Chapter 14: Child Telepsychiatry

Technological advances and changing demands from health care consumers and payors have led to significant changes in psychiatric service delivery models. ¹ There is a particular dearth of child and adolescent psychiatrists in the United States, with recent estimates of need exceeding 15 million children and adolescents and a current workforce of 6,800 child and adolescent psychiatrists. ² This makes it even more critical that care systems maximize psychiatric expertise to serve a large population of youth in need.

Like adult psychiatry, youth psychiatry is not dependent upon peripheral devices or instruments for patient assessment or treatment and is well suited for virtual treatment modalities. In addition, youth populations are particularly amenable to virtual treatment options. Members of the millennial generation, born after the 1989 debut of the Internet, are described as “digital natives,” having never experienced life without the ubiquitous presence of laptops, smart phones, tablets, and other e-devices. In 2015, the average two-year-old child had an online presence estimated to include over a thousand posted photos, and the average three-year old was quite familiar with the use of a smart phone. For digital natives, physical travel for services that can easily be accessed virtually may be considered outdated and wasteful, and concerns about digital personal health information (PHI) are negligible compared to prior generations—if those concerns exist at all. ^1,3,4 As members of the millennial generation become parents and their digital-native children receive treatment, child telepsychiatry services will be increasingly in demand. This chapter is designed to describe the treatment modalities and models that are used to support telepsychiatry services for children; summarize the evidence for virtual treatment efficacy; and provide an overview of the reimbursement, licensing, and legal and ethical considerations related specifically to telepsychiatry implementation for child populations—while not duplicating the adult telepsychiatry content of Chapter 10.

Child and adolescent telepsychiatry leverages the same two primary modalities as adult telepsychiatry. Synchronous modalities allow a child/adolescent; or a child/adolescent, a pediatrician, or other provider; and/or parent/guardian to virtually interact in real time using audio and/or video technology. ⁵ Asynchronous applications will likely expand future opportunities for cost savings and efficiency and may allow, for example, a pediatrician or other general practice professional to collect semi-structured interview data and store-and-forward this information via email or another web application for later review by a psychiatric provider. ^6–9 The asynchronous modality may be particularly helpful for youth and adolescent patients, but there are few clinical trials with youth populations, in contrast to more ample research with adults.

Asynchronous youth applications are receiving some attention as feasible intervention modalities for youth in supervised situations. Emerging research is promising, and a variety of online interventions are associated with reduced symptoms for depressed and anxious youth and adolescents. These seem to work best with mild disorder symptoms and as part of a care plan that also involves in-person treatment time. A noted advantage of asynchronous interventions is fidelity of treatment implementation. ¹⁰

Child and adolescent psychiatry typically goes beyond diagnoses and medication management and includes parent and teacher education and training. Home-based telepsychiatry can help to more accurately portray actual parent–child interactions for psychiatrist review and help refine parental education, training, and support. ¹¹

Like adult telepsychiatry, child telepsychiatry can be implemented using a variety of models that range from traditional behavioral health outpatient models to integrated primary care models. Some of those models are described in Chapter 10. Other common child-specific models include school-based and juvenile justice–based telepsychiatry.

School-based models are gaining increasing attention as a way to increase mental health access to youth, particularly those unlikely to access mental health services otherwise, reduce the stigma associated with mental health treatment, provide opportunities for mental health promotion and not just treatment, and substantially increase typical rates of care plan follow-up. ¹² Given the shortage of child and adolescent psychiatrists, many school-based models incorporate the psychiatrist as a consultant for medication management support into a multidisciplinary treatment team that may include parents, teachers, nurses, occupational therapists, and school-based mental health professionals such as school psychologists. School-based health clinics are a natural fit for telepsychiatry as they establish primary and integrated care settings within the school. Less frequently, psychiatrists provide direct, virtual patient care in the school setting. In instances of direct patient care, the virtual modality decreases the need for travel for both the psychiatrist and the patient and limits missed appointments as patients are already in the school setting. ¹²

Although more research is still needed, school-based telepsychiatry appears an effective and acceptable model. Both consultative and direct care applications have advantages for patients and families such as reduced scheduling demands, the opportunity for parents to participate in virtual sessions from their own work or homes, the support and engagement in school personnel in implementing and monitoring the patients’ progress on the care plan, and the potential increase in comfort level for parents who already trust the school's personnel.

