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

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Workforce Development to Enhance the Cognitive, Affective, and Behavioral Health of Children and Youth: Opportunities and Barriers in Child Health Care Training DISCUSSION PAPER Workforce Development to Enhance the Cognitive, Affective, and Behavioral Health of Children and Youth: Opportunities and Barriers in Child Health Care Training 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 Page 2 Published November 29, 2016 Workforce Development to Enhance the Cognitive, Affective, and Behavioral Health of Children and Youth 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
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