POLICY STATEMENT Organizational Principles to Guide and Define the Child HealthCare System and/or Improve the Health of all Children

Mental Health Competencies forPediatric PracticeJane Meschan Foy, MD, FAAP,a Cori M. Green, MD, MS, FAAP,b Marian F. Earls, MD, MTS, FAAP,c COMMITTEE ON PSYCHOSOCIALASPECTS OF CHILD AND FAMILY HEALTH, MENTAL HEALTH LEADERSHIP WORK GROUP

abstractPediatricians have unique opportunities and an increasing sense ofresponsibility to promote healthy social-emotional development of childrenand to prevent and address their mental health and substance use conditions.In this report, the American Academy of Pediatrics updates its 2009 policystatement, which proposed competencies for providing mental health care tochildren in primary care settings and recommended steps toward achievingthem. This 2019 policy statement affirms the 2009 statement and expandscompetencies in response to science and policy that have emerged since: theimpact of adverse childhood experiences and social determinants on mentalhealth, trauma-informed practice, and team-based care. Importantly, it alsorecognizes ways in which the competencies are pertinent to pediatricsubspecialty practice. Proposed mental health competencies includefoundational communication skills, capacity to incorporate mental healthcontent and tools into health promotion and primary and secondarypreventive care, skills in the psychosocial assessment and care of childrenwith mental health conditions, knowledge and skills of evidence-basedpsychosocial therapy and psychopharmacologic therapy, skills to function asa team member and comanager with mental health specialists, andcommitment to embrace mental health practice as integral to pediatric care.Achievement of these competencies will necessarily be incremental, requiringpartnership with fellow advocates, system changes, new paymentmechanisms, practice enhancements, and decision support for pediatriciansin their expanded scope of practice.

INTRODUCTION

A total of 13% to 20% of US children and adolescents experiencea mental* disorder in a given year.1 According to the seminal Great SmokyMountain Study, which has followed a cohort of rural US youth since 1992,19% of youth manifested impaired mental functioning without meetingthe criteria for diagnosis as a mental disorder (ie, subthreshold

aDepartment of Pediatrics, School of Medicine, Wake Forest University,Winston-Salem, North Carolina; bDepartment of Pediatrics, WeillCornell Medicine, Cornell University, New York, New York; andcCommunity Care of North Carolina, School of Medicine, University ofNorth Carolina at Chapel Hill, Chapel Hill, North Carolina

Policy statements from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, policy statements from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

Drs Foy, Green, and Earls contributed to the drafting and revising ofthis manuscript; and all authors approved the final manuscript assubmitted.

The guidance in this statement does not indicate an exclusive courseof treatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

To cite: Foy JM, Green CM, Earls MF , AAP COMMITTEE ONPSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH,MENTAL HEALTH LEADERSHIP WORK GROUP. Mental HealthCompetencies for Pediatric Practice. Pediatrics. 2019;144(5):e20192757

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symptoms).2 The authors of thisstudy have since shown that adultswho had a childhood mental disorderhave 6 times the odds of at least 1adverse adult outcome in the domainof health, legal, financial, or socialfunctioning compared with adultswithout childhood disorders, evenafter controlling for childhoodpsychosocial hardships. Adults whohad impaired functioning andsubthreshold psychiatric symptomsduring childhood—termed“problems” in this statement—have3 times the odds of adverse outcomesas adults.3 These findings underscorethe importance to adult health of bothmental health disorders and mentalhealth problems during childhood.

The prevalence of mental healthdisorders and problems (collectivelytermed “conditions” in thisstatement) in children andadolescents is increasing and,alarmingly, suicide rates are now thesecond leading cause of death inyoung people from 10 to 24 years ofage.4–6 Furthermore, nearly 6 millionchildren were considered disabled in2010–2011, an increase of more than15% from a decade earlier; amongthese children, reported disabilityrelated to physical illnessesdecreased by 11.8%, whereasdisability related toneurodevelopmental and mentalhealth conditions increased by20.9%.5 Although the highest rates ofreported neurodevelopmental andmental health disabilities were seenin children living in poverty, thegreatest increase in prevalence ofreported neurodevelopmental andmental health disabilities occurred,unexpectedly, among children livingin socially advantaged households(income $400% of the federalpoverty level).5

Comorbid mental health conditionsoften complicate chronic physicalconditions, decreasing the quality oflife for affected children andincreasing the cost of their care.7–12

Because of stigma, shortages of

mental health specialists,administrative barriers in healthinsurance plans, cost, and otherbarriers to mental health specialtycare, an estimated 75% of childrenwith mental health disorders gountreated.13–16 Primary carephysicians are the sole physicianmanagers of care for an estimated 4in 10 US children with attention-deficit/hyperactivity disorder(ADHD) and one-third with mentaldisorders overall.17

In 2009, the American Academy ofPediatrics (AAP) issued a policystatement, “The Future of Pediatrics:Mental Health Competencies forPediatric Primary Care,” proposingcompetencies—skills, knowledge, andattitudes—requisite to providingmental health care of children inprimary care settings andrecommending steps towardachieving them.18 In the policy, theAAP documented the many forcesdriving the need for enhancements inpediatric mental health practice.

