Why is there a shortage of Child & Adolescent Psychiatrists in the US?

[BlueSultan]

Hello! I'm an M3 student currently trying to decide which specialty I want to pursue. One of the fields I've been interested in is Child & Adolescent Psychiatry, and while I had some brief exposure to the field during my Psych rotation, I never got as much exposure as I would've liked. Unfortunately with COVID currently messing up every med student's schedule I'm not sure I'll get the chance to explore the field much more before application season, especially with Away Rotations being up in the air currently.

I was wondering why there is such a shortage of Child & Adolescent Psychiatrists in general, and whether this is just a product of there being few Psychiatrists in general and less that want to pursue extra fellowship training, or if there are any specific downsides to the field that tend to push people away from it? Please be brutally honest!

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[wolfvgang22]

Simply put , it's more work for the same pay.

 

[clozareal]

Because you have three patients instead of one.

 

[TexasPhysician]

It’s a bigger challenge than gen psych for a relatively small bump in average earnings. Adults can lie (often not well), but they can generally express their feelings. Child evaluations can involve parents (1 or 2), the child, teachers, etc. Children aren’t going to sit still and clearly explain their feelings. Parents can be selfish, expect you to fix their problems, and are more defensive.

I find it worth it, but I can understand that it isn’t for everyone.

 

[Bartelby]

The above captures a major part of it: having to work much more with the systems/people (parents, schools, etc.) surrounding the child in a way that is poorly compensated if it is compensated at all. Beyond that, I personally found children just plain less interesting than many of the adults I worked with. Add onto that the need for a two year fellowship (admittedly it can be one extra year with fast tracking) and it was an unappealing option.

With that said, C&A is extremely important and under served work. I'm so glad some people love it, but on a gut level it just wasn't for me. I suspect many others feel the same.

 

[SourceOfDenial]

Hello! I'm an M3 student currently trying to decide which specialty I want to pursue. One of the fields I've been interested in is Child & Adolescent Psychiatry, and while I had some brief exposure to the field during my Psych rotation, I never got as much exposure as I would've liked. Unfortunately with COVID currently messing up every med student's schedule I'm not sure I'll get the chance to explore the field much more before application season, especially with Away Rotations being up in the air currently.

I was wondering why there is such a shortage of Child & Adolescent Psychiatrists in general, and whether this is just a product of there being few Psychiatrists in general and less that want to pursue extra fellowship training, or if there are any specific downsides to the field that tend to push people away from it? Please be brutally honest!

Maybe because you have to work with children and adolescents?

 

[PikminOC]

Extra residency beyond the regular 4 years for Psychiatry.

But hey, nurse practitioner can see 6 years old and above with no additional training!

 

[dl2dp2]

I actually don't think it has anything to do with the nature of the work. i.e. it's not that people aren't willing to do the work, or that it's paid not well (which is firstly not universally true, and secondly makes no sense: things that don't pay well should have an overflow on the labor side rather than shortage). That aspect may be a reason where workforce is maldistributed.

The fundamental reason child psych has become more in demand, like the rest of the psychiatry but in more extreme ways, is that demand has increased significantly. In the 70s and 80s it's highly unusual for children and adolescents to be on ANY psych meds. These days, it's frankly commonplace and considered parental malpractice if your kid having bad grades ISN'T evaluated for ADHD at a minimum. The diagnosis of "autism" and "ODD" are also much more liberally given out, and [off label] prescription of antipsychotics also increased astronomically. This is all more or less driven by demand: doctors, some unethical ones not withstanding, imo by and large are very gingerly in prescribing. But parents are now much more trigger happy with meds.

The same is true in general for psychiatry. The number of psychiatric meds that are written now is much higher compared to 30 years ago. Is this a blessing or a curse? One might say it's a mix.

To be fair, when meds are used correctly, they make a huge difference. But just because the threshold ("stigma") has dropped, the demand for services also increased significantly which then causes shortage.

 

[wolfvgang22]

I actually don't think it has anything to do with the nature of the work. i.e. it's not that people aren't willing to do the work, or that it's paid not well (which is firstly not universally true, and secondly makes no sense: things that don't pay well should have an overflow on the labor side rather than shortage). That aspect may be a reason where workforce is maldistributed.

