TECHNICAL REPORT

Achieving the Pediatric MentalHealth CompetenciesCori M. Green, MD, MS, FAAP,a Jane Meschan Foy, MD, FAAP,b Marian F. Earls, MD, FAAP,c COMMITTEE ON PSYCHOSOCIAL ASPECTSOF CHILD AND FAMILY HEALTH, MENTAL HEALTH LEADERSHIP WORK GROUP

abstractMental health disorders affect 1 in 5 children; however, the majority ofaffected children do not receive appropriate services, leading to adverse adultoutcomes. To meet the needs of children, pediatricians need to take ona larger role in addressing mental health problems. The accompanying policystatement, “Mental Health Competencies for Pediatric Practice,” articulatesmental health competencies pediatricians could achieve to improve the mentalhealth care of children; yet, the majority of pediatricians do not feel preparedto do so. In this technical report, we summarize current initiatives andresources that exist for trainees and practicing pediatricians across thetraining continuum. We also identify gaps in mental health clinical experienceand training and suggest areas in which education can be strengthened. Withthis report, we aim to stimulate efforts to address gaps by summarizingeducational strategies that have been applied and could be applied toundergraduate medical education, residency and fellowship training,continuing medical education, maintenance of certification, and practicequality improvement activities to achieve the pediatric mental healthcompetencies. In this report, we also articulate the research questionsimportant to the future of pediatric mental health training and practice.

INTRODUCTION

Mental health disorders have surpassed physical conditions as the mostcommon reasons children have impairments and limitations.1 Mentalhealth disorders affect 1 in 5 children; however, a shortage of mentalhealth specialists, stigma, cost, and other barriers prevent the majority ofaffected children from receiving appropriate services.2–4 Pediatricianshave unique opportunities and a growing sense of responsibility topromote healthy social-emotional development of children and to preventand address their mental health and substance use problems. In 2009, theAmerican Academy of Pediatrics (AAP) published a policy statementproposing mental health competencies for pediatric primary care andrecommended steps toward achieving them.5 The policy statement

aDepartment of Pediatrics, Weill Cornell Medicine, Cornell Universityand New York–Presbyterian Hospital, New York, New York;bDepartment of Pediatrics, School of Medicine, Wake Forest University,Winston-Salem, North Carolina; and cCommunity Care of NorthCarolina, School of Medicine, University of North Carolina at ChapelHill, Chapel Hill, North Carolina

All authors contributed to the drafting and revising of this manuscriptand approved the final manuscript as submitted.

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

Technical reports from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, technical reports from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All technical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

DOI: https://doi.org/10.1542/peds.2019-2758

Address correspondence to Cori M. Green, MD, MS, FAAP. E-mail:cmg9004@med.cornell.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

To cite: Green CM, Foy JM, Earls MF, AAP COMMITTEE ONPSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH,MENTAL HEALTH LEADERSHIP WORK GROUP. Achieving thePediatric Mental Health Competencies. Pediatrics. 2019;144(5):e20192758

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“Mental Health Competencies forPediatric Practice,”6 accompanyingthis technical report, affirms and,importantly, provides updates toincorporate new science on earlybrain development, to articulate thepediatrician’s role in addressingsocial determinants of health andtrauma, and to consider mental healthpractice in subspecialty, as well asprimary care, settings.

Currently, the majority ofpediatricians do not feel prepared toachieve these mental healthcompetencies.7,8 Furthermore, morethan half of pediatric programdirectors (PDs) surveyed in 2011were unaware of the 2009competencies, making it unlikely thattraining programs have enhancedtheir curriculum to prepare futurepediatricians to achieve them.9 Withthis technical report, we aim tostimulate efforts to address thesegaps by summarizing educationalstrategies that have been applied andcould be applied to undergraduatemedical education, residency andfellowship training, continuingmedical education (CME),maintenance of certification, andquality improvement activities toachieve the pediatric mental healthcompetencies proposed in theaccompanying policy statement. Thisreport also articulates researchquestions important to the future ofpediatric mental health training andpractice.

HISTORY

Deficiencies in mental health traininghave been recognized for more than 4decades, and in the 1980s, the AAPfirst called for improved education ofpediatricians in the care of childrenwith psychosocial and mental healthproblems.10,11 Pediatric trainees andgraduates since the 1980s reportfeeling less prepared to care for thesechildren than they do children withother pediatric conditions.12,13

Surveys over 3 decades have

documented little change in theirreported preparedness, despite theconsiderable efforts describedbelow.14–16

In 1997, the Accreditation Council forGraduate Medical Education (ACGME)mandated that all pediatric residencyprograms include a 4-weekdevelopmental-behavioral pediatrics(DBP) rotation.17 Completion of all4 weeks of this rotation has hada positive effect on pediatricians’ self-reported competence, practices, andwillingness to accept responsibilityfor providing mental health care.18,19

However, change in mental healthpractice has been modest, asmeasured by the AAP’s periodicsurveys of members, and mentalhealth training is still not emphasizedduring residency and is considered tobe suboptimal per PDs.8,9,20,21

Advances in science have continuedto demonstrate the interplay betweenthe environment—particularly thechild’s social environment—and bothphysical and mental health; thepervasiveness of environmentalinfluence makes it evident thatmental health training needs toexpand beyond a single rotation.Well-meaning efforts to addressdeficiencies in mental competenciesby requiring DBP rotations and/oroffering clinical rotations inpsychiatry may have the unintendedconsequence of implying that mentalhealth is primarily the domain of DBPsubspecialists or child psychiatrists.22

Ideally, mental health content andpractice experiences would beintegrated throughout the pediatriccurriculum, during both inpatient andoutpatient experiences, conveying themessage that mental healthcompetencies are integral to allaspects of pediatric practice.

AAP RESPONSES

In response to the needs of practicingpediatricians, the AAP Task Force onMental Health (2004–2010)published a supplement to

Pediatrics23 describing the rationalefor enhancing pediatric mental healthcare, offering community-level andpractice-level strategies to supportenhanced pediatric mental healthcare, and presenting algorithms forintegrating mental health care intothe flow of primary care pediatricpractice. The task force alsopublished Addressing Mental HealthConcerns in Primary Care: A Clinician’sToolkit,24 providing an array ofpragmatic tools to assess a practice’scapacity for providing mental healthcare, to build capacity when needed,and to operationalize the process laidout in the supplement. Also, withinthis toolkit, symptom “cluster”guidance offered a pragmatic clinicalapproach to addressing the commonsymptom constellations faced inpediatrics: anxiety, low mood,disruptive behavior and aggression,inattention and impulsivity, substanceuse, learning difficulty, and social-emotional symptoms in youngchildren. This guidance hassubsequently been incorporated intoseveral publications of the AAP: Signsand Symptoms in Pediatrics,25

Textbook of Pediatric Care, SecondEdition,26 Pediatric Care Online,27 andMental Health Care of Children andAdolescents: A Guide for Primary CareClinicians.28 The AAP has alsopublished or endorsed clinicalguidelines, reports, or statementsguiding the assessment andmanagement of attention-deficit/hyperactivity disorder (ADHD),29

depression,30,31 maladaptiveaggression,32,33 early social-emotionalproblems,34 early childhood traumaand toxic stress,35 and substanceuse.36

