Mental Health Competencies for Pediatric Practice

A total of 13% to 20% of US children and adolescents experience a mental* disorder in a given year.¹  According to the seminal Great Smoky Mountain Study, which has followed a cohort of rural US youth since 1992, 19% of youth manifested impaired mental functioning without meeting the criteria for diagnosis as a mental disorder (ie, subthreshold symptoms).²  The authors of this study have since shown that adults who had a childhood mental disorder have 6 times the odds of at least 1 adverse adult outcome in the domain of health, legal, financial, or social functioning compared with adults without childhood disorders, even after controlling for childhood psychosocial hardships. Adults who had impaired functioning and subthreshold psychiatric symptoms during childhood—termed “problems” in this statement—have 3 times the odds of adverse outcomes as adults.³  These findings underscore the importance to adult health of both mental health disorders and mental health problems during childhood.

The prevalence of mental health disorders and problems (collectively termed “conditions” in this statement) in children and adolescents is increasing and, alarmingly, suicide rates are now the second leading cause of death in young people from 10 to 24 years of age.^4–6  Furthermore, nearly 6 million children were considered disabled in 2010–2011, an increase of more than 15% from a decade earlier; among these children, reported disability related to physical illnesses decreased by 11.8%, whereas disability related to neurodevelopmental and mental health conditions increased by 20.9%.⁵  Although the highest rates of reported neurodevelopmental and mental health disabilities were seen in children living in poverty, the greatest increase in prevalence of reported neurodevelopmental and mental health disabilities occurred, unexpectedly, among children living in socially advantaged households (income ≥400% of the federal poverty level).⁵ 

Comorbid mental health conditions often complicate chronic physical conditions, decreasing the quality of life for affected children and increasing the cost of their care.^7–12  Because of stigma, shortages of mental health specialists, administrative barriers in health insurance plans, cost, and other barriers to mental health specialty care, an estimated 75% of children with mental health disorders go untreated.^13–16  Primary care physicians are the sole physician managers of care for an estimated 4 in 10 US children with attention-deficit/hyperactivity disorder (ADHD) and one-third with mental disorders overall.¹⁷ 

In 2009, the American Academy of Pediatrics (AAP) issued a policy statement, “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,” proposing competencies—skills, knowledge, and attitudes—requisite to providing mental health care of children in primary care settings and recommending steps toward achieving them.¹⁸  In the policy, the AAP documented the many forces driving the need for enhancements in pediatric mental health practice.

In the years since publication of the original policy statement on mental health competencies, increases in childhood mental health morbidity and mortality and a number of other developments have added to the urgency of enhancing pediatric mental health practice. A federal parity law has required that insurers cover mental health and physical health conditions equivalently.^19,20  Researchers have shown that early positive and adverse environmental influences—caregivers’ protective and nurturing relationships with the child, social determinants of health, traumatic experiences (ecology), and genetic influences (biology)—interact to affect learning capacities, adaptive behaviors, lifelong physical and mental health, and adult productivity, and pediatricians have a role to play in addressing chronic stress and adverse early childhood experiences.^21–24  Transformative changes in the health care delivery system—payment for value, system- and practice-level integration of mental health and medical services, crossdiscipline accountability for outcomes, and the increasing importance of the family- and patient-centered medical home—all have the potential to influence mental health care delivery.^25–27  Furthermore, improving training and competence in mental health care for future pediatricians—pediatric subspecialists as well as primary care pediatricians—has become a national priority of the American Board of Pediatrics^28,29  and the Association of Pediatric Program Directors.³⁰ 

In this statement, we (1) discuss the unique aspects of the pediatrician’s role in mental health care; (2) articulate competencies needed by the pediatrician to promote healthy social-emotional development, identify risks and emerging symptoms, prevent or mitigate impairment from mental health symptoms, and address the mental health and substance use conditions prevalent among children and adolescents in the United States; and (3) recommend achievable next steps toward enhancing mental health practice to support pediatricians in providing mental health care. The accompanying technical report, “Achieving the Pediatric Mental Health Competencies,” is focused on strategies to train future pediatricians and prepare practices for achieving the competencies.³¹ 