The fundamental reason child psych has become more in demand, like the rest of the psychiatry but in more extreme ways, is that demand has increased significantly. In the 70s and 80s it's highly unusual for children and adolescents to be on ANY psych meds. These days, it's frankly commonplace and considered parental malpractice if your kid having bad grades ISN'T evaluated for ADHD at a minimum. The diagnosis of "autism" and "ODD" are also much more liberally given out, and [off label] prescription of antipsychotics also increased astronomically. This is all more or less driven by demand: doctors, some unethical ones not withstanding, imo by and large are very gingerly in prescribing. But parents are now much more trigger happy with meds.

The same is true in general for psychiatry. The number of psychiatric meds that are written now is much higher compared to 30 years ago. Is this a blessing or a curse? One might say it's a mix.

To be fair, when meds are used correctly, they make a huge difference. But just because the threshold ("stigma") has dropped, the demand for services also increased significantly which then causes shortage.

I agree with much of what you said. However, the shortage of psychiatrists willing and able to do child psych is very real outside of large cities (heck, it's real in big cities). Also, I don't understand why you think there would be "an overflow on the labor side" for similar pay to general psych.

For me, as a Child and Adolescent Psychiatrist, I no longer see children or adolescents because 1. It is more work for no more pay than general psychiatry, (yes, there are a handful of higher paying jobs, but not a lot) 2. In order to do child psych in my area I would have to go into private practice, because there is no significant child psych around my area, a challenge which I'm not ready to do personally at this time, and I am not ready to move. The closest child inpatient for this population is 2 hour drive away. Lack of support systems in my area makes child psych a huge challenge here. On the other hand, it could be a great opportunity for someone who is up for the challenge. I feel for families who are waiting 6 months to a year to see a child psychiatrist 2 hours away. I feel a little guilty having the training and knack for the field that is going unused.
I have met many child psychiatrists who are the same, only seeing adults and the odd teenager due to similar circumstances. Not very scientific, but it is my experience.

 

[Merovinge]

I actually don't think it has anything to do with the nature of the work. i.e. it's not that people aren't willing to do the work, or that it's paid not well (which is firstly not universally true, and secondly makes no sense: things that don't pay well should have an overflow on the labor side rather than shortage). That aspect may be a reason where workforce is maldistributed.

The fundamental reason child psych has become more in demand, like the rest of the psychiatry but in more extreme ways, is that demand has increased significantly. In the 70s and 80s it's highly unusual for children and adolescents to be on ANY psych meds. These days, it's frankly commonplace and considered parental malpractice if your kid having bad grades ISN'T evaluated for ADHD at a minimum. The diagnosis of "autism" and "ODD" are also much more liberally given out, and [off label] prescription of antipsychotics also increased astronomically. This is all more or less driven by demand: doctors, some unethical ones not withstanding, imo by and large are very gingerly in prescribing. But parents are now much more trigger happy with meds.

The same is true in general for psychiatry. The number of psychiatric meds that are written now is much higher compared to 30 years ago. Is this a blessing or a curse? One might say it's a mix.

To be fair, when meds are used correctly, they make a huge difference. But just because the threshold ("stigma") has dropped, the demand for services also increased significantly which then causes shortage.

I think to be more specific, there has certainly been an increase in psychotropic prescribing by psychiatrists over the past twenty years, part of which is that many of our interventions are now well evidenced based, however the huge increase is in PCPs, Peds, and mostly PA/NP practitioners who feel any unmanageable 5 year should be started on risperidone. The difference between when I was a med student and now as a CAP attending is astounding. Most PCPs/Peds would consider a single SSRI and 1-2 stimulant trials, anything past that was automatically coming to CAP, now I see kids with 5 different med "trials" (done incorrectly) including mood stabolizers and atypicals. With so many kids being Rxed heavy duty medications with numerous side-effects, once a parent complains, then it comes straight over a referral.

Old pathway was more like Peds manages expectations, occasionally starts 1 med, maybe see a child psychologist, they refer over a small portion to CAP.

