Just as public awareness is increasing regarding the risk factors that can lead to mental illness and suicide among children and adolescents, the country remains entrenched in a shortage of child psychiatrists.

Though Ohio ranks as one of the top five states in the country for the number of psychiatrists, the ratio is far short of what is needed. According to the Bureau of Labor Statistics, Ohio has approximately 1,300 psychiatrists, a figure that includes child specialists.

Some states, such as Iowa, Mississippi, Nevada and New Mexico have less than 200.

John Aller, executive director of Stark Mental Health and Addiction Recovery, said several factors play into what has been a longstanding issue.

"I think there's been a shortage of child psychiatrists for a number of years, including decades, " he said.

Some of the challenges, Aller said, include an aging workforce, reimbursement rates that tend to be lower than for other specialties, and a lack of operational support, which can lead to burnout.

"In dealing with psychiatric issues with kids, there's also a lot of paperwork and regulation," Aller said. "Because of these factors, if I'm going to medical school, sometimes child psychiatry is not going to have the appeal other specialties might."

Since 2017, StarkMHAR has overseen a pilot program in partnership with Child & Adolescent Behavioral Health and the Sisters of Charity, seeking to integrate psychiatric care and pediatrics while expanding its capacity and access.

Partnering with pediatrics

"A lot of kids being seen by pediatricians are being prescribed medication," Aller said. "What we're looking to do as a system is, if they are not enough psychiatrists available, using advance-practice nurses who have prescriptive authority and are trained in behavioral health."

Under the program, a pediatrician can refer a child to an advanced nurse practitioner, who is managed by a child psychiatrist. It also will enable a psychiatrist to act as a consultant to the pediatrician while still seeing the most severe cases, Aller said.

"We're also working on creating a partnership of workforce development with Kent State University and Walsh University to allow nurse-practitioner students to do internships with the hope that once they do an internship and understand the agencies and providers, they're more apt to stay," he said. "We can't influence the number of child psychiatrists, but we do think we can influence capacity and we can extend services by using nurse practitioners."

Joe French, CEO of Child & Adolescent Behavioral Health, said his agency currently has two advanced nurse practitioners on staff with plans to hire two more.

"The challenge initially was identifying the advance nurse practitioners we wanted to bring on," he said. "We worked with local colleges, Kent, Akron, and NEOMED, and reached out to them and made sure they knew what we were doing, and to help them understand our need for advanced nurse practitioners."

French said the lack of child psychiatry professionals has been ongoing.

"Ever since I could remember, even when I was in education, child psychiatry was always one of those areas (of shortage)" he said. "I'm not 100 percent sure why. There was a thought that you could write your own ticket because there is such a shortage, but maybe it's the rigor and training you have to go through."

French said Child & Adolescent is fortunate to have a child psychiatrist on staff, Dr. Elizabeth Hayford, who also is board-certified in family medicine and adult psychiatry.

French said that in conjunction with the pilot program, Child & Adolescent is reaching out to primary care and pediatricians with a plan for interoffice consultations. The agency will assign nurses to work with doctors in their own offices, with Hayford's supervision, he said.

"Many of them don't feel comfortable prescribing those kinds of drugs," he said. "We're in process of identifying sites we'll be located in."

French credits his agency's board for having the foresight to address the shortage issue. A grant from the Sisters of Charity is being used to retool its programs to attract qualified people.

"Community mental health is not always the most attractive field to work in," he said. "We needed to make sure we had the dollars to offset the costs through our partnership with StarkMHAR, which gave us the footing we needed."

Numerous barriers

Dr. Sumru Bilge-Johnson, director of the psychiatry fellowship program at Akron Children's Hospital, said as the number of children with mental illness grows, the need for child psychiatrists is at a crisis, adding that entire U.S. has just 8,300 practitioners.

Akron Children's offers inpatient services (teens only), partial hospitalization and outpatient services for teens and children.

"This has been an issue for several years," she said. "Twenty percent of youth and teens have some instance of mental illness and 10 percent have a severe impairment. In our state, we have 11 child psychiatrists per 100,000 children. We are one of the red zones; but there are so many red zones in the country. There are more than 15 million children with severe impairments."

Akron Children's fellowship program offers a two-year curriculum for adult psychiatrists who want to acquire board certification in child psychiatry. Currently, three students are set to graduate, Bilge-Johnson said.

She said other efforts are being made to recruit students.

"We're working with our local medical school, NEOMED," she said. "Also, we are trying to have medical students locate here early on in their third or fourth year, so they have exposure to child psychiatry."

Students, she said, also attend talks by practitioners.

But even with all this, Bilge-Johnson is not optimistic.

"We have good programs but 25 percent are not being filled for child psychiatry training," she said.

She cites economics as one factor for many medical students.

"They have debt and they don't want to go for two more years of training; that's one of the barriers, " she said. "Instead of being a fellow, they want to go out and practice. They have families."

Even so, the demand for services is growing.

"We are already in crisis," she said. " Our phone calls are non-stop. There's a two-to-three month wait to see a specialist. We are trying to help train pediatricians so they can help treat the more mild-to-moderate cases."

Bilge-Johnson, who is board-certified in the U.S. and in her native Istanbul, Turkey, said she pursued child psychiatry because it provides hope.

"If you catch mental illness early, the prognosis is better than with adults because their brains are still developing," she said. "Plus, I really like working with kids."

Charita Goshay is a staff writer for The Canton Repository.