Traditional concepts of mental health care as well as mental health payment systems build on the assumption that treatment must follow the diagnosis of a disorder. However, this diagnostic approach does not take into account the many opportunities afforded pediatricians, both in general and subspecialty practice, to promote mental health and to offer primary and secondary prevention. Nor do these traditional concepts address the issue that many children have impaired functioning although they do not meet the diagnostic criteria for a specific mental disorder. Consequently, pediatric mental health competencies differ in some important respects from competencies of mental health professionals. The unique role of pediatricians in mental health care stems from the “primary care advantage,” which is a developmental mind-set, and their role at the front lines of children’s health care.³²  Primary care pediatricians typically see their patients longitudinally, giving them the opportunity to develop a trusting and empowering therapeutic relationship with patients and their families; to promote social-emotional health with every contact, whether for routine health supervision, acute care, or care of a child’s chronic medical or developmental condition; to prevent mental health problems through education and anticipatory guidance; and to intervene in a timely way if and when risks, concerns, or symptoms emerge. Recognizing the longitudinal and close relationships that many pediatric subspecialists have with patients and families, the authors of this statement have expanded the concept of primary care advantage to the “pediatric advantage.”

Pediatric subspecialists, like pediatric primary care clinicians, need basic mental health competencies. Children and adolescents with somatic manifestations of mental health problems often present to pediatric medical subspecialists or surgical specialists for evaluation of their symptoms; awareness of mental health etiologies has the potential to prevent costly and traumatic workups and expedite referral for necessary mental health services.³³  Children and adolescents with chronic medical conditions have a higher prevalence of mental health problems than do their peers without those conditions; and unrecognized mental health problems, particularly anxiety and depression, often drive excessive use of medical services in children with a chronic illness and impede adherence to their medical treatment.³⁴  Furthermore, children and adolescents with serious and life-threatening medical and surgical conditions often experience trauma, such as painful medical procedures, disfigurement, separation from loved ones during hospitalizations, and their own and their loved ones’ fears about prognosis.³⁵  For these reasons, mental health competencies involving clinical assessment, screening, early intervention, referral, and comanagement are relevant to pediatric subspecialists who care for children with chronic conditions. Subspecialists have the additional responsibility of coordinating any mental health services they provide with patients’ primary care clinicians to prevent duplication of effort, connect children and families to accessible local resources, and reach agreement on respective roles in monitoring patients’ mental health care.

The AAP Task Force on Mental Health (2004–2010) spoke to the importance of enhancing pediatricians’ mental health practice while recognizing that incorporating mental health care into a busy pediatric practice can be a daunting prospect. The task force offered an algorithm, the “Primary Care Approach to Mental Health Care,” depicting a process by which mental health services can be woven into practice flow, and tied each step in the algorithm to Current Procedural Terminology coding guidance that can potentially support those mental health–related activities in a fee-for-service environment.³²  The AAP Mental Health Leadership Work Group (2011–present) recently updated this to the “Algorithm: A Process for Integrating Mental Health Care Into Pediatric Practice” (see Fig 1). The AAP has a number of resources to assist with coding for mental health care.

The pediatric process for identifying and managing mental health problems is similar to the iterative process of caring for a child with fever and no focal findings: the clinician’s initial assessment of the febrile child’s severity of illness determines if there is a serious problem that urgently requires further diagnostic evaluation and treatment; if not, the clinician advises the family on symptomatic care and watchful waiting and advises the family to return for further assessment if symptoms persist or worsen. Similarly, a mental health concern of the patient, family, or child care and/or school personnel (or scheduling of a routine health supervision visit [algorithm step 1]) triggers a preliminary psychosocial assessment (algorithm step 2). This initial assessment can be expedited by use of previsit collection of data and screening tools (electronic or paper and pencil), which the clinician can review in advance of the visit, followed by a brief interview and observations to explore findings (both positive and negative) and the opportunity to highlight the child’s and family’s strengths, an important element of supportive, family-centered care. Finding a problem that is not simply a normal behavioral variation (algorithm step 3) necessitates triage for a psychiatric and/or social emergency and, if indicated, immediate care in the subspecialty or social service system (algorithm steps 9 and 10). In making these determinations, it is important to understand the family context, namely, the added risks conferred by adverse social determinants of health, which may exacerbate the problem and precipitate an emergency. Intervention will need to include supports to address social determinants.