A disadvantage for some patients/families is the reduced privacy that comes from having a multidisciplinary school team involved in student mental health care. Other disadvantages from the psychiatric provider perspective include the potential for limited parent engagement in the care plan and the additional challenge presented by practicing psychiatry not just virtually, but within the unfamiliar culture of a school and a multidisciplinary school team. Some providers have recommended a hybrid model of in-person and virtual care for the most effective, culturally competent school-based telepsychiatry. ¹²

Juvenile justice populations have particularly high rates of psychopathology, barriers to care access, and particularly high care costs. As such, juvenile justice–based telepsychiatry models are increasingly being implemented in settings from community-based probation to secure commitment facilities to increase care access and decrease costs. ¹³ Similar to school-based models, juvenile justice–based models typically require the psychiatrist to work with a team of professionals and not just the parent and child, as in a typical outpatient application. In addition, juvenile justice settings must maintain a safety and security priority—which may affect the traditional patient–provider alliance and privacy assurances, as well as the ability of patients, parents, and/or correctional staff to implement care plans as designed. Other challenges may include treatment-resistant youth and/or parents/staff and particular difficulty accessing patient medical histories. Overall, however, there is growing evidence of feasibility across juvenile justice settings, and psychiatrists willing to work within the challenging environment have an opportunity to work at the top of their clinical scope and affect a population in severe need. ^13,14

Early videoconferencing applications demanded rare audio-video connections and bulky hardware and were expensive to implement. Now, most laptops, cell phones, and tablets enable patients and providers to use wireless Internet access to stream secure, integrated health care information using high-resolution cameras and display screens, audio input and output, and other data applications. ^1,15 Millennials and younger generations are best situated to benefit from continuing technological advances, as some are more comfortable with virtual than in-person interactions with psychiatrists and other providers. Their high levels of comfort with various forms of virtual interaction, including avatars, creates more opportunity for youth to access more cost-effective services in settings that reduce any stigma and discomfort, relative to their adult counterparts. ¹

Telepsychiatry has been well established as a feasible modality for psychiatric diagnosis, assessment, and treatment for children and adolescents. ^16,17 Virtual psychiatry is associated with increased care access and quality ¹⁸ across a variety of care settings from more traditional community mental health outpatient settings, to primary care and pediatric settings, as well as schools, daycare centers, juvenile justice, and child welfare settings. ^17–19 Telepsychiatry has been associated with measures of feasibility, efficacy, and acceptability across a variety of minority youth groups in the United States, including youth from Black, Hispanic, Hawaiian, Native American, and Alaskan Native populations. ¹⁷ It has been used to diagnose and treat a variety of disorders in children and adolescents, including depression, ADHD, obsessive compulsive disorder, oppositional defiant disorder, and others. ¹¹

Although more randomized controlled trials will help to inform situations in which virtual and in-person care is optimal in terms of patient outcomes and cost, telepsychiatry is increasingly practiced in diverse youth care settings. In many ways, these child and adolescent applications are similar to adult telepsychiatry applications. There are, however, important distinctions. Some are specific to the virtual modality, and others involve child-specific adaptations of traditional clinical practice to virtual settings.

