Need for and Steps Toward a Clinical Guideline for the Telemental Healthcare of Children and Adolescents

Abstract

Objective:

This article identifies and describes key considerations toward the development of a clinical guideline intended to optimize telemental healthcare (TMH) of children and adolescents.

Methods:

The literature was searched with key terms and title words. Of 2824 articles that met primary or secondary key word search criteria, 326 met both criteria, and 118 thematically related directly to child and adolescent TMH. Only 44 studies met levels of evidence I–III and expert recommendation criteria used in clinical guidelines; review of their references found 8 additional studies (52 total). Data from adult, child, and adolescent in-person psychiatric care and adult TMH were applied to provide context in developing the key considerations.

Results:

TMH guidelines for adults are well delineated, and TMH guidelines for children and adolescents are likely to closely overlap in terms of general clinical, technical, and administrative issues. However, for a child and adolescent focus, modifications of existing general guidelines appear necessary; for example, based on developmental status, family involvement, and patient-site modifications for space and sound. Additional clinical issues include specify who, exactly, is the “patient” (i.e., the patient, family, and /or other stakeholders), modalities of care (i.e., age-related psychotherapies such as play therapy or behavior management), and psychopharmacology.

Conclusions:

Specific clinical, administrative, and technical issues are key considerations – based on the nuances of established child and adolescent mental healthcare – and must be considered in developing a clinical guideline for TMH of these patients. Developing such guidance should proceed from a careful review of the growing evidence base, and through expert consensus processes.

Introduction

The evidence base supporting the effectiveness of care delivered to adults through telemental healthcare (TMH) has grown rapidly, related to quality of care, treatment, and novel applications to a variety of settings (Hilty et al. 2013b). The Telemental Health Institute (Telemental Health Institute 2015) has a wide range of clinical and ethical guidelines on TMH. The American Telemedicine Association's (ATA) telemental health guidelines covers clinical, technical, and administrative issues, including video-based online, specifically (American Telemedicine Association 2013; Turvey et al. 2013). Other important contributions are the America Psychological Association Guideline for the Practice of Telepsychology (2013) and the National Association of Social Workers (Standards for Technology and Social Work Practice [National Association of Social Workers 2005]).

The evidence base supporting the effectiveness of care delivered to children and adolescents through TMH is growing incrementally, and guidelines of care (Myers and Cain 2008) are being revised to consider the recent major advances in TMH. Meanwhile, obstacles for TMH are being overcome (Brooks et al. 2013) and the rate of program development for youth is outpacing development of the evidence base. Some preliminary guidance, or key considerations, will help clinicians and administrators in establishing a TMH program while awaiting forthcoming formal guidelines for TMH for youth and their families. The current article provides an overview of key considerations toward the development of a TMH guideline for children and adolescents. These key considerations encompass assessment, treatment, and other factors to inform development of a formal guideline of care and to assist clinicians and administrators in program development and best practices.

Several terms need clarification. We use the terms “youth,” as well as “children and adolescents,” to refer to the population covered in this article. Many terms have been used to refer to the site of TMH service such as “remote” and “originating” sites or “hub” and “spoke” sites. For clarity, we use the terms “patient site” and “clinician site.” As TMH includes a diverse group of specialists in mental healthcare, we use the term “clinician” when referring to the providers of TMH services, which include psychiatrists, psychologists, social workers, and other mental healthcare providers. The term indicates that TMH is not a specialty field of practice but a modality of service delivery that can be utilized by clinicians similarly to service delivery through traditional modalities. Finally, TMH as discussed here refers to two-way, interactive, real time mental healthcare between a patient and a clinician, typical of care that occurs in traditional clinical settings.

The Purpose of Guidelines of Care

The available general TMH guidelines for videoconferencing-based TMH (American Telemedicine Association 2009; Yellowlees et al. 2010) and video-based online TMH (Turvey et al. 2013) provide overarching strategies for best practices in TMH. Such guidelines review scope, as well as clinical, administrative, and technical applications. The Institute of Medicine (IOM) (Institute of Medicine 2011) defined clinical practice guidelines as “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” The standard for guidelines set by the IOM and partnering medical organizations usually employs strategies from the Agency for Healthcare Research and Quality (AHRQ) and capitalizes on the Cochrane Database of Systematic Reviews (Institute of Medicine 2011; Ransahoff et al. 2013; Agency for Healthcare Research and Quality 2014; Cochrane 2015). AHRQ provides a systematic literature review to a multidisciplinary guideline writing group to determine recommendations (and the strength of these recommendations) based on the evidence and on consensus, expert opinion. The approach includes identification and management of financial conflicts, if there are any.

Guidelines tangibly help by providing clinical criteria, protocols, algorithms, review criteria, and other components, all aimed at helping clinicians make the best clinical decisions and avoid bad outcomes, and to provide an approach in uncharted circumstances. Traditional guidelines strengthen impact by using “shall” (Webster 2015) and clinicians attend to these suggestions more carefully. However, the ultimate judgment regarding the care of a particular patient must be made by the clinician in light of all circumstances presented by the patient and that patient's family; the diagnostic and treatment options available; resources; and all pertinent clinical, administrative, and regulatory circumstances.

Developing Key Considerations for Child and Adolescent TMH

Key considerations for the development of a TMH guideline can be synthesized with data from the ATA guidelines (American Telemedicine Association 2009; Yellowlees et al. 2010; American Telemedicine Association 2013), the emerging child and adolescent TMH database, in-person care (adult, child, and adolescent), and the original “Practice Parameter for Telepsychiatry with Children and Adolescents” developed by the American Academy of Child and Adolescent Psychiatry (AACAP) (American Academy of Child and Adolescent Psychiatry 2008). Recently, foreseeing the need for updating this parameter, the AACAP Telepsychiatry Committee has further addressed important points regarding patient appropriateness, site locations, therapeutic space, technology, how to select a model of care, and risk management (American Academy of Child and Adolescent Psychiatry Telepsychiatry Committee 2014). The key considerations presented here build on all of these resources to give clinicians practical information for using TMH to deliver mental healthcare to specific groups of youth, including those presenting in difficult settings (e.g., emergency department TMH), and the ethical considerations in providing care to youth through TMH.