The AAP Mental Health LeadershipWork Group (2011 to present), incollaboration with other AAP groups,has offered additional resources: a setof videos on using motivationalinterviewing (MI) to address mentalhealth problems, e-mail notificationabout new publications relevant topediatric mental health, Webinars,

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a curriculum and course forcontinuity clinic preceptors (seebelow), and a Web site with mentalhealth resources.37,38 Unfortunately,dissemination and evaluation of theseapproaches remain a challenge, andthe mental health toolkit and othermaterials created to helppediatricians integrate mental healthinto their practice have not reachedthe majority of pediatricians.39,40

RESPONSES OF ACCREDITING BODIES

Improving training and competencein mental health care for futurepediatricians—subspecialists as wellas primary care pediatricians—hasincreasingly received nationalattention and is now a priority of theAmerican Board of Pediatrics(ABP).41,42 In 2013, the ACGME andABP created the “Pediatric MilestonesProject” to assess incrementalachievement of pediatriccompetencies across the career span,from novice to expert.43 Seventeenentrustable professional activities(EPAs)—professional units of workthat define a specialty—weredeveloped for general pediatrics.44,45

A number of EPAs have implicationsfor mental health care, and one—number 9—specifically states that thegeneral pediatrician should be able to“assess and manage patients withcommon behavior/mental healthproblems.”45 This EPA lists thefollowing functions expected of thepediatrician: (1) identify and managecommon behavioral/mental healthissues, (2) refer and/or comanagepatients with appropriatespecialist(s), (3) know mental healthresources available in one’scommunity, (4) know team memberroles and/or monitor care, and (5)provide developmentally andculturally sensitive care. This EPAreinforces many of the mental healthcompetencies from the 2009 AAPstatement5 and the accompanyingpolicy statement “Mental HealthCompetencies for Pediatric Practice.”

Pediatric medical subspecialtypractices are at times the de factomedical home for children withchronic conditions who are ata higher risk than their peers formental health problems.46,47

However, subspecialists often focuson their organ system, and studieshave revealed that subspecialists arenot routinely inquiring aboutpsychosocial and mental healthproblems in children with chronicmedical conditions or referring themfor mental health care.48,49

Promisingly, the majority of PDs agreethat all trainees, regardless of futurecareer plans, need to be competent inidentifying, referring, andcomanaging children with mentalhealth problems. However, only halfof PDs believe trainees going intoa subspecialty should be responsiblefor mental health treatment.42

PURPOSE OF THIS REPORT

With this report, we identify gaps inmental health clinical experience andeducation across the trainingcontinuum and describe innovativestrategies created and/or tested toimprove pediatricians’ ability to carefor children with mental healthproblems. As reflected in the materialbelow, efforts to date have beenfocused mainly on pediatric residencytraining programs and CME efforts.

PROMISING APPROACHES ACROSS THEEDUCATIONAL CONTINUUM

Undergraduate Medical Education

Currently, the Liaison Committee onMedical Education includescommunication skills as 1 of the 9mandated areas of content.50

Although there are no specificationsas to which skills should be taughtand how, medical school curriculaoffer opportunities to enhancephysician-patient communication andprofessionalism. The first step inaddressing any mental health concernis to engage the family and builda therapeutic relationship by using

communication skills such as MI anda “common-factors” approach, whichbuilds on MI (see Discussion inaccompanying policy statement6).These skills (eg, building hope,providing empathy, partnering withfamilies, rolling with resistance,managing conflict) are necessary inall aspects of patient care and shouldbe emphasized and taught throughoutthe continuum of medical education,starting with medical school.

It is essential that medical studentschoosing pediatrics be aware of andbe prepared for their role in caringfor pediatric mental health problems.The Council on Medical StudentEducation in Pediatrics does includepediatric behavior in its third-yearcompetencies and objectives.51

However, whether this is emphasizedand whether preceptors model theprovision of care to children withmental health problems duringpediatric rotations is unknown. Thesequestions should be addressed infurther study.

Graduate Medical Education

As of 2013, 68% of practicingpediatricians reported receiving notraining in MI during residencytraining, and more than half reportedreceiving no training in otherinterviewing techniques.19 Untilmedical schools consistently providethis training, residency programs willneed to provide it and ensuretrainees’ competence in these skills,and regardless of when it isintroduced, preceptors will need tomodel and reinforce evidence-basedcommunication skills.21,42

Unfortunately, only 20% of PDscurrently report that their residentsreceive optimal training in common-factors communication skills.21

It is promising that most residentsbelieve they are responsible foridentifying and referring childrenwith mental health problems, yet fewbelieve they are responsible fortreating them.52 In the unified theoryof health behavior change, intention is

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what is most predictive of behavior,53

yet for trainees and practicingpediatricians, perceivedresponsibility does not always lead topracticing in a way that is consistentwith that perception.18,54 Thisdiscrepancy between intent andpractice is likely the result ofa learning environment that does notprovide the teaching and supportneeded to practice the requisiteskills.54,55 Trainees requestexperiential learning opportunities tocare for children with mental healthproblems.55 This request aligns withprinciples of andragogy (ie, to buildself-efficacy, the clinical learningenvironment must provideopportunities to learn and practiceskills guided by knowledgeableclinicians who can role model anddemonstrate these skills).56

In response, educationalinterventions have included not onlycurriculum development but alsoa variety of instructional methods:role plays,38 videos,57,58 standardizedpatients (SPs),59,60 and trainingalongside mental health professionalsand trainees.52,61,62 Successfulinterventions have used multimodalapproaches, allowing trainees to gainknowledge and practice skills.Specifically, Fallucco et al59

demonstrated that interns whoreceived instruction using bothdidactics and SP trainings hadincreased knowledge and confidencein assessing for suicide comparedwith trainees who received only thelecture, those who received only theSP training, or controls who did notreceive either of these experiences.Jee et al60 had similar resultscombining case-based didactics withthe use of SPs, leading to increasedconfidence among trainees in use ofanxiety screening tools and laterpractices in performing a warmhandoff (ie, an in-person, facilitatedtransfer of care from the trainee toanother provider).

Additional examples highlightimportant caveats. One institution

created a multimodal instructionalapproach using role plays, cases, andSPs on screening for substance use,brief intervention, and referral totreatment, which increased trainees’knowledge and confidence in thescreening technique; however, thesegains declined over time.63 Anotherinstitution successfully implementeda multimodal curriculum foraddressing substance use usingscreening, brief intervention, andreferral to treatment while alsocreating an assessment tool tomeasure performance. Residentsimproved in patient-centereddiscussions and identifying motivesand plans when practicing skills withSPs.64 At another institution, thecombination of computer modulesand SPs to teach how to assess anddiagnose depression improvedtrainees’ interpersonal skills,diagnostic skills, and confidence intreatment of depression; however,gaps in history taking and assessmentfor comorbidities remained.65 Thesefindings reinforce the need forongoing assessment of trainees’ skillsand, importantly, their practice ofskills to supplement curricular efforts.

