Seventeen years ago, U.S. Secretary of Health and Human Services Donna Shalala sounded the alarm on a crisis that was leaving millions of ill children without proper care.
The problem, outlined in a report on the country's mental health system, was a "dearth" of child psychiatrists that forced primary care doctors to treat mentally ill youngsters, a "triage" environment that it said needed to change.
Instead, the crisis is arguably getting worse, as the United States grapples with an increase in depression and suicides among young people, and the number of child psychiatrists remains far too meager to help them.
Fewer child psychiatrists take insurance, repelled by low reimbursement rates and the effort required to appeal. More of them are approaching retirement. And not enough medical students want to enter the field.
"We're not replenishing ourselves," said Mark Olfson, who teaches and researches child psychiatry at Columbia University Medical Center in New York.
There are only about 8,500 child psychiatrists in America, not nearly enough for the estimated 15 million kids who need one, the American Academy of Child and Adolescent Psychiatry says. On the local level, the shortfall becomes more pronounced. No individual state meets the AACAP's standard of 47 child psychiatrists for every 100,000 children 17 or younger — or one for every 2,127 kids. In Wyoming, there is one child psychiatrist for 22,960 children, and in Texas the ratio is one per 12,122. Only Washington D.C., enjoys what the group calls "sufficient supply," with one child psychiatrist for every 1,797 children.
Failure to diagnose and treat mental illness early in a child's life increases the risk of suicide and other problems, including dropping out of school, unemployment, drug abuse, violence and teen pregnancy, according to researchers. The shortage has forced millions of ill children to go untreated, wait weeks for appointments or turn to pediatricians for help they may not be qualified to give, they say.
The deficit is particularly acute in rural or poor areas.
"In some parts of the country, there's not a child psychiatrist within a 100-mile radius," said Wun Jung Kim, director of the division of child and adolescent psychiatry at Robert Wood Johnson Medical School in New Jersey.
Kim studied the dilemma in 2003, when he headed an AACAP task force on workforce shortfalls. Back then, there were only about 6,300 child psychiatrists; a recruitment and lobbying campaign helped nudge the numbers up modestly — but not nearly enough to keep pace with demand, advocates say.
In 2014, the most recent year for which data is available, more than 2.7 million children reported experiencing a "major depressive episode," the highest number in at least a decade, according to the Substance Abuse and Mental Health Services Administration. The agency cited a range of possible explanations, from increased awareness of depression to the role of social media.
The same year, 428 children 14 and under killed themselves, the highest number on record with the Centers for Disease Control and Prevention.
Despite the need, Kim says child psychiatry suffers from a old stigma that it isn't scientific enough, compared, to, say, surgery or radiology — even as the field taps into new research about the brain.
Making matters worse, many kids who need child psychiatrists the most have fallen through society's safety nets — victims of abuse or neglect whose families can't afford proper care, Kim said. And the diagnoses psychiatrists provide are more open to questioning by insurance companies than those of other specialities.
"It's not like there is a lab test to tell if you have a psychiatric issue," Kim said. "They can question it — 'Is that person really suicidal?' — and these issues take away a lot of our time."
"If a medical student goes into child psychiatry, people say they are crazy."
It also takes more work to become a child psychiatrist. Beyond four years of medical school, the specialty requires a three-year residency working with adults, followed by two years of additional training with children. Those who make it through typically end up with massive student-loan debt.
Despite the relative high salary — child psychiatrists earn an average of about $200,000 a year — the drawbacks make it difficult to attract new practitioners, Kim said. And there are other specialties that promise far greater salaries; surgeons, for example, make about $500,000 a year on average.
"If a medical student goes into child psychiatry, people say they are crazy," Kim said.
The resulting shortfall creates excruciating waits for psychiatric appointments. Many families turn to their pediatricians, or other doctors will less training in treating mental illness in children. That has contributed to what critics describe as the over-prescribing of anti-psychotic medications.
"If you're in Wyoming and there is no psychiatrist in the area, that pediatrician will take the liberty of saying, 'Let's give Johnny an anti-psychotic,'" Steven Francisco, a former pharmaceutical industry executive whose 15-year-old son died in 2009 from a complication related to an anti-psychotic drug, told NBC News. "But has that pediatrician really made the right diagnosis? And does he really understand what these drugs really mean?"
Clinics have felt the pain as well. In Vermont, for example, Champlain Valley Physicians Hospital's Child and Adolescent Behavioral Health Unit stopped taking new patients earlier this year when its single child psychiatrist left.
In Massachusetts, a shortage of psychiatrists and psychologists has made it harder for high schools to deal with a rise in the number of students facing mental health issues, according to The Boston Globe.
Some states have responded by encouraging the use of "telepsychiatry" — visits by video conference — and by adopting "collaborative care" programs that connect psychiatrists with primary care physicians. Those proposals seem to be working, but not enough to solve the crisis, advocates say.
In another innovative approach, Texas this year began offering to pay off the student loans for mental health workers — including child psychiatrists — who agree to work in under-served areas of the state.
Researchers say those efforts alone won't overcome the "systemic" problems behind the shortage.
So they keep pushing for change.
"Kids are resilient," Kim said. "With proper help, they bounce back. So you have hope."
He could say the same about his profession.