Emerging trends such as social media, psychiatric apps, Internet-based education or therapies, and texting between doctors and patients are beyond the scope of this article but covered elsewhere (Hilty et al. 2015).

The purpose of this article is to:

1. Summarize the need for steps toward a formal child and adolescent TMH guideline, based on current evidence and progress with guidelines internationally.

2. Discuss “real-world” clinical, administrative, and technical issues related to TMH for clinicians and other interdisciplinary team members that will shape recommendations for assessment and treatment of youth through TMH.

3. Provide both an outline of and rationale for key considerations for inclusion in forthcoming child and adolescent TMH guidelines and examples of specific considerations to help readers to include TMH in their current clinical practice.

Methods

The methods for preparation of the key considerations presented here were organized in four ways: 1) A comprehensive review of the TMH literature, first on key words and then title words; 2) stratification of the data and article selection, based on guideline standards (Institute of Medicine 2011; Ransahoff et al. 2013; Agency for Healthcare Research and Quality 2014; Cochrane 2015) and comparable to psychiatry-specific (i.e., AACAP, American Psychiatric Association) guidelines (American Psychiatric Association 2013); 3) synthesis of data, identifying “holes,” which are filled with relevant adult data, when available; and 4) adapting the traditional format of the IOM and telemedical guidelines (e.g., ATA) to a brief, reader-friendly description of specific themes to consider in TMH best practices.

The comprehensive review of the telemental health literature was conducted in the MEDLINE^®, PubMed, PsychInfo, Embase, Science Citation Index, Social Sciences Citation Index, Telemedicine Information Exchange databases, Centre for Reviews and Dissemination, and The Cochrane Library Controlled Trial Registry databases for the period from July 2003 to March 2015 (a previous review covered 1965 through June 2003 [Hilty et al. 2004]). Key words in the initial search were divided into two tiers: Primary or necessary, including guideline, clinical, practice, parameter, telepsychiatry, telemental, health, telecare, telemedicine, e-health, videoconferencing, synchronous, asynchronous, children/child, and adolescent; and secondary, including effectiveness, efficacy, outcomes, satisfaction, quality of care, mental health, cost, cultural/culture, geriatric, population, scope, home health, medical home, emergency, face-to-face, in-person, reliability, validity, and international.

In developing key considerations, we adopted a system used widely in medicine for assessing both the strength of evidence (data-based) and recommendations (rating/grading of evidence and consensus of experts) (Institute of Medicine 2011; Agency for Healthcare Research and Quality 2014; Cochrane 2015) Table 1 shows this dual format. The strength of the evidence base is ranked in four tiers: I–IV. Level I is the best level with high quality, prospective, randomized controlled trials, no or few evident areas of conflict of interest in the studies, and systematic analysis. This usually implies that there is treatment benefit and relatively few harms. Level IV involves cases, case series, limited assessments (e.g., cost evaluation) and opinions by leaders.

Table 1.

Standard Criteria for Evidence Base (Levels I–IV) and Grades/Ratings of Expert Consensus Recommendations

Level	Description
I	High quality randomized trial or prospective study, testing of previously developed diagnostic criteria on consecutive patients, sensible costs and alternatives, values obtained from many studies with multiway sensitivity analyses, systematic review of Level I randomized controlled trials (RCTs) and Level I studies.
II	Lesser quality RCT, prospective comparative study, retrospective study, untreated controls from an RCT, lesser quality prospective study, development of diagnostic criteria on consecutive patients, sensible costs and alternatives, values obtained from limited studies, with multiway sensitivity analyses, systematic review of Level II studies or Level I studies with inconsistent results.
III	Case control study (therapeutic and prognostic study), retrospective comparative study, study of nonconsecutive patients without consistently applied reference “gold” standard, analyses based on limited alternatives and costs and poor estimates, systematic review of Level III studies.
IV	Case series, case control study (diagnostic study), poor reference standard, analyses with no sensitivity analyses, + include evidence from a panel of experts or put that in a “V”.

Grade	Descriptor	Qualifying evidence	Implications for practice
A	Strong recommendation	Level I evidence or consistent findings from multiple studies of levels II, III, or IV	Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present
B	Recommendation	Levels II, III, or IV evidence and findings are generally consistent	Generally, clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preferences
C	Option (suggested)	Levels II, III, or IV evidence, but findings are inconsistent	Clinicians should be flexible in their decision making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role
D	Option (possible)	< Level IV evidence: little or no systematic empirical evidence	Clinicians should consider all options in their decision making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role

Grading/rating into recommendations (via evidence base and expert consensus) by consensus is organized into A–D (strong recommendation, recommendation, option suggested, option possible). The top tier is Strong Recommendation (level I evidence or consistent findings from multiple studies of levels II, III, or IV; clinicians follow unless a clear and compelling rationale for an alternative approach is present). The second tier is Recommendation (Levels II, III, or IV evidence and findings are generally consistent; generally, clinicians follow this, but remain alert to new information and sensitive to patient preferences. The remaining tiers imply less evidence, relative benefit, some harms, or uncertainty (further research is needed, or it is impossible to be sure). Articles that did not meet all the criteria of a level (e.g., level I) were put in the level below (i.e., level II), and the same principle was applied to tiering of recommendations, when it was not clear from reading the article.

A total of 2824 articles met the primary or secondary key word search criteria, but only 326 met the primary and secondary search criteria. Those articles were reviewed, with 118 thematically, directly related to TMH and child and adolescent care; the others primarily focused on adult and child and adolescent in-person care, adult TMH, general guidelines, and other healthcare topics. These 118 articles included 44 studies with level I–III data based on the criteria described. A review of their references and presentations in the last 12 months found 8 additional studies: 52 total, 30 related to clinical outcomes in child and adolescent TMH, which are summarized in Table 2, and 22 specific to individual psychotherapy and pediatric psychology (see Table 1 in Nelson & Patton 2016).

