Key points

Introduction

Because of chronic and worsening specialist shortages across pediatrics specialties as well as limited access to empirically supported interventions, telemedicine is becoming more widely adopted with children and adolescents, with telemental health among the most active pediatric specialties. Telemedicine is defined as “the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status.” Telemental health, also called telebehavioral health, is an umbrella term to refer to all of the names and types of behavioral and mental health services that are provided via synchronous telecommunications technologies. About 20% of US children and adolescents aged 9 to 17 years have diagnosable psychiatric disorders. In addition, approximately 31% of children are affected by chronic conditions. Many other youth show subthreshold symptoms and stress and grief reactions that benefit from intervention. Younger children are at risk for developmental and behavioral disorders. However, there are a growing number of evidence-based psychotherapy approaches to support children and their families in coping with the range of psychiatric presentations, as well as pediatric psychology approaches for supporting children with acute and chronic medical conditions and their families.

However, the supply of child behavioral health specialists trained in the latest clinical advances is very small, with demand far outpacing supply across child and adolescent psychiatrists, child and adolescent therapists and other specialists, and developmental medicine. Thus, most children with behavioral health concerns do not receive any therapy, let alone evidence-based treatments delivered by behavioral health specialists. The rationale for telemental health is to bridge the gap between supply and demand, particularly in rural and other underserved communities that face declining economies, poor access to mental health insurance, and limited transportation options. Telemental health helps increase regular attendance by diminishing the financial and temporal barriers of travel and time from work as well as offering access to therapists outside the community via health clinics and schools, which may be less stigmatizing than traditional mental health settings.

Telemental health services build on a long history of moving mental health care for youth from the mental health clinic to the community in order to increase access to care; decrease stigma; increase adherence to treatment planning; and, it is hoped, enhance effectiveness and care coordination in naturalistic settings. These community settings provide advantages in gathering information from multiple informants/supporters about the broad range of contextual factors influencing children’s behaviors and mental health needs. In particular, telemental health offers a powerful opportunity for collaboration with pediatricians to help them address the increasing expectations to improve their skills in diagnosing and managing pediatric behavioral conditions.

Although telemental health services initially focused on rural settings, they are increasingly offered in diverse settings, including underserved parts of urban communities. Mental health centers and other child-serving facilities may provide infrastructure that facilitates the implementation of telemental health services. Many schools are seeking to understand their students’ mental health needs and are willing to use their videoconferencing systems to access telemental health services. Most behavioral health diagnoses across the developmental spectrum have been evaluated through videoconferencing consistent with patients in usual outpatient practice. Telemental health allows youth to be evaluated in their own communities accompanied by family or community members who may provide context and perspective that is not available if services are provided in distant health centers. Primary care practices are often key partners in telemental health services.

This article first summarizes the pediatric research to date across telemental health specialties. Underscoring ethical considerations, it then presents a case study emphasizing ethical considerations in best practice.

Introduction

Because of chronic and worsening specialist shortages across pediatrics specialties as well as limited access to empirically supported interventions, telemedicine is becoming more widely adopted with children and adolescents, with telemental health among the most active pediatric specialties. Telemedicine is defined as “the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status.” Telemental health, also called telebehavioral health, is an umbrella term to refer to all of the names and types of behavioral and mental health services that are provided via synchronous telecommunications technologies. About 20% of US children and adolescents aged 9 to 17 years have diagnosable psychiatric disorders. In addition, approximately 31% of children are affected by chronic conditions. Many other youth show subthreshold symptoms and stress and grief reactions that benefit from intervention. Younger children are at risk for developmental and behavioral disorders. However, there are a growing number of evidence-based psychotherapy approaches to support children and their families in coping with the range of psychiatric presentations, as well as pediatric psychology approaches for supporting children with acute and chronic medical conditions and their families.

