American Telemedicine Association Practice Guidelines for Telemental Health with Children and Adolescents

Need for Clinical Practice Guidelines for Telemental Health with Young People

Clinical practice guidelines, rather than more prescriptive practice parameters or standards, are particularly relevant to CATMH practice as the implementation of programs is outpacing the evidence base supporting their effectiveness. Therefore, guidelines for CATMH draw from the general TMH evidence base, ^{8 –10} child-specific research, ^{11 –16} the practice parameters for child and adolescent psychiatry disorders ¹⁷ guidelines for the practice of telepsychology, ^18,19 and the expertise of child and adolescent TMH providers. ^{20 –27}

The guideline utilizes a broad definition of youth, including up to 21 years old. This age range spans the continuum of development and includes the transition from pediatric to adult care. Child and adolescent practice poses important differences from adult practice in terms of scope of practice, young people's systems of care, ²⁸ and the diversity of settings providing specialized services. ^{25,29 –41} Child and adolescent mental health providers contend with disorders, developmental considerations, and environmental factors not commonly addressed in adult practice, such as the treatment of attention-deficit/hyperactivity disorder (ADHD), evaluation for autism and developmental disabilities, or determination of abuse and trauma.

These assessments depend on input both from the youth and relevant adults, often multiple adults, in the family and in the child's systems of care (e.g., case managers, teachers, and other informants). Interventions generally include a caregiver, sometimes the entire family and members of the youths' systems of care, such as teachers or day care providers, even peers. Evaluation and treatment modalities, such as assessment of play or parent–child interactions, require site- and technology-based adaptations that may differ from work with adults. ^26,42

For example, a larger room is often needed to observe a child's motor activity, exploratory skills, and interactions. A camera with pan-tilt-zoom feature helps to assess dysmorphia and monitor a child's affect. ^42,43 Behavioral providers of care to young people vary widely by training, discipline, expertise, and practice. They include child and adolescent psychiatrists and psychologists, masters trained therapists, pediatricians and family physicians, nurse specialists, behavior analysts, social workers, speech and language therapists, special education teachers and other school-based personnel, occupational therapists, and other professionals within the youth's system of care.

Increasing Need for Mental Health Services for Young People

In 2014, the Health Resources and Services Administration's Data Warehouse ⁴⁴ identified 2,000 mental health professional shortage areas designated in nonmetropolitan counties, affecting more than 66 million residents. County-Level Estimates of Mental Health Professional Shortage in the United States reports that higher levels of unmet need for mental health professionals exist for counties that were more rural and had lower income levels. ⁴⁵ The most disadvantaged and under-resourced communities are often those with the greatest need for mental healthcare providers, particularly child and adolescent specialists.

Approximately 20% of young people in the United States, ages 9 to 17, have diagnosable psychiatric disorders. ⁴⁶ Many others suffer from subthreshold symptoms and from stress and grief reactions that benefit from intervention. Younger children are at risk for developmental and behavioral disorders. In addition, ∼31% of children are affected by chronic medical conditions ⁴⁷ who may benefit from behavioral health strategies. A growing number of evidence-based psychological and behavioral interventions offer support to young people and their families in coping with the range of mental health conditions. ⁴⁸ There are also pediatric psychology approaches to help children with acute and chronic medical conditions and their families in coping with behavioral health concerns. ⁴⁹

However, the supply of youth-trained providers to deliver these clinical advances is small, with demand far outpacing supply. ⁵⁰ General-trained providers attempt to fill this void but may not have access to the training needed to update their skills due to multiple factors, such as distance from training centers, scarcity of appropriate clinical supervisors, or lack of agency funding to pay for training. ^{51 –53} General-trained providers are particularly under-equipped to address child conditions showing relatively low base rates and/or conditions requiring more complex treatment regimens. ⁵¹ Similarly, an increasing number of evidence-based pharmacological interventions offer treatment of the neuropsychiatric symptoms of early-onset psychiatric conditions, ⁵⁴ but there is a dearth of child and adolescent psychiatrists to deliver these treatments. Primary care providers (PCPs) increasingly fill this gap, but need support, particularly in treating complex psychiatric disorders with comorbid conditions.

