key: cord-0792475-pum8vm62
authors: Ghosh, Shweta; David, Jennie G; Amaro, Christina M; Gaultney, Wendy M; Schmidt, Alexandra M
title: Commentary: “How’s It Going?” Training Experiences of Pediatric Postdoctoral Fellows During COVID-19
date: 2021-01-26
journal: J Pediatr Psychol
DOI: 10.1093/jpepsy/jsaa132
sha: 7ba449bc0b537ebfa5cf05862bf730f1ef086f3c
doc_id: 792475
cord_uid: pum8vm62

The COVID-19 pandemic has impacted the lives and workplaces of individuals across the world substantially, in ways that are yet largely unknown. This commentary aims to provide an early snapshot of the experiences of pediatric postdoctoral fellows in academic medical settings; specifically, we will explore the impact of the pandemic on developing mastery within several competencies (e.g., research, professional development, clinical, interdisciplinary). These competencies are critical elements to fellowship to prepare for independent practice. Several models of training competencies for professional psychology and pediatric psychology exist, which focus on trainee skill development. Measures taken to minimize the spread of COVID-19 have directly impacted hospital systems and training, requiring programs to adapt competencies in various domains, such as increased familiarity with telehealth and virtual supervision. Additionally, fellows experienced an impact of the pandemic on securing employment following fellowship, conducting research and program development activities, and on cognitive flexibility and self-care. Governing bodies, such as the APA and Council of Chairs of Training Councils, have released statements and guidelines on addressing training of postdoctoral fellows including increasing flexibility of training methods, limiting in-person contact, and adjusting educational and licensing requirements. This paper offers informed commentary and diverse perspectives from current postdoctoral fellows engaged in a variety of clinical and research responsibilities regarding how the COVID-19 pandemic has impacted their training. We hope this paper will provide important insight into the unique experiences of postdoctoral fellows during the capstone year(s) of training prior to independent work and inform recommendations for postdoctoral training programs.

themselves in a state of emergency, and institutions rapidly made decisions regarding safety and precautionary measures, best ways to provide services to patients, and ways to balance the physical and mental health of their employees (Emanuel et al., 2020; Torales et al., 2020; World Health Organization, 2020) . Public health emergencies affect the safety, mental health, and well-being of communities (Pfefferbaum & North, 2020; Rajkumar, 2020) . Recent studies on the COVID-19 pandemic note a rise in stress, irritability, frustration, depression, and insomnia following the implementation of COVID-19 restrictions (Pfefferbaum & North, 2020) .

In the early weeks of the pandemic, pediatric psychologists were called upon by medical institutions to not only address mental health crises for patients, but also for fellow employees (APA, 2020; Bhatia et al., 2020) . Rapid public health legislation during the COVID-19 pandemic such as physical distancing measures, required face-covering, and isolation precautions became commonplace, and youth and adults found themselves isolated from their communities leading to an increase in fear, stress, and mental health concerns across the globe (Ho et al., 2020; Titov et al., 2020; World Health Organization, 2020) . Also illustrative of the increased need, the number of youth reporting hopelessness, social isolation, depression, and anxiety and presenting to emergency rooms in crisis increased during the pandemic (Bhatia et al., 2020; Liu, 2020; World Health Organization, 2020) . This led to an increased need for mental health services for youth as many received services from spaces that either paused, stopped, or closed because of the pandemic (Golberstein et al., 2020) . Many pediatric psychology training programs switched focus to support the demands for new clinical services; therefore, trainees in pediatric psychology programs adjusted their priorities in tandem to support the needs of their institutions. Additionally, hospital systems and training programs faced immense financial pressures while attempting to meet the needs of their patients and their trainees. As such, postdoctoral training adapted to provide additional clinical services, apply unique methods of service delivery (e.g., telehealth), and manage mental health and self-care needs in the midst of a global crisis.