In a recent and comprehensive review of current and evidence-based telemental and telepsychiatry practices for youth, Glof and colleagues ¹¹ note that Schedule II stimulants are frequently prescribed to youth and adolescents for behavioral health treatment and that these stimulants fall under specific rules that regulate online prescription. Further, youth behavioral health diagnoses typically require the evaluation/rule-out of a variety of developmental and cognitive disorders. The originating and provider sites must have the capacity to meet the criteria for both situations. Additionally, most youth care plans require the family and other important caregivers to be engaged in effective implementation. In some virtual care settings, including integrated and collaborative care models, the psychiatrist may have little to no direct contact with parents or other caregivers and must flexibly operate within alternative care models for the telepsychiatry to pragmatically work. ¹¹

Reimbursement and legal/regulatory issues are essentially the same for youth and adult patients, with payor-directed constraints on reimbursable activities and locations representing the primary obstacle to developing and sustaining youth telepsychiatry programs. ²⁰ Please see Chapter 10 for more detail about reimbursement and legal/regulatory issues related to telepsychiatry. The one regulatory exception where there is a child-specific legal requirement is consent. Telepsychiatrists must get informed consent to treat via telehealth from guardians, rather than directly from their minor patients, although the specifications for how this consent is obtained (ie, verbal or written format) falls under state jurisdiction and varies from state to state. ²¹ In what is described as the first attempt to develop practice guidelines and parameters for child and adolescent telepsychiatry, researchers Myers and Cain ²² note that child-specific originating sites such as schools, child welfare, or correctional facilities will likely complicate regulatory issues related to confidentiality, records management, and ethical standards. Whereas traditional medical clinics like hospital-based clinics and primary care clinics will be well versed in patient health records and Health Insurance Portability and Accountability Act (HIPAA) regulations, nonmedical originating sites will need support in maintaining secure medical information according to HIPAA rules, as well as other regulating policies such as Family Educational Rights and Privacy Act (FERPA). ²²

Similarly, the same ethical issues and potential pitfalls in a telepsychiatry environment apply to youth and adult populations. An important consideration in high-quality, ethical psychiatric care, whether in-person or virtual, however, is ensuring that diagnoses and treatment plans are made in the context of the patient's cultural identity and environment. For child and adolescent patients, these cultural considerations must extend equally to the patient's parents or caregivers. Savin and colleagues ¹⁷ note that clinicians must be familiar with parents’ childrearing practices, ideas about normal child behavior, and beliefs about mental illness etiology and effective treatment. This process of clinical ethnography is equally relevant to in-person and virtual treatment; however, the virtual medium may bring a psychiatrist into contact with increasingly diverse patient populations and make the ethnographic investigation more challenging. Whereas youth populations are increasingly comfortable with all forms of technology, parents and older caregivers may resist tele-interactions or may alter behavior during virtual sessions because of discomfort with the medium. Current guidelines recommend allowing time for parents and caregivers to ask questions and get used to the tele-interactions through casual conversation before initiating the first clinical session. ¹⁷

Despite reimbursement challenges from the majority of health care payors, home-based telepsychiatry is starting to expand, and this expansion presents the opportunity for new ethical concerns and potential clinical pitfalls. Child and adolescent psychiatrists must be aware of home-based safety concerns due to lack of onsite staff, privacy and technology concerns inherent in diverse individual home situations, and the increased risk for youth who are distracted to more easily leave a home telesession than they can an office visit. ¹¹ It is important for providers to think through various home-based pitfalls and develop back-up plans collaboratively with patients (ie, continue visit via phone if Internet connection is unstable, parent diversion for siblings if they are home and distracting, and/or ways to encourage youth patients to successfully complete sessions), as well as establish safety planning in the event of expressed and immediate suicide ideation or other emergencies (Table 14-1).

