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Why mental health care deserts persist for U.S. children

Despite an uptick in the number of child psychiatrists nationwide, one out of five U.S. children live in a county with no such provider, according to a study published this week in the journal Pediatrics, which also found that those specialists are largely concentrated in certain pockets of the country. Meanwhile, for various reasons, only half of U.S. children with a mental health condition are receiving treatment.

Nationwide, 70 percent of counties had no child psychiatrists, and children were less likely to have access to professional mental health services if they lived in counties with lower income and education levels. Six states — Idaho, Indiana, Kansas, South Carolina, South Dakota and North Dakota — reported a decline in the number of child psychiatrists during the decade studied.

That disparity persists even though the profession has grown by 21 percent from 2007 to 2016, to a rate of nearly 10 child psychiatrists per 100,000 people. At the same time, fewer Americans are choosing to have children, suggesting that there should be an “overall improvement in potential access to care,” the study said. Add to that improved health care coverage under the Affordable Care Act and the Children’s Health Insurance Program.

And yet those gains have not translated to better across-the-board access to children’s mental health care, said Ryan McBain, an associate policy researcher with the RAND Corporation and the study’s lead author.

For example, Massachusetts has as many child psychiatrists as Oklahoma, Indiana, Georgia, Mississippi and Tennessee combined, the study says, but those last five states altogether have five times as many children as Massachusetts.

“Just because people have access to care doesn’t mean that care is there for them to draw on,” McBain said. “If providers don’t exist, essentially, insurance is non-functional.”

What the study found

To arrive at these results, McBain and his team analyzed a decade of data from the Area Health Resource Files — a dataset that the Department of Health and Human Services compiles each year to list county-level health professionals. They looked for how many child psychiatrists — trained medical doctors who can prescribe medication to young patients — were in each county. These mental health care professionals differ from psychologists, who offer therapy and behavioral interventions to help patients with mental and emotional issues.

What they found was a profession gripped with a pipeline problem, McBain said. Obstacles to ramping up the ranks of child psychiatrists include the stagnant number of medical schools accredited to graduate these health care providers, and to the additional training that’s required for a specialist focused on children, he said.

He added that there is also a financial disincentive for medical professionals to pursue child psychiatry. A new medical school graduate who completes a residency could earn a starting salary of $500,000 as a dermatologist or $200,000 as a child psychiatrist.

These trends are colliding at a time when more children need ready access to mental health services. In October, a federal study of government data suggested that suicide rates are on the rise among children and young adults. Children struggling with mental health also may face stigma, leading to a greater reluctance to ask for help.

This shortage of child psychiatrists is not a new problem, said Wesley Boyd, an associate professor of psychiatry at Harvard Medical School and a staff psychiatrist at the Cambridge Health Alliance who was not involved with this study. He links the shortage to an additional financial disincentive for physicians — insurance reimbursement rates based on numbers set decades ago, which raise the expense of treating people with mental illness and passing the cost onto patients.

“People who are looking to use insurance to access child psychiatric services are often out of luck,” Boyd said. “If you’re middle income or lower, you might be priced out of services.”

How can communities get help now?

If it takes a community years to ramp up child mental health resources, how can kids get the help they need?

Telementoring, through efforts such as Project Echo, could be part of the short-term answer, McBain said. Through telementoring, internists and family physicians that children and their families already have access to, could turn to experts in the field of child psychiatry to learn about warning signs and intervention strategies, he said. And while this form of telemedicine needs more research, McBain said, Congress dedicated funding to evaluate outcomes linked to telemedicine versus in-person health care services.

There are no child psychiatrists in Madison County, Idaho, which stretches across 473 square miles. Of about 38,000 residents in Rexburg, Idaho, and the surrounding county, a third of them are under age 19, according to the latest Census Bureau data.

Nichole Stanford has taught English to high school students in her hometown of Rexburg for nine years. During that time, students occasionally submitted writing assignments that read like a cry for help, but Stanford said she did not know what to do.

Then, the high school where she teaches received a grant to train instructors how to identify students at risk of self-harm and offer help. Now, Stanford said she feels confident approaching a student, talking to them in the hallway and walking with them to the counselor’s office where students can receive more generalized guidance and can suggest additional mental health services

“They know there’s another teacher, another adult that’s in their corner,” she said.

And while she is grateful to know how to assist vulnerable students, the burden of knowing what haunts her pupils can take a toll on Stanford from time to time. She said when she feels upset, she drinks Coca-Cola, eats chocolate and confides in close friends who are also teachers and understand what she is going through.

Nearly 30 miles away in Idaho Falls, Idaho, child psychiatrist Craig Denny said he treats about 100 children in a typical week during sessions that last 15 minutes on average. Some patients travel as much as three hours to see him. Family practitioners and pediatricians typically offer mental health services to children in southeastern Idaho, Denny said, and that can result in misdiagnosed illness and inappropriate prescriptions.

“This is substandard care,” he said. “You don’t have the right professionals with the right training.”

People who want to pursue child psychiatry must wrestle with years of extra training, Denny said, and reimbursement rates do not make up the difference. He said child psychiatry should either be fast-tracked so that training lasts the same amount of time as adult psychiatry or reimbursement rates should go up to prevent child psychiatrists from being priced out of their practice.

Something has to change, he said, because states like Idaho “don’t have the resources to treat” kids who need help.

Editor’s Note: If you or someone you know may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (En Español: 1-888-628-9454; Deaf and Hard of Hearing: 1-800-799-4889) or the Crisis Text Line by texting HOME to 741741.