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The increasing prevalence of behavioral and/or mental health (B/MH) problems among children, adolescents, and young adults is rapidly forcing the pediatric community to examine its professional responsibility in response to this epidemic. Stakeholders involved in pediatric workforce training were brought together in April 2018, invited by the American Board of Pediatrics and the National Academies of Sciences, Engineering, and Medicine, to consider facilitators and barriers for pediatrician training to enhance care for B/MH problems and to catalyze commitment to improvement efforts. During the interactive meeting, parents, young adult patients, and trainees, together with leaders of pediatric training programs and health care organizations, acknowledged the growing B/MH epidemic and discussed past and current efforts to improve training and care, including integrated delivery models. Attendees committed in writing to making a change within their department or organization to improve training. There also was agreement that organizations that set the standards for training and certification bear some responsibility to ensure that future pediatricians are prepared to meet the needs of children and adolescents. Reports on commitments to change 12 months after the meeting indicated that although attendees had encountered a variety of barriers, many had creatively moved forward to improve training at the program or organizational level. This article describes the context for the April 2018 meeting, themes arising from the meeting, results from the commitments to change, and 3 case studies. Taken together, they suggest we, as a pediatric community, can and must collaborate to improve training and, by extension, care.

The importance of pediatrician competence to care for children, adolescents, and young adults (hereafter, “children”) with behavioral and mental health (B/MH) needs has been recognized in calls for enhanced education over the past 4 decades.14  Recent data suggest these needs have intensified. Approximately 13% to 20% of children in the United States experience a mental health (MH) disorder each year,5  and suicide is now the second leading cause of death for children ages 10 to 14 and youth ages 15 to 24, after unintentional injury.14,6  One-quarter of pediatric primary care office visits involve concern for B/MH problems.7,8  Estimates from 2005 to 2011 suggest the annual cost for treating B/MH problems had risen to $247 billion per year when including special education and juvenile justice services.9  Preventive B/MH programs that promote emotional well-being and resilience continue to be woefully underfunded.10 

Pediatricians have a professional responsibility to intervene in the prevention, identification, and management of these concerns in children, particularly because ∼50% of major MH disorders in adults begin in childhood and adolescence.11  However, pediatricians surveyed by the American Academy of Pediatrics (AAP) in 2013 were, by their own admission, not prepared to address the common B/MH problems facing their patients and families.12  They also acknowledged significant gaps in training despite efforts on the part of the AAP and others to highlight the importance of B/MH training and care and to provide toolkits for changing practice.1317 

Because of the frequency and the urgency of this problem, in 2016, the Strategic Planning Committee of the American Board of Pediatrics (ABP) identified B/MH concerns as the most pressing health need of children that was not being met by pediatricians but was amenable to influence by the ABP because of its regulatory and convening roles. The committee recommended that the ABP prioritize collaboration with pediatric and other national organizations focused on training to address the need for enhanced prevention, identification, management, and comanagement of B/MH problems by pediatricians.

Acting on those recommendations, the ABP has launched efforts to bring pediatric organizations together, and several convenings have taken place. A 2016 meeting involving representatives of 10 pediatric and child B/MH organizations, along with MH professionals from a variety of disciplines, explored models for enhanced pediatrician training in B/MH care and discussed needed resources. The ABP also partnered with the National Academies of Sciences, Engineering, and Medicine (NASEM) in a 2016 meeting to review and support efforts around improving B/MH training for all child-serving professionals (eg, physicians, nursing professionals, psychologists, social workers, and peer-to-peer leaders).1820  In April 2017, the ABP and the Association of Pediatric Program Directors (APPD) cosponsored a day-long workshop with the goals of identifying barriers and facilitators for incorporating robust experiences in B/MH into pediatric training programs and encouraging innovation and networking to achieve resident and fellow competence in providing appropriate B/MH care.21  That workshop further supported the notion that improving pediatric B/MH training would be possible only through continued collaboration among organizations and would require commitment on the part of leaders within and across training programs and organizations to change current training paradigms.

Those workshops informed the decision to host a meeting, jointly sponsored by the ABP and NASEM, that would bring together pediatric training programs and others to catalyze change. Below, we set the context for this 2-day stakeholder meeting (April 5–6, 2018), entitled “Preparing Future Pediatricians to Meet the Behavioral and Mental Health Needs of Children”; delineate 6 main themes arising from the meeting; describe commitments to change that each attendee personally committed to making in the 6 to 12 months after the meeting; and provide 3 case studies of pediatric programs that committed to and implemented change in their training programs from April 2018 to March 2019.

With the need for committed leadership and collaboration in mind, the goals of this meeting were to (1) identify facilitators and barriers to improving training from the perspectives of a variety of stakeholders, including pediatric academic programs, families, trainees, funders, accreditors and certifiers, and B/MH specialists from other disciplines; (2) build networks across academic institutions and critical organizations; and (3) catalyze change that would be introduced by and then disseminated from the programs represented to training programs around the country. A 14-member planning committee was composed of representatives from major pediatric organizations to address training as well as parent and child psychology representation.

