growth and distribution of child psychiatrists in the united states: … · 2019. 10. 31. · of...
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Growth and Distribution of ChildPsychiatrists in the United States:2007–2016Ryan K. McBain, PhD, MPH,a Aaron Kofner, MA, MS,b Bradley D. Stein, MD, PhD,c Jonathan H. Cantor, PhD,d William B. Vogt, PhD,e
Hao Yu, PhDf
abstractBACKGROUND: Historically, there has been a shortage of child psychiatrists in the United States,undermining access to care. This study updated trends in the growth and distribution of childpsychiatrists over the past decade.
METHODS: Data from the Area Health Resource Files were used to compare the number of childpsychiatrists per 100 000 children ages 0 to 19 between 2007 and 2016 by state and county.We also examined sociodemographic characteristics associated with the density of childpsychiatrists at the county level over this period using negative binomial multivariablemodels.
RESULTS: From 2007 to 2016, the number of child psychiatrists in the United States increasedfrom 6590 to 7991, a 21.3% gain. The number of child psychiatrists per 100 000 children alsogrew from 8.01 to 9.75, connoting a 21.7% increase. County- and state-level growth variedwidely, with 6 states observing a decline in the ratio of child psychiatrists (ID, IN, KS, ND, SC,and SD) and 6 states increasing by .50% (AK, AR, NH, NV, OK, and RI). Seventy percent ofcounties had no child psychiatrists in both 2007 and 2016. Child psychiatrists weresignificantly more likely to practice in high-income counties (P , .001), counties with higherlevels of postsecondary education (P , .001), and metropolitan counties compared with thoseadjacent to metropolitan regions (P , .05).
CONCLUSIONS:Despite the increased ratio of child psychiatrists per 100 000 children in the UnitedStates over the past decade, there remains a dearth of child psychiatrists, particularly in partsof the United States with lower levels of income and education.
WHAT’S KNOWN ON THIS SUBJECT: More than half ofthe children in the United States with a treatablemental health disorder do not receive treatment froma mental health professional. One of the drivingfactors contributing to this unmet need is a shortagein child psychiatrists.
WHAT THIS STUDY ADDS: We found that childpsychiatrists (per 100 000 children) increased by 22%from 2007 to 2016. However, 70% of US counties had nochild psychiatrists in 2007 or 2016, and childpsychiatrists were much less prevalent in low-incomeand less-educated communities.
To cite: McBain RK, Kofner A, Stein BD, et al. Growth andDistribution of Child Psychiatrists in the United States:2007–2016. Pediatrics. 2019;144(6):e20191576
aRAND Corporation, Boston, Massachusetts; bRAND Corporation, Arlington, Virginia; cRAND Corporation,Pittsburgh, Pennsylvania; dRAND Corporation, Santa Monica, California; eDepartment of Economics, University ofGeorgia, Athens, Georgia; and fDepartment of Population Medicine, Harvard Medical School, Harvard Universityand Harvard Pilgrim Health Care Institute, Boston, Massachusetts
Dr McBain helped conceptualize and design the study and identify, evaluate, and interpret the dataand led the drafting and revision of the manuscript; Mr Kofner generated figures and helpedevaluate and interpret the data and write and review the manuscript; Drs Stein and Cantor helpedconceptualized the study, interpreted the data, and assisted in the writing and review of themanuscript; Dr Vogt helped analyze and interpret the data and assisted in the review and writing ofthe manuscript; Dr Yu obtained funding support for the study, led the conceptualization of the study,helped interpret the data, and shared in writing and reviewing the manuscript; and all authorsapproved the final manuscript as submitted.