The Association of Psychology Postdoctoral and Internship Centers and Council of Chairs of Training Counsels (CCTC) released guidelines on ways to address the training needs of trainees including reducing the number of required clinical hours, providing adequate support for self-care, flexibility in service delivery, not utilizing trainees for nonclinical roles (e.g., administrative tasks), and emphasizing the overall well-being of trainees (CCTC, 2020) . One subsection of these trainees are postdoctoral fellows who saw a significant impact of the COVID-19 pandemic on their training including difficulty meeting licensure requirements, changes in supervision and program development, and challenges gaining employment because of the economic downturn. Additionally, training programs carried a large responsibility, such that in addition to quickly and drastically adapting services and patient care, they still had to meet training requirements and trainee needs. This required significant flexibility and creativity of training programs and supervisors while also managing requirements set forth by their institutions. As a result of COVID-19, there were notable changes to training and competencies for fellows in their 2019-2021 training year.

Previous work has identified six core competencies for pediatric psychology trainees (Palermo et al., 2014) , of which this paper will broadly address the domains of clinical, research, supervision, and professional development training as well as skills unique to the pandemic such as adjustment to technology, cognitive flexibility, and self-care. These competencies are crucial to develop throughout formal training opportunities, as trainees are expected to achieve specific behavioral benchmarks as they move through training to ultimately function as ethical, autonomous, and competent pediatric psychologists. As postdoctoral fellowship serves as the last formal training experience, fellowship represents a critical learning period to hone competencies. This commentary seeks to contextualize the aforementioned competencies and the adaptations made to meet these competencies because of the COVID-19 pandemic. We further highlight the need for ongoing support and assessment of the adaptations made to meet these competencies as many postdoctoral fellows training during the pandemic move into independent practice.

Given the multifaceted impact of the COVID-19 pandemic, this commentary aims to (a) summarize the effects of the pandemic on the authors' postdoctoral fellowship training experiences, (b) highlight how the authors navigated developing critical pediatric psychology training competencies, and (c) provide insight into strategies to support pediatric psychology fellowship training in the midst of global crises.

The pandemic created challenges at the institutional level for each of the authors of this commentary, and each institution addressed the challenges in ways that affected postdoctoral training. We will briefly describe the similarities, differences, and impact on training. All the authors completed fellowships at academic health systems situated in pediatric settings. Three of the authors were housed in children's hospitals, whereas the other two worked in a mix of children's and general hospitals. The percentage of dedicated research time varied from 10% to 75% FTE. Additionally, two authors were located in the Midwest, one on the east coast, and two on the west coast. Given that these geographic areas followed different physical distancing and COVID-19 restrictions, timelines of changes varied based on where each author worked. Several hospitals implemented work from home changes in early March 2020, whereas others followed suit several weeks later. Overall, most of the programs began to implement work from home and telehealth service delivery in the second half of March. Some authors noted reductions in clinical and/ or research productivity during March as a result of the shift, while other institutions remained at normal capacity. Several institutions supported the reduction of productivity in order to provide for adequate time for training in telehealth service delivery, which was not originally part of most of these training programs. Some institutions either already had access to a telehealth delivery system or rapidly developed new systems. When authors noted concerns for equity of patients' accessibility to telehealth services, all the authors' institutions were receptive and conveyed needs to institutional leadership.

Throughout April and May 2020, the authors worked exclusively from home with the exception of two authors, one of whom provided services at the hospital 1 day/week, and the other returned full time on site in May. All hospitals implemented universal masking procedures for those returning to work, conservation of personal protective equipment, and physical distancing measures. Overall, authors noted receiving supervision and mentorship through telehealth that addressed trainees' concerns and provided social support during this challenging time; please reference Technology Supports section below for additional information on the authors' experiences. In late May, two institutions began discussing the possibility of fellows returning to in-person work. COVID-19 legislature varied amongst these institutions, such that some remained work from home, some created a hybrid in-person and telehealth model, and others required fellows to return to work in person unless they met certain criteria (e.g., being at higher risk to . Though institutions demonstrated differences in approaching COVID-19 restrictions, they generally attempted to meet the individual needs of their trainees and balance their mental health, selfcare, and educational goals.

Although technology prior to the COVID-19 pandemic played an important role in care coordination, care delivery, and documentation, the role of technology substantially increased during the pandemic. For the authors, we managed technology concerns related to access to electronic devices, access and stability of secure WiFi, and availability of telehealth services. In addition to the impact these technological considerations had on clinical care, there was also a notable impact on our competency development as fellows.

