Spokane child psychiatrists are in short supply as the nation's youth mental health crisis persists

Sep. 21—Spokane likely has about 20,000 children and teens experiencing mental health disorders in any given year, according to national psychiatry data.

But the county has fewer than 15 psychiatrists, maybe even as low as 10, specializing in adolescent care — a woefully low number that is curbing services for children and their families. The American Academy of Child & Adolescent Psychiatry's recommendations for adequate staffing would call for about 50.

"There are not a lot of us," said Dr. Eric Lavy, medical director for Tamarack Center, a 16-bed residential treatment site for youth ages 12 to 18 with psychiatric illnesses. "There is a long training. There is a shortage. I don't have any answers. For me, it was a calling."

Local child psychiatrists work at clinics, hospitals, intensive day programs or inpatient residential care. They're all physicians with medical and psychiatry expertise to diagnose mental illness and prescribe and monitor specific medications for treatment of mental, emotional or behavioral disorders.

"Child psychiatrists are really the specialists in dealing with behaviors, emotional regulation and medication management when it comes to mental health and understanding normal childhood development," Lavy said.

When working with children, they also take into consideration a patient's medical history, developmental concerns and even childhood trauma and family issues.

Without enough psychiatrists, regional health care is affected. Providence Sacred Heart Medical Center closed its Psychiatric Center for Children and Adolescents two weeks ago, saying the shortage was among the reasons why the center, which was licensed for 24 beds, could only offer eight.

The problems aren't unique to Spokane.

The shortage is affecting cities across the United States as mental health struggles continue to afflict more kids. The psychiatry association estimates that one in six children ages 6-17 need psychiatric care. Some health facilities have other providers seeing to kids' mental health needs, such as psychiatric nurse practitioners.

Adding psychiatrists specializing in adolescent care to the ranks of medical providers isn't a simple fix. The requirement typically includes 13 years of post-secondary education and training, beginning with at least four years to complete a bachelor's degree, followed by four years of medical school and then a three-year general psychiatry residency and a two-year child specialty fellowship.

"When I try to think about what would you cut in training, I don't know what, because the idea is you go to medical school and do general medicine training, the rotations, and that is what allows you to recognize if what the person is coming in with is a medical problem that looks like psychiatric illness," said Dr. Katie Kist, a child and adolescent psychiatrist at Frontier Behavioral Health in Spokane.

"If somebody has hypothyroidism, it can look like depression. Without that medical training, I don't know that you would ever pick up on, this isn't actually depression," she said. "I look at medical history every single time."

She was drawn to the field in medical school after seeing how undiagnosed mental health manifested later into poor physical health, perhaps depression and inactivity. Treating kids now, she asks about in-utero exposures or traumas, complicated deliveries, developmental concerns, serious illnesses, heart conditions, seizures and sleep. Child psychiatrists also consider any abuse or neglect.

Kist said her caseload is about 160 patients, with a range of psychiatric disorders.

"I think we see pretty much everything — ADHD, depression, anxiety, schizophrenia, autism, OCD, eating disorders and substance use," she said.

The job goes beyond one psychiatrist and one child, with the doctor talking to family, caretakers, teachers, providers and anyone influencing a child's life.

"Kiddos are often a barometer of their home environment or entire environment," Kist said. "We try to figure out what's going on structurally in the family system to help treat."

The work requires a physician's focus on symptoms and causes, said Dr. Ned Atwood, a Frontier child and adolescent psychiatrist. Most patients are 9 to 17, but he sees some as young as 4 and up to 22.

"Psychiatrists really are the experts when it comes to mental illness, anything that would have the term 'disorder' after it," he said. "A lot of that requires being very granular about the severity of what we're seeing, like how often are they having these suicidal thoughts, how intense, how long are they lasting?

"If I see them in two weeks, I'll be asking them again a lot of those granular questions. There's a lot of pressure to get the right treatment on board right out the gate, which is easier said than done."

Typically a first visit is 60 minutes; follow-ups are 30 minutes. He sees children for such disorders as ADHD, autism, bipolar, depression, anxiety and severe mental illnesses.

Although he occasionally taps a psychologist to test for some conditions, Atwood said child psychiatrists typically diagnose the disorders that disrupt daily functions. Psychiatric medicines aren't always needed, he said, but he must understand them and what's effective for children.

"Even deciding what antidepressant to use, I have a logic," Atwood said. "Parents are probably thinking, why is he asking so many questions about sleep? I'm trying to dial in on what medication would be most likely to be successful."

Atwood doesn't think pay is an issue for people interested in the field. Typical pay is about $210,000 to $280,000 per year, according to job recruiters and direct online job postings in Spokane.

He advocates for reaching medical students early, before they set a path.

