суббота, 15 сентября 2012 г.

A national survey of PNP curricula: preparing pediatric nurse practitioners to meet the challenge in behavioral mental health.(Credentialing & Professionalism in Pediatric Nursing) - Pediatric Nursing

Pediatric nurse practitioners (PNPs) have been providing primary care to children and adolescents for over 35 years. The role of the PNP has continued to evolve throughout this period, expanding from the initial role of providing predominately well child care and management of common health problems to include a wide range of primary health care problems, including the management of children with chronic health conditions and the primary care of special populations. In response to this expanding role, graduate PNP education programs have similarly evolved to respond to changing demographics, increasingly complex health issues, and legislated scope of practice. In the past 15 years, graduate PNP curricula have begun to reflect increased attention to health problems of adolescents and college age youth, high risk newborns, and other vulnerable populations. While some of these changes occurred as a result of informal surveys and feedback from graduates and employers, other more formal mechanisms have also stimulated change, such as State Boards of Nursing requirements regarding content in advanced pharmacology, health assessment, and pathophysiology. An important influence encouraging curricular change in PNP programs has come from the Pediatric Nursing Certification Board (PNCB), formerly the National Certification Board of Pediatric Nurse Practitioners and Nurses. Through its national PNP Program Review process the PNCB has supported and reviewed educational programs for compliance with quality guidelines for PNP education established by the Association of Faculty of PNP Programs (AFPNP) in their Position Statement, Philosophy, and Conceptual Model for the Education of PNP's (AFPNP, 1996). Most recently, Nurse Practitioner Primary Care Competencies in Specialty Areas have been published, providing nurse practitioner educators another resource to shape nurse practitioner curricula (National Organization of Nurse Practitioner Faculties [NONPF] & American Association of Colleges of Nursing [AACN], 2002). An examination of these sources, however, leaves unanswered a growing question among educators of all primary care providers. In an era of increasing recognition of the burden of mental and behavioral health problems and limited resources for referral, how much training in the area of primary mental health care should students receive?

The pediatric primary care provider is now being urged to spend more time during office encounters attending to behavioral concerns of parents and youth. It is reported that approximately 20% of children and adolescents experience behavioral health problems consistent with psychiatric diagnoses (Burns et al., 1995; Costello et al., 1996; Roberts, Attkisson, & Rosenblatt, 1998). Yet fewer than one in five of these children will receive any kind of mental health services (USDHHS, 1999, 2001). The surgeon general called the emergent and unmet mental health needs of children a top national priority and, in a national report, called on pediatric primary care providers to assume an increasing role in the assessment and management of mental health problems in children and adolescents (USDHHS, 2001). The Institute of Medicine (IOM) has argued that prevention-minded treatment must be taught to those who are likely to have early and sustained contact with children (Mrazek & Haggerty, 1994). The pediatric primary care provider has a unique opportunity to identify children and families with behavior problems, to intervene with some, and to refer those children who need more intensive treatment. Repeated studies have concluded however, that pediatric clinicians often fail to accurately identify children with mental health problems and that pediatric clinicians will need more training in the area of mental health if they are going to assume this important role (Bernal et al., 2000; Costello, Costello, & Edelbrook, 1998; Lavigne, Binns, & Christoffel, 1993; Kelleher, McIrnerny, Gardner, Childs, & Wassermann, 2000). Recently many professional groups involved in the care of children, including the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry, and the National Association of Pediatric Nurse Practitioners (NAPNAP) have taken steps to close this gap. One important example is NAPNAP's KYSS Campaign, a multi-pronged, national initiative launched in 2001to improve the mental health care of children in this country (Melnyk et al., 2003).

Purpose

The purpose of this survey was to determine the extent of pediatric behavioral/mental health content currently taught in nationally recognized graduate PNP programs in the U.S. It was recognized that mental health content could be taught in a number of different ways, through distinct courses or by integrating content throughout various courses and clinical experiences. The authors sought to discern the level of preparation PNP students were receiving both in the classroom and clinically in the area of the assessment, diagnosis, and management of mental/behavioral health problems in children and adolescents.

