Child and Adolescent Psychiatry
Work Force; A Critical Shortage
and National Challenge
AACAP
Steering Committee for Workforce
Issues
“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 gatekeepers to
identify children for referral and treatment
decisions.” (Mental Health: A Report of
the Surgeon General, 1999)
2
Prevalence and Magnitude of Child
and Adolescent Psychiatric Problems
• About 20 percent of U.S. children and adolescents (15 million), ages 9 to 17,
have diagnosable psychiatric disorders (MECA, 1996, the Surgeon General,
1999)
• The Center for Mental Health Services (1998) estimated that 9 to 13 percent
of U.S. children and adolescents, ages 9 to 17, meet the definition of “serious
emotional disturbance” and 5 to 9 percent of U.S. children and adolescents,
“extreme functional impairment.”
• Only about 20 percent of emotionally disturbed children and adolescents
receive some kind of mental health services (the Surgeon General, 1999), and
only a small fraction of them receive evaluation and treatment by child and
adolescent psychiatrists.
• The demand for the services of child and adolescent psychiatry is projected to
increase by 100 percent between 1995 and 2020, and for general psychiatry,
by 19 percent (U.S. Bureau of Health Professions, DHHS, 2000).
• The population of children and adolescents under age 18 is projected to grow
by more than 40 percent in the next 50 years from the current 70 million to
more than 100 million by 2050 (U.S. Bureau of the Census,2000).
3
Prevalence and Magnitude of
Child and Adolescent Psychiatric
Problems

About 20 percent of U.S. children and
adolescents (15 million), ages 9 to 17, have
diagnosable psychiatric disorders (MECA,
1996, the Surgeon General, 1999)
4
Prevalence and Magnitude of Child
and Adolescent Psychiatric
Problems (continued)
• The Center for Mental Health Services
(1998) estimated that 9 to 13 percent of
U.S. children and adolescents, ages 9 to
17, meet the definition of “serious
emotional disturbance” and 5 to 9 percent
of U.S. children and adolescents, “extreme
functional impairment.”
5
Prevalence and Magnitude of Child
and Adolescent Psychiatric Problems
(continued)
• Only about 20 percent of emotionally
disturbed children and adolescents receive
some kind of mental health services (the
Surgeon General, 1999), and only a small
fraction of them receive evaluation and
treatment by child and adolescent
psychiatrists.
6
Prevalence and Magnitude of Child
and Adolescent Psychiatric Problems
(continued)
• The demand for the services of child and
adolescent psychiatry is projected to
increase by 100 percent between 1995
and 2020, and for general psychiatry, by
19 percent (U.S. Bureau of Health
Professions, DHHS, 2000).
7
Prevalence and Magnitude of Child
and Adolescent Psychiatric Problems
(continued)
• The population of children and adolescents
under age 18 is projected to grow by more
than 40 percent in the next 50 years from
the current 70 million to more than 100
million by 2050 (U.S. Bureau of the
Census, 2000).
8
•
•
•
•
•
Supply of Child and Adolescent
Psychiatrists
There are currently about 7,000 and adolescent psychiatrists practicing in the
U.S. (AMA, 2006).
In 1980, GMENAC recommended that the number of child and adolescent
psychiatrists be increased to 8,000 - 10,000 by 1990 in order to meet the
projected needs for treatment of child mental disorders.
In 1990, COGME reported that the nation would need more than 30,000 child
and adolescent psychiatrists by 2000, based on increasing rates of child mental
illnesses and managed care staffing models.
There is a severe maldistribution of child psychiatric services in the U.S., with
children in rural areas and areas of low SES having significantly reduced
access. The ratio of child and adolescent psychiatrists per 100,000 youth
ranges from 3.1 in Alaska to 21.3 in Massachusetts with an average of 8.7
(Thomas and Holzer, 2006).
While the U.S. Bureau of Health Professions (2000) projects that the number
of child and adolescent psychiatrists will increase by about 30 percent to 8,312
by 2020 if the funding and recruitment remain stable at the current level, this
is far less than the estimated 12,624 needed to meet demand.
