Abstract
We conducted a pre-post study of the effect of a telepsychiatry counselling service on youths housed in three juvenile detention facilities. In the first year of the telemedicine programme, 321 psychiatry consultations were conducted via telemedicine; in the second year of the programme, 573 psychiatry consultations were conducted. Records for 190 students were then examined by two raters. The total number of behavioural goals for each adolescent increased from 8.2 in the pre-telemedicine year to 8.7 in the first year of telemedicine and then to 10.0 in the second year (P < 0.05). In Year 2 of the study, subjects also had a significantly higher number of goals in four of the five categories: education, family, health and social skills (P < 0.05). Although other changes at the youth detention facilities or in the juvenile justice system may have been partly responsible for the effects observed, the study suggests that telemedicine may be useful for improving the rate of attainment of goals associated with family relations and personality/behaviour.
Introduction
Most of the evidence about the efficacy of telemedicine in prisons comes from the US. 1 One study from Greece suggested that the national health-care programme restricted the implementation of telemedicine in prisons, despite the promise of improved quality and accessibility of care. 2 The UK has also experienced success with prison telepsychiatry, noting that although there are operational challenges, they can be overcome to produce a cost-effective method of health-care delivery. 3
There is evidence to suggest that telemedicine increases access to appropriate care and the timeliness of that care in juvenile detention facilities. 4–7 It is not known, however, whether this has any effect on the three main goals of incarceration: treatment, education and rehabilitation. We therefore conducted a pre-post study of the effect of telemedicine on youths housed in juvenile detention facilities. The hypothesis was that the introduction of a telemedicine-based programme was associated with improved attainment of their individual programme plan (IPP) goals.
Methods
Telemedicine equipment was installed in four adolescent detention facilities in Tennessee for general telehealth purposes. To assess the goal attainment, student records from the year preceding telemedicine implementation and from the two years following implementation, were reviewed. Sufficient records were not available from one of the centres so it was excluded from further analysis.
The telemedicine equipment at the detention sites was identical. The peripherals included an intra-oral dental camera, handheld camcorder, otoscope, digital stethoscope and document camera. The videoconferencing equipment was connected at a bandwidth of 1.544 Mbit/s. Psychiatric counselling services were offered from Memphis via videoconferencing to all adolescents meeting the eligibility criteria. In addition, access to other specialists was provided, such as in dermatology and ENT. Clinical encounters were facilitated by a nurse, who presented the patient at each telemedicine centre in the detention facilities.
Subjects were eligible for inclusion in the study if they were residents of one of the detention facilities during the following periods:
Facility 1: 1 February 2002 to 30 January 2005 Facility 2: 1 December 2001 to 30 November 2004 Facility 3: 1 February 2002 to 30 January 2005
Subjects were excluded from the study if they did not consent to treatment or if they did not consent to participate in the study. They were also excluded if their IPP data were not available for review or if they did not have identified special needs.
Study population
The youths in the detention centres were aged 12–19 years (average 17) and were predominantly male. Fifty-five percent were African American. Sixty-four percent of them had been convicted of physically violent offences and 22% had been convicted of sexually violent crimes, including child rape and adult rape. The average daily census for the three correctional centres in the year prior to telemedicine implementation was 369; in the year after telemedicine implementation, it was 350.
Study data
Students were assessed every three months to determine their progress towards their goals. However, the IPP documentation was not complete at all detention facilities: when a child was discharged from a facility, his or her records were often sent to the relevant local authority and a copy was not always kept at the facility. Information was collected by retrospective review of the students' IPP.
Goals established and goals attained
The goals established for each subject were identified within five adolescent developmental areas:
health; education; social skills; personality/behaviour; family/community reunification.
Information about each subject was extracted from the charts by two raters. The inter-rater reliability between them was 0.93 using Cronbach's alpha.
The Goal Attainment Scale (GAS) was used to measure the success of treatment. 8 The GAS measures the level of achievement of treatment or intervention goals and can be applied to different kinds of treatment as well as clients with different numbers of treatment goals. The GAS also produces a score that allows progress to be tracked.
Goal attainment for each category (education, family, health, personality and social skills) was assessed on a five-point scale (from +2 for much more than expected to –2 for much less than expected) and then re-coded as a binary variable:
goal attained: expected (0), more than expected (+1), or much more than expected (+2); goal not attained: less than expected (–1) and much less than expected (–2).
Other measures
Other information collected for the subjects included the year of the study (pre-telemedicine year, Year 1 or Year 2), the length of incarceration, the offence type (physically violent, non-violent or other), the number of prior offences and the number of prior placements. Physically violent offences included rape, assault and battery. Non-physical offences included larceny, probation violations or drug possession with intent to sell. A small number of offences did not fit into either physical or non-physical offences.
Statistical methods
Analysis of variance was used to identify differences in outcome measures (length of incarceration, number of goals, number of goals attained and proportion of students achieving a goal in each of the five goal areas) between the pre-telemedicine year and Years 1 and 2 post-telemedicine. A general linear model was then used to examine the relationship between two dependent variables (number of goals established for each subject; number of goals attained) and the presence of telemedicine, controlling for offence type, number of previous offences and number of prior placements.
Results
In the first year of the telemedicine programme, 116 non-psychiatry consultations and 321 psychiatry consultations were conducted via telemedicine at the three centres. In the second year of the programme, 95 non-psychiatry consultations and 573 psychiatry consultations were conducted.
