The purpose of this study was to establish benchmark data to assist in identifying factors associated with mental health service needs and level of care for children living in a rural state. Clinical and psycho-social needs and strengths were assessed using retrospective chart review for all children and adolescents (n=150) with symptoms or a diagnosis of reactive attachment disorder who presented to a comprehensive treatment facility between January 1997 and December 1999. Logistic regression was used to predict factors associated with inpatient admission (n=15) vs. community-based care (n=135). Significant individual contributors to the prediction of inpatient care were more limited clinical/psycho-social strengths, history of inpatient use and history of sexual abuse. Although 80 percent of children admitted to inpatient care had a history of hospitalization, two-thirds had no history of receiving community-based services and presented to current treatment with a two-year or longer history of symptoms. Approximately two-thirds of children admitted to inpatient care had a history of sexual abuse; however, one-third of these children had no history of mental health service use and presented to current treatment with a two-year or longer history of symptoms. Findings raise concerns about current efforts in public health education, community awareness and health prevention and early intervention programs for children with mental/behavioral health challenges and children and families at risk for abuse and/or neglect living in rural areas.