Patterns of Child Mental Health Service Delivery in a Public System: Rural Children and the Role of Rural Residence

  • Craig Anne HeflingerEmail author
  • Virginia Shaw
  • Charmaine Higa-McMillan
  • Laurel Lunn
  • Ana Maria Brannan


This study uses existing data from Hawaii’s public mental health system for children and youth as an example of a state-level examination of service use patterns and health care disparities. The purpose of this study was to compare differences in mental health service utilization between rural and non-rural children, especially use of residential services. This study used a performance measure approach to conduct multi-level modeling on existing administrative data to examine the impact of community factors on service utilization. Rural children were found to have the most serious levels of mental health problems at intake, more likely to be placed in out-of-home care, more likely to receive only out-of-home care, more likely to in stay out-of-home longer, and less likely to receive follow-up care than their non-rural counterparts. Practice, policy, and research implications are discussed.


Mental Health Service Mental Health System Rural Child Mental Health Service Utilization Public Mental Health System 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors thank Robert Saunders, Ph.D., for his early work on the dataset. At the time the data for this study were pulled, Dr. Higa-McMillan was working for the Hawaii Department of Health, and Dr. Brannan was affiliated with Vanderbilt University. This research was supported by a grant from the National Institute of Mental Health (R01MH70680). The opinions contained in this document are those of the authors and do not necessarily reflect those of the funding source or the Hawaii Department of Health.

Conflict of Interest

There are no conflicts of interest or disclosures.


