Addressing the Behavioral and Mental Health Educational Gap in Pediatric Residency Training

In the study “Competency of Future Pediatricians Caring for Children With Behavioral and Mental Health Problems” in this issue of Pediatrics, Green et al¹  describe the continued deficit in pediatric resident competence in assessing and treating behavioral and mental health (B/MH) conditions based on survey questions asked during the 2018 initial pediatrics certifying examination application. B/MH concerns in pediatric practice are rising in prevalence. Approximately 13% to 20% of children in the United States experience a mental health disorder each year, and suicide is now the second leading cause of death for children ages 10 to 14 and adolescents and young adults ages 15 to 24.²  Nearly 25% of pediatric primary care visits involve a concern for B/MH issues.³ 

Throughout the pediatric education and training community, there has been a call for action to address the gap in trainee education on B/MH issues. The American Board of Pediatrics (ABP) entrustable professional activity 9 states that care of patients with B/MH concerns requires that a pediatrician be competent in (1) identifying and managing common B/MH issues; (2) referring and comanaging patients with the appropriate specialist(s) when indicated to match the patient’s needs, including pharmacotherapy; and (3) knowing the mental health resources available to patients in one’s community and using the appropriate resources for each patient’s needs.⁴  The authors’ survey questions focused on similar competency areas, including assessment, treatment, referral, and comanagement of common B/MH issues. The responses indicate a strong agreement by resident respondents that competence in each of these areas regarding B/MH concerns is important not only for residents entering primary care (>98% agreeing or strongly agreeing with each skill) but also for those entering subspecialty fellowships (>95% for assessment, referral, and/or comanagement by subspecialists).¹  Slightly less (86%) agreed that subspecialists required competence in treatment of B/MH conditions.¹ 

These data support B/MH training as important education for pediatric subspecialists in addition to general pediatricians.⁵  The opportunity to include B/MH training in the educational curriculum of subspecialty fellows aligns with current ABP initiatives focused on supporting the emotional health of children with chronic illness and their families.^5,6  Patients with chronic illness are often seeing their subspecialists more frequently than their primary care pediatricians and have an associated higher risk for mental health issues than the average population.^5–7  The involvement of regulatory agencies, such as the Accreditation Council for Graduate Medical Education and ABP, to revise specialty and subspecialty training requirements to include additional B/MH experiences across all disciplines could greatly support these ongoing efforts.

In this survey, smaller programs fared as well, if not better, in achieving resident competence in both the assessment and treatment of common B/MH conditions.¹  Although access to B/MH resources and specialized faculty is not specifically addressed here, this has been a barrier voiced by many program directors, particularly those of smaller programs.^8–11  However, if residents and primary care physicians in some settings must take more primary responsibility of these diagnoses because of fewer mental health providers, then an increased perception of competency in assessment and treatment in these smaller programs seems logical. If smaller residency programs tend to have a larger percentage of community-practice–focused graduates, these residents may have sought out additional experiences to increase their competence based on their future career path. This conclusion cannot be determined from the presented data.

Many residency programs and institutions have been actively working to improve overall delivery of care by addressing mental and physical health concerns together, instead of as separate entities.^8–11  Over 90% of survey respondents agreed or strongly agreed that their training program was committed to ensuring that graduating residents can address B/MH problems.¹  Rates of perceived competence in screening have slowly increased, with 52% of this sample reporting very good or excellent competence in diagnosing depression, for example, compared to 32% reported in a 2007 national survey.^1,12  Increases in treatment competence have been smaller but still present. These increases may reflect the impact of recent national or institutional initiatives and are perhaps even greater than reported because the current data are nearly 2 years old.¹ 

Because training programs focus on preparing their residents and fellows to address the B/MH needs of their patient population, it is unlikely that one standardized educational curriculum will address the needs and resources of every program. Differentiating high and low resource availability as caveats to the implementation of new curricula will allow programs the flexibility to develop more robust B/MH educational experiences that are operational in their setting.^8–10  Prevention, screening, and treatment should be equally emphasized in the care of patients with B/MH issues. Incorporating best practices learned from community pediatricians will also be key to success.⁹  Although much work remains to be done, program directors should be encouraged by the responses from this 2018 graduate survey and continue to move forward with educational initiatives aimed at increasing competence in screening, diagnosis, and particularly treatment of common B/MH conditions.

ABP

American Board of Pediatrics

B/MH

behavioral and mental health