If an identified problem is not an emergency, the clinician can undertake 1 or more brief interventions, as time allows, during the current visit or at follow-up visit(s) (algorithm step 11). These interventions may include iteratively expanding the assessment, for example, by using secondary screening tools, gathering information from school personnel or child care providers, or having the family create a diary of problem behaviors and their triggers. Brief interventions may also include referral of a family member for assistance in addressing his or her own social or mental health problems that may be contributing to the child’s difficulties. In addition, brief interventions may include evidence-informed techniques to address the child’s symptoms, as described in the section immediately below.

When indicated by findings of the assessment and/or by failure to respond to brief therapeutic interventions, a full diagnostic assessment can be performed, either by the pediatrician (algorithm step 15) at a follow-up visit or through referral to a specialist (algorithm step 16), followed by the steps of care planning and implementation, comanagement, and monitoring the child’s progress (algorithm steps 17 and 18).

Although disorder-specific, standardized psychosocial treatments have been a valuable advance in the mental health field generally, their real-world application to the care of children and adolescents has been limited by the fact that many young people are “diagnostically heterogeneous”; that is, they manifest symptoms of multiple disorders or problems, and their manifestations are variably triggered by events and by their social environment. These limitations led researchers in the field of psychotherapy to develop and successfully apply “transdiagnostic” approaches to the care of children and adolescents, addressing multiple disorders and problems by using a single protocol and allowing for more flexibility in selecting and sequencing interventions.³⁶ 

A number of transdiagnostic approaches are proving to be adaptable for use as brief interventions in pediatric settings. The goals of brief therapeutic interventions for children and adolescents with emerging symptoms of mild to moderate severity are to improve the patient’s functioning, reduce distress in the patient and parents, and potentially prevent a later disorder. For children and adolescents identified as needing mental health and/or developmental-behavioral specialty involvement, goals of brief interventions are to help overcome barriers to their accessing care, to ameliorate symptoms and distress while awaiting completion of the referral, and to monitor the patient’s functioning and well-being while awaiting higher levels of care. Brevity of these interventions, ideally no more than 10 to 15 minutes per session, mitigates disruption to practice flow. Although formal evaluation of these adaptations is in its early stages, authors of studies suggest that they can be readily learned by pediatric clinicians and are beneficial to the child and family.³⁷  Table 1 is used to excerpt several of these adaptations from a summary by Wissow et al.³⁷ 

All of these approaches feature prominently in the pediatric mental health competencies; 2 require further explanation.

“Common-factors” communication skills, so named because they are components of effective interventions common to diverse therapies across multiple diagnoses, are foundational among the proposed pediatric mental health competencies. These communication techniques include clinician interpersonal skills that help to build a therapeutic alliance—the felt bond between the clinician and patient and/or family, a powerful factor in facilitating emotional and psychological healing—which, in turn, increases the patient and/or family’s optimism, feelings of well-being, and willingness to work toward improved health. Other common-factors techniques target feelings of anger, ambivalence, and hopelessness, family conflicts, and barriers to behavior change and help seeking. Still other techniques keep the discussion focused, practical, and organized. These techniques come from family therapy, cognitive therapy, motivational interviewing, family engagement, family-focused pediatrics, and solution-focused therapy.³⁸  They have been proven useful and effective in addressing mental health symptoms in pediatrics across the age spectrum and can be readily acquired by experienced clinicians.³⁹  Importantly, when time is short, the clinician can also use them to bring a visit to a supportive close while committing his or her loyalty and further assistance to the patient and family—that is, reinforcing the therapeutic alliance, even as he or she accommodates to the rapid pace of the practice.

