Workforce Development to Enhance the Cognitive, Affective, and Behavioral Health of Children and Youth: Opportunities and Barriers in Child Health Care Training

DISCUSSION PAPER

Thomas F. Boat, MD, University of Cincinnati College of Medicine; Marshall L. Land, MD, University of Vermont College of Medicine; Laurel K. Leslie, MD, MPH, American Board of Pediatrics; Kimberly E. Hoagwood, PhD, New York University; Elizabeth Hawkins-Walsh, PhD, CPNP, PMHS, FAANP, The Catholic University of America; Mary Ann McCabe, PhD, George Washington University School of Medicine; Mark W. Fraser, PhD, University of North Carolina at Chapel Hill; Lisa de Saxe Zerden, MSW, PhD, University of North Carolina at Chapel Hill; Brianna M. Lombardi, MSW, University of North Carolina; Gregory K. Fritz, MD, American Academy of Child and Adolescent Psychiatry; Bianca Kiyoe Frogner, PhD, Univer- sity of Washington; J. David Hawkins, PhD, University of Washington; Millie Sweeney, MS, Family-Run Executive Director Leadership Association November 29, 2016

Responsibility for cognitive, affective, and behavioral innovation in this area has been carried out by pre- (CAB) health of children and adolescents (hereafter vention scientists who have created evidence-based “youth”) has traditionally been shared among fami- interventions, primarily targeting activities in commu- lies, education systems, communities, and the health nity settings, and has not focused on opportunities care delivery system. Within routine child health care, within primary or subspecialty child health care set- increasing but spotty attention is paid to early cogni- tings. Preventive interventions adapted for child health tive, emotional, and behavioral development. Those care settings and training programs are nascent and most intensively trained in emotional development will require a revision of training goals and curricula and the clinical behavioral sciences (e.g., child and as well as a reorganization of practice for successful adolescent psychiatrists and psychologists, behavioral implementation. and developmental pediatricians, and social workers) have historically been segmented from routine child Why Focus on Children’s Cognitive, Affective, health care. Roles of behavioral clinicians have focused and Behavioral Health? largely on treating those who have troublesome or Childhood mental health diagnoses are increasing in disabling CAB disorders. Relatively less attention has absolute numbers as well as in proportion to the total been paid by any segment of the health care field to childhood population (IOM, 2015b). Estimates are that CAB health promotion and disorder prevention, start- 13-20 percent of youth ages 3-17 in the United States ing early in life, or even to early detection and interven- experience a mental health disorder in any given year tion for behavioral problems of youth who do not meet (NRC and IOM, 2009b); these estimates do not take diagnostic criteria (NRC and IOM, 2009b). Much of the into account youth with autism spectrum and cognitive

Disclaimer|The views expressed in this Perspective are those of the authors and not necessarily those of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the Academies). The Perspective is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of, nor is it a report of, the NAM or the Academies. Copyright by the National Academy of Sciences. All rights reserved.

Perspectives | Expert Voices in Health & Health Care DISCUSSION PAPER

disorders or sub-threshold CAB symptoms. An in- 1971). All of these concerns can be addressed by the creased prevalence of diagnosed childhood CAB dis- medical care system if properly organized to provide orders is adding to the care and cost burden for chil- and promote family-focused, children’s CAB health dren at an alarming rate (AHRQ, 2014). Mental health and preventive interventions in the early years. disorders negatively affect youth outcomes; research estimates that 50 percent of high school students with Why Should Health Care Be a Preferred mental health disorders drop out of school (NAMI, Venue for CAB Health Promotion and What Are n.d.). Particularly alarming are the increasing rates Obstacles to Implementation? of psychotropic medication use and hospitalization Child health primary care provided in pediatric and among youth (Perou et al., 2013). A recent 2013 report family practice settings hold great promise for improv- by the Centers for Disease Control and Prevention ing CAB outcomes. A majority of children, estimated (CDC) estimated the costs of behavioral disorders in at 90 percent, are seen with their parents in primary youth to be approximately $247 billion per year when care settings on multiple occasions in the first several including health, educational, juvenile justice, and em- years of life, providing uniquely broad access and op- ployee productivity costs (Perou et al., 2013). Medicaid portunity (CDC, 2016). Child health care and health data from the first decade of the 2000s documented a care providers are trusted by most families (Graber, rate of increase that more than doubled reimbursed 2012). Anticipatory guidance, a standard component services for behavioral disorders of 3- through 17-year- of child health care during the frequent primary care old youth (IOM, 2015b). visits in the first years of life (Dosman et al., 2012), Furthermore, CAB disorders in youth frequently be- demonstrates that within this setting there is the abil- come disabling disorders in adults; in fact, 50 percent ity to address parenting practices that could better of lifetime cases of mental health disorders begin by support healthy CAB development. Several universal age 14, and 75 percent begin by age 24 (NRC and IOM, programs to mitigate risk —for instance, Reach Out 2009b). It is also recognized that over their lifetime and Read (ROR) and the Video Interaction Project (VIP), youth with CAB disorders are more vulnerable to risky which targets cognitive development (Mendelsohn et or negligent health-related behaviors and consequent al., 2007; Needlman et al., 2005)—have been widely in- physical health disorders (Felitti et al., 1998; Kessler corporated into primary care clinical and training pro- and Wang, 2008). The opportunity to mitigate risk for grams. Other programs, such as Incredible Years, have lifetime behavioral and related physical health condi- improved CAB outcomes when studied in primary care tions is likely to be greatest for young people, particu- settings (Perrin et al., 2014). Healthy Steps has also larly in the first 3-5 years of life (Shonkoff and Garner, been incorporated into dozens of practices across the 2012; Shonkoff et al., 2009). country (Briggs, 2016; IOM and NRC, 2014). Risks for disadvantageous CAB outcomes include In addition, screening for autism spectrum disor- family disruption, child abuse and neglect, exposure ders or adolescent depression is increasingly being to violence, food insecurity, unsafe housing, and many incorporated into pediatric practices (Cheung et al., other adverse early childhood experiences (Bitsko et 2007; Committee on Children With Disabilities, 2001; al., 2016; Shonkoff et al., 2009)—all of which lead to Robins, 2008). Screening mothers for their adverse unmitigated stress. The adverse CAB and physical experiences as a proxy to address their parenting skills health outcomes of early childhood risks, especially and providing parenting support through the Healthy the negative impact of multiple early adverse experi- Steps program have been shown in the Montefiore am- ences, are now well documented (Bethell et al., 2014; bulatory health care system in the Bronx to improve Jimenez et al., 2016). In addition, such common child- social-emotional development in children (Briggs et hood experiences as sleep deprivation, nutritional al., 2014). Assessing mothers for depression, which is deficits (e.g., iron deficiency), and excessive screen a risk for children’s CAB health (NRC and IOM, 2009a), time are generally recognized risk factors for disad- has become a more common practice in primary child vantageous CAB development (NRC and IOM, 2009b). health care, and there is now an allowable charge by Finally, chronic disease in childhood is a frequent and some state Medicaid programs. too often underappreciated risk factor for suboptimal A recent paper published by Stein et al., how- development of CAB potential (Pless and Roghmann, ever, demonstrated little change in primary care

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pediatricians’ skill set and comfort level with common health care disciplines are required to work with these CAB concerns outside of attention-deficit/hyperactivity behavioral health professionals to provide proactive disorder (Stein et al., 2016). It is imperative to improve and preventive behavioral care across the physical and the skills and engagement of physicians who provide behavioral health spectrum (IOM, 2015a). Though fam- primary child health care through training focused on ily disturbance is a contributor to poor CAB outcomes, important CAB pediatric health outcomes. wellness of the families who provide care for children Furthermore, the movement to accountable care, with chronic diseases is often unaddressed. consequent to the Patient Protection and Afford- In the future, the ability of health care profession- able Care Act (ACA), has incentivized new models of als to create effective integrated, interprofessional health care that affect both measurement and -deliv chronic care teams that promote children’s CAB health ery approaches, including the use of team-based ap- as well as advocate for diagnosis and treatment of be- proaches. The establishment of accountable care or- havioral disorders will be important for training. Yet, ganizations (ACOs) is a key feature of the ACA and is there is no requirement for either training in this mode designed to replace the fragmented and uncoordinat- or achievement of basic competency in CAB health ed care system with one that integrates care with pay- promotion by trainees in health professions that con- ment incentives targeting individual and population tribute to subspecialty team care. An exception may health outcomes (Fisher et al., 2007) and with team- be training in pediatric psychology, wherein trainees based approaches that require the blended expertise are expected to attend to the full continuum from of multiple providers (IOM, 2015c). Consequently, in- healthy growth and development, procedural distress tegrating other health professionals who can address and medication adherence, family adjustment, and CAB health at early ages into primary care settings for diagnosis and treatment of behavioral health condi- children where children are frequently evaluated is a tions. Increasingly, primary care physicians and nurse critical new development that emphasizes the need practitioners as participants in patient-centered medi- to organize training to promote acceptance of team- cal homes also contribute to the care of children with based care. chronic diseases. Their training must also provide ex- Primary health care is not the only medical setting perience with children with such chronic diseases as for enhancing children’s CAB health. Disabling chronic asthma and their families (Kolko and Perrin, 2014). disorders, which occur in an estimated 4-8 percent of Without immediate and sustained attention to de- youth (NASEM, 2015; Newacheck and Halfon, 1998), veloping a health care workforce ready to partner are diagnosed and treated largely in subspecialty around CAB health promotion and prevention as well medical care settings but with variable attention to the as treatment, the costs of mental health care will con- crippling behavioral dimensions of their disease. These tinue to adversely impact our nation. That workforce children are at risk for cognitive and behavioral issues must include all health professionals who serve chil- related to their primary condition or stemming from dren and families and must promote interdisciplin- treatments, including medical traumatic stress (Kazak ary, family-centric, community-linked, team-based et al., 2006). Disrupted school engagement, anxiety, methods for service provision. depression, and substance use are frequent (Hadland and Walker, 2016). Behavioral consequences and traumatic stress also accrue to parents and other family The Status of Health Care Workforce and members (Kazak et al., 2004; NASEM, 2016). For exam- Workforce Training That Addresses ple, a recent international survey of parents of recently Improvement of CAB Outcomes diagnosed patients with cystic fibrosis found a 30-40 At a macro-level, there appears to be an adequate percent prevalence of anxiety and /or depression number of pediatricians, family medicine physicians, (Quittner et al., 2015). In comprehensive chronic care pediatric psychologists, nurse practitioners, and so- programs, pediatric psychologists or behaviorally ori- cial workers who, if appropriately trained, can popu- ented social workers are embedded in the chronic care late efforts in health care that advance children’s CAB team, a practice that considerably antedates integrat- outcomes. Numbers of child and adolescent psychia- ed primary health care. Nevertheless, programs may trists and developmental and behavioral pediatricians, vary in the degree to which trainees from participating on the other hand, are insufficient to participate in

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broader efforts beyond their current focus on diag- discreet provider encounters to diagnose or treat spe- nosing and treating children with behavioral disorders cific conditions rather than for integrated, anticipatory (AACAP, 2016). Filling immediate needs for behavioral care or consultations among professionals. In systems expertise appears to fall largely on the shoulders of where insurance has been siloed for medical versus nonphysician behaviorally trained health profession- behavioral health claims, cost savings for promotion als. Estimates of mental health professionals in the and prevention have not been recognizable. Other im- United States determined that 96 percent of counties pediments include lack of standardized childhood out- had an unmet need for prescribing professionals and come measures for behavioral health promotion and 18 percent had an unmet need for non-prescribing behavioral disorder prevention and for judging com- mental health professionals (Konrad et al., 2009). The petence of trainees in these areas. latter gap was attributed to uneven distribution. Rural Obstacles to achieving a training experience that will and low-income populations are less well served by prepare health care professionals to foster child CAB mental health professionals, even though they repre- development and health are numerous and formi- sent populations of high need (Ricketts, 2005). Filling dable. They include insufficient numbers of well-pre- this gap may require participation by a broader array pared educators; lack of integrated, interprofessional of behavioral health care disciplines as well as the use training opportunities; practice facilities and organiza- of telemedicine to provide greater coverage. Greater tion that do not easily accommodate team practice; participation by primary care and subspecialty physi- and certification and accreditation expectations that cians (who, if adequately trained and supported by ap- do not address behavioral health in general or multi- propriate psychiatric consultation as needed, can be generational, family-focused CAB health promotion or prescribing mental health professionals), nurse prac- prevention. Other major obstacles include compensa- titioners, and social workers is needed. Creating an tion of care models that do not support interprofes- ideal workforce is a threefold challenge: to train health sional preventive care training and a resulting lack of professionals in sufficient numbers to fill current and institutional (hospital) support for preventive care. future needs; to focus training on preventive and pro- These obstacles can be overcome if there is a mandate motive (rather than only diagnostic and treatment) from standard setting bodies (e.g., certifying boards practices; and to set expectations for achievement of or program accreditation bodies, professional societ- specific competencies in training that cross all- disci ies, health care systems and organizations, and policy plines in the interests of promoting CAB health (Skill- makers) to train health care providers in team-based man et al., 2016; Annapolis Coalition on the Behavioral care in order to promote CAB health—and to reim- Health Workforce, 2007). burse these providers appropriately for that work. Symptom-focused training is still predominant in Workforce numbers are found in Table 1 (see page child health care settings. It will continue to be so be- 18 for full table), though they are not particularly help- cause the expanding body of knowledge is challenging ful in shaping a transformational plan to increase CAB to master, and disease is far from eradicated. Even health-related competencies of the child health care though there is increasing recognition of adverse ef- professional workforce. More specific and focused fects of behavioral disorders on physical health, care training opportunities and data from these opportuni- settings are not organized to address behavioral ties will be needed. health promotion and prevention needs. Medical and behavioral health care training have traditionally been Characteristics of a Health Care System That provided in separate venues. In addition, child health Will Promote Children’s CAB Health care, whether in the primary care or the subspecialty Individuals participating in children’s CAB-promot- setting, may focus on the child to the exclusion of par- ing health care teams can come from a number of ents, at a time when multigenerational, family-focused disciplines. A desired starting point would be pro- medical and preventive interventions are likely to be viders who integrate medical and behavioral care. the most effective. Importantly, characteristics of cur- Health care providers in the domains of nurse prac- rent child health care are driven or reinforced by reim- titioner, family medicine, obstetrics and gynecology, bursement systems—which at this time largely pay for and pediatric practice, as well as behavioral health