Meeting participants included 13 pediatric department chairs along with their respective residency program directors (or similarly positioned faculty members responsible for pediatric residency training at their institution) and stakeholders or experts from 31 other organizations that play a role in pediatric workforce training in B/MH care. The 13 department-chair–program-director dyads were selected on the basis of recommendations by APPD and Association of Medical School Pediatric Department Chairs (AMSPDC) leadership to include diverse departments of pediatrics by size, location, and type of institutional sponsorship (eg, medical school or hospital), without consideration of any current efforts to enhance B/MH training. The remaining 31 attendees included members of organizations involved in undergraduate and graduate medical education and pediatric training and B/MH care, representative funders, 2 parents and 1 young adult patient representing patient advocacy groups that were known to members of the planning committee, and 5 trainees identified by the ABP and AAP as having an interest in B/MH training (Table 1).

TABLE 1

Organizations Represented

Department of Pediatrics, department chair–training program leader dyads 
 Children’s Hospital Colorado 
 Cincinnati Children’s Hospital Medical Center 
 Goryeb Children’s Hospital, Atlantic Health System 
 MetroHealth Medical Center 
 Michigan State University 
 Morehouse School of Medicine 
 University of California, Davis 
 University of Massachusetts Medical School-Baystate 
 University of South Dakota 
 University of Virginia 
 University of Washington, Seattle Children’s 
 Weill Cornell Medicine 
 Wright State University Boonshoft School of Medicine 
National organizations 
 American Academy of Child and Adolescent Psychiatry 
 AAP 
 Association of American Medical Colleges 
 ABP 
 American Psychological Association 
 AMSPDC 
 APPD 
 Centers for Medicare and Medicaid Services 
 Council of Pediatric Subspecialties 
 Health Resources and Services Administration 
 NASEM 
 National Board of Medical Examiners 
 Society for Adolescent Health and Medicine 
 Society for Developmental and Behavioral Pediatrics 
 Substance Abuse and Mental Health Services Administration 
 Youth M.O.V.E.a 
Trainees 
 Boston Children’s Hospital 
 Children’s Hospital of Pittsburgh 
 Children’s Hospital of Philadelphia 
 Texas Tech University Health System 
 University of California, Irvine 
Other organizations 
 Alliance Behavioral Healthcare 
 Blue Cross Blue Shield of North Carolina 
 Center for Children and Families, Georgetown University 
 District of Columbia Department of Behavioral Healtha 
 McCourt School of Public Policy, Georgetown University 
 John Hopkins Bloomberg School of Public Health 
 Kaiser Permanente School of Medicine 
 Ohio Perinatal Quality Collaborative 
 Oregon Family to Family Health Information Centera 
Department of Pediatrics, department chair–training program leader dyads 
 Children’s Hospital Colorado 
 Cincinnati Children’s Hospital Medical Center 
 Goryeb Children’s Hospital, Atlantic Health System 
 MetroHealth Medical Center 
 Michigan State University 
 Morehouse School of Medicine 
 University of California, Davis 
 University of Massachusetts Medical School-Baystate 
 University of South Dakota 
 University of Virginia 
 University of Washington, Seattle Children’s 
 Weill Cornell Medicine 
 Wright State University Boonshoft School of Medicine 
National organizations 
 American Academy of Child and Adolescent Psychiatry 
 AAP 
 Association of American Medical Colleges 
 ABP 
 American Psychological Association 
 AMSPDC 
 APPD 
 Centers for Medicare and Medicaid Services 
 Council of Pediatric Subspecialties 
 Health Resources and Services Administration 
 NASEM 
 National Board of Medical Examiners 
 Society for Adolescent Health and Medicine 
 Society for Developmental and Behavioral Pediatrics 
 Substance Abuse and Mental Health Services Administration 
 Youth M.O.V.E.a 
Trainees 
 Boston Children’s Hospital 
 Children’s Hospital of Pittsburgh 
 Children’s Hospital of Philadelphia 
 Texas Tech University Health System 
 University of California, Irvine 
Other organizations 
 Alliance Behavioral Healthcare 
 Blue Cross Blue Shield of North Carolina 
 Center for Children and Families, Georgetown University 
 District of Columbia Department of Behavioral Healtha 
 McCourt School of Public Policy, Georgetown University 
 John Hopkins Bloomberg School of Public Health 
 Kaiser Permanente School of Medicine 
 Ohio Perinatal Quality Collaborative 
 Oregon Family to Family Health Information Centera 
a

Representative provided the perspective of the parent and/or youth.

