Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.

Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.

Working from a lifespan approach, this first practicum course for the psychiatric mental health nurse practitioner (PMHNP) is an introduction for the learner to child and adolescent psychiatry. Emphasis is placed on the psychiatric and/or mental health disorders that begin in childhood and adolescence and topics include psychiatric assessment, differential diagnosis, application of diagnostic criteria, appropriate diagnostic testing, and diagnostic formulation. Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent. The learner will select a combination of psychotherapeutic modalities coupled with psychopharmacologic approaches to treat common psychiatric mental health conditions of children and adolescents. The focus of the practicum experience is on application of didactic concepts to actual patient care situations.

The psychiatric services landscape for children and adolescents is broadly acknowledged
as insufficient to meet the need for services. While an ideal treatment team for
most youth would include a child and
adolescent psychiatrist (CAP), there are
relatively few CAPs in practice. Each of the other mental health professions has
a unique contribution to make to states and communities as they plan for and provide quality care to this underserved population.

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Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.In this article, we present data from a statewide survey of key informants from all counties in New York
State to highlight the current and potential role of nurse practitioners (NPs)
in mental health services for youth. Results are interpreted within the context
of current training for NPs, and recommendations are made for enhancing the
current capacity of the profession.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
BACKGROUND
Child and Adolescent Mental
Health Service Needs
Over the course of a year, one in five youth will develop a mental disorder (U.S. Department of Health and Human Services, 1999). It is estimated that 12% to 20% of children and adolescents experience mental health problems and that the prevalence of serious emotional disturbances, a mental
health classification of substantial functional impairment in family, school,
and community relations and activities, ranges from 9% to 13% for youth ages 9 to 17 (Kim & American Academy of Child and Adolescent Psychiatry Task Force on Workforce Needs, 2003).  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
For children who are in need of mental health services, unaddressed mental disorders can result in serious long-term outcomes, such as poor academic progress, higher risk for substance use, greater involvement with the correctional system, vocational problems, health
problems, and increased risk of suicide (Substance Abuse and Mental Health Services Administration, 2003). On the other hand, timely and appropriate interventions could limit the persistence,
chronicity, and comorbidity that may develop when childhood mental health disorders are left untreated.
Child and Adolescent Mental
Health Service Availability
Since 1980, several studies have documented significant gaps between the need
for child and adolescent mental health services and the availability of CAPs. It is estimated that there are approximately 6,300 CAPs to treat the millions of children with mental health conditions in the
United States; if a CAP were to treat just
ABSTRACT
The high prevalence of child and adolescent mental health disorders coupled with shortages in age appropriate mental health services pose a significant problem likely to be exacerbated over time. A survey
was designed to identify the current status of and need for child and adolescent psychiatrists (CAPs)
and mental health services, as well as strategies and recommendations to address identified needs in the
state of New York. Key informants from each county and New York City were surveyed by telephone (N =
58). Most respondents identified a shortage of child and adolescent psychiatry services and reported that
when CAPs are unavailable, nurse practitioners (NPs) are currently among the top four professional groups
who prescribe and/or monitor psychotropic medication. Almost half of the respondents (48%) identified
employing NPs with advanced certification in child and adolescent psychiatry as a promising strategy
to improve access to care. Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.Addressing the shortage
of CAPs can provide an opportunity for the nursing profession to advance its role in the provision of
mental health services to youth.
Earn
4.0 Contact
Hours
Journal of Psychosocial Nursing • Vol. 47, No. 3, 2009 35
© 2009 Images.com/JupiterImages Corporation
the most severely impaired children, each one would have to carry
a caseload of 750 severely disturbed
children at any given time (Kim &
American Academy of Child and
Adolescent Psychiatry Task Force
on Workforce Needs, 2003).
Currently, a key component of the care of children and adolescents with mental disorders is the
prescription of psychotropic medications. Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.During the 1990s, the development of new medications
such as selective serotonin reuptake inhibitors for the treatment of mental illness triggered significant growth in the rate of psychotropic prescriptions for children and adolescents, with prescription
rates tripling between 1987 and 1996 (Koppelman, 2004).
A Special Role for Nurse
Practitioners
Overall, NPs can serve as primary health care providers, be
specialists or generalists, provide
physical examinations, diagnose
and treat illness, prescribe medications, order laboratory tests and interpret the results, educate
on healthy lifestyle choices, and coordinate health care services
(The Nurse Practitioner Association New York State, n.d.).
Research indicates that NPs provide services that result in good
patient outcomes and often receive higher consumer satisfaction ratings than physicians (Elsom, Happell, & Manias, 2005).
Core to mental health nursing is
the relationship built with clients
through using a continuum of
intimacy ranging from friend to
professional (Jackson & Stevenson, 2000; Perraud et al., 2006).
Many steps have been taken in
an effort to support NPs, as well as
pediatricians and psychologists,
to provide children’s psychiatric
care. There has been a shift in
pediatric training in which residency programs are increasing
behavioral and developmental
requirements and a subspecialty in developmental and behavioral
pediatrics has been created (Koppelman, 2004). Another shift is a recent increase in the number
of advanced practice nursing programs available and the creation of psychiatric specialties in
advanced practice nursing (Delaney, 2008). Nurses need to be trained to address a broad scope
of practice including individual, group, and family therapy, as
well as medication management
(Campbell, Musil, & Zauszniewski, 1998). Prescribing rights have
been granted to nonphysicians
such as psychologists who complete specialized training in certain states, and NPs and other advanced practice nurses also have
prescribing rights, including for
psychotropic medications, in 50
states and the District of Columbia (National Alliance on Mental Illness, 2002). However, it is
estimated that pediatricians and
family physicians prescribe 85%
of all psychotropic medications
taken by children (Koppelman,
2004), and fewer than two thirds
of advanced practice psychiatric
nurses with prescribing authority
were using that authority to prescribe (Campbell et al., 1998).

