Adolescent Health Services: Missing Opportunities (2009)

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5 Preparing a Workforce to Meet the Health Needs of Adolescents Summary • The current professional adolescent health care workforce is multidisciplinary. • Existing adolescent health care training across disciplines fails to address many of the health needs of adolescents. • The licensing, certification, and accreditation of programs for health care providers in disciplines and specialties that may serve adolescents are minimal, inconsistent, and insufficient in their inclusion of adolescent health content and competencies. • Current adolescent health care training programs, including those that are high quality and interdisciplinary, are insufficient in num- ber to prepare postgraduate health care professionals for roles in the academic sector. • A few innovative discipline-specific and interdisciplinary ado- lescent health care training programs have been instrumental in defining curricular content, clinical practicums, and effective teaching modalities. A dolescents are best served by providers with an understanding of their key developmental features and health issues. In short, skills matter. Therefore, critical to improving the health of adolescents in the United States is having a workforce prepared to address the com- 240 

PREPARING A WORKFORCE TO MEET THE HEALTH NEEDS 241 plex needs of this age group. As Henry Kempe stated at the 1976 opening meeting of the Task Force on Pediatric Education, “All who care about children must care deeply about the education of those who provide their health services” (Cohen, 1984, p. 791). Education of the workforce is es- sential to the provision of health services for adolescents that are accessible, acceptable, appropriate, effective, and equitable in accordance with the framework set forth in Chapter 3. This chapter focuses on the contextual characteristic of provider skills and examines issues related to the adoles- cent health workforce. At all levels of professional education, providers in all disciplines serv- ing adolescents need to be equipped to work effectively with this age group. They must be attuned to the nature of adolescents’ health problems, as well as have in their clinical repertoire a range of effective strategies for risk assessment, disease prevention, care coordination, treatment, and health promotion. Current evidence, some of which is presented in this chapter, suggests this is currently not the case—that is, the skills of many provid- ers working with adolescents are inadequate. Whether providers report on their own perceptions of their competencies or adolescents describe the health services they have received, data reveal significant gaps in achieving the goal of a well-equipped workforce ready to meet the health needs of adolescents. In other words, too few health care providers in practice feel prepared to work with adolescents, even with regard to some of the most common health problems in this population, and the quality of services be- ing provided has suffered as a result. Given the adolescent health issues and health service needs presented in Chapters 2, 3, and 4, an important goal for the training of health care providers is for all those who will offer health services for adolescents in their practices to enter the workforce equipped to work effectively with this age group. This chapter begins by reviewing the composition of the current work- force providing adolescent health care services. It then examines gaps in the training of these providers and means that can be used to ensure their competence. The discussion turns next to some current models for training that show promise for imparting the knowledge and skills that need to be mastered by those who work with adolescents. Beyond basic-level training (i.e., educational programs for entry into a profession), specialists, educa- tors, and scholars require advanced-level training that will prepare them to teach others entering the workforce and equip them to conduct research that will expand the evidence base supporting adolescent health care prac- tice. The discussion therefore includes strategies for ensuring the training of adequate numbers of advanced-level adolescent specialists, educators, and scholars. The chapter then reviews challenges to training an adequate adolescent health care workforce. It should be noted that this chapter was not intended as a comprehensive review of education, training, and certi- 

242 ADOLESCENT HEALTH SERVICES fication in the adolescent life stage for all health professionals (or the lack there of); rather, the focus is on the most important gaps and challenges in the preparation of the adolescent health workforce and current models that show promise in ensuring competency for these providers. Advancing the competency and size of the adolescent health care work- force involves two critical questions. First, how can all levels of training in adolescent health—and in all pertinent disciplines—be of high quality? Second, what means can be used to expand the number of adolescent health specialists, educators, and scholars with the advanced teaching, leadership, and research skills necessary to work effectively in the salient educational and research settings? COMPOSITION OF THE CURRENT WORKFORCE PROVIDING ADOLESCENT HEALTH SERVICES The uniqueness of adolescent health problems—their social and be- havioral origins, their developmental nature, and the multisystem needs involved—demands a multidisciplinary workforce. As articulated at the 1986 Health Futures of Youth conference, which created a 10-year agenda for protecting and promoting the health of adolescents, no one discipline has garnered the requisite knowledge and skills to address the complex health problems of this population (Blum and Smith, 1988). The array of health and social service providers that may be called upon to work with adolescents extends beyond dentists, physicians, nurses, nutritionists, psy- chologists, physician assistants, and social workers. Likewise, the requisite expertise and specialization reach well beyond pediatrics, family medicine, or other foci. Given the contexts in which adolescents live and the social nature of their health problems, the roles of those who work in juvenile jus- tice, school health, mental health, reproductive health, substance use, and primary and secondary educational systems should be considered (Blum and Smith, 1988). Adolescents also seek out other specialists in the health care delivery system, such as dermatologists, chiropractors, and practitio- ners of alternative therapy. Moreover, the social nature of adolescent issues that are often embedded in multiple systems (family, school, community) means that public health interventions and case management (i.e., work- ing within and across systems) play a key role in promoting the health of adolescents. Box 5-1 provides a comprehensive listing of the many types of providers considered part of the adolescent health care workforce. It is essential to recognize that the diversity of the adolescent health care workforce extends beyond discipline or specialty. Cultural, racial, ethnic, socioeconomic, and geographic diversity are important as well, particularly with respect to reducing the disparities evident in a variety of health indica- 