Among the authors, several had pre-existing access to institutional devices with two of us having access to only an institutionally issued laptop and one author having both an institutionally issued laptop and a cell phone. Other authors were expected to use personal devices for clinical care, either in the short-term while institutions secured and delivered devices or in the longer-term. For one author, her institution had limited available devices that had telehealth capabilities, and she used a personal device even while on campus to provide virtual care. In the interim as institutions worked toward video telehealth visits, many of the authors used personal cell phones to conduct sessions by blocking personal numbers, being connected to patients via a hospital operator, or using third-party applications such as Jabber or Doximity. Many of our institutions had evolving policies around the use of personal devices for telehealth visits, which engendered challenges as we transitioned through various ways of coordinating and delivering care.

Authors also navigated access and stability of secure WiFi in providing telehealth services. One author described working to obtain ethernet cables to connect to her hospital's VPN remotely. Another author reported occasional challenges with her home WiFi dropping service, in turn prematurely ending telehealth visits and impeding her ability to write session notes in the electronic medical record system. Authors also navigated families' access to stable and secure WiFi, as many authors experienced frozen Zoom calls and challenges in consistent audio and video during sessions.

For many of the authors, telehealth services were a novel technology. One of our authors' institutions had telehealth services prior to the COVID-19 pandemic, and, in turn, she was competent with navigating telehealth appointments. Many of our institutions were in various stages of acquiring telehealth services prior to the COVID-19 pandemic, and many worked to expedite access to these services to clinicians. For one author, she was initially provided with a corporate Zoom account and would begin sessions manually by having families join her secure Zoom "room." Several of the authors currently have access to MyChart/Epic telehealth visits, where clinicians can begin a telehealth visit on Epic and all parties are transitioned to a secure Zoom "room." One author noted challenges in the merging of clinician and family to the Zoom "room" and often needing to call families to ask them to log out and log back in to begin the session. Telehealth services provided increased access to many families, particularly families who live far from a given institution. Of note, clinicians acclimating to telehealth now needed to routinely assess where the family was physically located for billing purposes.

The role of technology during our fellowships impacted the development of competencies, including professionalism, interpersonal, and application domains (Palermo et al., 2014) and notably contributed to authors' understanding of legal and ethical issues related to telehealth services. As an example, one author who was seeing a child for ongoing telehealth had to inform the family that one session was not able to happen as the family was out of state on vacation, and services could not be provided as the supervisor was not licensed in the state the family was presently in. Interpersonal concerns, such as effective electronic communication and problem-solving realtime technology snafus, were also notably impacted by technology issues. The application competency is significant in the context of technology and the COVID-19 pandemic, as authors worked to deliver evidence-based interventions (previously trained and delivered in person) to virtual platforms. Although all authors agree on the ever-important and evolving role of technology in clinical care, technology had significant positive and challenging impacts on competency development for us as fellows.

The COVID-19 pandemic engendered various impacts on clinical training for the authors, including offerings of novel clinical trainings, adjustment to providing clinical services in unexpected settings, management of maintaining productivity and clinical services, and modifications of clinical training goals. Additionally, these authors experienced significant impacts on clinical training related to changes to receiving and providing supervision and the role of technology on clinical services; these experiences are elaborated on in sections Supervision and Technology Supports and Transition to Telehealth, respectively.

For all the authors, our institutions began holding novel clinical trainings in the context of the COVID-19 pandemic and a sudden shift to offering telehealth services. Many of the trainings revolved around effectively transitioning in-person therapeutic skills to telehealth platforms, how to navigate and use telehealth services, and changes to billing and documentation for telehealth services. Some authors received additional training perceived to be uniquely applicable to the impact of the COVID-19 pandemic, such as utilizing motivational interviewing techniques to promote COVID-19 precautions (e.g., physical distancing) and the impact on vulnerable populations (e.g., economic pressures for caregivers to continue working, limited access to secure WiFi for telehealth appointments). Notably, many authors described that these clinical trainings were also attended by faculty and often that faculty and fellows were learning in real time together.

In our collective experiences, we also noted a significant impact on clinical training as we adjusted to providing clinical services in unexpected settings. With the sudden transition to working from home, we all found ourselves trying to establish appropriate workspaces in our homes that would be secure to privately discuss patients without roommates/significant others overhearing. Further, many of us engaged in problemsolving to identify ways to gain access to resources/ handouts for both ourselves and families in our home settings.

