Children and Families 

Telepsychiatry: A New Treatment Venue for Pediatric Depression (Roth, Ramtekkar & Zekovic-Roth, 2019) DOI: Key points: 1. Telepsychiatry is being used to treat pediatric depression in different models of care and benefits of using it in places like homes, schools, primary care offices, juvenile correction centers and residential facilities are well established. 2. Has potential to improve prevention, early identification, and treatment of pediatric depression by removing the geographic barrier between patients and providers, lowering costs and decreasing time. 3. Telepsychiatry outcomes and patient satisfaction ratings are sometimes higher than traditional face-to-face sessions. 4. Engaging, building relationships, and communicating with telepsychiatry patients are significantly different from traditional medical settings. 5. Webside manners and intentional shaping of an authentic treatment experience and provider-patient relationship is required for effectiveness. Properly using staging and nonverbal/verbal communication can make telepsychiatry sessions feel authentic and treatment outcomes meet/exceed traditional treatment. 

A National Examination of Child Psychiatric Telephone Consultation Programs’ Impact on Children’s Mental Health Care Utilization (Stein et al., 2019) This study assessed if a child psychiatric telephone consultation program increased the use of child mental health services. Researchers found that children living in states with a statewide child psychiatric telephone consultation program had significantly greater parent-reported child mental health service use than children in states without the service. The study showed that the telephone service programs could be an important tool in efforts to increase children’s mental health service use. 

Online Treatment and Virtual Therapists in Child and Adolescent Psychiatry (Schueller, Stiles-Shields & Yarosh, 2017) This article reviews the current state of practice for online and virtual therapies, as well as highlighting effective models. Lessons from the field and examples are given to discuss considerations and future directions for online therapy. 

Availability of Telephone-Based Child Psychiatry Consultation: Implications from a Survey of Pediatric Providers in Two States (Pidano et al., 2016) Pediatric primary care providers (PCPs) play a critical role in caring for children with mental health concerns. Some states have introduced programs to support PCPs in managing these patients more independently. The Massachusetts Child Psychiatry Access Project consultation program is one example. This study compared responses from PCPs in Massachusetts (n = 73) with PCPs in Indiana (n = 33), a state without a consultation program, to vignettes about children with possible attention-deficit/hyperactivity disorder or depression. Participants from MA indicated a stronger interest in behavioral health issues and were more likely to screen patients. PCPs from IN were more likely to have completed a rotation in developmental and behavioral pediatrics during residency. IN respondents were also more likely to choose the correct diagnosis for vignettes and less likely to refer to a psychiatric provider for psychotropic medication. Results suggest greater independence for PCPs in IN.

Effectiveness of a Telehealth Service Delivery Model for Treating Attention-Deficit/Hyperactivity Disorder: A Community-Based Randomized Controlled Trial (Myers et al., 2015) Objective: To test the effectiveness of a telehealth service delivery model for the treatment of children with attention-deficit/hyperactivity disorder (ADHD) that provided pharmacological treatment and caregiver behavior training. Method: The Children’s ADHD Telemental Health Treatment Study (CATTS) was a randomized controlled trial with 223 children referred by 88 primary care providers (PCPs) in 7 communities. Children randomized to the experimental telehealth service model received 6 sessions over 22 weeks of combined pharmacotherapy, delivered by child psychiatrists through videoconferencing, and caregiver behavior training, provided in person by community therapists who were supervised remotely. Children randomized to the control service delivery model received treatment with their PCPs augmented with a telepsychiatry consultation. Outcomes were diagnostic criteria for ADHD and oppositional defiant disorder (ODD) and role performance on the Vanderbilt ADHD Rating Scale (VADRS) completed by caregivers (VADRS-Caregivers) and teachers (VADRS-Teachers) and impairment on the Columbia Impairment Scale-Parent Version (CIS-P). Measures were completed at 5 assessments over 25 weeks. Results: Children in both service models improved. Children assigned to the telehealth service model improved significantly more than children in the augmented primary care arm for VADRS-Caregiver criteria for inattention (χ²[4] = 19.47, p < .001), hyperactivity (χ²[4] = 11.91, p = .02), combined ADHD (χ²[4] = 14.90, p = .005), ODD (χ²[4] = 10.05, p = .04), and VADRS-Caregiver role performance (χ² [4] = 12.40, p = .01) and CIS-P impairment (χ²[4] = 20.52, p < .001). For the VADRS-Teacher diagnostic criteria, children in the telehealth service model had significantly more improvement in hyperactivity (χ²[4] = 11.28, p = .02) and combined ADHD (χ²[4] = 9.72, p = .045). Conclusion: The CATTS trial demonstrated the effectiveness of a telehealth service model to treat ADHD in communities with limited access to specialty mental health services.

