry.
The problem of deficit of qualified specialists in child and adolescent psychiatry
Despite the great need for qualified specialists in child and adolescent psychiatry, there is a significant shortage of these physicians in most countries of the world [8-16]. This is especially true for African countries. There is not even information about the number of specialists for most countries in this region. According to available data, there are only 3 psychiatrists in Uganda [17, 18]. In the Middle East, the number of psychiatrists ranged from 12 (in the UAE) to 3,082 (in Egypt) . The number of qualified child/adolescent psychiatrists in the Far East ranged from 1 in Brunei to 13,534 in Japan. Importantly, there is no specialty "child/adolescent psychiatrist" in Japan. It is believed that "most qualified psychiatrists" are able to deal with the issues of mental health in children and adolescents . The countries of Latin America have similar indicators: there are about 365 psychiatrists in Mexico who have the right to provide psychiatric care for children and adolescents , 468 child psychiatrists in Brazil (with large number of psychologists), i. e. 31.8 per 100,000 [21, 22], about 500 specialists for child and adolescent psychiatry in Argentina. There are about 356 specialists for child psychiatry in Chile .
According to available data, there are 18 child psychiatrists in Hong Kong (2.5 per 1000000), 16 specialists in Malaysia (0.5 per 1000000), 13 specialists in Singapore (2.8 per 1000000) .
According to the American Academy of Child and Adolescent Psychiatry, there are approximately 8,300 specialists for child and adolescent psychiatry in the United States. Moreover, over 15 million children and adolescents require a specialized care. Despite available medical care, there is a gap between clinical manifestation and medical care up to 8-10 years. Moreover, this gap often occurs within in the most critical years of development in a child's life. It is well known that prolonged period between the onset of symptoms and initiation of treatment is followed by more difficult and expensive management of mental illness. This process significantly increases expenses in health care system. The lack of specialists is considered to be one of the reasons for these problems .
According to the report “Child and adolescent psychiatry: meeting future workforce needs” prepared by the Royal Australian and New Zealand College of Psychiatrists, there are 1.6 and 1.0 specialists per 100000 children in these countries, respectively .
According to the European Health Information Gateway, availability of child psychiatrists is highly variable in the countries of the WHO Regional Office for Europe. For example, there are 41 psychiatrists per 100 000 children in Finland, 101 per 100 thousand in Estonia, 55 per 100 thousand in Switzerland. At the same time, there are 23 psychiatrists per 100 thousand children in Sweden, 2 per 100 thousand in Denmark and 18 specialists per 100 thousand in Austria and Germany. There is only 1 specialist per 100 000 children in Azerbaijan, Kyrgyzstan, Turkmenistan and the Czech Republic. In Tajikistan, there are no child psychiatrists at all .
Thus, there is an obvious shortage of highly qualified specialists for child and adolescent psychiatry in most countries of the world including developed and developing ones.
In Russia, 1,368 psychiatrists provided psychiatric care to children in 2015. Multiple jobholding rate was 1.56 . According to official statistics , the total number of child psychiatrists (0-14 years old) and district child psychiatrists has decreased in recent years (2017 — 2018) from 1394 to 1370 and from 743 to 724, respectively. There are no child psychiatrists at all in 3 Russian regions (the Nenets Autonomous Area, the Chechen Republic and the Jewish Autonomous Area). One child psychiatrist works in the Kaluga Region, the Karachay-Cherkess Republic and the Altai Republic. The situation with adolescent psychiatrists (15-17 years old) is even worse. In 2018, there were 115 specialists in Russia including 70 district adolescent psychiatrists . In 2018, mean number of adolescent psychiatrists was 0.28 per 10 000 adolescents. There are no adolescent psychiatrists at all in 28 subjects of the Russian Federation.
Training of specialists for child and adolescent psychiatry around the world
Child and adolescent psychiatry is not recognized as an independent specialty in all countries. Therefore, there are significant differences in programs for training of highly qualified specialists in different countries of the world. For example, there are no own programs for training of specialists in the majority of African countries and certain programs are only occasionally realized with participation of the invited specialists, as a rule, from European countries or the United States [18, 29].
