"Young and far away," a Fresno Bee series about children's mental health services published in April 2012
The families in these stories shared their experiences to help people understand that mental illnesses are brain diseases and should be treated as such. They asked to remain anonymous to shield their children from the stigma of mental illness. The Bee has given them pseudonyms or omitted their last names.
Part One: Parents must travel far to save their mentally-ill children
Part Two: Fresno County's critical shortage of psychiatric care
Eleven-year-old Emma sobbed and screamed in the back of the car.
Mania had control of the slender girl with the long, blonde curls, and there was no ordering the rage to end.
Emma needed help; but there was nothing for her in Fresno. Her parents would have to rush her 3½ hours away to a psychiatric hospital for children at the University of California at Los Angeles.
In the back seat, Emma's father wrapped her in a bear hug. He wanted to soothe her, but first he had to restrain her after she had tried to leap over the seat and grab the steering wheel from her mother.
In the driver's seat, Emma's mother glanced in the rear-view mirror, catching Emma's frightened gaze. She looked straight ahead and drove.
Fresno County does not have a hospital for children who are suicidal, hallucinating or raging uncontrollably.
Parents either watch in terror as their children are strapped inside ambulances headed to psychiatric hospitals hours away, or they do their best to keep them restrained as they make the drive themselves.
There is no alternative.
A county-run crisis center offers only the briefest of help, and hospital emergency rooms can do little more than stabilize a child for the road trip ahead.
The nearest child/adolescent psychiatric hospital is in Bakersfield, more than 100 miles from Fresno. Often parents drive more than 3 hours to Southern California or the Bay Area.
In California, psychiatric hospitals for children and adolescents are scarce and scattered -- 45 counties have no beds. Fresno, with almost 1 million people, is the second-largest county without a hospital. Santa Clara County, with almost 2 million people, also lacks one.
It hits the middle class the hardest. Fresno County arranges with hospitals in other counties to accept children on Medi-Cal, the state-federal insurance program for low-income families.
But middle-income parents with private insurance can wait days for a hospital bed for a child.
Emma's family, which has private insurance through her father's job, waited a week for the bed in 2010. Last month, Emma needed to be hospitalized again, and the wait was more than a week.
Emma's mother can't forget the wait in 2010. Emma's moods swung wildly from depression to rage. The only thing that calmed her was riding in the car down Van Ness Avenue to look at the old, big homes.
"Fortunately," Emma's mother said, "Emma doesn't remember much of that time."
A long way from home
Nobody keeps track of how many children in the midst of a psychotic break are sent hundreds of miles from home to get better.
American Ambulance -- which serves Fresno County -- gets more than 200 calls a year to transport children -- mostly on Medi-Cal -- to psychiatric hospitals.
And there is no record of the trips made by parents with children held down in back seats.
Emma's family has made five car trips -- one to a Northern California hospital and four to UCLA -- in seven years. Two were with son Tanner, 17, who is diagnosed as bipolar and with a pervasive development disorder similar to autism. The other three were with Emma, now 12, who suffers from a mood disorder, anxiety and an obsessive compulsive disorder.
Medication and therapy have helped Emma. Most of the time, she is a busy teenager who can spend hours in her bedroom singing -- Christina Aguilera's "Beautiful" is her favorite song. When she doesn't have friends over, she is talking with them on the phone.
But sometimes she needs help.
This winter, Emma's family considered hospitalization for her. But her mother said they thought "it's better to handle it at home than for her to be separated from us."
Last month, with Emma fighting depression, there was no choice, she said.
Getting children to hospitals is just the beginning of the hardship for parents. Visiting their children means time off from work, finding child care for siblings left at home and figuring out where to stay -- and how to pay for it.
Emma's mother stays with family and friends in Los Angeles. But after getting his daughter settled at the hospital, Emma's father has had to return to his job and to care for the couple's two sons.
Emma's mother shook her head when talking about it: "We live in a city with almost one-half million people and we have nowhere to take her without splitting our family up?"
It's bad medicine to separate severely ill children from their parents while they receive treatment, advocates for the mentally ill say.
Family therapy needs to be part of the hospital treatment for the child, said Mark Allen, a retired Fresno special-education program manager who has served on several mental health committees in the county.
"You can't send a child home from a hospital without the family having had therapy," he said. "It's like sending a drug addict back to the street where the drug dealer lives around the corner."
