Mental Health Training in Pediatric Residency: Where Can We Go?

Abstract

Between 13% and 20% of children have mental health conditions, yet far fewer are identified.1O'Connell M.E. Boat T. Warner K.E. Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. National Research Council and Institute of Medicine. Preventing mental, emotional, and behavioral disorders among young people: progress and possibilities. Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults: research Advances and Promising Interventions. The National Academies Press, Washington, DC2009Google Scholar Only 25% of children who could benefit from treatment actually receive care.2Jensen P.S. Goldman E. Offord D. Costello E.J. Friedman R. Huff B. et al.Overlooked and underserved: “action signs” for identifying children with unmet mental health needs.Pediatrics. 2011; 128: 970-979Crossref PubMed Scopus (93) Google Scholar One-half of all mental health conditions have their onset in childhood or adolescence; adults with mental health conditions have higher rates of unemployment, poverty, and use of medical care.3Kessler R.C. Chiu W.T. Demler O. Walters E.E. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R).Arch Gen Psychiatry. 2005; 62: 617-627Crossref PubMed Scopus (8416) Google Scholar The pediatric primary care setting is ideal for assessing and managing common mental health concerns for children and adolescents. Common complaints often have emotional and behavioral underpinnings, which may have origins in the child or in the caregivers. However, many primary care practices do not feel comfortable identifying or treating these problems routinely and perceive that their mental health colleagues are inaccessible, or that families perceive societal stigmatization with mental health care.4Boreman C.D. Thomasgard M.C. Fernandez S.A. Coury D.L. Resident training in developmental/behavioral pediatrics: where do we stand?.Clin Pediatr. 2007; 46: 135-145Crossref PubMed Scopus (43) Google Scholar, 5Freed G.L. Dunham K.M. Switalski K.E. Jones D.M. McGuinness G. Research Advisory Committee of the American Board of Pediatrics. Recently trained general pediatricians: perspectives on residency training and scope of practice.Pediatrics. 2009; 123: S38-S43Crossref PubMed Scopus (75) Google Scholar, 6Rosenberg A.A. Kamin C. Glicken A.D. Jones Jr., M.D. Training gaps for pediatric residents planning a career in primary care: a qualitative and quantitative study.J Grad Med Educ. 2011; 3: 309-314Crossref PubMed Google Scholar, 7Stein R.E. Storfer-Isser A. Kerker B.D. Garner A. Szilagyi M. Hoagwood K.E. et al.Beyond ADHD: how well are we doing?.Acad Pediatr. 2016; 16: 115-121Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar There has been growing recognition of the need to bolster mental health education during pediatric residency training. The Accreditation Council for Graduate Medical Education mandates block rotations in developmental-behavioral pediatrics and adolescent health. Recommendations were made to include mental health surveillance, screening, recognition, and counseling in the developmental-behavioral pediatrics curriculum.8Accreditation Council for Graduate Medical EducationACGME program requirements for graduate medical education in pediatrics.2017Google Scholar The American Academy of Pediatrics published Mental Health Competencies in 2009 that called for innovation in residency training and urged the enhanced commitment of individual clinicians. Areas of focus for expanded knowledge and skills included attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, substance abuse, and recognizing psychiatric and social emergencies. Additional areas of emphasis unique to primary care included building resilience and promoting healthy lifestyles; preventing, mitigating, and identifying risk factors for mental health problems; and partnering with families, schools, and other community agencies to plan assessment and care.9American Academy of PediatricsPolicy Statement-- the future of pediatrics: mental health competencies for pediatric primary care.Pediatrics. 2009; 124: 410-421Crossref PubMed Scopus (275) Google Scholar The American Board of Pediatrics (ABP) released the pediatric entrustable professional activities in 2013, which highlighted the need for the pediatrician to demonstrate the ability to assess and manage patients with common behavioral and mental health issues.10American Board of PediatricsEntrustable professional activities for general pediatrics.www.abp.org/entrustable-professional-activities-epasGoogle Scholar Despite these recommendations, pediatric program directors and residents have identified gaps in mental health education, knowledge, comfort, and confidence leading to a tendency to ignore mental health issues. Five years after their introduction, only 45% of program directors recognized these competencies.11Green C. Hampton E. Ward M.J. Shao H. Bostwick S. The current and ideal state of mental health training: pediatric program director perspectives.Acad Pediatr. 2014; 14: 526-532Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 12Hampton E. Richardson J.E. Bostwick S. Ward M.J. Green C. The current and ideal state of mental health training: pediatric resident perspectives.Teach Learn Med. 2015; 27: 147-154Crossref PubMed Scopus (22) Google Scholar The program directors who were aware of the guidelines, however, rated their residents' patient care and communication skills higher than program directors who were uninformed. Pediatric residents have no formal mental health education beyond routine ADHD care, the first mental health condition to have a published set of guidelines. Today it is screened for more than any other behavioral health issue and is the condition for which pediatricians report the most confidence in diagnosis and treatment.13Bunik M. Talmi A. Stafford B. Beaty B. Kempe A. Dhepyasuwan N. et al.Integrating mental health services in primary care continuity clinics: a National CORNET Study.Acad Pediatr. 