Gaps in mental health training pose imminent crisis for pediatric care
According to the National Institute of Mental Health, approximately 13% of children aged 8 to 15 years in the United States will experience a severe mental disorder at some point in their lives. Most mental health conditions develop by the age of 24, with 50% of lifetime cases of disorders emerging by the age of 14 in the form of autism, attention-deficit/hyperactivity disorder, anxiety, behavioral problems and depression. Left untreated, severe mental health conditions can lead some children to take their own lives; suicide remains the third leading cause of death among youth aged 10 to 24, with a higher mortality rate than AIDS, cancer, heart disease, birth defects, stroke, pneumonia, influenza and chronic lung disease — combined.
Despite these disturbing statistics, in a 2013 survey conducted by the AAP, 65% of pediatricians believed they lacked the necessary training in the treatment of children with mental health problems, 40% responded they lacked the ability to diagnose mental health problems and more than 50% reported they lacked confidence in their ability to treat these patients.
More than ever, pediatricians and other primary care providers are finding themselves on the front line of child mental health care, whether screening for autism, initiating medications for ADHD or depression, or providing counsel for parents of children with behavioral problems. Where once there was an opportunity to outsource mental health problems, national shortages of pediatric medical specialists have returned responsibility to individual providers; further compounding this problem is that current pediatric residency training requirements no longer necessitate curricular elements or assessment requirements in mental health.
“A vicious circle exists where the service demands of residency programs and the hospitals that fund them do not give residents the experience and the teaching that they need,” Julia A. McMillan, MD, FAAP, professor emerita of of pediatrics and the pediatric residency program at Johns Hopkins School of Medicine. “Those pediatric residents become faculty for the subsequent generation of pediatric residents who also do not receive the training and the experience that they need.”
Inadequate training leaves primary care providers unprepared to identify children with mental health needs, which can further delay referral to an already depleted workforce of early intervention providers. Even once a referral is made, a child suspected of having mental health conditions can spend months on a waiting list for evaluation from a subspecialist.
To determine the scope and implications of this issue, Infectious Diseases in Children spoke with several experts, including psychiatric and pediatric experts, about the difficulties PCPs face in stemming the tide of behavioral and mental health problems among children, and how new training and reimbursement procedures may alter the role of primary care in identifying, diagnosing and managing pediatric mental health conditions.
No longer the ‘new morbidity’ on the block
“We have known for several decades that there were behavioral and mental health issues among children that were not being adequately addressed by pediatric providers — there is simply a growing recognition now because there are growing problems,” McMillan said in an interview.
In 1999, U.S. Secretary of Health and Human Services Donna Shalala released the first-ever Surgeon’s General Report on Mental Health, a historic report that noted that shortages of child psychiatrists were among the main problems plaguing the mental health care system. Per the report, these shortages placed additional diagnostic and treatment burden on pediatricians and PCPs, who were “unlikely to have the time and specialized training to do an evaluation.”
Although the report may have been intended as a rallying cry for revamping the mental health paradigm, the crisis has only continued to worsen; national shortages of child psychiatrists persist while pediatricians contend with increasingly complicated ‘newer morbidities’ beyond the scope of their limited training, such as bullying, sexual abuse, substance abuse and school violence.
“Even when I was a resident, there was discussion about the ‘new morbidity,’ which it was not even then,” Michelle M. Macias, MD, director of the Division of Developmental-Behavioral Pediatrics at the Medical University of South Carolina, said in an interview. “Since this ‘new morbidity’ was first addressed in the 1970s, people have the idea that this is a growing crisis that was not there before. However, I think it was always there and, instead, the ‘growth’ we are seeing is an increasing recognition of the spectrum of behavioral and mental health disorders, especially in pediatrics.”
To face the increasing prevalence of pediatric mental health disorders, the U.S. Bureau of Health Professions has estimated the need for 13,000 practicing child and adolescent psychiatrists by 2020 — an unlikely goal considering there are currently only 8,300, according to the American Academy of Child and Adolescent Psychiatry.