Data Collection

A five-page questionnaire was developed that attempted to capture the multiple ways that PNP programs might be including this content. The questionnaire was divided into two parts. Part I sought information regarding the structure of the particular PNP curriculum and whether mental health content was provided in specific courses or woven throughout the program. Questions addressed the presence of required or elective courses in mental health content, the existence of a specialty or sub-specialty courses in pediatric mental health, the use of mental health specialists as clinical preceptors, and faculty intent to increase the amount of content in this area. Part II provided an outline of specific content grouped in categories related to the various components of pediatric primary mental health care. The responder was asked whether the topic was taught and how much time was devoted to it. The content list was developed by a comprehensive review of the literature, which included relevant pediatric and mental health journals and pediatric primary care texts. Additional resources included the PNCB's national primary care PNP role delineation study (Brady & Neal, 2000); the PNP Test Content Outline for 2002, published by PNCB; and consultation with members of the AFPNP Programs. The content list included topics related to assessment, screening tools, diagnoses, interventions, psychopharmacologic therapy, and the use of alternative clinical settings, which might reinforce knowledge of the management of children with mental health and behavioral problems. The term 'behavioral/mental' health problem was deliberately chosen to be inclusive of a wide range of both internal emotional states and external behaviors that are troubling and of concern even if not part of a mental health diagnosis.

Data collection involved two distinct phases. It was believed those faculties who teach and direct the PNP programs would be in the best position to provide the information sought in the questionnaire. The AFPNP Programs is the professional membership organization for faculty who teach in PNP programs in the U.S. Membership is voluntary. In this initial phase, all members of the AFPNP were contacted via e-mail and asked to participate by completing the questionnaire. At the time of the questionnaire AFPNP members represented 40 distinct PNP Programs from almost all regions of the U.S. The questionnaires were returned by e-mail, fax, or mail. Identifying information was optional. Eighteen questionnaires were returned, representing 45% of the programs contacted.

The second phase of the data collection was undertaken in collaboration with the PNCB. Permission was granted by the PNCB providing access to PNP curricula collected from the 84 PNP programs participating in the PNCB's PNP program review process. As the leading certification organization for PNPs, the certification program of the PNCB is endorsed by the AFPNP, NAPNAP, and the AAP. The PNCB conducts comprehensive PNP program review to recognize those PNP graduate programs that are in compliance with national PNP education standards and competencies endorsed by the AFPNP and the National Task Force on Quality NP Education. Currently, there are 84 national PNP programs recognized by PNCB. The PNCB maintains comprehensive and unique data files of all recognized PNP programs, including admission requirements; core and specialty curriculum; all course syllabi including topic outlines, clinical experiences, and requirements; and both preceptor and faculty qualifications. Permission was sought and obtained from the PNCB to review the PNP educational materials maintained in their PNP Program Review data files in order to better answer the question of mental health content in PNP programs. The sixty additional PNP programs whose records were retrievable were reviewed in order to provide the information sought in the survey. Data from both surveys were combined in the final results.

Results

The final survey included a total of 78 nationally recognized PNP programs, a representation of approximately 93% of all the graduate PNP programs in the U.S. Information about 18 programs came from the self-report survey, while information from the remaining 60 programs was obtained by a direct review of program materials submitted to the PNCB.

Programs offering a pediatric behavioral/mental health specialty or sub-specialty. Five programs (6%) were identified as having a separate pediatric behavioral/mental health specialty. Three of these programs are clearly a combined PNP and clinical nurse specialist (CNS) role in child psychiatric/mental health, where graduates are prepared to sit for certification as both a primary care PNP and a child and adolescent psychiatric/mental health CNS. An additional four programs offered a mental health specialty, but not in pediatrics.

Behavioral/mental health content. All programs included some behavioral/mental health content in the curriculum either as specific content in an established course, as a thread throughout the curriculum, or as a separate course offering. Twenty-two programs (28%) were identified as requiring a separate course devoted to mental /behavioral health. Many of these courses were titled specifically to indicate mental/behavioral health. The title of others did not clearly reflect the behavioral/mental health content; however upon review it was determined that the course included a majority of mental/behavioral health content. In addition, four programs offered an elective in behavioral/mental health for children. Six of the courses required a specific clinical experience. These practica ranged from 30-112 hours. While most courses did not require a clinical component, some indicated that clinical was integrated with other practica (see Table 1 for list of required courses). In those programs that did not have a special course related to behavioral mental health, the content was found in traditional PNP courses such as Health Assessment; Health Promotion; Common Problems; Chronic Problems; Child Development; Family Theories; Stress; Adolescent course; Well Child Care courses; Clinical Applications; and Advanced Practice Nursing. Many programs indicated that students were required to prepare presentations on common behavior problems. The exact topics included each semester might vary based on the number of students and student choice.