As an attempt to stimulate mentalhealth training nationally, the AAPcreated a curriculum and training forpediatric continuity clinic preceptorsand trainees in the common-factorsapproach.38 This curriculum wascreated with various teachingmodalities, including videos and roleplays, with flexibility inimplementation so that it can beadapted regardless of programcharacteristics. A faculty guide wasincluded as an attempt to provideguidance for preceptors who may nothave learned these concepts already.The curriculum has beendisseminated by the AAP online andat national meetings as an attempt totrain preceptors to deliver themodules. However, this curriculumhas yet to be evaluated, and themajority of PDs are not familiar withthe contents of the AAP curriculum.40

Trainees have stated that the mosteffective way they will learn toprovide mental health care is for theirown pediatric preceptors to modelthe mental health practices,55 yetmany pediatricians, includingcontinuity preceptors, do not feelcompetent to serve as role models formental health practice.8,20,55 As anattempt to fill this gap, more than halfof residency continuity clinics have anon-site developmental-behavioralpediatrician, social worker, childpsychiatrist, psychologist, or othermental health specialist.21,42 Althoughthe role of these mental healthspecialists is not clear and likelyvaries between sites, PDs andresidents trained in clinics withenhanced mental health services doreport increased confidence andcompetence in systems-basedpractice and in coordinating andcollaborating with mental healthspecialists.9,52,61,62

One study revealed that residentstraining on-site with mental healthprofessionals were more likely toidentify and refer patients with ADHDand reported that having the supportof an on-site professional made themmore comfortable to delve into theirpatients’ problems.52 However, asstated in the accompanying policystatement, pediatricians should beable to manage common mentalhealth problems themselves, andhaving an on-site mental healthprovider has not been shown toincrease trainees’ practice of treatingmental health problems. It isnecessary to clarify the role of on-sitemental health professionals asteachers rather than simply referralsources; their purpose is to increasethe knowledge and skills of traineesand preceptors rather than offer thema way to avoid caring for mentalhealth issues that are withinpediatricians’ scope of practice.Further study is needed to delineatehow an on-site mental healthprofessional can best impact practicesbecause there are currently no

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financial structures to support themas preceptors without direct patientcare responsibilities.

Study of successful integrated modelshas underscored the importance ofpreparing behavioral health providersto work within a primary care culture—for example, accommodatinginterruptions for consultation,participating in interdisciplinarymeetings for peer-to-peer problemsolving, and allowing unscheduledtime for collaboration with otherteam members on unanticipatedbehavioral health issues.66

Educational resources, including well-developed competencies, areavailable to guide mental health/substance use professionals inserving as primary care teammembers, comanagers, orconsultants.67 Some psychiatryresidency programs and a number ofother mental health professionalprograms have started traininglicensed mental health trainees inintegrated programs (ie, programsthat combine mental health andprimary care services in a singlesite).68,69 One innovative programproviding interdisciplinary training isthe “buddy system,” in whichpediatric and mental health traineeswere paired to teach skills inintegration and collaboration; itspremise is that interdisciplinary teammeetings help clinicians fromdifferent backgrounds to develop andunderstand each other’s work andservices.70 Impacts of this programare currently unknown, but it willlikely lead to improved skills incollaboration between primary carepediatricians and mental healthspecialists. In 1 pediatric residencyprogram, having pediatric and mentalhealth trainees see patients in thesame clinic has improvedcollaboration skills.71

The ACGME requires 6 months ofindividualized learning for pediatricresidents; because subspecialty-bound residents are likely to focus ontheir future subspecialty during this

time, this requirement may result intheir receiving less training in caringfor mental health problems.72

Currently, the ACGME guidelines forsubspecialty training in pediatrics dospecify communication andinterpersonal skills that are expectedof all fellows, regardless of specialty,including working and collaboratingas a team member, but there is nomention of providing fully integratedcare that would include addressingpsychosocial and mental healthconcerns.73 Many pediatricsubspecialty clinics incorporatea mental health professional asa team member, and there is likelysome crossfertilization of the fellowsand subspecialists who participate inthese models; however, the mentalhealth professional typically hasa clinical rather than an educationalrole and is often stretched thin withinpatient duties.49 Additionalresearch is needed to address howbest to prepare future specialists tointegrate mental health care into theirpractice.

The need to improve pediatricgraduates’ training in mental healthhas been established, and theinitiatives discussed above revealpromise. However, at this point,evaluation of educationalinterventions has mainly been limitedto self-reported confidence,competence, and practices.18,19,52

More assessment tools to measurecompetence are needed to evaluatethe impact of educationalinnovations.42 It will also beimportant to study actual practicesand patient outcomes related toeducational interventions.

Education of Experienced Clinicians

Educational efforts have successfullyreached experienced pediatricians,building on skills they havedeveloped over years of working withchildren and families. For instance,Wissow et al74 have demonstratedthat experienced primary careclinicians (PCCs) can acquire

common-factors skills (described inthe accompanying policy statementand above) and that the skills arehelpful across a range of mentalhealth conditions.75,76 Childrentreated by PCCs trained in thecommon-factors techniques haveshown modest but significantimprovement in mental healthfunctioning, and their parents haveshown reduction in distresscompared with children treated byclinicians who did not receive thistraining.75,76

Practicing pediatricians often feel thattreating mental health problems isoutside their scope of practice andoften report that they do not havetime to effectively implementpsychosocial interventions.8,18 Briefinterventions that pediatricians canlearn readily and implement ina short time period may offera solution. See the accompanyingpolicy statement for a full discussion.6

Research will be necessary to developand hone strategies for trainingresidents and fellows in theseapproaches.

Several groups of mental healtheducators have successfullydeveloped comprehensive trainingand CME programs to prepare mentalhealth specialists and primary careprofessionals for their respectiveroles in collaborative practice.77–79

The AAP is collecting informationabout such trainings on its MentalHealth Initiatives Web site (https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/Collaborative-Projects.aspx). The following are severalexamples:

The Resource for AdvancingChildren’s Health Institute offers a 3-day mini-fellowship for primary carephysicians using active learningmethods to teach how to improveskills in recognition, diagnosis, andtreatment of children with mentalhealth disorders. This is followed by6 months of biweekly case

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conferences. This program haschanged physicians’ practice patterns,as measured by an increase in thequality of referrals and a decrease inemergency department referrals, bothof which can lead to decreased healthcare costs.80 In New York, ProjectTraining and Education for theAdvancement of Children’s Healthuses the Resource for AdvancingChildren’s Health mini-fellowship totrain primary care physicians andoffers a telepsychiatry consult line forsupport in diagnosis andmanagement and to help findappropriate referrals. This programhas trained more than 600 primarycare physicians and consulted on over8000 children and adolescents usingtelepsychiatry. Trained physicians feltmore confident in addressing mentalhealth problems with their patientsand were motivated by the supportiveand positive interactions with mentalhealth specialists.77,81

In Massachusetts, a regional networkof child psychiatrists offering real-time telephone consultation andreferral to PCCs in Massachusettsenhanced the capacity of PCCs to carefor children with diagnosticcomorbidity, complicated ADHD,anxiety, and depression.82–85 TheMassachusetts Child PsychiatryAccess Program has the resources toprovide consultation and carecoordination to 95% of the state’schildren, and in 2013, it had alreadyserved more than 10 500 children.86

This program has been well receivedby pediatricians and now hasexpanded to offer support formothers with depression.87 At least27 states have such consultationnetworks.88 Congress authorizedPediatric Mental Health Care Accessgrants (x10002) that are modeledafter the Massachusetts Child PsychiatryAccess Program to support thedevelopment of new or improvement ofexisting pediatric mental health caretelehealth access programs.89

Clinicians may also work towardenhancing mental health competence

in maintenance of certification byusing such quality improvementprograms as Education in QualityImprovement for Pediatric Practice,AAP chapter-led quality improvementlearning collaboratives, anddevelopment of relevant pay-for-performance and quality indicatorsfor health plans. A growing number ofeducational resources developed bythe AAP, the ABP, the AmericanAcademy of Family Physicians, theNational Association of PediatricNurse Practitioners, the AmericanPsychiatric Association, the NationalAssociation of Social Workers, theAmerican Academy of Child andAdolescent Psychiatry, and theAmerican Psychological Associationare available on each organization’sWeb site.

