Why are there so few autism (FASD) specialists?

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When Natasha Marrus started her residency in general psychiatry in 2007, none of her 11 classmates ever mentioned autism. They eagerly discussed schizophrenia and bipolar disorder, and occasionally a “really tough” resident would talk up personality disorders, recalls Marrus, now a child psychiatrist at the Autism Clinical Center at Washington University in St. Louis, Missouri. But even those who were considering working with children did not share her interest in autism.

Sarah Spence had a similar experience while training to become a neurologist in the 1990s. “My boss was thrilled I wanted to do autism, because nobody in neurology did this,” says Spence, co-director of the Autism Spectrum Center at Boston Children’s Hospital.

Decades later, both scientists are still in the minority: According to the latest estimates, there are more than 1 million autistic children in the United States but only about 8,300 child psychiatrists, 1,500 child neurologists and 1,000 developmental-behavioral pediatricians. And within those small numbers, autism remains an unpopular choice: “It’s not a perfect analogy, but I feel like autism within psychiatry is like psychiatry within medicine,” Marrus says.

These doctors are not alone on the frontlines of autism. Psychologists play a crucial role in screening for the condition, and some also provide behavioral therapy. But autistic children must generally see a specialist to receive a diagnosis. And because these children frequently have additional psychiatric conditions, as well as physical ones such as epilepsy, frequent infections, sleep disorders and gastrointestinal problems, they benefit greatly from the medical expertise specialized pediatricians can offer.

Hard hit by the shortage are rural communities in the U.S., where many people with autism receive specialist medical attention only in an emergency, when a behavioral crisis has become too much for their families to handle. In South Dakota, for example, there is approximately one child psychiatrist for every 100,000 children under age 18.

The situation is no better elsewhere in the world. Regions such as North Africa, the Middle East and South Asia are home to the majority of children living with autism and intellectual disability, according to a report in The Lancet in August, but have few medical personnel qualified to care for these children. “This is a global problem, and the problem is much more pronounced in low- and middle-income countries,” says Rosa Hoekstra, senior lecturer in psychology at King’s College London.

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