Table 2.

Summary of Clinical Outcome Studies for Child and Adolescent Telemental Healthcare (Not Inclusive of Satisfaction-Only Studies)

Citation (old to new)	Design	Sample	Assessment	Findings
Blackmon et al. 1997	Descriptive	43 Children Parents	Routine clinical	All children and 98% of parents report satisfaction equal to in-person care
Elford et al. 2000	RCT	25 Children Various diagnoses	Diagnostic interviews	96% concordance between video and in-person evaluations; no difference in satisfaction
Elford et al. 2001	Descriptive	23 Children	Routine clinical	Diagnosis and treatment recommendation - equal to usual, in-person care
Glueckauf et al. 2002	Modified RCT Pre vs. post	22 Adolescents 36 Parents	Issue-specific measure of family problems (ISS, IFS, ICS) Teen functioning (Social Skills Rating System – [SSRS]) Working Alliance Inventory Adherence to appointments	Improvement for problem severity and frequency in all conditions. Therapeutic alliance high; teens rated alliance lower for video
Nelson et al. 2003	RCT	28 Children Depression	Diagnostic interview and scale	Video = in-person for improvement of depressive symptoms in response to therapy
Myers et al. 2004	Descriptive	159 youth (age 3-18)	Comparison of patients evaluated through TMH vs. face-to-face (FTF) in clinic	Video similar to in-person outpatients demographically, clinically, and by reimbursement Video > “adverse case mix”
Greenberg et al. 2006	Descriptive	NS Children, 35 PCPs, 12 caregivers	Not specified Focus groups with PCPs, interviews with caregivers	PCP and caregiver satisfied with video; frustrated with limitations of local supports Family caregivers and service providers frustrated with limitations of the video
Myers et al. 2006	Descriptive	115 Incarcerated youth (age 14-18)	11 item Satisfaction Survey	80% successfully prescribed medications, and they expressed confidence in the psychiatrist by video Youth expressed concerns about privacy
Myers et al. 2007	Descriptive	172 Patients (age 2-21) and 387 visits	11 item Provider/PCP Satisfaction Survey	Video to patients at 4 PCP sites: high satisfaction with services; pediatricians > family physicians
Fox 2008	Pre-post	190 Youth in juvenile detention	Goal Attainment Scale (GAS)	Improvement in the rate of attainment of goals associated with family relations and personality/behavior
Myers et al. 2008	Descriptive	172 Patients Parental satisfaction	12 item Parent Satisfaction Survey	Parents' with school-aged children satisfaction higher than those with adolescents Adherence high for return appointments
Yellowlees 2008c	Pre-post	41 Children in rural primary care	Child Behavior Check List (CBCL)	At 3 months, improvements in the Affect and Oppositional Domains of the CBCL
Myers et al. 2010	Descriptive	701 Patients, 190 PCPs	Collection of patient demographics, diagnoses, and utilization of services	Video feasible; psychiatrists adjust practice from in-person well
Pakyurek et al. 2010	Descriptive	12 Children Autism spectrum in primary care	Routine clinical	Video might actually be superior to in-person for consultation
Lau et al. 2011	Descriptive and advanced assessment	45 Children/ adolescents	Patient characteristics, reason for consultation, and treatment recommendations	Video reaches a variety of children, with consultants providing diagnostic clarification and modifying treatment
Stain et al. 2011	Descriptive and RCT	11 Adolescents/young adults	Diagnostic Interview for Psychosis Diagnostic Module (DIP-DM)	Strong correlation of assessments done in person vs. video
Storch et al. 2012	RCT	31 Children and teenagers	Routine clinical and measures 1. ADIS-IV-C/P 2. Clinician-admin. CY-BOCS 3. Clinical Global Impressions Scales (CGI) 4. Others: obsessive, anxiety, depression inventory.	Video was superior to in-person on all primary outcome measures, higher % meeting remission. Consultants providing diagnostic clarification and modifying treatment
Himle et al. 2012	RCT	20 Children Tourette's disorder or chronic motor tic disorder	Routine clinical assessment with Yale Global Tic Severity Scale (YGTSS); Parent Tic Questionnaire (PTQ) Clinical Global Impressions Severity & Improvement Scales (CGI-S and CGI-I)	Both treatment delivery modalities resulted in significant tic reduction with no between-group differences
Nelson et al. 2012	Service utilization chart review	22 Children	Routine clinical	No factor inherent to the video delivery mechanism impeded adherence to national ADHD guidelines
Reese et al. 2012	Pre-post	8 Children; Asian	Routine clinical ADHD	Families reported improved child behavior and decreased parent distress via video format of Group Triple P Positive Parenting Program
Szeftel et al. 2012	Descriptivechart review	45 Patients; 31 < 18 years	Routine clinical – medication changes, frequency of patient appointments, diagnostic changes, symptom severity, and improvement	Video led to changed Axis I psychiatric diagnosis (excluding developmental disorders) 70%, and changed medication 82% of patients initially, 41% at 1 year and 46% at 3 years Video helped PCPs with recommendations for developmental disabilities
Heitzman-Powell et al. 2013	Pre-post	NS Youth not reported 7 Parents	OASIS training program Problem Behavior Recording (PBR) Incidental Teaching Checklist (ITC)	Parents increased their knowledge and self-reported implementation of behavioral strategies
Reese et al. 2013	Descriptive and RCT	21 Children; 90% Caucasian	Autism Diagnostic Observation Schedule (ADOS) – Module 1 Autism Diagnostic Interview – Revised (ADI-R) Parent Satisfaction	No difference in reliability of diagnostic accuracy, ADOS observations, ratings for ADI-R parent report of symptoms, and parent satisfaction
Rockhill et al. 2013	RCT	223 Children with ADHD + ODD + Anxiety	Caregiver distress assessed with Patient Health Questionnaire-9, Parenting Stress Index, Caregiver Strain Questionnaire, Family Empowerment Scale	Parents of children with ADHD and a comorbid disorder had significantly more distress than parents of those with ADHD alone
Xie et al. 2013	RCT	22 Children Behavioral disorder	Routine clinical Parent Child Relationship Questionnaire (PCQ-CA), Vanderbilt Assessment Scales, C-GAS, CGI-S	Parent training through video was as effective as in-person training and was well accepted by parents
Comer et al. 2014	Pre-post	5 Children (age 4-8)	Behavioral intervention with child, facilitated by parent; OCD rating scale by parent	Child OCD symptoms and diagnoses declined; child global functioning improved
Myers et al. 2015	RCT	223 Children with ADHD + ODD + anxiety	CBCL screening, DISC-IV diagnostic assessment, ADHD rating scales (inattention, hyperactivity, combined, ODD, role performance) and Columbia Impairment Scale	Caregivers reported significantly greater improvement for inattention, hyperactivity, combined ADHD, ODD, role performance for video vs. those treated in primary care Teachers reported significantly greater improvement in ODD and role performance for video group, as well
Tse et al. 2015	RCT Subsample	37 Caregivers of children with ADHD + ODD + anxiety	Caregiver Behavior Training (CaBT) delivered via. CBCL screening, DISC-IV diagnostic assessment, ADHD rating scales (inattention, hyperactivity, combined, ODD, role performance) and Columbia Impairment Scale	Caregivers reported comparable improvements for children's outcomes whether CaBT video = in person; no improvement in caregivers' distress when CaBT provided through video.
Rockhill et al., 2015	DescriptiveTelepsychiatrists in RCT	223 Children with ADHD + ODD + anxiety, the telepsychiatrists and PCPs	Telepsychiatrists' adherence to guidelines-based care, ADHD outcomes by prescriber based on comorbidity status	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