Considering this continued scarcity, pediatricians have been responsible for providing the bulk of psychiatric care. In their 2015 study in Pediatrics, Van Cleave and colleagues found that 35% of children who received care for mental health conditions in office-based settings were treated solely by primary care physicians, compared with 26% who were treated by psychiatrists and 15% who were treated by psychologists or social workers.
“There has certainly been an increase in difficulties accessing mental health services for children, and I think that that has to do with a combination of factors, including the workforce shortage,” Barry Sarvet, MD, from Division of Child and Adolescent Psychiatry at Baystate Medical Center, and associate clinical professor of psychiatry at Tufts University School of Medicine, said in an interview. “Additionally, there have also been other ways in which these children’s mental health needs have been met in the past, through different social supports, such as schools, which are increasingly underfunded and distressed.”
“When these systems are not able to provide adequate support for children, mental health crises become more urgent and lead to a sense of frustration and desperation. Pediatricians have always been the so-called ‘default provider’ — when the system is not working, the pediatrician ends up being left to pick up the pieces.”
At the heart of the problem: Training
Despite a long history with the ‘new morbidity,’ program requirements for pediatric residency training in the United States did not include a requirement for “evidence of structured educational experiences in adolescent medicine, child development [and] child psychology” until 1990. Building upon this foundation, in 2000, pediatric residency programs were required to incorporate a 1-month training block in behavioral and developmental aspects of pediatrics.
However, the requirements of the Accreditation Council for Graduate Medical Education do not specify what proficiency residents should have in these aspects of child care, which leaves a conspicuous gap in quality evaluation for practitioners hoped to bridge the void in pediatric mental health.
“The principal reason for the lack of mental health training among [PCPs] is that residency training is incredibly time-limited,” Susan Guralnick, MD, associate dean of graduate medical education and student affairs and Designated Institutional Official for Winthrop University Hospital, said in an interview. “Over the years, there has been an increasing amount of information that residents have had to learn during training, and the depth of the curriculum makes it difficult to provide residents with the knowledge and experiences they need to provide appropriate behavioral and mental health care.”
When subspecialty certification of developmental and behavioral pediatricians was first offered by the American Board of Pediatrics in 2002, it was hoped to address this very hole in pediatric training: providing specially trained pediatricians who could be educators for the following generation within their training programs.
“However, those individuals are functioning very much like other pediatric subspecialists with a need to generate their own clinical income by caring for very complex patients,” McMillan said. “Rather than teaching residents in a primary care setting, they are treating children with devastating and complex developmental and behavioral needs in their own clinics. While these specialists are providing a wonderful service for complex patients, they are not in an environment where they are teaching pediatric residents what they need to know.”
Additionally, board-certified pediatric developmental/behavioral subspecialists, much like child psychiatrists, remain too thinly spread across the country: 775 subspecialists available nationwide translate to a single subspecialist for every 300,000 children in some states. Given the continued lack of specialized personnel, there are further proposals to broaden the responsibility for mental health intervention across the spectrum of health care subspecialties.
“While we have often seen mental health as a priority of the primary care provider, it also needs to be a priority of the subspecialty team that is caring for children and adolescents with special health care needs,” Laurel K. Leslie, MD, MPH, professor of medicine and pediatrics at Tufts Medical Center, and vice president of research at the American Board of Pediatrics, said in an interview.
“Mental health is critical to be thinking about, no matter whether you are in primary care or in a subspecialty setting. Training can occur not only in continuity or developmental or behavioral pediatrics clinics, but also in hematology/oncology with a family starting chemotherapy, or in gastrointestinal in a child with ulcerative colitis. These also represent opportunities for teaching about mental health screening, identification, treatment and referral, and for doing a better job of managing children’s needs.”
Stepping outside the comfort zone
Adding to the lack of training for pediatricians and the dearth of available mental health specialists, inadequate reimbursement from government and private insurance plans remains one of the main barriers to mental health care access. Overwhelmed by low reimbursement rates compared with other services and the effort required to appeal, many pediatricians have opted instead to refer out many of their pediatric mental health problems.