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METHOD
Survey Sample
The study used a purposive
sampling strategy to identify one
person with extensive knowledge
about mental health services in
each county. An organization
of county mental health directors and the individual directors
themselves familiar with county
personnel assisted in this process.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
Respondents were community
mental health directors, commissioners, or a party of comparable
status representing each of the
58 counties in New York State.
For the purposes of this study,
New York City was treated as one
county and defined as the population and area made up of all five
boroughs (Queens, Kings, Bronx,
Richmond, and Manhattan).
To provide more comprehensive information, participants
could invite additional staff to
participate in the interview, and
13 counties did so, for a total of 76
individuals. All 58 counties participated in the survey for a 100%
response rate. More than 40% of
the participants were directors
of community, child and family,
mental health, and clinical services. The rest were a mix of assistant or deputy directors, supervisors, coordinators, and clinicians
(e.g., supervisory social worker,
single point of access coordinator,
psychiatrist). On average, participants had been in their current
job for 7 years and had been living
in the community for 16 years.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
Survey Instrument
Survey questions were based
on a review of the literature,
similar surveys, and consultations
with experts in the field, as well
as an advisory committee composed of county mental health
directors and a family advocate
for child and adolescent mental
health services. The instrument
was designed to be administered
over the telephone and contained
open-ended and closed-ended
questions within five sections:
l Current status of CAPs in
each county.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
l The need for CAPs and additional psychiatric services.
l Alternative strategies to
CAPs.
l Influences on child psychiatric services.
l Respondent priorities.
Once developed, the survey was
pretested, and feedback from the
reviewers was incorporated into
the final survey design.
Data Collection
Prior to administering the
survey, efforts were made to in36 JPNonline.com
crease participation and data
quality. The study was promoted
by a statewide mental health directors’ membership organization
through its newsletter, as well as a
presentation by the researchers to
mental health directors. Project
staff sent advance e-mails to each
identified participant announcing
the upcoming survey and scheduled a time to complete the survey by telephone. An electronic
copy of the instrument and informed consent were e-mailed to
the participants. The University
at Albany’s Institutional Review
Board approved this project. Data
quality was further enhanced by
providing respondents with survey results for their verification.
Interviews were conducted using a computer-assisted telephone
interviewing program—software
that is able to customize the flow
of the questionnaire on the basis
of the answers provided and information known about the participant. Interview time was affected
by county size and nuances, as
well as the number of individuals
who participated from the county
on the telephone call. On average, the interviews took approximately 60 minutes to complete,
with the longest interview lasting
more than 2 hours. All interviews
were conducted between October
and December 2007.
RESULTS
Provider Availability and
Role of NPs
Approximately 20% of counties have no CAPs providing services within their county. Another
9 county representatives reported
only one CAP providing services.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
Of the 58 counties, nearly all (n =
53) reported the need for additional CAPs. Of the county representatives who expressed a need for
more CAPs, almost all reported
that this need significantly affects
the county (n = 50) and that there
is a strain on other professionals
providing mental health services
as a direct result of the shortage of
CAPs (n = 51).
Of the eight options offered
to county representatives as ways
their counties currently supplement the child psychiatry workforce, reliance on nurse practitioners with advanced certification
(NPACs) in child psychiatry
was endorsed most often; nearly
half of the counties (48%) use
NPACs in this capacity. NPs
were also among the top four
professional groups responsible
for prescribing and/or monitoring
psychotropic medication for children and adolescents in addition
Figure 1. Percentage of counties with professional group prescribing and/or monitoring
psychotropic medications.
Note. CAPs = child and adolescent psychiatrists; NPs = nurse practitioners. Percentage of Counties
Professional Groups
Pediatricians
Primary Care Physicians
NPs
Adult Psychiatrists
Neurologists
Developmental
Behavioral Pediatricians
Psychiatry Residents
CAP Fellows
100
90
80
70
60
50
40
30
20
10
0
Figure 2. Percentage of counties using strategies to supplement the child and adolescent
psychiatrist workforce.
Note. CAPs = child and adolescent psychiatrists; NPs = nurse practitioners.
a
Locum tenens is temporary employment for physicians. Percentage of Counties
Strategy
NPs
Telepsychiatry
Locum Tenensa
Special Training
Work with CAP Training
Program
Developmental Behavioral
Pediatricians
International Graduate
Medical Residents
Limited Permit CAP
60
50
40
30
20
10
0
Journal of Psychosocial Nursing • Vol. 47, No. 3, 2009 37
to or instead of CAPs. Pediatricians most commonly prescribe
and monitor medications (93%
of the counties), followed by primary care physicians (89%) and
NPs and adult psychiatrists (both
with 78%) (Figure 1).  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
Regarding the use of other strategies, approximately one third of the counties used locumtenens (temporary employment for physicians) and telepsychiatry, and nearly another third provided training for other professionals, including pediatricians,n primary care physicians, and adult psychiatrists (Figure 2).