Updates to the Previous Statement

In the years since publication of theoriginal policy statement on mentalhealth competencies, increases inchildhood mental health morbidityand mortality and a number of otherdevelopments have added to theurgency of enhancing pediatricmental health practice. A federalparity law has required that insurerscover mental health and physicalhealth conditions equivalently.19,20

Researchers have shown that earlypositive and adverse environmentalinfluences—caregivers’ protectiveand nurturing relationships with thechild, social determinants of health,traumatic experiences (ecology), andgenetic influences (biology)—interactto affect learning capacities, adaptivebehaviors, lifelong physical andmental health, and adult productivity,and pediatricians have a role to playin addressing chronic stress andadverse early childhoodexperiences.21–24 Transformative

changes in the health care deliverysystem—payment for value, system-and practice-level integration ofmental health and medical services,crossdiscipline accountability foroutcomes, and the increasingimportance of the family- and patient-centered medical home—all have thepotential to influence mental healthcare delivery.25–27 Furthermore,improving training and competencein mental health care for futurepediatricians—pediatricsubspecialists as well as primary carepediatricians—has become a nationalpriority of the American Board ofPediatrics28,29 and the Association ofPediatric Program Directors.30

In this statement, we (1) discuss theunique aspects of the pediatrician’srole in mental health care; (2)articulate competencies needed bythe pediatrician to promote healthysocial-emotional development,identify risks and emergingsymptoms, prevent or mitigateimpairment from mental healthsymptoms, and address the mentalhealth and substance use conditionsprevalent among children andadolescents in the United States; and(3) recommend achievable next stepstoward enhancing mental healthpractice to support pediatricians inproviding mental health care. Theaccompanying technical report,“Achieving the Pediatric MentalHealth Competencies,” is focused onstrategies to train future pediatriciansand prepare practices for achievingthe competencies.31

Uniqueness of the Pediatrician’s Rolein Mental Health Care

Traditional concepts of mental healthcare as well as mental health paymentsystems build on the assumption thattreatment must follow the diagnosisof a disorder. However, this diagnosticapproach does not take into accountthe many opportunities affordedpediatricians, both in general andsubspecialty practice, to promotemental health and to offer primary

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and secondary prevention. Nor dothese traditional concepts address theissue that many children haveimpaired functioning although theydo not meet the diagnostic criteria fora specific mental disorder.Consequently, pediatric mental healthcompetencies differ in someimportant respects fromcompetencies of mental healthprofessionals. The unique role ofpediatricians in mental health carestems from the “primary careadvantage,” which is a developmentalmind-set, and their role at the frontlines of children’s health care.32

Primary care pediatricians typicallysee their patients longitudinally,giving them the opportunity todevelop a trusting and empoweringtherapeutic relationship with patientsand their families; to promote social-emotional health with every contact,whether for routine healthsupervision, acute care, or care ofa child’s chronic medical ordevelopmental condition; to preventmental health problems througheducation and anticipatory guidance;and to intervene in a timely way ifand when risks, concerns, orsymptoms emerge. Recognizing thelongitudinal and close relationshipsthat many pediatric subspecialistshave with patients and families, theauthors of this statement haveexpanded the concept of primary careadvantage to the “pediatricadvantage.”

Pediatric subspecialists, like pediatricprimary care clinicians, need basicmental health competencies. Childrenand adolescents with somaticmanifestations of mental healthproblems often present to pediatricmedical subspecialists or surgicalspecialists for evaluation of theirsymptoms; awareness of mentalhealth etiologies has the potential toprevent costly and traumaticworkups and expedite referral fornecessary mental health services.33

Children and adolescents withchronic medical conditions have

a higher prevalence of mental healthproblems than do their peers withoutthose conditions; and unrecognizedmental health problems, particularlyanxiety and depression, often driveexcessive use of medical services inchildren with a chronic illness andimpede adherence to their medicaltreatment.34 Furthermore, childrenand adolescents with serious and life-threatening medical and surgicalconditions often experience trauma,such as painful medical procedures,disfigurement, separation from lovedones during hospitalizations, andtheir own and their loved ones’ fearsabout prognosis.35 For these reasons,mental health competencies involvingclinical assessment, screening, earlyintervention, referral, andcomanagement are relevant topediatric subspecialists who care forchildren with chronic conditions.Subspecialists have the additionalresponsibility of coordinating anymental health services they providewith patients’ primary care cliniciansto prevent duplication of effort,connect children and families toaccessible local resources, and reachagreement on respective roles inmonitoring patients’ mentalhealth care.

Integration of Mental Health CareInto Pediatric Workflow

The AAP Task Force on Mental Health(2004–2010) spoke to theimportance of enhancingpediatricians’ mental health practicewhile recognizing that incorporatingmental health care into a busypediatric practice can be a dauntingprospect. The task force offered analgorithm, the “Primary CareApproach to Mental Health Care,”depicting a process by which mentalhealth services can be woven intopractice flow, and tied each step inthe algorithm to Current ProceduralTerminology coding guidance that canpotentially support those mentalhealth–related activities in a fee-for-service environment.32 The AAPMental Health Leadership Work

Group (2011–present) recentlyupdated this to the “Algorithm: AProcess for Integrating Mental HealthCare Into Pediatric Practice” (seeFig 1). The AAP has a number ofresources to assist with coding formental health care.

The pediatric process for identifyingand managing mental healthproblems is similar to the iterativeprocess of caring for a child withfever and no focal findings: theclinician’s initial assessment of thefebrile child’s severity of illnessdetermines if there is a seriousproblem that urgently requiresfurther diagnostic evaluation andtreatment; if not, the clinician advisesthe family on symptomatic care andwatchful waiting and advises thefamily to return for furtherassessment if symptoms persist orworsen. Similarly, a mental healthconcern of the patient, family, or childcare and/or school personnel (orscheduling of a routine healthsupervision visit [algorithm step 1])triggers a preliminary psychosocialassessment (algorithm step 2). Thisinitial assessment can be expeditedby use of previsit collection of dataand screening tools (electronic orpaper and pencil), which the cliniciancan review in advance of the visit,followed by a brief interview andobservations to explore findings(both positive and negative) and theopportunity to highlight the child’sand family’s strengths, an importantelement of supportive, family-centered care. Finding a problem thatis not simply a normal behavioralvariation (algorithm step 3)necessitates triage for a psychiatricand/or social emergency and, ifindicated, immediate care in thesubspecialty or social service system(algorithm steps 9 and 10). In makingthese determinations, it is importantto understand the family context,namely, the added risks conferred byadverse social determinants of health,which may exacerbate the problemand precipitate an emergency.

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Intervention will need to includesupports to address socialdeterminants.