Importantly, each invitee was notified that he or she would be asked to make a formal commitment to change at the conclusion of the meeting and to implement that change over the upcoming 6 to 12 months, with follow-up and assistance provided by planning committee members at regular intervals during that time. This process drew on the Institute for Healthcare Improvement’s principles for leading change that highlight the role of a public commitment to change in enhancing success.22,23  Participants were asked to construct their commitments to change to include the vision that motivated their plan, the techniques they proposed to accomplish the change, the assets and resources available to them, a measurable aim, and a time line for achieving the change to which they were committing themselves and the organization they represented.

The themes and concepts described below reflect the comments and conclusions of participants at the meeting. The meeting agenda, a list of the planning committee members, and all presentations are available on the ABP Web site (https://www.abp.org/foundation/behavioral-mental-health).

Both quantitative data about the growing B/MH crisis as well as data and narratives from programs around the country highlighted the urgency of the current B/MH crisis. Although progress has been made since the 1978 publication of the initial Future of Pediatric Education Task Force report highlighted B/MH as the “new morbidity” (referred to in that report as “biosocial,” “psychosocial,” and “behavioral” problems),1  pediatrics has not yet fully embraced its professional responsibility as child health clinicians, advocates, and educators to improve training and care in this area.

Specific challenges for pediatric training and recommendations for improvement raised by parents, patients, and trainees strongly informed this theme (Table 2). Parents and young adult patients often look to their general pediatricians or subspecialists as the first point of contact for recognition of B/MH concerns. Their experiences with seeking and receiving care can help inform gaps in training. Similarly, the perspectives of residents and subspecialty fellows provide input into training needs and goals.

TABLE 2

Parent, Patient, and Trainee Perspectives on Pediatric Training: Problems and Solutions

Current ChallengesRecommendations
Parent and PatientTrainee (Resident and Subspecialty)Parent and PatientTrainee (Resident and Subspecialty)
Limited focus on prevention, promotion of emotional resilience, and treatment of B/MH problems Inadequate engagement in B/MH care from pediatric subspecialists or from primary care pediatricians Embed parents, youth, and young adult voice throughout the entirety of training Decrease time spent covering topics such as asthma or bronchiolitis that are less common than B/MH concerns 
Fragmentation of health care environment Variability in the types of curricula and the hands-on training experiences being offered across programs Solicit help from family and peer support groups to develop scripts for trainees or practicing pediatricians who may be unsure of how to start conversations about B/MH Offer opportunities for general pediatrics trainees to spend less time in subspecialized inpatient services and more time undergoing intensive B/MH training 
Limited recognition of the B/MH issues that children, adolescents, and their families with acute, life-threatening or chronic conditions face Poor preparation of residents to differentiate between low- and high-risk behaviors and normal and abnormal behaviors and to make decisions regarding clinically appropriate next steps Expand trainees’ understanding of development to include considerations of well-being Offer clinical opportunities related to B/MH in subspecialty training programs 
 Negative self-efficacy and professional identity development resulting from powerlessness to address concerning psychosocial problems Discard preconceived notions about what the typical child or typical family should like and how they might respond to life events, including acute and chronic illness or other family stressors  
 Trainee opportunities for learning reduced by faculty discomfort with treating patients with B/MH concerns   
 Lack of care continuity leading to residents having inadequate hands-on training in how to manage chronic MH conditions   
Current ChallengesRecommendations
Parent and PatientTrainee (Resident and Subspecialty)Parent and PatientTrainee (Resident and Subspecialty)
Limited focus on prevention, promotion of emotional resilience, and treatment of B/MH problems Inadequate engagement in B/MH care from pediatric subspecialists or from primary care pediatricians Embed parents, youth, and young adult voice throughout the entirety of training Decrease time spent covering topics such as asthma or bronchiolitis that are less common than B/MH concerns 
Fragmentation of health care environment Variability in the types of curricula and the hands-on training experiences being offered across programs Solicit help from family and peer support groups to develop scripts for trainees or practicing pediatricians who may be unsure of how to start conversations about B/MH Offer opportunities for general pediatrics trainees to spend less time in subspecialized inpatient services and more time undergoing intensive B/MH training 
Limited recognition of the B/MH issues that children, adolescents, and their families with acute, life-threatening or chronic conditions face Poor preparation of residents to differentiate between low- and high-risk behaviors and normal and abnormal behaviors and to make decisions regarding clinically appropriate next steps Expand trainees’ understanding of development to include considerations of well-being Offer clinical opportunities related to B/MH in subspecialty training programs 
 Negative self-efficacy and professional identity development resulting from powerlessness to address concerning psychosocial problems Discard preconceived notions about what the typical child or typical family should like and how they might respond to life events, including acute and chronic illness or other family stressors  
 Trainee opportunities for learning reduced by faculty discomfort with treating patients with B/MH concerns   
 Lack of care continuity leading to residents having inadequate hands-on training in how to manage chronic MH conditions   