Benefits and Drawbacks Regarding the Role of NPs
Counties who used NPACs were asked in an open-ended question about the benefits and drawbacks of employing them.
The benefit most frequently mentioned by county representatives (n = 10) regarding the use
of NPACs was cost effectiveness;

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NPAC services are less costly
than CAP services. Other benefits included increased capacity,
reduction or elimination of wait
times, and ability to prescribe
medications when CAPs were
not available. County representatives commented on the high
quality of their work and reported that NPACs were well liked
by families and children and
have experience with and enjoy
working with youth, particularly
younger children. County representatives also reported that
NPACs are more accessible and
spend more time with clients
than CAPs. Overall, county representatives reported that NPACs
are easier to recruit than CAPs,
are a stable workforce, and have
extensive knowledge of medications and medication management. In addition, in response to
questions about the impact of the
significant need for additional
CAPs, a few county representatives (n = 4) mentioned the critical role that NPs and psychiatric
nurses are beginning to play.
Respondents noted drawbacks
associated with NPACs that
stemmed from their lower level
of training and expertise compared with CAPs. The most frequently noted drawback was the
required supervision by a CAP
(n = 8), which creates additional
paperwork for CAPs and in at
least one case precluded using
an NPAC given CAP unavailability. The challenge of finding
required supervision was also
mentioned in a related question
about the significant impact of
the shortage on counties. One
county representative reported
that some physicians are not willing to supervise NPACs, possibly
due to liability concerns, and another reported that they have to
contract for supervision at a cost.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
In addition, NPACs cannot conduct court-ordered evaluations.
According to a few respondents
(n = 5), some CAPs and families
believe NPACs provide a lower
standard of care than CAPs. In
some counties, the availability of
NPACs as well as CAPs was limited. Five respondents noted difficulties in recruiting NPACs, and
another 2 reported that NPACs
have high salary expectations.
Overall, county representatives reported that while relying
on other professionals to prescribe and monitor psychotropic
medication in addition to or in
place of CAPs has been helpful,
these strategies do not adequately
meet the mental health needs of
children and adolescents. Mental
health treatment is time consuming because of the requirements
for prescribing, monitoring, follow up, and collateral contacts. In
particular, physicians with busy
practices in their primary fields
do not have adequate time or
capacity to sufficiently bridge the
gap. Some county representatives
noted that this has negatively affected the quality of assessments,
follow up, and monitoring.
The lack of availability of
CAPs to act in consultation
with all health professionals
was noted. County representatives reported that professionals
thought they required additional
expertise regarding medication
side effects, differences in dosages
for children, how to make medication adjustments, and multiple
1. The current shortage of child and adolescent psychiatrists (CAPs) along with the
high prevalence of child and adolescent mental health disorders need attention
and action.
2. In New York State, nurse practitioners play a significant role in addressing some
of these needs by prescribing and monitoring psychotropic medication. Mental
health administrators identified nurse practitioners with advanced certification
(NPAC) in child psychiatry as a promising alternative strategy.
3. Findings indicate that the quality of care is high and that NPACs are successfully
providing services to children and families.
4. Addressing the shortage of CAPs can provide an opportunity for the nursing
profession to advance its role in the provision of mental health services to youth.
Do you agree with this article? Disagree? Have a comment or questions?
Send an e-mail to Karen Stanwood, Executive Editor, at kstanwood@slackinc.com.
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K E Y P O I N T S
38 JPNonline.com
medications management. It
was suggested that consultation
with CAPs could support other
providers in their decision making, but this kind of CAP time is
largely unavailable.
DISCUSSION
This study validates the fact
that the current system does
not provide sufficient access to
specialty care for children and
adolescents with psychiatric problems and that, fundamentally, the
access problem stems from limited
availability of practitioners with
advanced training or specialization in children’s mental health.
Increasing the number of CAPs
and NPACs is a logical tactic
and arguably should be a priority
for the professions of medicine
and nursing. In the short term,
addressing the shortage of CAPs
may be more difficult because
there are several barriers to the
recruitment of CAPs, starting
with the length of training. After
4 years of medical school and at
least 3 years of residency, the CAP
specialty requires an additional 2
years of training. For NPACs,
however, completing a program
to receive a master of science in
nursing degree typically takes 1.5
to 2 years. This degree is needed
to apply to an NP program with
advanced certification in child
psychiatry, which usually takes 1
to 2 additional years to complete.
Thus, within 4 years an NPAC
would be ready to provide services
in the community compared with
9 years for a CAP.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
Currently, there are five closely related kinds of advanced nursing programs designed to address the
needs of children with mental health issues. These programs generally include courses on child pathology and psychopharmacology and direct care or practicum hours for skill development. While some of these programs have operated for years, such as the Child and Adolescent Clinical Nurse Specialists program, others are new,such as the Child and Adolescent
Psychiatric Mental Health-Nurse
Practitioner and Family Psychiatric Mental Health-Nurse Practitioner programs (Delaney, 2008).