Study programs differ significantly from each other in Latin American countries. For example, there are no uniform programs in Brazil . In Argentina, education lasts for 3 or 4 years and obligatory includes pediatrics (6-month course) and pediatric neurology (3-month course). At the same time, various programs include such mandatory parts as scientific work, psychotherapy (mainly cognitive-behavioral and family) . In Chile, duration of education is 3 years. The first and the third years imply practice in child and adolescent psychiatry hospitals. The second year is divided into 3 cycles: 4 months — in-hospital adult psychiatry, 4 months — outpatient adult psychiatry, 4 months — neurology .
In India, child and adolescent psychiatry is recognized as a "super specialty of psychiatry", i.e. "subspecialty". A 3-year doctorate includes a special training program designed for 1-2 years. According to this program, any specialist should complete study of general psychiatry and then specialize in child and adolescent psychiatry. At the same time, doctorate is necessary if a specialist plans to engage in research and / or pedagogy . In Malaysia, child and adolescent psychiatry is similarly recognized as a subspecialty, and the specialist must complete an 18-month education .
Total duration of training program for psychiatry in the Middle East ranged from 3 to 5 years (Oman, Lebanon, Jordan, Kuwait). In some countries, the educational program for child psychiatry (3 — 6 months) is included into general curriculum. No data on training for child psychiatry in Qatar and Syria were reported .
Child and adolescent psychiatry is recognized as a separate specialty in 12 out of 17 countries of the Far East region. Mean duration of education for psychiatry is 36 months (from 12 months in Mongolia to 72 months in Hong Kong). In the last one, specialist can focus on child and adolescent psychiatry within the specialty "psychiatry" lasting 6 years . Child and adolescent psychiatry was introduced into curriculum in 12 out of 17 countries. Mean duration of training for child and adolescent psychiatry as a part of general course is 3 months (from 2 to 6 months in different countries). Postgraduate educational program for child and adolescent psychiatry is available in 10 countries of this region. Mean duration is 30 months (range 12 — 48). At the same time, only 4 countries have a National Program for training of these specialists . In Japan, child psychiatry is a subspecialty of psychiatry and pediatrics . To date, there is no standardized training program for child and adolescent psychiatrists in Japan, since each university’s hospital develops own curriculum. Therefore, education program and clinical experience differ in various hospitals. There are several professional communities in child and adolescent psychiatry that have their own certification systems for specialists: the Japanese Society for Child and Adolescent Psychiatry (JSCAP), the Japanese Society for Adolescent Psychiatry (JSAP), the Japanese Society of Child Psychiatry and Neurology (JSPPN) and the Japanese Society of Psychosomatic Pediatrics (JSPP). For example, the JSCAP certification requirements include: more than 5-year clinical experience including over 2 years in general psychiatry and over 3 years in child and adolescent psychiatry. At the same time, the authors emphasize a serious shortage of specialists for child and adolescent psychiatry in Japan. One of their conclusions is statement about the need for a standardized educational system for these specialists .
Educational programs for child and adolescent psychiatry in Australia and New Zealand, the United States, Canada and European countries are the most structured.
In Australia and New Zealand, the student can choose certain specialization including child and adolescent psychiatry after 3-year training in general psychiatry . In general, the training program consists of 3 stages. At the first stage, education for general psychiatry lasts 12 months. At least 6 months are spent in a hospital for experience in the treatment of acute conditions. The second 24-month stage includes practical training with several "cycles": at least 6 months of outpatient consultations, at least 6 months in child and adolescent psychiatry and 2 cycles by 6 months for additional specialties (narcology, forensic psychiatry, adult psychiatry, gerontopsychiatry, ethnocultural psychiatry, child and adolescent psychiatry). The third stage lasts 24 months and consists of 4 "cycles" by 6 months (narcology, forensic psychiatry, adult psychiatry, gerontopsychiatry, ethnocultural psychiatry, child and adolescent psychiatry, research work, psychotherapy). It is possible to go through several cycles within the same direction. At the same time, if one chose child and adolescent psychiatry, at least 6-month practice in inpatient and outpatient departments is required. Unlike some European countries, this program does not include hours of practice in pediatric neurology .
