Poor access to child and adolescent psychiatrists has long been a concern raised by pediatricians, families, and other stakeholders. Wait times for new appointments can be many months, and families may be required to travel long distances. In the article “The Growth and Distribution of Child Psychiatrists in the United States: 2007–2016” in this issue of Pediatrics, McBain et al1 evaluate whether we have made any progress in expanding the child psychiatry workforce, both in number and distribution. They found that from 2007 to 2016, the number of child psychiatrists increased by 21%, and the number of children in the United States declined slightly. The United States now has 9.75 child psychiatrists per 100 000 children aged 0 to 19. However, they found an eightfold variation in prevalence per 100 000 children among states, ranging from a low of 3.3 in Idaho to a high of 26.5 in Massachusetts. Child psychiatrists are still concentrated in metropolitan areas; 70% of counties do not have one.
There are challenges in evaluating how much the increase addresses the shortage. As the authors note, they counted the number of practicing psychiatrists but did not determine how much of their time was devoted to clinical practice with children. The authors also could not examine changes in the prevalence or severity of pediatric mental illness. Unfortunately, there is evidence that the burden of mental illness in youth has significantly increased over the past decade. In the United States, the rate of death by suicide in children aged 10 to 19 increased by 86% from 2007 to 2017.2 Recent data indicate that there has been an increase in the prevalence of pediatric mental health diagnoses, including depression, attention-deficit/hyperactivity disorder, bipolar disorder, and autism spectrum disorders.3,4 Access to care is clearly a concern. Pediatric emergency department visits for mental health conditions have risen steadily.5 A recent report found that 16.5% of youth (7.7 million) in the United States have an identifiable mental health condition.6 However, only 49% of them were receiving treatment from any mental health professional, let alone a psychiatrist.
This leads to the question: how many child psychiatrists do we need? The American Academy of Child and Adolescent Psychiatry estimates that 47 child psychiatrists per 100 000 children would be sufficient, which is quadruple the rate found by McBain et al.1,7 The recently published Health Resources and Services Administration (HRSA) “Behavioral Health Workforce Projections, 2016–2030” made the unsubstantiated determination that at most, the demand for child psychiatric services in 2016 exceeded the supply by 20%.8 Using this evaluation of current shortage, the HRSA projected an oversupply of 3720 child psychiatrists in 2030. This flawed analysis illustrates the importance of the McBain et al1 data. The HRSA estimated an annual rate of increase in child psychiatrists that was double (4.28% vs 2.17%) what was found by McBain et al.1 There is no reason to expect such a rapid increase.
Assuming that the child psychiatrist shortage is closer to what American Academy of Child and Adolescent Psychiatry estimates, the current rate of increase will not meet the need for child psychiatric services over the next decade. There have been a number of proposals to expand the child psychiatry workforce that have merit, including making child psychiatrists eligible for federal loan repayment programs, offering a 4-year child psychiatry residency as an alternative to the traditional 5-year postgraduate training, and improving coding rules and reimbursement to compensate for the additional time and complexity that accompanies working with children.
Another way to address the shortage is to more effectively use the limited child psychiatry workforce: how can child psychiatrists make the greatest impact for the most children? This population health approach requires a reconceptualization of the child psychiatrist’s role, particularly in ambulatory settings. The child psychiatrist serves as a leader for multidisciplinary teams that may include advanced practice providers, psychologists, nurses, therapists, and other mental health professionals. The psychiatrist evaluates and treats the subset of patients who truly need psychiatric expertise and works with administrative leadership to devise the best system of care while serving as a consultant to guide members of the team. The psychiatrist can also consult to primary care and school settings while using telehealth capabilities to extend care to underserved areas and improve the quality and efficiency of consultation. To effectively implement this kind of model, child psychiatry training will need to emphasize communication, administrative, leadership, and consultation capabilities. Reimbursement strategies must be adjusted, and many psychiatrists will need to be willing to perform more team-based and consultative care instead of exclusively working with patients on an individual basis.
Investment in developing better systems of care with thoughtful integration of child psychiatrists is more likely to lead to the best outcomes for our children rather than focusing only on increasing the number of psychiatrists. We need to start making this investment and be open to change and innovation to improve our children’s mental health.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-1576.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: Dr Axelson receives royalties from Wolters Kluwer UpToDate.