Even when practicing pediatriciansacquire the knowledge and skillsneeded to integrate mental healthinto primary care, time and otherpractice barriers (culture, processes)may impede intentions frombecoming practices. Building MentalWellness was a state initiativedeveloped by the Ohio Chapter of theAAP as a way to engage practices andprimary care physicians in integratingmental health.90 This initiativesuccessfully taught physicians skillsin prevention, identification, andmanagement of mental healthproblems using online educationalsessions. Importantly, this programalso addressed organizational climate,culture, and care processes. Study ofuptake of this program revealed thatpractice organization and culturewere associated with the uptake ofinterventions, suggesting thateducation alone will not transformpediatricians’ practices, but focus onoffice processes, culture, and climateis needed as well.91

The American Medical Associationhas suggested 10 steps to improveoffice culture including firstdiagnosing team culture by usingmeasurement tools andbrainstorming improvements and

creating processes to improveteamwork and communication tochange a practice’s culture.92 Asdiscussed in the policy statement,thinking of a mental health concern(eg, inattention and impulsivity)similarly to fever may help clarifyprocesses: an initial visit to assessseverity and offer symptomatic care(antipyretic for fever or briefcommon-elements intervention suchas helping parents apply effectivebehavioral management techniquesfor inattention and impulsivity),follow-up visits and furtherassessment possibly using objectivemeasures if symptoms persist (acomplete blood cell count for fever ora rating scale such as the Vanderbiltto assess for ADHD), targetedtreatment if a diagnosis is made(antibiotics for a pneumonia orstimulants and behavioral therapy forADHD), and referral if first-linetreatment fails and/or severityworsens (the emergency departmentfor respiratory distress or mentalhealth specialist for complicatedADHD).

The AAP mental health toolkit, asmentioned previously, offers tools tosupport mental health processes inpractices. Other tools have beendeveloped and studied, such as a briefintervention for anxiety using ananxiety action plan.93 Study of thistool, which is comparable to anasthma action plan, has shown it to befeasibly implemented into primarycare and helpful in reducingchildren’s symptoms. Maternaldepression screening wassuccessfully implemented intopractice in North Carolina byCommunity Care of North Carolinathrough a guided Maintenance ofCertification Part 4 activity thatreached over 100 PCCs (www.communitycarenc.org). Outreach byregional quality improvementcoordinators in 14 regions across thestate and “1-pagers” for practicesresulted in high rates ofimplementation of perinatal

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depression screening (87% at all 1-month well visits, as of quarter 4,2018). Technical assistance topractices included use of thescreening tool, support resources formothers, evidence-based dyadictherapies, referral, and follow-up.Similar progress has been seen withadolescent depression screening.Lastly, approaching mental healthconcerns through a stepwiseapproach as described through theAAP algorithm (see accompanyingpolicy statement) can make it morefeasible to implement in busypractices.

Expansion of the medical home teamto include a mental health provider isfinancially feasible in some paymentenvironments and clinically beneficialto patients and families.94–97 Inaddition, it offers PCCs the benefit ofcrossdisciplinary learning throughexperiences such as collaborative careplanning, clinical problem solving,and comanagement of patients withmental health morbidities andcomorbidities.98–100 These integratedmodels of care in which a licensedmental health specialist is on-site ina primary care practice have shownpromise in improving access tomental health care for patients,improving patient functioning andproductivity, and improving patientand provider satisfaction.94,100–103

The majority of mental health care isprovided during well-child visits andspans the continuum from promotion,to screening, to initiation ofmedications.28 However, simplyplacing a mental health specialist on-site in pediatric practices may notnecessarily enhance pediatricians’own mental health skills or practice;the roles of both the mental healthspecialist and pediatrician(s) must bewell thought out and clear to avoidinappropriate referral to the on-sitemental health specialist of patientsideally managed by the PCC.104 Inaddition, there are barriers tosustaining integrated models of carein fee-for-service plans because

productivity of the mental healthprofessional is variable.102,105 Asmentioned in the accompanyingpolicy statement, systems changes areneeded for pediatricians to achievethe proposed mental healthcompetencies.

For some subspecialties, guidelineshave specified inclusion of a mentalhealth professional as a teammember. For example, theInternational Society for Pediatricand Adolescent Diabetes “ClinicalPractice Consensus Guidelines 2014”for care of children and adolescentswith type 1 diabetes mellitus state“Resources should be made availableto include professionals withexpertise in the mental health andbehavioral health of children andadolescents within theinterdisciplinary diabetes health careteam. These mental health specialistsshould include psychologists, socialworkers, and psychiatrists.”106 Arecent supplement to Pediatric Bloodand Cancer outlined 15 evidence-based standards for the psychosocialcare of children with hematologic andoncologic conditions and theirfamilies, including 1 on integratinga mental health team member.107

Even when such standards exist,however, there is no assurance thatan integrated model can beimplemented or sustained in a givenclinical setting.108 Additional researchis needed to assess whether thesemodels of care better integratemental health into the care ofchildren with chronic physicalconditions.

PROMISING DIRECTIONS

Achieving the proposed competencieswill require new educationalapproaches and evaluation of theireffectiveness, as well as significantenhancement in the interest andcompetence of pediatric facultymembers who serve as teachers androle models. On the basis ofexperiences described above and the

opinion of experts, the followingstrategies seem most promising andare offered here for the considerationof pediatric educators:

• prioritize training in common-factors communication skills for allpediatric faculty and for learners atall levels;

• incorporate the mental healthcompetencies into curricularobjectives, as described in the ABPEPA number 9, “assess and managepatients with common behavior/mental health problems,”45 inaccordance with the level oftraining;

• incorporate the promotion ofhealthy social-emotionaldevelopment into the residencycurriculum, including reinforcingstrengths in the child and familyand identifying risks to healthysocial-emotional development andemerging symptoms to prevent ormitigate impairment from futuremental health symptoms;

• prepare medical educators andpreceptors to model, teach, andassess mental health competencies;

• consider including mental healthspecialists and/or developmentalspecialists as copreceptors andteam members in teaching clinics(both general pediatric andsubspecialty), inpatient rounds, andother clinical teaching settings,taking care to ensure that learnersparticipate in mental health care,not just refer to specialists;

• consider incorporating trainees inpsychology, social work, childpsychiatry, DBP, and otherspecialties as team membersin continuity and subspecialtyclinics;

• consider addition of clinicalexperience(s) in child psychiatry topediatric residency programs,either as a block rotation or,preferably, a longitudinalexperience;

• monitor their learners’ success inachieving the mental health

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competencies and ensure ongoingopportunities to practice skills; and

• participate in and/or supportresearch to answer suchquestions as:

• ○ What do medical students knowabout the role pediatricians playand will play in caring for childrenwith mental health problems?

• ○ How much exposure is thereduring the pediatric clerkship tomental health promotion, primaryand secondary prevention, and careof pediatric mental healthproblems?

