Jennifer Townsend reads to two of her children before a parenting class in the Leland Medical Clinic’s parent center.

LELAND — Jennifer Townsend was shocked when she found a note written by her oldest child, a 14-year-old: The teen was planning to commit suicide.

Townsend, a mother of four who lives in this rural Mississippi Delta town, wanted to get help for her daughter immediately. She called a nearby state-funded community mental health clinic to ask for counseling. The clinic told her they had a wait list of at least six months. And even if the teen got in, they would only be able to see the girl once a month.

“I didn’t think one time a month was good enough,” Townsend said. “She was suicidal.”

In Mississippi, many children with severe mental health needs have few local options for care. They must go to psychiatric institutions, often far from their homes, to receive mental health support and services.

Townsend — and her daughter — were lucky. Townsend was enrolled in a nonprofit parenting program she could turn to for help. The group connected her with a therapist who could counsel her daughter in personal home visits. Now, Townsend said, her daughter turns to the therapist for help and anticipates her visits.

Nearly a decade after Mississippi was sued by the Southern Poverty Law Center for its treatment of children with mental health needs, the state still remains near the bottom of national rankings for getting help to youth with mental or emotional issues. Despite state attempts to increase funding and expand some programs, many children, especially those in Mississippi’s most rural areas, still lack access to desperately needed mental health services.

In Mississippi, more than 62 percent of youth who suffer a major depressive episode — 13,000 kids — don’t get any professional help, according to national statistics from a 2017 report.

The state has tried to address the problem by expanding some mental health services for children with more severe mental or emotional problems and has made an effort to divert some funds away from psychiatric institutions and into community-based services, but the efforts are often stymied by a lack of funding. The state’s Department of Mental Health has cut hundreds of staff members, reduced some services, and closed programs, including one that provided community-based mental health services to at-risk youth.

Mississippi’s effort to reach more children is hampered by more than scarce resources: Another major hurdle to providing mental health care is the fact that 44 percent of the state’s children live in rural communities.

Experts agree that the state’s dispersed population makes it harder to connect kids to mental health services. “That is one reason that these families are saying, ‘I called the mental health center. They wouldn’t come help me,’” said Joy Hogge, executive director of the Jackson-based nonprofit Families as Allies.

A lack of mental health services can lead to poor outcomes for children and youth that Mississippi, already facing multiple problems affecting children’s well-being, can ill-afford.

Youth suffering from untreated mental or emotional problems are at an increased risk of incarceration, face difficulties in school, and have higher suspension and drop-out rates, and are more likely to commit suicide. Children who don’t receive treatment for mental illness use more health care services as adults and are more at risk for poverty and unemployment.

Teri Brister, director of information and support for the Washington-based National Alliance on Mental Illness (NAMI) said that she hasn’t seen any state develop a strong, statewide system for children’s mental health care, but Mississippi’s system is especially troubling.

“I don’t know if anybody is as disjointed as we are,” Brister said. She speaks from experience: Brister spent more than 20 years working for the Mississippi community health system before joining NAMI in 2005.

Related: Rural schools find an online resource to fill gaps in mental health services for students

The play therapy room at the Leland Medical Clinic where children can get counseling, physical therapy, occupational therapy, and speech therapy in an effort to fill the gap.

Mississippi’s 14 community health centers are scattered around the state. Although the centers are certified by the state Department of Mental Health, they are run independently by separate boards and offer different services.

Theresa Parsons, director of children’s services at Region IV, which serves five counties in north Mississippi, said Region IV sends therapists to visit local schools every day. However, the program still struggles to reach residents in the most rural parts of the local counties.

“Are we meeting all the needs? I can’t say we are,” Parsons said. “There are always ones out there we’re not reaching.”

Transportation is a major issue in the more rural areas in Region IV, Parsons said. Her case managers often drive up to 30 miles to pick up individuals and take them to medical appointments, a task that is outside of their main job responsibilities and and adds to their already swollen caseloads. “A lot of times, our case managers have to step in and help with things,” Parson said. “It is a lot.”

It can also be difficult to find staff members. As of late May, Parsons had several positions that were open for an August 1 start date.

Nonprofits try to help fill the void

In addition to the health centers, the state also supports mobile crisis response teams, often made up of one therapist and two support specialists, who can react quickly to assist children and adults suffering a mental health crisis. In fiscal year 2017, the response teams received 23,168 calls for help, and provided 15,668 face-to-face visits.

Since FY 2014, the state has indirectly beefed-up its mental health offerings by slowly increasing the number of children served by wraparound programs, which can include long-term mental health care. The programs, which served about 1,700 children in FY 17, create a team of adults who meet every 30 days in a child’s community to carry out a support plan for that child. The plan may include referral to mental health and other services in the community.

The state also helps serve children who have serious emotional disturbances through Mississippi Youth Programs Around the Clock (MYPAC). The program, administered by various nonprofits with financial support from the state, provides ongoing individual and family therapy, along with connections to other people in the community, like teachers, counselors, and neighbors who can also give support. Unlike other programs, MYPAC delivers services to children at home.