PREPARING A WORKFORCE TO MEET THE HEALTH NEEDS 243 BOX 5-1 Providers Involved in Health Care for Adolescents Professional and Related Occupations • Chiropractors • Clinical laboratory technologists and technicians • Counselors • Dental hygienists • Dentists • Diagnostic-related technologists and technicians • Dieticians and nutritionists • Emergency medical technicians and paramedics • Health educators • Licensed practical and vocational nurses • Medical records and health information technicians • Optometrists • Pharmacists • Physician assistants • Physicians and surgeons • Podiatrists • Psychologists • Registered nurses • Social and human service assistants • Social workers • Speech–language pathologists • Support technicians for health diagnosing and treating practitioners • Therapists Service Occupations • Dental assistants • Home health aides • Medical assistants • Nursing aides, orderlies, and attendants • Personal and home care aides • Occupational therapists, assistants, and aides • Physical therapists, assistants, and aides • Receptionists and information clerks SOURCE: Bureau of Labor Statistics and U.S. Department of Labor (2007). tors (e.g., rates of pregnancy, suicide, homicide, and substance use) among various subpopulations of adolescents, as described in Chapter 2. Each discipline has differing pathways and levels at which basic edu- cation, specialization, and continuing education may and can occur. A half-century ago, pediatric medicine set the pace for creating a focus in the 

244 ADOLESCENT HEALTH SERVICES field of adolescent health. Considered the father of adolescent medicine, J. Roswell Gallagher first articulated the need for adolescent medicine as a subspecialty in pediatrics (Emans et al., 1998; Gallagher, 1957). Two decades later, in 1978, a taskforce of the American Academy of Pediatrics recommended that pediatric training in medicine take full responsibility for improving adolescent health services, stating, “The health needs of adolescents are being inadequately met” (Task Force on Pediatric Educa- tion, 1978, p. ix). Since then, the inadequacy of professional education in adolescent health has been the subject of increased attention among a number of other disciplines interacting with or specializing in health ser- vices for adolescents (Blum and Smith, 1988; Farrow and Saewyc, 2002). Critical questions have been raised regarding the adequacy of existing training programs, the articulation and inclusion of core competencies in adolescent health, and appropriate levels of expectations and requirements set by regulatory bodies (for licensure, certification, accreditation, and maintenance of licensure or certification) to ensure the adequacy of training at the individual and institutional levels (Blum and Smith, 1988). This increased attention to adolescent health needs has prompted some positive developments. For example, the American Academy of Pediatric Dentistry first responded in 1986 by adopting adolescent-specific guide- lines (American Academy of Pediatric Dentistry, 2005). With the stimula- tion of federal support through the Partnership in Program Planning for Adolescent Health (PIPPAH), these guidelines were expanded in 2005 to include consideration of youth development, psychosocial concerns, eating disorders, and the transition to adult health services. Nonetheless, dentistry, like other disciplines outside of medicine, has yet to establish a substantive focus on workforce training that meets the specific needs of adolescents. PIPPAH goals such as promoting awareness about adolescent oral health within dentistry and integrating oral health with other professions’ care for adolescents require adequate training of new oral health professionals. Yet there are currently no accreditation standards, nationally recognized curricula, faculty development guides, targeted web resources, texts, or other supporting materials for the training of general or pediatric dentists specifically in the care of this age group. To meet the national need for providers equipped to work with adoles- cents, many more such providers will need to enter the workforce over the next decade. For example, considering just pediatricians who are certified in adolescent medicine, there is on average a ratio of 1 adolescent medicine  Partnershipin Program Planning for Adolescent Health: https://grants.hrsa.gov/web External/FundingOppDetails.asp?FundingCycleId=FC9AE007-1379-438E-8C70-2C29 C340CE3A&ViewMode=EU&GoBack=&PrintMode=&OnlineAvailabilityFlag=&page Number=&version=&NC=&Popup. 

PREPARING A WORKFORCE TO MEET THE HEALTH NEEDS 245 physician to 105,000 adolescents in the United States. Seven states presently have no certified adolescent medicine specialists available. The current ratio is in dramatic contrast to the American Academy of Pediatrics’ recommen- dation that 1 adolescent medicine specialist have the capacity to care for about 6,000 adolescents. Beyond the field of medicine (i.e., pediatrics, in- ternal medicine, and family medicine), it is impossible to determine the size of today’s workforce that specializes in adolescent health because no other discipline offers subspecialty board certification with this specific focus. As noted above, ensuring a competent workforce for adolescent health care requires multiple levels of expertise, from generalist to educator/ scholar. Translated into educational nomenclature, training in adolescent health may be acquired in basic or entry-level professional programs (e.g., M.D. program for physicians, A.D. or B.S.N. for nurses, D.D.S. or D.M.D. for dentists), in graduate school (e.g., master’s, practice doctorate, D.Sc., or Ph.D. programs), or in postgraduate programs. Moreover, skills need to be maintained for the duration of professional practice through in-service programs, certification courses, and continuing education offerings. Using medicine as an example, a recent Institute of Medicine (IOM) report (2007), Physicians for Public Health Careers, addresses the training of physicians in that field. The report proposes three levels of providers, based on the breadth and depth of practice with certain population groups, the complexity of health issues being addressed, and the nature of the roles of the provider (e.g., primary care provider versus adolescent health educa- tor). Building on this work of the IOM and that of Denninghoff and col- leagues (2002), the committee identified three levels of providers necessary to ensure a qualified adolescent health care workforce: • Generalists—professionals who serve populations that include ado- lescents and provide health care services for adolescents full- or part-time, even though they are not defined as adolescent health care providers or specialists (e.g., pediatric or family physicians; nurse practitioners; physician assistants; women’s health care pro- viders, such as gynecologists and midwives; general and pediatric dentists; psychologists; dieticians; and social workers). • Specialists—professionals specializing in health services for adoles- cents, whether they do so for their entire career or as a change in specialty/focus at some point (e.g., adolescent or sports medicine specialists, adolescent nursing specialists, child and adolescent psy- chologists and psychiatrists, orthodontists, youth workers, school nurses). Primary care providers may provide services to adolescents in the capacity of either a generalist or a specialist, as defined above. • Educator and/or scholar—professionals with recognized expertise 

