A Review of Pediatric Telemental Health

A review of risks, adverse effects and mitigation strategies when delivering mental health services using telehealth

BACKGROUND

This paper presents a scoping review of the peer-reviewed literature regarding reported risks, adverse effects and mitigation factors related to providing mental health services using telehealth.

AIMS

The paper aims to describe risks and risk management strategies.

METHODS

Publications were included if they reported upon risks, adverse events or mitigation factors experienced, hypothesised or discussed for: any population (any country, any age), service (any mental health services), intervention (telehealth), English language, 2010 to 10 July 2021, any publication type (commentary, research, policy), excluding protocol papers, and self-help tools. The following databases were searched: PsycINFO (from 2010 to 10 July 2021), MEDLINE (2010 to 10 July 2021) and the Cochrane Database from 2010 to 10 July 2021.

RESULTS

The search strategy resulted in 1,497 papers and after exclusions a final 55 articles were selected. Results of this scoping review are presented in terms of types of risk, risk by client population, risk by modality (eg group therapy using telehealth) and risk management.

CONCLUSIONS

Recommendations for future research include gathering and publishing more detailed information regarding near-miss and actual adverse events when delivering mental health assessment and care using telehealth. In clinical practice, training is required for potential adverse events, and to prevent them and reporting mechanisms in place to collate and learn from these.

Development and Implementation of a Telemental Health Program for Caregivers in a Children's Hospital Setting

Introduction: Caregivers of children with chronic illness, such as hematology-oncology conditions, face numerous stressors, and a subset experience persistent distress and poor psychological outcomes. Many logistical and ethical barriers complicate the provision of mental health care to caregivers in children's hospital settings. Telemental health (TMH) is one method to increase access and reduce barriers. Methods: A partnership was established with an outside TMH agency to provide mental health care to caregivers of children with hematology-oncology conditions. Development and implementation strategies are described, and feasibility was measured on four dimensions. Results: One hundred twenty-seven (n = 127) caregivers were referred for TMH services in the first 28 months of program implementation. Of the total, 63/127 (49%) received TMH services for at least one session. Most caregivers had a child in active medical treatment (89%). A small portion (11%) of caregivers were bereaved or had a child in hospice care. Program feasibility was enhanced by hospital leadership support and availability of staffing, financial, and technology resources. Available resources also contributed to the practicality of program development and swift implementation and integration within the defined hospital system. Discussion: Partnership with an outside TMH agency increased access to care and reduced barriers to treating caregivers in a children's hospital setting. Offering mental health interventions to caregivers aligns with evidence-based standards of care. Future research will elucidate caregiver satisfaction with this modality of treatment and whether use of TMH reduces disparities in caregiver receipt of mental health care in children's hospital settings.

Culturally Responsive Telepsychology & mHealth Interventions for Racial-Ethnic Minoritized Youth: Research Gaps and Future Directions

Telepsychology and mHealth (TPmH) services for youth and their families have become increasingly prevalent in recent years. However, significant limitations in theory, research, and policy introduce questions about the effectiveness of such interventions, particularly for racial-ethnic minoritized youth and their families, who already contend with inequities in mental health treatment access and outcomes. Although TPmH have the potential to reduce barriers to mental health services in ways that may benefit racial-ethnic minoritized youth and their families, the mental health field must first grapple with limitations in culturally responsive TPmH work to avoid perpetuating existing mental health inequities. As such, this article begins by briefly reviewing extant literature on (1) TPmH for youth, (2) culturally adapted or culturally responsive evidence-based interventions for racial-ethnic minoritized youth and families, and (3) the intersection of TPmH and culturally responsive interventions. Informed by the gaps identified by this review, we provide recommendations for future directions in culturally responsive TPmH for racial-ethnic minoritized youth and families. These recommendations have been organized into four overarching categories: (1) conceptual and theoretical recommendations, (2) research priorities, (3) practice and policy recommendations, and (4) engagement and access recommendations. These recommendations offer novel ideas for researchers, clinicians, funding agencies, policy-makers, and other key stakeholders and are intended to facilitate equity in TPmH for racial-ethnic minoritized youth and their families.

