McLean Hospital Guest Blogger
By Gil Noam, EdD, PhD
What can we do to address the recently reported shortage of trained psychiatrists in the US? As a clinical and developmental psychologist who trains child and adolescent psychiatrists in developmental thinking and practice at Harvard Medical School, I can see that we need a multidisciplinary approach to stem the epidemic of psychiatric illness, and we need to do it quickly. According to the National Center for Education Statistics (NCES), the US has 55 million students attending elementary and secondary schools this year. When considering National Institute of Mental Health (NIMH) reports that 13% of children ages 8 to 15 have had a diagnosable mental disorder within the previous year, 20% of youth ages 13-18 have a severe mental disorder, and 46% will experience some form of mental health disorder in their lifetime, this means that there are more than 10 million students, by conservative estimates, who are in need of mental health support and intervention in a system lacking the capacity to deliver these services. The true number of students in need is likely larger because that estimate doesn't factor in the mental health needs of children younger than age 8 or children who exhibit subclinical symptoms that may lead to the future development of a diagnosable mental disorder.
Even with proper identification and diagnoses, today's dwindling pool of child psychiatrists and other child mental health professionals is not equipped to serve the needs of millions of children. According to the American Academy of Child & Adolescent Psychiatry (AACAP), there are approximately 8,300 practicing child and adolescent psychiatrists in the United States. Most of these practitioners are concentrated in urban centers, leaving an even greater shortage in many parts of the country. This is happening at a time when psychotherapy and psychopharmacology are making significant progress for some widespread conditions, such as ADHD, depression, anxiety disorder, and suicidality. Additionally, there are even more students who are suffering from traumatic events, chronic stress, and pre-clinical conditions that, if left untreated, will often lead to diagnosable psychiatric disorders.
Approaching mental health as a purely medical issue is not enough. I believe the issue of youth access to mental health services is not just an issue of increasing the number of psychiatrists or other mental health professionals. Though many more are undoubtedly needed, the solution has to lie in teams that combine pediatricians, social workers, and psychologists. But even with teams in place, we need an innovative approach to reach children and deliver services. There is a significant opportunity for early detection and intervention that we need to focus on to stem this growing crisis: the education system.
Youth spend a significant amount of their time in school, an institution that is in charge of learning but has increasingly begun to focus on addressing the barriers that prevent learning, including social problems, lack of out-of-school-time opportunities, and physical and mental health issues. In my many years of working with schools as the director of a mental-health-in-schools center at McLean Hospital, I've seen that if we want to improve mental health in this country, we need to be reaching young people (and their educators) much earlier. Our current policy of waiting until a person is in crisis, with a full-blown disorder, is much too late. If we want to handle the avalanche of mental health issues, we need to address these challenges early, especially when they're subclinical, when sadness has not yet evolved into depression, and anger has not yet turned into conduct disorders.
We need to adopt a similar approach to our mental health supports as we use for physical and dental health. We don't wait until a person's teeth rot out of their mouth to teach them about oral health: we train children from an early age to create routines around brushing and flossing, with regular check-ups at the dentist. Of course, there are disparities in how we reach children and families, but best-practice systems span promotion, targeted prevention, and intervention. We need to start teaching children and their parents and teachers about mental health by using the same approach, and we need to meet children where they are--in schools. Now imagine having only 8,300 dentists to service the entire child population of the US? Fortunately, there are an estimated 3.1 million full-time teachers, with a pupil/teacher ratio close to 16 to 1, and a focus on personalized learning and social-emotional development that is gaining traction within education policy--the moment is right to take action. Look at recent studies and it quickly becomes clear that embedding social-emotional support in schools isn't just a policy fad, it's imperative if we want our students to have a chance at living successful lives.
By connecting mental health professionals with educators, as we've done in our work, you can see that even small numbers of psychiatrists and psychologists can have a very significant impact on programs that can reach children before they hit crisis. This approach requires new thinking. People talk about prevention, but this is about putting prevention and early intervention into action. We need to address mental health issues when they first appear, before the need for crisis intervention by a small number of expensive, highly trained professionals that operate outside of our education system and are often only available to children of the wealthy. Simultaneously, we need to increase the number of child psychiatrists as well as child psychologists and other child mental health professionals who support those with serious mental disorders. The approach, however, cannot simply be to add more and more expensive professionals without addressing the problem "upstream" with preventative, social-emotional-focused programs in schools that reduce the numbers of children who go on to become ill or whose resilience is undermined by unaddressed trauma and toxic stress.
Gil Noam, EdD, PhD (Habil), is the founder and director of The PEAR Institute: Partnerships in Education and Resilience at Harvard University and McLean Hospital. The PEAR Institute is a translational center that connects research to practice and is dedicated to serving "the whole child-the whole day." An associate professor of Psychiatry at Harvard Medical School focusing on prevention and resilience, he trained as a clinical and developmental psychologist and psychoanalyst in both Europe and the United States. Dr. Noam has a strong interest in translating research and innovation to support resilience in youth in educational settings.
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