Texas is a vast state with regional differences in geography, population size, demographic, and socioeconomic characteristics. This section provides an overview of these variations and the existing health care availability and access challenges as well as cultural literacy and effectiveness in meeting the health needs of Texas mothers, children, and their families.

Geography

Texas is the second largest state in the United States (behind Alaska) in square miles.  The Lone Star State encompasses approximately 262,000 square miles and accounts for 7.4 percent of total United States (U.S.) land area. Total Texas land area is equal to all six New England states, Ohio, New York, Pennsylvania, and North Carolina combined [[1]]. Texas is slightly longer than it is wide with the greatest straight-line distance from the northwest edge of the Panhandle to the southern tip of Texas below Brownsville on the Rio Grande spanning 801 miles [[2]]. The broadest expanse from east to west is 773 miles from the Sabine River in Newton County to the western bulge of the Rio Grande just above El Paso [2].

Texas geography is as varied as it is large. Texas includes 254 counties classified as either rural or urban (Figure 1). with 88.5 percent of the population residing in urban counties as of 2021[[3]]. The five largest metropolitan areas in Texas are located around the cities of Houston, San Antonio, Dallas, Austin, and Fort Worth and these areas encompass multiple counties. Given the immense size of Texas, the distance some individuals must travel to receive health care services can be a significant challenge to accessing and receiving those services especially for those living in rural counties (Figure 1).

 

 

 

 

 

Figure 1. Rural and Urban County Designations in Texas, 2020

 

For administrative purposes, each of the 254 Texas counties is assigned to one of 8 public health regions. Figure 2 outlines the eight public health regions and the city where each regional office is located. Regions 8, 9/10, and 11 contain border counties. There are 32 border counties as defined by the 1983 La Paz Agreement. Approximately 2.9 million people live in border counties[[4]].

 

 

Figure 2. Texas Public Health Regions.

 

Population

Just as the Texas geography is varied, so is the population distribution. (Figure 3). Differences in race/ethnic composition, along with the high percentage of foreign-born residents, present cultural literacy and effectiveness challenges when it comes to meeting maternal and child health (MCH) needs.

 

 

Figure 3. Texas Total Population, 2021

 

Texas also has the second-largest population size in the U.S. (behind California), with a population of over 29.5 million in 2021 [[5]]. According to U.S. Census annual estimates, Texas has been one of the fastest-growing states in the nation since 2010 with a 16.9 percent increase in the Texas population from 2010 to 2021. The Texas Demographic Center predicts that by 2050, the population in Texas will exceed 47 million people [[6]]. Most Texans live in the northeast, east, central, south, and gulf coast regions of the state (Figure 3).

Race/Ethnicity

The population of Texas is racially/ethnically diverse with 40.7 percent non-Hispanic White (hereafter referred to as White in the text and graphs), 39.8 percent is Latino or Hispanic, 11.8 percent is non-Hispanic Black (hereafter referred to as Black in the texts and graphics). 5.0 percent is non-Hispanic Asian (hereafter referred to as Asian), and 0.2 percent American Indian and Alaska Native [[7]]. Counties with the highest proportions of Hispanic populations are primarily located in the southern and western regions of Texas along the Texas-Mexico border. In 2020, three major cities in Texas (Brownsville, Laredo, and El Paso) were located in counties where over 75 percent of the population was Hispanic and three other cities (San Antonio, Corpus Christi, and Odessa) were located in counties where over 50 percent of the population was Hispanic (Figure 4).

 

 

 

 

Figure 4. Percent of the Population who are Hispanic or Latino, 2021.

 

The distribution of the Texas Black population (Figure 5) differed from the Hispanic population. Based on 2020 Texas Demographic Center data, counties with the highest proportions of Black populations were largely concentrated in the northeastern, eastern, and north gulf-coast regions of the state.

 

Figure 5. Percent of the Texas Population who are Black, 2021.

