Psychiatric disorders affect 7% to 20% of the nation’s children. Most of these children never receive any mental health treatment due to the chronic shortage of child mental health specialists, particularly child and adolescent psychiatrists,1 and the lack of availability of empirically supported mental health treatments beyond major metropolitan centers.2,3 When families do seek care, they most often present to their primary care physicians (PCPs). The American Academy of Pediatrics (AAP) has committed to serving the psychosocial needs of children and actively collaborates with child mental health specialists in finding new approaches to meet these needs.4,5 One approach, proposed by the Surgeon General, is the use of telecommunications technologies.6 Telemedicine is a form of telecommunication that virtually transports clinicians to meet with PCPs and/or families in their own communities. Telemedicine has been defined as the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status.7 This article limits the discussion of telemedicine to the real-time provision of care interactively through videoteleconferencing (VTC) that is usually provided in person. When telemedicine refers generally to the delivery of mental health care and mental health clinicians, we will use the term “telemental health” (TMH) and “teleclinician,” and when it refers specifically to psychiatric care, we will use the terms “telepsychiatry” and “telepsychiatrist.”
Advantages and Disadvantages of TMH
Health care professionals look to TMH as a way to support PCPs’ efforts in caring for children with mental health problems and to increase children’s access to expert mental health treatment. Families seek TMH care in order to readily access specialty mental health care that otherwise would be difficult to obtain due to multiple challenges, such as taking time off from work, missing school, financial burden related to travel, and the inconveniences of navigating an unfamiliar city and medical center. Families especially appreciate TMH care that is integrated into their PCP’s office, as co-location indicates approval by their PCP, provides easy coordination of care, and avoids the stigma associated with attending a mental health care facility. Some patients may even prefer TMH if they are not comfortable meeting face-to-face with mental health clinicians. Mental health care clinicians may prefer TMH over traveling to a community to provide in-person care because they may see more patients in a dedicated period of time, thereby improving their productivity. Also, they do not have to take time away from family or office obligations. TMH-facilitated care may be more cost-efficient for health care organizations. No contraindications have been developed regarding care provided through TMH.
Disadvantages of TMH care include families’ potential difficulty in developing trust and rapport through telecommunications, although endorsement of TMH by the PCP improves families’ confidence in this modality. Controlled medications, such as stimulants, may be delayed in reaching families as they must be mailed, although the telepsychiatrist may coordinate prescriptions with the PCP. Emergency appointments are difficult to arrange. TMH appointments require the coordination of three schedules (the patient site, the patient, and the teleclinician) and sometimes the availability of equipment. Coordinating and maintaining records may be more complicated, particularly if the teleclinician’s and patient’s sites do not share the same electronic medical record.
Implementation of the Patient Protection and Affordable Care Act (ACA) will likely include TMH in any strategic solution to rectify disparities in access to specialty mental health care.8 Many barriers to the widespread adoption of TMH remain, but they are falling. The Centers for Medicare and Medicaid approve reimbursement for telepsychiatric care, and many commercial insurers are following their lead. At least 13 states now mandate that insurers include telemedicine services in their coverage, and other states are reviewing their policies. Technological advances have reduced the costs of VTC equipment and connectivity, making TMH feasible for many organizations that could not afford higher-end technologies. Further work is needed to determine the needs of PCPs who seek TMH collaboration.9 Finally, psychiatrists and other mental health clinicians have been slower than families to accept TMH. However, the increasing options for the private practice of TMH may be decreasing their reluctance. Teleclinicians may join a “virtual group practice” with a commercial vendor that provides a salary for the treatment of defined populations, they may purchase a “virtual meeting room” to consult with a specific organization, or more adventurous mental health clincians may contract with a secure server to provide care on their own.
