ACKNOWLEDGEMENTS

The American Telemedicine Association (ATA) wishes to express sincere appreciation to the ATA
Telemental Health with Children and Adolescents Practice Guidelines Leadership team,
Contributors and the ATA Practice Guidelines Committee for the development of these
guidelines. Their hard work, diligence and perseverance are highly appreciated.

• Telemental Health with Children and Adolescents Work Group •

Co-Chair: Kathleen M. Myers, MD, MPH, MS, FAACAP, Professor of Psychiatry and Behavioral
Sciences, University of Washington and Director of Telemental Health, Seattle Children's
Hospital, Seattle WA

Co-Chair: Eve-Lynn Nelson, PhD, Director, KU Center for Telemedicine & Telehealth, Professor,
School of Medicine, University of Kansas Medical Center

Donald M. Hilty, MD, Chief of Psychiatry & Addiction Medicine and Residency Program
Director, Kaweah Delta Medical Center, UC Irvine Affiliate, Professor, Psychiatry and Behavioral
Sciences, Keck School of Medicine at USC, Strategic Advisor, Research and Health Services,
Aligned Telehealth

Terry Rabinowitz, MD, DDS, Professor of Psychiatry and Family Medicine, University of Vermont
College of Medicine

• Contributors and Reviewers •

(alphabetical order)

Deborah C. Baker, JD, Director of Legal & Regulatory Policy, Legal & Regulatory Affairs, Practice
Directorate, American Psychological Association
Sara Smucker Barnwell, PhD
Partner, Seattle Psychology PLLC, Clinical Faculty, Department of Psychiatry and Behavioral
Sciences, University of Washington

Geoffrey Boyce, MBA, Executive Director, Insight Telepsychiatry, LLC
Lynn F. Bufka, PhD, Associate Executive Director, Practice Research and Policy, Practice
Directorate, American Psychological Association
Sharon Cain, MD, Professor & Director of Child and Adolescent Psychiatry Division, University of
Kansas Medical Center

Lisa Chui, ARNP, Psychiatric Mental Health Nurse Practitioner, Department of Psychiatry and
Behavioral Health, Seattle Children's Hospital

© American Telemedicine Association
Jonathan S. Comer, PhD, Professor of Psychology and Psychiatry, Director, Mental Health
Interventions and Technology (MINT) Program, Center for Children and Families, Florida
International University

Carroll Cradock, PhD, President, CAC Consulting Group

James R. Varrell, MD, President and Medical Director, CFG Health Network, Insight
Telepsychiatry, LLC

Felissa Goldstein, MD, Child Psychiatrist, Lee Specialty Clinic

Barb Johnston, MSN, MLM, CEO, HealthLinkNow

Katherine Lo, ARNP, Psychiatric Mental Health Nurse Practitioner, Department of Psychiatry and
Behavioral Health, Seattle Children's Hospital

David Luxton, PhD, MS, Faculty, Department of Psychiatry & Behavioral Sciences, University of
Washington School of Medicine & Workforce Development Administrator at the Office of
Forensic Mental Health Services, State of Washington

David McSwain, MD, MPH, Medical Director, Telehealth Optimization, MUSC Center for
Telehealth, Associate Professor, Pediatric Critical Care Medicine, Medical University of South
Carolina (MUSC) Children’s Hospital

Jennifer McWilliams, MD, Child Psychiatrist, Child and Adolescent Psychiatrist, Omaha
Children's Hospital & Medical Center

Steve North, MD, MPH, Medical Director and Founder, Center for Rural Health Innovation,
Spruce Pine, NC, Clinical Director, Mission Virtual Care, Asheville, NC, AAFP Liaison
Jay Ostrowski, MA, LPC-S, NCC, Director of Product and Business Development, National Board
for Certified Counselors and Associates, Inc.
Antonio Pignatiello, MD, FRCP (C), Associate Psychiatrist-in-Chief, Medical Director, TeleLink
Mental Health Program, The Hospital for Sick Children, Director, Child, Youth, & Family Health,
Medical Psychiatry Alliance, Associate Professor, Department of Psychiatry, University of
Toronto
David Roth, MD, FAAP, FAPA
Psychiatrist, Mind and Body Works, Inc.

