291 - Rural-Urban Disparities in Children’s Mental and Behavioral Health in the US: a Scoping Review

Publication Number: 3280.291

Amanda C. Coyle, University of Alberta Faculty of Medicine and Dentistry, Edmonton, AB, Canada; Mary Arakelyan, Queen's University, Lebanon, NH, United States; Ashley Boardman, Geisel School of Medicine at Dartmouth, Christiansburg, VA, United States; Ian J. Lichtenstein, Geisel School of Medicine at Dartmouth, Santa Monica, CA, United States; Sophie Kodak, Geisel School of Medicine at Dartmouth, Cambridge, MA, United States; Ellie Acquilano, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, United States; JoAnna Leyenaar, The Dartmouth Institute of Health Policy & Clinical Practie, Lebanon, NH, United States

Background: One-in-five children and adolescents in the United States are diagnosed with a mental or behavioral health condition. Rural-residing children may be at heightened risk given higher rates of poverty, isolation, mental health stigma, and decreased access to mental health services.

Objective: To summarize studies reporting rural-urban differences in child and adolescent mental and behavioral health symptoms, diagnoses, assessment and treatment in the United States.

Design/Methods: We performed a comprehensive literature search in MEDLINE, Embase, CENTRAL, Cochrane Library, PsycInfo, Scopus, and ClinicalTrials.gov, including eligible studies published 01/01/1987 until 2/16/2024. Following systematic review of titles, abstracts and eligible full text articles, we extracted two categories of outcomes, including i) prevalence of symptoms, diagnoses, and behaviors and ii) assessment and treatment, in rural compared to urban areas. Some studies presented multiple outcome measures and thus addressed both categories of outcomes. Results were synthesized narratively, stratifying findings based on whether the study included the general pediatric population or a population with 1 or more mental or behavioral health conditions.

Results: After screening 6,624 citations and 232 full-text articles, 44 articles met inclusion criteria (Figure 1). Five federally supported definitions of rurality were used in 27 studies, while 17 used alternative definitions (Table 1). Most studies focused on the general pediatric population, with 20 reporting on prevalence and 11 on assessment/treatment (Figure 2). Among studies focused on children with mental or behavioral conditions, 8 reported on prevalence and 13 on assessment/treatment. Suicide, depressive disorders, and attention-deficit/hyperactivity disorder were the most studied conditions. We found consistent evidence of an increased risk for suicide mortality in rural-residing children, along with increased acute care utilization for mental health. Among children with mental or behavioral health diagnoses, rural-residing children were more likely to have co-occurring mental health diagnoses. We did not observe consistent rural-urban disparities in the prevalence of other mental health diagnoses, or in their assessment or treatment.

Conclusion(s): Rural-residing children are at increased risk of suicide, but findings related to other mental and behavioral health diagnoses are limited and inconsistent. Future research is needed to understand and address rural-urban differences in mental and behavioral health and to direct public health efforts.

PRISMA Flow Diagram
*Databases were first searched January 20-21, 2021, then re-searched using the same search strategies on February 16-19, 2024. Records extracted from the second search for screening were limited to those published in January 2021 and after. A search of EMBASE was not conducted in the second round of searches as access to this database was no longer available, and most journals in Embase are included in Scopus.
**The deduplication feature in Rayyan was used to identify potential duplicates, which a reviewer manually resolved.
***Included reports represent n=44 studies.

From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71.

Characteristics of included studies
Abbreviations: USBC (US Bureau of the Census Urban-Rural Classification), USOMB (United States Office of Management and Budget Metropolitan and Micropolitan Statistical Areas), RUCC (Rural-Urban Continuum Codes), RUCA (Rural Urban Commuting Areas), NCHS (National Center for Health Statistics Urban-Rural Classification Scheme); NR (not reported).
* "Other System" includes studies that used Rural/Urban Classification Systems other than the federally supported definitions; "Author-defined/NR" includes the authors' own definition of rural and urban and when the classification system or definitions used were not reported/specified.
** Sample sizes reported include rural and urban groups. Unweighted sample sizes are reported for studies that used survey weights to represent data from a broader population. For studies that included multiple caregiver respondents for each child, the number of children is reported.

Mental and behavioral health diagnosis groups examined in studies reporting rural-urban comparisons
* Main categories from the Diagnostic and Statistical Manual of Mental Disorders - 5th edition, excluding categories not commonly diagnosed in children (sexual dysfunctions, neurocognitive disorders, and paraphilic disorders). Included also are "suicide-related behaviors and outcomes," which are classified as "Conditions for Further Study".
** Studies may contribute to counts in multiple rows (e.g. a study reporting on the prevalence of ADHD and Anxiety disorders) but are not double-counted within a cell (e.g. a study reporting on the prevalence of considering or planning for suicide in a general population of children contributes a count of 1 to the corresponding cell).
*** Specific diagnoses within the category of Neurodevelopmental Disorders. Specified given the heterogeneity of symptoms and presentations for each condition within this category.