The Accreditation Council for Graduate Medical Education (ACGME), which accredits residency and subspecialty fellowship programs, and the ABP, which certifies individuals who have completed accredited programs and meet other qualifying criteria, work synergistically to ensure the alignment of requirements and training goals. Each has the potential to help advance pediatric education and training so that program graduates are better prepared to care for children with B/MH concerns. To date, the ABP has discussed several recommendations with the ACGME’s Pediatric Review Committee: (1) using the third-year graduating resident survey to ask about perceived competence to identify and treat anxiety, depression, and other B/MH topics; (2) developing competency-based requirements related to B/MH; (3) mandating enhanced exposure to B/MH (eg, longitudinal experiences and incorporating B/MH into as many resident experiences as possible); (4) requiring graduating residents to demonstrate “entrustment” as independent providers of B/MH care; and (5) modifying the subspecialty fellowship requirements to incorporate B/MH. The ACGME is planning an overall review of the pediatrics general requirements in the future after the completion of the current internal medicine review; that review process may provide an opportunity for some of these recommendations to be considered.

The ABP, in its role as the certifying body for general and subspecialty pediatrics, similarly plays a role in determining what criteria an individual pediatrician must meet to sit for the initial certification examination. Its content outlines also drive training curricula. Its continuing certification program provides opportunities for practice improvement in B/MH. Attendees encouraged the ABP to take steps to provide greater emphasis on B/MH as a requirement for initial certification through its expectations for clinical competence, its content outlines for certifying examination questions, and its practice improvement programs.

If pediatrics embraces the goal of ensuring that all pediatric graduates are competent to promote emotional health and resilience, identify risk factors for the development of B/MH concerns, and provide treatment in conjunction with other B/MH providers, the following components of improved training must also be embraced: (1) clarity regarding fundamental curricular elements and valid, feasible assessment tools; (2) opportunities for experience with integrated and collaborative care and training; (3) faculty development and leadership; (4) family and community involvement; and (5) advocacy for appropriate reimbursement.

One mechanism for moving forward in defining curricular elements and assessment tools is the competency-based medical education framework of entrustable professional activities (EPAs). EPA 9, “Assess and manage patients with common behavioral and MH problems,” states that pediatricians must be able to assess behavioral wellness; address prevention; and anticipate, identify, and manage B/MH needs as well as recognize when consultation is needed.24  It also delineates the curricular components that should be part of residency training to achieve entrustment in this area. EPAs have been developed for the pediatric subspecialties; these also incorporate language regarding B/MH. The ABP is currently supporting several research projects to examine barriers to and facilitators of the implementation of the general pediatric and subspecialty EPAs, including EPA 9, as standards for evaluating resident competence.

Suggestions for addressing the other components listed above are summarized in Table 3.