The Evidence Base Supporting the Use of TMH Care with Children
TMH programs are growing rapidly, but the evidence base supporting TMH as an effective service delivery model lags far behind. Most of the evidence comes from research with adults. Only four randomized, controlled trials have been reported with children. One study has shown that TMH can be used to make valid and reliable psychiatric diagnoses.10 Three randomized, controlled intervention trials support the effectiveness of providing treatment through TMH, including psychotherapy for children diagnosed with depression (n = 28),11 comprehensive treatment of children (n = 223) with attention-deficit/hyperactivity disorder,12 and parent-training skills (n = 22) for parents of children with behavioral disorders.13 One pre- to post-consultation study has supported the benefits of using TMH to provide consultation to PCPs regarding children’s mental health care.14 Other reported studies have described innovative programs and the satisfaction of providers,15,16 parents,9 and youth with TMH care.17
Models of TMH Collaboration with Primary Care
TMH services vary according to the models requested by referring PCPs and/or the child’s system of care. Most approaches involve direct services, particularly for diagnostic assessments and pharmacological care.18,19 Other models have been described in which telepsychiatrists conduct assessments and then make recommendations to a team in which the PCP prescribes medications and a community therapist provides behavioral health care.14,17 In the “consultation conference,” a telepsychiatrist meets virtually with several PCPs who seek consultation on specific cases or educational input on children’s mental health care.20 This model has the advantage of developing a network of PCPs with expertise in children’s mental health care who can then support and consult each other. The most promising models integrate TMH into the medical home or into a child’s system of care. TMH programs have been established in naturalistic settings such as schools,21 which reduces the possibility of missed appointments and has the advantage of assisting teachers in managing children’s behavior and learning problems. Providing TMH in juvenile correction facilities addresses the needs of youth with established psychiatric disorders and identifies youth with undiagnosed disorders that may have led to their incarceration.22 Ongoing care has been provided to residential facilities and consultation to emergency rooms.
Technology Used to Provide TMH Services
There is no best approach to the choice of technology to provide TMH.23 Factors to consider include the patient site, the location of the TMH provider, and costs for initial equipment purchase, as well as for connectivity, maintenance, and support staff. The minimum requirements include a codec in order to code and decode the visual and auditory signals, camera, monitor, microphone, and connectivity with adequate bandwidth for the service to be provided. The available technologies fall into two broad categories.
The phrase “standards-based applications” refers to the secure, point-to-point transmission of high-bandwidth (> 386 kbits/sec) signals over satellite or fiberoptic (“T1 lines” or integrated services digital networks) systems that provide high-definition video and audio signals. These systems typically include a camera with zoom and pan/tilt features that allow the teleclinician to examine the child’s facial features and to follow the child’s motor activity around the room (Figure 1). Standards-based applications allow multipoint conferencing and interoperability with other systems. These systems typically are only used in medical centers due to their high initial investment and the subsequent cost of maintenance, as well as the high cost of technical staff and infrastructure.
An example of standards-based videoteleconferencing.
Images courtesy of Felissa Goldstein, MD, FAPA.
Consumer-grade applications are provided over the internet using software that encrypts the transmission and that can be readily loaded onto personal computers; therefore, they are much more accessible, and many options exist (see: www.americantelemed.org). Vendors that provide the software for clinical work sign a business agreement attesting that they have taken due diligence to comply with HIPAA.24 Connectivity is at a much lower bandwidth than provided with standards-based applications, but new technologies allow the bandwidth to be “compressed” so that the observed transmission provides sufficient resolution of the video and audio signals for clinical work. Consumer-grade applications make TMH available in almost any setting that has internet access (Figure 2).
An example of consumer-based videoteleconferencing.
Disadvantages include potentially less-secure transmissions and lower-quality audio and video streams. Consumer-based applications do not generally provide interoperability and are only available between personal computers running the manufacturer’s software. Most do not include zoom and pan/tilt features. However, technical advances may make these features available in the near future.
The use of consumer-grade VTC software within health care has been a point of concern, particularly systems offered at no cost by a vendor. These systems may encrypt their signals adequately, but their companies do not enter a business agreement attesting to compliance with HIPAA regulations. There is no legal precedent addressing teleclinicians’ potential breach of HIPAA regulations when providing direct clinical service through these systems.