Telepsychiatry in Juvenile Justice Settings (Kaliebe, Heneghan & Kim, 2011) This article explores the various systems and settings in juvenile corrections and reviews case-studies of telepsychiatry usage in different correctional systems across the United States. 

Child and Youth Telepsychiatry in Rural and Remote Primary Care (Pignatiello et al., 2011) This article walks through how a telepsychiatry program called TeleLink, was developed, the components and results after 10 years of operation. This program is based out of Canada and included children ages 0-18. Key takeaways include: the importance of acknowledging the social context of various communities, positive experiences of families due to reduced burden after telepsychiatry services, and enhanced capacity of service providers to deal with complex mental health issues. 

Bridging Cultures: Child Psychiatry via Videoconferencing (Savin et al., 2011) This article walks through cultural aspects of telepsychiatry related to specifically to children. Cultural challenges that children and families encounter while using technology is the main focus of the article.

Telepsychiatry for Children with Developmental Disabilities: Applications for Patient Care and Medical Education (Szeftel et al., 2011) Telemedicine is able to provide specialized care to rural patients with limited access. The developmentally disabled population is highly suited to this modality and can be seen in general and specialized clinics. The collaborative care model, which is useful for this population, provides ongoing collaboration with both the local primary care provider and the local treatment team. Telepsychiatry can be used for education of trainees working together with an attending physician. These clinics can become exceptional opportunities to provide exposure to the specialty of child psychiatry for young doctors in training. As new programs develop, telepsychiatry for treatment and telepsychiatry for training should go hand in hand.

Telepsychiatry Assessments of Child or Adolescent Behavior Disorders: A Review of Evidence and Issues (Diamond & Bloch, 2010) Psychiatric assessments and treatments provided via two-way videoconferencing (telepsychiatry) have been used to increase the availability of child psychiatrists. This literature review of telepsychiatry assessment of children and adolescents focuses on the comparability of telemedicine to in-person treatment for child or adolescent patients. This review of papers between 1996 and 2009 shows acceptance and concurrence of diagnosis compared with in-person assessments.

Feasibility, Acceptability, and Sustainability of Telepsychiatry for Children and Adolescents (Myers, Valentine & Melzer, 2007) OBJECTIVE: This study examined the feasibility, acceptability, and sustainability of a telepsychiatry service for children and adolescents living in nonmetropolitan communities. METHODS: Using high-bandwidth interactive video teleconferencing, psychiatrists at a children’s hospital provided care to patients of primary care physicians at four nonmetropolitan sites. Review of one-year utilization provided feasibility data. Surveys of referring physicians examined acceptability of telepsychiatry. Reimbursement records provided sustainability data. RESULTS: Overall, 387 sessions were provided to 172 youths (mean=2.25 sessions) whose clinical profiles were representative of national samples. Referring providers endorsed high satisfaction with telepsychiatric care, although pediatricians were consistently more satisfied than family physicians. Sustainability of telepsychiatry is challenged by infrastructure costs and low reimbursement by public payers. CONCLUSIONS: Telepsychiatry is a feasible and acceptable approach to providing psychiatric services to youths in underserved communities. Sustainability will depend on developing financial alternatives to fee-for-service, especially if caseloads emphasize publicly funded programs.

Telepsychiatry with Children and Adolescents: Are Patients Comparable to Those Evaluated in Usual Outpatient Care? (Myers, Sulzbacher & Melzer, 2004) Several studies have described successful applications of telepsychiatry with children and adolescents. However, there has been little examination of the populations served by telepsychiatry and the ability to evaluate youth accurately through this medium. In this article, we examined whether telepsychiatry patients are representative of those in usual outpatient care. Participants included 369 patients 3-19 years old evaluated at two clinics. A new telepsychiatry clinic (TPC) developed to provide services to under-served communities, and a child and adolescent psychiatric outpatient clinic (CAPOC) that served youth from predominantly metropolitan areas were included in the study. The telepsychiatry sites were linked using ISDN lines at 384 KB/sec. We examined these two samples regarding demographics, payor status, and diagnostic profiles. Results indicated that youth evaluated through the TPC were broadly comparable to youth evaluated in the CAPOC. Therefore, telepsychiatry appears to serve youth that are representative of those seeking psychiatric care, and it is not restricted to youth with no medical insurance or with selected diagnoses. The similarity of diagnoses further suggests that telepsychiatry provides adequate technical resolution and doctor-patient rapport to detect psychopathology of youths. These findings suggest the need for further systematic investigation of telepsychiatry as a tool for providing psychiatric care to young people.

