Rural Children’s Mental Health: Will Sustainable Help Be on the Way?

In 2009, the headlines read that rural children’s mental health was being overlooked and disregarded.” Fast forward nearly 10 years, and the headlines still remain more or less the same, even in the days leading up to this week’s Children’s Mental Health Awareness Day.

It is tragic that today more than 25 percent of all children living in the United States have been diagnosed with a mental illness. For children living in rural America, the stakes are even higher. According to the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report, parents of children ages 2-8 reported that their offspring have the highest rates of mental, behavioral, and developmental disorders (MBDDS).

As the nation observes Children’s Mental Health Awareness Day, the healthcare community’s national focus is on the importance of integrating behavioral health and primary care for children, youth, and young adults with mental and/or substance use disorders. The national theme for 2017 is “Partnering for Health and Hope.” 

Sponsored by the Substance Abuse and Mental Health Services Administration (SAMSHA), the national event takes place today, with a ceremony set for 7 p.m. EST in Washington, D.C. The event will feature national honorary chairpersons and U.S. Olympic champions Michael Phelps and Allison Schmitt, along with the acting administrator for the U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA), James Macrae. 

The event will feature interactive panel discussions about understanding the connection between physical and behavioral health; improving communication between primary care providers, behavioral health providers, youth, and families; and supporting the mental health needs of youth who are experiencing chronic illness. 

Say It Isn’t So

According to the U.S. Department of Agriculture (USDA), one in four rural children in the United States lives in poverty, a situation that has the potential to cause deep social impact and hamper brain development. 

Sadly, just over one-third of all children with a mental health problem received a mental health visit in the last year.

According to national data, among 1,253 small, rural counties, nearly 75 percent lack a psychiatrist, and 95 percent do not have a child psychiatrist. At the same time, more than 90 percent of all psychologists and psychiatrists and 80 percent of professionals with master’s degrees in social work only practice in urban areas.

Factors contributing to the increase in the aforementioned MBDDS begin in early childhood and often affect lifelong health and wellbeing. Rural children, as reported, often have more health-related disparities than those living in urban environments. This situation often leads to poorer health among children, who often experience more stress and appear to engage in behaviors that pose risk to their health. These children also tend to  experience food security issues and have less access to health resources such as primary and specialty care or a patient-centered, coordinated primary care model.  Furthermore, living in remote locations, these children often have a parent being treated for a mental health disorder or who has gone undiagnosed.

Financial issues also contribute to a lack of access to adequate healthcare services. As families continue to struggle financially due to employment issues or a number of other reasons, they are forced to live in areas that typically have inadequate public transportation, thus limiting their access to exercise and wellness programs and educational opportunities.

Additional Challenges Within Rural Communities

From 2002-2016, most studies on rural health have found that residents of rural communities are far less likely than urban residents to report needing mental healthcare. This same population is significantly less likely to receive treatment for mental health issues and expanded behavioral health complexities. Hence, as painful as the reported statistics are, there is clearly underreporting going on

Additionally, in rural areas there are higher rates of suicide among children and adults, who are particularly impacted by barriers to care and are at a substantially higher risk of abuse as well. These conditions make the situation especially difficult within dangerous domestic relationships.

Unfortunately, opioid and alcohol usage among adults can create lower birth rates and developmental delays of children, thus creating greater risk for behavioral disorders.

There are also larger number of chronic diseases, including diabetes, heart disease, high blood pressure, and obesity within rural populations. The presence of these health issues among families makes rural children more at risk of one or more of them.

Finally, more than 60 percent of all rural Americans live in an area with a shortage of mental health professionals. If any mental health treatment is available, it is typically through primary care providers that may not have adequate training to diagnose mental health issues appropriately, especially in children. 

The Bridge to Hope: Addressing the Barriers of the “4 A’s.”

The aforementioned obstacles notwithstanding, all research seems to support the fact that this issue boils down to developing rural behavioral health reform, comprehensive policy framework, and innovative models of care and approaches. This situation is characterized by the four “A’s”— availability, accessibility, affordability, and acceptability of behavioral health services.

1. Availability: Rural populations experience higher rates of chronic disease and have specialized needs. Yet there is a shortage of mental health and related services, and also a lack of recruitment resources.
2. Accessibility: Knowledge of available options and services often aren’t provided or shared. Lack of transportation to services and lack of access to adequate insurance coverage also contribute to the issue, along with an absence of any social service system or coordination of care.
3. Affordability: Costs of care and the lack of benefits and insurance for behavioral services continues to impact affordability.
4. Acceptability: The mental and social price of negative perceptions and stigma attached to seeking these services also hinders the delivery of healthcare services in the rural setting.

More Innovation Equates to Transformation

The following areas could be addressed in order to provide adequate mental health services to children and families:

1. Increased reimbursement and support policies.
2. Patient-centered and specialty-coordination of focused care delivered by way of primary and specialty care models.
3. More telehealth legislation for reimbursement, together with broadband and online security for virtual care and user-friendly technology platforms. These formats include phones and mobile apps, especially as privacy and sophistication of programs are built and expanded.
4. Expanded use of community health workers (CHWs).
5. Expansion and duplication of an extended care health option (ECHO) that provides financial assistance to beneficiaries with special needs who would benefit from an integrated set of services – such as the specialty model that would equip primary care with behavioral services.
6. More collaboration among agencies within state, public health, academic, school-based, and community-based programs.
7. Sharing of evidence-based practices and centers of excellence.
8. Increased transportation services such as ride shares and vouchers.
9. Increased child care services.
10. Genetic screenings for early diagnosis and identification of appropriate medical care, including additional chronic disease care management.
11. Rural wellness programs that would enhance well-being through access to exercise and sports at schools and within community programs.
12. More social interaction and less social media, with a focus on good citizenship activities made available with funds for families that might not have financial resources but have a desire for their children to participate in youth programs.
13. Availability of community art, theater, music, and poetry (not to take the place of healthcare, but to for channel appropriate energy, response, communication, and expression).
14. More funding for National Health Service Corps mental health providers in underserved/designated shortage areas (mirroring the success of services provided at Federally Qualified Health Centers, or FQHCs.
15. More funding for state loan repayment programs.
16. More funding for behavioral workforce education and training (applications due by June 12).
17. Revival of safety net programs to help families, such as block grants.
18. Expansion of mental health first aid programs.
19. Innovation within Medicaid services to treat the mind, body, and spirit.
20. Increased legislation for scope of practice, training, and funding for professionals.

The rural “tyranny of distance” for specialized mental health services (as coined back in 2004) finally needs to be eradicated.

The bottom line is that America’s children can’t afford another negative headline, or for another 10 years to tragically slip by only for them to remain “out of sight, out of mind.”

Together, hand-in-hand we “Partner for Help and Hope,” including heart-to-heart and head-to-head. 

Remember to register for the national Children’s Mental Health Awareness Day for live discussions and webinars. You can become part of the national discussion and help create a transformational movement for positive sustainable change and impact. 

To attend, go to BPHC.hrsa.gov. 

James Macrae
Acting Administrator for the U.S. Department of Health and Human Services (HHS) Health Resources
and Services Administration (HRSA)