telemental health for children and adolescents
TRANSCRIPT
International Review of Psychiatry, 2015VOL. 27, NO. 6, 513–524http://dx.doi.org/10.3109/09540261.2015.1086322
REVIEW
Telemental health for children and adolescents
Nicole E. Gloff1, Sean R. LeNoue2,3,4, Douglas K. Novins4,5,6 and Kathleen Myers7,8
1Division of Child and Adolescent Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, 2Denver Health MedicalCenter, Colorado, 3Children’s Hospital Colorado, University of Colorado Hospital, University of Colorado School of Medicine, Aurora,Colorado, 4Department of Psychiatry, University of Colorado School of Medicine, 5Division of Child and Adolescent Psychiatry, University ofColorado School of Medicine, 6American Indian and Alaska Native Health, Colorado School of Public Health, Aurora, Colorado, 7School ofMedicine, University of Washington, and 8Telemental Health Service, Seattle Children’s Services, Seattle, Washington, USA
ABSTRACTMost children and adolescents across the USA fail to receive adequate mental health services,especially in rural or underserved communities. The supply of child and adolescent psychiatrists isinsufficient for the number of children in need of services and is not anticipated to grow. This callsfor novel approaches to mental health care. Telemental health (TMH) offers one approach toincrease access. TMH programmes serving young people are developing rapidly and availablestudies demonstrate that these services are feasible, acceptable, sustainable and likely as effectiveas in-person services. TMH services are utilized in clinical settings to provide direct care andconsultation to primary care providers (PCPs), as well as in non-traditional settings, such as schools,correctional facilities and the home. Delivery of services to young people through TMH requiresseveral adjustments to practice with adults regarding the model of care, cultural values,participating adults, rapport-building, pharmacotherapy and psychotherapy. Additional infrastruc-ture accommodations at the patient site include space and staffing to conduct developmentallyappropriate evaluations and treatment planning with parents, other providers, and communityservices. For TMH to optimally impact young people’s access to mental health care, collaborativemodels of care are needed to support PCPs as frontline mental health-care providers, therebyeffectively expanding the child and adolescent mental health workforce.
ARTICLE HISTORY
Received 6 July 2015Revised 17 August 2015Accepted 19 August 2015Published online4 November 2015
KEYWORDS
Telepsychiatry, telementalhealth, telemedicine,telehealth, video teleconfer-encing, e-health, child andadolescent, youth
Introduction: child and adolescent telementalhealth
Disparities in children’s and adolescents’ access
to evidence-based care
As noted in other articles, the ‘‘aging-out effect‘‘ of thecurrent supply of psychiatrists and the projectedinadequate supply of new psychiatrists has called fornovel approaches to mental healthcare (AmericanMedical Association, 2010; Insel, 2011). This disparityis especially poignant for child and adolescent mentalhealth specialists (American Psychological Association,2008; Thomas & Holzer, 2006). Therefore, children andadolescents living outside major metropolitan areas haveparticular difficulties in accessing needed services, par-ticularly evidence-based interventions (AmericanPsychological Association, 2008; Comer & Barlow,2013; Muskie School of Public Service, 2009; Sandleret al., 2005). These current and projected disparities areoccurring at the same time as the broadening imple-mentation of federal and state mental health parity laws,such as the Patient Protection and Affordable Care Act
(ACA) (US 111th Congress, 2010), raising the risk thatwe will be unable to meet the increase in demand forchild specialist mental health services.
Telemental health (TMH) offers one approach toimprove access to evidence-based mental health care foryoung people and their families. This article presents anoverview of TMH services to children and adolescentsbased on the available evidence base and currentexperience. We specifically address the practices ofchild and adolescent psychiatrists (telepsychiatrists)and use the term TMH to include the broad array ofservices that telepsychiatrists provide.
Telemental health to reduce disparities and toimprove the quality of child and adolescent
mental health care
Programmes using TMH to deliver services directly toyoung people and their families have developed rapidlyacross the country but the evidence base supportingtheir effectiveness is emerging more gradually. Table 1summarizes the current evidence base; in sum, these
Correspondence: Nicole E. Gloff, MD, [email protected], Telemental Health, Division of Child and Adolescent Psychiatry, University ofMaryland School of Medicine, Baltimore, Maryland, USA.
� 2015 Taylor & Francis
Tab
le1.
Sum
mar
yo
fcl
inic
alo
utc
om
est
ud
ies
for
child
and
ado
lesc
ent
tele
men
tal
hea
lth
(200
0to
2015
).
