Nurse Practitioners: Integrating MentalHealth in Pediatric Primary CareSusan N. Van Cleve, DNP, PMHS, Elizabeth Hawkins-Walsh, PhD, PMHS, andSheree Shafer, DNP, PMHCNS-BC

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ABSTRACTThere is increasing recognition of the critical need for pediatric primary care providers toattend to the developmental, behavioral, and mental health needs of children and adolescentsin their practices. Children and families have difficulty accessing psychiatric care because ofscarce psychiatric specialists, stigma associated with referrals, and service fragmentation. The useof pediatric and family nurse practitioners with expertise in developmental, behavioral, andmental health care to provide this care within the pediatric health care home is a solution toaddress the growing need for integration of accessible, quality mental health services in primarycare.

Keywords: integration of mental health, nurse practitioner role, pediatric primary care� 2013 Elsevier, Inc. All rights reserved.

t has been over a decade since the US SurgeonGeneral called upon pediatric primary care pro-

Ividers (PCPs) to expand their scope of practice to

attend to the mental health needs of children andadolescents.1 Since that time, calls for pediatric PCPsto better address the unmet mental health care (MHC)needs of US children and adolescents have onlyincreased.2,3 The need for integratedMHCwithin theprimary care setting is supported by multiple factors,both those that are pragmatic—the high incidenceof children and adolescents who need MHC andface barriers to access4-6—as well as those that reflecta growing philosophical argument that true primarycare cannot be easily dichotomized into mental healthand physical health.1

Compelling arguments have been made to sup-port the call for PCPs to expand their traditional rolesbeyond that of parent and child advisor, counselor,and educator and to provide primaryMHC in pediatricprimary care settings. These include a continuing andprojected lack of access to mental health specialists,7

the unique position and developmental training ofthe pediatric PCP,8,9 the availability of valid screeningtools designed for use in primary care,10 the avoidanceof stigma associated with mental health, new oppor-tunities for specialty training,11 the increasing avail-ability of effective interventions,12,13 certification of

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pediatric PCPs in evidence-based primaryMHC,14 andrecent progress by PCPs in obtaining reimbursement forMHC within primary care.15

Pediatric and family nurse practitioners (PNPs/FNPs) who have expertise in development, behaviormanagement, and mental health as PCPs or subspe-cialists with this population may be a solution toaddressing the growing demand for mental healthservices for children and adolescents who have mildto moderate mental health conditions and who pres-ent to primary care practices.16 These PNPs/FNPsmay help to close the gap in services and address thegrowing need.

The definition of the term mental health used inthis article is based on the Committee on Psychoso-cial Aspects of Child and Family Health and TaskForce on Mental Health Policy Statement from theAmerican Academy of Pediatrics: “The Future ofPediatrics: Mental Health Competencies for PediatricPrimary Care.”3 Mental health encompasses be-havioral, neurodevelopmental, psychiatric, andemotional conditions.

BACKGROUNDThe prevalence of mental, emotional, and behavioraldisorders in children under 18 years old is estimatedat between 17%-20%.6 Half of the mental health

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disorders that are seen in adults have been found toemerge by age 14 and nearly 75% by 21.17 Thesituation is magnified by the studies that documenta continuing severe national shortage of child andadolescent psychiatrists and psychiatric advancedpractice registered nurses (APRNs) who are preparedto practice with children,4,7,18 with even fewer childand adolescent psychiatrists practicing in rural orlower income areas.1,4

In addition, decreasing numbers of developmentalbehavioral pediatricians (DBPs) are being trained,which compounds the problem of available specialiststo respond to the growing need for services.19 Only1 in 5 children with mental health problems arebelieved to receive MHC, even when they areinsured.1 PCPs report frustration with the lack oftimely access to support from psychiatrists or DBPs,managed care restrictions, and inconsistent commu-nication between referring provider and the mentalhealth specialist, often resulting in delayed evaluationand treatment.20

In those children identified in need of a mentalhealth referral, the rate of follow-through withreferral to behavioral health services is less than half.21