ISS, Impact on School Scale; IFS, Impact on Family Scale; ICS, Impact on Child Scale; PCP, primary care provider; RCT, randomized controlled trial; ADIS-IV-C/P, Anxiety Disorders Interview Schedule-Child and Parent; CY-BOCS, Children's Yale-Brown Obsessive Compulsive Scale; ADHD, attention-deficit/hyperactivity disorder; ODD, oppositional defiant disorder; C-GAS, Children's Global Assessment Scale; OCD, obsessive-compulsive disorder; DISC-IV, Diagnostic Interview Schedule for Children, Version IV; TMH, telemental healthcare.

Overall, the literature focused on TMH clinical applications related to assessment and treatment. Topics less discussed in the child and adolescent literature, compared with the adult literature, were selection of a model of service delivery, particularly consultation-liaison for psychosomatic medicine to the medical setting, although there is an emerging literature in the pediatric psychology literature related to psychosomatic medicine in pediatrics (Nelson et al. in press, this volume).

The phrase “clinical applications” used in the adult guidelines actually refers to three subsections: Clinical care, technical issues, and other administrative issues. The evidence base focuses almost exclusively on clinical studies with outcomes. The accompanying literature involving all ages related to TMH, adds context and concrete planning steps on technical and administrative factors. Therefore, we organized these key considerations toward the approach; scope; and clinical, administrative, technical, and other factors for TMH for youth, with comments on the evidence base and recommendations in italics. When the word “parties” is used, it refers to instances in which clinicians, administrators, technical, and other staff all collaborate.

An Approach to TMH Service Delivery to Youth: Patient Selection, Technical Issues, and Administrative Issues

Introduction

The general ATA TMH Guideline, AACAP Practice Parameter and the Telepsychiatry Committee of the AACAP (2014) form a foundation for this article, as they cover the approach; scope; and clinical, administrative and technical aspects of services delivered through TMH (American Academy of Child and Adolescent Psychiatry 2008; Myers and Cain 2008; American Telemedicine Association 2009; Yellowlees et al. 2010; American Telemedicine Association 2013;). This article considered the contemporary context of healthcare changes, improvements in technology, and the evidence base.

Child and adolescent mental health practice is significantly different from adult practice in terms of the scope of practice, the diversity of providers, and the variety of specialized settings. First, child and adolescent mental healthcare clinicians contend with developmental disorders and disorders with early onset that often require family and systems work. Treatment modalities such as parent management, play therapy, or behavior training require site- and technology-based modifications that may not be considered in work with adults (e.g., remote site room design, camera options such as zoom/control/tracking, and audio/sound detection). Second, some patient populations and treatment settings – corrections/juvenile hall, home health and school settings – require additional skill sets, particularly with nonclinical professionals. Clinicians must extrapolate knowledge and skills from the usual settings.

Approach

TMH, like telemedicine, is an intentionally broad term referring to the provision of mental health and substance abuse services from a distance. TMH services can significantly impact the quality, timeliness, and availability of services in almost any mental healthcare delivery system (American Telemedicine Association 2009; Hilty et al. 2013b; Shore 2013; Yellowlees et al. 2010). The ATA provides the core standards for telemedicine operations and provides overarching guidance for administrative, clinical, and technical standards (American Telemedicine Association 2009; Yellowlees et al. 2010). TMH sites of practice include hospitals, emergency rooms, community mental health centers, clinics, physician offices, nursing homes, assisted living facilities, prisons/corrections facilities, emergency rooms, schools, and patient homes.

TMH to child and adolescent populations involves family/system issues, a variety of clinical services (e.g., direct care, consultation, and triage), many types of providers (e.g., psychiatrist, psychologist, and other allied mental health professionals) and numerous technologies. Generally, the attitude, skill, and knowledge of the provider are matched with patient needs. Alignment with scope of work is important in child and adolescent key considerations because of three factors: 1) Data are extrapolated from adult in-person, child, and adolescent in-person, adult TMH, and limited child and adolescent TMH studies; 2) there are still some “holes” in the database that must be temporarily filled with experience from clinical practice (e.g., emergency telepsychiatry) (Shore et al. 2007; Yellowlees et al. 2008a); and 3) some services may be contextualized in subspecialty practice, as well (e.g., child psychosomatic medicine) such that clinicians must be mindful of their clinical portfolio before doing the work.

