Practice Parameter for Telepsychiatry With Children and Adolescents

doi:10.1097/CHI.0b013e31818b4e13

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 47, Issue 12, December 2008, Pages 1468-1483

https://doi.org/10.1097/CHI.0b013e31818b4e13 Get rights and content

Abstract

This practice parameter discusses the use of telepsychiatry to provide services to children and adolescents. The parameter defines terms and reviews the status of telepsychiatry as a mode of health service delivery. Because many of the issues addressed are unique to telepsychiatry, the parameter presents principles for establishing a telepsychiatry service and optimizing clinical practice within that service. The principles presented are based on existing scientific evidence and clinical consensus. Telepsychiatry is still evolving, and this parameter represents a first approach to determining “best practices.” The parameter emphasizes the integration of telepsychiatry within other practice parameters of the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Adolesc. Psychiatry, 2008;47:(12)1468–1483.

Section snippets

Methodology

The list of references for this practice parameter was developed in several ways. First, Medline and Psychological Abstracts searches were conducted in June 2004 and updated regularly over the ensuing months until publication. These searches used the following terms: telemedicine, telepsychiatry, telemental health, telehealth, interactive videoteleconferencing, and teleconferencing. The addition of the terms child and adolescent and psychiatry, individually or in combination, did not yield more

Definitions

•
E-health refers to health services provided from a clinician to a patient or the lay public through any electronic medium, including the Internet, telephone, or facsimile transmission.
•
ITV communication refers to the interaction of two or more individuals in real time to share information through electronic media.
•
Telemedicine refers to the use of ITV for the provision of medical care that is usually delivered in person.
•
Telepsychiatry is a specific term designating psychiatric applications of

Historical Overview

The earliest documentation of telemedicine was from the University of Nebraska, where, in the 1950s, a two-way closed-circuit television system was used for educational and medical purposes, mainly in psychiatry.⁸ In 1973, the term telepsychiatry was first used to describe consultation services provided from Massachusetts General Hospital to a medical site in Boston.⁹ Shortly thereafter, telepsychiatry was reported with children and adolescents when a child guidance clinic in New York City was

Developmental and Clinical Considerations

Applications of telepsychiatry have been described across developmental groups and most diagnostic categories. School-aged children comprise the modal treatment group, similar to usual outpatient care.*26, *35, *42, 43, 44, *46, 48 Children as young as 3 years have been evaluated and treated.*26, *33 Autistic or other devel-opmentally impaired children may not be able to provide their own perspectives, but their parents' history, school records, and telepsychiatrist's observations can readily

Establishing a Telepsychiatry Service

Principle 1. The Need for Child and Adolescent Psychiatric Services and Whether Telepsychiatry Is an Option for Meeting That Need Should Be Determined.

Before providing any clinical services, potential tele-psychiatrists should determine whether a telepsychiatry service is needed, feasible, and sustainable. It is critical to consider how telepsychiatry services will be integrated with and use existing local community services and resources.*24, *68 The first step in this process is to review

Principle 9. Rapport, Confidence, and Collaboration With Staff at the Patient Site Should Be Fostered

Staff at the patient site will represent the telepsychiatry service to families and the youth's system of care.⁸⁶ It is important for these staff and the telepsychiatrist to have confidence in each other, even if they never meet in person. The telepsychiatrist must decide whether collaboration can be accomplished over ITV or whether initial or intermittent on-site contact is needed.

One method for fostering rapport with professionals at the patient site is to schedule additional ITV time before

Parameter Limitations

AACAP practice parameters are developed to assist clinicians in psychiatric decision making. These parameters are not intended to define the standard of care, nor should they be deemed inclusive of all proper methods of care or exclusive of other methods of care directed at obtaining the desired results. The ultimate judgment regarding the care of a particular patient must be made by the clinician in light of all the circumstances presented by the patient and his/her family, the diagnostic and