DOI: https://doi.org/10.1542/peds.2019-1576
Accepted for publication Sep 3, 2019
PEDIATRICS Volume 144, number 6, December 2019:e20191576 ARTICLE by guest on May 27, 2021www.aappublications.org/newsDownloaded from
More than half of the children in theUnited States with a treatable mentalhealth disorder do not receivetreatment from a mental healthprofessional.1–3 One of the drivingfactors contributing to this unmetneed is a shortage in childpsychiatrists, which is compoundedby growing demand for treatmentthat places additional pressure ona limited supply of providers.4
Improved screening and diagnostictools for childhood mental disorders,5
expanded child health insurancecoverage,6,7 and greater caregiverawareness of pediatric mental healthconditions all contribute to thisincreased demand. As a result, accessto mental health care for children hasbeen highly variable across states andcounties.8
Historically, the shortage of childpsychiatrists has been most acuteamong disadvantaged populations,such as racial and ethnic minorityyouth,9 as well as youth living inimpoverished and rural areas.8,10 TheAmerican Academy of Child andAdolescent Psychiatry estimates, forexample, that Rhode Island has.6 times as many child psychiatristsper capita as Wyoming does.11 Toattract physicians to rural and remotecommunities, mechanisms like theHealth Resources and ServicesAdministration’s National HealthService Corps (NHSC) LoanRepayment Program have offeredfinancial incentives for childpsychiatrists and other physicians toserve in designated healthprofessional shortage areas.12
However, as little as 13% ofphysicians who participate in loanforgiveness programs select the NHSCover alternatives.13,14 As such, itremains unclear whether and to whatextent recent policies and programssuch as the NHSC’s have improvedaccess to child psychiatrists inunderserved communitiesthroughout the United States.Moreover, although there has been anoverall increase in the number of
mental health providers in the UnitedStates, the current literature does notprovide specifics on the growth in thenumber of child psychiatrists over thepast decade and where the growthhas occurred.
To provide an assessment of nationaltrends in the growth and distributionof child psychiatrists in the UnitedStates, we examined the ratio of childpsychiatrists per 100 000 childrenthroughout all US counties for themost recent 10-year period data wereavailable: 2007–2016. Thisinformation extends an earlier studyof child psychiatrist levels in theUnited States completed in 2006.15
Separately, we examined therelationship between county-levelsociodemographic characteristics andchild psychiatrist workforce supply toidentify characteristics associatedwith greater access to services overthis period.
METHODS
Study Design
This retrospective time-seriesanalysis of all 50 US states employedrepeated cross-sectional data from2007 to 2016 based on the 5 datasources described below. Data wereaggregated at the county level basedon US county Federal InformationProcessing Standard codes.16 Theresearch was deemed exempt fromreview by Dr McBain’s institutionalreview board.
Data Sources
Child Psychiatrists
The Area Health Resource Files(AHRF) of the Department of Healthand Human Services maintainsa county-level inventory of healthprofessionals, including the numberof child psychiatrists, on an annualbasis. These data draw from theAmerican Medical Association (AMA)Physician Masterfile,17 for whichphysicians (including childpsychiatrists) report their primarylocation of practice, including
outpatient facilities and hospitals.More specifically, our analysescomprised licensed physicians whohave met educational andcredentialing requirements topractice as child psychiatrists,including doctors of medicine anddoctors of osteopathy. Residentphysicians are included. Historically,the AMA Physician Masterfile hasbeen considered to maintain highcompleteness, with only a smallproportion of licensed physiciansbeing labeled “missing,” largelybecause of how the AMA and statelicensing agencies update their files.18
Children
Counts of youth ages 0 to 19 wereobtained from the Census ofPopulation and Housing, which isprepared by the US Census Bureau.19
Additionally, the US Census Bureaureports on population density, whichis measured as the total populationrelative to land area in square miles.
County Characteristics
The AHRF contains a repository ofcounty characteristics, elements ofwhich were selected on the basis ofPenchansky and Thomas’s20
canonical framework for consideringdeterminants of access. First, weincluded rural-urban continuumcodes, which classify countiesaccording to population size anddegree of isolation.21 We consolidatedthis measure into 5 commonly usedlevels22–24 that reflect population sizeand proximity to metropolitan areas:counties in metropolitan areas (levels1, 2, and 3), urban counties adjacentto metropolitan areas (levels 4 and 6),urban counties not adjacent tometropolitan areas (levels 5 and 7),rural counties adjacent tometropolitan areas (level 8), andrural counties not adjacent tometropolitan areas (level 9).