See Table 2 for the HELP mnemonic, developed by the AAP Task Force on Mental Health to summarize components of the common-factors approach.

“Common-elements” approaches can also be used as brief interventions. They differ from common factors in that instead of applying to a range of diagnoses that are not causally related, common elements are semispecific components of psychosocial therapies that apply to a group of related conditions.^40–43  In this approach, the clinician caring for a patient who manifests a cluster of causally related symptoms—for example, fearfulness and avoidant behaviors—draws interventions from evidence-based psychosocial therapies for a related set of disorders—in this example, anxiety disorders. Thus, as a first-line intervention to help an anxious child, the pediatrician coaches the parent to provide gradual exposure to feared activities or objects and to model brave behavior—common elements in a number of effective psychosocial treatments for anxiety disorders. Such interventions can be definitive or a means to reduce distress and ameliorate symptoms while a child is awaiting mental health specialty assessment and/or care. Table 3 is used to summarize promising common-elements approaches applicable to common pediatric primary care problems.

Certain evidence-based complementary and integrative medicine approaches may also lend themselves to brief interventions: for example, relaxation and other self-regulation therapies reveal promise in assisting children to manage stress and build their resilience to trauma and social adversities.⁴³  Other brief interventions include coaching parents in managing a particular behavior (eg, “time-out” for disruptive behavior⁴⁴ ) or, more broadly, strategies to reduce stress in the household and to foster a sense of closeness and emotional security, for example, reading together,⁴⁵  sharing outdoor time,⁴⁶  or parent-child “special time”—a regularly scheduled period as brief as 5 to 10 minutes set aside for a one-on-one, interactive activity of the child’s choice.⁴⁷  Self-help resources may also be useful (eg, online depression management).⁴⁸  Encouragement of healthy habits, such as sufficient sleep (critically important to children’s mental health and resilience as well as their parents’), family meals, active play, time and content limits on media exposure, and prosocial activities with peers can be used as “universal” brief interventions across an array of presenting problems as well as a means to promote mental wellness and resilience.⁴⁹ 

For a more detailed summary of psychosocial interventions and the evidence supporting them, see PracticeWise Evidence-Based Child and Adolescent Psychosocial Interventions at www.aap.org/mentalhealth. Psychosocial interventions that have been studied in primary care are listed in Common Elements of Evidence-Based Practice Amenable to Primary Care: Indications and Sources at www.aap.org/mentalhealth. With training, pediatricians can achieve competence in applying brief interventions such as these in primary care or, potentially, subspecialty settings.^37,50–52 

The Accreditation Council for Graduate Medical Education has organized competencies into 6 domains: patient care, medical knowledge, interpersonal and communication skills, practice-based learning and improvement, professionalism, and systems-based practice.⁵³  We have used this framework to develop a detailed outline of pediatric mental health competencies for use by pediatric educators; this outline is available at www.aap.org/mentalhealth. Competencies most salient to this statement are listed in Tables 4 and 5.

All pediatricians need skills to promote mental health, efficiently perform psychosocial assessments, and provide primary and secondary preventive services (eg, anticipatory guidance, screening). They need to be able to triage for psychiatric emergencies (eg, suicidal or homicidal intent, psychotic thoughts) and social emergencies (eg, child abuse or neglect, domestic violence, other imminent threats to safety). Pediatricians need to be able to establish a therapeutic alliance with the patient and family and take initial action on any identified mental health and social concerns, as described above. All pediatricians also need to know how to organize the care of patients who require mental health specialty referral or consultation, facilitate transfer of trust to mental health specialists, and coordinate their patients’ mental health care with other clinicians, reaching previous agreement on respective roles, such as who will prescribe and monitor medications and how communication will take place. The care team might include any of the individuals listed in Table 6, on- or off-site. For a discussion of collaborative care models that integrate services of mental health and pediatric professionals, see the accompanying technical report.³¹ 

The clinical role of the pediatrician will depend on the patient’s condition and level of impairment, interventions and supports needed, patient and family priorities and preferences, pediatrician’s self-perception of efficacy and capacity, and accessibility of community services.