 

 

 

 

Foreign-Born

In 2012, Texas had a higher percentage of foreign-born residents (17.2 percent) compared to the nationwide average (13.6 percent) In total, 58.3 percent of Texas foreign-born residents were not U.S. citizens. Over 65.3 percent of Texas foreign-born residents were born in Latin America which is  15 percentage points more than the national level [[8], [9]]. Approximately 34.9 percent of Texans spoke a language other than English at home in 2021. Almost 30 percent of Texans spoke Spanish at home compared with 13.2 percent of U.S. residents [6,7]. Texas border counties had high percentages of foreign-born residents in 2017-2021, as did several other counties in west and northwest Texas (Figure 6). Counties containing non-border cities of Houston, Dallas, and Austin also had high concentrations of foreign-born residents. Given these demographic and social variations, the Texas Department of State Health Services’ (DSHS) Community Health Worker (CHW) program increased the number of certified CHWs to address cultural literacy and effectiveness needs [[10]].

 

 

 

 

Figure 6. Percent of the Population who are Foreign Born, 2017-2021.

Age

According to 2021 American Community Survey 1-year estimates, Texas has the third youngest population in the United States, with a median age of 35.5 years, behind Utah (median age 31.8 years), and District of Columbia (median age 34.8) [[11]].

In 2021, Texas had the second-largest proportion of the population comprised of children younger than 18 years old (25.3 percent) in the nation [[12]] (Figure 7). About 6.4 percent of the Texas population were younger than 5 years old and 14.5 percent were 5 to 14 years old. Texans younger than 21 years of age accounted for 29.4 percent of the total population in 2021.

Figure 7. Percent of Population Under 18

Source: U.S. Census Bureau, American Community Survey 2021 Prepared by: Maternal and Child Health Epidemiology Unit, Mar 2023

 

 

 

 

 

 

 

 

 

 

Figure 8. Percent of the Population Under 21 Years Old, 2021.

 

Women comprised half of the total Texas population and women between 18 and 44 years of age, considered women of reproductive age, accounted for 18.7 percent of the total population of Texas in 2020 [10]. Urban counties with large metropolitan areas (including counties containing the cities of Dallas-Fort Worth, Houston, San Antonio, Austin, and El Paso) had the highest proportions of women of reproductive age (Figure 9).

 

 

Figure 9. Percent of the Population Who Are 18-44 Years Old and Female, 2021.

 

The 2020-2021 National Survey of Children’s Health (NSCH) estimated that 17.5 percent of Texas children ages 0-17 had a special health care need. Rates of CSHCN among different race/ethnic groups differed. The White, non-Hispanic group had the highest proportion of CSHCN with 19.8 percent, followed by Black, non-Hispanic with 18.4 percent, then Hispanic with 16.4 percent, and the other, non-Hispanic group with the lowest proportion of CSHCN with 12.6 percent [[13]].

Socioeconomic Characteristics

Socioeconomic characteristics such as income and poverty, education, unemployment, and crime rates are added challenges for meeting the health needs of mothers, children, and families in Texas. The presence of an increased number of risk factors of this nature in a community poses a danger to the health of the individuals within that community throughout the entire life course.

Income and Poverty

Income inequalities exist within different areas in Texas and largely reflect gender and race/ethnic differences. In 2021, Texas’ median household income was $66,963, which was slightly lower than the national median household income of $69,717 [[14]].

The Federal Poverty Level (FPL) is set by the U.S. Census Bureau based on income thresholds that vary by family size and composition. If a family’s total income is less than their determined income threshold then that family and every individual in that family is in poverty. These poverty thresholds are used throughout the mainland U.S. and do not vary geographically. However, they are updated each year to account for inflation. According to 2021 American Community Survey estimates, Texas had a higher proportion (14.2 percent) of people living below the FPL than the national average of 12.8 percent [[15]].

The proportion of people living below the FPL varies geographically and by sex. Counties with a large proportion of people living below the FPL in 2017-2021 were concentrated in the Texas-Mexico border region. Several counties in east Texas, north central Texas, and the Texas Panhandle also had high rates of people living below 200 percent FPL (Figure 10).

Figure 10. Percent of the Population Below 200 Percent Federal Poverty Level, 2017 - 2021.

 

In 2021, it was estimated about 15.5 percent of the female population lived below the FPL in Texas which is slightly higher than the rate for males (13.0 percent) [15]. Counties in the Texas-Mexico border region had high rates of women living below the FPL as did several counties in rural East Texas, west of Fort Worth, and between Lubbock and Amarillo in the Panhandle. The fastest growing major metropolitan areas – Austin, Houston, and San Antonio – had a relatively low proportion of women living below the FPL (Figure 11).

