Shortage of Child Psychiatrists

Several weeks ago I was incredibly saddened by the news from a colleague and dear friend of mine, also a Duke child psychiatrist, that one of our mentors had passed away in his mid-80’s. He meant so much to me, I wish to mention and memorialize his name in my own little way in this humble esoteric blog. He was Dr. Marc (Marcelino) Amaya (with ‘Amaya y Rosas’ being his full last name).

He was one of the original child psychiatrists in a group that came down to Durham NC from Northeastern training centers to help start the department and to staff it. The other faculty was as were in all major medical centers of the last 50 years, superb instructors and fantastic clinicians that often left us rookies with our veritable mouths open at their insights.

Dr. Amaya started a complete children’s psychiatric hospital I think in the early or mid-1960’s to house what Duke could not offer on its grounds because it was private and not state affiliated and for funding issues. The Children’s Psychiatric Institute (CPI) was a fabulous training center on the level of such other state hospital affiliated and also lesser known than the more celebrated upper crust programs, but every bit as good as any of the Ivy League (Boston, NYC, Philly, etc.) centers such as the late and venerated Dr. Ralph Rabinovich of the University of Michigan at Ann Arbor. CPI has a short term and long term outpatient clinic, a family therapy program that was expanded by this writer and one of the veteran incredibly skilled social workers at CPI, Anne K. Parrish ACSW, LCSW, into a training program for child mental health trainees from Duke and UNC-Chapel Hill medical and graduate schools. Dr. Amaya was a superb supervisor and I always learned untold concepts, techniques, and gems at his feet so to speak. I also accompanied him to the testify in the Golden Days of Psychiatry and Psychology in this country to testify annually before the NC General Assembly (state legislature) as we would advocate for our state funded programs, but also for the private inpatient and outpatient programs at Duke and UNC! So there we would be harassing clinically and statistically the legislators (who in those days seemed to listen matter their party affiliation). It was quite ironic but demonstrated the dedication that Dr. Amaya had to the delivery of mental health services to ALL children of the state and to any agency, institution, training program that was trying to provide such. His program was not his first concern in the statewide scheme of things, it was just another important part of the overall system of resources he foresaw for the state decades before some of them came into existence. He was a short man with a lyrical Hispanic accent that I as a Southwesterner could listen all day long and always feel like, when I was with him, I was a little bit ‘back home’ in the Southwest.”

His passing though jolted me into remember a long standing interest/concern/worry and growing for THREE decades dread of the then coming shortage of child psychiatrists that so many of us foresaw coming way back in the 1980’s and some even before that. Funding for child psychiatry as one of the non-favored medical sub specialties suffered for decades. It seemed that the kinds of lobbying and explaining and justifying that Dr. Amaya did decades ago that I watched and learned from, was no longer heeded or taken seriously. I remember one session of a legal body I will not mention that accused a group of lobbying psychiatrists just wanting more money somehow out of pleas for more training funds. It fell on deaf ears that more graduates equaled more providers equaled more competition and better workings of ‘market forces’ which hopefully would be true, but that we thought seriously and naively would appeal to the political ethos and ideologies of the lawmakers we were begging to. Alas, we learned that publicly long pronounced (or as the wise farmer would say in some kind of “Oh Brother, Where Art Thou,” movie, “speechified,” were not part of those lawmakers’ consciences or concerns for the “people.”

This was happening at the federal level and the leaders of the big national organizations, the “professional guilds,” if you will for all the mental health progressions’ training programs saw their standing eroded, if not dismissed and funds lost or cut, training programs reduced nationwide. Everyone saw the coming crisis of the shortage of all kinds of mental health providers, especially the more expensive ones to train, Ph.D. psychologists, M.D. psychiatrists with their 3-5 years of added on residencies and M.D. child psychiatrists who had minimums of 4 years of post-M.D. residencies and fellowships.

To illustrate how long this has been going on, in an article, “Decades Into Crisis, Kids Still Suffer From Shortage of Psychiatrists,” published 17 years ago the then Secretary of Health and Human Services, Donna Shalala, now President of the University of Miami, called attention in a publication that shortage in which Herculean efforts had raised the numbers to only 8,500 or so. That citation stated, “There are only about 8,500 child psychiatrists in America, not nearly enough for the estimated 15 million kids who need one, the American Academy of Child and Adolescent Psychiatry says. On the local level, the shortfall becomes more pronounced. No individual state meets the AACAP’s standard of 47 child psychiatrists for every 100,000 children 17 or younger — or one for every 2,127 kids. In Wyoming, there is one child psychiatrist for 22,960 children, and in Texas, the ratio is one per 12,122. Only Washington D.C.,” sufficient practitioners, largely because of the concentration of child psychiatry training programs and research programs and centers since the National Institute of Mental Health is in the D.C. area. The same could be said for parts of Boston with nearly a half jillion medical schools.

So now we have a decade or more “hit us” over and over all over the country of the horrendous shortage of especially child psychiatrists. I have written of this as part of recent past blogs but the passing one of my most revered mentor, Dr. Amaya, galvanized me into addressing this issue more fully. For a stretch of time, a decade or so ago our numbers sank to below 7,000 for the country. At those times we were frankly fearful we were not replacing child psychiatrists who retired or passed away.

Finally, bills increasing and creating new sources and methods of funding have appeared with retired Rep. Patrick Kennedy’s mental health professionals funding bill with ingenious but not new incentives to induce graduates to practice in practitioner-deprived areas and have loans forgiven and other practice and retention oriented incentives and aids. And last year the Helping Families in Mental Health Crisis Act (21st Century Cures) sponsored by the exemplary congressmen working in a rare bipartisan fashion, Reps.Tim Murphy (R) and Congr.Eddie Johnson (D. This bill has, even more, training funds and provisions for extending services all over the country and in my mind, biased as I am, one of the best pieces of legislation that came out of last year’s somewhat bogged down national Congress. But I am very thankful for it.

It will take at least four years of training future mental health practitioners to emerge in larger and larger numbers but at least they are coming and that will be an enormous improvement that I trust will not stop but actually grow in magnitude.



Author: Frank

I am a older child, adult, geriatric teaching psychiatrist with over 30 years' practice experience in North Carolina, first at Duke as clnical teaching faculty, then in Western NC as a primary child psychiatry specialist. I have taught and supervised child psychiatrists and psychiatrists in training and many other mental health professionals and taught at two medical schools. I have served in many public and private practice settings. My primary interest is in observing and documenting the ongoing mental health reform efforts in the State of North Carolina and documenting its sucessess and failures at all levels. My favorite pastime among many others is spoofing my friends and kids with my deadpan sense of humor.

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