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providers (whether physicians, psychologists, social of further comment, but all of them are important con- workers, nurses and nurse practitioners) can be key siderations in the creation of integrated care training contributors in promoting children’s CAB health. Fami- programs that more effectively promote CAB health ly medicine providers have the advantage of being able for all children. to work with parents during the prenatal and postnatal care periods. Obstetricians and gynecologists are ide- Interprofessional Care ally situated to play an important role as providers of Integrated care has gained considerable popularity in parent counseling for expectant parents around the the health care field and provides an ideal framework impact of healthy fetal development on children’s CAB for child health care trainees to experience and devel- health. Nurse practitioners are increasingly providing op competency in the area of child behavioral health primary care for children and families. Some pediat- promotion and disorder prevention. In practice, it is ric practices provide a single prenatal visit for parents, unlikely that, alone, a physician, a psychologist, a social which is an opportunity for positive parenting interven- worker, an advanced nurse practitioner, a trained par- tions before the birth of their child. Child psychiatrists ent peer support provider, or any other practitioner do not provide primary care, but increasingly they are will be able to devote the time and provide all of the participating—either on-site or through telehealth—in expertise needed to work optimally with each family primary care practices (AACAP, 2012) and could be in a around these issues. Behavioral health promotion and position to provide consultation on the optimal prepa- prevention efforts will require an integrated team ef- ration of parents to promote CAB wellness of their fort, and trainees must have an opportunity to develop children. comfort and confidence in interactive, coordinated, Not surprisingly, training of health care profession- and collaborative health care delivery. Understanding als who serve children and families varies considerably the strengths and limitations in the expertise of other across disciplines. The expectations for training to cre- disciplines is fundamental to effective collaboration. ate an integrated workforce need to be defined both Ideally, interprofessional care extends beyond coloca- within disciplines and between them. Interprofessional tion of various disciplines to team contributions that training needs greater primacy. Indeed, there are com- include joint care planning as well as coordinated, effi- mon themes that should be included in discipline-spe- cient care delivery. Opportunities for each discipline to cific and interprofessional training programs. These work up to the high end of their competency will allow themes promote understanding of the perspectives for the highest levels of professional satisfaction and and capacities of all disciplines and professions en- value as participants in interdisciplinary care delivery. trusted with the physical and behavioral well-being of children and youth (Schmitt et al., 2013). Box 1 lists 10 Family-Centered Care themes that are applicable to training content across Perhaps most important is the acknowledgment of disciplines. Several of these themes will be the subject parents as providers of health care for their children

BOX 1 10 Themes for Training the Future Health Care Workforce Across Disciplines to Improve Behavioral Health Outcomes for Children, Youth, and Families

1. Recognize the social determinants of child and family health. 2. Build on family strengths to promote wellness, resilience, and child care capacity. 3. Foster parenting skills. 4. Promote CAB health for children starting in infancy. 5. Recognize and mitigate risks for children’s healthy CAB development. 6. Identify and intervene for problem behaviors early. 7. Provide care for behavioral disorders in a non-stigmatizing and supportive setting. 8. Recognize chronic disease as a risk factor for behavioral disorders of children and their families. 9. Work effectively within an integrated, interprofessional team. 10. Understand how to partner with community support services for children and families.

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and as important members of the health care team. across disciplines that is better prepared to promote Adolescents themselves are also important consumers CAB health and development. and members of health teams. The concept of coproduction of health care (Batalden et al., 2015) involving Community-Linked Care both health care professionals and patients or family Many supportive services for children and families members encapsulates a fundamental tenant of fam- that address CAB issues are community-based, among ily-focused care: it is especially critical when dealing them home visitation programs, preschools and with children and adolescents given their dependency schools, community health programs, and community on their families. agencies. Just as it is essential for health care profes- Understanding and acknowledging the importance sionals working with children to understand the con- of shared decision making that opens the door to ex- text for care in the home, it is equally important for pression of patient/family needs and preferences is an those professionals to understand the context for so- important competency for health care professionals. cial engagement in other environments in which chil- Ideally, parents will be fully accepting of those roles dren spend a significant part of their lives (e.g., school). and eager to promote optimal CAB development for Trainees in the health care system should be familiar their child. As is the case for all team members, par- with community-based resources and gain facility with ents and other family members benefit from educa- linking families to them as seamlessly as possible. tion and training to contribute to the full extent of their Trainees should be exposed to and participate in edu- abilities. In a number of settings, parenting groups are cational sessions concerning the social determinants a main source of information, problem solving, and of health. In addition, they should have firsthand expe- encouragement for all participants (Breitenstein et al., rience with community-based support programs. Or- 2012). Health professionals should be trained at the ganizing effective bridges for health care providers to earliest opportunity to work with parents as partners community partners can be an important step in creat- in care decisions and implementation of care plans for ing training experiences that lead to lifelong comfort their children. An important characteristic of health and competence in extending CAB health promotion care professionals’ increasingly effective work with beyond the walls of health care settings. children will be their ability to understand the context for care in the home and to tailor considerations Current Training Across Participating for CAB promotion of children to the resources in the Disciplines family setting. This section addresses a number of disciplines that should be prepared to participate in family-focused Multigenerational Care CAB health promotion and prevention activities with- Historically, pediatric health care has targeted the in primary and subspecialty health care. Within the well-being of the child. Increasingly, it is recognized description of each discipline, it addresses current that care at home that leads to satisfactory or opti- training pathways and outlines the relevant certifica- mal children’s CAB health and development depends tion processes, program accreditation bodies, and on the health and well-being of the parents and oth- discipline-specific expectations for behavioral health er family members. Pediatric practices have begun training in general and training for CAB health promo- to consider how to contribute to multigenerational tion in particular. health by assessing the health of the parents: for example, by screening for exposure to adverse experi- Training Physicians ences and behavioral disorders such as depression Clinical experiences in medical school provide opportuni- (Briggs et al., 2014; Dubowitz, 2014), and by embed- ties to introduce the topic of children’s CAB health; how- ding help with economic, social, and behavioral issues ever, the topic at this time is not considered a fundamen- in the practice. Family medicine practices have the op- tal component of medical knowledge, and exposure to it portunity to coordinate multigenerational care. Train- is inconsistent. Topics such as the social determinants of ing within the context of addressing the health needs health, interprofessional training, and team-based care of all members of the family will provide a workforce are finding their way into student clinical exposures and

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provide hope that children’s CAB health will one day be a itz, 2014). The application of these models to training part of every student’s clinical experience. experiences and training outcomes has not been The usual pathway in the United States for residency systematically addressed, however. Neither training training in general pediatrics, family medicine, psychia- program accreditation nor certification requirements try, or obstetrics and gynecology is a three- or four-year and expectations speak to CAB health promotion curriculum in an accredited program. Training in most and risk prevention and mitigation; multigeneration- subspecialty areas of pediatrics and other specialties al health needs; promotion of parenting skills; early requires an additional 1 to 3 years, including in pedi- screening; and interventions for behavioral risk or con- atrics 1 to 2 years that are devoted to scholarly activ- cerns. ity. American Board of Medical Specialties (ABMS) core The American Academy of Pediatrics (AAP) has ad- competencies for all medical specialties are organized dressed the behavioral health needs of children and into six categories: Patient Care and Procedural Skills; adolescents and recommended pertinent training ex- Medical Knowledge; Practice-based Learning and Im- periences and competencies (Committee on Psychoso- provement; Interpersonal and Communication Skills; cial Aspects of Child and Family Health and Task Force Professionalism; and Systems-based Practice (ABMS, on Mental Health, 2009). Additionally, at this time, the 2016). These competencies are outlined at a high level ABP is publishing a statement of the need for behav- and do not address specific training goals such as the ioral health training in pediatrics in the form of a “Call ability to identify and treat/refer behavioral disorders to Action” paper (McMillan et al., in press), but as yet or participate in efforts to promote CAB health and the ABP has not addressed behavioral health promo- prevent behavioral disorders. The Accreditation Coun- tion and risk prevention. A detailed statement by the cil for Graduate Medical Education (ACGME), through ABP that addresses training of subspecialists (Freed its program review committees, does not mandate et al., 2014) does not include expected competency of training experiences that address family-focused trainees for participation in CAB health promotion or behavioral prevention and care interventions. behavioral care of their patients. Serious gaps are noted when pediatric residents are Pediatrics surveyed about their perceived competency as a result For general pediatrics training, the Residency Review of their training experiences (Fox et al., 2010; Horwitz Committee of the ACGME requires that one unit (usu- et al., 2010). In most training programs there is little ally 4 weeks) must be in developmental-behavioral pe- if any coordination among the several potential expo- diatrics. Residents can opt for additional behavioral pe- sures to behavioral health, and therefore there is no diatrics by participating in one unit of Child Abuse and/ thoughtful or integrated curriculum for this vital area or Child and Adolescent Psychiatry (ACGME, 2016f). of child health. Furthermore, because neophyte pedia- Thus, resident formal experience with the behavioral tricians are focused on acquiring the basic skills and dimensions of child health is limited, particularly if the identity of pediatrics they are often less interested in Developmental-Behavioral rotation is heavily oriented learning the subtleties of mental health prevention. to developmental disabilities or if the resident takes va- It is later, when they have completed training and cation time during this rotation. A continuity ambulato- entered practice, that surveys of pediatricians about ry pediatrics experience includes focus on anticipatory training deficiencies usually find behavioral health as guidance of the parents and older children. Promotion the most frequently cited deficiency. Likewise, even of children’s CAB health is not a major component of though expected pediatric competencies include re- this activity in most programs. The American Board of lating to other health professionals, there is no men- Pediatrics (ABP) mentions promotion of health as a tion in program requirements or trainee competency target competency, but nearly all dimensions of com- expectations of an ability to function effectively within petence relate to diagnosis and treatment of disorders the context of interdisciplinary team care. (ABP, 2016). A number of reports in the literature de- Some academic training programs are using social- scribe models for assessing behavioral risk and inter- emotional as well as developmental screening tools as vening for disorders in primary care practice (Dubow- a routine part of health surveillance. Pediatric residents

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have been successfully inserted into adverse experi- extent to which health promotion and preventive ap- ence screening of families as part of the SEEK program proaches to CAB health are incorporated into trainee (Dubowitz, 2014) or parenting training using the Triple experiences is at best uneven. P program (McCormick et al., 2014), both showing that residents’ knowledge and skills were improved. These General Psychiatry are isolated examples of activities that increasingly General psychiatry training includes exposure to child should be considered for pediatric training. mental health, and individuals trained at this basic level Most pediatric subspecialty training programs may be involved with youth. ACGME requirements for are academically based. Program accreditation and general psychiatry training programs mention preven- trainee certification are separate processes for each tion but almost exclusively target diagnosis and treat- subspecialty area. Because behavioral and emotional ment of behavioral disorders. There is no mention of problems are common in children with disabling and behavioral health promotion, identification of risks and life-threatening chronic disease, the opportunity to their mitigation, family-focused care, or engagement prospectively address patient and family wellness as with community programs that embrace these top- well as behavioral problems and disorders should be ics. There is a single mention of resident participation acknowledged and increasingly addressed as a joint on interprofessional teams, but there is no language responsibility of the entire team. At this time, pedi- defining an interprofessional practice or site, and no atric subspecialty training for the most part does not language outlining what preparation for interdisciplin- prepare learners to participate effectively in family- ary or integrated practice might entail. A single state- focused, multigenerational CAB support and care. Nei- ment notes that on completion of training residents ther the pediatric subspecialty training accreditation should understand sociocultural issues. The most nor the subspecialist certification processes have com- frequent and successful integration efforts involving municated expectations for preparation of trainees to psychiatrists have been directed at adult care and are address CAB health. diagnosis and treatment oriented (ACGME, 2016g). One exception may be the training of developmental and behavioral pediatric subspecialists. Their behav- Child and Adolescent Psychiatry ioral training orientation is largely diagnosis and treat- Numbers of child psychiatrists are estimated to be as ment. The ACGME program requirements for this sub- low as 20 percent of the workforce need (AACAP, 2016) specialty area include “understanding the biological, and have limited their ability to move beyond tradition- psychological and social influences on development in al care of children and adolescents who are seriously the emotional, social, motor, language and cognitive compromised by behavioral disorders. Nevertheless, domains” and focus on “mechanisms for primary and all child psychiatry residents are required to train in secondary prevention of disorders in behavior and de- school-based settings, allowing for exposure to an velopment” (ACGME, 2016d). There are only 38 training alternative system and a broader spectrum of youth. programs in developmental and behavioral pediatrics The integration of psychiatric care into primary care and relatively few subspecialists in this field (ACGME, pediatric settings is beginning to receive attention. The 2016h). Interdisciplinary team experiences during most successful integration efforts have been directed training are most advanced for developmental and be- at adult care and are diagnosis and treatment orient- havioral pediatrics. ed. Discussions about integration of child psychiatry Although accreditation requirements for training in practice into pediatric primary care are active at the adolescent medicine largely ignore the CAB dimen- professional society level (Fritz, 2016), but applications sions of adolescent health, trainees in this subspe- are scattered and largely carried out as pilot programs. cialty (who can come from core training in pediatrics, The ACGME training program requirements for the internal medicine, or family medicine) are exposed to child psychiatry fellowship, which follows a general areas such as eating disorders, depression and screen- psychiatry residency, are much the same as for general ing for this disorder, suicide prevention, LGBTQ health psychiatry resident training (ACGME, 2016c). Child and concerns, and substance use (ACGME, 2016b). The adolescent psychiatry training is defined to include