246 ADOLESCENT HEALTH SERVICES in adolescent health care who contribute to educating/training the future workforce of providers of such care and to the research/ science of adolescent health services (e.g., academic faculty). Finding: The current professional adolescent health care workforce is multidisciplinary. GAPS IN THE TRAINING OF PROVIDERS The prevailing notion among both health care providers and consumers is that all practitioners who work with adolescents have had the training to do so. Evidence strongly suggests that this is not the case. It has become increasingly clear that meeting this expectation is challenged by the com- plexities of adolescents’ health needs and the U.S. health care system that delivers services to meet those needs, along with the struggles of educational programs in producing competent professionals with the required knowl- edge and skills. Identifying the gaps between providers’ knowledge and skills and adolescents’ health needs and standards for health care services that can meet those needs is essential if corrective action is to be taken. Two sources of evidence point to the limitations and inadequacies of current training in adolescent health care: (1) surveys of health care provid- ers’ self-perceived competencies, and (2) evaluations of services provided, using, for example, chart reviews or patient reports. Self-Perceived Inadequacies in Training Health care providers’ self-assessments of their competencies offer evi- dence of the limitations and inadequacies of their current training. Multiple disciplines have conducted surveys of graduates and professionals practic- ing in the field of adolescent health to determine their self-perceived com- petencies in meeting the physical, mental, and social health service needs of adolescents. Some of these surveys have been specific to certain disciplines, such as medicine (Biro et al., 1993; Blum, 1987; Cull et al., 2003; Emans et al., 1998; Klitsner et al., 1992; Korczak, MacArthur, and Katzman, 2006; Krol, 2004), nursing (Bearinger et al., 1992; Nerdahl et al., 1999; Saewyc et al., 2006), and nutrition (Hughes, 2003; Story et al., 2000). Others have examined competencies across multiple disciplines (Blum and Smith, 1988; Hellerstedt et al., 2000; Story et al., 2002). Some have encompassed child specialists, including pediatricians. On the other hand, some disciplines have yet to assess student and trainee preparation or self-perceived compe- tencies specifically in adolescent care. For example, the American Dental Education Association’s annual survey of graduating students queries senior students on their self-perceived preparation regarding 25 domains of prac- 

PREPARING A WORKFORCE TO MEET THE HEALTH NEEDS 247 tice, but does not distinguish adolescents from children. Nonetheless, the responses to this survey give some sense of how graduates perceive their competency in meeting the needs of adolescents: each year approximately 10 percent of respondents report that they are less than prepared in the field of pediatric dentistry (which includes routine care of adolescents), and slightly more than half report that they are unprepared to deliver orthodon- tic services (which are provided most frequently to adolescents) (Chmar et al., 2007; Weaver, Haden, and Valachovic, 2002a,b, 2004; Weaver et al., 2005). There is a similar lack of information on how other child specialists (e.g., child psychologists and psychiatrists) perceive their competency with particular respect to adolescent health needs. Further detailed investigation into the adequacy of the training of child specialists in relation to adolescent health is needed. Generally, surveys aimed at determining self-perceived competencies in adolescent health solicit self-reports from respondents drawn from the rosters of professional organizations whose members are likely to have had adolescents in their practice populations (e.g., the American Academy of Pediatrics, National Association of Pediatric Nurse Practitioners, American Dietetic Association, American School Health Association). Respondents to these surveys typically are asked to identify their self-perceived levels of competency in dealing with a host of common adolescent health problems. In addition, they are often asked about the frequency with which they observe these problems in their practice, as well as their interest in further education in the area. Although the topics or health issues included in these self-report sur- veys vary somewhat by discipline, common themes emerge. Frequently self- assessed areas of inadequacy include oral health (Krol, 2004), sexual and reproductive health (Hellerstedt et al., 2000; Klitsner et al., 1992), eating and weight problems, psychological problems, substance use (Klitsner et al., 1992; Story et al., 2000, 2002), sports medicine, violence, and psycho- logical assessment (Emans et al., 1998). To take one disciplinary example (Saewyc et al., 2006), more than 25 percent of 520 nurses who reported working with adolescents identified low levels of knowledge/skills in 14 of 28 common health issues among adolescents, including depression, eating disorders, and violence; more than half reported low levels of knowledge of issues affecting more vulnerable populations—those who are in the foster care system, homeless, or gang-affiliated. Nurses’ self-perceived competence in working with lesbian, gay, bisexual, and transgender (LGBT) adoles-   The group referred to as “lesbian, gay, bisexual, and transgender” sometimes also encom- passes the term “questioning” and is commonly referred to by the acronym LGBT (or GLBT) or LGBTQ (or GLBTQ). For the purposes of this report, the identifier “lesbian, gay, bisexual, and transgender” or LGBT is used. 

248 ADOLESCENT HEALTH SERVICES cents had not improved over a decade (Bearinger et al., 1992), and comfort in counseling about pregnancy options had declined. Evaluation of Services Provided The development of standards or guidelines for the delivery of adoles- cent health services makes it possible both to assess the gaps between what is expected and what is observed in the provision of such services and to take appropriate corrective action (typically through training). Several stan- dards or guidelines for the delivery of child and adolescent health services are available to practitioners. Examples include Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents (Green, 1994), produced by the Maternal and Child Health Bureau within the Health Resources and Services Administration, Department of Health and Human Services (DHHS); the American Academy of Pediatrics’ Health Supervision Guidelines (Stein, 1997); The Clinician’s Handbook of Preventive Services (U.S. Department of Health and Human Services, 1994); the Guide to Clinical Preventive Services, developed by the U.S. Preventive Services Task Force (1996); the Clinical Guideline on Adolescent Oral Health Care of the American Academy of Pediatric Dentistry (2005); and the American Medical Association’s Guidelines for Adolescent Preventive Services (GAPS) (Elster and Kuznets, 1994). Since the mid-1990s, a number of studies have examined the extent to which such standards and guidelines for adolescent health care have been adopted and put into routine use. The most widely evaluated have been GAPS, whose implementation has been assessed in managed care and other group practice arrangements, as well individual private practices. On the basis of physician self-report surveys, Ozer and colleagues (1998) concluded that managed care settings were more conducive than other prac- tice arrangements to systematic and widespread implementation of GAPS, although routine incorporation of the guidelines still fell below expected thresholds even in those settings. Klein and colleagues (2001) assessed the implementation of GAPS in community and migrant health centers, using practitioner and adolescent reports as well as chart reviews. They found that system-level policies were instrumental in the adoption of practice standards for adolescent health services, facilitated by provider training, resource materials, and administrative reinforcement. Despite these success- ful mechanisms, however, provision of preventive services to adolescents still fell short of the guidelines, particularly in psychosocial and behavioral areas. Using chart reviews to assess providers’ adherence to the GAPS rec- ommendations for comprehensive psychosocial assessment of adolescents, Blum and colleagues (1996) derived similar findings. Providers with high levels of experience in adolescent health who were working in adolescent- 