If an identified problem is not anemergency, the clinician canundertake 1 or more briefinterventions, as time allows, duringthe current visit or at follow-upvisit(s) (algorithm step 11). Theseinterventions may include iterativelyexpanding the assessment, forexample, by using secondaryscreening tools, gatheringinformation from school personnel orchild care providers, or having thefamily create a diary of problembehaviors and their triggers. Briefinterventions may also includereferral of a family member forassistance in addressing his or her

own social or mental health problemsthat may be contributing to the child’sdifficulties. In addition, briefinterventions may include evidence-informed techniques to address thechild’s symptoms, as described in thesection immediately below.

When indicated by findings of theassessment and/or by failure torespond to brief therapeuticinterventions, a full diagnosticassessment can be performed, eitherby the pediatrician (algorithm step15) at a follow-up visit or throughreferral to a specialist (algorithm step16), followed by the steps of careplanning and implementation,comanagement, and monitoring thechild’s progress (algorithm steps 17and 18).

Brief Interventions: AddressingMental Health Symptoms in theContext of a Busy Pediatric PracticeAlthough disorder-specific,standardized psychosocial treatmentshave been a valuable advance in themental health field generally, theirreal-world application to the care ofchildren and adolescents has beenlimited by the fact that many youngpeople are “diagnosticallyheterogeneous”; that is, they manifestsymptoms of multiple disorders orproblems, and their manifestationsare variably triggered by events andby their social environment. Theselimitations led researchers in the fieldof psychotherapy to develop andsuccessfully apply “transdiagnostic”approaches to the care of childrenand adolescents, addressing multiple

FIGURE 1Mental health (MH) care in pediatric practice. ACE, adverse childhood experience; RHS, routine health supervision; S-E, social-emotional.

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disorders and problems by usinga single protocol and allowing formore flexibility in selecting andsequencing interventions.36

A number of transdiagnosticapproaches are proving to beadaptable for use as briefinterventions in pediatric settings.The goals of brief therapeuticinterventions for children andadolescents with emerging symptomsof mild to moderate severity are toimprove the patient’s functioning,reduce distress in the patient andparents, and potentially preventa later disorder. For children andadolescents identified as needingmental health and/or developmental-behavioral specialty involvement,goals of brief interventions are tohelp overcome barriers to theiraccessing care, to amelioratesymptoms and distress whileawaiting completion of the referral,and to monitor the patient’sfunctioning and well-being whileawaiting higher levels of care. Brevityof these interventions, ideally nomore than 10 to 15 minutes persession, mitigates disruption topractice flow. Although formalevaluation of these adaptations is inits early stages, authors of studiessuggest that they can be readilylearned by pediatric clinicians and arebeneficial to the child and family.37

Table 1 is used to excerpt several ofthese adaptations from a summary byWissow et al.37

All of these approaches featureprominently in the pediatric mentalhealth competencies; 2 requirefurther explanation.

“Common-factors” communicationskills, so named because they arecomponents of effective interventionscommon to diverse therapies acrossmultiple diagnoses, are foundationalamong the proposed pediatric mentalhealth competencies. Thesecommunication techniques includeclinician interpersonal skills that helpto build a therapeutic alliance—thefelt bond between the clinician andpatient and/or family, a powerfulfactor in facilitating emotional andpsychological healing—which, inturn, increases the patient and/orfamily’s optimism, feelings of well-being, and willingness to work towardimproved health. Other common-factors techniques target feelings ofanger, ambivalence, and hopelessness,family conflicts, and barriers tobehavior change and help seeking. Stillother techniques keep the discussionfocused, practical, and organized.These techniques come from familytherapy, cognitive therapy, motivationalinterviewing, family engagement,family-focused pediatrics, and solution-focused therapy.38 They have beenproven useful and effective inaddressing mental health symptoms inpediatrics across the age spectrum andcan be readily acquired by experiencedclinicians.39 Importantly, when time isshort, the clinician can also use them tobring a visit to a supportive close whilecommitting his or her loyalty andfurther assistance to the patient andfamily—that is, reinforcing thetherapeutic alliance, even as he or sheaccommodates to the rapid pace of thepractice.

See Table 2 for the HELP mnemonic,developed by the AAP Task Force on

Mental Health to summarizecomponents of the common-factorsapproach.

“Common-elements” approaches canalso be used as brief interventions.They differ from common factors inthat instead of applying to a range ofdiagnoses that are not causallyrelated, common elements aresemispecific components ofpsychosocial therapies that apply toa group of related conditions.40–43 Inthis approach, the clinician caring fora patient who manifests a cluster ofcausally related symptoms—forexample, fearfulness and avoidantbehaviors—draws interventions fromevidence-based psychosocialtherapies for a related set ofdisorders—in this example, anxietydisorders. Thus, as a first-lineintervention to help an anxious child,the pediatrician coaches the parent toprovide gradual exposure to fearedactivities or objects and to modelbrave behavior—common elementsin a number of effective psychosocialtreatments for anxiety disorders.Such interventions can be definitiveor a means to reduce distress andameliorate symptoms while a child isawaiting mental health specialtyassessment and/or care. Table 3 isused to summarize promisingcommon-elements approachesapplicable to common pediatricprimary care problems.

Certain evidence-basedcomplementary and integrativemedicine approaches may also lendthemselves to brief interventions: forexample, relaxation and other self-regulation therapies reveal promise

TABLE 1 Promising Adaptations of Mental Health Treatment for Primary Care

Pediatric Settings Parallels in Mental Health Services

Emphasis on patient-centered care and joint decision-making building trustand activation

Common-factors psychotherapeutic processes promoting engagement,optimism, alliance

Initial treatment often presumptive or relatively nonspecific Stepped-care models with increasing specificity of diagnosis and intensity oftreatment

Treatment based on brief counseling focused on patient-identified problems "Common elements"Links with community services, advice addressing family and socialdeterminants

Peer and/or family navigators

Adapted from Wissow LS, van Ginneken N, Chandna J, Rahman A. Integrating children’s mental health into primary care. Pediatr Clin North Am. 2016; 63(1):101.