As a result of these discrepancies, most young people with mental health conditions do not receive any interventions; and of those who do receive clinical care, the majority do not receive evidence-based treatments largely due to the insufficient numbers of child and adolescent trained mental health specialists and their concentration in urban/suburban areas and academic hubs. ⁵⁵ These disparities in access to and quality of care have been noted most prominently for child and adolescent psychiatrists, ^{56 –58} but are relevant to all child and adolescent mental health specialists ^{59 –62} and are anticipated to persist or worsen into the foreseeable future. ^{56,59,60,63,64}

These disparities and the projected decreasing supply of child and adolescent mental health specialists are occurring at the same time as the broadening implementation of federal and state mental health parity laws that will likely further increase the demand for specialty mental healthcare for young people. ^{65 –67} New approaches to meeting this demand are needed, as well as to meeting expectations for enhanced care coordination among primary care and behavioral health providers as part of medical home initiatives. The Patient Protection and Affordable Care Act has called for the meaningful use of telehealth technologies to improve healthcare and population health for all citizens. ^{65 –67}

Factors Determining Access to Telemental Health for Youth

Increasing access to mental health services for young people is often the rationale for the implementation of TMH programs. The technology may be used to bridge the gap between specialist supply and demand, particularly in rural and other underserved communities that face declining economies, poor access to mental health insurance, and limited transportation options. ^51,68,69 In addition to addressing availability and accessibility, child-friendly TMH settings such as schools and primary care offices may reduce perceived stigma associated with mental health services and increase the ecological validity of providing these services. TMH is an especially good fit with youth due to their frequent use and proficiency with technology. Technological literacy is dramatically improving across patients, families, and providers, and adolescents' literacy increases families' overall literacy. ^70,71

However, according to the Federal Communications Committee's 2015 Broadband Progress Report, the United States is failing to keep pace with advanced, high-quality voice, data, graphics and video offerings, particularly in rural areas. ⁷² This impacts the ability to provide high-quality TMH, particularly to some of the very populations in greatest need of more accessible services. A significant digital divide remains between urban and rural America and the divide is still greater on tribal lands and in U.S. territories. The U.S. Department of Commerce's National Telecommunications & Information Administration ⁷³ plans to increase connectivity in rural and other underserved communities to close the urban/rural divide. A digital divide also persists along economic lines.

Mobile devices provide an emerging way to deliver TMH, both in supervised and unsupervised settings. According to the Pew Research Center Internet, Science and Tech Report, in 2015, ∼68% of the American population overall had smartphones and 45% had tablet computers. ⁷⁴ More specifically, 88% of American teens ages 13 to 17 had or had access to a mobile phone of some kind, and a majority of teens (73%) had smartphones. ⁷⁵ Given adolescents' technology literacy and their increasing access to mobile devices, new models can be anticipated for delivering mental healthcare to young people. Anecdotally, many families are using videoconferencing for social purposes, including Skype^® or Face Time™, with relatives and friends across the country and the world. ²⁰ This familiarity is anticipated to enhance overall comfort using videoconferencing for clinical applications, including TMH. Guidelines are needed to ensure the quality of such innovative care. ⁷⁶

Clinical Interventions and the Supporting Evidence Base

TMH may be especially suited for youth who are accustomed to the technology, especially adolescents who may respond to the personal space and feeling of control allowed by videoconferencing. There is some preliminary evidence that videoconferencing offers advantages, including less self-consciousness, increased personal space, and decreased confidentiality concerns as the provider is outside of the local community. ⁷⁷

Due to the small but emerging child literature, lessons are often drawn as a downward extension from adult literature. A recent extensive review of the empirical literature for TMH across the life span following rigorous inclusion criteria concluded that there is strong and consistent evidence of the feasibility of TMH, as well as high acceptability across teleproviders and patients. ⁷⁸ There was indication of improvement in symptomology and quality of life among patients across a broad range of demographic and diagnostic groups.

Multiple studies have demonstrated the feasibility of implementing TMH services with young people across diverse settings. ^{14,23,79 –86} Diagnostic assessments have been reliably conducted through videoconferencing for youth with various disorders evaluated in outpatient settings, ^31,33,87,88 including disruptive behavior disorders, ¹² autism and other developmental disorders, ^41,89 and psychotic disorders. ⁹⁰ Multiple studies have demonstrated the acceptability to referring PCPs, parents, and youth of delivering child mental health services through videoconferencing. ^{41,79–80,83 –85,88,91 –97} Satisfaction studies demonstrate the ability to develop a therapeutic alliance with youth and families through TMH ⁴² and suggest effectiveness.

