Young and alone
MATHEW BACON, 9, struggles with schoolwork, can’t follow rules and sometimes becomes violent, beating up younger kids and striking out at his 5-year-old sister. He’s been diagnosed with oppositional defiant disorder, depression and ADHD.
Christina Tamez battles mood swings, attention problems and tics. At 13, she’s been diagnosed with bipolar depression, a condition recently exacerbated by puberty. In sixth grade, she began threatening suicide.
But they and their parents -- like millions of other families -- are largely forsaken by the nation’s mental health system. They struggle to find child psychiatrists with available appointments, sometimes searching for years to find a doctor. They wait for weeks for a five-minute review of their child’s complex problems. And they travel for miles for even the briefest exams.
When they need help the most, some families find, they’re on their own.
“It would be the equivalent of your child getting a concussion, in pain, vomiting, and not being able to get any medical help,” says Sandra Betler, an Orange County woman whose daughter began cutting herself and talking of suicide last spring but who couldn’t find a doctor to see her child. “You think they’re going to die at any time.”
About 15 million U.S. children ages 9 to 17 are thought to have a serious mental or addictive disorder -- such as depression, anxiety, attention deficit hyperactivity disorder (ADHD), eating disorders, early onset schizophrenia or bipolar disorder. Psychiatry has long focused on adults, but knowledge about children’s mental health has grown over the last two decades. New studies have helped clarify what is normal and abnormal behavior in children, while genetics research has revealed strong family patterns for mental illnesses, many of which can first appear in childhood or adolescence.
Such knowledge has led to diagnosis at earlier ages than ever before, says Dr. Greg Fritz, medical director of Bradley Hospital in East Providence, R.I., and a spokesman on the issue for the American Academy of Child and Adolescent Psychiatry. Parents today are also less bothered by the stigma of mental illness, he adds, and are more likely to seek treatment -- especially medication -- that can help their children. From 1987 through 1996, psychotropic drug use among children and teens nearly tripled to more than 2 million children, according to a study published in 2003 in the Journal of the American Academy of Child and Adolescent Psychiatry.
Similarly, visits by children, ages 12 to 17, for mental health treatment or counseling increased by almost 900,000 visits from 2002 through 2004, a federal government survey found.
But only about 7,500 child psychiatrists are currently practicing in the United States -- and only 300 new child and adolescent psychiatrists complete training each year. The profession -- the only board-certified medical specialty that trains physicians to treat mental disorders in children and teens -- is experiencing one of the most severe labor shortages among all medical specialties.
Those doctors who are available are often concentrated in urban areas, leaving some rural counties without a single child psychiatrist.
“Every child psychiatrist in the country has a waiting list,” says Fritz, an expert on the workforce shortage. “I’ve never talked to one who didn’t. Many will not even put people on a waiting list because it’s too long and ridiculous.”
Simply put, there are too few child and adolescent psychiatrists and too many kids with serious, even life-threatening, mental illnesses.
The crunch is expected to worsen.
Even first-line physicians -- pediatricians and other primary care doctors -- are now reluctant to treat children with mental disorders.
Some have been scared off, experts say, by the new warnings on antidepressants prescribed for children. The warnings state that the drugs’ increased suicide risk requires closer monitoring of patients -- something many primary care doctors are disinclined to do, Fritz says.
Others say they simply don’t know enough about the use of psychotropic drugs in children or about the latest diagnostic and treatment information for childhood mental illnesses.
“Pediatricians are feeling overburdened and underqualified,” says Fritz. “Increasingly, they are having to deal with problems they are uncomfortable with. They say, ‘This is beyond what I’m trained to do. I’m only doing it because the child is desperate.’ ”
Although psychologists, school counselors and licensed certified social workers can provide effective therapy for many children, they are not allowed to prescribe the medication that many children so desperately need. (Only in Louisiana and New Mexico can psychologists prescribe medication.) In any case, social workers who treat children and school counselors are in short supply too.
Children and their families are suffering as a result.
Searching for stability
The Bacon family first sought help for Mathew when he was 3, an exuberant boy who couldn’t sit still and had trouble sleeping. Though he was quickly diagnosed with ADHD, his behavior has deteriorated over time -- and long-term guidance has been nonexistent.