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prevention, diagnosis, and treatment of behavioral specific expectations related to these competencies at disorders. The extensive outline of requirements for the specialty board or ACGME levels (ACGME, 2016a). training programs and trainee experiences has always included the expectation that child psychiatry trainees Family Medicine understand the stages of normal development from Family Medicine physicians have the advantage of pro- infancy through adolescence. The ACGME child and viding multigenerational care and have traditionally adolescent psychiatry milestones project has for the been trained, more so than pediatricians, to diagnose first time added requirements relating to the- identi and treat behavioral health issues. As is the case for fication of factors contributing to wellness and resil- all specialty areas of the ABMS, competencies to be ience. Experience of at least a month in a community acquired by a family medicine physician are outlined psychiatry setting is required, with the content of the only in broad topical areas that have been adopted by experience being determined by the local community all specialty boards. ACGME program requirements for resources. Although child and adolescent fellows are GME in family medicine are more detailed and include expected to have training experiences as participants several statements about competencies in behavioral on interprofessional teams, no mention is made of health. These include “[D]iagnose, manage and coor- experience in clinical settings, either ambulatory or dinate care for common mental illness and behavioral hospital, where behavioral and physical medicine are issues in patients of all ages.”; “The curriculum must systematically integrated. Consultation experiences be structured so behavioral health is integrated into within primary and/or specialty pediatric care are a the residents’ total education experience.”; and “There required part of psychiatric training; they usually oc- must be a structured curriculum in which residents are cur on inpatient units with youth who are acutely or trained in the diagnosis and management of common chronically ill enough to require hospitalization (AC- mental illnesses” (ACGME, 2016e.). Further, the compe- GME, 2016c). tency requirements include an ability to “assess community, environmental, and family influences on the Combined Training Programs health of patients,” to “provide preventive care,” and Combined training programs in pediatrics, adult psy- to “address population health, including the health of chiatry and child and adolescent psychiatry (Triple the community” (ACGME, 2016e). The requirements Board, 2016) and combined training in family medi- also specify that residents must work in interprofes- cine and psychiatry are approved by the individual sional teams to enhance patient safety and care qual- boards and lead to trainee certification in each of ity. There is no language in the training program re- these specialties. Both programs would seem to quirements for exposure to or competence in areas provide excellent training venues for individuals of behavioral health promotion or prevention of risks who have an interest in integrated behavioral and for problematic behaviors. While some family medi- traditional medical practice; indeed, a number of cine physicians are in a position to work with families trainees from these programs are now providing around conception, pregnancy, and birthing, there is leadership for integrated care pilot programs us- no training requirement that addresses prenatal and ing a variety of models. Training program accredita- postnatal family-focused behavioral wellness or par- tion guidelines for combined training largely mir- enting promotion competencies. ror training guidelines for the individual specialties The American Academy of Family Physicians (AAFP) and are diagnosis and treatment focused. As with has published its recommended curriculum guide- the parent specialty training program guidelines, no lines for residents, entitled Human Behavior and Mental training program guidelines or requirements for goals Health, first in 1986 and most recently in 2015 (AAFP, or experiences relating to children’s CAB development 2015). These guidelines comprehensively address ac- and health are specified. Behavioral health promotion quisition of competencies, attitudes, knowledge, and and prevention of risks for problem behaviors may skills related to behavioral health. Family medicine be addressed at some level within individual train- residents are expected both to assess risk of patients ing programs, but there is little available evidence of for abuse, neglect, and other disruptive family-related

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factors and to screen for traumatic experiences. They Training Nonphysicians are likewise expected to recognize the impact of com- Pediatric Psychology (1) plex family and social factors on individual health and the psychosocial dynamics that influence human Psychology providers are increasingly participating as behavior. Understanding the importance of multidis- key members of child health care sites and systems, ciplinary approaches to health care is emphasized. whether targeting child and family needs owing to Knowledge acquisition addresses not only mental chronic disease and disability or the process of well- health disorders but also basic human behaviors, in- child care and acute care. cluding psychosocial growth and development as well The training pathway for pediatric psychologists as interrelationships among biologic, psychologic, and includes the following training experiences: social factors. While emphasizing family context and 1. Graduate training leading to a Ph.D. or Psy.D. relationships, little attention is paid in these guidelines that includes clinical practicum training and a either to child behavioral and cognitive development 1-year clinical internship/residency. and health or to the critical role of nurturing parental 2. One-year internships in accredited pediatric roles in behavioral health promotion. psychology programs provide clinical experienc- There are a limited number of combined family es and scholarship (possibly including research), medicine and psychiatry residency training programs leading to a specified level of clinical compe- (Association of Medicine and Psychiatry, 2015). These tence. Hospital-based internships may provide trainees should be advantageously positioned to take experience in primary care settings. Satisfactory on a lead role for child and family behavioral health completion of this experience, usually off-site promotion and risk prevention. from the graduate program, is a requisite for the award of a doctoral degree. Obstetrics and Gynecology 3. Postdoctoral fellowships in pediatric psychology Obstetricians and gynecologists (OB/GYNs) provide are common and consist of 1 to 2 years of pedi- primary care for many women and are positioned to atric clinical training and, in some cases, inten- influence outcomes of family planning and the arrival sive research experiences. Fellowships can be of children. OB/GYN practices frequently offer classes differentiated based on program clinical focus. for expectant couples, but the content of these classes While many are hospital-based and concentrate more often addresses physical care of children and clinical experiences on children with serious breast-feeding than positive parenting. OB/GYN physi- acute and chronic disorders, a growing number cians have an ideal opportunity to influence CAB out- of fellowships target the fellow’s clinical expe- comes before and in the early stages of parenting. No riences and competence goals to the primary mention is made, however, of board or residency pro- care area. gram review expectations for resident participation in Pediatric psychologists are licensed by states in learning about relevant prenatal counseling. There is which they practice. Some states require an additional also no mention in the ACGME program requirements year (or even 2) of supervised experience beyond the about stress and other adverse exposures leading to doctoral degree (which may be a fellowship) for license epigenetic modifications of gene expression that can eligibility, while other states will grant license eligibil- be harmful to the child. A statement of relevance to ity if the completion of a Ph.D. or Psy.D. has provided CAB health mentions that residents must have an op- the requisite number of years of supervised clinical portunity to work as a member of effective interdis- experience. ciplinary teams and must be able to demonstrate a Evaluation of trainee competence as a clinician personal role in the provision of family-centered care is largely the task of each sequential training pro- (ACGME, 2016i). gram. Palermo et al. (2014) defined core competencies for pediatric psychology across training levels that are being used by many programs as a framework for evaluation of candidates. This set of

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recommendations was created by a task force that was Clinical competence is assessed as a step in the li- assembled by the Society of Pediatric Psychology (Di- censure process in many states. Candidates for licen- vision 54 of the American Psychological Association). sure must pass an examination that is generic, nation- These recommendations include themes that are high- ally administered, and agnostic regarding training or ly relevant to family-focused prevention, such as having practice focus, but some states require an additional knowledge of the effects of families and socioeconomic oral examination that may be clinically based. Simi- factors on CAB development and health and the roles larly, maintenance of competence is assessed by state of other disciplines in achieving behavioral health pro- licensing boards, largely through verification of par- motion. Hoffses et al. (2016) have adapted these rec- ticipation in approved continuing education programs. ommendations for pediatric psychology training specif- There is a certification process that is conducted by ic to the primary care setting. Other recent publications the American Board of Professional Psychology. This have also addressed core competencies. McDaniel et independent board certifies individuals with training al. published detailed competency recommendations in 15 different specialty areas within psychology, one for psychology practice in primary care in six broad of which is “Clinical Child and Adolescent Psychology.” domains (McDaniel et al., 2014). Piazza-Waggoner et al. Board certification is optional for psychologists, and it (2015) built on the Palermo et al. (2014) recommenda- appears that many pediatric psychologists are not cer- tions by suggesting a training developmental trajectory tified. assessment and the need to map professional compe- While a number of internship and fellowship pro- tencies to health outcomes of children and youth. grams are heavily focused on behavioral dimensions Accreditation of psychology internships and fellow- of childhood chronic disease—and a growing number ships is done generically—that is, for all programs, both of other programs focus on behavioral health in pri- adult and pediatric—by the American Psychological mary care settings—a common feature of child psy- Association (APA), and accredited programs are recog- chology training programs is preparation for interdis- nized as meeting criteria set forth by the Association ciplinary, family-focused, team-based child behavioral of Psychology Postdoctoral and Internship Centers (AP- health care practice that includes a health promotion PIC). APPIC also conducts an internship match and is and prevention orientation. Thus, unlike the training considering a postdoctoral fellowship match process for a number of other health care specialty careers, in the future. There are no stated criteria for provision there may be less urgency in psychology to expand of specific training experiences. Criteria largely deal current program content and trainee experience to with program structure, processes, and goals. Flex- achieve a workforce that can advance the CAB health ibility across and within programs regarding specific of children through promotion, prevention, and early training experiences is supported by the current ac- intervention activities in health care settings. The ex- creditation process and various program content rec- tent to which promotion and prevention components ommendations. It has been estimated that less than are implemented today in training and their impact on 10 percent of the approximately 900 psychology train- post-training practice are unclear, however. ing programs are focused on preparation for careers Research training and competence is expected of all addressing the needs of children and adolescents. Ph.D. pediatric psychology programs. A thesis is also Numbers of practicing pediatric psychologists are dif- an expected product for the Psy.D., and many trainees ficult to ascertain, as licensure is granted generically to have publications in the peer-reviewed literature by all applied psychologists by state boards. Geographic the time they graduate. Fellowship programs, especial- distribution is uneven, and a 2007 report, An Action ly those of 2 year’s duration, also provide postdoctoral Plan for Behavioral Health Workforce Development (An- research experiences. Thus, many pediatric psycholo- napolis Coalition on the Behavioral Health Workforce, gists are engaged in rigorous research after training, 2007), prepared for the Substance Abuse and Mental and they should be positioned to make important Health Services Administration (SAMHSA) stated that contributions to outcomes and program improvement the behavioral health workforce in general is unin- research related to improving children’s CAB health. formed about and unengaged in health promotion and Psychologists in the medical setting are prevention activities (APA, 2014). currently reimbursed for diagnosis, psychological