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in assisting children to manage stressand build their resilience to traumaand social adversities.43 Other briefinterventions include coachingparents in managing a particularbehavior (eg, “time-out” for disruptivebehavior44) or, more broadly,strategies to reduce stress in thehousehold and to foster a sense ofcloseness and emotional security, forexample, reading together,45 sharingoutdoor time,46 or parent-child“special time”—a regularly scheduledperiod as brief as 5 to 10 minutes setaside for a one-on-one, interactiveactivity 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 (criticallyimportant to children’s mental healthand resilience as well as theirparents’), family meals, active play,time and content limits on mediaexposure, and prosocial activitieswith peers can be used as “universal”brief interventions across an array of

presenting problems as well asa means to promote mental wellnessand resilience.49

For a more detailed summary ofpsychosocial interventions and theevidence supporting them, seePracticeWise Evidence-Based Childand Adolescent PsychosocialInterventions at www.aap.org/mentalhealth. Psychosocialinterventions that have been studiedin primary care are listed in CommonElements of Evidence-Based PracticeAmenable to Primary Care:Indications and Sources at www.aap.org/mentalhealth. With training,pediatricians can achieve competencein applying brief interventions suchas these in primary care or,potentially, subspecialtysettings.37,50–52

MENTAL HEALTH COMPETENCIES

The Accreditation Council forGraduate Medical Education hasorganized competencies into 6

domains: patient care, medicalknowledge, interpersonal andcommunication skills, practice-basedlearning and improvement,professionalism, and systems-basedpractice.53 We have used thisframework to develop a detailedoutline of pediatric mental healthcompetencies for use by pediatriceducators; this outline is available atwww.aap.org/mentalhealth.Competencies most salient to thisstatement are listed in Tables 4 and 5.

Clinical Skills

All pediatricians need skills topromote mental health, efficientlyperform psychosocial assessments,and provide primary and secondarypreventive services (eg, anticipatoryguidance, screening). They need to beable to triage for psychiatricemergencies (eg, suicidal orhomicidal intent, psychotic thoughts)and social emergencies (eg, childabuse or neglect, domestic violence,other imminent threats to safety).

TABLE 2 Common-Factors Approach: HELP Build a Therapeutic Alliance

H = HopeHope facilitates coping. Increase the family’s hopefulness by describing your realistic expectations for improvement and reinforcing the strengths and assets

you see in the child and family. Encourage concrete steps toward whatever is achievable.E = EmpathyCommunicate empathy by listening attentively, acknowledging struggles and distress, and sharing happiness experienced by the child and family.

L2 = Language, LoyaltyUse the child or family’s own language (not a clinical label) to reflect your understanding of the problem as they see it and to give the child and family an

opportunity to correct any misperceptions.Communicate loyalty to the family by expressing your support and your commitment to help now and in the future.

P3 = Permission, Partnership, PlanAsk the family’s permission for you to ask more in-depth and potentially sensitive questions or make suggestions for further evaluation or management.Partner with the child and family to identify any barriers or resistance to addressing the problem, find strategies to bypass or overcome barriers, and find

agreement on achievable steps (or simply an achievable first step) aligned with the family’s motivation. The more difficult the problem, the more importantis the promise of partnership.

On the basis of the child’s and family’s preferences and sense of urgency, establish a plan (or incremental first step) through which the child and family willtake some action(s), work toward greater readiness to take action, or monitor the problem and follow-up with you. (The plan might include, eg, keepinga diary of symptoms and triggers, gathering information from other sources such as the child’s school, making lifestyle changes, applying parentingstrategies or self-management techniques, reviewing educational resources about the problem or condition, initiating specific treatment, seeking referralfor further assessment or treatment, or returning for further family discussion.)

Adapted from Foy JM; American Academy of Pediatrics, Task Force on Mental Health. Enhancing pediatric mental health care: algorithms for primary care. Pediatrics. 2010;125(suppl 3):S110.

TABLE 3 Most Frequently Appearing Common Elements in Evidence-Based Practices, Grouped by Common Presenting Problems in Pediatric Primary Care

Presenting Problem Area Most Common Elements of Related Evidence-Based Practices

Anxiety Graded exposure, modelingADHD and oppositionalproblems

Tangible rewards, praise for child and parent, help with monitoring, time-out, effective commands and limit setting, responsecost

Low mood Cognitive and/or coping methods, problem-solving strategies, activity scheduling, behavioral rehearsal, social skills building

Adapted from Wissow LS, van Ginneken N, Chandna J, Rahman A. Integrating children’s mental health into primary care. Pediatr Clin North Am. 2016; 63(1):103.

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Pediatricians need to be able toestablish a therapeutic alliance withthe patient and family and take initialaction on any identified mental healthand social concerns, as describedabove. All pediatricians also need toknow how to organize the care ofpatients who require mental healthspecialty referral or consultation,facilitate transfer of trust to mentalhealth specialists, and coordinatetheir patients’ mental health carewith other clinicians, reachingprevious agreement on respectiveroles, such as who will prescribe andmonitor medications and how

communication will take place. Thecare team might include any of theindividuals listed in Table 6, on- oroff-site. For a discussion ofcollaborative care models thatintegrate services of mental healthand pediatric professionals, see theaccompanying technical report.31

The clinical role of the pediatricianwill depend on the patient’s conditionand level of impairment,interventions and supports needed,patient and family priorities andpreferences, pediatrician’s self-perception of efficacy and capacity,

and accessibility of communityservices.

