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©AmericanTelemedicineAssociation

ACKNOWLEDGEMENTS

TheAmericanTelemedicineAssociation(ATA)wishestoexpresssincereappreciationtotheATATelementalHealthwithChildrenandAdolescentsPracticeGuidelinesLeadershipteam,ContributorsandtheATAPracticeGuidelinesCommitteeforthedevelopmentoftheseguidelines.Theirhardwork,diligenceandperseverancearehighlyappreciated.

•TelementalHealthwithChildrenandAdolescentsWorkGroup•Co-Chair:KathleenM.Myers,MD,MPH,MS,FAACAP,ProfessorofPsychiatryandBehavioralSciences,UniversityofWashingtonandDirectorofTelementalHealth,SeattleChildren'sHospital,SeattleWACo-Chair:Eve-LynnNelson,PhD,Director,KUCenterforTelemedicine&Telehealth,Professor,SchoolofMedicine,UniversityofKansasMedicalCenterDonaldM.Hilty,MD,ChiefofPsychiatry&AddictionMedicineandResidencyProgramDirector,KaweahDeltaMedicalCenter,UCIrvineAffiliate,Professor,PsychiatryandBehavioralSciences,KeckSchoolofMedicineatUSC,StrategicAdvisor,ResearchandHealthServices,AlignedTelehealth

TerryRabinowitz,MD,DDS,ProfessorofPsychiatryandFamilyMedicine,UniversityofVermont

CollegeofMedicine

•ContributorsandReviewers•(alphabeticalorder)

DeborahC.Baker,JD,DirectorofLegal&RegulatoryPolicy,Legal&RegulatoryAffairs,PracticeDirectorate,AmericanPsychologicalAssociationSaraSmuckerBarnwell,PhDPartner,SeattlePsychologyPLLC,ClinicalFaculty,DepartmentofPsychiatryandBehavioralSciences,UniversityofWashingtonGeoffreyBoyce,MBA,ExecutiveDirector,InsightTelepsychiatry,LLCLynnF.Bufka,PhD,AssociateExecutiveDirector,PracticeResearchandPolicy,PracticeDirectorate,AmericanPsychologicalAssociationSharonCain,MD,Professor&DirectorofChildandAdolescentPsychiatryDivision,UniversityofKansasMedicalCenterLisaChui,ARNP,PsychiatricMentalHealthNursePractitioner,DepartmentofPsychiatryandBehavioralHealth,SeattleChildren'sHospital


JonathanS.Comer,PhD,ProfessorofPsychologyandPsychiatry,Director,MentalHealthInterventionsandTechnology(MINT)Program,CenterforChildrenandFamilies,FloridaInternationalUniversityCarrollCradock,PhD,President,CACConsultingGroupJamesR.Varrell,MD,PresidentandMedicalDirector,CFGHealthNetwork,InsightTelepsychiatry,LLCFelissaGoldstein,MD,ChildPsychiatrist,LeeSpecialtyClinicBarbJohnston,MSN,MLM,CEO,HealthLinkNowKatherineLo,ARNP,PsychiatricMentalHealthNursePractitioner,DepartmentofPsychiatryandBehavioralHealth,SeattleChildren'sHospitalDavidLuxton,PhD,MS,Faculty,DepartmentofPsychiatry&BehavioralSciences,UniversityofWashingtonSchoolofMedicine&WorkforceDevelopmentAdministratorattheOfficeofForensicMentalHealthServices,StateofWashingtonDavidMcSwain,MD,MPH,MedicalDirector,TelehealthOptimization,MUSCCenterforTelehealth,AssociateProfessor,PediatricCriticalCareMedicine,MedicalUniversityofSouthCarolina(MUSC)Children’sHospitalJenniferMcWilliams,MD,ChildPsychiatrist,ChildandAdolescentPsychiatrist,OmahaChildren'sHospital&MedicalCenterSteveNorth,MD,MPH,MedicalDirectorandFounder,CenterforRuralHealthInnovation,SprucePine,NC,ClinicalDirector,MissionVirtualCare,Asheville,NC,AAFPLiaisonJayOstrowski,MA,LPC-S,NCC,DirectorofProductandBusinessDevelopment,NationalBoardforCertifiedCounselorsandAssociates,Inc.AntonioPignatiello,MD,FRCP(C),AssociatePsychiatrist-in-Chief,MedicalDirector,TeleLinkMentalHealthProgram,TheHospitalforSickChildren,Director,Child,Youth,&FamilyHealth,MedicalPsychiatryAlliance,AssociateProfessor,DepartmentofPsychiatry,UniversityofTorontoDavidRoth,MD,FAAP,FAPAPsychiatrist,MindandBodyWorks,Inc.CarolynTurvey,PhD,MS,Professor,Psychiatry&Epidemiology,UniversityofIowaShawnaWright,PhD,Director,WrightPsychologicalServices;AssistantDirector,KUCenterforTelemedicine&Telehealth

•ATAPracticeGuidelinesCommittee•Chair:ElizabethA.Krupinski,PhD,Professor&ViceChairforResearch,DepartmentofRadiology&ImagingSciences,EmoryUniversity


•CommitteeMembers•

NinaAntoniotti,RN,MBA,PhD,ExecutiveDirectorofTelehealthandClinicalOutreach,SIUSchoolofMedicineJillBerg,PhD,RN,FAHA,FAAN,VicePresidentofEducation,AscensionHealthWisconsin,President,ColumbiaCollegeofNursingDavidBrennan,MSBE,Director,TelehealthInitiatives,MedStarHealthAnneBurdick,MD,MPH,AssociateDeanforTelemedicineandClinicalOutreach,ProfessorofDermatology,Director,LeprosyProgram,UniversityofMiamiMillerSchoolofMedicineJerryCavallerano,PhD,OD,StaffOptometrist,AssistanttotheDirector,JoslinDiabetesCenter,BeethamEyeInstituteHelenK.Li,MD,AdjunctAssociateProfessor,UniversityofTexasHealthScienceCenter

•ATAStaff•JordanaBernard,MBA,ChiefProgramOfficerJonathanD.Linkous,CEO


PRACTICEGUIDELINESFORTELEMENTALHEALTHWITHCHILDRENANDADOLESCENTS

TABLEOFCONTENTS

PREAMBLE 1

SCOPE 2

INTRODUCTION 3

REVIEWOFCLINICALTELEMENTALHEALTHWITHYOUTH 6

GUIDELINESFORTHEPRACTICEOFTELEMENTALHEALTHWITHYOUTH 9

ADDITIONALTELEMENTALHEALTHCONSIDERATIONSWITHSPECIALCONSIDERATIONSFORYOUTH 21

SUMMARY 24

CONCLUSIONS 24

APPENDIX 26References 26

Glossary 40 Table:EffectivenessofChildandAdolescentTelementalHealth 42

©AmericanTelemedicineAssociation|Page1

PREAMBLEBackground.TheAmericanTelemedicineAssociation(ATA),withmembersfromthroughouttheUnitedStatesandtheworld,istheprincipalorganizationbringingtogethertelemedicineproviders,healthcareinstitutions,vendorsandothersinvolvedinprovidingremotehealthcareusingtelecommunications.ATAisanonprofitorganizationthatseekstobringtogetherdiversegroupsfromtraditionalmedicineandhealthcare,academia,technologyandtelecommunicationscompanies,e-health,alliedprofessionalandnursingassociations,medicalsocieties,governmentandotherstoovercomebarrierstotheadvancementoftelemedicinethroughtheprofessional,ethicalandequitableimprovementinhealthcaredelivery.ATAhasembarkedonanefforttoestablishpracticeguidelinesandtechnicalrequirementsfortelemedicinetohelpadvancethescienceandtoassuretheuniformqualityofservicetopatients.Theseguidelines,basedonclinicalandempiricalexperience,aredevelopedbyworkgroupsthatincludeexpertsfromthefieldandotherstrategicstakeholdersanddesignedtoserveasbothanoperationalreferenceandaneducationaltooltoaidinprovidingappropriatecareforpatients.ThepracticeguidelinesandrequirementsgeneratedbyATAundergoathoroughconsensusandrigorousreview,withfinalapprovalbytheATABoardofDirectors.Existingproductsarereviewedandupdatedperiodicallyastimeandresourcespermit.Board-approvedpracticeguidelineswillbeconsideredforaffirmation,update,orsunsetatleastevery4years.Practiceguidelinesthathavebeensunsetmaycontinuetohaveeducationalvaluebutmaynotrepresentthemostcurrentknowledgeandinformationaboutthesubjectmatter.

Disclaimer.Thepracticeofhealthcareisanintegrationofboththescienceandartofpreventing,diagnosing,andtreatingdiseases.Accordingly,itshouldberecognizedthatcompliancewiththeseguidelineswillnotguaranteeaccuratediagnosesorsuccessfuloutcomeswithrespecttothetreatmentofindividualpatients,andATAdisclaimsanyresponsibilityforsuchoutcomes.Theseguidelinesareprovidedforinformationalandeducationalpurposesonlyanddonotsetalegalstandardofmedicalorotherhealthcare.Theyareintendedtoassistprovidersindeliveringeffectiveandsafemedicalcarethatisfoundedoncurrentinformation,availableresources,andpatientneeds.Thepracticeguidelinesandtechnicalrequirementsrecognizethatsafeandeffectivepracticesrequirespecifictraining,skills,andtechniques,asdescribedineachdocument,andarenotasubstitutefortheindependentprofessionaljudgment,training,andskilloftreatingorconsultingproviders.Ifcircumstanceswarrant,aprovidermayresponsiblypursueacourseofactiondifferentfromtheguidelineswhen,inthereasonablejudgmentoftheprovider,suchactionisindicatedbytheconditionofthepatient,restrictionsorlimitsonavailableresources,oradvancesininformationortechnologysubsequenttopublicationoftheguidelines.Likewise,thepracticeguidelinesandtechnicalrequirementsinthisdocumentdonotpurporttoestablishbindinglegalstandardsforcarryingouttelemedicineinteractions.Rather,theyaretheresultoftheaccumulatedknowledgeandexpertiseoftheATAworkgroupsandtheirreviewofthecurrentliteratureinthefieldandareintendedtoimprovethetechnicalqualityandreliabilityoftelemedicineencounters.Theadministrativeproceduresandtechnicalaspectsofspecifictelemedicinearrangementsmayvarydependingontheindividualcircumstances,includinglocationoftheparties,resources,


natureoftheinteraction,andinthecaseofchildrenandadolescents,theadultsresponsiblefortheirwelfareuntiltheageofmajority.

SCOPEThisdocumentprovidesaclinicalguidelineforthedeliveryofchildandadolescentmentalhealthandbehavioralservicesbyalicensedhealthcareproviderthroughrealtimevideoconferencing.PleaserefertotheGlossaryinAppendixAfordefinitionsutilizedintheguideline,withparticularattentiontotheequivalencyoftheterminology“telementalhealth”and“telebehavioralhealth.”However,tomaintainconsistencywithpriortelementalhealthguidelines,1-2thisguidelineusesthetermchildandadolescenttelementalhealth(CATMH)throughoutthedocument.Generalguidelinesforthepracticeoftelementalhealthusingpopularinternet-based(aka“consumer-grade”)videoconferencing,1aswellasmoretraditionaltelephone-based,highdefinition,point-to-point(aka“standardsgrade”)videoconferencinghavebeenpublished.2,3Providersarestronglyencouragedtorefertothegeneraltelementalhealthguidelinesforoverallrecommendations,particularlyinareasthatencompassbothadultandpediatricpractice.Insomeinstances,thegeneralrecommendationsorsupportingevidencefromtheseguidelinesmayberepeatedhereifthereisaspecificrelevancetoCATMHpracticeortoprovideupdatedinformation.Additionally,basedonagrowingevidence-baseandexpertconsensus,thisguidelineincludesfournewsectionsrelevanttotelementalhealthcareacrosstheagespectrum:EthicalConsiderations;TelementalHealthCompetencies;ClinicalSupervisionandTelementalHealth;andFutureDirections.Consistentwiththegeneralpracticeguidelines,theCATMHguidelinefocusesoninteractivevideoconferencingbetweentwoormoresiteswithemphasisonprovidingthesamelevelofservicethatisdeliveredin-personincludingconsultation,collaboration,anddirectservicedelivery.Directservicesspantherangeofmentalandbehavioralhealthinterventions,includingprevention,earlyinterventionandcopingstrategies,treatment,andmaintenance/support.Theseguidelinesapplytovideoconferencingusingbothstandards-basedandconsumer-gradeconnectivity.4,5Emergingproductsblurthelinesbetweenstandards-basedandconsumer-gradeapproaches,offeringthedistributedhostingandinternet-basedconnectivityofconsumer-orientedsystemswiththeinteroperabilityofstandards-basedplatforms.6MobilehealthormHealthuseswirelessdevicesandcellphonetechnologiesthatmaybeappliedtoCATMH.mHealthallowsthedeliveryofCATMHthroughconsumer-gradehardwareandcloud-basedvideoconferencingsolutions,allowinggreaterpatientandprovidermobility.Althoughatelementalhealthservicemayincorporatevarioustechnologyapproaches,itshouldbenotedthattelehealth,asynchronousstore-and-forwardtelemedicine,7eHealth,andnon-videocomponentsofmHealtharebeyondthescopeofthisguideline.Otherareasbeyondthisguideline’sscopeincludeonlineinteractiveinstruction,in-homemonitoring,mobileapplications(apps),wearabletechnologies,e-mailcorrespondence,textreminders,andsocial


media.Thecurrentdocumentmaintainstheapproachandterminologyofthegeneralguidelines.Itcontainsrequirements,recommendations,oractionsthatareidentifiedbytextcontainingthekeywords“shall,”“should,”and“may.”“Shall”indicatesarequiredactionwheneverfeasibleandpracticalunderlocalconditions.“Should"indicatesanoptimalrecommendedactionthatisparticularlysuitable,withoutmentioningorexcludingothers.“May”indicatesadditionalpointsthatmaybeconsideredtofurtheroptimizethetelementalhealthcareprocess.