In the United States, child and adolescent psychiatry is accepted as a separate specialty. There are various systematic training programs for this specialty including traditional training programs (3 years of general psychiatry and 2 years of child and adolescent psychiatry), complex training programs (5 years of general, child and adolescent psychiatry at the same time), 3-course programs (2 years of pediatrics, 1.5 years of general psychiatry and 1.5 years of child and adolescent psychiatry), as well as postgraduate programs for pediatricians (3 years of general psychiatry, child and adolescent psychiatry after pediatrics residency) . According to the Accreditation Council for Graduate Medical Education (ACGME) , all curricula for child and adolescent psychiatry should include education and assessment of the main fields (patient care, medical knowledge, hands-on learning and development, interpersonal communication, professionalism and systemic practice) .
In Canada, educational program for child and adolescent psychiatry lasts 6 years. The first 4 years are devoted to general psychiatry. Next, the student can choose a 2-year specialization in child and adolescent psychiatry after entrance exam. A 24-month program includes in-hospital internship (at least 6 months), outpatient training (at least 6 months), work with difficult patients under supervision of an experienced specialist (at least 6 months) and emergency psychiatric care for children and adolescents (at least 1 month). Outpatient training should include practice at least in 3 hospitals (at least 1 month in each one): polyclinic, day hospital and consultations in the pediatric service (inpatient or outpatient). Moreover, the resident should take part in medical care at home, group trainings and family health teams. Students can choose the courses (at least 1 month) in adolescent psychiatry, narcology, forensic psychiatry, neurology, pediatrics, etc., as well as gain experience in scientific work, healthcare organization, pedagogy, etc. After 4-year education for general psychiatry according to the programs accredited by the Royal College, successful completion of 2-year training in child and adolescent psychiatry and scientific work, any specialist can pass an exam and receive a certificate in child and adolescent psychiatry [36-38].
In European countries, there are 3 main models of training in child and adolescent psychiatry. The first one involves education in general psychiatry with possible specializations that are not the same (5 out of 33 countries). This group includes, in particular, Spain, although separation of adult and child/adolescent psychiatry was initiated in this country . The second model implies a complete differentiation of specialties. Therefore, students undergo a specialized training after basic medical education. This model is implemented in 15 countries. The third model consists of training in general psychiatry and subsequent specialization that prolongs training period (5 countries) .
The European Society for Child and Adolescent Psychiatry and the European Federation of Psychiatric Trainees (EFPT) are the leading organizations addressing the issues of training and promoting child psychiatry in Europe . Duration of training ranges from 12 to 96 months (mean 59.71 months). The curricula for these specialists are different in various countries. In some countries, curricula include pediatrics, pediatric neurology (compulsory in 13 countries), endocrinology, neurosurgery (Romania), otorhinolaryngology and ophthalmology (Serbia and Montenegro). Psychotherapy training is compulsory in 19 of the 28 countries surveyed . In 2012, M. Simmons et al.  questioned representatives of 28 out of 34 European countries regarding organization of training in child and adolescent psychiatry. According to their data, trainees in child and adolescent psychiatry have basic training in general psychiatry in 7 out of 28 countries (25%) (similar to adult psychiatrists). In 8 countries, scientific work is also required to complete training in this specialty.
Considering certain differences of educational pathways in different European countries , the European Union of Medical Specialists (UEMS) develops a standard curriculum in child and adolescent psychiatry. The last one includes at least 3-year study, certain basic competencies, as well as the process of approval and audit by government structures responsible for education and training . Thus, we can emphasize higher number of common features in teaching for child and adolescent psychiatry in Europe despite certain differences .
Training of specialists for child and adolescent psychiatry in Russia
Child psychiatry was excluded from the nomenclature of medical specialties in Russia after 1995. Insufficient attention to the issues of child psychiatry is observed during university education. Indeed, even training of pediatricians in this specialty is based on priority of adult psychiatry. It is largely due to the limited number of hours allocated for this specialty (psychiatry). Child psychiatry is usually taught to students as “features” of diagnosis and treatment of mental disorders in childhood and adolescence compared to adult psychiatry as a “gold standard”. Thus, child psychiatry finds itself on the background of educational process (“in the shadow” of adult psychiatry). At the same time, some experts believe that child psychiatry "is more difficult for diagnosis and prediction, as well as more unstable" .