Key Consideration 1. Choice of TMH versus other service delivery methods

The clinician assesses whether to use in-person, TMH and/or specific TMH options based on the clinical scope of the work. Level 2/Recommendation: There is little to no difference between TMH and in-person care in quantitative measures. Level 3/Option: There is little to no difference between TMH and in-person care in qualitative measures.

Scope of services and patient appropriateness for TMH

Common TMH applications with adults that may be useful for youth include prehospitalization assessment and post-hospital follow-up care, and scheduled and urgent outpatient visits. However, the limited evidence base with youth has focused on outpatient evaluations, consultation, and medication management (Myers et al. 2004; Greenberg et al. 2006; Myers et al. 2008, 2010; Spaulding et al. 2010; Pignatiello et al. 2011; Glueck 2013) and some focus has been on psychotherapy (Nelson et al. 2003, 2006; Greene et al. 2010; Glueck 2013) and parent training (Reese et al., 2012; Xie et al, 2013; Tse et al. 2015; Carpenter et al. 2014) including in-home parent training (Comer et al. 2014; Comer et al. 2015). Patient selection as a topic is generally not controversial and is determined by mutual agreement of the patient and clinician following ethical guidelines for informed consent (Nelson et al. 2013).

Ability to obtain an accurate history and conduct an appropriate clinical and developmental evaluation per best practices (American Academy of Child and Adolescent Psychiatry 1997, 2007) is the core factor in determining scope of services, and includes the ability to obtain collateral information from relevant adults at the patient site (Glueck 2013; Goldstein and Myers 2014). Developmental observations and mental status examinations are conducted through direct interaction with the youth over the telemonitor, observation of youths' interactions with their accompanying caregivers, and, when needed, having local staff interact or play with the youth under the clinicians' direction (Myers et al. 2008; Savin et al. 2011; Glueck 2013).

The literature and extrapolation of data from adult TMH care indicate there may be instances in which TMH is a preferred option over in-person care (Pakyurek et al. 2010; Hilty et al. 2013b). These include, but are not limited to, patient system and community issues, such as patients with autism who are difficult to transport, anxiety that leads to phobic avoidance of care and other settings, and patients in small communities who fear lack of privacy with local providers (e.g., a tribal community). Generational effects may come into play as teenagers may share more and appreciate the technology. This may make TMH a preference for some youth (Comer et al. 2014; Lieberman et al. 2014).

Key Consideration 2. Patient appropriateness

Parties ensure that patients are suitable for TMH, that patient and clinician expectations are reasonable, and that preferences can be honored. Level I/Strong recommendation: Data indicate any patient is appropriate for TMH.

Key Consideration 3. Selecting TMH rather than in-person care

Parties determine administrative, clinical, and technical factors that indicate that TMH may be the preferred short- or long-term service modality, and the scope of services offered. Level III/Option: Data support that TMH may be better than in-person care for subpopulations.

Administrative standards for clinical care

TMH services to youth and families may be delivered in several models or care, including triage, consultation, direct care, collaborative care (Fortney et al 2015), and medical home integration (Fortney et al. 2007, 2013; McWilliams 2015). The ATA has developed administrative guidelines for the implementation of TMH care across models of care. These guidelines are appropriate for telepsychiatry services delivered to children, adolescents, and families, with adaptations appropriate to adhere to the best practices outlined in the AACAP practice parameters for evaluation, treatment, and specific disorders (American Academy of Child and Adolescent Psychiatry 1997, 2007, 2009, 2014, 2015).

Key Consideration 4. Administrative management for clinical care – patient selection

Parties follow the general adult TMH guidelines and in-person child and adolescent guidelines to ensure quality of care or triage of potential patients to alternative services.

There is no evidence base on which to evaluate this, but good administration is a precondition for all health services.

Key Consideration 5. Administrative management for clinical care – model of care

Parties establish a model of care and communicate it to parties involved, within the scope of usual in-person care, with the usual requisite components (e.g., prescriptions, scheduling, contact between sessions). Standards of medical practice apply and there are no data to the contrary for TMH; new models of care (e.g., video combined with web-based interventions) are more possible.

Key Consideration 6. Administrative management for clinical care - best practices

Parties integrate the established general adult TMH guidelines (American Telemedicine Association 2009; Yellowlees et al. 2010; American Telemedicine Association 2013) with other AACAP guidelines, and parties at the clinician and the patient sites communicate, evaluate and employ process-based planning to ensure best practices for youth and families. Standards of medical practice related to administrative, clinical, and technical parties apply. Satisfaction is so high with TMH that no studies can assess differences between in-person and TMH.

Technical standards

A wide array of standards-grade (high definition, point-to-point connectivity) and consumer-based software programs (Internet delivery) (Spargo et al. 2013; Chow et al. in press) is available to provide a high quality videoconferencing experience. Each technology has its pros and cons, which may vary with the specific application, site, connectivity options, and resources. The system selected must be matched to the clinical service delivered, be cost effective for the participating parties, and integrate into a telepsychiatrist's practice (Glueck 2011, 2013). Determination of an optimal system is made in collaboration between the two sites and tested prior to any expenditure or installment, to ensure the ability to facilitate quality care.

Key Consideration 7. Technical management

The clinician, administration, and technical support team organize services and match technology to site and application needs. Administrative, clinical and technical standards from in-person care and adult services are applied to TMH and in-person child and adolescent care. Level I/Strong recommendation: Data suggest that satisfaction of all users is based on at least 384 kilobits/second (KBPS). Level III/Option: Data suggest that secure leased bandwidth is preferred. (Level IV/Option: Data may suggest that some adolescents are reasonably satisfied with lower bandwidth options, but this has not been researched.)