Optimizing an Adolescent Hybrid Telemedical Mental Health Service: Staff Scheduling using Mathematical Programming (Preprint)

BACKGROUND

According to the World Health Organization, globally, one in seven 10- to 19-year-olds experiences a mental disorder, accounting for 13% of the global burden of disease in this age group. Half of all mental illnesses begin by the age of 14 years and some teenagers with severe presentations must be admitted to the hospital and assessed by highly skilled mental health care practitioners. Digital telehealth solutions can be useful for the assessment of young individuals remotely. Ultimately, this technology can save travel costs for the health service rather than assessing adolescents in person at the corresponding hospital. Especially in rural regions, where travel times can be high, this innovative approach can make a difference to patients by providing quicker assessments.

OBJECTIVE

The aim of this study is to share insights on how we developed a decision support tool to assign staff to days and locations where adolescent mental health patients are assessed face to face. Where possible, patients are seen through video consultation. The model not only seeks to reduce travel times and consequently carbon emissions but also can be used to find a minimum number of staff to run the service.

METHODS

To model the problem, we used integer linear programming, a technique that is used in mathematical modeling. The model features 2 objectives: first, we aim to find a minimum coverage of staff to provide the service and second, to reduce travel time. The constraints that are formulated algebraically are used to ensure the feasibility of the schedule. The model is implemented using an open-source solver backend.

RESULTS

In our case study, we focus on real-world demand coming from different hospital sites in the UK National Health Service (NHS). We incorporate our model into a decision support tool and solve a realistic test instance. Our results reveal that the tool is not only capable of solving this problem efficiently but also shows the benefits of using mathematical modeling in health services.

CONCLUSIONS

Our approach can be used by NHS managers to better match capacity and location-dependent demands within an increasing need for hybrid telemedical services, and the aims to reduce traveling and the carbon footprint within health care organizations.

Pediatric Consultation-Liaison Psychology: Insights and Lessons Learned During the COVID-19 Pandemic

COVID-19 has presented a variety of challenges to the provision of psychology services. In the first month of the pandemic, pediatric consultation–liaison (CL) psychologists reported significant changes in methodology of service delivery (Steinberg et al. in Clin Pract Pediatr Psychol 9:1, 2020). To better understand how and if these changes persisted, as well as other emerging trends, a follow-up study examined changes and challenges six months into the pandemic. An anonymous questionnaire assessed topics related to pediatric CL psychology including practice changes, perception of changes, and institutional support. The questionnaire was sent to the APA Society of Pediatric Society’s special interest group listservs. Thirty responses were analyzed. Quantitative results showed participants’ beliefs that telemedicine is equally efficacious to in-person services for outpatient psychological care, but less effective for inpatient care. Participants reported their perception of how institutions supported their safety, psychology trainee safety and training goals, and patient care. Qualitative results demonstrated that most psychologists experienced changes related to their dynamics with medical teams, which included changes in team efficiency, workload, transition, and team collaboration.

CTiBS and Clinical Social Work: Telebehavioral Health Competencies for LCSWs in the Age of COVID-19

Licensed Clinical Social Workers (LCSWs) have been integrating technology into psychotherapy practice for at least two decades, but the COVID-19 pandemic dramatically shifted the primary method of service delivery for diagnostic assessment and therapy to telebehavioral health. By developing telebehavioral health competencies, the 250,000 + LCSWs in the US can ensure and enhance the quality of care both during and after the COVID public health emergency (PHE). This article applies an evidence- and consensus-based, interprofessional telebehavioral health (TBH) competency framework to the field of social work. This framework was developed by the Coalition for Technology in Behavioral Science (CTiBS), initially published in 2017. It has seven competency domains: (1) clinical evaluation and care; (2) virtual environment and telepresence; (3) technology; (4) legal and regulatory issues; (5) evidence-based and ethical practice (comprised of Standards and Guidelines and Social Media); (6) mobile health and apps; and (7) telepractice development. The framework outlines three competency levels (novice, proficient, and authority) covering 49 specific objectives and 146 measurable competencies or practices. The TBH competencies support existing in-person clinical practices and are intended for trainees and practitioners who are implementing TBH in practice. This competency framework can also be used to integrate clinical social work professional development, research, and training. Additionally, considerations for other behavioral health professions regarding licensure, certification, and policy may apply to clinical social work. Future research is needed on implementation and evaluation of the competencies.