INTRODUCTION

Theguidelinesaddressthreeaspectsofservicedelivery:administration/management,clinicalpractice,andtechnicaldesignandarchitecture.Undereachaspect,theguidelinesarepresentedintheformofthreelevelsofexpectedadherence:“Shall”indicatesrequiredactionwheneverfeasibleand/orpractical.“Shallnot”indicatesaproscriptionoractionthatisstronglyadvisedagainst.“Should”indicatesrecommendedactionwithoutexcludingothers.“May”indicatesappropriateactionsthataredeemedappropriatebutnotmandatorytooptimizethetelemedicineencounterandthepatientexperience.Theseindicationsarepresentedinboldlettersthroughoutthedocumenttofacilitatetheirvisibility.ATAurgeshealthprofessionalsusingtelemedicineincaringforburnpatientsintheirpracticestofamiliarizethemselveswiththeseguidelines,aswellasotherclinicalguidelinesorbestpracticestandardsissuedbytheirprofessionalorganizationsorsocietiesandtoincorporatebothsetsintotheirtelemedicinepractice.TheseguidelinespertaintohealthcareservicesdeliveredviatelemedicinewhenbothpatientandproviderarewithintheUnitedStates(US).Otherjurisdictionsmayusetheseguidelinesattheirdiscretion.

A.NeedforClinicalPracticeGuidelinesforTelementalHealthwithYoungPeopleClinicalpracticeguidelines,ratherthanmoreprescriptivepracticeparametersorstandards,areparticularlyrelevanttoCATMHpracticeastheimplementationofprogramsareoutpacingtheevidence-basesupportingtheireffectiveness.Therefore,guidelinesforCATMHdrawfromthegeneraltelementalhealthevidencebase,8-10child-specificresearch,11-16thepracticeparametersforchildandadolescentpsychiatrydisorders17guidelinesforthepracticeoftelepsychology,18-19andtheexpertiseofchildandadolescenttelementalhealthproviders.20-27

Theguideline(pleaseseeGlossary,AppendixA)utilizesabroaddefinitionofyouth,includingupto21yearsold.Thisagerangespansthecontinuumofdevelopmentandincludesthetransitionfrompediatrictoadultcare.Childandadolescentpracticeposesimportantdifferencesfromadultpracticeintermsofscopeofpractice,youngpeople’ssystemsofcare,28andthediversityofsettingsprovidingspecializedservices.25,29-41Childandadolescentmentalhealthproviderscontendwithdisorders,developmentalconsiderations,andenvironmentalfactorsnotcommonlyaddressedinadultpractice,suchasthetreatmentofattention-deficithyperactivitydisorder(ADHD),evaluationforautismanddevelopmentaldisabilities,ordeterminationofabuseandtrauma.Theseassessmentsdependoninputbothfromtheyouthandrelevantadults,oftenmultipleadults,inthefamilyandinthechild’ssystemsof


care(e.g.,casemanagers,teachers,andotherinformants).Interventionsgenerallyincludeacaregiver,sometimestheentirefamilyandmembersoftheyouth’systemsofcare,suchasteachersordaycareproviders,evenpeers.Evaluationandtreatmentmodalities,suchasassessmentofplayorparent-childinteractions,requiresite-andtechnology-basedadaptationsthatmaydifferfromworkwithadults.26,42Forexample,alargerroomisoftenneededtoobserveachild’smotoractivity,exploratoryskills,andinteractions.Acamerawithpan-tilt-zoomfeaturehelpstoassessdysmorphiaandmonitorachild’saffect.42,43Behavioralprovidersofcaretoyoungpeoplevarywidelybytraining,discipline,expertise,andpractice.Theyincludechildandadolescentpsychiatristsandpsychologists,master’strainedtherapists,pediatriciansandfamilyphysicians,nursespecialists,behavioranalysts,socialworkers,speechandlanguagetherapists,specialeducationteachersandotherschool-basedpersonnel,occupationaltherapists,andotherprofessionalswithintheyouth’ssystemofcare.

B.IncreasingNeedforMentalHealthServicesforYoungPeople

In2014,theHealthResourcesandServicesAdministration’s(HRSA’s)DataWarehouse44identified2,000mentalhealthprofessionalshortageareasdesignatedinnon-metropolitancounties,affectingmorethan66millionresidents.County-LevelEstimatesofMentalHealthProfessionalShortageintheUnitedStatesreportsthathigherlevelsofunmetneedformentalhealthprofessionalsexistforcountiesthatweremoreruralandhadlowerincomelevels.45Themostdisadvantagedandunder-resourcedcommunitiesareoftenthosewiththegreatestneedformentalhealthcareproviders,particularlychildandadolescentspecialists.Approximately20%ofyoungpeopleintheUnitedStates(U.S.)ages9to17,havediagnosablepsychiatricdisorders.46Manyotherssufferfromsub-thresholdsymptomsandfromstressandgriefreactionsthatbenefitfromintervention.Youngerchildrenareatriskfordevelopmentalandbehavioraldisorders.Inaddition,approximately31%ofchildrenareaffectedbychronicmedicalconditions47whomaybenefitfrombehavioralhealthstrategies.Agrowingnumberofevidence-basedpsychologicalandbehavioralinterventionsoffersupporttoyoungpeopleandtheirfamiliesincopingwiththerangeofmentalhealthconditions.48Therearealsopediatricpsychologyapproachestohelpchildrenwithacuteandchronicmedicalconditionsandtheirfamiliesincopingwithbehavioralhealthconcerns.49However,thesupplyofyouth-trainedproviderstodelivertheseclinicaladvancesissmall,withdemandfaroutpacingsupply.50General-trainedprovidersattempttofillthisvoid,butmaynothaveaccesstothetrainingneededtoupdatetheirskillsduetomultiplefactors,suchasdistancefromtrainingcenters,scarcityofappropriateclinicalsupervisors,orlackofagencyfundingtopayfortraining.51-53General-trainedprovidersareparticularlyunder-equippedtoaddresschildconditionsshowingrelativelylowbaseratesand/orconditionsrequiringmorecomplextreatmentregimens.51Similarly,anincreasingnumberofevidence-basedpharmacologicalinterventionsoffertreatmentoftheneuropsychiatricsymptomsofearlyonsetpsychiatricconditions,54butthereisadearthofchildandadolescentpsychiatriststodeliverthesetreatments.Primarycareprovidersincreasinglyfillthisgap,butneedsupport,particularlyintreatingcomplexpsychiatricdisorderswithcomorbidconditions.Asaresultofthesediscrepancies,mostyoungpeoplewithmentalhealthconditionsdonotreceiveanyinterventions;andofthosewhodoreceiveclinicalcare,themajoritydonotreceiveevidence-basedtreatmentslargelyduetotheinsufficientnumbersofchildandadolescenttrainedmentalhealthspecialistsandtheirconcentrationinurban/suburbanareasandacademichubs.55Thesedisparitiesinaccesstoandqualityofcarehavebeennotedmostprominentlyforchildandadolescentpsychiatrists,56-58butarerelevanttoallchildandadolescentmentalhealthspecialists59-62andareanticipatedtopersist


orworsenintotheforeseeablefuture.56,59,60,63,64

Thesedisparitiesandtheprojecteddecreasingsupplyofchildandadolescentmentalhealthspecialistsareoccurringatthesametimeasthebroadeningimplementationoffederalandstatementalhealthparitylawsthatwilllikelyfurtherincreasethedemandforspecialtymentalhealthcareforyoungpeople.65-67Newapproachestomeetingthisdemandareneeded,aswellastomeetingexpectationsforenhancedcarecoordinationamongprimarycareandbehavioralhealthprovidersaspartofmedicalhomeinitiatives.ThePatientProtectionandAffordableCareAct(ACA)hascalledforthemeaningfuluseoftelehealthtechnologiestoimprovehealthcareandpopulationhealthforallcitizens.65-67

C.FactorsDeterminingAccesstoTelementalHealthforYouthIncreasingaccesstomentalhealthservicesforyoungpeopleisoftentherationalefortheimplementationoftelementalhealthprograms.Thetechnologymaybeusedtobridgethegapbetweenspecialistsupplyanddemand,particularlyinruralandotherunderservedcommunitiesthatfacedecliningeconomies,pooraccesstomentalhealthinsurance,andlimitedtransportationoptions.51,68,69Inadditiontoaddressingavailabilityandaccessibility,child-friendlytelementalhealthsettingssuchasschoolsandprimarycareofficesmayreduceperceivedstigmaassociatedwithmentalhealthservicesandincreasetheecologicalvalidityofprovidingtheseservices.Telementalhealthisanespeciallygoodfitwithyouthduetotheirfrequentuseandproficiencywithtechnology.Technologicalliteracyisdramaticallyimprovingacrosspatients,families,andproviders,andadolescents’literacyincreasesfamilies’overallliteracy.70,71

However,accordingtotheFederalCommunicationsCommittee’s2015BroadbandProgressReport,theUnitedStatesisfailingtokeeppacewithadvanced,high-qualityvoice,data,graphicsandvideoofferings,particularlyinruralareas.72Thisimpactstheabilitytoprovidehighqualitytelementalhealth,particularlytosomeoftheverypopulationsingreatestneedofmoreaccessibleservices.AsignificantdigitaldivideremainsbetweenurbanandruralAmericaandthedivideisstillgreateronTriballandsandinU.S.territories.TheUnitedStatesDepartmentofCommerce’sNationalTelecommunications&InformationAdministration73planstoincreaseconnectivityinruralandotherunder-servedcommunitiestoclosetheurban-ruraldivide.Adigitaldividealsopersistsalongeconomiclines.Mobiledevicesprovideanemergingwaytodelivertelementalhealth,bothinsupervisedandunsupervisedsettings.AccordingtothePewResearchCenterInternet,Science&TechReport,in2015,approximately68%oftheAmericanpopulationoverallhassmartphonesand45%havetabletcomputers.74Morespecifically,88%ofAmericanteensages13to17haveorhaveaccesstoamobilephoneofsomekind,andamajorityofteens(73%)havesmartphones.75Givenadolescents’technologyliteracyandtheirincreasingaccesstomobiledevices,newmodelscanbeanticipatedfordeliveringmentalhealthcaretoyoungpeople.Anecdotally,manyfamiliesareusingvideoconferencingforsocialpurposes,includingSkype®orFaceTime™withrelativesandfriendsacrossthecountryandtheworld.20Thisfamiliarityisanticipatedtoenhanceoverallcomfortusingvideoconferencingforclinicalapplications,includingtelementalhealth.Guidelinesareneededtoensurethequalityofsuchinnovativecare.76


REVIEWOFTELEMENTALHEALTHSERVICESWITHYOUTH

Theevidencebasesupportingthefeasibility,acceptabilityandeffectivenessoftelementalhealthwithchildrenandadolescentsisemergingincrementally.

A.ClinicalInterventionsandtheSupportingEvidence-Base

Telementalhealthmaybeespeciallysuitedforyouthwhoareaccustomedtothetechnology,especiallyadolescentswhomayrespondtothepersonalspaceandfeelingofcontrolallowedbyvideoconferencing.Thereissomepreliminaryevidencethatvideoconferencingoffersadvantages,includinglessself-consciousness,increasedpersonalspace,anddecreasedconfidentialityconcernsastheproviderisoutsideofthelocalcommunity.77

Duetothesmallbutemergingchildliterature,lessonsareoftendrawnasadownwardextensionfromadultliterature.Arecentextensivereviewoftheempiricalliteraturefortelementalheathacrossthelifespanfollowingrigorousinclusioncriteriaconcludedthatthereisstrongandconsistentevidenceofthefeasibilityoftelementalhealth,aswellashighacceptabilityacrossteleprovidersandpatients.78Therewasindicationofimprovementinsymptomologyandqualityoflifeamongpatientsacrossabroadrangeofdemographicanddiagnosticgroups.Multiplestudieshavedemonstratedthefeasibilityofimplementingtelementalhealthserviceswithyoungpeopleacrossdiversesettings.14,23,79-86Diagnosticassessmentshavebeenreliablyconductedthroughvideoconferencingforyouthwithvariousdisordersevaluatedinoutpatientsettings,31,33,87,88including:disruptivebehaviordisorders,12autismandotherdevelopmentaldisorders,41,89andpsychoticdisorders.90Multiplestudieshavedemonstratedtheacceptabilitytoreferringprimarycareproviders(PCPs),parents,andyouthofdeliveringchildmentalhealthservicesthroughvideoconferencing.41,79-80,83-85,88,91-97Satisfactionstudiesdemonstratetheabilitytodevelopatherapeuticalliancewithyouthandfamiliesthroughtelementalhealth42andsuggesteffectiveness.Thedeliveryofpharmacotherapythroughtelementalhealthhasbeendescribedwithyouthinschools,98mentalhealthcentersanddaycare,39outpatientsettings31,83-85andjuvenilejusticefacilities.30,99,100Onerecentlargecommunity-basedrandomizedtrialprovidessolidevidenceoftheeffectivenessofshort-termpharmacotherapyforADHDdeliveredbychildandadolescenttelepsychiatristscomparedtotreatmentinprimarycarecomplementedbyasingletelepsychiatryconsultation.12Telepsychiatristsdemonstratedgoodadherencetoguideline-basedpharmacotherapyandgreaterassertivenessinpharmacologicmanagementthanthePCPs.101

