CHILD PSYCHIATRY IN CANADA: PHYSICIAN RESOURCES

Introduction

Child psychiatrists are physicians with 5 additional years of specialized training. The Canadian Academy of Child Psychiatry (CACP) recognizes for full membership a physician qualified by the Royal College of Physicians and Surgeons of Canada (RCPSC) or the Quebec College of Physicians as a specialist in Psychiatry who has had 2 years of training in child psychiatry at an accredited postgraduate training program (1). The Royal College has before it a submission sponsored by the Canadian Psychiatric Association requesting the recognition of Child Psychiatry as a subspecialty.

In Canada and the United States (2) there is emerging concern about a shortage of child psychiatrists that is predicted to get worse. This paper addresses relevant factors affecting supply and demand for child psychiatry services and makes a number of recommendations to address the problem.

The Role of Child Psychiatrists

The child and adolescent psychiatrist works with children, adolescents and their families, in a hospital and in a variety of settings such as schools, courts, universities, private offices, social agencies and other community organizations. Some become specialized experts in a particular age group (such as infants or adolescents), a particular diagnosis (such as anxiety or eating disorders), or a particular treatment modality (such as pediatric psychopharmacology or custody evaluations). In the public arena, child psychiatrists can become active in their community or government as advocates for child mental health. Many child and adolescent psychiatrists are actively involved in educating medical students (3), residents in family practice (4), pediatrics (5), general psychiatry (6), career trainees in child psychiatry (7) other physicians (such as general practitioners) and the public. Other child psychiatrists are actively involved in research in the area of children’s mental health. Still others are involved in administration of clinical services, program development and management and leadership roles.

Supply And Demand For Child Psychiatrists

There is no well-documented estimate of need or recommendations to guide physician resource management. Supply and demand for child psychiatry services includes 3 key factors: need, demand, and productivity. The “need” for physician services is primarily influenced by epidemiology of illnesses and population sociodemographic characteristics such as poverty, nutrition, biologic vulnerabilities, maternal health, family stability, migration, environment and life experience. The “demand” for services is influenced by standard of living, educational sophistication about health care, method of health care financing and society’s willingness to address mental health problems through the health care system (8). Given Canada’s relatively high standard of living and high level of educational achievement, and given our universal health care system, one would expect that the demand for psychiatric care for children with mental health problems would be relatively high compared with other geographic regions (9). The “productivity” of child psychiatrists is influenced by work schedules, the number of patients seen per hour, the model of health care delivery, and technical innovations (8). Other factors affecting productivity include the scarce numbers of child psychiatrists in rural and remote areas, travel time to nonurban communities, and the need to provide services to some adult psychiatric patients.

Epidemiological studies (10,11) identify the prevalence of childhood emotional and behavioural disorders as 15 to 20%. The incidence and severity of childhood mental health disorders appear to be increasing. In the US, 50% of children and adolescents afflicted with major psychiatric illness receive no treatment from anyone (12). Canada’s universal health care services may be thought to provide some advantage but the Ontario Child Health Study revealed that only 1 in 6 of the 18.1% of the children with a psychiatric disorder were seen by one or both of child welfare or mental health services. (10) Numeric definition of needs is complicated as there is no clear standard regarding optimal numbers of child psychiatrists per unit population of children and youth. Ratios stated in the 1988 Royal College Report (13) were never officially sanctioned by the RCPSC's governing Council nor were they intended to be used for planning purposes (14). The objectives of the "review" were to respond to the 1985 study of the Federal-Provincial Advisory Committee on Health Manpower (15) and to validate the Canadian Medical Association’s (CMA’s) physician resource data bank.

A simple head count of child psychiatrists is not useful (16) because this approach assumes that all physicians provide services in equal quantity and of a uniform nature - which is inaccurate. In child psychiatry, a good many are teachers, researchers, directors of departments or services, and, therefore, only part of their time is devoted to direct clinical care. Another factor is gender. Women appear to be entering the profession of medicine at a rate about equal to that of men (9). Some evidence indicates that female physicians tend to work fewer hours than their male counterparts (15). Because of their relative scarcity many child and adolescent psychiatrists use a consultation model in which they provide backup support to other professionals dealing with children with mental health concerns.