Access to Outpatient Pediatric Mental Health Care After Emergency Department Discharge

OBJECTIVES

Pediatric mental health presentations to emergency departments (EDs) have shown dramatic increases nationally. This study aimed to identify the ability of patients discharged with mental health from the ED to establish outpatient care.

METHODS

This was a cross-sectional study of all mental health patients aged 7 to 19 years who were seen by a child psychiatry consult team in a tertiary care pediatric ED from September 2016 to January 2017. Patients were contacted by phone at least 6 months after discharge. Data obtained included time to follow-up, reasons for delayed follow-up, type of provider seen, and frequency of outpatient visits.

RESULTS

Two hundred twenty-eight charts were reviewed and 51 were successfully interviewed. The median age was 14 years and 61% were female. Most patients (61%) reported seeing a psychiatrist or therapist, whereas 19% reported a primary care provider and 19% reporting "other." The majority were able to establish care within 1 month (73%), whereas 9% reported never obtaining outpatient follow-up. Most patients (58%) were able to be seen more than once per month. The most common reason for delayed follow-up was provider availability.

CONCLUSIONS

This study found that a large number of patients were able to be seen within 1 month of discharge for mental health care. However, almost 10% of patients never established outpatient care, which is concerning and is an area needing further research.

Reviewing the availability, efficacy and clinical utility of Telepsychology in dialectical behavior therapy (Tele-DBT)

BACKGROUND

Telepsychology is increasingly being implemented in mental health care. We conducted a scoping review on the best available research evidence regarding availability, efficacy and clinical utility of telepsychology in DBT. The review was performed using PRISMA-ScR guidelines. Our aim was to help DBT-therapists make empirically supported decisions about the use of telepsychology during and after the current pandemic and to anticipate the changing digital needs of patients and clinicians.

METHODS

A search was conducted in PubMed, Embase, PsycARTICLES and Web of Science. Search terms for telepsychology were included and combined with search terms that relate to DBT.

RESULTS

Our search and selection procedures resulted in 41 articles containing information on phone consultation, smartphone applications, internet delivered skills training, videoconferencing, virtual reality and computer- or video-assisted interventions in DBT.

CONCLUSIONS

The majority of research about telepsychology in DBT has focused on the treatment mode of between-session contact. However, more trials using sophisticated empirical methodologies are needed. Quantitative data on the efficacy and utility of online and blended alternatives to standard (i.e. face-to-face) individual therapy, skills training and therapist consultation team were scarce. The studies that we found were designed to evaluate feasibility and usability. A permanent shift to videoconferencing or online training is therefore not warranted as long as face-to-face is an option. In all, there is an urgent need to compare standard DBT to online or blended DBT. Smartphone apps and virtual reality (VR) are experienced as an acceptable facilitator in access and implantation of DBT skills. In addition, we have to move forward on telepsychology applications by consulting our patients, younger peers and experts in adjacent fields if we want DBT to remain effective and relevant in the digital age.