Disorders such as maladaptive aggression^54,55  and bipolar disorder⁵⁶  may require medications for which pediatricians will need specialized training or consultation from physician mental health specialists to prescribe (eg, antipsychotics, lithium). Comanagement—formally defined as “collaborative and coordinated care that is conceptualized, planned, delivered, and evaluated by 2 or more health care providers”⁵⁷ —is a successful approach for complex mental conditions in children and adolescents. Both general pediatricians and pediatric subspecialists will benefit from these collaborative skills. These skills also enable pediatricians to help adolescents with mental health conditions and their families transition the adolescent’s care to adult primary and mental health specialty care at the appropriate time, as pediatricians do other patients with special health care needs.

Misperceptions about privacy regulations (eg, the Health Insurance Portability and Accountability Act of 1996,⁵⁸  federal statutes and regulations regarding substance abuse treatment [42 US Code § 290dd–2; 42 Code of Federal Regulations 2.11],⁵⁹  and state-specific regulations) often impede collaboration by limiting communication among clinicians who are providing services. In most instances, pediatricians are, in fact, allowed to exchange information with other clinicians involved in a patient’s care, even without the patient or guardian’s consent. Pediatricians need an accurate understanding of privacy regulations to ensure that all clinicians involved in the mutual care of a patient share information in an appropriate and timely way (see https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/HIPAA-Privacy-Rule-and-Provider-to-Provider-Communication.aspx).

Other necessary clinical skills are specific to the age, presenting problem of the patient, and type of therapy required, as described in the following sections.

For infants and preschool-aged children, the signs and symptoms of emotional distress may be varied and nonspecific and may manifest themselves in the child, in the parent, or in their relationship. When consistently outside the range of normal development, these young children and families typically require specialized diagnostic assessment (based on the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood⁶⁰ ), intensive parenting interventions, and treatment by developmental-behavioral specialists or mental health specialists with expertise in early childhood. Consequently, pediatric mental health competencies for the care of this age group involve overcoming any barriers to referral, guiding the family in nurturing and stimulating the child, counseling on parenting and behavioral management techniques, referring for diagnostic assessment and dyadic (attachment-focused) therapy as indicated, and comanaging care. When social risk factors are identified (eg, maternal depression, poverty, food insecurity), the pediatrician’s role is to connect the family to needed resources.

The AAP Task Force on Mental Health identified common manifestations of mental health problems in school-aged children and adolescents as depression (low mood), anxious and avoidant behaviors, impulsivity and inattention (with or without hyperactivity), disruptive behavior and aggression, substance use, and learning difficulty and developed guidance to assist pediatric clinicians in addressing these problems.⁶¹  Recognizing that 75% of children who need mental health services do not receive them, the AAP went on to publish a number of additional educational resources on these topics, specifically for pediatricians.^62–64  Additional tools are available online at www.aap.org/mentalhealth. Children and adolescents who have experienced trauma may manifest any combination of these symptoms.^65,66  Children and adolescents with an underlying mental condition may present with somatic symptoms (eg, headache, abdominal pain, chest pain, limb pain, fatigue) or eating abnormalities.^67,68  Furthermore, children and adolescents may experience impaired functioning at home, at school, or with peers, even in the absence of symptoms that reach the threshold for a diagnosis.^2,69,70 

