Zachary became a different kid.
Gone was the outgoing, energetic boy who pursued ice hockey with a passion and dreamed of playing pro. In his place was a moody, defiant teenager who didn't want to do much but sleep. Zachary's grades fell. When the pressures of middle and high school stressed him out, he turned to smoking and partying.
"Kind of like a regular teenage thing, but a little bit more," said his mother, Lois Libby. "He would get really sad. He felt like, 'I'm not worth this,' or, 'I'm not worth that.'"
Eventually, Zachary quit his beloved hockey team and walked away from those dreams.
It wasn't "a regular teenage thing." His pediatrician diagnosed depression.
But while a diagnosis meant Zachary and his family finally knew what was wrong, they had to find someone who could treat it.
And in Maine, particularly rural Maine, that's a problem. Child psychiatrists — mental health professionals licensed to prescribe medication to children and teens — are in short supply.
In their hometown of Oxford, and the surrounding area, Zachary's family couldn't find a single one. The closest child psychiatrist was in Lewiston, 30 minutes away, and even then it took a referral from Zachary's pediatrician and approval from the family's health insurance company. And after that, the psychiatrist had to find an opening in the schedule.
The process would take up to three months, longer than the teen could wait.
Depressed and overwhelmed, he told his mother he didn't know what to do. She feared he'd hurt himself.
At his pediatrician's urging, Libby took her son to St. Mary's Regional Medical Center in Lewiston, where he was admitted for adolescent inpatient psychiatric treatment.
He could find help in a crisis but not help to prevent the crisis.
It's an irony that mental health experts say most parts of Maine are grappling with. And one they're working to remedy.
"When you've got a kid that's really suffering, waiting three months to get an appointment is heartbreaking," said Michael Kelley, chief medical officer for St. Mary's Behavioral Health Department.
Some counties have none
The problem isn't new, or limited to Maine.
For at least 30 years, experts have been sounding the alarm about the shortage of child psychiatrists across the country. In 1980, the Graduate Medical Education National Advisory Committee said so many children and teens were projected to need help that the U.S. would require 8,000 to 10,000 child and adolescent psychiatrists by 1990. In 1990,the Council on Graduate Medical Education said the country would need 30,000 by the year 2000.
Neither goal was met.
In 1999, the surgeon general said only about 20 percent of mentally ill children received mental health services and only a fraction of that 20 percent got that help from a child psychiatrist. Today, according to the American Medical Association, there are about 7,600 practicing child and adolescent psychiatrists in the county, less than experts said the U.S. would need 23 years ago.
Urban areas typically have the easiest time finding and keeping psychiatrists. Rural areas struggle the most.
And Maine is very rural.
"I see a huge need," said Sandra Fritsch, a child psychiatrist and president of the Maine Council of Child Adolescent Psychiatry.
She created a map to show the number of child psychiatrists in each county in Maine. In 2011, Cumberland County had the most at 22. Androscoggin County had four.
Oxford, Franklin and three other counties had none.
But even patients in areas with psychiatrists have no guarantee of actually seeing one. Some doctors care only for hospitalized children. Others have limited hours. Some have since left the area or stopped practicing
Aroostook County, for example, had three child psychiatrists in 2011. Fritsch believes it's now down to one.
Experts say part of the problem is that too few students are pursing careers in child psychology, often because that path takes too long (about 13 years, including college, medical school, residency and fellowship) or costs too much (hundreds of thousands of dollars ). And some students simply don't know enough about child psychiatry to even consider it. Medical schools often don't expose students to the specialty, and general psychiatry residency programs only require a two-month experience.
Because of the shortage, those who do practice have their choice of where to go. Often, that is not to rural areas.
Small cities can have a slightly easier time recruiting and retaining psychiatrists, but it's still not easy.
"I think we've sort of gently been looking for a psychiatrist for the last 10 years," Kelley said. Always one behind. I probably right now could add two child psychiatrists and could have both of their practices 100 percent full within six weeks. The backlog is that bad."
That's a problem for children and families.
"It can take months and months to get an appointment for a child psychiatry patient," Kelley said.
Libby, whose teenage son was diagnosed with depression by his pediatrician, knows that wait.
Now 21, he's doing well. He's in a relationship and his depression is under control, thanks in part to the coping skills he learned from psychiatrists at St. Mary's, his mother said. But the help came too late to save one major aspect of his life: hockey.
His mother wonders whether he'd still be playing if he'd gotten help earlier.
"It's too bad. I really think he would have been able to do something with it," she said.
While her older son is grown, Libby's struggles to find a child psychiatrist aren't over. Her younger son has attention-deficit hyperactivity disorder, known as ADHD, a problem that requires medication.
His psychiatrist moved out of state in August.
For now, his pediatrician prescribes his medication, but a significant change — such as a stronger dosage — could require a licensed psychiatrist.
"What probably would happen is (his pediatrician) would, obviously, evaluate him, and then she would suggest him seeing another psychiatrist, probably in that area, in Lewiston," Libby said. "Another, probably, three-month process . . . because there is nobody around."
