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Report of a Joint Association of Pediatric Program Directors–American Board of Pediatrics Workshop: Preparing Future Pediatricians for the Mental Health Crisis

2018; Elsevier BV; Volume: 201; Linguagem: Inglês

10.1016/j.jpeds.2018.06.044

1097-6833

Julia A. McMillan, Marshall L. Land, Angie Mae Rodday, Kelly Wills, Cori M. Green, Laurel K. Leslie,

Child and Adolescent Psychosocial and Emotional Development

On April 5, 2017, the Association of Pediatric Program Directors (APPD) and the American Board of Pediatrics (ABP) cohosted a day-long workshop targeting program directors, associate program directors, and medical education leaders in conjunction with the APPD Annual Meeting. The workshop, entitled "The Mental Health Crisis: Preparing Future Pediatricians to Meet the Challenge," aimed to enhance recognition of the magnitude and urgency of the behavioral and mental health (B/MH) crisis, identify barriers and facilitators for incorporating robust experiences in B/MH into pediatric training programs, and encourage innovation and networking to achieve resident and fellow competence in providing appropriate care. This report describes the planning and proceedings of the workshop, including recommendations by participants for initiatives needed to enhance training in B/MH. The urgent driver for this workshop was the increasing recognition of the high rates of B/MH issues and resulting morbidity and mortality, which pediatricians generally are not prepared to address. B/MH issues are among the most common disorders facing the patients of general and subspecialty pediatricians.1Mojtabai R. Olfson M. Han B. National trends in the prevalence and treatment of depression in adolescents and young adults.Pediatrics. 2016; 138 (e20161878)Crossref PubMed Scopus (740) Google Scholar, 2Houtrow A.J. Larson K. Olson L.M. Newacheck P.W. Neal Halfon N. Changing trends of childhood disability, 2001-2011.Pediatrics. 2014; 134: 530-538Crossref PubMed Scopus (156) Google Scholar, 3Anderson L.E. Chen M.L. Perrin J.M. Van Cleave J. Outpatient visits and medication prescribing for US children with mental health conditions.Pediatrics. 2015; 136: e1178-e1185Crossref PubMed Scopus (98) Google Scholar, 4Centers for Disease Control and Prevention Mental Health Surveillance among children—United States, 2005-2011.MMWR Suppl. 2013; 62: 1-35Google Scholar Recent surveys indicate that 1 in 7 children younger than 8 years and 1 in 5 adolescents have a diagnosable behavioral, mental, or developmental disorder.5Bitsko R.H. Holbrook J.R. Robinson L.R. Kaminski J.W. Ghandour R. Smith C.R. et al.Health care, family, and community factors associated with mental,behavioral, and developmental disorders in early childhood—United States, 2011-2012.MMWR Morb Mortal Wkly Rep. 2016; 65: 221-226Crossref PubMed Scopus (93) Google Scholar Between 2001 and 2011, childhood disability related to mental health and neurodevelopmental conditions increased by more than 20%, even as disability due to physical health conditions decreased by almost 12%.2Houtrow A.J. Larson K. Olson L.M. Newacheck P.W. Neal Halfon N. Changing trends of childhood disability, 2001-2011.Pediatrics. 2014; 134: 530-538Crossref PubMed Scopus (156) Google Scholar In 2015, the Centers for Disease Control and Prevention reported that suicide was the second-leading cause of death for individuals between 15 and 25 years and the third most common cause of death for children between 10 and 14 years.6Centers for Disease Control and Prevention Injury prevention and control: data& statistics.http://www.cdc.gov/injury/wisqars/leadingcauses.htmlDate accessed: May 18, 2018Google Scholar Between 2006 and 2011, hospitalization for B/MH conditions increased by 50% for children aged 10-14 years; the cost of hospital visits alone for these conditions was $11.6 billion7Torio C.M. Encinosa W. Berdahl T. McCormick M.C. Simpson L.A. Annual report on health care for children and youth in the United States: national estimates of cost, utilization and expenditures for children with mental health conditions.Acad Pediatr. 2015; 15: 19-35Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar; and total cost of providing care for B/MH problems in children was estimated at $247 billion in 2007.8National Research Council and Institute of Medicine Preventing mental, emotional, and behavioral disorders among young people. National Academies Press, Washington (DC)2009: 241Google Scholar Only approximately 20% of children in need of mental health services receive specialty care.9Kataoka S.H. Zhang L. Wells K. Unmet need for mental health care among U.S. children: variation by ethnicity and insurance status.Am J Psychiatry. 