Figure 11. Estimated Percent of the Female Population Below 100% Federal Poverty Level, 2017-2021.

Food Security

Food security refers to a household’s ability to provide enough food to keep each member of the family active and healthy. Along with negative health outcomes, food insecurity can make it difficult for children to learn and grow [[16]]. Overall, the food insecurity rate in the United States is 10.9 percent of the population. In the United States, an estimated 16.1 percent of children live in food insecurity. As of 2020, there are approximately 3,720,710 food insecure people in Texas. Rates differ significantly across ethnicities and race as 24.0 percent of the Black population, 19.0 percent of the Latino and Hispanic population, and 7.0 percent of the white experience food insecurity. Throughout the state, 18.9 percent of children are food insecure and Texas has nine counties where more than 32.0% of children experience food insecurity [[17]].

Education

As higher educational attainment has been associated with positive health outcomes and it is crucial to understand education within the context of Texas [[18]]. In 2021, among people 25 years and older, a greater percentage of both men (15.4 percent) and women (13.8 percent) in Texas had less than a high school education compared to their national counterparts (11.4 percent for men and 9.9 percent for women). Additionally, 24.6 percent of Texas residents aged 25 and older had a high school diploma or equivalent as their highest level of educational attainment and 35.3 percent had a bachelor’s degree or higher [[19]]. Educational attainment levels are not evenly distributed throughout the state. There were nine counties where the educational attainment of a bachelor’s degree or higher was greater than 40 percent among individuals 25 years of age and older [[20]]. There were 12 counties where less than 10 percent of the people aged 25 years and older had a bachelor’s degree or higher and these counties are largely clustered in the south and panhandle of Texas [20].

Unemployment

While Texas had a higher percentage of adults without a high school diploma compared to the nation, it had about the same unemployment rate (5.4 percent) as seen nationwide (5.5 percent) for  population between 25 and 64 years of age in 2021 [[21]]. Even among persons aged 25-64 without a high school diploma, Texas had a lower rate of unemployment (7.0 percent) compared to the national average for this educational attainment group (9.5 percent). Consistent with nationwide trends, the Texas unemployment rate increases as education level decreases. In 2021, the Texas unemployment rate was as low as 3.4 percent among those with a bachelor’s degree or higher [20].

Crime

Crime impacts the physical and behavioral health and wellbeing of mothers, children, and their families. Neighborhood crime can be detrimental to the safety of children by creating unstable living environments. By assessing communities where crimes occur more frequently, it is possible to identify areas where high risk populations reside and help prevent adverse consequences. In 2021, Texas’ Crime Rate was 3,410 crimes per 100,000 persons [[22]].

Texas index crime statistics include two major categories of crime: property and violent crimes. Property crimes consist of burglary, larceny-theft, and motor vehicle theft. The 2021 property crime rate was 2,122.8 crimes per 100,000 Texans, a 4.5 percent decrease from the previous year. The highest property crime rates in 2021 were primarily localized within larger Texas cities and their surrounding areas (Figure 12) [22].

 

 

 

 

 

 

 

Figure 12. Property Crime Rate per 100,000, 2021.

Violent crimes recorded in the Uniform Crime Report index include murder, rape, robbery, and aggravated assault. In 2021, the violent crime rate was 440.0 crimes per 100,000 Texans which is 0.6 percent lower than 2020. The highest violent crime rates in 2021 were primarily concentrated near the larger cities of the panhandle: Odessa, Lubbock, and Amarillo (Figure 13). Houston, Dallas, San Antonio, Corpus Christi and surrounding areas also had a high concentration of violent crimes [[23]].

Figure 13. Violent Crime Rate per 100,000, 2021.

 

Violence within Texas families has also been recognized as a growing threat to the safety of Texans. The 2021 Texas Department of Public Safety Crime Report indicated 231,207 family violence incidents  which is an 8.1 percent increase from the previous year. Although the largest percentage of family violence was between other family members (61.6 percent), family violence also occurred among spouses/couples (22.6 percent) and within parent-child relationships (15.9 percent). Females were more likely to be victims in family violence. Of the victims whose sex was known, 71.2 percent were female and 28.8 percent were male. Conversely, of the offenders whose sex was known, 72.9 percent were male and 27.1 percent were female. The 25-29 age group had the highest number of victims in family violence followed closely by the 30-34 age group [22].

