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Introduction and Overview

“Between what is known and what is done is what is taught.”

Laurel K. Leslie, Tufts University School of Medicine, Workshop Planning Committee Cochair

Childhood diagnoses of cognitive, affective, and behavioral disorders are increasing in absolute numbers as well as in proportion to the total childhood population in the United States (Institute of Medicine, 2015). This documented increase is adding to the care and cost burden for children and adolescents (hereafter referred to as children in most cases in this publication) at alarming rates. An estimated 13 to 20 percent of children ages 3 to 17 in the United States experience a behavioral health disorder in any given year (National Research Council and Institute of Medicine, 2009a), and this rate does not include autism spectrum and cognitive disorders or subthreshold cognitive, affective, and behavioral health symptoms. Furthermore, behavioral disorders in children are very often a source of disability in adulthood.

Increasing numbers of evidence-based interventions have proven effective in preventing and treating behavioral disorders in children (Institute of Medicine and National Research Council, 2014). However, the adoption of these interventions in the health care system and other systems that affect the lives of children has been slow. Moreover, with few exceptions, current training in many fields that involve the behavioral health of children falls short of meeting the needs that exist. In general, this training fails to recognize that behavioral health disorders are among the largest challenges in child health and that changing cognitive, affective, and behavioral health outcomes for children will require new and more integrated forms of care at a population level in the United States.

To examine the need for workforce development across the range of health care professions working with children and families, as well as to

identify innovative training models and levers to enhance training, the Forum on Promoting Children’s Cognitive, Affective, and Behavioral Health held a workshop on November 29–30, 2016, titled “Training the Future Child Health Care Workforce to Improve Behavioral Health Outcomes for Children, Youth, and Families.” (Appendix A provides the statement of task for the workshop.) Established in 2014, the forum was created to bring together patients and family members, health care providers, researchers, government representatives, philanthropists, representatives of professional associations, and others to connect prevention, treatment, and the

implementation sciences with the settings where children receive care. Its primary aim is to inform a forward-looking agenda for building a stronger research and practice base around the development and implementation of programs, practices, and policies to promote all children’s cognitive, affective, and behavioral health. Box 1-1 summarizes some of the themes that have characterized the past work of the forum.

LEVERS FOR CHANGE

Obvious gaps, flaws, and shortfalls characterize the training of professionals and others involved in delivering behavioral health care to children and their families, said Laurel K. Leslie, vice president of research at the American Board of Pediatrics, professor of medicine, pediatrics, and community medicine and public health at Tufts University School of Medicine, and cochair of the planning committee for the workshop. For example, comparisons of survey data from 2004 and 2013 found that training continues to be a significant barrier for pediatricians in the identification of behavioral health problems and in the treatment of children and adolescents (Horwitz et al., 2015). Many trainees in the behavioral health professions (e.g., psychology, child and adolescent psychiatry) have relatively little exposure to treatments that have proven effective (Weissman et al., 2006). Whether within a specific discipline or across disciplines, training is fragmented and lacks essential elements of core knowledge about the promotion of child and family well-being and the identification and treatment of behavioral problems. Training models that yield continuous, integrated, team-based, and family-focused behavioral health care exist but are rare and have limited sustainability and spread, Leslie said.

Different disciplines bring unique competencies and contributions to the prevention and treatment of behavioral problems, said Leslie. Drawing on earlier work by Hugh Barr (1998), Leslie commented that delineating them will be essential for an integrated, effective workforce. Common competencies are shared by all disciplines that deal with the cognitive, affective, and behavioral health of children. Complementary competencies are specific to a professional role but enhance the work of other professionals as well. Collaborative competencies allow professionals to work together across roles and across sectors. Building these competencies “has to be a priority for us moving forward as we think about how to train a future workforce,” Leslie said.

Leslie explained that the planning committee for the workshop conceptualized levers for change in three primary areas: education and training, governance and regulatory oversight, and alignment of efforts.

Discussing the first, education and training, Leslie said, “We need to think about how we develop new content and formats that take into ac-

count changing the policy, practice, and science.” For example, new modalities such as online and simulation tools can increase educational efficiency and reduce challenges for geographically isolated and smaller, less resourced training programs. However, many faculty are not necessarily ready to use innovations in education to provide information to their trainees, and faculty development will be necessary. It may also be essential to reconceptualize how curriculum is developed. One promising approach, she said, is to flip the usual pathway of curriculum development, which starts with the curriculum and then defines educational objectives and assessments, to an approach that starts with the health needs of children and in turn informs competencies and objectives for training, curricular components, and assessment (Frenk et al., 2010). “This approach is being put forward in several disciplines as a way to change what we’re doing and align our training with what families need,” Leslie stated.