2002; 159: 1548-1555Crossref PubMed Scopus (1086) Google Scholar, 10Martini R. Hilt R. Marx L. Chenven M. Naylor M. Sarvet B. et al.Best principles for integration of child psychiatry into the pediatric health home.https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/systems_of_care/best_principles_for_integration_of_child_psychiatry_into_the_pediatric_health_home_2012.pdfDate accessed: May 18, 2018Google Scholar, 11Tyler E.T. Hulkower R.L. Kaminski J.W Behavioral Health Integration in Pediatric Primary Care: Considerations and Opportunities for Policymakers, Planners, and Providers.https://www.milbank.org/publications/behavioral-health-integration-in-pediatric-primary-care-considerations-and-opportunities-for-policymakers-planners-and-providers/Date: 2012Date accessed: May 18, 2018Google Scholar Although pediatricians in general practice feel responsible for identifying these problems, many do not feel adequately trained to do so, nor do they feel competent to treat them.12Horwitz S.M. Storfer-Isser A. Kerker B.D. Szilagyi M. Garner A. O'Connor K.G. et al.Barriers to the identification and management of psychosocial problems: changes from 2004 to 2013.Acad Pediatr. 2015; 15: 613-620Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar Leaders in both child and adolescent psychiatry13American Academy of Child and Adolescent Psychiatry Child and adolescent psychiatry workforce crisis: solutions to improve early intervention and access to care.https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/workforce_issues/workforce_brochure_2013.pdfDate accessed: May 18, 2018Google Scholar and developmental/behavioral pediatrics have forecast workforce shortages, leading to increasing calls for general and subspecialty pediatricians and other healthcare professionals to develop skills, enhance interprofessional training, and implement care models.14Bridgemohan C. Bauer N.S. Nielsen B.A. DeBattista D. Ruch-Ros H.S. Paul L. et al.A workforce survey on developmental-behavioral pediatrics.Pediatrics. 2018; 141 (e20172164)Crossref Scopus (68) Google Scholar, 15Leslie L.K. Baum R. Turner A. Revisiting the viability of the developmental-behavioral health care workforce.Pediatrics. 2018; 141 (e20174132)Crossref Scopus (6) Google Scholar, 16Boat T.F. Land Jr, M.L. Leslie L.K. Health care workforce development to enhance mental and behavioral health of children and youths.JAMA Pediatr. 2017; 171: 1031-1032Crossref PubMed Scopus (28) Google Scholar Although workshop organizers recognized the need to enhance the skill and knowledge of pediatricians already in practice, the focus for this workshop was on pediatricians in training, who will become the generalists and subspecialists of the future. The Strategic Planning Committee of the ABP was appointed in 2014 to recommend initiatives through which the ABP could improve outcomes for children. The committee identified B/MH needs as the greatest priority gap in care that the ABP should address using its influence on the education and certification of pediatricians, its maintenance of certification program, and its advocacy efforts. In 2016, that committee recommended to the Board of Directors that "the ABP engage in activities to ensure that graduating residents are prepared to prevent and recognize B/MH problems and provide knowledgeable, effective, efficient, coordinated care for children affected by these conditions." The recommendation acknowledged the ongoing work and the tools already developed by the American Academy of Pediatrics (AAP). The ABP's intention to partner with the AAP and other organizations to ensure that pediatric residents and fellows develop the competence needed to meet the B/MH needs of their patients was highlighted in a call to action published in Pediatrics in early 2017.17McMillan J.A. Land Jr, M.L. Leslie L.K. Pediatric residency education and the behavioral and mental health crisis: a call to action.Pediatrics. 2017; 139 (e20162141)Crossref PubMed Scopus (77) Google Scholar In April 2016, the ABP convened a workshop involving representatives from 10 pediatric and child B/MH organizations with an interest in pediatric training. The overall goal for that workshop was to share information and develop a strategy to help ensure that current and future pediatric residents develop the knowledge and competencies needed to provide appropriate care for children with B/MH problems, along with mental health professionals, including developmental/behavioral and adolescent medicine pediatricians and neurodevelopmental disabilities specialists. Even though all organizational representatives agreed on the urgency of this effort, there was acknowledgement that the APPD, with membership from virtually all pediatric residency programs and many fellowship programs, would be critical partners for enhancing