Thereisanemergingliteraturesupportingthefeasibilityandeffectivenessofpsychotherapywithchildrenandadolescentsdeliveredthroughvideoconferencing.Theevidence-baseispredominantlydrawnfromadownwardextensionfromtheadultliterature.8,9,102,103Backhausandcolleagues8completedareviewof65studiesacrosspsychotherapymodalitiesdeliveredovervideoconferencing.Theyconcludedthatvideoconferencing-deliveredpsychotherapyisfeasible,applicabletodiversepopulations,inavarietyoftherapeuticformatsandisgenerallyassociatedwithhighusersatisfaction.Mostimportantly,clinicaloutcomesforpsychotherapydeliveredthroughvideoconferencingappearcomparabletocaredeliveredintraditionalpsychotherapy.Grosandcolleagues9conductedareviewof26studiesfrom2000to2012basedspecificallyonthedeliveryofcognitive-behavioraltherapy(CBT)-relatedstrategiesovervideoconferencingwithvaryingtechnologies.Theyconcludedthatthemajority


ofthestudiessupportedtheeffectivenessofusingvideoconferencingtodeliverpsychotherapy.Mostpublishedstudiesofpsychotherapyconductedspecificallywithyoungpeoplehavebeendescriptive,withonlyahandfulofoutcomestudies.14,23NelsonandPatton27identifiedtenpsychotherapystudieswiththegeneralpopulationofchildrenandadolescentsexperiencingamentalhealthconcern.MostofthesestudieswereinterventionsforADHD,butalsoincludedavarietyofsinglestudyexamples.Emergingcasereportssupportthefeasibilityofteletherapyinhighneedareaswithadolescents,includingfamily-basedinterventionsforeatingdisorders104andtelementalhealthoncollegecampuses.34Additionalresearchwithadolescentsandsubstanceabusetreatmenthasbeenencouraging.102Interventionapproachesvariedinfocusontheyouthortheparentandrangedfromfeasibilitytrialstopre-postdesigns,andahandfulofrandomizedcontrolledtrials.11,13,15,16Consistentwiththemorerobustadultindividualtherapyliterature,8-10findingswereoverallpositiverelatedtofeasibility,satisfaction,andoutcomes.Thisreviewalsoidentifiedadozenpediatricpsychologystudies,addressingmentalhealthapproacheswithchildrenandadolescentswithacuteandchronicconditions.Inrelationtopediatricpsychologyapproachesusingtelemedicinewithchildrenwithchronicmedicalconditions,mostinformationisfromcasereportandsmallpilots,27reflectingsuccessfulimplementationwitharangeofconditions(pediatriccancer,pediatricfeedingconditions,diabetes,irritableboweldisorder,pediatricepilepsy,congenitalheartdefect,amongothers).Therearealsocasereportsreflectingpediatricpsychologyservicesovertelemedicineforsleepdisordersandtoiletingdisorders.Severaltrialshavefoundpositiveresultstreatingpediatricobesityovervideoconferencing,bothtoruralschoolsandtoruralprimarycarepractices.105-106

Thereisalsoverylimitedinformationaboutgrouptherapyapproachesusingtelemedicinewithyouth,withreportsdescribingtheapproachsuccessfullyutilizedwithpediatricobesity107andadolescentsonhomeparenteralnutritionandtheircaregivers.108Severalrandomizedtrialsofpsychotherapyarenoteworthy.Nelsonandcolleaguesfoundcomparablereductionsforchildhooddepressivesymptomstreatedwitheightsessionsofcognitive-behavioraltherapy(CBT)deliveredthroughvideoconferencingversusin-person.13,109Twosmallrandomizedtrials15,110testedtheeffectivenessoftreatmentforobsessive-compulsivedisorder(OCD)andfoundthatcomparedtoyouthtreatedin-personthosetreatedthroughtelementalhealthhadcomparableorsuperioroutcomes.Thebehavioraltreatmentofticsthroughtelementalhealthhasalsobeenfoundtobecomparabletoin-persontreatment.11Foursmalltrialshavedemonstratedtheeffectivenessofprovidingfamilyinterventionsandparent-managementtrainingthroughvideoconferencing16,111,112,113

B.TelementalHealthServiceDeliverytoClinicalSettings

Childandadolescenttelementalhealthservicesarebeingdeliveredtomultipleclinicalsettingstomeetdiverseclinicalneedsofchildrenandadolescents.11-16,23,26,29-35,38-42Currently,thepointofdeliveryfortelementalhealthservicesisasvariedasthetypeofservicesthatarebeingprovided.Mostdescribedintheliteratureareprimarycareclinics,communitymentalhealthcenters,physicianoffices,outpatientclinics,schools,andcorrectionalsettings.Individualreportsdescribedeliverytoothersettingssuchasresidentialtreatmentfacilities,criticalaccesshospitals,grouphomes,AreaHealthEducationCenters,colleges,sitesservingfostercare,militarybases,anddaycares.Mostreportsfocusonruralandothernon-metropolitancommunities,33buttelementalhealthcaretochildreninurbansettings39hasbeenreported.Unsupervisedsettingsincludingpatienthomesareemergingpointsofservicedeliverywhichbringbothnewbenefitsandrisks.35,71,110,114Recentpresentationsdescribedtelepsychiatryservicesto


aninpatientpsychiatryunit.115andtoanemergencyroom.116Commercialvendorsandprivatepracticeprovidersaredeliveringservicestomultiplesites.Eachofthesesiteshasitsownneedsandresourcestoimplementatelementalhealthservice.Trainingshouldbetailoredtoeachpointofservicedelivery,includingcoordinationofcarewithon-sitestaffandcommunityproviders.Reportedworkintelementalhealthwithchildrenandadolescentshasfocusedondirectcare12-16,25-27,31,39,42,43,84,102,104andpatient-centeredconsultationwithrecommendationstothereferringprimarycareproviderfortreatment.12,88,93,97,98,117Consultationconferenceswithagroupofprimarycareprovidershasbeendescribedtoimprovetheirownskillsandbuildasupportnetworkforongoingclinicalcareofyoungpeople’smentalhealthproblems.98,118-119TelementoringmodelssuchastheExtensionofCommunityHealthcareOutcomes(ECHO)arealsobeingevaluatedinADHD,autism,andotherchildbehavioraltopicareas119inordertosupportprimarycarepractices.Twounder-reportedareasforchildandadolescenttelementalhealthcareincludespecialistconsultationtotherapistsindistantcommunitiesandtoyouthinstatecustody.12

C.TelementalHealthPracticeinCommunitySettings

Thereisalonghistoryofmovingmentalhealthcareforyouthfromthementalhealthclinictothecommunitytoimproveaccesstocare,increaseadherencetotreatmentplanning,andtoprovideservicesinnaturalisticsettings.Consistentwiththispattern,telementalhealthservicesarebeingmovedoutsideoftraditionalmentalhealthcaresettings.Whentelementalhealthservicesareimplementedincommunitysettings,theyoffertheopportunitytoascertaincontextualfactorsinvolvedinyouths’behaviorandmentalhealthneeds,aswellastoinvolvestakeholdersinyouths’careandoutcomes.Inparticular,telementalhealthoffersapowerfulopportunityforcollaborationwithpediatricianstohelpthemaddresstheincreasingexpectationstoimprovetheirskillsindiagnosingandmanagingcommonmentalhealthconditionsofyoungpeople.25,26,29,37,39,88,93,98,117,120-123Collaborativecaremodelsinwhichapsychiatristandprimarycareproviderjointlymanageapopulationofpatientswithacaremanagerhavebeendescribedwithadults,124,125andhavepotentialforincorporationintothepediatricmedicalhome.126Providingmentalhealthcaretostressedfamiliesofchildrenwithchronicmedicalillnessesfaceschallengesinboththemedicalandmentalhealthservicesectors.Pediatrictelepsychologyhasshownfeasibilityinovercomingsomeofthesechallengeswhenprovidingservicesduringmedicalvisitsorathome.127-132Further,familieshaveshownsatisfactionwithservicesandincreasedknowledgeofhealth-relatedbehaviors.105-106,131-132Thereissomesupportforcosteffectivenessofhealthpsychologyservicesprovidedthroughvideoconferencingtothesesettings.128,131Thesestudiessupporttheneedforfurtherworkintegratingtelementalhealthintothepediatricmedicalhome.126School-basedtelementalhealthservicesengageyouthduringtheschooldaytherebyreducingdistancesyouthmusttraveltoaclinic-basedCATMHservice,decreasingmissedschooldays,disruptioninthechild’sclassroomtimeandparent’sworkday,allowingparentstobeinvolvedinasettingthatisfamiliarandconvenient,andincorporatingschoolpersonnelintotreatmentplanning.40,133-134Utilizationoftelementalhealthallowstheyouth’sprovidertobeefficientlyinvolvedinmultidisciplinaryplanning,studentevaluation,IndividualizedEducationPlan(IEP)/504planmeetings,andcollaborationwithteachers,schoolspecialists(e.g.,schoolpsychologists,socialworkers,andalliedhealthspecialists),nurses,andadministrators.40Examplesofservicesthatmaybedeliveredbytheprovidertotheschoolsysteminclude,butarenotlimitedto,mentalhealthevaluations,behavioralinterventions,medicationtreatment,ongoingsessionswithstudentsandfamilies,evaluationforsupportservices,continuingeducationforstaffandconsultationonbothclassroomspecificandgeneralschoolissuesand


consultationintheeventorthreatofaneventthatmayadverselyimpacttheschoolcommunity(e.g,untimelydeathofastudentorteacher,naturaldisaster,threatofviolentact).Anotherareaofschool-basedtelementalhealthisthedeliveryofeducationalsupportservices,suchascounseling,occupationaltherapy,orspeechtherapy,toyouthwhoarehome-boundorasameanstocontinueserviceswhenschoolisoutofsession.Theemergingevidence-baseindicatesthatschool-basedCATMHisfeasibleandacceptable.40,133NelsonandcolleagueshaveshowngoodadherencetotheAmericanAcademyofPediatrics’(AAP)guideline-basedevaluationforADHDwhenconductedinschoolsettings.135Reeseandcolleagues89havedescribedaninnovative,cost-effective,IntegratedSystemsUsingTelemedicine(ISUT)Modelforautism.Thistelemedicinemodellinksstudentsandfamilies,trainedearlyinterventionprovidersandeducatorsatthechild’sschool,andateamofuniversity-basedmedicalprofessionalsattheacademichealthcenter.Residentialtreatmentcentersandcorrectionalsettingsoftenrequireprolongedseparationsoffamiliesfromayouthwhoisconfinedinafacilityfardistantfromfamilyandprovider.Telementalhealthallowsfamiliestoparticipateinayouth’streatmentwhileremainingintheirhomecommunitiesortelecommuteamentalhealthspecialisttotheyouth’sfacility.Forexample,themultipointcapabilitiesoftelementalhealthcandelivermulti-systemictherapy,whichincludesanetworkofcaregivers,schoolofficials,peers,andneighborstopromotepositivebehavioralchanges.Deliveringtelementalhealthservicestosuchfacilitiesprovideschallengestoprivacyandconfidentiality.30,99-100Home-basedtelementalhealthofferspotentialadvantagestoobservetheyouthinanaturalisticsettingandtopracticeskillsinthelivedenvironment.Comerandcolleaguesaretestingtheeffectivenessoftelementalhealthindeliveringbehavioralinterventionsforearlyonsetbehaviordisorders.70-71,110,136Theyusevideoconferencingtoobservetheyouth’sbehaviorandthentoguideparentsinfacilitatingbehavioralinterventions.Successfuloutcomesaredescribedforacaseseriesofchildrenwithobsessive-compulsivedisorder(OCD).70Furtherworkindeliveringparent-childinteractiontherapy(PCIT)throughvideoconferencingisinprogress.Casereportsoftelementalhealthservicestothehomehavealsoaddressedsupportgroupservicesforhomeboundindividualsandtheircaregivers108andhome-basedservicesforchildrenwhohaveexperiencedtrauma.32

GUIDELINEFORTHEPRACTICEOFTELEMENTALHEALTHWITHYOUTH

TheATACoreandotherTelementalHealthGuidelinesshouldbeconsultedforadministrativeandtechnicalaspectsthatarecommontomosttelemedicineapplicationareas.Detailedhereareaspectsspecifictochildandadolescenttelementalhealth.

A.AdministrationGuideline:NeedsAssessmentandStandardOperatingProcedures

IfimplementinganewCATMHprogram,oraddingservicestoanexistingprogram,aneedsassessmentmaybeconducted,24,25,includingassessmentofsitereadinessandscalability.137-138Theneedsassessmentassistsproviderstoidentifycommunitiesthataremostlikelytoadoptvideoconferencingservicestofilltheaccessgapbycommunicatingwithcommunityorganizations,consumergroups,andotherkeystakeholders,particularlyassomeunderservedcommunitiesmustallocatetheirmental


healthcarefundingtotheadultchronicallymentallyill,leavinglimitedresourcesforyouth.Aneedsassessmentallowstheprovidertoidentifytheagegroups,behavioralpresentations,andinterventionsthatwillsupportactiveclinics.Providersmayvisitpotentialsitestodeveloprelationshipswithstaffandthebroadercommunityaswellasgainingabetterunderstandingofthelocalcultureofpotentialpatientsandtheirfamilies.Thisisparticularlyimportantwithyouthpopulationsbecausestaffatthedistantsiteneedtofeelcomfortableassistingwithchildrenandadolescents.Needsassessmentisanongoingprocessinordertoevaluateandimproveservicesofferedthroughnewandestablishedtelementalhealthpracticesandinresponsetohealthcarereforms.Theneedsassessmentgoeshand-in-handwithcarefulbusinessplanningfortelepracticewithyouth,bothfortheprovider25,137andforthedistantsite.139Thisincludesdeterminingwhichdisordersmeetmedicalnecessitycriteriabythirdpartypayersinthejurisdictioninordertoensuresustainabilityofthetelementalhealthprogram.140-142Providersshouldchecktodeterminecoverageforthedifferenttypesofchild,adolescentandfamilysessionsthataregenerallycoveredbyCurrentProceduralTerminology(CPT)codes.143Detailedprogrammaticdataconcerningtheimplementationofevidence-supportedtreatmentbyyouth-trainedspecialists,aswellasprocessandoutcomedata,mayalsobeutilizedtomakeacaseforchildandadolescenttelementalhealthservicesamonglocalinsurers.Telementalhealthorganizationsandprovidersshallensurethatappropriatestaffistrainedandavailabletomeettheyouth’s,thefamily’s,andprovider’sneedsbefore,during,andaftertelementalhealthsessions.Theseneedsmaydifferfromthoseencounteredinclinicalworkwithindividualadults,aschildrenmayunexpectedlybecomedisruptive,ateenmaythreatensuicide,oraparentmaydecompensate.Protocolsshouldalsodescribethetelepracticeworkflowandassociatedstaffresponsibilities.Forexample,familiesoftenbringsiblingstotelementalhealthsessionsforwhomamanagementprotocolmaybehelpful.Thepresentermayalsoassistwithmanagingtheflowofparticipants(e.g.,patient,caregivers,schoolpersonnel,casemanager,etc.)inandoutofthevideoconferencingroomandwithensuringprivacyofthesessions.Parentsandyouthmaydifferintheirliteracyandprimarylanguage.Theprovidershalldeterminewhetheraninterpreterisneededratherthanrelyingontheyouthorfamilymembersand/orhowtoaddressthefamily’sverbalandwrittencommunicationneeds.144Theprovidershallassesshis/hercompetencewithevaluatingandtreatingchildrenandadolescentsacrosstelementalhealthareas,andseekadditionaltraining/mentoringifgapsarenoted.