Once a pediatrician has identified a child or adolescent with 1 or more of these manifestations of a possible mental health condition (collectively termed “mental health concerns” in this statement, indicating that they are undifferentiated as to disorder, problem, or normal variation), the pediatrician needs skills to differentiate normal variations from problems from disorders and to diagnose, at a minimum, conditions for which evidence-based primary care assessment and treatment guidance exists—currently ADHD,⁷¹  depression,^72,73  and substance use.⁷⁴  Pediatricians also need knowledge and skills to diagnose anxiety disorders, which are among the most common disorders of childhood, often accompany and adversely affect the care of chronic medical conditions, and when associated with no more than mild to moderate impairment, are often amenable to pediatric treatment.⁶⁶  A number of disorder-specific rating scales and functional assessment tools are applicable to use in pediatrics, both to assist in diagnosis and to monitor the response to interventions; these have been described and referenced in the document “Mental Health Tools for Pediatrics” at www.aap.org/mentalhealth.

Although the diagnostic assessment of children presenting with aggressive behaviors often requires mental health specialty involvement, pediatricians can use a stepwise approach to begin the assessment and offer guidance in selecting psychosocial interventions in the community for further diagnosis and treatment, as outlined in the guideline, “Treatment of Maladaptive Aggression in Youth (T-MAY),” available at www.ahrq.gov/sites/default/files/wysiwyg/chain/practice-tools/tmay-final.pdf.

Many pharmacologic and psychosocial therapies have been proven effective in treating children with mental health disorders. Pharmacologic therapies may be more familiar to pediatricians than psychosocial therapies; however, psychosocial therapies, either alone or in combination with pharmacologic therapies, may be more effective in some circumstances. For example, American Academy of Child and Adolescent Psychiatry guidelines recommend at least 2 trials of psychosocial treatment before starting medication in young children up to 5 years of age.⁷⁵  Studies involving children and adolescents in several specific age groups have revealed the advantage of combined psychosocial and medication treatment over either type of therapy alone for ADHD in 7- to 9-year-old children,⁷⁶  common anxiety disorders in 7- to 9-year-old children,⁷⁷  and depression in 12- to 17-year-old children,⁷⁸  and benefits of combined therapy likely go well beyond these age groups. Furthermore, many children with mild or subthreshold anxiety or depression are likely to benefit from psychosocial therapy, mind-body approaches, and self-help resources without medication.^48,66,79  Although pediatricians may feel pressured to prescribe only medication in these and other situations because it is generally more accessible and/or expedient,⁸⁰  knowledge of these other approaches is necessary to offer children these choices. If needed community services are not available, pediatricians can use common-elements approaches in the pediatric office and advocate for evidence-based therapies to be offered by the mental health community.

Certain disorders (ADHD, common anxiety disorders, depression), if associated with no more than moderate impairment, are amenable to primary care medication management because there are indicated medications with a well-established safety profile (eg, a variety of ADHD medications and certain selective serotonin reuptake inhibitors).⁸¹  Ideally, pediatric subspecialists would also be knowledgeable about these medications, their adverse effects, and their interactions with medications prescribed in their subspecialty practice. Necessary clinical skills are summarized in Table 4.

Effective mental health care requires the support of office and network systems. Competencies requisite to establishing and sustaining these systems are outlined in Table 5.

Despite many efforts to enhance the competence of pediatric residents and practicing pediatricians (see accompanying technical report “Achieving the Pediatric Mental Health Competencies”³¹ ), change in mental health practice during the last decade has been modest, as measured by the AAP’s periodic surveys of members. National data reveal that in 2013, only 57% of pediatricians were consistently treating ADHD and less than a quarter were treating any other disorder.⁸²  Although fewer barriers were reported in 2013 than in 2004, most pediatricians surveyed in 2013 reported that they had inadequate training in treating child mental health problems, a lack of confidence to counsel children, and limited time for these problems.⁸³ 

In the accompanying technical report, we address the barriers of training and confidence.³¹  The barrier of limited time for mental health care may one day become an artifact of volume-based care and the payment systems that have incentivized it. Value-based payment, expanded clinical care teams, and integration of mental health care into pediatric settings may provide new incentives and opportunities for mental health practice, improve quality of care, and result in improved outcomes for both physical and mental health conditions. In the interim, the AAP recognizes that although the proposed competencies are necessary to meet the needs of children, pediatricians will necessarily achieve them through incremental steps that rely on improved third-party payment for their mental health services and access to expertise in mental health coding and billing to support the time required for mental health practice.