“The point of these services is to provide tools, skills, and resources so the family can operate without us,” said Patrick McLaughlin, assistant director of community-based programs for the nonprofit Youth Villages in Mississippi, one of several organizations that administers the program. “We can help build them up.”

Despite the promise of MYPAC’s model, McLaughlin said there are challenges, especially in rural areas. If a family doesn’t have a car, they may not be able to go to a medical appointment or psychiatric evaluation. That can add to the isolation people can experience as they deal with mental health issues, McLaughlin said. “A lot of families we have … They are craving this help and support,” McLaughlin said.

In some of the most rural parts of Mississippi, nonprofits and schools have tried to fill the void in mental health services by offering free services or by training teachers about suicide prevention. But building a workforce that is knowledgeable about mental health has not been easy.

Few caregivers and scarce insurance coverage

The majority of Mississippi’s counties, and especially its rural counties, had no psychiatrists or psychologists as of 2015. Some of these rural areas also lacked pediatricians, who are often the first professionals parents turn to with concerns about their child’s mental health.

When families do find a provider, wait lists can be lengthy. Nearly 15 percent of children in Mississippi are without insurance coverage for mental health services, one of the highest rates in the nation. Providers say driving to rural communities to meet families can be taxing and difficult for staff members.

Related: Nonwhite students slow to seek mental health counseling for which they’re more in need

Many experts say more help needs to be available in schools, where kids spend the majority of their days, and especially in schools in rural towns.

Yet the number of school psychologists in Mississippi decreased by 20 percent between 2005 and 2010. In 2017, there were fewer than 400 clinical, counseling and school psychologists in the state, most of them employed in the more-populated Jackson area, in southern Mississippi, and along the border between Mississippi and Tennessee.

Students who turn to school counselors for mental health help may find that their counselors are too overburdened with paperwork or other aspects of the job to provide mental health support.

Michelle Cresap, a school counselor in Rankin County, said she has been responsible for enrollment, compiling records, and coordinating testing on top of meeting with students. “Not all schools are supportive of their school counselor,” Cresap said. “They see them as school secretaries.”

In her current position, Cresap, who is also president of the Mississippi School Counseling Association, is one of three counselors at the school working with students in grades nine to 12.

She provides individual counseling, connects students to outside counselors if needed, flags kids with discipline issues for more support and provides guidance on going to college. Cresap estimates that 80 percent of her time is spent face-to-face with students, which is what allows her to be a support for kids. “If you let me get a hold of that child, I can help that child,” she said.

In a statewide survey and a series of town hall meetings with Mississippi residents in 2016 and 2017, the nonprofit Families as Allies discovered many parents didn’t know about the state’s mental health services. Those who did know about the offerings often could not afford or get to them. Some parents said they resorted to calling 911 to get help dealing with their child during mental health episodes.

Despite a 2010 lawsuit, Mississippi has continued to rely on institutions to treat children with depression and other mental health issues. Nearly half the state’s funding for children’s mental health went to services in private and public institutional settings, according to a 2015 report. That report also found that the number of youth who were admitted to inpatient psychiatric hospitals increased by 22 percent between FY 2010 and FY 2014.

In 2010, the SPLC lawsuit accused the state of failing to provide early screening and treatment services for which children are eligible under Medicaid. In the years after the lawsuit was filed, Mississippi’s overall spending for mental health services for children receiving Medicaid decreased. (In 2013, Mississippi lawmakers, unlike those in the majority of the country, chose not to expand Medicaid, foregoing health insurance for more than 300,000 additional residents, including children.)

Funding uptick, telemedicine help fill gaps

Still, officials can point to some progress.

For the last five years, the Mississippi legislature has appropriated $16.1 million to expand community-based mental health services. Using those funds, the state has expanded programs that serve kids with the most severe problems.

The beneficiaries of the funding include a suicide prevention outreach program, an intervention program for young adults ages 15-30 who have experienced their first episode of psychosis, and a program that helps youth and young adults suffering serious emotional disturbance transition to adult mental health services and prepare for independent living.

A room at the Leland Medical Clinic is equipped with equipment for telemedicine.

In the upcoming fiscal year, the state’s Department of Mental Health will move $10 million from its budget for institutions to expand best practices in the community and “reduce reliance on institutional care,” according to Adam Moore, director of communications for the Mississippi Department of Mental Health. Most of the money will go to the state’s 14 Community Mental Health Centers to expand crisis services. As of June 2017, the state had also closed 50 beds in its two institutions for youth.

Related: Schools with more black students are less likely to steer students to mental health services

Experts say the new funds may not be enough to make up for current gaps. Across Mississippi, more than 2 million people live in what the federal government has designated “mental health care shortage areas,” in which there are as many as 30,000 people per mental health provider.

Ron Manderscheid, executive director of the National Association for Rural Mental Health, said the shortages are even worse for youth. In rural areas, there is often nobody who can provide mental health care for children.