Carolyn Turvey, PhD, MS, Professor, Psychiatry & Epidemiology, University of Iowa
Shawna Wright, PhD, Director, Wright Psychological Services; Assistant Director, KU Center for
Telemedicine & Telehealth

• ATA Practice Guidelines Committee •

Chair: Elizabeth A. Krupinski, PhD, Professor & Vice Chair for Research, Department of
Radiology & Imaging Sciences, Emory University

© American Telemedicine Association


• Committee Members •

Nina Antoniotti, RN, MBA, PhD, Executive Director of Telehealth and Clinical Outreach, SIU
School of Medicine

Jill Berg, PhD, RN, FAHA, FAAN, Vice President of Education, Ascension Health Wisconsin,
President, Columbia College of Nursing

David Brennan, MSBE, Director, Telehealth Initiatives, MedStar Health

Anne Burdick, MD, MPH, Associate Dean for Telemedicine and Clinical Outreach, Professor of
Dermatology, Director, Leprosy Program, University of Miami Miller School of Medicine

Jerry Cavallerano, PhD, OD, Staff Optometrist, Assistant to the Director, Joslin Diabetes Center,
Beetham Eye Institute

Helen K. Li, MD, Adjunct Associate Professor, University of Texas Health Science Center

• ATA Staff •

Jordana Bernard, MBA, Chief Program Officer

Jonathan D. Linkous, CEO

© American Telemedicine Association




PRACTICE GUIDELINES FOR TELEMENTAL HEALTH
WITH CHILDREN AND ADOLESCENTS

TABLE OF CONTENTS


PREAMBLE 1
SCOPE 2
INTRODUCTION 3
REVIEW OF CLINICAL TELEMENTAL HEALTH WITH YOUTH 6
GUIDELINES FOR THE PRACTICE OF TELEMENTAL
HEALTH WITH YOUTH 9
ADDITIONAL TELEMENTAL HEALTH CONSIDERATIONS WITH
SPECIAL CONSIDERATIONS FOR YOUTH 21
SUMMARY 24
CONCLUSIONS 24
APPENDIX 26
References 26
Glossary 40
Table: Effectiveness of Child and Adolescent Telemental Health 42

© American Telemedicine Association
 PREAMBLE

Background. The American Telemedicine Association (ATA), with members from throughout
the United States and the world, is the principal organization bringing together telemedicine
providers, healthcare institutions, vendors and others involved in providing remote healthcare
using telecommunications. ATA is a nonprofit organization that seeks to bring together diverse
groups from traditional medicine and healthcare, academia, technology and
telecommunications companies, e-health, allied professional and nursing associations, medical
societies, government and others to overcome barriers to the advancement of telemedicine
through the professional, ethical and equitable improvement in healthcare delivery. ATA has
embarked on an effort to establish practice guidelines and technical requirements for
telemedicine to help advance the science and to assure the uniform quality of service to
patients. These guidelines, based on clinical and empirical experience, are developed by work
groups that include experts from the field and other strategic stakeholders and designed to
serve as both an operational reference and an educational tool to aid in providing appropriate
care for patients. The practice guidelines and requirements generated by ATA undergo a
thorough consensus and rigorous review, with final approval by the ATA Board of Directors.
Existing products are reviewed and updated periodically as time and resources permit. Board-
approved practice guidelines will be considered for affirmation, update, or sunset at least every
4 years. Practice guidelines that have been sunset may continue to have educational value but
may not represent the most current knowledge and information about the subject matter.

