Article: New Program Treats Rural Youth and Targets Barriers to Care

Adolescents and teens with emotional and behavioral problems will receive treatment as part of a new study in eight of the poorest Appalachian counties in Eastern Tennessee. Researchers will work with judges, school administrators, and community leaders to overcome barriers to mental health services. The project is structured to ensure that successful therapies and partnerships with state funding agencies and organizations will continue after the study ends. The 5-year, more than $4 million grant to the University of Tennessee was funded by the National Institute of Mental Health (NIMH), a part of the National Institutes of Health (NIH).

"This study offers a solid team approach in addressing a major public health problem," said NIH Director Dr. Elias A. Zerhouni. "It is a great example of how the right partnerships can improve the health of children in local communities and across the nation."

The Rural Appalachia Project is a community development model for reducing the social and economic costs of juvenile delinquency in rural areas. In Tennessee 60,000 children are referred annually to juvenile courts for delinquency and other illegal acts. Studies show that home-based, family-oriented health services for children referred to juvenile court can improve their behavior and keep them out of custody. In addition to providing treatment, the study will work with opinion leaders to explain how early and effective intervention can improve lives and decrease the costs of incarceration and residential care in their state.

"Although delinquency is associated with urban areas, it is a problem in every community," according to principal investigator Dr. Charles A. Glisson, who will head the study at the University of Tennessee Children's Mental Health Services Research Center. "In fact, the highest rates of children referred to juvenile court in Tennessee are in some of the most rural counties in Appalachia. Children from these areas are at greater risk of being placed in state custody and stay there longer than children from urban areas."

The study will include 720 children with serious conduct and other mental health problems, ages 9 to 17 years old, who were referred to juvenile courts. Half of the children selected from each county will receive an evidence-based practice called multisystemic therapy (MST). The other half will receive the usual care for children referred to juvenile court from community mental health centers, private practitioners, and state child welfare and juvenile justice systems.

MST typically lasts for 4 to 5 months. The duration and frequency of treatment sessions varies with circumstances, needs, and progress. A family setting allows therapists to observe and help change behaviors in a normal environment rather than a clinical setting. The state's largest private children's mental health service provider will treat children in their homes who are eligible for Medicaid and children of the working poor who are not eligible, with reimbursement by the Medicaid-waiver health insurance program.

For the second part of the study, psychologists trained in organizational and community development will work with local opinion leaders to support mental health treatment and family care. This intervention, which will assist therapists serving children in widely dispersed, isolated communities, aims to change the social context in which treatment occurs.

"This strategy will provide immediate help for children in these communities," said NIMH Director Dr. Thomas Insel. "These special partnerships can also serve as a model, yielding information on improving the mental and behavioral health care of children in communities nationwide."

To assess community change toward treatment, leaders from key institutions will be interviewed at baseline and at 6-month intervals. Research suggests that different perceptions in the way a problem is understood may emerge. For example, school superintendents often operate under "zero-tolerance" policies, i.e., infractions that result in expulsion regardless of circumstances, which can conflict with a therapist's treatment. Agents will use information, feedback, participatory decisions, and conflict resolution to identify barriers to service and recommend improvements to mental health services, judicial policies, and school systems.

"By uniting university researchers with state policymakers, service providers, and opinion leaders, we hope to develop solutions that can be sustained long after this study is completed," Glisson said.

NIMH is part of the National Institutes of Health (NIH), the Federal Government's primary agency for biomedical and behavioral research. NIH is a component of the U.S. Department of Health and Human Services.