There are approximately 55 programs in the United States offering a post-master’s degree in psychiatric nursing (Perraud et al., 2006) and at least four programs in New York State, one of which focuses solely on children and
adolescents. Continued support of existing programs and strategic development of others, in areas with high need and/or minimal
service availability, would be an
important way to address the services gap. In addition, programs may consider developing incentives for graduates to locate to areas where need is high.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
As psychiatrists and NPs develop a corps of children’s mental health specialists, the professions will need to consider the licensing and regulatory implications of the differential training experiences of CAPs and NPACs. The additional years of CAP training provide in-depth knowledge and expertise in child psychiatry beyond what most NPACs will acquire in their programs. The intensity and implementation of supervisory relationships between physicians or CAPs and NPACs should be considered,
along with liability concerns and associated supervisory costs, and
will vary from state to state.
Because it is likely that the availability of CAPs for engagement in treatment teams and for supervision and consultation will continue to be limited, communities may need to support and
facilitate creative links across providers. For example, telepsychiatry has been used to increase
access to psychiatric care for children and adolescents (Pesämaa et al., 2004). In this arena, too, regulations for supervision and funding of services would need to
be established.
CONCLUSION and
implications
Evidence from several sources points to a critical role for NPACs in the field of child and adolescent
mental health. Research suggests that outcomes under the care of NPs are similar to those obtained
when care is provided by a physician, and often satisfaction with
NP services is higher than with
physician services (Elsom et al., 2005). This study’s results suggest that quality of care is high and
NPACs are successfully providing
services to children and families.
To quote one county representative, “We’d be out of business” if it were not for psychiatric nurses.
To the extent that this study supports the development of NPs with advanced degrees in child
psychiatry as a viable means to address shortages in care, it is important to recognize that this
study is based on the perceptions of one set of key informants, albeit informants from an entire state
with a large and diverse population living in densely populated
and rural areas. Further investigation of these topics with groups representing other stakeholders,
including families using mental health services, CAPs, and NPs
themselves is needed to further inform this strategy. Data from these perspectives would add to
the understanding of NP roles, the value placed on their contribution, and additional ideas for
taking the steps needed to improve access to effective care for youth with mental health needs.
REFERENCES
Campbell, C.D., Musil, C.M., & Zauszniewski, J.A. (1998). Practice patterns of advanced practice psychiatric
nurses. Journal of the American Psychiatric Nurses Association, 4, 111-120.
Delaney, K.R. (2008). Addressing children’s
Journal of Psychosocial Nursing • Vol. 47, No. 3, 2009 39
mental health needs: Educational preparation of advanced practice nurses.
Journal of Child and Adolescent Psychiatric Nursing, 21, 57-59.
Elsom, S., Happell, B. & Manias, E. (2005).
Mental health nurse practitioner:
Expanded or advanced? International
Journal of Mental Health Nursing, 14,
181-186.
Jackson, S., & Stevenson, C. (2000). What
do people need psychiatric and mental
health nurses for? Journal of Advanced
Nursing, 31, 378-388.
Kim, W.J., & American Academy of Child
and Adolescent Psychiatry Task Force
on Workforce Needs. (2003). Child
and adolescent psychiatry workforce: A
critical shortage and national challenge.
Academic Psychiatry, 27, 277-282.
Koppelman, J. (2004). The provider system
for children’s mental health: Workforce
capacity and effective treatment (NHPF
Issue Brief No. 801). Retrieved January 9, 2009, from http://www.nhpf.org/
pdfs_ib/IB801_ChildMHProvider_10-
26-04.pdf
National Alliance on Mental Illness.
(2002). Policy topics: Prescribing privileges
for psychologists: An overview. Retrieved
January 9, 2009, from http://www.nami.
org/Template.cfm?Section=Issue_
Spotlights&template=/ContentManagement/ContentDisplay.
cfm&ContentID=8375
The Nurse Practitioner Association New
York State. (n.d.). About nurse practitioners. Retrieved June 17, 2008,
from http://thenpa.affiniscape.com/
displaycommon.cfm?an=1&subarticlen
br=169#whatcan
Perraud, S., Delaney, K.R., Carlson-Sabelli,
L., Johnson, M.E., Shepard, R., &
Paun, O. (2006). Advanced practice
psychiatric mental health nursing, finding our core: The therapeutic relationship in the 21st century. Perspectives in
Psychiatric Care, 42, 215-226.
Pesämaa, L., Ebeling, H., Kuusimäki, M.L.,
Winblad, I., Isohanni, M., & Moilanen,
I. (2004). Videoconferencing in child
and adolescent telepsychiatry: A systematic review of the literature. Journal of
Telemedicine and Telecare, 10, 187-192.
Substance Abuse and Mental Health Services Administration. (2003, February 5). Policy options: Subcommittee on
children and family. Promoting preserving and restoring children’s mental health.
Retrieved March 1, 2008, from http://
www.mentalhealthcommission.gov/
subcommittee/children_family020703.
doc
U.S. Department of Health and Human Services. (1999). Mental health:
A report of the Surgeon General. Retrieved January 9, 2009, from http://
www.surgeongeneral.gov/library/
mentalhealth/home.html
Dr. Kaye is Research Scientist, Dr. Lewandowski is Director, Ms. Greene is Associate Director, and Ms. Chiarella is Research
Support Specialist, Center for Human Services Research, University at Albany; Dr.
Kaye is also Assistant Research Professor,
Dr. Warner and Dr. Lewandowski are Associate Professors, and Ms. Acker is Research Assistant, School of Social Welfare,
University at Albany, The State University
of New York, Albany, New York.
The authors disclose that they have
no significant financial interests in any
product or class of products discussed
directly or indirectly in this activity.