The second lever for change identified by the planning committee is governance and regulatory oversight by the wide range of agencies that establish standards for training programs and set and assess qualifications both for professions and for individuals. Training programs are reviewed to make sure that they are meeting established criteria; the settings in which people are trained also undergo review. Individuals are certified, indicating that they have completed training and have met standards of excellence established for their discipline. They may also undergo licensure at the local, state, or national level. The power of these accrediting, credentialing, and licensing bodies has not been tapped. “This is a very complex world but a potential lever for change,” said Leslie.

The third lever identified is alignment with local, state, and national efforts that are funded by the public and private sectors. “Exciting change efforts” are under way, said Leslie, adding, “What if we aligned all of these change efforts together and were able to build on the strengths of those opportunities?”

To limit the potentially very wide scope of the discussion, the workshop was focused on behavioral health and well-being, not on physical, cognitive, or educational disabilities, even though, as Leslie pointed out, they often coexist. The workshop also focused on the future health professional workforce and the settings in which they work, not on educators, child care providers, or other practitioners; these topics are being addressed by other groups within the National Academies of Sciences, Engineering, and Medicine.¹ Finally, the workshop did not consider clinical practice

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¹ In 2015, another committee at the National Academies published a consensus report on training the workforce related to development and education for children ages 0 to 8 (Institute of Medicine and National Research Council, 2015). See https://www.nap.edu/catalog/19401/transforming-the-workforce-for-children-birth-through-age-8-a [October 2017].

environments that trainees enter after their classroom training. “This is an incredibly important topic to be thinking about because those settings reinforce trainees’ experiences, or they don’t, but we could not tackle that in the course of these 2 days,” she explained.

During a breakout session on the first day of the workshop, the participants divided into subgroups to further delineate potential levers for change and barriers to change in preparing the future health care workforce to deliver behavioral health care for children and families. As an introduction to the broad range of issues discussed at the workshop, Box 1-2 summarizes the subgroups’ discussions.

ORGANIZATION OF THE WORKSHOP

This proceedings largely follows the workshop agenda (see Appendix B). The first panel of the workshop featured the voices of parents and patients (Chapter 2). They recounted their personal stories as well as lessons they have learned in addressing the physical, emotional, and behavioral health and well-being of children.

The next panel outlined the national landscape of health care training and workforce processes (Chapter 3). As part of this discussion, Thomas Boat, cochair of the workshop planning committee, introduced a paper released the day of the workshop titled “Workforce Development to Enhance the Cognitive, Affective, and Behavioral Health of Children and Youth: Opportunities and Barriers in Child Health Care Training,” which compares

the competencies required across different disciplines to initiate a discussion about developing a fundamental list of shared core competencies.²

Promising training models that constructively take advantage of levers of change under the area of education and training was the next topic examined (Chapter 4). Six presenters described models that have created improvements in such areas as incorporation of evidence-based practices, interprofessional training and team-based care, and the care of children with chronic medical conditions.

Workshop participants next investigated accreditation, certification, and credentialing as levers for change in workforce development (Chapter 5). Five presenters addressed the functions of regulatory bodies that accredit

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² The paper is available at https://nam.edu/workforce-development-to-enhance-the-cognitive-affective-and-behavioral-health-of-children-and-youth-opportunities-and-barriers-in-child-health-care-training [September 2017].

programs and certify individuals as part of a broader look at how regulatory oversight can influence the workforce.

The agenda then turned to the third lever for change: alignment with local, state, and national efforts that are funded by the public and private sectors (Chapter 6). Presenters discussed other child-serving systems and changes to enhance care in those settings. They reported that training, reimbursement, and supervision can all improve behavioral health care for children involved in these systems.

The final panel examined current efforts involving financing, training, and delivery models being fostered by federal agencies, professional organizations, and foundations to highlight opportunities for collaboration (Chapter 7).

On the second day of the workshop, participants again broke into subgroups to identify possible next steps that could be taken to achieve the objectives identified earlier in the meeting. A list of these possible steps and the reflections of workshop organizers and presenters conclude this proceedings (Chapter 8).

In addition to the panel sessions, the workshop highlighted a number of research programs related to integrated, interprofessional care for children and their families in a poster session. Abstracts for each poster are available in Appendix C. Appendix D provides biographical sketches of planning committee members, workshop speakers, and moderators.