"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
First came the tantrums, so wild his agitation scared his parents.
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At 3½, Bobby wasn't sleeping through the night. By kindergarten, he didn't sleep at all some nights. At age 7, he was up all night break dancing, his eyes shimmering and his cheeks flushed.
His pediatrician suspected bipolar disorder and recommended a psychiatric evaluation. His mother called for an appointment, but the psychiatrist couldn't see him for three months.
Bobby grew more frenetic.
A month later, the doctor's office called -- two days before Christmas -- to say there was a cancellation and the doctor could see him in three hours.
That sent the family into a frenzy. "We scrambled to find a babysitter for our daughter and we left a family gathering," Bobby's mother said. "My husband twisted his foot in the yard and broke it -- but we kept going.
"We were desperate for the appointment and we didn't want to wait another two months."
Fresno County parents of troubled kids say they will do almost anything to get their children to psychiatrists. They have little choice. The county has a shortage of all mental health professionals -- especially psychiatrists.
And middle-income families struggle the hardest for appointments.
Four child psychiatrists see most of the children with private insurance in Fresno County, said Karen Kraus, an assistant clinical professor in the UCSF-Fresno psychiatry residency program. She is one of them.
Nobody tracks how many middle-class children here receive mental health care from private psychiatrists, but a recent state report said nearly 13,000 Fresno County children who live above the poverty level need services.
Meanwhile, the county's Department of Behavioral Health has six doctors for the 6,600 children on Medi-Cal, the state-federal insurance for the low-income. It's not enough -- but it's more than the county has had in years.
"Historically, we think of the Medi-Cal kids as more underserved, and that's true to a certain degree," Kraus said, "but right now the group of people most underserved in this community are kids with private insurance."
Luck paid off for Bobby's family when he needed a psychiatrist two years ago.
Today, Bobby's mother said, she wouldn't get an appointment with the psychiatrist, Dr. David Fox of the Sullivan Center for Children in Fresno. His practice is full and he is not accepting new patients.
Fox refers four to five callers a week to other doctors, hoping they can squeeze them in. Occasionally, he refers children to doctors out of town.
Most of the time, parents simply wait for appointments, Fox said. "That's basically what they do or they try to work with a therapist and family care physician when possible."
Nationwide shortages of child psychiatrists mean doctors can choose where they practice.
"They can kind of write their own ticket in terms of where they want to go," said Dr. Scott Ahles, chief of psychiatry at the University of San Francisco's medical education program in Fresno. And doctors choose Los Angeles or the Bay Area when considering jobs in California, he said.
Other obstacles to attracting child psychiatrists here: Workloads are heavy because of the doctor shortage, and there is no local hospital for doctors to send children who are severely ill.
Ahles has hopes that a proposed UCSF fellowship program to train child psychiatrists will help. "We've had many people in our adult program who wanted to do child fellowships and they've gone somewhere else because there was nothing here, which is really unfortunate."
But for now, families wait for doctors.
Its common to get calls from parents who have been unable to find help, Kraus said. "My sense is it's really grim out there right now."
Under a California law approved last year, families have the right to an appointment with a specialist within 15 days, and health plans say they are complying.
To meet the timely access requirement, Kraus said, health plans will send children to adult psychiatrists when child psychiatrists are not available. But the doctor may or may not be trained to treat children, she said.
And although parents tell of waiting weeks for appointments, they aren't complaining to state regulators who are charged with enforcing the timely access law.
The state Department of Managed Health Care has had only a handful of complaints about children and adult access -- none originating from Fresno County -- since the law took effect in January 2011.
Advocates for the mentally ill said they're not surprised.
Many parents are unaware of the state's new timely access law, the advocates said. Plus, parents are too overwhelmed caring for ill children to deal with the paperwork, they said.
It can all be too much for parents who don't have the energy, money or time for the challenge, said Joe Mawhinney, a San Diego psychiatrist who chairs the Access to Care Committee for the California Psychiatric Association.
Kraus said many parents are worn out. They've come to expect -- and accept -- the lack of mental-health providers and services in Fresno County, she said. "Our perspective about what is a reasonable standard for care has been really distorted by the lack of resources in this area."