PREPARING A WORKFORCE TO MEET THE HEALTH NEEDS 249 focused community clinics incorporated the greatest number of prescribed screening questions into their protocols. Adherence to the recommended guidelines for preventive services corresponded to the extent of training in adolescent health (e.g., through fellowship programs). In contrast, those in private practice who served clients of all ages (who were also less likely to have received specialized adolescent health training) were the least likely to use the GAPS protocols, particularly in addressing adolescents’ psycho- social health issues and concerns. Finding: Existing adolescent health care training across disciplines fails to address many of the health needs of adolescents. MEANS OF ENSURING THE COMPETENCE OF THE WORKFORCE Multiple sources of evidence pointing to deficits in knowledge and skills among the workforce serving adolescents raise the question of what com- petencies are necessary to provide quality health services for adolescents, and of these, which are common across disciplines and unique to particular disciplines. In 2004, Hoge and colleagues published a summary of stake- holder consensus on recommended best practices for improving workforce education, in this case specific to behavioral rather than adolescent health. The first of 16 recommendations posits that “education and training is competency-based” (Hoge et al., 2004, p. 94). Essential knowledge and skills in adolescent health are key to devel- oping providers’ abilities to deliver quality health care services to this age group. Practitioners are expected to synthesize developmental theories and interdisciplinary knowledge about adolescent health with discipline-spe- cific research and wisdom regarding practice in the delivery of health care services. Moreover, the breadth of biopsychosocial knowledge required to provide effective care for adolescents continues to expand at a rapid pace. Beyond knowledge and skills for direct service delivery, each provider needs to acquire skills for collaboration with an interdisciplinary team that typically functions within a complex, multifaceted health care delivery system. Requisite knowledge and skills, or competencies, serve as guideposts for designing and ensuring adequate training and continual education for all health professionals. In the context of the present discussion, compe- tencies are tangible criteria that have four primary purposes: (1) defining scope of practice, (2) providing guidance for curricular development and evaluation of learner outcomes, (3) establishing standards by which an individual’s acquisition of knowledge and skills can be assessed (e.g., for purposes of licensure or credentialing) and the quality of an educational institution can be measured (for purposes of accreditation) (Astroth, Garza, 

250 ADOLESCENT HEALTH SERVICES and Taylor, 2004), and (4) serving as a standard against which the quality of clinical services can be compared (i.e., whether the services provided reflect specific competencies of the provider) (Blum et al., 1996). Some of the literature on competencies (particularly in the areas of youth develop- ment, behavioral health, and child/adolescent psychiatry) examines the usefulness of and need for competencies in defining scope of practice and guiding the entry-level training required for employment or certification in certain disciplines and specialties. Competencies are typically categorized into broad areas or domains considered fundamentally necessary for providers who, in the present con- text, deliver care to adolescents. Within each competency domain, expecta- tions for knowledge and skill acquisition differ according to the discipline and level of the professional (i.e., generalist, specialist, educator/scholar). In terms of curricular development, the teaching of competencies can be ordered such that each level builds on the knowledge and skills learned previously. The continual assessment of competencies acquired can serve as a measure of learning and readiness for practice. Many competencies in adolescent health cut across all or most dis- ciplines, whereas others vary in accordance with a specific disciplinary perspective or scope of practice, being tailored to certain roles or types of providers (Astroth, Garza, and Taylor, 2004; Beresin and Mellman, 2002; Denninghoff et al., 2002; Hoge, Huey, and O’Connell, 2004; Hoge et al., 2002; Shelton, 2003). At the 1986 Health Future of Youth conference, the Study Group Report on Training of Health Professions in Adolescent Health Care defined five broad components of entry-level training consid- ered to be “baseline knowledge, skills and attitudes necessary for all who work with youth” (Blum and Smith, 1988, p. 46S): (1) growth and develop- ment, (2) psychological and physical morbidities, (3) communications and problem solving, (4) community services, and (5) attitudes. While each of these components might be applicable across the life span, the study group described special concerns for each within the context of adolescents and their environments. Training at the specialist level prepares professionals for leadership roles, particularly in education and clinical services focused primarily on adolescents. Specialist training builds on the core knowledge and skills defined for entry-level professionals. The Health Future study group’s re- port briefly outlined priorities for specialist training, but only for five dis- ciplines: medicine, nursing, nutrition, psychology, and social work (Blum and Smith, 1988). Since the publication of that report, only one discipline/ specialty—pediatrics—has identified elements of curriculum required for board certification in an adolescent medicine subspecialty. Some disciplines have worked toward specific standards for practice. For example, standards 