Disclaimer. The practice of healthcare is an integration of both the science and art of
preventing, diagnosing, and treating diseases. Accordingly, it should be recognized that
compliance with these guidelines will not guarantee accurate diagnoses or successful outcomes
with respect to the treatment of individual patients, and ATA disclaims any responsibility for
such outcomes. These guidelines are provided for informational and educational purposes only
and do not set a legal standard of medical or other health care. They are intended to assist
providers in delivering effective and safe medical care that is founded on current information,
available resources, and patient needs. The practice guidelines and technical requirements
recognize that safe and effective practices require specific training, skills, and techniques, as
described in each document, and are not a substitute for the independent professional
judgment, training, and skill of treating or consulting providers. If circumstances warrant, a
provider may responsibly pursue a course of action different from the guidelines when, in the
reasonable judgment of the provider, such action is indicated by the condition of the patient,
restrictions or limits on available resources, or advances in information or technology
subsequent to publication of the guidelines. Likewise, the practice guidelines and technical
requirements in this document do not purport to establish binding legal standards for carrying
out telemedicine interactions. Rather, they are the result of the accumulated knowledge and
expertise of the ATA work groups and their review of the current literature in the field and are
intended to improve the technical quality and reliability of telemedicine encounters. The
administrative procedures and technical aspects of specific telemedicine arrangements may
vary depending on the individual circumstances, including location of the parties, resources,

© American Telemedicine Association | Page 1
nature of the interaction, and in the case of children and adolescents, the adults responsible for
their welfare until the age of majority.

SCOPE

This document provides a clinical guideline for the delivery of child and adolescent mental
health and behavioral services by a licensed health care provider through real time
videoconferencing. Please refer to the Glossary in Appendix A for definitions utilized in the
guideline, with particular attention to the equivalency of the terminology “telemental health”
and “telebehavioral health.” However, to maintain consistency with prior telemental health
guidelines, 1-2 this guideline uses the term child and adolescent telemental health (CATMH)
throughout the document.

General guidelines for the practice of telemental health using popular internet-based (aka
“consumer-grade”) videoconferencing,1 as well as more traditional telephone-based, high
definition, point-to-point (aka “standards grade”) videoconferencing have been published.2,3
Providers are strongly encouraged to refer to the general telemental health guidelines for
overall recommendations, particularly in areas that encompass both adult and pediatric
practice. In some instances, the general recommendations or supporting evidence from these
guidelines may be repeated here if there is a specific relevance to CATMH practice or to provide
updated information. Additionally, based on a growing evidence-base and expert consensus,
this guideline includes four new sections relevant to telemental healthcare across the age
spectrum: Ethical Considerations; Telemental Health Competencies; Clinical Supervision and
Telemental Health; and Future Directions.

Consistent with the general practice guidelines, the CATMH guideline focuses on interactive
videoconferencing between two or more sites with emphasis on providing the same level of
service that is delivered in-person including consultation, collaboration, and direct service
delivery. Direct services span the range of mental and behavioral health interventions, including
prevention, early intervention and coping strategies, treatment, and maintenance/support.
These guidelines apply to videoconferencing using both standards-based and consumer-grade
connectivity.4,5 Emerging products blur the lines between standards-based and consumer-grade
approaches, offering the distributed hosting and internet-based connectivity of consumer-
oriented systems with the interoperability of standards-based platforms.6

Mobile health or mHealth uses wireless devices and cell phone technologies that may be
applied to CATMH. mHealth allows the delivery of CATMH through consumer-grade hardware
and cloud-based videoconferencing solutions, allowing greater patient and provider mobility.
Although a telemental health service may incorporate various technology approaches, it should
be noted that telehealth, asynchronous store-and-forward telemedicine,7 eHealth, and non-
video components of mHealth are beyond the scope of this guideline. Other areas beyond this
guideline’s scope include online interactive instruction, in-home monitoring, mobile
applications (apps), wearable technologies, e-mail correspondence, text reminders, and social

© American Telemedicine Association | Page 2
media.

The current document maintains the approach and terminology of the general guidelines. It
contains requirements, recommendations, or actions that are identified by text containing the
key words “shall,” “should,” and “may.” “Shall” indicates a required action whenever feasible
and practical under local conditions. “Should" indicates an optimal recommended action that is
particularly suitable, without mentioning or excluding others. “May” indicates additional points
that may be considered to further optimize the telemental healthcare process.


