The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care

Definitions and Scope

The term “mental” throughout this statement is intended to encompass “behavioral,” “neurodevelopmental,” “psychiatric,” “psychological,” “emotional,” and “substance abuse,” as well as family context^1–6 and community-related concerns such as child abuse and neglect, separation or divorce of parents, domestic violence, parental or family mental health issues, natural disasters, school crises, military deployment of children's loved ones, and the grief and loss accompanying any of these issues or the illness or death of family members. The term also encompasses somatic manifestations of mental health issues, such as eating disorders and functional gastrointestinal symptoms. This is not to suggest that the full range or severity of all mental health problems falls within the scope of pediatric primary care practice but, rather, that children and adolescents may suffer from the full range and severity of mental health conditions and psychosocial stressors. As such, children with mental health needs, similar to children with special physical and developmental needs, are children for whom pediatricians, family physicians, pediatric nurse practitioners, and physician assistants provide a medical home.⁷

The Diagnostic and Statistical Manual for Primary Care (DSM-PC) classification system⁸ distinguishes between developmental variations (behaviors that may raise concern but are within the range of expected behaviors for the age of the child), problems (behaviors serious enough to disrupt functioning but not to a level severe enough to warrant the diagnosis of a disorder), and disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV]⁹). Because the PCC has a role in providing reassurance and/or care for children with behaviors in each of these categories, all fall within the scope of this document. Authors have used the term “concerns” when referring to behavioral issues not differentiated into 1 of these categories.

Many PCCs engage in mental health screening, assessment, diagnosis, and treatment. The term “mental health specialists” is intended to distinguish PCCs from those who specialize in the assessment and care of children and adolescents with mental health concerns. Thus, the term “mental health specialists,” as used in this report, includes physicians and nonphysicians such as psychiatrists, clinical psychologists, clinical social workers, licensed professional substance abuse counselors, nurses with advanced psychiatric training, family therapists, neurologists, early intervention specialists, developmental-behavioral pediatricians, and adolescent medicine specialists. Each of these disciplines has specific training and licensing requirements. Other individuals outside the mental health profession who have an effect on the mental health of children include teachers, counselors, coaches, religious leaders, and community and extended family members. Providers of complementary and alternative (integrative) medicine (CAM), both licensed and unlicensed, also may address children's mental health, and a large number of families self-select CAM treatments for their children's mental health conditions.^10–14 A growing body of literature describes the potential benefits of CAM approaches^15–17 and risks of CAM therapies, including interactions of herbal remedies and dietary supplements with prescription medications.^18,19 Although 1 randomized, controlled trial of St John's wort was conducted with adolescents with depression,^20,21 most studies of herbal medication for mental health disorders have been completed in adults. These developments underscore the importance of knowing the medical evidence and considering CAM therapies and CAM providers in the context of pediatric mental health care.

Need for Statement

The need for this statement was driven by the following forces:

• the recognition that adverse psychosocial experiences in childhood have lifelong adverse effects on mental and physical health and on psychosocial status^22–25;

• the high prevalence of mental health disorders and substance abuse among children and adolescents: an estimated 10% to 11% of children and adolescents have both a mental health disorder and evidence of functional impairment²⁶;

• the prevalence of children who do not meet DSM-IV criteria for a disorder but who have clinically significant impairment (“problems” in DSM-PC terminology⁸), which is estimated to be equal to twice the prevalence of children with severe emotional disorders^26–28;

• the prevalence of mental health concerns in pediatric populations^29,30;

• the recognition that fully half of the adults in the United States with a mental health disorder had symptoms by the age of 14 years³¹;

• the low percentage of children receiving care for their mental health or substance abuse problems (∼20%)^26,32;

• the shortage and inaccessibility of specialty mental health services,³³ especially for underserved children from low-income families who do not fall within the target population of public/community mental health services;

• the disproportionate effects of unmet mental health needs on minority populations³⁴;

• the recognition that unidentified mental health comorbidities, such as anxiety and depression, are a significant force driving utilization of medical services³⁵; and