B.LegalandRegulatoryIssues

Duringtheneedsassessment,theprovidershouldincludeapolicyandpracticestandardsreview.145Thisincludesacomprehensivereviewofregulatoryguidelinesregardingthementalhealthtreatmentofyouthinboththejurisdictionandsettingofthepracticewithparticularattentiontoissuessuchastheageofmajorityandreportingofsuspectedmaltreatment.Sitesandjurisdictionsmayvaryintheirmandatesforadditionalresponsibilitiesinthecareofvulnerablepopulations,suchasyouthinfostercareandincorrectionalsettings.Aswithonsitepatients,providersshouldfollowprofessionalpracticeguidelinesinrelationtothechronologicalageoftheyouthaswellasconsiderationofthedevelopmentalage.Asinonsitesettings,theprovidershouldestablishthelegalguardianshipoftheyouthaswellascustodyarrangements,whenapplicable.Clarificationshouldbeobtainedregardingparentalrightsindecidingtreatmentforayouthwhoisinstatecustody.Providersaremandated


reportersandshallbeawareoftheirjurisdiction’srequirements,aswellastrainstaffinproceduresandprotocolstosupporttheyouthinpotentiallyharmfulsituations.Theyshouldalsobeawareofconsiderationsassociatedwithdisclosureofbehaviors(e.g.,sexualactivity,substanceuse/abuse,etc.)toparentsofadolescentclients.Providersshallfollowtherequirementsandrestrictionsoflicensure,includingconsiderationoftheprovider’sscopeofpracticeandexpertisewithyouth.1,2,145Justasinadultcare,cautiousreviewshouldincludeconsiderationofthelegalandregulatoryrequirementsineffectatboththepatientandproviderlocations,withparticularconsiderationregardingageofmajorityintheprovider’sownandintheyouth’sjurisdiction,dutytowarnandprotectrequirements,andcivilcommitment.146Providersmayverifythattheirprofessionalliabilityinsurancecoversactivitiesinalloftheirsitesoftelepracticeandseeklegalconsultationforanyjurisdictionalconcernsregardingtelepractice.Statesvaryintheirrequirementforspecificwrittenconsentforcaredeliveredthroughvideoconferencing.Accordingtothestate’sguideline,theprovidershouldcompleteinformedconsentwithlegalguardiansforchildrenandwithpatientsovertheageofmajorityorfor“matureminors”instateswithsuchdesignation.Theconsentprocessshouldensureabasicunderstandingof,andagreementto,thespecificuseoftelementalhealth.Providersshouldchecklocal,regionalandnationallawsregardingtherequirementforverbalorwrittenconsentfordeliveringcarethroughvideoconferencing,1,145withconsiderationtotheage,developmentlevel,literacy,andlanguagepreferences.Youthmayneedtoprovidewrittenconsenttoreleasetheirrecordstotheirparents.Someprogramsmayrequirewrittenconsentwiththeyouth’s,parent’s,andprovider’ssignaturesonthesameforms.Thepresentermayhelptocompleteanyrequiredmedicationconsentforms.Somesitesmayallowthepresentertosigntheconsentformattestingthattherisksandbenefitswerereviewedwiththetelepsychiatrist.Othersitesmayrequirethattheformbesenttothetelepsychiatristforasignature.Providersshouldestablishproceduresforsharinginformationwithpediatriciansorotherprimarycareproviders.Bothadolescentsandparentsmustconsenttosharingtheinformation.Providersshallabidebyconfidentialityrequirementsrelatedtoboththeclinicalsetting147andtheschoolsetting148,149andfollowtheethicalguidelinesoftheirprofessionalorganization.Ifanytelehealthencounteristoberecorded,providersshallbeawareofstate-specificlawsregardingtherecordingofprivateconversations,andshalldisclosetothepatientandparent/guardianthattheencounterwillberecordedandreceivewrittenconsentfortherecording.

C.GeneralTelementalHealthPracticeswithYouth

Specificconsiderationsasneededinworkingwithyoungpeoplearedescribedbelow.

1. PhysicalLocation/TelementalHealthSpaceTherearenospecificguidelinesforthespaceinwhichchildandadolescenttelementalhealthsessionsareconducted,buttherearesomeconsiderations.Providersshouldcommunicatethe


specificroomrequirementstopatientsitesbeforeclinicalservicescommence.Someremotesitesproposeusingasmallroomthataccommodatesadulttelehealthservices,oraconvenientconferenceroom,oramedicalexaminationroom.Allofthesemayhavedisadvantagesfortelementalhealthwithchildrenandadolescents.20,24,42,43Theroomshouldbelargeenoughforatleastonetotwoadultstoattendandbeincludedonscreen.Ifmoreindividualswilltypicallyinteractwiththeyouthandprovideratonetime,suchasteam-basedassessmentsorgrouptherapy,alargerroomshouldbeconsidered.Boththedistantsiteandoriginatingsiteshouldannounceallpartieswhoarepresentintheirrespectiverooms,regardlessofwhoisoncamera.Theroomshouldallowthechildtomovearound,bothforthechild’scomfortandtoallowanappropriateexaminationofhis/herskill,particularlyforyoungerchildrenwhosemotorskillsandexploratoryabilitiesmaybecompromised.Toolargearoom,suchasaconferenceroom,mayallowthechildtowander,makingitdifficulttomaintainapresenceonscreenespeciallyifthecameraatthepatientsitedoesnothavepan/tiltcapabilities.Amedicalexaminationroommayoverstimulatethechildandriskdamagetoequipment.Thechoiceofroomshouldalsobeaccessibletoyouthwithmobilitychallenges.Oneapproachtodetermineadequateroomsizeandconfigurationistoprovideroomdimensionstothesite,askastafftositabouteightfeetfromtheproposedcameraplacement,andsendadigitalphotographtotheprovidertodeterminewhetherthereisadequatefullbodyviewofboththeyouthandparent.Thespaceatthepatientsiteshouldbeconservativelyequippedaccordingtotheclinicalintervention.Forexample,psychotherapysessionsmaywarrantacomfortablebutsparselydecoratedroomtominimizedistractions.Parentaltrainingforchildren’sbehavioraldisordersmaybefacilitatedbyspecificroomarrangementstoassisttheparentingiving“clearinstructions”tothechild.Diagnosticsessionsarehelpedbyincludingdevelopmentallyappropriateimplementssuchasadeskandcrayonsthatallowassessmentofthechild’sfinemotorskills,creativity,andattentionspan.Thechild’seagernesstoshareanddescribehis/herworkconveysinterpersonalandcommunicationskills.Asmallselectionoftoysmaybeprovidedtodeterminethechild’sinterestsandabilities,butnoisy,multiplecomponent,andmessytoysshouldbeavoidedasthesensitivemicrophoneswillpickupthenoiseandcompromiseconversation.Clean-upafterthesessionmakesadditionalworkforstaffatthepatientsite.Lightingiscrucialsothatthewholeroomshouldbeeasilyvisualizedandinteractionsoftheyouthandparentappreciated.Naturallightingcanchangeduringthedayfloodingtheimageonthescreen.Ceilinglightingoftencastsshadows.Roomchoiceshouldconsiderthepresenceandplacementofwindows,generallygivingpreferencetoroomswithoutwindowsandwithhorizontallighting.Lightingshouldallowfullappreciationoftheyouth’sfacialfeaturesorexpressions.Whentelementalhealthsessionsareconductedoutsideoftraditionalclinicsettings,suchasschoolorhome,findingtheoptimallysized,lighted,andprivatespacemaybechallenging.Inschoolsettings,theprovidershouldassesswhethertheschoolhasadequateinfrastructuretosupportatelementalhealthprogramasfindingaprivatespaceincrowded,under-resourcedschoolsmaybedifficult.40,133Manyindividualsmayparticipateintheschool-basedencounter,includingthechild,parent,schoolnurse,teacher(s),administrativepersonnel,casemanager,socialworker,schoolpsychologists,andothers.40,150Theprovidershouldensurethattheroomcanaccommodateallparticipatingindividualson-screenwithoutobscuringobservationoftheyouth.Whenprovidinggrouptherapyovervideoconferencing,theroomsizeshouldalsobe


reviewed.Whenusingmobiledevicesforhome-basedworkwithactiveyouth,caseswithstandsareoftenrecommendedtoprotectthedeviceaswellasdeliverastablevideoimage.Becausemobiledevicesmakeitfeasibletomovethroughoutthehometoobservethechild’sbehavior,familiesmayneedreminderstosetthedeviceonatableinordertomaximizethetransmissionqualityaswellasminimizedistractions.

2. PresenterAssistanceinTelementalHealthSessionsMostcommunity-basedsettingsutilizeapresenter(oftenalsothetelemedicinecoordinator)inthetelementalhealthencounters151forbothqualitycareandforreimbursementrequirements.Apresentermaybemoreimportantforworkwithyoungpeoplethanwithadultsduetothemultipleindividualsandproceduresinvolvedintheyouth’ssystemofcare.Theprovidershoulddeterminethescopeofthepresenter’sassistancebeforethesession(withscheduling,paperwork,andsocializationtothebehavioralhealthsystem);duringthesession(withtechnicalandclinicalsupport,includingtakingvitalsignsandassistinginemergencysituations);andafterthesession(withimplementingrecommendations,facilitatingreferrals,andcoordinatingwiththeyouth’ssystemofcare).Theprovidermaydecidewhentoincludethepresenterinthesession;forexample,ifthepresenterisoutsideoftheroom,theprovidershoulddeterminehowhe/shewillbecontactedtojointhesessionsshouldtherebeaneedforassistance.Acrosscommunitysettings,theprovidershouldconsiderthetrainingneedsofthepresenter,includingtheabilitytoworkwithyouthwithbehavioralhealthconcernsandexpectationsassociatedwiththementalhealthsetting(e.g.,highlevelofconfidentiality).Aheadofinitiatingtelepractice,theprovidershouldcollaboratewiththepatientsiteandthepresentertoestablishasafetyprotocolintheeventthattheyouthexpressesimminentdangerousnessthatrequiresaninterventionordisclosesharmtohim/herselfthatrequiresmandatedreportingtoauthorities.

3. PatientAppropriatenessforTelementalHealthServices

Therearenoestablishedindicationsorcontraindicationsfortelementalhealthserviceswithyoungpeople,otherthantheyouthorparentrefusingservices.Ifcareisdeliveredinatraditionalclinicsetting,theprovidershallalertstafftoanyriskstotheyouth’ssafetysothattheycanbeawareofneedtoassistornotifysecurityorotherresources.Ifcareisdeliveredoutsideofatraditionalclinicsetting,suchasschool,theprovidershalldeterminewhethertheschoolwillbeabletoassistwiththesessionsandongoingengagementofstudentandfamily.40,133Priortoinitiatingtelementalhealthservices,theprovidershouldobtainknowledgeofschoolculture,resources,andcapabilitiesanddefineexpectationswithintheschoolsystem.Theprovidershoulddetermineifhe/sheisgoingtoprovidedirectpatientcareorserveasaconsultanttoschoolstaff,aswellasoutlinetheroleofschoolpersonnelintheyouth’scare.Intheschoolsetting,particularattentionshouldbepaidtoprivacy.Ifcareisdeliveredathome,32,35,70,71,136theyouthmaybeatincreasedrisktoelopeortoactout.Aresponsible,trusted,andcapableadultshouldbeonsiteandaccessibletotheprovidertoassistinassessingpotentialharmortointerveneinthesituation,ifnecessary.Familieswithmaltreatmenthistoriesmaynotbeappropriateforremotetreatmentdeliveredtounsupervisedsettings,suchasthehome.


Insomecases,ayouthmayactouteveninthepresenceofanadult,forexampleaveryhyperactivepreschooler,oppositionalchild,oruncooperativeteenmayattacktheequipment,aggressthecaregiver,hide,ortrytoleave.Often,parentsofchildrenseekingmentalhealthcarearethemselvessufferingpsychiatricdisordersandmaybecompromisedintheirabilitytosupervisetheyouthduringthevideoconferencingsessions.Thus,theprovidershouldconductasimilarassessmentoftheabilityoftheaccompanyingadulttocontaintheyouthand/orfortheadulthim/herselftosafelyparticipateinsessionsandfollowtreatmentrecommendations.Relativecontraindicationsforchildandadolescenttelementalhealthservicestoconsiderincludeassessmentinsettingsthatarenotconsideredneutral,suchastheyouth’shomeorothercaresite.71Examplesincludechildcustodyassessments,forensicevaluations,andinvestigationofallegationsofabuseorneglect,familytherapywithahistoryofinterpersonalviolenceinthefamilyand/oravolatilecaregiver/parent.Thechildmaynotfeelfreetobecandidabouthis/herenvironmentorcircumstancewithapotentiallyoffendingcaregivernearby.Inaddition,inthehomeenvironment,theproviderhaslessabilitytoredirectthesituationshouldthecaregiverbecomeangry/losecontrol.Theenvironmentitselfmaybeintimidatingtotheyouth.Somechildrenwithdevelopmentalorpsychoticdisordersmaynottoleratethevideoconferencingplatform.Therefore,theprovidershalldetermineappropriatenessforthesite’stelementalhealthservicesconsideringtheyouth’sandparent’spreferences,referralquestion,developmentalanddiagnosticconsiderations,personnelandotherresourcesavailableatthepatientsite.Theprovidershallascertainwhethertheyouthcansafelyengageinthesessioneitheraloneorwiththeparentintheroomandshallensurethatresourcesatthepatientsiteareabletodealwithanypotentialriskstothepatient,others,ortheequipment.Theprovidershallassessthechild'swillingnessandcapabilitytofollowtheprovider’sinstructionswithoutlocaladultinvolvement.