Records for 190 students (a total of 262 assessments) were included in the study (Table 1). The average age of these students was similar to that of the general population of the correctional centres (16.7 years versus 16.8 years) and was relatively constant during the three years of the study (16.7 years in the pre-telemedicine year, 16.8 in Year 1 and 16.6 in Year 2).
Number of study participants
The average length of incarceration for students was 294 days in the pre-telemedicine period (Year 0), increasing to 368 days in Year 1, but falling to 243 days in Year 2. Analysis of variance indicated that these changes over time were significant (P = 0.001). Post-hoc testing (using Tukey's Studentized Range test) indicated that the only between year difference which was significant (P < 0.05) was that between Years 1 and 2.
The total number of goals for each adolescent increased from 8.2 goals in the pre-telemedicine year to 10.0 in Year 2 (P < 0.05) (Table 2). In Year 2 of the study, subjects also had a significantly higher number of goals in four of the five categories: education, family, health and social skills (P < 0.05).
Number of goals per student. The mean values are shown with SDs in parentheses
There were also significant increases in the proportion of students who were able to achieve goals in specific areas post-telemedicine. Specifically, when comparing the proportion of students who achieved goals in the five goal areas (education, family, health, personality and social skills), in Year 0 versus Year 2, we observed significant increases in the family, health and social skills goal areas (Table 3).
Proportion of students achieving goals
Because the number of goals and goal attainment could be influenced by more than just the presence or absence of the telemedicine programme, we also conducted multivariate analyses to control for the effects of other explanatory variables. Specifically, fixed effects general linear models were used to examine the relationship between implementation of the telemedicine programme and (1) the total number of goals set and (2) the total number of goals achieved, after adjusting for other potential confounding variables (Table 4). The analyses allowed for the fixed effects of the youth detention centre, offence type (physical, non-physical, other), sexual offence type (sexual vs. non-sexual) and year of the telemedicine intervention. The results indicated that presence of the telemedicine intervention (in Year 2, relative to pre-telemedicine and Year 1) and sexual offence type were associated with an increased number of goals. In contrast, only the presence of the telemedicine intervention (in Year 2) appeared to have an effect on the number of goals attained.
General linear model predicting the number of goals and the number of goals attained (SE shown in parentheses)
*P < 0.001
aCompared to Year 2 telemedicine
Discussion
Because telemedicine increases access to and timeliness of behavioural and specialty care in juvenile justice facilities, it may increase the opportunities for treatment and reduce the number of missed diagnoses, treatment delays and time-consuming trips from the detention centre to obtain care. In turn, these improvements in care may help students to meet their personal goals more quickly and, thus, be ready for discharge sooner. A comparison of the lengths of incarceration pre- and post-telemedicine in the present study suggests that the improved access to care may have had some effect. Over the course of the study, the average number of goals for each adolescent increased from 8.2 goals per year (pre-telemedicine) to 10.0 in Year 2. Despite this increase in the number of goals, the proportion of students attaining goals in the five goal areas remained similar (education, personality) or increased (family, health, social skills).
A significant limitation of the study was the pre-post study design. This does not allow us to rule out the possibility that other changes at the youth detention facilities or in the juvenile justice system occurred contemporaneously with the introduction of telemedicine and may have been partly responsible for the effects observed. A minor limitation with the retrospective review of charts should also be noted. While the scores were facilitated by an objective review, if any data were missing from the student's record, this information was unable to be included in the scores.
There were several reasons why telemedicine might have been effective in improving the rate of attainment of goals associated with family relations and personality/behaviour. First, behavioural health counselling delivered with less delay gave the students an improved opportunity to learn coping techniques and strategies to deal with interpersonal relationships. Secondly, both adolescents and counsellors found that telemedicine facilitated effective interaction: adolescents served by telemedicine expressed a perception that the counsellor was more focused on them than they had experienced with previous face-to-face interactions, while physicians noted that students seemed to ‘open up more’ via video than they did in face-to-face contact. We believe that this perception is due to the nature of interactive video, in which the participants watch each other through the cameras and monitors, thus creating a visual impression of increased focus. Third, the adolescents surveyed remarked on the attractiveness of using technology for counselling, which probably increased their acceptance of the therapy. Fourth, if an appointment had to be re-scheduled, it could easily be re-scheduled for later in the same day because travel outside the facility was not involved, thus reducing disruption to the patient and keeping them on-site to participate in other activities such as classes, school work and group counselling sessions. Finally, the presence of a dedicated clinician facilitated timely and appropriate treatment when compared to the previously existing situation where a group of travelling physicians would visit the facility, which created difficulties in ensuring the continuity of care.
Significant improvements in the attainment of goals associated with behavioural health are important from clinical, educational and policy perspectives. Clinically, providing interpersonal relationship skills can limit potential exacerbations for psychiatric conditions or violent behaviours. These conditions, when untreated or under-treated in a population growing into adulthood, can result in behaviour patterns that follow the individual through the rest of his or her life and lead to recidivism. Likewise, children who receive the tools they need for relationships are more likely to have their behaviour under control sooner, which assists with their academic performance. From a policy perspective, states need to implement programmes offering satisfactory access to counselling in order to demonstrate their responsiveness to the complaints and lawsuits facing the juvenile justice system.
Footnotes
Acknowledgements
Financial support for the study was provided by the Department of Children's Services, State of Tennessee. The telemedicine equipment was funded by a US Department of Agriculture Rural Utilities Service grant.