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Organization and Delivery of Mental Health Services to Adolescents and Children with Persistent and Serious Mental Illness in Frontier AreasLetter to the Field 16by Morton O. Wagenfeld, Ph.D., Western Michigan University, Kalamazoo, MI 49008 (1) Table of Contents Introduction | Models of Service Delivery | Summary | References IntroductionThis is one of a series of Letters to the Field dealing with different aspects of delivery of mental health services to persons in sparsely-populated frontier areas-a historically-underserved group living in a special and unique part of the United States. This letter deals with the organization and delivery of services to children and adolescents with serious mental illness (SMI). It is based on published and unpublished literature, and interviews with planners and providers. A companion Letter will complete the picture by presenting the highlights of two study groups-one for providers, and the other for parents held in a frontier area. These Letters are intended for a wide audience of lay persons, planners, and practitioners and are written in a non-technical way, with a minimum of references. An extended, fully-documented version, covering a number of at-risk groups, in addition to children and adolescents, is available from the Frontier Mental Health Services Resource Network. Additional Letters and state-of-the-art papers dealing with the need for services, telecommunications, finance, and managed care, among others, are also available. Models of Service DeliveryChildren and adolescents are an important part of any community as a resource for the future. Attention to their problems of mental disorder, the abuse of alcohol and other drugs (AODA), and developmental disability should, therefore, be a priority. A number of papers and interviews with planners and providers have highlighted numerous impediments to service delivery for this group, as well as delivery models. To begin with, an important impediment is the problem of cases crossing systems when they involve minors (e.g., school, juvenile justice, welfare, etc.). Often, and this is by no means unique to child and adolescent services, there is a lack of coordination between systems and a lack of information sharing. Providers view categorical funding of services, in itself, as a possible barrier, inasmuch as it limits flexibility. In other words, if moneys are available for inpatient or institutional services, that, rather than the needs of the child may drive treatment plans. As a result, these approaches may not necessarily tap into available and local informal systems, particularly, the families of the children or community value systems. A number of authors have considered the general problems of service delivery to rural children and adolescents. Kelleher, Taylor, and Rickert (1992) note that there are four barriers unique to rural areas:
In addition, there is the well-documented problem of recruiting and retaining qualified providers. Like other aspects of frontier mental health services, the lack of child and adolescent specialists is a significant problem. In North Dakota, specialty mental health services decline as one moves west from the population centers at the eastern edge of the state. It is not unusual for a family to have to travel more than 100 miles one way to see a child psychiatrist. The response of rural providers has generally been to rely on federal and state dollars and focus on noncategorical and preventive services. The use of paraprofessionals and natural helper systems has helped to provide needed services in a resource-poor environment. Petti and Leviton (1986) developed some policy guidelines for serving rural youth. They proposed that a practical option is developing personnel trained to function as extenders of service delivery by certified child psychiatrists and psychologists. Petti developed and evaluated a specific consultative model in a rural area of western Pennsylvania (Petti, Cornely, & McIntyre, 1993). Sheldon-Keller, Koch, Watts, and Leaf (in press) feel that mental health and social services for rural children and adolescents should address four areas:
A new approach that overcomes many of the rural impediments is what has been termed "wraparound services". Here, services are needs-based (as defined by an assessment), flexible, individualized, and "wrapped aroundî the family. The service plan can use both formal and informal local resources. Wraparound services are flexible, capitalize on local support systems, and involve the family in planning. Such flexibility and reliance on local resources make it ideal for frontier communities. Arizona, North Dakota, and Idaho are three states providing these types of services to frontier populations. Linkage with school systems is particularly important for working with children and adolescents. Consultation can be provided to the schools through special education districts and the human services or mental health centers. A problem here is a low level of recognition of mental health problems or issues in schools. School personnel tend not to be trained in the assessment of these problems (Ronnigen & Sweet, personal communication, 1997). A number of specific models of delivery will be discussed in the following sections for mental disorder, alcohol and other drugs of abuse, and developmental disability. The programs highlighted here are all from rural areas in ten states and one region (Appalachia). Some of these were from states with significant frontier populations (e.g., Alaska, Idaho, North Dakota, Wyoming), while others were from less isolated rural areas (e.g., Florida, Michigan, New York, North Carolina, Wisconsin, Virginia). Understanding where the models were developed and have been practiced is important in assessing the applicability of these programs to the special needs of the frontier. Mental Disorder. Several models for delivering services to children and adolescents in rural and frontier areas with SMI have been reported. The Family Living Model was developed in a rural area of central Oregon as an alternative to traditional residential care. It focuses on reducing costs, maintaining the child (aged 3-12) in his or her local culture, using community resources, and forming a network of support for the children. The principal program element is day treatment, with a supplementary plan enabling one to three children to be placed with residential Family Living parents. The children usually return to their own homes on weekends. This often avoids placement in a more traditional residential setting. The model is based on the Teaching Family Model of Boys Town, Nebraska (Tovey, 1983). Schools are an obvious venue for the prevention and detection of mental illness. Several school-based prevention models have been developed. A structured 8-week program to target all 11-to 13-year-old youths in an 11-county rural school district in Florida had three goals:
