Child and Adolescent Psychiatry: The Next 10 Years

Psychiatry is changing so rapidly that it seems impossible to predict 1 year ahead, let alone 10 years. In 1967, when my psychiatry training ended, the community psychiatry movement had just begun, DSM-II was in the works, and the biological revolution was still around the corner. Psychiatrists of that era were deeply psychodynamic in their orientation. My view of developments over the next decade stems largely from my perspective as a recently retired academic child and adolescent psychiatrist. While many of the programs that I managed were based in community settings, I am not a community psychiatrist. And although I saw private patients throughout my career, I have never been in full-time private practice. So beware: future predictions are most likely biased by past experiences.

In 1967, who would have predicted that psychiatry would have returned to mainstream medicine, that stigma would be significantly lessened both for our patients and for our profession, or that we would have such a large and diverse armamentarium of effective treatments? Do these advances suggest that the profession of psychiatry has arrived, that our understanding of mental disorders and treatments is complete, and that stigma has disappeared? Not at all! More work remains to be done, obstacles still need to be overcome, and more changes are on the way.

Child and adolescent psychiatry is a unique subspecialty with some very formidable challenges, but our challenges are not too dissimilar from those of many of our physician colleagues. As part of the US healthcare system, all of us need to work collaboratively to shape our future. The following discussion of the future of child and adolescent psychiatry will focus on 5 interrelated areas: workforce, access, stigma, research, and ethics and public perception.

Workforce
There is a serious crisis in the child and adolescent psychiatry workforce.¹ There are far too few of us, and large parts of the country—especially rural and inner city areas—have few if any child and adolescent psychiatrists.^2,3 Many studies over the years, including reports from presidential commissions, surgeons general,^4-7 the Council of Graduate Medical Education,⁸ and the Institute of Medicine,⁹ attest to the dire shortage of child and adolescent psychiatrists relative to the almost 20% of our nation's children who are deemed in need of care. This shortage embraces all children's mental health professions and severely impacts access. Fewer than half of the children in need of care are evaluated, and even fewer are treated effectively.

Projections from the studies mentioned above estimate a need for 30,000 child and adolescent psychiatrists.¹⁰ Currently, there are about 7000. However, since many of these child and adolescent specialists also treat adult patients and/or engage in administrative, supervisory, or other nonclinical activities, the direct care workforce is well below that number. Will we reach the goal of 30,000 in the next decade when there has been virtually no change in our numbers over the past decade?

I predict that by 2018, resulting in part from recent efforts by the American Academy of Child & Adolescent Psychiatry (AACAP), we will see a modest 30% increase in the number of medical students and general psychiatry residents choosing child and adolescent psychiatry as a career. One of the AACAP's recruitment efforts includes earlier exposure of medical students to child and adolescent psychiatry. The AACAP's partnership with the Harvard Macy Program for Educators in the Health Professions is increasing the number of competent teachers of medical students to serve as role models. The Klingenstein Third Generation Foundation's generous support of medical student fellowship programs in 12 medical schools is providing an incentive for medical students in their first and second years to participate in clinical experiences mentored by child and adolescent psychiatrists. A similar effort is being mounted by the American Psychiatric Association (APA) in support of the Psychiatry Student Interest Group Network, a national organization of medical students interested in psychiatry. Additional AACAP efforts have spawned new training pathways to child and adolescent psychiatry. The Post Pediatrics Portal Project, recently approved by the Accreditation Council on Graduate Medical Education, will attract board-eligible and board-certified pediatricians who wish to switch careers. They will train for 36 months (instead of 48 months) in integrated child and general psychiatry programs. For medical students who express an interest in early exposure to children, more flexible Residency Review Committee requirements provide greater opportunities for parallel child and general psychiatry experiences throughout training. The academic research training track in child and adolescent psychiatry, initiated at the Yale Child Study Center and now spreading to other sites, is yet another pathway for attracting the brightest to child and adolescent psychiatry. Finally, the triple-board program remains popular with medical students who are interested in integrating their training with pediatrics. Despite these innovations, however, I expect we will not have 10,000 child and adolescent psychiatrists a decade from now.

Rather, I predict that more intensive behavioral health training will emerge for primary care physicians and general psychiatrists both during their residencies and through postgraduate courses. Such advanced courses will lead to recognition of special competencies in childhood behavior and mental disorders. I also believe that physician extenders such as psychiatric clinical nurse specialists will be used more widely and that more psychologists will be specially trained and licensed to prescribe. Finally, the Internet and technological advances such as telepsychiatry will serve to expand the scope of practice so that child and adolescent psychiatrists will be used much more as educators and consultants.