2013; 13: 551-557Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Thus, the first step in tackling the gaps in mental health training in pediatric residency may be to increase the awareness of the issues through the dissemination of guidelines to program directors. Low availability of experts and high demands of graduation requirements make mandating additional rotation requirements unrealistic. McMillan et al listed faculty development, appropriate learning environment, universal communication skills, integrating mental health into required rotations, and increased resident accountability as elements needed for success.14McMillan J. Land M. Leslie L. Pediatric resident education and the behavioral and mental health crisis: a call to action.Pediatrics. 2017; 139: e20162141Crossref PubMed Scopus (77) Google Scholar Didactics or specialist observation are not adequate; clinicians gain capacity through exposure and practice. Pediatric residency programs vary greatly in structure and in their ability to meet these needs. Accessibility to mental health specialists to teach residents varies greatly between programs and can be a barrier to this training. The main goal stated in the ABP report was to graduate residents who could identify and manage common mental health conditions without supervision. We are proposing a model for pediatric resident mental health training that would use resources already in practice, and a method that minimizes the need for direct mental health specialist input, to improve confidence, competency, and culture around addressing childhood mental health needs. The contextual curriculum model integrates mental health teaching within required rotations instead of relying on isolated clinic experiences. Emphasis is given to the pediatric core faculty as the experts at the appropriate level for mental health care within their scope of practice. Pediatric core faculty carry the responsibility of teaching mental health topics identified for that rotation. Specific learning objectives are included in the required rotations whenever relevant, creating what we refer to as a contextual mental health curriculum. Ideal topics for inpatient hospitalist rotations include somatic symptom disorders, conversion disorder, and eating disorders. Safety evaluations, substance abuse, urgent medication side effects from psychotropic medications, and systems of care can be covered during the emergency medicine rotations. Attachment and the consequences of substance exposures in utero may be addressed during neonatal intensive care or developmental rotations and delirium can be addressed during pediatric intensive care and emergency department rotations. When developing this model for a training program, core competencies that each residency values should be identified. Basic competencies include completing a safety evaluation, identifying autism, and identifying and initiating first line treatment for depression, ADHD, substance use disorders, and anxiety. Alternatively, a program may choose to focus training more broadly on specific areas that have been prioritized. Other advanced topics can be added as the curriculum is developed. Common problems might be assigned to specific rotations depending on faculty expertise and interest or unique population needs and cultural considerations. It is important to include an emphasis beyond disease-focused models to enhance communication strategies. Faculty who do not feel confident in the skills to teach the curriculum may collaborate with mental health specialists. More advanced topics in psychiatry and behavioral health should access specialist input, including the treatment of disordered eating, gender dysphoria, resistant depression, bipolar disorder, and serious emotional disturbances. The introduction of principles and practice can occur during the required rotations, but when reinforced in the continuity clinic, residents will develop a deeper foundation in these concepts and benefit from observing the natural progression over time. Child and adolescent psychiatry training includes similar supervisory experiences for more than a year to ensure competence. Universal themes that should be covered during all rotations include motivational interviewing and active listening, which are cross-cutting skills that facilitate behavior change. One option is to emphasize core communication skills during the developmental-behavioral pediatrics and adolescent medicine rotations. This educational model may be used to gradually develop the curriculum over time, starting with the core concepts and adding advanced knowledge over time. This approach allows the core faculty time to develop skills, knowledge, and educational materials to cover each topic during the rotation. The assessment of capacity in mental health skills would build developmentally throughout training, starting with no knowledge, being introduced to identification of risk and protective factors, and treatments available. A step above this would be to start applying skills and early tailoring of anticipatory guidance, with an awareness of need for more training and practice. Then skills improve around the ability to frequently apply information and confidence around engaging families from various resource levels. Mastery of mental health capacity would include the ability to help and coach others to tailor their treatment options and management regarding family circumstances and developmental factors. To evaluate the effectiveness of the curriculum developed using this model, quality improvement measures should be used. One example includes pretests and post-tests to measure the resident's knowledge, skill level, and comfort with treating the identified mental health need for that rotation. Adding mental health requirements to patient logs also helps to add accountability for learning each identified topic (eg, 2 patients with childhood depression where resident identified/initiated treatment and had 2 follow-up appointments). It is also helpful