Jennifer, another mother in Oxford, knows what it's like. Her 6-year-old son, Carter, has been diagnosed with a host of problems, including autism, anxiety, depression, oppositional defiant disorder, a pervasive developmental delay and sensory processing issues.
His violent rages are what most trouble Jennifer.
When he's out of control, the angelic-looking boy will kick, scream, head-butt, punch holes in the wall and fight anyone who tries to hold him.
Jennifer — who asked that the Sun Journal not release the family's last name to protect family members' privacy — said she desperately loves her young son and can handle almost anything from him, but rages that were troublesome at age 2 are dangerous at age 6. Just under 5 feet tall and weighing 70 pounds, he gets harder and harder to control, and his mother is afraid he's going to hurt himself or someone else.
Recently, during a severe meltdown over getting dressed for school, Carter unbuckled his seat belt and swung open the car door on Route 26. His teenage brother held him back from jumping.
"He has no fear," Jennifer said.
Carter has received early-intervention services since he was a toddler, but never help from a psychiatrist. Although Jennifer has tried for months to get him an appointment, she said she hasn't been able to find an available child psychiatrist who accepts her insurance. She's applied for the Katie Beckett program, a widely accepted MaineCare option for children with physical or mental disabilities, but that process can take months, and once approved she still would have to find a psychiatrist with an open appointment.
As scared as she is for her son now, she's terrified about the future that looms if he doesn't get help.
"People who know this (kind of situation) say the teenage years are horrific," she said.
As a stopgap, Carter's pediatrician began prescribing Prozac in October. It helped, but not enough.
That rage on Route 26 happened while he was on that medication, and Jennifer drove him to the hospital to be admitted. He'd reached a crisis point.
The first-grader spent the next seven days in Spring Harbor Hospital, a psychiatric facility in Westbrook. There, finally, he saw a psychiatrist who could prescribe additional medication.
"I can get him antibiotics, but I can't get him medication to keep him even," Jennifer said. "I don't know how to fix it, but they need to do something."
Hope and fear
Maine mental health experts are working on that "something."
Maine Medical Center in Portland started a child psychiatry residency program in 1974 and increased the number of slots from two to three in 2007. Although some doctors from that program have moved out of the area or have gone on to practice adult psychiatry, others became child psychiatrists and stayed.
"The jobs are pretty full down there," said Lindsey Tweed, medical director for the Maine Department of Health and Human Services' Office of Child and Family Services.
In Bangor, Acadia Hospital has had some recruiting success, as well. The psychiatric facility, which is often the only resource for families from mid-Maine to the northern Canadian border, recently hired three child psychiatrists, more than doubling its number of child psychiatrists. But while the psychiatric hospital is always searching for new doctors, this additional staff came by happenstance.
One doctor finished her fellowship at the hospital and stayed on. Another was contacted by a recruiter and liked the area so much that she encouraged a friend to apply, as well. Both were hired.
"It's one of those things that happened to be right place, right time," said Chief Medical Officer Anthony Ng.
Experts agree, though, that Maine can't count on residency programs, recruiters or luck to fill the need. Some have started looking in a different direction.
Fritsch, with the Maine Council of Child Adolescent Psychiatry, is also physician leader for the Child Psychiatry Access Program, known as CPAP. The program connects pediatricians with psychiatrists who provide consultations, teach them about child mental health issues and offer referrals.
Started in 2009 with a grant from the Maine Health Access Foundation, the program is now funded through a donation by philanthropists Judy and Al Glickman of Cape Elizabeth. The program currently works with more than two dozen pediatric providers in southern, western and mid-coast Maine. Those providers cover 38,000 children.
Pediatricians are trained to handle broken bones and stomachaches, not suicidal teenagers or youngsters with crippling anxiety. But during a recent CPAP Lunch and Learn program, doctors at Western Maine Pediatrics in Norway estimated that one-third to one-half of their patients come in with mental or behavioral issues.
CPAP's Fritsch has helped talk them through cases, and has provided recommendations and offered support. It's not full-fledged psychiatric care, but for some families it can be enough, particularly those who have a rapport with their pediatrician and are leery about seeing another doctor. For others, it's a temporary solution until a child psychiatrist can be found, providing enough help to keep a child out of the hospital or enough warning to tell parents their child is in crisis.
"For a lot of these kids, you're changing the entire direction they go in their lives," said one pediatrician during the lunch event.
There is also a push in Maine to increase the number of mental health professionals who can care for kids but who aren't doctors, including licensed clinical social workers, licensed clinical professional counselors and child psychiatric nurse practitioners.
They can't do everything doctors can do and there have been issues in getting insurance to cover their services. Medicare doesn't recognize licensed clinical professional counselors, for example. But experts believe those mental health professionals can care for simple cases, taking some of the burden off Maine's few child psychiatrists.
"There's one ray of sunshine in the field," Kelley said of nurse practitioners.
Doctors fear the future for those kids who don't get the help they need. Untreated ADHD can lead to failure in school and, later, work. Untreated depression can lead to suicide. Untreated mental illness can lead to lifelong struggles.
Parents fear, too.
"It's just that long process," Libby said. "In the meantime, you can be sitting here and this person can be a walking time bomb and there's nothing you can do other than bring them to the emergency room."