A second set of AHRF countycharacteristics comprisessocioeconomic measures. Here, weextracted measures of income,
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education, and employment. The first,median income per capita at thecounty level unadjusted for inflation,was derived from the US Departmentof Commerce.25 The second,percentage of adults by county with 4or more years of college education,was obtained from the US CensusBureau, drawing from the AmericanCommunity Survey.19 Lastly,percentage unemployment amongadults ages 16 and older wasextracted from the US Bureau ofLabor Statistics Current PopulationSurvey.26
A third set of measures from the USCensus Bureau quantified the racialand/or ethnic composition ofcounties. This was representedaccording to 3 categories: percentagenon-Hispanic African American, othernon-Hispanic, and Hispanic.19 Lastly,we used Small Area Health InsuranceEstimates files from the US CensusBureau to measure the percentage ofindividuals ,65 years of age in eachcounty without public or privatehealth insurance coverage27 as wellas the county-level averagemalpractice insurance premium forinternal medicine physicians basedon data from the Medical LiabilityMonitor.28
Data Analysis
After inspecting measures of centraltendency and dispersion,29 we made3 adjustments to account fornonlinearity in measures. First, toaddress the right skew of county-levelmedian income per capita, wesegmented income into quartiles.Second, to account for nonlinearity inthe growth of child psychiatrists overtime, we constructed year variables(1 for each year) and included all ofthem in the analysis except 2007,which was used as the reference.Third, based on the right skew ofpopulation characteristics, weperformed log transformations ofchild population and populationdensity and introduced a square-of-log term for child population.
We next estimated a multivariablenegative binomial regression modelwith state-level fixed effects. Thenegative binomial distribution wasselected over 0-inflated Poissonbecause the former more accuratelyaccounted for overdispersion in thedata based on the Pearson x2
dispersion statistic.30 Fixed effectswere entered for each state toaddress the potential of omittedvariable bias, such as state-levelpolicies that might influenceworkforce supply, by removing state-specific variance components.31 SEswere clustered at the state level toaccount for within-cluster correlation.
We included the following covariatesin the negative binomial model: time(year), child population at the countylevel, urbanicity as connoted by rural-urban continuum code categories,county-level socioeconomic variables(income, education, and employmentcharacteristics), and county-levelracial and/or ethnic composition. Toaid the interpretation of results, wecomputed predicted counts usingStata’s margins command (Stata Corp,College Station, TX).32 Predictedcounts quantified the number of childpsychiatrists in a county on the basisof fitted models calculated withcovariates specified at median valuesfor the subgroup of interest. All testswere 2 sided, used an a level of .05,and were conducted in Stataversion 15.0.
RESULTS
Child Psychiatrists per 100 000Population
Between 2007 and 2016, the numberof practicing child psychiatrists in theUnited States increased from 6590 to7991: a 21.3% gain. Over this sametime period, the number of childrenin the United States ages 0 to 19modestly declined, from 82.22 millionto 81.95 million. As such, the ratio ofchild psychiatrists grew from 8.01child psychiatrists per 100 000children in 2007 to 9.75 child
psychiatrists per 100 000 children in2016. These trends are reflected inFig 1.
The state-level growth of childpsychiatrists varied widely. In 2007,10 states had ,5 child psychiatristsper 100 000 children compared withonly 5 states in 2016 (Table 1).Meanwhile, the number of states with10 or more child psychiatrists per100 000 children increased from 11to 14. Child psychiatrists per 100 000children increased by .50% in 6states (AK, AR, NV, NH, OK, and RI).Conversely, the ratio of childpsychiatrists per 100 000 childrendeclined in 6 other states: Idaho,Indiana, Kansas, North Dakota, SouthDakota, and South Carolina. In severalcases, this was due to faster growth inchild population than in childpsychiatrists (eg, KS), whereas inothers, this reflected an absolutedecline in child psychiatrists (eg, ND).