The delivery of pharmacotherapy through TMH has been described with youth in schools, ⁹⁸ mental health centers and day care, ³⁹ outpatient settings, ^{31,83 –85} and juvenile justice facilities. ^30,99,100 One recent large community-based randomized trial provides solid evidence of the effectiveness of short-term pharmacotherapy for ADHD delivered by child and adolescent telepsychiatrists compared to treatment in primary care complemented by a single telepsychiatry consultation. ¹² Telepsychiatrists demonstrated good adherence to guideline-based pharmacotherapy and greater assertiveness in pharmacologic management than the PCPs. ¹⁰¹

There is an emerging literature supporting the feasibility and effectiveness of psychotherapy with children and adolescents delivered through videoconferencing. The evidence base is predominantly drawn from a downward extension from the adult literature. ^8,9,102,103

Backhaus et al. ⁸ completed a review of 65 studies across psychotherapy modalities delivered over videoconferencing. They concluded that videoconferencing-delivered psychotherapy is feasible, applicable to diverse populations, in a variety of therapeutic formats, and is generally associated with high user satisfaction. Most importantly, clinical outcomes for psychotherapy delivered through videoconferencing appear comparable to care delivered in traditional psychotherapy. Gros et al. ⁹ conducted a review of 26 studies from 2000 to 2012 based specifically on the delivery of cognitive-behavioral therapy (CBT)-related strategies over videoconferencing with varying technologies. They concluded that the majority of the studies supported the effectiveness of using videoconferencing to deliver psychotherapy.

Most published studies of psychotherapy conducted specifically with young people have been descriptive, with only a handful of outcome studies. ^14,23 Nelson and Patton ²⁷ identified 10 psychotherapy studies with the general population of children and adolescents experiencing a mental health concern. Most of these studies were interventions for ADHD, but also included a variety of single-study examples. Emerging case reports support the feasibility of teletherapy in high-need areas with adolescents, including family-based interventions for eating disorders ¹⁰⁴ and TMH on college campuses. ³⁴ Additional research with adolescents and substance abuse treatment has been encouraging. ¹⁰² Intervention approaches varied in focus on the youth or the parent and ranged from feasibility trials to pre- and postdesigns, and a handful of randomized controlled trials. ^11,13,15,16

Consistent with the more robust adult individual therapy literature, ^{8 –10} findings were overall positive related to feasibility, satisfaction, and outcomes. This review also identified a dozen pediatric psychology studies, addressing mental health approaches with children and adolescents with acute and chronic conditions.

In relation to pediatric psychology approaches using telemedicine with children with chronic medical conditions, most information is from case report and small pilots, ²⁷ reflecting successful implementation with a range of conditions (pediatric cancer, pediatric feeding conditions, diabetes, irritable bowel disorder, pediatric epilepsy, congenital heart defect, among others). There are also case reports reflecting pediatric psychology services over telemedicine for sleep disorders and toileting disorders. Several trials have found positive results treating pediatric obesity over videoconferencing, both to rural schools and to rural primary care practices. ^105,106

There is also very limited information about group therapy approaches using telemedicine with youth, with reports describing the approach successfully utilized with pediatric obesity ¹⁰⁷ and adolescents on home parenteral nutrition and their caregivers. ¹⁰⁸

Several randomized trials of psychotherapy are noteworthy. Nelson et al. found comparable reductions for childhood depressive symptoms treated with eight sessions of CBT delivered through videoconferencing versus in person. ^13,109 Two small randomized trials ^15,110 tested the effectiveness of treatment for obsessive-compulsive disorder (OCD) and found that compared to youth treated in person, those treated through TMH had comparable or superior outcomes. The behavioral treatment of tics through TMH has also been found to be comparable to in-person treatment. ¹¹ Four small trials have demonstrated the effectiveness of providing family interventions and parent management training through videoconferencing. ^{16,111 –113}