  1. 1.
    Stroul BA, Friedman RM. A System of Care for Severely Emotionally Disturbed Children and Youth. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center, 1986.Google Scholar
  2. 2.
    Stroul BA, Blau G, Friedman RM. Updating the System of Care Concept and Philosophy. Washington, DC: Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children’s Mental Health, 2010.Google Scholar
  3. 3.
    Hawaii Department of Health. Child and Adolescent Mental Health Performance Standards, State of Hawaii. Honolulu, HI: Author, 2012.Google Scholar
  4. 4.
    Substance Abuse and Mental Health Services Administration (SAMHSA). The Comprehensive Community Mental Health Services for Children and Their Families Program, Evaluation Report: Annual report to Congress 2010. Rockville, MD: Author, 2012.Google Scholar
  5. 5.
    National Committee on Quality Assurance (NCQA). The Healthcare Effectiveness Data and Information Set (HEDIS). Washington, DC: Author, n.d.Google Scholar
  6. 6.
    Dougherty Management Associates. Children’s Mental Health Benchmarking Project: Year 4. Lexington, MA: Author, 2005.Google Scholar
  7. 7.
    Perlman SB, Nechasek SL, Dougerty RH. Children’s Mental Health Benchmarking: Progress and potential. Behavioral Healthcare Tomorrow 1999; 10(14):36–37.Google Scholar
  8. 8.
    Saunders RC, Heflinger CA. Access to and patterns of use of behavioral health services among children and adolescents in TennCare. Psychiatric Services 2003; 54:1364–1371.PubMedCrossRefGoogle Scholar
  9. 9.
    Garnick DA, the Washington Circle Public Sector Workgroup. Adapting Washington Circle Performance Measures for public sector substance abuse treatment systems. Journal of Substance Abuse Treatment 2008; 36(3):265–277.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Garnick DW, Lee MT, Chalk M, et al. Establishing the feasibility of performance measures for alcohol and other drugs. Journal of Substance Abuse Treatment 2002; 23:375–385.PubMedCrossRefGoogle Scholar
  11. 11.
    Substance Abuse and Mental Health Services Administration (SAMHSA). Mental Health Statistics Improvement Program: Consumer-oriented mental health report card. Rockville, MD: SAMHSA Center for Mental Health Services, 1996.Google Scholar
  12. 12.
    Scholle SH, Sampsel SL, Davis NE, et al. Quality of Child Health Care: Expanding the Scope and Flexibility of Measurement Approaches. Washington, DC: National Committee on Quality Assurance, 2009.Google Scholar
  13. 13.
    Mandell DS, Morales KH, Xie M, et al. Age of diagnosis among Medicaid-enrolled children with autism 2001–2004. Psychiatric Services 2010; 61:822–829.PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Zito JM, Burcu M, Ibe A, et al. Antipsychotic use by Medicaid-insured youths: Impact of eligibility and psychiatric diagnosis across a decade. Psychiatric Services 2013; 6:223–229.CrossRefGoogle Scholar
  15. 15.
    Semansky RM, Xie M, Lawer LJ, et al. How states use Medicaid to fund community-based services to children with autism spectrum disorders. Psychiatric Services 2013; 64:1051–1055.PubMedCrossRefGoogle Scholar
  16. 16.
    Davis M, Abrams MT, Wissow LS, et al. Identifying young adults at risk of Medicaid enrollment lapses after inpatient mental health treatment. Psychiatric Services 2014; 65:461–468.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Pullmann MD, Heflinger CA, Satterwhite LM. Patterns of Medicaid disenrollment for youth with mental health problems. Medical Care Research and Review 2011; 67:657–675.CrossRefGoogle Scholar
  18. 18.
    Hartley D, Britain C, Sulzbacher S. Behavioral health: Setting the rural health research agenda. Journal of Rural Health 2002; 18:242255.PubMedCrossRefGoogle Scholar
  19. 19.
    Pullmann MD, Van Hooser SE, Hoffman C, et al. Barriers to and supports of family participation in a rural system of care for children with serious emotional problems. Community Mental Health Journal 2010; 46:211–220.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Heflinger CA, Christens B. Rural behavioral health services for children and adolescents: An ecological and community psychology analysis. Journal of Community Psychology 2006; 34:379–400.CrossRefGoogle Scholar
  21. 21.
    United States Census Bureau. United States Census 2000. Available online at Accessed April 28, 2014.
  22. 22.
    Brannan AM, Brashears F, Gyamfi P, et al. Implementation and development of federally-funded systems of care over time. American Journal of Community Psychology 2012; 49:467–482.PubMedCrossRefGoogle Scholar
  23. 23.
    Chorpita BF, Donkervoet CM. Implementation of the Felix Consent Decree in Hawaii: The impact of policy and practice development efforts on service delivery. In: RG Steele, MC Roberts (Eds.), Handbook of Mental Health Services for Children, Adolescents, and Families. New York: Kluwer, 2005, pp. 317–332.CrossRefGoogle Scholar
  24. 24.
    Bates MP. The Child and Adolescent Functional Assessment Scale (CAFAS): Review and current status. Clinical Child and Family Psychology Review 2001; 4:63–84.PubMedCrossRefGoogle Scholar
  25. 25.
    Hodges K, Wong MM. Psychometric characteristics of a multidimensional measure to assess impairment: The Child and Adolescent Functional Assessment Scale (CAFAS). Journal of Child and Family Studies 1996; 5:445–467.CrossRefGoogle Scholar
  26. 26.
    Mueller CW, Tolman R, Higa-McMillan CK, et al. Longitudinal predictors of youth functional improvement in a public mental health system. Journal of Behavioral Health Services and Research 2010; 37:350–362.PubMedCrossRefGoogle Scholar
  27. 27.
    Simonelli SH. School based behavioral health review: Creating a context. Effective Practices Brief. Center of Disability Studies, University of Hawai'i at Manoa, 2001.Google Scholar
  28. 28.
    National Center for Education Statistics (NCES). Census 2000 School District Tabulation (STP2). Washington, DC, n.d.Google Scholar
  29. 29.
    Accountability Resource Center Hawaii (ARCH). Trend report: Educational and Fiscal Accountability. Trend Reports 2007. Google Scholar
  30. 30.
    Hawaii Department of Education. Felix' integrated performance monitoring reports. Honolulu, HI: Author, 2007.Google Scholar
  31. 31.
    Hart LG, Larson EH, Lishner DM. Rural definitions for health policy and research. American Journal of Public Health 2005; 95:1149–1155.PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    WWAMI Rural Health Research Center. Rural Urban Commuting Codes (Version 2.0). Seattle, WA: University of Washington, 2006.Google Scholar
  33. 33.
    Washington State Department of Health. Guidelines for using rural–urban classification systems for public health assessment. Tumwater, WA, 2006.Google Scholar
  34. 34.
    Raudenbush SW, Bryk AS, Congdon R. HLM 6 for Windows [Computer software]. Skokie, IL: Scientific Software International, Inc., 2004.Google Scholar
  35. 35.
    Raudenbush S, Bryk A, Cheong YF, et al. HLM 6: Linear and nonlinear modeling. Lincolnwood, IL: Scientific Software International, Inc., 2004.Google Scholar
  36. 36.
    Hodges K, Xue Y, Wotring J. Use of the CAFAS to evaluate outcome for youths with severe emotional disturbance served by public mental health. Journal of Child and Family Studies 2004; 13(3):325–339.CrossRefGoogle Scholar
  37. 37.
    Levey NN. Hawaii’s trailblazing healthcare underscores disparity. LA Times 2014, April 4. Available online at,0,6814666.story. Accessed April 28, 2014.Google Scholar
  38. 38.
    Rosas SR, Behar LB, Hydaker WM. Community readiness within systems of care. Journal of Behavioral Health Services and Research (published online, 2014). Available online at 10.1007/s11414-014-9401-3 . Accessed April 28, 2014.
  39. 39.
    Lunn L, Heflinger CA, Wang W, et al. Community characteristics and implementation factors for successful systems of care. Journal of Behavioral Health Services and Research 2011; 38:327–341. PubMedCrossRefGoogle Scholar
  40. 40.
    Rones M, Hoagwood K. School-based mental health services: A research review. Clinical Child and Family Psychology Review 2000; 3:223–241.PubMedCrossRefGoogle Scholar
  41. 41.
    Mueller C, Orimoto L. Factors related to the recruitment, training and retention of family day care providers. Child Welfare 1995; 74:12051221.Google Scholar
  42. 42.
    Schopp LH, Demiris G, Glueckauf RL. Rural backwaters or front-runners? Rural telehealth in the vanguard of psychology practice. Professional Psychology: Research and Practice 2006; 37(2):165–173.CrossRefGoogle Scholar
  43. 43.
    Perle JG, Nierenberg B. How psychological telehealth can alleviate society's mental health burden: A literature review. Journal of Technology in Human Services 2013; 31:22–41.CrossRefGoogle Scholar

Copyright information

© National Council for Behavioral Health 2015

Authors and Affiliations

  • Craig Anne Heflinger
    • 1
    Email author
  • Virginia Shaw
    • 2
  • Charmaine Higa-McMillan
    • 3
  • Laurel Lunn
    • 1
  • Ana Maria Brannan
    • 4
  1. 1.Vanderbilt UniversityNashvilleUSA
  2. 2.Hawaii Department of Health, Child and Adolescent Mental Health DivisionMaui Family Guidance CenterKahaluiUSA
  3. 3.University of HawaiiHiloUSA
  4. 4.Indiana UniversityBloomingtonUSA

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