faculty expertise, developing curricula and assessment tools, and advocating for needed changes in resident and fellow training environments. The APPD and ABP agreed to cohost a workshop specifically focused on B/MH training before the April 2017 APPD meeting. The workshop planning committee chose to frame the workshop using a competency-based education framework. During the last 2 decades, medical education has moved toward competency-based education, as embodied in the milestones developed and implemented by Accreditation Council for Graduate Medical Education in 200918Schumacher D.J. Lewis K.O. Burke A.E. Smith M.L. Schumacher J.B. Pitman M.A. et al.The pediatrics milestones: initial evidence for their use as learning road maps for residents.Acad Pediatr. 2013; 13: 40-47Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar and the more recent framework of entrustable professional activities (EPAs), currently being developed and piloted by the Association of American Medical Colleges19Brown D.R. Warren J.B. Hyderi A. Drusin R.E. Moeller J. Rosenfeld M. et al.Finding a path to entrustment in undergraduate medical education: a progress report from the AAMC core entrustable professional activities for entering residency entrustment concept group.Acad Med. 2017; 92: 774-779Crossref PubMed Scopus (57) Google Scholar in undergraduate medical education and the ABP in pediatric graduate medical education (Table I). Currently, 20 pediatric residency training programs are implementing the 17 proposed EPAs for general pediatricians and participating in a study of their validity through the APPD's Longitudinal Educational Assessment Research Network. The workshop's planning committee employed the activities and curricular components of EPA #9 (B/MH EPA), "Assess and manage patients with common B/MH problems," as the basis for workshop activities. Open invitations were distributed to all APPD members, including directors and associate/assistant program directors of residency and fellowship programs, to attend a day-long workshop before the APPD meeting.Table IEPAs in general pediatricsEPAs•Provide an agreed-on list of activities within a given subspecialty that a physician should be expected to be able to perform competently and without supervision•Are observable and measurable•Require integration of competencies (knowledge, skills, attitudes) across domains of the 6 core competencies and the behavioral milestones for the specialty•Assign goals for training into the context of the activity in which they are taught and assessedEPA #9: Assess and manage patients with common B/MH problemsB/MH issues are central to pediatric practice. Care of patients with B/MH problems requires that the pediatrician engage with the family to:•Identify and manage common B/MH issues (eg, low mood, inattention and impulsivity, disruptive behavior, and aggression, anxiety, learning difficulty, substance use, and social-emotional issues in young children), including the initiation and monitoring of treatment effects for psychosocial interventions and, when indicated for certain disorders (ADHD, depression, anxiety), pharmacotherapy•Refer and comanage patients with the appropriate specialist(s) when indicated to match the patient's needs, including pharmacotherapy (eg, CBT for depression, specialist in trauma focused CBT for post-traumatic stress disorder, child psychiatrist for assistance in medication management)•Know the mental health resources available to patients in one's community and use the appropriate resources for each patient's needs•Know the role of each member of the interprofessional team and coordinate and monitor care provided outside one's practice (eg, mental health professionals, community social services, support groups, early intervention, and school personnel) to optimize patient care•Provide care that is sensitive to the developmental stage of the patient and the cultural context of the patient and family around issues of mental healthADHD, attention-deficit/hyperactivity disorder; CBT, cognitive behavior therapist.For information, go to https://www.abp.org/sites/abp/files/pdf/gen_peds_epa_9.pdf. Open table in a new tab ADHD, attention-deficit/hyperactivity disorder; CBT, cognitive behavior therapist. For information, go to https://www.abp.org/sites/abp/files/pdf/gen_peds_epa_9.pdf. Drawing on a recognized approach to curriculum development and evaluation termed "Context, Input, Process, and Product,"20Stufflebeam D.L. Coryn C.L.S. Evaluation theory, models, & applications.2nd ed. Jossey-Bass, San Francisco (CA)2014Google Scholar the planning committee chose to distribute a voluntary, Web-based meeting questionnaire to all registrants to develop a context analysis of attendees before the workshop. This type of analysis