In a rural area of New York State, a consortium of school-based programs for early detection and prevention of school adjustment problems was established. The program expanded the reach of early services to young children and stimulated communication, interaction, and support among professionals in participating districts (Farie, Cowen, & Smith, 1986). Another school-based program, one that would likely be suitable for remote or frontier areas, was developed in southeastern Washington. The area was almost totally without services. No state or county social or health agencies, not even a satellite center, were located in any of the towns. A program of helping skills intervention was developed in five schools. With the coordination of a mental health worker, outreach personnel from county agencies talked to the students. They focused on enhancing self-concept, increasing sensitivity and response to other people and their situations, problem solving, and the knowledge and skills to seek assistance appropriately. Results indicate that the program was successful in increasing support among students and promoting cooperation between schools and county agencies (Mooney & Eggleston, 1986). The increase of suicide in younger populations has forced communities to develop prevention and intervention programs. One such program in rural Maryland, Lifelines, utilized a systems approach to the development of a community-based suicide prevention program. The model employed three levels: awareness, intervention, and post-intervention. Because it is not a resource-intensive program, it appears feasible for isolated rural areas (Gray & Cannon, 1987). A model developed specifically for a frontier area (in Idaho) was the Citizen Companion Program (Sword & Longden, 1989). It has proven useful for adults with SMI. A version for children and adolescents-The Childrenís Companion Program-was subsequently put in place. Adults serve as companions in school or at home. It is currently referred to as Youth Trackers and is even more popular than the original adult program (Sword, personal communication, 1997). To be eligible for Youth Trackers, children or adolescents, in addition to a diagnosis of a severe mental disorder, must:
Child abuse and neglect programs are badly needed in rural areas, but their implementation faces a number of barriers. Sefcik and Ormsby (1978) review some of these problems:
Project Children is a rural child abuse/neglect program serving a five-county area in south-central Indiana. The purpose of this program is twofold. First, to develop a service network in which the various agencies' roles and relationships are clear. Second, to provide the best system for helping families by avoiding overlapping functions and ensuring that essential services are available in the community. The program consists of a hospital child protection team, parent aides, community education, and prevention efforts. The hospital child protection team uses a physician, a Department of Public Welfare worker, and a psychologist and/or psychiatric social worker. The initial focus of prevention efforts was on two identified needs:
Alcohol and Other Drugs of Abuse. In recent years there has been great concern about the AODA problems of children and adolescents. A number of prevention and treatment models have been developed specifically for rural areas or adapted from urban models. AODA prevention programming can be a special challenge in rural areas. Edwards, Egbert-Edwards, D'Anda, and Perez (1988) provided a good overview of several special considerations. As in most areas involving professional resource deployment, the staff members working in prevention activities have often been trained in urban settings. It is important to provide these professionals with orientation to the rural environment. The Upper Peninsula Teen Leadership Program (UPTLP) in Michigan involved networking to provide quality substance abuse prevention and early intervention services to high school students (Lindenberger, 1994). The program was based on peer leadership to prevent substance abuse by strengthening resiliency factors. One of the developers noted: ìIt promotes the concept that prevention is not something that we can do to our teens, but something that we must do with them, as partners." The New Holstein Student Assistance Program was developed in a rural area of Wisconsin and was designed to serve students in grades K-12. In addition to students and school staff, the program involved parents and the community-at-large. The program offered identification, assistance, referral, and support services for students with problems related to the use of alcohol or other drugs. Three kinds of support groups were available: use/abuse groups, concerned persons groups, and aftercare groups. The program was seen as an alternative to strict disciplinary codes that too often resulted in dropouts, expulsions, and the loss of educational opportunities (Wieser, 1988). In any discussion of delivery of services to remote populations, Alaska - the ultimate frontier - needs to be mentioned. The Group for the Advancement of Psychiatry (GAP, 1995) published a book on delivering mental health services to remote populations in this state. Illustratively, providing treatment services to an adolescent girl living in an alcoholic family in a remote village was problematic. Little help could be offered, even by the itinerant regional workers. In this case, the psychiatrist attempted to help her by periodic, brief telephone calls and letters, supplemented by contacts with regional providers. Many mental health professionals in these situations must choose between providing sub-optimal clinical services or expending effort to develop local capacity. Many professionals are opting for the latter. A major effort is underway in Alaska to develop village capacity to deal with alcoholic families. Paraprofessional village counseling positions have been developed, as well as regional teen substance abuse outreach and aftercare coordinators. As noted (GAP, 1995, p.120):