It is recommended that child psychiatry consultation in rural centers be provided through outreach rather than locating one physician for a region (that is, population < 25 000) (17). The use of interactive telemedicine is another recent advance that has been initiated in parts of Canada (18). Another type of practice to consider when considering ratios is the hospital setting. Where acute care beds are located for any given region a 0.5 full time equivalent (FTE) child and adolescent psychiatrist is required to manage 5 beds where the length of stay is 4 weeks, whereas a 1.0 FTE will be required for 5 beds providing emergency coverage and admission up to 72 hours. In Canadian hospital centers this must be considered a minimum. Day hospital psychiatric consultants can be estimated at 0.5 FTE for 10 patient spaces where the length of stay is up to 3 months. Physician resources must be sufficient to provide coverage for situations such as absence or emergency coverage.

Every study released by the Graduate Medical Education National Advisory Committee (GMENAC) up until the 1990s said that child psychiatry was among the specialties in the USA with the greatest shortages. The latest study (19), revisited in great detail for child psychiatry and coupled with the latest Canadian statistics (20), gives a need ratio of one child psychiatrist per 4 305 children/youth (1:4 305).

Using a different route, the Canadian Psychiatric Association (21), starting with an often used need ratio for adult psychiatry (22), and considering that

• the assumption is that the population of children is 25% of the general population,

• the proportion of mentally ill children is 20%, and

• the nature of work with children involves longer assessments in the family context and involves more individuals and systems (a factor of 3 can be applied to complexity and time parameters),

recommends a need ratio of 1 child psychiatrist per 3 800 children and youth. These need ratios are in keeping with clinical needs perceived in the field. For example, with ratios of 1:4 305 and 1:3 800 children and adolescents, the needs for child psychiatrists in Quebec would be of 410 child psychiatrists in contrast to the actual number of 145 FTE, all types of work included (23). A recent Ontario study revealed that there is currently one child psychiatrist to 6,148 children with mental health needs, that is one child psychiatrist per 32 356 children and youth (9), which is grossly inadequate.

The purpose of studies seeking to assess resource needs is to place some marker in human resources assessments by which to judge existing resources and future needs. The answer, from the above work, is that there is a clear and strong future need for child psychiatrists in numbers far exceeding present resources. The fact that this number is so much higher than present resources has important implications for training programmes, incentives to professionals to work with children, recruitment and government resource allocation and services to children and youth in society. Much work remains to be done in these areas.

Number Of Child Psychiatrists In Canada

As mentioned earlier, there are no exact figures for the actual number of child psychiatrists in Canada and there is no Canadian agency or organization that monitors the actual numbers of psychiatrists who practice with children and adolescents, the percentage of their time devoted to child related practice, or their level of expertise in the field of child psychiatry (9). There are approximately 350 members of the CACP but this does not represent all psychiatrists treating children and adolescents. There is no formal recognition of the subspecialty to assist in recording licensed child psychiatrists. Provincial Colleges of Physicians and Surgeons license general psychiatrists. Some psychiatrists practising full time child psychiatry have 1 year of training and have not applied for membership of CACP where their years of practice and one year of training allowed them eligibility. Other qualified adult psychiatrists may also provide consultation and service to children, especially in areas where there are no child psychiatrists. The older adolescent falls between child psychiatry and adult psychiatry in many jurisdictions. Finally, child psychiatrists may work with both children and adults, especially family members.

The number of child psychiatrists is expected to decrease as these subspecialists reach retirement age, training positions decrease and challenges of recruitment and training persist and even increase (24). The need is increasing with both the population expansion and the recognition that childhood mental health disorders often need active and complex treatments.

The Canadian Academy of Child Psychiatry is in the process of attempting to survey the needs and, in due time, inform our specialty organizations, professional colleges, universities and governments of the severe shortage of child psychiatrists. We are no different in this respect than the US. The 1999 US Surgeon General’s Report on Mental Health, which took 2 years to prepare, noted “the dearth of child psychiatrists” and the fact that “many barriers remain that prevent children, teenagers and their parents from seeking help from the small number of specially trained professionals who are available” (25).

Training Child Psychiatrists

Postgraduate psychiatric training programs have focused on general psychiatry and sub specialization has been included within that context. Residency programs are currently 5 years in duration of which 6 months child psychiatry is mandatory and 12 months is encouraged. Some psychiatric residents are able to complete an additional 12 to 18 months of child psychiatry training within their 5 years of training. However, in many programs residents have more program-mandated fixed rotations, and child psychiatry trainees may need to go on to a fellowship year to complete their specialty training.

