Children's Access to Mental Health Care

Much of the conversation about health care reform has focused on the uninsured and on reducing the costs of medical care. Some attention has been paid to access to services, in particular, the effect of declining numbers of primary care physicians available to treat patients. Often left out of the discussion is access to mental health care.

It's been known for some time that the majority of children and adolescents with mental illness are not getting the treatment they need. The Surgeon General reported ten years ago that 1 in 5 children and adolescents have a diagnosable mental illness; 1 in 10 suffer significant impairment in their day-to-day lives; yet, only 20% of those needing treatment in any one year are identified and receive mental health services.

Shape Sorter

A recent study illustrates some of the reasons children don't get treatment. A survey of primary care physicians found that two-thirds report being unable to get outpatient mental health services for their patients. Internists, family practitioners, and pediatricians all reported similar problems in referring patients due to no or inadequate health insurance. But it was the pediatricians who reported the greatest difficulty due to health plan barriers and a shortage of mental health providers.(Cunningham, P. J. (Apr. 14, 2009). "Beyond Parity: Primary Care Physicians’ Perspectives on Access to Mental Health Care, Health Affairs Web Exclusive, w490–w500.)

In an op-ed in the Boston Globe, pediatrician Claudia Gold describes her problems in referring children she treats for ADHD when they develop symptoms of serious mental illness. Although the standard-of-care requires referral to a specialist, she has difficulty finding child psychiatrists who can take her patients. In the meantime, she remains responsible for their care. She asks:
So how have we gotten to this unfortunate situation where primary care doctors, who are clearly not qualified, are expected and encouraged to treat children with serious mental illness? I believe three main factors are at work. First, the pharmaceutical industry has been successful at promoting the idea that a pill will fix these often complex problems. Second, the insurance industry has made it very difficult for primary care doctors to refer patients for any mental health services. And third, there is a severe shortage of child psychiatrists.
In my area of the country (outside of Washington, D.C.), the shortage is not so much the number of available child psychiatrists but the number who participate in insurance panels. There is no monetary incentive for them to accept insurance. They can easily fill their practices with patients whose parents are willing to pay their fee. Families who must use their insurance may have to wait two to three months for an appointment.

Primary care physicians are put in the unenviable position of being asked to fill the gap in psychiatric services despite their all-too-justified reservations about doing so. Dr. Rob of Musings of a Distractible Mind tells his own story about a child patient needing medication, and I credit his post for raising my awareness of the primary care physician's side of the problem. He also offers a solution--raise low reimbursement rates to encourage more physicians to specialize in psychiatry.
This post was featured in Grand Rounds, Vol. 5, No. 47 - Cost Containment In Healthcare : The Covert Rationing Blog


  1. The medical economics always boggles the mind. But I can confirm, living with one, that the pri-cares had best know quite a bit of psychiatry.

  2. It's really hard to make the decision to go into child psychiatry. I'm a third year medical student trying to make a decision between child psychiatry and general pediatrics. Neither is that lucrative, but the bigger issue is how psychiatrists are viewed both in the medical community and outside of it. Other physicians sometimes look at psychiatrists as not being "real" doctors and moves to give psychologists prescribing privileges is making the situation worse- if people without a medical degree can do the job, then what use is the M.D? Also, because pediatricians do take care of children with ADHD, depression, anxiety, etc., the children sent to psychiatrists tend to be heavily slanted towards the most severely ill- children who are less likely to have a positive outcome and might need medications with dangerous side effect profiles. That can be rewarding, but it can also be a recipe for burnout. The media worsens the image of child psychiatrists even more- articles either seem to talk about the sad plight of children who can't get into child psychiatrists or talk about how psychiatrists overdiagnose and overmedicate children. It's like the news reporters are undecided- half the time they think that there's a desperate need and the other half of the time they think that child psychiatrists are quack docs who give children unnecessary medications for imaginary diseases-- There's very little positive coverage to be found....
    Also, for those of us who love kids, it's very difficult to have to go through an adult psychiatry residency first.(The post pediatrics portal project might offer a different way, but that's only offered a couple places)
    I'm not sure what I'll end up doing, but it's not just reimbursement issues that are keeping people from entering the field.

  3. Anonymous, thank-you for your sharing your perspective. You make a number of good points. Child psychiatrists are greatly under-appreciated. I had the good fortune to do a joint internship in child psychiatry and behavioral pediatrics at a medical school. Working with medical staff and child psychiatry residents on an inpatient unit was a great experience!

    I happen to be one of many psychologists who are against our gaining prescription privileges. I know that some states now allow it, but that doesn't mean that the entire profession is headed that way. I believe that those who are interested should get an additional degree, if not an M.D., then one of the others that have prescribing privilege such as nurse-practitioners.

    I'm not familiar with the "post pediatrics portal project" but you might want to look into a behavioral and developmental pediatrics program if you decide not to go the psychiatry route. I think with your love of kids, no matter which way you go, you'll end up helping kids with emotional problems. Good luck with your career!


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