• ○ What are the best educationalstrategies to change attitudes andencourage the pediatric communitythat mental health care is withintheir scope of practice?

• ○ What are the most effective waysto teach foundationalcommunication skills toinexperienced as well asexperienced clinicians?

• ○ How can common elements ofevidence-based psychosocialtreatments be most effectivelyadapted for pediatric practice?What impact do they have? Howcan they be incorporated intoresidency training and CME?

• ○ Which competencies are mostrelevant to subspecialty pediatricpractice and therefore necessary toresidency and/or fellowshiptraining?

• ○ How can achievement ofcompetence in providing mentalhealth care be assessed within thecontext of residency and fellowshiptraining?

• ○ How can practicing subspecialistsbe engaged in enhancing theirmental health practice andimproving coordination with PCCsand mental health specialistsaround the mental health needs oftheir patients?

• ○ Which collaborative models aremost effective with respect tooutcomes for children? Which are

most effective for enhancingpediatricians’ competence?

• ○ How can pediatricians notcurrently able or motivated toenhance their mental healthcompetence or practice best beengaged?

• ○ Will better preparingpediatricians to care for mentalhealth problems in their practiceimprove the mental health care ofchildren and reduce the societalburden of untreated mental healthproblems?

CONCLUSIONS

Attainment of the mental healthcompetencies proposed in theaccompanying AAP policy statementwill require innovative educationalmethods and research as described inthis report. Significant enhancementin pediatric faculty competence,medical education, pediatricresidency and fellowship training,and practicing pediatricians’ owneducational efforts will also beneeded, along with effectiveassessment methods to documentlearners’ progress toward achievingthe competencies. These changes willcontinue to require investments bythe AAP and its partner organizations,pediatric educators, and pediatriciansworking at both the community andpractice levels.

AAP RESOURCES

Clinical Tools and/or Tool Kits

AAP clinical tools and/or tool kitsinclude the following:

Addressing Mental Health Concernsin Primary Care: A Clinician’sToolkit;

Common Elements;

Hope, Empathy, Loyalty, Language,Permission, Partnership, Plan(“HELP”) mnemonic;

Mental Health Algorithm; and

Mental Health Symptom ClusterGuidance.

Education, Training Materials, and/or Videos

AAP education, training materials,and/or videos include the following:

Mental Health Residency Curriculum;and

Implementing Mental HealthPriorities in Practice video series.

PUBLICATIONS AND/OR BOOKS

AAP publications and/or booksinclude the following:

Developmental Behavioral Pediatrics;

Mental Health Care of Children andAdolescents: A Guide for PrimaryCare Clinicians; and

Pediatric Psychopharmacology forPrimary Care.

Reports

AAP reports include the report“Reducing Administrative andFinancial Barriers.”

Web Site

Web site resources include the AAPmental health Web site.

LEAD AUTHORS

Cori M. Green, MD, MS, FAAP

Jane Meschan Foy, MD, FAAP

Marian F. Earls, MD, FAAP

COMMITTEE ON PSYCHOSOCIALASPECTS OF CHILD AND FAMILYHEALTH, 2018–2019

Arthur Lavin, MD, FAAP, Chairperson

George LaMonte Askew, MD, FAAP

Rebecca Baum, MD, FAAP

Evelyn Berger-Jenkins, MD, FAAP

Thresia B. Gambon, MD, FAAP

Arwa Abdulhaq Nasir, MBBS, MSc,MPH, FAAP

Lawrence Sagin Wissow, MD,MPH, FAAP

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FORMER COMMITTEE ONPSYCHOSOCIAL ASPECTS OF CHILD ANDFAMILY HEALTH MEMBERS

Michael Yogman, MD, FAAP, FormerChairperson

Gerri Mattson, MD, FAAP

Jason Richard Rafferty, MD, MPH,EdM, FAAP

LIAISONS

Sharon Berry, PhD, ABPP, LP – Societyof Pediatric Psychology

Edward R. Christophersen, PhD, FAAP– Society of Pediatric Psychology

Norah L. Johnson, PhD, RN, CPNP-BC– National Association of PediatricNurse Practitioners

Abigail Boden Schlesinger, MD –American Academy of Child andAdolescent Psychiatry

Rachel Shana Segal, MD – Section onPediatric Trainees

Amy Starin, PhD – NationalAssociation of Social Workers

MENTAL HEALTH LEADERSHIP WORKGROUP, 2017–2018

Marian F. Earls, MD, FAAP,Chairperson

Cori M. Green, MD, MS, FAAP

Alain Joffe, MD, MPH, FAAP

STAFF

Linda Paul, MPH

ABBREVIATIONS

AAP: American Academy ofPediatrics

ABP: American Board of PediatricsACGME: Accreditation Council for

Graduate MedicalEducation

ADHD: attention-deficit/hyperactivity disorder

CME: continuing medicaleducation

DBP: developmental-behavioralpediatrics

EPA: entrustable professionalactivity

MI: motivational interviewingPCC: primary care clinicianPD: program directorSP: standardized patient

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES

1. Halfon N, Houtrow A, Larson K,Newacheck PW. The changinglandscape of disability inchildhood. Future Child. 2012;22(1):13–42

2. American Academy of Child andAdolescent Psychiatry, Committee onHealth Care Access and EconomicsTask Force on Mental Health.Improving mental health services inprimary care: reducing administrativeand financial barriers to access andcollaboration. Pediatrics. 2009;123(4):1248–1251

3. Merikangas KR, He JP, Brody D, et al.Prevalence and treatment of mentaldisorders among US children in the2001-2004 NHANES. Pediatrics. 2010;125(1):75–81

4. Merikangas KR, He JP, Burstein M,et al. Service utilization for lifetimemental disorders in U.S. adolescents:results of the National ComorbiditySurvey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry.2011;50(1):32–45

5. Committee on Psychosocial Aspects ofChild and Family Health; Task Force onMental Health. Policy statement–thefuture of pediatrics: mental healthcompetencies for pediatric primarycare. Pediatrics. 2009;124(1):410–421

6. Foy JM, Green CM, Earls MF;Committee on Psychosocial Aspects ofChild and Family Health; Mental HealthLeadership Work Group. Mental healthcompetencies for pediatric practice.Pediatrics. 2019;144(5):e20192757

7. Fox HB, McManus MA, Klein JD, et al.Adolescent medicine training inpediatric residency programs.Pediatrics. 2010;125(1):165–172

8. Horwitz SM, Storfer-Isser A, Kerker BD,et al. Barriers to the identification andmanagement of psychosocialproblems: changes from 2004 to 2013.Acad Pediatr. 2015;15(6):613–620

9. Green C, Hampton E, Ward MJ, Shao H,Bostwick S. The current and idealstate of mental health training:pediatric program director

perspectives. Acad Pediatr. 2014;14(5):526–532

10. Haggerty RJ. The changing role of thepediatrician in child health care. AmJ Dis Child. 1974;127(4):545–549

11. Green M, Brazelton TB, Friedman DB,et al; American Academy of PediatricsCommittee on Psychosocial Aspects ofChild and Family Health. Pediatrics andthe psychosocial aspects of child andfamily health. Pediatrics. 1982;70(1):126–127

12. Burns BJ, Scott JE, Burke JD Jr, KesslerLG. Mental health training of primarycare residents: a review of recentliterature (1974-1981). Gen HospPsychiatry. 1983;5(3):157–169