However, the supply of child behavioral health specialists trained in the latest clinical advances is very small, with demand far outpacing supply across child and adolescent psychiatrists, child and adolescent therapists and other specialists, and developmental medicine. Thus, most children with behavioral health concerns do not receive any therapy, let alone evidence-based treatments delivered by behavioral health specialists. The rationale for telemental health is to bridge the gap between supply and demand, particularly in rural and other underserved communities that face declining economies, poor access to mental health insurance, and limited transportation options. Telemental health helps increase regular attendance by diminishing the financial and temporal barriers of travel and time from work as well as offering access to therapists outside the community via health clinics and schools, which may be less stigmatizing than traditional mental health settings.

Telemental health services build on a long history of moving mental health care for youth from the mental health clinic to the community in order to increase access to care; decrease stigma; increase adherence to treatment planning; and, it is hoped, enhance effectiveness and care coordination in naturalistic settings. These community settings provide advantages in gathering information from multiple informants/supporters about the broad range of contextual factors influencing children’s behaviors and mental health needs. In particular, telemental health offers a powerful opportunity for collaboration with pediatricians to help them address the increasing expectations to improve their skills in diagnosing and managing pediatric behavioral conditions.

Although telemental health services initially focused on rural settings, they are increasingly offered in diverse settings, including underserved parts of urban communities. Mental health centers and other child-serving facilities may provide infrastructure that facilitates the implementation of telemental health services. Many schools are seeking to understand their students’ mental health needs and are willing to use their videoconferencing systems to access telemental health services. Most behavioral health diagnoses across the developmental spectrum have been evaluated through videoconferencing consistent with patients in usual outpatient practice. Telemental health allows youth to be evaluated in their own communities accompanied by family or community members who may provide context and perspective that is not available if services are provided in distant health centers. Primary care practices are often key partners in telemental health services.

This article first summarizes the pediatric research to date across telemental health specialties. Underscoring ethical considerations, it then presents a case study emphasizing ethical considerations in best practice.

Summary of telemental health evidence with children and adolescents

Studies were included if they (1) consisted of videoconferencing applications across the pediatric age range; (2) included psychiatry/pharmacotherapy, psychotherapy and/or a pediatric psychology intervention, and/or developmental medicine intervention; and (3) included videoconferencing as the method of intervention across assessment or treatment. Studies were excluded if they (1) were conducted using telephone or mobile interactions without video, (2) used Web-based or e-health interventions as a primary method for service delivery (ie, predominantly asynchronous Web-delivered content), and/or (3) focused solely on education/training or population description. These criteria were established in a previous review. As presented in Table 1 , the telemental health evidence is presented in 3 sections: child psychiatry, child clinical psychology, and pediatric psychology.