Mobile products, such as tablets and cell phones, use software that communicates with VTC infrastructure located elsewhere, such as a personal computer, a remote server, or the internet. The remote software, not the mobile device, manages calls. Concerns regarding the use of mobile products for health care delivery are similar to concerns regarding software-based applications. The use of TMH in health care is still novel and must balance the competing goals to increase access and to ensure confidentiality.
Clinical Practice of TMH
The Clinical Session
The TMH session differs from in-person psychiatry sessions in several ways. Often, TMH equipment at community sites is set up in a small, unused space or conference room. These arrangements pose challenges. A small room may not allow teleclinicians to observe the child’s motor functions and play, and too large a room may be over-stimulating for the child. A medical examination room risks equipment damage. Children are usually accompanied at TMH sessions by a parent, and adequate space is needed to capture their interactions. Communications must be private, and equipment should be placed to minimize interruptions during appointments — all requirements that may be challenging if TMH sessions are conducted in a busy facility.
Furthermore, technology may impact clinical care. Mental health clinicians rely on the observation of subtle aspects of patients’ affect, communication, and movements for diagnosis and medical decision-making. The ability to observe these subtleties is related to having sufficient bandwidth (> 384 kbits/sec) and monitor resolution (> 30 frames/second). If the transmission has fluid motion and good resolution, motor features such as tremors, tics, and fine motor skills are easily evaluated. Affective withdrawal due to internal stimuli and oddities in prosody can be appreciated. Low bandwidth may interfere with these functions and with the establishment of rapport, as the video signal may be pixilated or the audio signal may be delayed. Cameras at the patient site with pan/tilt and zoom capability that the teleclinicians can manipulate remotely allow optimal assessment of the child’s actions and developmental status.
Perhaps the most vexing issue is the assessment of children’s eye contact, which is impacted by camera placement. Typically, teleclinicians and children relate to one another over the telemonitor, but the camera is placed above, below, or to the side of the monitor so that eye contact is perceived as looking down, up, or deviated to the side, respectively. Therefore, teleclinicians must always query parents and children about the child’s ability to make eye contact.
Finally, auditory relatedness is an important aspect of the examination. The microphones are very sensitive. Street sounds or noisy toys will interfere with communication. Auditory comprehension is helped by reducing hard surfaces at the patient sites by placing rugs on the floor, draperies on the windows, or textiles on the walls to decrease ambient noise. A sound machine outside the TMH room decreases interference from outside noise and increases auditory privacy for patients.
Establishing Therapeutic Rapport
One of the major clinical barriers to the growth of TMH has been clinicians’ willingness to practice through this medium. Teleclinicians have endorsed a higher working alliance during “in-person” care over TMH care, although their patients may not express such a difference. Even when adult patients express a better alliance during in-person care, clinical outcomes may not differ.25 Although there is no research on how rapport with children may affect outcomes of TMH-mediated care, parents’ acceptance of this medium is evidenced by their attendance at multiple sessions and endorsement of high levels of satisfaction with their care.9,17 Rapport-building techniques with youth include interacting through toys, drawing pictures and sharing over the telemonitor, and the use of a more pronounced communication style.18 Teleclinicians must individualize their work to ensure that they use the technology and adjust their style to optimize rapport.
