The 15-year action gap: Children lose in long waits from recommendation to practice


It’s a puzzle that we pediatric primary and acute healthcare providers need to rethink and solve: Why does it continue to take more than 15 years to put either strong clinical or practice improvement recommendations into clinical practice? Or to conduct research studies that may help improve long-term outcomes for children with chronic illnesses?

Why the delay?

Because pediatric providers care for children from birth to 21 years of age, taking 15 years for practice implementation represents three-quarters of the time in which the children/adolescents are in our care without the benefit of findings from clinical research.

Ms. Nierengarten’s description of a practice improvement in the March 2017 Contemporary Pediatrics article “Mental health services in primary care” is a prime example of one such action gap. The article points out that the initial recognition of the need for mental health management for children dates back as early as the 1999 Surgeon’s General report. Another clinical topic featured in the same issue, “BPD: Complication of prematurity,” the author relates, was a condition initially described at a 2001 workshop sponsored by the National Institute of Child Health and Human Development (NICHD).

Thus, the question: Why is it taking so long to make changes in the care of our pediatric patients? After all, these are changes that may reduce barriers to achieving health and well-being outcomes for the pediatric population and, of course, later to the health and well-being of the adult population.

Regarding the specific issues on mental health issues in the pediatric/adolescent population as identified in Ms. Nierengarten’s article, what strategies can Pediatric Nurse Practitioners (PNPs), Family Nurse Practitioners (FNPs), Child/Adolescent Psychiatric and Mental Health Clinical Nurse Specialists (CNS), or Psychiatric-Mental Health Nurse Practitioners (PMHNP) implement in primary care settings to care for children presenting with mental and behavioral health problems? The article provides several recommendations including integrating behavioral health services in primary care settings within the framework of the patient-centered medical home. The suggestions for an integrated practice reflect consideration of the type of provider equipped to work within the primary care setting to provide mental health services, and the importance of identifying those mental and behavioral health diagnoses that can be treated within that setting and those that should be referred.

Credentialed to serve

Identification and recognition of a pediatric primary care-focused mental health skill set has been established through research evidence for pediatric primary care providers, PNPs, FNPs, CNSs, and PMHNPs to safely manage children with specific behavioral health problems within the pediatric primary care setting. In fact, the Pediatric Nursing Certification Board (PNCB) created a national certification examination for PNPs, FNPs, CNSs, and PMHNPs to demonstrate their competencies for certification as pediatric primary care mental health specialists (PMHS) ( The PNCB and studies that examined the role of the PMHS (Boat TF, et al; 2016) have clearly defined the role of the PMHS for diagnosing, managing, co-managing, and referring children with behavioral health problems.

Certification as a PMHS provides a unique and beneficial aspect to primary care practices as the children and adolescents can receive comprehensive primary and behavioral healthcare within one setting. It is time to evaluate the practice settings that offer these dual-care models and to evaluate outcomes of the practices as well as child/adolescent and parent satisfaction with the primary care and behavioral health services that are offered in a patient/family-centered medical home.



Boat TF, Land ML, Leslie LK, et al. Workforce development to enhance the cognitive, affective, and behavioral health of children and youth: Opportunities and barriers in child health care training. Discussion paper presented at: National Academy of Medicine, Washington, DC; November 29, 2016. Available at: Accessed March 28. 2017.

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