Clinical settings. The clinical settings used to provide students with clinical experience in pediatric behavioral/mental health were identified. The most frequently named clinical settings other than traditional pediatric practices were school-based health care settings (24%) and day care settings (22%). Less frequently used settings were: outpatient mental health facilities (4%); juvenile detention centers (3%); child adolescent treatment centers (one program); a special education facility (one program); and a counseling or crisis center (one program). In a few instances, programs indicated that they used specialty preceptors to mentor behavioral/mental health training such as child and adolescent CNSs and other mental health specialists.

Class time devoted to behavioral/mental health. The number of classroom hours devoted specifically to behavioral/mental health content varied considerably. The investigators recognized that it might be difficult for programs to accurately distinguish this content from the traditional growth and development content found in well child courses. The actual number of hours ranged from 5-60. Twenty-four programs (31%) required 20 hours or more of behavioral/mental health content, with five of these requiring 45 hours or more; 32 (41%) programs required between 10 and 19 hours, and 22 (28%) programs required 10 hours or less (see Figure 1).

[FIGURE 1 OMITTED]

Additional specific content. Neuropsychology and neurophysiology. As knowledge has grown regarding the neurophysiologic basis for many mental health problems, it can be expected that more content related to this area will be found in the curriculum, possibly in the required pathophysiology course. Two programs reported discussing the neurophysiological basis of problems briefly, but in general, the pathophysiology and the clinical course syllabi reviewed did not appear to reflect this subject area. No separate courses for neuropsychology were required. However-, one program did offer a three credit elective in neuropsychology.

Assessment and screening tools. Programs were reviewed to determine what specific screening tools were included that related to identifying children at risk for behavioral/mental health problems or diagnoses. Only five tools specific to behavioral/mental health assessment were identified (see Table 2). Most programs did not specify which tools they taught to assess attention deficit hyperactivity disorder (ADHD), substance abuse, or depression. Exceptions included the Connor scale for ADHD and the Cage Scale (one program each).

While there were few screening tools identified as specific to behavioral/mental health, most programs included screening tools related to growth and development. A total of 21 screening tools were identified. The Denver II was the most frequent tool listed and was found in almost all programs. Other developmentally related tools included less frequently were the Carey Infant Temperament Scale (12 programs, 15%), the Infant and Toddler Home Observation for Measurement of Environment (HOME) (4 programs, 5%), the Denver Articulation Speech Evaluation (DASE) (3 programs, 4%), the Early Language Milestone Scale (ELM) (2 programs, 2%), and School Readiness (2 programs 2%). Additional tools listed by individual programs were the Clinical Linguistic and Auditory Milestone Test (CLAMS), the Vineland, Bayley, Peabody, Draw a Person, Brazelton Infant Behavioral Assessment Tool, and the Nursing Child Assessment Satellite Training (NCAST). Family focused tools taught included the Calgary Family Behavior Tool and the Family Assessment Tool (one program each).

Specific mental/behavioral health problems/diagnoses. The overwhelming majority (95%) of programs in both surveys included specific content related to ADHD. The second most frequently listed mental health topics included eating disorders, depression, and child abuse/sexual abuse followed by addictive disorders/substance abuse and violence. Infrequently listed behavioral/mental health problems included: sexual identity problems, school refusal, sleep disorders, stress, autism, grief, loss, trauma/post traumatic stress disorder (PTSD), phobias, anxiety, bipolar disorder, adjustment disorder, schizophrenia, conduct disorder, and oppositional defiant disorder (see Table 3).

In some cases, specific groups of children with potential for behavioral problems were identified as separate topics. These included: incarcerated youth; foster children; children with chronic illness, and children with developmental disabilities.

Fifteen programs (12%) included information related to the use of either the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) or the DSM for Primary Care with a range of 1-3 hours devoted to the topic.

