Getting Rural Children through the Door: Perceived Barriers to Mental Health Care for School-Aged Children in Rural Areas

Jacob Blackstock, Ki Byung Chae, Gary W. Mauk, Angela McDonald


With creativity and collaboration, children in rural communities who have the same mental health needs as children in urban areas can achieve access to mental health care. This review of the literature explores barriers to mental health services facing school-aged children residing in rural communities and focuses on how challenges unique to rural communities affect the type of care rural children ultimately receive. This review aligns with the NREA Research Agenda priority area “access to counseling/mental health services” (NREA, 2018). The discussion incorporates national trends in the treatment of children with mental health concerns and highlights some surprising facts about the state of mental health care in rural school and examines the following factors: (1) belief, (2) family poverty, (3) school support, (4) community resources, and (5) awareness. The review concludes by outlining opportunities for advocacy and proposed solutions for improving mental health care access for rural children and suggesting directions for future research.


awareness; mental health care; poverty; rural community; school-aged children; stigma


Anderson, L. E., Chen, M. L., Perrin, J. M., & Van Cleave, J. (2015). Outpatient visits and medication prescribing for US children with mental health conditions. Pediatrics, 136, 1179–1185. doi: 10.1542/peds.2015-0807

Anderson, N. J., Neuwirth, S. J., Lenardson, J. D., & Hartley, D. (2013). Patterns of care for rural and urban children with mental health problems. Rural Health Research & Policy Centers, 49, 1–15.

Anderson, R. L., & Gittler, J. (2005). Unmet need for community-based mental health and substance use treatment among rural adolescents. Community Mental Health Journal, 41(1), 35–49. doi:10.1007/s10597-005-2598-0

Aud, S., Wilkinson-Flicker, S., Kristapovich, P., Rathbun, A., Wang, X., & Zhang, J. (2013). The condition of education 2013. IES National Center for Education Statistics. Washington DC: U.S. Department of Education.

Bain, S. F., Rueda, B., Mata-Villarreal, J., & Mundy, M. A. (2011). Assessing mental health needs of rural schools in South Texas: Counselors’ perspectives. Research in Higher Education Journal, 14, 1–11.

Blaber, C., & Bershad, C. (2011). Realizing the promise of the whole-school approach to children’s mental health: A practical guide for schools. Waltham, MA: Education Development Center. Retrieved from

Boydell, K. M., Pong, R., Volpe, T., Tilleczek, K., Wilson, E., & Lemieux, S. (2006). Family perspectives on pathways to mental health care for children and youth in rural communities. Journal of Rural Health, 22(2), 182–188. doi: 10.1111/j.1748-0361.2006.00029.x

Bradley, J. M., Werth, J. L., & Hastings, S. L. (2011). Social justice advocacy in rural communities: Practical issues and implications. The Counseling Psychologist, 40, 363–384. doi: 10.1177/0011000011415697

Bradley, K. L., McGrath, P. J., Brannen, C. L., & Bagnell, A. L. (2010). Adolescents’ attitudes and opinions about depression treatment. Community Mental Health Journal, 46(3), 242–251. doi: 10.1007/s10597-009-9224-5

Bull, J. D. (2011). Adolescent attitudes toward help-seeking and mental illness: A rural-urban comparison. (Order No. DP20317, Xavier University). ProQuest Dissertations and Theses, 127. Retrieved from (1430425777).

Centers for Disease Control and Prevention. (2017). Access to mental health services for children in rural areas (Rural Health Policy Brief). Atlanta, GA: Author. Retrieved from

Comer, J. S., & Myers, K. (2016). Future directions in the use of telemental health to improve the accessibility and quality of children’s mental health services. Journal of Child and Adolescent Pharmacology, 26(3), 286–300.

Compton, S. N., March, J. S., Brent, D., Albano, A. M., Weersing, V. R., & Curry, J. (2004). Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review. Journal of the American Academy of Child & Adolescent Psychiatry, 43(8), 930–959.

Currie, J., Stabile, M., & Jones, L. (2014). Do stimulant medications improve educational and behavioral outcomes for children with ADHD? Journal of Health Economics, 37, 58–69. doi: 10.1016/j.jhealeco.2014.05.002

Curtin, L., & Hargrove, D. S. (2010). Opportunities and challenges on rural practice: Managing self and ambiguity. Journal of Clinical Psychology: In Session, 66, 549–561.

Daniels, Z. M., VanLeit, B. J., Skipper, B. J., Sanders, M. L., & Rhyne, R. L. (2007). Factors in recruiting and retaining health professionals for rural practice. The Journal of Rural Health, 23(1), 62–71. doi: 10.1111/j.1748-0361.2006.00069.x

DeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon, R. M., ...Gallop, R. (2005). Cognitive therapy vs medications in the treatment of moderate to severe depression. Archives of General Psychiatry, 62(4), 409–416. doi: 10.1001/archpsyc.62.4.409

Dikel, W. (2014). The teacher’s guide to student mental health. New York, NY: W. W. Norton.