Spokane has specific training for child psychiatrists through Providence: Psychiatry Residency Spokane for general residency and a two-year child and psychiatry fellowship, open for four positions each year.

Currently, only one person is in the program completing a second year, said Dr. Erik Loraas, the fellowship's director. Since starting summer 2021, the fellowship has graduated five child psychiatrists, with a sixth expected in June 2025.

Nationally, such fellowship programs haven't filled, Loraas said.

"Any given year, only a half or just over half of available training spots actually fill," he said. "The reality is more and more people are going into (general) psychiatry. I think about 13% of medical school grads go into psychiatry. Of that, maybe 1 to 2% go on to do a fellowship."

Among nearly 30,000 U.S. medical school graduates a year, that means about 300 might enter such a fellowship.

Loraas is a child psychiatrist for Providence's outpatient RISE — Resources, Insights, Support and Empowerment — an intensive daytime mental health treatment for adolescents. He can think of only about 10 regional child psychiatrists.

"Last I looked, Whitman County has one child psychiatrist, but that's essentially it for most of Eastern Washington," Loraas said. "You're looking at an entire half of the state being served by maybe 10 child and adolescent psychiatrists, so it quickly becomes like a regional dearth."

Patient need is increasing, he said. RISE teens start five days a week and eventually taper to two, while learning mental health skills. Providence also runs BEST, Behavior and Educational Skills Training, a day treatment for ages 7-12.

"RISE is kind of the ideal treatment setting for kids with acute issues or exacerbation of chronic concerns, when there is not an immediate risk to themselves," Loraas said. "We have kids in our program who are actively suicidal, but that's a large part of what we do in the program is problem-solve that," including working with families.

Kids stay engaged as much as possible in daily lives while getting the specialized, intensive mental health treatment they need.

"Back in the day, these kids would be hospitalized. They would be inpatient for a month or more. A lot of these things we do at RISE were being done in an inpatient unit. But with managed care, admissions to psychiatric units have gone down in terms of length of stay, exponentially."

Psychiatrists face challenges other doctors don't, he said. They're diagnosing a collection of symptoms without an identifiable disease and clear causes. To help a kid, psychiatrists might need to confront family issues or parental substance use. They need to understand behavior, complex for anyone, but more so for children.

"It's in individuals who can't necessarily articulate what they're feeling, because they're young," Loraas said. "A lot of where child and adolescent psychiatry runs into trouble is there are assumptions it's like other fields of psychiatry or is somehow like other fields of medicine.

"We're not quite there yet. The brain is incredibly complex, and our understanding of it is so primitive."

Nationally, he said psychiatrists can feel helpless with a lack of support resources, such as therapists who specialize in young clients, targeted programs for autism, and hospital beds.

"In a lot of places, there are no options," he said. "In a good part of the country, it's multiple hours to the nearest hospital that can take a kid.

"You quickly feel almost a helpless sense. I'm sitting here with a kid and family who need tremendous help, more than what I'm able to give as an individual, and there aren't these other resources. I think that leads to burnout."

In Spokane, Inland Northwest Behavioral Health offers psychiatric inpatient care with 25 beds for teens. Kootenai Health's inpatient Youth Acute Unit treats kids ages 10-17.

Washington has four psychiatric residential treatment facilities where children are admitted voluntarily or by court order: Tamarack, ones in Yakima and Tacoma, and the state-operated Child Study and Treatment Center in Lakewood, with residential cottages for ages 5 to 18.

Kist said sometimes a hospital's child psychiatry unit is necessary. In the past four years, she sent some to Sacred Heart for reasons such as self-harm, being a danger to others, inability to do crucial functions, such as eating and sleeping, or urgency to monitor a medication change.

"Up until PCCA closed, at almost any given time, I'd have one to three kids on the unit," Kist said. "I very rarely didn't have somebody there, so now it's gone.

"The closure of PCCA is devastating to the care kids can access now. We have been in a really hard spot for a long time for little kids who are having safety issues, because we haven't had an inpatient hospital for little kids. Now, that problem is getting worse because it's been decreased a lot in the level of care we can offer for teenagers, too."

Excelsior Wellness is using a newer model called Certified Community Behavioral Health Clinic, overseen by Dr. Tara James, a child and adolescent psychiatrist. It has a focus on mental health and substance use disorders, offering 24-hour crisis services, family support and care management.

James said part of the picture is an overall increase in child and adolescent psychiatric disorders since 2020.

She said it's partly "increasing stressors" from socioeconomic ones to a rise in social media use.

"In some cases," James said, "it's unrestricted online exposure that children and adolescents have that they didn't have in prior generations."

But specialists are also more experienced at knowing what to look for now.

"We are better now at recognizing and diagnosing children," James said. "Part of that is that pediatricians and family medicine doctors have more training now in identifying mental health conditions ."