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assessment, treatment, and behavioral health consul- As pediatric practices embrace the role of the medi- tations (“health and behavior” Current Procedural Ter- cal home, roles for nurses within these settings are minology codes) with medical patients. Compensation likely to grow. Nurses bring specific training in the role models that reimburse efforts to promote and prevent of health educator and counselor as well as a concep- risks for children’s CAB health represent an important tual framework of caring that positions them well to challenge for public and private payers, and not all re- contribute to CAB health promotion. imburse health and behavior codes. Nurse Practioners Nurses Nurses who choose to become an Advanced Prac- Licensed registered nurses graduate from a school of tice Registered Nurse (APRN) return to an accredited nursing within a college or university that is accredited university program at the level of a master’s or doc- by one of two national accreditation agencies (Com- toral degree. They select one of four APRN roles: the mission on Collegiate Nursing Education [CCNE] or nurse practitioner, the clinical nurse specialist, the cer- Accreditation Commission for Education in Nursing tified nurse anesthetist, or the certified nurse midwife. [ACEN]). Upon graduation they must sit for a national APRNs in all of these roles will hold a second license, licensing exam (NCLEX). Nurses do not specialize in a which provides them with an expanded scope of prac- specific population while becoming RNs. Nurses at all tice. Nurse practitioner programs prepare the student levels of training do participate in child health care, for an expanded role with a specific population: that specifically the behavioral dimensions of child health. is, pediatric nurse practitioner – primary care; family Health promotion and risk reduction are cornerstones nurse practitioner; or psychiatric mental health nurse of a nursing curriculum. Nurses also take coursework practitioner. These programs typically involve 2-4 in community health and are placed in field experienc- years of didactic coursework, simulation experiences, es with community agencies. Pediatric nursing courses standardized patients, and clinical rotations. focus on the “protection, promotion, and optimization • Pediatric nurse practitioner–primary care: Stu- of the health and abilities for children from newborn dents typically spend 1 or 2 days a week seeing age through young adulthood” (NAPNAP, 2015). During patients in pediatric primary care settings under their nursing programs students take formal classes in the supervision of a pediatrician or pediatric nurse growth and development and pediatric health and ill- practitioner. Additionally, they often elect rota- nesses and have a clinical rotation in pediatrics. Upon tions in the hospital, the community, and in school- completion and licensure and after gaining experience based health clinics. Electives in developmental- working with children, a registered nurse (RN) may behavioral settings have limited availability. choose to sit for an additional elective certification • Family nurse practitioner: Students focus on the exam (e.g., as a pediatric nurse or school nurse). health and illnesses of patients of all ages from School nurses have an expanding role in health birth through old age. Therefore, the pediatric promotion, surveillance, and the care of school-age focus within an FNP program may be limited to a children, including preschool children in some set- semester. tings. Some have the opportunity to work in a school- • Psychiatric mental health nurse practitioner: Stu- based clinic, which serves as the child’s medical home dents focus on individuals across the life span, through which care is coordinated with local child families, and populations at risk for developing health practices (AAP Council on School Health, 2016). or having a diagnosis of psychiatric disorders or Certificates in school nursing (NCSN) are available mental health problems. The PMHNP provides to licensed RNs who have had 1,000 hours of school continuity care to patients seeking mental health nursing experience and successfully pass a voluntary services in a wide range of settings. Upon success- certification exam administered by the National Board ful completion of an NP program, the graduate for Certification of School Nurses (NBCSN). Recertifica- is eligible to sit for a national certifying examination occurs every 5 years and can be accomplished by tion (Pediatric Nursing Certification Board [PNCB], testing or continued education credits. There are more American Nurses Credentialing Center [ANCC], than 3,500 school nurses with the NCSN certificate. or American Academy of Nurse Practitioners

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Certification Program [AANPCP]) that matches Health Care in Pediatric Primary Care Settings, NAPNAP their area of study. These examinations are based (2013) recommends that its more than 8,500 members upon the competencies identified through role consider certification in primary mental health care. delineation studies conducted every 3-5 years Certification is granted for 3 years, at which time recer- and endorsed by all major nurse practitioner edu- tification is required. cational bodies (National Organization of Nurse There is considerable opportunity for specialized Practitioner Faculties [NONPF]). Recognized com- nurse practitioners to bolster the workforce that is pre- petencies have been expanded to include inter- pared to promote children’s CAB health. professional teamwork and greater attention to behavioral health. There has been an outgrowth of new courses that are Nurse Midwives co-taught by faculty from two or more programs (nurs- The certification examination for certified nurse mid- ing, social work, and psychology). A pediatric health as- wives (CNMs) and certified midwives (CMs) falls under sessment course provides students with the skills to the American Midwifery Certification Board (see: www. assess behavioral and mental health risks as well as amcbmidwife.org) and is taken every 5 years. The ac- physical health. In 2004 the Association of Faculties of crediting agency requires that the certification exam Pediatric Nurse Practitioners (AFPNP) was awarded a be based upon those tasks being done by recently em- grant by the Commonwealth Fund to implement and ployed CNMs. There are approximately 11,200 current- evaluate a national curriculum for students in 20 PNP ly practicing CNMs and fewer than 100 CMs (ACNM, programs that promoted the use of validated screen- 2016). In recent years, close to 500 new CNMs enter ing tools and evidence-based interventions for mental practice each year. They contribute significantly to the health concerns in primary care (Hawkins-Walsh et al., prenatal and postnatal care of women. In the most re- 2011; Melnyk et al., 2010). Licensure as a nurse practi- cent task analysis, certified CNMs and CMs reported tioner is dependent upon continued maintenance of the education of new mothers and preparation for in- certification. fant care as significant tasks as well as screening for Specialty training beyond the NP perinatal depression. CNMs have gained attention in some locales for their role in sponsoring and conduct- PNPs and FNPs who are employed in primary care pe- ing group prenatal visits that address parenting skills. diatric settings and have interest in primary mental It appears that CNMs are able to play an important role health care can acquire additional expertise through in the CAB health of young families. continuing education programs, conferences, formal coursework, and on-the-job training. (Examples in- Licensed Professional Counselors and School Counselors clude the Keep Yourself Safe and Secure [KYSS] and While not common, there are primary health care prac- Research, Education, Advocacy, and Child Health Care tices that employ counselors for behavioral-health-re- [REACH] programs). A subspecialty certification is avail- lated expertise and contributions to interdisciplinary able to these NPs through an additional examination, care. Numerous counseling degrees are being offered; the Primary Care Mental Health Specialist (PMHS), ad- two common ones are school counselors and licensed ministered by the PNCB (2016). A survey of 270 nurses professional counselors (LPCs). School counselors working in this role listed the five highest-ranking tasks. provide evaluations and, in some cases, therapeutic At the top of the list was “promoting positive parent- interventions. School counselors participate in school- ing” (Hawkins-Walsh and Van Cleve, 2013). More than based health clinics and can be an important source of 350 NPs have been certified for the PMHS certification, information related to a child’s health surveillance and and in addition to pediatric practices, a small num- maintenance through the medical setting. LPCs, number of those with the PMHS certification are working bering more than 120,000 in the United States, are in developmental-behavioral pediatrics, in their own recognized in all 50 states (American Counseling Asso- independent practice, in school-based health care, or in ciation, 2011). Licensure requires a combination of a group child psychiatric, neurology, or psychology prac- master’s or doctoral degree and counseling experience tices. In its recent statement on Integration of Mental

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with supervision, in addition to a passing grade on a Furthermore, psychiatric social workers must earn national examination. Academic course work features an MSW degree and be licensed to practice in their normal growth and development as well as social de- state. In general, they are part of psychiatric treat- terminants of health, but it does not specify exposure ment teams, often hospital based. Their participation or competency in the area of children’s CAB health and in primary or subspecialty child health care is infre- development. Certification for LPCs is optional and quent and their focus is not often on children’s CAB can be obtained from the National Board for Certified health and development. Counselors (see: www.nbcc.org). Certification can also Large academic primary care practices and Fed- be obtained for such children’s CAB relevant specialty erally Qualified Health Centers employ social- work areas as mental health counseling and school counsel- ers to support family needs around issues raised by ing. No information concerning standards for graduate adverse health-related social determinants. Social school curricula has been identified. The number of re- workers also provide parent training programs in quired hours of supervised clinical experience is vari- many settings, including primary care, schools, and able and is designated by each state licensure board. child welfare agencies. For example, in a randomized controlled trial in pediatric primary care, Perrin et al. Social Workers (2014) demonstrated the benefits of an adapted ver- Social workers are often important participants in child sion of the Incredible Years program with parents of health care delivery, in primary care settings where the children with oppositional behavior; the intervention social determinants of health are major factors, and for was provided by social workers and psychologists. youth who have disabling or life-threatening chronic Accredited by the Council on Social Work Education diseases that require compliance with complex treat- (CSWE), training programs in social work emphasize ment plans in home and community settings. The func- both academic and applied practice preparation. tions of social workers in pediatric primary care follow The CSWE Educational Policy and Accreditation Stan- two alternative and complementary models. Under the dards (CSWE, 2016a) outline general educational re- Chronic Care Model, social workers serve as care man- quirements and, in part because social workers are agers—often in collaboration with nurses—for families employed in so many service systems, do not explic- with children who have sustained medical and psycho- itly address child health, behavioral health, the social social needs that require multiple caretaker involve- determinants of health, or prevention. Many social ment. Second, following the long-standing involvement work programs, however, do offer “concentrations” of social work in the provision of mental health ser- or specializations that focus on behavioral health and vices, some social workers serve as behavioral health clinical practice. Field education is considered a core specialists who conduct standardized assessments and pedagogy of the profession. Graduate students spend provide discrete, evidence-based behavioral health in- up to half of their time in internships. If students are terventions for children, adolescents, and families. So- in a health concentration, their internships are likely cial workers are the largest group of clinically trained to be in integrated or hospital-based settings. Course mental health providers in the country (SAMHSA, 2013). work in social work helps students understand how Social workers can focus their baccalaureate training social contexts influence health through a person- so as to be qualified as children, youth, and families in-environment perspective. Curriculum content in social workers. Master of Social Work (MSW) trainees health concentrations considers the full array of bio- are viewed as advanced practitioners in this area. Cer- psychosocial determinants of behavioral and physical tification in this social work specialty area is available. health. In 2012, CSWE launched a special curriculum Another specialty option relevant to children’s CAB development initiative focused on the expansion of health is school social work. Many social workers are integrated behavioral health curricula (CSWE, 2016c). employed by social service agencies or schools. Many Further, in 2014 the Health Resources and Servic- MSW social workers go on to qualify for a license in es Administration (HRSA) awarded 62 MSW social clinical social work (LCSW). Schools of social work and work programs in excess of $26 million to expand professional organizations offer a variety of certificate training in behavioral health for integrated care set- programs for advanced training (NASW, 2016). tings (CSWE, 2016b).

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MSW social workers are viewed as advanced practi- Health (NFFCMH) created a Certification Commission tioners, and demand for them is increasing in health for Family Support (http://certification.ffcmh.org/) and care. The Bureau of Labor Statistics projects that competencies to be considered for certification have 30,900 additional health care social workers—a 19 been identified. There is broad consensus about tasks percent increase over 2014—and 22,300 additional to be performed by PPSSs (Obrochta et al., 2011; NFF- behavioral health social workers—a 19 percent in- CMH, 2011) but little guidance for individual program crease over 2014—will be needed in the United States evaluation and improvement. by 2024 (BLS, 2015). A training program to support skill acquisition by PPSSs, funded by the National Institute of Mental Family Peer Advocates, Parent Coaches, Health Educators, Health (NIMH), was developed in New York State and and Community Health Workers has trained and credentialed more than 550 parent Parent peer support specialists (PPSSs; also known as peer partners. Called the Parent Engagement and family peer advocates and family support specialists) Empowerment Program (PEP), the original training have gained acceptance as important contributors to program included a 1-week on-site training session fol- support of families of children and adolescents with lowed by distance learning sessions on a biweekly ba- mental health issues. The professionalization of the sis for the next 6 months. The current training model role of parent partners has grown from the early ac- involves both online modular curriculum completion knowledgment of the importance of family-centered and case consultation (see: http://www.ftnys.org/pep- care (Stroul and Friedman, 1994). Parents and com- training/). munity members with special skills represent a grow- Related supportive professional roles include ing workforce with training programs and national and trained health educators as parent coaches for fami- state credentialing bodies. lies of infants in primary care practice. These coaches PPSSs are parents or relatives of children/adoles- work with parents around issues of preventive care cents with mental health needs and who increasingly measures (anticipatory guidance), and parents re- are trained and credentialed to work as members of ported enhanced behavioral/developmental aware- teams providing mental health support to families ness as well as enhanced satisfaction with the primary (Hoagwood, 2005; Koroloff et al., 1994, 1996; Osher care experience (Beck et al., 2016). Bachelor’s degrees et al., 2008). They work in a variety of settings, largely in health education are available and the U.S. Bureau community-based but also in primary health care and of Statistics listed nearly 57,000 health educators in schools. 2013. The National Commission for Health Education In about 25% of states, family support services de- Credentialing gives an examination that, if passed, cer- livered by parent peers are now billable through pub- tifies each graduate as a health education specialist. lic funding mechanisms (CHCS, 2012). PPSSs model, To bridge primary care practices to communities coach, and empower parents to cope with, advocate and cultures from which their patient population is for, and better utilize health and mental health sys- derived, some practices have employed community tems. PPSSs can help families connect through formal health workers. Originally created in underserved and informal support networks, and promote advo- countries to provide health information and support cacy at the local systems as well as policy levels. Social in the absence of sufficient numbers of health profes- support promotes parents’ own behavioral health and sionals, the concept is now applied to bring value to ability to cope with family needs. It also improves ac- practices where adverse social determinants of neigh- cess to resources that can promote adjustment of their borhood health are particularly prominent. Education children (Ireys et al., 2001a,b). of individuals to play this role is variable and differs The evidence for efficacy of parent-delivered- fam from location to location. Some states offer certificates ily support should be strengthened (Blau et al., 2010; for community health workers. For example, Ohio Hoagwood et al., 2010; Kutash et al., 2011). In an effort certifies these individuals through the Ohio Board of to promote standards and competency needed for this Nursing. Texas provides certificates through the Texas growing workforce related to children’s CAB health, the Department of State Health Services. The American National Federation of Families for Children’s Mental Public Health Association (APHA) has a section for