Cit
atio
nD
esig
nSa
mp
leA
sses
smen
tFi
nd
ing
s
Elfo
rdet
al.,
2000
RC
T25
child
ren
Var
iou
sd
iag
nos
esD
iag
no
stic
inte
rvie
ws
96%
con
cord
ance
bet
wee
nvi
deo
and
in-p
erso
nev
alu
atio
ns;
no
diff
eren
cein
sati
sfac
tio
nEl
ford
etal
.,20
01D
escr
ipti
ve23
child
ren
Ro
uti
ne
clin
ical
Dia
gn
osi
san
dtr
eatm
ent
reco
mm
end
atio
n–
equ
alto
usu
al,
in-p
erso
nca
reG
luec
kau
fet
al.,
2002
Mod
ified
RC
TPr
eve
rsu
sp
ost
22ad
ole
scen
ts36
par
ents
Issu
e-sp
ecifi
cm
easu
rem
ent
of
fam
ilyp
rob
lem
s(I
SS,
IFS,
ICS)
Teen
fun
ctio
nin
g(S
SRS)
Wo
rkin
gA
llian
ceIn
ven
tory
Ad
her
ence
toap
po
intm
ents
Imp
rove
men
tfo
rp
rob
lem
seve
rity
and
freq
uen
cyin
all
con
dit
ion
s.Th
erap
euti
cal
lian
ceh
igh
;te
ens
rate
dal
lian
celo
wer
for
vid
eo
Nel
son
etal
.,20
03R
CT
28ch
ildre
nD
epre
ssio
nD
iag
no
stic
inte
rvie
wan
dsc
ale
Vid
eo¼
in-p
erso
nfo
rim
pro
vem
ent
of
dep
ress
ive
sym
pto
ms
inre
spo
nse
toth
erap
yM
yers
etal
.,20
04D
escr
ipti
ve15
9yo
un
gp
eop
le(a
ge
3–18
)C
om
par
iso
no
fp
atie
nts
eval
uat
edth
rou
gh
TMH
vers
us
FTF
incl
inic
Vid
eob
asic
ally
sim
ilar
toin
-per
son
ou
tpat
ien
tsd
emo
gra
ph
ical
ly,
clin
ical
ly,
and
by
reim
bu
rsem
ent
Vid
eo4
‘ad
vers
eca
sem
ix’
Gre
enb
erg
,20
06D
escr
ipti
veN
Sch
ildre
n,
35PC
Ps,
12ca
reg
iver
sN
SFo
cus
gro
up
sw
ith
PCPs
,in
terv
iew
sw
ith
care
giv
ers
PCP
and
care
giv
ersa
tisf
ied
vid
eo;
fru
stra
ted
wit
hlim
itat
ion
so
flo
cal
sup
por
tsFa
mily
care
take
rsan
dse
rvic
ep
rovi
der
sfr
ust
rate
dw
ith
limit
atio
ns
of
the
vid
eoM
yers
etal
.,20
06D
escr
ipti
ve11
5in
carc
erat
edad
oles
cen
ts(a
ge
14–
18)
11-i
tem
sati
sfac
tio
nsu
rvey
80%
succ
essf
ully
pre
scri
bed
med
icat
ion
san
dth
eyex
pre
ssed
con
fiden
cein
the
psy
chia
tris
tb
yvi
deo
Yo
un
gp
eop
leex
pre
ssed
con
cern
sab
ou
tp
riva
cyM
yers
etal
.,20
07D
escr
ipti
ve17
2p
atie
nts
(ag
e2–
21)3
87vi
sits
11-i
tem
pro
vid
er/P
CP
sati
sfac
tio
nsu
rvey
Vid
eoto
pat
ien
tsat
4PC
Psi
tes:
hig
hsa
tisf
acti
on
wit
hse
rvic
es;
pae
dia
tric
ian
s4fa
mily
ph
ysic
ian
sFo
xet
al.,
2008
Pre-
po
st19
0yo
un
gp
eop
lein
juve
nile
det
enti
on
GA
SIm
pro
vem
ent
inth
era
teo
fat
tain
men
to
fg
oals
asso
ciat
edw
ith
fam
ilyre
lati
on
san
dp
erso
nal
ity/
beh
avio
ur
Mye
rset
al.,
2008
Des
crip
tive
172
pat
ien
tsPa
ren
tal
sati
sfac
tio
n12
-ite
mp
aren
tsa
tisf
acti
on
surv
eySa
tisf
acti
on
of
par
ents
wit
hsc
ho
ol-
aged
child
ren
hig
her
than
tho
sew
ith
adol
esce
nts
Ad
her
ence
hig
hfo
rre
turn
app
oin
tmen
tsY
ello
wle
es,
2008
Pre-
po
st41
child
ren
inru
ral
pri
mar
yca
reC
BC
LA
t3
mo
nth
s,im
pro
vem
ents
inth
eA
ffec
tan
dO
pp
osit
ion
alD
om
ain
so
fth
eC
hild
Beh
avio
rC
hec
klis
tM
yers
etal
.,20
10D
escr
ipti
ve70
1p
atie
nts
,19
0PC
PsC
olle
ctio
no
fp
atie
nt
dem
og
rap
hic
s,d
iag
no
ses,
and
uti
lizat
ion
of
serv
ices
Vid
eofe
asib
le;
psy
chia
tris
tsad
just
pra
ctic
efr
om
in-
per
son
wel
l
Paky
ure
ket
al.,
2010
Des
crip
tive
12ch
ildre
nA
uti
smsp
ectr
um
inp
rim
ary
care
Ro
uti
ne
clin
ical
Vid
eom
igh
tac
tual
lyb
esu
per
ior
toin
-per
son
for
con
sult
atio
nLa
uet
al.,
2011
Des
crip
tive
and
adva
nce
das
sess
men
t45
child
ren
/ad
oles
cen
tsPa
tien
tch
arac
teri
stic
s,re
aso
nfo
rco
nsu
ltat
ion
,an
dtr
eatm
ent
reco
mm
end
atio
ns
Vid
eore
ach
esa
vari
ety
of
child
ren
,w
ith
con
sult
ants
pro
vid
ing
dia
gn
osti
ccl
arifi
cati
on
and
mo
dify
ing
trea
tmen
tSt
ain
etal
.,20
11D
escr
ipti
vean
dR
CT
11ad
ole
scen
ts/y
ou
ng
adu
lts
DIP
-DM
Stro
ng
corr
elat
ion
of
asse
ssm
ents
do
ne
inp
erso
nve
rsu
svi
deo
Sto
rch
etal
.,20
12R
CT
31ch
ildre
nan
dte
enag
ers
Ro
uti
ne
clin
ical
and
mea
sure
s
1.1
AD
IS-I
V-C
/P2.
