Where have all the experts gone?

expertHave you ever wondered where all the expertise in children’s mental health is hiding? The experts are probably out there but they seem harder and harder to find. For parents whose child with mental health needs is “complicated” or “serious” or even both, expertise is critical to good care. There are far too many families reporting that while they’ve had care for their child, that child’s symptoms have not improved nearly enough.

When my son was nine, he had a still-learning psychiatrist, Dr. G, working with him. Fortunately, Dr. G was supervised and mentored by someone extremely experienced and knowledgeable. My son hid, terrified of unspecified things, under the chairs in the waiting room and became manic and rather wild at other times, even rampaging through Dr. G’s office one day. Appointments were never the same twice. When Dr. G left to go to a different position, he said, “Thank you for the opportunity to work with your son. I’ve never met anyone like him before.” While that was somewhat unsettling to hear, I’ve always hoped that he could help the next child and family that much better.

When we saw Dr. G, I expected that he would observe certain behaviors and say, Aha! I know what that means. I thought he would see my son’s fear, mania and depression and have effective, wise advice. But he was learning right beside me. What made the difference was that he had close access to a very experienced clinician, who had helped complicated, serious children before. While there was a measure of trial and error, we had the benefit of someone else’s expertise.

This isn’t always the case for many families.

There is a real mental health workforce shortage here in Massachusetts as well as nationwide. In an Annapolis Coalition report authors note that there is a critical shortage of individuals trained to meet the needs of children, youth and their families. As one example, the federal government has projected the need for 12,624 child and adolescent psychiatrists by 2020 while the projected supply is 8,312. In addition, there is a growing lack of racial and ethnic diversity in the workforce.

The number of therapists is declining while the need grows. We are identifying more children through screening and a focus on early childhood mental health that need mental health care. But these numbers only focus on access. What about expertise?

In April 2015, the Congressional Research Services issued a report on the mental health workforce. “The quality of mental health care, they wrote, is influenced by the skills of the people providing the care, while access relies on, among other things, the number of skilled providers available.”

Expertise matters. Many families search for a therapist, clinician, psychiatrist or program for weeks. They then find that the wait to get in is often even longer. When they get that first appointment or walk through that door, they are looking for someone who recognizes their child’s symptoms or behaviors and can say, I’ve seen children like this before. Or if they haven’t, they have a colleague to consult.

When my son was a little older, he was in a therapeutic school where there were clinicians on staff. They took one look at his mental health record and wisely matched him with a very experienced psychologist. She was patient, smart and skillful. She understood how to help both his teacher and me create an external structure (routine, limits and predictability) when his internal self was in chaos. She never ran out of strategies and used whatever resources were at hand. She explained to me that medication was to help him become more available for therapy and therapy was to help him manage his illness. She had seen children quite like him before.

Many families hold child psychiatrists in high regard, believing them to be the best trained and most knowledgeable. But their appointments are limited by insurers to short increments of time and are usually focused on medication management not detailed observation or strategy sessions. They are also in short supply. As a result, psychiatric nurses often prescribe and see children who need medication. There are psychologists, social workers and bachelor level therapists out there as well. But families report that many are early career, just starting out. Does a lot of time and less experience work? Or does greater expertise but short appointments work better for children, teens and their families?

When my son was nine and I moved back to Massachusetts, I made 16 calls before I found someone who was willing to see a complicated, serious, hard-to-treat child. I found someone by calling hospitals and other institutions because they knew where the expertise was within their walls, although they didn’t know what was in my community. That first person I found led to the second and then a third, who was Dr. G. I had to track down someone like a bloodhound follows a trail. I don’t think it’s easier finding expertise today but I’m willing to be proven wrong.

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3 thoughts on “Where have all the experts gone?

  1. My son is now older but continues to see the psychiatrist he started with almost 14 hrs ago. But it is basically for meds. If a med is changed we have to make another appointment if the insurance is denied & requires a prior authorization, he will refuse to do it at that over the phone.That said we struggle until we can get another one scheduled. Since I am in the field he often asks me what I would use for rationale. Now I just bring the document filled out to be signed by him.
    As for clinicians we recently waited 5 months to get a therapist. The center has a location about 1/4 of a mile from our home but they only see kids there so my son rides his bike or walks 2.miles to the appointment each way.
    Part of the issue is many good clinicians have gone into private practice and don’t take Mass Health. Their sliding fee begins at $100 an hour for a 45-50 minute session. Most families can’t afford that each week. Agencies have started to put productivity above all else which means that these clinicians may be great but with cancellations they don’t meet productivity and lose their health insurance. So in essence by going into private practice they make more money and either their spouse has insurance or they are able to afford insurance privately or through the affordable care act.

  2. Our current approach to “managing care” and “managing behaviors” doesn’t always work for those who also need healing, especially those who have been traumatized by external or internal forces. Maybe those who understand the difference don’t choose to practice in the insurance based system anymore. Many of them now practice on their own and don’t accept insurance. We’ve created a system whereby those who can afford the expertise can find it, but those who can’t miss out on the opportunity. There’s not much economic justice here anymore.

  3. Sometimes the “expert” doesn’t necessary have the answer and peer support systems and wellness educational methods can be looked at in many situations. We need to redirect our energies to other helpers since the system isn’t providing the help.

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