Disorders such as maladaptiveaggression54,55 and bipolar disorder56

may require medications for whichpediatricians will need specializedtraining or consultation fromphysician mental health specialists toprescribe (eg, antipsychotics,lithium). Comanagement—formallydefined as “collaborative andcoordinated care that isconceptualized, planned, delivered,and evaluated by 2 or more healthcare providers”57—is a successful

TABLE 4 Core Pediatric Mental Health Competencies: Clinical Skills

Pediatricians providing care to children and adolescents can maximize the patient’s and family’s health, agency, sense of safety, respect, and partnership bydeveloping competence in performing the following activities:Promotion and primary preventionPromote healthy emotional development by providing anticipatory guidance on healthy lifestyles and stress managementRoutinely gather an age-appropriate psychosocial history, applying appropriate tools to assist with data gathering

Secondary preventionIdentify and evaluate risk factors to healthy emotional development and emerging symptoms that could cause impairment or suggest future mental health

problems, applying appropriate tools to assist with screening and refer to community resources when appropriate (ie, parenting programs)AssessmentRecognize mental health emergencies such as suicide risk, severe functional impairment, and complex mental health symptoms that require urgent

mental health specialty careAnalyze and interpret results from mental health screening, history, physical examination, and observations to determine what brief interventions may be

useful and whether a full diagnostic assessment is neededDiagnose school-aged children and adolescents with the following disorders: ADHD, common anxiety disorders (separation anxiety disorder, social phobia,

generalized anxiety disorder), depression, and substance useTreatmentApply fundamental (common factors, motivational interviewing) communications skills to engage youth and families and overcome barriers to their help

seeking for identified social and mental health problemsApply common-factors skills and common elements of evidence-based psychosocial treatments to initiate the care of the following:Children and youth with medical and developmental conditions who manifest comorbid mental health symptomsDepressed mothers and their childrenInfants and young children manifesting difficulties with communication and/or attachment or other signs and symptoms of emotional distress (eg,

problematic sleep, eating behaviors)Children and adolescents presenting with the following:

Anxious or avoidant behaviorsExposure to trauma or lossImpulsivity and inattention, with or without hyperactivityLow mood or withdrawn behaviorsDisruptive or aggressive behaviorsSubstance useLearning difficulties

When a higher level of care is needed for symptoms listed above, integrate patient and/or family strengths, needs, and preferences, the clinician’s ownskills, and available resources into development of a care plan for children and adolescents with mental health problem(s), alone, with the practice careteam, or in collaboration with mental health specialists

Demonstrate proficiency in selecting, prescribing, and monitoring (for response and adverse effects) ADHD medications and selective serotonin reuptakeinhibitors that have a safety and efficacy profile appropriate to use in pediatric care

Develop a contingency or crisis plan for a child or adolescentDevelop a safety plan with patients and parents for children and adolescents who are suicidal and/or depressedApply strategies to actively monitor adverse and positive effects of nonpharmacologic and pharmacologic therapyFacilitate a family’s and patient’s engagement with and transfer of trust (ie, “warm handoff”) to a mental health professionalDemonstrate an accurate understanding of privacy regulationsRefer, collaborate, comanage, and participate as a team member in coordinating mental health care with specialists and in transitioning adolescents with

mental health needs to adult primary care and mental health specialty providers

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approach for complex mentalconditions in children andadolescents. Both generalpediatricians and pediatricsubspecialists will benefit from thesecollaborative skills. These skills alsoenable pediatricians to helpadolescents with mental healthconditions and their familiestransition the adolescent’s care toadult primary and mental healthspecialty care at the appropriate time,as pediatricians do other patientswith special health care needs.

Misperceptions about privacyregulations (eg, the Health InsurancePortability and Accountability Act of1996,58 federal statutes andregulations regarding substance

abuse treatment [42 US Code x290dd–2; 42 Code of FederalRegulations 2.11],59 and state-specificregulations) often impedecollaboration by limitingcommunication among clinicians whoare providing services. In mostinstances, pediatricians are, in fact,allowed to exchange information withother clinicians involved in a patient’scare, even without the patient orguardian’s consent. Pediatriciansneed an accurate understanding ofprivacy regulations to ensure that allclinicians involved in the mutual careof a patient share information in anappropriate and timely way (seehttps://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 arespecific to the age, presentingproblem of the patient, and type oftherapy required, as described in thefollowing sections.

Infants and Preschool-aged Children

For infants and preschool-agedchildren, the signs and symptoms ofemotional distress may be varied andnonspecific and may manifestthemselves in the child, in the parent,or in their relationship. Whenconsistently outside the range ofnormal development, these youngchildren and families typically requirespecialized diagnostic assessment(based on the Diagnostic Classificationof Mental Health and DevelopmentalDisorders of Infancy and EarlyChildhood60), intensive parentinginterventions, and treatment bydevelopmental-behavioral specialistsor mental health specialists withexpertise in early childhood.Consequently, pediatric mental healthcompetencies for the care of this agegroup involve overcoming anybarriers to referral, guiding the familyin nurturing and stimulating thechild, counseling on parenting andbehavioral management techniques,referring for diagnostic assessment

TABLE 5 Core Pediatric Mental Health Competencies: Practice Enhancements

Pediatricians providing care to children and adolescents can improve the quality of their practice’s (and network’s) mental health services by developingcompetence in performing the following activitiesEstablish collaborative and consultative relationships—within the practice, virtually, or off-site—and define respective roles in assessment, treatment,

coordination of care, exchange of information, and family supportBuild a practice team culture around a shared commitment to embrace mental health care as integral to pediatric practice and an understanding of the

impact of trauma on child well-beingEstablish systems within the practice (and network) to support mental health services; elements may include the following:Preparation of office staff and professionals to create an environment of respect, agency, confidentiality, safety, and trauma-informed care;Preparation of office staff and professionals to identify and manage patients with suicide risk and other mental health emergencies;Electronic health record prompts and culturally and/or linguistically appropriate educational materials to facilitate offering anticipatory guidance and to

educate youth and families on mental health and substance use topics and resources;Routines for gathering the patient’s and family’s psychosocial history, conducting psychosocial and/or behavioral assessment;Registries, evidence-based protocols, and monitoring and/or tracking mechanisms for patients with positive psychosocial screen results, adverse

childhood experiences and social determinants of health, behavioral risks, and mental health problems;Directory of mental health and substance use disorder referral sources, school-based resources, and parenting and family support resources in the

region;Mechanisms for coordinating the care provided by all collaborating providers through standardized communication; andTools for facilitating coding and billing specific to mental health.

