Academic Psychiatry 27:277-282, December 2003
© 2003 Academic Psychiatry
Child and Adolescent Psychiatry Workforce: A Critical Shortage and National Challenge
Wun Jung Kim, M.D., M.P.H., The American Academy of Child and Adolescent Psychiatry Task Force on Workforce Needs
Dr. Kim is Professor of Psychiatry and Director of Child and Adolescent Psychiatry, Medical College of Ohio, Toledo, Ohio. Members of the American Academy of Child and Adolescent Psychiatry Task Force on Workforce Needs include: Donald Bechtold, M.D., Beth Ann Brooks, M.D., Norbert Enzer, M.D., Paramjit Joshi, M.D., Carolyn King, M.D., Carolyn Robinowitz, M.D., Dorothy Stubbe, M.D., Eva Szigethy, M.D., Ph.D., Peter Tanguay, M.D., Kayla Pope, J.D., M.A., Ms. Mary Crosby and Ms. Virginia Anthony. Address correspondence to Dr. Kim, MCO-Kobacker Center, 3130 Glendale Avenue, Toledo, OH 43614-5810.
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ABSTRACT
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Despite the decades-long projection of an increasing utilization of child and adolescent psychiatry services and an undersupply of child and adolescent psychiatrists, the actual growth and supply of child and adolescent psychiatrists have been very slow. Inadequate support in academic institutions, decreasing graduate medical education (GME) funding, decreasing clinical revenues in the managed care environment, and a devalued image of the profession have made academic child and adolescent psychiatry programs struggle for recruitment of both residents and faculty, although child and adolescent psychiatry has made impressive progress in its scientific knowledge base through research, especially in neuroscience and developmental science. While millions of young people suffer from severe mental illnesses, there are only about 6,300 child and adolescent psychiatrists practicing in the United States. There is also a severe maldistribution of child and adolescent psychiatrists, especially in rural and poor, urban areas where access is significantly reduced. By any method of workforce analysis, it is evident that there will continue to be a shortage of child and adolescent psychiatrists well into the future. Medical/psychiatric educators have a mission to encourage medical students and general psychiatry residents to enter child and adolescent psychiatry and provide crucial mental health care and health care advocacy for our country's youngest and most vulnerable citizens. This article stems from the work of the American Academy of Child and Adolescent Psychiatry Task Force on Work Force Needs, which led to its 10-year recruitment initiative.
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Historical Background
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The inception of child psychiatry began with an investigation of normal child development and the child guidance movement of the early part of the twentieth century. The dilemma of caring for difficult young offenders prompted juvenile courts to seek the professional help of child care workers. Leo Kanner was appointed the first academician in child psychiatry at the Johns Hopkins Medical School, and in 1935, he wrote the first textbook on child psychiatry in the United States (1). In 1953, the American Academy of Child Psychiatry was established primarily by analytically trained child psychiatrists and became a major professional organization for the field. It was only in 1959 that the field became recognized as a subspecialty by the American Board of Psychiatry and Neurology (ABPN), and the standards for training child psychiatrists were established afterward by the Accreditation Council for Graduate Medical Education (ACGME).
The subspecialty designation of child psychiatry was later expanded to include the adolescent population, and its name was officially changed to Child and Adolescent Psychiatry by the ABPN and the American Academy of Child and Adolescent Psychiatry (AACAP). To date, the movement by the American Society of Adolescent Psychiatry and some adult psychiatrists to create a separate subspecialty of adolescent psychiatry under the auspice of the ABPN has been unsuccessful. Another notable event was the creation of the Triple Boards Residency Program by the ABPN in 1986, which offered combined training in psychiatry, child and adolescent psychiatry, and pediatrics. The Triple Boards Residency Program hoped to capture the interest of medical students in child and adolescent psychiatry and recruit them directly into the combined residency. However, the number of residency programs and the number of recruited residents have remained relatively small, with about 10 and 20 each year, respectively (2).
