Association of Behavioral and Mental Health Professionals in Continuity Clinic with Resident-Reported Competence.

OBJECTIVE: To assess whether residents who trained with a colocated or integrated behavioral/mental health professional (B/MHP) reported greater competence in the assessment and management of behavioral/mental health (B/MH) conditions than those who trained without an onsite B/MHP. We hypothesized that having an onsite B/MHP would be associated with greater self-reported competence, especially if integrated into clinic. STUDY DESIGN: Cross-sectional survey of applicants for the initial American Board of Pediatrics (ABP) certifying examination. The independent variable was training in a continuity clinic with no onsite B/MHP, a colocated B/MHP, or an integrated B/MHP. Outcome variables were self-reported competence in 7 B/MH assessment skills and 9 treatment skills, summarized as 2 composite measures. Competence was rated on a 5-point scale; high competence was defined as mean scores ≥4. Logistic regression assessed relationships between independent and outcome variables adjusting for covariates including individual and residency program characteristics. RESULTS: Of 1503 eligible respondents, 645 (42.9%) reported no onsite B/MHP, 390 (26.0%) a colocated B/MHP, and 468 (31.1%) an integrated B/MHP. In multivariable models, respondents with a colocated B/MHP reported greater levels of B/MH assessment competence (aOR 1.40, 95% CI1.06-1.86) and treatment competence (aOR 1.45, 95% CI 1.03-2.05) compared with those with no B/MHP. Respondents with an integrated B/MHP similarly reported greater odds of assessment (aOR 1.33, 95%CI 1.02-1.74) and treatment competence (aOR 1.53, 95% CI 1.10-2.13) than the reference group. CONCLUSIONS: Although specific mechanisms were not tested, training with an onsite B/MHP within a continuity clinic may improve pediatric trainees' competence for addressing B/MH conditions.

Do Children with Special Health Care Needs with Anxiety have Unmet Health Care Needs? An Analysis of a National Survey.

OBJECTIVE: To describe differences in health care needs between Children with Special Health Care Needs (CSHCN) with and without anxiety and examine the association between anxiety and unmet health care needs. METHODS: We analyzed data from the 2009/2010 national survey of CSHCN. The independent variable was anxiety. The main outcomes were health care needs and unmet needs. Covariates included demographics, other co-morbid conditions, and the presence and quality of a medical home. We used bivariate analyses and multivariable logistic regression to assess the relationships among anxiety, covariates, and the outcomes. We stratified our analysis by age (6-11 years, 12-17 years). Propensity score matched paired analysis was used as a sensitivity analysis. RESULTS: Our final sample included 14,713 6-11 year-olds and 15,842 12-17-year-olds. Anxiety was present in 16% of 6-11 year-olds and 23% or 12-17 year-olds. In bivariate analyses, CSHCN with anxiety had increased health care needs and unmet needs, compared to CSHCN without anxiety. In multivariable analyses, only children 12-17 years old with anxiety had increased odds of having an unmet health care need compared to those children without anxiety (OR 1.44 [95% CI 1.17-1.78]). This was confirmed in the propensity score matching analysis (OR 1.12, [95% CI 1.02-1.22]). The specific unmet needs for older CSHCN with anxiety were mental health care (OR 1.54 [95% CI 1.09-2.17]) and well child checkups (OR 2.01 [95% CI 1.18-3.44]). CONCLUSION: Better integration of the care for mental and physical health is needed to ensure CSHCN with anxiety have all of their health care needs met.

Do Subspecialists Ask About and Refer Families with Psychosocial Concerns? A Comparison with General Pediatricians.