Clin
icia
n-a
dm
inis
tere
dC
Y-B
OC
S3.
CG
I4.
4.O
ther
s:o
bse
ssiv
e,an
xiet
y,d
epre
ssio
nin
ven
tory
.
Vid
eow
assu
per
ior
toin
per
son
on
all
pri
mar
yo
utc
om
em
easu
res,
hig
her
per
cen
tag
em
eeti
ng
rem
issi
on
.C
on
sult
ants
pro
vid
ing
dia
gn
ost
iccl
arifi
cati
on
and
mo
dify
ing
trea
tmen
t
Him
leet
al.,
2012
RC
T20
child
ren
Tour
ette
’sd
isor
der
or
chro
nic
mo
tor
tic
dis
ord
er
DIP
-DM
Ass
essm
ent
wit
hY
GTS
S;PT
Q;
CG
I-S
and
CG
I-I
Bo
thtr
eatm
ent
del
iver
ym
od
alit
ies
resu
lted
insi
g-
nifi
can
tti
cre
du
ctio
nw
ith
no
bet
wee
ng
rou
pd
iffer
ence
sN
elso
net
al.,
2012
Serv
ice
uti
lizat
ion
char
tre
view
22ch
ildre
nR
ou
tin
ecl
inic
alN
ofa
cto
rin
her
ent
toth
evi
deo
del
iver
ym
ech
anis
mim
ped
edad
her
ence
ton
atio
nal
AD
HD
gu
idel
ines
(co
nti
nu
ed)
514 N. E. GLOFF ET AL.
Tab
le1.
Co
nti
nu
ed
Cit
atio
nD
esig
nSa
mp
leA
sses
smen
tFi
nd
ing
s
Ree
seet
al.,
2012
Pre-
po
st8
child
ren
;A
sian
Ro
uti
ne
clin
ical
AD
HD
Fam
ilies
rep
ort
edim
pro
ved
child
beh
avio
ur
and
dec
reas
edp
aren
td
istr
ess
via
vid
eofo
rmat
of
Gro
up
Trip
leP
Posi
tive
Pare
nti
ng
Pro
gra
mSz
efte
let
al.,
2012
Des
crip
tive
Ch
art
revi
ew45
pat
ien
tsw
ith
dev
elo
pm
enta
ld
is-
abili
ties
;315
18ye
ars
Ro
uti
ne
clin
ical
–m
edic
atio
nch
ang
es,
freq
uen
cyo
fp
atie
nt
app
oin
tmen
ts,
dia
gn
ost
icch
ang
es,
sym
pto
mse
veri
tyan
dim
pro
vem
ent
Vid
eole
dto
chan
ged
psy
chia
tric
dia
gn
osi
sfo
r70
%,
and
chan
ged
med
icat
ion
of
82%
of
pat
ien
tsin
itia
lly,
41%
at1
year
and
46%
at3
year
sV
ideo
hel
ped
PCPs
wit
hre
com
men
dat
ion
sfo
rd
evel
-o
pm
enta
ld
isab
iliti
esH
eitz
man
-Po
wel
let
al.,
2013
Pre-
po
stN
SA
ge
not
rep
ort
ed7
par
ents
OA
SIS
trai
nin
gp
rog
ram
me
PBR
ITC
Pare
nts
incr
ease
dth
eir
kno
wle
dg
ean
dse
lf-re
po
rted
imp
lem
enta
tio
no
fb
ehav
iou
ral
stra
teg
ies
Mye
rsan
dV
and
erSt
oep
,20
13R
CT
223
youn
gp
eop
leR
ou
tin
ecl
inic
alD
ISC
-IV
,C
BC
LA
DH
Dra
tin
gsc
ales
Car
egiv
ers
rep
ort
edim
pro
ved
inat
ten
tio
n,
hyp
er-
acti
vity
,co
mb
ined
AD
HD
,O
DD
,ro
lep
erfo
rman
ceTe
ach
ers
rep
ort
edim
pro
vem
ent
inO
DD
and
role
per
form
ance
Ree
seet
al.,
2013
Des
crip
tive
and
RC
T21
child
ren
;90
%C
auca
sian
AD
OS
–M
od
ule
1A
DI-
RPa
ren
tsa
tisf
acti
on
No
diff
eren
cein
relia
bili
tyo
fd
iag
no
stic
accu
racy
,A
DO
So
bse
rvat
ion
s,ra
tin
gs
for
AD
I-R
par
ent
rep
ort
of
sym
pto
ms,
and
par
ent
sati
sfac
tio
nR
ock
hill
etal
.,20
13R
CT
223
child
ren
wit
hA
DH
D±
OD
D±
anxi
ety
Car
egiv
erd
istr
ess
asse
ssed
wit
hPa
tien
tH
ealt
hQ
ues
tio
nn
aire
-9,
Pare
nti
ng
Stre
ssIn
dex
,C
areg
iver
Stra
inQ
ues
tio
nn
aire
,Fa
mily
Emp
ow
erm
ent
Scal
e
Pare
nts
of
child
ren
wit
hA
DH
Dan
da
co-m
orb
idd
isor
der
had
sig
nifi
can
tly
mo
red
istr
ess
than
tho
sew
ith
AD
HD
alo
ne
Xie
etal
.,20
13R
CT
22ch
ildre
nB
ehav
iora
ld
isor
der
Ro
uti
ne
clin
ical
PCQ
-CA
,V
AS,
CG
AS,
CG
ISPa
ren
ttr
ain
ing
thro
ug
hvi
deo