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community health workers. The value of these individu- Schoenwald et al., 2009; Stein et al., 2008, 2009). The als in health care team approaches to family-centered, new workforce challenges described in this paper high- culturally appropriate CAB health promotion and pre- light the need for more integrative training that takes vention would be important to document. advantage of different expertise drawn from multiple disciplines, with the goal of enhancing collaboration and Interdisciplinary, Family-Centered Models promoting quality of care in children’s health. Designing The federal Leadership Education in Neurodevelopmen- a research agenda to support this integrative training tal and Related Disabilities (LEND) training programs paradigm is likely to require attention to five areas: (a) (AUCD, 2011) for children with developmental disabili- comparative effectiveness studies that contrast training ties are highly interdisciplinary. LEND programs are fo- and supervision modalities (online, in person, etc.) and cused on providing services for children with a range that target collaborative teamwork; (b) studies of the im- of disabilities, including those in the behavioral health plications of alternative fiscal models (value-based pur- realm. Since the primary focus of these programs is chasing; pay for performance) on training effectiveness; diagnosis, treatment, and functional rehabilitation, the (c) comparative studies of different structural configura- content of these training programs may not provide tions of the interface of child medical care and behav- an inclusive framework for interdisciplinary training ioral health support (colocation, networked, discrete) in promotion-/prevention-focused health care experi- on integrative services and training; (d) development ences. It is likely that training program redesign will be of quality indicators that assess competencies for inte- an important component of preparation of the health grative team training and that lead to improved health care workforce to promote children’s CAB health. Model outcomes for children; and (e) study of new, integrated development, sharing of best interprofessional training training models for children with chronic, disabling dis- practices, and testing of training outcomes will be im- orders as well as for children in primary care. portant activities to foster and fund. Improving the feasibility and reach of training via alternative modalities (e.g., distance learning, online A Research Agenda to Support Integrative modules, and long distance consultation) is a focus of Workforce Training research in some health professions (e.g., psychology, Training health professionals to carry out effective re- social work). But these studies and the models upon search as well as clinical programs will be essential to which they are based do not typically include attention the development of a strong evidence base for chil- to integrative work with other professions. Integrative dren’s CAB health promotion in the medical setting. training models require clear differentiation of roles, es- Physicians who opt for pediatric subspecialty training tablishment of different competencies and indicators of are expected to conduct research or a scholarly project competence, joint contributions to configuring and as- that can be focused on documenting program or edu- sessing the care model, and attention to quality moni- cational outcomes. Health professionals who complete toring. Research in these areas is needed. a Ph.D. or the equivalent have an intensive research A range of new fiscal incentives, driven in large mea- experience that may prepare them to contribute sub- sure by Centers for Medicare and Medicaid Services stantially to the documentation of intervention and (CMS) and the Medicaid reforms that are under way in training outcomes. Effective multidisciplinary research more than two dozen states, affects delivery of service with these goals will require attention to workforce and places new demands on the workforce to collabo- development. rate across disciplines, to share expertise, and to bill for Research on effective training models has focused both integrative services as well as discrete specialty largely on single disciplines and, at times, on supervi- care. Promotion and prevention will be difficult to sus- sion models that support training in and delivery of ev- tain in this setting unless payers reimburse for more idence-based practices (Bridge et al., 2008; Goodfriend than diagnosable disorders. Center for Medicare and et al., 2006; Henggeler and Brondino, 1997; Hogue et al., Medicaid Innovation (CMMI) has opened the door for 2013; Horwitz et al., 2015; Leaf et al., 2004; Manuel et studies of team-based delivery models that are effective al., 2009; Regehr et al., 2007; Schoenwald et al., 2000a,b; and provide value. The impact of different fiscal models

Page 16 Published November 29, 2016 Workforce Development to Enhance the Cognitive, Affective, and Behavioral Health of Children and Youth

on training approaches has not been a focus of research and costs of fully integrated care and training that allow yet, but it is needed. broad or universal consideration of this model of care The health care changes in this country are also af- by training program leadership, professional societies, fecting where services are being delivered and how credentialing and accreditation bodies, and both public connections among different providers are structured. and private payers. These structural configurations can include colocation of behavioral health providers within primary care of- Conclusion fices, networked connections among health care- pro Health professionals should be and are entrusted to viders under one entity, contracted referral services promote the behavioral health and well-being of chil- to improve access, and assumption of responsibility of dren, youth, and families. Training processes and re- health care institutions such as children’s hospitals for quired competencies, however, vary across disciplines. neighborhood or community health, etc. The impact of The expectations for training to create an integrated these different structural connections on the delivery of workforce need to be defined relative to each discipline, integrative health services has not been examined. but there are common themes—promoting CAB health Finally, health care services are increasingly held to and resilience in children and families—that should be new accountability standards that, among other re- included in training programs for all of those caring for quirements, necessitate documentation of workforce children. competencies and indicators that quality care is being delivered. These include competencies and indicators Notes for “alternative” workforce staff, including parent peer 1. Child clinical psychologists are not fully distin- support specialists (Olin et al., 2014). These accountabil- guishable from pediatric psychologists (and ity standards and workforce competencies or skills exist some are both). Training requirements are simi- for some professions, but they are uneven across the lar for both specialties. Child clinical psycholo- range of disciplines that are needed to create integrative gists typically focus on children and youth with services. Development of these standards would benefit behavioral health conditions; pediatric psychol- from research on the differential skill sets and compe- ogists commonly work with children and youth tencies that lead to improved pediatric outcomes. Ulti- with medical conditions or in primary care. mate goals include the documentation of effectiveness

Published November 29, 2016 NAM.edu/Perspectives Page 17

DISCUSSION PAPER

ated elsewhere. elsewhere. ated

have been initi been have

tion programs programs tion

Similar educa Similar

months. months.

sessions for 6 6 for sessions

tance learning learning tance

biweekly dis biweekly

followed by by followed

site experience experience site

weeklong on- weeklong

is an intense, intense, an is

ing. The training training The ing.

eligible for train for eligible

challenges are are challenges

mental health health mental

ily member with with member ily

caring for a fam a for caring

lived experience experience lived

Parents with with Parents

•

Program (PEP). Program

Empowerment Empowerment

Engagement and and Engagement

sity in the Parent Parent the in sity

Columbia Univer Columbia

are trained by by trained are

ily peer advocates advocates peer ily

In New York, fam York, New In

by state. by

requirements vary vary requirements

training, and exam exam and training,

modules, length of of length modules,

CMH. Curriculum Curriculum CMH.

through the NFF the through

Certification Certification

Support Provider Provider Support

the National Parent Parent National the

cies identified in in identified cies

the 11 competen 11 the

is usually based on on based usually is

curriculum. Training Training curriculum.

a standard national national standard a

though there is not not is there though

number of ways, ways, of number

are trained in a a in trained are

port specialists specialists port

Parent peer sup peer Parent

Health Workers Health

and Community Community and

Parent Coaches, Coaches, Parent

Specialists, Specialists,

Support Support

Parent Peer Peer Parent

and addiction. and

substance use use substance

social work, and and work, social

direct practice practice direct

family, clinical or or clinical family,

care, youth and and youth care,

health, health health health,

grated behavioral behavioral grated

areas include inte include areas

Relevant specialty specialty Relevant

study

ship each year of of year each ship

placement intern placement

Required field field Required

the profession. profession. the

pedagogy of of pedagogy

is the signature signature the is

•Field education education •Field

vanced practice vanced

students for ad for students

•Prepares •Prepares

Work: 2 years years 2 Work:

Master in Social Social in Master

generalist practice generalist

students for for students

degree prepares prepares degree

Baccalaureate Baccalaureate

Social Work Social

and psychiatry and

family medicine medicine family

Combined

medicine: 3 years 3 medicine:

Core family family Core

Medicine

Community Community

Family and and Family

based

and primary care care primary and

tracks: hospital hospital tracks:

CAB-relevant CAB-relevant

in 2 children’s children’s 2 in

training available available training

training. Clinical Clinical training.

tional research research tional

include addi include

training. May May training.

years of clinical clinical of years

Fellowship of 1-2 1-2 of Fellowship

Ph.D. or Psy.D. or Ph.D.

required for a a for required

ship/residency ship/residency

clinical intern clinical

and a 1-year 1-year a and

Clinical practicum practicum Clinical

Psychology

Pediatric Pediatric

(RN): (RN):

is an an is

may be be may

Family nurse practi nurse Family

specialist (PMHS) specialist

care mental health health mental care

Pediatric Pediatric • primary

cies.

and FNP competen FNP and

cate builds upon PNP PNP upon builds cate

Subspecialty Certifi Subspecialty

Nurse Practitioner Practitioner Nurse

health (PMHNP) health

Psychiatric Psychiatric • mental

tioner (FNP) or (FNP) tioner

•

care (PNP) or (PNP) care

Pediatric Pediatric • primary

population, such as: such population,

care for a specific specific a for care

Nurse practitioners Nurse

years) level. years)

(2 years) or DNP (3 (3 DNP or years) (2

Educated at the MSN MSN the at Educated

the scope of an RN. an of scope the

provide care beyond beyond care provide

a second license to to license second a

midwives. They carry carry They midwives.

ists, Certified nurse nurse Certified ists,

clinical nurse special nurse clinical

nurse practitioners, practitioners, nurse

istered nurses nurses istered

Advanced practice reg practice Advanced

additional licensure licensure additional

and certification. No No certification. and

ployment, training, training, ployment,

occurs through em through occurs

tings. Specialization Specialization tings.

of health care set care health of

children in a variety variety a in children

RN who cares for for cares who RN

Pediatric nurse Pediatric

(NCLEX)

licensing exam exam licensing

passing a national national a passing

Become an RN upon upon RN an Become

degree (2 years) years) (2 degree

years) or associate associate or years)

baccalaureate (4 (4 baccalaureate

Registered nurse nurse Registered

Nursing

pediatric training pediatric

years of core of years

project) following 3 3 following project)

tion of a scholarly scholarly a of tion

(including comple (including

A 3-year fellowship fellowship 3-year A

Pediatrics

and Behavioral Behavioral and

Developmental Developmental

3 years of general general of years 3

3 years of pediatrics of years 3

3 years of general general of years 3

2 years of pediatrics of years 2

5 years of general general of years 5

2 years of CAP CAP of years 2

4 years of of years 4

psychiatry and CAP and psychiatry

•

Residency

Post-Pediatric Portal Portal Post-Pediatric

psychiatry and CAP CAP and psychiatry

•

dency

Triple Board Resi Board Triple

psychiatry and CAP CAP and psychiatry

•

Integrated Residency Integrated

•

track”)

(or 3 years with “fast “fast with years 3 (or

general psychiatry psychiatry general

•

residency

Traditional Traditional

Psychiatry

Adolescent Adolescent

Child and and Child

programs)

certification (30 (30 certification

generalist, no no generalist,

Academic Academic

programs)

Child abuse (28 (28 abuse Child

programs)

medicine (28 (28 medicine

Adolescent Adolescent

programs)

pediatrics (38 (38 pediatrics

and behavioral behavioral and

Developmental Developmental

certification

subspecialty subspecialty

ing; 14 leading to to leading 14 ing;

19 areas of train of areas 19

of child abuse child of

Elective: 1 month month 1 Elective:

psychiatry

and adolescent adolescent and

month of child child of month

Elective: 1 1 Elective:

experience

ity ambulatory ambulatory ity

month continu month

1-2 days per per days 1-2

pediatrics

and behavioral behavioral and

developmental developmental 1 month of of month 1

Workforce Training Pathways, Competencies, and Numbers by Discipline

•

relevant areas: relevant

Children’s CAB CAB Children’s

•

training

after general general after

pediatrics: 3 years years 3 pediatrics:

Subspecialty Subspecialty

•

training

Children’s CAB related related CAB Children’s

pediatrics: 3 years 3 pediatrics:

General General

Pediatrics

Table 1 |

Pathways

Training Training Discipline

Page 18 Published November 29, 2016 Workforce Development to Enhance the Cognitive, Affective, and Behavioral Health of Children and Youth

Training is variable; insertion into primary child health care sites has occurred in a variety of settings.

Parent Peer Support Specialists, Parent Coaches, and Community Health Workers Health educators have been used as parent coaches for families with infants in primary care and are trained at both the baccalaureate and the master’s degree level (Ameri can Academy of Pediatrics Council on School Health, 2016).

Community health workers come from the neighborhoods and communities in which they are employed. •

Several curricula for PPSS are available for purchase or from state de veloped training programs.

Curriculum guide lines for health edu cator degrees are institution-specific.

Curriculum for community health workers is variable and usually includes on-the-job training.

Social Work

The Educational Policy and Ac creditation Stan dards of the CSWE (2015) outline general require ments and do not specify curriculum content for child health, behavioral health, and the social determi nants of health or health-related prevention.

Field experience is required. Cur riculum requires theory and practice, policy, research, and hu man behavior in the social environ ment coursework.

Family and Community Medicine

ACGME Guide lines for Family Medicine Program include a struc tured, integrated curriculum for diagnosis and management of common mental illness; assess ment of com munity/environ mental influences on family health, preventive care, and work in pro fessional teams.

Pediatric Psychology

Curriculum is determined by individual programs (in accordance with program accredi tation standards of the American Psychological As sociation).

Trainee compe tence is assessed by each pro gram. Proposed guidelines have been published: Palmero et al. (2014), McDan iel et al. (2014), Piazza-Waggoner et al. (2015), Hoff ses et al. (2016).

- -

Model curriculum for PNPs in early mental health pro motion and psycho social morbidities (Melnyk et al., 2010). NAPNAP (PNP) Statement on Inte gration of Mental Health Care in Pedi atric Primary Care Settings (NAPNAP, 2013) includes… “provide mental and behavioral health promotion and standardized screening (including mothers).”