Cultural Aspects of TMH
Teleclinicians must consider how to incorporate patients’ cultural needs during TMH sessions.26 TMH is often utilized by communities with large populations of racial and ethnic minorities who differ culturally from the teleclinician. These communities may have concerns about accessing mental health services due to prior experiences with governmental, medical, and other institutions that have led them to feel disenfranchised or disinterested in pursuing treatment from outside sources. They may be reluctant to engage in services that may not be available over the long-term. TMH interventions may be more acceptable to these populations if it allows care to be ongoing, without frequent turnover, and/or if patients do not have to encounter the teleclinician in their home communities. Further, extended family members who would not be able to travel to distant sites to participate in the youth’s treatment may do so through TMH.27
Clinic Staff as Facilitators of Rapport and Cultural Competence
Staff at the community clinic can facilitate teleclinicians’ establishment of therapeutic rapport and cultural competence. Their perception of TMH influences families’ perspective. TMH requires that selected staff are responsible for logistical issues. They greet and register patients, schedule sessions, provide documents, and set up and troubleshoot equipment. Staff assist the telepsychiatrist by obtaining vital signs, laboratory tests, and communicating with PCPs. Staff may also assist telepsychiatrists in the assessment of side effects of medications. These staff can provide cultural and ecological context. For example, they help the teleclinician to understand that families may not be available during certain times of year if they are engaged in subsistence fishing or that guns cannot readily be removed from the home of a family that relies on hunting for their food supply. It is often helpful for the teleclinician to provide staff a perspective of the “added value” of TMH due to the barriers that families may face in accessing expert mental health care outside of their community. Staff may also be familially related to patients, which raises concerns about confidentiality. Teleclinicians often learn innovative ways to work with the clinic staff to improve the clinical experience for families and their communities.
Vignette: A Telepsychiatry Service for Children with Autism
TMH evolved as a means to increase access to expert mental health care, but particularly to provide psychiatry services to underserved communities. Children with autism and other developmental disabilities in these communities particularly benefit from access to child and adolescent telepsychiatrists, as illustrated in the following vignette.
In Atlanta, GA, at the Marcus Autism Center (MAC), a part of Children’s Healthcare of Atlanta, Dr. Felissa Goldstein conducts a TMH clinic that specializes in children with developmental disabilities. She dedicates 1.5 days a week to the evaluation and treatment of patients at sites that participate in the Georgia Partnership for Telehealth Network (GPT). GPT is a nonprofit corporation that promotes improvements in healthcare and healthcare facilities in rural and underserved communities throughout the state of Georgia by assisting in the establishment of telemedicine programs.28
MAC initiated their telemedicine program to provide care for families with children with developmental disabilities outside of metropolitan Atlanta. Nationally, the median age of diagnosis of autism spectrum disorder (ASD) is 4.5 years, and early intervention is key to optimizing children’s functioning and improving their prognosis.29 In rural communities, the average age of diagnosis of ASD is 7 years.30 The MAC telemedicine program has facilitated earlier diagnosis and interventions for children with developmental delays, psychiatric disorders, and behavioral problems. After her evaluation, Dr. Goldstein refers patients either to MAC for further evaluation or helps the family to identify local resources, such as early intervention agencies, behavioral intervention programs, support groups, school systems, or psychologists. When a pharmacological intervention is indicated, Dr. Goldstein prescribes and monitors responses. Often, these encounters involve close collaboration with the child’s PCP, as the PCP knows the child well and the family trusts his/her judgment regarding care. As a supplement to direct patient care, the VTC equipment is used to provide educational sessions regarding developmental disorders to physicians, educators, and parents, thereby strengthening the child’s system of care in the community.
An alternative to the MAC model provides a single consultation session, after which the telepsychiatrist makes recommendations to the referring PCPs for ongoing care at their discretion, including any recommendations for pharmacologic treatment. This model improves access to specialty care for more children, but may not provide the optimal level of assistance that PCPs seek. Further, a high no-show rate and a lack of referrals hindered the success of this model for one program in Georgia, possibly indicating that PCPs prefer that telepsychiatrists manage children’s mental health care needs.31
Other models of TMH-mediated care may be helpful, such as an integrated behavioral care model in which the telepsychiatrist co-locates at the primary care clinic in order to maintain the locus of treatment with the PCP and to assist them in implementing treatment decisions.