The workforce of child and adolescent psychiatry in this article deals exclusively with specialists who are trained in the subspecialty of child and adolescent psychiatry, though many general psychiatrists practice adolescent psychiatry. Child and adolescent psychiatry has developed its identity, its scientific base, and its workforce gradually over the latter part of the twentieth century.(3)
Magnitude and Prevalence of Psychiatric Illnesses in Children and Adolescents
Toward the end of the 1980s, policymakers became aware of youth mental health problems and the lack of systematic data and scientific understanding about them. The Office of Technology Assessment (1987), Institute of Medicine (1989), and National Institute of Mental Health (NIMH) (1991) independently reviewed existing epidemiological data and concluded that approximately 12% of the nation's children and adolescents suffered from functionally impairing mental disorders (4). Modern epidemiological studies employing scientifically sound methods of sampling, assessment, and statistical analysis in North America and developed countries throughout the world have since demonstrated that the prevalence rates are actually closer to 20% (5,6). Furthermore, using functional criteria, the Center for Mental Health Services (1998) estimated that 9% to 13% of children and adolescents aged 9 to 17 had "serious emotional disturbances," and 5% to 9% had "extreme functional impairments" (7). It is of note that the field still lacks reliable studies on the prevalence of psychiatric disorders in children under age 9. Considering the magnitude of the problem, the need for preventive and intervention services is evident. The NIMH, the Surgeon General (1999), and other groups have reported that only about 20% of emotionally disturbed children and adolescents receive some kind of mental health care, and only a small fraction of them receive evaluation and treatment by child and adolescent psychiatrists (8).
The History of Child and Adolescent Psychiatry Workforce
The dearth of child and adolescent psychiatrists has long been recognized within the field as well as by several study groups and national commissions. The earliest report within the field, "Career Training in Child Psychiatry," recommended an increase in the number of training programs in child psychiatry, with a goal to increase the number of child psychiatrists (9). It was only in the last two decades of the 20th century that public attention has focused on the child and adolescent psychiatry workforce. In 1980, the Graduate Medical Education National Advisory Council (GMENAC) examined physician workforce distribution and recommended that the number of child and adolescent psychiatrists be increased to 8,000 to 10,000 by 1990 (10). At that time, it was acknowledged that the number derived from a needs-based analysis of prevalence rates was far greater than the recommended number, but it was scaled down for practical reasons. A decade later, the Council on Graduate Medical Education (COGME) reanalyzed data used for the GMENAC report and estimated that the nation would need more than 30,000 child and adolescent psychiatrists by the year 2000 (11). It is important to note that the COGME recommended an increase in the number of graduating child and adolescent psychiatrists while it continued to stress the need for an increase of generalist physicians and a decrease in the number of specialist physicians throughout the 1990s. In the backdrop of economic prosperity and improving health care, an increase in youth suicide and violence has caused significant public concern and become a national public health issue. The Surgeon General's report on Mental Health in 1999 (8) and the Report of the Surgeon General's Conference on Children's Mental Health in 2000 (12) deplored society's failure to provide adequate care to a growing number of children suffering needlessly with emotional, behavioral, and developmental disorders. The Surgeon General's report specifically focused on the lack of workforce in relation to access to care: "There is a dearth of child psychiatrists. ... Furthermore, many barriers remain that prevent children, teenagers, and their parents from seeking help from the small number of specially trained professionals ... this places a burden on pediatricians, family physicians, and other gate keepers to identify children for referral and treatment decisions" (8).
Workforce Models
There are different methods of projecting the need and demand of the current and future workforce of a certain specialty. The GMENAC report utilized an "adjusted needs model" that estimated the current and projected supply of physicians that was required to address disease prevalence. The 1990 COGME report utilized a combination of the "adjusted needs model" and the "requirements model" that was derived from the staffing patterns of the growing health delivery system of health maintenance organizations (HMOs). Another often-used model, the "socioeconomic model," projects the effects of socioeconomic and demographic factors of the availability of future practice opportunities for physicians. Richard Cooper, M.D., and others commissioned by the Council of Medical Specialties Societies and the COGME recommended a complex "trend model" for future physician workforce planning (personal communication with Dr. Cooper, 2001). This new proposal encompasses the major models used in previous workforce studies and takes into consideration the geographical distribution of physicians, scope of practice, and physician substitutes. This dynamic workforce model needs to be further refined, and different specialties, including child and adolescent psychiatry, would have to come to consensus on the scope of practice and the role of a specialist in order to establish a pragmatic model. Regardless, it is well known that there is a severe maldistribution of child and adolescent psychiatrists in the United States, with children in rural areas and areas of low socioeconomic status having significantly reduced access (13).