As fellows, we all managed ongoing expectations for maintaining productivity and clinical services. Although our training directors and institutions acknowledged normative decreases across trainees' and faculty's productivity early in the transition, many of us made concerted efforts to compensate for reduced productivity, particularly in the first month of transition in March 2020. Some authors described engagement in workforces and other professional development opportunities, while others described increasing outpatient caseloads. Of note, several of the authors described a significant shift between being at 60-80% of productivity in March 2020 and then being at 110-120% of productivity in April 2020.

Authors also experienced changes to clinical training goals, ranging from diversifying patient caseloads to meet clinic needs, integrating the trainee into a new clinic, pausing of program development projects, increasing umbrella supervision, and increasing responsibilities in restructuring and piloting integrated telehealth visits. For some fellows, these changes in clinical training goals were largely aligned with the overall training program, while others described that pivoting of goals was less aligned with the overall training program and more aligned with institutional needs.

Collectively, the various impacts of the COVID-19 pandemic on these authors' training are relevant to the application competency described by Palermo et al. (2014) . The application competency comprises the core skills of a pediatric psychologist's clinical care, including evidence-based assessment, consultation, and intervention (Palermo et al., 2014) . This competency development is critical to fostering pediatric psychologists who are knowledgeable, competent, and confident in applying evidence-based care. Per COVID-19 pandemic disruptions to clinical training and care, this competency has likely been impacted for pediatric psychology fellows and will be important to continue supporting development into further fellowship training or the transition to a faculty position. Furthermore, this focus on continued development is also aligned with the field of psychology's value on continued education and learning.

Supervision is an integral component of training more broadly, including at the fellowship level, where supervisors serve as crucial gatekeepers to the public and help to socialize trainees into the profession of psychology (Falender & Shafranske, 2004) . Fellowship functions as the last step in formal training where fellows receive further guidance from supervisors as they solidify clinical and research skills, seeking additional experiences to prepare them for entry to practice as pediatric psychologists. Although being supervised, fellows also build on their own skills to perform in supervisory roles.

During the COVID-19 pandemic, core components of supervision did not change, but the format in which it took place was modified as a consequence of institutional and state policies (e.g., working from home). Authors reported meeting virtually (e.g., Zoom), by phone, and in person when on site. Scheduling supervision sometimes posed a challenge (e.g., difficulty finding a joint time to meet given shifts in schedules), and some authors reported difficulties with unexpected disruptions during supervision calls. Immediate supervision was accessible in emergent situations, though it required back and forth electronic communication to connect. Working from home also reduced opportunities for "on-the-fly" supervision and consultation with supervisors as well as other trainees, which was much more commonplace within hospital and outpatient settings because of shared spaces with others. Some authors also noted that their supervisors were able to continue observing evaluations and therapy sessions via telehealth, though this process was initially disjointed as individuals adjusted to this "new normal."

Collectively, authors reported an increase in overall support from supervisors during supervision meetings, including more frequent check-ins about fellows' selfcare and personal considerations. In many ways, these conversations were much appreciated as we navigated this novel and challenging situation, particularly as we were all adjusting to working from home. At the same time, we acknowledge the power differential that is inherent within this supervisory relationship. Perhaps at times we felt less forthcoming about answering questions about how we were doing for a variety of reasons, including weighing strategic disclosure with a need to address cases from the previous week. Similarly, it was challenging to decline additional meetings and opportunities given unclear expectations (e.g., were these requirements, truly optional, to benefit our training in a creative way). Overall, we agreed it was helpful when supervisors were compassionate and checked in about our well-being and self-care but were also open about training expectations and transparent about any changes at the division and institutional level.

To build supervisory skills, many authors reported providing umbrella supervision to residents (both psychology and medical residents) and/or psychology practicum students as an important fellowship training goal, often to be completed during the second half of the training year. All authors noted a significant reduction in their interactions with other trainees. For some authors, consequences of the COVID-19 pandemic stymied goals related to building supervision skills, as practicum programs were postponed at some institutions, for instance. Other authors continued to provide umbrella supervision when on site or through virtual interactions with trainees. Furthermore, authors continued to have didactics on supervision, which offered an opportunity to examine models of supervision and discussions on important supervision considerations. Taken together, the COVID-19 pandemic influenced competency development in the area of supervision (Palermo et al., 2014) . Although trainees likely continued to use supervision effectively to further develop skills, supervision was also a time to process aspects of the current situation. Furthermore, current fellows have a range of experiences with umbrella supervision as well as unique perspectives as a result of the current situation that will likely influence our supervisory practices in the future.