Objectives Calls for pediatricians to tend to children's psychosocial concerns have existed for decades because they are known to negatively impact child health. Children with chronic illnesses frequently have child- and family-level psychosocial concerns that complicate the care provided by their pediatric subspecialists. This study compares pediatricians who exclusively practice general pediatrics with subspecialists regarding their inquiring/screening and referring for psychosocial concerns. Physician and practice characteristics associated with these behaviors were examined. Methods We conducted a cross-sectional study using the 2013 American Academy of Pediatrics Periodic Survey of Fellows. Respondents included 304 pediatricians who exclusively practice general pediatrics and 147 subspecialists. The primary analysis compared the current practices of generalists vs. subspecialists with regard to inquiring/screening and referring children with 10 different psychosocial concerns. Covariates included socio-demographics, practice characteristics, and training experiences. Weighted univariate, bivariate and multivariable analyses were performed. Results Less than half of all pediatricians in the sample reported routinely inquiring/screening for most psychosocial concerns, and 2/3 of subspecialists failed to routinely inquire/screen for most of these conditions. Pediatricians who practice general pediatrics exclusively were more likely to inquire/screen (incident rate ratio (IRR) 1.41, p < .05) and refer (IRR 1.59, p < .001) for a greater number of psychosocial concerns than subspecialists, after adjusting for provider and practice characteristics. Having attended a child or adolescent mental health (MH) lecture/conference in the past 2 years was also related to inquiring/screening (IRR 1.24, p < .05). Conclusions Pediatricians infrequently inquire/screen and refer psychosocial concerns, with subspecialists addressing these concerns even less frequently.

The current and ideal state of mental health training: pediatric resident perspectives.

UNLABELLED: PHENOMENON: Mental health (MH) problems are prevalent in the pediatric population, and in a setting of limited resources, pediatricians need to provide MH care in the primary medical home yet are uncomfortable doing so citing a lack of training during residency as one barrier. APPROACH: The purpose of this study is to describe pediatric residents' experiences and perspectives on the current and ideal states of MH training and ideas for curriculum development to bridge this gap. A qualitative study using focus groups of pediatric residents from an urban academic medical center was performed. Audio recordings were transcribed and analyzed using a grounded theory approach. FINDINGS: Twenty-six residents participated in three focus groups, which is when thematic saturation was achieved. The team generated five major themes: capabilities, comfort, organizational capacity, coping, and education. Residents expressed uncertainty at every step of an MH visit. Internal barriers identified included low levels of comfort and negative emotional responses. External barriers included a lack of MH resources and mentorship in MH care, or an inadequate organizational capacity. These internal and external barriers resulted in a lack of perceived capability in handling MH issues. In response, residents reported inadequate coping strategies, such as ignoring MH concerns. To build knowledge and skills, residents prefer educational modalities including didactics, experiential learning through collaborations with MH specialists, and tools built into patient care flow. Insights: Pediatric residency programs need to evolve in order to improve resident training in MH care. The skills and knowledge requested by residents parallel the American Academy of Pediatrics statement on MH competencies. Models of collaborative care provide similar modalities of learning requested by residents. These national efforts have not been operationalized in training programs yet may be useful for curriculum development and dissemination to enhance trainees' MH knowledge and skills to provide optimal MH care for children.

Meaningful Work, Career Fit, and Professional Well-Being of Pediatric Academicians in the United States.

OBJECTIVE: Examine associations between time spent in academic activities perceived as meaningful and professional well-being among academic pediatrics faculty. METHODS: The sample comprised 248 full-time pediatric faculty (76% female, 81% white, non-Hispanic, 41% instructor or assistant professor) across the United States who completed an online survey in November 2019. Survey items included sociodemographic and professional characteristics, professional well-being measures (Stanford Professional Fulfillment Index; Maslach Burnout Inventory; Intention to Leave Academic Medicine), perceived meaningfulness of academic activities and assigned time to those activities. We defined global career fit as total percentage time assigned to professional activities considered meaningful by individuals, and activity-specific career fit as percentage time assigned to each meaningful professional activity. RESULTS: As global career fit scores increased, professional fulfillment increased (r = 0.45, P < .001), whereas burnout (r = -0.29, P < .001) and intention to leave (r = -0.22, P < .001) decreased. Regarding activity-specific career fit, for individuals who considered patient care meaningful, as assigned time to patient care increased, professional fulfillment decreased (r = -0.14, P = .048) and burnout (r = 0.16, P = .02) and intention to leave (r = 0.26, P < .001) increased. There was no significant correlation between assigned time for teaching, research, or advocacy and professional well-being. Faculty were less likely to intend to leave academic medicine as assigned time increased for administrative or leadership activities if considered meaningful (r = -0.24, P = .01). CONCLUSIONS: Time assigned to meaningful work activities may relate to professional well-being of academic pediatrics faculty. More time assigned to patient care, despite being meaningful, was associated with poor self-reported professional well-being. Effort allocation among diverse academic activities needs to be optimized to improve faculty well-being.