Mental/behavioral health interventions. The majority of programs included content on non-specific counseling related to behavioral issues such as fighting, bullying, and disruptive behavior; shyness; sadness; divorce; exposure to violence; chronic illness; cultural conflict; and other issues. However, the inclusion of specific mental health therapies or interventions could only be found in a few programs. It was not possible to determine in most instances whether the content was theoretical or also included the application of interventions or therapies. When indicated, therapies included: behavior change (6 programs, 8%), cognitive behavioral therapy (3 programs, 4%), group therapy (3 programs, 4%), family therapy (3 programs, 4%), play therapy (2 programs, 3%), art therapy (2 programs, 3%), and crisis intervention (2 programs, 3%). Other therapies listed by one program included: reminiscence therapy, solution-focused therapy, supportive therapy, and complimentary therapies such as therapeutic touch, acupuncture, massage therapy, relaxation, and herbs/vitamins. The range of reported hours devoted to this content varied from 2-45 hours.

Thirteen programs (17%) included content on collaborative management of mental behavioral health problems. Six programs (8%) included content on program planning related to mental health prevention and mental health promotion, and four programs (5%) included content on conducting parenting groups or classes. In most cases the amount of time devoted to this content was not specified, but when indicated, it ranged from 2-20 hours total.

Psychopharmacology content. Psychopharmacology was specifically identified in fifteen programs (20%). The range of hours devoted to this content was 1-8 hours, with most programs offering 1-3 hours. When specific classifications of agents were provided, central nervous system stimulants and antidepressants were listed.

Faculty preparation. As part of this survey, 18 PNP faculty program directors responded to whether they believed additional behavioral/mental health should be included and whether they were adequately prepared to teach this content. Twelve of the programs indicated a need to increase the amount of mental health content (both knowledge and skills) in their current programs. Seven reported that they were planning changes in the near future, and one is planning a new subspecialty in mental health. Five did not see a need to increase behavioral/mental health content. Seven respondents noted that they felt adequately prepared to teach the increased content, while eight reported that they did not. However, four of these programs used outside experts to teach some or all of this content. Most of the faculty who did not feel adequately prepared reported an interest and plan to seek additional preparation in this area.

Limitations

There were several limitations to this study. First was the universal problem of knowing what is actually taught in a classroom. Topic outlines listing content within a course generally require approval by an oversight committee such as a university curriculum committee. Faculty is expected to follow approved curriculum outlines. However, it is recognized that there is the possibility that faculty discuss much more than is listed on the syllabi. Similarly, individual faculty may choose to spend more or less time on individual topics. For example, psychopharmacology related to specific mental health diagnoses might be included in topics related to the problem but not actually listed in the course content. It is recognized that important teaching also occurs outside the classroom when faculty meet with students individually to process logs and do clinical conferencing. It is possible that this survey did not adequately capture those learning opportunities. The dynamic nature of this content makes it very possible that many programs have already or are planning to increase the amount and specificity of behavioral/mental health content. This survey could only capture what was available at the time of the survey (2002-2003).

A second limitation involved the first phase of data collection using the AFPNP member list. The first set of responses came from those in that group who chose to respond to the survey, creating a self-selected sample. Faculty members who do not belong to the AFPNP were not provided that opportunity.

A third limitation that needs mention is the continuing difficulty in clearly defining what is meant by the term 'behavioral/mental' health. It is clear from the literature and from incidental report that a lack of consensus continues to exist regarding the definition, placement, and division of content that is considered development, behavior, and mental health.

Discussion

Nearly all of the nationally recognized PNP programs that currently exist in the U.S. were represented in this survey (total of 78 graduate PNP programs). As such, the survey represents the most comprehensive assessment of what is available at this time in PNP curricula nationally. However, the task of clearly determining what belongs in the domain of behavioral/mental health was complicated by the universal ambiguity that surrounds this field of health. The boundaries are often vague and overlapping along the continuum of developmental health, behavioral health, and mental health. This is not to imply that clear distinctions are realistic or even desirable in the practice of providing comprehensive health care to children where the integration of the physical and psychosocial components of the child and family are essential. The academic pursuit of teaching pediatric nursing, however, has traditionally delineated core knowledge or essential content. Traditionally the education of PNPs has distinctly contained a strong focus on child development and the anticipatory guidance associated with each stage of normal development. In time, this evolved to contain an increased emphasis on the common behavioral problems associated with normal development. The recognition, assessment, and management of more complex behavioral and mental health problems, however, were left to the specialty of child psychiatry and child psychiatric nursing. The changing epidemiology of mental health problems and the limitations of the current health care system have increasingly moved its burden to primary care. It is evident that PNP education has tried to respond, often within the confines of existing curricula, by adding content related to more complex behavioral/mental health problems to already established courses.

