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Reports expand mental health competencies, strategies for practice :

October 21, 2019

Pediatricians have unique opportunities to integrate mental health care into practice given their longitudinal, trusting and empowering relationships with patients and their families. Their role in combating the mental health crisis is critical given this “pediatric advantage” along with a growing responsibility to promote healthy social-emotional development of children and address mental health and substance use problems.

One in five children has a mental health problem, and suicide is the second leading cause of death starting at age 10. Most children never receive the mental health care they need, partially due to a shortage of specialists. The need to address gaps in care is urgent, but pediatricians' ability to play a more effective role in mental health depends on developing or honing their knowledge and skills.

An updated AAP policy statement and a new technical report recommend competencies pediatricians should achieve to meet the mental health needs of today's children.

The policy, Mental Health Competencies for Pediatric Practice, updated from 2009, and the technical report, Achieving the Pediatric Mental Health Competencies, are available at https://doi.org/10.1542/peds.2019-2757 and https://doi.org/10.1542/peds.2019-2758 and will be published in the November issue of Pediatrics. Both documents are from the Committee on Psychosocial Aspects of Child and Family Health and Mental Health Leadership Workgroup.

Improving skills

The competencies are organized in the framework used for medical education: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice.

Patient care skills highlighted include:

  • primary prevention strategies to promote healthy social-emotional development and resilience to stress;
  • secondary prevention strategies to address risks to healthy social-emotional development and emerging symptoms;
  • recognition of suicidality and other mental health emergencies;
  • engagement of families in caring for emerging problems and helping relieve distress, using motivational interviewing and other communication skills;
  • provision of treatment with appropriate brief psychosocial interventions, even if planning to involve a mental health specialist;
  • assessment and diagnosis of common disorders (e.g., attention-deficit/hyperactivity disorder [ADHD], anxiety, depression and substance use);
  • initiation of pharmacologic treatment when indicated (ADHD medications and selective serotonin reuptake inhibitors); and
  • initiation of referrals for management or co-management of moderate to severe disorders as appropriate given the pediatrician's comfort and skills, and the parents’ preferences.

Need for systemic changes

To attain these skills and integrate them into practice, the AAP recommends that pediatricians adopt the following systemic changes, as needed:

  • Partner with stakeholders to improve the organizational and financial base of mental health care.
  • Pursue quality improvement and maintenance of certification activities that enhance mental health practice.
  • Explore collaborative care models of practice. Build relationships with mental health specialists.
  • Pursue educational strategies to build on knowledge and skills.
  • Advocate for innovations in the education for all levels of learners.
  • Promote and participate in research on the delivery of mental health services in pediatric primary care and subspecialty settings.

Achieving the competencies

Pediatricians' attitudes, skills and practices vary in how they care for children with mental health problems and in their access to mental health specialists. Therefore, the AAP recommends pediatricians develop new skills and change their practices incrementally, starting with competencies that build on current skills and are most relevant to their practice.

Achieving the competencies will require new educational approaches and significant enhancement in the interest and competence of pediatric faculty members who serve as teachers and role models.

Since the 2009 policy, the AAP has published several policy statements and technical reports on specific mental health problems and disorders, providing further guidance for pediatricians to integrate mental health into practice. These include early childhood adversity and toxic stress, early social-emotional development, maternal depression, child and adolescent depression, substance use disorder and ADHD.

Educational improvements

The technical report summarizes successful educational innovations in the training of pediatric residents, fellows, preceptors and practicing pediatricians, along with areas that still need innovation. Pediatric educators can consider the following strategies:

  • Prioritize training in “common factors” communication skills (components of effective interventions common to a variety of therapies).
  • Incorporate the mental health competencies into curricular objectives.
  • Incorporate the promotion of healthy social-emotional development into the residency curriculum.
  • Prepare medical educators and preceptors to model, teach and assess mental health competencies.
  • Include mental health specialists and/or developmental specialists as co-preceptors and team members in all aspects of care.
  • Incorporate trainees in psychology, social work, child psychiatry, developmental-behavioral pediatrics and other specialties as team members in continuity and subspecialty clinics.
  • Add clinical experience(s) into residency, preferably a longitudinal experience.
  • Monitor learners’ success in achieving the competencies and ensure ongoing opportunities to practice skills.
  • Participate in and/or support research on how to best train learners at each level.

Dr. Green is a lead author of the policy statement and technical report and was a member of the Mental Health Leadership Workgroup.

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