What Do Pediatric Subinterns Say About Their Learning and Assessment? A Qualitative Analysis of Individual Learning Plans.

OBJECTIVE: To perform a qualitative content analysis of learning and assessment strategies that pediatric subinterns describe in Individualized Learning Plans (ILPs) and to explore barriers and facilitators to their learning. METHODS: We analyzed ILPs from medical students enrolled in pediatric subinternships at 10 US medical schools that utilized a standardized curriculum and were recruited to reflect diversity in geographic location, funding, and enrollment. Students used an ILP to record 3 or more selected learning objectives, rationale for selection, and reflection on learning and assessment strategies. Investigators used the constant comparative method to perform a content analysis of the ILPs, grouping codes into themes, and verifying relationships between codes within themes. RESULTS: Two hundred and four ILPs that included student reflections on 850 learning objectives were analyzed. Content was analyzed in 5 categories: rationale for selecting objectives, learning strategies, assessment strategies, challenges to learning, and facilitators of learning. Students showed strong commitment to individualized, self-directed learning, developed a wide range of creative learning strategies, and relied heavily on self-reflection to assess their progress. The learning environment both helped and hindered students' ability to make and assess progress on their selected learning objectives. CONCLUSIONS: Through ILP-guided reflection and a formal curriculum, students can choose well-justified learning objectives and demonstrate resourcefulness and independence in developing self-directed learning and assessment strategies. The strategies that students identified in this study provide a menu of learning and assessment options for subinterns. Identified challenges and facilitators of learning provide guidance for educators who seek to enhance the clinical learning environment.

A National Survey of Pediatricians' Experiences and Practices With Suicide Prevention.

OBJECTIVE: Describe pediatricians' experiences, attitudes, and practices around suicide prevention within primary care, and examine associations between pediatricians' experiences and practices. METHODS: The nationally representative Periodic Survey of American Academy of Pediatrics members provided data on pediatricians' patient experience with suicide risk, perceived barriers to screening for suicidal ideation (SI), preparedness to counsel about suicide prevention, interest in learning more about suicide prevention strategies, and frequency of screening for and managing suicidal ideation. Multivariable analyses examined the effect of having a patient die by or attempt suicide on screening practices. RESULTS: A total of 41% responded to the survey with 377 respondents in the analytic sample. A total of 93% of pediatricians had a patient screen positive for SI and 81% had a patient attempt or die by suicide. A total of 61% always screened for SI and 63% reported using a standardized depression screening tool and 9% a suicide-specific tool. Respondents who had a patient attempt or die by suicide were more likely to screen for SI (OR, 2.05, 95% CI, 1.16-3.63) and use a standardized depression screening instrument (OR, 2.34, 95% CI, 1.29-4.24). Patient reluctance to discuss mental health was the most frequently cited barrier (51%) followed by lack of time (49%) and lack of treatment options (43%). Over 90% of respondents assessed for a plan and referred to mental health services when suicidal ideation was identified. CONCLUSION: Although pediatricians frequently see patients with suicide risk, 39% do not always screen for SI. Educational efforts are needed to improve pediatricians' assessment and management of suicide risk given new guidelines.

Association Between Educational Resources and Pediatric Fellows' Mental Health Attitudes and Self-Reported Competence.

BACKGROUND/OBJECTIVES: Children with chronic medical conditions (CCMC) have high rates of mental health (MH) conditions. This study examines associations between MH educational resources during fellowship and 3 dependent variables: fellows' interest, perceived responsibility, and self-reported competence in assessing MH concerns of CCMC. METHODS: Subspecialty fellows taking the American Board of Pediatrics in-training examinations in February 2020 were invited to participate in a survey inquiring about MH educational resources. Logistic regression examined associations between MH educational resources and the 3 dependent variables, adjusting for demographics and program-level characteristics. RESULTS: Of the 97.7% (4216) fellows who responded, 3870 were included in analyses. About 37.5% reported formal MH teaching sessions; 36.7% reported on-site MH professionals engaged in teaching; 41.6% reported co-assessing patients with MH specialists; and 28.3% reported performance evaluation of their MH skills. All 4 resources were significantly and positively associated with self-reported competence in adjusted analyses, with odds ratios (OR) ranging from 1.28 (95% confidence interval (95% CI): 1.03-1.58) for formal teaching sessions to 2.14 (95% CI: 1.73-2.65) for performance evaluation. Resources were positively associated with the dependent variables in a "dose-response" pattern. Respondents who reported having all 4 educational resources compared to zero resources had an OR of 2.20 (95% CI: 1.74-2.78) for high MH interest, 3.18 (95% CI: 2.45-4.12) for high perceived responsibility, and 4.38 (95% CI: 3.43-5.60) for high self-reported competence CONCLUSIONS: Access to mental health educational resources was associated with higher interest, perceived responsibility, and self-reported competence; investing in these resources may improve fellows' skills in addressing the emotional needs of CCMC.