provides information regarding curricular goals, priorities, and needed interventions by assessing needs, problems, assets, and opportunities. The questionnaire was launched in Novi-Survey (https://novisurvey.net/) and focused on registrants' perceptions of their expected and current B/MH training outcomes, their conceptualization of the existing resources and rotations at their site, and their programs' knowledge of and experience with the EPAs in general and the B/MH EPA specifically. Results were shared with the planning committee members to inform the workshop agenda. Attendees who did not complete the questionnaire before arrival were offered the opportunity to complete a paper-based questionnaire at the meeting. No identifying information regarding the respondents' personal information or program was collected. The questionnaire was determined to be exempt by Schulman and Associates, the ABP's institutional review board of record. Descriptive statistics of all responses, including frequencies and proportions, were conducted with SAS Enterprise Guide 7.1 (SAS Institute, Inc, Cary, North Carolina). One hundred eighteen individuals registered for the workshop, not including APPD and ABP leadership; 103 self-identified as program/associate program directors and the rest as "other" (eg, clinical competency member, faculty member, administrator). Registrants represented 86 training programs. A total of 107 registrants completed most of the preworkshop questionnaire (denominators are displayed in the text and tables, given variable responses to individual questions). Although 89.7% (87/97) of registrants self-rated as knowledgeable (moderate/extensive knowledge on a 5-point Likert scale ranging from unaware to extensive knowledge) about milestones, fewer were knowledgeable about the EPAs for general pediatricians or the B/MH EPA specifically (48/97, 49.5% and 20/97, 20.6% respectively). Approximately one-quarter agreed or strongly agreed on a 5-point Likert scale (ranging from strongly disagree to strongly agree) that EPAs had been introduced into trainee assessment at their institution (28/96, 29.2%), were being used to inform clinical competency committee reviews and decisions (25/96, 26.0%), and that their faculty who assess resident performance understood the EPAs (24/96, 25.0%). However, only 7.3% (7/96) were using the B/MH EPA to assess residents' readiness for practice with respect to common childhood mental health problems. Registrants agreed/strongly agreed on a 5-point Likert scale (ranging from strongly disagree to strongly agree) that graduating residents going into primary care and subspecialty care should be competent in the identification (104/107, 97.2%; 101/107, 94.4% respectively) and referral/comanagement of common childhood mental health problems (104/107, 97.2%; 87/107, 81.3% respectively); responses varied for primary care and subspecialty care regarding management of these problems (94/107, 87.9%; 57/107, 53.3% respectively) (Table II). The vast majority (90/106, 84.9%) endorsed that their training program was committed to ensuring graduating residents could address common childhood mental health problems.Table IIRespondents' expectations and perceptions of graduating residents' competence and comfort with common childhood mental health problems*Including inattention, hyperactivity, depression, anxiety, and behavioral problems (eg, social-emotional difficulties, disciplinary issues).Expected competence (n = 107)Strongly disagree/ disagreen (%)Neutraln (%)Agree/strongly agreen (%)Graduating residents going into primary care should be competent in the… Identification of common childhood mental health problems3 (2.8)0 (0.0)104 (97.2) Management of common childhood mental health problems5 (4.7)8 (7.5)94 (87.9) Referral and comanagement of common childhood mental health problems3 (2.8)0 (0.0)104 (97.2)Graduating residents going into subspecialty care should be competent in the… Identification of common childhood mental health problems4 (3.7)2 (1.9)101 (94.4) Management of common childhood mental health problems17 (15.9)33 (30.8)57 (53.3) Referral and comanagement of common childhood mental health problems6 (5.6)14 (13.1)87 (81.3)Perceived comfort (n = 97-100)Not at all comfortablen (%)Neutraln (%)Very comfortablen (%)Perception of your graduating residents' comfort with the following mental health competencies†Denominators vary for each item due to variable response rate to individual questions. Providing anticipatory guidance around common behavioral health problems2 (2.0)18 (18.0)80 (80.0) Eliciting parent/patient concerns about mental health problems in an empathetic manner1 (1.0)11 (11.0)88 (88.0) Managing behavioral problems14 (14.1)30 (30.3)55 (55.6) Using evidence-based tools like