As I travel around the country, I have the opportunity to meet many pediatricians who share with me information about the focus of their practice. Many report seeing a swelling tide of children with developmental, behavioral and mental health problems. I use the swelling tide metaphor not just because of the numbers of patients, but also in the sense of feeling overwhelmed by a subject area for which there was inadequate preparation during residency. The American Academy of Pediatrics (AAP) has issued several reports drawing attention to this problem. Are the readers of this blog also seeing developmental, behavioral and mental health disorders as the major chronic disease in their primary care practices? (If that’s not what you are seeing, then please share what are the most prevalent problems in your practice.) Do you feel prepared to meet the needs of patients with these problems? All of this has got me thinking how ABP’s responsibilities apply if mental health is as important in primary care as my conversation partners have suggested. So let me offer a few opinions and pose some dilemmas.
- ABP will need to encourage training programs to enhance the preparation of the graduates in mental health. This involves dialogue and collaboration with training programs and the Accreditation Council for Graduate Medical Education, but also a declared intent by ABP to increase the emphasis on these topics in the initial certifying examination.
- Pediatricians must identify the child with mental health needs and then coordinate care with early intervention services, mental health professionals, schools, and various agencies. The complexity and variability of coordinating this type of care is reflected in the complexity of designing exam question scenarios that involve decision-making skills, judgment and complex analysis on this topic. For instance, one could imagine a question on the indications for referral of a child with anxiety or depression to a mental health specialist. This is a critical judgment call, where either under-referral or over-referral can harm the child. Yet the boundaries of what can be handled by a pediatrician vs. a mental/behavioral health specialist may vary depending on specialist availability, insurance plans, Medicaid waivers, school programs, etc.
- One thing the pediatrician can control is an accurate self-assessment of her or his knowledge base in the management of these disorders. ABP-approved MOC part 2 self-assessment activities and/or a part 4 quality improvement activities can help. View a list of these activities. The AAP also offers excellent educational and assessment tools on this topic.
- Mental health disorders are chronic diseases and as such should benefit from the patient-centered medical home model with extensive care coordination, involvement with the school, and practice quality improvement. How can ABP promote this model?
- The ABP and AAP are also actively engaged in an Institute of Medicine effort to address children’s mental health needs. If you have developed an innovative model of caring for these children, we would like to hear from you.
Since the days of typhoid fever, pediatricians have always stepped forward to answer urgent child health needs when no one else could or would. Today’s pediatricians carry forward that tradition in extending themselves to tackle the mental health crisis among the young. This is what I think. If you would like to let me know what you think, leave your comment below.