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We estimate that 6,035,402 children and adolescents in the United States (approximately 10%) have inadequate in-person and digital availability of child psychiatric services within their counties. Although this was true for only 3% of children and adolescents in urban counties, this applied to more than half (51%) in rural counties (adjusted odds ratio [AOR] = 2.71; 95% CI = 1.94, 3.78; p < .001). Likewise, only 3% of children and adolescents in high-income counties had insufficient digital and physical access, compared to more than 4 in 10 children and adolescents (41%) in low-income counties (AOR = 0.43; 95% CI = 0.30-0.61; p < .001). Counties with a higher density of Black and Hispanic residents had greater likelihood of service availability (p < 0.001), potentially a function of living in metropolitan communities.
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Citation Excerpt :
Several avenues for future research and development of DMHIs exist. These include dissemination and implementation efforts aimed at getting DMHIs used in the community, harnessing emerging technologies (e.g., passive sensors, context-triggered assessment and intervention, etc.) and improving regulations around the use of DMHIs (see Myers et al., 2008; Myers et al., 2017), and developing partnerships with industry to facilitate the ongoing development and maintenance of DMHIs (see Carper et al., 2013, and Hill et al., 2018). Despite support for the efficacy of DMHIs in research settings and the over 2000 apps that exist and are marketed for anxiety (Chan et al., 2014), these interventions are rarely used by practicing clinicians, highlighting the need in the field for a better understanding of factors that facilitate and/or impede successful implementation and longer-term sustainability outcomes.
Anxiety disorders are the most common mental health conditions in children, with approximately 13% of kids struggling with excessive anxiety. The vast majority do not have access to effective treatments and there continues to be a disjunction between treatments that are empirically supported and those that are available in the community. Digital mental health interventions (DMHI) can increase efficiency, reach, and standardization as well as reduce costs of providing of mental health care. Here we review the extant research on DMHI, including web- or cloud-based programs, mobile applications (apps), virtual reality (VR), and digital assessment methods such as ecological momentary assessment (EMA) for the delivery and/or support of evidence-based care in child anxiety. Preliminary research is promising for these tools to improve access and efficiency of evidence-based practice. However, ethics and practice guidelines are needed and questions remain regarding what level and quality of therapeutic involvement is needed to maximize treatment completion and outcomes in youth and whether DMHIs are contraindicated for certain populations or whether they are similarly effective with those with comorbid conditions is unclear.
COVID-19: Practice and ethics of videoconsultation assessment of children with autism spectrum disorder
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La crise sanitaire liée au COVID-19 a favorisé la levée de nombreux freins à la pratique de la télémédecine. Dans ce contexte, et pour les enfants suspects de troubles du spectre de l’autisme (TSA), il a été nécessaire de définir le cadre d’une bonne pratique en vidéoconsultation. Ainsi, décrire les outils utilisés et définir quelques règles éthiques sont les garants d’une pratique de qualité en télémédecine.
Depuis 2013, nous avons réalisé des évaluations cliniques en vidéoconsultations au sein du Centre de diagnostic et d’évaluation de l’autisme du GHU Paris psychiatrie et neurosciences. Nous avons développé des outils d’information et des procédures pour l’évaluation des enfants suspects de TSA. Amenés à réfléchir sur l’éthique de notre pratique, notre réflexion est devenue partie prenante de nos procédures.
Les bénéfices et risques sont exposés, le consentement recueilli en amont de la téléconsultation. Nous utilisons des outils diagnostiques validés qui sont analysés au regard de l’expérience clinique des professionnels. L’intimité des personnes est préservée et la relation patient-médecin renforcée du fait d’une perception d’empowerment accrue pour les familles.
La crise du COVID-19 a renforcé l’intérêt de la vidéoconsultation avec un risque accru dans sa pratique tant pour les familles que pour les professionnels du fait de l’accessibilité soudaine à celle-ci. Ses qualités cliniques et éthiques sont ainsi questionnées et doivent être étudiées plus avant. Au décours de la crise sanitaire, il sera temps de penser à l’équité de la pratique et la possibilité d’une télémédecine pour tous.
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This parameter was developed by Kathleen Myers, M.D., M.P.H., and Sharon Cain, M.D., primary authors; the Work Group on Quality Issues (WGQI): William Bernet, M.D., Oscar Bukstein, M.D., M.P.H., and Heather Walter, M.D., M.P.H., Co-Chairs, and Scott Benson, M.D., Allan Chrisman, M.D., Tiffany Farchione, M.D., John Hamilton, M.D., Helene Keable, M.D., Joan Kinlan, M.D., Ulrich Schoettle, M.D., Matthew Siegel, M.D., and Saundra Stock, M.D. American Academy of Child and Adolescent Psychiatry (AACAP) Staff: Kristin Kroeger Ptakowski and Jennifer Medicus.

The AACAP practice parameters are developed by the AACAP WGQI in accordance with American Medical Association policy. Parameter development is an iterative process between the primary author(s), the WGQI, topic experts, and representatives from multiple constituent groups, including the AACAP membership, relevant AACAP components, the AACAP Assembly of Regional Organizations, and the AACAP Council. Details of the parameter development process can be accessed on the AACAP Web site. Responsibility for parameter content and review rests with the author(s), the WGQI, the WGQI Consensus Group, and the AACAP Council.

The AACAP develops both patient-oriented and clinician-oriented practice parameters. Patient-oriented parameters provide recommendations to guide clinicians toward best treatment practices. Recommendations are based on empirical evidence (when available) and clinical consensus (when not) and are graded according to the strength of the empirical and clinical support. Clinician-oriented parameters provide clinicians with the information (stated as principles) needed to develop practice-based skills. Although empirical evidence may be available to support certain principles, principles are primarily based on expert opinion derived from clinical experience. This parameter is a clinician-oriented parameter.