Recruitment Issues

Requirement for additional years of residency has challenged a system that has faced cutbacks in funding and competition from other subspecialties (26). Increasing inflexibility has put pressure on medical students to select a career course in their early years and it is extremely difficult to switch tracks. In the past, psychiatry has recruited from other areas of medicine such as General Practice, Internal Medicine, and Pediatrics. In some provinces, the government has dramatically reduced the opportunity for practising physicians to enter psychiatric residency training (9). Another influence is that Canadian policies regarding acceptance of international medical graduates have changed over the past years, reducing the numbers of foreign medical graduates selecting psychiatric residency training in some provinces (8). There are very few funded fellowship positions in the Canadian system, and as yet there is no administrative or government response to the need to fund more trainees in child psychiatry, problems that were anticipated in the US (27).

Another significant factor that has contributed to the lack of child psychiatrists is the amount of nonremunerated time such as consultations to school teachers and discussions with case managers. Most provincial pay schedules favor direct treatment over mental health consultation to other front-line professionals. For child psychiatrists’ skills to be optimized, their work must be remunerated, and recruitment strategies need to be developed and implemented (18). Additionally, in most provinces, those specialists working with children have been historically under funded in comparison with other medical and surgical specialists. Nonfunded activities and funding inequities combined with overworked, short-in-supply specialists serve further to hinder recruitment and harm morale.

Child Psychiatry offers an expanding field with increasing basic science and research opportunities but there is a need for more research in the area of children’s mental health. The lack of subspecialty recognition is a serious problem that undermines financial rewards, status, professional identity and appeal to students. The Canadian scene has not kept pace with subspecialty recognition in other countries, United States, Britain, Australia, nor have training programs and standards been accredited. The number of all medical specialists has been falling and this is likely to adversely affect recruitment to child psychiatry in an already unlevel playing field. The exposure of medical students to child psychiatry in the early years of training, which is positive, rewarding, and enjoyable, will affect their career choice (28).

Summary

There is a shortage and maldistribution of child psychiatrists in Canada and elsewhere, which is a long-standing problem and is likely to worsen, as replacement is not keeping pace with either the need for services or retirement. Access to child psychiatry expertise and mental health services cannot meet demand (29,30). The training of child psychiatrists, recruitment of candidates, and the education of primary care physicians and pediatricians require support from government, university and accrediting colleges.

Recommendations

1. Adoption of standards for resources to supply 1 FTE child psychiatrists per 4 000 children and adolescents (or 6 per 100 000 population). This ratio applies to clinical needs only and does not address the needs for research, teaching, training and administration.

2. The Royal College of Physicians and Surgeons of Canada recognize child psychiatry as a subspecialty.

3. Training programs in child psychiatry in Canada be accredited and standards set.

4. Training positions be identified and funded specifically for child psychiatry career trainees.

5. Reentry training positions for candidates from other medical specialties be increased.

6. Work with the with the Canadian College of Family Physicians and the Canadian Pediatric Society to ensure that child psychiatry be a recognized and accredited component of postgraduate education for family physicians and pediatrics.

7. Child psychiatry be an identified component of undergraduate medical student education.

8. Sessional fees (that is, block payments for time) should be made available for indirect service by child psychiatrists to hospitals, community agencies and other programs.

9. Funding for direct contracts should be made available to attract child psychiatrists to under serviced areas.

10. Child psychiatrists need to be remunerated for both direct and indirect work; therefore, multiple funding sources including fee for service should be available.

11. Child psychiatry be funded at least at the middle range of specialty level physicians.

12. Alternative models of service delivery, including video conferencing, need to be developed and evaluated to address the maldistribution of child psychiatrists in Canada.

13. The use of interactive video technology needs to be available and funded to train professionals outside of traditional academic settings. A mechanism for ongoing funding needs to be developed. Some of these initiatives have been started in parts of the country, such as the Atlantic Provinces.

References

1. Canadian Academy of Child Psychiatry Constitution / Constitution de l'Académie canadienne de pédopsychiatrie.

2. Thomas CR, Holzer III GE. National distribuion of Adolescent and Child Psychiatrists. J Am Acad Child Adolescent Psychiatry. 1999;38:9-16.