This study was supported by the New
York State Conference of Local Mental
Hygiene Directors as part of their Solution
to End Psychiatric Shortages (STEPS)
Initiative.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
Address correspondence to Lara Kaye,
PhD, MSW, Research Scientist, Center for
Human Services Research, and Assistant
Research Professor, School of Social
Welfare, Richardson 184, University at
Albany, 135 Western Avenue, Albany, NY
12222; e-mail: lkaye@uamail.albany.edu.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.

 

Working from a lifespan approach, this first practicum course for the psychiatric mental health nurse practitioner (PMHNP) is an introduction for the learner to child and adolescent psychiatry. Emphasis is placed on the psychiatric and/or mental health disorders that begin in childhood and adolescence and topics include psychiatric assessment, differential diagnosis, application of diagnostic criteria, appropriate diagnostic testing, and diagnostic formulation. Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent. The learner will select a combination of psychotherapeutic modalities coupled with psychopharmacologic approaches to treat common psychiatric mental health conditions of children and adolescents. The focus of the practicum experience is on application of didactic concepts to actual patient care situations.

The psychiatric services landscape for children and adolescents is broadly acknowledged
as insufficient to meet the need for services. While an ideal treatment team for
most youth would include a child and
adolescent psychiatrist (CAP), there are
relatively few CAPs in practice. Each of the other mental health professions has
a unique contribution to make to states and communities as they plan for and provide quality care to this underserved population.

ORDER  A PLAGIARISM FREE PAPER  NOW

Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.In this article, we present data from a statewide survey of key informants from all counties in New York
State to highlight the current and potential role of nurse practitioners (NPs)
in mental health services for youth. Results are interpreted within the context
of current training for NPs, and recommendations are made for enhancing the
current capacity of the profession.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
BACKGROUND
Child and Adolescent Mental
Health Service Needs
Over the course of a year, one in five youth will develop a mental disorder (U.S. Department of Health and Human Services, 1999). It is estimated that 12% to 20% of children and adolescents experience mental health problems and that the prevalence of serious emotional disturbances, a mental
health classification of substantial functional impairment in family, school,
and community relations and activities, ranges from 9% to 13% for youth ages 9 to 17 (Kim & American Academy of Child and Adolescent Psychiatry Task Force on Workforce Needs, 2003).  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
For children who are in need of mental health services, unaddressed mental disorders can result in serious long-term outcomes, such as poor academic progress, higher risk for substance use, greater involvement with the correctional system, vocational problems, health
problems, and increased risk of suicide (Substance Abuse and Mental Health Services Administration, 2003). On the other hand, timely and appropriate interventions could limit the persistence,
chronicity, and comorbidity that may develop when childhood mental health disorders are left untreated.
Child and Adolescent Mental
Health Service Availability
Since 1980, several studies have documented significant gaps between the need
for child and adolescent mental health services and the availability of CAPs. It is estimated that there are approximately 6,300 CAPs to treat the millions of children with mental health conditions in the
United States; if a CAP were to treat just
ABSTRACT
The high prevalence of child and adolescent mental health disorders coupled with shortages in age appropriate mental health services pose a significant problem likely to be exacerbated over time. A survey
was designed to identify the current status of and need for child and adolescent psychiatrists (CAPs)
and mental health services, as well as strategies and recommendations to address identified needs in the
state of New York. Key informants from each county and New York City were surveyed by telephone (N =
58). Most respondents identified a shortage of child and adolescent psychiatry services and reported that
when CAPs are unavailable, nurse practitioners (NPs) are currently among the top four professional groups
who prescribe and/or monitor psychotropic medication. Almost half of the respondents (48%) identified
employing NPs with advanced certification in child and adolescent psychiatry as a promising strategy
to improve access to care. Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.Addressing the shortage
of CAPs can provide an opportunity for the nursing profession to advance its role in the provision of
mental health services to youth.
Earn
4.0 Contact
Hours
Journal of Psychosocial Nursing • Vol. 47, No. 3, 2009 35
© 2009 Images.com/JupiterImages Corporation
the most severely impaired children, each one would have to carry
a caseload of 750 severely disturbed
children at any given time (Kim &
American Academy of Child and
Adolescent Psychiatry Task Force
on Workforce Needs, 2003).
Currently, a key component of the care of children and adolescents with mental disorders is the
prescription of psychotropic medications. Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.During the 1990s, the development of new medications
such as selective serotonin reuptake inhibitors for the treatment of mental illness triggered significant growth in the rate of psychotropic prescriptions for children and adolescents, with prescription
rates tripling between 1987 and 1996 (Koppelman, 2004).
A Special Role for Nurse
Practitioners
Overall, NPs can serve as primary health care providers, be
specialists or generalists, provide
physical examinations, diagnose
and treat illness, prescribe medications, order laboratory tests and interpret the results, educate
on healthy lifestyle choices, and coordinate health care services
(The Nurse Practitioner Association New York State, n.d.).
Research indicates that NPs provide services that result in good
patient outcomes and often receive higher consumer satisfaction ratings than physicians (Elsom, Happell, & Manias, 2005).
Core to mental health nursing is
the relationship built with clients
through using a continuum of
intimacy ranging from friend to
professional (Jackson & Stevenson, 2000; Perraud et al., 2006).