9
Supply of Child and Adolescent
Psychiatrists
• There are currently about 7,000 child and
adolescent psychiatrists practicing in the
U.S. (AMA, 2006).
10
Supply of Child and Adolescent
Psychiatrists (continued)
• In 1980, GMENAC recommended that the
number of child and adolescent
psychiatrists be increased to 8,000 - 10,000
by 1990 in order to meet the projected
needs for treatment of child mental
disorders.
11
Supply of Child and Adolescent
Psychiatrists (continued)
• In 1990, COGME reported that the
nation would need more than 30,000
child and adolescent psychiatrists by
2000, based on increasing rates of child
mental illnesses and managed care
staffing models.
12
Supply of Child and Adolescent
Psychiatrists (continued)
• There is a severe maldistribution of child
psychiatric services in the U.S., with
children in rural areas and areas of low
SES having significantly reduced access.
The ratio of child and adolescent
psychiatrists per 100,000 youth ranges
from 3.1 in Alaska to 21.3 in
Massachusetts with an average of 8.7
(Thomas & Holzer, 2006).
13
Supply of Child and Adolescent
Psychiatrists (continued)
• While the U.S. Bureau of Health
Professions (2000) projects that the
number of child and adolescent
psychiatrists will increase by about 30
percent to 8,312 by 2020 if the funding
and recruitment remain stable at the
current level, this is far less than the
estimated 12,624 needed to meet demand.
14
Recruitment Problems
•
•
•
•
•
There has been a steady decline in the recruitment of PGYI USMG’s into general
psychiatry through the NRMP, from 664 in 1990 to 481 in 2000, although increasing to
524, 564, 597, 641, 653, 643 in 2001-2006. However, the total number of psychiatric
residents has remained relatively stable, about 6000.
The number of child and adolescent psychiatry residents has not increased in the past
decade of the 20th century; 712 in 1990, and 718 in 2000. The number of child and
adolescent psychiatry training programs has decreased by 5 to 114 in the same period.
However, the numbers have been increasing slightly; 723, 742, 766 in 2004-6 and 3 new
programs opening (ACGME, 2006)
The proportion of IMG’s in child and adolescent psychiatry residency programs has
substantially increased from about 20 percent in 1990 to 34.8 percent (AMA, 2006).
The recommendation made in the 14th COGME report (1999) to enforce exchange visa
status of IMG’s to return to their home country after training and post 9-11 events will
likely further reduce the future workforce.
Close to 13 percent of child and adolescent psychiatry residency positions were
unfunded or unfilled in 2006; 766 residents filled 882 approved positions (ACGME,
2006).
It is estimated that about 20 percent of U.S. medical schools do not sponsor child and
adolescent psychiatry residency programs and more than 30 percent of U.S. medical
students have minimum or no clinical clerkship arrangement in child and adolescent
psychiatry–a critical void in the recruitment and education of future physicians. 15
Recruitment Problems
• There has been a steady decline in the
recruitment of PGYI USMG’s into
general psychiatry through the NRMP,
from 664 in 1990 to 481 in 2000,
although increasing to 524, 564, 597,
641, 653, 643 from 2001 to 2006.
However, the total number of
psychiatric residents has remained
relatively stable, about 6000.
16
Recruitment Problems
(continued)
• The number of child and adolescent
psychiatry residents has not increased
in the last decade of the 20th century;
712 in 1990, and 718 in 2000. The
number of child and adolescent
psychiatry training programs has
decreased by 5 to 114 in the same
period. However, the numbers have
been increasing slightly; 723, 742, 766
in 2004-6 and 3 new programs opening
(ACGME, 2006).
17
ACGME Resident Census
And *GME Track (AMA/AAMC, APA)
APPROVED
POSITIONS
ACADEMIC
YEAR
FILLED
POSITIONS
Years 1 & 2
APPROVED
POSITIONS
FILLED
POSITIONS
APPROVED
POSITIONS
FILLED
POSITIONS
Year 1
Year 1
Year 2
Year 2
*GME
Track,
APA
Census
1999 – 2000
874
718
2002 – 2003
834
673
434
338
400
335
664
2003 – 2004
852
709
443
354
409
355
692
2004 – 2005
881
723
455
366
426
357
720
2005 – 2006
879
742
454
368
425
374
706
2006 – 2007
882
766
Zip: Kim_ACGME Census 1999-06
669
18
CHILD PSYCHIATRY MATCH
TABLE 1
NRMP Child and Adolescent Psychiatry Program Statistics
Appt.