Mobility/Migration

Moving or relocating is one of life’s most stressful events and can impact individual health and well-being. For example, results from the Texas School Survey of Substance Use show that  relocation may influence risk behaviors in youth as students in grades 7 to 12 living in their current school district for three years or less are more likely to use illicit drugs than those living there more than three years [[24]]. Additionally, sudden  population numbers and demographic changes can lead to ill-equipped health care programs and systems that must adapt to meet their changing network needs  [[25]]. Texas demographic data illustrates migration patterns  that include moving into the state from other states and countries and moving within the state between counties. In 2021, 745,025 moved into Texas from a different state or country [[26]].  Texas’ overall population growth  between 2020 and 2021 was 310,288. This is more than any other state in the country. Approximately 54.7% of  this growth is attributed to domestic migration [[27]].  

Out-of-State Mobility/Migration

Between 2017-2021 some Texas rural counties also had high levels of out-of-state migration  particularly  parts of the state bordering Oklahoma,  the Panhandle, and West Texas (Figure 14) [3]. The majority of Texas counties had little to no new residents from other states.

Figure 14. Percent of Population that Moved from Another State to Texas, 2017-2021.

In-State Mobility/Migration

Another aspect of mobility is the number of people who move within or between counties in Texas. While out-of-state migration may reflect job growth, mobility of populations within a county and between counties is more complicated. In 2021, about 1,057,286 people  moved from a different to a new Texas county within the last year[26].

 Texas counties with universities and colleges were among the highest rates of within-county relocations over a one-year period [11]. College Station, Austin, Lubbock, and San Antonio are home to four of the ten largest Texas universities which partially explains the high rates of within-county relocations in these areas. College students tend to move often within the same county to take advantage of lower rents.

Health Care Coverage and Access

Health insurance and access to care providers are fundamental to the health of Texans. Texas currently has the largest proportion of uninsured people in the country at 18.0 percent which is significantly higher than the national rate of 8.6 percent [[28]]. Although each of the Texas Public Health Regions’ uninsured numbers sit well above the national rate there are considerable differences between them. Region 11, the southernmost Public Health Region, has the highest uninsured rate of 28.9 percent while the centrally located Region 7 has the lowest rate of uninsured people at 16.8 percent.

Table 1: 2020 Percent of Texas Population <65 that is Uninsured by State and Public Health Region

Public Health Region Percent Uninsured 1 16.1% 2/3 20.3% 4/5N 20.5% 6/5S 25% 7 21.8% 8 15.7% 9/10 21.4% 11 20.8% Texas Total 19.9%

Source: United States Census Bureau (2020). Small Area Health Insurance Estimates, 2020. Prepared by: Maternal and Child Health Epidemiology Unit, Mar 2023

 

Health Insurance

In 2021, Texas had higher proportions of uninsured children, uninsured women, and uninsured individuals living below 100 percent FPL than the corresponding uninsured percentages for these groups nationwide [28]. In Texas, 8.7 percent of children younger than 6 years old were uninsured and approximately 16.8 percent of Texas women were uninsured. Furthermore, 30.4 percent of Texans living below 100 percent FPL were uninsured [27]. In addition, 2020-2021 NSCH data showed that 14.1 percent of children ages 0 to 17 in Texas had no health insurance or periods of no coverage during the year prior to the survey. This is significantly higher than the nationwide children rate of 8.6 percent. An estimated 9.4 percent of CYSHCN had no health insurance or periods of no coverage during the past 12 months [[29]]. Counties with high proportions of uninsured children younger than 6 years of age were concentrated in West Texas between Odessa and San Antonio and in the Panhandle (Figure 16). The Texas-Mexico border regions and several counties outside Lubbock and Waco had high proportions of women aged 19 to 44 without health insurance (Figure 17).

 

 

 

 

 

 

 

 

 

 

 

Figure 16. Children Younger than 6 Years Old Without Health Insurance, 2017-2021.

Figure 17. Percent of Females (19-44 Years) Without Health Insurance, 2016-2020.

Access to Health Care

Given the large size of the state and the vast distances between points of care for rural health services, Texas access to care can be a challenge. There has been a slight increase in the number of primary care physicians in the past five years. In 2016, there were 20,530 (74.0 per 100,000 population) which grew to 22,984 (76.0 per 100,000 population) in 2021. However, thirty-three Texas counties still had no primary care physicians in 2021 (Figure 18).