TABLE 3

Suggestions for Advancing Pediatric Training in B/MH

Topic 1: establishing curricula, goals, experience, and assessment 
 Critical curricular components 
  Prevention of B/MH problems, including fostering child and family resiliency and strength-based approaches 
  Screening and early identification of B/MH problems by using functional assessment tools, including 2 generational family history, prenatal risks, and adverse childhood experiences 
  Socioemotional and MH “review of systems” incorporated into all health supervision visits 
  Recognition and understanding of social determinants of health and ACEs 
  Recognition and understanding of the importance of B/MH in physical health outcomes 
  Evidence-based skills training, including motivational interviewing 
  Cultural and linguistic competency training 
  Competence in psychopharmacology 
  Experiences with nonpediatrician MH providers, including psychologists, child psychiatrists, and social workers 
  Community experiences 
 Curricular approaches 
  Integrate B/MH competency goals and assessment across the entire training curriculum; primary as well as subspecialty care 
  Create a system for true continuity of patient contact with resident as primary contact for patients, which might include a year-long continuity experience, exclusive of other clinical responsibilities 
  Institute home visits 
  Include parents and patients in development of curriculum 
  Institute general pediatrician-led B/MH clinics 
  Institute regular mentoring by MH specialists 
  Incorporate self-reflection and/or Balint groupsa to promote resident resilience 
  Develop simulated experiences, including use of technology to simulate patient and family encounters 
  Incorporate telehealth to access MH care of trainee patients 
  Include use of social media in addressing B/MH needs 
 Assessment methods 
  Use case logs of screenings performed by trainees 
  Include direct observation, including by nonpediatrician faculty (social workers, psychologists, psychiatrists, or nurses) and parents in trainee assessment 
  Develop 360-degree assessment of video-recorded clinical encounters, some done by nonexperts with simple training 
  Include assessment of simulated patient encounters 
  Develop PALS-like certification course on interviewing skills 
  Create assessment tools based on curricular elements of EPA 9 
  Enhance B/MH content specifications and certifying examination questions 
Topic 2: enhancing faculty engagement and development 
 Faculty engagement 
  Identify a faculty champion, preferably the department chair or other department leader, who would promote a sense of urgency and passion for promoting B/MH care 
  Develop a departmental policy or statement of goals to enhance a culture for improving B/MH training and care, including developing a scorecard to ensure accountability 
  Identify or assign a faculty member, possibly as associate program director, with responsibility for integrating B/MH curriculum and assessment throughout training 
  Identify family voices to inform and motivate 
  Solicit and review feedback from parents and adolescent patients related to B/MH care 
  Create a safe environment for faculty development with feedback and opportunities for improvement 
  Develop quality improvement projects, including part 4 MOC credit, related to B/MH care 
  Incentivize interprofessional teaching activities and faculty attendance at meetings and conferences at which B/MH training and care is discussed 
  Encourage influential non-B/MH faculty members who develop B/MH approaches to model their newly developed skills 
  Identify opportunities for faculty members to discuss their own family struggles with MH and patient care incidents related to B/MH 
 Faculty development 
  Perform a faculty needs assessment: identify needed knowledge and skills 
  Identify community resources for involving faculty and residents in B/MH care 
  Take advantage of national resources for faculty development, for example: 
   National Network of Child Psychiatry Access Programs (http://www.nncpap.org/
   The REACH Institute (http://www.thereachinstitute.org/
   LEND, Maternal and Child Health Bureau, Health Resources and Services Administration (https://mchb.hrsa.gov/training/projects.asp?program=9
   AAP MH resources (www.aap.org/mentalhealth
  Integrate developmental/behavioral faculty member(s) and/or MH professional(s) into clinics, daily rounds, grand rounds and conference schedules 
  Encourage participation in networking opportunities to learn about successful models for interprofessional training 
Topic 1: establishing curricula, goals, experience, and assessment 
 Critical curricular components 
  Prevention of B/MH problems, including fostering child and family resiliency and strength-based approaches 
  Screening and early identification of B/MH problems by using functional assessment tools, including 2 generational family history, prenatal risks, and adverse childhood experiences 
  Socioemotional and MH “review of systems” incorporated into all health supervision visits 
  Recognition and understanding of social determinants of health and ACEs 
  Recognition and understanding of the importance of B/MH in physical health outcomes 
  Evidence-based skills training, including motivational interviewing 
  Cultural and linguistic competency training 
  Competence in psychopharmacology 
  Experiences with nonpediatrician MH providers, including psychologists, child psychiatrists, and social workers 
  Community experiences 
 Curricular approaches 
  Integrate B/MH competency goals and assessment across the entire training curriculum; primary as well as subspecialty care 
  Create a system for true continuity of patient contact with resident as primary contact for patients, which might include a year-long continuity experience, exclusive of other clinical responsibilities 
  Institute home visits 
  Include parents and patients in development of curriculum 
  Institute general pediatrician-led B/MH clinics 
  Institute regular mentoring by MH specialists 
  Incorporate self-reflection and/or Balint groupsa to promote resident resilience 
  Develop simulated experiences, including use of technology to simulate patient and family encounters 
  Incorporate telehealth to access MH care of trainee patients 
  Include use of social media in addressing B/MH needs 
 Assessment methods 
  Use case logs of screenings performed by trainees 
  Include direct observation, including by nonpediatrician faculty (social workers, psychologists, psychiatrists, or nurses) and parents in trainee assessment 
  Develop 360-degree assessment of video-recorded clinical encounters, some done by nonexperts with simple training 
  Include assessment of simulated patient encounters 
  Develop PALS-like certification course on interviewing skills 
  Create assessment tools based on curricular elements of EPA 9 
  Enhance B/MH content specifications and certifying examination questions 
Topic 2: enhancing faculty engagement and development 
 Faculty engagement 
  Identify a faculty champion, preferably the department chair or other department leader, who would promote a sense of urgency and passion for promoting B/MH care 
  Develop a departmental policy or statement of goals to enhance a culture for improving B/MH training and care, including developing a scorecard to ensure accountability 
  Identify or assign a faculty member, possibly as associate program director, with responsibility for integrating B/MH curriculum and assessment throughout training 
  Identify family voices to inform and motivate 
  Solicit and review feedback from parents and adolescent patients related to B/MH care 
  Create a safe environment for faculty development with feedback and opportunities for improvement 
  Develop quality improvement projects, including part 4 MOC credit, related to B/MH care 
  Incentivize interprofessional teaching activities and faculty attendance at meetings and conferences at which B/MH training and care is discussed 
  Encourage influential non-B/MH faculty members who develop B/MH approaches to model their newly developed skills 
  Identify opportunities for faculty members to discuss their own family struggles with MH and patient care incidents related to B/MH 
 Faculty development 
  Perform a faculty needs assessment: identify needed knowledge and skills 
  Identify community resources for involving faculty and residents in B/MH care 
  Take advantage of national resources for faculty development, for example: 
   National Network of Child Psychiatry Access Programs (http://www.nncpap.org/
   The REACH Institute (http://www.thereachinstitute.org/
   LEND, Maternal and Child Health Bureau, Health Resources and Services Administration (https://mchb.hrsa.gov/training/projects.asp?program=9
   AAP MH resources (www.aap.org/mentalhealth
  Integrate developmental/behavioral faculty member(s) and/or MH professional(s) into clinics, daily rounds, grand rounds and conference schedules 
  Encourage participation in networking opportunities to learn about successful models for interprofessional training 

ACE, adverse childhood experience; LEND, Leadership Education in Neurodevelopmental Disabilities; MOC, Maintenance of Certification; PALS, pediatric advanced life support; REACH, Resource for Advancing Children’s Health.

a

Balint groups: a group of clinicians who meet regularly to present clinical cases to improve and better understand the clinician-patient relationship. It focuses on enhancing the clinician’s ability to connect with and care for the patient sustainably.