DuPaul, G. J., Eckert, T. L., & Vilardo, B. (2012). The effects of school-based interventions for Attention Deficit Hyperactivity Disorder: A meta-analysis 1996–2010. School Psychology Review, 21, 387–412.

Elder, G. H., & Conger, R. D. (2000). Children of the land: Adversity and success in rural America. Chicago: The University of Chicago Press.

Evans, G. D., Radunovich, H. L., Cornette, M. M., Wiens, B. A., & Roy, A. (2008). Implementation and utilization characteristic of a rural, school-linked mental health program. Journal of Child and Family Studies, 17(1), 84–97.

Fabiano, G. A., Pelham, W. E., Coles, E. K., Gnagy, E. M., Chronis-Tuscano, A., & O'Connor, B. C. (2009). A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder. Clinical Psychology Review, 29(2), 129–140. doi: 10.1016/j.cpr.2008.11.001

Fabiano, G. A., Schatz, N. K., Aloe, A. M., Chacko, A., & Chronis-Tuscano, A. (2015). A Systematic Review of Meta-Analyses of Psychosocial Treatment for Attention-Deficit/Hyperactivity Disorder. Clinical Child and Family Psychology Review, 18(1), 77–97. doi: 10.1007/s10567-015-0178-6

Fortney, J. C., Harman, J. S., Xu, S., & Dong, F. (2010). The association between rural residence and the use, type, and quality of depression care. Journal of Rural Health, 26(3), 205–213. doi: 10.1111/j.1748-0361.2010.00290.x

Gamm, L., Stone, S.., & Pittman, S. (2003). Mental health and mental disorders – A rural challenge: A literature review. In L. D. Gamm, L. Hutchinson, B. J. Dabney, & A. M. Dorsey (Eds.), Rural Healthy People 2010: A companion document to Healthy People 2010. Vol. 2 (pp. 97–113). College Station, TX: The Texas A&M University Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.

Girio-Herrera, E., Owens, J. S., & Langberg, J. M. (2013). Perceived barriers to help-seeking among parents of at-risk kindergarteners in rural communities. Journal of Clinical Child and Adolescent Psychology, 42(1), 68–77.

Gray, J. S. (2011). Rural mental health research white paper. Grand Forks, ND: University of North Dakota, Center for Rural Health. Retrieved from

Heflinger, C. A., Wallston, K. A., Mukolo, A., & Brannan, A. M. (2014). Perceived stigma toward children with emotional and behavioral problems and their families: The Attitudes about Child Mental Health Questionnaire (ACMHQ). Journal of Rural Mental Health, 38(1), 9–19. doi:10.1037/rmh0000010

Hilty, D. M., Ferrer, D. C., Parish, M. B., Johnston, B., Callahan, E. J., & Yellowlees, P. M. (2013). The effectiveness of telemental health: A 2013 review. Telemedicine Journal and E-Health, 19(6), 444–454.

Hilty, D. M., Shoemaker, E. Z., Myers, K., Snowdy, C. E., Yellowlees, P. M., & Yager, J. (2016). Need for and steps toward a clinical guideline for the telemental healthcare of children and adolescents. Journal of Child and Adolescent Pharmacology, 26(3), 283–295.

Huber, B. J., Austen, J. M., Tobin, R. M., Meyers, A. B., Shelvin, K. H., & Wells, M. (2016). Overcoming barriers to rural children’s mental health: An interconnected systems public health model. Advances in School Mental Health Promotion, 9, 219 – 241. doi: 10.1080/1754730X.2016.1224121

Jensen, P. S., Hinshaw, S. P., Swanson, J. M., Greenhill, L. L., Conners, C. K., Arnold, L. E., ... Wigal, T. (2001). Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers. Journal of Developmental & Behavioral Pediatrics, 22(1), 60–73. doi: 0196-206X/00/2201-0060

Johnson, J., Showalter, D., Klein, R., & Lester, C. (2014). Why rural matters 2013–2014: The condition of rural education in the 50 States. Rural School and Community Trust. Retrieved from

Keller, P. A., Murray, J. D., & Hargrove, D. S. (1999). A rural mental health research agenda: Defining context and setting priorities. The Journal of Rural Health, 15(3), 316–325.

Kennard, B., Silva, S., Vitiello, B., Curry, J., Kratochvil, C., Simons, A., … March, J. (2006). Remission and residual symptoms after short-term treatment in the Treatment of Adolescents with Depression Study (TADS). Journal of the American Academy of Child & Adolescent Psychiatry, 45(12), 1404–1411. doi: 10.1097/01.chi.0000242228.75516.21

Larson, N. C., & Dearmont, M. (2002). Strengths of farming communities in fostering resilience in children. Child Welfare: Journal of Policy, Practice, and Program, 81(5), 821 – 835.

Lee, S. W., Lohmeier, J. H., Niileksela, C., & Oeth, J. (2009). Rural schools' mental health needs: Educators' perceptions of mental health needs and services in rural schools. Journal of Rural Mental Health, 33(1), 26–31. doi:10.1037/h0095970

Macklem, G. L. (2014). Preventive mental health at school: Evidence-based services for students. New York, NY: Springer.