Postdoctoral training can provide increased research time to hone trainees' competencies in an area of specialty to prepare for careers in independent or collaborative research (Drotar et al., 2003) . The time dedicated to research during fellowship can vary between positions, and, for the authors of this commentary, dedicated research time ranged from 10% to 75% FTE. The impact of the COVID-19 pandemic on fellowship research training varied between the authors' fellowships depending on dedicated time to research activities and the feasibility of ongoing projects amid the pandemic.

Research training in pediatric psychology involves a variety of activities. Traditional research activities that rely on interaction with others in physical spaces (e.g., lab experiments) were most changed by the pandemic because of governmental stay-at-home orders and institutional policies. For the authors, one of the notable changes was a halt to in-person data collection at the outset of the pandemic, which was followed by substantial protocol revisions to include adequate safety measures for participants and staff to resume data collection when local and institutional policies allowed.

However, some research activities were less affected by the COVID-19 pandemic (e.g., grant applications, manuscript preparation, literature reviews) because they were more easily adapted for working from home. In fact, as noted by Stiles-Shields et al. (2020) , the pandemic offered some additional opportunities for clinical researchers in pediatric psychology to evaluate the impact of the pandemic on individuals, families and communities. The National Institutes of Health and other funding sources quickly released calls for grant submissions related to the pandemic, and several of the authors' institutions prioritized COVID-19-related research projects by offering funding for projects and/or by giving priority for IRB review. However, in some cases, COVID-19 created delays and changes to timelines for grant applications and funding dates. Some funding sources halted grant applications altogether. Because of the time-limited nature of fellowships, fellows with grant-writing goals had to adapt to uncertainties in grants and proposed projects.

Another area that was immediately impacted by the pandemic was participation in research conferences and other historically in-person events. Many of the scheduled research conferences chose to either postpone, cancel, or move to an online format. These changes affected networking opportunities as well as opportunities to hone skills in dissemination (Palermo et al., 2014) .

The current pandemic also made an impact on professional development in areas such as program development, multidisciplinary collaboration, and didactic opportunities. Furthermore, authors also noted challenges related to hiring freezes and completing licensure requirements. The impacts of COVID-19 on the professional development competencies in readiness for entry into practice are aligned with the competencies of professionalism and interpersonal domains outlined by Palermo et al. (2014) . These competencies refer to a pediatric psychologist's ability to maintain professional values and attitudes, knowledge of diversity, and ethical and legal standards; lead interprofessional teams; promote effective relationships amongst teams; and participate in continuing education in pediatric psychology. Given the abrupt changes related to COVID-19, it is likely that these two competency areas were impacted for pediatric psychology fellows.

Authors noted changes in program development opportunities at their respective institutions.

Postdoctoral fellows who were part of creating new pediatric psychology programs (e.g., practicum or new service line delivery) found those on hold or postponed for the next academic year. Additionally, given the constraints of telehealth, authors who worked as part of multidisciplinary teams found it difficult to participate in comprehensive team meetings, patient visits, and follow-up care. Some authors described the limitations in building rapport with multidisciplinary team members with the lack of shared physical space while providers worked from home/virtually. Other authors noted challenges in scheduling co-visits with medical teams and glitches in telehealth appointments. These authors also described changes in didactic trainings or development opportunities such as attending rounds, reduced number of education opportunities (e.g., didactics, seminars, lectures), and reduced capacity to participate in advocacy of pediatric psychology services.

We also noted one significant impact of the COVID-19 pandemic on obtaining employment and completing licensure requirements. Because of restrictions related to the pandemic, authors reported delays in applying for licensure, approval to take the EPPP, and finding open testing centers to take licensing exams. Additionally, as noted in the Clinical Training section of this article, there were a reduced number of clinical hours, and some fellows found it difficult to obtain the number of clinical hours necessary to take the EPPP or get approved for licensure. Some authors also noted marked challenges in obtaining employment, as many pediatric institutions instated hiring freezes forcing fellows to consider alternative options such as taking another fellowship year, waiting to apply to open positions, or applying to jobs that were not aligned with their career goals adding to the uncertainty of the upcoming 2020-2021 year.

