For parents dealing with a troubled child, the months most have to wait before they can see a psychiatrist could be life or death.
“A lot can happen in those months,” said Dr. James Matsuda, director of pediatric hospitalists at Mercy Medical Center. "For kids 10 to 17-years-old, (suicide) is one of the leading causes of death."
About one in five children in the United States today has a mental health disorder, according to the American Academy of Child and Adolescent Psychiatry (AACAP). But only 21 percent of those affected actually receive the needed treatment.
This is because nationwide there is a shortage of child psychiatrists. A 2006 report from the AACAP found that the demand for child and adolescent psychiatric services will double between 1995 and 2020.
The number of psychiatrists, however, will not.
The report estimated that in 2020, about 12,624 child psychiatrists would be needed, but only 8,312 would be practicing, based on current funding and recruitment projections.
This shortage can be felt across a wide range of situations involving children — by parents and schools seeking treatment for their children, younger patients who need special attention before and after life-threatening surgeries and in the court system in cases involving children custody, crime or violence.
In Iowa, the report noted there were 35 child psychiatrists for the whole state. And though this information is a bit dated, Dr. Samuel Kuperman, director of the child and adolescent psychiatry division at the University of Iowa Hospitals and Clinics, said he doubts this number has improved much.
The Corridor and Des Moines have higher concentrations of mental health services for both children and adults. But even with a greater access to these resources, not every hospital is able to afford inpatient treatment facilities, which are too expensive due to security measures and difficult to staff because of the expertise needed.
Mercy Medical Center does not have an inpatient treatment facility and instead refers patients elsewhere, often to UnityPoint Health-St. Luke’s Hospital, which has the largest inpatient facility in the state.
Kent Jackson, director of St. Luke's Children's Specialty Services, said the hospital has 74 psychiatric beds — 24 of which are for children, 32 for adults and 18 for geriatric patients.
The University of Iowa Hospitals and Clinics has about 14 psychiatric beds for children.
These beds can be in high demand, which can result in shuffling children around hospitals, sometimes far away from their home. In DHS cases in which a psychiatrist deems the child is in an unsafe environment, the child may be put up in the inpatient facility.
"In those issues where we can't send them home, it takes a bed out of service," Kuperman said.
But many small, rural areas have no psychiatrists specializing in children, which is a big problems, experts said, because this could discourage parents and courts from seeking any kind of treatment for children.
“Families either have to travel, go without or settle with a therapist, when many need medication and psychotherapy together,” Jackson said. He added that 65 of Iowa's 99 counties have no psychiatrists.
Advances in telemedicine have helped somewhat, but cameras can't catch everything, he added, such as facial expressions or fidgeting.
Long training, lower pay
Psychiatrists, unlike psychologists, counselors or therapists, are medical doctors and can write prescriptions. They must complete medical school before attending a residency in which they specialize in psychiatry and receive training in mental health.
Those who specialize in child psychiatry must undergo a five-year residency, one year longer than those interested in adult psychiatry. This long training is one possible reason contributing to the shortage, experts said.
“There’s a lot of debt incurred, and it’s not one of the higher paid specialties,” Mercy Medical Center's Matsuda said.
Physicians are paid based on the number of procedures they perform. This means that child psychiatrists, who must spend lots of time to work with the whole family, are not paid as highly as surgeons, radiologists and other specialists.
And because child psychiatrists are so in demand nationwide, Iowa can be a hard sell.
“They can pick anywhere, so this can be a hard place to recruit,” Jackson said. “People who decide to stay here usually have family in the area … and the schools are attractive here.”
Jackson said St. Luke’s has been recruiting nonstop for several years, and even when the hospital finds an interested candidate, they generally prefer to work with adults rather than children.
“They say it’s too time consuming, too difficult and sad – there’s such a high percentage (of children in treatment) that have been abused or have trauma in their lives,” he said.
Expanding the number of slots in residency programs for child psychiatrists could help solve this problem. However, Kuperman said federal dollars fund the majority of residencies, and there’s only so much money to go around.
“It you give us one slot, you’d have to take a slot away from someone else,” he said.
Experts believe that loan repayment programs are a good place to start when it comes to attracting more child psychiatrists.
Much like the Rural Physician Loan Repayment Program, which pays off the student loans for up to 20 students who agree to work five years in a rural part of Iowa, a similar program could attract more medical students to specialize in psychiatry.
The Pediatric Subspecialty Loan Repayment Program, a federal program, aims to do just that.
The bill, which is still sitting in a Congressional subcommittee, wants to increase training in pediatric subspecialties by offering loan repayment to participants who in turn agree to work full-time for at least two years in a pediatric medical specialty, a pediatric surgical specialty or in child and adolescent mental and behavioral health in a medically underserved area.
In return, the program will pay up to $35,000 in loan repayment for each year of service, for a maximum of three years.“Money talks,” Jackson said.