Telemental Health Service Delivery to Clinical Settings

Child and adolescent TMH services are being delivered to multiple clinical settings to meet diverse clinical needs of children and adolescents. ^{11 –16,23,26,29 –35,38 –42} Currently, the point of delivery for TMH services is as varied as the type of services that are being provided. Most described in the literature are primary care clinics, community mental health centers, physician offices, outpatient clinics, schools, and correctional settings. Individual reports describe delivery to other settings such as residential treatment facilities, critical access hospitals, group homes, area health education centers, colleges, sites serving foster care, military bases, and day cares. Most reports focus on rural and other nonmetropolitan communities, ³³ but TMH care to children in urban settings ³⁹ has been reported. Unsupervised settings, including patient homes, are emerging points of service delivery that bring both new benefits and risks. ^{35,71,110,114} Recent presentations described telepsychiatry services to an inpatient psychiatry unit ¹¹⁵ and to an emergency room. ¹¹⁶ Commercial vendors and private practice providers are delivering services to multiple sites. Each of these sites has its own needs and resources to implement a TMH service. Training should be tailored to each point of service delivery, including coordination of care with on-site staff and community providers.

Reported work in TMH with children and adolescents has focused on direct care ^{12 –16,25 –27,31,39,42,43,84,102,104} and patient-centered consultation with recommendations to the referring PCPs for treatment. ^{12,88,93,97,98,117} Consultation conferences with a group of PCPs have been described to improve their own skills and build a support network for ongoing clinical care of young people's mental health problems. ^98,118,119 Telementoring models such as the Extension of Community Healthcare Outcomes are also being evaluated in ADHD, autism, and other child behavioral topic areas ¹¹⁹ to support primary care practices. Two underreported areas for child and adolescent TMH care include specialist consultation to therapists in distant communities and to youth in state custody. ¹²

Telemental Health Practice in Community Settings

There is a long history of moving mental healthcare for youth from the mental health clinic to the community to improve access to care, increase adherence to treatment planning, and to provide services in naturalistic settings. Consistent with this pattern, TMH services are being moved outside of traditional mental healthcare settings. When TMH services are implemented in community settings, they offer the opportunity to ascertain contextual factors involved in youths' behavior and mental health needs, as well as to involve stakeholders in youths' care and outcomes. In particular, TMH offers a powerful opportunity for collaboration with pediatricians to help them address the increasing expectations to improve their skills in diagnosing and managing common mental health conditions of young people. ^{25,26,29,37,39,88,93,98,117,120 –123} Collaborative care models in which a psychiatrist and PCP jointly manage a population of patients with a care manager have been described with adults, ^124,125 and have potential for incorporation into the pediatric medical home. ¹²⁶

Providing mental healthcare to stressed families of children with chronic medical illnesses faces challenges in both the medical and mental health service sectors. Pediatric telepsychology has shown feasibility in overcoming some of these challenges when providing services during medical visits or at home. ^{127 –132} Furthermore, families have shown satisfaction with services and increased knowledge of health-related behaviors. ^{105,106,131,132} There is some support for cost-effectiveness of health psychology services provided through videoconferencing to these settings. ^128,131 These studies support the need for further work integrating TMH into the pediatric medical home. ¹²⁶

School-based TMH services engage youth during the school day thereby reducing distances youth must travel to a clinic-based CATMH service, decreasing missed school days, disruption in the child's classroom time and parent's workday, allowing parents to be involved in a setting that is familiar and convenient, and incorporating school personnel into treatment planning. ^40,133,134 Utilization of TMH allows the youth's provider to be efficiently involved in multidisciplinary planning, student evaluation, Individualized Education Plan (IEP)/504 plan meetings, and collaboration with teachers, school specialists (e.g., school psychologists, social workers, and allied health specialists), nurses, and administrators. ⁴⁰

Examples of services that may be delivered by the provider to the school system include, but are not limited to, mental health evaluations, behavioral interventions, medication treatment, ongoing sessions with students and families, evaluation for support services, continuing education for staff and consultation on both classroom-specific and general school issues, and consultation in the event or threat of an event that may adversely impact the school community (e.g, untimely death of a student or teacher, natural disaster, threat of violent act). Another area of school-based TMH is the delivery of educational support services, such as counseling, occupational therapy, or speech therapy, to youth who are homebound or as a means to continue services when school is out of session.