Developmentally Disabled: A group not at all well served in rural areas are children with developmental disabilities. Federal legislation mandating educational and preschool services for all developmentally disabled children places additional pressure on local resources. When services to these children are to be delivered in "mainstream" settings, there are particular concerns that need to be addressed. Gerber and Semmel (1983) describe two technical assistance systems-Virginia's Technical Assistance Centers (TACs), and California's Special Education Resource Network (SERN)-that illustrate important issues in providing comprehensive special education services to preschool children in rural areas. The obstacles to delivery of these services share a number of the same problems as rural service delivery in general. They include recruitment and retention of staff, higher per-capita costs, and difficulty in achieving economies of scale. Both TACs and SERN utilize a mix of core staff and paid consultants that overcomes the limitations of both center-based and home-based delivery systems. In essence, a resource center "travels" to where the primary service provider is located. The arrangement allows for adaptation, adjustable funding arrangements, and data-based responsiveness to clients and their requests. They also assert that the effectiveness of these models might be enhanced by some of the advances in telecommunications and microcomputer technology: e.g., computer-assisted self-instructional modules; videotape and disc storage and retrieval systems; closed-circuit or microwave transmission of lectures, workshops, and demonstrations; and remote monitoring and evaluation systems (2). A model of family-centered, community-based case management for families with developmentally-disabled children was developed in Appalachia. The goal was the empowerment of parents as caretakers and planners for their children. Master's level social work case managers staffed the program (Fiene & Taylor, 1991). In a rural area of North Carolina a program of peer support (Parents Supporting Parents) was developed for parents of children with developmental disabilities. Support was given either face-to-face or over the phone. The program provided training in basic listening skills and the availability of community resources. The program was inexpensive to develop and, therefore might be applicable in a wide variety of areas (Scott, 1989). SummaryThis Letter sketched out a number of models for the delivery of services to children and adolescents in frontier areas. Nearly all were rural models, but are they applicable for frontier or remote areas? Three general principles can help guide us in this decision:
Using these principles, most of the models described in this Letter are modifiable for frontier areas. The salience accorded services to children in various frontier programs speaks well for the concern for the well-being of this vital part of our society. ReferencesEdwards, E.D., EgbertEdwards, M., D'Anda, T., & Perez, E. (1988). Prevention of substance abuse in rural communities. Report to the OSAP Conference Cluster. Rockville, MD: Office of Substance Abuse Prevention. Farie, A.M., Cowen, E.L. & Smith, M. (1986). The development and implementation of a rural consortium program to provide early, preventive school mental health services. Community Mental Health Journal, 22 (2), 94-103. Fiene, J.I. & Taylor, P.A. (1991). Serving rural families of developmentally disabled children: A case management model. Social Work, 36 (4), 323-327. Gerber, M.M., & Semmel, M.I. (1983). Models for delivery of technical assistance for rural special education of preschool handicapped children. International Journal of Mental Health, 12, 144-158. Gray, J.B. & Cannon, G. (1987). A model of suicide prevention and intervention in rural areas. Rural Special Education Quarterly, 10 (1), 17-25. Group for the Advancement of Psychiatry. (1995). Mental health in remote rural developing areas (Report No. 139). Washington, DC: American Psychiatric Press. Idaho, State of. (1997). Mental health plan for adults and children. Boise: Department of Health and Welfare. Kelleher, K.J., Taylor, J.L., & Rickert, V.I. (1992). Mental health services for rural children and adolescents. Clinical Psychology Review 12, 841-852. Lindenberger, D. (1994). The Upper Peninsula teen leadership program: Marquette-Alger Intermediate School District. In Rural issues in alcohol and other drug abuse treatment (Technical Assistance Publication Series #10. DHHS Publication No. (SMA) 94-2063, pp. 11-24). Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Mooney, K.C. & Eggleston, M. (1986). Implementation and evaluation of a helping skills intervention in five rural schools [Special Issue: Prevention and promotion]. Journal of Rural Community Psychology, 7 (2), 27-36. Petti, T.A., Cornely, P.J., & McIntyre, A. (1993). A consultative study as a catalyst for improving mental health services for rural adolescents. Hospital and Community Psychiatry 44 (3), 262-265. Petti, T.A. & Leviton, L.C. (1986). Re-thinking rural mental health services for children and adolescents. Journal of Public Health Policy 7 (2), 58-77. Richmond, J. & Peeples, D. (1984). Rural drug abuse prevention: A structured program for middle schools. Journal of Counseling and Development, 63 (2), 113-114. Scott, S. (1989). Use and training of peer counselors. Rural Community Mental Health Newsletter, 16, 1, 9. Sefcik, T.R., & Ormsby, N.J. (1978). Establishing a rural child abuse/neglect treatment program. Child Welfare 57 (3), 187-195. Sheldon-Keller, A.E.R., Koch, J., Watts, A.C., & Leaf, P.J. (in press). The provision of services for rural youth with serious emotional and behavioral problems: Virginia's comprehensive services act. Community Mental Health Journal. Sword, M., & Longden, G. (1989). The Idaho Citizen Companion Program. Human Services in the Rural Environment 12(4), 34-36. Tovey, R. (1983). The family living model: Five-day treatment in a rural environment. Child Welfare, 62 (5), 445-449. Wieser, J. (1988). New Holstein student assistance program. Student Assistance Journal 1 (1), 23-26.
Frontier Mental Health Resource Network
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