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Issue Brief 76: Preparing Future Pediatricians to Address Behavioral Health Needs of Children: Opportunities in Pediatric Residency Training Programs

September 28, 2020issue brief banner.png

Preparing Future Pediatricians to Address Behavioral Health Needs of Children

Opportunities in Pediatric Residency Training Programs

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The American Academy of Pediatrics (AAP) has increasingly called on pediatric primary care providers to recognize and treat patients with common behavioral health disorders. However, pediatricians indicate concerns about their capacity to do so.1 In a recent survey conducted by the AAP, pediatricians reported lack of training and confidence in their ability to address behavioral health disorders.1

Pediatric residency training programs, which prepare pediatricians, family physicians and nurse practitioners to deliver care to children, require extensive training in primary care and are the ideal place to better prepare future child health providers to address common behavioral health disorders. Pediatric residency training is the period of graduate medical education that offers in-depth training designed to confer the knowledge and skills required for comprehensive pediatric health care.

The Number of Children Needing Behavioral Health Support is Rising

Behavioral health is important to the overall health and well-being of children. More than one in six children has a behavioral health disorder such as depression or anxiety,2 and that number is growing. According to the Centers for Disease Control and Prevention, diagnosed depression and anxiety among children ages 6 to 17 years old increased from 5.4% in 2003 to 8.4% in 2012.2  Suicide rates increased 56% between 2007 and 2017 among children ages 10 to 14 years old and is now the second leading cause of death in this age group.3 In Connecticut, the prevalence of diagnosed behavioral health conditions or developmental delay among children ages 3 to 17 years old increased from 16% in 2007 to 25% in 2018.4

According to the Centers for Disease Control and Prevention,

  • 9.4% (approximately 6.1 million) of children nationally have been diagnosed with ADHD
  • 7.4% (approximately 4.5 million) have a diagnosed behavior problem
  • 7.1% (approximately 4.4 million) have been diagnosed with anxiety
  • 3.2% (approximately 1.9 million) have been diagnosed with depression.2

Pediatric Primary Care Providers Play a Critical Role in Identifying and Treating Common Behavioral Health Disorders

Pediatric primary care providers are well positioned to identify and treat children with common behavioral health disorders. Ninety percent of children attend an annual well-child visit, and many visit the pediatrician’s office several times per year.5  The long-term relationship that primary care providers have with families can ensure proper and early identification of behavioral health concerns, opportunities for on-going support, and monitoring of treatment progress in children with a behavioral health diagnosis.  Primary care can also help connect families to appropriate behavioral health services.  However, there is a need for enhanced competency in identifying and treating behavioral health conditions among primary care providers.1

Current Pediatric Residency Programs Lack Robust Training Experiences in Behavioral Health

Pediatric, family medicine, and nurse practitioner residency programs are responsible for developing competent child health providers and ensuring they can address behavioral health issues.  The AAP recognizes this and has been calling for enhancements to residency programs for more than forty years.6,7  However, there is little consensus about how to fully prepare resident trainees to identify, treat, and manage care for children with behavioral health disorders.1, 8, 9

In 2018, the American Board of Pediatrics and the National Academy of Sciences, Engineering, and Medicine brought together a workgroup to improve the capacity of residency programs to provide comprehensive training experiences in behavioral health.9 The workgroup identified barriers to learning in current residency programs that, when fully addressed, could help prepare future pediatricians to address the behavioral health needs of their patients. Barriers articulated included inconsistencies in curricula and hands-on training experiences across residency programs; inadequate resident training to identify, diagnose, and manage care for children with behavioral health disorders; and faculty discomfort treating patients with behavioral health concerns.9  These barriers are also common in family medicine and nurse practitioner training.

Hands-on Training Experiences in Residency Programs are a Promising Solution to Improving Behavioral Health Competencies among Pediatric Primary Care Providers

Opportunities for improvement in residency training still exist despite excellent intentions and substantial improvements to behavioral health curricula over the last decade.1, 8-10 This past year, the Child Health and Development Institute of Connecticut (CHDI) partnered with residency programs to identify training gaps and advance strategies to improve behavioral health training. A grant program funded by the Children’s Fund of Connecticut (CFC) and administered by CHDI awarded grants to five, Connecticut-based, pediatric primary care, family medicine, and nurse practitioner residency programs to support the planning and implementation of innovative, hands-on experiences in behavioral health care for their trainees. Although each residency program currently includes elements of clinical, didactic, and/or community-based experiences in behavioral health, the programs recognized opportunities for improving trainee experiences in behavioral health.