• the growing realization (articulated in the President's New Freedom Commission Report³⁶; Mental Health: A Report of the Surgeon General²⁶; the Future of Pediatric Education II (FOPE II)³⁷ study; and Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition³⁸; and by American Academy of Pediatrics [AAP] members [annual leadership forum resolutions]) that PCCs have a critical role to play in meeting children's mental health needs; in fact, at least 1 state is now requiring, by court order, universal mental health screening by PCCs for all children on Medicaid in that state.³⁹

Uniqueness of the PCC's Role

PCCs have a role in mental health care that differs substantively from that of mental health specialists, many of whom may be unfamiliar with problems as they present in primary care. The recommended competencies reflect these differences. Children and families who seek care from a mental health specialist do so because they have recognized a mental health need or because some crisis has compelled them. Children and families seeking care at primary care offices typically have not framed the visit as “mental health”–related. They may be seeking routine health supervision, acute care for a physical complaint, help with a challenging behavior, or simply reassurance. Ideally, PCCs would elicit psychosocial and mental health concerns from children and families in each of these situations. They would find ways to support and help the family that is resistant to seeking mental health care and to recognize those emergent situations that compel an immediate intervention. If and when a family is ready to address a problem, PCCs may choose to assess and manage the child himself or herself—in roles similar to those of mental health specialists—or they may choose to guide the family toward appropriate referral sources. Whether providing mental health services alone or collaboratively, PCCs would monitor the child and family's functioning and progress in care, applying chronic care principles as they would for other children and youth with special health care needs.⁴⁰ PCCs ideally would be able to provide these mental health services within the constraints of a busy practice without compromising the efficiency and financial viability of the practice.

The Primary Care Advantage

The AAP recognizes the unique strengths of PCCs and the opportunities inherent in the primary care setting—“the primary care advantage”⁴¹—on which mental health competencies can build:

• a longitudinal, trusting, and empowering therapeutic relationship with children and family members;

• the family-centeredness of the medical home^1–6,42,43;

• unique opportunities to prevent future mental health problems through promoting healthy lifestyles, anticipatory guidance, and timely intervention for common behavioral, emotional, and social problems encountered in the typical course of infancy, childhood, and adolescence (as described in Bright Futures)^38,44,45;

• understanding of common social, emotional, and educational problems in the context of a child's development and environment³⁸;

• experience working with specialists in the care of children with special health care needs and serving as coordinator and case manager through the medical home; and

• familiarity with chronic care principles and practice-improvement methods.

Framework for Behavioral and Mental Health Competencies

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) initiated the Outcome Project.⁴⁶ Through it, the ACGME established competencies to serve as the framework for residency curricula, organized into 6 domains: systems-based practice; patient care; medical knowledge; practice- based learning and improvement; interpersonal and communication skills; and professionalism. The competencies proposed in this report build on the ACGME framework with the expectation that they will be useful in setting goals for personal and professional growth in pediatric practice, for future board certification and recertification, and for residency training. Because achievement of system changes necessarily precedes other enhancements in mental health practice, the table of proposed mental health competencies for pediatric PCCs (Appendix 1) departs from the usual ACGME sequence, which includes systems-based practice as the final set of competencies, and instead begins with competencies for systems-based practice.

Assumptions

Traditional concepts of mental health care build on the assumption that treatment must follow diagnosis of a disorder; however, this approach offers only partial help for most children with mental health problems seen in primary care—those with significant dysfunction in the absence of a specific diagnosis.²⁷ The primary care setting offers the unique opportunity for patient-clinician interaction to positively influence the clinical outcome of emerging problems, problems that do not meet the criteria of a DSM-IV disorder, and mild or undiagnosed disorders (“problems” in the DSM-PC classification⁸). The proposed competencies assume that PCCs can, in many instances, have a positive effect on a child's mental health problems without knowing precisely the child's diagnosis and in situations in which the child's symptoms do not meet the criteria of a DSM-IV disorder.^47–49

“Generic” mental health skills proposed in this report are drawn from the literature on “common factors” in mental health care—techniques used to increase patients' optimism, feelings of well-being, and willingness to work toward improvement, regardless of the specific diagnosis or problem identified.^50–56 Other skills target symptoms that occur commonly across multiple mental health problems—feelings of anger, ambivalence, and hopelessness—and the family conflicts frequently associated with these problems. These skills come from family therapy,⁶ cognitive therapy,⁵⁷ motivational interviewing,⁵² family engagement,⁵⁸ family-focused pediatrics,^42,43 and solution-focused therapy.⁵⁹