McWhirter, J. J., McWhirter, B. T., McWhirter, E. H., & McWhirter, R. J. (2013). At-risk youth: A comprehensive response for counselors, teachers, psychologists, and human service professionals. Belmont, CA: Brooks/Cole.

Merikangas, K. R., He, J. P., Brody, D., Fisher, P. W., Bourdon, K., & Koretz, D. S. (2010). Prevalence and treatment of mental disorders among U.S. children in the 2001–2004 NHANES. Pediatrics, 125, 75–81. doi:10.1542/peds.2008-2598

Mohatt, D. F., Bradley, M. M., Adams, S. J., & Morris, C. D. (2005). Mental health and rural America: 1994-2005. U.S. Department of Health and Human Services, Health Resources and Services Administration, Office of Rural Health Policy. Retrieved from

Molina, B. S., Flory, K., Hinshaw, S. P., Greiner, A. R., Arnold, L. E., Swanson, J. M., ... Wigal, T. (2007). Delinquent behavior and emerging substance use in the MTA at 36 months: prevalence, course, and treatment effects. Journal of the American Academy of Child & Adolescent Psychiatry, 46(8), 1028–1040. doi: 10.1097/chi.0b013e3180686d96

Murphy, C. E. (2005). Parental perceptions of barriers to care: An examination of rural Appalachian parents' expectancies of the availability, process, and outcome of mental health services for elementary school-aged children. (Order No. 3218012, Ohio University). ProQuest Dissertations and Theses. Retrieved from (305432760)

National Association of School Psychologists. (2015). The importance of mental and behavioral health services for children and adolescents [Position statement]. Bethesda, MD: Author. Retrieved from

National Rural Education Association (2018). National Rural Education Association (NREA) Research Agenda – 2016-2021. Retrieved from

New Freedom Commission on Mental Health (2004). Subcommittee on rural issues: Background paper. DHHS Pub. No. SMA-04-3890. Rockville, MD. Retrieved from

Painter, K., & Scannapieco, M. (2015). Understanding the mental health problems of children and adolescents. Chicago, IL: Lyceum Books.

Polaha, J., Dalton, W. T., & Allen, S. (2011). The prevalence of emotional and behavior problems in pediatric primary care serving rural children. Journal of Pediatric Psychology, 36(6), 652–660. doi: 10.1093/jpepsy/jsq116

Powell, M. (2017, May 10). Equity barriers in rural schools. ASCD SmartBrief. Retrieved from

Pullmann, M., VanHooser, S., Hoffman, C., & Heflinger, C. (2010). Barriers to and supports of family participation in a rural system of care for children with serious emotional problems. Community Mental Health Journal, 46(3), 211–220. doi:10.1007/s10597-009-9208-5

Richards, D., & Viganó, N. (2013). Online counseling: A narrative and critical review of the literature. Journal of Clinical Psychology, 69(9), 994–1011. doi: 10.1002/jclp.21974

Simon, D. J. (2016). School-centered interventions: Evidence-based strategies for social, emotional, and academic success. Washington, DC: American Psychological Association.

Smith, A. J. (2003). Rural mental health counseling: One example of practicing what the research preaches. Journal of Rural Community Psychology, E6(2), 1–9. Retrieved from

Stephan, S., Lever, N., Bernstein, L., Edwards, S., & Pruitt, D. (2016). Telemental health in schools. Journal of Child and Adolescent Pharmacology, 26(3), 266–272.

Swanson, J. M., Hinshaw, S. P., Arnold, L. E., Gibbons, R. D., Marcus, S. U. E., Hur, K., ... & Wigal, T. (2007). Secondary evaluations of MTA 36-month outcomes: propensity score and growth mixture model analyses. Journal of the American Academy of Child & Adolescent Psychiatry, 46(8), 1003–1014.

doi: 10.1097/CHI.0b013e3180686d63

Tamukong, D. & Schroeder, S. (2017). Rural behavioral health. Rural Health Research Recap. Washington, DC: Federal Office on Rural Health Policy. Retrieved from

United States Census Bureau. (2010). Urban and Rural Classification. Retrieved from

U.S. Department of Health and Human Services. (2011). Rural behavioral health programs and promising practices. Washington, DC: Health Resources and Services Administration, Office of Rural Health Policy.

Wilger, S. (2015). Special considerations for mental health services in rural schools (Issue Brief). Rockville, MD: Substance Abuse and Mental Health Services Administration, Now Is the Time Technical Assistance Center, Retrieved from

Williams, S. L., & Polaha, J. (2014). Rural parents’ perceived stigma of seeking mental health services for their children: Development and evaluation of a new instrument. Psychological Assessment, 26(3), 763–773. doi:10.1037/a0036571

Ziller, E. C., Anderson, N. J., & Coburn, A. F. (2010). Access to rural mental health services: Service use and out-of-pocket costs. Journal of Rural Health, 26(3), 214–224. doi: 10.1111/j.1748-0361.2010.00291.x

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