The primary intended audience for AACAP practice parameters is child and adolescent psychiatrists; however, the information contained therein may also be useful for other mental health clinicians.

The authors acknowledge the following experts for their contributions to this parameter: Debra Glueck, M.D., Linda Godleski, M.D., Donald Hilty, M.D., Debra Katz, M.D., Antonio Pignatiello, M.D., John Sargent, M.D., and Christopher Thomas, M.D.

This parameter was reviewed at the Member Forum at the AACAP Annual Meeting in October 2006.

From September 2007 to February 2008, this parameter was reviewed by a Consensus Group convened by the WGQI. Consensus Group members and their constituent groups were as follows: WGQI (Heather Walter, M.D., M.P.H., Chair; Ulrich Schoettle, M.D., Shepherd; Joan Kinlan, M.D., and Tiffany Farchione, M.D., Members); Topic Experts (Douglas K. Novins, M.D., and Christopher Thomas, M.D.); AACAP Components (Antonio Pignatiello, M.D., Telepsychiatry Committee); AACAP Assembly of Regional Organizations (Gabrielle Shapiro, M.D., and George Realmuto, M.D.); and AACAP Council (Charles Zeanah, Jr., M.D., and J. Michael Houston, M.D.).

This practice parameter was approved by the AACAP Council on June 5, 2008.

This practice parameter is available on the Internet (www.aacap.org).

Reprint requests to the AACAP Communications Department, 3615 Wisconsin Avenue, NW, Washington, DC 20016.

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AACAP Official ActionPractice Parameter for Telepsychiatry With Children and Adolescents

Abstract

Section snippets

Methodology

Definitions

Historical Overview

Developmental and Clinical Considerations

Establishing a Telepsychiatry Service

Principle 9. Rapport, Confidence, and Collaboration With Staff at the Patient Site Should Be Fostered

Parameter Limitations

J Adolesc Health

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Pain Symptom Manage

Psychosomatics

Int J Med Inform

Child Adolesc Psychiatr Clin N Am

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Diagnosis, access and outcomes: update of a systematic review of telemedicine services

J Telemed Telecare

Technological advances in psychiatry

Prim Psychiatry

Psychiatrists' satisfaction with telepsychiatry

Telemed J E Health

State Medicaid and private payer reimbursement for telemedicine: an overview

J Telemed Telecare

Telepsychiatry. Canadian Psychiatric Association Clinical Guidelines and Position Papers. Canadian Psychiatric Association Web site. Published 2006

Telecommunications and videoconferencing for psychiatry

Two-way television: helping the medical center reach out

Am J Psychiatry

Telepsychiatry: psychiatric consultation by interactive television

Am J Psychiatry

The use of two-way TV in bringing mental health services to the inner city

Am J Psychiatry

A survey of telepsychiatry in the USA

J Telemed Telecare

Medicaid and Telemedicine, 2004. Centers for Medicare and Medicaid Services Web site

Telemedicine Reimbursement Report

Telemedicine Research Center Report on US Telemedicine Activity With an Overview of Non-US Activity

Private payer reimbursement information directory. AMD Telemedicine Web site

Private payer reimbursement for telemedicine services in the United States

Telemed J E Health

A review of the first five years of the University of Arizona telepsychiatry programme

J Telemed Telecare

Clinical and educational telepsychiatry applications: a review

Can J Psychiatry

A multi-phase telepsychiatry programme in Michigan: organizational factors affecting utilization and user perceptions

J Telemed Telecare

Telepsychiatry in the Canary Islands: user acceptance and satisfaction

J Telemed Telecare

The effectiveness of telepsychiatry measured using the Health of the Nation Outcome Scale and the Mental Health Inventory

J Telemed Telecare

The status of telepsychiatry services in Canada: a national survey

J Telemed Telecare

Telepsychiatry: assessment of televideo psychiatric interview reliability with present and next-generation internet infrastructures

Acta Psychiatr Scand

Telemental Health Toolkit

Telepsychiatry with children and adolescents: are patients comparable to those evaluated in usual outpatient care?

Telemed J E Health

A randomized, controlled trial of child psychiatric assessments conducted using videoconferencing

J Telemed Telecare

A prospective satisfaction study and cost analysis of a pilot child telepsychiatry service in Newfoundland

J Telemed Telecare

Treating childhood depression over videoconferencing

Telemed J E Health

Using telemedicine to conduct behavioral assessments

J Appl Behav Anal

Delivery of family therapy in the treatment of anorexia nervosa using telehealth

Telemed J E Health

A child and adolescent psychiatric outreach service for rural New South Wales: a telemedicine pilot study

J Paediatr Child Health

Evaluating satisfaction with a child and adolescent psychological telemedicine outreach service

J Telemed Telecare

AACAP Official Action
Practice Parameter for Telepsychiatry With Children and Adolescents