The proposed competencies further assume that collaboration—among PCCs and staff members within the primary care practice and between the PCC/practice and families, mental health specialists, educators, case managers, social service workers, juvenile justice staff, and other agency personnel—is a central requirement in caring for children with mental health problems. Collaboration between PCCs and mental health specialists may take the form of a referral with formal exchange of information, a special referral relationship with regular communication, meeting(s) to discuss cases, meeting(s) of both the PCC and mental health specialist(s) with patients, or full integration of mental health and primary care services.⁶⁰ Models in which a licensed mental health specialist is integrated into a primary care practice have shown promise in improving access to services and treatment adherence, increasing efficiency and effectiveness of care, decreasing medical costs, increasing patient functioning and productivity, and improving patient and provider satisfaction.^61–64 A regional network of child psychiatrists⁶⁵ offering real-time telephone consultation and referral to PCCs in Massachusetts enhances the capacity of PCCs to care for children with diagnostic comorbidity, complicated attention-deficit/hyperactivity disorder (ADHD), anxiety, and depression. The proposed competencies reflect the importance of clinicians' staying abreast of collaborative approaches applicable to their particular setting and applying the growing body of evidence evaluating the effectiveness of various models.

A final assumption is that PCCs can expand their capacity beyond managing ADHD to care effectively for children with other commonly occurring pediatric mental health problems: anxiety, depression, and substance abuse.^63,66–68 By routinely screening for mental health problems, recognizing symptoms early, educating children and families about self-management strategies, and offering first-line treatment, PCCs have the potential to improve the lives of many children and their families who might otherwise not receive mental health care or receive care only after problems become more severe and impairing.³⁸ In the case of children with a chronic medical condition and comorbid anxiety and depression, mental health care may also result in improvements in their physical health and decreases in their utilization of emergency department and hospital services.³⁵

Systems-Based Practice

Systemic changes will necessarily precede other enhancements in mental health practice. Competencies in this area will empower clinicians to work with other mental health advocates toward improving the organizational and financial base of care and, with that base in place, to establish effective coding and billing practices that will sustain mental health services.^69,70

Another skill set involves building collaborative relationships with individuals and agencies that provide mental health services and with organizations that represent youth and families who are experiencing mental illness. These relationships will enable clinicians to address service gaps, define respective roles, and coordinate services. A final set of systems-based competencies involves selecting tools and establishing systems within the practice to normalize and systematize integration of mental health and to apply medical home principles and the chronic care model to children with mental health problems.

Patient Care

Competencies in this area include clinical skills to build resilience, promote healthy lifestyles, and prevent or mitigate mental health problems in children; identify risk factors and emerging mental health problems in children and their families; screen for mental health issues; conduct an assessment of a child presenting with mental health concerns or a positive screening test; overcome barriers (perceived and/or experienced by children and their families) in seeking help for mental health concerns; provide guidance to families on managing common behavioral problems and coping with adverse life events; and recognize mental health emergencies. A critical patient care skill is integrating child and family strengths, needs, and preferences; the use of clinicians' own skills (interpersonal, relational, assessment, diagnosis and management); and available resources into developing a care plan for children with mental health problems, involving mental health specialists when appropriate. The proposed competencies suggest that PCCs develop the capacity to provide care to children with ADHD, anxiety, depression, and substance abuse.

Medical Knowledge

This set of competencies focuses on applying current science to the mental health screening and assessment process and to decision-making about pharmacologic and psychosocial interventions in primary care. Foundational elements include the diagnostic classification of mental health variations, problems, and disorders in primary care (DSM-PC)⁸ and the evidence base for screening, therapeutic interventions, and behavior change science, as applied to mental health practice.

Practice-Based Learning and Improvement

This skill set enables the clinician to set and achieve learning and practice-improvement goals. Components include development of office protocols for the assessment and care of children with mental health problems and implementation of a quality-improvement program.