The Current Status of the Workforce
Although its accuracy is sometimes debated, the most reliable source of specialist census is the American Medical Association (AMA) Physician Masterfile. Thomas and Holzer (13), relying on the 1990 AMA Physician Masterfile and other data contained in the Area Resource File of the Department of Health and Human Services, reported that the nation had 4,212 child and adolescent psychiatrists, with a mean of 6.73 child and adolescent psychiatrists per 100,000 children and adolescents under the age of 18. The distribution ranged from 0.81 in Mississippi to 18.9 in Massachusetts per 100,000 youths. The author's recalculation of the most recent data from the Area Resource File and AMA Physician Masterfile in 2000 indicates a persistent maldistribution of child and adolescent psychiatrists. The ratio of child and adolescent psychiatrists per 100,000 youths ranged from 1.32 in West Virginia to 17.53 in Massachusetts, with a mean of 7.51. The total number of allopathic and osteopathic child and adolescent psychiatrists practicing at least part-time in the United States in 2000 was estimated to be 6,300, according to the AMA Physician Masterfile and the U.S. Bureau of Health Professions in the Department of Health and Human Services. Translating this number of child and adolescent psychiatrists into a ratio of the population under age 18 results in about 15,000 youths per one child and adolescent psychiatrist. In other words, if a child and adolescent psychiatrist is to take care of the most severely impaired children and adolescents (5% of population), each one has to carry a caseload of 750 severely disturbed children and adolescents at any given time. This certainly would be a daunting task, even if one maintains a short-term evaluation and management practice model, especially considering the recommendations made for comprehensive initial evaluations in the AACAP's Practice Parameters for the Psychiatric Assessment of Children and Adolescents (14).
The Future Projection of the Workforce
The number of child and adolescent psychiatrists increased by one-half during the last 2 two decades by new additions and slow attritions, as a result of the natural progression of a young medical specialty (13). Considering the many different factors affecting recruitment and training programs, the projection of future workforce trends is a difficult and complex task. The U.S. Bureau of Health Professions tracks specialty workforce trends based on "demand-utilization models" that project the demand of physicians required to provide health care services at the current levels of utilization, primarily based on the availability of services and health benefits. The Bureau of Health Professions follows such projections for all specialties, including general psychiatry, but not for child and adolescent psychiatry. The research arm of the Bureau of Health Professions, the National Center for Health Work Force Information and Analysis, performed the data analysis for the AACAP's Task Force on Work Force Needs and reported that the demand for child and adolescent psychiatry services was projected to increase by 100% between 1995 and 2020. The demand for adult psychiatry services was projected to increase by 19%. This estimation translates into 12,624 child and adolescent psychiatrists that will be needed to meet the demand in 2020 and is far greater than the projected supply of 8,312 child and adolescent psychiatrists. That is, even if the funding and recruitment remain stable at the current level, there will be 4,312 less child and adolescent psychiatrists in 2020 than needed in order to maintain the level of utilization in 1995. Taken together, available past and current workforce data as well as workforce projections present indisputable evidence of an absolute shortage of child and adolescent psychiatrists for the foreseeable future.
Trends of Graduate Medical Education in Child and Adolescent Psychiatry
Throughout the 1990s, the number of residents enrolled in general psychiatry and child and adolescent psychiatry remained steady, at about 5,000 and 700, respectively (www.psy.org/med_ed/final_report and personal communication with Ms. Linda Thorsen, Residency Review Committee (RRC) for psychiatry, 2001). However, these stable numbers have been achieved only by a substantial increase in the recruitment of international medical graduates (IMGs). The number of U.S. medical school graduates (USMGs) matching into general psychiatry PG-I positions decreased precipitously to below 500 per year in most of the 1990s, following the peak of 745 per year in 1988. In 2001, there was a 9% increase over 2000 levels to a total of 524, which was the first significant increase in a decade. This was followed by another increase, in 2002, to 564. Child and adolescent psychiatry, dependent on general psychiatry for recruitment of residents, has followed the same path as general psychiatry. By 2001, IMGs constituted more than 40% of child and adolescent psychiatry residents (2), lagging a few years behind the trend in general psychiatry. The proportion of IMGs in general psychiatry residency programs is now close to 50%. Another notable demographic change is the steady increase in female residents in the last two decades, now more than 50% in child and adolescent psychiatry. The increasing representation of female students in medical schools throughout the country will likely accelerate this trend.
While achieving greater diversity through recruitment of IMGs and female residents, demographic changes may actually lead to a decrease in the child and adolescent psychiatry workforce in real terms. The clinician practice profile data have consistently demonstrated fewer practice hours for female physicians (15), and opportunities for IMGs to train and practice in the U.S. after completion of training are likely to diminish due to stricter enforcement of immigration laws, which reportedly became worse after the September 11 tragedy in 2001. The recruitment of IMGs into residency training programs might be seriously affected by the recently instituted Clinical Skills Assessment examination. IMGs must pass this examination in order to be allowed to participate in graduate medical education in the United States. Ever increasing levels of financial debt with which USMGs are burdened may also discourage them from seeking longer training beyond general psychiatry residency. The newly created subspecialty psychiatric training programs in geriatrics, forensics, and addictionology compete for a limited pool of available general psychiatry residents for advanced training. The majority of residents in the newly established psychiatric subspecialty training programs are IMGs (2). All these factors suggest that the difficulties in recruiting residents into child and adolescent psychiatry will likely continue well into the future.