New pathway, NP-in-a-box prescribes psychotropics, either "they don't work" or SE happen, CAP referral, often with no therapist ever being involved.

That's a huge portion of the demand, as well as lack of stigma (which is very good overall but does have some cost)

 

[Sushirolls]

Just recently I saw a second opinion young adult who had an ARNP that was managing since adolescence. This young adult was on:
SNRI
Trazodone PRN
Lamictal
Non-generic antipsychotic
clonidine
stimulant
benzo

Second opinion was largely because patient was not getting communicated to what the diagnosis was, what/why for the meds, and poor explanation why the patients theory of a diagnosis was/wasn't accurate.

 

[adiradirim]

Non-generic antipsychotic

Was it Vraylar? It's always Vraylar in my area...
Very frustrating

 

[nexus73]

I assume the start of child psych fellowships played a role in this.

We all finish a GENERAL psychiatry residency after which it's actually not unreasonable to see child patients. But most "adult" psychiatrists choose not to for the reasons listed above. But also I think there is an idea that now with child fellowship trained doctors, only they should see children because general psychiatrists don't have the training.

It's strange that as a general psychiatrist who treats adult I am apprehensive about seeing a depressed 11 year old. While pediatricians are managing some of the most severe child psych patients, especially when you get to smaller cities and rural areas. And the pediatricians have almost no psych training.

 

[Merovinge]

I assume the start of child psych fellowships played a role in this.

We all finish a GENERAL psychiatry residency after which it's actually not unreasonable to see child patients. But most "adult" psychiatrists choose not to for the reasons listed above. But also I think there is an idea that now with child fellowship trained doctors, only they should see children because general psychiatrists don't have the training.

It's strange that as a general psychiatrist who treats adult I am apprehensive about seeing a depressed 11 year old. While pediatricians are managing some of the most severe child psych patients, especially when you get to smaller cities and rural areas. And the pediatricians have almost no psych training.

I personally think you should be scared to see a depressed 11 year old if your practice is largely to entirely adult and you have no CAP fellowship. There are almost innumerable differences both for consultation, prescribing, and more wrap-around care (mainly school but others come up) and believe it or not gen peds sees about 30-40 patients a day on average and roughly 10% of those are for mental health. They both have the expectation of PCPs to initially manage, as well as know warning signs for referral, most know many peds specific therapy resources in the area and are infinitely better connected with local school administration, SW, etc.

Every field of medicine is basically split adult/peds. I have repeatedly ran into adult cards, ID, endo, rhum, etc that will not see a 17.5 year old. Now is the difference between Peds Neurosurgery and Adult Neurosurgery bigger than difference between adult and child psych? Absolutely. But I'd hope you consider how different CAP is, why we have the biggest sub-specialty of psych, why we read entirely different journals, see different diagnosis, and practice differently.

 

[dl2dp2]

Just recently I saw a second opinion young adult who had an ARNP that was managing since adolescence. This young adult was on:
SNRI
Trazodone PRN
Lamictal
Non-generic antipsychotic
clonidine
stimulant
benzo

Second opinion was largely because patient was not getting communicated to what the diagnosis was, what/why for the meds, and poor explanation why the patients theory of a diagnosis was/wasn't accurate.

LOL this combination is not unusual. BPD is the diagnosis, which is why it's not communicated--which is an error, of course, I tell everyone at eval now that they have BPD. Problem is if you stop any one of these meds patients will complain, and their attachment style is that they don't stick around for consistent therapy. Usually I focus on stopping the benzo first, but even that takes months if not years.

In my experience to turn around a case like this takes a minimum of 1-2 years of weekly combined treatment. Even then it's about 50/50. You need pretty good OON insurance to do this. People with personality disorders often don't do well with therapists who don't have specific training.

 

[nexus73]

I personally think you should be scared to see a depressed 11 year old if your practice is largely to entirely adult and you have no CAP fellowship. There are almost innumerable differences both for consultation, prescribing, and more wrap-around care (mainly school but others come up) and believe it or not gen peds sees about 30-40 patients a day on average and roughly 10% of those are for mental health. They both have the expectation of PCPs to initially manage, as well as know warning signs for referral, most know many peds specific therapy resources in the area and are infinitely better connected with local school administration, SW, etc.

