“I don’t know exactly what happened to drive that young man in Aurora to shoot those people, but I do know that many people like him suffer while undiagnosed and untreated,” said Jess Shatkin, an associate professor of child and adolescent psychiatry at New York University.
July 20 marks one year since James Eagan Holmes massacred 12 people and injured 70 more inside an Aurora, Colorado movie theater. Since then, Adam Lanza opened fire in a Newtown, Connecticut elementary school; a 20-year-old college student killed four people in Orange County, California during a drive-by shooting; and a 19-year-old in New Orleans opened fire on a Mother’s Day parade.
In each of these tragedies, images of isolated and despondent young male perpetrators have emerged in the aftermath. And after each tragedy, the nation vowed to launch a national discussion of mental health.
In fact, millions of young people in America are suffering from untreated mental illness, and the American healthcare system is not equipped to care for them, according to experts in child and adolescent psychiatry. The U.S. Surgeon General’s office estimates that only 20 percent of emotionally disturbed children receive mental health services.
Those children do not automatically shed their emotional problems on their 18th birthday. They become adults with mental illness. Some find treatment as adults; some turn to drugs and alcohol to manage their symptoms; and some lose control.
The American Medical Association estimates that there are 15 million American children in need of psychiatric care and just 7,000 child and adolescent psychiatrists to treat them.
This discrepancy can leave families waiting months for their children see a therapist, which can take a toll on individual families and the community, said Christopher Thomas, the director of child psychiatry residency training at the University of Texas, Galveston.
Untreated adolescents who struggle with emotional problems can fall behind in school, develop substance abuse problems and engage in dangerous and risky behavior, Thomas said.
“Well over 80 percent of youth in juvenile justice placement have a substance abuse problem. More than half likely have a mental disorder,” Thomas said. “The juvenile justice system is becoming the de facto mental health provider for a large number of these youths, sadly.”
Thomas has spent over a decade studying the shortage and distribution of child and adolescent psychiatrists in the U.S. His 1999 paper in the Journal of the American Association of Child and Adolescent Psychiatrists (AACAP) spurred the AACAP to launch a task force on workforce issues, which aims to recruit medical students into the specialty.
Both Shatkin—the current chair of the AACAP Workforce Issues Committee—and Thomas said that recruiting new students into the field continues to be an uphill battle more than a decade later.
The specialty requires an additional two years of training beyond the three years of general psychiatry studies. The extra time and student loans discourage potential students, Shatkin says.
“The best we can hope for is staying pretty much in the situation that we are already in, but I fear that we might actually be falling further behind,” Thomas said.
Meanwhile, children around the country wait months for the necessary care.
While the number of untreated children varies around the country, the AACAP has found a shortage of providers in every state.
Even Massachusetts, which has the highest per-capita ratio of child and adolescent psychiatrists, falls short of meeting the need in many communities, says Stuart Goldman, senior associate in psychiatry and co-director of the Mood Disorder Program at Boston Children’s Hospital.
That shortage is compounded by an unequal distribution along socioeconomic lines, with the majority of child and adolescent psychiatrists practicing in affluent communities, Goldman said.
While many wealthy neighborhoods of Boston have an abundance of private practice and outpatient hospital physicians, areas like South Boston, Dorchester, and Roxbury do not have many local providers.
“One of the issues [exacerbating the problem] is that kids who are living in poverty have higher mental health problem rates,” said Goldman. “Just the problem of being poor is a challenge, but they also live in communities with lower property taxes and lower housing costs, which typically translate to poorer schools and fewer community services”
These disparities persist throughout the country. The communities most in need tend to have the least access to mental health services. The problem becomes self-perpetuating.
Many doctors who start out in a clinic setting quickly become overwhelmed by the heavy caseload, Shatkin says.
As part of his residency training, Shatkin worked in an Arkansas clinic where he says he routinely saw 15 patients a day, 10 new patients a week, and still had a six-month waiting list.
In medical school, child and adolescent psychiatrists are taught to take time to get to know patients and to reach out to the various caregivers in their lives to learn how they function in the real world, Shatkin said.
“We all started with the best intentions, but it becomes very difficult to practice psychiatry the way you know you should practice psychiatry when you are so crammed with patients,” he explained.
In the end, many practitioners opt to leave the clinic setting. Instead they open up private practices where patients can afford to pay service-based fees.
“Everybody gets sick and needs care, so it’s not like you’re doing the wrong thing treating these people. They need help, too, and they are able to pay for the time. To be honest, treating people when you have the time is a delight,” Shatkin said.
That is of little comfort to the low-income families struggling to cope with their children’s emotional issues. The current economic climate has deepened the problem, as it has placed added strain on both family budgets and social services.
Thirty years ago, community mental health centers provided local counseling services to residents in their own neighborhoods, Goldman recalls. “Many dried up in the 1990s, and more dried up in the economic downturn of the last five years,” he said.
“While we want to be a society that protects and cares for the least fortunate . . . in tough budget times, the services for indigent care and for child care suffer,” Goldman said.
–Noelle Swan
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