motivational interviewing to encourage engagement in treatment23 (23.7)34 (35.1)40 (41.2) Identifying ADHD1 (1.0)8 (8.0)91 (91.0) Monitoring clinical response and medication side effects using rating scales for ADHD11 (11.0)13 (13.0)76 (76.0) Treating ADHD with medications12 (12.2)20 (20.4)66 (67.3) Comanaging treatment of ADHD in collaboration with a mental health professional9 (9.1)16 (16.2)74 (74.7) Identifying depression and/or anxiety5 (5.1)19 (19.2)75 (75.8) Monitoring clinical response and side effects using rating scales for depression and/or anxiety31 (31.0)32 (32.0)37 (37.0) Treating depression and/or anxiety with medications49 (49.0)28 (28.0)23 (23.0) Comanaging treatment of depression and/or anxiety in collaboration with a mental health professional19 (19.2)29 (29.3)51 (51.5)* Including inattention, hyperactivity, depression, anxiety, and behavioral problems (eg, social-emotional difficulties, disciplinary issues).† Denominators vary for each item due to variable response rate to individual questions. Open table in a new tab Regarding outcomes about registrants' perception of their graduating residents' comfort with mental health competencies (Table II), more than three-quarters endorsed that their residents were comfortable/very comfortable on a 5-point Likert scale (not at all comfortable to very comfortable) with providing anticipatory guidance around common behavioral health problems (80/100, 80.0%), eliciting parent/patient concerns about mental health problems in an empathetic manner (88/100, 88.0%), and identifying attention-deficit hyperactivity disorder (91/100, 91.0%). Perceived comfort was much lower for managing behavior problems (55/99, 55.6%), using evidence-based tools like motivational interviewing to encourage engagement in treatment (40/97, 41.2%), monitoring clinical response and side effects using rating scales for anxiety/depression (37/100, 37.0%), and treating depression/anxiety with medications (23/100, 23.0%). Respondents rated the importance (minimum, moderate, maximum) and availability (not available, yes to some, yes to all) of resources for training regarding common childhood mental health problems (Table III). More than two-thirds assigned maximum importance to faculty leadership around mental health training (78/98, 79.6%), including on-site mental health faculty interacting with trainees (71/98, 72.4%), and leadership that is committed to mental health training (70/98, 71.4%).Table IIIRespondents self-report on preworkshop survey of resources for training regarding common childhood mental health problems*Including inattention, hyperactivity, depression, anxiety, and behavioral problems (eg, social-emotional difficulties, disciplinary issues). (n = 97-98)†Denominators vary for each item due to variable response rate to individual questions.ImportanceAvailabilityMinimumn (%)Moderaten (%)Maximumn (%)Not at alln (%)Yes to somen (%)Yes to alln (%)Stated goals for mental health training6 (6.1)42 (42.9)50 (51.0)17 (17.5)46 (47.4)34 (35.1)Teaching tools7 (7.1)52 (53.1)39 (39.8)37 (37.8)43 (43.9)18 (18.4)Identified faculty to lead efforts around mental health training2 (2.0)18 (18.4)78 (79.6)18 (18.4)40 (40.8)40 (40.8)On-site mental health faculty interacting with trainees0 (0.0)27 (27.6)71 (72.4)10 (10.2)47 (48.0)41 (41.8)Integrated, interdisciplinary trainee experiences1 (1.0)33 (33.7)64 (65.3)15 (15.3)49 (50.0)34 (34.7)Incorporation of assessment regarding mental health competencies in residency review process9 (9.2)60 (61.2)29 (29.6)51 (52.0)34 (34.7)13 (13.3)Leadership committed to enhancing mental health training1 (1.0)27 (27.6)70 (71.4)13 (13.3)53 (54.1)32 (32.7)Access to both physical and mental health records in the EMR5 (5.1)33 (33.7)60 (61.2)18 (18.4)39 (39.8)41 (41.8)EMR, electronic medical record.* Including inattention, hyperactivity, depression, anxiety, and behavioral problems (eg, social-emotional difficulties, disciplinary issues).† Denominators vary for each item due to variable response rate to individual questions. Open table in a new tab EMR, electronic medical record. Building off the results of the context analysis, the workshop focused on development of a shared understanding of the need for enhanced B/MH care on the part of pediatricians and activities expected of pediatricians, with B/MH EPA as a guide. Before the workshop, registrants were provided with a copy of B/MH EPA, including expected activities and curricular components that are included in the EPA document. Additional material provided to attendees at the workshop included a compilation of personal stories by parents who have dealt with difficulties accessing pediatric B/MH care and a list of suggestions for enhancing B/MH training and experiences for pediatric trainees compiled by the