was
asef
fect
ive
asin
-p
erso
ntr
ain
ing
and
was
wel
lac
cep
ted
by
par
ents
Co
mer
&B
arlo
w20
14Pr
e-/p
ost
5ch
ildre
n(a
ge
4–8)
Beh
avio
ura
lin
terv
enti
on
wit
hch
ild,
faci
litat
edb
yp
aren
t;O
CD
rati
ng
scal
eb
yp
aren
t
Ch
ildO
CD
sym
pto
ms
and
dia
gn
oses
dec
lined
;ch
ildg
lob
alfu
nct
ion
ing
imp
rove
d
Mye
rset
al.,
2015
RC
T22
3ch
ildre
nA
DH
D±
OD
D±
anxi
ety
CB
CL
scre
enin
g,
DIS
C-I
Vd
iag
nos
tic
asse
ssm
ent,
AD
HD
rati
ng
scal
es(in
atte
nti
on
,h
yper
acti
vity
,co
m-
bin
ed,O
DD
,ro
lep
erfo
rman
ce)
and
CIS
Car
egiv
ers
rep
ort
edsi
gn
ifica
ntl
yg
reat
erim
pro
vem
ent
for
inat
ten
tio
n,
hyp
erac
tivi
ty,
com
bin
edA
DH
D,
OD
D,
role
per
form
ance
for
vid
eove
rsu
sth
ose
trea
ted
inp
rim
ary
care
Teac
her
sre
po
rted
sig
nifi
can
tly
gre
ater
imp
rove
men
tin
OD
Dan
dro
lep
erfo
rman
cefo
rvi
deo
gro
up
,to
oTs
eet
al.,
2015
RC
Tsu
bsa
mp
le37
care
giv
ers
of
child
ren
wit
hA
DH
D±
OD
D±
anxi
ety
CaB
Td
eliv
ered
via
CB
CL
scre
enin
g,
DIS
C-I
Vd
iag
no
stic
asse
ssm
ent,
AD
HD
rati
ng
scal
es(in
atte
nti
on
,h
yper
acti
vity
,co
mb
ined
,O
DD
,ro
lep
erfo
rman
ce)
and
CIS
Car
egiv
ers
rep
ort
edco
mp
arab
leim
pro
vem
ents
for
child
ren
’so
utc
om
esw
het
her
CaB
Tvi
deo¼
inp
erso
n;
no
imp
rove
men
tin
care
giv
ers’
dis
tres
sw
hen
CaB
Tp
rovi
ded
thro
ug
hvi
deo
.
Ro
ckh
illet
al.
(201
5)D
escr
ipti
ve;
Tele
psy
chia
tris
tsin
RC
T22
3ch
ildre
nw
ith
AD
HD
±O
DD
±an
xiet
y,th
ete
lep
sych
iatr
ists
and
PCPs
Tele
psy
chia
tris
ts’
adh
eren
ceto
gu
ide-
lines
-bas
edca
re,
AD
HD
ou
tco
mes
by
pre
scri
ber
bas
edo
nco
-mo
rbid
-it
yst
atu
s
Tele
psy
chia
tris
tsad
her
edto
gu
idel
ine-
bas
edca
re,
use
dh
igh
erm
edic
atio
nd
ose
sth
anPC
Ps,a
nd
thei
rp
atie
nts
reac
hed
targ
eto
f50
%re
du
ctio
nin
AD
HD
sym
pto
ms
mo
reo
ften
than
wit
hPC
Ps
AD
HD
,at
ten
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INTERNATIONAL REVIEW OF PSYCHIATRY 515
studies show that services delivered through TMH arefeasible, acceptable, have been delivered across develop-mental status, and to young people with varied disorders.Early work suggests that outcomes are comparable toservices delivered in person.
TMH services are being provided in traditional clinicalsettings to collaborate with PCPs in the management ofchildren’s mental health needs (Goldstein & Myers, 2014;Greenberg et al., 2006; Lau et al., 2011; Myers et al., 2007;Yellowlees et al., 2008), and to provide ongoing treatmentto young people and their families (Duncan et al., 2014;Glueck, 2011; 2013b; Myers et al., 2008, 2010; 2015; Reeseet al., 2012; Tse et al., 2015; Xie et al., 2013). TMH alsoallows care to be delivered outside traditional clinicalsettings to reach young people in naturalistic settings suchas schools (Grady et al., 2011b; Stephan et al., 2014),correctional settings (Bastastini, 2013; Kaliebe et al.,2011), day care (Spaulding et al., 2011) and the home(Comer & Barlow 2014).