Nursing

•

“Understanding the biological, psychologi cal, and social influences on development in the emotional, social, mo tor, language, and cognitive domains.” A focus on “mechanisms for primary and secondary prevention of disorders in behavioral and development.”

Developmental and Behavioral Pediatrics

ACGME guidelines for program content include: •

•

Child and Adolescent Psychiatry

Largely diagnosis and treatment oriented

Behavioral health promotion/preven tion largely not addressed

No published guide lines for children’s CAB related experi ences

Workforce Training Pathways, Competencies, and Numbers by Discipline

Pediatrics

Behavioral medicine training is gener ally meager and largely diagnosis, referral, and treat ment oriented. The American Academy of Pediatrics and the American Board of Pediatrics have provided guidelines for enhanced train ing and adoption of behavioral medi cine into pediatric practice (Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health, 2009; ABP, in press).

Table 1 |

Discipline Training Pathways (cont.)

Curriculum Guidelines

Published November 29, 2016 NAM.edu/Perspectives Page 19 DISCUSSION PAPER

Parent Peer Support Specialists, Parent Coaches, and Community Health Workers

Specific children’s CAB competencies are defined through the National Parent Support Provider Certification (www.ffcmh.org). Some states have modified this list, as well as included state-specific information regard ing child-serving systems or regulations.

Parent support provider certificates awarded on comple tion of training within a state or service system or national PSP certi fication is awarded on achievement of an acceptable test score on the national exam.

Social Work

None specified by published certify ing standards

Licensure in Clinical Social Work (LCSW) is administered by states. Licensure typically requires 2 years of post- MSW supervised clinical practice and passage of an examination.

Family and Community Medicine The American Academy of Family Physicians has published curriculum Guide lines for Human Behavior and Mental Health (AAFP reprint, 270, revised in 2015) that include psychosocial development. No expectations for children’s CAB relatedcompeten cies in American Board of Family Medicine (ABFM) guidelines

American Board of Family Medi cine (ABFM)

Maintenance of certification is required.

Pediatric Psychology

Targeted compe tencies include interdisciplinary, family-focused, team-based prac tice in hospital or primary care set tings (see above references).

Stated guidelines fortraining target ing children’s CAB health.

Competence variably assessed by state licensure boards.

Some states re quire supervised training beyond the doctorate for license eligibility (which can be met through a fellow ship).

(Hawkins-

Nursing The PMHNP training experiences focus on patients already seeking mental health services. Behavioral health promotion and risk prevention are usu ally secondary.

PNP and FNP com petencies defined in NONPF population— focused NP com petencies, updated 2013

Role delineation for pediatric primary care mental health specialist Walsh and Van Cleve, 2013): Identify risks, screen, diagnose, and offer treatment for common and un complicated mental health diagnoses in youth. Competence in collaboration and coordination of care in community, and advocacy for child and family. Pediatric Nursing Certification Board (PNCB) for PNPs and pediatric primary care mental health specialists

American Nurses Credentialing Center (FNPs & PMHNPs) and AANP-CP for FNPs

Developmental and Behavioral Pediatrics

The Ameri can Board of Pediatrics does not list expected competencies for certification.

The American Board of Pediatrics (ABP)

Maintenance of certification is required.

Child and Adolescent Psychiatry

No published expectations by the ABPM or program requirements by the ACGME

American Board of Psychiatry and Neurology (ABPM)

Workforce Training Pathways, Competencies, and Numbers by Discipline

Pediatrics Programs for improving early cognitive develop ment and assess ing social-emotion al development are increas ingly embedded in training.

The American Board of Pedi atrics does not list expected competencies for certification.

American Board of Pediatrics (ABP)

Maintenance of certi fication required

Table 1 |

Discipline Curriculum Guidelines (cont.)

CAB Competencies

Certification

Page 20 Published November 29, 2016 Workforce Development to Enhance the Cognitive, Affective, and Behavioral Health of Children and Youth

Ohio certifies through the Board of Nurs ing. Texas certifies through the Department of Health Services.

Parent Peer Support Specialists, Parent Coaches, and Community Health Workers Certification of health educators by the National Commission for Health Education Credentialing, Inc.

Certified health education special ist and master certified health education special ist (the latter has met experience as well as academic competency standards).

Some states offer certification for community health workers: •

•

A number of states (such as Alaska) require organiza tions that offer peer support services to become accredited through CARF or COA. Parent peer support is often not provided through traditional clinical practices and thus family organizations offering parent peer support struggle to meet some accredi tation standards.

No specific ac creditation process found for any of these training pathways.

Social Work Continuing educa tion is required to maintain licen sure. See: http:// www.behavioral healthworkforce. org/wp-content/ uploads/2016/09/ FA3P2_SWSOP_ Policy-Brief.pdf.

The National Association of Social Workers offers a variety of credentials in advanced practice specializations, including youth and family, clini cal, health care, education (school social work), and addictions. See: http://www. socialworkers.org/ credentials/.

Council on So cial Work Educa tion (CSWE)

Family and Community Medicine

ACGME

Pediatric Psychology American Board of Professional Psychology (ABPP) certification is available, including child clinical/pediatric specific certifica tion through the American Board of Clinical Child and Adolescent Psychology, but it is not universally subscribed.

Internships are accredited by the American Psychological Association (APA) using criteria set by the Association of Psychology Postdoctoral and InternshipCenter (APPIC).

Post-doctoral fel lowship accredita tion is optional.

Standards set by APPIC are not pediatric specific

Nursing National Board for Certification of School Nurses

Maintenance of certi fication required for licensure as NPs.

Commission on Collegiate Nursing Education or Accreditation Com mission for Educa tion in Nursing

Developmental and Behavioral Pediatrics

ACGME

Child and Adolescent Psychiatry

ACGME

Pediatrics

Accreditation Council for Gradu ate Medical Educa tion (ACGME)

Workforce Training Pathways, Competencies, and Numbers by Discipline

Table 1 |

Discipline Certification (cont.)

Accreditation

Published November 29, 2016 NAM.edu/Perspectives Page 21 DISCUSSION PAPER

Parent Peer Support Specialists, Parent Coaches, and Community Health Workers Unknown

The Federation of Families has a list of nationally certified PPSS providers. In states where a certification process is defined for parent peer support, the certifying entity maintains a roster of certified persons.

Social Work As of October 2016, in the UnitedStates there are 511 ac credited Bacca laureate of Social Work programs (BSW); 249 ac credited Master of Social Work programs (MSW); and 17 BSW and 16 MSW programs in candidacy for accreditation.

More than 650,000 people hold social work degrees.

Social work is one of the fastest-growing careers in the United States. Profession is ex pected to grow by 19% between 2012-2024, primarily in the health sector.

Family and Community Medicine 498

9,200 family medi cine andgeneral physicians.

No estimates of supply and demand found. Critical for child care in sparsely populatedareas.

Pediatric Psychology Estimated 10% of approximately 900 programs are pediatric-focused.

Many pediatric clinical training sites are listedas “integrated.”

There is a perception of a short supply.

No numbers found for total or practicing pediat ric psychologists.

Nursing 100 PNP programs ? FNP programs ? PMHNP programs

350 pediatric primary care mental health specialists 14,000 PNP—PPCs 100,000 FNPs 6,000 PMHNPs

Developmental and Behavioral Pediatrics 37

Short supply gen erally acknowl edged

Child and Adolescent Psychiatry 110

Approximately 8,000 (AMA data)

Projected needs range from 13,000- 30,000.

Developmental and behavioral pediatrics (38 programs) Adolescent medicine (28 programs) Child abuse (28 programs) Academic generalist, no certification (30 programs)

Pediatrics 204 accredited general training programs.

Subspecialties: •

•

Overall demand and supply bal anced (Committee on Pediatric Work force, 2013).

Access variable owing to uneven distribution.

Workforce Training Pathways, Competencies, and Numbers by Discipline

Table 1 |

Discipline Training Program Numbers

Workforce Numbers

NOTE: CARF= Commission on Accreditation of Rehabilitation Facilities; COA = Council on Accreditation; NFFCMH = National Federation of Families for Children’s Mental Mental Children’s for Families of Federation NFFCMH = National =Accreditation; Council on COA Facilities; Rehabilitation of Accreditation on CARF= Commission NOTE: Health

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References Agency for Healthcare Research and Quality (AHRQ). 2014. Medical expenditure panel survey: Statistical brief Accreditation Council for Graduate Medical Education #434: The five most costly children’s conditions, 2011: (ACGME). 2016a. Accreditation Council for Graduate Estimates for U.S. civilian noninstitutionalized children, Medical Education. Retrieved November 18, 2016, ages 0-17. Retrieved November 5, 2016, from https:// from https://www.acgme.org/. meps.ahrq.gov/data_files/publications/st434/stat434. ACGME. 2016b. ACGME program requirements for grad- shtml. uate medical education in adolescent medicine. Re- American Academy of Child and Adolescent Psychia- trieved November 6, 2016, from http://www.acgme. try (AACAP). 2012. Best principles for integration of org/Portals/0/PFAssets/2013-PR-FAQ-PIF/321_ado- child psychiatry into the pediatric health home. Re- lescent_med_peds_07012013.pdf. trieved November 5, 2016, from https://www.aacap. ACGME. 2016c. ACGME program requirements for grad- org/App_Themes/AACAP/docs/clinical_practice_cen- uate medical education in child and adolescent psychi- ter/systems_of_care/best_principles_for_integra- atry. Retrieved November 6, 2016, from https://www. tion_of_child_psychiatry_into_the_pediatric_health_ acgme.org/Portals/0/PFAssets/ProgramRequire- home_2012.pdf. ments/405_child_and_adolescent_psych_2016.pdf. AACAP. 2016. Workforce issues. Retrieved November 6, ACGME. 2016d. ACGME program requirements for 2016, from http://www.aacap.org/aacap/resources_ graduate medical education in developmental-behav- for_primary_care/Workforce_Issues.aspx. ioral pediatrics. Retrieved November 6, 2016, from American Academy of Family Physicians (AAFP). 2016. http://www.acgme.org/Portals/0/PFAssets/2013- Human behavior and mental health. Retrieved Novem- PR-FAQ-PIF/336_developmental_behavioral_ ber 18, 2016, from http://www.aafp.org/dam/AAFP/ peds_07012013.pdf. documents/medical_education_residency/program_ ACGME. 2016e. ACGME program requirements for grad- directors/Reprint270_Mental.pdf . uate medical education in family medicine. Retrieved American Academy of Pediatrics (AAP). 2016. Bright November 6, 2016, from http://www.acgme.org/ futures/American Academy of Pediatrics: Recommen- portals/0/pfassets/programrequirements/120_fam- dations for preventive pediatric health care. Retrieved ily_medicine_2016.pdf. October 31, 2016, from https://www.aap.org/en-us/ ACGME. 2016f. ACGME program requirements for Documents/periodicity_schedule.pdf. graduate medical education in pediatrics. Retrieved AAP Council on School Health. 2016. Role of the school November 6, 2016, from https://www.acgme.org/ nurse in providing school health services: Policy state- Portals/0/PFAssets/ProgramRequirements/320_pe- ment. Pediatrics, 137(6), 34-39. diatrics_2016.pdf. American Board of Medical Specialties (ABMS). 2016. ACGME. 2016g. ACGME program requirements for Based on core competencies. Retrieved Novem- graduate medical education in psychiatry. Retrieved ber 6, 2016, from http://www.abms.org/board- November 6, 2016, from https://www.acgme.org/ certification/a-trusted-credential/based-on-core- Portals/0/PFAssets/ProgramRequirements/400_psy- competencies/. chiatry_2016.pdf. American Board of Pediatrics (ABP). 2016. Physician com- ACGME. 2016h. Number of accredited programs aca- petencies. Retrieved November 6, 2016, from https:// demic year 2016-2017, United States. Retrieved Novem- www.abp.org/content/physician-competencies. ber 6, 2016, from https://apps.acgme.org/ads/Public/ American College of Nurse-Midwives (ACNM). 2016. Reports/ReportRun?ReportId=3&CurrentYear=2016& Essential facts about midwives. Retrieved November AcademicYearId=2016. 18, 2016, from http://www.midwife.org/acnm/files/ ACGME. 2016i. Obstetrics and gynecology. Retrieved ccLibraryFiles/Filename/000000005948/Essential- November 18, 2016, from https://www.acgme.org/ FactsAboutMidwives-021116FINAL.pdf. Specialties/Overview/pfcatid/12.