Enhancing B/MH training will require a concerted effort across pediatric organizations, academic medical centers, medical education organizations, and federal and private funders in a number of areas, including the development of innovative curricula and assessment tools, national dissemination of best practices, and robust leadership providing advocacy for needed changes in training paradigms (Table 4).

TABLE 4

Recommendations for Efforts on the Part of National Organizations

CategoriesRecommendations
Collaboration Continue to work with other national pediatric organizations to influence training requirements (ACGME), revise curricula and assessment (APPD), provide needed resources and experiences (AMSPDC and AAP), and engage those responsible for UME curriculum (COMSEP) 
 Collaborate with national MH stakeholder organizations (eg, AACAP and APA) and with community MH organizations and schools to create a sense of urgency and identify solutions 
 Continue to engage national family and youth organizations in support of pediatric training 
 Engage with leaders of pediatric subspecialties, including SDBP and SAHM, to promote enhanced B/MH training and care 
Dissemination Maintain momentum for change by ABP, NASEM, and others hosting similar meetings and continuing to disseminate information about the urgency of B/MH needs 
 Disseminate best practices, curricula and assessment tools, and policy statements through multiple modalities 
Advocacy Advocate for payer support for B/MH care by pediatricians and others 
CategoriesRecommendations
Collaboration Continue to work with other national pediatric organizations to influence training requirements (ACGME), revise curricula and assessment (APPD), provide needed resources and experiences (AMSPDC and AAP), and engage those responsible for UME curriculum (COMSEP) 
 Collaborate with national MH stakeholder organizations (eg, AACAP and APA) and with community MH organizations and schools to create a sense of urgency and identify solutions 
 Continue to engage national family and youth organizations in support of pediatric training 
 Engage with leaders of pediatric subspecialties, including SDBP and SAHM, to promote enhanced B/MH training and care 
Dissemination Maintain momentum for change by ABP, NASEM, and others hosting similar meetings and continuing to disseminate information about the urgency of B/MH needs 
 Disseminate best practices, curricula and assessment tools, and policy statements through multiple modalities 
Advocacy Advocate for payer support for B/MH care by pediatricians and others 

AACAP, American Academy of Child and Adolescent Psychiatry; APA, American Psychological Association; COMSEP, Council on Medical Student Education in Pediatrics; SAHM, Society for Adolescent Health and Medicine; SDBP, Society for Developmental and Behavioral Pediatrics; UME, undergraduate medical education.

Development of the curricula, training environments, and pediatrician and nonpediatrician faculty needed to train pediatricians to provide effective, knowledgeable B/MH care will require local and national leaders, including payers, to give B/MH training and care the priority they deserve, recognizing the frequency and importance of those problems in childhood and adolescence. Government funding through Medicare and Children’s Hospitals Graduate Medical Education Payment Program currently constrains innovation that could enhance B/MH training because funds are allocated to hospitals (which typically deploy trainees to meet patient care needs) rather than training programs.

If the goal is a future in which effective B/MH care is provided in the context of pediatric primary care and subspecialty visits, training programs and practices will have to adopt integrated care delivered by interprofessional teams in all settings (inpatient and outpatient; virtual telehealth); innovative approaches for prevention, identification, and treatment of B/MH problems; and importantly, reimbursement models that reward integrated care and reimburse pediatricians when they provide B/MH care. Reimbursement patterns are frequently cited as factors that limit practicing pediatricians’ ability to provide effective B/MH care and negatively affect the ability to provide trainees with robust experiences in that care. Capitated payment models provide a method for integrating physical health, behavioral health, and community-based support services, with health homes providing care management and coordination. Other creative funding mechanisms will need to be explored.

Commitments to change developed at the meeting varied in their focus and extent. Examples of commitments made by leaders of various pediatric departments included developing or enhancing interprofessional training in partnership with child psychiatry and psychology colleagues; identifying a leader for B/MH training within the department, incorporating MH experts in pediatric family-centered rounds, establishing expectations for competence in B/MH care at each level of residency training, and discussing a B/MH focus with potential donors. Several national pediatric organizations’ commitments included focusing their organizations’ annual meeting on B/MH training and conducting surveys or launching workgroups to facilitate further attention to this issue and disseminate best practices.

