•  Child and Adolescent Telepsychiatry
•  Ranna Parekh, M.D., M.P.H.

Telepsychiatry’s evidence base for child and adolescent psychiatry is developing, with a considerable increase in the past 10 years. Most published work has related to program development, with reports of feasibility of implementation and acceptability/satisfaction to families, teens, and referring primary care providers. There is an evolving evidence-base supporting the effectiveness of interventions provided through videoconferencing. These studies include pre-to-post intervention outcomes and a few randomized controlled trials, mostly with small samples using study designs that compare services delivered through videoconferencing versus services delivered in person. One large community-based trial demonstrated superiority of a short term telepsychiatry intervention for ADHD versus management in primary care following a teleconsultation. Overall, the evidence-base indicates:

• Satisfaction has been rated as very high by parents, teens, and referring providers.
• A variety of disorders have been successfully treated, starting with depression in the early 2000s, and extending to anxiety, obsessive-compulsive disorder, tics, attention-deficit hyperactivity, and behavioral disorders (e.g., Oppositional Defiant Disorder).
• Models of care are varied, from traditional video-based direct care, to collaborative care by telepsychiatry, to primary care, as well as consultative and collaborative services with other professionals in non-clinic settings.
• With this population, various sites of service have been utilized, including mental health clinics, primary care settings, schools, juvenile correctional facilities, state health agencies, and in the home.

The American Association of Child and Adolescent Psychiatry (AACAP) has taken the lead in putting together helpful a “practice parameter” in 2008, which reviewed the evolution of services, offered information on starting a service, and detailed administrative issues. This type of “parameter” is sometimes called “strategies...for the service” or minimal standards. More recently, AACAP has provided key considerations about patient appropriateness, site locations, therapeutic space, technology, how to select a model of care, and risk management.

The American Telemedicine Association’s Telemental Health Interest Group is working on a Clinical Practice Guideline, complementing the adult guideline, but will provide further specifications on a few key issues pertinent to this population:

• Pre-visit planning for assessing the youth (e.g., room configuration)
• Preparing for specific levels of interaction (e.g., toys to show interests and skills; a child-sized table; materials for drawing to demonstrate fine motor skills, etc.; internet access for teens to show favorite You Tube recording)
• Training staff, if needed, to facilitate the interview or play with the child, or for managing sibling interactions
• Augmenting the visit by linking with teachers or others by telephone or videoconferencing
• Remembering “who” the patient is, mainly the child/adolescent, siblings, parents, social workers, teachers, and others in the community
• Collaboration with stakeholders in the youth’s system of care
• Implementing the AACAP’s guidelines for diagnosis and treatment of specific disorders
• Prescribing controlled substances within the DEA guidelines

Highlights about clinical trends include:

• For some youth who pose challenges (e.g., behavioral) to traditional clinic settings, telepsychiatry may be a preferable alternative.
• Use of school-based telepsychiatry is increasing rapidly but not well described in the literature. It offers the opportunity to reach the most youth in need of services, in a comfortable setting, and with incorporation of parents who are acquainted with their child’s educational experiences while minimizing disruptions to their work schedules.
• Home-based telepsychiatry is the newest setting to be explored and to be described in the literature. In-home telepsychiatry offers the opportunity to assess the youth in a naturalistic and ecologically valid setting with minimal disruptions to the family’s day, although new challenges in service delivery must be addressed.
• Correctional settings are another growing, but under-reported, area of success for child and adolescent telepsychiatry. As these youth have high rates of under-diagnosed and/or untreated psychiatric disorders, telepsychiatry offers an opportunity to provide needed care. Telepsychiatry also presents an opportunity to educate correctional staff regarding the role of mental health disorders in adolescents’ conduct problems.
• Kids and youth like to use technology, so things like social media are being researched for how they change care for the better and (potentially) for the worse.

References

1. Myers KM, Cain S and the Workgroup on Quality Issues. Practice Parameter for Child and Adolescent Telepsychiatry. Journal of The American Academy of Child and Adolescent Psychiatry 47: 1468-1483, 2008
2. Hilty DM, Ferrer DC, Parish MB, et al. The Effectiveness of telemental health: A 2013 review. Telemed J E Health 2013;(19):444-454.
3. Myers K, Vander Stoep A, Zhou C, et al. Effectiveness of a telehealth service delivery model for treating attention-deficit hyperactivity disorder: results of a community-based randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2015;54(4):263-74.
4. Yellowlees PM, Shore JH, Roberts L, et al. Practice Guidelines for Videoconferencing-Based Telemental Health. Telemed J E-Health 2010;16(10):1074-89.