Many steps have been taken in
an effort to support NPs, as well as
pediatricians and psychologists,
to provide children’s psychiatric
care. There has been a shift in
pediatric training in which residency programs are increasing
behavioral and developmental
requirements and a subspecialty in developmental and behavioral
pediatrics has been created (Koppelman, 2004). Another shift is a recent increase in the number
of advanced practice nursing programs available and the creation of psychiatric specialties in
advanced practice nursing (Delaney, 2008). Nurses need to be trained to address a broad scope
of practice including individual, group, and family therapy, as
well as medication management
(Campbell, Musil, & Zauszniewski, 1998). Prescribing rights have
been granted to nonphysicians
such as psychologists who complete specialized training in certain states, and NPs and other advanced practice nurses also have
prescribing rights, including for
psychotropic medications, in 50
states and the District of Columbia (National Alliance on Mental Illness, 2002). However, it is
estimated that pediatricians and
family physicians prescribe 85%
of all psychotropic medications
taken by children (Koppelman,
2004), and fewer than two thirds
of advanced practice psychiatric
nurses with prescribing authority
were using that authority to prescribe (Campbell et al., 1998).

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METHOD
Survey Sample
The study used a purposive
sampling strategy to identify one
person with extensive knowledge
about mental health services in
each county. An organization
of county mental health directors and the individual directors
themselves familiar with county
personnel assisted in this process.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
Respondents were community
mental health directors, commissioners, or a party of comparable
status representing each of the
58 counties in New York State.
For the purposes of this study,
New York City was treated as one
county and defined as the population and area made up of all five
boroughs (Queens, Kings, Bronx,
Richmond, and Manhattan).
To provide more comprehensive information, participants
could invite additional staff to
participate in the interview, and
13 counties did so, for a total of 76
individuals. All 58 counties participated in the survey for a 100%
response rate. More than 40% of
the participants were directors
of community, child and family,
mental health, and clinical services. The rest were a mix of assistant or deputy directors, supervisors, coordinators, and clinicians
(e.g., supervisory social worker,
single point of access coordinator,
psychiatrist). On average, participants had been in their current
job for 7 years and had been living
in the community for 16 years.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
Survey Instrument
Survey questions were based
on a review of the literature,
similar surveys, and consultations
with experts in the field, as well
as an advisory committee composed of county mental health
directors and a family advocate
for child and adolescent mental
health services. The instrument
was designed to be administered
over the telephone and contained
open-ended and closed-ended
questions within five sections:
l Current status of CAPs in
each county.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
l The need for CAPs and additional psychiatric services.
l Alternative strategies to
CAPs.
l Influences on child psychiatric services.
l Respondent priorities.
Once developed, the survey was
pretested, and feedback from the
reviewers was incorporated into
the final survey design.
Data Collection
Prior to administering the
survey, efforts were made to in36 JPNonline.com
crease participation and data
quality. The study was promoted
by a statewide mental health directors’ membership organization
through its newsletter, as well as a
presentation by the researchers to
mental health directors. Project
staff sent advance e-mails to each
identified participant announcing
the upcoming survey and scheduled a time to complete the survey by telephone. An electronic
copy of the instrument and informed consent were e-mailed to
the participants. The University
at Albany’s Institutional Review
Board approved this project. Data
quality was further enhanced by
providing respondents with survey results for their verification.
Interviews were conducted using a computer-assisted telephone
interviewing program—software
that is able to customize the flow
of the questionnaire on the basis
of the answers provided and information known about the participant. Interview time was affected
by county size and nuances, as
well as the number of individuals
who participated from the county
on the telephone call. On average, the interviews took approximately 60 minutes to complete,
with the longest interview lasting
more than 2 hours. All interviews
were conducted between October
and December 2007.
RESULTS
Provider Availability and
Role of NPs
Approximately 20% of counties have no CAPs providing services within their county. Another
9 county representatives reported
only one CAP providing services.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
Of the 58 counties, nearly all (n =
53) reported the need for additional CAPs. Of the county representatives who expressed a need for
more CAPs, almost all reported
that this need significantly affects
the county (n = 50) and that there
is a strain on other professionals
providing mental health services
as a direct result of the shortage of
CAPs (n = 51).
Of the eight options offered
to county representatives as ways
their counties currently supplement the child psychiatry workforce, reliance on nurse practitioners with advanced certification
(NPACs) in child psychiatry
was endorsed most often; nearly
half of the counties (48%) use
NPACs in this capacity. NPs
were also among the top four
professional groups responsible
for prescribing and/or monitoring
psychotropic medication for children and adolescents in addition
Figure 1. Percentage of counties with professional group prescribing and/or monitoring
psychotropic medications.
Note. CAPs = child and adolescent psychiatrists; NPs = nurse practitioners. Percentage of Counties
Professional Groups
Pediatricians
Primary Care Physicians
NPs
Adult Psychiatrists
Neurologists
Developmental
Behavioral Pediatricians
Psychiatry Residents
CAP Fellows
100
90
80
70
60
50
40
30
20
10
0
Figure 2. Percentage of counties using strategies to supplement the child and adolescent
psychiatrist workforce.
Note. CAPs = child and adolescent psychiatrists; NPs = nurse practitioners.
a
Locum tenens is temporary employment for physicians. Percentage of Counties
Strategy
NPs
Telepsychiatry
Locum Tenensa
Special Training
Work with CAP Training
Program
Developmental Behavioral
Pediatricians
International Graduate
Medical Residents
Limited Permit CAP
60
50
40
30
20
10
0
Journal of Psychosocial Nursing • Vol. 47, No. 3, 2009 37
to or instead of CAPs. Pediatricians most commonly prescribe
and monitor medications (93%
of the counties), followed by primary care physicians (89%) and
NPs and adult psychiatrists (both
with 78%) (Figure 1).  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
Regarding the use of other strategies, approximately one third of the counties used locumtenens (temporary employment for physicians) and telepsychiatry, and nearly another third provided training for other professionals, including pediatricians,n primary care physicians, and adult psychiatrists (Figure 2).