Every field of medicine is basically split adult/peds. I have repeatedly ran into adult cards, ID, endo, rhum, etc that will not see a 17.5 year old. Now is the difference between Peds Neurosurgery and Adult Neurosurgery bigger than difference between adult and child psych? Absolutely. But I'd hope you consider how different CAP is, why we have the biggest sub-specialty of psych, why we read entirely different journals, see different diagnosis, and practice differently.

I appreciate your examples and I agree, I wouldn’t see kids after years of adult only psych. Just like a family doctor who was doing only adult medicine for years, with no OB and no peds, I wouldn’t want them treating my kid or delivering my baby.

I think a better example than adult vs pediatric cardiology and the like, is family medicine vs pediatrics. General psychiatry does have child psych training required, much like family medicine. Whereas an adult cardiologist has no pediatric exposure at all during residency or fellowship, so they're completely split from the time training begins. A pediatric cardiologist wouldn't be treating adults for this reason. But a child psychiatrist would be reasonably expected to have expertise treating adults from training in their Gen Pysch residency. And I'd argue a psychiatrist recently out of a good residency with good child psych exposure could maintain that practice and provide good care to children and adolescents.

 

[Merovinge]

And I'd argue a psychiatrist recently out of a good residency with good child psych exposure could maintain that practice and provide good care to children and adolescents.

That's a common argument, although I really disagree. When I did my 2 months inpatient second year and very small outpatient therapy practice 3rd year along with one specialty outpatient clinic I felt like I was in good shape to start a CAP fellowship. I went to an above average academic program with significantly above average prite scores and boy was the start of fellowship like a glass of cold water thrown on my face. The number of things I didn't know that I didn't know was eye opening and now that I have continued to do full-time attending CAP work I only further see how little adult psychiatry residency trained me for my job.

I'm sure there are some adult residents who love CAP, did a 6 month elective their 4th year, always took CAP patients during residency, but somehow just could not stomach the idea of 1 extra year of training. They go to AACAP yearly, read the orange journal, and stay up to date. All five of those folks in the country I can handle seeing a significant portion of their practice as children by intention.

Now if we want to argue the adult psychiatrist compared to the NP/PA with zero training in anything, that's a pretty simple argument, but this rapid descent in standard-of-care I find so incredibly alarming and scary, particularly among the most vulnerable populations.

 

[Monocles]

I'm a CAP fellow and I looooove working with kids and teenagers. Perhaps I am one of the few on this forum that wants to exclusively work with kids and teens (okay, and "transitional age" individuals but no grown ups).

Not to rehash too much about salary and time etc, but at the end of the day even though the kiddos are awesome... a lot of times the family can be very difficult and blame you for random things ("why can't you give little Timmy a pill so he can get into harvard and bring prestige to family etc etc") and every day you run into un-winnable situations (abusive households, lack of resources, no stable adult figures in a kid's life, etc). I think many people just get really discouraged and end up walking away...

 

[When is graduation again?]

In addition to all the above, in my residency, my C&A CL experience involved a heavy dose of calling collateral. For each initial consult, I spent an hour seeing the patient, 30min-2 hours talking with one or both parents (sometimes they weren't together so I had to talk to them separately), another hour or so with documentation, and occasionally had to call outpatient providers.

Is this the equation in other fellowships? Are there programs where there are more SWs and admin staff to handle the more tedious collateral and grunt work? I go back and forth about whether I want to do a fellowship, but the idea of spending 2 years engaged in the above formula always makes me go back to probably not.

 

[wolfvgang22]

Is this the equation in other fellowships? Are there programs where there are more SWs and admin staff to handle the more tedious collateral and grunt work?

To answer your questions:
Generally, yes.
No.

 

[calvnandhobbs68]

I actually don't think it has anything to do with the nature of the work. i.e. it's not that people aren't willing to do the work, or that it's paid not well (which is firstly not universally true, and secondly makes no sense: things that don't pay well should have an overflow on the labor side rather than shortage). That aspect may be a reason where workforce is maldistributed.