General Telepsychiatry Research

Proposed Competencies for Providing Integrated Care via Telepsychiatry (Crawford, Sunderji, Serhal & Teshima, 2017)  This article walks through and synthesizes the different literature on telemental health competencies and practices for integrated care. It also provides direction for future training for those obtaining degrees in psychiatry to work in the telepsychiatry field. 

Review of Key Telepsychiatry Outcomes (Hubley et al., 2016) DOI: 10.5498/wjp.v6.i2.269    Researchers found that overall patients and providers are generally satisfied with telepsychiatry services, but providers express more concerns about the adverse effects of telepsychiatry on therapeutic rapport. Research also shows that telepsychiatry is comparable to face-to-face services based on it’s reliability of assessments and outcomes, and some cases where non-inferiority designs were used telepsychiatry performed better than face-to-face services.

Usefulness of Telepsychiatry: A Critical Evaluation of Videoconferencing-Based Approaches Telepsychiatry, i.e., the use of information and communication technologies to provide psychiatric services from a distance, has been around for more than half a century now. Research over this period has shown that videoconferencing-based telepsychiatry is an enabling and empowering form of service delivery, which promotes equality of access, and high levels of satisfaction among patients. The range of services offered by videoconferencing-based telepsychiatry, potential users and points of delivery of such services are theoretically limitless. Telepsychiatry has both clinical utility and non-clinical uses such as administrative, learning and research applications. A large body of accumulated evidence indicates that videoconferencing-based telepsychiatric assessments are reliable, and clinical outcomes of telepsychiatric interventions are comparable to conventional treatment among diverse patient populations, ages and diagnostic groups, and on a wide range of measures. However, on many aspects of effectiveness, the evidence base is still relatively limited and often compromised by methodological problems. The lack of cost-effectiveness data in particular, is a major hindrance, raising doubts about the continued viability of telepsychiatric services. Added to this are the vagaries of technology, negative views among clinicians, poor uptake by providers, and several legal, ethical and administrative barriers. These hamper the widespread implementation of telepsychiatry and its integration with routine care. Though further advances in technology and research are expected to solve many of these problems, the way forward would be to promote telepsychiatry as an adjunct to conventional care, and to develop hybrid models, which incorporate both traditional and telepsychiatric forms of mental health-care.

Practice-Based Versus Telemedicine-Based Collaborative Care for Depression in Rural Federally Qualified Health Centers: A Pragmatic Randomized Comparative Effectiveness Trial (Fortney et al., 2012) OBJECTIVE: Practice-based collaborative care is a complex evidence-based practice that is difficult to implement in smaller primary care practices that lack on-site mental health staff. Telemedicine-based collaborative care virtually co-locates and integrates mental health providers into primary care settings. The objective of this multisite randomized pragmatic comparative effectiveness trial was to compare the outcomes of patients assigned to practice-based and telemedicine-based collaborative care. METHOD: From 2007 to 2009, patients at federally qualified health centers serving medically underserved populations were screened for depression, and 364 patients who screened positive were enrolled and followed for 18 months. Those assigned to practice-based collaborative care received evidence-based care from an on-site primary care provider and a nurse care manager. Those assigned to telemedicine-based collaborative care received evidence-based care from an on-site primary care provider and an off-site team: a nurse care manager and a pharmacist by telephone, and a psychologist and a psychiatrist via videoconferencing. The primary clinical outcome measures were treatment response, remission, and change in depression severity. RESULTS: Significant group main effects were observed for both response (odds ratio=7.74, 95% CI=3.94-15.20) and remission (odds ratio=12.69, 95% CI=4.81-33.46), and a significant overall group-by-time interaction effect was observed for depression severity on the Hopkins Symptom Checklist, with greater reductions in severity over time for patients in the telemedicine-based group. Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care evidence base in the telemedicine-based group. CONCLUSIONS: Contracting with an off-site telemedicine-based collaborative care team can yield better outcomes than implementing practice-based collaborative care with locally available staff.

Telepsychiatry in Private Practice (Gleuk, 2011) This article looks at the challenges that are unique to the private practice setting when using telepsychiatry and proposes adaptations to increase provider comfort and the success of the endeavor in that setting. Three main categories: 1. concerns about the adequacy and support 2. provider comfort with care delivery in this medium 3. concerns about financial feasibility. 