13. Dworkin PH, Shonkoff JP, Leviton A,Levine MD. Training in developmentalpediatrics. How practitioners perceivethe gap. Am J Dis Child. 1979;133(7):709–712

14. Freed GL, Dunham KM, Switalski KE,Jones MD Jr, McGuinness GA; ResearchAdvisory Committee of the American

PEDIATRICS Volume 144, number 5, November 2019 9 by guest on March 12, 2021www.aappublications.org/newsDownloaded from

Board of Pediatrics. Recently trainedgeneral pediatricians: perspectives onresidency training and scope ofpractice. Pediatrics. 2009;123(suppl 1):S38–S43

15. Camp BW, Gitterman B, Headley R, BallV. Pediatric residency as preparationfor primary care practice. Arch PediatrAdolesc Med. 1997;151(1):78–83

16. Rosenberg AA, Kamin C, Glicken AD,Jones MD Jr. Training gaps for pediatricresidents planning a career in primarycare: a qualitative and quantitativestudy. J Grad Med Educ. 2011;3(3):309–314

17. Coury DL, Berger SP, Stancin T, TannerJL. Curricular guidelines for residencytraining in developmental-behavioralpediatrics. J Dev Behav Pediatr. 1999;20(suppl 2):S1–S38

18. Horwitz SM, Caspary G, Storfer-Isser A,et al. Is developmental and behavioralpediatrics training related to perceivedresponsibility for treating mentalhealth problems? Acad Pediatr. 2010;10(4):252–259

19. Stein RE, Storfer-Isser A, Kerker BD,et al. Does length of developmentalbehavioral pediatrics training matter?Acad Pediatr. 2017;17(1):61–67

20. Stein RE, Storfer-Isser A, Kerker BD,et al. Beyond ADHD: how well are wedoing? Acad Pediatr. 2016;16(2):115–121

21. Shahidullah JD, Kettlewell PW, PalejwalaMH, et al. Behavioral health training inpediatric residency programs:a national survey of training directors.J Dev Behav Pediatr. 2018;39(4):292–302

22. Stein RE. Are we on the right track?Examining the role of developmentalbehavioral pediatrics. Pediatrics. 2015;135(4):589–591

23. Foy JM; American Academy ofPediatrics Task Force on Mental Health.Enhancing pediatric mental health care:algorithms for primary care. Pediatrics.2010;125(suppl 3):S109–S125

24. American Academy of Pediatrics.Addressing Mental Health Concerns inPrimary Care: A Clinician’s Toolkit. ElkGrove Village, IL: American Academy ofPediatrics; 2010

25. Adam H, Foy J. Signs and Symptoms inPediatrics. Elk Grove Village, IL:American Academy of Pediatrics; 2015

26. McInerny TK, Adam HM, Campbell DE,eds, et al. Textbook of Pediatric Care,2nd ed. Elk Grove Village, IL: AmericanAcademy of Pediatrics; 2016

27. American Academy of Pediatrics.Pediatric care online. Available at:https://pediatriccare.solutions.aap.org/Pediatric-Care.aspx. AccessedNovember 3, 2018

28. Foy JM. Mental Health Care of Childrenand Adolescents: A Guide for PrimaryCare Clinicians. Itasca, IL: AmericanAcademy of Pediatrics; 2018

29. Wolraich ML, Hagan JF Jr., Allan C, et al;Subcommittee on Children andAdolescents With Attention-Deficit/Hyperactive Disorder. Clinical practiceguideline for the diagnosis, evaluation,and treatment of attention-deficit/hyperactivity disorder in children andadolescents. Pediatrics. 2019;144(4):e20192528

30. Zuckerbrot RA, Cheung A, Jensen PS,Stein REK, Laraque D; GLAD-PC SteeringGroup. Guidelines for AdolescentDepression in Primary Care (GLAD-PC):part I. Practice preparation,identification, assessment, and initialmanagement. Pediatrics. 2018;141(3):e20174081

31. Cheung AH, Zuckerbrot RA, Jensen PS,Laraque D, Stein REK; GLAD-PC SteeringGroup. Guidelines for AdolescentDepression in Primary Care (GLAD-PC):part II. Treatment and ongoingmanagement. Pediatrics. 2018;141(3):e20174082

32. Knapp P, Chait A, Pappadopulos E,Crystal S, Jensen PS; T-MAY SteeringGroup. Treatment of maladaptiveaggression in youth: CERT guidelines I.Engagement, assessment, andmanagement. Pediatrics. 2012;129(6).Available at: www.pediatrics.org/cgi/content/full/129/6/e1562

33. Scotto Rosato N, Correll CU,Pappadopulos E, et al; Treatment ofMaladaptive Aggressive in YouthSteering Committee. Treatment ofmaladaptive aggression in youth: CERTguidelines II. Treatments and ongoingmanagement. Pediatrics. 2012;129(6).Available at: www.pediatrics.org/cgi/content/full/129/6/e1577

34. Gleason MM, Goldson E, Yogman MW;Council on Early Childhood; Committeeon Psychosocial Aspects of Child and

Family Health; Section onDevelopmental and BehavioralPediatrics. Addressing early childhoodemotional and behavioral problems.Pediatrics. 2016;138(6):e20163025

35. Garner AS, Shonkoff JP; Committee onPsychosocial Aspects of Child andFamily Health; Committee on EarlyChildhood, Adoption, and DependentCare; Section on Developmental andBehavioral Pediatrics. Early childhoodadversity, toxic stress, and the role ofthe pediatrician: translatingdevelopmental science into lifelonghealth. Pediatrics. 2012;129(1).Available at: www.pediatrics.org/cgi/content/full/129/1/e224

36. Levy SJ, Williams JF; Committee onSubstance Use and Prevention.Substance use screening, briefintervention, and referral to treatment.Pediatrics. 2016;138(1):e20161211

37. American Academy of Pediatrics.Mental health initiatives: implementingmental health priorities in practice.Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/implementing_mental_health_priorities_in_practice.aspx. AccessedMay 17, 2019

38. American Academy of Pediatrics.Mental health initiatives: residencycurriculum. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/Residency-Curriculum.aspx.Accessed May 17, 2019

39. Garner AS, Storfer-Isser A, Szilagyi M,et al. Promoting early brain and childdevelopment: perceived barriers andthe utilization of resources to addressthem. Acad Pediatr. 2017;17(7):697–705

40. Green C. Mental health initiatives. In:Association of Pediatric ProgramDirectors 2017 Annual Spring MeetingPre-Meeting Workshop: The Behavioral/Mental Health Crisis: Preparing FuturePediatricians to Meet the Challenge:April 5, 2017; Anaheim, CA. Available at:https://www.appd.org/home/pdf/ABP_APPD_Training_Behavioral_Mental_Health.pdf. Accessed September 27,2019

41. McMillan JA, Land M Jr, Leslie LK.Pediatric residency education and thebehavioral and mental health crisis:

10 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 12, 2021www.aappublications.org/newsDownloaded from

a call to action. Pediatrics. 2017;139(1):e20162141

42. McMillan JA, Land ML Jr, Rodday AM,et al. Report of a joint association ofpediatric program directors-AmericanBoard of Pediatrics workshop:preparing future pediatricians for themental health crisis. J Pediatr. 2018;201:285–291

43. Hicks PJ, Englander R, Schumacher DJ,et al. Pediatrics milestone project: nextsteps toward meaningful outcomesassessment. J Grad Med Educ. 2010;2(4):577–584