Published November 29, 2016 NAM.edu/Perspectives Page 23 DISCUSSION PAPER

American Counseling Association. 2011. Who are li- Breitenstein, S.M., Gross, D., Fogg, L., Ridge, A., Gar- censed professional counselors? Retrieved November vey, C., Julion, W., and Tucker, S. 2012. The Chicago 20, 2016, from https://www.counseling.org/Pub- parent program: Comparing 1-year outcomes for licPolicy/WhoAreLPCs.pdf. African American and Latino parents of young chil- American Psychological Association (APA). 2014. dren. Research in Nursing & Health, 35(5), 475-489. Guidelines for prevention in psychology. American Bridge, T.J., Massie, E.G., and Mills, C.S. 2008. Prioritiz- Psychologist, 69(3), 285-296. ing cultural competence in the implementation of an Annapolis Coalition on the Behavioral Health Work- evidence-based practice model. Children and Youth force. 2007. An action plan for behavioral health Services Review, 30(10), 1111-1118. workforce development—a framework for discus- Briggs, R.D. 2016. Integrated early childhood behavioral sion. Retrieved November 5, 2016, from http://attc- health in primary care: A guide to implementation and network.org/find/respubs/docs/WorkforceAction- evaluation. Switzerland: Springer International Pub- Plan.pdf. lishing. Association of Medicine and Psychiatry. 2015. Residen- Briggs, R.D., Silver, E.J., Krug, L.M., Mason, Z.S., Schrag, cy programs: Family medicine/psychiatry. Retrieved R.D.A., Chinitz, S., and Racine, A.D. 2014. Healthy November 20, 2016, from https://assocmedpsych. steps as a moderator: The impact of maternal trau- org/studentstrainees/residency-programs/. ma on child social-emotional development. Clinical Association of University Centers on Disabilities Practice in Pediatric Psychology, 2(2), 166-175. (AUCD). 2011. About LEND. Retrieved November 6, Bureau of Labor Statistics (BLS). U.S. Department 2016, from https://www.aucd.org/template/page. of Labor. 2015. Occupational outlook handbook. Re- cfm?id=473. trieved October 26, 2016, http://www.bls.gov/ooh/ Batalden, M., Batalden, P., Margolis, P., Seid, M., Arm- Community-and-Social-Service/Social-workers. strong, G., Opipari-Arrigan, L., and Hartung, H. 2015. htm#tab-6. Coproduction of healthcare service. BMJ Quality & Centers for Disease Control and Prevention (CDC). Safety. doi:10.1136/bmjqs-2015-004315. 2016. Ambulatory care use and physician office visits. Beck, A.F., Tschudy, M.M., Coker, T.R. 2013. Determi- Retrieved November 18, 2016, from http://www.cdc. nants of Health and Pediatric Primary Care Practices. gov/nchs/fastats/physician-visits.htm. Pediatrics, 137(3). Center for Health Care Strategies, Inc. (CHCS). 2012. Bethell, C.D., Newacheck, P., Hawes, E., and Halfon, N. Medicaid financing for family and youth peer support: 2014. Adverse childhood experiences: Assessing the A scan of state programs. Retrieved on November 18, impact on health and school engagement and the 2016, from http://www.chcs.org/resource/medic- mitigating role of resilience. Health Affairs, 33(12), aid-financing-for-family-and-youth-peer-support-a- 2106-2115. scan-of-state-programs-3/. Bitsko, R.H., Holbrook, J.R., Robinson, L.R., Kaminski, Cheung, A.H., Zuckerbrot, R.A., Jensen, P.S., Ghalib, K., J.W., Peacock, G., Ghandour, R., and Smith, C. 2016. Laraque, D., and Stein, R.E. 2007. Guidelines for ado- Health care, family, and community factors associ- lescent depression in primary care (GLAD-PC): Treat- ated with mental, behavioral, and developmental ment and ongoing management. Pediatrics, 120(5), disorders in early childhood United States, 2011- 1313-26. 2012. Morbidity and Mortality Weekly Report, 65(9), Committee on Children With Disabilities. 2001. Tech- 221-226. nical report: The pediatrician’s role in the diagnosis Blau, G.B., Caldwell, B., Fisher, S., Kuppinger, A., Levin- and management of autistic spectrum disorder in son-Johnson, J., and Lieberman, R. 2010.The Building children. Pediatrics, 107(5). Bridges Initiative: Residential and community-based Committee on Pediatric Workforce. 2013. Pediatrician providers, families, and youth coming together to workforce policy statement. Pediatrics, 132(2), 390- improve outcomes. Child Welfare, 89(2), 21-38. 397.

Page 24 Published November 29, 2016 Workforce Development to Enhance the Cognitive, Affective, and Behavioral Health of Children and Youth

Committee on Psychosocial Aspects of Child and Fam- Fritz, G. (April 25, 2016). Presentation at the Mental ily Health and Task Force on Mental Health. 2009. The Health Education Conference: A Call to Action. future of pediatrics: Mental health competencies for Goodfriend, M., Bryant, T., 3rd, Livingood, W., and pediatric primary care. Pediatrics, 124(1), 410-421. Goldhagen, J. 2006. A model for training pediatri- Council on Social Work Education (CSWE). 2016a. Edu- cians to expand mental health services in the com- cation policy and accreditation standards for baccalau- munity practice setting. Clinical Pediatrics, 45(7), 649- reate and master’s social work programs. Retrieved 654. November 18, 2016, from http://www.cswe.org/File. Graber, L.K. 2012. Family child care providers as aspx?id=81660. health educators and advocates: Perspectives of CSWE. 2016b. HRSA behavioral health workforce educa- parents, health care providers and community ser- tion and training for professionals awardees. Retrieved vice providers. Yale Medicine Thesis Digital Library. November 18, 2016, from http://www.cswe.org/ New Haven, Connecticut. News/NewsArchives/76956.aspx. Hadland, S.E., and Walker, L.R. 2016. Medical comor- CSWE. 2016c. Social work and integrated behavioral bidity and complications. Child and Adolescent Psychi- healthcare project. Retrieved November 18, 2016, atric Clinics of North America, 25(3), 533-548. from http://www.cswe.org/CentersInitiatives/Data- Hawkins-Walsh, E., and Van Cleve, S. 2013. The pedi- Statistics/IntegratedCare.aspx. atric mental health specialist: Role delineation. The Dosman C, and Andrews, D. 2012. Anticipatory guid- Journal for Nurse Practitioners, 9(3), 142-148. ance for cognitive and social-emotional develop- Hawkins-Walsh, E., Crowley, A., Mazurek Melnyk, B., ment: Birth to five years. Pediatrics & Child Health, Beauschesne, M., Brandt, P., and O’Haver, J. 2011. 17(2), 75-80. Improving health-care quality through an AFPNP na- Dubowitz, H. 2014. The safe environment for every tional nursing education collaborative to strengthen kid (SEEK) model: Helping promote children’s health, PNP curriculum in mental/behavioral health and development, and safety. SEEK offers a practical ebp: Lessons learned from academic faculty and model for enhancing pediatric primary care. Child clinical preceptors. Journal of Professional Nursing, Abuse and Neglect, 38(11), 1725-1733. 27(1). Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Henggeler, S.W., and Brondino, M.J. 1997. Multisys- Spitz, A.M., Edwards, V., Koss, M.P., and Marks, J.S. temic therapy with violent and chronic juvenile of- 1998. Relationship of childhood abuse and house- fenders and their families: The role of treatment hold dysfunction to many of the leading causes of fidelity in successful dissemination. Journal of Con- death in adults: The adverse childhood experiences sulting and Clinical Psychology, 65(5). (ACE) study. American Journal of Preventive Medicine, Hoagwood, K.E., Cavaleri, M.A., Olin, S., Burns, B.J., 14(4), 245-258. Slaton, E., Gruttadaro, D., and Hughes, R. 2010. Fam- Fisher, E.S., Staiger, D.O., Bynum, J.P., and Gottlieb, ily support in children’s mental health: A review and D.J. 2007. Creating accountable care organizations: synthesis. Clinical Child and Family Psychology Review, The extended hospital medical staff. Health Affairs, 13(1), 1-45. 26(1). Hoffses, K.W., Ramirez, L.Y., Berdan, L., Tunick, R., Fox, H.B., McManus, M.A., Klein, J.D., Diaz, A., Elster, Honaker, S.M., Meadows, T.J., Shaffer, L., Robins, A.B., Felice, M.E., Kaplan, D.W., Wibbelsman, C.J., and P.M., Sturm, L., and Stancin, T. 2016. Topical review: Wilson, J.E. 2010. Adolescent medicine training in Building competency: Professional skills for pediat- pediatric residency programs. Pediatrics, 125(1), 165- ric psychologists in integrated primary care settings. 172. Journal of Pediatric Psychology, 41(10), 1144-1160. Freed, G.L., Dunham, K.M., Moran, L.M., Spera, L., Mc- Hogue, A., Ozechowski, T.J., Robbins, M.S., and Waldron, Guinness, G.A., and Stevenson, D.K. (2014). Pediatric H.B. 2013. Making fidelity an intramural game: Localiz- subspecialty fellowship clinical training project: Cur- ing quality assurance procedures to promote sustain- rent fellows. Pediatrics, 133(S58). ability of evidence-based practices in usual care. Clini- cal Psychology: Science and Practice, 20(1), 60-77.

Published November 29, 2016 NAM.edu/Perspectives Page 25 DISCUSSION PAPER

Horwitz, S.M., Caspary, G., Storfer-Isser, A., Singh, M., Kazak, A.E., Kassam-Adams, N., Schneider, S., Ze- Fremont, W., Golzari, M., and Stein, R.E.K. 2010. Is likovsky, N., Alderfer, M.A., and Rourke, M. 2006. developmental and behavioral pediatrics training re- An integrative model of pediatric medical traumatic lated to perceived responsibility for treating mental stress. Journal of Pediatric Psychology, 31(4), 343-355. health problems? Academic Pediatrics, 10(4), 252-259. Kessler, R.C., and Wang, P.S. 2008. The descriptive epi- Horwitz, S.M., Storfer-Isser, A., Kerker, B.D., Szilagyi, demiology of commonly occurring mental disorders M., Garner, A., O’Connor, K.G., Hoagwood, K.E., and in the United States. Annual Review Public Health, 29, Stein, R.E.K. 2015. Barriers to the identification and 115-129. management of psychosocial problems: Changes Kolko, D.J., and Perrin, E. 2014. The integration of from 2004 to 2013. Academic Pediatrics, 15(6), 613- behavioral health interventions in children’s health 620. care: Services, science, and suggestions. The Official Institute of Medicine (IOM). 2015a. Measuring the im- Journal for the Society of Clinical Child and Adolescent pact of interprofessional education on collaborative Psychology, American Psychological Association, Divi- practice and patient outcomes. Washington, DC: Na- sion 53, 43(2), 216-228. tional Academies Press. Konrad, T.R., Ellis, A.R., Thomas, K.C., Holzer, C.E., and IOM. 2015a. Mental disorders and disabilities among Morrissey, J.P. 2009. County-level estimates of need low-income children. Washington, DC: National Acad- for mental health professionals in the United States. emies Press. Psychiatric Services, 60(10), 1307-1314. IOM. 2015b. Vital signs: Core metrics for better health Koroloff, N.M., Elliott, D.J., Koren, P.E., and Friesen, at lower cost. Washington, DC: National Academies B.J. 1994. Connecting low-income families to mental Press. health services: The role of the family associate. Jour- IOM and National Research Council (NRC). 2014. Strat- nal of Emotional and Behavioral Disorders, 2(4), 240- egies for scaling effective family-focused preventive in- 246. terventions to promote children’s cognitive, affective, Koroloff, N.M., Elliott, D.J., Koren, P.E., and Friesen, and behavioral health: Workshop summary. Washing- B.J. 1996. Linking low-income families to children’s ton: National Academies Press. mental health services: An outcome study. Journal of Ireys, H.T., Chernoff, R., DeVet, K.A., and Kim, Y. 2001a. Emotional and Behavioral Disorders, 4(1), 2-11. Maternal outcomes of a randomized controlled trial Kutash K., Duchnowski, A.J., Green A.L., and Ferron, J. of a community-based support program for families 2011. Supporting parents who have youth with emo- of children with chronic illnesses. Archives of Pediat- tional disturbances through a parent-to-parent sup- rics & Adolescent Medicine, 155(7), 771. port program: A proof of concept study using ran- Ireys, H.T., Chernoff, R., Stein, R.E., DeVet, K.A., and Sil- dom assignment. Administration and Policy in Mental ver, E.J. 2001b. Outcomes of community-based fami- Health and Mental Health Services Research, 38, 412- ly-to-family support: Lessons learned from a decade 427. of randomized trials. Children’s Services: Social Policy, Leaf, P.J., Owens, P.L., Leventhal, J.M., Forsyth, B.W., Research, and Practice, 4(4), 203-216. Vaden-Kiernan, M., Epstein, L.D., Riley, A.W., and Jimenez, M.E., Wade, R., Jr., Lin, Y., Morrow, L.M., and Horwitz, S.M. 2004. Pediatricians’ training and identi- Reichman, N.E. 2016. Adverse experiences in early fication and management of psychosocial problems. childhood and kindergarten outcomes. Pediatrics, Clinical Pediatrics, 43(4), 355-365. 137(2). Manuel, J. I., Mullen, E. J., Fang, L., Bellamy, J. L., and Kazak, A.E., Alderfer, M., Rourke, M.T., Simms, S., Bledsoe, S. E. 2009. Preparing social work practitio- Streisand, R., and Grossman, J.R. 2004. Posttraumat- ners to use evidence-based practice: A comparison ic Stress Disorder (PTSD) and Posttraumatic Stress of experiences from an implementation project. Symptoms (PTSS) in families of adolescent child- Research on Social Work Practice, 19(5), 613-627. hood cancer survivors. Journal of Pediatric Psychol- ogy, 29(3).