4. WorkingwithDiverseYouthandFamiliesTelepracticeofteninvolvesaracial,ethnic,andculturalgapbetweenprovidersandpatients.152WithCATMH’sexpandedreach,comesproviders’obligationtoassesstheircompetencewithdiversechildandadolescentpopulations.However,thereislimitedresearchregardingthedeliveryoftelementalhealthservicestochildrenandfamiliesacrosscultures.Therefore,culturalhumility153isrecommended,recognizingthelife-long,process-orientedapproachtostrivingtowardcompetencywiththevulnerablegroupsservedintelepractice.Followingtheirdiscipline’sethicalbestpractices,providersshouldconsidertheirpatients’uniqueneedsbasedonage,sex,genderidentity,race,ethnicity,culture,nationalorigin,religion,sexualorientation,disability,language,andsocioeconomicstatus154,155withadaptationtotelepractice.3,24,144,156Providersshouldcarefullyattendtobothverbalandnonverbalcommunicationcluesandcommunicationstylesthatmayvaryacrosscultures.Forinstance,storytellingapproachesmaybecommoninsomeAmericanIndianculturesandadditionaltimeshouldbeutilizedtoaccommodatethispreferredstyle.144Theprovidermayformulatethepatient/client’sneedswithinaculturalframework,includingconsiderationoftheyouth’sculturalidentity;culturalconceptualizationofdistress;psychosocialstressorsandresilience;andculturalfeaturesoftheclient-providerrelationship.114Theimpactoftechnologyontheculturalformulationshouldbeconsidered.Culturallysensitiveprotocolsshouldbeconsidereddrawingonbroadcommunityinputandfamilies’preferencesforbilingualprovidersfromthesameculturalbackground.157,158


Arelatedconcerninnon-metropolitancommunitiesisthedifferencefromvaluesheldbyurbanproviders,aswellasovergeneralizingaboutruralcommunities.68,69Todeveloprapportandatherapeuticalliance,providersmaylearnaboutthefamily’scommunity,theirvalues,andresources.Thelocaltelemedicinecoordinatorand/ortelepresenter,aswellascommunityhealthworkers(whenavailable),canprovidevaluableinformationaboutthecommunitytoassisttheprovider.Forexample,anurban-basedprovidermaybeconcernedaboutgunsinthehomeofayouthwhoisdepressed,butfamiliesinruralcommunitiesmaynotreadilyremovegunsfromthehome.ACaucasianproviderpracticinginamajorsuburbmaynotunderstandthatanInupiatfamilylivingasubsistencelifestylemaynotattendappointmentsduringfishingorhuntingseason.Firstgenerationchildreninimmigrantfamiliesmaydifferintheiracculturationandlanguagefromtheirparentsprovidingcomplexculturalissuesforevaluation.Respectfulquestionsaboutculturalandameansofassessingculturaldifferencesshouldbeestablishedsothattheprovidercanoptimizeculturalcompetenceintheirtelepracticewiththeyouthandparent.Avisittothepatientsitemayhelptoappreciateculturaldifferences.

5. ConsultRequestDataInformationshouldbeavailablethatmeetslegalandregulatoryrequirementsforreferralandthatpreparestheproviderforthetelementalhealthevaluationandtreatment.Theassessmentofchildrenandadolescentsoftenrequiresinformationbeyondthatobtainedforadults.Multipleinformantsarecommon.Youthoftenhavehadpriorassessments,suchasdevelopmentalevaluations,psychologicaloreducationaltesting,andimplementationofanIEP.Proceduresshallbeestablishedbetweenorganizationsandprovidersforsharingpatientinformationrelevanttothetelementalhealthevaluation.

6. ClinicalFindingsandReportsThesharingofclinicalhistoryandresultsshallcomplywithestablishedlegalandregulatoryrequirements.Providersandorganizationsshallhaveagreementsinplacethatoutlinetheprocedureformaintainingclinicalhistoryandresults.ForCATMHencountersincommunitysettingssuchasschoolsorcorrectionalsettingsorinunsupervisedsettingssuchasthehome,providersshallestablishproceduresforinformationsharingthatcomplywithguidelinesoutlinedbytheirprofessionalorganizationsforcareprovidedoutsideoftraditionalclinicalsettings.134,159Carecoordinationneedsacrosssystemsofcareshouldbeconsideredinrelationtoclinicalfindingsandreports.Bestpracticesinsecuredataexchangeshouldbefollowed.

D.TechnologyConsiderations

Thereisnoclearevidencethatthespecifictechnologyaffectsthequalityofclinicalcareoroutcomes.Theprovidershouldchoosevideoconferencingtechnologythatisappropriatetoandadequatefortheclinicalservicestobedeliveredtochildrenandadolescents.Determinationoftheoptimaltechnologyshouldconsiderclinicalfactorssuchasassessmentofthedevelopmentalmentalstatusexaminationandmonitoringoftreatmentresponse,aswellassystemsfactorssuchasresourcesatthepatientsite,otherservicesavailable,andtimelinessofservices.


Youtharedependentupontheirparentstoaccesscare.Therefore,providersshouldestablishatherapeuticalliancewiththeparentaswellastheyouth.Thetechnologymayposeachallengetoalliance-building.Providersmayincludeanintroductiontoandexplanationofthetechnologyinuser-friendlytermsandensurethatbothyouthandparentsfeelthattheirperspectivesareunderstood.Asdistortionofthevideoandaudiosignalscaninterferewithalliance-building,theprovidershouldusebandwidthsufficienttodetectaccuratevisual,auditory,andinteractionalcuesthatrepresenttheyouth’sandparent’saffectivestatesandinterpersonalrelatedness.Sufficientbandwidthisalsoneededfordiagnosticdeterminationandtreatmentmonitoring.Forexample,ticsmaybeidiopathicandpresentpriortoanytelementalhealthappointmentormaydevelopinresponsetopharmacotherapy.Affectivebluntingmaybepresentatinitialevaluationduetoanautismspectrumdisorder,amooddisorder,orinternalstimuli—ormaydevelopasaresponsetoneuroleptictreatment.Sufficientbandwidthisneededtominimizethetimedelayinverbaltransmissionsothattheprovidercanreadilyassessanyanomaliesofthechild’slanguageuse,speechandprosody.Youngerchildren’svoicesmaynotcarryaswellasadolescents’orparents’voices.Therefore,providersshouldensurethatmicrophonesaresensitivetotheauditoryrangeofadults’,adolescents,andchildren’svoicesandthattheyareplacedcloseenoughtodetectchildren’svocalrangebutnotirrelevantnoiseduetochildren’splayorenvironmentalsounds.Cameraswithpan-tilt-zoomcapabilitiesatboththeprovider’sandpatient’ssiteshaveparticularrelevanceforworkwithchildrenandadolescents.Theprovidermayestablishrapportwithyouthbygivingthematouraroundtheiroffice,showingthemthatnooneelseisintheoffice,aswellasscanningthepatient’sroomtounderstandwhoispresent.Controlofthecameraatthepatientsiteassistsinevaluatingdysmorphologyanddevelopmentalanomaliesbyzoominginonfacialfeatures,andassessingmotorandactivityskillsbyfollowingthepatientaroundtheroom.Evenwithadequatebandwidthandapan-tilt-zoomcamera,itmaynotbepossibletofullyassesseyecontactduetotheplacementofthecamera.Assessingeyecontactisanessentialcomponentofthedevelopmentalevaluationofyoungpeople,particularlyduringatelementalhealthencounterwhenthereisdecreasedaccesstoothernon-verbalmeansofcommunicationasoccursduringain-personencounter.Theprovidershalldeterminewhetherapparentdecreasedeyecontactrepresentsatechnicallimitationorclinicalimpairment.Providersmayquerytheyouthandparentabouttheyouth’sabilitytosustaineyecontactandtherelatedcontext.Overall,untilfurtherresearchclarifiestherelationshipofbandwidthandtechnologytoclinicaloutcomes,providersshouldconsidertheirplannedclinicalworkinthecontextoftherelevanttechnology.Forexample,diagnosticassessmentsmayrequirehigherbandwidthandscreenresolutionthanongoingtreatmentwhentheproviderandclienthaveanestablishedworkingalliance.Moreworkisparticularlyneededtodeterminewhetherthedeliveryofservicesthroughmobiledevicesaffectsthequalityoroutcomesofcare.

E.TelementalHealthInterventionswithYouth


1. GeneralAssessment,OutcomeEvaluationandPsychologicalTesting

InitialassessmentthroughtelementalhealthshouldbeconsistentwithprofessionalbestpracticessuchastheAACAPPracticeParameter“AssessmentofChildrenandAdolescents”.160

Theprovidershalloverseealignmentwithstandardsofcareandmodifyaccordinglytoaddnecessaryelements(e.g.,interpreter)andadvocateforadditionalspecializedassessment,asindicated,evenifnotavailablethroughvideoconferencingTheprovidershallconsiderallinformationnecessarytoinformdecision-makingduringthetimewiththepatientandfamily.Asforin-personcare,standardclinicalassessmentshallattendtointerviewlogistics,settings,andthevarietyofpartiesinvolved.Thisincludescollectingpre-sessioninformation,history,mentalstatusexamination,physicalexamination,laboratoryorimagingstudies,andotherpre-sessioninformationnecessaryfortheservicedeliveryinquestion.Thesameattentionshouldbegiventopatientengagementstrategiesandtothepatient’sculturalcontextasinthein-personsetting.81,144Asdocumentationofmeasurement-basedcareisbecomingthestandardforusualpractice,providersshoulddocumenttheefficacyofallmentalhealthinterventions,anycomplicationsoftreatment,andthedecision-makingtakentoimprovetreatmentresponseandminimizeadverseeffects.Providersmayuseavarietyofapproachestodocumentation,particularlyquantitativemeasuresthatcanbereadilyreviewedacrossproviders.Thereislittleinformationconcerningcognitiveandneurocognitivetestingofyouthusingvideoconferencing,eitherwithself-administeredorstaff-assistedinstrumentsatthepatientsites.Informationregardingpsychologicalassessmentovervideoconferencingislargelyadownwardextensionfromadultfindingswhichreflectthatsuchtestingisfeasibleandaccurateacrossavarietyofadultpopulationsanddisorders.2,161Reliabilityandvalidityofthetestinginstrumentinthetelementalhealthcontextshouldbeconsidered.Onestudywithchildrenandyoungadults,comparedin-personandvideoconferencingmodalitiestoassessneuropsychologicalstatusinruralyouthexperiencingearlyonsetpsychosisandfoundthatvideoconferencingproducedhigherratingsthanthein-personassessments,andthatparticipantsweresatisfiedwiththevideoconferencingmodality.90Anongoingpediatrictrialassessingtheutilityandvalidityofanautismspectrumdisorder(ASD)assessmentprotocolconductedviavideoconferencingisusingwell-validatedassessmentmeasures(e.g.,theAutismDiagnosticObservationSchedule-Module1andtheAutismDiagnosticInterview-Revised).Preliminaryresultsarepromising.89

Inschool-basedtelementalhealth,theprovidercanreadilyobtaininputfromthecurrentteacherinrelationtootherstudentsinhis/herclassaswellasinputfromthepriorteacher,andcoordinateinformationfrommultipledocumentsaswellasratingscalescompetedonline.Suchsystems-basedassessmentlaysthefoundationforamulti-prongedtreatmentapproach,consistentwithbestpractices.135

2. Pharmacotherapy

Aswithadulttelementalhealthpractice,2expertpharmacotherapyisoneofthemostfrequentlyrequestedservicesforyoungpeople.Thepharmacotherapyservicesdeliveredandtheinfrastructureneededatthepatient’sandtelepsychiatrist’ssitesmaybedeterminedinpartby


themodelofcare,i.e.,provider-focusedconsultation,patient-focusedconsultation,collaborativecare,ordirectservice.Whiletelepsychiatristsarethemostfrequentprovidersofpharmacotherapyusingvideoconferencing,theguidanceisapplicableacrossprovidersservingyouth,includingdevelopmentalpediatricians,generalpediatricians,familypracticephysicians,nursepractitioners,andphysicianassistants.Providersdeliveringpharmacotherapyservicesshallbeawareoftheirprofessionalorganizations’positionsontelepsychiatry.Proceduresshouldensureeffectivecommunicationbetweenthesites,guidemedicalrecorddocumentation,andmaintaincompliancewithregulatoryguidelines.Fordirectservices,thetelepsychiatristsshallfollowtheATA’sgeneralguidelinestoestablishandcommunicatetoallpartiesmethodsforobtaininginitialprescriptions,medicationrefills,andforreportinganddocumentingadverseeffects.1,2,3Thedeliveryofpharmacotherapyviatelepsychiatrytochildrenandadolescentsisguidedbyevidence-basedandconsensus-basedtreatmentsestablishedfortraditionalin-persontreatment,54extrapolationfromgeneralvideoconferencingreports,1,2,3,162descriptivetelementalhealthreportswithchildrenandadolescents21,22andthelimitedoutcomestudiesconductedwithyouth.12,83,85,101TheprescribingtelepsychiatristshallcomplywiththepracticeparametersestablishedbytheAmericanAcademyofChildandAdolescentPsychiatry54,163-164forpharmacotherapyingeneralandforspecificdisorders.Childandadolescenttelepsychiatrymayentailafewconsiderationsbeyondin-personcare.Ahighqualityaudio-videoconnectionhelpstodiscerndetailsrelevanttodevelopmentalandclinicalexaminationduringboththeinitialevaluationandfollow-upmedicationassessments.Asparentsmustconsenttopharmacotherapyfortheirchildrenundertheageofmajority,telepsychiatristsshallensurethatparentsunderstandtherisksandbenefitsofpharmacotherapyandprovideeducationalinformationasindicated.Initialmedicationsandrefillsfornon-controlleddrugsareprovidedthroughusualproceduresestablishedforin-personcare.Federalregulations165nowallowe-prescribingofcontrolledsubstancesduringin-personcare.However,federallegislationregardingtheprescriptionofcontrolledsubstancesthroughvideoconferencing165-166hasimplicationsfortelemedicine,especiallyforthetreatmentofchildrenwithADHD.TheRyanHaightOnlinePharmacyConsumerProtectionActof2008166wasdesignedtoexpungeillegitimateonlinepharmaciesthatdispensedcontrolledsubstanceswithoutcontactwiththeindividualandwithoutphysicianoversight.TheActplacedcertainrestrictionsaroundthepracticeof“prescribingbymeansoftheinternet.”WhiletheActspecificallydesignatesthattelemedicineisanexceptiontotheAct,ittechnicallyrequiresthatprovidersconductatleastonein-personevaluationofthepatientpriortoprescribingacontrolledsubstanceviatelemedicine.Alternatively,patientsbeingtreatedbyandphysicallylocatedinahospitalorclinicregisteredwiththeDEAinthepresenceofaDEA-registeredpractitionermaybeprescribedcontrolledsubstancesviatelemedicine.Theletterofthislegislationisdifficulttofollowandseverelydilutesthevalueoftelemedicinepractice.However,theDEArecentlynotedthatitdoesnotintendtointerferewiththelegitimateprescribingofcontrolledsubstancesduringtelemedicinepractice.167Ithasfurtherpromisedtopromulgatefuturerulesaroundtelemedicineprescribingandtoestablishaspecialtelemedicineregistration.Unfortunately,theseprovisionshavebeenleftincompletesince2008.Severalstateshaveenactedlegislationtoallowtheprescriptionofcontrolledsubstancesthroughtelemedicinepractice,particularlyfortelepsychiatry.Providersshouldcarefullyreviewbothfederalandstateguidelinesinestablishingtheirtelepracticeregardingtheprescriptionofcontrolledsubstancesandactinthebestinterestsoftheirpatients.