PREPARING A WORKFORCE TO MEET THE HEALTH NEEDS 251 for pediatric nursing are currently being developed jointly by the Society for Pediatric Nursing and the National Association of Pediatric Nurse Practi- tioners (personal communication with the American Academy of Nursing’s Expert Panel for Child, Adolescent, and Family Nursing, November 10, 2007). Overall, however, there continues to be a lack of clarity and con- sistency regarding the requisite knowledge and skills that make up compe- tencies in adolescent health within each discipline and at various provider levels (generalist, specialist, and educator/scholar). Areas or domains of competency common across disciplines reflect the behavioral and contextual characteristics presented in Chapter 1 and discussed throughout this report. For example, health and health behavior need to be understood within pertinent social contexts (context matters); segments of the adolescent population have unique health needs (need matters); and adolescence is characterized by significant and dramatic de- velopmental changes (development matters). Other domains of competency applicable to all disciplines relate more to the delivery of services, paral- leling the underlying assumptions that families are partners in adolescents’ health and their use of health services (family matters); that achieving optimal health for adolescents requires public health interventions involv- ing integration and coordination of individual- and population-focused services (community matters); and that the availability, nature, and content of health services for adolescents are profoundly affected by financing sys- tems and related policies (money matters, and policy matters). With respect to financing, currently only one federal agency in the United States—the Maternal and Child Health Bureau within DHHS—offers training grants focused solely on adolescent health. Annually, it commits $2.64 million to the support of seven interdisciplinary Leadership Education in Adolescent Health (LEAH) programs housed in seven universities nationwide (de- scribed below). Given that there are almost 42 million adolescents aged 10–19 in the United States (U.S. Census Bureau, 2006), this means that each year the federal government invests approximately 6 cents per adolescent in training specialists and educators/scholars in the skills required to teach tomorrow’s adolescent health care providers. In summary, the extant literature, though quite limited, describes do- mains of competency that vary by discipline. Some competencies relate specifically to the health and service needs of adolescents, while others focus more on the delivery of services within interdisciplinary health care settings and on larger contextual issues. Greater consistency is needed in the delineation of domains of competency, and greater clarity is needed regarding required competencies at the various levels of training. Meeting these needs is the next step in ensuring an adequate workforce trained to meet the health needs of adolescents. 

252 ADOLESCENT HEALTH SERVICES Finding: The licensing, certification, and accreditation of programs for health care providers in disciplines and specialties that may serve adolescents are minimal, inconsistent, and insufficient in their inclusion of adolescent health content and competencies. CURRENT MODELS FOR TRAINING SPECIALISTS AND EDUCATORS/SCHOLARS Nearly three decades ago, leaders in the field of adolescent health, us- ing a variety of models and strategies, began making concerted efforts to expand and improve professional training for those who might eventually work with adolescents. Models for such training, as well as curricular em- phases and teaching modalities, vary according to the range of competen- cies delineated above. Beyond the competencies that need to be taught in basic educational programs for all those entering a health profession (e.g., B.S.N. for nursing, M.P.A. and M.D. for medicine, D.D.S. and D.M.D. for dentistry, Ph.D. for psychology), models for adolescent health train- ing range from formal 1- to 5-year advanced degree programs (e.g., M.S., M.A., M.S.W., Ph.D.) to postgraduate subspecialty fellowship programs. Additionally, once these competencies have been incorporated into the core requirements in basic and specialty programs, they must continue to be assessed in an ongoing, reinforcing manner through recertification or maintenance-of-certification programs. Models for Formal Training Programs Interdisciplinary Adolescent Health Programs In 1977 the Maternal and Child Health Bureau began funding the inter- disciplinary LEAH programs with the specific goal of preparing leaders in the field of adolescent health. The intent was to create a cadre of adolescent health specialists and educators/scholars who in turn would advance clini- cal practice, research, and the training of an expanded workforce by assum- ing leadership roles in the academic and public health sectors. The seven programs funded initially were required to include five disciplines in their leadership training: medicine, nursing, nutrition, psychology, and social work. Typically, only one new fellow in each discipline matriculates in each of 5 years in each of the seven programs. Of the major health disciplines discussed throughout this report, only dentistry is excluded from the pro- grams. The intensity and duration of training within each program vary by discipline, ranging from several months to 3 years (required for a pediatric subspecialty in adolescent medicine). Fellows are expected to advance their 

PREPARING A WORKFORCE TO MEET THE HEALTH NEEDS 253 knowledge and skills in clinical care of adolescents while developing their research and teaching capacity for work in the field of adolescent health. Since the mid-1970s, the LEAH programs have competed every 5 years for new awards that support faculty and fellows across the five disciplines. Today support continues for training in the five disciplines in each of the seven funded programs. The funding level for each program has re- mained almost stationary over the 30-year period, with an annual total of $2,640,000 being dedicated to support for the seven programs. As noted above, the LEAH programs are the only educational programs supported by federal funds specifically targeting adolescent health. In addi- tion, a few other interdisciplinary training programs for various specialties and educator/scholar levels focused on adolescent health are supported by federal funds, although these funds do not target adolescent health train- ing. For example, the Centers for Disease Control and Prevention (CDC) currently supports Prevention Research Centers (PRCs) housed in schools of medicine and public health nationwide. However, only 6 of the 33 cur- rently funded PRCs emphasize adolescent-related issues in their research and training; only one to two research fellows are in training in each of these 6 programs. Moreover, PRC training is not clinically focused. Likewise, 3 years ago CDC launched an initiative focused on health protection research. Although the request for proposals for this CDC ini- tiative did not target adolescent health, one of the three funded programs (at the University of Minnesota School of Nursing) has this emphasis. Cur- rently, 18 pre- and postdoctoral trainees in medicine, nursing, nutrition, and psychology receive support from this CDC-funded program. Discipline-Specific Programs and Certification for Specialists and Educators/Scholars Single-discipline training programs far outnumber interdisciplinary pro- grams in adolescent health. Adolescent medicine is not a primary discipline like, for example, pediatrics; therefore, options include adolescent medicine subspecialties in pediatric, family, and internal medicine, as well as master’s and clinical and research doctorates focused on adolescent health in the areas of nutrition, nursing, psychology, public health, and social work, to name but a few. Unquestionably, medicine has led the other disciplines in defining training requirements and establishing a certification process for adolescent health care. Postresidency fellowship programs for those subspecializing in adolescent medicine  Training programs in adolescent medicine for physicians were established in the 1960s. These programs require training in comprehensive 