Urban Telepsychiatry: Uncommon Service for a Common Need (Spaulding, Cain & Sonnenschein, 2011) This article focuses on the urban practice of telepsychiatry in Kansas and other urban practices around the U.S. Unique clinical operational and clinical issues are discussed as well as illustrations from the Kansas practice. Key points: Telekidcare (school based telemedicine) reduced costs and increased efficiency in schools and 96% of all TeleKidcare consultations are for mental health. An urban infrastructure can be more supportive of telehealth from technical and clinical support perspectives (special/emergent situations). Ability to leverage telehealth for a greater number of patients in an urban area compared with a rural area can be substantial. Barriers for rural and urban communities are equally challenging. 

Children and Families 

Using Videoconferencing to Deliver Individual Therapy and Pediatric Psychology Interventions with Children and Adolescents (Nelson & Patton, 2016)  BACKGROUND: Because of the widening access gap between need for individual and pediatric psychology services and child specialist availability, secure videoconferencing options are more needed than ever to address access challenges across underserved settings. METHODS: The authors summarize real-time videoconferencing evidence to date across individual therapy with children and pediatric psychology interventions using videoconferencing. The authors summarize emerging guidelines that inform best practices for individual child therapy over videoconferencing. RESULTS: The authors present three case examples to illustrate best practices. The first behavioral pediatrics case summarizes evidence-based approaches in treating a rural young adolescent with attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and hearing impairment. The second pediatric psychology case describes similarities and difference between on-site and videoconferencing services in treating a rural child with toileting concerns. The third adolescent case describes treatment of an urban honors student with depression. CONCLUSIONS: Videoconferencing is an effective approach to improving access to individual and pediatric psychology interventions for children and adolescents. Videoconferencing approaches are well accepted by families and show promise for disseminating evidence-based treatments to underserved communities.

Using Videoconferencing to Provide Psychological Services to Rural Children and Adolescents: A Review and Case Example (Duncan, Velasquez & Nelson, 2014)Children and adolescents living in rural areas have difficulty accessing psychological services due to a lack of psychologists and other behavioral health professionals, especially those with expertise in treating youth. Telepsychology helps bridge this access gap. This article extends evidence supporting videoconferencing for psychological assessment and treatment in adults to support telepsychological treatment for youth. In addition, the basic components needed to begin and sustain a telepsychological practice are explored. Finally, a case example of an adolescent presenting with depression and disordered eating illustrates the practice of, and ethical standards needed for, telepsychology. Future technologies and applications around telepsychology are also discussed.

Telepsychology Outcome Research with Children and Adolescents: A Review of the Literature (Slone, Reese & McClellan, 2012) Using technology as a service medium has been touted as a potentially feasible and effective alternative and/or adjunct to in-person services. The telepsychology literature has given less attention to children and adolescents in comparison to adults. This review provides a summary and critique of the empirical research focused on psychological services provided to children and adolescents using three technology media (i.e., videoconferencing, Internet, and telephone). The evidentiary support for providing services with each of these media for a range of concerns is encouraging. The quantity and quality of research, however, both need to be enhanced to better understand how technology mediates the provision of youth services, as well as to elevate telepsychology within professional psychology. Future research and its subsequent impact on policy and practice are considered.

Telepsychology: Research and Practice Overview (Nelson, Bui & Velasquez, 2011) This article reviews the telepsychology literature and then builds on early telepsychology guidance for the current practice environment. Main takeaways are that televideo for psychology services continues to depend on parents’ preferences, developmental and diagnostic considerations, personnel and other resources at the distant site and psychologist comfort. 

The feasibility of Videoconferencing for Neuropsychological Assessments of Rural Youth Experiencing Early Psychosis (Stain et al., 2011)  We conducted a pilot study of the feasibility of videoconferencing as a mode of neuropsychological assessment in young people (14-30 years) from a rural area of New South Wales experiencing early psychosis. All participants (n = 11) completed assessments both face-to-face and by videoconference at a bandwidth of 384 kbit/s. Assessments included confirmation of diagnosis, quality of life and neurocognitive functioning. There was a strong correlation between modes of assessment for most instruments. Bland-Altman plots indicated that in general the mean difference between face-to-face and videoconference modes of assessment was close to zero with significant bias only evident for general cognitive functioning (WTAR), where videoconferencing produced higher ratings than face-to-face assessments. Feedback from the participants indicated strong acceptability of assessment by videoconferencing, thus supporting further investigation of use of this mode of assessment for clinical and research purposes.

The Use of Telemedicine in Pediatric Psychology: Research Review and Current Applications (Allen, Davis & Lassen, 2011) DOI: This article reviews the literature regarding telehealth specifically focused on televideo in pediatric psychology, with clinical and research applications from the authors depicted. The studies show that telemedicine is a feasible and satisfactory way to provide most psychological treatments for children with chronic/acute illness and their families.