Despite the challenges presented by the COVID-19 pandemic on professional development, authors demonstrated novel approaches to obtaining experiences to meet training competencies in this domain. Some authors participated in trainings with other medical teams, sought out other program development opportunities (e.g., participating in curriculum development for the training program), participated in virtual webinar series on career development, and grew through problem-solving telehealth challenges on multidisciplinary teams.

Cognitive flexibility has been the crux of successful adaptation of many who are navigating the COVID-19 pandemic, as well as acceptance that the only constant during the COVID-19 pandemic is inconsistency. From changes in provider workflows, fluctuations in patient needs, and changing requirements for patient care, the authors recognize that cognitive flexibility-though not formally a competency-moved to the forefront as a necessary skill imperative to continue development of formal competencies and grew immensely throughout the pandemic. Factors that facilitated cognitive flexibility included transparency from supervisors when weighing out mandates of the state and institution with fellow needs, bidirectional communication about concerns between fellows and supervisors, and supervisor support of the fellow engaging in self-care.

Self-care is a crucial domain in the competency of Professionalism outlined by Palermo et al. (2014) and was significantly impacted throughout the many stages and changes associated with the COVID-19 pandemic. As described previously, all authors experienced a sudden transition to working from home; this shift blurred the line physically between work life and home life, and fellows who had limited space in their living environments or shared spaces with others carried the added stressor of negotiating and advocating for private workspaces for patient care. These lines also became blurred for social and emotional functioning. On a personal level, authors were impacted by concerns for safety related to personal chronic medical conditions, fears for safety of their loved ones, physical distance from support systems as a result of one to several moves for clinical training, and challenges acquiring goods for day-to-day living. On a professional level, authors were impacted by changes in their training, increased stress in the training environment, and added hurdles to licensing and acquiring employment following fellowship.

The authors described a variety of experiences related to the ability to engage in self-care and support that were offered by institutions and supervisors. Regarding personal health and safety, all institutions implemented workflows for precautions and physical distancing. Authors at institutions that quickly moved to remote work, laid out slow and careful processes for reintegration of on-site services, and supported fellow decisions to work off site experienced less stress related to personal safety. Fluctuation in caseloads also impacted self-care and overall well-being of fellows. With the need to learn a new venue through which to provide services, a decrease in patient caseload supported the ability to place appropriate effort into learning telehealth. However, most fellows engaging in clinical work experienced an overall increase in client loads and weekly sessions in the months of April, May, and June from caseloads pre-COVID because of administration efforts to "make up" lost visits. Authors reported overall better well-being when caseloads returned to prepandemic levels rather than a higher than initial caseload and when supervisors checked in with fellows about management of caseload.

Regarding supports, all institutions provided general psychosocial supports for employees including wellness activities and access to psychotherapeutic services; however, only one author engaged in formal supports (e.g., several free therapy sessions). All the authors received check-ins from supervisors, as well as other group supports such as virtual happy hours, trainee peer-support groups, book clubs, etc. However, with the amount of screen time required for adapting to fellowship demands, such as seeing patients and engaging in meetings and supervision, coupled with the adjustment to personal social interactions limited to video, supports offered in the form of a virtual forum were not always an effective selfcare activity.

Overall, authors felt that supervisor check-ins about self-care were a critical component to feeling supported as a postdoctoral fellow. In particular, recognition of the impact of the pandemic across a broad range of personal life issues as well as work was valuable. Of note, none of the authors accessed formal supports provided through their institutions, and future exploration of this may be beneficial.

Reflecting on our experiences during the COVID-19 pandemic, we identified several shared experiences (e.g., changes in professional development opportunities) and some notable differences (e.g., various exposure to telehealth prior to the pandemic). We also acknowledge the value of growing in self-compassion, noting that there are days when we are present and able to be productive; however, there are other times when we need to take more breaks than we are accustomed to. As such, cognitive flexibility and self-care remain vital. Notably, the competency of self-care should be emphasized throughout graduate and fellowship training, and work by Callan et al. (2020) may be informative for program directors. Collectively, we also agreed that open communication with supervisors during the fluctuating situation was beneficial. As the pandemic is likely to be ongoing for some time, it would be beneficial to regularly check in with fellows and reevaluate strategies to support pediatric psychology fellowship training, while being mindful of the inherent power differential in these relationships. In addition to describing the experiences of the authors' training during the COVID-19 pandemic, this commentary also sought to provide insights on strategies to ameliorate the training experience during unexpected crises. Recommendations and examples can be found summarized in Table I . We hope these recommendations can serve as a starting point and should be tailored by programs to meet the unique needs of their training programs.

