‘Youth are more in crisis.’ What that mental health toll looks like in Fresno County
California’s ill-equipped mental health system has failed many children — in Fresno County in particular, where demand for services skyrocketed by more than 40% in recent years.
Data obtained by The Bee offer a glimpse of the mental health crisis’ toll among children under the age of 18 in Fresno County. The story of a Fresno girl through the lens of her family shows the impact mental health can have on local families, and how their struggles can be compounded when Child Protective Services gets involved.
In the city of Fresno alone, some 3,000 children ages 18 and younger were involved in involuntary mental holds by the Fresno Police Department in the last three years, according to police incident data obtained through a public records act request. However, several incident reports are duplicated, and some cases involving children as young as only a few months old appear on the incident reports because a parent — not the child — was placed on a mental hold. Others are null.
An involuntary mental hold is when a person who is considered to be a danger to themselves or others is held for up to 72 hours for an evaluation. The focus of involuntary mental holds among children is to assess their needs and connect them to treatment, says Fresno County Department of Behavioral Health Interim Director Susan Holt.
But it’s difficult to get a full and accurate picture of these holds among children and to quantify them. That’s in part due to the difficulty in accessing data across the various jurisdictions.
But one thing is clear:
“It cannot be understated that the need for (youth) behavioral health is growing,” Holt says.
In fact, the county’s Department of Behavioral Health saw a 43% increase in the number of children it served under the age of 18 from 2018 to 2021.
The pandemic has exposed “a lot of systemic challenges and flaws” in behavioral health, and more so, in services for children, says Michelle Cabrera, executive director of the County Behavioral Health Directors Association of California.
The increase in demand for mental health services is not unique to Fresno County. The need for children’s mental health services spiked across the state over the last two years, she said.
“Children and youth are more in crisis,” Cabrera told The Bee. “Their needs are more acute than they were pre-pandemic.”
President Joe Biden during his first State of the Union address called for a better capacity of mental health, especially for children “whose lives and education have been turned upside down” during the COVID-19 pandemic. But children, the president said, were struggling even before the pandemic due to bullying, violence, trauma and the harms of social media.
Fresno County children placed on mental holds
A voluminous number of children get placed on involuntary mental holds every year in Fresno County. But the full extent of these holds on children is unclear due to the difficulty in accessing complete data from the various jurisdictions that track them, and other entities not having the information available.
For example, the Clovis Police Department says its system doesn’t allow officers to pull out only the juvenile cases for these kinds of holds. And the Fresno Police Department’s data include cases where children were not actually placed on a hold, but it’s difficult to know how many of the more than 3,000 cases in 2019, 2020 and 2021 appear in the incident reports because one of the parents was placed on a hold.
The Fresno County Sheriff’s Office referred the request on mental holds among children to CPS and/or the county’s Behavioral Health Department. Fresno County officials said to pull this information from a child welfare system would take weeks “at the expense of meeting the needs of other mandated activities.”
And data obtained from the county’s Department of Behavioral Health doesn’t provide a clearer picture, either. These data cover a wider area in Fresno County, including the metro areas and triage in the west and east rural areas, but it’s difficult to access mental holds on children ages 16-17.
For the current fiscal year 2021-22, which began July 1, a total of 385 children ages 0-15 were placed on mental holds as of early February, with the metro areas representing the majority with 261 holds. The department’s data also tracks the information by age group of 16-24, but the cases involving minors, ages 16-17, cannot be easily pulled.
The total number of holds for children 0-15 for fiscal year 2020-21 was 483, with 332 of those holds in the metro areas. The total number of holds across all ages, 0 to 65 and older, was more than 4,000 in 2020-21 alone.
Some hospitals track these holds but others don’t. A total of 573 children were placed on mental holds in 2021 at Community Regional Medical Center and Clovis Community Medical Center.
“There is not a specified target or benchmark that defines the right number of applications for an involuntary hold for any given community,” Holt says. “Comparison across communities is also a challenge. Fresno is the fifth-largest city in the state, but our demographics differ from the other large cities.”
The struggle of a child behind the numbers
As Fresno and Madera counties wrestle to house foster youth with complex needs, the long struggles of children with a history of mental health illness come into focus.
A 14-year-old girl from Fresno has grappled with a history of mental health since she was in kindergarten. By the age of 13, she had at least 10 different diagnoses, had been placed on multiple revolving involuntary mental holds, and had even spent time in an out-of-state locked mental health facility and inpatient facilities in California, her mother, Gina Jones, says.
The Bee doesn’t usually identify mental health patients or their family members, but the mother is being identified because Jones wanted to share her family’s story of the difficulty dealing with CPS at a time when she was having to battle to get her daughter treatment.
The girl’s family for years had tried to get her the right treatment, facing various obstacles ranging from revolving mental health holds to facilities not equipped to address the girl’s needs and high out-of-pocket insurance costs.
Then Fresno County’s CPS stepped in and removed the child from her parents’ home instead of offering services to help the family with their daughter’s long struggle with mental health, Jones says. The girl was removed by CPS after she took pills for a third time within three months last June.