Child and Adolescent Psychiatry Training Programs and Funding
The number of child and adolescent psychiatry residency programs decreased from 130 in 1980 to 114 in 2002 (www.ama-assn.org/frieda). Since several new programs have opened in the last two decades, it is evident that more than 20 programs have closed or merged with other programs during this time period. Closure of training programs reflects the changing health care financing trends, the recruitment failure of both faculty and trainees, and the decreasing sources of academic funding. Several factors have contributed to this trend. First, the reorganization of NIMH under NIH as a primarily research institution in the early 1980s eliminated the federal funding support for child and adolescent psychiatry residency training. Second, the acceleration of deinstitutionalization and the growth of community-based clinical services by state governments resulted in the closure of residency programs that were based in state-operated facilities or state-supported child and adolescent psychiatry residency programs (16). Third, the advance of managed care and the decrease in clinical revenues have made it difficult for child and adolescent psychiatry academic programs to survive. Fourth, the 1997 Balance Budget Act (BBA), not only put a cap on the number of GME positions, but it also reduced direct GME funding by 50% for subspecialty training beyond the primary specialty board eligibility. The effects of the 1997 BBA have been particularly ominous for child and adolescent psychiatry, since it promotes a decrease in the number of residents in revenue poor and recruitment poor subspecialty training programs such as child and adolescent psychiatry, and it discourages recruitment of residents who have previously completed other specialty training such as pediatrics.
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Discussion and Conclusion
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There have been both negative and positive developments in child and adolescent psychiatry. The expansion of a high-quality workforce in clinical, academic, and research arenas remains to be a major goal of the field, as it has been since the beginning of its history. There are many complex intertwined factors, at both individual and institutional levels, that have affected recruitment of medical students into child and adolescent psychiatry. Lack of exposure to child and adolescent psychiatry during medical school education, increasing levels of educational debt burden, long years of residency training, and relatively smaller income potential in general psychiatry as well as in child and adolescent psychiatry are factors that influence a medical student's career decision (17,18). Inadequate support in academic institutions, decreasing GME funding, decreasing clinical revenues in the managed care environment, and the devalued image of the profession have made academic child and adolescent psychiatry programs struggle for the recruitment of both residents and faculty (19). Overwhelming external forces, especially the managed care environment and federal/state funding cuts in favor of training in primary care specialties, have had a major impact on many subspecialties, but on child and adolescent psychiatry in particular. In the face of growing demands and a chronic undersupply of practitioners, child and adolescent psychiatry is in danger of marginalization since it cannot provide needed services and contributions to society.
However, in spite of continuing predicaments and a demoralizing environment, child and adolescent psychiatry has made impressive progress in its scientific knowledge base through research, especially in neuroscience and developmental science, e.g., neuroimaging, genetics (3). There is also a growing recognition of the need for child and adolescent psychiatry by policymakers and the public at large. The Surgeon General's Conference on Children's Mental Health in 2000; a pending bill (H.R. 1928) introduced by Representative Pete Stark; a bill (H.R. 5078) introduced by Representative Patrick Kennedy and Representative Ileana Ros-Lehtinen that would provide full GME funding for shortage specialties such as child and adolescent psychiatry and a loan forgiveness program for child and adolescent psychiatry trainees; and increasing news coverage on the mental health problems of children and adolescents are all specific examples of increased public awareness. The growing demand for child and adolescent psychiatry services and continuing undersupply of child and adolescent psychiatrists have also improved job opportunities, financial remuneration, and other desirability factors to a noticeable degree (Web: http://chws.albany.edu).
The negative and positive changes in the field provide both challenges and opportunities. By any method of workforce analysis, it is evident that there will continue to be a shortage of child and adolescent psychiatrists well into the future. However, the many workforce reports and recommendations by governmental agencies have not yet resulted in any significant support for improving the child and adolescent psychiatry workforce. Therefore, the AACAP declared, in 2001, that recruitment into the profession of child and adolescent psychiatry will be the top priority of the organization for the next 10 years, and it is planning to invest its resources and efforts into the recruitment initiative. The child and adolescent psychiatry workforce is a crucial issue in relation to the profession's role in society, since it determines access to quality care for mentally ill children and adolescents. If it is to thrive as a medical specialty in the twenty first century, child and adolescent psychiatry must carefully assess society's future needs and demands and actively formulate the direction of its future professional growth and development in a manner that responds to those needs and demands. It must also generate the support of medical/psychiatric educators, governmental agencies, and the public at large to provide needed services to the nation's children, adolescents, and their families.
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ACKNOWLEDGMENTS
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The author thanks Larry Faulkner, M.D. for editorial support and the anonymous reviewers for helpful suggestions.
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ABSTRACT
Historical Background