Systematically analyze the practice by using quality improvement methods with the goal of mental health practice improvement

TABLE 6 Potential Mental Health Care Team Members

Patient and familyOne or more PCCAny other pediatric team member who has forged a bond of trust with the family (eg, nurse, front deskstaff, medical assistant)

Mental health medical consultant (eg, child psychiatrist, developmental-behavioral pediatrician,adolescent specialist, pediatric neurologist), directly involved or consulting with PCC by phone ortelemedicine link

Psychologist, social worker, advanced practice nurse, substance use counselor, early interventionspecialist, or other licensed specialist(s) trained in the relevant evidence-based psychosocial therapy

School-based professionals (eg, guidance counselor, social worker, school nurse, school psychologist)Representative of involved social service agencyMedical subspecialist(s) or surgical specialistParent educatorPeer navigatorCare manager

PCC, primary care clinician.

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and dyadic (attachment-focused)therapy as indicated, and comanagingcare. When social risk factors areidentified (eg, maternal depression,poverty, food insecurity), thepediatrician’s role is to connect thefamily to needed resources.

School-aged Children and Adolescents

The AAP Task Force on Mental Healthidentified common manifestations ofmental health problems in school-aged children and adolescents asdepression (low mood), anxious andavoidant behaviors, impulsivity andinattention (with or withouthyperactivity), disruptive behaviorand aggression, substance use, andlearning difficulty and developedguidance to assist pediatric cliniciansin addressing these problems.61

Recognizing that 75% of childrenwho need mental health services donot receive them, the AAP went on topublish a number of additionaleducational resources on these topics,specifically for pediatricians.62–64

Additional tools are available onlineat www.aap.org/mentalhealth.Children and adolescents who haveexperienced trauma may manifestany combination of thesesymptoms.65,66 Children andadolescents with an underlyingmental condition may present withsomatic symptoms (eg, headache,abdominal pain, chest pain, limb pain,fatigue) or eating abnormalities.67,68

Furthermore, children andadolescents may experience impairedfunctioning at home, at school, orwith peers, even in the absence ofsymptoms that reach the thresholdfor a diagnosis.2,69,70

Once a pediatrician has identifieda child or adolescent with 1 or moreof these manifestations of a possiblemental health condition (collectivelytermed “mental health concerns” inthis statement, indicating that theyare undifferentiated as to disorder,problem, or normal variation), thepediatrician needs skills todifferentiate normal variations from

problems from disorders and todiagnose, at a minimum, conditionsfor which evidence-based primarycare assessment and treatmentguidance exists—currently ADHD,71

depression,72,73 and substance use.74

Pediatricians also need knowledgeand skills to diagnose anxietydisorders, which are among the mostcommon disorders of childhood, oftenaccompany and adversely affect thecare of chronic medical conditions,and when associated with no morethan mild to moderate impairment,are often amenable to pediatrictreatment.66 A number of disorder-specific rating scales and functionalassessment tools are applicable to usein pediatrics, both to assist indiagnosis and to monitor theresponse to interventions; these havebeen described and referenced in thedocument “Mental Health Tools forPediatrics” at www.aap.org/mentalhealth.

Although the diagnostic assessmentof children presenting withaggressive behaviors often requiresmental health specialty involvement,pediatricians can use a stepwiseapproach to begin the assessment andoffer guidance in selectingpsychosocial interventions in thecommunity for further diagnosis andtreatment, as outlined in theguideline, “Treatment of MaladaptiveAggression in Youth (T-MAY),”available at www.ahrq.gov/sites/default/files/wysiwyg/chain/practice-tools/tmay-final.pdf.

Pharmacologic and PsychosocialTherapies

Many pharmacologic andpsychosocial therapies have beenproven effective in treating childrenwith mental health disorders.Pharmacologic therapies may bemore familiar to pediatricians thanpsychosocial therapies; however,psychosocial therapies, either aloneor in combination withpharmacologic therapies, may bemore effective in some circumstances.

For example, American Academy ofChild and Adolescent Psychiatryguidelines recommend at least 2trials of psychosocial treatmentbefore starting medication in youngchildren up to 5 years of age.75

Studies involving children andadolescents in several specific agegroups have revealed the advantageof combined psychosocial andmedication treatment over eithertype of therapy alone for ADHD in 7-to 9-year-old children,76 commonanxiety disorders in 7- to 9-year-oldchildren,77 and depression in 12- to17-year-old children,78 and benefitsof combined therapy likely go wellbeyond these age groups.Furthermore, many children withmild or subthreshold anxiety ordepression are likely to benefit frompsychosocial therapy, mind-bodyapproaches, and self-help resourceswithout medication.48,66,79 Althoughpediatricians may feel pressured toprescribe only medication in theseand other situations because it isgenerally more accessible and/orexpedient,80 knowledge of theseother approaches is necessary to offerchildren these choices. If neededcommunity services are not available,pediatricians can use common-elements approaches in the pediatricoffice and advocate for evidence-based therapies to be offered by themental health community.

Certain disorders (ADHD, commonanxiety disorders, depression), ifassociated with no more thanmoderate impairment, are amenableto primary care medicationmanagement because there areindicated medications with a well-established safety profile (eg,a variety of ADHD medications andcertain selective serotonin reuptakeinhibitors).81 Ideally, pediatricsubspecialists would also beknowledgeable about thesemedications, their adverse effects,and their interactions withmedications prescribed in theirsubspecialty practice. Necessary

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clinical skills are summarized inTable 4.

Practice Enhancements

Effective mental health care requiresthe support of office and networksystems. Competencies requisite toestablishing and sustaining thesesystems are outlined in Table 5.