254 ADOLESCENT HEALTH SERVICES inpatient and outpatient services while also encompassing psychosocial competencies. Postgraduate fellowship training in adolescent medicine follows com- pletion of an accredited residency in pediatrics, internal medicine, or family medicine. The required length of the training varies by specialty: 2 years for internal and family medicine and 3 years for pediatrics. After completion of an accredited fellowship program, a board certification exam must be taken and passed. In addition, the American Board of Pediatrics requires all subspecialty candidates to show evidence of scholarly achievement. The first certification exam in adolescent medicine in pediatrics was administered in 1994, and yielded 209 board-certified pediatricians with a subspecialty in adolescent medicine; today more than 500 pediatricians have been certi- fied in this subspecialty (Althouse and Stockman, 2007). According to the American Board of Medical Specialties, 170 certificates in adolescent medi- cine were issued from 1996 to 2006 in internal medicine (39) and family medicine (131) (American Board of Medical Specialties, 2007). Together, then, approximately 700 pediatricians and internal and family medicine physicians have been certified in adolescent medicine. The first 16 fellow- ship programs for a subspecialty in adolescent medicine were accredited in 1998 by the Accreditation Council on Graduate Medical Education; cur- rently there are 26 such accredited programs nationwide. Limited data exist on the characteristics of physicians who are board- certified in adolescent medicine, yet several trends warrant noting. Accord- ing to the American Board of Pediatrics, the American Board of Family Medicine, and the American Board of Internal Medicine, from 2004 to 2005 the number of pediatrician, family medicine physician, and internal medicine physician fellows in adolescent medicine (i.e., pursuing subspe- cialty certification) decreased by 10 percent, from 74 to 66. In 2006, 66 pediatricians, family medicine physicians, and internal medicine physi- cians enrolled in an adolescent medicine fellowship; only 17 percent were male. Just as pediatrics in general has seen an increase in the proportion of women entering the field, the proportion of females in training for a subspecialty in adolescent medicine has increased to a high of 83 percent; the reasons for this change remain unclear (Althouse and Stockman, 2007). Particularly concerning is the lack of interest in the adolescent medicine subspecialty among pediatricians. In 2005, of 866 first-time candidates applying for the general pediatrics examination who indicated an inter- est in one of the 16 subspecialty areas offered by the American Board of Pediatrics, only 1.4 percent cited adolescent medicine, which was fifteenth among the 16 subspecialties (ahead only of medical toxicology) (Althouse and Stockman, 2007). 

PREPARING A WORKFORCE TO MEET THE HEALTH NEEDS 255 Master’s or doctoral degrees focused on adolescent health  The level at which various disciplines in fields other than medicine specialize, in this case in adolescent health, varies. Specialization typically occurs in master’s or doctoral programs. Such is the case, for example, in nursing, nutrition, psychology, and social work. Just as in medicine, providers who seek a focus in adolescent health are likely to be drawn from the child, family, adult, and public health arenas. University programs offering degrees with an emphasis or major in related areas such as these likely offer a set of courses that focus on various content related to adolescent health. Practi- cum options provide opportunities for a variety of clinical experiences with adolescents, including those in public health settings. Although there are no uniform requirements or competencies for such training as there are for fel- lowships in adolescent medicine, adolescent health courses generally include content covering some or all of the competencies identified above. In contrast to the defined criteria for board certification in the subspe- cialty of adolescent medicine for physicians (e.g., length and content of fel- lowship training, adolescent medicine exam), such a set of requirements has been articulated for no other discipline except psychology. To receive board certification as a clinical child and adolescent psychologist, one must obtain a doctoral degree from an accredited program, be licensed or certified for independent practice as a psychologist, and complete a specialty training program accredited by the American Psychological Association. All eligible psychologists also must have completed an approved internship and 1 year of supervised practice, with an additional year of work focused primarily on children and adolescents, or have completed a postdoctoral residency program in clinical child and adolescent psychology. The Academy of Clini- cal Child and Adolescent Psychology is a member of the American Board of Professional Psychology, which has a 60-year history of overseeing stan- dards and processes for certification. Continuing education  The competencies that are incorporated into the core requirements and certification in basic and specialty programs may continue to be assessed in an ongoing, reinforcing manner through recertification or maintenance-of-certification programs. For example, members of the American Board of Medical Specialties have established core requirements to monitor and maintain necessary competencies for specialty medical cer- tification, called Maintenance of Certification™ (Miller, 2005). Summary  Certification criteria set by boards of professional academies for the disciplines of both medicine and psychology provide standards for   See http://www.clinicalchildpsychology.net/27610/index.html. 

256 ADOLESCENT HEALTH SERVICES training that have been instrumental in defining curricular content, clinical practicums for educational programs, and continuing education that prepare specialists or educators/scholars in the field of adolescent health. Although some other disciplines offer options for specializing in adolescent health, the lack of certification for providers and accreditation at the programmatic level means there is no uniformity in curricular expectations and offerings across programs for this specialty. Articulating sets of competencies tailored to each discipline and offering accreditation (at the institutional level) and certification (at the individual level) would lead to consistency of training in adolescent health among disciplines, and could be instrumental in ensuring an adequate workforce of specialists and educators/scholars prepared to teach others and conduct research to inform practice in the field. Innovative Strategies for Training in Adolescent Health Several innovative teaching strategies can contribute to ensuring a competent adolescent health workforce. Some of these strategies are aimed at directly improving clinical practice through either hands-on training or distance learning, while others are designed to equip educators/trainers with up-to-date content and effective teaching approaches. Some examples are described in this section. One strategy involves using adolescents as simulated patients to teach health care providers across multiple disciplines and at various levels (e.g., medicine and nursing students, medical residents, nurse practitioners, pharmacy students). For example, Brown and colleagues (2005) piloted a program, designed for residents and medical students, aimed at develop- ing skills in the core competency of communication related specifically to mental health issues. The program consisted of lectures followed by practice sessions using adolescents as simulated patients. Those in training, as well as the simulated patients, reacted positively to the experience, concluding that it was an effective approach for teaching interviewing skills to address even complex patient issues. Hardoff and Schonmann (2001) likewise rec- ommended the use of adolescents as simulated patients, employing role-play exercises to develop communication skills. Those who have implemented training using adolescent simulated patients advise that faculty collaborate with high schools and college units having drama departments to identify adolescent actors (Schultz and Marks, 2007). The availability of online, Internet-based train-the-trainer programs has significantly increased the likelihood that teachers and faculty will be bet- ter equipped to teach clinicians in adolescent health. Online resources also make it possible to reach more diverse and geographically dispersed groups of providers who work with adolescents. A group consisting primarily of 