A preponderance of all US counties(76%) experienced no change in thelevel of child psychiatrists between2007 and 2016, as illustrated byFig 2, which is largely a function ofthe 70% of counties that contained0 child psychiatrists in both 2007 and2016. Among the remaining counties,the degree of change in the density ofchild psychiatrists from 2007 to 2016was substantial. Within states such asCalifornia, Florida, andMassachusetts, an increase in childpsychiatrists per 100 000 children inspecific counties corresponded withdeclining levels in neighboringcounties.
Distribution by Urbanicity
Compared with the ratio of childpsychiatrists per 100 000 children inmetropolitan areas from 2007 to2016, there were fewer childpsychiatrists in urban countiesadjacent to metropolitan areas(P = .02) as well as rural countiesadjacent to metropolitan counties(P = .01). There was not a statisticallysignificant difference in the ratio ofchild psychiatrists per 100 000
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children between metropolitan areasand urban areas nonadjacent tometropolitan areas and, separately,between metropolitan areas and ruralcounties nonadjacent to metropolitanareas (P . .05).
Distribution by SociodemographicCharacteristics
Child psychiatrists were significantlymore likely to practice inhigher–income-quartile counties(fourth versus first income quartile;P , .001), with 74% of childpsychiatrists residing in top-income-quartile counties and 92% in the top-2–income-quartile counties, between2007 and 2016. As of 2016, theexpected number of childpsychiatrists per 100 000 children inlowest–income-quartile counties was1.40 compared with 5.04 in thehighest-quartile counties: more thana threefold difference (Table 2). Aneven more stark contrast wasobserved for education level of thecounty. Counties in the fifth percentile
for completion of postsecondaryeducation would be expected to have1.10 child psychiatrists comparedwith 9.79 in the 95th percentile(P , .001). We observed nostatistically significant relationshipbetween county-level unemploymentand the number of child psychiatrists(P . .05), although counties withlower levels of employment did onaverage have fewer child psychiatrists(Table 2). We further found nosignificant relationship between thedensity of child psychiatrists andpercentage of individuals withoutpublic or private health insurance(P . .05) or between the density ofchild psychiatrists and averageinsurance premium for physicians inthe county (P . .05).
There was a slightly larger ratio ofchild psychiatrists per 100 000children in counties with larger non-Hispanic African Americanpopulations when adjusting for childpopulation and all other
sociodemographic characteristics(P , .001). There was no suchevidence that child psychiatrists weremore abundant in counties withlarger Hispanic populations (P . .05)or in counties with larger percentagesof individuals who self-identified asnon-Hispanic other (P . .05).Supplemental Table 3 provides anoverview of all results from theregression analysis.
DISCUSSION
This analysis provides a timelyupdate on the level and distributionof child psychiatrists in the UnitedStates over the past decade. Althoughthe density of child psychiatrists hasincreased from 2007 to 2016, thereremain ∼70% of counties in theUnited States with no childpsychiatrists. The distribution of childpsychiatrists also remainsinequitable, with a state likeMassachusetts having as many childpsychiatrists as Oklahoma, Indiana,
FIGURE 1Child psychiatrists and children ages 0 to 19 in the United States (2007–2016). Y-axis 1 (right-hand side) signifies the number of child psychiatrists in theUnited States for each year from 2007 to 2016, whereas y-axis 2 (left-hand side) signifies the number of children ages 0 to 19 in the United States over thisperiod.