His pediatrician finally said she couldn’t help anymore, that Mathew’s case was too complex. An adult psychiatrist agreed to meet the Corona family, but he was overbooked and couldn’t see them as often as they needed. Nor did he return the family’s desperate phone calls seeking advice during times of crisis. Other doctors refused to take their insurance -- a problem for many families seeking help. By the time Mathew’s parents found his present doctor, a certified child and adolescent psychiatrist in San Bernardino County, they were running out of options.
Mathew’s mother, Marcella, is grateful that the family found a doctor to guide her son’s care. But, she says, he’s only in the office on Wednesday, already has a full caseload, and can see Mathew only once a month, at most -- and then only for 20 minutes. And every visit requires an hour’s drive each way in rush-hour traffic.
“I don’t have enough time to go over everything with the doctor,” she says. “Basically, I get the medication. It’s hard to find a doctor who can spend enough time with a child to know what is going on.”
Christina Tamez’s parents are still looking for a steady doctor, seven years after she began experiencing mood swings, attention problems and tics at the age of 6.
First came the diagnosis of bipolar depression at a clinic that evaluated children but did not offer treatment. One doctor was helpful in explaining child behavior and advising how best to deal with their daughter, but he recommended a child psychiatrist when Christina’s symptoms became more serious. The east Los Angeles County family, who have private health insurance, couldn’t find one who took their insurance and also wasn’t fully booked with existing patients.
They eventually found a licensed certified social worker who specializes in children. She made time for them when the family needed urgent help, such as when Christina threatened suicide. But she too is overbooked and can’t see the family on a regular basis. And, of course, she can’t prescribe medications.
The recent flare-up of Christina’s symptoms has launched her mother, Laurie J. Quadros-Tamez, on the hunt again for a doctor, one who can not only prescribe medication but who can see Christina on a timely basis.
“We just need to plug on and keep trying to find the person who will be good for her,” says Quadros-Tamez. “You can’t give up.”
Kids with mental health problems simply aren’t treated with the same urgency as children with physical ailments, even when that health takes a precipitous dive, says Sandra Betler, whose daughter has bipolar disorder, a serious mental illness in which bouts of deep depression alternate with euphoric moods.
Last spring, the family was forced to wait for days for a chance to see a physician, even as the 13-year-old grew more morose and, eventually, suicidal.
The girl had suffered a bout of depression at age 10 but seemed to improve after counseling from a psychologist. In May, however, the teenager began failing math, crying frequently and cutting her legs with scissors or a razor.
Betler contacted three highly recommended child psychiatrists, but the first opening any of them had was in a month.
“Her condition continued to deteriorate,” says Betler. “She couldn’t even get out of bed. She was sleeping 12 to 14 hours a day. She was crying out of the blue. She stayed home from school three days in a row.”
After three weeks on pins and needles, the family finally wrangled an appointment with a child psychiatrist. Although the doctor prescribed an antidepressant, the girl’s mood worsened. She began writing morbid poetry, smoking and once tackled her mother during an outburst of anger. The formerly empathetic, cheerful girl began reading magazine articles about suicide.
Their anxiety mounting, Betler and her husband repeatedly called the psychiatrist seeking guidance. When he returned their calls, which was infrequently, he often left hurried medication instructions with the teenager, who later couldn’t recall exactly what he had said. Betler sought another office appointment, but was put on a waiting list.
“Every day we were prepared for something new and disastrous to come up,” she says. “You’re living with this constant fear. What is happening with my child? And this case just wasn’t important to [the doctor]. We wondered, did he even remember who she is?”
Unwilling to wait for help any longer, Betler and her husband took their child to a hospital emergency room. She was diagnosed with hallucinations and other psychotic symptoms and was hospitalized for 13 days.
Eventually, the family found consistent -- and attentive -- care with a child and adolescent psychiatrist just out of training who was referred by the hospital. But the experience left them shaken.
“Even though [a few weeks] doesn’t sound like a huge amount of time, when you’re fearful for your child’s health, it feels like forever,” Betler says.
Change from within
The widening gap between the number of doctors and the needs of patients has become the priority of the American Academy of Child and Adolescent Psychiatry.
