Area facing shortage in youth psychiatrists
But when a child’s behavior or state of mind warrants help, parents, teachers and caregivers traditionally have turned to child and adolescent psychiatrists or other specialists who work to ensure children can be their best, mentally.
A continuing issue in the country, including Texas and Tarrant County, is the lack of child and adolescent psychiatrists, however. The few physicians who are trained in this subspecialty are in high demand while the number of children needing care increases, and mental health professionals say any health care reforms need to include mental health parity.
A September 2006 study in the Journal of the American Academy of Child & Adolescent Psychiatry used 2000 U.S. Census data to look at the number of child and adolescent psychiatrists in each state, and Texas had 6.5 of these physicians per 100,000 children in 2001, roughly the same rate as Illinois, Louisiana, Tennessee and Washington. The national average for 2001 was 8.67.
Another study, this one from the Hogg Foundation for Mental Health in May 2008, found 192 child psychiatrists in Texas in 2007.
“I think there are going to be fewer and fewer doctors,” said Dr. Carol Nati, who is board certified in child, adolescent and adult psychiatry.
Nati is psychiatry clerkship director and assistant professor at the Texas College of Osteopathic Medicine, and she also sees patients at various locations, such as the JPS Health System adolescent inpatient unit, and through various organizations, like MHMR of Tarrant County. Because there is such a shortage, many specialists, like her, end up spread over many outlets to get care to as many children as possible.
“I drive all over town to see these kids,” she said.
The shortage in child and adolescent psychiatrists has been coming for some time and will continue to increase due to a host of factors, some financial.
Dr. Joyce Elizabeth Mauk, president, CEO and medical director of the Child Study Center, recently hired a child and adolescent psychiatrist to join the staff at the center. Mauk, a neurodevelopmental pediatrician (a specialty that does have some overlap with the specialized psychiatrists), said there is still a stigma against mental illness and reimbursement rates from insurance companies are much lower than for medical illness.
“It’s a shame we still have such horrible stigma about mental illness,” she said. “There is just not a family that is not touched by these disorders.”
Such low reimbursements means it is difficult for a physician to finish his or her medical training and then bring in enough income to pay off debts and keep a practice going, said Dr. M Christine Banner, medical director of child psychiatry at Cook Children’s. Medical students and young doctors can be reluctant to go into a specialty that almost automatically comes with financial worries, she said.
“Most folks who pursue a medical degree have a pretty substantial debt by the end of their training . . . so if they also know going in that they’re faced with financial difficulties in terms of financial reimbursement, that’s certainly going to be a deterrent,” she said.
Cook Children’s and some other health care systems are willing to subsidize some of the most expensive programs, Banner said, which is a help for children who need the most care. The in-hospital program at Cook Children’s, for example, is expensive because children require 24-hour care in a health care facility and may have other complex medical issues as well.
However, it’s not unusual for psychiatrists (including child and adolescent psychiatrists) who practice alone or in small groups to not accept insurance at all. A cash-only business makes it easier for the physician to make a living, Nati said, but can provide a roadblock to families and patients who need help but can’t afford to pay for it.
The 2006 study on the shortage of these specialized psychiatrists examined not only the rate of physicians per 100,000 children for each state but also the percentage of children in that state who live in poverty, and one in five Texas children were at or below the federal poverty line. The stresses of living in poverty may lead to an increased occurrence of mental illness, Nati said, and it almost certainly leads to a lack of access.
Referrals and wait times to see a child and adolescent psychiatrist can be lengthy, throwing up another roadblock to treatment. Pediatricians — the physicians most likely to see a child — are helping to fill some of the need for mental health services, said Lee LeGrice, executive director of the Mental Health Association of Tarrant County.
“There’s no stigma attached to seeing your pediatrician,” LeGrice said.
Increasingly, pediatricians can assess whether a child has some common types of mental illness — like depression, attention deficit hyperactivity disorder or autism — and pediatricians also can treat and manage some illnesses, LeGrice said.
The complication comes when a condition is complicated by psychosocial factors, the age of the child or other influences, LeGrice said. Diagnosing and treating a child must take into account the family’s history and things like a lack of access due to low socioeconomic status.
“Some of these conditions don’t fit in nice, neat little categories. They’re complex,” she said.
The complexity can come because physicians of all sorts can be reluctant to give a major, definitive diagnosis to a child because a disease can evolve as a child grows older and finally presents itself as something other than initially thought, Nati said. However, an equally worrisome thing to physicians is to not diagnose or recognize a condition and start treatment as soon as possible. Delays could exacerbate illness down the road, she said.
When it comes to attracting more physicians to child and adolescent psychiatry, offering equitable reimbursements for service and working to alleviate student debt are important steps. Increasing training opportunities also is important, Nati said.
The 2006 study found 742 child and adolescent psychiatry residents in the United States during the 2005-2006 school year. Ten years prior, there were 758, and the number had dipped as low as 655 nationwide during that time span.
Creating residency opportunities in areas that have a need, like Tarrant County, could help bring in and retain specialists, Nati said.
“Most of the time when you train people locally, they often stay locally to practice,” she said. “So there is always a hope that in Tarrant County we will try to get a child and adolescent psychiatry program here.”
There are many more problems surrounding child and adolescent psychiatry, all of which will need to be addressed at some point in order to offer the best possible care to children.
It’s a field that can lead to early burnout, Mauk said, and child-specific research is still lagging behind adult psychiatry.
Banner pointed out that if children don’t have a medical home and regular pediatrician, then even those physicians can’t contribute toward a front-line management of mental illness.
There can be demographic issues and the small population of child and adolescent psychiatrists doesn’t necessary reflect the patient population, LeGrice said, pinpointing a local need for specialists who speak fluent Spanish.
When children present with physical ailments like stomachaches or headaches, Nati said, it may be caused by a mental worry or anxiety and not have a physical origin, complicating diagnosis.
All of the professionals agreed that one of the first steps to getting care to a child is a parent, teacher or caregiver to recognize something is unusual, such as a child having some issue that inhibits everyday life, and to seek out a medical professional. Mauk said she hopes any health care changes in the future will realize mental health is as crucial to well-being as physical health and that financial and educational support can be put in place on all levels to contribute to healthier — and happier — children.
“For years, mental health care has been carved out of health care,” she said.