Rapid Implementation of Telerehabilitation for Pediatric Patients During Covid-19

The COVID-19 pandemic necessitated a sudden limitation of in-person outpatient occupational and physical therapy services for most patients at a large, multisite pediatric hospital located in the Midwest, United States. To ensure patient and staff safety, the hospital rapidly shifted to deliver most of these services via telerehabilitation. The purposes of this study were to (1) describe the rapid implementation of telerehabilitation during the COVID-19 pandemic, (2) describe the demographic characteristics of patients who continued in-person services and those who received telerehabilitation, and (3) evaluate the therapists' perceptions of telerehabilitation for physical and occupational therapy. Most of the children (83.4% of n=1352) received telerehabilitation services. A family was more likely to choose to continue in-person visits if their child was <1-year-old, had a diagnosis of torticollis, received serial casting, or was post-surgical. Occupational and physical therapy therapists (n=9) completed surveys to discern their perceptions of the acceptability of telerehabilitation, with most reporting that telerehabilitation was as effective as in-person care.

A Survey of Residents/Fellows, Program Directors, and Faculty About Telepsychiatry: Clinical Experience, Interest, and Views/Concerns

The effectiveness of telepsychiatry video for clinical care is well established, and clinician and psychiatry resident interest in it is growing—particularly in light of the COVID-19 impact. Still, few residency programs in the United States have core curricula, rotations/electives available, and competencies, and many faculty have no experience. A survey was sent via national organization listserves for residents, fellows, faculty, and program directors to complete. The survey queried demographics, clinical experience and interest, and views/concerns, using Likert-like and yes/no questions. Descriptive statistics and other analyses compared the groups to assess impact of clinical experience on interest and views/concerns. Respondents (N = 270) have limited clinical experience with telepsychiatry (46% none), with trainees having less than others, and yet, most were very interested or interested in it (68%). Trainees (N = 123) have concerns about being prepared for future practice. Clinical experience with video in the range of 6–20 h appears to dramatically increase interest and reduce concerns, though less time has a positive effect. Respondents have concerns about connectivity, medico-legal issues, and clinical effectiveness (e.g., diverse populations, psychosis, and emergencies) with telepsychiatry. More research is needed to assess current clinical and curricular experience, interest, and concerns. Additional curricular interventions during residency and fellowship training could build skills and confidence, if this is feasible, and the benefits outweigh the costs.

Children and Telehealth in Mental Healthcare: What We Have Learned From COVID-19 and 40,000+ Sessions

Objective

Of the many impacts of COVID-19 on contemporary healthcare is the rapid and overwhelming shift to remote telehealth (TH) service. The precise effect of TH on treatment is yet unknown, and the possible child/adult differences are an essential point of clarification for the utility of TH services and efforts to improve upon them.

Methods

The current study considers data reflecting pre-, during-, and post-COVID-19 lockdown over the first six months of 2020. Data comprise records of N = 43,294 services delivered to N = 2520 unique clients across multiple outpatient mental health sites at a Certified Community Based Mental Health Clinic (CCBHC) in Rockland County, NY, an area hard hit by COVID-19.

Results

Results demonstrate significant differences between child and adult sessions with a relative decrease in the number of child mental health services with the switch to TH in March 2020 (onset of lockdown) and a relatively rapid shift back to face-to-face among child services when in-person services resumed in May and June 2020. Results further highlight significant differences between child age and service type, with psychiatry less affected by TH than psychotherapy.

Conclusions

Implicit in the data is the ability to offer remotely, a high volume of ongoing behavioral intervention. Findings support TH as less preferred for children than adults while indicating that child TH is favored for psychiatry and support services, less so for psychotherapy. Implications for enhancing child TH delivery and directions for continued research include relational factors, platform (phone/video) and screen salience.

A Survey Comparing Adult and Child Psychiatry Trainees, Faculty, and Program Directors' Perspectives About Telepsychiatry: Implications for Clinical Care and Training

