Who Should be Responsible? Service Providers' Perspectives on Challenges of Serving Children with High Needs In Rural Foster Care

Background and Purpose: Children in foster care experience disproportionately high rates of mental health disorders (40-85%), yet less than one-third receive adequate treatment. Unmet mental health needs further destabilize placements, creating cycles of disruption that compound trauma for children and families. While existing literature broadly documents these service gaps, little is known about how these challenges manifest specifically within rural child welfare systems. This qualitative study explores perspectives of multiple service providers on the unique challenges of serving children with high needs in a rural foster care context.

Methods: Semi-structured interviews and focus groups were conducted with foster care youth (n=2), mental health providers (n=4), GALs (n=4), county child welfare workers (n=8), and foster care parents (n=3) in a rural county in western North Carolina (total N=21). Participants were recruited through purposive sampling via child welfare agency referrals. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis in Dedoose qualitative software, following an inductive approach.

Findings: Three themes were developed: (1) Training gaps — trauma-informed training was widely needed but often inaccessible due to distance and limited availability; (2) Service resource shortages — long waitlists and limited local providers meant children could not access timely mental health services, with some requiring out-of-state placements for higher-level care; (3) Crisis-driven placement instability — PRTFs frequently rejected or discharged high-needs children, leaving youth housed in child welfare offices or emergency rooms for extended periods.

Conclusions and Implications: Findings highlight critical gaps in rural child welfare systems, where rural location, workforce shortages, and fragmented service coordination compound trauma for high-needs foster youth. Practice implications include mandating trauma-informed training for service providers and foster parents, establishing dedicated mental health case managers in rural counties, and creating accountability structures for PRTFs serving high-needs youth. Policy efforts must prioritize rural-specific investments in child welfare infrastructure to prevent further harm to children and families.