Vignette: TMH Modalities to Deliver Evidence-Based Care to Children with Attention-Deficit/Hyperactivity Disorder
Attention-deficit/hyperactivity disorder (ADHD) is a chronic and impairing disorder of childhood that often is treated by a PCP. Children with severe and complicated cases of ADHD provide challenges to treatment for which PCPs may request consultation to optimize the management of the child’s ADHD symptoms and functioning. The practice parameter for ADHD recommends pharmacologic, psychoeducational, and behavioral interventions.32,33 TMH can help to implement these guidelines in several ways. Telepsychiatrists at Seattle Children’s Hospital use TMH to provide psychiatric services to children in multiple underserved communities throughout the states of Washington and Alaska. They may consult with PCPs to strengthen their management of children with ADHD in their practice or may provide ongoing direct service, including prescribing stimulant medications and following these children’s care over months to years. TMH may then be used to provide parent management training to caregivers13 or to train local therapists remotely in evidence-based behavioral interventions for children and their parents.12,34
This approach has demonstrated benefits in improving the mental health care and outcomes for children with ADHD who lack access to specialty mental health care in their home communities.12 It has the advantage of making services readily available to youth over time as initial benefits may wane and/or children may develop comorbidities as they enter adolescence.
Future Directions in TMH
The future of TMH with children is promising for children, their families, and PCPs, but much work remains to be done. Barriers must be overcome, including child mental health specialists’ willingness to provide services through TMH, the ability of teleclinicians to collaborate with referring PCPs in managing their young patients’ care, less expensive technologies, and universal reimbursement for TMH-facilitated care. It will be important to ensure that care provided through TMH is evidence-based and produces the same outcomes as care provided in person. Enactment of the ACA is expected to make many more children eligible to receive care. The time has come to integrate TMH into mainstream health care and to examine its effectiveness in improving the mental health care and outcomes for children with mental health care needs.
- Thomas C, Holzer C. The continuing shortage of child and adolescent psychiatrists. J Am Acad Child Adolesc Psychiatry. 2006;45(9):1023–1031.
- American Medical Association. Physician Characteristics and Distribution in the U.S. Washington, DC: American Medical Association Press; 2010.
- American Psychological Association. Underserved Populations: Practice Setting Matters. 2011. Available at: http://www.apa.org/workforce/. Accessed January 16, 2014.
- American Psychological Association. 2008APA survey of psychology health service providers. Available at: http://www.apa.org/workforce/publications/08-hsp/index.aspx. Accessed January 15, 2014.
- American Academy of Pediatrics. The new morbidity revisited: a renewed commitment to the psychosocial aspects of pediatric care. Committee on Psychosocial Aspects of Child and Family Health. Pediatrics. 2001;108(5):1227–1230.
- United States Public Health Service Office of the Surgeon General. Mental Health: A Report of the Surgeon General. Rockville, MD: Department of Health and Human Services, U.S. Public Health Service, 1999.
- American Telemedicine Association. Telemedicine Nomenclature. Available at: http://www.americantelemed.org/practice/nomenclature#T. Acccessed January 15, 2014.
- Centers for Medicare and Medicaid Services. The Affordable Care Act: Lowering Medicare Costs by Improving Care. Available at: http://www.cms.gov/apps/files/ACA-savings-report-2012.pdf. Accessed January 15, 2014.
- Myers KM, Valentine JM, Melzer SM. Child and adolescent telepsychiatry: utilization and satisfaction. Telemed J E-Health. 2008;14(2):131–137.
- Elford DR, White H, Bowering R, et al. A randomized, controlled trial of child psychiatric assessments conducted using videoconferencing. J Telemed Telecare. 2000;6(2):73–82.
- Nelson EL, Barnard M, Cain S. Treating childhood depression over videoconferencing. Telemed J E-Health. 2003;9(1):49–55.
- Myers KM, Vander Stoep A, McCarty CA. The Children’s ADHD Telemental Health Treatment Study (CATTS): children and caregivers outcomes. Paper presented at: 16th Scientific Meeting of the International Society for Research in Child and Adolescent Psychopathology. ; June 14, 2013. ; Leuven, Belgium. .
- Xie Y, Dixon JF, Yee OM, et al. A study on the effectiveness of videoconferencing on teaching parent training skills to parents of children with ADHD. Telemed J E-Health. 2013;19(3):192–199.