The emerging evidence base indicates that school-based CATMH is feasible and acceptable. ^40,133 Nelson et al. have shown good adherence to the American Academy of Pediatrics' guideline-based evaluation for ADHD when conducted in school settings. ¹³⁵ Reese et al. ⁸⁹ have described an innovative, cost-effective, Integrated Systems Using Telemedicine Model for autism. This telemedicine model links students and families, trained early intervention providers and educators at the child's school, and a team of university-based medical professionals at the academic health center.

Residential treatment centers and correctional settings often require prolonged separations of families from a youth who is confined in a facility far distant from family and provider. TMH allows families to participate in a youth's treatment while remaining in their home communities or telecommute a mental health specialist to the youth's facility. For example, the multipoint capabilities of TMH can deliver multisystemic therapy, which includes a network of caregivers, school officials, peers, and neighbors, to promote positive behavioral changes. Delivering TMH services to such facilities provides challenges to privacy and confidentiality. ^30,99,100

Home-based TMH offers potential advantages to observe the youth in a naturalistic setting and to practice skills in the lived environment. Comer et al. are testing the effectiveness of TMH in delivering behavioral interventions for early-onset behavior disorders. ^{70,71,110,136} They use videoconferencing to observe the youth's behavior and then to guide parents in facilitating behavioral interventions. Successful outcomes are described for a case series of children with OCD. ⁷⁰ Further work in delivering parent/child interaction therapy (PCIT) through videoconferencing (I-PCIT) has shown comparable outcomes to PCIT delivered in traditional clinic settings. ¹³⁶ Case reports of TMH services to the home have also addressed support group services for homebound individuals and their caregivers ¹⁰⁸ and home-based services for children who have experienced trauma. ³²

Administrative Guideline: Needs Assessment and Standard Operating Procedures

If implementing a new CATMH program, or adding services to an existing program, a needs assessment may be conducted, ^24,25 including assessment of site readiness and scalability. ^137,138 The needs assessment assists providers with identifying communities that are most likely to adopt videoconferencing services to fill the access gap by communicating with community organizations, consumer groups, and other key stakeholders, particularly as some underserved communities must allocate their mental healthcare funding to the adult chronically mentally ill, leaving limited resources for youth.

A needs assessment allows the provider to identify the age groups, behavioral presentations, and interventions that will support active clinics. Providers may visit potential sites to develop relationships with staff and the broader community as well as gaining a better understanding of the local culture of potential patients and their families. This is particularly important with youth populations because staff at the distant site need to feel comfortable assisting with children and adolescents. Needs assessment is an ongoing process to evaluate and improve services offered through new and established TMH practices and in response to healthcare reforms.

The needs assessment goes hand-in-hand with careful business planning for telepractice with youth, both for the provider ^25,137 and for the distant site. ¹³⁹ This includes determining which disorders meet medical necessity criteria by third party payers in the jurisdiction to ensure sustainability of the TMH program. ^{140 –142} Providers should check to determine coverage for the different types of child, adolescent, and family sessions that are generally covered by current procedural terminology codes. ¹⁴³ Detailed programmatic data concerning the implementation of evidence-supported treatment by youth-trained specialists, as well as process and outcome data, may also be utilized to make a case for child and adolescent TMH services among local insurers.

TMH organizations and providers shall ensure that appropriate staff are trained and available to meet the youth's, the family's, and provider's needs before, during, and after TMH sessions. These needs may differ from those encountered in clinical work with individual adults, as children may unexpectedly become disruptive, a teen may threaten suicide, or a parent may decompensate.

Protocols should also describe the telepractice workflow and associated staff responsibilities. For example, families often bring siblings to TMH sessions for whom a management protocol may be helpful. The presenter may also assist with managing the flow of participants (e.g., patient, caregivers, school personnel, and case manager) in and out of the videoconferencing room and with ensuring privacy of the sessions. Parents and youth may differ in their literacy and primary language. The provider shall determine whether an interpreter is needed rather than relying on the youth or family members and/or how to address the family's verbal and written communication needs. ¹⁴⁴ The provider shall assess his or her competence with evaluating and treating children and adolescents across TMH areas, and seek additional training/mentoring if gaps are noted.