The recommendations that follow build on the 2009 policy statement¹⁸  and assumptions drawn from review of available literature; the recognized, well-documented, and growing mental health needs of the pediatric population; expert opinion of the authoring bodies; and review and feedback by additional relevant AAP entities. There are striking geographic variations in access to pediatric mental health services from state to state and within states, from urban to rural areas.⁸⁴  By engaging in the kind of partnerships described in the first point below, pediatricians can prioritize their action steps and implement them, incrementally, in accordance with their community’s needs. With the pediatric advantage in mind, the AAP recommends that pediatricians engage in the following:

• partner with families, youth, and other child advocates; mental health, adolescent, and developmental specialists; teachers; early childhood educators; health and human service agency leaders; local and state chapters of mental health specialty organizations; and/or AAP chapter and national leaders with the goal of improving the organizational and financial base of mental health care, depending on the needs of a particular community or practice; this might include such strategies as:

  • advocating with insurers and payers for appropriate payment to pediatricians and mental health specialists for their mental health services (see the Chapter Action Kit in Resources);

  • using appropriate coding and billing practices to support mental health services in a fee-for-service payment environment (see Chapter Action Kit in Resources);

  • participating in development of models of value-based and bundled payment for integrated mental health care (see the AAP Practice Transformation Web site in Resources); and/or

  • identifying gaps in key mental health services in their communities and advocating to address deficiencies (see Chapter Action Kit in Resources);

• pursue quality improvement and maintenance of certification activities that enhance their mental health practice, prioritizing suicide prevention (see Quality Improvement and/or Maintenance of Certification in Resources);

• explore collaborative care models of practice, such as integration of a mental health specialist as a member of the medical home team, consultation with a child psychiatrist or developmental-behavioral pediatrician, or telemedicine technologies that both enhance patients’ access to mental health specialty care and grow the competence and confidence of involved pediatricians (see AAP Mental Health Web site in Resources);

• build relationships with mental health specialists (including school-based providers) with whom they can collaborate in enhancing their mental health knowledge and skills, in identifying and providing emergency care to children and adolescents at risk for suicide, and in comanaging children with primary mental health conditions and physical conditions with mental health comorbidities (see Chapter Action Kit in Resources);

• pursue educational strategies (eg, participation in a child psychiatry consultation network, collaborative office rounds, learning collaborative, miniature fellowship, AAP chapter, or health system network initiative) suited to their own learning style and skill level for incrementally achieving the mental health competencies outlined in Tables 4 and 5 (see accompanying technical report for in-depth discussion of educational strategies);

• advocate for innovations in medical school education, residency and fellowship training, and continuing medical education activities to increase the knowledge base and skill level of future pediatricians in accordance with the mental health competencies outlined in Tables 4 and 5; and

• promote and participate in research on the delivery of mental health services in pediatric primary care and subspecialty settings.

In the accompanying technical report,³¹  we highlight successful educational initiatives and suggest promising strategies for achieving the mental health competencies through innovations in the training of medical students, pediatric residents, fellows, preceptors, and practicing pediatricians and through support in making practice enhancements.

The AAP recognizes pediatricians’ unique opportunities to promote children’s healthy socioemotional development, strengthen children’s resilience to the many stressors that face them and their families, and recognize and address the mental health needs that emerge during childhood and adolescence. These opportunities flow from the pediatric advantage, which includes longitudinal, trusting, and empowering relationships with patients and their families and the nonstigmatizing, family friendliness of pediatric practices. Fully realizing this advantage will depend on pediatricians developing or honing their mental health knowledge and skills and enhancing their mental health practice. To that end, this statement outlines mental health competencies for pediatricians, incorporating evidence-based clinical approaches that are feasible within pediatrics, supported by collaborative relationships with mental health specialists, developmental-behavioral pediatricians, and others at both the community and practice levels.