Considerations for providing telemental healthservices to children and adolescents
The delivery of services to children and adolescentsthrough TMH requires a number of adjustments topractice with adults. For example, referrals to child andadolescent psychiatrists often entail the assessment ofdevelopmental and cognitive disorders, such as autism, orthe consideration of early trauma. The telepsychiatristneeds to consider parent/guardian status and the ability tomeet the child’s needs and participate in treatment.Collaboration with community stakeholders is a standardexpectation that involves the participation of teachers,therapists and other professionals in addition to parentsand often other family members. Psychotherapy includesinterventions such as parent management training andplay therapy that involve other participants in treatment,the use of developmentally appropriate therapeutic aids,and modification of space and staffing. Pharmacotherapyinvolves medication choices, outcomes and side effectsthat may differ from adult treatment, and frequentlyinclude stimulants, Schedule II medications with specialregulation when prescribed online (US Department ofJustice Drug Enforcement Administration, 2009).
As guidelines for providing evidence-based care toyoung people through TMH are evolving (Hilty et al., inpress; Myers & Cain, 2008), child and adolescenttelepsychiatrists must utilize knowledge from the prac-tice parameters developed by the American Academy ofChild and Adolescent Psychiatry for usual patient care(aacap.org/aacap/families_and_use/resource_centers/home.afpx), apply skills from in person practice settings,and extrapolate from guidelines developed for general
TMH service delivery (Turvey et al., 2013; Yellowleeset al., 2010).
Models of care and sites of service for childrenand adolescents
Models of care to provide services to young
people through videoconferencing
Many non-metropolitan communities allocate theirlimited mental health care resources to the adultchronically mentally ill leaving few resources for youngpeople. Therefore, the first step in selecting the model ofcare is to determine whether a TMH service for youngpeople is needed, feasible, easily integrated and sustain-able based upon community services and resources(Glueck, 2011; Grady et al., 2011a). The next step is todetermine the site of care, which may be either a clinical(e.g. outpatient mental health clinic, primary care clinic)or a non-clinical setting (e.g. educational, juvenilecorrections, home). The treatment setting has implica-tions regarding available resources, patient monitoring,emergency planning, and capabilities of available staff(Carlisle, 2013; Glueck, 2013a). A successful model ofcare and TMH services partner with the communitystakeholders (Jones et al., 2014).
A clear model of care is often established at the time ofdesigning services. Three models utilized in TMH withyoung people and families include direct, consultative, orcollaborative care (Carlisle, 2013). In the direct caremodel the telepsychiatrist provides ongoing treatment ofthe patient. This model does not expand the pool of childand adolescent psychiatrists, but redistributes the work-force and may be most relevant to more serious disordersor selected settings. This contrasts with the consultationmodel in which the telepsychiatrist provides expertise toa provider who, in turn, maintains ongoing care of thepatient (Glueck, 2013a; Kriechman & Bonham, 2013;Myers & Cain, 2008). Consultation models may beconsultee-centred or client-centred. In the consultee-centred approach, the telepsychiatrist consults with thereferring provider about a patient either with or withoutthe patient being present and offers suggestions to thereferring provider. In client-centred consultation theyoung person and caregiver(s) participate in the sessionand the telepsychiatrist then makes recommendations tothe referring provider; however, this provider is often notpresent during the session. In the collaborative caremodel, the telepsychiatrist works alongside and followspatients jointly with a PCP (Fortney et al., 2013; Glueck,2013a; Kriechman & Bonham, 2013). The collaborativecare model is promising as an approach to integratingtelepsychiatry services into the paediatric medical home
516 N. E. GLOFF ET AL.
(McWilliams, unpublished). Consultation and collabora-tive models seek to increase the expertise of localproviders in providing mental health care. Models ofdirect care and consultation are most commonlydescribed with young people and families.
Sites of service and providing care
Outpatient settings and general considerations forproviding TMH care
Telepsychiatric care for children and adolescents mostcommonly occurs in outpatient settings. Multiple studieshave demonstrated that parents, providers, and youngpeople rate high levels of satisfaction with outpatientTMH care (Boydell et al., 2010; Grady et al., 2011a;Myers et al., 2007, 2008).
Crisis care may not be as readily available for childrenand adolescents as for adults in underserved commu-nities, thus it is advantageous to establish procedures forcrises using knowledge of local community resourcesprior to commencing services (Shore et al., 2007).Additionally, it is useful for the telepsychiatrist to workwith parents and staff at the patient site to establishprocedures for interim care.
Primary care
Due to the severe shortage of child and adolescentpsychiatrists in non-metropolitan communities (Birdet al., 2001; Connor et al., 2006), PCPs have becomedefault mental health providers (American Academy ofPediatrics, 2001). However, PCPs often want assistancein treating complex child mental health conditions thatthey encounter in their practices (Stiffman et al., 1997).Consultative (Boydell et al., 2007; Kriechman & Bonham,2013; Yellowlees et al., 2008) and collaborative(Kriechman & Bonham, 2012; Fortney et al., 2013)models support PCPs in building skills to provide mentalhealth care to their young patients, thereby increasingthe pool of mental health expertise (Goldstein & Myers,2014). Consultative and collaborative care models inprimary care settings are associated with high levels ofsatisfaction (Boydell et al., 2010; Greenberg et al., 2006;Myers et al., 2008). TMH shows promise for integrationinto the paediatric medical home model of care(McWilliams, unpublished).