Telepsychiatry’s effectiveness is well established, and interest in it is growing, despite few residency/fellowship core curricula and rotations. A link to a cross-sectional survey was sent via national organization listservs for psychiatry residents, fellows, faculty, and program directors to complete. The survey queried demographics, clinical experience, and views/concerns about telepsychiatry. Descriptive statistics and other analyses compared groups to assess the impact of amount clinical experience and psychiatric specialty (general vs. child and adolescent psychiatry), on interest, and views/concerns about the practice of telepsychiatry. All respondents (N = 270; child psychiatry N = 89) have limited clinical experience with telepsychiatry (46% overall; 49% of non-child had none versus 40% child). Trainees (N = 123; child N = 43) expressed less interest than others. All respondents expressed worry about ability to do a physical exam, connectivity, medico-legal issues, and fit for diverse populations. Child respondents expressed less concern than others, but they reported more worry about loss of nonverbal cues. Clinical experience with telepsychiatry in the range of 6–20 h appears to build interest and allay concerns, though 1–5 h also may have a positive impact. More research is needed to assess clinical experience, interest, and concerns for adult and child psychiatry trainees and clinicians. Replicable, curricular interventions appear to be indicated.

Feasibility and Acceptability of Clinical Pediatric Telerehabilitation Services

Objective

Telerehabilitation has long been recognized as a promising means of providing pediatric services; however, significant barriers such as cost, payor reimbursement, and access prevented widespread use. The advent of the COVID-19 pandemic necessitated rapid adoption of telerehabilitation into clinical practice to provide access to care while maintaining social distancing. The purpose of this study is to present clinical data on the feasibility and acceptability of speech-language pathology, developmental occupational and physical therapies, and sports and orthopedic therapies telerehabilitation delivered in a pediatric hospital setting.

Methods

Telerehabilitation services were rapidly implemented in three stages: building the foundation, implementing, and refining this service delivery model. Paper patient satisfaction surveys were administered as part of ongoing quality improvement efforts throughout 2019 and were adapted for online administration in 2020 for telerehabilitation patients. Outpatient visit counts by type (in-person, phone, and video) were extracted from the electronic medical record using data warehousing techniques.

Results

Historical patient satisfaction rates from 2019 indicated high patient satisfaction (98.97% positive responses); these results were maintained for telerehabilitation visits (97.73%), indicating that families found telerehabilitation services acceptable. Patient volume returned to 73.5% of pre-pandemic volume after the implementation of telerehabilitation services.

Conclusions

Pediatric telerehabilitation is feasible to provide in clinical settings, and the services are acceptable to patient families. Future work is needed to evaluate the impact of telerehabilitation services on patient care and applications for ongoing use of this delivery model.

The Impact of COVID-19 on the Delivery of an Evidence-Based Child Maltreatment Prevention Program: Understanding the Perspectives of SafeCare® Providers

Child maltreatment (CM) is a global public health problem. Evidence-based home visiting programs, such as SafeCare®, reduce CM risk, and enhance parent-child relationships and other protective factors. As the result of the COVID-19 pandemic and resulting restrictions, SafeCare Providers transitioned from home to virtual delivery for the SafeCare curriculum. The purpose of this study is to 1) examine active SafeCare Providers' opinions on the feasibility and effectiveness of SafeCare via remote delivery, and 2) better understand workforce concerns for human service professionals within the context of COVID-19 mitigation efforts. Data are from a cross-sectional survey of SafeCare Providers (N = 303) in the United States, Canada, and Australia. The majority of Providers reported they were actively delivering SafeCare virtually and were comfortable with the delivery format. Providers indicated that the majority of SafeCare families are making progress on target skills, and that engagement is high among many families. Some service delivery challenges were reported, ranging from family data plan limitations to difficulty with delivery of specific components of the SafeCare curriculum related to modeling and assessment. The impact of COVID-19 on Providers' daily routines, stress level, and work-life balance has been significant. Remote, virtual delivery of CM prevention programming offers the opportunity to continue serving vulnerable families in the midst of a pandemic. Barriers related to family technology and data access must be addressed to ensure reach and the effective delivery of prevention programming during the pandemic and beyond.

Outcomes of Depression Screening for Adolescents Accessing Pediatric Primary Care-Based Services

PURPOSE

Assess outcomes of depression screening among adolescents accessing pediatric primary care-based services. These findings will contribute to development of clinical protocols for depression screening and intervention in primary care settings.