Clinical Applications: Adjustments for Assessment, Consultation, and Treatment by TMH

Standard, modified, and adjunct clinical assessments

Assessment by TMH should be consistent with the AACAP Practice Parameter “Assessment of Children and Adolescents” (American Academy of Child and Adolescent Psychiatry 2014). Standard clinical assessment attends to interview logistics, settings, and the variety of parties involved in the care of children and adolescents, such as primary care providers (PCPs), family, teachers, social services, and other community organizations. Modified standard assessment conducted through TMH may include, but not be limited to, additional collateral information, phone or video-based interpreters, or assessment by a remote clinician of treatment-induced side-effects (e.g., extrapyramidal side effects [EPS]). Adjunct services include, but are not limited to, psychological testing, interpreters, sign language specialists, and cultural consultation (Yellowlees et al. 2008b). Neurocognitive assessment has not been widely used in child and adolescent TMH, but the adult literature indicates that it may be conducted in terms of psychological (Manchanda and McLaren 1997; Stevens et al. 1999; Nelson and Bui 2010), intelligence, and/or neurocognitive testing (Grosch et al. 2015). Finally, in selected sites and situations such as school or home, TMH may be used to obtain a more comprehensive and contextual perspective of a youth's symptoms, behaviors, and triggers than is possible in a typical office visit (Glueck 2013; Comer et al. 2014; Stephan et al., in press).

Adjustment of clinical procedures

Duration of the appointment

The duration of the appointment may need to be adjusted, or the planning and service delivery for the appointment may need to be modified to consider involvement of various parties at the patient site, such as family or a TMH coordinator, therapist, case manager, teacher, or the PCP. Duration and planning are considered in determining the model of care for TMH services.

Clinical and administrative preparation

The amount of forward planning also can save time during the TMH session (e.g., by collating history in advance). Web- or phone-based questionnaires may help the clinician to focus the interview, and provide a basis for subsequent evidence-based interventions (Brondbo et al. 2012). Clinicians or coordinators may make preemptive calls to collateral sources of information, if clinically applicable information is needed beforehand (e.g., vital signs, palpation for EPS, olfactory data) (Glueck 2011, 2013).

Adjustments to the physical setting

The room at the patient site facilitates the assessment, interactions between parties, and intervention according to the clinical application. For diagnostics, behavior training, and pharmacotherapy applications, the physical setting needs to be a large enough space to include the youth and a parent, and one to two other individuals, and to allow the camera to observe subjects' motor skills as they move about the room, play, and separate from their parents. Videoconferencing equipment that allows the provider to remotely operate the camera at the patient site is optimal, but may not be available with consumer-based systems. A table may provide a surface for the youth to draw or play while the parent relates the history, as long as it does not interfere with communication or viewing the youth's motor skills. Some simple toys may be provided both to occupy the patient and to allow assessment of skills and may be selected based on age-appropriateness and child safety standards. For psychotherapy applications, a simpler space may be preferable to engage the youth and limit distractions.

Key Consideration 8. Clinical assessment and care

The clinician oversees alignment with in-person care standards and modifies necessary elements to: 1) Facilitate clinical decision making and augmentation (e.g., interpreter), 2) consolidate the administrative approach, and 3) adjust the physical building and adjust TMH technology to facilitate engagement, assessment, and decision making with the patient and family. Standard practice for in-person child and adolescent psychiatry is applied to TMH; no evidence suggests otherwise.

Medical Settings: Emergency room, outpatient triage, and consultation services

Adjusting services to ensure quality

TMH clinicians need to provide services consistent with national standards to specific settings (e.g., emergency rooms, medical inpatient units, or primary care offices) in terms of time, scope, and legal and other issues (Shore et al. 2007; Yellowlees et al. 2008a; Williams et al. 2009; Glueck 2011; Savin et al. 2011; Glueck 2013). For example, consultations to emergency departments require preplanning, to handle potentially dangerous behaviors, with increased attention to legal issues, responsibility, and teamwork, but little data have been collected on the use of TMH with adults or youth. Therefore, clinicians are guided by national standards in delivering care through TMH to child and adolescent patients in the emergency department.

For consultation to primary care, models of care have been studied with adults, including low-, medium-, and high-intensity models (Hilty et al. 2015), which may be adapted to child and adolescent populations. A summary of adult studies has been conducted (Hilty et al. 2013b), including available randomized controlled trials of disease management (Hilty et al. 2007a), collaborative care models (Fortney et al. 2007, 2013, 2015) and asynchronous telepsychiatry (Yellowlees et al. 2013). The few available child and adolescent studies include integrated programs for screening and consultation (Greenberg et al. 2006; Neufeld et al. 2007; Yellowlees et al. 2008c; Boydell et al. 2010; Pakyurek et al. 2010; Savin et al. 2011; Jacob et al. 2012) and several intervention models (Glueckauf et al. 2002; Myers et al. 2004; Fox et al. 2008; Myers et al. 2010; Spaulding et al. 2010; Lau et al. 2011; Himle et al. 2012; Glueck 2013; Heitzman-Powell et al. 2013; Comer et al. 2014), particularly for attention-deficit/hyperactivity disorder (ADHD) (Nelson et al, 2012; Vander Stoep and Myers. 2013; Myers et al. 2015; Rockhill et al. 2015).

Key Consideration 9. Adjusting services and model selection

The clinician oversees alignment with in-person care standards; makes reasonable adaptations of the adult evidence base to the child and adolescent population; and adds necessary administrative, clinical, and team-building elements to ensure quality of care through TMH. Coordination with the site coordinator for vital signs, assisting with difficult behaviors and responding to emergencies is suggested; for an emergency, it is important to determine what resources, such as staff, security, or community (i.e., police, mental health worker, others) are regularly available versus having been put on stand-by versus having been deployed in advance. As mentioned, there are no data to suggest problems for adjusting care or models related to TMH; more flexibility is possible and new models of care (e.g., video combined with web-based interventions) have arisen.

Age-, disorder-, and setting-based issues

Young children

Using play for rapport building, assessment, and in ongoing psychotherapy is standard practice among child and adolescent clinicians. Play is especially important in engaging young children. Some forms of play are possible through TMH, such as drawing and sharing pictures, “virtual high fives,” telling stories with action figures or puppets, and playing games. Some play may require a clinician or other person at the patient site to engage the child while being directed by the distance clinician (Savin et al. 2006), and hyperactivity or impulsivity may require more preparation and supervision at the patient site (Nelson and Bui 2010).

