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Zac, a 12-year-old Native American child living on an isolated reservation, was referred for a telepsychiatry consultation by his primary care physician for a diagnostic opinion as to whether he had attention deficit hyperactivity disorder (ADHD). He had a colorful history of recurrent aggression, fighting, truancy and school suspensions going back several years, and had already been diagnosed by a pediatrician visiting the community as having an oppositional disorder and possible ADHD, with the suggestion that a trial of stimulants would be worthwhile. Zac had likely suffered from fetal alcohol syndrome at birth, and his polysubstance-abusing mother died when he was 2. He lived with his father, an ex-alcoholic who had been sober since then, and who came to the consultation with him. During the consultation Zac was observed sitting quietly and politely next to his father, who gave most of the history and confirmed on questioning that there was minimal evidence supporting ADHD and that Zac could be well behaved, calm, and loving when he wanted to be, but also had significant tantrums and poor behavior if he felt threatened. His behavior was generally reported to be much worse at school than at home, and Zac openly admitted that he liked being suspended as he had more “freedom.” When seen alone Zac admitted to taking marijuana quite regularly and expressed concern that he found it hard to keep up with his classmates academically and knew that poor behavior led to exclusion which, for him, solved this problem. During feedback to his primary care physician (PCP), the telepsychiatrist confirmed that Zac did not have ADHD and that stimulants were not required. Instead changes to his Individual Educational Plan to help support him academically were recommended, as well as commencing a urine monitoring program, with rewards for negative screens, and a similar positive behavioral program across school and home. Zac's father and PCP were both pleased with these recommendations, as neither had felt he had ADHD, but they had been put in a difficult position by the pediatrician's recommendations.

INTRODUCTION

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 ...

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