Benefits and Drawbacks Regarding the Role of NPs
Counties who used NPACs were asked in an open-ended question about the benefits and drawbacks of employing them.
The benefit most frequently mentioned by county representatives (n = 10) regarding the use
of NPACs was cost effectiveness;

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NPAC services are less costly
than CAP services. Other benefits included increased capacity,
reduction or elimination of wait
times, and ability to prescribe
medications when CAPs were
not available. County representatives commented on the high
quality of their work and reported that NPACs were well liked
by families and children and
have experience with and enjoy
working with youth, particularly
younger children. County representatives also reported that
NPACs are more accessible and
spend more time with clients
than CAPs. Overall, county representatives reported that NPACs
are easier to recruit than CAPs,
are a stable workforce, and have
extensive knowledge of medications and medication management. In addition, in response to
questions about the impact of the
significant need for additional
CAPs, a few county representatives (n = 4) mentioned the critical role that NPs and psychiatric
nurses are beginning to play.
Respondents noted drawbacks
associated with NPACs that
stemmed from their lower level
of training and expertise compared with CAPs. The most frequently noted drawback was the
required supervision by a CAP
(n = 8), which creates additional
paperwork for CAPs and in at
least one case precluded using
an NPAC given CAP unavailability. The challenge of finding
required supervision was also
mentioned in a related question
about the significant impact of
the shortage on counties. One
county representative reported
that some physicians are not willing to supervise NPACs, possibly
due to liability concerns, and another reported that they have to
contract for supervision at a cost.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
In addition, NPACs cannot conduct court-ordered evaluations.
According to a few respondents
(n = 5), some CAPs and families
believe NPACs provide a lower
standard of care than CAPs. In
some counties, the availability of
NPACs as well as CAPs was limited. Five respondents noted difficulties in recruiting NPACs, and
another 2 reported that NPACs
have high salary expectations.
Overall, county representatives reported that while relying
on other professionals to prescribe and monitor psychotropic
medication in addition to or in
place of CAPs has been helpful,
these strategies do not adequately
meet the mental health needs of
children and adolescents. Mental
health treatment is time consuming because of the requirements
for prescribing, monitoring, follow up, and collateral contacts. In
particular, physicians with busy
practices in their primary fields
do not have adequate time or
capacity to sufficiently bridge the
gap. Some county representatives
noted that this has negatively affected the quality of assessments,
follow up, and monitoring.
The lack of availability of
CAPs to act in consultation
with all health professionals
was noted. County representatives reported that professionals
thought they required additional
expertise regarding medication
side effects, differences in dosages
for children, how to make medication adjustments, and multiple
1. The current shortage of child and adolescent psychiatrists (CAPs) along with the
high prevalence of child and adolescent mental health disorders need attention
and action.
2. In New York State, nurse practitioners play a significant role in addressing some
of these needs by prescribing and monitoring psychotropic medication. Mental
health administrators identified nurse practitioners with advanced certification
(NPAC) in child psychiatry as a promising alternative strategy.
3. Findings indicate that the quality of care is high and that NPACs are successfully
providing services to children and families.
4. Addressing the shortage of CAPs can provide an opportunity for the nursing
profession to advance its role in the provision of mental health services to youth.
Do you agree with this article? Disagree? Have a comment or questions?
Send an e-mail to Karen Stanwood, Executive Editor, at kstanwood@slackinc.com.
We’re waiting to hear from you!
K E Y P O I N T S
38 JPNonline.com
medications management. It
was suggested that consultation
with CAPs could support other
providers in their decision making, but this kind of CAP time is
largely unavailable.
DISCUSSION
This study validates the fact
that the current system does
not provide sufficient access to
specialty care for children and
adolescents with psychiatric problems and that, fundamentally, the
access problem stems from limited
availability of practitioners with
advanced training or specialization in children’s mental health.
Increasing the number of CAPs
and NPACs is a logical tactic
and arguably should be a priority
for the professions of medicine
and nursing. In the short term,
addressing the shortage of CAPs
may be more difficult because
there are several barriers to the
recruitment of CAPs, starting
with the length of training. After
4 years of medical school and at
least 3 years of residency, the CAP
specialty requires an additional 2
years of training. For NPACs,
however, completing a program
to receive a master of science in
nursing degree typically takes 1.5
to 2 years. This degree is needed
to apply to an NP program with
advanced certification in child
psychiatry, which usually takes 1
to 2 additional years to complete.
Thus, within 4 years an NPAC
would be ready to provide services
in the community compared with
9 years for a CAP.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
Currently, there are five closely related kinds of advanced nursing programs designed to address the
needs of children with mental health issues. These programs generally include courses on child pathology and psychopharmacology and direct care or practicum hours for skill development. While some of these programs have operated for years, such as the Child and Adolescent Clinical Nurse Specialists program, others are new,such as the Child and Adolescent
Psychiatric Mental Health-Nurse
Practitioner and Family Psychiatric Mental Health-Nurse Practitioner programs (Delaney, 2008).
