There’s a huge shortage of mental health providers for kids who need help

Published on
May 6, 2019

Reggie was exposed to methamphetamines in utero and his birth mother couldn’t care for him. A month after he was born, I was his doctor in the foster care clinic at Harbor-UCLA Medical Center. He was adopted by one of my fellow pediatricians at the hospital and her husband (the boy’s name has been changed).

I’ve written about Reggie before, but his struggles again expose the gaps in mental health care for children.

Reggie, now 6, was a happy, healthy toddler. His parents were optimistic that he had escaped the toxic effects of meth on his developing brain. But, when he was 5, things changed. The daily social demands of preschool were too much. His behavior spun out of control. He became defiant, disobedient, aggressive and started hitting strangers. His parents enrolled him in a therapeutic preschool, but Reggie needed more individual help.

He was referred to a psychiatrist. But, instead of prompt attention, he landed on a month-long waiting list for a psychiatrist who accepted his insurance. He has Medi-Cal, California’s health program for low-income people, foster children and other qualifying individuals, such as those with disabilities.

Reggie’s long wait for care is emblematic of a much larger problem of too few mental health providers for low-income kids on public coverage.

In California, nearly one in 13 kids suffers with a mental disorder severe enough to disrupt daily living. California has fewer than 1,135 child and adolescent psychiatrists to serve almost 10 million children and teens younger than 18 years. This mismatch means many kids do not have access to care. 

The dearth of mental health providers is especially problematic in areas of the state that are poor, rural or have mostly immigrant populations. In a community, as the rate of poverty increases, so does the rate of mental illness. But the number of licensed mental health professionals decreases. For example, in Los Angeles County 17 percent of people live in poverty and there are about 20 psychiatrists per 100,000 people. In comparison, the wealthier counties of San Francisco and Marin have poverty rates below 10 percent. But they have the highest rates of psychiatrists in the state, at 76 and 70 per 100,000 people, respectively.

This isn’t just a problem in California — there’s a nationwide shortage of psychiatrists and therapists, especially for children and teens. Half of all mental illnesses begin by age 14, according to the American Psychiatric Association. Nearly one in eight school-age children have a mental health disorder, such as attention deficit hyperactivity disorder (ADHD), depression, anxiety or behavior problems. Suicide rates are skyrocketing — it’s currently the third leading cause of death in adolescents and young adults. Depression is a major contributor to suicide.

The social stigma surrounding mental health problems is a major reason individuals with mental illness do not seek care. However, for people who do look for help, it can be hard to find and even harder to pay for.

Some mental health providers only accept cash up front. Some insurance plans offer limited or no mental health benefits, or their plans aren’t accepted by psychiatrists. That’s often because the reimbursement from insurers is so low. These hurdles can lead to long waits or no appointments, especially for children who are minorities or live in rural or poor urban areas.

Medi-Cal covers mental health services, but the number of providers who accept it is limited and most have a waiting list, as Reggie’s family discovered.

With the paucity of mental health providers for children, primary care medical doctors have become the front lines of mental health care. More than one-third of kids with mental health conditions are cared for by pediatricians. However, two-thirds of pediatricians reported feeling unprepared to provide mental health care, according to a survey by the American Academy of Pediatrics. As part of general practice, pediatricians perform screening for autism, ADHD, behavior problems and developmental delays, as well as prescribe medications for less complicated diagnoses, such as ADHD. Professional pediatric organizations are working to increase psychiatric training during pediatric residency to improve pediatricians’ skill sets.

This month, the American Academy of Child and Adolescent Psychiatrists issued an update to their 2002 report offering a long-term plan to tackle the workforce shortage. The report suggested increasing exposure to the child psychiatry specialty among medical students and recruiting more medical graduates into psychiatric residency programs. The report also identified strategies to address the daunting educational expense for trainees, the poor reimbursement for practitioners, and steps to boost federal funding for psychiatric training programs. The academy also proposed a community education program to destigmatize mental illness. 

After being on the waiting list for five weeks, Reggie recently started his psychiatric care. Despite the delay, he’s one of the more fortunate kids — he’s getting help.