Workforce data suggest the need for a public healthmodel for delivery of MHC for children that reliesheavily upon better trained pediatric PCPs for firstline “primary mental health” care and uses morehighly trained specialists (ie, child psychiatrists,psychiatric APRNs, child psychologists, socialworkers) for more severe problems3—a coordinatedsystem in which “scope of practice (is) matched tolevel of child symptom severity and need.”18

PRIMARY MENTAL HEALTH CARE“Primary mental health” has been described asa population-based approach to mental health thataddresses the needs of all patients upon first point ofcontact. Primary care for mental health commonlyrefers to mental health services that are integratedinto general health care at a primary care level andare influenced both by patient need and PCP skill.22

The framework of the well child visit, the backboneof the relationship that develops between the infant/family dyad and the pediatric provider within theprimary health care home, is 1 such population-based approach.9 Well child visits are designated as

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rich opportunities to pre-emptively address orthwart early potential threats to a child’s well-beingthrough such interventions as parental educationand screening.

Today’s parental concerns are largely psychosocialand often related to behavior. The frequency of wellchild visits and the special relationship that developsbetween the PCP and family provide uniqueopportunities to recognize those children at greatestrisk, to learn of parental concerns, and to provideanticipatory mental health promotion, parentteaching, and simple behavioral approaches. Parentsand providers alike are understandably reluctant toprematurely label a child’s behavior as a disorder. Yet,at the same time, an increasing body of researchprovides evidence that early identification of truebehavioral and mental health problems is critical toimproved outcomes for children.23 Behavioralproblems in young children that persist and are notmanaged appropriately are more likely to worsen.24

The relationship that develops between parentsand PCPs around discussions of common parentingconcerns may provide an important foundation forthe trust and confidence so critical for ongoingtherapeutic encounters. The PCP who has observeda child over time may be in the best position torecognize behaviors that appear to be more thanvariations of normal development.

Additionally, the availability of valid and reliablescreening instruments for pediatric mental healthconcerns has improved the PCP’s ability to identifychildren who are at risk and who will benefit fromcareful clinical assessment.10 Furthermore, familieswho may otherwise avoid mental health servicesbecause of perceived stigma may be open to MHCwhen it is provided within a familiar pediatric healthcare home.24

FREQUENT BARRIERS TO INTEGRATIVE MENTALHEALTH CAREDespite the documented high rate of behavioralconcerns among parents, the quality of services foremotional and behavioral health provided withinprimary care varies.25 Screening, evaluating, andmanaging children with concerns about behavior istime consuming and requires expertise in skilledinterviewing, the use of standardized measures, skills

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in behavioral management and counseling, and, attimes, the use of psychopharmacotherapeutics.

Studies have found that only a small percentage ofchildren with mental health problems are identifiedin primary care.21,26 Zuckerbrot et al27 reported that2 in 3 depressed youth are not identified by theirPCPs and do not receive behavioral health care. Theamount of time required to adequately assess andtreat mental health disorders is often cited asa problem in primary care practices.4 Inadequatetraining and lack of knowledge in how to obtainreimbursement for primary MHC are reported asadditional barriers.4 Although the evidence supportsthe integration of mental health care in the pediatricprimary care setting, the challenges exist for practiceswho wish to provide MHC in a systematic, com-prehensive manner.

USING AN NP IN AN INTEGRATED MODELVarious models of integrated pediatric primary carehave been explored,28 including a consultationmodel where mental health experts are available byphone or videoconferencing to PCPs for consulta-tion regarding diagnoses, medication management,or care coordination.28 Another model is co-location of services within pediatric practices. In thismodel, physical space is shared with mental healthproviders within a pediatric primary care practice.28

Limitations of this model include problems withbilling by non-medical providers and sepa-rate records.

Campo16 described a model for a child andadolescent behavioral health program that effectivelybridges the gap between primary and behavioralhealth care by using an NP to provide a behavioralhealth program within a pediatric primary care office.In this third type of model, PNPs/FNPs who haveadded expertise through postgraduate education andpractice in the areas of developmental/behavioralpediatrics and mental health are being recognized asparticularly well suited to meet the need to providecare to children and adolescents with mild tomoderate mental health disorders within primary caresettings.15 These subspecialists may function withinprimary care practices where they are able to pro-vide truly comprehensive health care to childrenand teens.