Adolescents

Usual approaches to the in-person evaluation of the adolescent, such as alternating time with the teen, caregiver, then both together, remain the same in TMH. For some teenagers, in-person care may feel confrontational, resulting in discomfort, whereas TMH may feel more collaborative (Savin et al. 2011); for example for teens with autism (Pakyurek et al. 2010), developmental disabilities (Szeftel et al. 2012), and obsessive-compulsive disorder (OCD) (Nelson and Bui 2010; Nelson et al. 2013; Nelson and Patton, 2016). TMH clinicians also must attend to legal guidelines and laws, particularly if they are crossing a state line for evaluation of an adolescent (to provide care, a license would be required in the state of the adolescent).

Key Consideration 10. Care based on age

The clinician considers clinical and developmental aspects of the clinical session – including patient age, participants, and family/system issues – and preassesses the need to modify care, adapt the technology, and train/educate staff at the patient site. Standard practice for in-person child and adolescent psychiatry with no clear evidence base to suggest in-person versus TMH differences. Level IV/Option: Data suggest higher level of complexity.

Treatment/clinical care and services

Psychopharmacotherapy

The AACAP has published guidelines for psychotropic medication treatment for children and adolescents (American Academy of Child and Adolescent Psychiatry 2007, 2009, 2015). The American Psychological Association (APA) has published a guideline on e-prescribing (American Psychological Association 2013), which is becoming more widely available and utilized. However, there are limited outcome data regarding the effectiveness of psychopharmacotherapy for children and adolescents delivered through TMH (Myers et al. 2015). Support for such treatment comes from studies with adults, which have shown that consultation to and collaboration with PCPs through TMH improves their skills in medication practice (Fortney et al. 2007; Hilty et al. 2007b; Fortney et al. 2013; Hilty et al. 2013c). Direct service to adults with depression has shown outcomes comparable with those from treatment provided in person (Ruskin et al. 2004; O'Reilly et al. 2007).

Pharmacotherapy requires access to laboratory assessment, imaging, and consultations with PCPs. A health system that hosts the TMH program and that uses an electronic health record (EHR) has all of the pertinent resources for managing and monitoring medications. An academic program, medical center, or a private practice program with multiple patient sites may not have access to such centralized information, which may necessitate staff helping to collate the needed information for pharmacotherapy practice.

Key Consideration 11. TMH psychopharmacology

The clinician maintains the quality of care and supporting documentation, and ancillary services are similar to those for in-person care. Standard practice in medicine and for in-person child and adolescent psychiatry is applied to TMH; no evidence suggests otherwise.

Psychotherapy, family therapy, and case management

The evidence base supporting the effective delivery of psychotherapy through TMH is growing. High levels of satisfaction and working alliance between the patient and provider have been shown in multiple studies with adults (Morland et al. 2010; Hilty et al. 2013b) and youth (Blackmon et al. 1997; Elford et al. 2001; Myers et al. 2004; Greenberg et al. 2006; Myers et al. 2006, 2008; Boydell et al. 2010; Myers et al. 2010; Lau et al. 2011). Positive outcomes of psychotherapy have also been demonstrated with adults (Morland et al. 2010; Hilty et al. 2013b). The core issues are the impact of technology, patient education, exploring the virtual connection (Glueck 2013), and adjusting some behaviors and verbal statements to convey empathy and a therapeutic alliance (Hilty et al. 2013). Several small studies with youth have supported the effectiveness of therapy delivered through TMH for children with OCD (Comer et al. 2014), tics (Himle et al. 2012), and depression (Nelson et al. 2003, 2006). One child and adolescent case series showed that therapy delivered through TMH may achieve better outcomes than treatment delivered in person (Pakyurek et al. 2010). Guidelines for conducting psychotherapy by videoconferencing have been explored (Nelson et al. 2013; Nelson and Patton in press).

Family work

Family interventions are integral to adequate assessment and treatment of children and adolescents. TMH, along with other healthcare changes focusing on efficiency, highlight opportunities to streamline such care, but also require the clinician to analyze options carefully. Issues include, but are not limited to, patient/family openness to technology, family dynamics, and building/technology issues. Families involve multiple individuals, each with a different level of comfort with TMH. Families may need more or less education and time to acclimate to the experience of talking to another person about private information over a telemonitor. Younger family members seem intrigued by TMH technology and eager to engage this way (Savin et al. 2011), but older adults do not necessarily need more time to acclimate (Hilty et al. 2007a), as technical literacy is growing rapidly across the country. There is an emerging evidence base supporting TMH in the delivery of family-based services, including family therapy (Glueckauf et al. 2002), parent behavior training for children with disruptive behavior disorders (Reese et al, 2012; Xie et al. 2013; Tse et al. 2015), and in-home, family-facilitated treatment of OCD (Comer et al. 2014).

Case management

The ATA 2009 Guideline briefly discusses issues related to case management that apply to TMH with children and adolescents. Considering the multiple stakeholders in youths' treatment, a “hybrid model” of engagement may be indicated and be more feasible with one professional engaged through TMH, another with the patient in person, and still another linked in by telephone. Recently, such novel “hybrid models care” was described in which a combination of in-person and technology-delivered care produced effective outcomes for children with ADHD (Yellowlees and Nafiz 2010; Hilty et al. 2015; Myers et al. 2015).

Key Consideration 12. Psychotherapy

The clinician directs psychotherapy services within the TMH setting, using and adapting evidence-based and empirically supported treatments that incorporate the clinician's professional association's standards, and documents any adaptations needed to ensure best practices. Level II/Recommendation: Data suggest that a therapeutic alliance developed mainly via nonverbal communication at high bandwidth TMH appears similar to that developed through in-person care. Level III/Option: Data suggest that TMH may better augment services not usually available with in-person care.