Residency training programs funded by CFC include:

  • Asylum Hill Family Medical Center, Family Medicine Residency Program in Hartford - Medical residents and staff will be trained in trauma screening, referral, and family education during well-child and home visits using the Child Trauma Screen (CTS).11 
  • Community Health Center, Inc., Nurse Practitioner Residency Program in Middletown - Training experiences that address socio-emotional health and provide support to families will be developed and evaluated for nurse practitioner residents. Enhanced training will include trauma-informed care, adolescent behavioral health, and lactation support.
  • Connecticut Children’s, Pediatric Residency Program in Hartford - Medical residents will develop and implement office-based projects that address infant and child emotional and behavioral health through caregiver education at well-child visits.
  • Yale School of Medicine, Pediatric Residency Program in New Haven - Behavioral health simulations will be developed and implemented for residents to practice the following skills: gathering a comprehensive health and behavioral health history, using clinical screening tools, working through a differential diagnosis, collaborating with a behavioral health professional, and monitoring children’s socio-emotional development in the pediatric primary care setting.
  • Yale School of Nursing, Pediatric Nurse Practitioner Program in New Haven - An integrated behavioral health educational experience for residents will be designed and implemented. The experience will offer a new opportunity for nurse practitioner residents to learn and receive supervision from behavioral health providers in the pediatric primary care setting to help them build the capacity to manage common behavioral health problems.

Recommendations

In collaboration with the five grantees, CHDI will explore improvements in Connecticut’s pediatric residency training experiences with the goal of informing change in residency training across the state. Collaboration among national pediatric organizations is also needed to improve and influence behavioral health curricula and clinical experiences nationally.8

References


  1. McMillan JA, Land M, Leslie LK. Pediatric residency education and the behavioral and mental health crisis: a call to action. Pediatrics. 2017;139(1):e20162141. doi: 10.1542/peds.2016-2141.
  2. Centers for Disease Control and Prevention. Data and Statistics on Children’s Mental Health.  Accessed on September 3, 2020 at https://www.cdc.gov/childrensmentalhealth/data.html.
  3. Curtin SC, Heron M. Death rates due to suicide and homicide among persons aged 10–24: United States, 2000–2017. NCHS Data Brief, no 352. Hyattsville, MD: National Center for Health Statistics. 2019. Accessed on September 24, 2020. Available at https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf.
  4. The Annie E. Casey Foundation Kids Count Data Center. Accessed on September 3, 2020. Available at https://datacenter.kidscount.org/data/tables/10668-children-who-have-one-or-more-emotional-behavioral-or-developmental-conditions?loc=8&loct=2#detailed/2/8/false/1648/any/20457,20456.
  5. Child Trends Databank. Well-child visits. 2018. Accessed on September 3, 2020. Available at https://www.childtrends.org/?indicators=well-child-visits.
  6. American Academy of Pediatrics Taskforce on Pediatric Education. The Future of Pediatric Education. Evanston, IL: American Academy of Pediatrics; 1978.
  7. Leslie L, Rappo P, Abelson H, Jenkins R, Sewall S. Final report of the FOPE II Pediatric Generalists of the Future Workgroup. Pediatrics. 2000;106(suppl 5):1199-1223.
  8. Green C, Walkup JT, Bostwick S, Trochim W. Advancing the agenda in pediatric mental health education. Pediatrics. 2019;144(3):e20182596. doi.org/10.1542/peds.2018-2596.
  9. McMillan JA, Land M, Tucker AE, Leslie LK. Preparing future pediatricians to meet the behavioral and mental health needs of children. Pediatrics. 2020;145(1):e20183796.
  10. Shahidullah JD, Kettlewell PW, Palejwala MH, Forman SG, Billups A, Anismatta SL, Benjamin M. Behavioral health training in pediatric residency programs: national survey of training directors. J Dev Behav Pediatr. 2018;39:292-302. doi: 10.1097/DBP.0000000000000548.
  11. Child Health and Development Institute of Connecticut. Screening Children for Trauma.n.d. www.chdi.org/our-work/mental-health/trauma-informed-initiatives/ct-trauma-screen-cts.

This Issue Brief was prepared by Susan Macary, MPH, Senior Associate for Health Initiatives at CHDI. For more information, contact Susan Macary at macary@uchc.edu or visit www.chdi.org.

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