Interpersonal and Communication Skills

These skills are central to effective mental health practice within the rapid pace of a primary care practice, including common-factors approaches that are effective across a range of mental health conditions (see “Assumptions”). They also encompass effective exchange of information between PCCs and others involved in the care of the child and family.⁷¹

Professionalism

These skills build on respect for children and their families and sensitivity to cultural differences. In addition to facilitating child-clinician and family-clinician empathic relationships, which are the heart of effective mental health practice, they enable the clinician to discuss such issues as confidentiality and his or her own professional limitations.^72,73

Strategies for Residency Education

Just as mental health practice in primary care settings is collaborative, the process of training PCCs for primary care practice will necessarily be collaborative. Content experts (eg, developmental-behavioral pediatricians, child psychiatrists, adolescent medicine specialists, clinical psychologists, nurses with advanced psychiatric training, social workers) can join with primary care experts—clinicians who are effective in delivering primary medical care and managing children's chronic conditions in partnership with families—to train the next generation of PCCs. For academic generalists who have not received mental health training, collaboration with mental health specialist(s) to train PCCs will be particularly important. This training might take the form of coprecepting in residency continuity clinics, partnering to conduct inpatient rounds, and codeveloping didactic programs. While benefiting from the content expertise of their mental health colleagues, pediatric academicians will have the opportunity to model the collaborative, multidisciplinary relationships that underlie effective mental health practice.

Data from the 2007 AAP Graduating Residents Survey suggest that completion of an elective child psychiatry rotation and more training in mental health assessment, education, and treatment related to children are associated with greater confidence in identifying and treating pediatric mental health problems.⁷⁹ Additional research will be necessary to determine which educational methodologies are associated with the best outcomes. These findings have significant implications for the apportionment of time to mental health training within pediatric residency programs. Clearly, the 1-month developmental-behavioral pediatric rotation (often shortened by vacation time) is insufficient to accommodate necessary additions to the curriculum.

Strategies for Education of Experienced Clinicians

Experienced PCCs will benefit from approaches that build on skills they have developed over years of working with children and families. Wissow et al⁴⁹ have demonstrated that experienced PCCs can, in appropriate circumstances, provide evidence-based care of children with mental health and substance abuse problems or disorders of mild severity and functional impairment across diagnostic categories. Children treated by PCCs trained in mental health communication techniques have shown modest but significant improvement in mental health functioning, and their parents showed reduction in distress, compared with children treated by clinicians who did not receive training in mental health care.⁴⁹ Additional research will be necessary to adapt these techniques to the training of less-experienced clinicians.

Collaborative office rounds have been established in various communities for the purpose of enhancing mental health knowledge and skills of PCCs and their communication with mental health specialists.^80,81 One- to 2-hour sessions typically involve psychiatrists and/or developmental-behavioral pediatricians and PCCs in a case-based discussion.

Several groups of mental health educators have developed comprehensive training to prepare mental health specialists and primary care professionals for their respective roles in collaborative practice.^82,83 The AAP Task Force on Mental Health is collecting information about such trainings on its Web site (www.aap.org/mentalhealth) and has begun the process of keying proposed educational sessions at the National Conference and Exhibition and other AAP events to the mental health competencies put forward in this document. Clinicians may also work toward enhancing mental health competence by monitoring their psychosocial care in maintenance of certification by using such quality- improvement programs as eQIPP (Education in Quality Improvement for Pediatric Practice) and developing relevant pay-for-performance and quality indicators for health plans.

The most fundamental of all the proposed mental health competencies is the capacity to assess one's own knowledge and skills in mental health care and to establish a mechanism to update them, addressing the gaps that inevitably accompany gains in science. A growing number of educational resources developed by the AAP, the American Academy of Family Physicians, the National Association of Pediatric Nurse Practitioners, the American Psychiatric Association, the National Association of Social Workers, the American Academy of Child and Adolescent Psychiatry, and the American Psychological Association are available on their respective Web sites (Appendix 2). A powerful educational strategy is the cross-fertilization that occurs through a PCC's relationship with mental health specialists—authentic collaboration in the assessment and management of children in their mutual care and regular exchange of information about the child's and family's progress. This type of collaboration, together with openness to applying new science, will be essential for achieving and maintaining competence in mental health practice.