Key Consideration 13. Patient/family/system work

The clinician evaluates the positive and negative impact of TMH on patient and family care in order to: 1) Preserve the approach, methods, and anticipated therapeutic outcomes; and 2) adapt to additional complexity. Standard practice in child and adolescent psychiatry is applied, because there is no evidence base to suggest otherwise for TMH. Level IV/Option: Data suggest a higher level of complexity. Level II/Recommendation: Data suggest that a therapeutic alliance is developed mainly via nonverbal communication at high bandwidth via TMH. Level IV/Option: Data suggest a higher level of complexity.

Key Consideration 14. Case management

The clinician arranges case management as indicated for in-person service and considers the patient/family engagement, feasibility, and other impact if case management is conducted by TMH, in order to preserve quality of care (Nelson et al. 2006; Myers et al. 2013). Level IV/Option: Little data exist at best and significant research is needed.

Setting-based issues

There is increasing interest in providing care through TMH in community settings such as the home or school. These settings may involve adults who are relevant to the youth's progress, and provide a broader perspective of the youth than would be obtained in an office-based visit. Providing care in such community sites may also reduce the stigma associated with traditional mental healthcare (Grady et al. 2011; Pignatiello et al. 2011; Savin et al. 2011; Comer et al. in press; Stephan et al. in press).

Home

Home-based TMH may provide a “better quality” view or “picture” of life than the office, and engage the parent and child in ecologically valid interactions (Comer et al. 2014). The space, upkeep, level of organization, and choice of “where” to engage via TMH reveal the youth's and family's current resources and stressors. A pilot project with teenagers with early-onset psychosis and using TMH to the home revealed positive levels of acceptance across cultures, enjoyment of the technology by the teens and young adults, and no major problems; one unanticipated event for young adults with roommates was privacy, as they had to find private space in an apartment (Hilty et al. 2013a). A case series of children with OCD demonstrated the feasibility and preliminary effectiveness of providing behavioral therapy through TMH to the home using parents to facilitate the exposure and response prevention treatment components (Comer et al. 2014). Parent–child interaction therapy (PCIT) is being examined for delivery to the home setting (Comer et al. in press).

School

Most youth who obtain mental healthcare receive those services at school. School-based TMH is a logical progression in service delivery. Having children and families “visit” their TMH provider at school may minimize families' fear of being stigmatized if they enter a designated mental health clinic (Savin et al. 2011), and can engage parents in their children's care in the familiar setting of school, and with teachers whom they know (Stephan et al. in press). Teachers can participate by providing their input regarding the child's academic and social functioning and progress during treatment. TMH services have been used to provide functional behavioral analysis with the teacher in the classroom, and a psychologist collaborating through TMH (Barretto et al. 2006; Grady et al. 2011).

Correctional settings

Youth in correctional setting have a great need for specialty child and adolescent mental health services, and there is an increasing focus on providing this care through TMH services (Kaliebe et al. 2011). TMH may increase access to care, reduce attrition of providers, and reduce inefficiencies (Bastastini et al. 2013; Bastastini in press). Adolescents in correctional settings have shown a high level of acceptance of TMH- facilitated care (Myers et al. 2006; Kaliebe et al. 2011), but have expressed concerns about privacy (Myers et al. 2006).

Key Consideration 15. Settings and TMH

The clinician determines in advance, the clinical care model according to site of service delivery and the legal, regulatory, and other pertinent administrative issues at the site of service; adapts TMH to site needs; and conducts ongoing quality improvement assessments to guide for appropriate adaptations in the model of care.

Discussion

The rapid growth of TMH with children and adolescents and the increasing, but limited evidence base supporting the effectiveness of care delivered through TMH suggest a need to develop and expand a TMH guideline specific to children and adolescents (Myers and Cain 2008). A formal guideline based on consensus should be informed by a range of mental or behavioral health professionals and professional organizations. It should be consistent with traditional in-person care and complement the existing general adult TMH guidelines (American Telemedicine Association 2009; Yellowlees et al. 2010; American Telemedicine Association 2013). A guideline for child and adolescent TMH will need modifications or additions to the adult guidelines to consider youths' development, involvement of relevant adults, treatment modality, sites of care, and appropriate technology.

The key considerations are a significant step toward a consensus guideline for many reasons. First, the key considerations compile themes and data into statements that clinicians, administrators, and others can use as a starting place for consensus guidelines; a scorecard of the game shows how it was played out. Second, the key considerations provide a de facto list or a composite of the questions asked (so far) in research studies, which may help others fill holes in the evidence base with studies requisite for consensus guidelines. In the meantime, the key considerations provide a template for clinicians and administrators interested in providing services to youth and families through TMH until a formal guideline is available.

Conclusions

The evidence base for child and adolescent TMH care of patients and their families is growing, and this article identifies the need for, and steps toward, developing a consensus guideline to help “real-world” clinicians and administrators. Clinicians may use these key considerations until guidelines are formally completed. These key considerations have not been vetted by professional organizations and do constitute the standard of care. As such, they should not be deemed inclusive of all proper methods of care, and the clinician must exercise clinical judgment in light of all circumstances encountered in providing TMH care to youth and families.

Clinical Significance

The evidence base supporting the effectiveness of care delivered to children and adolescents through TMH has grown rapidly, related to quality of care, treatment, and novel applications to a variety of settings. Key considerations encompass assessment, treatment, and other factors to assist clinicians and administrators until clinical guidelines are available. Since TMH is not a specialty field of practice but a modality of service delivery, these considerations are derived in part from traditional modalities, with adaptations for being at a distance through the technology. Guidelines in the future will provide clinical criteria, protocols, algorithms, review criteria, and other components—all aimed to help clinicians make the best clinical decisions, avoid bad outcomes, and to provide an approach in uncharted circumstances.

Footnotes

Acknowledgments

We thank the American Telemedicine Association, Telemental Health Special Interest Group; the American Telemedicine Association; the American Academy of Child and Adolescent Psychiatry; the American Psychiatric Association; the Institute of Medicine; and telemedicine and telepsychiatry pioneers, authors, organizational leaders, and innovators.

Disclosures

No competing financial interests exist.

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