The fundamental reason child psych has become more in demand, like the rest of the psychiatry but in more extreme ways, is that demand has increased significantly. In the 70s and 80s it's highly unusual for children and adolescents to be on ANY psych meds. These days, it's frankly commonplace and considered parental malpractice if your kid having bad grades ISN'T evaluated for ADHD at a minimum. The diagnosis of "autism" and "ODD" are also much more liberally given out, and [off label] prescription of antipsychotics also increased astronomically. This is all more or less driven by demand: doctors, some unethical ones not withstanding, imo by and large are very gingerly in prescribing. But parents are now much more trigger happy with meds.

The same is true in general for psychiatry. The number of psychiatric meds that are written now is much higher compared to 30 years ago. Is this a blessing or a curse? One might say it's a mix.

To be fair, when meds are used correctly, they make a huge difference. But just because the threshold ("stigma") has dropped, the demand for services also increased significantly which then causes shortage.

Yeah so your "labor" statement doesn't make sense. Medicine isn't a great market for talking about wages and labor, since reimbursement is largely driven by insurance reimbursement which basically has nothing to do with supply/demand. Many pediatric subspecialties are in critically short supply mostly BECAUSE they make marginally more (or even less) than pediatric generalists for multiple more years of training. Insurance companies don't just adjust rates because there's a shortage of a certain specialty. And TBH there are a limited supply of people who can afford to pay $350 eval/$175 followup rates (or whatever your going rate may be) for child psychiatry cash practices.

I agree with the ADHD evaluation statement. Also agree with the (in my opinion) inappropriate boom in prescribing of antipsychotics for any "disruptive" kid. However, general pediatricians manage the majority of ADHD in this country. Just like PCPs are the biggest prescribers of SSRIs. There's been a labor shortage in child psychiatry for quite some time...even stretching back into the 80s. Here's a NYT article from 1991.

In Child Psychiatrist Shortage, Young Must Wait (Published 1991)

When Dr. Rose Tharakan, a pediatrician, encounters a child with serious psychological problems in her practice in Sturbridge, Mass., she calls in Dr. Zamir Nestelbaum, a psychiatrist from the nearby town of Southbridge. But Dr. Nestelbaum is a general psychiatrist and there are some cases, he...

www.nytimes.com

So yes demand for services may have gone up but most of it still gets filtered through PCPs and the shortage has been there for quite some time.

I agree with the other posters that I also think it has to do with the nature of the work. Adult psych is overall easier from a social standpoint for the same amount or a little less (although it's marginal when you take into account the 2 years of lost adult salary). You don't have to deal with custody issues, schools, DCFS, etc. You don't have to get two (or even three) people agreeing with every decision you make (if you count the kid who has to actually agree to do what you want them to do and the parent). You have to balance what the parent want and what the child wants and what's actually best for the child, all three of which may be different things in the most complex situations. Inpatient psych for kids is definitely less interesting than for adults...like 90 percent SI/SA and aggressive/impulsive ADHD type kids. Inpatient CL for kids is less interesting than adults...again mostly SI/SA +/- delirium depending on how good your general floors/ICU are with managing that.

 

[calvnandhobbs68]

Was it Vraylar? It's always Vraylar in my area...
Very frustrating

Yeah you can always tell when the Vraylar reps have been making the rounds.

 

[calvnandhobbs68]

That's a common argument, although I really disagree. When I did my 2 months inpatient second year and very small outpatient therapy practice 3rd year along with one specialty outpatient clinic I felt like I was in good shape to start a CAP fellowship. I went to an above average academic program with significantly above average prite scores and boy was the start of fellowship like a glass of cold water thrown on my face. The number of things I didn't know that I didn't know was eye opening and now that I have continued to do full-time attending CAP work I only further see how little adult psychiatry residency trained me for my job.

I'm sure there are some adult residents who love CAP, did a 6 month elective their 4th year, always took CAP patients during residency, but somehow just could not stomach the idea of 1 extra year of training. They go to AACAP yearly, read the orange journal, and stay up to date. All five of those folks in the country I can handle seeing a significant portion of their practice as children by intention.