According to the official website of the Ministry of Health of the Russian Federation, certain educational proposals for child psychiatry are stated only by 18 institutions among 3 specialized scientific institutions and 51 institutions of higher professional education. As a rule, these proposals are related to postgraduate professional education or advanced trainings. Thus, only one-third (33.3%) of the above-mentioned specialized institutions of our country ensure professional training of specialists for child psychiatry in one way or another. If we consider only federal state-funded educational institutions, this value is even less than a third (31.4%). Moreover, there is currently only one specialized department of child psychiatry and psychotherapy in the Russian Medical Academy of Postgraduate Education. The Department of Child Psychiatry, Psychotherapy and Medical Psychology (under the leadership of professor E.G. Eidemiller) functioned in the St. Petersburg Medical Academy of Postgraduate Education until 2011. Later, some employees of this department began to work at the Department of Psychotherapy, Medical Psychology and Sexology of the Mechnikov North-Western State Medical University.
A total of 40 cycles in postgraduate professional education system are devoted to child psychiatry in all accredited institutions of higher professional education in the Russian Federation. Most of these cycles are spent every 6 months (i.e. twice a year). Thus, the total number of cycles for child psychiatry actually conducted throughout the Russian Federation ranges from 70 to 80 annually. Of these, the cycles containing the most complete data on child psychiatry make up only 25% (10 cycles). Duration of 7 cycles is 144 hours, 1 cycle — 72 hours and 2 cycles — 36 hours (within postgraduate professional education). Overall duration of these cycles is 1152 hours. In addition, 6 cycles devoted to actual issues of child psychiatry are conducted. Only one of them lasts 144 hours, 2 cycles — 72 hours, other cycles — 36 and 18 hours (2 + 1). Overall duration of all cycles is 378 hours. Five cycles are primarily devoted to age features of mental disorders. Duration of 1 of these cycles is 216 hours, 3 cycles — 72 hours, 1 cycle — 36 hours (within postgraduate professional education). Overall duration of these cycles is 468 hours. A total of 9 cycles are devoted to child psychiatry and clinical psychology. Duration of these cycles is 144 (n=2), 72 (n=3) and 36 hours, respectively (4 within postgraduate professional education). Overall duration is 648 hours. Only one specialized cycle for child and adolescent addictology (within postgraduate professional education) lasts 36 hours. There are significantly more different cycles for child and adolescent psychotherapy (n=7) with various duration (144 hours (n=3), 72 hours (n=2) and 36 hours (n=2)). Overall duration is 648 hours. There are only 2 cycles for pediatric neuropsychiatry by 144 and 36 hours (clinical epileptology of childhood, within postgraduate professional education). Overall duration is 180 hours. Thus, a total of 3510 hours are devoted to child psychiatry in our country.
In some institutions of higher professional education of the Russian Federation, child psychiatry is taught at the stage of undergraduate education. For example, it is "optional discipline" within the residency program for psychiatry (Izhevsk State Medical Academy) or thematic course "Addictive and behavioral disorders in children and adolescents" within the same program (Kuban State Medical University). Moreover, there is a module on autism spectrum disorders in the database of electronic educational modules of the Pirogov Russian National Research Medical University.
Thus, training of highly qualified specialists for child and adolescent psychiatry differs significantly not only in different parts of the world, but also in different countries of the same region. Duration of training, as well as training systems and programs vary greatly. The most structured and completed programs including assessment and audit system are presented in European countries, the USA and Canada, Argentina, Chile, Australia and New Zealand. Overall "educational potential" in child psychiatry and current educational system for this discipline are insufficient in Russia compared to the majority of other countries. We have to agree with the opinion of most national experts that the main negative effect is associated with liquidation of child psychiatry as a specialty in 1995. In this regard, the reforms of higher professional education for child psychiatry should be based on the earliest changes in national legislation and establishing the official status of this medical specialty. It is necessary for improvement of child and adolescent psychiatry in the Russian Federation.
The authors declare no conflicts of interest.