australia), in that trainees must generally demonstrate competency in general adult psychiatry prior to commencing sub-speciality training. certification and continuing education in the us, having completed the child and adolescent psychiatry residency, the child and adolescent psychiatrist is eligible to take the additional certification examination in the subspecialty of child and adolescent psychiatry from the american board of psychiatry and neurology (abpn) or the american osteopathic board of neurology and psychiatry (aobnp). although the abpn and aobnp examinations are not required for practice, they are a further assurance that the child and adolescent psychiatrist with these certifications can be expected to diagnose and treat all psychiatric conditions in patients of any age competently. training requirements are listed on the web site of the american academy of child & adolescent psychiatry. shortage of child and adolescent psychiatrists in the united states the demand for child and adolescent psychiatrists continues to far outstrip the supply worldwide. there is also a severe maldistribution of child and adolescent psychiatrists, especially in rural and poor, urban areas where access is significantly reduced. as of 2016, there are 7991 child and adolescent psychiatrists in the united states. a report by the us bureau of health professions (2000) projected a need by the year 2020 for 12,624 child and adolescent psychiatrists, but a supply of only 8,312. in its 1998 report, the center for mental health services estimated that 9-13% of 9- to 17-year-olds had serious emotional disturbances, and 5-9% had extreme functional impairments. in 1999, however, the surgeon general reported that "there is a dearth of child psychiatrists." only 20% of emotionally disturbed children and adolescents received any mental health treatment, a small percentage of which was performed by child and adolescent psychiatrists. furthermore, the us bureau of health professions projects that the demand for child and adolescent psychiatry services will increase by 100% between 1995 and 2020. cross-cultural considerations steady growth in migration of immigrants to higher-income regions and countries has contributed to the growth and interest in cross-cultural psychiatry. families of immigrants whose child has a psychiatric illness must come to understand the disorder while navigating an unfamiliar health care system. criticisms subjective diagnoses one criticism against psychiatry is that psychiatric diagnoses lack complete "objectivity," particularly when compared with diagnoses in other medical specialties. however, for several major psychiatric disorders interrater reliability, which shows the degree to which psychiatrists agree on the diagnosis, is generally similar to those in other medical specialties. in 2013, allen frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests." traditional deficit and disease models of child psychiatry have been criticized as rooted in the medical model which conceptualizes adjustment problems in terms of disease states. it is said by these critics that these normative models explicitly characterize problematic behavior as representing a disorder within the child or young person and these commentators assert that the role of environmental influences on behavior has become increasingly neglected, leading to a decrease in the popularity of, for example, family therapy. there are criticisms of the medical model approach from within and without the psychiatric profession (see references): it is said to neglect the role of environmental, family, and cultural influences, to discount the psychological meaning of behavior and symptoms, to promote a view of the "patient" as dependent and needing to be cured or cared for and therefore undermines a sense of personal responsibility for conduct and behavior, to promote a normative conception based on adaptation to the norms of society (the ill person must adapt to society), and to be based on the shaky foundations of reliance on a classificatory system that has been shown to have problems of validity and reliability (boorse, 1976; jensen, 2003; sadler et al. 1994; timimi, 2006). prescription of psychotropic medications since the late 1990s, use of psychiatric medication has become increasingly common for children and adolescents. in 2004 the u.s. food and drug administration (fda) issued the black box warning on antidepressant prescriptions to alert patients of a research link between use of medication and apparent increased risk of suicidal thoughts, hostility, and agitation in pediatric patients. the most common diagnoses for which children receive psychiatric medication are adhd, odd, and conduct disorder. some research suggests that children and adolescents are sometimes given antipsychotic drugs as a first-line treatment for mental health problems or behavioral issues other than a psychotic disorder. in the united states, the usage of these drugs in young people has greatly increased since 2000, especially among children from low-income families. more research is needed to specifically assess the efficacy and tolerability of antipsychotic medications in pediatric populations. because of the risk of metabolic syndrome and cardiovascular events with long-term antipsychotic use, use in pediatric populations is highly scrutinized and recommended in combination with psychotherapy and effective parent-training interventions. electroconvulsive therapy in 1947, child neuropsychiatrist lauretta bender published a study on 98 children aged between four and eleven years old who had been treated in the previous five years with intensive courses of electroconvulsive therapy (ect). these children received ect daily for a typical course of approximately twenty treatments. this formed part of an experimental trend amongst a cadre of psychiatrists to explore the therapeutic impact of intensive regimes of ect, which is also known as either regressive ect or annihilation therapy. in the 1950s bender abandoned ect as a therapeutic practice for the treatment of children. in the same decade the results of her published work on the use of ect in children was discredited after a study showing that the condition of the children so treated had either not improved or deteriorated. commenting on his experience as part of bender's therapeutic program, ted chabasinski said that, "it really made a mess of me ... i went from being a shy kid who read a lot to a terrified kid who cried all the time." following his treatment, he spent ten years as an inmate of rockland state hospital, a psychiatric facility now known as the rockland psychiatric center.