Child and Adolescent Psychiatry: The Next 10 Years

May 02, 2008

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.

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.

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.

To summarize, about 300 residents currently enter child and adolescent psychiatry training each year. These numbers are likely to increase to about 400 over the next decade. The increase will result from earlier exposure of medical students to the field and a broader set of training pathways that will satisfy their interests. There will also be a much larger group of interdisciplinary practitioners providing primary mental health care for children and their families, including prevention and early intervention. There will be more formal collaborative networks, supported by interactive electronic communication, that use the scarce child and adolescent psychiatrist as both a consultant and an educator.

As the workforce becomes more interdisciplinary and collaborative, involving peers and consumers, mental health and health services will be truly integrated in local communities. Community systems will become more prominent, providing a continuum of care in the least restrictive environment. More home-based services, integrated classrooms, and wrap-around programs will keep children with mental and developmental disorders in the mainstream. Parent support groups and peer counseling programs will grow. The silos of professional isolationism and noncommunicating/collaborating agencies, buttressed by misinterpretations of the Health Insurance Portability and Accountability Act, will break down as families assume an ever more active role in partnering with professionals and participating on community boards.

I anticipate that child and adolescent psychiatrists will become more skilled in integrative, consultative, and collaborative roles. They will become better adult learners and educators, and they will become more engaged in prevention and early intervention, as well as better trained for leadership and building teams and for managing systems of care characterized by shared governance.

In short, access will be significantly facilitated by teamwork using child and adolescent psychiatrists in new roles. Electronic, Web-based, and interactive information transfer, including telepsychiatry consultation between well-resourced sites and more remote sites, will expand. Further, I envision that the AACAP, through public education campaigns focused on risk and resiliency, developmental milestones, prevention, and early intervention, will organize prospective parents who will become advocates of healthy emotional and psychological development. Starting in pregnancy, parents will receive information from the AACAP through each stage of their child's social and emotional development. Timely educational materials about typical cognitive, social, and emotional milestones, combined with information about early warning signs of disturbance, will be distributed to parents at specific points pertinent to their child's development-times when they are most receptive to learning and growth.11 An ongoing relationship with a group of families, built over time but starting in the prenatal period, that emphasizes prevention and early intervention will reduce stigma, foster positive therapeutic alliances with the field of child and adolescent psychiatry, and ultimately lessen the demand for higher-level specialty services later. Finally, I predict that the AACAP will develop Web-based iterative and interactive services that will guide both parents and professionals to better evidence-based information.

Stigma regarding mental disorders, especially in children, has been an effective barrier to receiving treatment. On one hand, parents are reluctant to bring children for care; on the other, insurance companies have "carved out" mental health benefits inequitably and have prescribed how different mental health professions should practice. Stigma also exists in school systems, where children in need may be overlooked or labeled inappropriately, and it remains among our medical colleagues who counsel bright medical students interested in psychiatry to choose a more "rigorous" specialty. But over the past several years, a reduction in stigma at all levels has occurred. Our research advances have provided more and better treatments. Parent advocacy groups have become more strident and politically active. Over the next decade, alliances between parent groups and professional organizations will become stronger. Joint lobbying efforts and public awareness campaigns at the federal, state, and local levels will become ever more popular.

The AACAP executive team has formed a national summit of partners that includes executive leadership teams from the National Alliance on Mental Illness, Children and Adults with Attention Deficit/Hyperactivity Disorder, the Autism Society of America, the National Mental Health Association, the Federation of Families for Children's Mental Health, and the Child and Adolescent Bipolar Foundation. The group meets twice yearly to work on issues of mutual interest, with discussions often focused on access and stigma, and jointly visits Capitol Hill on an annual basis. The APA has developed a comparable program of collaborative lobbying. The Paul Wellstone Mental Health and Addiction Equity Act is likely to become law and will certainly contribute to the reduction of stigma. In the next 10 years, these national partnerships will spread to regional levels, with local parent groups partnering with local child psychiatry and pediatric professional groups. I also expect that universal health care with mental health parity will come to pass. The stigma of mental illness and substance abuse will largely vanish.

The research imperative
Research currently drives our field, and I expect that it will continue to do so in the years ahead. Propelled by NIMH's highly successful Decade of the Brain and the subsequent delineation of the human genome, the field of neuroscience has made major advances in our understanding of the structure and function of the brain and how biology interacts with the environment to affect behavior and mental disorders. The speed of the advances in our knowledge over the past 10 years will only increase over the next 10. Thomas Insel, MD, the current director of NIMH, has wondered why so few medical students choose careers in psychiatry when so many majored in neuroscience as undergraduates. After all, psychiatry is one of the few medical specialties that comprises clinical neuroscience. It is my prediction that given some of the workforce and stigma reduction efforts outlined above, this lack of interest in clinical neuroscience will dissipate.

Research in genetics, genomics, proteonomics, and neuropharmacology will continue to advance and attract the brightest MDs and PhDs to our field. Research will lead to even better, more specific individualized treatments for mental disorders. Responses to treatment will be more rapid and more sustained. Medications will have fewer adverse effects. An increased focus on developmental neuroscience will specifically result in better treatments for children and attract more people into child and adolescent psychiatry. More research- focused, academic training programs for child psychiatrists, similar to those developed at Yale and the University of Colorado, will appear.