Pediatric Mental Health Emergencies During 5 COVID-19 Waves in New York City.

OBJECTIVES: To describe the proportion of pediatric mental health emergency department (MH-ED) visits across 5 COVID-19 waves in New York City (NYC) and to examine the relationship between MH-ED visits, COVID-19 prevalence, and societal restrictions. METHODS: We conducted a time-series analysis of MH-ED visits among patients ages 5 to 17 years using the INSIGHT Clinical Research Network, a database from 5 medical centers in NYC from January 1, 2016, to June 12, 2022. We estimated seasonally adjusted changes in MH-ED visit rates during the COVID-19 pandemic, compared with predicted prepandemic levels, specific to each COVID-19 wave and stratified by mental health diagnoses and sociodemographic characteristics. We estimated associations between MH-ED visit rates, COVID-19 prevalence, and societal restrictions measured by the Stringency Index. RESULTS: Of 686 500 ED visits in the cohort, 27 168 (4.0%) were MH-ED visits. The proportion of MH-ED visits was higher during each COVID-19 wave compared with predicted prepandemic trends. Increased MH-ED visits were seen for eating disorders across all waves; anxiety disorders in all except wave 3; depressive disorders and suicidality/self-harm in wave 2; and substance use disorders in waves 2, 4, and 5. MH-ED visits were increased from expected among female, adolescent, Asian race, high Child Opportunity Index patients. There was no association between MH-ED visits and NYC COVID-19 prevalence or NY State Stringency Index. CONCLUSIONS: The proportion of pediatric MH-ED visits during the COVID-19 pandemic was higher during each wave compared with the predicted prepandemic period, with varied increases among diagnostic and sociodemographic subgroups. Enhanced pediatric mental health resources are essential to address these findings.

Where Do Future Pediatricians Learn Behavioral and Mental Health Skills?

OBJECTIVE: This national study identified the rotations in which pediatric residents received training in the assessment and treatment of behavioral/mental health (B/MH) problems, and examined associations between learning B/MH skills during multiple clinical rotations and resident-reported interest in B/MH issues. METHODS: Cross-sectional survey of applicants for the initial American Board of Pediatrics certifying exam (62.4% response rate; 1555 eligible respondents). Respondents reported their overall interest in B/MH issues, and specified where they had received training in 7 B.M. assessment skills and 8 treatment skills. Logistic regression models were estimated to identify associations between learning B/MH assessment and treatment skills in multiple clinical rotations and resident-reported B/MH interest, adjusting for respondent characteristics. RESULTS: Respondents reported continuity clinic as the predominant site of B/MH learning, followed by development-behavioral and adolescent rotations. Multisite learning varied across B/MH skills, ranging from 45.1 % (n = 678) for using rating scales to titrate medications to 82.1% (n = 1234) for eliciting parent concerns. 946 (63.2%) reported having overall interest in B/MH issues. Adjusting for respondent characteristics, learning the majority of B/MH skills in >1 rotation was associated with an increased odds of B/MH interest for both assessment and treatment domains (adjusted odds ratio [aOR] = 1.46, 95% confidence interval [CI] 1.16-1.83 for assessment skills and aOR = 1.36, 95% CI 1.09-1.69 for treatment skills). CONCLUSIONS: The majority of residents report learning B/MH skills in continuity clinic, with substantial variation in the proportion learning these skills in more than one rotation. Teaching B/MH skills during multiple clinical rotations may enhance resident interest in B/MH care delivery for children.