PROGRESS TO DATE

Despite many efforts to enhance thecompetence of pediatric residentsand practicing pediatricians (seeaccompanying technical report“Achieving the Pediatric MentalHealth Competencies”31), change inmental health practice during the lastdecade has been modest, as measuredby the AAP’s periodic surveys ofmembers. National data reveal that in2013, only 57% of pediatricians wereconsistently treating ADHD and lessthan a quarter were treating anyother disorder.82 Although fewerbarriers were reported in 2013 thanin 2004, most pediatricians surveyedin 2013 reported that they hadinadequate training in treating childmental health problems, a lack ofconfidence to counsel children, andlimited time for these problems.83

In the accompanying technical report,we address the barriers of trainingand confidence.31 The barrier oflimited time for mental health caremay one day become an artifact ofvolume-based care and the paymentsystems that have incentivized it.Value-based payment, expandedclinical care teams, and integration ofmental health care into pediatricsettings may provide new incentivesand opportunities for mental healthpractice, improve quality of care, andresult in improved outcomes for bothphysical and mental healthconditions. In the interim, the AAPrecognizes that although theproposed competencies are necessaryto meet the needs of children,pediatricians will necessarily achievethem through incremental steps thatrely on improved third-party payment

for their mental health services andaccess to expertise in mental healthcoding and billing to support the timerequired for mental health practice.

RECOMMENDATIONS

The recommendations that followbuild on the 2009 policy statement18

and assumptions drawn from reviewof available literature; the recognized,well-documented, and growingmental health needs of the pediatricpopulation; expert opinion of theauthoring bodies; and review andfeedback by additional relevant AAPentities. There are striking geographicvariations in access to pediatricmental health services from state tostate and within states, from urban torural areas.84 By engaging in the kindof partnerships described in the firstpoint below, pediatricians canprioritize their action steps andimplement them, incrementally, inaccordance with their community’sneeds. With the pediatricadvantage in mind, the AAPrecommends that pediatriciansengage in the following:

partner with families, youth, andother child advocates; mentalhealth, adolescent, anddevelopmental specialists;teachers; early childhoodeducators; health and humanservice agency leaders; local andstate chapters of mental healthspecialty organizations; and/orAAP chapter and national leaderswith the goal of improving theorganizational and financial base ofmental health care, depending onthe needs of a particularcommunity or practice; this mightinclude such strategies as:

advocating with insurers and payersfor appropriate payment topediatricians and mental healthspecialists for their mental healthservices (see the Chapter Action Kitin Resources);

using appropriate coding and billingpractices to support mental health

services in a fee-for-servicepayment environment (see ChapterAction Kit in Resources);

participating in development ofmodels of value-based and bundledpayment for integrated mentalhealth care (see the AAP PracticeTransformation Web site inResources); and/or

identifying gaps in key mental healthservices in their communities andadvocating to address deficiencies(see Chapter Action Kit inResources);

pursue quality improvement andmaintenance of certificationactivities that enhance their mentalhealth practice, prioritizing suicideprevention (see QualityImprovement and/or Maintenanceof Certification in Resources);

explore collaborative care models ofpractice, such as integration ofa mental health specialist asa member of the medical hometeam, consultation with a childpsychiatrist or developmental-behavioral pediatrician, ortelemedicine technologies thatboth enhance patients’ access tomental health specialty care andgrow the competence andconfidence of involvedpediatricians (see AAP MentalHealth Web site in Resources);

build relationships with mentalhealth specialists (includingschool-based providers) withwhom they can collaborate inenhancing their mental healthknowledge and skills, in identifyingand providing emergency care tochildren and adolescents at risk forsuicide, and in comanagingchildren with primary mentalhealth conditions and physicalconditions with mental healthcomorbidities (see Chapter ActionKit in Resources);

pursue educational strategies (eg,participation in a child psychiatryconsultation network, collaborativeoffice rounds, learning

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collaborative, miniature fellowship,AAP chapter, or health systemnetwork initiative) suited to theirown learning style and skill levelfor incrementally achieving themental health competenciesoutlined in Tables 4 and 5 (seeaccompanying technical report forin-depth discussion of educationalstrategies);

advocate for innovations in medicalschool education, residency andfellowship training, and continuingmedical education activities toincrease the knowledge base andskill level of future pediatricians inaccordance with the mental healthcompetencies outlined in Tables 4and 5; and

promote and participate in researchon the delivery of mental healthservices in pediatric primary careand subspecialty settings.

In the accompanying technicalreport,31 we highlight successfuleducational initiatives and suggestpromising strategies for achievingthe mental health competenciesthrough innovations in the trainingof medical students, pediatricresidents, fellows, preceptors, andpracticing pediatricians and throughsupport in making practiceenhancements.

CONCLUSIONS

The AAP recognizes pediatricians’unique opportunities to promotechildren’s healthy socioemotionaldevelopment, strengthen children’sresilience to the many stressors thatface them and their families, andrecognize and address the mentalhealth needs that emerge duringchildhood and adolescence. Theseopportunities flow from the pediatricadvantage, which includeslongitudinal, trusting, andempowering relationships withpatients and their families and thenonstigmatizing, family friendlinessof pediatric practices. Fully realizingthis advantage will depend on

pediatricians developing or honingtheir mental health knowledge andskills and enhancing their mentalhealth practice. To that end, thisstatement outlines mental healthcompetencies for pediatricians,incorporating evidence-based clinicalapproaches that are feasible withinpediatrics, supported by collaborativerelationships with mental healthspecialists, developmental-behavioralpediatricians, and others at boththe community and practice levels.

Enhancements in pediatric mentalhealth practice will also depend onsystem changes, new methods offinancing, access to reliable sources ofinformation about existing evidenceand new science, decision support,and innovative educational methods(discussed in the accompanyingtechnical report31). For this reason,attainment of the competenciesproposed in this statement will, formost pediatricians, be achievedincrementally over time. Gains arelikely to be substantial, including theimproved well-being of children,adolescents, and families andenhanced satisfaction of pediatricianswho care for them.