Assessingtheeffectsofpharmacotherapyrequirestimelyfollow-up,historyfromtheyouthandparent,inputfromotherrelevantadults,assessmentofside-effects,andmonitoringofselectedphysiologicparameters.Adherencetotheseguidelineswillrequireassistanceatthepatientsite,forexampletomonitorvitalsigns,heightandweight.21,22Telepsychiatristsshouldensurethatsuchassessmentsaremadeinaccordancewithtreatmentguidelinesandthatstaffobtainsappropriatetraininginconductingtheassessments.TheymayalsoconsidertrainingstafftoassistwithotherassessmentssuchasscreeningforabnormalmovementswiththeAbnormalInvoluntaryMovementScale.168-169Thestaffmaybeinstructedintheappropriatedisseminationandcompletionofratingscalesforroutineoutcomesmonitoringorotheraidstomonitoringtreatmentresponse.12,101,170-171Iftheoptimalfrequencyoffollow-upvisitsisnotfeasibleduetoagencylimitations,telepsychiatristsmayarrangewithastaffatthepatientsiteorthePCPtocheckinwiththefamilyandcommunicatefindingswiththetelepsychiatrist.Finally,thetelepsychiatristmaytrainstaffatthepatientsitetoassistincoordinatingcarewiththeyouth’ssystemofcareincludingobtaininganylaboratoryorimagingstudies.

3. PsychotherapyApproaches

Thereisanincreasingrequestforpsychotherapyservicesforchildrenandadolescentsdeliveredthroughvideoconferencingtodiversesettingsincludingclinics,schools,corrections,andhome.102AsoutlinedinthegeneralATAtelementalhealthguidelines,standardpracticeguidelinesfortherapyshalldirectpsychotherapyserviceswithinthetelemedicinesetting.1,2,3Evidence-basedpracticeandempiricallysupportedtreatmentsshallbefollowedandadaptedbythetelementalhealthproviderasappropriateforvideoconferencingwiththechildandadolescentgroupandtheirparents.Personsengagedinprovidingpsychotherapyservicesshallbeawareoftheirprofessionalorganizationspositionsontelementalhealthandincorporatetheprofessionalassociationstandardswheneverpossible.Theprovidershallapproximateallintroductoryapproachesasinonsitesettings,includingintroducingtherationaleforpsychotherapyandbuildingrapportwiththeyouthandparent.Thepatientandparentshouldbeencouragedtoprovideinputaboutstrengthsandchallengesofdeliveringservicesovervideoconferencingthroughoutthecourseoftherapy.Providersshallprovideallkeyelementsoftheindividualandfamilyapproaches.Thisincludesattentiontobothsessioncontentandprocess.Psychotherapyoutcomeshouldbemonitoredinwaysconsistentwiththeonsitesetting,includingmonitoringprocessmeasures(e.g.,relationship,satisfaction)andclinicaloutcomemeasures,aspartofcontinuousimprovementprocesses.Thereisverylimitedinformationaboutindividualandfamilytherapywithyouthusingvideoconferencing.Providersshouldconsideradaptingbestpracticesandevidence-supportedapproachesfromthein-personsetting,171followingprofessionalguidancearounddisseminationandimplementation.60Similarly,providersshouldfollowallbestpracticesindeliveringpediatricpsychologyinterventions.172Todate,nospecifictheoreticalorientationorapproachhasbeencontraindicatedspecifictotelemedicine.Cognitivebehavioralapproachesareamongthemostcommonapproachesreportedintheadultandyouthliteratureandmaylendthemselvestothetelemedicineformatduetostructureandskillsbuildingfocus.102Asinin-personsettings,bestpracticeswithchildrenandadolescentsoftenincludeworkingbothtogetherandalonewiththechildandwithhis/herparent.Providersshouldworkwithpresenterstoassistwithmanagingattendees’entrytothe


roomandparticipationinthesessionandtoensureprivacy(e.g.,noeavesdropping).Inhome-basedsettings,providersshouldacknowledgetheirdecreasedabilitytomanageattendeesandtheirrelianceonthepatient/parenttoassisttheprovider.Sometherapymodalitiesthatrequiredirectone-on-oneinteraction(e.g.,playtherapy)mayrequireadditionalconsiderationwhenimplementedthroughvideoconferencing.Someapproachesmayrequireadditionalcoachingofparentsratherthandirectimplementationbythetherapist(e.g.,time-outstrategies).Theexpectationsconcerningparentparticipationshouldbeestablishedbeforeserviceinitiation.Forexample,iftelementalhealthservicesareprovidedattheschoolsetting,thelevelandmeansofparentparticipationshouldbediscussed.Whenprovidinggrouptherapyandsupportgroupsovervideoconferencing,theprovidershallfollowthesamebestpracticesutilizedintraditionalsettings.Inonemodel,thereisagroupatadistantsiteandthegroupleader(s)connectsbyvideoconferencing.Inanothermodel,thegroupmembersandthegroupleader(s)areallatdifferentlocationsandallconnectusingmulti-pointfunctionsofthetechnology.Thegrouptherapyleader(s)shouldconsiderthetelepresentingneedsatthedistantsite.Forexample,ifthepresenterisassistinginmanaginganangermanagementgroup,thepresentermayneedtrainingaheadoftimetodefusepossibleoutbursts.

4. CaseManagement

Videoconferencingallowscollaborationamongmultipleparticipantsandinputintotreatmentplansfromvariousexpertsregardlessofgeographiclocation.2,3,173Coordinationofcareisespeciallyimportantforhighriskyouthwhohavemultipleagenciesinvolvedintheirlives.28TheseyouthmayneedmorefrequentclinicalcontactthancanbeprovidedbytheCATMHprovider.Therefore,CATMHprovidersshouldworkwithPCPs,clinicians,casemanagers,andstakeholderstoindividualizeclinicalcontactswithintheyouth’ssystemofcare.28,154TheseinterimcontactsmaybenefitfromindirectcollaborationwiththeCATMHprovider,suchasthroughtelephoneoremail.Inordertofacilitatecarecoordination,providersshallshareinformationwithotherstakeholdersasindicatedintheyouth’streatmentplanandwithappropriateconsent,aswellasreceiveinformationfromsuchstakeholderstoinformthetreatmentplanandassessoutcome.Thesecarecoordinationeffortsshallfollowallbestpracticesforthesecureexchangeofclinicalinformation.Finally,thoseprovidersemployingcasemanagementshouldfollowbestpracticesfromonsitecasemanagement.

F.MentalHealthEmergencieswithYouth

Providingmentalhealthcaretochildrenandadolescentsviavideoconferencinginvolvesparticularconsiderationsregardingpatientsafetyinbothsupervisedandunsupervisedsettings.114,174-176Thisisparticularlytrueastelementalhealthextendsaccesstounderservedpopulations(e.g.,ruralpopulations,diversepopulations)thathaveincreasedriskforsuicide.Inadditiontomentalhealthemergencies,theprovidershouldconsiderwhethertherearerisksofgeneralhealthemergencies,suchasservicestohomeboundpatientsoryoungpeoplereceivinghospicecare,andshouldplanaccordinglywiththecaregivers.Theprovidershallabidebytheaforementionedlegalandregulatoryguidelines(Section5b)inthejurisdictionwherethepatient(s)isreceivingservices.ProvidersshouldreferencetheATAPracticeGuidelinesforPediatricTelehealthforbroaderguidanceaboutmanagementofpediatricemergencycontingencies.


Whentelementalhealthservicesareprovidedtoyouthincommunitysettingssuchasalocalclinic,community-basedoutpatientclinic,schoolsite,orotherfacilitywherededicatedstaffmaybepresent,providersshallbecomefamiliarwiththefacility’semergencyprocedures(ifalreadyestablished).Ifthefacilitydoesnothaveproceduresinplace,theprovidershouldcoordinatewiththepatientsitetoestablishbasicprocedures,including:1)identifyinglocalemergencyresourcesandphonenumbers;2)becomingfamiliarwithlocationofthenearesthospitalemergencydepartmentcapableofmanagingpsychiatricemergencies;and3)havingpatient’sfamily/supportcontactinformation.4)collectionofcontactinformationforotherlocalprofessionalassociations,suchasthecity,countyorstate,provincialorotherregionalprofessionalassociation(s)incasealocalreferralisneededtofollow-upwithalocalprofessional.Ifthepatientisinasettingwithoutclinicalstaff(e.g.,thehome),theprovidershoulddiscussemergencyprocedureswiththepatientandcaregiveraspartoftheinformedconsentprocessanddocumenttheplan.Theplanshouldincludeareleaseofinformationtocontactafamilyorcommunitymemberwhocouldprovidesupportinanemergency,includingassistinginevaluatingthenatureoftheemergencyand/orinitiating9-1-1fromthepatient’shometelephone.Providersshouldconsiderriskstosafetyinthepatient’sphysicalenvironment,suchasaccesstoweaponsinthehomeenvironment,proximitytowindows,orotherhouseholdhazards.Suffocationisbecominganincreasingriskforyouththatshouldbemonitored.177Providersshouldalsobeawareofotheryouthinthehomeasthismayimpactsafetymanagementplanning.Whetheranemergencyoccursinaclinicallysupervisedorunsupervisedsetting,theprovidershallconsiderthepotentialdelayforemergencyresponseduetogeographicallocation.Further,theteammaynothaveextensiveexperienceinmentalhealthemergencieswithyouth.Theprovidershouldremainavailabletotheemergencyresponderstofacilitateevaluationanddispositionplanning.Itispossiblethatapatientorparent(s)willnotcooperateintheyouth’semergencymanagement,whichunderliesthepracticeofinvoluntarycivilcommitment.Therefore,anyemergencyplanshallincludeknowledgeoflocalcivilcommitmentlaw,proceduresforcommitment,andresourcestoassistintheprocess.Strategiesfortransportationorotherlogisticalissuesincaseofanemergencyshallbedevelopedpriortoinitiatinganinterventiontreatmentforpatientsinclinicallyunsupervisedsettings.

ADDITIONALTELEMENTALHEALTHCONSIDERATIONSWITHYOUNGPEOPPLE

A.EthicalConsiderations

Ethicalconsiderationsmaybemagnifiedinthetelementalhealthsettingduetoitsfocusonreachingunderservedandvulnerablepopulations.178Leadingtelemedicineandmentalhealthassociationsemphasizetheimportanceoftranslatingestablishedethicalbestpracticetothetelementalhealthsetting,includingworkwithchildrenandfamilies.Practiceguidelinesfromprofessionalorganizationsassistininformingbestethicalpractice.SuchorganizationsincludetheAmericanTelemedicineAssociation,179theAmericanAcademyofChildandAdolescentPsychiatry,180-181theAmericanPsychologicalAssociation,18AmericanPsychiatricAssociation,EthicsCommittee,182NationalAssociationofSocialWorkers,183theNationalBoardforCertifiedCounselors,184andtheOhioPsychological


Association,185amongothers.Practicingatadistancecreatesauniquerelationshipwiththepatientthatrequiresattentiontoandadherencetoprofessionalethicalprinciples,includingspecialconsiderationswithchildrenandfamilies.Anorganizationorhealthprofessionalthatadherestoethicaltelementalhealthprinciplesshall:

a. Incorporateorganizationalvaluesandethicsstatementsintotheadministrativepoliciesandproceduresfortelementalhealth;

b. Beawareofmedicalandotherprofessionaldisciplinecodesofethicswhenusingtelementalhealth;

c. Informthepatientandparentoftheirrightsandresponsibilitieswhenreceivingcareatadistance(throughtelementalhealth)includingtherighttorefusetousetelementalhealth;

d. Providepatients,parents,andproviderswithaformalprocessforresolvingethicalquestionsandissuesthatmightariseasaresultofatelementalhealthencounter;and

e. Eliminateanyconflictofinteresttoinfluencedecisionsmadeabout,for,orwithpatientswhoreceivecareviatelementalhealth.Bestethicalresearchpracticesshallalsobefollowedintelementalhealth,asinalltelemedicinesetting.