There are approximately 55 programs in the United States offering a post-master’s degree in psychiatric nursing (Perraud et al., 2006) and at least four programs in New York State, one of which focuses solely on children and
adolescents. Continued support of existing programs and strategic development of others, in areas with high need and/or minimal
service availability, would be an
important way to address the services gap. In addition, programs may consider developing incentives for graduates to locate to areas where need is high.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
As psychiatrists and NPs develop a corps of children’s mental health specialists, the professions will need to consider the licensing and regulatory implications of the differential training experiences of CAPs and NPACs. The additional years of CAP training provide in-depth knowledge and expertise in child psychiatry beyond what most NPACs will acquire in their programs. The intensity and implementation of supervisory relationships between physicians or CAPs and NPACs should be considered,
along with liability concerns and associated supervisory costs, and
will vary from state to state.
Because it is likely that the availability of CAPs for engagement in treatment teams and for supervision and consultation will continue to be limited, communities may need to support and
facilitate creative links across providers. For example, telepsychiatry has been used to increase
access to psychiatric care for children and adolescents (Pesämaa et al., 2004). In this arena, too, regulations for supervision and funding of services would need to
be established.
CONCLUSION and
implications
Evidence from several sources points to a critical role for NPACs in the field of child and adolescent
mental health. Research suggests that outcomes under the care of NPs are similar to those obtained
when care is provided by a physician, and often satisfaction with
NP services is higher than with
physician services (Elsom et al., 2005). This study’s results suggest that quality of care is high and
NPACs are successfully providing
services to children and families.
To quote one county representative, “We’d be out of business” if it were not for psychiatric nurses.
To the extent that this study supports the development of NPs with advanced degrees in child
psychiatry as a viable means to address shortages in care, it is important to recognize that this
study is based on the perceptions of one set of key informants, albeit informants from an entire state
with a large and diverse population living in densely populated
and rural areas. Further investigation of these topics with groups representing other stakeholders,
including families using mental health services, CAPs, and NPs
themselves is needed to further inform this strategy. Data from these perspectives would add to
the understanding of NP roles, the value placed on their contribution, and additional ideas for
taking the steps needed to improve access to effective care for youth with mental health needs.
REFERENCES
Campbell, C.D., Musil, C.M., & Zauszniewski, J.A. (1998). Practice patterns of advanced practice psychiatric
nurses. Journal of the American Psychiatric Nurses Association, 4, 111-120.
Delaney, K.R. (2008). Addressing children’s
Journal of Psychosocial Nursing • Vol. 47, No. 3, 2009 39
mental health needs: Educational preparation of advanced practice nurses.
Journal of Child and Adolescent Psychiatric Nursing, 21, 57-59.
Elsom, S., Happell, B. & Manias, E. (2005).
Mental health nurse practitioner:
Expanded or advanced? International
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181-186.
Jackson, S., & Stevenson, C. (2000). What
do people need psychiatric and mental
health nurses for? Journal of Advanced
Nursing, 31, 378-388.
Kim, W.J., & American Academy of Child
and Adolescent Psychiatry Task Force
on Workforce Needs. (2003). Child
and adolescent psychiatry workforce: A
critical shortage and national challenge.
Academic Psychiatry, 27, 277-282.
Koppelman, J. (2004). The provider system
for children’s mental health: Workforce
capacity and effective treatment (NHPF
Issue Brief No. 801). Retrieved January 9, 2009, from http://www.nhpf.org/
pdfs_ib/IB801_ChildMHProvider_10-
26-04.pdf
National Alliance on Mental Illness.
(2002). Policy topics: Prescribing privileges
for psychologists: An overview. Retrieved
January 9, 2009, from http://www.nami.
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Spotlights&template=/ContentManagement/ContentDisplay.
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The Nurse Practitioner Association New
York State. (n.d.). About nurse practitioners. Retrieved June 17, 2008,
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Perraud, S., Delaney, K.R., Carlson-Sabelli,
L., Johnson, M.E., Shepard, R., &
Paun, O. (2006). Advanced practice
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Psychiatric Care, 42, 215-226.
Pesämaa, L., Ebeling, H., Kuusimäki, M.L.,
Winblad, I., Isohanni, M., & Moilanen,
I. (2004). Videoconferencing in child
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www.surgeongeneral.gov/library/
mentalhealth/home.html
Dr. Kaye is Research Scientist, Dr. Lewandowski is Director, Ms. Greene is Associate Director, and Ms. Chiarella is Research
Support Specialist, Center for Human Services Research, University at Albany; Dr.
Kaye is also Assistant Research Professor,
Dr. Warner and Dr. Lewandowski are Associate Professors, and Ms. Acker is Research Assistant, School of Social Welfare,
University at Albany, The State University
of New York, Albany, New York.
The authors disclose that they have
no significant financial interests in any
product or class of products discussed
directly or indirectly in this activity.
This study was supported by the New
York State Conference of Local Mental
Hygiene Directors as part of their Solution
to End Psychiatric Shortages (STEPS)
Initiative.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.
Address correspondence to Lara Kaye,
PhD, MSW, Research Scientist, Center for
Human Services Research, and Assistant
Research Professor, School of Social
Welfare, Richardson 184, University at
Albany, 135 Western Avenue, Albany, NY
12222; e-mail: lkaye@uamail.albany.edu.  Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent.

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