RESOURCES

AAP Clinical Tools and/or Tool Kits

AAP clinical tools and/or tool kitsinclude the following:

Addressing Mental Health Concernsin Primary Care: A Clinician’sToolkit;

Health Insurance Portability andAccountability Act of 1996 PrivacyRule and Provider to ProviderCommunication;

Mental Health Initiatives ChapterAction Kit; and

AAP Coding Fact Sheets (AAP log-onrequired).

AAP Policies

AAP policies include the following:

ADHD: Clinical Practice Guideline forthe Diagnosis, Evaluation, and

Treatment of Attention-Deficit/Hyperactivity Disorder in Children

and Adolescents (November 2011);

Guidelines for Adolescent Depressionin Primary Care (GLAD-PC): Part I.Practice Preparation, Identification,Assessment, and InitialManagement (endorsed by the AAPMarch 2018);

Guidelines for Adolescent Depressionin Primary Care (GLAD-PC): Part II.Treatment and OngoingManagement (endorsed by the AAPMarch 2018);

Policy Statement: IncorporatingRecognition and Management ofPerinatal and PostpartumDepression Into Pediatric Practice(January 2019);

Technical Report: IncorporatingRecognition and Management ofPerinatal and PostpartumDepression Into Pediatric Practice(January 2019);

Policy Statement: Early ChildhoodAdversity, Toxic Stress, and theRole of the Pediatrician:Translating Developmental ScienceInto Lifelong Health (January 2012;reaffirmed July 2016);

Technical Report: The Lifelong Effectsof Early Childhood Adversity andToxic Stress (January 2012;reaffirmed July 2016);

Clinical Report: Mind-Body Therapiesin Children and Youth (September2016);

The Prenatal Visit (July 2018);

Clinical Report: Promoting OptimalDevelopment: Screening forBehavioral and EmotionalProblems (February 2015);

Policy Statement: Substance UseScreening, Brief Intervention, andReferral to Treatment (July 2016);and

Clinical Report: Substance UseScreening, Brief Intervention,and Referral to Treatment (July2016).

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Quality Improvement and/orMaintenance of Certification

Quality improvement and/orMaintenance of Certificationresources include the following:

Education in Quality Improvement forPediatric Practice: Bright Futures -Middle Childhood and Adolescence;

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

American Board of Pediatrics QualityImprovement Web site.

AAP Publications

AAP publications include thefollowing:

AAP Developmental BehavioralPediatrics, Second Edition;

Mental Health Care of Children andAdolescents: A Guide for PrimaryCare Clinicians;

Promoting Mental Health in Childrenand Adolescents: Primary CarePractice and Advocacy;

Pediatric Psychopharmacology forPrimary Care;

Quick Reference Guide to CodingPediatric Mental Health Services2019; and

Thinking Developmentally.

AAP Reports

AAP reports include the following:

Improving Mental Health Services inPrimary Care: A Call to Action forthe Payer Community (AAP log-onrequired); and

Reducing Administrative andFinancial Barriers.

Web Sites

Web site resources include thefollowing:

AAP Mental Health Web site;

AAP Practice Transformation Website;

National Center for Medical HomeImplementation;

The Resilience Project; and

Screening Technical Assistance andResource Center.

Lead Authors

Jane Meschan Foy, MD, FAAP

Cori M. Green, MD, MS, FAAP

Marian F. Earls, MD, MTS, FAAP

Committee on Psychosocial Aspectsof Child and Family Health,2018–2019

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

Former Committee on PsychosocialAspects of Child and Family HealthMembers

Michael Yogman, MD, FAAP, FormerChairperson

Gerri Mattson, MD, FAAP

Jason Richard Rafferty, MD, MPH,EdM, FAAP

Liaisons

Sharon Berry, PhD, ABPP, LP – Societyof Pediatric Psychology

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

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

Abigail Boden Schlesinger, MD –American Academy of Child andAdolescent Psychiatry

Rachel Shana Segal, MD – Section onPediatric Trainees

Amy Starin, PhD – NationalAssociation of Social Workers

Mental Health Leadership WorkGroup, 2017–2018

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

Cori M. Green, MD, MS, FAAP

Alain Joffe, MD, MPH, FAAP

Staff

Linda Paul, MPH

ABBREVIATIONS

AAP: American Academy ofPediatrics

ADHD: attention-deficit/hyperactivity disorder

*The term “mental” throughout this statement is intended to encompass “behavioral,” “psychiatric,” “psychological,” “emotional,” and “substance use” as well as

family context and community-related concerns. Accordingly, factors affecting mental health include precipitants such as child abuse and neglect, separation or

divorce of parents, domestic violence, parental or family mental health issues, natural disasters, school crises, military deployment of children’s loved ones,

incarceration of a loved one, and the grief and loss accompanying any of these issues or the illness or death of family members. Mental also is intended to

encompass somatic manifestations of psychosocial issues, such as eating disorders and gastrointestinal symptoms. This use of the term is not to suggest that the

full range or severity of all mental health conditions and concerns falls within the scope of pediatric practice but, rather, that children and adolescents may suffer

from the full range and severity of mental health conditions and psychosocial stressors. As such, children with mental health needs, similar to children with special

physical and developmental needs, are children for whom pediatricians provide care in the medical home and in subspecialty practice.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements

with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of

Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

12 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 19, 2020www.aappublications.org/newsDownloaded from

DOI: https://doi.org/10.1542/peds.2019-2757

Address correspondence to Jane Meschan Foy, MD, FAAP. E-mail: foy.jane@gmail.com

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

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

FUNDING: No external funding.

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

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HEALTH LEADERSHIP WORK GROUPPSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, MENTAL

Jane Meschan Foy, Cori M. Green, Marian F. Earls and COMMITTEE ONMental Health Competencies for Pediatric Practice

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Jane Meschan Foy, Cori M. Green, Marian F. Earls and COMMITTEE ONMental Health Competencies for Pediatric Practice

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