Table 1

Telemental health intervention using videoconferencing

Study	Population	Sample Description and Sample Size	Study Design	Summary of Findings
Child Psychiatry Intervention Using Videoconferencing
Elford et al, 2000	Various diagnoses	n = 25 youth Age: 4–16 y	RCT, VC vs F2F	96% concordance between VC and F2F diagnostic evaluations, no difference in patient or parent satisfaction between VC and F2F, 91% of parents reported preference for VC to long-distance travel
Elford et al, 2001	Various diagnoses	n = 23 youth	Descriptive, VC	Diagnosis and treatment recommendation were equal to usual, in-person care
Greenberg et al, 2006	Various diagnoses	No children, 35 PCPs, 12 caregivers	Descriptive, focus groups with PCPs and caregivers	PCP and caregivers satisfied with VC and frustrated with limitations of local supports. Family caretakers and service providers frustrated with limitations of VC
Lau et al, 2011	Various diagnoses	n = 45 youth Age: 3–17 y	Descriptive, VC	Use of VC showed a large variation in patient characteristics, such as age, current living situation, and psychological symptoms. The most common reason for VC referral was for diagnostic clarification (67%). Telepsychiatrists recommended a change in medication for most (80.8%) who were already on medication and to begin medications for those not on medication at time of consult (63.2%)
Myers et al, 2006	Incarcerated adolescents	n = 115 youth Age: 14–18 y	Descriptive, VC satisfaction	80% successfully prescribed medications and expressed confidence in the psychiatrist by video, and youth expressed concerns about privacy
Myers et al, 2007	Various diagnoses	n = 172 patients Age: 2–21 y 387 clinic visits	Descriptive, VC satisfaction	High satisfaction with services, more so with pediatricians vs family physicians
Myers et al, 2010	Various diagnoses	n = 701 patients referred by 190 PCPs	Descriptive, use of VC	Pediatricians referred to VC services more frequently than family providers, reported VC as feasible, acceptable, and increasing access to mental health services
Myers et al, 2013	ADHD	n = 223 youths Age: 5.5–12.9 y	RCT, feasibility of VC	Demonstrated feasibility of conducting RCT with the use of VC with children living in underserved communities, clinicians showed high fidelity to treatment protocols, minor technical difficulties did not interfere with providing care
Myers et al, 2015	ADHD, ODD, anxiety	n = 223 youth	RCT, VC vs F2F	Caregivers reported significantly greater improvement for inattention, hyperactivity, combined ADHD, ODD, and role performance for VC compared with those treated in primary care, teachers also reported significantly greater improvement in ODD and for performance for VC
Pakyurek et al, 2010	Various diagnoses	n = 12 youth	Descriptive, VC vs F2F	VC may be superior to F2F for routine clinical consultation in primary care
Rockhill et al, 2013	ADHD, ODD, anxiety	n = 223 children Telepsychiatrists and PCPs of these children	RCT	Telepsychiatrists adhered to guideline-based care, used higher medication doses than PCPs, and their patients reached target of 50% reduction in ADHD symptoms more often than with PCPs
Szeftel et al, 2012	Developmental disability	n = 45 youth	Descriptive	VC led to changed psychiatric diagnosis for 70%; changed medication in 82% of patients initially, 41% at 1 y, and 46% at 3 y; VC helped PCPs with recommendations for developmental disabilities
Yellowlees, 2008	Various diagnoses	n = 41 youth	VC pre-post	At 3 mo following psychiatric diagnostic evaluation, improvements in the Affect and Oppositional domains of the Child Behavior Checklist were observed
Myers et al, 2004	Various diagnoses	n = 159 youth Age: 3–18 y	Comparison of patients evaluated using VC vs F2F	Demographically, clinically, and by reimbursement, patients look similar between VC and F2F, VC had greater adverse case mix
Myers et al, 2008	Various diagnoses	n = parents of 172 youths	Descriptive, VC satisfaction	Satisfaction was higher in parents of school-aged children vs those with adolescents, high adherence for return appointments
Child Clinical Psychology Intervention Using Videoconferencing
Fox et al, 2008	Juvenile offenders	n = 190 youth Age: 12–19 y	VC pre-post	Youth increased goal achievement in areas of health, family, and social skills
Heitzman Powell et al, 2014	Autism	n = 7 parents Youth age not reported	VC pre-post	Parents increased their knowledge and self-reported implementation of behavioral strategies
Himle et al, 2012	Tic disorders	n = 18 youth Age: 8–17 y	RCT, VC vs F2F	Across groups, significant improvements in tic behaviors and strong ratings for acceptability and therapist/client alliance. No differences between treatment groups
Tse et al, 2015	ADHD	n = 37 youth M (Teletherapy) = 9.15 y M (F2F) = 9.39 y	Substudy of larger clinical trial, VC vs F2F	Families in the 2 caregiver training conditions showed comparable attendance at sessions and satisfaction with their care. Caregivers in both conditions reported comparable outcomes for their children’s ADHD-related behaviors and functioning, but caregivers in the teletherapy group did not report improvement in their own distress