44. Ten Cate O, Chen HC, Hoff RG, et al.Curriculum development for theworkplace using EntrustableProfessional Activities (EPAs): AMEEguide No. 99. Med Teach. 2015;37(11):983–1002

45. American Board of Pediatrics.Entrustable professional activities forgeneral pediatrics. 2016. Available at:https://www.abp.org/entrustable-professional-activities-epas. AccessedMay 23, 2019

46. Boat TF, Land ML Jr, Leslie LK. Healthcare workforce development toenhance mental and behavioral healthof children and youths. JAMA Pediatr.2017;171(11):1031–1032

47. Perrin JM, Gnanasekaran S, Delahaye J.Psychological aspects of chronic healthconditions. Pediatr Rev. 2012;33(3):99–109

48. Green C, Stein REK, Storfer-Isser A, et al.Do subspecialists ask about and referfamilies with psychosocial concerns? Acomparison with general pediatricians.Matern Child Health J. 2019;23(1):61–71

49. Samsel C, Ribeiro M, Ibeziako P, DeMasoDR. Integrated behavioral health care inpediatric subspecialty clinics. ChildAdolesc Psychiatr Clin N Am. 2017;26(4):785–794

50. Liaison Committee on Education.Functions and Structure of a MedicalSchool: Standards for Accreditation ofMedical Education Programs Leading tothe MD Degree. Washington, DC:Association of American MedicalColleges and American MedicalAssociation; 2018

51. Council on Medical Student Educationin Pediatrics. Curricular competenciesand objectives. 2017. Available at:

https://www.comsep.org/curriculum-competencies-and-objectives/ AccessedSeptember 27, 2019

52. Ragunanthan B, Frosch EJ, Solomon BS.On-site mental health professionals andpediatric residents in continuity clinic.Clin Pediatr (Phila). 2017;56(13):1219–1226

53. Guilamo-Ramos V, Jaccard J, Dittus P,Collins S. Parent-adolescentcommunication about sexualintercourse: an analysis of maternalreluctance to communicate. HealthPsychol. 2008;27(6):760–769

54. Green C. How can we use education toimprove the mental health of today’schildren? In: Association of PediatricProgram Directors 2017 Annual SpringMeeting Pre-Meeting Workshop: TheBehavioral/Mental Health Crisis:Preparing Future Pediatricians to Meetthe Challenge: April 5, 2017; Anaheim,CA. Available at: https://www.appd.org/home/pdf/ABP_APPD_Training_Behavioral_Mental_Health.pdf.Accessed September 27, 2019

55. Hampton E, Richardson JE, Bostwick S,Ward MJ, Green C. The current andideal state of mental health training:pediatric resident perspectives. TeachLearn Med. 2015;27(2):147–154

56. Kaufman DM. Applying educationaltheory in practice. BMJ. 2003;326(7382):213–216

57. Bauer NS, Sullivan PD, Hus AM, DownsSM. Promoting mental healthcompetency in residency training.Patient Educ Couns. 2011;85(3):e260–e264

58. Kutner L, Olson CK, Schlozman S, et al.Training pediatric residents andpediatricians about adolescent mentalhealth problems: a proof-of-conceptpilot for a proposed nationalcurriculum. Acad Psychiatry. 2008;32(5):429–437

59. Fallucco EM, Hanson MD, Glowinski AL.Teaching pediatric residents to assessadolescent suicide risk witha standardized patient module.Pediatrics. 2010;125(5):953–959

60. Jee SH, Baldwin C, Dadiz R, Jones M,Alpert-Gillis L. Integrated mental healthtraining for pediatric and psychologytrainees using standardized patient

encounters. Acad Pediatr. 2018;18(1):119–121

61. Garfunkel LC, Pisani AR, leRoux P, SiegelDM. Educating residents in behavioralhealth care and collaboration:comparison of conventional andintegrated training models. Acad Med.2011;86(2):174–179

62. Bunik M, Talmi A, Stafford B, et al.Integrating mental health services inprimary care continuity clinics:a national CORNET study. Acad Pediatr.2013;13(6):551–557

63. Schram P, Harris SK, Van Hook S, et al.Implementing adolescent Screening,Brief Intervention, and Referral toTreatment (SBIRT) education ina pediatric residency curriculum. SubstAbus. 2015;36(3):332–338

64. Ryan S, Pantalon MV, Camenga D,Martel S, D’Onofrio G. Evaluation ofa pediatric resident skills-basedscreening, brief intervention andreferral to treatment (SBIRT)curriculum for substance use.J Adolesc Health. 2018;63(3):327–334

65. Lewy C, Sells CW, Gilhooly J, McKelvey R.Adolescent depression: evaluatingpediatric residents’ knowledge,confidence, and interpersonal skillsusing standardized patients. AcadPsychiatry. 2009;33(5):389–393

66. Cohen DJ, Davis MM, Hall JD, GilchristEC, Miller BF. A Guidebook ofProfessional Practices for BehavioralHealth and Primary Care Integration:Observations From Exemplary Sites.Rockville, MD: Agency for HealthcareResearch and Quality; 2015

67. Miller BF, Gilchrist EC, Ross KM, WongSL, Blount A, Peek CJ. Corecompetencies for behavioral healthproviders working in primary care.2016. Available at: http://farleyhealthpolicycenter.org/wp-content/uploads/2016/02/Core-Competencies-for-Behavioral-Health-Providers-Working-in-Primary-Care.pdf.Accessed May 17, 2019

68. Burkey MD, Kaye DL, Frosch E. Trainingin integrated mental health-primarycare models: a national survey of childpsychiatry program directors. AcadPsychiatry. 2014;38(4):485–488

69. Zomorodi M, de Saxe Zerden L,Alexander L, Nance-Floyd B; Healthcare

PEDIATRICS Volume 144, number 5, November 2019 11 by guest on March 12, 2021www.aappublications.org/newsDownloaded from

PROMISE team. Engaging students inthe development of aninterprofessional population healthmanagement course. Nurse Educ. 2017;42(1):5–7

70. Moran M. Innovative ‘buddy system’teaches collaboration. Psychiatr News.2014;49(9). Available at: https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2014.5a15/. AccessedMay 17, 2019

71. Pisani AR, leRoux P, Siegel DM.Educating residents in behavioralhealth care and collaboration:integrated clinical training of pediatricresidents and psychology fellows. AcadMed. 2011;86(2):166–173

72. Accreditation Council on GraduateMedical Education. ACGME corecompetencies. Available at: https://www.ecfmg.org/echo/acgme-core-competencies.html. Accessed March 9,2018

73. Accreditation Council on GraduateMedical Education. ACGME programrequirements for graduate medicaleducation in the subspecialties ofpediatrics. 2016. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRFellowship2019.pdf Accessed September 27, 2019

74. Wissow LS, Gadomski A, Roter D, et al.Improving child and parent mentalhealth in primary care: a cluster-randomized trial of communicationskills training. Pediatrics. 2008;121(2):266–275

75. Wissow LS, Brown JD, Krupnick J.Therapeutic alliance in pediatricprimary care: preliminary evidence fora relationship with physiciancommunication style and mothers’satisfaction. J Dev Behav Pediatr. 2010;31(2):83–91

