Preparing Pediatricians to Treat Behavioral and Mental Health

As behavioral and mental health problems become more prevalent among children and adolescents, pediatricians have an increasing responsibility to meet their needs, say the authors of “Preparing Future Pediatricians to Meet the Behavioral and Mental Health Needs of Children,” a special article in the December issue of Pediatrics.1

Dr. Julia McMillan“Behavioral and mental health concerns are the most common complaints raised by parents and patients during office visits,” says Dr. McMillan, MD, Professor Emerita of Pediatrics at Johns Hopkins School of Medicine. “Yet pediatricians themselves acknowledge that they have had limited training to address those problems.”

Dr. McMillan was one of the organizers of a two-day meeting in Washington, DC, sponsored by the ABP and the National Academies of Sciences, Engineering, and Medicine in April 2018. The 70 attendees included parents, young adult patients, pediatric trainees, leaders of pediatric training programs, and health care organizations.

“Attendees committed in writing to making a change within their department or organization to improve training,” Dr. McMillan and her co-authors wrote.

One year after the meeting, most programs reported progress toward their commitments. The article delves into the themes that arose from the meeting and case studies of new programs.

Dr. Marshall Land“The wide array of commitments coming out of this meeting was inspiring,” says Marshall Land Jr., MD, a general pediatrician in South Burlington, VT, and a co-author of the article. “They reflect the passion, dedication, and determination that training programs, national organizations, parents, patients, and trainees have to work collaboratively to help improve the behavioral and mental health care of children and adolescents.”

Here are just a few of the projects being pursued.

Michigan State University: MSU works to improve behavioral and mental health competencies along the continuum from medical students and residents to practicing physicians.

The pediatric residency program in Lansing has begun training residents in Mental Health First Aid (MHFA), a national program managed by the National Council for Behavioral Health. Residents were enthusiastic about the training and asked that it be added to the curriculum as mandatory training.

In Grand Rapids, the program optimized training in behavioral and mental health with a number of programs and initiatives. For example, they set up an immersive primary care rotation for interns in their first or second month that focuses on wellchild care and anticipatory guidance, using the Keystones of Development curriculum. They also developed a new senior rotation that combines developmental–behavioral pediatrics (DBP) and child psychiatry components. This rotation is in addition to the required DBP rotation and electives in DBP and child psychiatry.

To help practicing pediatricians, pediatrics trainees, and family medicine trainees in the Upper Peninsula of Michigan, MSU child psychiatrists provide virtual office hours for physicians based in Marquette.

“Our premise is that increasing the knowledge base, awareness, and skill set of pediatricians can lead to increased recognition and treatment of mental health conditions,” says Zakia Alavi, Assistant Professor of Pediatrics and Human Development at MSU’s College of Human Medicine. “We began providing virtual peer-to-peer consultation to physicians in November, and the response has been robust and highly encouraging.”

CAP fellow Dr. Rebecca Fein (left) discusses a case at Weill Cornell Medical College with pediatrics resident Dr. Eric Wilsterman.Weill Cornell Medical College: Weill Cornell teams have embedded psychologists both in ambulatory and inpatient settings. The new addition to the inpatient setting helps each team address issues such as anxiety and adjustment disorder in patients with chronic illness. Additionally, they have developed a buddy system that pairs a pilot group of pediatrics residents with child and adolescent psychiatry (CAP) fellows. Each CAP trainee is assigned to four or five pediatric trainees. Buddies are available to each other for informal consultations, handoffs for shared patients, shadowing experiences, and leading collaborative case conferences. Ten collaborative case conferences, facilitated by general pediatrics and CAP trainees, have been held or scheduled during the year.

Children’s Hospital of Colorado: The Children’s Hospital of Colorado teaches residents about common behavioral issues through a longitudinal thread over the three years of training. A formal curriculum on adolescent behavior and mental health issues is built into the adolescent rotation in the first year and in one of their inpatient rotations (primarily patients with eating disorders) during years one and three. Initial exposure to psychiatry intakes takes place in the DBP rotation in the first year of training. Mental health providers have been embedded into the clinics, giving residents frequent exposure through consultation on patients in their panels as well as dedicated time with the mental health providers during years one and two. Residents are exposed to behavioral and mental health screening tools in the clinics. This past summer, the pediatric residency program began an elective with the Child Psychiatry Department of a one- or two-week consolidation experience for all third-year residents.

The Colorado team also established a working group that comprises program directors, psychologists, faculty from the departments of Child Psychiatry and Adolescent Medicine, and a behavioral and developmental specialist. This group coordinates the many elements of behavioral and mental health training in the residency program.

1McMillan JA, Land M Jr, Tucker AE, Leslie LK. Preparing future pediatricians to meet the behavioral and mental health needs of children. Pediatrics. 2020;145(1):e20183796. doi: 10.1542/peds.2018-3796.

Bottom photo: CAP fellow Dr. Rebecca Fein (left) discusses a case at Weill Cornell Medical College with pediatrics resident Dr. Eric Wilsterman.