The county knows it's a bad situation for children and families, said Donna Taylor, director of the Department of Behavioral Health.
It's costly, too. Fresno County placed 193 Medi-Cal children in out-of-county hospitals from July 2010 to June 2011 at a cost of almost $1.2 million.
Taylor would prefer that children be hospitalized close to home. But every area hospital has been approached by the county about opening an inpatient children's psychiatric unit -- with no takers, she said.
It's expensive to run a psychiatric hospital for children, Taylor said. Children require more staff than adults, and it's hard to predict staffing needs because the number of patients fluctuates more than in adult hospitals.
The county has been without children's psychiatric beds since 2002, when Cedar Vista Hospital closed. Community Medical Centers bought the building and relocated its adult psychiatric services there. Today, Community operates a 61-bed locked adult psychiatric hospital at the north Fresno site.
For Community to consider opening children's beds, the unit would have to pay for itself, said Dawan Utecht, chief executive officer at Behavioral Health Center. Right now, there is no room for children, and adults are routinely turned away.
Last year, a children's mental health subcommittee of the Hospital Council of Northern and Central California talked about the need for a children's psychiatric hospital. The group was hopeful that Children's Hospital Central California in Madera County might be a location.
Dr. Gordon Alexander, CEO at Children's Hospital from March 2010 until November 2011, participated in the advisory-group meetings. While sympathetic, Alexander said psychiatric beds were not in Children's plans: Providing them would mean taking away from other medical services.
Jill Wagner, public relations manager for the hospital, said in an email this month that the hospital "remains committed to working with our community partners to discover ways to best serve children who have behavioral health issues. There is no single answer to this very complex issue, but we believe collaborative efforts will lead to a solution."
The county doesn't have the money or staff to operate a hospital, Taylor said. "Unless there becomes a compelling reason for a hospital to financially go into this business, I don't think it's going to happen."
In the midst of a child's psychiatric meltdown, parents have only two local options: Head for a hospital emergency room or to the county's children's crisis center. Both are temporary and expensive.
Parents and health professionals agree emergency rooms are no place for mentally ill children. Typically, children are quickly transferred elsewhere.
That leaves the county's crisis center at Millbrook and Shields avenues -- the location of the old Valley's Children Hospital emergency department. The center has rooms where children are examined and given medication. There are rooms where chairs can be pulled out into beds and a day room where children can play games. About 120 children a month are brought there.
But children can stay there only 23 hours and 59 minutes before they must be discharged. The county arranges for follow-up mental health counseling appointments or finds hospital beds for children who are too ill to go home.
But after the crisis, the bills come due.
Medi-Cal pays the county for the time children of low-income families spend at the center, usually about about $1,000 a visit, but middle-class parents often are stuck with the bill.
Insurance reimbursement typically is at the "prevailing rate," which is less than the cost for the care -- and the county bills families for the balance, Taylor said. "It's unfortunate for families ... but we can't do it for free."
Many insurance companies don't pay for a stay at the crisis center, and an ambulance ride to a psychiatric hospital could cost hundreds of dollars, depending on the insurance.
Linda, a Clovis mother of two boys, is appealing an insurance denial from 2011, when her youngest son, Ben, was at the crisis unit and then went to an out-of-county psychiatric hospital.
Ben, 15, has bipolar disorder and spent more than a week at Heritage Oaks Hospital in Sacramento. He had asked to be hospitalized because he was afraid he would hurt himself.
Insurance wouldn't pay for the crisis stay and didn't cover all of the costs for the Sacramento doctors, who did not belong to the company's contracted network of providers, Linda said. She now owes about $2,000, she said.
Two years ago, medical debt caused the family to declare bankruptcy. They had medical bills of about $10,000. Linda is a teacher, and her husband has been unable to work since having a pancreas transplant in 2010.
Linda has an older son, Mitch, 17, who suffers from depression. Both boys have been ill since about the age of 10. But Ben has had mood swings that can hurl him into rages or deep depression.
"You expect a 10-year-old to throw a dirt clod through the window," Linda said. "You don't expect a 10-year-old to threaten to kill himself."
She has rushed him to the Fresno County children's crisis unit seven times. He has been hospitalized four times, she said. "Every time we've gone to the crisis unit, we wish we were Medi-Cal and that's pretty sad."