Educational settings
Approximately 70–80% of children and adolescents whoreceive mental health services access that care in theschool setting (Rones & Hoagwood, 2000). School-based
mental health-care services offer the advantage ofevaluating children in the familiar and ecologicallyvalid setting of school with minimal disruptions totheir classroom time or parents’ workday (Goldstein &Myers, 2014; Grady et al., 2011b). TMH is a natural nextstep to expand the availability of psychiatric care inschools. While the evidence-base on school-based TMHis evolving, our experience indicates that both direct andconsultative care models are feasible and acceptableapproaches. The telespsychiatrist may provide a varietyof services, including evaluations, medication manage-ment, ongoing sessions with students and families,evaluation for support services, continuing educationfor staff, and consultation on specific and general schoolissues (Grady et al., 2011b). If providing consultation, therole of the telepsychiatrist is typically broader than therole for traditional in-person services. The telepsychia-trist may consult to a multidisciplinary team includingeducators, school administrators, mental health clin-icians and other school team members (Stephan et al.,2014) and may participate in coordination of mentalhealth care to students via involvement in multidiscip-linary planning, student evaluation and meeting withteachers, school clinicians and administrators. Thisenhanced coordination of care allows for improvedmental health and educational progress for young peopleand support for teachers (Grady et al., 2011b; Sanderset al., 2012).
Challenges to implementing TMH in the schoolsetting are privacy, adequate space and other infrastruc-ture for the service, especially in overcrowded schools(Stephan, 2014). Schools that are able to make theseaccommodations have demonstrated benefit to youngpeople and educators (Cunningham et al., 2013).
Juvenile corrections
The rates of mental illness among incarcerated youngpeople exceed that of the general population(Wasserman et al., 2004) and psychiatric services inthe Juvenile Justice System remain scarce. TMH has beensuccessfully utilized to fill this void for young peoplewith a range of psychiatric diagnoses (Fox, 2008; Kaliebeet al., 2011; Myers et al., 2006). TMH offers severaladvantages, such as eliminating the need for youngpeople to travel outside of the correctional facility forappointments, coordination of care with onsite staff andtimely evaluation and ongoing treatment (Bastastiniet al., 2013).
There are some challenges when working with thisvulnerable population. There is a risk of acting with dualagency to both the juvenile justice facility and to thepatient. The telepsychiatrist must have knowledge of the
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juvenile justice system, help correctional staff to under-stand how mental health conditions affect youngpeople’s behaviour while incarcerated, and ensure theirprivacy (Kaliebe et al., 2011).
Home-based telepsychiatry
TMH services provided directly to the patient’s home isan area that is expanding with adults (Luxton et al.,2012) and emerging with children (Comer et al., 2014;2015; Lieberman et al. 2014). The telepsychiatrist hasthe opportunity to observe children and their familiesin a naturalistic setting and services can be delivered inthe context where the child’s behaviors occur. This maybe particularly useful for interventions that involveparent–child interactions, parent-facilitated behaviourtraining, or helping youngsters to implement learnedskills within their home environment (Comer et al.,2014; 2015).
In the traditional outpatient TMH clinic, the tele-psychiatrist has access to onsite staff who are available totend to safety issues. Home-based TMH services may notbe appropriate if there is a serious concern for patientsafety. The development of a safety and crisis plan withthe child and parents will help the telepsychiatrist todetermine the family’s ability to safely participate in careand to inform the family of conditions under which thetelepsychiatrist may break confidentiality to contact anemergency provider (Luxton et al., 2012).
Other challenges to delivering services to the homeinclude difficulty in ensuring privacy and addressingtechnical difficulties that may emerge during the video-conference. Children may be less manageable andengaged in sessions conducted in the familiarity oftheir home, and the risk of elopement is likely higherthan in a clinic.
Establishing a therapeutic space for providingcare through videoconferencing with youngpeople
Infrastructure, technology, and staffing needs
Delivering services to young people and their familiesthrough videoconferencing entails practical consider-ations of the infrastructure, technology, and staffing notencountered during services delivered in person orthrough TMH with adults.
Room selection at the patient site
Rooms used for evaluation of an adult may not provide asufficient space to evaluate a young person. The room
must be large enough to accommodate the youngster andat least two other adults. It should allow the child tomove freely so that the telepsychiatrist can assess grossmotor skills, activity level and engagement, but not solarge that a hyperactive or agitated child strays offcamera. Medical examination rooms may overstimulatechildren and risk damage to equipment from curious ordisruptive youngsters. Ideally, the room would be set upaccording to the clinical focus of the session. Forexample, diagnostic sessions may be facilitated byproviding selected toys, drawing materials, or activities,but a psychotherapy session may require a sparselyendowed room without such distractions.
