Pediatricians, FPs Help Tackle Child Psychiatrist Shortage

Deborah Brauser

February 21, 2013

A severe shortage of child and adolescent psychiatrists (CAPs) has led to the rise of several programs aimed at training pediatricians and family physicians (FPs) to meet the mental health needs of US youth.

With an estimated 6 million children and adolescents in the United States suffering from mental illness and only 7400 practicing CAPs, the Mayo Clinic calculates that this translates into an "impossible caseload" of 811 patients for each available psychiatrist.

Dr. Martin Drell

Although the reasons for the continuing shortage are unclear, Martin J. Drell, MD, president of the American Academy of Child and Adolescent Psychiatry (AACAP), speculates that reimbursement may be a main concern. Child psychiatry, he notes, is among "the most modestly paid disciplines."

Dr. Drell notes there is a great need for innovative solutions.

"As we move ahead and have fiscal restraints and have more people coming into care, I think we're going to have to be innovative, flexible, and open to all new ideas — and then test them in the marketplace to see if they do or do not work," Dr. Drell told Medscape Medical News.

Several novel initiatives have already been launched to address the CAP shortage, among them the Triple Board Training for residents, the Post Pediatric Portal Pilot Project (PPPP), aimed specifically at pediatricians, and programs by the Resources for Advancing Children's Health (REACH) Institute.

REACH's Fellowship in Primary Pediatric Psychopharmacology training program is designed to empower pediatricians and FPs to initiate and treat youth with behavioral problems and psychiatric problems. As of December 2012, 1000 clinicians had completed the program.

Dr. Peter Jensen

"This is an important milestone because it means each year, 100,000 kids with emotional problems will have access to help from their family pediatrician," said Peter Jensen, MD, president and CEO of REACH, in a release.

"These are kids who otherwise would not be likely to get such help at an early stage of their difficulty," added Dr. Jensen, who is also professor of psychiatry and vice-chair for research in the Department of Psychiatry and Psychology at the Mayo Clinic in Rochester, Minnesota.

Empowering Clinicians

Launched in 2006, REACH teaches medical professionals across the country to assess, treat, and manage childhood depression, anxiety, attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, and aggression as well as other mental health issues.

Dr. Jensen told Medscape Medical News that in the past, these clinicians often did not feel empowered to treat these young patients.

"Pediatricians aren't trained in the most common kinds of mental health issues that parents would hope their kids' doctors would know how to treat. They get a little training in ADHD or attention problems, but that's it," he said.

"Yet there are just as many, if not more, problems with anxiety, depression, parenting problems, and learning disabilities. And most of the national surveys indicate that pediatricians are not comfortable treating these conditions."

The REACH training program provides coaching sessions, including how to sensitively approach parents with the possibility that their child may have a mental health problem.

The program begins with a 3-day interactive session, followed by a 6-month long-distance learning program that includes group teleconferences and "case-based clinical rounds."

"The easiest part for these participants is learning the medicines and the dosages. They already do that whenever a new medication comes out. This training is all about developing a sense of confidence and mastery that they actually know what the child's problem is," he said.

"Once they know this is the correct diagnosis, then they become much more comfortable. That's why a little more than half of the first 3 days are giving them tools and lots of practice through patient simulations."

Growing Success

Also aimed at pediatricians are the PPPP programs. Launched in 2007, data from the pilot program were presented at the 2010 annual meeting of the American Psychiatric Association and reported by Medscape Medical News at that time.

Here, board-eligible pediatricians can switch to child psychiatry at the end of 3 additional years of training compared with 4 to 5 additional years, which has commonly been needed. Currently, PPPP programs are offered at Case Western Reserve Hospital in Cleveland, Ohio, the Children's Hospital of Philadelphia, Creighton University in Omaha, Nebraska, and Maine Medical Center in Portland.

In addition, other organizations "are actively submitting applications," said Tami Benton, MD, PPPP training director and executive director in the Department of Child and Adolescent Psychiatry and Behavioral Science at Children's Hospital of Philadelphia in Pennsylvania.

"Each program is producing about 2 graduates per year, and these graduates are doing exactly what the program hoped for — working to increase the workforce by training future child psychiatrists or working in communities that have a shortage of child psychiatrists, or both," added Dr. Benton.

In addition, Triple Board Programs, which began 15 years ago, expedite combined training for pediatrics, adult psychiatry, and child psychiatry from 7 years to 5 years for residents and "has been very successful," said Dr. Drell.

He pointed out that this is especially important because it allows clinicians to treat children and their parents.

Incentives Key

Dr. Drell, who is also head of the Section on Infant, Child, and Adolescent Psychiatry at the Louisiana State University Health Science Center in New Orleans, also noted that medical school loan forgiveness plans could play an important role in decreasing the current shortage of CAPs.

"There's very good information that people pick specialties based on their need to pay off loans. And quite interestingly, among the most modestly paid disciplines are pediatrics, family practice, and child psychiatry — the practices that deal with children," he explained.

He also said that incentives could be very important.

"Life is simple. You just incentivize it more and make sure their salaries are commensurate with the wonderful work they do. And suddenly people in medical school will choose these professions rather than ones known for being more lucrative."

However, Dr. Jensen noted that the shortage of CAPs has been a problem "for 20 years now."

"There's a very small pipeline that more child psychiatrists are being trained. Many of us have come to terms with saying, 'never in our lifetime will there be enough of these specialists.' But there are some wonderful skills that most pediatricians can learn and use that are no more complex than asthma care," said Dr. Jensen.

"REACH's goal is to build an army of professionals who can effectively intervene in the lives of children and adolescents," he added. "Early intervention by trained professionals is the best way to reduce costs and limit the developmental damage of child behavioral and emotional disorders."

Information on the REACH Programs, the PPPP, and the Triple Board Training program are available online.