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Within the primary care setting, PNPs/FNPswith added training and competencies in primaryMHC may provide mental health promotion;early prevention; psychoeducation; screening andclinical assessments; diagnosis of common devel-opmental, behavioral, and mental health disorders;and counseling of parents on differential diagnoses,expected outcomes, and recommendations fortreatment options. The specialized PNP/FNP mayoffer evidence based pharmacologic and/or non-pharmacologic treatments for children and ado-lescents with common mild to moderate mentalhealth disorders and is prepared to refer thosepatients with more complicated histories andpresentations. These PNPs/FNPs are well posi-tioned to collaborate with or refer to psychiatricor DBP colleagues in the management of morecomplex cases, as well as those children withchronic problems.

The PNPs/FNPs who function in this role maybill for their services using Medical Evaluation andManagement medical codes and are able to followchildren and teens over time. There may be greatvariability in how individual practice settings use thePNP/FNP with added primary care mental healthcompetencies. Some PNPs/FNPs will continue toprovide traditional physical care in addition toMHC, while in other settings the PNP/FNP willfocus primarily on the mental health needs ofpatients (Table 1).

DEVELOPMENT OF NP MENTAL HEALTH EXPERTISEWhile primary care PNPs/FNPs may be well posi-tioned to conduct screening and provide early andpreventive evidence-based interventions for pediatricmental health conditions, the interest, skill level, andcompetency of PNPs/FNPs in the area of pediatricprimary MHC is variable. Most PNPs/FNPs willrequire more specialized training before assumingthis role.

Several national initiatives have taken place toprovide them with added competencies to respond tothe demand for quality MHC within the primarycare setting. Directors of PNP programs recognizedthe need for a curriculum that provided PNPstudents with more mental health content andopportunities for skill development.29 In recognition

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Table 1. Exemplar of a Nurse Practitioner Role in Mental Health in a Primary Care Setting

A pediatric nurse practitioner who has expertise in mental health and has obtained certification as a pediatric primary care

mental health (PMHS) works as a subspecialist within a pediatric primary care practice. The PMHS has over 10 years of

clinical experience working in developmental behavioral pediatrics and mental health. The role of the PMHS is to perform

assessments, make diagnoses, and treat children with mental health disorders who are patients in the practice. The PMHS

follows these children over time and complements the role of primary care provider.

The PMHS has her own schedule. She schedules new patients for 60-minute visits and follow-up patients for 30 minutes.

She bills using ICD9 codes for billing and bills level 99214 or 99215 visits. Billing is based on time for counseling and care

coordination. Most of the children the PMHS sees have diagnoses of developmental or behavioral concerns—attention

deficit hyperactivity disorder, anxiety, autism, or depression; most have comorbid conditions. She also sees children who

have genetic disorders with comorbid developmental/behavioral conditions (eg, Fragile X).

The PMHS works with a registered nurse (RN) who is dedicated as a coordinator of mental health on a full-time basis. The

RN performs intake interviews and schedules all patients and sends out screening tools before the visits. The RN refers all

complex patients who need more intensive care to local providers and follows up to ensure that appointments and referrals

have been made.

Before a patient is seen, the PMHS reviews his or her chart, screening tools, and the intake evaluation. The PMHS performs

a comprehensive mental health history and complete physical exam on all initial visits, with particular attention to

neurologic status, as well as assessment for genetic conditions. The PMHS meets with the child and parent separately,

depending on the child’s age, to assess the child’s level of development (using brief assessments if indicated). The PMHS

makes diagnoses and recommends pharmacologic and nonpharmacologic treatments. She consults with providers in the

practice if she has concerns or questions about diagnosis or management.

