From June of last year to late this past spring, an average of five children a week were being admitted to the medical school’s teaching hospital at East Carolina University in Greenville, N.C., after overdosing on medications such as acetaminophen, opiates, antidepressants and even Ritalin.
Diamond, director of the school’s division of Child and Adolescent Psychiatry, is on the front lines of a coronavirus-aggravated crisis. There simply aren’t enough psychiatrists, psychologists, developmental pediatricians or school psychologists to care for the mental health needs of the country’s children, say parents, doctors, and professional associations.
Diamond was as frustrated as he was stunned. The 50-bed hospital didn’t have a single bed for children in emotional crises. Kids would have to wait for days in the emergency department and then travel with a sheriff’s deputy for up to two hours to another hospital. He also worried about how they would fare once released, since eastern North Carolina’s few mental health therapists all have long waiting lists.
“Parents are frantic and desperate,” says Nathalie Thandiwe, a public health expert in Los Angeles who counsels families seeking help for children with attention-deficit/hyperactivity disorder and other neurodevelopmental ailments. “Before the pandemic, there were waits of four to six months to see an expert. Now sometimes it’s indefinite.”
The problem is complex, as are its effects. Pediatricians and nurse practitioners are overwhelmed with mental health crises they’re often not trained to handle. Exasperated parents complain that some psychiatrists and psychologists have closed their practices or no longer accept payments through insurance. (Barely half of all psychiatrists now accept private insurance, according to a 2013 study in JAMA Psychiatry.)
Emergency departments have meanwhile become a tattered safety net for adolescent mental health care. One recent study mirrored Diamond’s experience, showing that suspected suicide attempts dramatically increased among adolescents ages 12 to 17 last February and March. Girls’ visits to emergency departments after suicide attempts soared by nearly 51 percent over 2019, and rose to a high of more than 1,000 weekly visits by spring 2021.
“In the last year, there’s been an avalanche of very severely depressed and anxious children and adolescents. It’s overwhelming,” says San Francisco child psychiatrist Michelle Guchereau, who adds that it has been “heartbreaking” to have to turn some away.
Young people’s mental health deteriorated during the pandemic, when cabin fever exacerbated family conflicts and closed schools left children isolated from normal activities and peers.
At last count, there were on average only 9.75 U.S. child psychiatrists per 100,000 children under age 19. The American Academy of Child and Adolescent Psychiatry (AACAP) says we need more than four times that many. The psychiatrists also congregate in big cities. More than two-thirds of U.S. counties don’t have even one.
In K-12 classrooms, where children’s problems are often first identified, there is only 1 school psychologist for every 1,211 students, when the ratio should be 1 to 500, says Katherine Cowan, spokeswoman for the National Association of School Psychologists.
Parents seeking a developmental pediatrician are also often out of luck, with long waits for appointments and high volumes of nonreimbursed care.
Psychologists have reported a 30 percent increase in demand for services for children under 13 and a 16 percent increase for adolescents. At one hospital in Michigan, admissions of adolescents with eating disorders more than doubled during the pandemic.
The crisis didn’t begin with the pandemic, however.
In 2012, a report by the American Academy of Child & Adolescent Psychiatry (AACAP) — citing statistics from 1999 — estimated that only about 20 percent of children with mental, emotional or behavioral disorders were getting care from a specialized mental health care provider.
“The increased pathology of kids has made this so much more acute,” Diamond says. “As kids got more severe, the infrastructure became insufficient.”
By many accounts, teenage depression, anxiety, self-harm and suicide have risen sharply over the past two decades. From 2004 to 2019, the rates of adolescent depression nearly doubled. The suicide rate for those ages 10 to 24 rose by more than 57 percent from 2007 to 2018 — from 6.8 per 100,000 to 10.7 per 100,000.
Despite these alarming statistics, it still takes on average eight to 10 years between the onset of symptoms and treatment, according to the AACAP, arguing that the lack of trained professionals is a major reason for the delays.
Experts cite multiple reasons for the shortage of children’s mental health specialists.
“It’s not a glorious field. There’s no wonderful new technology,” says Wun Jung Kim, director of the division of child and adolescent psychiatry at Robert Wood Johnson Medical School in New Jersey. Mental health problems are often chronic, he adds — with routine management and few rewarding victories.
Child psychiatrists must also spend more time and money in training, with two years of training with children following three or four years of a residency working with adults, all added to those four years of medical school. Once they start practicing — and paying off huge student debts — they’ll still earn substantially less than a surgeon or dermatologist, largely because insurance firms reward procedures at a higher rate than office visits. The net result is that new students aren’t rushing into the field, while families must search high and low for qualified help.
Parents are feeling the pinch even in big urban settings like the San Francisco Bay area, where “every other person is a therapist,” child psychologist Lisa White says jokingly.
When her 14-year-old daughter needed help, “I must have called 15 people,” says White, who works in Walnut Creek, Calif. “Many didn’t even return my call. Some only called back months later.”
“I just don’t think there’s a will to make the changes,” Diamond says. “We’re saying we’ll stumble along for now, not caring about the expenses down the road.”
Many mental health problems begin in childhood. And when untreated, they can increase the risk of troubles including school dropouts, unemployment and suicide. In 2002, the National Alliance on Mental Illness estimated that untreated mental illness costs the nation $113 billion a year.
Nearly 20 years ago, the AACAP released an urgent call to action to close the treatment gap. “CHILDREN NEED OUR HELP!” the front page of it read. Committees were formed, research was done and the gap kept growing. The organization continues to lobby for student loan forgiveness, a faster training track and insurance-reimbursement reforms, with few successes to celebrate.
Kim, who co-chaired one of the task forces from 1999 to 2001, is encouraged by a House bill, pending Senate approval, that includes $25 million in appropriations for loan repayments for pediatric subspecialists, including child and adolescent psychiatrists, who pledge to work in underserved areas.
President Biden’s proposed budget also includes $1 billion in new grants aimed at improving access to school mental health services, which schools could use for expenses including hiring additional counselors, psychologists and social workers.
Cowan says she is encouraged. “This is the first time in a very long time that there has been this much substantive fact-based attention to this issue, with some real budget heft behind it,” she says.
Wider use of technology has also raised hopes. Many mental health experts switched to serving their clients via the Internet during the pandemic, with mixed results. For some families, it was a godsend, saving commute times and providing a greater choice of therapists. Yet those without good Wi-Fi were left out, and many clinicians worry that therapeutic relationships suffer when they’re limited to screens.
One possible solution is the growth of integrative practices, in which psychiatrists can maximize their time by consulting with others with less academic experience.
“There is such a need for more child psychiatrists that even if we dramatically increase the number we can’t meet the need without an integrative model,” Guchereau says.
In 2019, she co-founded the Well Coast Medical Corporation, which employs two other psychiatrists and eight nurse practitioners in California and Oregon. Unlike many Bay Area specialists, they take insurance, even though Guchereau says that means a 50 percent cut in her income.
The American Rescue Plan, as the covid-19 stimulus package is known, includes $14.2 million to expand telehealth services through which somewhat similar state and regional integrative networks support pediatric primary care providers treating children with emotional and behavioral problems. The next round of grants will be announced in September, targeted to groups focusing on expanding access to underserved rural, ethnic and racial recipients.
White offered her own small dose of hope. Her daughter, after watching her mother work so hard to find her help, recently declared that she wants to become a psychiatrist — and work with adolescents.