Competencies for Pediatric Psychology Practice in Primary Care Settings: A work in progress
Lynne A. Sturm, PhD, and Terry Stancin, PhD
Health care reform has enormous implications for expanding roles and opportunities for psychologists in primary care settings due to increased expectations for behavioral health care services. Primary care as it is currently conceptualized refers to the provision of integrated and accessible health care services by an interdisciplinary team of clinicians. Models of “collaborative” or “integrated” care emphasize the collective responsibility of the team for patient care and have been shown to improve health outcomes and reduce costs, especially with adults (CITE). However, as a field, pediatric psychology has focused more on tertiary care and chronic illness than on primary care, and so most child and family psychologists have had limited training or may be unsure about the skills and expertise necessary to function effectively in a primary care context (consider O'Donohue, 2008 reference). Moreover, there has not been a general consensus on the competencies psychologists need to work in primary care medical settings, whether adult or child-focused. An introduction to the roles of pediatric psychologists in primary care can be found in Stancin, Perrin and Ramirez (2009).
Several recent initiatives have recognized and addressed the need to delineate competencies for psychologists who wish to practice in pediatric primary care settings. First, 2012 American Psychological Association (APA) President Suzanne Bennett Johnson, PhD, convened the Inter-Organizational Work Group on Competencies for Primary Care Psychology Practice. This group consisted of representatives from nine national organizations with a vested interest in collaborative care. Susan McDaniel served as chair of the Work Group and the APA Education Directorate (led by Catherine Grus) provided administrative and technical support. Terry Stancin and Lynne Sturm represented APA Div. 54, Society of Pediatric Psychology (SPP), on the Work Group. The product of this Work Group was a consensus document intended to inform education, practice and research in primary care psychology and to be a tool for psychologists working in primary care environments to assess their competence.
However, the consensus competency document is general and not specific to children, so a mapping of the competencies to the pediatric primary care context has yet to be accomplished. Two initiatives by SPP hope to bridge that gap. A Task Force on Competencies and Best Training Practices in Pediatric Psychology (co-chairs Tonya Palermo and David Janicke), was charged with proposing competencies for pediatric psychology education and training. This Task Force is finalizing a Proposed Competency Model for Pediatric Psychology Education and Training (Palermo et al. 2013) that uses the Benchmarks framework described below (Hatcher et al., in press) to delineate proposed competencies and behavioral anchors for pediatric psychologists across settings and at different levels of experience.
Recently, a Task Force on Integrated Care was convened by SPP with co-chairs Terry Stancin and Lynne Sturm. One of the goals of the Task Force is to integrate goals, objectives and strategies from these different documents to describe the unique body of knowledge and skills, grounded in behavioral anchors, needed to practice in pediatric primary care as it evolves in this era of the Affordable Care Act. Priorities of this Task Force include developing a competent workforce of pediatric psychologists to provide services, supervise trainees and serve in leadership roles in primary care health settings, as well as advocacy to support psychologist compensation for their efforts.
What does the “Competencies for Psychology Practice in Primary Care” document mean for pediatric settings?
The Inter-Organizational Work Group adopted the framework of the Competency Benchmarks Work Group (Hatcher et al., in press) which drafted essential components and behavioral anchors for broader competency cluster areas. The final document (McDaniel et al., under review) outlines six broad competency clusters: science, systems, professionalism, relationships, application and education. Within each cluster, essential knowledge, skills and attitudes needed for practicing in primary care settings (Essential Components) as well as behavioral examples (Behavioral Anchors) are provided. The work group endeavored to supplement existing benchmarks for clinical practice by including components that were unique to primary care (as opposed to general competencies). Each of the competencies as articulated for primary care practice by the Inter-Organizational work group will be described, with examples of how they might apply to pediatric settings.
Providing services in primary care settings, requires broader scientific knowledge than is traditionally provided in training for health service psychologists, including approaches such as population-based interventions to prevent and manage costly chronic diseases (e.g., childhood asthma, childhood obesity) (McDaniel et al., in press). In the Science Cluster, one essential component is “application of research skills for evaluating primary care practice, interventions and programs.” A corresponding behavioral anchor that illustrates this competency is “evaluates the effectiveness of screening or prevention programs used in primary care.” In the primary care setting, a pediatric psychologist might be asked to help a clinic team implement the American Academy of Pediatrics (AAP) recommendations for standardized developmental screening at 9, 18 and 30 months. Not only can a pediatric psychologist assist in the selection and implementation of screening tools, but can also provide expertise in evaluating effectiveness and outcomes of procedures. In fact, the proposed Competency Model for Pediatric Psychology suggests that pediatric psychologists entering practice should be competent to lead research efforts. Thus, the psychologist's expertise in evaluation, psychometrics and research design serves as a value-added service for the clinical team, many of whom have clinical benchmarks to meet for quality assurance.
In the Systems Cluster, an essential component is “Appreciates that primary care takes place in the larger ‘healthcare neighborhood,' within the community and social context. A behavioral anchor is “engages schools, community agencies and healthcare systems to support optimal patient care and functioning.” In the pediatric primary care setting, this might translate into helping health care providers establish systems for rapid communication between clinic and school staff to coordinate medication and symptom management for attention deficit hyperactivity disorder (ADHD).
In the Professionalism Cluster, an essential component to the competency pertaining to professional values and attitudes listed is “values the culture of the primary care setting and conveys an attitude of flexibility.” A behavioral anchor that would demonstrate this essential component is that the primary care psychologist is “willing to assume or to adapt role activities of consultant, team leader, advocate, case manager, health educator and community liaison.” In a pediatric primary care setting, the psychologist needs to be flexible and wear many hats. They may need to serve as the case manager for a child who is served by subspecialists and general pediatrics providers, consult on quality improvement project ideas proposed by the clinic team, and provide curbside consults to providers about children they see in the course of their daily work. Willingness to provide clinical interventions outside the traditional “50 minute hour” is essential for functioning within the primary care culture.