Jones says her daughter’s removal had nothing to do with her parenting style, but rather actions that stemmed from her daughter’s long history of mental health issues.
Removing her from the home didn’t fix the problem. It exacerbated it.
The girl took pills again and overdosed under Fresno County’s watch. She also ran away several times while under the county’s custody, including from the Child Welfare office in downtown Fresno where she was initially housed.
She ended up in inpatient facilities in the Bay Area and Santa Rosa, her mother says.
Soon after CPS removed her daughter from her home, Jones says, there was “realization in the meetings” that the child had more behavioral issues than the county was “prepared to deal with.”
“I was livid. I was furious. I was so angry,” Jones told The Bee. “All I could think was, ‘You are telling me I can’t keep my child safe and she needs to be removed from my home, but you can’t even manage her.”
Right before the COVID-19 pandemic hit the region, the girl was placed in a second residential facility in Utah by her family; this one was a locked institution since the first facility was not equipped to handle the girl’s needs, her mother says. The girl was there from February 2020 to December 2020, and the time was “hugely unsuccessful for her.”
“Being in a locked facility, you’re with these other people who have the same behaviors, if not worse, and she picked up some really, really bad traits — more cutting, so a lot of suicidal ideation,” her mother says.
In March 2021, the then-13-year-old girl took pills at her parents’ home. Within hours after being discharged from the hospital, she took pills again, and had to be rushed back to the emergency room. In June, she took pills again. She had stashed them in her room. That’s when she was removed by CPS, her mother says.
Jones says CPS just chose to take her daughter instead of offering mental health resources. According to CPS, there had been a delay in taking the girl to the emergency room, the mother said.
“I’ve been doing this for 10 years, what makes you think that you can come into it better?” she recalled thinking of when CPS took her child. “I think the premise behind child services is needed, but also there’s times when they just overstep their boundaries.”
Tricia Gonzalez, deputy director at the Fresno County Department of Social Services overseeing child welfare, said she can’t speak on a child-specific case, but in general, she says these kinds of cases can be difficult.
“What I will say is that when we bring in youth with severe mental health issues, oftentimes the parents have been working on them and doing their best with them, and so it’s not for a lack of parenting,” she says. “It gets very complex, depending on just what the behaviors and what the actions are.”
The intervention from CPS didn’t do much to alleviate the girl’s behavioral and mental health needs. The mother filed a grievance in July against Rainbow Valley, the group home where Fresno County placed her daughter, and where her daughter took pills again.
According to records obtained by The Bee through a request, an unannounced inspection was done at the Merced group home on Sept. 10, 2021 to investigate allegations of medications not being properly stored. The claim was substantiated.
“The medications were not locked and a window left open resulting in a client accessing medication and overdosing,” according to the investigation’s records.
Scott Murray, a spokesman with the California Department of Social Services, said Rainbow Valley Group Home, Inc. operates as a Foster Family Agency. The agency ran two short-term residential therapeutic programs (STRTPs), formerly known as group homes, that voluntarily closed on Oct. 4, 2021. The substantiated complaint on the improper medication storage was against one of the STRTPs, and not the agency as a whole.
All foster children have been returned to the counties that placed them in the STRTPs. The umbrella agency is now closing due to financial hardship, Murray said.
The whole experience with CPS, Jones says, was an unnecessary “nightmare,” and it was very difficult for her to get information about her daughter from social workers. The first time her daughter ran away from the child welfare office, she says, she learned about it through police who showed up at her home.
“I’m not saying that this is the norm, but this is our story,” she says.
Eventually, the girl’s parents regained custody. The girl returned home with no services to help improve her mental health, her mother says.
“Bottom line, it came to, ‘Well, mom makes too much money and has private health care so Fresno County can’t help,” she says.
Children with mental health needs in the child welfare system
The Fresno Bee in October reported that children under Fresno County’s care were being housed in a Child Welfare office in downtown. More recently, a similar picture emerged in Madera County after revelations that a foster youth with severe mental health issues had been housed in an office for up to months.
In both counties, officials cited an inadequate number of placements for foster children with complex needs. The shortage, officials said, is due to changes in state continuum of care laws that have resulted in fewer placement options for children with high needs. Some placement agencies have also closed.
Although state reforms are well-intended as they encourage officials not to institutionalize children, but rather, place them with families, the changes have proven to be problematic, says Gonzalez of Fresno County.
Foster families need more resources and support to be able to “safely care for the kids,” Gonzalez says.
“As these laws have been passed, we’ve been advocating and saying that we were concerned that we would be in a place that we didn’t have the adequate resources, and it kind of fell on deaf ears,” she told The Bee.
Now, Gonzalez says, state officials are responding, but there are still issues and delays with counties being able to tap into the much-needed resources.
“They are giving some of us money, but it still requires quite a bit of documentation and planning, and so, while we have the money allocated, we still don’t have the ability to use it all today,” she said.
Fresno County has been allocated $1.1 million from the state to help care for children with greater needs. However, in late January, Gonzalez said that funding was helpful, but not enough.