“Pediatricians are aware that reimbursement for the time spent working with behavioral and mental health problems is not sufficient — that visits in outpatient settings have to be short to be able to support a pediatrician and their practice — and the incentive to provide that care is diminished as a result,” McMillan told Infectious Diseases in Children.
In a 2015 study in Academic Pediatrics, Stein and colleagues examined whether the emphasis on the role of the pediatrician for mental health issues had affected pediatrician comfort level in managing care for these children. In two separate surveys of pediatricians in 2004 and 2013, the researchers examined self-reported behaviors of treating/managing/comanaging, or referring patients for ADHD, anxiety, depression, behavioral problems or learning problems.
Although researchers noted incremental improvements in treating and managing anxiety and depression, ADHD remained the only mental health condition for which most pediatricians treated/managed/comanaged (57%).
“ADHD is a mental health condition that many practitioners feel relatively comfortable with, but even there, we are still only looking at a comfort level in providing care in a little above 50% of practitioners,” Leslie said. “Contrastingly, for depression, anxiety, and common behavioral management problems, comfort with identification, treatment and management is quite low.”
She added, “While I think we have done a great deal to educate physicians about ADHD management, including medications, we have not done as good a job for depression, anxiety and behavioral management problems. For those conditions, it is recommended to start with and use core skills like motivational interviewing to engage children and families in identifying steps for change; many pediatricians are not necessarily aware of those skills.”
She added, “While I think we have done a great deal to educate physicians about ADHD management, including medications, we have not done as good a job for depression, anxiety and behavior management problems. For those conditions, it is recommended to start with counseling, to use core skills like motivational interviewing to engage children and families in coming up with steps for change; many pediatricians are not necessarily aware of those skill sets.”
Although no single health care provider seems capable of tackling the overwhelming number of pediatric mental health conditions, leaders in the pediatric field have proposed the creation of collaborative networks between primary care, mental health specialists, families and school personnel. This network could provide a sphere of individuals invested in the child’s well-being, with each branch of the network able to inform the PCP about different aspects of the child’s life.
For example, with approximately 55 million children enrolled, schools present an important opportunity for recognizing early signs of mental health problems in children, and school nurses and school-based health centers are uniquely positioned to provide early warning to families and PCPs to link students with effective services and supports.
“It would be wonderful if PCPs could have a conversation with the different members of the network, including family, school personnel or a psychologist, and then form a plan and set goals,” Guralnick told Infectious Diseases in Children. “PCPs could have a schedule of follow-up intervals and reports back so that they know what care is working and what is not working — sometimes what works for the child does not for the family, and what works for the family does not for the school. This kind of network is not commonly available, but it should be because it sits very well with the whole concept of ‘medical home,’ in which the [PCP] would be the center for communication among all the different groups.”
Additionally, the AAP recently recommended the increased use of paraprofessionals, such as family navigators and family support workers, to improve mental health care access for low-income children and families in primary care settings. Usually for the parent or caregiver of a child with mental health needs who has overcome similar challenges, family navigators can provide peer support, as well as share knowledge about the support service and delivery systems with other families.
“In developmental and behavioral pediatrics, we are increasing our use of family navigators; when we talk about patient-centered medical home, you want to use the patients and families that are there,” Macias said. “Targeted care coordination can really help with establishing those links with schools and other resources, and using the family navigators or family support workers can help tremendously in achieving that access to care. Each practice should look at the available services in the community for themselves to see how they would work best, but as I always tell pediatricians and primary care providers, schools would love to hear from you.”
Retooling for the future
In addition to tapping into previously underused or unconnected personnel resources, several educational initiatives have been introduced to address the mental health specialist shortage, most notably the Post Pediatric Portal Pilot Project, specifically geared toward pediatricians, and programs from the Resources for Advancing Children’s Health (REACH) Institute.
Launched in 2006, the REACH training program is intended to instruct PCPs to assess, diagnose and manage a wider range of mental health issues, including anxiety, bipolar disorder, and depression.