Although this commentary provides the perspectives of a few pediatric psychology postdoctoral fellows in various settings at different institutions, it cannot describe the full range of experiences of current postdoctoral fellows. For example, none of the authors engaged in assessment as part of their fellowship training. As such, it will be important to conduct empirical studies to gain a broader understanding of the impact of the COVID-19 pandemic on pediatric psychology postdoctoral training. In addition to a focus on training, other potential affected areas, such as financial strain and personal hardships, should be examined. It will also be important to hear from a range of postdoctoral students, including fellows who are parents and those with caregiving responsibilities. Taking a social-ecological approach, understanding perspectives at the supervisory, division, and institutional level would be beneficial. Furthermore, the current commentary focused on the COVID-19 pandemic only and did not address the co-occurring unveiling of racism, as a separate commentary could be dedicated to this topic. It is critical that future studies address the impact of this co-occurring stressor on postdoctoral fellows and training.

As we each continue our journey within pediatric psychology, with some starting faculty positions and others continuing fellowship, this shared experience has helped us to place a greater emphasis on cognitive flexibility and self-care. These skills have been imperative in balancing various professional and personal demands as well as the significant ongoing uncertainty. Although there have been a variety of hardships during the pandemic, the current situation has also sparked creative training and professional development opportunities over the past few months, which uniquely contributed to our training and will undoubtedly have an impact on our practice and research within pediatric psychology.

Conflicts of interest: None declared. Determine what devices/technological support trainees need to perform their responsibilities securely for improved planning Identify availability of computer and phone/webcams, assess trainee comfort with telehealth and access to secure WiFi, review legal/ethical considerations (e.g., safety concerns) Clinical training

Monitor trainee productivity and potentially adjust expectations for sustainable productivity Discuss caseload at supervision sessions and collaboratively problem-solve ways to balance productivity with other domains (e.g., professional development, self-care) Professional development Proactively identify professional development opportunities that can be versatile to in-person or virtual settings may help to reduce barriers Create a list of professional development opportunities for trainees to review and choose, including formal (e.g., webinars) and informal (e.g., virtual coffee chat) options; engage in collaborative conversations with trainees about opportunities Supervision

Engage in ongoing adjustment of supervision needs for support and fostering of competencies as supervisors and fellows alike navigate crises Engage in monthly assessment of supervision needs from the supervisor and supervisee perspective and adjust as needed Cognitive flexibility and self-care

Provide ongoing efforts to protect trainee time for self-care to optimize trainee wellness

Offer 1 day/week where the trainee can flex their start or end time (i.e., begin the work day an hour late or end work an hour early), provide didactics on well-being and self-care

Connecting with children and adolescents via telehealth during COVID-19

How to talk to your anxious child or teen about coronavirus

Training future psychologists to be competent in self-care: A systematic review. Training and Education in Professional Psychology

Statement on education and training considerations during COVID -19 pandemic

Recommendations for the training of pediatric psychologists: Implications for postdoctoral training

Fair allocation of scarce medical resources in the time of Covid-19

Clinical supervision: A competency-based approach

Coronavirus disease 2019 (COVID-19) and mental health for children and adolescents

Mental health strategies to combat the psychological impact of COVID-19 beyond paranoia and panic

Mental health considerations for children quarantined because of COVID-19. The Lancet

Recommendations for training in pediatric psychology: Defining core competencies across training levels

Mental health and the Covid-19 pandemic

COVID-19 and mental health: A review of the existing literature

Considerations and future directions for conducting clinical research with pediatric populations during the COVID-19 pandemic

Rapid report: Early demand, profiles and concerns of mental health users during the coronavirus (COVID-19) pandemic

The outbreak of COVID-19 coronavirus and its impact on global mental health

Mental health and psychosocial considerations during the COVID-19 outbreak