B.TelementalHealthCompetencies

Thegrowthoftelementalhealthpracticehasledtogrowingfocusonestablishingandmaintainingcompetenciesfordeliveringclinicalcare.Thus,providersareencouragedtoseektraining,educationalopportunitiesandpeermentorshipinordertomaintainhighqualitycare,facilitatetherapeuticengagementandproducepositiveoutcomes;inthelatterregard,extantstudieshaveshowncomparableoutcomestoin-personcare.Theprovidershouldmaintaincompetenceinintegrityofboththeprocess(e.g.,buildingrapportandestablishingatrustedenvironment)andthecontent(i.e.,treatmentcomponents)oftheinterventioninrelationtothetechnologyandsite’sresources.Guidedbyresearchandavailableguidelines,theprovidershouldcarefullyconsideranyadaptationstointerventionsbasedonthetechnologysetting(e.g.,thecontextualsettingforplay,spaceforfamily).Competencyisbestconsideredonacontinuumoflifelonglearning,asprovidersinpracticeandtraineesneedtostaycurrentwithrapidlyevolvingtechnologies,telementalhealthresearchfindings,andpolicies.Foremost,providersshouldassesstheirclinicalcompetenceinprovidingcareforchildandadolescentpopulations,inthefaceofpressuretoincreaseaccesstoservicesforthisunderservedpopulation.OnemaptotelementalhealthcompetencieshasbeencontextualizedusingthetrainingmilestonessetforthbytheAccreditationCouncilofGraduateMedicalEducation(ACGME).186ACGMEusesatemplatewithpatientcare,systems-basedpractice(SBP),interpersonalcommunication,professionalism,practice-basedlearningandknowledgedomains;atechnologycompetencyandSBPcomponentsonadministration,culture,andcommunityengagementwereaddedrecently.Whenworkingwithprimarycaresites,providersmayconsidercompetenciesformedical-psychiatricillness,inter-professionalpractice,andintegratedcare.Thereisagrowingconsensusacrossalliedmentalhealthdisciplinesforsuchcompetencies.187

Severalstrategieshelpproviderstobuildandmaintaincompetencies.Providersandtraineesmaycompleteself-study.114,188Thereisarangeofonlineresourcesthatprovidedynamicinformationonthechangingtelemedicinelandscape,including:professionalorganizations;189telehealthresourcecenters;190federalresources;191grant-supportedresources;192andprivatecompanies.Potentialtelementalhealthprovidersmayshadowanestablishedprovidertohelpconsolidateinterestandskills,


oroptnottousetelementalhealthifitisnotagoodprofessionalfit.Participatingintelementalhealthcommitteesorprofessionalworkgroupsandongoingpeer-to-peersupportbuildknowledgeandskills.Increasingly,trainingprogramsareincorporatingtelementalhealthrotationsandseminarstoteachtechnologicalapproachestohealthcare,aswellastoprovideexperiencewithimprovingaccesstocarefordiversepatientpopulations(e.g.,ruralfamilies,AmericanIndians).

C.ClinicalSupervisionandTelementalHealth

Giventheworkforceshortages(seeSection3.c)withyouthbehavioralhealth,itisappealingtoworkwithhealthcaretraineesinordertoexposethemearlyintheirtrainingtobothtelementalhealthbestpracticesandopportunitiestoworkwithunderservedpopulations.Theseexperiencesmayrangefromshadowingatelementalhealthprovidertoformaltelementalhealthtrainingrotations.Thesupervisormayconsidertherangeoftelementalhealthtrainingresources(e.g.,onlineresources,readings,guidelines,etc.)tosupportthelearningexperience.Inaddition,videoconferencing-basedsupervision,or“telesupervision,”offersinnovativewaystoextendsupervisionopportunities.114Videoconferencingoffersanefficientmeanstoprovideconsultationinevidence-basedinterventionstothestaffatlocalmentalhealthcenters,primarycareoffices,orotherdistantsitesservingyouth.12

D.FutureDirectionsinTelementalHealthwithYouth

Interventionsthathavebeensuccessfullyutilizedovertelehealthforadultpopulations(e.g.,exposuretherapies)shouldbeevaluatedwithyouthpopulations.DocumentationofsuccessfulinterventionswillhelptoexpandtheevidencebaseforCATMHasrequestsforservicesaccelerateduetotheincreasingdisparitybetweenthedemandformentalhealthcareservicesandthesupplyofchildandadolescent-trainedproviders.ThisincreasingdisparityalsocallsfortheinclusionofCATMHinevolvingmodelsofcollaborativeandintegratedcare.191Manyemergingevidence-basedinterventionssupportcommunity-engagedapproachesthatareavailabletocollaboratewithchild-servingsystemstoaddressthecomplexproblemsfacedbyyouthandtheirfamilies.Telementalhealthmayefficientlylinkchild-servingsystemsandteamstogethertoenhancecare.Establishinginitialandongoingcompetenciesisencouragedtoensurethatthesamelevelofsafeandeffectivecareisdeliveredusingtelementalhealthasduringin-personcare,particularlyastheregulatoryandtechnologicallandscapechanges.Goingforward,expandedCATMHwillbesupportedbythecontinuedevolutionofsecure,highspeed,mobilevideoconferencingoptionsacrosstherangeofcurrentandfuturedevices.Thiswillfurtherexpandtelementalhealthservicedeliverysitesandtounsupervisedsettingssuchasthehomeandyouthmobiledevices.Withthisexpansioncomestheneedforcarefulconsiderationandevaluationofservicestomaximizebenefitforyouthandfamilies,minimizerisk,andoptimallysupportcommunitystakeholders.Researchwillbeneededtotestmodelsofcare,toevaluatequalityimprovementefforts,andtoexaminetheeffectivenessofCATMHservices,particularlywithdiversepopulations.TheseeffortsarefacilitatedbytheATA’slexicon193andbyeffortstowardastandardtelementalhealthevaluationmodel.194Emergingbehavioralhealthmodels195lookatmatchingtherangeofhealthtechnologiestotheneedsofyouthandtheirfamilies.CATMHproviderscanlooktoafuturethatintegratestelementalhealthserviceswithapplicationsinsocialmedia,asynchronousmentalhealth,mHealth,virtualtechnologies,virtualreality,augmentedreality,intelligentwearabledevices,andartificialintelligence—alltoimprove


thequalityandeffectivenessofyouth-centeredcareforallyoungpeopleinneedofmentalhealthcareservices.

SUMMARY

Theevidence-basesupportingtheeffectivenessofCATMHisdevelopingincrementally.Theexistingresearch,publishedreports,andclinicalexpertiseindicatethatCATMHisfeasible,acceptabletoreferringPCPsaswellastopatientsandtheirfamilies,andincreasesaccesstocareforyouthwhoarenotwellservedbytraditionalmodelsofcare.Multiplestudieshavefoundthatthetherapeuticrelationshipispreservedduringsessions.Clinicaloutcomesappearcomparabletothesameinterventionsdeliveredin-personandsuperiortocarethatisroutinelyavailableindistantcommunities.FurtherworkisnowneededtoinvestigatetherangeofapplicationsappropriateforCATMHandtoexaminetheireffectiveness.Whileawaitingfurtherresearchtoestablishanevidence-base,bestpracticesforCATMHindicateconsiderationofseveralmodificationsfromgeneraladultpractice.AneedsassessmentwilldeterminethefeasibilityandsustainabilityofaCATMHprogram,particularlyasscarceresourcesareallocatedtotheadultchronicallymentallyill.Legalguidelinesmayvaryforservicesdeliveredtoyouth.Collaborativerelationshipsareneededwithcommunitystakeholders,suchasschoolsandPCPs.Theteleprovidermustworkcarefullywiththesitetodeterminetheresourcesrequiredforsuccessfulsessions,suchasthesizeandconfigurationofthetreatmentroom,itsaccoutrements,andaccommodationsforaccompanyingadults.Thetelepresenters’roleswillusuallybeexpandedbeyondtasksoutlinedforadultsessions,includingassistancewithbehavioralmanagementduringthesessionandcoordinationwiththeyouths’systemofcarebetweensessions.Asforadulttelementalhealthpractice,thechoiceoftechnologiesshouldconsiderresourcesatboththeproviderandpatientsites,butshouldadditionallyconsiderthebandwidth,monitorresolution,andcamerafunctionalityneededtoassesschildren’sclinicalfeaturesandtopracticeinterventionssuchasteachingparentsbehavioralmanagementskills.Asthegrowingneedforchild-andadolescent-trainedmentalhealthproviderswillnotbemetintheforeseeablefuture,technologywillbeleveragedtoincreaseaccesstoandimprovethequalityofmentalhealthcareavailableforallyouth.CATMHprogramsshould,andmustbe,implementedaspartofmainstreammentalhealthcare.

CONCLUSIONS

Toconclude,thetentop,ormostsalient,modificationsoftelementalhealthpracticeforworkwithchildrenandadolescents,includesthefollowing:

• Technologyoptionsmayvarybysite.Providersshallchoosevideoconferencingtechnologythatisappropriatetotheclinicalapplication.Bandwidth,screensize,andcamerafunctionalityallaffecttheyouth’sdevelopmentalassessmentincludingappreciationofmotorskills,languageabilities,interestsandrelatedness.


• Environmentshouldfacilitatetheassessment,particularlyofyoungerchildren,byprovidinganadequateroomsize,furniturearrangement,toys,andactivitiesthatallowtheyouthtoengagewiththeaccompanyingparent,presenter,andprovideranddemonstrateage-appropriateskills.

• Legalandregulatoryguidelinesvaryacrossstates.Theprovidershallpracticewithinthejurisdictionalpoliciesandregulationsforthetreatmentofyouthwithparticularattentiontotheageofmajority,consenttocare,andmandatedreporting.Specialattentionshouldfocusonregulatoryissuesinthetreatmentofvulnerableyouth,suchasthoseinstatecustody.

• Extendedparticipationoffamilymembers,orotherrelevantadults,istypicalofmentalhealthtreatmentofchildrenandadolescents,includingCATMH.Providersshouldadheretousualin-personpracticeforincludingrelevantadults,withappropriatemodificationsfordeliveringservicethroughvideoconferencing.Extendedparticipationmayincludea“presenter.”Providersshouldconsiderhowthe“presenter”mayfacilitatesessions(e.g.,vitalsigns,assistancewithratingscales,managingactivechildren,assistingwithanyurgentinterventions)andtrainthe“presenter”accordingly.Providersshouldconsiderhowthepresenter’sinvolvementmayadverselyaffectservicedelivery(e.g.,socialfamiliaritywiththefamily,perceivedconfidentiality,sharinginformationwithotherteammembers).

• Medicationinterventions,theirtherapeuticbenefitsandadverseeffectsshouldbemonitoredanddocumented.Providersmaychoosetheapproachtomonitoringanddocumentation.Medicationsdesignatedas“controlledsubstances”bytheDEAneedspecialconsiderationsforCATMH,particularlyforthetreatmentofyouthwithADHD.

• Extra-clinicsettingsarecommontreatmentsitesforyouthduetotheirinvolvementinschool-basedhealthclinics,telementalhealthconsultationtoayouth’ssystemofcare,andtocorrectionalsettings.WhenCATMHservicesaredeliveredoutsideoftraditionalclinicsettings,providersshouldworkwithstafftoensuresafety,privacy,appropriatesetting,andaccommodationsparticularlyifmultiplestaffparticipateinsessions,suchasinschoolIEPmeetingsorforensicevaluations.

• Needsassessmentmayhelptodeterminethesite’sreadinessandfeasibilityforimplementingatelementalhealthtreatmentserviceforyouth,aswellasthepotentialforsustainabilityinthefaceofmultiplecompetingfundingdemands.

• Teletherapyshouldadheretoevidence-basedandbestpracticeguidelinesdevelopedforin-persontreatmentwithconsiderationofmodificationsneededtoreliablyimplementinterventionsthroughvideoconferencing.Providersshouldworkwith“presenters”tosetupandfacilitatethesessions,asneeded.Therapeuticbenefitsandadverseeffectsshouldbedocumented.

• Appropriatenessfortelementalcareshallconsidersafetyoftheyouth,theavailabilityofsupportiveadults,thementalhealthstatusofthoseadults,andabilityofthesitetorespondtoanyurgentoremergentsituations.Safetyprotocolsshouldbeestablished

• Learnandupdatecompetencieswithyouth.Thevarietyofsitesinwhichmentalhealthcareservicesaredeliveredtoyouth(e.g.,mentalhealthclinics,primarycareclinics,schools,communitysites,home)andthevarietyofproviders(master’strainedtherapists,primarycare


providers,psychologists,psychiatrists,schoolcounselors,behavioraltherapists,others)indicateconsiderabledifferencesacrossprovidersintrainingandskillsfortreatingyouth.CliniciansprovidingCATMHservicesshallensuretheircompetenciesintreatingyouthanddeliveringtreatmentthroughvideoconferencing.

APPENDIX

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GLOSSARY

ThisguidelineusesthenomenclaturesetforthbytheAmericanTelemedicineAssociation,196andusedinotherguidelinesaswellastheCaliforniaTelemedicineandeHealthCenterGlossary.197Severaltermsspecifictochildandadolescentmentalhealthfollow:

• Youngpeopleoryouth:theguidelineisbroadlyinclusiveofchildrenandadolescentsacrossthe0-21yearagerange,asdefinedbytheNationalInstitutesofHealth.Ifasectionisspecifictochildrenoradolescents,theguidelineusesthatdevelopmentallyspecificterm.Foryouthbeingseenthroughtelementalhealth,theterms“patient”and“client”areusedinterchangeably.

• Parents:theadultswithresponsibilityforcaringfortheyouth,includingbiologicalparents,adoptiveparents,fosterparents,relatives,andotheradultguardianswhoareintheparentingrole.

• Mentalhealth:“astateofwell-beinginwhichtheindividualrealizeshisorherownabilities,cancopewiththenormalstressesoflife,canworkproductivelyandfruitfully,andisabletomakeacontributiontohisorhercommunity.”198


• Mentalillness:“collectivelyalldiagnosablementaldisorders”or“healthconditionsthatarecharacterizedbyalterationsinthinking,mood,orbehavior(orsomecombinationthereof)associatedwithdistressand/orimpairedfunctioning.”Inthisguidelinewealsoincludeyouthwithdevelopmentaldisabilitieswhopresentformentalhealthcare.199

• Mentalhealthservices:servicesthatpromotementalhealthand/orinterveneinrelationto

mentalillness,includingprevention,assessment,treatment,consultation,andmaintenance/support

• Providers:alsocalled“teleproviders”.Anylicensedprofessionalusingvideoconferencingtoprovidecaresynchronouslyregardlessofdiscipline.

• Telemedicine:theuseofmedicalinformationexchangedfromonesitetoanotherviaelectroniccommunicationstoimprovepatients'healthstatus.

• Telehealth:thetermisoftenusedtoencompassabroaderdefinitionofremotehealthcarethatdoesnotalwaysinvolveclinicalservices.Videoconferencing,transmissionofstillimages,eHealthincludingpatientportals,remotemonitoringofvitalsigns,continuingmedicaleducationandnursingcallcentersareallconsideredpartoftelemedicineandtelehealth.

• Telementalhealth:alsocalledtelebehavioralhealth.Anumbrellatermtorefertoallofthenamesandtypesofbehavioralandmentalhealthservicesthatareprovidedviasynchronoustelecommunicationstechnologies.

• Telepractice:Theclinicalpracticeofmentalhealthcarethroughvideoconferencing.

