Virginia Data Shows Severe Shortage of Child and Adolescent Psychiatrists

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RICHMOND, Va. — As a teacher and mother to a child with autism, Elizabeth Callahan is all too familiar with flaws in the Virginia mental health care system.

“I see the longevity of it, and there’s just so many holes,” Callahan said.

Callahan’s son was diagnosed by a developmental pediatrician at the onset of his symptoms, which included speech issues, she said. He went to occupational therapy for years until COVID-19 halted in-person visits.

Her child’s therapist quit during the pandemic because “she said she would make more on unemployment,” according to Callahan.

Callahan watches her students struggle to be seen by psychiatrists for diagnoses. Though schools provide some resources for students, they cannot provide an official diagnosis.

“I just see it taking forever for families to get appointments,” Callahan said. “It takes months.”

There is a significant shortage of practicing child and adolescent psychiatrists, or CAPs, across the United States, according to data from the American Academy of Child and Adolescent Psychiatry. These physicians specialize in the diagnosis and treatment of mental and behavioral patterns that affect children. They complete medical school and have a three-year residency.

The AACAP data classified states into four groups: States with a sufficient supply of CAPs, a high shortage, a severe shortage and no CAPs. Virginia is in a severe shortage, with just 264 CAPs in the state as of 2019, the most recent data available.

That means on average there are 14 CAPs available per 100,000 children in Virginia, which is also the national average. The academy defines a “mostly sufficient supply” as more than 47 per 100,000 children. Nationwide, few counties meet that standard.

For example, the city of Richmond has 22 CAPs and almost 40,000 children under the age of 18. By the AACAP ranking, the city has 55 CAPS per 100,000 children — considered a sufficient supply. It is 1 of 9 localities in Virginia that does, out of 133. Eighty-five counties in the state have no CAP.

Children have been unable to receive timely mental health care because of the shortage, according to Callahan.

Virginia ranks No. 37 among states when it comes to accessing mental health services, according to the 2022 Mental Health America state rankings. There are nine measures in the ranking, which include adults and youth who did not receive or could not afford treatment and mental health workforce availability.

Why are there so few CAPs?

Emily Moore, policy analyst with Voices for Virginia’s Children, said there is a lack of mental health care for children due to a system that is not “structured and designed with young people in mind,” and because COVID-19 exacerbated workforce issues.

People enter the field because they want to make change, she said.

“They’re realizing that they are up against a system that is not designed to support people the way that they need to be supported,” Moore said.

Moore encouraged families on long waitlists to look into nonprofit agencies in Virginia designed with mental health in mind, though they are not substitutes for treatment, according to Moore.

“Until we can truly transform the system rather than just patch it up and put Band-Aids on it, resilience is a part of our work,” Moore said.

She also said the state legislature needs to provide adequate funding for children’s mental health care, and that early mental health intervention should be prioritized and normalized to avoid mental health crises. The crisis system should not be the entry point to the mental health system, Moore said.

What is Virginia doing to fix it?

Mental health-related emergency room visits at the beginning and height of the pandemic went up, while physical-related visits went down, according to Dr. Bela Sood. Emergency room doctors and pediatricians were not prepared for the mental health emergencies they faced, she said.

Sood is lead CAP for the Virginia Mental Health Access Program, or VMAP, and oversees the work of all child psychiatrists involved in the program.

VMAP is a statewide initiative that strives to give kids greater mental health access by teaching pediatricians to function like psychiatrists. Pediatricians are taught how to screen, diagnose, manage and treat mental health in children.

“It’s amplifying the knowledge that we have as child psychiatrists into the world of general pediatrics,” Sood said.

Sood had tried to pitch programs like VMAP to the state since 2001, but said the program didn’t receive funding until 2018. The Virginia Department of Behavioral Health and Developmental Services is the umbrella funding agency for programs like VMAP.

Her biggest concern with the shortage is the lack of therapists.

“Even as a practicing child psychiatrist, when I refer for therapy, I have no idea who’s going to be treating the child I’m sending them, and what kind of treatment they’re going to deliver,” Sood said.

Virginia needs to design a platform that can be sustained through collaboration and shared resources, or else child health care will remain fragmented, according to Sood.

“As rich a country as the United States, the manner in which health care delivery is spun out into a place is shocking and unconscionable,” Sood said.

She also said Virginia needs to “ramp up” its ability to train therapists and saturate them across the state to help with the understaffing issue.

“Child mental health is one of those arenas where people are naturally collaborative,” Sood said. “The collaboration really yields very good results.”

Mitigating the CAP shortage

The Richmond Behavioral Health Authority, or RBHA, provided behavioral and primary medical services to over 5% of the population of Richmond in 2019. The agency states that one-third of its clients cannot pay for vital services.

RBHA serves adults and children. It has attempted to mitigate a CAP shortage through telehealth options, increased caseload for staff and temporary staff hired from temp agencies, according to John Lindstrom, RBHA chief executive officer.

The RBHA has tried to “get pretty creative” with solutions but cannot meet all the need, he said.

The community health agency has to occasionally “turn off the spigot” if they get overloaded in terms of capacity and certain service areas, Lindstrom said.

“Ideally we should not be running the vacancy rates that we run if we want to offer a robust set of services to anybody that needs them,” Lindstrom said. “That is really our goal.”

The child and adolescent behavioral health staffing shortage is part of a nationwide health care staffing shortage, Lindstrom said. There are incredible pressures on the system.

The RBHA is focused on immediate problems they can address, such as hiring incentives, job retention and recruitment efforts.

Funding mental health

Another way to increase mental health access is to increase their services in schools, said Moore, with Voices for Virginia.

“Our young people are asking explicitly for more support in the school system, and it really is both a matter of making it happen from a legislative standpoint and putting those laws and budget funding in place,” Moore said.

The state budget appropriated $2.5 million for integrated mental health services in schools during the last fiscal year. The amount was bumped to $7.5 million this year after lawmakers passed the budget in September.

More than $12 million was allocated for child psychiatry and children’s crisis response services, to be divided throughout the state based on current services already offered. The funds can be used to hire or contract child psychiatrists to provide clinical services, or to train. Mental health advocates have said the budget makes “significant investments” in mental health services across the state.

Despite the recent urgency behind the issue, Virginia still doesn’t have an adequate number of school psychologists or licensed professional counselors, Moore said.

“We're very lucky that there is now an urgency behind changing the system and also realizing at the same time that that doesn't mean tomorrow,” Moore said. “I hate to have to ask families to be resilient. It's not fair. They shouldn't have to be resilient.”

Families should continue to share stories with local leaders and lawmakers to illustrate the urgency behind needed changes, Moore said.

Callahan, who has taught for 15 years, does not know how things got this bad, but is ready for a solution.

“I eat, sleep and breathe this every day,” Callahan said. “The year that we’re in, how are we not having more resources readily available to families? Why is this taking months and months?”

VCU InSight journalist Daemon Hollinshed contributed to this report.

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