76. Wissow L, Anthony B, Brown J, et al. Acommon factors approach to improvingthe mental health capacity of pediatricprimary care. Adm Policy Ment Health.2008;35(4):305–318

77. Gadomski AM, Wissow LS, Palinkas L,et al. Encouraging and sustainingintegration of child mental health intoprimary care: interviews with primarycare providers participating in ProjectTEACH (CAPES and CAP PC) in NY. GenHosp Psychiatry. 2014;36(6):555–562

78. Integrated Primary Care. The portal toinformation and tools for theintegration of behavioral health andprimary care. Available at: https://sites.google.com/view/integratedprimarycare2/training.Accessed September 27, 2019

79. The Resource for Advancing Children’sHealth Institute. Child and adolescenttraining institute in evidence-basedpsychotherapies (CATIE). Available at:www.thereachinstitute.org/services/for-healthcare-organizations/staff-training/child-adolescent-training-in-evidence-based-psychotherapies-catie-1. Accessed March 26, 2019

80. McCaffrey ESN, Chang S, Farrelly G,Rahman A, Cawthorpe D. Mental healthliteracy in primary care: CanadianResearch and Education for theAdvancement of Child Health(CanREACH). Evid Based Med. 2017;22(4):123–131

81. Kaye DL, Fornari V, Scharf M, et al.Description of a multi-universityeducation and collaborative care childpsychiatry access program: New YorkState’s CAP PC. Gen Hosp Psychiatry.2017;48:32–36

82. Dvir Y, Wenz-Gross M, Jeffers-Terry M,Metz WP. An assessment of satisfactionwith ambulatory child psychiatryconsultation services to primary careproviders by parents of children withemotional and behavioral needs: theMassachusetts Child Psychiatry AccessProject University of Massachusettsparent satisfaction study. FrontPsychiatry. 2012;3:7

83. Massachusetts Child Psychiatry AccessProject. Available at: www.mcpap.org.Accessed March 26, 2019

84. Sarvet B, Gold J, Bostic JQ, et al.Improving access to mental health carefor children: the Massachusetts ChildPsychiatry Access Project. Pediatrics.2010;126(6):1191–1200

85. Van Cleave J, Le TT, Perrin JM. Point-of-care child psychiatry expertise: theMassachusetts Child Psychiatry AccessProject. Pediatrics. 2015;135(5):834–841

86. Straus JH, Sarvet B. Behavioral healthcare for children: the MassachusettsChild Psychiatry Access Project. HealthAff (Millwood). 2014;33(12):2153–2161

87. Byatt N, Biebel K, Moore Simas TA, et al.Improving perinatal depression care:the Massachusetts Child PsychiatryAccess Project for Moms. Gen HospPsychiatry. 2016;40:12–17

88. National Network of Child PsychiatryAccess Programs. Available at: http://web.jhu.edu/pedmentalhealth/nncpap_members.html. Accessed September 27,2019

89. Health Resources and ServicesAdministration. Pediatric Mental HealthCare Access Program. Available at:https://www.hrsa.gov/grants/fundingopportunities/default.aspx?id=f1fe7b69-4d80-4a92-a3e8-aecee0fbbdee.Accessed March 26, 2019

90. American Academy of Pediatrics OhioChapter. Building mental wellness.Available at: http://ohioaap.org/projects/building-mental-wellness/.Accessed March 26, 2019

91. King MA, Wissow LS, Baum RA. The roleof organizational context in theimplementation of a statewide initiativeto integrate mental health services intopediatric primary care. Health CareManage Rev. 2018;43(3):206–217

92. Association Medical Association. Teamculture: strengthen team cohesion andengagement. 2015. Available at: https://edhub.ama-assn.org/steps-forward/module/2702515. Accessed March 26,2019

93. Ginsburg GS, Drake K, Winegrad H,Fothergill K, Wissow L. An open trial ofthe Anxiety Action Plan (AxAP): a briefpediatrician-delivered intervention foranxious youth. Child Youth Care Forum.2016;45(1):19–32

94. Asarnow JR, Rozenman M, Wiblin J,Zeltzer L. Integrated medical-behavioralcare compared with usual primarycare for child and adolescentbehavioral health: a meta-analysis.JAMA Pediatr. 2015;169(10):929–937

95. Richardson LP, McCarty CA, Radovic A,Suleiman AB. Research in theintegration of behavioral health foradolescents and young adults inprimary care settings: a systematicreview. J Adolesc Health. 2017;60(3):261–269

96. Kaplan-Sanoff M, Talmi A, Augustyn M.Infusing mental health services intoprimary care for very young children

12 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 12, 2021www.aappublications.org/newsDownloaded from

and their families. Zero Three. 2012;33(2):73–77

97. Talmi A, Fazio E. Commentary:promoting health and well-being inpediatric primary care settings: usinghealth and behavior codes at routinewell-child visits. J Pediatr Psychol. 2012;37(5):496–502

98. Greene CA, Ford JD, Ward-ZimmermanB, Honigfeld L, Pidano AE. Strengtheningthe coordination of pediatric mentalhealth and medical care: pilotinga collaborative model for freestandingpractices. Child Youth Care Forum.2016;45(5):729–744

99. Pidano AE, Marcaly KH, Ihde KM,Kurowski EC, Whitcomb JM.Connecticut’s enhanced care clinicinitiative: early returns from pediatric-behavioral health partnerships. FamSyst Health. 2011;29(2):138–143

100. Talmi A, Muther EF, Margolis K, et al. Thescope of behavioral health integrationin a pediatric primary care setting.

J Pediatr Psychol. 2016;41(10):1120–1132

101. Blount A, ed. Integrated Primary Care:The Future of Medical and MentalHealth Collaboration. New York, NY: W.W. Norton and Company, Inc; 1998

102. Kolko DJ, Perrin E. The integration ofbehavioral health interventions inchildren’s health care: services,science, and suggestions. J Clin ChildAdolesc Psychol. 2014;43(2):216–228

103. Williams J, Shore SE, Foy JM. Co-location of mental health professionalsin primary care settings: three NorthCarolina models. Clin Pediatr (Phila).2006;45(6):537–543

104. Horwitz S, Storfer-Isser A, Kerker BD, et al.Do on-site mental health professionalschange pediatricians’ responses tochildren’s mental health problems? AcadPediatr. 2016;16(7):676–683

105. Ader J, Stille CJ, Keller D, et al. Themedical home and integrated

behavioral health: advancing thepolicy agenda. Pediatrics. 2015;135(5):909–917

106. Delamater AM, de Wit M, McDarby V,Malik J, Acerini CL; International Societyfor Pediatric and Adolescent Diabetes.ISPAD Clinical Practice ConsensusGuidelines 2014. Psychological care ofchildren and adolescents with type 1diabetes. Pediatr Diabetes. 2014;15(suppl 20):232–244

107. Wiener L, Kazak AE, Noll RB, PatenaudeAF, Kupst MJ. Standards for thepsychosocial care of children withcancer and their families: anintroduction to the special issue.Pediatr Blood Cancer. 2015;62(suppl 5):S419–S424

108. Freeman DS, Hudgins C, Hornberger J.Legislative and policy developmentsand imperatives for advancing thePrimary Care Behavioral Health (PCBH)model. J Clin Psychol Med Settings.2018;25(2):210–223

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Cori M. Green, Jane Meschan Foy, Marian F. Earls and COMMITTEE ONAchieving the Pediatric Mental Health Competencies

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