Planning committee members, with support from the ABP, contacted representatives of each organization at ∼3-, 6-, and 12-month intervals after the meeting to provide encouragement and support, share the work being done by other organizations, and identify successes and barriers to success. Commitments to change were modified over the follow-up period for a number of reasons (eg, lack of resources, changing priorities at the home institution, and unearthed barriers that needed to be addressed before making the specified change). The 12-month follow-up confirmed the value of the meeting for participants and their organizations. By that time, all of the residency program dyads had some plans in place in their institutions to significantly enhance the B/MH training experience for their residents. With respect to facilitators of success, many cited faculty and leadership buy-in as key to developing these programs, including integration of training and care in partnership with other disciplines. Identifying a B/MH “champion” within their organization was often helpful. Barriers such as resources, time commitment, and competing priorities were certainly noted, but as 1 pediatric department chair pointed out, these are “speedbumps, not roadblocks.” Others emphasized that making a public commitment encouraged more tenacity in their ongoing efforts. Most stressed the importance of sharing successes and best practices with other programs. Most of the nondyad participants from medical education and pediatrician organizations also had plans in place for activities for themselves or their organizations to strive to improve training for pediatricians to care for children and adolescents with B/MH issues. Examples of commitments to change on the part of national organizations included the development of curricula and assessment tools that could be adopted broadly, advocacy for B/MH screening and enhanced competence on the part of pediatric subspecialists, and the dissemination of successful subspecialty fellowship approaches through workshops, meetings, and publications (see Table 5 for a categorization of the changes made by organizations and individuals as reported 12 months after the meeting).

TABLE 5

Categories of Commitments to Change, 12-Month Follow-up

Type of Organization No. Engaged in Change 
Pediatric departments and residency programs (total =13)  
 Curriculum enhancement 12 
  Curriculum developed by interprofessional team of faculty 
  Curriculum includes subspecialty experiences 
  New or restructured rotation that includes B/MH 
  B/MH integrated into every rotation 
  Developed longitudinal experience that includes B/MH 
  Skills training (eg, CBT and SBIRT) 
 Assessment approaches for B/MH 
 Faculty training 
 Introduced interprofessional faculty and/or trainees 
 B/MH leadership enhancement 
 Enhanced B/MH care 
  Patient screening 
  B/MH training for pediatrician practices 
 Development of consultation program for pediatrician practices 
 Development of an integrated care facility 
 Secured or submitted grant to support interprofessional training and care 
National organizations (total = 15)  
 Collaborative development of curriculum and assessment tools 
 Advocacy and awareness 
 Enhanced regulatory efforts and accountability 
 Development of screening tools for subspecialists 
 Development and dissemination of best practices in training and practice 
 Payment incentives for enhanced B/MH care 
 Enhancing the B/MH workforce 
 Focus national meetings on B/MH education and training 
Individuals (trainees and parents) (total = 6)  
 Enhanced B/MH care 
 Curricular development 
 B/MH screening for subspecialty patients 
Type of Organization No. Engaged in Change 
Pediatric departments and residency programs (total =13)  
 Curriculum enhancement 12 
  Curriculum developed by interprofessional team of faculty 
  Curriculum includes subspecialty experiences 
  New or restructured rotation that includes B/MH 
  B/MH integrated into every rotation 
  Developed longitudinal experience that includes B/MH 
  Skills training (eg, CBT and SBIRT) 
 Assessment approaches for B/MH 
 Faculty training 
 Introduced interprofessional faculty and/or trainees 
 B/MH leadership enhancement 
 Enhanced B/MH care 
  Patient screening 
  B/MH training for pediatrician practices 
 Development of consultation program for pediatrician practices 
 Development of an integrated care facility 
 Secured or submitted grant to support interprofessional training and care 
National organizations (total = 15)  
 Collaborative development of curriculum and assessment tools 
 Advocacy and awareness 
 Enhanced regulatory efforts and accountability 
 Development of screening tools for subspecialists 
 Development and dissemination of best practices in training and practice 
 Payment incentives for enhanced B/MH care 
 Enhancing the B/MH workforce 
 Focus national meetings on B/MH education and training 
Individuals (trainees and parents) (total = 6)  
 Enhanced B/MH care 
 Curricular development 
 B/MH screening for subspecialty patients 

SBIRT, screening, brief intervention, and referral to treatment.

In addition to the changes reported at individual programs and organizations, it is important to note that participants described the meeting as catalyzing collaborative efforts between and among departments and organizations that were intended to facilitate and support an enlarging national commitment to expanding the care provided by general and subspecialty pediatricians. Importantly, these cooperative efforts between individuals and training leaders continue to evolve informally with the dissemination of best practices and at national meetings.

Below, we provide 3 examples of commitments to change across 3 training programs to illustrate the variability in change strategies employed as well as examples of program successes.