Competency of Future Pediatricians Caring for Children With Behavioral and Mental Health Problems.

BACKGROUND AND OBJECTIVES: There is an urgent need to prepare pediatricians to care for children with behavioral and mental health (B/MH) conditions. In this study, we evaluate the perceived competence of pediatric residents and recent graduates in the assessment and treatment of B/MH conditions, characterize variation in competence across residency programs, and identify program characteristics associated with high competence. METHODS: Cross-sectional survey of applicants for the initial certifying examination in pediatrics. Questions were focused on (1) who should be competent in B/MH skills, (2) institutional support around B/MH training, and (3) perceived competence in 7 B/MH assessment skills and 9 treatment skills. Competence was rated on a 5-point scale, and high levels of assessment and treatment competence were defined as scores of ≥4. Composite measures for B/MH assessment and treatment were calculated as mean scores for each domain. We examined variation in residents' self-reported competence across programs and used linear regression to identify factors associated with high levels of competence at the program level. RESULTS: Of applicants, 62.3% responded to the survey (n = 2086). Of these, 32.8% (n = 595) reported high competence in assessment skills and 18.9% (n = 337) in treatment skills. There were large variations in reported competence across programs. Respondents from smaller programs (<30 trainees) reported higher competence in assessment and treatment than those from large programs (P < .001). CONCLUSIONS: Current and recent pediatric trainees do not report high levels of perceived competence in the assessment and treatment of children with B/MH conditions. The substantial variation across programs indicates that the pediatric community should create standards for B/MH training.

Mental Health Competencies for Pediatric Practice.

Pediatricians have unique opportunities and an increasing sense of responsibility to promote healthy social-emotional development of children and to prevent and address their mental health and substance use conditions. In this report, the American Academy of Pediatrics updates its 2009 policy statement, which proposed competencies for providing mental health care to children in primary care settings and recommended steps toward achieving them. This 2019 policy statement affirms the 2009 statement and expands competencies in response to science and policy that have emerged since: the impact of adverse childhood experiences and social determinants on mental health, trauma-informed practice, and team-based care. Importantly, it also recognizes ways in which the competencies are pertinent to pediatric subspecialty practice. Proposed mental health competencies include foundational communication skills, capacity to incorporate mental health content and tools into health promotion and primary and secondary preventive care, skills in the psychosocial assessment and care of children with mental health conditions, knowledge and skills of evidence-based psychosocial therapy and psychopharmacologic therapy, skills to function as a team member and comanager with mental health specialists, and commitment to embrace mental health practice as integral to pediatric care. Achievement of these competencies will necessarily be incremental, requiring partnership with fellow advocates, system changes, new payment mechanisms, practice enhancements, and decision support for pediatricians in their expanded scope of practice.

Achieving the Pediatric Mental Health Competencies.

Mental health disorders affect 1 in 5 children; however, the majority of affected children do not receive appropriate services, leading to adverse adult outcomes. To meet the needs of children, pediatricians need to take on a larger role in addressing mental health problems. The accompanying policy statement, "Mental Health Competencies for Pediatric Practice," articulates mental health competencies pediatricians could achieve to improve the mental health care of children; yet, the majority of pediatricians do not feel prepared to do so. In this technical report, we summarize current initiatives and resources that exist for trainees and practicing pediatricians across the training continuum. We also identify gaps in mental health clinical experience and training and suggest areas in which education can be strengthened. With this report, we aim to stimulate efforts to address gaps by summarizing educational strategies that have been applied and could be applied to undergraduate medical education, residency and fellowship training, continuing medical education, maintenance of certification, and practice quality improvement activities to achieve the pediatric mental health competencies. In this report, we also articulate the research questions important to the future of pediatric mental health training and practice.

Advancing the Agenda in Pediatric Mental Health Education.