Year
Participating
Programs w/
Rank Order List
Program
withdrawls
/ No ROL
Positions
Offered
1996
88
5
1997
89
1998
Positions Filled
Programs Filled
n
%
n
%
270
170
63
36
41
7
272
193
71
43
48
82
7
244
177
73
38
46
1999
80
15
234
179
76
45
56
2000
76
7
229
167
73
40
53
2001
75
11
230
167
73
35
47
2002
77
0
242
177
73
41
53
2003
78
7
243
173
71
39
50
2004
81
4
259
223
86
59
73
2005
83
3
275
236
86
61
73
2006
2007
84
91
0
2
293
308
246
263
84
85
50
61
60
67
19
Note: NRMP=National Resident Matching Program
CHILD PSYCHIATRY MATCH
TABLE 2
NRMP Child and Adolescent Psychiatry Applicant Statistics
n
%(M)
Applicant*
Withdrawls / No Rank
Order List (W)
189
170
90
20
1997
215
193
90
33
1998
202
177
88
43
1999
208
179
86
50
2000
206
167
81
43
2001
181
167
92
24/23
2002
191
177
93
56
2003
208
173
83
40/21
2004
256
223
87
27
2005
291
236
81
39
2006
2007
269
297
246
263
91
89
20/19
9/17
Appt.
Year
Active Applicant
(A)
1996
Applicants Matched
Note: NRMP=National Resident Matching Program
20
Total Enrollment= A+W, Unmatched= A-M, *Total Combined or Separate numbers in some years
Recruitment Problems
(continued)
• The proportion of IMG’s in child and adolescent
psychiatry residency programs has substantially
increased from about 20 percent in 1990 to 34.8
percent (AMA, 2006). The recommendation made
in the 14th COGME report (1999) to enforce
exchange visa status of IMG’s to return to their
home country after training and post 9-11 events
will likely further reduce the future workforce.
21
Recruitment Problems
(continued)
• Close to 13 percent of child and adolescent
psychiatry residency positions were
unfunded or unfilled; 766 residents filled
882 approved positions (ACGME, 2006).
22
Recruitment Problems
(continued)
• It is estimated that about 20 percent of
U.S. medical schools do not sponsor child
and adolescent psychiatry residency
programs and more than 30 percent of
U.S. medical students have minimum or
no clinical clerkship arrangement in child
and adolescent psychiatry–a critical void
in the recruitment and education of future
physicians.
23
Recruitment Problems
(continued)
• Increasing educational debt, pressure and
incentives to pursue a primary care career in
the 1990’s, a long training period, further
sub-specialization of medicine including
psychiatry and reimbursement problems in
the managed care era are some of the
factors that discourage medical students in
choosing a career in child and adolescent
psychiatry.
24
Funding Problems
• Governmental agencies and the medical community have promoted a
decrease in the overall physician workforce, an increase of primary care
workforce, a reduction of specialty workforce, and a decrease in the
number of IMG’s entering graduate medical education–a so called 50-5010 model; 50 percent generalists, 50 percent specialists, 10 percent
IMG’s (COGME, 1992, 1994, 1995; Pew Health Professions
Commission, 1995; the 1997 consensus statement by AAMC, AACOM,
AMA, AOA, AAHC, NMA).
• The Balanced Budget Act (BBA) of 1997 reduced direct GME funding
by 50 percent for subspecialty training beyond the primary specialty
board eligibility. This is an added cut to child and adolescent psychiatry
that had not received indirect GME funding in the past.
• The 1997 BBA provided incentives to teaching hospitals for reduction of
GME positions. It also resulted in the severe reduction of Medicare
reimbursement to teaching hospitals. Although the BBA of 2000 will
provide some temporary relief to teaching hospitals, the GME programs,
especially child and adolescent psychiatry residency programs will suffer
25
from funding cuts.