to outline the goals and objectives for each rotation to include the mental health topics identified. In addition, it may also be advantageous for the residency to create milestones related to the resident's competence in evaluating and managing mental health concerns. This step will help hold the residents accountable for learning and the residency accountable for teaching the mental health concepts they deem essential for the practice of pediatrics. Innovative approaches to curriculum design and assessment are encouraged. Exploring opportunities for engaged rather than passive experiences will facilitate learning, confidence, and competence. Examples might include faculty-supported and resident-driven case discussion series on topics such as the identification and treatment of and recovery from adolescent depression. Experimenting with integrated care models in ambulatory specialty or primary care settings in which pediatricians work side by side with psychologists and behavioral health specialists is another option. Studies have found that pediatric residents practicing with on-site mental health professionals are more likely to report mental health services as available in their clinics, to inquire about ADHD, and to refer patients for ADHD, depression, and behavior problems.15Colburn M. Harris E. Klein M. Lehmann C. The depression curriculum: primary care, case-based training on caring for adolescents with depression from screening to pharmaceutical management.J Adolesc Health. 2018; 62: S13-S14Abstract Full Text Full Text PDF Google Scholar Hand-offs to the behavioral health team increases first appointment show rates, which are only 50% when scheduled at a later date.13Bunik M. Talmi A. Stafford B. Beaty B. Kempe A. Dhepyasuwan N. et al.Integrating mental health services in primary care continuity clinics: a National CORNET Study.Acad Pediatr. 2013; 13: 551-557Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 16Ragunanthan B. Frosch E.J. Solomon B.S. On-site mental health professionals and pediatric residents in continuity clinic.Clin Pediatr. 2017; 56: 1219-1226Crossref Scopus (6) Google Scholar Program directors who report integrated or collaborative care mental health models in continuity clinics rate their residents' system-based practice and medical knowledge competencies higher than programs with traditional clinics.11Green C. Hampton E. Ward M.J. Shao H. Bostwick S. The current and ideal state of mental health training: pediatric program director perspectives.Acad Pediatr. 2014; 14: 526-532Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar However, one study found that integrated clinics identified mental health issues more frequently than nonintegrated programs, but pediatricians in the integrated programs reported that it was their responsibility to assess and provide education about these identified issues less often than pediatricians in traditional programs.13Bunik M. Talmi A. Stafford B. Beaty B. Kempe A. Dhepyasuwan N. et al.Integrating mental health services in primary care continuity clinics: a National CORNET Study.Acad Pediatr. 2013; 13: 551-557Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Thus, pediatricians may still lack the tools needed to adequately help patients suffering from mental health or behavioral disorders. Also, brief behavioral health and communication training built into the regular work day helps residents to develop skills to elicit parent and child concerns and has been shown to decrease mental health symptoms for minority children.17Pisani A.R. LeRoux P. Siegel D.M. Educating residents in behavioral health care and collaboration.integrated 1Acad Med. 2011; 86: 166-173Google Scholar Children with chronic diseases and their family members often present with mental health concerns. It is imperative for specialty providers to be aware of the importance of assessing the well-being of the child and the caregivers so that they can identify these conditions early to avoid delays and improve outcomes.18Wissow L.S. Gadomski A. Roter D. Larson S. Brown J. Zachary C. et al.Improving child and parent mental health in primary care: a Cluster-randomized trial of communication skills training.Pediatrics. 2008; 121: 266-275Crossref PubMed Scopus (110) Google Scholar, 19Clancy K.M. Lipshultz S.E. Training pediatric cardiologists to meet the needs of patients with neurodevelopmental disorders.Prog Pediatr Cardiol. 2017; 44: 63-66Crossref Scopus (2) Google Scholar Scant evidence exists on how to best train subspecialists for supporting patients with these mental health problems. One study presents data from an integrated health care model in a pediatric endocrinology clinic. After 18 months, the clinic was profitable and was given favorable reviews by patients.20Yarbro J.L. Mehlenbeck R. Financial analysis of behavioral health services in a pediatric endocrinology clinic.J Pediatr Psychol. 2016; 41: 879-887Crossref Scopus (10) Google Scholar However, no data are available on the psychosocial or medical outcomes of patients seen for behavioral health appointments in a subspecialty setting. Efforts are underway through the ABP Foundation Roadmap Project to support specialists in promoting resilience, emotional health, and mental health in children and families affected by chronic conditions.21American Board of Pediatrics FoundationThe Roadmap Project.www.abp.org/foundation/roadmapDate accessed: April 19, 2019Google Scholar Mental health is mainstream pediatrics. A contextual curriculum model integrated across the continuum of training experiences is an option for preparing pediatric residents to screen for and identify mental health problems, manage mild to moderate concerns, and collaborate with colleagues in psychology and psychiatry for their patients with moderate to severe issues. The intentional inclusion of relevant goals and objectives related to children's mental health throughout residency training should enhance the knowledge, competence, and confidence of our future pediatricians.