American Academy of Child and Adolescent Psychiatry, the Academic Pediatric Association, the Society for Developmental and Behavioral Pediatrics, and the Society for Adolescent Health and Medicine. The list includes suggestions to integrate B/MH care providers into pediatric practice/continuity clinic/inpatient teams, develop or enhance developmental/behavioral screening, ensure that developmental/behavioral rotations expose residents to a variety of patients in a variety of settings, enhance trainee exposure to child psychiatry/psychology, and improve the skills of both faculty and trainees to provide B/MH care in the primary care setting. In the opening exercise to the workshop, attendees were asked, "What aspects of training would be likely to produce trainees who are incompetent to provide B/MH care?" Attendees highlighted current systems and practices that mitigate against effective training, including (1) failure of faculty members to acknowledge, screen, or assess for B/MH problems and minimize responsibility ("That's not our problem"); (2) silo B/MH care, managing B/MH issues exclusively in child psychiatry; (3) making documentation and productivity, rather than patient care, the priority; (4) focusing only on physical health issues in settings like intensive care units and emergency departments without addressing B/MH issues; (5) assigning residents disproportionally to intensive care unit and emergency department rotations without attention to B/MH in outpatient settings; (6) prioritizing block rotations rather than longitudinal experiences; and (7) eliminating or minimizing the importance of adolescent medicine and developmental/behavioral rotations, including allowing vacation during those rotations. Subsequent discussions and presentations were intended to prompt program leaders to develop and share ideas and strategies that would enhance training in B/MH. Dr Cori Green (Weill Cornell Medicine, New York, New York) described the results of the research she has undertaken to understand the current status of B/MH training in pediatric residency programs and demonstrated the importance of knowledgeable preceptors in influencing trainees' practices in caring for children with B/MH problems. A panel of training program leaders next described efforts in their programs to enhance B/MH training. Dr Lynn Garfunkel (University of Rochester, Rochester, New York) has demonstrated that integrating child psychology trainees and their faculty into a pediatric resident continuity clinic enhances preparation for collaboration with B/MH care providers. Dr Molly Broder (Albert Einstein College of Medicine, Bronx, New York) described her residents' experiences with colocated B/MH care providers in their continuity clinic and behavior clinic. Dr Keith Ponitz (Rainbow Babies and Children's Hospital, Cleveland, Ohio) outlined his program's B/MH curriculum, which includes didactic sessions, a mental health journal club, interdisciplinary lectures involving pediatric and child psychiatry trainees, inpatient and outpatient child psychiatry electives, and B/MH care providers embedded in resident continuity clinic. Dr Janet Serwint (Johns Hopkins School of Medicine, Baltimore, Maryland) described her program's required 2-week child psychiatry experience as well as on-site B/MH clinicians in the program's primary care clinic, which has resulted in demonstrated improvement in resident screening and identifying B/MH problems among their patients. Dr Lawrence Wissow (Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland) then described an evidence-based training program for enhancing core B/MH communication skills needed by pediatricians, highlighted the need for family engagement, and called for a clinical context that encourages incorporation of B/MH care on a sustained basis. Three pediatric subspecialists representing pediatric organizations were asked to suggest initiatives that they felt would be critical for making necessary programmatic changes. Dr John Duby (Association of Medical School Pediatric Department Chairs, Wright State University Boonshoft School of Medicine, Dayton, Ohio) recommended convincing institutional leaders to commit to a goal of improved training; raising awareness among medical students that B/MH is an important component of careers in pediatrics; and engaging subspecialists and fellowship program leaders. Dr Nathan Blum (Society for Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania) suggested that B/MH training should be built around basic principles of behavior change and patient engagement; evidence-based approaches to positive parenting should be an important part of training and approaches to assessment and management of common B/MH conditions should be consistent (including consistent