It is apparent that some schools of nursing have begun to develop a subspecialty in the area of behavioral/mental health for nurse practitioners. These programs may be a result of collaboration with other advanced practice nursing colleagues in psychiatric/mental health nursing. Pediatric advanced practice subspecialties have emerged many times in the past when a defined body of knowledge and skills were developed in response to a recognized need. Examples include: adolescent health, children with special needs, human lactation, school health, and genetics. PNP programs in schools that offer such subspecialties often benefit from the breadth and depth of the content available in these specialized courses, either as electives or through informal diffusion of new content across courses. However, as universities are forced to downsize and consolidate programs due to economic constraints, program enrichment from subspecialty courses is threatened.

In summary it should be noted that all programs included some content that could clearly be indicated as behavioral/mental health. It is noteworthy that one third of the programs either required or offered as an elective, a distinct course in behavioral/mental health. This appears to represent a significant growth in the attention given to this area and the subsequent building of a clear core component of knowledge considered essential for inclusion in many PNP programs. It is recognized that some programs may contain more content than is apparent in this survey, but label it as development. It is also possible that behavioral/mental health content was imbedded in more general topic areas such as 'new morbidities,' 'chronic conditions,' or 'children with special needs.'

Specific content could only be assessed based on the information provided by self-report or what was provided in course syllabi submitted to the PNP Program Review Committee of the PNCB. In the majority of programs, it was not clear that support courses such as pathophysiology had been 'updated' to reflect new understanding of some of the neurophysiologic basis for mental health problems. All programs indicated that they included general assessment of behavior in children in all of the age groups from infancy to adolescence, but when the reviewers tried to determine the selection and utilization of specific screening tools for behavioral mental health it was apparent that very few programs included this information.

Given the strong documentation of the availability of valid and reliable screening tools to identify children at risk for significant behavioral/mental health problems, it is noteworthy that such tools did not have a clear presence in the curricula (Glascoe, 2000). Early identification and early intervention has been the cornerstone of the PNP's role in primary care, yet fewer than 10% of programs appeared to include the teaching of specific screening tools beyond the Denver II which does not assess the behavioral mental health of the child. A few programs have incorporated the use of mental health screening tools in the required health assessment course. This appears to be a logical place to introduce the foundation for more sophisticated assessment early in the student's training. As more PNP students enter graduate programs with a comprehensive foundational assessment course, the inclusion of a more advanced approach to assessment makes sense. The screening tools taught should be those that evidence demonstrates are most effective at identifying 'at risk' children. It is not clear at the present time how the particular tools taught are chosen. For example, even though the CRAFFT is the most valid and reliable tool to identify substance abuse in adolescents, only the CAGE was specifically listed by programs (Knight, Sherritt, Harris, Gates, & Chang, 2003). One area of screening that has not received much attention in PNP programs is the area of screening for strengths and assets or protective factors. Nursing has historically made a significant contribution to the recognition of the importance of resiliency in assessing children and families. However, specific screening tools to identify these assets have not been utilized. Recently, valid tools have been developed that will serve this purpose such as the Strengths and Difficulties questionnaire (Goodman, 2001). It is also worth noting that a difference appears to exist between the most commonly taught mental health diagnoses and the mental health problems that occur most frequently. While anxiety is the most commonly occurring mental health diagnosis in children today, it is only twelfth on the list of problems taught (see Tables 3 & 4).

This survey revealed a wide variance in the number of hours devoted to behavioral/mental health content in PNP programs. While it is not clear what the minimum number of hours should be, given the competing demands on the curriculum, it will be important for programs to prioritize topic areas to reflect the actual morbidities and mortalities seen in pediatrics.