Program A, a large program, set out to develop a “vision to integrate B/MH in inpatient and outpatient settings with training based on EPA 9.” By 4 months, the program had completed the evaluation of its resources; dealt with potential barriers to incorporating this plan throughout the residents’ training, including in private clinics (partly by viewing other programs’ experiences); and worked with child psychiatry and developmental and behavioral pediatrics (DBP) specialists to incorporate residents’ training into their disciplines’ schedules. By 1 year, they had in place a program covering common behavior issues in their primary care clinic curriculum, adolescent issues in their adolescent and inpatient rotations, MH providers embedded into first and second year pediatric resident clinic months, exposure to appropriate screening tools in their clinics, partnership with child psychiatry on a mandatory consolidation experience for all third year residents (including emergency department exposure), and a working group including program directors, psychologists, child psychiatry, DBP specialists, and adolescent medicine, putting together all the elements of this longitudinal thread in residency. Program A indicated a barrier to be establishing a consistent, uniform curriculum across all settings hosting continuity clinics. Facilitators included identifying available financial and human resources, member support in the planning committee, and the ability to modify commitment to change so that it was feasible for their organization.

Committing to work toward integration of B/MH care into all facets of pediatric training and at all sites of training was the stated goal of Program B, a small-to-medium–sized program. Program B first created a task force consisting of faculty (including child psychiatry, child psychology, DBP, and primary care) and residents. The task force made 2 initial recommendations: (1) enhance experiences related to B/MH in the continuity clinic and (2) create a required MH rotation. To achieve these goals, the program embedded a B/MH faculty member as a part of the continuity experience and initiated a “train the trainer” program in which B/MH experts help the primary care pediatric faculty develop the skills needed to provide and teach B/MH care. This effort was reported as having been greeted enthusiastically by the primary care faculty. Residents are also now assigned to accompany a B/MH provider during the continuity clinic at least monthly. In addition, a subcommittee of the task force worked with child psychiatry faculty to develop goals (and is developing assessment tools) for a required MH rotation for second year residents in which pediatric residents are an integral part of the child psychiatry team, participating in group sessions, intakes, and outpatient visits. The residents will also participate with child psychiatrists in a telephone consultation service. The program director highlighted the importance of public commitment on the part of both the chair and the program director as being critical to this effort. Financial resources were cited as limitations to implementing some of the additional changes that had been recommended.

Program C, a large program, made a commitment to amplify their initiatives in B/MH by (1) identifying a MH coordinator for their residency program; (2) expanding the number of multidisciplinary MH providers in primary care, subspecialty services, and the emergency department; (3) developing cognitive-behavioral therapy (CBT) training for residents; and (4) strengthening their grand rounds and continuing medical education curriculum in MH by adding offerings on prevention, parenting, motivational interviewing, and screening. Over the course of 12 months, they identified a point person for their psychiatry and behavioral medicine teaching program and for their longitudinal resident curriculum; gradually embedded MH providers (typically psychologists) in all of their primary care clinics, subspecialty clinics, and inpatient teams; and introduced CBT training to primary care pathway interns. In addition, they have focused on the dissemination of their and others’ efforts through grand rounds and other didactic sessions and at national meetings, supporting other programs to establish B/MH curricula. The chair and program director highlighted that faculty and administration buy-in were critical factors for success with their commitment to change; mobilizing human and financial resources were mentioned as barriers. Thinking broadly, but using a detailed, longitudinal time line to achieve goals, was felt to be key. In addition, the AAP MH curriculum (https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/Education.aspx) was identified as a practical tool for implementing their curricular plans.

The urgency and magnitude of the B/MH crisis facing children has been well documented.5,2527  Organizations that set standards for training and certification (ACGME and ABP) have opportunities to foster and recognize best practices and set standards that ensure that future pediatricians are prepared to meet the needs of children. Pediatric departments and organizations must be willing to invest in creatively addressing this gap; infrastructure to support change will continue to be needed.

This 2-day meeting was not designed to address all of the many challenges related to innovations in training and practice, including funding and reimbursement, but rather the goals were to highlight the urgency, gather ideas, gain commitments to making effective change, and set the stage for future collaboration. The necessary innovations in training and practice will require collaborative commitment from and among individuals and institutions to address the epidemic of B/MH problems affecting our children.

The authors acknowledge the thoughtful leadership of the planning committee in determining and conducting the agenda for this meeting as well as participating in the follow-up outreach to participants. Their names are listed at https://www.abp.org/sites/abp/files/pdf/abpf-nasem-agenda-book-2018.pdf.

Dr McMillan wrote the original draft of the article; Drs Land and Leslie and Ms Tucker contributed to the content and revisions; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

AAP

American Academy of Pediatrics

ABP

American Board of Pediatrics

ACGME

Accreditation Council for Graduate Medical Education

AMSPDC

Association of Medical School Pediatric Department Chairs

APPD

Association of Pediatric Program Directors

B/MH

behavioral and/or mental health

CBT

cognitive-behavioral therapy

DBP

developmental and behavioral pediatrics

EPA

entrustable professional activity

MH

mental health

NASEM

National Academies of Sciences, Engineering, and Medicine

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Competing Interests

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

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