As many as 50 percent of youth nationally meet criteria for having a mental health disorder, including anxiety disorders and behavior disorders. Twelve percent of youth ages 12 to 17 report suffering from at least one “major depressive episode,” which may include an inability to concentrate or engage in normal activities and thoughts of suicide, according to the nonprofit Mental Health America. The rates are higher for children living in poverty.

The state’s efforts to increase mental health services could get some help from the federal government: The omnibus budget signed by President Donald Trump earlier this year allocated increases in funding to support mental health programs, including a $700 million increase for a grant program that provides mental health services in schools and $5 million for early childhood mental health programs.

Experts say this is a good place to start: More access to early mental health care is critical for mitigating the long-term impact of mental illness.

“The earlier you intervene and support them and support their caregiver, the better they’re going to do,” said Hogge from Families as Allies.

Another solution is “telemedicine,” which uses video-chat technology for medical examinations and consultations. Mississippi was an early adopter of telemedicine for a variety of services. In 2017, the state, along with 14 others, received the highest grade from the American Telemedicine Association for the use of telemedicine for mental health. But the state still lags in something that is critical for telemedicine success: internet connectivity.

Some states, like Utah and Georgia, have doubled down specifically on telemedicine as a way to use technology to bring psychologists and counselors to rural children. Last year, Tennessee passed a bill requiring insurers to cover school telehealth services. Texas also passed legislation requiring reimbursement for some telehealth services used by schools.

McLaughlin from Youth Villages said the organization has helped enable families to participate in video chats when they are unable to go to an in-person medical appointment or psychological evaluation. But, if there is no Internet service or cell coverage is poor, “that can play a role in a family not being able to get access to everything they need,” McLaughlin said.

Manderscheid said the use of more technology needs to be paired with an effort to train therapists and other providers willing to put down roots in rural areas. The state should encourage rural students to go into behavioral health fields “because they’re the most likely people to want to go back and work in rural areas.” he said.

Some states with large rural populations, like Oregon, have tried to train primary care doctors that are already present in rural areas to provide care for children with mental health needs.

Signs of mental health issues often missed

Teachers also need more training in recognizing signs of mental health issues. “We need the people who are with the kids the majority of the time to know what they see, when they see it, and be comfortable doing something about it,” said Teri Brister from NAMI.

Labella Preston, a school-based therapist for LifeHelp, a community mental health center, said she has seen children who suffer depression miss out on receiving help early-on because teachers think they are just quiet or disengaged, ands don’t realize those are signs of a mental illness. “I try to get my teachers to understand and look for all those signs,” Preston said. “Not just children who are up fighting.”

In Sunflower County, where 47 percent of children live in poverty, the nonprofit Delta Health Alliance has tried to fill the void left by Mississippi’s disjointed system.

In the absence of more community-based mental health services, nonprofit-supported centers like the Leland Medical Center are trying to fill the gap.

In addition to running the parenting program that connected Jennifer Townsend’s daughter with a therapist and several other initiatives, the nonprofit has put money and resources into the Leland Medical Clinic.

Children can get counseling, physical therapy, occupational therapy, and speech therapy at the clinic, a single-story brick building tucked away in a residential neighborhood. One patient room in the clinic is equipped with video conference equipment for residents to use to talk to psychologists or therapists in another part of the state.

Erinisha Johnson sits at her desk in a room that does double duty as both her office and the play therapy room.

In Erinisha Johnson’s play therapy room, children paint, play in a ball pit, or listen to music and write in a journal as part of the program’s play therapy.

“If I notice a child is creative, that’s typically the place to get them to open up,” Johnson said. She mostly sees kids between the ages of 3 and 18, some of whom have ADHD, Oppositional Defiance Disorder, depression, social anxiety, or anger management. Many have “irrational thoughts” and think they are “not as good as other children” or blame themselves for bad situations at home.

The Delta Health Alliance also runs a program that connects parents with community resources.

Leland resident Constance Butler met a liaison from the program through her son’s school. Carmeloe, 9, had repeated first grade and was in danger of failing second grade. Dorothy Fowler, a liaison with LINKS, a DHA program connecting kids to services, visited their home, where Butler explained her son was not excited about school, wouldn’t do his work, and was having trouble paying attention. Fowler immediately told her “that’s not normal.”

Fowler referred the family to the clinic, where Carmeloe was diagnosed with Attention Deficit Disorder. He was prescribed medication that Butler said has made him “a whole lot better.” If it weren’t for the counseling, she said she would have relied on Google to give her insight into her son’s behavior.

Constance Butler meets with Dorothy Fowler at the Leland Medical Center.

“I’ve seen progress,” Butler said. “He’s paying more attention, he’s conversing better.”

But, Butler said, if there were more mental health services available, including more information available for parents and more people available to diagnose children, she could have intervened before Carmeloe fell so far behind in school. “I could have caught it,” she said. “I wish I would have known then what I know now.”

This story about mental health care for rural children  was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for the Hechinger newsletter.

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