Gonzalez said the state’s Department of Social Services “made a unique agreement to consider temporarily licensing” the county’s University Medical Center campus after advocacy from the county supervisors. That’s where the county began to house children who are harder to place after it became public the children were being housed in a government CPS office.
A license application was submitted by the county to the state on Feb. 3, and is pending final approval. It’s illegal for counties to house children in unlicensed facilities.
“The focus on licensing and longer-term solutions are among several top priorities to improve placement and conditions for our most vulnerable youth facing complex circumstances,” she said.
Cathy Senderling-McDonald, executive director of the County Welfare Directors Association of California, said the state in its most recent budget included money as part of a $139 million investment to help struggling counties build capacity and to help with child-specific cases.
“We want funding to get out the door as quickly as possible because we feel an urgency to build the capacity,” she said.
Senderling-McDonald estimates the number of children in foster care with complex needs is anywhere between 300 and 500, which is relatively small compared to the overall number of children in the system of around 60,000 statewide.
But STRTPs, formerly known as group homes, have the ability to say no to a county when officials are seeking a placement. Children also get placed in STRTPs through the juvenile justice and educational systems. And there are fewer placements available for all 58 counties across California, Senderling-McDonald said.
“We are just competing with each other for this shrinking pool of service, and that’s not a great place to be in,” she told The Bee.
A county may have to make a dozen calls, if not more, in the attempt to find a group home that will take a child, and the answer is often “no and no,” she said.
That leads to situations like in Fresno County where foster children were housed in an office. Senderling-McDonald said her organization has heard of similar isolated incidents in other counties over the last year or so.
“I wouldn’t say it’s rampant, but unfortunately, it has occurred,” she said.
Now, every county is trying to work closely with providers and the state’s Department of Social Services to get technical assistance and help in identifying placement locations for youth.
“We’re really in need of some state level coordination and leadership to help us both navigate what we’ve got already in a way that isn’t kind of cannibalizing each other, you know, taking placements away from one county and using them in another one...,” she said. “But also, how do we build more of these emergency and transitional type of placements so it’s not an office or a hotel.”
Senderling-McDondald said they are exploring ideas on how to increase placement capacity and her organization has a proposal in the state’s budget for a couple potential actions. Some of them are to create intensive assessment and transitional facilities so children can get treatment they need while they wait for a permanent placement. The estimated price tag would be around $8.5 million.
But many other ideas are also in the works as the struggle to get children, in general, the behavioral health treatment they need has been seen in the past 10 to 20 years, she said.
Assembly Bill 226 that aimed to build more capacity for children’s intensive needs — as an alternative to psychiatric hospitalization — was vetoed despite strong bipartisan support during the last legislative session, Senderling-McDonald wrote in a commentary for CalMatters. She told The Bee she believes the bill, which would benefit children with the most significant needs in the state, will be reintroduced during this year’s legislative session.
A mental health crisis and a system that’s inadequate
The mental health crisis that Fresno and the rest of California and the nation is seeing comes at a time when “we have not had a really great behavioral health system, in general,” and that’s despite state efforts to improve it, says Cabrera, the county association leader. Behavioral health has historically been underfunded, in particular, on the safety net side.
“Right now, we are sort of trying to hold up a safety net system for Medi-Cal beneficiaries who are uninsured, but we also end up filling in gaps and propping up a very dysfunctional private system,” she says.
People with private insurance are seeing two things: Their needs are increasing, and “there’s not a lot of health (services) out there for them,” Cabrera says. Additionally, with the out-of-pocket costs, sometimes the private insurance benefits are out of reach for people.
This was true for Jones and her daughter. Prior to the CPS removal, the girl’s pediatrician wanted to send her to the Bay Area for testing that would cost around $8,000.
“I was like, I just don’t have $8,000 sitting around to pay,” the mother recalled. “Our kids are suffering, and when there are supports and services out there, ...you can’t access them or maybe you don’t know how to access them.”
Gov. Gavin Newsom’s administration has made significant investments to improve the system and signed legislation to “try to compel private commercial insurance to do better,” Cabrera says.
But the state is going to have to move away from “the one-time nature of some of these investments” in order to create long-standing changes in the system. It will also need to think differently, and collectively, to develop a “new workforce,” Cabrera says.
“The Central Valley, in particular, has a significantly lower percentage of licensed behavioral health professionals per capita than other regions in the state,” Holt says. But there are efforts locally to try to change that.
Cabrera says mental health is not like elective surgery, it’s “life-saving treatment and intervention.”
“That’s the core of what’s sort of broken here, is that we’ve really downplayed the importance of behavioral health,” she says. “Right now, oftentimes consumers are going to a well that’s completely dried.”
Jones, the girl’s mother, says the mental health system is failing children.
But her daughter remains hopeful.
“One day you will tell your story of how you overcame what you went through, and it will be someone else’s survival guide,” the girl read her favorite quote out loud from her smartphone.
Tim Sheehan contributed to this report.
This story was originally published March 17, 2022 at 5:00 AM.
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