Many providers have questioned the appropriate use and relevance of the DSM IV in pediatric primary care. The plasticity of children and the significance of environmental factors in the mental health problems of children make the rigid use of mental health diagnoses less useful in many cases. Yet, the need to communicate across disciplines; the importance of diagnoses to support specific treatments, including medications; and the frequent requirement of using DSM IV criteria for purposes of reimbursement justify the inclusion of this content.

The evolution of prescriptive privileges of nurse practitioners and the rapidly growing use of psycho pharmaceutical agents in the treatment of children raises some important questions regarding the preparedness of nurse practitioners to prescribe or collaborate in the pharmacologic treatment of children. The content of psychopharmacology found in this survey was significantly limited relative to the increasing role of PNPs in mental health.

Pediatric primary care providers are also being encouraged to develop the knowledge and skills necessary to conduct brief interventions and short-term therapies that may preclude the need for a specialized referral or may support the child and family while referral is pending. The literature increasingly reports evidence that interventions such as cognitive-behavioral therapy, psycho-educational groups, and behavioral conditioning are effective with select groups of children and parents (Center for School Mental Health Assistance, 2002; Christopherson & Mortweet, 2001). It is expected that the curriculum of PNP programs will continue to reflect the growing importance to clinicians of acquiring these skills.

Skills can be clinically taught in many ways including the use of traditional settings where a preceptor is skilled in behavioral/mental health care, school-based health centers where a team approach may include a mental health therapist, or an inpatient/outpatient mental health setting. It is recognized that the traditional pediatric primary care setting is too often not a setting where students see behavioral/ mental health care role modeled. The growing opportunities for interdisciplinary approaches to mental health care that are found in schools and day care settings are reflected in this survey.

Conclusion/Recommendations

This survey did not attempt to answer the question of what is the essential content for PNP curricula in the area of behavioral/mental health, but rather to determine how programs are responding to the challenge now before them. It is expected that as the primary health care environment evolves, recognition of the need to determine essential content in the area of behavioral/mental health in PNP programs will take on increasing importance. Based on the current epidemic of behavioral/mental health problems and disorders and the paucity of specialty resources for referral, it seems evident that certain components of the assessment and management of behavioral/mental health of children do belong in all PNP curricula today. These components should be chosen from evidence based research and practice. While some programs will continue to offer subspecialties in pediatric behavioral health, it appears reasonable to encourage all pediatric nurse practitioner curricula to offer some content related to the following areas:

1. Specific, evidence-based screening tools to identify children at risk for behavioral/mental health problems, such as the Pediatric System Checklist, CRAFFT, and Strengths and Difficulties Questionnaire.

2. Advanced interviewing skills focused on assessing and counseling children and families around behavioral/mental health issues.

3. Specific behavioral/mental health problems and diagnoses that reflect current morbidity and mortality.

4. Appropriate use of diagnostic criteria such as the DSM IV and DSM for Primary Care.

5. Additional neuropsychology and pathophysiology of mental health disorders.

6. Additional psychopharmacology.

7. Brief intervention modalities suited for primary care such as cognitive behavioral therapy and psycho educational groups.

8. Case management focusing on collaboration and referral, and reimbursement mechanisms.

9. Program planning for prevention strategies and advocacy.

Concurrently, faculty will have to become better prepared to teach this content. Lack of faculty preparation in this growing subspecialty and lack of qualified preceptors to mentor students and faculty as well as appropriate clinical sites complicates the call to respond to the challenge. When given the opportunity to self-report, the majority of programs did indicate a concern and interest in adding additional knowledge and skills in the behavioral/mental health area. As the role of the PNP continues to expand and demands to increase content and clinical training continue to be placed on educators of PNP programs, the burden of providing a sound education in a feasible time frame will be an increasing challenge.