PREPARING A WORKFORCE TO MEET THE HEALTH NEEDS 257 physicians, representing 11 European countries and under the direction of Pierre-Andre Michaud, an adolescent medicine specialist from the Univer- sity of Lausanne, Switzerland, designed an easy-to-use, up-to-date curricu- lum, including content, teaching strategies, tools for educators/trainers, and evaluation methods (Michaud et al., 2004). Called EuTEACH (European Training in Effective Care and Health), this online resource is a flexible curriculum with 17 thematic modules on topics ranging from adolescent development to youth advocacy. In the United States, Lawrence Neinstein, a physician who has authored a leading textbook on adolescent health, created an online curriculum each section of which includes background, cases, questions and answers, and web links, plus references. The curriculum is designed for both teachers and service providers. Intended as a source of supplemental instruction, the interactive website, while not exhaustive, addresses common adolescent health topics including puberty, communication, confidentiality, sexuality, medical problems, dermatology, eating disorders, and substance use. The National Adolescent Health Information Center (NAHIC), lo- cated at the University of California, San Francisco, offers another online resource. Guided by a team of nationally renowned adolescent health researchers and with funding from the Maternal and Child Health Bureau, NAHIC offers a variety of resources and tools for adolescent health care providers and educators/scholars, including fact sheets, reports synthesizing research data, and guides for program development. It also includes a broad range of curriculum tools, including a sample syllabus that can be adapted for different disciplines and courses, recommended reading materials, data sources, suggested assignments, case studies, links to other useful resources, and sample presentations. Examples of unit topics include violence, mental health and suicide, sexuality/teen pregnancy/sexually transmitted infections, and community interventions. The Rocky Mountain Public Health Education Consortium (RMPHEC) is another source for adolescent health training curriculum. RMPHEC’s mission is to improve the health status of and eliminate health disparities among women, children, and families, including those with special health needs. An online course on adolescent health is provided to increase the knowledge, skills, and capacity of public health professionals, paraprofes- sionals, organizations, and systems in the Rocky Mountain and surround- ing states and tribes within the region.   See http://www.euteach.com.   See http://www.usc.edu/student-affairs/Health_Center/adolhealth.   See http://nahic.ucsf.edu.   See http://services.tacc.utah.edu/rmphec/index.asp. 

258 ADOLESCENT HEALTH SERVICES Pediatrics in Practice offers online continuing medical education courses based on the American Academy of Pediatrics’ guidelines for pro- viding health supervision of infants, children, and adolescents (Green and Palfrey, 2002). The program, called Bright Futures, includes courses focused on health promotion and faculty development. Interactive health promotion modules cover such topics as health, partnership, communication, educa- tion, and cultural competency, while teaching modules impart strategies designed to enhance instruction in the health promotion curriculum. Finally, in 1996 the Office of Adolescent Health within the Maternal and Child Health Bureau launched PIPPAH, a collaborative of adolescent- related professional associations whose scope includes adolescents and their families. Partnering organizations include the American Academy of Pediatrics, the American College of Prevention Medicine, the American Bar Association, CityMatCH, the Healthy Teen Network, the National Asso- ciation of County and City Health Officials, the National Conference on State Legislatures, and the National Institute for Health Care Management. PIPPAH is dedicated to improving the health of adolescents through system- level strategic organization, program development, and collaboration. One mission of this initiative is the training of health care providers through the creation of online toolkits, policy briefs, tip sheets, and a listing of recom- mended resources. An example of a product resulting from this initiative is the continuing education online course available through the American Nurses Association.10 Findings: •  urrent adolescent health care training programs, including those C that are high quality and interdisciplinary, are insufficient in num- ber to prepare postgraduate health care professionals for roles in the academic sector. •  few innovative discipline-specific and interdisciplinary adolescent A health care training programs have been instrumental in defin- ing curricular content, clinical practicums, and effective teaching modalities. CHALLENGES TO TRAINING A COMPETENT WORKFORCE A number of factors impede progress toward ensuring a competent adolescent health workforce. Some come into play at the individual level   See http://www.pediatricsinpractice.org.   See http://www.socialworkers.org/pippah/about.asp. 10  See http://nursingworld.org/mods/archive/mod4/ceah1.htm. 

PREPARING A WORKFORCE TO MEET THE HEALTH NEEDS 259 and affect both the number and competencies of providers; others exert their influence at the institutional or systemwide level. Attitudes and Economics As noted above, the number of providers seeking a career in adoles- cent health is inadequate to meet the needs of the adolescent population. Deterrents to entering the field are both attitudinal and economic. Many providers avoid working with adolescents because they are uncomfort- able with addressing the complex biopsychosocial issues faced by this age group; this discomfort is attributable primarily to providers’ lack of rel- evant training and preparation (Conard et al., 2003; Golden et al., 2001; Kaslow et al., 2004; Nerdahl et al., 1999; Remschmidt and Belfer, 2005). As for economic disincentives, adolescent health practitioners tend to have among the lowest levels of remuneration across disciplines because so many of their encounters with patients are focused on process more than procedure, thereby garnering less reimbursement (Golden et al., 2003; Kim and American Academy of Child and Adolescent Psychiatry Task Force on Workforce Needs, 2003; Rickert, 2003). In the case of medicine, as noted above, specialization in adolescent health requires 3 years of additional training following completion of residency (e.g., in pediatrics or family medicine). While the subspecialty certification in adolescent medicine helps to ensure physicians’ readiness to address the wide range of health issues confronting adolescents, the postponement of entry into the workforce be- yond residency status can serve as a disincentive (Althouse and Stockman, 2007; Jay, 2007). Educational Priorities A number of unmet challenges within educational systems make it difficult to ensure competency in adolescent health among providers at all levels—generalist, specialist, and educator/scholar. Educators raise the ques- tion of what curricular content can be eliminated to allow for the addition of content on adolescent health. As a result, classroom lectures, textbooks, and overall curricular plans often neglect adolescent health content, instead moving from childhood to adulthood with little attention to the unique concerns and needs of the adolescent population. Coupled with the likeli- hood that licensure exams will not test in the area of adolescent health and accrediting bodies will not require this competency (with the exception of pediatric medicine and child and adolescent psychology as detailed above), there is little external incentive to shift curriculum to include a strong ado- lescent health focus. 