- Yellowlees PM, Hilty DM, Marks SL, Neufeld J, Bourgeois JA. A retrospective analysis of a child and adolescent e-mental health program. J Am Acad Child Adolesc Psychiatry. 2008;47(1):103–107.
- Elford DR, White H, St John K, et al. A prospective satisfaction study and cost analysis of a pilot child telepsychiatry service in Newfoundland. J Telemed Telecare. 2001;7(2):73–81.
- Myers KM, Valentine JM, Melzer SM. Feasibility, acceptability, and sustainability of telepsychiatry for children and adolescents. Psychiatr Serv. 2007;58:1493–1496.
- Boydell K, Volpe T, Pignatello A. A qualitative study of young people’s perspectives on receiving psychiatric services via televideo. J Can Acad Child Adolesc Psychiatry. 2010;19(1):5–11.
- Glueck DATelepsychiatry in private practice. Child Adolesc Psychiatr Clin N Am. 2011;2091):1–11.
- Myers KM, Vander Stoep A, McCarty CA, et al. Child and adolescent telepsychiatry: variations in utilization referral patterns and practice trends. J Telemed Telecare. 2010;16(3):128–133.
- Dobbins MI, Roberts N, Vicari SK, et al. The consultation conference: a new model of collaboration for child psychiatry and primary care. Acad Psychiatry. 2011;35(4):260–262.
- Grady B, Lever N, Cunningham D, Stephan S. Telepsychiatry and school mental health. Child Adolesc Psychiatr Clin N Am. 2011;20:81–94.
- Kaliebe KE, Heneghan J, Kim TJ. Telepsychiatry in juvenile justice settings. Child Adolesc Psychiatr Clin N Am. 2011;20(1):113–123.
- Polycom. Video Communications: Building Blocks for a Simpler Deployment. 2001. Available at: http://www.polycom.com/global/documents/whitepapers/video_communication_building_blocks_for_simpler_deployment.pdf. Accessed January 15, 2014.
- United States Department of Health and Human Services. The Health Insurance Portability and Accountability Act of 1996 (HIPPA). Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf. Accessed January 15, 2014.
- Morland LA, Greene CJ, Rosen CS, et al. Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: a randomized noninferiority trial. J Clin Psychiatry. 2010;71(7):855–861.
- Brooks E, Spargo G, Yellowlees P, O’Neil P, Shore J. Integrating culturally appropriate care into telemental health practice. In: Myers K, Turvey C, eds. Telemental Health: Clinical, Technical and Administrative Foundations for Evidence-based Practice. London, UK: Elsevier; 2013:63–79.
- Carlisle LL. Child telemental health. In: Myers K, Turvey C, eds. Telemental Health: Clinical, Technical and Administrative Foundations for Evidence-based Practice. London, UK: Elsevier;2013:197–214.
- Georgia Partnership for Telehealth. About Georgia Partnership for Telehealth. Available at: http://www.gatelehealth.org/index.php/about/about-gpt/2013. Accessed January 15, 2014.
- U.S. Centers for Disease Control and Prevention. Prevalence of autism spectrum disorders. Autism and developmental disabilities monitoring network, 14 sites, United States, 2008. Morb Mortal Wkly Rep MMWR. 2012;61(SS03):1–19.
- Shattuck PD. Timing of identification among children with an autism spectrum disorder: findings from a population-based surveillance study. J Am Acad Child Adolesc Psychiatry. 2009;48(5):474–483.
- Jacob M, Larson J, Craighead W. Establishing a telepsychiatry consultation practice in rural Georgia for primary care physicians: a feasibility report. Clin Pediatr. 2012;51(11):1041–1047.
- American Academy of Pediatrics. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105(5):1158–1170.
- American Academy of Pediatrics. American Academy of Pediatrics. Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics. 2001;10894):1033–1044.
- Vander Stoep A, Myers K. The Children’s Attention-deficit Hyperactivity Disorder (ADHD) Telemental Health Treatment Study: methodology for conducting a trial of telemental health in multiple underserved communities. Clin Trials. 2013;10:949–958.