Page 26 Published November 29, 2016 Workforce Development to Enhance the Cognitive, Affective, and Behavioral Health of Children and Youth

McCormick, Erin, Suzanne E.U. Kerns, Heather McPhil- NAPNAP . 2013. Position statement on the integration lips, Jeffrey Wright, Dimitri A. Christakis, and Freder- of mental health care in pediatric primary care set- ick P. Rivara. 2014. Training pediatric residents to tings. Journal of Pediatric Health Care, 27(4), A15-A16. provide parent education: A randomized controlled National Association of Social Workers (NASW). 2016. trial. Academic Pediatrics, 14(4), 353-360. NASW professional social work credentials and ad- McDaniel, S.H., Grus, C.L., Cubic, B.A., Hunter, C.L., Ke- vanced practice specialty credentials. Retrieved No- arney, L.K., Schuman, C.C., Karel, M.J., Kessler, R.S., vember 18, 2016, from https://www.socialworkers. Larkin, K.T., McCutcheon, S., Miller, B.F., Nash, J., org/credentials/list.asp. Qualls, S.H., Connolly, K.S., Stancin, T., Stanton, A.L., National Federation of Families for Children’s Mental Sturm, L.A., and Johnson, S.B. 2014. Competencies Health (NFFCMH). 2011. Job Task: Analysis Parent for psychology practice in primary care. American Support Providers. Orlando, FL. Psychologist, 69(4). NRC and IOM. 2009a. Depression in parents, parenting, McMillan, J.A., Land, M., and Leslie, L.K. (in press). Pe- and children: Opportunities to improve identification, diatric residency education and the behavioral and treatment, and prevention. Washington, DC: National mental health crisis: A call to action. Pediatrics. Academies Press. Melnyk, B.M., Hawkins-Walsh, E., Beauchesne, M., NRC and IOM. 2009b. Preventing mental, emotional, Brandt, P., Crowley, A., Choi, M., and Greenburg, E. and behavioral disorders among young people: Prog- 2010. Strengthening PNP curricula in mental/behav- ress and possibilities. Washington, DC: The National ioral health and evidence-based practice. Journal of Academies Press. Pediatric Health Care, 24(2), 81-94. Needlman, R., Toker, K.H., Dreyer, B.P., Klass, P., and Mendelsohn, A.L., Valdez, P.T., Flynn, V., Foley, G.M., Mendelsohn, A.L. 2005. Effectiveness of a primary Berkule, S.B., Tomopoulos, S., Fierman, A.H., Tineo, care intervention to support reading aloud: A mul- W., and Dreyer, B.P. 2007. Use of videotaped inter- ticenter evaluation. Ambulatory Pediatrics, 5(4), 209- actions during pediatric well-child care: Impact at 215. 33 months on parenting and on child development. Newacheck, P.W., and Halfon, N. 1998. Prevalence and Journal of Developmental and Behavioral Pediatrics, impact of disabling chronic conditions in childhood. 28(3), 206-212. American Journal of Public Health, 88(4), 610-617. National Academies of Sciences, Engineering, and Obrochta, C., Anthony, B., Armstrong, M., Kalil, J., Medicine (NASEM). 2015. Opportunities to promote Hust, J., and Kernan, J. 2011. Issue Brief: Family-to- children’s behavioral health: Health care reform and family peer support: Models and evaluation. Atlanta, beyond: Workshop summary. Washington, DC: Na- GA: ICF Macro, Outcomes Roundtable for Children tional Academies Press. and Families. NASEM. 2016. Ensuring quality and accessible care for Olin, S.S., Williams, N., Pollock, M., Armusewicz, K., children with disabilities and complex health and edu- Kutash, K., Glisson, C., and Hoagwood, K.E. 2014. cational needs: Proceedings of a workshop. Washing- Quality indicators for family support services and ton, DC: National Academies Press. their relationship to organizational social context. National Alliance on Mental Illness (NAMI). (n.d.). Administration and Policy in Mental Health, 41(1), 43- NAMI ending the silence. Retrieved November 5, 2016, 54. from http://www.nami.org/Find-Support/NAMI-Pro- Osher, T., Penn, M., and Spencer, S.A. 2008. Partner- grams/NAMI-Ending-the-Silence. ships with families for family-driven systems of care. National Association of Pediatric Nurse Practitioners In: Stroul BA, Blau GM, editors. The system of care (NAPNAP). 2015. Pediatric nursing: Scope and stan- handbook: Transforming mental health services for dards of practice. Silver Spring, MD: American Nurs- children, youth, and families. Baltimore, MD: Brookes es Association. Publishing, pp. 249-274.

Published November 29, 2016 NAM.edu/Perspectives Page 27 DISCUSSION PAPER

Palermo, T.M., Janicke, D.M., McQuaid, E.L., Mullins, Robins, D.L. 2008. Screening for autism spectrum dis- L.L., Robins, P.M., and Wu, Y.P. 2014. Recommenda- orders in primary care settings. Autism: The Interna- tions for training in pediatric psychology: Defining tional Journal of Research and Practice, 12(5), 537-556. core competencies across training levels. Journal of Schmitt, M.H., Gilbert, J.H.V., Brandt, B.F., and Wein- Pediatric Psychology, 39(9), 965-984. stein, R.S. 2013. The coming of age for interprofes- Pediatric Nursing Certification Board (PNCB). 2016. sional education and practice. The American Journal The PMHS. Retrieved November 18, 2016, from of Medicine, 126(4), 284-288. http://www.pncb.org/ptistore/control/exams/mh/ Schoenwald, S.K., Brown, T.L., and Henggeler, S.W. pmhs_role. 2000a. Inside multisystemic therapy: Therapist, su- Perou, R., Bitsko, R.H., Blumberg, S.J., Pastor, P., Ghan- pervisory, and program practices. Journal of Emotion- dour, R.M., Gfroerer, J.C., Hedden, S.L., Crosby, A.E., al and Behavioral Disorders, 8(2), 113-127. Visser, S.N., Schieve, L.A., Parks, S.E., Hall, J.E., Brody, Schoenwald, S.K., Henggeler, S.W., Brondino, M.J., D., Simile, C.M., Thompson, W.W., Baio, J., Avenevoli, and Rowland, M.D. 2000b. Multisystemic therapy: S., Kogan, M.D., and Huang, L.N. 2013. Mental health Monitoring treatment fidelity. Family Process, 39(1), surveillance among children—United States, 2005- 83-103. 2011. Morbidity and Mortality Weekly Report, 62(Suppl Schoenwald, S.K., Sheidow, A.J., and Chapman, J.E. 2), 1-35. 2009. Clinical supervision in treatment transport: Ef- Perrin, E.C., Sheldrick, R.C., McMenamy, J.M., Henson, fects on adherence and outcomes. Journal of Consult- B.S., and Carter, A.S. 2014. Improving parenting skills ing and Clinical Psychology, 77(3), 410-421. for families of young children in pediatric settings: A Shonkoff, J.P., and Garner, A.S. 2012. The lifelong ef- randomized clinical trial. JAMA Pediatrics, 168(1), 16- fects of early childhood adversity and toxic stress. 24. Pediatrics, 129(1), 232-246. Piazza-Waggoner, C., Karazsia, B.T., Hommel, K.A., Shonkoff, J.P., Boyce, W.T., and McEwen, B.S. 2009. and Modi, A.C. 2015. Considerations for assessing Neuroscience, molecular biology, and the childhood competencies in pediatric psychology. Clinical Prac- roots of health disparities: Building a new frame- tice in Pediatric Psychology, 3(3), 249-254. work for health promotion and disease prevention. Pless, I.B., and Roghmann, K.J. 1971. Chronic illness JAMA, 301(21), 2252-2259. and its consequences: Observations based on three Skillman, S.M., Snyder, C.R., Frogner, B.K., and Pat- epidemiologic surveys. The Journal of Pediatrics, terson, D.G. 2016. The behavioral health workforce 79(3), 351-359. needed for integration with primary care: Information Quittner, A.L., Abbott, J., Georgiopoulos, A.M., Gold- for health workforce planning. Seattle, WA: Center for beck, L., Smith, B., Hempstead, S.E., Marshall, B., Health Workforce Studies, University of Washington. Sabadosa, K.A., and Elborn, S. 2015. International Stein, R.E., Horwitz, S.M., Storfer-Isser, A., Heneghan, Committee on Mental Health in Cystic Fibrosis: Cystic A., Olson, L., and Hoagwood, K.E. 2008. Do pediatri- Fibrosis Foundation and European Cystic Fibrosis So- cians think they are responsible for identification ciety consensus statements for screening and treat- and management of child mental health problems? ing depression and anxiety. Thorax, doi:10.1136/tho- Results of the AAP periodic survey. Ambulatory raxjnl-2015-207488. Pediatrics, 8(1). Regehr, C., Stern, S., and Shlonsky, A. 2007. Operation- Stein, R.E., Horwitz, S.M., Storfer-Isser, A., Heneghan, alizing evidence-based practice: The development of A.M., Hoagwood, K.E., Kelleher, K.J., O’Connor, K.G., an institute for evidence-based social work. Research and Olson, L. 2009. Attention-deficit/hyperactivity on Social Work Practice, 17(3), 408-416. disorder: How much responsibility are pediatricians Ricketts, T.C. 2005. Workforce issues in rural areas: taking? Pediatrics, 123(1), 248-255. A focus on policy equity. American Journal of Public Stein, R.E.K., Storfer-Isser, A., Kerker, B.D., Garner, A., Health, 95(1), 42-48. Szilagyi, M., Hoagwood, K.E., O’Connor, K.G., and Mc- Cue Horwitz, S. 2016. Beyond ADHD: How well are we doing? Academic Pediatrics, 16(2), 115-121.

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Stroul, B.A. and Friedman, R.M. 1994. A system of care Mason University; Mark W. Fraser, PhD, is John A. for children and youth with severe emotional distur- Tate Distinguished Professor, School of Social Work, bances. Washington, DC: CASSP Technical Assistance University of North Carolina at Chapel Hill; Lisa de Center, Center for Child Health and Mental Health Saxe Zerden, MSW, PhD, is Senior Associate Dean Policy, Georgetown University Child Development for MSW Education, School of Social Work, Univer- Center. sity of North Carolina at Chapel Hill; Brianna M. Substance Abuse and Mental Health Services Admin- Lombardi, MSW, is Ph.D. Candidate, School of Social istration (SAMHSA). 2013. Behavioral health, United Work, University of North Carolina; Gregory K. Fritz, States, 2012. HHS Publication No. (SMA) 13-4797. MD, is President, American Academy of Child and Ado- Rockville, MD: SAMHSA. lescent Psychiatry, is Academic Director, E.P. Bradley Hospital, and is Professor and Director, Division of Suggested Citation Child and Adolescent Psychiatry and Vice Chair, Depart- Boat, T.F., M.L. Land, L.K. Leslie, K.E. Hoagwood, ment of Psychiatry and Human Behavior, Warren Alp- E. Hawkins-Walsh, M.A. McCabe, M.W. Fraser, L. ert Medical School of Brown University; Bianca Kiyoe de Saxe Zerden, B.M. Lombardi, G.K. Fritz, B.K. Frogner, PhD, is Associate Professor and Director, Cen- Frogner, J.D. Hawkins, and M. Sweeney. 2016. Workforce ter for Health Workforce Studies, Department of Family Development to Enhance the Cognitive, Affective, and Medicine, University of Washington; J. David Hawkins, Behavioral Health of Children and Youth: Opportunities PhD, is Endowed Professor of Prevention, Social Devel- and Barriers in Child Health Care Training. Discussion opment Research Group, School of Social Work, Uni- Paper, National Academy of Medicine, Washington, versity of Washington; Millie Sweeney, MS, is Deputy DC. https://nam.edu/wp-content/uploads/2016/11/ Director, Family-Run Executive Director Leadership Workforce-Development-to-Enhance-the-Cognitive- Association. Affective-and-Behavioral-Health-of-Children-and- Youth.pdf. Acknowledgements The authors would like to thank Sarah M. Tracey, Asso- Author Information ciate Program Officer, National Academies of Sciences, Engineering, and Medicine, for her insights and assis- Thomas F. Boat, MD, is Professor of Pediatrics and tance in writing this discussion paper. Dean Emeritus, University of Cincinnati College of Med- icine, Cincinnati Children’s Hospital Medical Center; Disclaimer Marshall L. Land, MD, is R. James McKay, Jr., MD Green The views expressed in this Perspective are those of & Gold Professor of Pediatrics, University of Vermont the authors and not necessarily of the authors’ orga- College of Medicine, and Consultant, American Board nizations, the National Academy of Medicine (NAM), or of Pediatrics for Strategic Planning; Laurel K. Leslie, the National Academies of Sciences, Engineering, and MD, MPH, Vice President of Research, American Board Medicine (The Academies). The Perspective is intend- of Pediatrics and is Professor, Pediatrics and Medi- ed to help inform and stimulate discussion. It has not cine, Tufts University School of Medicine; Kimberly E. been subjected to the review procedures of, nor is it a Hoagwood, PhD, is Cathy and Stephen Graham Pro- report of, the NAM or the Academies. Copyright by the fessor of Child and Adolescent Psychiatry, Depart- National Academy of Sciences. All rights reserved. ment of Child and Adolescent Psychiatry, School of Medicine, New York University; Elizabeth Hawkins- Walsh, PhD, CPNP, PMHS, FAANP, is Director, Pedi- atric Nurse Practitioner Programs, Gowan School of Nursing, The Catholic University of America; Mary Ann McCabe, PhD, is Associate Clinical Professor of Pedi- atrics, George Washington University School of Medi- cine and is Affiliate Faculty in Psychology, George

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