260 ADOLESCENT HEALTH SERVICES Inconsistency or Lack of an Adolescent Focus in the Criteria of Regulatory Bodies Requirements for licensure and certification of health care providers and accreditation of entry-level, graduate, and postgraduate/fellowship programs vary significantly by discipline, state, and governing regulatory body/accreditation council or board. Moreover, requisite levels of education for licensure can range from baccalaureate to doctoral degrees. In nursing, for example, one can take a registered nurse licensure exam after com- pleting a 2-year associate’s degree or a 4-year baccalaureate degree. This variation makes it difficult to provide an overall picture of the consistency with which health care providers are expected to be competent in the array of knowledge and skills needed to work with adolescents. For example, in their effort to summarize core competencies for physicians in general and for psychiatric specialists in particular, Beresin and Mellman (2002) identi- fied six national organizations involved in residency education, training, accreditation, and certification that have input on the question of what is essential. Another example that speaks to the variation in requirements is drawn from the field of counseling for drug and alcohol use and mental health counseling. Kerwin and colleagues (2006) examined state requirements for U.S. providers in these specialties and found two distinct training models. For drug and alcohol counselors, expectations include formal curricular plans; in contrast, an apprentice model guides the training of mental health counselors. Along with these differing training expectations, certification requirements vary from state to state. As a further example, current dental education accreditation standards require no adolescent-specific content. Adolescents are cited only in a gen- eral competency requirement that graduates be prepared to provide dental services appropriate to “the child, adolescent, adult, and geriatric patient” (Commission on Dental Accreditation, 2007, p. 15). Similarly, there are no unique or specific accreditation requirements for specialty training pro- grams in pediatric dentistry that focus on adolescents. Rather, adolescents are expressly included with children in the definition of the specialty and in each of the clinical competency requirements for the target population (Commission on Dental Accreditation, 1998). SUMMARY At the individual, institutional, and systemwide levels, certain impedi- ments challenge the ability to ensure an adequately prepared workforce ready to meet the often complex biopsychosocial needs of adolescents. Elsewhere in this report, additional challenges have been discussed. To- 

PREPARING A WORKFORCE TO MEET THE HEALTH NEEDS 261 gether, these challenges have a considerable impact on adolescents’ access to quality health services, which is determined in part by the competencies of health care providers (as outlined in Chapter 3). Adolescents are best served by those with an understanding of their key developmental features and health issues. The responsibility for adequately equipping health care providers with the essential knowledge and skills needed to work with adolescents rests with educational programs. Yet evidence from providers reporting on their own self-assessed competencies in adolescent health, as well as data gathered from chart reviews and patient reports, reveals that educational programs are falling far short of fulfilling this responsibility. Another goal is to create a critical mass of specialists and educators/scholars in a variety of disciplines who can educate a diverse group of providers to meet the health needs of diverse groups of adolescents. Ensuring an adequate workforce requires the support and sustainment of a specialty in adolescent health that has the potential to produce educators/scholars. REFERENCES Althouse, L. A., and Stockman, J. A. (2007). Pediatric workforce: A look at adolescent medi- cine data from the American Board of Pediatrics. Journal of Pediatrics, 150, 100.e2– 102.e2. American Academy of Pediatric Dentistry. (2005). Guidelines on Adolescent Oral Health Care. Available: http://www.aapd.org/media/Policies_Guidelines/G_Adoleshealth.pdf [Novem- ber 12, 2007]. American Board of Medical Specialties. (2007). Moving Forward Together. Evanston, IL: American Board of Medical Specialties. Astroth, K. A., Garza, P., and Taylor, B. (2004). Getting down to business: Defining com- petencies for entry-level youth workers. New Directions for Youth Development, 104, 25–37. Bearinger, L. H., Wildey, L., Gephart, J., and Blum, R. W. (1992). Nursing competence in adolescent health: Anticipating the future needs of youth. Journal of Professional Nurs- ing, 8, 80–86. Beresin, E., and Mellman, L. (2002). Competencies in psychiatry: The new outcomes-based ap- proach to medical training and education. Harvard Review of Psychiatry, 10, 185–191. Biro, F. M., Siegel, D. M., Parker, R. M., and Gillman, M. W. (1993). A comparison of self- perceived clinical competencies in primary care residency graduates. Pediatric Research, 34, 555–559. Blum, R. (1987). Physicians’ assessment of deficiencies and desire for training in adolescent care. Journal of Medical Education, 62, 401–407. Blum, R., and Smith, M. (1988). Training of health professionals in adolescent health care. Study group report. Journal of Adolescent Health Care, 9, 46S–50S. Blum, R. W., Beuhring, T., Wunderlich, M., and Resnick, M. D. (1996). Don’t ask, they won’t tell: Health screening of youth. American Journal of Public Health, 86, 1767–1772. Brown, R., Doonan, S., and Shellenberger, S. (2005). Using children as simulated patients in communication training for residents and medical students: A pilot program. Academic Medicine: Journal of the Association of American Medical Colleges, 80, 1114–1120. 

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