APPENDIX 1

Proposed Mental Health Competencies for Pediatric PCCs

“Systems-based practice”: clinicians providing primary care to children and adolescents should be able to do the following
    “Improve the organizational and financial base of care”
        1.Apply collaborative strategies applicable to advocating with insurers and payers for appropriate payment to PCCs and mental health specialists for their mental health services
        2.Utilize appropriate coding and billing practices to support mental health services
    “Build community collaborations”
        3.Establish collaborative relationships with support groups; professionals available within the community (eg, early intervention specialists, school personnel, child care professionals, mental health specialists); and/or community agencies (eg, departments of social services, juvenile justice system, nonprofit agencies providing mental health and substance abuse services to children and families) and define respective roles in assessment, treatment, coordination of care, exchange of information, and family support
        4.Participate in multidisciplinary meetings, appropriately applying such skills as reflective listening, mediation, and leadership skills
        5.Apply collaborative approaches involving parents and mental health specialists to advocate for services and educational resources relevant to the full range of children's/adolescents' and families' mental health needs, including those of special populations, such as abused children, children in foster care, homeless children, children of international political refugees and other recent immigrants, children with physical or mental disabilities, children displaced by disasters, children of separated and divorced parents, children of parents deployed for military service, and youth involved in the juvenile justice system
    “Enhance the practice”
        6.Establish systems within their practice to support mental health services; elements include
            a.a directory of mental health and substance abuse referral sources and family support resources in the region
            b.established procedures for
            promoting healthy lifestyles, including exercise, sleep, optimal nutrition, stress management, decreasing exposure to environmental toxins and stressors, and seeking support within the community
            eliciting a history of patients' involvement in mental health specialty care
            requesting consent to collect information from collateral sources such as mental health professionals, schools, and social service agencies
            obtaining and documenting the child's and family's psychosocial history
            managing psychiatric emergencies
            screening for occult mental health problems
            c.registries of patients with mental health problems (including children for whom psychopharmacologic agents have been prescribed and children/families not prepared to take action on mental health concerns)
            d.evidence-based protocols and monitoring/tracking mechanisms for the care of children with mental health problems
            e.culturally and linguistically appropriate educational materials on mental health topics for children and families
            f.tools for facilitating coding and billing specific to mental health
        7.Establish a practice environment that normalizes integration of mental health and incorporates medical home principles for the care of children with mental health concerns as for children and youth with other special health care needs
“Patient care”: clinicians providing primary care to children and adolescents should be able to do the following
  1. Promote mental health resilience through reinforcing child and family strengths and counseling families in healthy lifestyles (eg, nutrition, exercise, play, limited screen time, sleep, family time, stress management, decreased exposure to environmental toxins, and promotion of social capital)

  2. Integrate a brief psychosocial update into acute care visits

  3. Select, use, and interpret tools appropriate to the primary care setting for such purposes as screening for mental health problems, functional assessment of children and families, collection of information from collateral sources (eg, schools, agencies, juvenile justice system, other health professionals), and diagnostic assessment

  4. Conduct history, physical assessment, and observations of parent-child interaction indicated by presenting mental health concerns and/or positive screening test(s) results

  5. Differentiate normal behavioral variations, mental health problems and disorders, physical conditions with mental health manifestations, and adverse medication effects

  6. Identify potential behavioral, mental health, and/or learning differences/problems reflected in report cards, academic test results, Individualized Family Service Plans, or Individualized Education Plans

  7. Recognize common mental health comorbidities in children with physical and cognitive disabilities, chronic medical conditions, and mental health disorders

  8. Plan diagnostic assessment, alone or in collaboration with mental health specialists, of children and youth with special health care needs who have comorbid mental health issues; infants and young children manifesting difficulties with communication and/or attachment; and children and adolescents presenting with anxious or avoidant behaviors, inattention and hyperactivity, depressive or withdrawn behaviors, oppositional or aggressive behaviors, problems with eating, substance use, exposure to trauma or loss, learning differences, and poor academic performance

  9. Analyze results from mental health screening, history, and physical assessment to determine a child's/family's need for further assessment and/or intervention

  10. Provide guidance to families on managing common mental health problems; on coping with adverse life events such as parental separation and illness or death of a loved one; and on use of educational resources appropriate to their literacy level and cultural and individual needs