Children usually respond positively to videoconferencing and find it a natural and easy environment within which to interact. In general, videoconference-based youth assessments are similar to in-person consultation. Typically, parents are the primary respondents during a youth assessment. The child and possibly other family members initially listen and are invited to contribute later in the session, if they wish. This style of interviewing gives the telepsychiatrist the opportunity to both take a history and observe the parent–child interaction. Teleclinicians have noted that children are actually more natural in interactions with their parents over videoconferencing, as they are not as aware of being observed as they are when in a physical office. Therefore from a clinical perspective, some have argued that for certain clinical situations, the use of telepsychiatry with children should be the new standard of practice. ^23–24

It is very important that parents, family members, and/or legal guardians provide informed consent and be involved as clinically appropriate. The recent guidelines from the American Academy of Child Psychiatry ² note that ideally the room at the patient's end should be large enough for children to move around and play separately from their parents so that the virtual psychiatrist can assess motor skills and other important abilities and issues. Just as in the clinic setting, children may be asked to wait outside the room with a caregiver during parts of the interview, and parents or other family members may be asked to wait outside during other parts. This allows issues to be discussed privately with individuals as necessary, rather than with a whole family group. A separate table, paper, crayons, and age-appropriate toys should be available for children to use, and the formal child psychiatry assessments should follow the guidelines from the American Academy of Child and Adolescent Psychiatry. ¹⁶

The telepsychiatry parameters developed specifically for child and adolescent populations note that the inclusion of an onsite clinical “presenter” can help ease any technology issues, help manage agitated or uncooperative children, and help succinctly present clinical concerns to maximize the time of the virtual psychiatrist. This presenter is often a nurse or psychologist who may be responsible for diverse duties such as obtaining vital signs, providing patient/family education, and coordinating care. In some models they may provide more onsite assessment and treatment—roles that may be relegated to the psychiatric provider in other models. As with adult implementations, the guidelines recommend written telepsychiatry protocols to specify which professional performs what function across intake, evaluation, and treatment to clarify roles and address process issues quickly. ²² The American Telemedicine Association has a special interest group that is in the process of developing telehealth guidelines specifically for pediatric patients. Some of their specific goals include promoting sound state and federal policies to improve access to care for children in both rural and in urban areas; encouraging a research agenda specific to pediatric applications of telehealth; and engaging the American Academy of Pediatrics, the Society for Pediatric Research, the Pediatric Academic Societies, and the American Association of Family Practice in collaborative work regarding pediatric telehealth service. ²⁵

Telepsychiatry is expanding as a care modality that can leverage technology to maximize a limited supply of child and adolescent specialists. As a patient population, youth are particularly well suited for technology-based care delivery, typically regarding virtual treatment as not only acceptable, but preferable, to in-person care that includes long wait times and unnecessary physical travel. The youth telepsychiatry research is currently focused on synchronous models, with outcomes that include increased care access and quality across a variety of models and settings, as well as diverse youth populations. Youth-specific settings with a growing evidence base include school and juvenile justice, and there are also documented applications in daycare and child welfare agencies. There is less research regarding asynchronous applications with youth populations. As the adult telepsychiatry literature identifies expanding cost savings and efficiencies associated with this store-and-forward model, however, it is likely to receive more research attention as a promising model in pediatric and other youth settings.

The majority of youth-specific telepsychiatry considerations mirror in-person care considerations and include obtaining informed consent from parents/guardians in addition to obtaining youth consent and identifying appropriate strategies to solicit youth and parent/guardian input, both separately and in group settings. A potential benefit associated with the virtual medium is the ability to observe youths’ natural interactions with other family members via camera, which clinicians report, is more easily forgotten by young patients than the in-person presence of the psychiatry specialist. A challenge specifically associated with the virtual medium includes online prescribing limitations associated with common prescriptions for childhood behavioral challenges. With the evidence base for telepsychiatry continually growing and policy decisions providing increasing support for virtual care applications, child and adolescent telepsychiatry currently faces payment and reimbursement issues as its predominant obstacles. As research increases for home-based applications and practices and payors develop and pilot new and innovative payment models, it is likely that models and applications of child and adolescent telepsychiatry will continue to expand opportunities for increased care access, quality, and efficiency.