DESIGN AND METHODS

Retrospective chart review conducted via electronic medical records at a pediatric primary care-based clinic to extract PHQ-9 data for adolescents screened from 1/17/2018 to 4/18/2018. De-identified data included age, gender, ethnicity, provider, PHQ-9, and referral/follow-up/medication status.

RESULTS

Data included 1213 adolescents of whom N = 600 were depressed without additional comorbidities; 96 adolescents had PHQ-9 scores >5. Descriptive analyses by age, gender, ethnicity, referral type, follow-up, and provider services identified targeted primary care-based interventions for depression and referral. Depression screening occurred primarily at well child visits. 82.5% of those with PHQ-9 scores >5 were not currently receiving treatment. Overall, referrals by physicians (45.8%) and nurse practitioners (42.9%) were equivalent with more referrals for adolescents with moderate-severe depression. Nurse practitioners provided more counseling than physicians among adolescents with mild to moderate depression.

CONCLUSIONS

Adolescent mental health necessitates an enhanced continuum of care. Primary care-based interventions provided by pediatric nurse practitioners are imperative to address adolescent mental health needs. Findings provide practical means to incorporate protocols for depression enhancing primary care-based mental health access.

PRACTICE IMPLICATIONS

Need for incorporation of practical modalities for depression assessment and follow up as recommended by American Academy of Pediatrics. Future study for comparison of methods (phone/text reminder, follow up appointment, online resource reminder, telehealth), indicated to enhance follow-up care for adolescents experiencing depression.

Use of Technology to Promote Child Behavioral Health in the Context of Pediatric Care: A Scoping Review and Applications to Low- and Middle-Income Countries

Background: The burden of mental, neurological, and substance (MNS) disorders is greater in low- and middle-income countries (LMICs). The rapid growth of digital health (i.e., eHealth) approaches offer new solutions for transforming pediatric mental health services and have the potential to address multiple resource and system barriers. However, little work has been done in applying eHealth to promote young children's mental health in LMICs. It is also not clear how eHealth has been and might be applied to translating existing evidence-based practices/strategies (EBPs) to enable broader access to child mental health interventions and services. Methods: A scoping review was conducted to summarize current eHealth applications and evidence in child mental health. The review focuses on 1) providing an overview of existing eHealth applications, research methods, and effectiveness evidence in child mental health promotion (focused on children of 0-12 years of age) across diverse service contexts; and 2) drawing lessons learned from the existing research about eHealth design strategies and usability data in order to inform future eHealth design in LMICs. Results: Thirty-two (32) articles fitting our inclusion criteria were reviewed. The child mental health eHealth studies were grouped into three areas: i) eHealth interventions targeting families that promote child and family wellbeing; ii) eHealth for improving school mental health services (e.g., promote school staff's knowledge and management skills); and iii) eHealth for improving behavioral health care in the pediatric care system (e.g., promote use of integrated patient-portal and electronic decision support systems). Most eHealth studies have reported positive impacts. Although most pediatric eHealth studies were conducted in high-income countries, many eHealth design strategies can be adapted and modified to fit LMIC contexts. Most user-engagement strategies identified from high-income countries are also relevant for populations in LMICs. Conclusions: This review synthesizes patterns of eHealth use across a spectrum of individual/family and system level of eHealth interventions that can be applied to promote child mental health and strengthen mental health service systems. This review also summarizes critical lessons to guide future eHealth design and delivery models in LMICs. However, more research in testing combinations of eHealth strategies in LMICs is needed.

Considerations for Conducting Telemental Health with Children and Adolescents

Innovative technologies are increasingly used in order to address gaps in access to child behavioral health care. Telemental health is one technological modality in which child behavioral services can be practiced successfully across psychiatry, psychology, and developmental medicine. The authors discuss relevant issues related to delivering telemental health, including why this modality is necessary for delivery, what models and evidence for telemental health exist, when it should be considered across legal/regulatory and ethical considerations, where telemental health services are delivered, who is involved in delivery, and how best telemental health practices may be implemented with diverse youth.