Funding Problems
• Governmental agencies and the medical community
have promoted a decrease in the overall physician
workforce, an increase of primary care workforce, a
reduction of specialty workforce, and a decrease in
the number of IMG’s entering graduate medical
education–a so called 50-50-10 model; 50 percent
generalists, 50 percent specialists, 10 percent IMG’s
(COGME, 1992, 1994, 1995; Pew Health
Professions Commission, 1995; the 1997 consensus
statement by AAMC, AACOM, AMA, AOA, AAHC,
NMA).
26
Funding Problems (continued)
• The Balanced Budget Act (BBA) of 1997
reduced direct GME funding by 50 percent
for subspecialty training beyond the primary
specialty board eligibility. This is an
additional cut to child and adolescent
psychiatry that had not received indirect
GME funding in the past.
27
Funding Problems (continued)
• The 1997 BBA provided incentives to teaching
hospitals for reduction of GME positions. It
also resulted in the severe reduction of Medicare
reimbursement to teaching hospitals. The
reductions in health care services and health
professions training grants in 2001 have
affected, and the state and federal budgetary
problems will further affect negatively teaching
hospitals, the GME programs, especially child
and adolescent psychiatry residency programs.28
SUMMARY:
The need and voice of child and adolescent psychiatry have
been buried under the sweeping forces of the federal mandates
and national medical organizations’ consensus on the
oversupply of specialists. They have failed to recognize the
continuing critical shortage of child and adolescent
psychiatrists. The serious undersupply of practitioners has
resulted in children receiving inadequate care from mental
health professionals who lack the necessary training.
However, there have been increasing recognition of
shortage of physicians in general but also child and
adolescent psychiatrists, resulting in increasing numbers
of new residents and programs.
29
A CALL TO ACTION: CHILDREN
NEED OUR HELP
STRATEGIC PLAN
American Academy of
Child and Adolescent Psychiatry
10 year initiative
Recruitment/Workforce
•
•
•
•
•
Biopsychosocial
developmental
multimodal
Systems intervention
Multilevel collaboration
31
EXPANDING THE PORTALS OF ENTRY
FOR CAP TRAINING
•
•
•
•
•
Traditional Program (5 or 6 Years); 3 to 4 yrs GP + 2 yrs CAP
Triple Board Program (5 Years); 2 yrs Peds+3 yrs GP & CAP
Integrated Training (5 Years); traditional + CAP exposure
Integrated Training, Innovative (5-6 Years); + research
Pediatrician track (6 Years); 3 yrs Peds + 3 yrs GP & CAP
32
Legislative efforts;
• Stark bill to support GME funding for shortage
specialties, e.g. CAP, nephrology, etc. failed by
2000
• The Child Healthcare Crisis Relief Act, H.R.
1106; bipartisan by Kennedy (D-RI) and RosLehtinen (R-FL)
• Senate Companion Bill (S.537); bipartisan by Sen.
Bingaman (D-NM) and Collins (R-ME),
33
The Child Healthcare Crisis Relief
Act
• Recognition of national shortage of child mental
health professionals
• Incentives to help recruit and retain child mental
health professional by loan repayments,
scholarships and grants
• Increase of CAP by extending Medicare GME
years and cap for GME funding
• Total appropriation; $45 mill annually for 4 years
34
Advocacy
• Public image; media
• Governmental; federal (DHHS:FDA, NIH,
SAMHSA, etc)), congress, state, local
• Mental health community; consumer
groups, CMHC, hospitals
• Medical community; professional
organizations (AMA, ACGME, AAMC,
AAP, etc), medical schools
35
Medical Education & Mentoring
• Education of medical students: curriculum
• Exposure to clinical child psychiatry by
medical students
• Availability of mentor in ROCAP
• Information on professional satisfaction, job
market and life style
36
Survey of graduating residents
• Center for Health Work Force Studies at SUNY,
Albany (http://chws.albany.edu)
• all graduating residents and fellows in NY (44004500) and CA(2600-2700) in 27-28 specialties
each year in 1998-2002
• 40 to 65 % response rates
• Child and adolescent psychiatry ranked #1 in
many categories of career opportunity, although
the rankings from NY survey in 2003-2005 were
lower.
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