Legal and Regulatory Issues

During the needs assessment, the provider should include a policy and practice standards review. ¹⁴⁵ This includes a comprehensive review of regulatory guidelines regarding the mental health treatment of youth in both the jurisdiction and setting of the practice with particular attention to issues such as the age of majority and reporting of suspected maltreatment. Sites and jurisdictions may vary in their mandates for additional responsibilities in the care of vulnerable populations, such as youth in foster care and in correctional settings. As with on-site patients, providers should follow professional practice guidelines in relation to the chronological age of the youth as well as consideration of the developmental age.

As in on-site settings, the provider should establish the legal guardianship of the youth as well as custody arrangements, when applicable. Clarification should be obtained regarding parental rights in deciding treatment for a youth who is in state custody. Providers are mandated reporters and shall be aware of their jurisdiction's requirements, as well as train staff in procedures and protocols to support the youth in potentially harmful situations. They should also be aware of considerations associated with disclosure of behaviors (e.g., sexual activity, substance use/abuse) to parents of adolescent clients.

Providers shall follow the requirements and restrictions of licensure, including consideration of the provider's scope of practice and expertise with youth. ^1,2,145 Just as in adult care, cautious review should include consideration of the legal and regulatory requirements in effect at both the patient and provider locations, with particular consideration regarding age of majority in the provider's own and in the youth's jurisdiction, duty to warn and protect requirements, and civil commitment. ¹⁴⁶ Providers may verify that their professional liability insurance covers activities in all of their sites of telepractice and seek legal consultation for any jurisdictional concerns regarding telepractice.

States vary in their requirement for specific written consent for care delivered through videoconferencing. According to the state's guideline, the provider should complete informed consent with legal guardians for children and with patients over the age of majority or for “mature minors” in states with such designation. The consent process should ensure a basic understanding of, and agreement to, the specific use of TMH. Providers should check local, regional, and national laws regarding the requirement for verbal or written consent for delivering care through videoconferencing, ^1,145 with consideration to the age, development level, literacy, and language preferences. Youth may need to provide written consent to release their records to their parents. Some programs may require written consent with the youth's, parent's, and provider's signatures on the same forms.

The presenter may help to complete any required medication consent forms. Some sites may allow the presenter to sign the consent form attesting that the risks and benefits were reviewed with the telepsychiatrist. Other sites may require that the form be sent to the telepsychiatrist for a signature. Providers should establish procedures for sharing information with pediatricians or other PCPs. Both adolescents and parents must consent to sharing the information.

Providers shall abide by confidentiality requirements related to both the clinical setting ¹⁴⁷ and the school setting ^148,149 and follow the ethical guidelines of their professional organization. If any telehealth encounter is to be recorded, providers shall be aware of state-specific laws regarding the recording of private conversations, and shall disclose to the patient and parent/guardian that the encounter will be recorded and receive written consent for the recording.

General Telemental Health Practice Issues with Youth

Specific considerations as needed in working with young people are described below.

Telemental Health Interventions with Youth

Ethical Considerations

Ethical considerations may be magnified in the TMH setting due to its focus on reaching underserved and vulnerable populations. ¹⁷⁸ Leading telemedicine and mental health associations emphasize the importance of translating established ethical best practice to the TMH setting, including work with children and families. Practice guidelines from professional organizations assist in informing best ethical practice. Such organizations include the ATA, ¹⁷⁹ the American Academy of Child and Adolescent Psychiatry, ^180,181 the American Psychological Association, ¹⁸ American Psychiatric Association, Ethics Committee, ¹⁸² National Association of Social Workers, ¹⁸³ the National Board for Certified Counselors, ¹⁸⁴ among others.

Practicing at a distance creates a unique relationship with the patient that requires attention to and adherence to professional ethical principles, including special considerations with children and families. An organization or health professional adhering to ethical TMH principles shall do the following:

(a) Incorporate organizational values and ethics statements into the administrative policies and procedures for TMH.

Telemental Health Competencies

The growth of TMH practice has led to growing focus on establishing and maintaining competencies for delivering clinical care. Thus, providers are encouraged to seek training, educational opportunities, and peer mentorship to maintain high-quality care, facilitate therapeutic engagement, and produce positive outcomes; in the latter regard, extant studies have shown comparable outcomes to in-person care. The provider should maintain competence in integrity of both the process (e.g., building rapport and establishing a trusted environment) and the content (i.e., treatment components) of the intervention in relation to the technology and site's resources. Guided by research and available guidelines, the provider should carefully consider any adaptations to interventions based on the technology setting (e.g., the contextual setting for play, space for family).