Technological considerations
The assessment of children and adolescents is facilitatedby selected technology features. Utilizing high bandwidth(384 kbits/s) allows the telepsychiatrist to observesubtleties in the child’s speech, facial expressions andmovements, e.g. prosody, affective blunting, and tics. Italso allows the telepsychiatrist to respond fluidly to thepatient and family so that elements of the interactions,such as empathy and emotional tone are adequatelyconveyed (Glueck, 2013b). Appropriate camera place-ment optimizes the ability of the telepsychiatrist to assessthe youngster’s eye contact, an important developmentalskill that is crucial to conducting the mental statusexamination of the child (Carlisle 2013; Glueck, 2011). Itis particularly helpful to have a camera that can pan theroom at the patient site to follow the child’s movement,zoom in to examine for dysmorphia and affect, andadjust the view to simultaneously observe both the childin play and the parent during conversation. However,such capabilities may not be possible with onlinevideoconferencing systems, which may be a disadvantagein the context of the telepsychiatrist’s clinical goals.
Clinic protocols and staffing considerations
Staff at the patient site can extend the reach of thetelepsychiatrist in managing sessions and may providetasks beyond those required for adult services (Glueck,2011; Glueck, 2013b; Myers & Cain, 2008). For example,staff may provide collateral information regardingobservations of a depressed teen while in the waitingroom, or may remain with the family during the sessionto help manage a child while the telepsychiatrist speakswith the parent, or may structure a behavioural inter-action for the child (Savin et al., 2006). Staff can alsoincrease efficiency of services by enabling the telepsy-chiatrist to interview an adolescent or parent privatelywhile the local clinician works with the other family
518 N. E. GLOFF ET AL.
members. The staff may serve as a care manager tocommunicate with other professionals involved in theyoung person’s care, facilitate the filling of prescriptions,coordinate interim care, and monitor treatmentresponse. The care manager must be able to operatethe videoconference equipment as well as comfortablyhelp to manage behavioural problems with children(Myers et al., 2010). Finally, clinic protocols need toconsider specific legal issues related to children andadolescents. This includes the age of majority in the statein which the young person resides as well as lawsregarding child abuse reporting.
Systems, cultural and community considerations
Child and adolescent psychiatrists regularly navigatecomplex and varied systems of care, not only in treatingthe patient but also in coordinating services andaccessing the myriad of individuals and resourcesinvolved in the young person’s life (e.g., schools, primarycare providers). In addition to a child’s nuclear family,extended family members and other kinship relationsmay play pivotal roles in providing care to young people(Carlisle 2013; Chatters et al., 1994). These systems areembedded in the family’s culture and community whichpresent additional complexities to delivering culturally-informed, evidence-based psychiatric care (Kataokaet al., 2010; Rockhill, 2013), particularly as telepsychia-trists may be located hundreds of miles away from theirpatients and unfamiliar with their community, its cultureand service systems. In some respects, the challenge andsuccess of child and adolescent telepsychiatrists rests intheir ability to unify these systems, community andcultural factors into a cohesive set of supports for thechildren and their families. Several TMH programmeshave overcome these challenges to deliver high-qualitycare to geographically and ethnically diverse groups,including Alaska Native, American Indian, Cambodian,Chinese, and Hispanic communities across state linesand international borders (Kataoka et al., 2003; Mucic2010; Savin et al., 2006; Shore & Manson 2005; Yeunget al., 2011).
Shore and colleagues (Shore et al., 2005) recommendthe use of a six-stage process for developing TMHservices that is particularly applicable for programmesfocused on children and families. These include a carefulevaluation of the specific needs of the population, anassessment of the existing child and family-servingsystem, development of a TMH service delivery structurethat will take advantage of existing programmes, fillservice delivery gaps, and allow for coordinated care, andthen piloting services on a small scale before expandingservices to full capacity. Cultural issues are addressed
throughout this process (Shore & Manson 2005, 2006;Savin et al., 2011). Child and adolescent TMH providerscan cultivate their role with the youngsters by familiar-izing themselves with the local community and culture,and by knowing about common recreational activities,community events, local industries, employment, and byaligning with key community supports. Site visits duringthe development of TMH services and periodicallythroughout the operation of the programme are particu-larly helpful in developing such knowledge and buildingpartnerships with stakeholders. Children and adolescentsoften enjoy meeting in person with the stakeholders.
Clinical interventions
Evaluation and establishing therapeutic alliance
Therapeutic alliance is a strong predictor of outcome inmental health treatment and this is thought to beparticularly important when working with children andadolescents (Elvins & Green, 2008). The reportedhigh satisfaction rates with TMH services suggestthat a solid therapeutic alliance develops (Elford et al.,2001; Greenberg et al., 2006; Myers et al., 2008).Telepsychiatrists employ creative approaches to establisha therapeutic alliance. It is helpful to assure young people,particularly adolescents, that there are procedures toensure patient confidentiality and that the sessions willnot be recorded or shared (Glueck, 2013b). Access to theInternet during a session allows the telepsychiatrist toengage adolescents by exploring an online site, such asYouTube or Facebook. Children enjoy drawing picturesthat they then share through the camera while telling astory. Drawings also help the telepsychiatrist to assesschildren’s attention, fine motor skills and creativity whichare then integrated into their interactions with the child.Children use play figures, such as dolls or action figures, todemonstrate their ability for symbolic play and revealtheir thought content regarding human interactions.Some children simply like to play hide and seek. Otherhelpful approaches include the ability to share the desktopfor behavioural training or for the patient to share itemsabout their school, community or favourite songs andvideos. But, the single most effective means of establishingan alliance with young people is conversation, just likeadult in-person treatment.