“Pediatricians certainly do not worry about treating pneumonia or otitis media, because they have been trained very well for these conditions and that training has been reinforced in daily practice,” Macias said. “Through programs like the REACH Institute, there has been an effort to help practices and individual pediatricians become similarly comfortable treating common mental health conditions.”
Similarly, some states have responded to the continued shortage of psychiatric providers by encouraging the use of telepsychiatry and by adopting programs that connect psychiatrists with primary care physicians on an ‘as needed’ basis. Regional services include the Behavioral Health Integration in Pediatric Primary Care in Maryland program and the Massachusetts Child Psychiatry Access Project (MCPAP), which provides Massachusetts PCPs with prompt access to child psychiatry expertise, education and referral assistance.
“This program is designed to be a combination of a clinical service delivery model with consultation for pediatricians to help them determine how to help specific children they are treating,” Sarvet, the statewide medical director for MCPAP, told Infectious Diseases in Children. “On the other hand, the program is an education model through what we consider to be case-based education to aid pediatricians over years to gradually learn more about how to properly care for these mental health problems.”
Sarvet described the three main types of service offered by MCPAP:
- Telephone consultation: Pediatric providers have access to a ‘warmline,’ through which they can speak with a child psychiatrist within a short period of time. Child psychiatrists can answer questions and provide the PCPs with informal advice about treating a specific patient.
- Evaluation: A subset of children receive evaluations following the initial telephone consultation, with MCPAP providing an expedited process to get children in for psychiatric evaluation, which serves as a formal consult.
- Resource/referral support: Following consultation or evaluation, MCPAP can identify necessary resources to help them navigate the mental health system in their community. MCPAP can also provide information directly to the provider about what services are available and how to obtain them, or work directly with the family if the patient has higher risk issues.
“By helping pediatricians care for the patients who they can treat appropriately and safely, this frees up the workforce so that psychiatrists are not working with children whose conditions are relatively straightforward,” Sarvet said. “In some ways, this serves as a triage system: We try to help the pediatrician determine whether the patient needs a child psychiatrist to treat him or her or if they can treat the patient with the help of child psychiatrists as part of the MCPAP team.”
Because it is commonly held that the U.S. is unlikely to achieve a ‘sufficient’ number of mental health specialists to stem the current time of pediatric mental health conditions, pediatricians are once again stepping forward to answer the crisis, in whatever measure they can.
“Pediatricians need to find ways to partner with mental health providers, whether they are social workers or child psychologists or child psychiatrists,” McMillan said “There are too few of these specialists, but we need to figure out ways to take advantage of those who do exist and think about organizing practices in a way that includes those people as either part of the practice or as collaborators, where communication is seamless.” – by Bob Stott
- McMillan JA, et al. Pediatrics. 2016;doi:10.154/peds.2016-2141.
- Stein REK, et al. Acad Pediatr. 2016; doi: 10.1016/j.acap.2015.08.012
- Van Cleave J, et al. Pediatrics. 2015; doi: 10.1542/peds.2015-0807
- For more information:
- Susan Guralnick, MD, can be reached at Winthrop-University Hospital, 222 Station Plaza N. Suite 510, Mineola, N.Y. 11501; email: email@example.com.
- Laurel K. Leslie, MD, MPH, can be reached at 111 Silver Cedar Court Chapel Hill, NC 27514; email: firstname.lastname@example.org.
- Michelle M. Macias, MD, can be reached at 135 Rutledge Avenue, MSC 567, Charleston SC, 29425-0567; email: email@example.com.
- Julia A. McMillan, MD, FAAP, can be reached at Johns Hopkins Children’s Center, Room 8491, 1800 Orleans Street, Baltimore, MD 21287; email: firstname.lastname@example.org.
- Barry Sarvet, MD, can be reached at Baystate Medical Center/Tufts School of Medicine, 3300 Main Street, 4th Floor, Springfield, MA 01199; email: Barry.Sarvet@baystatehealth.org.
Disclosures: Guralnick, Leslie, Macias, McMillan and Sarvet report no relevant financial disclosures.