3. Canadian Academy of Child Psychiatry. Child Psychiatry teaching for undergraduate medical students. August 1994.

4. Children’s mental health in Family Practice: Teaching objectives for Family Medicine trainees as set out by the Canadian Academy of Child Psychiatry. CACP 1994.

5. Canadian Academy of Child Psychiatry. Guidelines for training in Child Psychiatric aspects of Pediatric practice. September 1994.

6. Canadian Academy of Child Psychiatry. Child Psychiatry training for general psychiatry. September 1989.

7. Canadian Academy of Child Psychiatry. Training guidelines for career trainees in Child Psychiatry. Revised, September 1990.

8. El-Guebaly N, Beausejour P, Woodside B, Smith D, Kapkin I. The geographical distribution of psychiatrists in Canada: unmet needs and remedial strategies. Can J Psychiatry 1993; 38:212-216.

9. Steele MM, Wolfe, VV. Child psychiatry practice patterns in Ontario. Can J Psychiatry 1999;44: 788-792.

10. Offord DR, Boyle MH, Szatmari P, Rae-Grant N, Links PS, Cadman DT, et al. Ontario Child Health Study. II. Six-month prevalence of disorder and rates of service utilization. Arch Gen Psychiatry 1987;44: 832-836.

11. Breton JJ, Bergeron L, Valla JP, Berthiaume C, Lambert J, St-Georges M, et al. Quebec Child Mental Health Survey: Prevalence of DSM III-R Mental Health Disorders. J Child Psychology and Psychiatry 1999;40(3);375-384.

12. Who's watching (and taking care of) our children. Allan Tasman, MD, President of the American Psychiatric Association. Psychiatric News, March 17, 2000, p.3.

13. The Royal College of Physicians and Surgeons of Canada, National Specialty Physician Review, Ottawa: 1988.

14. Royal College Vignettes/Portraits et esquisses. Annals RCPSC, 2000:33(3); 200.

15. Federal-Provincial Advisory Committee on Health Manpower. Physician Manpower in Canada 1980-2000: A report of the Federal-Provincial Advisory Committee on Health Manpower. Ottawa (ON): Health Manpower Division, Health and Welfare Canada, 1985.

16. The physician numbers in the 1988 RCPSC and the 1985 Federal-Provincial Advisory Committee Report were head counts.

17. Dubois RD, Nugent K, Broder E. Psychiatric consultation with children in under serviced areas: lessons from experiences in Northern Ontario. Can J Psychiatry 1991;36:456-461.

18. Steele M. A proposal for better meeting Ontario?s children?s mental health needs: a companion document to putting care first. Canadian Child Psychiatry Review 1998; 7:95-99.

19. Plante M. Physician requirements - 1990 for Psychiatry Office of Graduate Medical Education, U.S. Department of Health and Human Services, May 1991, pp.28-37.

20. Statistics Canada, Division de la démographie, estimation de la population, 25 février 2000: www.sta/gouv.qc.ca/donstat/demograp/general.

21. Canadian Psychiatric Association Physician Resource Document (in development).

22. 1:8,400 population (all ages included / tous les âges inclus).

23. The number of children and youth 0-17 (inclusive) in Quebec, as of July 1999, is 1,661,039 / Le nombre d'enfants et d'adolescents, incluant le groupe des 17 ans, était de 1,661,039, au Québec, à la date de juillet 1999.

24. Canadian Institute for Health Information. (CIHI) 1999.

25. American Academy of Child and Adolescent Psychiatry News, March/April 2000, 31(2), p.55.

26. Gray JD, Ruedy J. Undergraduate and postgraduate medical education in Canada. CMAJ 1998; 158:1047-1050.

27. McKelvey RS. The coming crisis in funding child psychiatry training. Am J Psychiatry 1990; 147: 1220-1224.

28. Weintraub W, Plaut M, Weintraub E. Recruitment into psychiatry: increasing the pool of applicants. Can J Psychiatry 1999;44.

29. Doan RJ. Who needs a child psychiatrist? Child mental health problems in family practice. Poster presentation. Canadian Academy of Child Psychiatry. Halifax, September 1998.

30. Le Journal de l'Association des médecins psychiatres du Québec, Vol. 3, No. 4, April 2000, p. 5, and Vol. 3, No. 5, May/June 2000, p. 3.