BACKGROUND AND OBJECTIVES: There is an urgent need to advance mental health (MH) education and/or training in pediatric residency programs, yet no consensus on how to achieve this. We created an operational framework from ideas provided by a diverse group of stakeholders on how to advance MH education. METHODS: Concept-mapping methodology was used, which involves brainstorming ideas by completing a focus prompt, sorting ideas into groups, and rating them for importance and feasibility. Multidimensional scaling and hierarchical cluster analysis grouped ideas into clusters. Average importance and feasibility were calculated for each statement and cluster and compared statistically in each cluster and between subgroups. RESULTS: Ninety-nine ideas were generated. Sorted ideas yielded a 7-cluster concept map: (1) modalities for MH training, (2) prioritization of MH, (3) systems-based practice, (4) self-awareness and/or relationship building, (5) training in clinical assessment of patients, (6) training in treatment, and (7) diagnosis-specific skills. Two hundred and sixteen participants rated ideas for importance and 209 for feasibility. Four clusters had a statistically significant difference between their importance and feasibility ratings (P < .001). Suburban and rural area respondents (versus urban) rated clusters higher in importance and feasibility (P < .004), trainees rated all clusters higher in feasibility than practicing clinicians, and MH professionals rated prioritization of MH higher in feasibility (3.42 vs 2.98; P < .001). CONCLUSIONS: This comprehensive set of ideas, especially those rated highly in both importance and feasibility, should inform curricular and policy initiatives. Differences between importance and feasibility may explain why there has been little progress in this field.

Preparedness of Pediatric Subspecialty Fellows to Address Emotional and Mental Health Needs Among Children With Chronic Medical Conditions.

This survey study investigates pediatric subspecialty fellows' attitudes about and perceived competence in addressing emotional and mental health needs of pediatric patients with chronic medical conditions.

Promoting Early Brain and Child Development: Perceived Barriers and the Utilization of Resources to Address Them.

OBJECTIVE: Efforts to promote early brain and child development (EBCD) include initiatives to support healthy parent-child relationships, tools to identify family social-emotional risk factors, and referrals to community programs to address family risk factors. We sought to examine if pediatricians perceive barriers to implementing these activities, and if they utilize resources to address those barriers. METHODS: Data were analyzed from 304 nontrainee pediatricians who practice general pediatrics and completed a 2013 American Academy of Pediatrics Periodic Survey. Sample weights were used to decrease nonresponse bias. Bivariate comparisons and multivariable regression analyses were conducted. RESULTS: At least half of the pediatricians agreed that barriers to promoting EBCD include: a lack of tools to promote healthy parent-child relationships, a lack of tools to assess the family environment for social-emotional risk factors, and a lack of local resources to address family risks. Endorsing a lack of tools to assess the family environment as a barrier was associated with using fewer screening tools and community resources. Endorsing a lack of local resources as a barrier was associated with using fewer community resources and fewer initiatives to promote parent-child relationships. Interest in pediatric mental health was associated with using more initiatives to promote healthy parent-child relationships, screening tools, and community resources. CONCLUSIONS: Although the majority of pediatricians perceive barriers to promoting EBCD, few are routinely using available resources to address these barriers. Addressing pediatricians' perceived barriers and encouraging interest in pediatric mental health may increase resource utilization and enhance efforts to promote EBCD.

Does Length of Developmental Behavioral Pediatrics Training Matter?

OBJECTIVE: Since 1997 pediatric residencies have been required to provide a 4-week block rotation in developmental and behavioral pediatrics (DBP), but it is not known whether this has altered the care and management of children by practicing pediatricians. The objective of this study was to compare the self-reported practice patterns of pediatricians who were trained with 4 or more weeks of DBP with the practice patterns of those who were trained for <4 weeks. METHODS: We used self-reported practices from the American Academy of Pediatrics Periodic Survey 85. Pediatricians were asked whether they never, sometimes, or usually inquired about and screened for, and whether they treated/managed/comanaged attention deficit hyperactivity disorder, depression, anxiety, behavior problems and learning problems. They were also asked about a series of barriers to care. Analyses were weighted to account for low response rates. RESULTS: Those with more DBP training were significantly more likely to treat/manage/co-manage depression, anxiety, behavior problems and learning problems, but were still doing so less than one third of the time. There were no differences in the care of patients with attention deficit hyperactivity disorder or in screening or inquiring about mental health conditions. Those with more training were more likely to perceive somewhat fewer barriers and to report more specific familiarity with some Diagnostic and Statistical Manual of Mental Disorders criteria and some treatment modalities. CONCLUSIONS: Longer length of training is associated with more treatment, but significant deficits in self-reported practice remain, leaving much room for additional improvement in the training of clinicians in DBP.