Pharmacotherapy
Prescribing medications for children and adolescents isone of the most frequently requested services intelepractice and entails a few considerations beyondcare with adults. Telepsychiatrists must determine the
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age at which a young person is legally required toprovide his/her written consent to medication treatment.In evaluating the need for medication, as well asmonitoring the patient’s progress, the mental statusexamination (MSE) serves as the patient’s ‘vital signs ofmental health.’ Several studies have shown that the MSEperformed via videoconference is comparable to thatconducted in person (Elford et al., 2000; Reese et al.,2013; Stain et al., 2011). Monitoring of vital signs isroutine due to the potential adverse effects of medicationon growth and development and the co-occurrence ofmedical conditions in young people with psychiatricdisorders. Prior to the initiation of TMH services it iscustomary for the telepsychiatrist to determine whetherhe/she prefers to order medications and laboratoryassessments themselves or with assistance from theyoung person’s PCP. Particular attention must be givento the use of stimulants, Schedule II medications, whichhave additional regulations for prescribing throughTMH (US Department of Justice, Drug EnforcementAdministration, 2009). The delivery of hard copySchedule II prescriptions to the pharmacy is requiredand may require additional coordination with theoriginating site.
In general, it is important to develop a relationshipwith a local PCP and pharmacist to ensure the ability ofthe telepsychiatrist to draw on local expertise whenneeded. Indeed, some states require that telepsychiatristsshare all assessments and progress notes with thepatient’s PCP (Conn, 2014). Prescribing via TMH is anevolving area. It is important for telepsychiatrists to stayinformed regarding state and federal laws, as they remainin flux.
Rating scales are routinely used in child and adoles-cent psychiatry practice to monitor treatment responseand side effects. The Abnormal Involuntary MovementScale (AIMS) has been shown to be reliable for theassessment through videoconferencing of movementdisorders in adults taking antipsychotic medicationsand is used to monitor young people as well(Amarendran et al., 2011). It is helpful to set up apatient portal for families and teachers to completesymptom-based rating scales online during TMH care(Myers et al., 2015).
Psychotherapy
Access to evidence-based psychotherapy and providerstrained to treat young people are limited in non-metropolitan communities. Teletherapy studies con-ducted with adults through videoconferencing haveconsistently demonstrated outcomes that are comparableto outcomes for the same therapy delivered in person
(Day & Schneider, 2002; Morland et al., 2010; Ruskinet al., 2004). The feasibility of delivering psychotherapyto young people through videoconferencing has beendemonstrated for multiple disorders, including atten-tion-deficit/hyperactivity disorder (ADHD), bulimianervosa, panic disorder, agoraphobia, obsessive–com-pulsive disorder (OCD), depression, post-traumaticstress disorder (PTSD), and adjustment disorder(Nelson et al., 2011).
However, the evidence base supporting the effective-ness of TMH-delivered psychotherapy with youngpeople is developing incrementally (Table 1). Furtherrandomized trials are needed comparing TMH-facili-tated versus in person delivered care and demonstratingthe benefits of enhancing PCP care with TMH consult-ation (Myers et al., 2015).
Given the current and projected disparity between thedemand and supply of child and adolescent psychiatrists,novel approaches have looked to asynchronous TMHprogrammes. One example is BRAVE-Online, developedfor the treatment of anxiety and depression in youngpeople (Spence et al., 2008). The self-administeredintervention is augmented with minimal support from atherapist which can be provided through TMH. Internet-delivered psychotherapy offers the potential to makeevidence-based treatments widely available for timely,efficient, and effective care. TMH offers the opportunityto keep young people engaged in self-administeredtreatments and to apply new skills to daily life.
Discussion: clinical implications and futuredirections
Child and adolescent telepsychiatry is a feasible, accept-able and sustainable approach to address the gap inaccess to services for underserved populations. Over thepast 15 years, the use of TMH to serve children andadolescents has moved from the realm of small proof ofconcept studies and niche services to randomized clinicaltrials and an ever-broadening array of care models. Thelimited available research suggests that care deliveredthrough TMH is effective. However, more research isneeded to know whether the quality of care andoutcomes delivered to young people are comparable toservices provided in person. Treating young people viaTMH requires accommodations that are not neededwhen working with adults, but these can be easily metwith the assistance of a coordinator at the patient site. Italso requires that the provider keep up to date on stateand federal laws and regulations related to providingservices via TMH as these remain in flux. TMH is oneapproach for child and adolescent psychiatrists toexpand their practice according to their specific
520 N. E. GLOFF ET AL.
expertise, interests and resources. It also providesflexibility for the provider at various stages of theirprofessional and family life.
TMH is becoming a key component of our mentalhealth service delivery system and will likely becomeeven more important in the years to come. In addition torefining service delivery models, particularly in non-traditional settings such as school and the home, it willbe important to assess the true impact of TMH inimproving the quality and accessibility of mental healthservices more broadly. As we note at the start of thispaper, the child and adolescent mental health workforceis not anticipated to grow over the next decade, yet theneed for mental health services will likely grow. ForTMH to have a real impact on access to care, we willneed to pay particular attention to models in whichmedical and mid-level providers are supported by mentalhealth specialists and are thus able to effectively expandthe child and adolescent mental health workforce. It is inthis arena that the true promise of TMH lies.
Declaration of interest
The authors report no conflicts of interest. The authors aloneare responsible for the content and writing of the paper.
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