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TABLE1Child
Psychiatristsin
theUnitedStates
(2007vs
2016)
State
2007
2016
PercentChange
Child
Population
Child
Psychiatrists
Child
Population
Child
Psychiatrists
Child
Population
Child
Psychiatrists
Total
Rate
Total
Rate
Total
Rate
Alabam
a1251776
695.5
1223109
816.6
22.3
17.4
20.1
Alaska
197703
105.1
201614
209.9
2.0
100.0
96.1a
Arizona
1833847
995.4
1819004
115
6.3
20.8
16.2
17.1
Arkansas
777002
364.6
783451
577.3
0.8
58.3
57.0a
California
10487746
809
7.7
10129459
1002
9.9
23.4
23.9
28.2
Colorado
1314762
136
10.3
1404877
164
11.7
6.9
20.6
12.9
Connecticut
919657
158
17.2
857498
217
25.3
26.8
37.3
47.3
Delaware
231302
177.3
229392
219.2
20.8
23.5
24.6
Florida
4489589
267
5.9
4612753
359
7.8
2.7
34.5
30.9
Georgia
2788367
129
4.6
2791134
163
5.8
0.1
26.4
26.2
Hawaii
317588
5517.3
339037
6318.6
6.8
14.5
7.3
Idaho
450317
153.3
481885
163.3
7.0
6.7
20.3b
Illinois
3574275
223
6.2
3256545
272
8.4
28.9
22.0
33.9
Indiana
1762882
874.9
1757412
704.0
20.3
219.5
219.3b
Iowa
800818
405.0
822142
435.2
2.7
7.5
4.7
Kansas
777148
567.2
795569
577.2
2.4
1.8
20.6b
Kentucky
1110344
797.1
1124893
897.9
1.3
12.7
11.2
Louisiana
1211660
594.9
1229535
746.0
1.5
25.4
23.6
Maine
313521
4614.7
287787
4716.3
28.2
2.2
11.3
Maryland
1520036
246
16.2
1503031
283
18.8
21.1
15.0
16.3
Massachusetts
1621137
333
20.5
1584016
420
26.5
22.3
26.1
29.1
Michigan
2734750
177
6.5
2459552
194
7.9
210.1
9.6
21.9
Minnesota
1406836
936.6
1428901
114
8.0
1.6
22.6
20.7
Mississippi
856700
283.3
804073
364.5
26.1
28.6
37.0
Missouri
1583410
101
6.4
1543666
123
8.0
22.5
21.8
24.9
Montana
245161
135.3
253503
187.1
3.4
38.5
33.9
Nebraska
498642
336.6
526284
428.0
5.5
27.3
20.6
Nevada
715156
253.5
741723
395.3
3.7
56.0
50.4a
NewHampshire
334516
329.6
297413
4916.5
211.1
53.1
72.2a
NewJersey
2288504
222
9.7
2201976
276
12.5
23.8
24.3
29.2
NewMexico
558558
458.1
545258
5510.1
22.4
22.2
25.2
NewYork
4994163
834
16.7
4693711
941
20.0
26.0
12.8
20.1
NorthCarolina
2462736
194
7.9
2568891
250
9.7
4.3
28.9
23.5
NorthDakota
165743
1710.3
198855
168.0
20.0
25.9
221.6b
Ohio
3064656
217
7.1
2916458
245
8.4
24.8
12.9
18.6
Oklahoma
998488
313.1
1065347
514.8
6.7
64.5
54.2a
Oregon
956460
808.4
966539
110
11.4
1.1
37.5
36.1
Pennsylvania
3155295
324
10.3
3020981
368
12.2
24.3
13.6
18.6
RhodeIsland
269314
4014.9
243505
6426.3
29.6
60.0
77.0a
SouthCarolina
1188713
112
9.4
1228625
114
9.3
3.4
1.8
21.5b
SouthDakota
219891
177.7
236526
187.6
7.6
5.9
21.6b
Tennessee
1627003
825.0
1664765
945.6
2.3
14.6
12.0
Texas
7300611
410
5.6
8057140
564
7.0
10.4
37.6
24.6
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Georgia, Mississippi, and Tennesseecombined, despite these latter stateshaving 5 times as many children ages0 to 19.
The shortage of child psychiatristsis consonant with previousfindings,10,15,33 although we did findthat the 1 child psychiatrist for every12 477 children in 2007 increased to1 child psychiatrist for every 10 256children in 2016: a 21.7%improvement. This trend reflects anuptick in the number of childpsychiatrists in the United States overthis period, from 6590 to 7991, aswell as a modest decline in the childpopulation,34 indicating overallimprovement in potential accessto care.