Figure 18. Number of Primary Health Care Physicians per 100,000 Population, 2021.

In 2021, the approximated number of obstetricians and gynecologists (OB/GYNs) in Texas was 1,830. Most of these OB/GYNs (1,330) are located in major metropolitan areas of Dallas-Fort Worth, San Antonio, and Houston[[30]]. The full range of women’s health providers include certified nursing midwives, direct entry midwives, nurse practitioners with a specialty in women’s health, physicians‘ assistants focused  on women’s health, and OB/GYNs. In 2019, of the 254 Texas counties exactly half did not have a single women’s health provider. A total of 376,795 women between the ages of 15 and 42 live in a county with no women’s health provider [[31]].

Health Resources and Services Administration (HRSA) uses four criteria to designate Primary Care Health Professional Shortage Areas (HPSA). They consider the population-to-provider ratio, percent of the population below 100% of FPL, Infant Health Index based on Infant Mortality Rate and Low Birth Weight Rate, and travel time to the nearest care source outside the HPSA designation area. They also consider areas with a provider shortage for a specific group of people within the area such as low-income individuals. Additionally, if the county is home to a Federally Qualified Health Center (FQHC) it is also considered an HPSA. Recruiting and retaining health care professionals is an ongoing challenge not only in rural areas, but in some urban areas as well. In rural areas, health care professional retention is mostly due to population size whereas in some urban areas access is limited because many providers do not accept Texas Medicaid or patients are not enrolled in Medicaid and are unable to pay out-of-pocket for services [[32]]. Most Texas counties are designated as a low-income population, geographic or high needs geographic HPSA, or have an FQHC (Figure 19).

 

 

 

 

 

 

 

Figure 19. Texas Primary Care Health Professional Shortage Areas, September 2021.

 

Texas parents who responded to the Title V Community Outreach Survey indicated finding a mental or behavioral health professional was very or extremely difficult especially finding providers who treat children. The National Association for School Psychologists recommends a student-to-psychologist ratio of 500:1 [[33]]. In 2021, five out of 254 counties met this requirement. One hundred and four counties did not have a school psychologist (Figure 20).

Figure 20. Ratio of Students to School Psychologists, 2021.

 

 

Psychiatrist shortage is also a concern. The HPSA Mental Health scoring is based on seven factors: population-to-provider ratio, percent of population below 100% of FPL, elderly ratio, youth ratio, alcohol abuse prevalence, substance abuse prevalence, and travel time to the nearest care source outside the HPSA designation area. The HPSA recommendation ratio for population to provider is 30,000 people or residents to one psychiatrist and 20,000peopleor residents to one psychiatrist in areas with high needs [[34]]. In 2021, One hundred and sixty-eight counties did not have a psychiatrist and many that do have at least one psychiatrist meet the HPSA criteria for the mental health shortage designation (Figure 21) [[35]].

Additional challenges exist in identifying psychiatrists who specialize in child psychiatry. The American Academy of Child and Adolescent Psychiatry considers a sufficient provider-to-population ratio to be 47:100,000. Only Kendall County met this ratio in 2019. There were approximately 646 Child and Adolescent Psychiatrists in Texas with almost none operating outside of major cities [[36]].

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 21. Number of Psychiatrists per 100,000 Population, 2021.

Emerging Issues

Texas is committed to addressing the national opioid crisis with efforts to pro the health and safety of all Texans. The Texas Targeted Opioid Response (TTOR) is a public health initiative operated by Health and Human Services (HHSC) through federal funding from the Substance Abuse and Mental Health Services Administration. TTOR's mission is to save lives and provide Texans lifelong support with opioid and stimulant use disorders by expanding prevention services, integrated services, treatment services and recovery support services. DSHS is involved in multiple efforts throughout the statewide regions.

