Child and Adolescent Psychiatry: Recent Advances Shape the Future
Behavioral Health Insights
By Micah Hoffman, MD, DABPN, FAPA, QME, CIME, CHCQM
AllMed Behavioral Health Medical Director
Nearly one in five children in the United States has a mental, emotional, or behavioral disorder in any given year.1 Yet, amid an ongoing shortage of child and adolescent psychiatrists (CAPs), only half receive the specialized care they need.1 Despite this persistent gap, there are reasons for optimism. Innovative initiatives and wider use of telehealth are helping stretch limited resources and expand access to services. An increased focus on prevention is yielding new programs that teach young people coping skills. Finally, new medications are earning FDA approval to treat mental health conditions in children and adolescents. One of these is a non-stimulant ADHD drug that, for the first time, offers an alternative to children who cannot tolerate traditional stimulants.
This article, the first of three on child and adolescent psychiatry, focuses on these recent advances. Subsequent articles will discuss the nuances of referring CAP patients to the right level of care and the ramifications of child boarding in emergency rooms, a growing trend.
Unique Needs Call for Specialized Training and Treatment
Psychiatric treatment of children and adolescents differs notably, in several ways, from treatment of adults. First, because young people are still developing physically, cognitively, and emotionally, their mental health conditions may manifest differently and require different treatment than the same conditions in adults. Second, unlike adults who typically initiate their own treatment, children are usually referred by adults who are concerned about them. These adults often remain deeply involved in the child’s treatment and beyond, making them, in a sense, patients, too. These distinctions and complex treatment needs mean clinicians working with young patients need specialized training.
Becoming a child and adolescent psychiatrist requires completing medical school, a general psychiatry residency at least three years long, and a two-year residency focused on mental health disorders in children and adolescents. The length and intensity of the career path may, in part, explain the national shortage. In 2022, there were only 10,500 practicing child and adolescent psychiatrists in the U.S. Ratios per 100,000 children vary widely by state, ranging from 4 to 65.1 Even before the pandemic, the Substance Abuse and Mental Health Services Administration (SAMHSA) estimated that the U.S. needed at least an extra 48,000-49,000 child and adolescent psychiatrists to meet treatment needs for children with severe mental health problems.2 Since then, the need has grown as the number of children experiencing mental health problems has increased.3
Complicating matters further, existing treatment resources are often geared toward adults and siloed (operated by different agencies). For example, there is very little overlap between addiction treatment and other mental health treatments. Yet virtually all substance use disorders begin in adolescence and, in young people, co-occur with other mental health disorders.
Overcoming these challenges is a top focus of healthcare professionals and policy leaders nationwide.
Narrowing the Resource Gap
To increase early intervention, children’s hospitals around the country are training pediatricians to diagnose and treat mild-to-moderate behavioral health conditions in the primary care setting—before they escalate to a crisis. Given that 50 percent of mental illness begins by age 14 and 75 percent by age 24, this initiative can make a significant difference.4
Similarly, evolving collaborative care models between pediatric primary care providers and child and adolescent psychiatrists open possibilities for more young patients to receive treatment. This model conserves the scarce specialists for severe and complex psychiatric disorders by shifting specialty tasks such as assessment, basic psychosocial intervention, basic psychopharmacology, and care coordination to primary care. Care can be delivered in various ways, from coordinated to co-located care. This integrated approach shows strong results, improving clinical outcomes and patient satisfaction while constraining costs.5
Newer care delivery modalities, such as telepsychiatry and mobile apps, offer clinicians additional opportunities to broaden their impact.6 Through telepsychiatry, young patients can connect with providers from home or even from school. For families in rural areas, where the shortage of providers is severe, the ability to use technology this way can be a lifeline.
Mobile apps may benefit patients in certain circumstances if well-designed and properly vetted.6 However, the clinical value of mental health apps is still being assessed. While not a substitute for help from a human professional, an app may be a useful supplemental treatment tool.
These initiatives increase access to developmentally appropriate treatment for children and adolescents. Together, they represent a meaningful step toward narrowing the resource gap.
The Role of Medication
While access to care is fundamental to helping children with mental health issues, medication can play an important role in a comprehensive treatment plan. Currently, many children rely on medications to help manage attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), autism, obsessive-compulsive disorder (OCD), depression, anxiety, and other mental health conditions.
Prescription stimulant medications like Adderall and Ritalin have long been the gold standard of treatment for children with ADHD, but they come with downsides. Patients may experience agitation or sleeplessness and, as the medication wears off, feel a “crash.” Worse, stimulants are easy to abuse with potentially debilitating effects. In recent years, the demand for these drugs—which are controlled substances—has grown. But last year, a faltering pharmaceutical supply chain and increased scrutiny of controlled substances led to shortages and severe disruption for many families. The problems have continued this year, leaving patients frustrated. Drug manufacturers, the Food and Drug Administration, and the Drug Enforcement Administration are working to alleviate the shortages as quickly as possible.
In the longer-term view, researchers are exploring the potential of psychedelics and cannabidiol (CBD) to treat depression in adults and, ultimately, in children. However, these efforts are in the early stages, and significantly more medical research will be needed before any determinations can be reached.
While using medication to help with mental health challenges is becoming more common among children, a comprehensive assessment and careful evaluation of the risks, benefits, and alternatives should precede each prescribing decision. Finding the right medication and determining how much a child should take require specialized expertise. A child and adolescent psychiatrist can focus on the whole child, in every context (family, school, social), to make an informed decision about the role psychotropic medication might play in an optimal treatment plan.
Ensuring the Right Care at the Right Time for Children and Adolescents
Advances in medication development and new care delivery methods are shaping the future of child and adolescent psychiatry. Through these innovations, healthcare professionals and policymakers are recognizing and prioritizing the unique needs of this young patient population. At AllMed, the board-certified child and adolescent psychiatrists on our behavioral health panel bring deep knowledge and current clinical experience to every review. They consider the specific circumstances of each child to determine an appropriate treatment plan. Call on our experts for informed guidance to help safeguard the mental health of your young members.
- https://www.aacap.org/aacap/zLatest_News/Severe_Shortage_Child_Adolescent_Psychiatrists_Illustrated_AACAP_Workforce_Maps.aspx
- Substance Abuse and Mental Health Services Administration. Behavioral Health Workforce Report. December 28, 2020. Available from https://www.mamh.org/library/behavioral-health-workforce-report.
- Chavira, Denise A et al. “The impact of COVID-19 on child and adolescent mental health and treatment considerations.” Behaviour research and therapy vol. 157 (2022): 104169. doi:10.1016/j.brat.2022.104169
- American Psychiatric Association. Warning Signs of Mental Illness. 2022. https://www.psychiatry.org/patients-families/warning-signs-of-mental-illness. Accessed August 23, 203.
- American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues. Electronic address: clinical@aacap.org. and American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues. “Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Pediatric Primary Care.” Journal of the American Academy of Child and Adolescent Psychiatry 62,2 (2023): 91-119. doi:10.1016/j.jaac.2022.06.007
- https://nyulangone.org/news/child-psychiatrists-use-digital-technologies-advance-research-share-knowledge-enhance-access-care