Despite the trend of more childpsychiatrists over time, we alsofind that this growth is largelyrestricted to specific geographicareas of the United States andvaries significantly at the stateand county levels. At the statelevel, we observed a decliningratio of child psychiatrists per100 000 children in 6 states (ID,IN, KS, ND, SD, and SC) and anannualized growth ,2% in halfof all US states. By contrast, 6 statesobserved a 50% or greater increasein the ratio of child psychiatristsper 100 000 children over thisperiod (AK, AR, NV, NH, OK, and RI).These findings parallel trends inthe distribution of mental healthprofessionals in the United Statesgenerally8 as well as psychiatry asa discipline specifically.35 Futureresearch in this area should explorewhether variable growth in thenumber of child psychiatrists is tiedto specific legislative efforts at thenational, state, and local levels.36
Examinations at a local level would beparticularly warranted in settings likeCalifornia or Florida, where we foundthat growth in the number of childpsychiatrists in many countiescorresponded with decliningnumbers in adjacent counties.
One conspicuous factor shaping thedistribution of child psychiatristswas, unsurprisingly, child population:although three-quarters of counties(74.7%) had no child psychiatrists in2016, 80% of children in the UnitedStates reside in a county with at least1 child psychiatrist. In other words,child psychiatrists aredisproportionately located in countieswith larger child populations,suggesting that the general allocationfacilitates access to care. Thisobservation is true more generally forthe distribution of human resourcesfor health in the United States. Forexample, Cummings et al8 found thatmental health treatment resources inthe United States are more heavilyconcentrated in urban areas, servinglarger, more densely populatedcounties. However, 1 in 5 children stilllive in a county without a childpsychiatrist, highlighting the ongoingchallenge of providing children withlocal access to psychiatric services.
Similar to findings reported regardingprimary care physicians,37 countieswith higher levels of education andhigher incomes commonly hadgreater access to child psychiatrists.For example, a county in the 95thpercentile of college graduates wouldbe expected to have 9.8 times asmany child psychiatrists as a countyin the fifth percentile. A similargradient was observed for income,with 3.6 times as many childpsychiatrists expected in counties inthe highest income quartile comparedwith counties in the bottom incomequartile. A number of factors maycontribute to these trends. Forexample, wealthier and more highlyeducated families may be more likelyto seek mental health care and beable to pay cash or afford insurancecopayments, deductibles, and out-of-pocket expenditures.38 Affordabilityof child psychiatric services, asa conceptual feature of access tocare,20 is particularly problematicbecause many child psychiatrists donot accept Medicaid, a form of publicTA
BLE1
Continued
State
2007
2016
PercentChange
Child
Population
Child
Psychiatrists
Child
Population
Child
Psychiatrists
Child
Population
Child
Psychiatrists
Total
Rate
Total
Rate
Total
Rate
Utah
901353
414.5
1012075
515.0
12.3
24.4
10.8
Verm
ont
150407
2516.6
139166
3021.6
27.5
20.0
29.7
Virginia
2041450
178
8.7
2092529
204
9.7
2.5
14.6
11.8
Washington
1701487
109
6.4
1802456
137
7.6
5.9
25.7
18.6
WestVirginia
434287
225.1
419018
286.7
23.5
27.3
31.9
Wisconsin
1478223
124
8.4
1442699
134
9.3
22.4
8.1
10.7
Wyoming
139909
64.3
153726
74.6
9.9
16.7
6.2
aIncrease
.50%.
bDecliningrate.