Now if we want to argue the adult psychiatrist compared to the NP/PA with zero training in anything, that's a pretty simple argument, but this rapid descent in standard-of-care I find so incredibly alarming and scary, particularly among the most vulnerable populations.

I also agree with this. Adult psych minimum requirements are an extremely limited amount of child exposure. 3 months total out of 3-4 years of residency is not adequate exposure when the rest of the time is all adult rotations. Even from just a medical standpoint adult psych residents basically know very little to nothing about normal child development (very important when a kid who has "ADHD" comes in who actually has a obvious learning disability or speech delay that hasn't been picked up on for some reason), milestones, common co-morbid childhood conditions, differences in metabolism of medications between children and adults, what's actually FDA approved for kids compared to adults (as we know wayyy more limited which means even routine things you would use for adults are technically off label in kids). Even things like the various different types of stimulants and their formulations (it can be very helpful to be aware of the liquid/chewable formulations available) I've found that many adult residents don't know a ton about. And that's no fault of their own, they're spending 95% of their time with adults so why would anyone expect them to be up to date on things like child development!

But to compare it to family med where they have years of longitudinal family medicine clinics multiple days a week where they're seeing some portion of <18 usually every day is not really a fair comparison. Most family medicine doctors right out of residency should be pretty comfortable handling basic problems in kids (although I'd say probably not as comfortable as a pediatrician of course). Most adult psych residents get like 1 year of one half day of outpatient child clinic.

And yes of course if I had to choose I would choose an adult psychiatrist to manage a kid rather than an NP without adequate supervision. But I think most people who aren't adequately trained (and even many who are) have the tendency to overprescribe or prescribe aggressively inappropriately to placate parents.

 

[MedMan80]

Im CAP and love seeing CAP patients vs my adult patients (see some young adults), but its more work for the same money. I get the same amount of time with my kids than I do for my adults and its frustrating.. (intakes and followups)

 

[PikminOC]

Psychologists who prescribe can also prescribe to 6 years olds. Fun Fact!

 

[BlueSultan]

Thank you so much for all of your responses, it's been really valuable to see the perspectives that people have on this!

 

[Merovinge]

Im CAP and love seeing CAP patients vs my adult patients (see some young adults), but its more work for the same money. I get the same amount of time with my kids than I do for my adults and its frustrating.. (intakes and followups)

This does actually vary depending on the job. I have seen a variety of places advertise 20 min f/u for adults and 30 min f/u for kids. The reimbursement clearly does not follow along for private practice but there are still a variety of places that will give more time for kids.

 

[MedMan80]

This does actually vary depending on the job. I have seen a variety of places advertise 20 min f/u for adults and 30 min f/u for kids. The reimbursement clearly does not follow along for private practice but there are still a variety of places that will give more time for kids.

I agree it depends on state reimbursement for medicaid, where I am it's the same. I could opt to spread out to multiple intakes and bill separately but that ultimately means more work for me as my loads are fairly heavy..

 

[adaptation1]

Wot. Aren't kids just mini-adults?

... I love saying that to my C+A and pediatric colleagues.

 

[phagocytosis41]

According to Psych residents I speak to about this topic: not much higher pay, loss of attending pay for 2 years during fellowship and increased stress due to the nature of a field involving children (you have 3-4 patients not just 1). Those that do it love it or plan to move to a remote area where the pay is much higher for CAP. But it's strange, many I speak want to do it for the slightly higher pay.

 

[calvinhobbes]

Actually depending on where you work and if you have your own practice you can significantly increase your earnings vs. adult. You can do a mix of both too (telepsych adult or inpatient coverage on the side, whenever you want). Keep in mind that when treating teenagers and young adults, you’re the specialist that many have referred to, and often times you have the satisfaction of treating an adolescent and impacting them greatly for life (it’s not just 6 year olds with ADHD).

 

[Jenghiz_Khaan]

Because the parents often have a diagnosis of their own, and that's extra luggage few want to do deal with