Enhancements in pediatric mental health practice will also depend on system changes, new methods of financing, access to reliable sources of information about existing evidence and new science, decision support, and innovative educational methods (discussed in the accompanying technical report³¹ ). For this reason, attainment of the competencies proposed in this statement will, for most pediatricians, be achieved incrementally over time. Gains are likely to be substantial, including the improved well-being of children, adolescents, and families and enhanced satisfaction of pediatricians who care for them.

AAP clinical tools and/or tool kits include the following:

• Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit;

• Health Insurance Portability and Accountability Act of 1996 Privacy Rule and Provider to Provider Communication;

• Mental Health Initiatives Chapter Action Kit; and

• AAP Coding Fact Sheets (AAP log-on required).

AAP policies include the following:

• ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents (November 2011);

• Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management (endorsed by the AAP March 2018);

• Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management (endorsed by the AAP March 2018);

• Policy Statement: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice (January 2019);

• Technical Report: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice (January 2019);

• Policy Statement: Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health (January 2012; reaffirmed July 2016);

• Technical Report: The Lifelong Effects of Early Childhood Adversity and Toxic Stress (January 2012; reaffirmed July 2016);

• Clinical Report: Mind-Body Therapies in Children and Youth (September 2016);

• The Prenatal Visit (July 2018);

• Clinical Report: Promoting Optimal Development: Screening for Behavioral and Emotional Problems (February 2015);

• Policy Statement: Substance Use Screening, Brief Intervention, and Referral to Treatment (July 2016); and

• Clinical Report: Substance Use Screening, Brief Intervention, and Referral to Treatment (July 2016).

Quality improvement and/or Maintenance of Certification resources include the following:

• Education in Quality Improvement for Pediatric Practice: Bright Futures - Middle Childhood and Adolescence;

• Education in Quality Improvement for Pediatric Practice: Substance Use - Screening, Brief Intervention, Referral to Treatment; and

• American Board of Pediatrics Quality Improvement Web site.

AAP publications include the following:

• AAP Developmental Behavioral Pediatrics, Second Edition;

• Mental Health Care of Children and Adolescents: A Guide for Primary Care Clinicians;

• Promoting Mental Health in Children and Adolescents: Primary Care Practice and Advocacy;

• Pediatric Psychopharmacology for Primary Care;

• Quick Reference Guide to Coding Pediatric Mental Health Services 2019; and

• Thinking Developmentally.

AAP reports include the following:

• Improving Mental Health Services in Primary Care: A Call to Action for the Payer Community (AAP log-on required); and

• Reducing Administrative and Financial Barriers.

Web site resources include the following:

• AAP Mental Health Web site;

• AAP Practice Transformation Web site;

• National Center for Medical Home Implementation;

• The Resilience Project; and

• Screening Technical Assistance and Resource Center.

Jane Meschan Foy, MD, FAAP

Cori M. Green, MD, MS, FAAP

Marian F. Earls, MD, MTS, FAAP

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

Michael Yogman, MD, FAAP, Former Chairperson

Gerri Mattson, MD, FAAP

Jason Richard Rafferty, MD, MPH, EdM, FAAP

Sharon Berry, PhD, ABPP, LP – Society of Pediatric Psychology

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

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

Abigail Boden Schlesinger, MD – American Academy of Child and Adolescent Psychiatry

Rachel Shana Segal, MD – Section on Pediatric Trainees

Amy Starin, PhD – National Association of Social Workers

Marian F. Earls, MD, MTS, FAAP, Chairperson

Cori M. Green, MD, MS, FAAP

Alain Joffe, MD, MPH, FAAP

Linda Paul, MPH

AAP

American Academy of Pediatrics

ADHD

attention-deficit/hyperactivity disorder