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health insurance that is the singlelargest payer for mental healthservices in the United States.39
Additionally, we identified 2 sets ofsomewhat surprising results. First,urban and rural counties adjacent tometropolitan counties haveproportionally fewer childpsychiatrists. It is possible that accessto care is more limited inmetropolitan-adjacent countiesbecause child psychiatrists relocate toaffluent metropolitan communitieswith greater social amenities. Second,we observed a slightly greater densityof child psychiatrists in counties withlarger African American populations
after adjusting for all other factors.One possibility is that habitation incommunities with a larger AfricanAmerican representation is merelya proxy for living in specificmetropolitan neighborhoods, anobservation that has been reportedelsewhere.40 If this were the case,examination of the distribution ofchild psychiatrists at the census-tractlevel could provide greater resolutionon where child psychiatristscongregate within metropolitanregions. Unfortunately, these data arenot available. This finding meritsfurther investigation because thebroader literature indicates wide-ranging patterns of access to and use
of mental health services amongAfrican American children andadolescents.41–43
Several limitations should be noted.First, to identify year-on-year trends,population data were drawn from theUS Census Bureau, which classifieschildren ages 0 to 19. This contrastswith previous studies that examinedthe age range of 0 to 17, preventingdirect comparisons. Relatedly, thevariable used for uninsured statusexamined individuals through age 65,not just children ages 0 to 19. Second,the large number of counties with0 psychiatrists precluded our abilityto examine interactions between time
FIGURE 2County-level change in child psychiatrists per 100 000 children (2007–2016).
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and county characteristics. It may bethe case that, over a longer timehorizon or by pooling childpsychiatrists with other mentalhealth professionals, theseinteractions could be studied ata broader level. Third, althoughour models included state-levelfixed effects, other omitted variablesmay have been present at thecounty level. We attempted toaccount for this by a broadinclusion of covariates.
Lastly, we have no informationabout the offices that a childpsychiatrist is practicing at norindividuals’ level of engagement inthe practice. Although the AMAPhysician Masterfile is consideredrobust,44 recent research has raisedconcern about the accuracy ofaddress-level information.45 As
such, we used the file to studychild psychiatrist numbers atthe county and state levelsrather than at a more local level.44
Level of active provider engagementcould also shape unmet need. Forexample, a community with highlevels of need for services mightbe undersupported if childpsychiatrists practice infrequently.In this case, the AMA data wouldoverestimate the availability ofservices. That said, it is also likelythat such measures would beendogenous with the outcomeof interest: namely, countieswith more child psychiatristscould have a greater prevalence ofchild mental illness becausediagnoses in these counties are morefrequent due to the presence of childpsychiatrists.
CONCLUSIONS
We find evidence that the supply ofchild psychiatrists in the UnitedStates has improved over the past10 years but that a shortage is stillprofound in large segments of thecountry. Local and state policies havemade efforts to address this throughseveral mechanisms, such as studentloan forgiveness programs and higherreimbursement rates, to promoteequity in access to services.46
However, our findings suggest thatmore structural community features,such as average wealth andeducation, are closely tied to the levelof child psychiatrists; as such,broader policies that influenceeducational and economicopportunity may be required. Absentthese, counties with few or no childpsychiatrists may need to look toalternative or complementaryframeworks to address child mentalhealth needs, including integration ofbehavioral health in pediatric primarycare settings,47 school-based mentalhealth services,48 child psychiatrytelephone consultation accessprograms,49 and new models oftelepsychiatry.50
ABBREVIATIONS
AMA: American MedicalAssociation
AHRF: Area Health Resource FilesNHSC: National Health Service
Corps
Address correspondence to Ryan K. McBain, PhD, MPH, RAND Corporation, 20 Park Plaza, #920, Boston, MA 02116. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2019 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the National Institute of Mental Health (R01MH112760). Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10/1542/peds.2019-2646.
TABLE 2 Expected Number of Child Psychiatrists per 100 000 Children by Characteristic
Characteristic Expected ChildPsychiatrists
LowerBound
UpperBound
Income quartileFirst (lowest) 1.40 1.01 1.79Second 2.29 1.79 2.78Third 3.53a 2.88 4.17Fourth (highest) 5.06a 4.19 5.92
Education level, percentileFifth 1.10 0.78 1.4195th 10.77a 9.71 11.84
Unemployment level,percentileFifth 3.56 2.26 4.5095th 1.19a 0.81 1.58
a Difference is significant at P , .05 compared with the reference group: first quartile or fifth percentile. Expectednumber of child psychiatrists based on fitted values from negative binomial models with year set to 2016, childpopulation set to 100 000, and covariate characteristics set to median values within the county type of interest. Upperand lower bounds represent the fifth and 95th percentile estimates, respectively.
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