use of terminology) across primary care, inpatient, and subspecialty rotations. Dr Laura Richardson (Society for Adolescent Health and Medicine, Seattle Children's, Seattle, Washington) recommended that pediatric trainees be taught skills in measurement and tracking of B/MH symptoms, including use of screening tools, with ongoing role in follow-up; learn appropriate roles, responsibilities, and boundaries of care among care providers, including indications for subspecialty care; and have opportunities for interdisciplinary learning. Participants had opportunities, during breakout sessions and panel discussions, to describe efforts in their programs that are intended to enhance B/MH care and to propose innovations for overcoming constraints through better use of currently available resources (including nonpediatrician faculty), adopting interprofessional training models, and taking advantage of curricula developed by the AAP and others. During breakouts and discussions, attendees endorsed the importance of improving the capacity of general and subspecialty pediatricians to deal effectively with B/MH problems and to coordinate care when referral is needed. There was general recognition, however, that achieving that goal will require leadership; engagement of nonpediatrician mental health clinicians (such as psychologists, social workers, advanced practice nurses) and parents as educators for pediatric trainees; development of pediatrician faculty expertise; restructuring of resident and fellow clinical experiences; and creation of effective tools for teaching and assessing resident activities described in B/MH EPA. Many attendees expressed doubts that needed resources and program reorganization, including changes that would allow time for trainees to engage in longitudinal care, would be possible in the absence of an explicit mandate for B/MH experiences and outcomes assessment. Steps they identified that could be undertaken by individual programs and by national leadership organizations, including the APPD, the ABP, the AAP, and others are included in Table IV.Table IVInitiatives to improve training in B/MHInitiatives that can be developed in individual programs•Identify a faculty champion to lead on making recommendations for curricular changes, make faculty aware of EPA #9, and suggest assessment approaches.•Conduct a survey of possible local resources, including pediatricians and nonpediatricians who could serve as teachers, and experiences in clinical settings that would enhance B/MH experiences.•Inform nonpediatricians (nurses, social workers, psychologists, psychiatrists, and parents) of outcome goals for pediatric trainees, empowering them as faculty and requesting that they provide assessments.•Engage adolescent medicine and developmental/behavioral pediatricians and specialists in neurodevelopmental disabilities in efforts to enhance B/MH training.•Identify pediatrician faculty who are interested in B/MH care and support their professional development as educators in this effort.•Develop opportunities in a variety of clinical settings for pediatric trainees to work alongside child psychology and child psychiatry trainees and to learn from their faculty experts.•Use ABP part 4 MOC requirements to encourage faculty participation in program projects.Initiatives that will require leadership from national organizations•Develop behavioral milestones to be assessed in the context of the activities described in EPA #9.•Create online curricular content for residency and fellowship programs.•Develop collaborative research programs to investigate and assess best practices in B/MH training and assessment of pediatricians.•Institute mentorship programs for faculty members in small programs.•Continue to advocate for reimbursement and systems of care that include B/MH care.•Offer professional education opportunities (eg, through PREP and part 2 MOC) in B/MH for practicing pediatricians.•Work with the Pediatric Review Committee and the ABP to develop requirements that emphasize the importance of trainee entrustment in B/MH care to improve B/MH training.MOC, Maintenance of Certification; PREP, Pediatrics Review and Education Program. Open table in a new tab MOC, Maintenance of Certification; PREP, Pediatrics Review and Education Program. There is evidence of significant unmet need for available and effective B/MH care for children and adolescents. The ABP, the AAP, and the American Academy of Child and Adolescent Psychiatry have called for pediatricians to develop competence to help meet that need, recognizing both the importance of general and subspecialty pediatricians as medical home providers and the shortage of behavioral/developmental pediatricians and child psychiatrists and psychologists.21American Academy of Pediatrics Task Force on Pediatric Education The future of pediatric education. American Academy of Pediatrics, Evanston (IL)1978Google Scholar, 22Leslie L. Rappo P. Abelson H. Jenkins R.R. Sewall S.R. Final report of the FOPE II pediatric generalists of the future workgroup.Pediatrics. 