The Relationships Cluster subsumes interprofessionalism and building and sustaining relationships in primary care. Pediatric psychologists need strong skills in collaboration with other healthcare professionals and knowledge of team function and dysfunction. One of the essential components is “develops collaborative relationships to promote healthy interprofessional team functioning that is characterized by mutual respect and shared values”. A behavioral anchor which could apply in pediatric settings is “promotes and participates in team huddles prior to clinical work”. Here the pediatric providers, learners, psychologists and other team members (e.g., social worker, nutritionist, front desk registration clerk) meet to review cases that will be seen that day to plan the best way to provide for the family's “medical home.”
In the Application Cluster, as essential component pertaining to interventions is “effectively uses current evidence-based interventions appropriate for primary care to treat health and mental health-related issues.” A behavioral anchor for this component is: “implements evidence-based interventions (e.g. cognitive behavior therapy, Parent Child Interaction Therapy, Motivational Interviewing, Family Psychoeducation, problem solving therapy).” In pediatric primary care, the psychologist may need to adapt evidence-based interventions to serve populations of children. For example, they may provide Family Psychoeducation in the context of ADHD Well Child Group Visits, and brief trauma-focused cognitive behavioral therapy to children identified by pediatric providers.
Educational roles of the pediatric psychologist are substantially broader than is typical in inpatient hospital settings. Learners include clinic team members, some of whom may not be as well versed as the pediatric psychologist with a biopsychosocial framework for understanding patient behavior related to illness and disease, as well as pre-professional learners (e.g. psychology pre-doctoral interns, medical students, nursing students). In the Education Cluster, an essential component to the competency pertaining to training is “Completes needs assessment and understands teaching approaches used by other health professions about behavioral health issues”. A behavioral anchor that would demonstrate this essential component is that the primary care psychologist “adapts teaching methods used by other disciplines for integrated care training (e.g., structured direct observation with checklists for ratings, Objectives Structured Clinical Examinations (OSCEs), use of standardized patient observation and feedback, etc.).” For example, in pediatric primary care setting as in an academic medical setting, a psychologist on the pediatric faculty would need to stay current with changes in ACGME requirements (e.g. ACGME pediatric milestones for residency training) as well as pediatric adaptations of standardized observation tools for the psychologist to provide structured feedback to residents as they develop physician-patient communication skills.
Other behavioral health care providers are also preparing to claim some of the shrinking health care dollars. Not only are we are seeing traditional master's level behavioral providers (e.g., mental health counselors and social workers) being recruited to primary care settings to provide behavioral services, but also life/health coaches, dieticians and nurse practitioners. There are opportunities for pediatric psychologists to emerge as leaders in integrated primary care settings. In order to do so, pediatric psychologists will need to articulate how our skills differ from other behavioral health and health care providers. Many of us who work in primary care believe that there is ample work for a variety of professionals. To be successful in primary care, pediatric psychologists will need to transform broad benchmarks into meaningful training activities that lead to evaluating competencies across different levels of experience. Psychologists are poised to gain a great deal in the process if we are able to do so.
Hatcher, R.L., Fouad, MN.A.,Grus, C.L., Campell, L.F., McCutcheon, S.R. & Leahy, K.L. (in press). Competence benchmarks: Practical steps toward a culture of competence. Training and Education in Professional Psychology.
McDaniel, S.H. and the APA Interorganizational Workgroup (under review).Competencies for Psychology Practice in Primary Care.
Palermo, T., Janicke, D., McQuaid, E., Mullins, L., Robins, P., & Wu, Y. Proposed Competency Model for Pediatric Psychology Education and Training : Report developed by the Task Force on Competencies and Best Training Practices in Pediatric Psychology (in preparation).
Stancin, T., Perrin, E.C., Ramirez, L. (2009). Pediatric psychology and primary care. In M. Roberts & R. Steele (Eds). Handbook of Pediatric Psychology, fourth edition, ( pp.630-648). New York: Guilford Press.
Terry Stancin, PhD, is professor of Pediatrics, Psychiatry and Psychology at Case Western Reserve University. She serves as Director of Child and Adolescent Psychiatry and Psychology and Vice-Chair for Research in Psychiatry at MetroHealth Medical Center in Cleveland, Ohio. She is a pediatric psychologist and with expertise in pediatric mental health issues in primary care and is actively involved in research pertaining to outcomes of pediatric traumatic brain injuries, having collaborated on federally funded investigations for more than twenty years. Stancin has authored more than 100 book chapters, reviews and scientific publications. She serves on editorial boards of several scientific journals and is active in national pediatric and psychology organizations.
Lynne Sturm, PhD, is a pediatric clinical psychologist in the Riley Child Development Center and the Division of General & Community Pediatrics, Indiana University School of Medicine. She completed her graduate training at Duke University, pre-doctoral clinical internship at University of Colorado Health Sciences Center and post-doctoral training in pediatric psychology at Rainbow Babies and Children's Hospital in Cleveland, Ohio. She has a long-standing interest in integrated behavioral health care in pediatric primary care settings and serves as Co-chair of the Div. 54 (Society of Pediatric Psychology) Task Force on Integrated Care (Terry Stancin, PhD, Co-chair). Sturm served as a representative of Div. 54 on the American Psychological Association Inter-organizational Task Force on Competencies for Psychological Practice in Primary Care, chaired by Susan McDaniel, PhD.