Currently, medical students who choose to specialize in child psychiatry are required to complete a three-year residency in adult psychiatry before beginning a two-year residency in child psychiatry. But this format often discourages young doctors from studying child psychiatry, says Dr. George Fouras, a San Francisco child psychiatrist and chairman of the California Psychiatric Assn.'s child and adolescent committee.
“A lot of medical students really don’t even get exposed to child psychiatry until much later in the process when they’ve already made decisions about what they want to do in their career,” he says.
The academy is now trying to create a single five-year psychiatry residency that combines adult and child psychiatry -- an idea that is gaining momentum, says Dr. Thomas Anders, the academy’s president. The organization has also proposed that trained pediatricians be allowed to become board certified in child psychiatry by completing an abbreviated residency -- three years in child psychiatry. It’s too soon to tell whether schools and hospitals will support such a proposal.
Child psychiatrists and mental health advocates are also supporting a bill before Congress that would create scholarships and repay loans for people who study child mental health. The bill would also increase the number of child and adolescent psychiatrists permitted in a Medicare program that pays hospitals a specific amount of money to train new doctors.
Around the country, doctors are also discovering innovative ways to deal with the shortage.
Child psychiatrists at UC Davis, for example, have turned to telemedicine, relying on high-speed video hookups to communicate with primary care doctors in underserved pockets of California, such as rural Northern California and the Central Valley. Together, they devise treatment plans for children with serious mental illnesses who might otherwise lack specialist care.
And in Kern County -- which until recently had only two child psychiatrists for a population of 730,000 people -- county health officials have launched the first new psychiatry residency program in California in 33 years.
The UCLA-Kern Residency Program now has 10 young doctors in training, several of whom will probably specialize in child psychiatry, says Dr. Tai P. Yoo, director of the program and joint chairman of psychiatry for the Kern County Mental Health department. Residents can treat patients with supervision. But, Yoo says, the hope is that the trainees remain in the community upon completion of their residency.
“We are now able to provide much better access and a higher quality of care than previously available,” he says. “Soon we’ll be able to take care of all of our patients without sending them out of the county.”
The 2004 passage of Prop. 63, the Mental Health Services Act, should also help ease the workforce shortage in California somewhat, experts say, by providing money for training and educating mental health professionals, including psychiatrists.
The bill places a 1% surcharge on taxable income over $1 million to generate funds for mental health services. But some of the money will be spent to attract new professionals into the field, such as by offering tuition credits and low-cost student loans, says Robert Garcia, chief deputy director of the California Department of Mental Health.
Holding out hope
Families would welcome the extra attention.
Ressie Christopherson of Long Beach says the stress of trying to find the best care for her teenage daughter, who suffers from depression, can be overwhelming.
The family has had trouble finding a doctor. And, although she and her daughter like their current one, Christopherson worries that the 15-year-old isn’t seen often enough. “Even if the doctor says we need to come back in six weeks, we still can’t get an appointment,” she says.
When openings do arise, Christopherson often rushes from work, hoping her boss will understand. The stress has aggravated her high blood pressure and caused her teenage son to become depressed as well, she says. The Long Beach mother says she wishes she had more control over the situation.
But, she says, child psychiatric care “has a lot to do with luck and prayer.”
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Where to find help
Resources for children and teens with mental illness:
* National Alliance for the Mentally Ill, California: This organization of families and people affected by mental illness offers local affiliates, support groups and a statewide listing of individual therapists. www.namicalifornia.org.
* Mental Health Assn. in California: This advocacy group offers local chapters, resources and information. www.mhac.org or (916) 557-1167.
* County mental health departments: These agencies typically provide mental health programs, information and some services to low-income families:
Los Angeles County Department of Mental Health. www.dmh.co.la.ca.us or (800) 854-7771.
Orange County Health Care Agency. www.ochealthinfo.com/behavioral/children.htm or (714) 834-5015.
County of Ventura Behavioral Health. www.vchca.org/bh/children.htm or (805) 652-6737.
Riverside County Department of Mental Health. appsweb.co.riverside.ca.us/mentalhealth/opencms// (951) 358-4500.
San Bernardino County Department of Behavioral Health. www.co.san-bernardino.ca.us/dbh/default.htm or (909) 421-9434.