2000; 106: 1199-1223PubMed Google Scholar, 23American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health The new morbidity revisited: a renewed commitment to the psychosocial aspects of pediatric care.Pediatrics. 2001; 108: 1227-1230Crossref PubMed Scopus (111) Google Scholar, 24AACAP Committee on Collaboration with Medical ProfessionalsCall to action: collaborative care training.https://www.aacap.org/App_Themes/AACAP/docs/Collaborative%20care%20training%20call%20to%20action.docxDate accessed: May 18, 2018Google Scholar There is growing evidence that general pediatricians can develop the skills25McCaffrey E.S.N. Chang S. Farrelly G. Rahman A. Cawthorpe D. Mental health literacy in primary care: Canadian Research and Education for the Advancement of Child Health (CanREACH).Evid Based Med. 2017; 22: 123-131Crossref PubMed Scopus (17) Google Scholar, 26Wissow L.S. Gadomski A. Roter D. Larson S. Brown J. Zachary C. et al.Improving child and parent mental health in primary care: a cluster-randomized trial of communication skills training.Pediatrics. 2008; 121: 266-275Crossref PubMed Scopus (110) Google Scholar and the practice environment27Kaye D.L. Fornari V. Scharf M. Fremont W. Zuckerbot R. Foley C. et al.Description of a multi-university education and collaborative care child psychiatry access program: New York State's CAP PC.Gen Hosp Psychiatry. 2017; 48: 32-36Crossref PubMed Scopus (13) Google Scholar, 28Gadomski A.M. Wissow L.S. Palinkas L. Hoagwood K.E. Daly J.M. Kaye D.L. Encouraging and sustaining integration of child mental health into primary care: interviews with primary care providers participating in Project TEACH (CAPES and CAP PC) in NY.Gen Hosp Psychiatry. 2014; 36: 555-562Crossref PubMed Scopus (36) Google Scholar, 29Fallucco E.M. Seago R.D. Cuffe S.P. Kraemer D.F. Wysocki T. Primary care provider training in screening, assessment, and treatment of adolescent depression.Acad Pediatr. 2015; 15: 326-332Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 30Dayton L. Agosti J. Bernard-Pearl D. Earls M. Farinholt K. Groves B.M. et al.Integrating mental and physical health services using a socio-emotional trauma lens.Curr Probl Pediatr Adolesc Health Care. 2016; 46: 391-401Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar needed to achieve recommended competencies. Research has demonstrated that pediatric training programs, in general, have minimized the time and attention given to these important areas of care. As a consequence, by their own admission,12Horwitz S.M. Storfer-Isser A. Kerker B.D. Szilagyi M. Garner A. O'Connor K.G. et al.Barriers to the identification and management of psychosocial problems: changes from 2004 to 2013.Acad Pediatr. 2015; 15: 613-620Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar pediatrician competence in this area is limited. More than 90% of the training program leaders surveyed before this workshop agreed that general and subspecialty pediatricians should be competent to identify and comanage children with common B/MH problems, yet far fewer (40%-55%) had confidence in their trainees' ability to identify and manage the most common mental health diagnoses or skillfully address behavior problems. Initiatives proposed at this workshop, including developing the skills of pediatrician faculty and integration of mental health specialists within the entire pediatric residency and fellowship training environment, will be possible only through committed and coordinated work of pediatric educational and professional leadership to overcome the barriers identified by meeting attendees. There is an urgent and growing need for enhanced pediatric training to address B/MH needs of children and adolescents. The workshop described in this report brought together leaders of pediatric training programs from around the country to identify barriers and facilitators and to share strategies for improving pediatric B/MH training. The results of the preworkshop questionnaire and comments from workshop attendees, taken together, provide a needs assessment for organizations and leaders in pediatric education as they work together to identify mechanisms for improving the prevention, identification, management, and collaborative treatment of children, adolescents, young adults, and their families who are at stake as we seek to address the B/MH crisis in our country. Progress on this issue will require collaboration and commitment to changes that will challenge current training paradigms.