Ten-Year Initiative for Recruitment of Child and Adolescent Psychiatrists

The field of child and adolescent psychiatry is rooted in the child guidance clinic movement at the turn of the twentieth century. Leo Kanner, the psychiatrist who coined the term “infantile autism”, was the first academic child psychiatrist; he was appointed to the faculty of John Hopkins Medical School and wrote the first textbook of child psychiatry in 1935. Exactly one half century ago, in 1953, a group of analytically trained child psychiatrists launched the first professional organization of child psychiatry, the American Academy of Child Psychiatry (now American Academy of Child and Adolescent Psychiatry, AACAP). In 1959, a new medical sub-specialty of child psychiatry was officially recognized by the American Board of Psychiatry and Neurology (ABPN). In 1986, the ABPN piloted a triple board residency program that offered five-year combined training in adult psychiatry, child and adolescent psychiatry (CAP), and pediatrics. This program was intended to recruit medical students who are interested in both pediatrics and CAP directly from medical school rather than via general psychiatry training.

Initially, child psychiatry, a relatively small and young branch of medicine, has provided its expert medical care to a small proportion of emotionally disturbed children. The limited access problem has not improved much despite the opening of new training programs in the 1960’s and 70’s and by the triple boards programs in the 80’s and 90’s. It is believed that 15 million children and adolescents in the U.S. suffer from diagnosable psychiatric conditions, and about seven million of them exhibit severe to extreme functional impairments due to their psychiatric conditions. The epidemic of child psychiatric conditions and the inadequate mental health care system, especially inadequate access to child psychiatrists, have drawn significant attention from the public in general and governmental agencies as evidenced by recent and frequent coverage of child psychiatric issues by the media and several governmental commissions over the years. Several commissions by government agencies (including Presidential commissions) and professional organizations have reviewed the status of CAP work force in the last four decades. All of these commissions have recognized a marked shortage of child and adolescent psychiatrists. In the last four decades, various recruitment ideas have been proposed to expand the field to meet the needs of the nation’s children and adolescents. However, the number of training programs and the number of trainees, in fact, have decreased in the past decade, from 120 to 113 and 712 to 680 respectively from 1990 to 2003. This decrease occurred in spite of the major advances in our understanding and treatment of childhood mental disorders. Why did the field shrink even as it became more exciting? Increasing educational debt, pressure to pursue a primary care specialty career, and a relatively long training period are some of the factors that might discourage medical students from choosing a career in CAP. There is an urgent need for more child psychiatrists.

Recognizing that the critical shortage of child and adolescent psychiatrists amounts to a public health crisis, the AACAP formed a task force to reexamine the work force status in 1999. In response to the sobering report of the task force regarding the plight of the nation’s children with mental illness and the severe access problem, the AACAP, for the first time in its history, decided to set the recruitment of medical students and residents into CAP as the first priority of the organization and formulated a ten-year recruitment initiative. The AACAP was determined this time to follow through with the recommendations made by the task force and formed a steering committee on work force issues to orchestrate multi-level efforts to achieve a lofty goal of increasing recruitment by 10% each year in the next ten years beginning in 2004. The Steering Committee proposed the following three-pronged strategy.

1. Attraction: Get the data, tell the story.
1. The AACAP is developing a comprehensive “report card” to collect data from each medical school and CAP training program relating to recruitment such as faculty resources, students’ exposure to CAP, etc. This will help us understand what fosters recruitment.
2. The AACAP is developing a user-friendly web site, specifically designed for medical students and general psychiatry residents. We want you to know how rewarding, and vital, a career in child and adolescent psychiatry can be.
3. The AACAP Training Committee in association with the local branches of the AACAP is developing a mentoring program for medical students and general psychiatry residents to foster their interest in CAP.
4. ) The AACAP and its members are acutely aware of stigma attached to mental illness and psychiatry in general, including child and adolescent psychiatry. In addition to general public relation efforts by all members, medical students and residents need to be informed about exciting scientific developments, especially in developmental science and neuroscience, that have been transforming CAP. They would be also attracted to CAP more if only they were better informed about the market dynamics of demand and supply of medical specialists resulting in the highest rankings by CAP in the survey of graduating residents in terms of number of job offers, geographical flexibility, the rate of increase in income, and several other criteria (www.chws.albany.edu/reports).
2. Expansion: Multiple portals of entry.
   Triple boards programs would be publicized widely to medical students who may be interested in CAP even before entering general psychiatry residency. Many medical students who are interested in CAP may be reluctant to undergo three to four years of general psychiatry training first, or some may lose interest in CAP during their general psychiatry residency because of lengthy training and financial burden. The AACAP is actively collaborating with several professional and accreditation organizations to develop alternative user-friendly training paths to CAP including integrated child and adolescent and adult psychiatry training tracks and CAP-only training.
3. Support: Access and advocacy
   Multiple legislative strategies have been developing in collaboration with sister professional organizations and advocacy groups. Parity of mental health coverage will hopefully soon be passed by Congress. The AACAP has been working with the government and insurance industry for fair and appropriate reimbursement of CAP clinical work. The most exciting of all is “Child Health Care Crisis Relief Act”, a bipartisan bill in both the House (H.R.1359) and Senate (S.1223). This bill is designed (1) to support training programs for child mental health care, especially a shortage specialty like CAP (i.e., full GME funding instead of current 50% funding); (2) to support trainees taking child mental health training in the form of scholarship or loan repayment (i.e., CAP residents could receive up to $35,000 a year to pay for their student loans). The AACAP is taking a lead role in garnering enough co-sponsors to pass this critical legislation to support the training programs as well as trainees of CAP.

The members of the Steering Committee on Work Force Issues, co-chaired by Thomas Anders, M.D., and Gregory Fritz, M.D., are determined to bring about positive outcomes and are optimistic about the success of our initiative. Through the tremendous investment of time, energy and resources by the AACAP and its individual members, we can certainly reverse the decline in recruitment seen during the past ten years to a robust increase over the next decade.

By Wun jung Kim, M.D.,M.P.H.
Professor and Director
Division of Child and adolescent Psychiatry
Medical College of Ohio
Former Chair of the AACAP Task Force on Work Force Needs
Member of the AACAP Steering Committee on Work Force issues