I doubt, however, that our new-found knowledge will ever determine that all psychiatric disorders are uniquely genetic. We will become more knowledgeable about how genes are regulated at the molecular level by environmental events and developmental experiences. In short, we will learn much more about behavioral genetics and about the multi-dimensional context of behavior. In 10 years, I predict that child and adolescent psychiatrists will practice a much more sophisticated version of evidence-based developmental psychiatry with more individually relevant evidence to inform our clinical decisions.

But there are also dangers ahead. The budgetary constraints that are affecting our economy in general and our research enterprise in particular are significantly curtailing our research productivity. The politicization of research priorities and federal prohibitions on some kinds of research potentially add to the loss of the US research enterprise's competitive edge. Globalization of research has intensified competition and may result in a reverse brain drain. These political, economic, and regulatory pressures have impacted the morale of scientists and altered the public's perception of our research enterprise. At least in the press and in the halls of Congress, there appears to be a progressive loss of confidence in our work.12,13 These perceptions have often, although not exclusively, been particularly directed at general and child and adolescent psychiatry.

Despite these concerns, I anticipate that the current economic and political pressures will lessen and that our research results will lead to even better understanding of basic mechanisms of brain function and behavior and to ever better treatments for mental disorders. I am optimistic that our economy will strengthen and that our nation's commitment to innovation through research will again flourish. I further predict that the public's trust in medicine in general and psychiatry in particular will be restored after a period of reflection and soul searching by our professional groups as we resolve serious concerns related to ethics and influence. In 10 years, the psychiatry research enterprise (basic and clinical neuroscience) will be more vigorous than it is today, and a developmental focus will dominate the research agenda and involve more child and adolescent psychiatrists.

Ethics, influence, and public perception
There are forces afoot that are undermining our credibility with the public and our relationships with our patients and their families. They have come at us from several sides. On one hand, antipsychiatry groups question our scientific integrity and portray us as greedy practitioners who lack a research base for our clinical decisions. They suggest that psychiatric disorders, for the most part, are a figment of our imagination and that child and adolescent psychiatrists pathologize what is within the bounds of typical development. On the other side, extraordinarily large marketing expenditures and controversial marketing practices by the pharmaceutical and medical device industries influence our clinical judgment and professional behavior.

Gifts and honoraria, large and small; biased Continuing Medical Education (CME) activities; kickbacks; and "free lunches" of various kinds have been designed to influence and reward physicians' specific decision making.14 Direct advertising to consumers also affects prescribing practices.15 Industry-supported clinical trials in academic medical centers, advertising in medical journals, and lavish exhibits at annual meetings all have contributed to the credibility gap with the public.16 Yet, how would many professional and advocacy organizations fare without such direct and indirect industry support? How much would subscription prices for journals need to be increased without such advertising? And how would physicians' competence and knowledge be affected without industry-supported CME programs and office visits by sales forces? These are complicated issues that affect all the specialties of medicine and certainly psychiatry and child and adolescent psychiatry.

The media have investigated these marketing practices and recently have begun to paint a grim picture of child and adolescent psychiatrists' diagnostic inconsistencies, individual ethical lapses, and clinical prescribing practices guided by pharmaceutical influence.17-19 The public's perception of our professionalism has dimmed as a result of these media reports, as has its belief in the integrity of our research findings.

I believe that industry influence can and should not be eliminated. The pharmaceutical companies have successfully contributed to the success of our research agenda. Child and adolescent psychiatry as a field is better off because of that support. However, it is a good sign that at all levels, academic institutions, professional organizations, and individuals have begun to openly discuss the issues. Verbal and written dialogue among members of the AACAP and between industry leaders and the AACAP about acceptable ethical practices mirrors the discussions within other professional and academic groups. Similarly, the recent dialogue begun between the Journal of Child and Adolescent Psychopharmacology and its readership is laudable.20 A similar effort has been mounted in the AACAP's newsletter. These efforts will guide us in our efforts to manage conflict. We will never be able to eliminate conflict, but we need to become more capable of managing it. I predict that 10 years from now, the management of influence and conflict will be significantly improved, resulting in significantly greater transparency through more pertinent and meaningful disclosure. The relationships among industry, practitioners, professional organizations, and academic centers will become more transparent and trusted, and the public's confidence in our skills, knowledge, and professionalism will be restored.

So how will the professional lives of child and adolescent psychiatrists change over the next 10 years? I expect that our practices will be largely unrecognizable in terms of current practice patterns. As specialists, we will be much more knowledgeable about brain and behavior mechanisms at both cellular and systems levels, and our treatments will be much more individually specific and effective. However, our numbers will continue to be inadequate, and direct care will be provided by a variety of professionals who will work collaboratively with us. Our roles will be as educators, consultants, and leaders of teams. Parent partnerships with professionals around advocacy and collaborative treatment will prevail as will strategies focused on prevention and early intervention. Parity and universal health insurance will reduce stigma and improve access. Finally, I am confident that the public's trust in our competence and professionalism will be restored. As a result, in 2018, children with mental disorders and their families will receive much better treatment than they do today.




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