Region 4/5N staff provided Narcan and Fentanyl education to approximately 2,700 students, staff, and parents through approximately 30 events. Activities included school assemblies, red ribbon week presentations, partnership with local substance abuse coalition, trainings offered by education service centers (ESCs), school advisory councils (SHACs), parent education nights, school and community health fairs, and implementation of a new American Heart Association algorithm to new and recertified CPR participants. Groups targeted by these efforts include students, parents, school staff, nurses, administrators, school resource officers, coaches, bus staff, cafeteria workers, parents, local communities, and DSHS staff. Texas counties reached through the efforts included Anderson, Camp, Cherokee, Gregg, Harrison, Henderson, Nacogodoches Panola, Rusk, Smith, Titus, Upshur, Van Zandt, and Wood.

Agency Leadership Update

In December 2022, Texas Health and Human Services Executive Commissioner Cecile Erwin Young named Dr. Jennifer Shuford Commissioner of the Texas Department of State Health Services. Dr. Shuford has served as interim commissioner since September 2022 when former commissioner, Dr. John Hellerstedt, retired from state service. Before being named interim commissioner, she served as DSHS Chief State Epidemiologist. Dr. Shuford graduated from Colorado College with a bachelor’s degree in Chemistry and received her Doctor of Medicine degree from The University of Texas Southwestern Medical School. She completed an internal medicine residency at Presbyterian Hospital of Dallas where she served as chief resident. Dr. Shuford completed an infectious disease fellowship at the Mayo Clinic in Rochester, Minnesota. She earned her Master of Public Health degree from Harvard School of Public Health. Prior to joining DSHS in 2017, Shuford practiced medicine in Austin as an infectious disease physician. Dr. Shuford serves on the faculty of the DSHS Preventive Medicine and Public Health Residency Program and is a member of the Travis County Medical Society and the Infectious Disease Society of America. She is also a member of the Texas Medical Association, serving as a consultant to TMA’s Committee on Infectious Diseases.

Legislative Update

The Texas Legislature convened for the 88th Regular Session from January 10, 2023, through May 29, 2023. During the legislative session, the Community Health Improvement (CHI) Division tracked 245 bills. Ultimately, 17 bills and resolutions will be implemented for CHI, including 6 bills, riders, or exceptional items that impact to Maternal and Child Health. These items primarily focused on the agency staff support of the Maternal Mortality and Morbidity Review Committee and adding additional membership on Maternal Mortality and Morbidity Review Committee.

 

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[3] Texas Demographic Center, 2021 Population Estimates Program. U.S. Census Delineation Files, 2018.

[4] Texas HHS. Texas Border Public Health (2022). Retrieved from https://www.dshs.state.tx.us/hivstd/reports/border/sec3.shtm

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[10] Promotor(a) or Community Health Worker Training and Certification Advisory Committee (2019). 2018 Annual Report. Retrieved from https://www.dshs.state.tx.us/chs/hprc/publications/2020/CHW_factsheet_2020.pdf

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[17] Feeding America: Map the Meal Gap (2020). Child Food Insecurity in Texas. Retrieved from https://map.feedingamerica.org/county/2020/overall/texas

[18] Hahn, R. A., & Truman, B. I. (2015). Education Improves Public Health and Promotes Health Equity. International journal of health services: planning, administration, evaluation, 45(4), 657–678. https://doi.org/10.1177/0020731415585986

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[31] Health Professions Resource Center. Women and women’s health providers: metro v. non-metro, 2021. Retrieved from https://www.dshs.texas.gov/chs/hprc/publications/WomensHealthProviders.pdf

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[33] National Association of School Psychologists (2021). Research Summaries: Shortages in School Psychology: Challenges to Meeting the Growing Needs of U.S. Students and Schools. Retrieved from https://www.nasponline.org/research-and-policy/research-center/research-summaries

[34] Bureau of Health Workforce, Health Resources and Services Administration (HRSA), United States Department of Health & Human Services (2020, March 31). Designated Health Professional Shortage Area Statistics, Second Quarter of Fiscal Year 2020, Designated HPSA Quarterly Summary. Retrieved from https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport

[35] Center for Health Statistics, Texas Department of State Health Services (2021). Psychiatrists, 2021. Retrieved from https://healthdata.dshs.texas.gov/dashboard/health-care-workforce/hprc/health-profession-supply

[36] American Academy of Child & Adolescent Psychiatry (2019). Workforce Issues. Retrieved from https://www.aacap.org/aacap/Resources_for_Primary_Care/Workforce_Issues.aspx#:~:text=There%20are%20approximately%208%2C300%20practicing,a%20child%20and%20adolescent%20psychiatrist.