 Table 1. Titles of Individual Courses in Pediatric Behavioral/Mental Health                                                             Number of COURSE TITLES                                               credits  Capstone Course in Behavioral Pediatrics                   3  Mental Health Nursing Intervention for Families            3 Psychiatric Management                                     2 Child Adolescent and Family Illness & Loss                 2 Implications of Growth & Development on Health Promotion in Families                                                3 Ecological Approaches to Child Health                      3 Advanced Nursing Practice Pediatric Primary Care III       3  Assessment and Management of Child Psychiatric Symptoms    2 Advanced Primary Care Nursing of Children  Infancy: The Context of Relationships                      4 Common Developmental and Behavioral Problems               2 Children With Special Health Care Needs and Their families and Communities                                   4 Infant Child and Adolescent Health/Wellness                3 Advanced Concepts in Child & Adolescent Development        Unknown Psychosocial Assessment Strategies:                        3 Childhood Development                                      2 Health Problems of Behavior & Development: Birth through Adolescence                                                Unknown Behavioral Health for APN's                                1 Violence and Abuse                                         1 Social Environmental Health Problems                       1 Families At Risk                                           Unknown Early Intervention                                         Unknown                                                             Clinical COURSE TITLES                                              component  Capstone Course in Behavioral Pediatrics                   90 hours                                                            1day/wk Mental Health Nursing Intervention for Families            60 hours Psychiatric Management                                     30 hours Child Adolescent and Family Illness & Loss                 N/A Implications of Growth & Development on Health Promotion in Families                                                N/A Ecological Approaches to Child Health                      N/A Advanced Nursing Practice Pediatric Primary Care III       60 hours                                                            4hrs/week Assessment and Management of Child Psychiatric Symptoms    N/A Advanced Primary Care Nursing of Children                  112 hours                                                            8 hrs/week Infancy: The Context of Relationships                      Integrated Common Developmental and Behavioral Problems               Integrated Children With Special Health Care Needs and Their families and Communities                                   Integrated Infant Child and Adolescent Health/Wellness                Unknown Advanced Concepts in Child & Adolescent Development        N/A Psychosocial Assessment Strategies:                        N/A Childhood Development                                      N/A Health Problems of Behavior & Development: Birth through Adolescence                                                Unknown Behavioral Health for APN's                                Unknown Violence and Abuse                                         Unknown Social Environmental Health Problems                       Unknown Families At Risk                                           Unknown Early Intervention                                         Unknown  Note: N/A: no clinical attached to the course  Table 2. Utilization of specific Screening Tools for Behavioral/Mental Health  Child Behavior Symptom Checklist            7/78    9%  Pediatric Symptom Checklist                 7/78    9%  ADHD screening tools                        5/78    6%  Substance Abuse screening tools             4/78    5%  Depression screening tools (non-specific)   2/78    2%  Figure 1. Number of Hours of Behavioral Mental Health Content in PNP Programs  more than 45 hours                              6%  10 to 19 hours                                 25%  20 to 45 hours                                 41%  less than 10 hours                             28%  Note: Table made from pie chart.  Table 3. Mental Health Diagnoses Taught in Order of Frequency  1. Attention Deficit Hyperactivity Disorder  2. Mental Retardation/Learning Disabilities  3. Eating Disorders  4. Depression  5. Child Abuse/sexual abuse  6. Addiction Disorders/Substance Abuse  7. Violence  8. Behavioral Aspects of Chronic Illness  9. Sexual Identity Disorders  10. Phobias  11. Autism  12. Anxiety Disorder, Bi-Polar Disorder, PTSD  13. Schizophrenia, Conduct Disorder  Table 4. Prevalence of Mental Health Diagnoses in Children  1. Anxiety Disorders             8-10 %  2. Conduct Disorders                 7%  3. Depression                        6%  4. Learning Disorders                5%  5. Attention Disorders               5%  6. Eating Disorders                  1%  7. Substance Abuse              Unknown  From: USDHHS/SAMSA Center for Mental Health Services (1999) 

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Elizabeth Hawkins-Walsh, DNSc, CPNP, is an Assistant Professor at The Catholic University of America School of Nursing; and Director, Pediatric Nurse Practitioner Program, Washington DC.

Carole Stone, MSN, CPNP, is Adjunct Assistant Professor at The Catholic University of America School of Nursing, Pediatric Nurse Practitioner Program, Washington DC.

This column provides information and explores credentialing issues of interest to the pediatric nurse professional, Content and creativity is emphasized and efforts made to include opinion profiles from employers and practicing nurses, as well as analytical data describing professional issues facing today's pediatric nurse, For information contact Janet Wyatt PhD, RN, CRNP--Section Editor at Pediatric Nursing Journal East Holly Ave., Box 56, Pitman, NJ 08071-0056