• Telepsychiatry:thespecificprovisionofpsychiatriccarethroughvideoconferencing

• Telepsychology:thespecificprovisionofpsychologicalcarethroughvideoconferencing.

• Presenter(PatientPresenter),alsoknownasatelepresenter:Anindividualwithaclinicalbackgroundtrainedintheuseoftelehealthequipmentwhomustbeavailableattheoriginatingsiteto“present”thepatient,managethecamerasandperformany“hands-on”activitiestocompletethetele-examsuccessfully

• Facilitator,alsoknownasatelefacilitator:Anindividualwhomayormaynothaveaclinicalbackgroundwhoispresentwiththepatientduringatelemedicineencounter.Responsibilitiesmayvarywithpracticesite,butmayincludescheduling,organizing,executingtheconnectionand/orpatientpresenterfunctions.Examplesmayincludeaclinicalprovider,supportstafforparent/guardian.

• Telemedicinecoordinator:thetelemedicinecoordinatorisoftenthepresenter.Thisprofessional,atthepatientsite,servesasaliaisonbetweentheproviderandthefamilyandassistswithscheduling,paperwork,andfollow-up.

• ProviderSite:thelocationoftheclinicianrenderingthespecialtyorconsultativeservices.Thishasbeenreferredtoasthe“remotesite”or“hub”forprogramsthatcoordinateservicestomultiplepatientsites.


• PatientSite:Thesitewherethepatientispresentedduringatelemedicineencounter,orwheretheprofessionalrequestingconsultationwithaspecialistislocated.Thishasbeenreferredtoasthe“originatingsite”orthe“spokesite”forprogramsthatdeliverservicestomultipledifferentsites.Forclarityweusethetermpatientsite.

• Videoconferencing:Alsocalledtelevideoorvideoteleconferencing.Interactiveteleconferencingwithvideocapabilities.

• Clinicallysupervisedsetting.Telementalhealthsettingswithclinicalstaffonsitewiththeyouth,mostoftenincludingapresenter.

• Clinicallyunsupervisedsetting.Telementalhealthsettingswithoutclinicalstaffonsitewiththeyouth,suchaswhencareisprovideddirectlytoapatientwhoislocatedinhisorherhomeatthetimeofthecontact.

TABLE:EFFECTIVENESSOFCHILDANDADOLESCENTTELEMENTALHEALTH

EFFECTIVENESSOFCHILDANDADOLESCENTTELEMENTALHEALTH

CITATION SAMPLE&TOPIC ASSESSMENTMETHODS COMMENTSONFINDINGS

OutcomeofRandomizedControlledTrialsbyDisorder

Nelsonetal.,13

200328youth(age8-14years;M=10.3years)Depression

Diagnosticinterviewandratingscalefordepression

CBTinterventionfordepression;TMHandin-personinterventionshowedcomparablereductionindepressivesymptoms

Storchetal.,152011

31youth(age7-16y/o;M=11.1y/o)OCD

DiagnosticinterviewandratingscalesforOCD,anxietyanddepression

TMHsuperiortoin-personinterventiononallmeasures

Himleetal.,112012

20children(age8-17y/o)Tourette’sDisorderorChronicMotorTicDisorder

Diagnosticinterviewandratingscalesforticdisordersandfunctionalimpairment

TMHandin-personinterventionsshowedcomparablesymptomreductionandfunctionalimprovements

Xie,etal.,162013

22children(age6-14y/o)ADHDandBehavioraldisorders

Symptomratingscales,parentingskills,functionalimpairment

TMH-servicedeliveryaseffectiveasin-persondeliveryforparentskillsandchildren’simprovedbehaviors

Myersetal.,122015

223youth(age5–12y/o)ADHDandODD

Diagnosticinterview,symptomratingscales,functionalimpairment

TMHshortterminterventionwasmoreeffectivethansinglePCPteleconsultationinimprovingADHD,ODD,roleperformanceandimpairment


Tseetal.,1132015

38youth(ages5to12y/o)ADHDandODD

Diagnosticinterview,symptomratingscales,functionalimprovement

TMHdeliveryofparenttrainingaseffectiveasin-persondelivery

Comeretal.,1102016

22children(4-8y/o;M=6.5y/o)OCD

Family-basedCBTforOCD;utilization,engagement,satisfactionratingscales,functionalimpairment.

TMHwasfeasibleforthedeliveryofFB-CBT;SymptomandfunctioningutcomeswerecomparableforTMHandin-persontreatmentatpost-treatmentandfollow-up

Pre-PostorComparisonStudies

Glueckaufetal.,1112002

22adolescents(age:M=15.4y/o)36parentsFamilyconflictandchildrenwithepilepsy

Symptomratingscales,alliance,issue-specificmeasuresoffamilyproblems,adherencetotreatment

TMH,telephone,andin-personequallyeffectiveinreductionofsymptomsandproblemseverity.Therapeuticalliancehigh.

Fox,etal.,292008

190youthinjuveniledetention(age12-19y/o;M=17y/o)GoalAttainment

Attainmentofgoalsformulatedduringincarceration

TMHserviceswereassociatedwithteens’attaininggoalsformulatedduringincarcerationtoimprovefamilyrelationsandproblematicbehaviors.

Yellowlees,etal.,1222008

41childreninane-mentalhealthprogramOppositionalbehaviorsinboys;Affectivesymptomsingirls

Broadbandratingscaleassessingspectrumofbehaviorandsymptoms(ChildBehaviorChecklist)

VideoconsultationtoPCPsassociatedwith3-monthimprovementsintheAffectandOppositionalDomainsoftheChildBehaviorChecklist.

Reeseetal.,1122012

8children(age:M=7.6y/oADHD

Parentingintervention’ratingscales TMHassociatedwithimprovedchildbehaviorsanddecreasedparentdistress

Satisfaction,FeasibilityandUtilizationStudies

Blackmonetal.,911997

43children(age2-15y/o;M=9y/o)

Consultationevaluationscale TMHcomparabletoin-personintervention

Elfordetal.,922001

30children(age:4-16y/o;M=13y/o)Variousdisorders

Questionnaire TMHevaluationassociatedwithhighsatisfactionofchildren,teens,parents,andpsychiatrists

Kopeletal.,962001

136“youngpersons”Variousdisorders

Questionnaire TMHconsultationassociatedwithhighsatisfactionbyfamiliesandruralhealthworkersinAustralia.

Myersetal.,832004

159youth(age3-18y/o)Variousdisorders

Demographic,diagnostic,utilization,payerstatus

TMHpatientsindistantcommunitiesweredemographicallyandclinicallyrepresentativeofpatientsinin-personclinic.More“adversecasemix”forTMHsample.Parentsendorsedhighsatisfactionwithcare.

Greenbergetal.,932006

35PCP’s,12caregivers(Meanage:9.3y/o)Variousdisorders

FocusgroupswithPCP’s,interviewswithcaregivers

PCPsandcaregiversinruralCanadaendorsedhighsatisfactionwithTMHconsultationsbutfrustrationwith


abilitytoimplementtelepsychiatrists’recommendations

Myersetal.,1002006

115incarceratedyouth(age14-18y/o)Variousdisorders

Satisfactionsurvey IncarceratedyouthendorsedhighsatisfactionwithTMHcare.Describesdiagnosticassessmentandmedicationmanagementofincarceratedyouth;consultationwithstaff

Hilty,etal.,942006

15PCP’sforchildrenandadults---400patients(numberofchildrennotspecified)Variousdisorders

PCPsatisfactionsurvey PCPsatisfactionwashighandincreasedovertime

Boydelletal.,792007

100consultationsand54casemanagersVariousdisorders

Interviewswithcasemanagerstelepsychiatrists’recommendations

Multiplesystem-levelandpatient-levelfactorsandlocalavailabilityofresourcesaffectedimplementationofrecommendations.Technologywasnotidentifiedasanissue

Myersetal.,842007

172patients(age2-21yearsold)387visitsVariousdisorders

Satisfactionsurvey PCPsendorsedhighsatisfactionwithTMHservicesPediatriciansmoresatisfiedthanfamilyphysicians

Myersetal.,852008

172patients(age2-21y/o)387visitsVariousdisorders

Parentsatisfactionsurvey ParentsendorsedhighsatisfactionwithTMHservices;greatersatisfactionforTMHwithchildrenthanwithteens.

Boydelletal.,802010

30“youngpeople”Variousdisorders

Qualitativestudyofyouths’perspective Participantsexpressedtheimportanceoftheirrelationshipwiththepsychiatristandnotedhowtheyactivelytookresponsibilityandexertedcontrolwithinthesession

Myersetal,312010

190PCP’s701patients(7to18y/o)Variousdisorders

Patientdemographics,diagnoses,utilization.

TMHwithyoungpeoplewasfeasibleandacceptable;variableimplementationacrosstelepsychiatrists

Pakyureketal.,97

20105Children/adolescentinprimarycareCasestudies

Descriptiveeffectiveness Generalsatisfaction;opinionthatTMHmaybesuperiortoin-personforconsultationforselectedpatients

Lauetal.,882011

45childrenandadolescents(age:3-17y/o;M=9.7y/o)Variousdisorders

Descriptionofpatientsreferredforconsultation,reasonforconsultation,treatmentrecommendations

TMHreachesavarietyofchildren,withconsultantsprovidingdiagnosticclarificationandmodifyingtreatmentplans

Jacobetal.,952012

15children(age4-18y/o;M=9.73y/o)Variousdisorders

ParentSatisfactionSurvey PatientsatisfactionhighandPCPsfoundrecommendationshelpful.


Nelsonetal.,135

201222youth(M=9.3y/o)ADHD

Chartreview TMHdeliveryofADHDtreatmentfeasible.

Szefteletal.,412012

45patients–31ofthemunder18y/oDevelopmentaldisorders

Descriptionofutilization,diagnosticevaluation,symptomseverity,medicationchanges,symptomimprovement

TMHconsultationaltereddiagnosisandchangedmedicationregimen.TMHhelpedPCPswithrecommendationsfordevelopmentaldisabilities.

DiagnosticValidity

Elfordetal.,87 2000

25children(age4-16y/o)Variousdisorders

Diagnosticinterviews TMHevaluationshowed96%concordancewithin-personevaluation.

Stainetal.,902011

11adolescentsandyoungadults(age14-30y/o)Psychoticdisorders

Diagnosticinterview TMH-assesseddiagnoseswerestronglycorrelatedwithassessmentsconductedin-person

Reeseetal.,892013

21children(age:3-5y/o)Autism

Diagnosticinterviews,symptomratingscales,parentsatisfaction

TMHandin-personstructureddiagnosticevaluationscomparableinreliability,accuracy,observer-reportandparent-reportofsymptoms,andparentsatisfaction

PsychosomaticPediatricsInterventions

Clawsonetal.,1282008

15youth(age8months–10y/o)Pediatricfeedingdisorders

Ratingscalesforfamilysatisfaction,psychiatrists’satisfaction,outcomes

TMHwasfeasiblewiththepediatricfeedingdisorderpopulationandresultedincost-savings.Psychiatristssatisfiedwithmodality

Shaikhetal.,1062008

99youth(age1-17y/o)Obesityandweightmanagement

Retrospectivereviewofpatientmedicalrecords

TMHconsultationassociatedwithchangestodiagnoses.Asubtestofpatientswithrepeatedsessionsshowedimprovedhealthbehaviors,weightmaintenance,and/orweightloss

Witmansetal.,1302008

89children(age1-18y/o;M=7.5y/o)Sleepdisorders

Sleepdiary;ChildhoodSleepHabits;ratingscales;satisfactionsurvey

TMHconsultationonsleepmanagementwasfeasible.PatientsweresatisfiedwiththedeliveryofmultidisciplinarypediatricsleepmedicineservicesthroughTMH

Mulgrewetal.,1292011

25youth(age4-11y/o)Obesity/weightmanagement

Consultingpsychiatrists’listeningskillsandpatients’easeofunderstandinginstructions,qualityofcare,satisfaction

TMHconsultationforweightmanagementwasratedbyparentsaslesseffectivethanin-personconsultationsinexplainingchildren’shealthcondition.Parentsendorsedcomparablesatisfactionwiththetwoservicedeliverymodels.

Davisetal.,1052013

58youth(age5-11y/o;M=8.6y/o)

Family-basedmulti-disciplinarybehavioralgroupintervention.BodyMassIndex(BMI),

TMHmulti-disciplinaryinterventionandastructuredPCPvisitshowedcomparable


Obesity/weightmanagement

24-hrdietaryrecallActiGraph,ratingscalesFeedingassessmentscale

improvementsregardingBMI,nutrition,physicalactivity.TMHappearsafeasibleapproachtointerventionsforweightmanagement

Freemanetal.,1272013

71youth(Meanage=15y/o)Teenswithpoorlycontrolleddiabetes

Family-basedbehavioralintervention,ratingscalefortherapeuticalliance,serviceutilization

TMHandin-personservicedeliveryshowedcomparabletherapeuticallianceforyouthwithpoorlycontrolleddiabetesandtheirparents.TMHtreatmentofyouthwithdiabetesisfeasible

Hommeletal.,1312013

9youth(M=13.7y/o)Inflammatoryboweldisease

Briefinterventionformulti-componentnon-adherencetreatmentprotocolPillcount,diseaseseverity,feasibility,acceptability,

TMHinterventionforinflammatoryboweldiseaseisfeasibleandwellacceptedbyfamilieswithcostsavingsduetodecreasedtravel.Adherencetotreatmentregimenvariedforthemedicationsinvolved.

Lipanaetal.,1322013

243youth(M=11y/o)Obesity/weightmanagement

Reviewofmedicalrecordscomparingpatientsindifferentservicemodelsregardingdemographics,utilization,diagnosticchange,nutrition,activitylevel,screentime,weightmanagement

TMHservicedeliverywasfeasible.Outcomeswerecomparabletothenon-randomizedin-personcomparisongroupregardingenhancednutrition,increasingactivity,anddecreasingscreentime

ADHD:attention-deficithyperactivitydisorder;CBCL:ChildBehaviorChecklist;CBT:cognitive-behavioraltherapy;PCP:primarycareprovider;OCD:obsessivecompulsivedisorder;ODD:oppositionaldefiantdisorder;PCP:primarycareprovider;TMH:telementalhealth

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