Competency is best considered on a continuum of lifelong learning, as providers in practice and trainees need to stay current with rapidly evolving technologies, TMH research findings, and policies. Foremost, providers should assess their clinical competence in providing care for child and adolescent populations, in the face of pressure to increase access to services for this underserved population. One map to TMH competencies has been contextualized using the training milestones set forth by the Accreditation Council of Graduate Medical Education (ACGME). ¹⁸⁵ ACGME uses a template with patient care, systems-based practice (SBP), interpersonal communication, professionalism, practice-based learning and knowledge domains; a technology competency and SBP components on administration, culture, and community engagement were added recently. When working with primary care sites, providers may consider competencies for medical/psychiatric illness, interprofessional practice, and integrated care. There is a growing consensus across allied mental health disciplines for such competencies. ¹⁸⁶

Several strategies help providers to build and maintain competencies. Providers and trainees may complete self-study. ^114,187 There is a range of online resources that provide dynamic information on the changing telemedicine landscape, including professional organizations, ¹⁸⁸ telehealth resource centers, ¹⁸⁹ federal resources, ¹⁹⁰ grant-supported resources, ¹⁹¹ and private companies. Potential TMH providers may shadow an established provider to help consolidate interest and skills, or opt not to use TMH if it is not a good professional fit. Participating in TMH committees or professional work groups and ongoing peer-to-peer support build knowledge and skills. Increasingly, training programs are incorporating TMH rotations and seminars to teach technological approaches to healthcare, as well as to provide experience with improving access to care for diverse patient populations (e.g., rural families, American Indians).

Clinical Supervision and Telemental Health

Given the workforce shortages (see Section 3.c) with youth behavioral health, it is appealing to work with healthcare trainees to expose them early in their training to both TMH best practices and opportunities to work with underserved populations. These experiences may range from shadowing a TMH provider to formal TMH training rotations. The supervisor may consider the range of TMH training resources (e.g., online resources, readings, and guidelines) to support the learning experience. In addition, videoconferencing-based supervision, or “telesupervision,” offers innovative ways to extend supervision opportunities. ¹¹⁴ Videoconferencing offers an efficient means to provide consultation in evidence-based interventions to the staff at local mental health centers, primary care offices, or other distant sites serving youth. ¹²

Future Directions in Telemental Health with Youth

Interventions that have been successfully utilized over telehealth for adult populations (e.g., exposure therapies) should be evaluated with youth populations. Documentation of successful interventions will help to expand the evidence base for CATMH as requests for services accelerate due to the increasing disparity between the demand for mental healthcare services and the supply of child- and adolescent-trained providers. This increasing disparity also calls for the inclusion of CATMH in evolving models of collaborative and integrated care. Many emerging evidence-based interventions support community-engaged approaches that are available to collaborate with child-serving systems to address the complex problems faced by youth and their families. TMH may efficiently link child-serving systems and teams together to enhance care. Establishing initial and ongoing competencies is encouraged to ensure that the same level of safe and effective care is delivered using TMH as during in-person care, particularly as the regulatory and technological landscape changes.

Going forward, expanded CATMH will be supported by the continued evolution of secure, high-speed, mobile videoconferencing options across the range of current and future devices. This will further expand TMH service delivery sites and to unsupervised settings such as the home and youth mobile devices. With this expansion comes the need for careful consideration and evaluation of services to maximize benefit for youth and families, minimize risk, and optimally support community stakeholders. Research will be needed to test models of care, to evaluate quality improvement efforts, and to examine the effectiveness of CATMH services, particularly with diverse populations. These efforts are facilitated by the ATA's lexicon ¹⁹² and by efforts toward a standard TMH evaluation model. ¹⁹³

Emerging behavioral health models ¹⁹⁴ look at matching the range of health technologies to the needs of youth and their families. CATMH providers can look to a future that integrates TMH services with applications in social media, asynchronous mental health, m-health, virtual technologies, virtual reality, augmented reality, intelligent wearable devices, and artificial intelligence—all to improve the quality and effectiveness of youth-centered care for all young people in need of mental healthcare services.