Nelson et al, 2006	Depression	n = 28 youth M = 10.3 y	RCT, VC vs F2F	Treatment yielded significant improvement for depression in both conditions, with no between-group differences
Nelson et al, 2012	ADHD	n = 22 youth M = 9.3 y	VC feasibility	No factor inherent to the VC delivery mechanism impeded adherence to national ADHD guidelines
Reese et al, 2012	ADHD	n = 8 youth M = 7.6 y	VC pre-post	Using group Triple P Positive Parenting Program instead of VC, families reported improved child behavior and decreased parent distress
Reese et al, 2013	Autism	n = 21 youth	RCT, VC vs F2F	No difference in reliability of diagnostic accuracy, ADOS observations, ratings for ADI-R parent report or symptoms, and parent satisfaction
Reese et al, 2015	Autism	Autism Diagnostic Teams	VC feasibility	Using VC provided families in rural and underserved areas improved access to diagnostic services, parents equally satisfied with services received through VC and through university-based medical team
Stain et al, 2011	Psychosis	n = 11 youth Age: 14–30 y	VC feasibility	Differences between VC and F2F modes of neuropsychological assessment were close to zero, VC produced higher ratings for general cognitive functioning (WTAR) compared with F2F assessments, strong acceptability of VC assessment from participants
Storch et al, 2011	OCD	n = 31 youth Age: 7–16 y M = 11.1 y	Waitlist control, VC vs F2F	VC was superior to F2F on all primary outcome measures, with a significantly higher percentage of individuals in the VC group meeting remission criteria than in the F2F group
Xie et al, 2013	ADHD	n = 22 parents Child M = 10.4 y	RCT, VC vs F2F	Parent training via VC showed same degree of improvement in disciplinary practices, ADHD symptoms, and overall functioning as F2F
Pediatric Psychology Intervention Using Videoconferencing
Bensink et al, 2008	Pediatric cancer	n = 8 youth Not reported	VC feasibility	Using VC rather than videophone to families with children diagnosed with cancer, the study noted technical feasibility and high parental satisfaction
Clawson et al, 2008	Pediatric feeding disorders	n = 15 youth Age: 8 mo to 10 y old	VC feasibility	VC was feasible with the pediatric feeding disorder population and resulted in cost savings
Davis et al, 2013	Pediatric obesity	n = 58 youth Age: 5–11 y M = 8.6 y	RCT, VC vs F2F physician visits	Both groups showed improvements in BMIz, nutrition, and physical activity, and the groups did not differ significantly on primary outcomes
Davis et al, 2016	Pediatric obesity	n = 103 youth	RCT, VC vs telephone	Participants highly satisfied with both intervention methods, completion rates higher compared with other pediatric obesity interventions, both methods highly feasible
Freeman et al, 2013	Diabetes adherence	n = 71 youth VC M = 15.2 y F2F M = 14.9 y	RCT, VC vs F2F	No differences in therapeutic alliance between the groups
Glueckauf et al, 2002	Pediatric epilepsy	n = 22 (Youth) M = 15.4 y	RCT, VC, F2F, and telephone	All groups improved in psychosocial problem severity and frequency and child prosocial behavior, with no significant differences across groups. No differences in adherence between the groups were noted
Hommel et al, 2013	IBD, adherence	n = 9 youth M = 13.7 y	VC pre-post	The VC approach resulted in improved adherence and cost savings across patients
Lipana et al, 2013	Pediatric obesity	n = 243 youth M = 11 y	Pre-post, VC, and F2F	Using a nonrandomized design, the VC group showed more improvement than the F2F group in enhancing nutrition, increasing activity, and decreasing screen time
Morgan et al, 2008	Congenital heart disease	n = 27 parents Child age: 0–25 mo	RCT, VC, and telephone	The VC approach decreased parent anxiety significantly more than phone, and resulted in significantly greater clinical information
Mulgrew et al, 2011	Pediatric obesity	n = 25 youth Age: 4–11 y	VC feasibility	No significant difference in parent satisfaction between consultations for weight management delivered by VC or F2F
Shaikh et al, 2008	Pediatric obesity	n = 99 youth Age: 1–17 y	VC pre-post	VC consultations resulted in substantial changes/additions to diagnoses. For a subset of patients, repeated VC consultations led to improved health behaviors, weight maintenance, and/or weight loss
Wilkinson et al, 2008	Cystic fibrosis	n = 16 youth Not reported	RCT, videophone vs F2F	No significant differences in quality of life, anxiety levels, depression levels, admissions to hospital or clinic attendances, general practitioner calls, or intravenous antibiotic use between the 2 groups
Witmans et al, 2008	Sleep disorders	n = 89 Age: 1–18 y	VC feasibility	Patients were very satisfied with the delivery of multidisciplinary pediatric sleep medicine services rather than VC

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