After the visit, the RN and PMHS provide phone follow-up and are available for questions related to medications,

management, referrals, and educational issues. Patients are followed by the PMHS until they are stable and can be referred

back to the primary care provider for ongoing management. Patients are scheduled for urgent visits if needed. The practice

receives payment for the visits with the PMHS and can pay for the salaries of the PMHS and RN from these payments.

of this gap, the Commonwealth Fund supporteda major initiative in 2004 by the Association ofFaculties of Pediatric Nurse Practitioners to develop,implement, and evaluate a model PNP curriculum inevidence-based primary pediatric MHC and psycho-social morbidities.30

Numerous major initiatives have also targetedcurrently practicing pediatric PCPs. Workshops areheld yearly at the National Association of PediatricNurse Practitioner’s conference to assist PNPs/FNPscontinue their development of mental health com-petencies including building resiliency, coping skills,developmental assets, evidence-based psychother-apies, psychopharmacology, and mechanisms forreimbursement for MHC in primary care.31 TheREACH (Resource for Advancing Children’sHealth) Institute offers several programs for PCPs,either in the form of intensive workshops or onlineprograms with support from experts in the field.11

These programs include training in the areas ofassessment, diagnosis, and treatment of childhoodmental health disorders, as well as in programimplementation.

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PEDIATRIC PRIMARY CARE MENTAL HEALTHSPECIALIST (PMHS) SPECIALTY CERTIFICATIONAs more PNPs/FNPs in pediatric practice havegained added knowledge and skills in primary MHC,many have begun to seek validation of these addedcompetencies. In 2010 the Pediatric Nursing Certi-fication Board conducted a role-delineation study toidentify the responsibilities of the APRN who pro-vides primary behavioral and MHC services forchildren and adolescents.14 A content valid certifi-cation examination was developed after this study,and the Pediatric Primary Care Mental HealthSpecialist (PMHS) certification exam was firstadministered in the fall of 2011.14

CONCLUSIONS AND RECOMMENDATIONSThe traditional role of the PNP/FNP is to providehealth promotion, prevention, screening, early iden-tification of problems, counseling, management, andfollow-up of identified problems and to integrateprevention, early screening, and identification ofmental health problems into the routine pediatrichealth visits.2 With additional training, PNPs/FNPs

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are key health care professionals who can meet thegrowing demand for integrating primarymental healthservices into pediatric primary care settings. They canprovide bothmedical and psychosocial care to childrenand adolescents and are excellent candidates to pro-vide mental health promotion, screenings, and earlyidentification to diagnose common mental healthproblems and to initiate treatment, including phar-macotherapeutic interventions.2

Furthermore, they are ideal providers todevelop skills in evidence-based behavioral andcounseling techniques, such as motivational inter-viewing, cognitive behavioral techniques, problemsolving, and family communication used in mentalhealth treatment. They can coordinate andcollaborate with traditional psychiatric and DBPcolleagues, refer children and adolescents withmore complex mental health problems, andmonitor outcomes.

With additional training, skill development, andpractice, PNPs/FNPs will have an opportunity topursue a new added specialty credential in the area ofpediatric behavioral and mental health to validatetheir role as experts in primary MHC.14 Mostimportantly, US children and adolescents will havenew early access to quality MHC within their pedi-atric health care home.

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Susan N Van Cleve, DNP, RN, CPNP, PMHS, is anassociate professor in the School of Nursing and Health Sciencesat Robert Morris University in Moon Township, PA; she canbe reached at vancleve@rmu.edu. Elizabeth Hawkins-Walsh,PhD, RN, CPNP, PMHS, is the assistant dean for master’sprograms & outreach, director of pediatric nurse practitionerprograms, and a clinical associate professor in the School ofNursing at the Catholic University of America in Washington,

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DC. Sheree Shafer, DNP, RN, FNP-BC, PMHCNS-BC,PMHS, is a family nurse practitioner and psychiatric mentalhealth clinical nurse specialist at the Children’s CommunityPediatrics of Armstrong in Kittanning, PA. In compli-ance with national ethical guidelines, the authors report no

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relationships with business or industry that would pose a conflictof interest.

1555-4155/13/$ see front matter

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