  11. Recognize mental health emergencies, severe functional impairment, and complex mental health symptoms that require mental health specialty care

  12. Assist families in seeking and using care of a mental health specialist and/or facility that provides evidence-based services appropriate to a child's/family's needs and preferences

  13. Develop a contingency or crisis plan for a child or adolescent with an urgent mental health problem

  14. Apply strategies to monitor adverse and positive effects of nonpharmacologic and pharmacologic therapy

  15. Integrate child/family strengths, needs, and preferences; clinician's own skills; and available resources into development of a care plan for children with mental health problems, alone or in collaboration with mental health specialists (including further assessment; child/family education about the condition[s]; evidence-based nonpharmacologic and, if indicated, pharmacologic interventions; communication with family and collaborating professionals; monitoring mechanisms; and routine health supervision)

  16. Initiate the process of care, alone or in collaboration with other clinicians, for children experiencing functional impairment from ADHD, anxiety, depression, or substance use/abuse, as desired by the child or family

“Medical knowledge”: clinicians providing primary care to children and adolescents should be able to do the following
  1. Access current data about the safety and efficacy of common pharmacologic and psychosocial interventions in children and adolescents

  2. Access current data about interactions between prescription drugs and dietary supplements commonly used for mental health problems

  3. Apply the DSM-PC criteria for the diagnoses of ADHD, major depressive disorder, and other disorders for which the clinician considers pharmacologic therapy

  4. Use evidence-based interventions for children and adolescents with anxiety disorders (including posttraumatic stress disorder), ADHD, depression, and substance abuse

  5. Apply principles of behavior-change science to mental health practice

“Practice-based learning and improvement”: clinicians providing primary care to children and adolescents should be able to do the following
  1. “Identify strengths, deficiencies, and limits in one's own knowledge and expertise” concerning mental health and substance abuse assessment and care

  2. “Set learning and improvement goals”

  3. “Identify and perform appropriate learning activities”

  4. “Locate, appraise, and assimilate evidence from scientific studies related to their patients' problems”

  5. “Use information technology to optimize learning”

  6. Apply learning to development of office protocols for the assessment and care of children with mental health disorders

  7. “Systematically analyze practice, using quality improvement methods, and implement changes with the goal of practice improvement” in mental health care

“Interpersonal and communication skills”: clinicians providing primary care to children and adolescents should be able to do the following
  1. Elicit mental health concerns from a child or adolescent and family

  2. Explore the cultural context of a child and family's symptoms or concerns

  3. Collaborate with child/adolescent and family to establish the agenda for an outpatient visit involving a mental health issue

  4. Identify and address barriers preventing a child and/or family from seeking or accepting help for a mental health problem (eg, sense of hopelessness, inadequate insurance or financial resources, family conflict, stigma)

  5. Manage resistance or anger in child/adolescent and/or family

  6. Apply motivational interviewing techniques, family engagement strategies, and behavioral contracts to seek consensus on a mental health plan of action and to prepare the family for a mental health consultation

  7. Interpret to families current evidence related to the safety and efficacy of relevant therapeutic options

  8. Promote healthy lifestyles that contribute to mental health

  9. “Communicate effectively with physicians, other health professionals, health-related agencies” and educators in the mutual care of children and adolescents

  10. Clarify and discuss psychological test results, mental health findings, and concerns to children, adolescents, and families in language that is appropriate for age, education level, and cultural norms

  11. Bring a mental health visit to a close in a supportive, efficient manner

“Professionalism”: clinicians providing primary care to children and adolescents should be able to do the following
  1. “Demonstrate compassion, integrity, and respect” for all children and family members

  2. Demonstrate sensitivity to cultural differences and family preferences in addressing mental health concerns

  3. Establish clear expectations in children, adolescents, and their families about conditional confidentiality (specific to state laws), exchange of protected health information, and business practices

  4. Discuss one's professional limitations in knowledge and skills as part of the referral process

  • The ACGME has published “general competencies,” which in some cases overlap those outlined in this document but bear restatement in the context of mental health care. ACGME wording is shown in quotes. The AAP recognizes that achievement of the competencies proposed in this table is a long-term goal, requiring training and resources that have yet to be developed. The AAP is committed to the development of the resources and training needed to assist pediatricians in achieving these competencies.