INTRODUCTION

The guidelines address three aspects of service delivery: administration/management, clinical practice,
and technical design and architecture. Under each aspect, the guidelines are presented in the form of
three levels of expected adherence: “Shall” indicates required action whenever feasible and/or
practical. “Shall not” indicates a proscription or action that is strongly advised against. “Should”
indicates recommended action without excluding others. “May” indicates appropriate actions that are
deemed appropriate but not mandatory to optimize the telemedicine encounter and the patient
experience. These indications are presented in bold letters throughout the document to facilitate their
visibility.

ATA urges health professionals using telemedicine in caring for burn patients in their practices to
familiarize themselves with these guidelines, as well as other clinical guidelines or best practice
standards issued by their professional organizations or societies and to incorporate both sets into their
telemedicine practice. These guidelines pertain to healthcare services delivered via telemedicine when
both patient and provider are within the United States (US). Other jurisdictions may use these guidelines
at their discretion.

A. 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 are outpacing the evidence-
base supporting their effectiveness. Therefore, guidelines for CATMH draw from the general telemental
health evidence base,8-10 child-specific research,11-16 the practice parameters for child and adolescent
psychiatry disorders17 guidelines for the practice of telepsychology,18-19 and the expertise of child and
adolescent telemental health providers.20-27

The guideline (please see Glossary, Appendix A) 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

© American Telemedicine Association | Page 3
care (e.g., case managers, teachers, and other informants). Interventions generally include a caregiver,
sometimes the entire family and members of the youth’ systems of care, such as teachers or daycare
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, master’s 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.

B. Increasing Need for Mental Health Services for Young People

In 2014, the Health Resources and Services Administration’s (HRSA’s) Data Warehouse44 identified 2,000
mental health professional shortage areas designated in non-metropolitan 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 (U.S.) ages 9 to 17, have diagnosable
psychiatric disorders.46 Many others suffer from sub-threshold symptoms and from stress and grief
reactions that benefit from intervention. Younger children are at risk for developmental and behavioral
disorders. In addition, approximately 31% of children are affected by chronic medical conditions47 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 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 specialists59-62 and are anticipated to persist

© American Telemedicine Association | Page 4
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 health care 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 (ACA) has called for the meaningful use
of telehealth technologies to improve health care and population health for all citizens.65-67

C. 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 telemental health 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 telemental health 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. Telemental health 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 telemental health,
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 United States Department of Commerce’s National Telecommunications &
Information Administration73 plans to increase connectivity in rural and other under-served
communities to close the urban-rural divide. A digital divide also persists along economic lines.

Mobile devices provide an emerging way to deliver telemental health, both in supervised and
unsupervised settings. According to the Pew Research Center Internet, Science & Tech Report, in 2015,
approximately 68% of the American population overall has smartphones and 45% have tablet
computers.74 More specifically, 88% of American teens ages 13 to 17 have or have access to a mobile
phone of some kind, and a majority of teens (73%) have smartphones.75 Given adolescents’ technology
literacy and their increasing access to mobile devices, new models can be anticipated for delivering
mental health care 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 telemental health. Guidelines are needed to ensure the quality of such innovative
care.76

© American Telemedicine Association | Page 5
 REVIEW OF TELEMENTAL HEALTH SERVICES WITH YOUTH

The evidence base supporting the feasibility, acceptability and effectiveness of telemental health with
children and adolescents is emerging incrementally.

A. Clinical Interventions and the Supporting Evidence-Base

Telemental health 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 telemental heath across the
lifespan following rigorous inclusion criteria concluded that there is strong and consistent evidence of
the feasibility of telemental health, 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 telemental health 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 primary care providers
(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 telemental health42 and suggest effectiveness.

The delivery of pharmacotherapy through telemental health has been described with youth in schools,98
mental health centers and daycare,39 outpatient settings31, 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 and colleagues8
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 and colleagues9 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

© American Telemedicine Association | Page 6
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 Patton27 identified ten
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 disorders104 and telemental health 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-post designs, 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 obesity107 and adolescents on
home parenteral nutrition and their caregivers.108

Several randomized trials of psychotherapy are noteworthy. Nelson and colleagues found comparable
reductions for childhood depressive symptoms treated with eight sessions of cognitive-behavioral
therapy (CBT) delivered through videoconferencing versus in-person.13, 109 Two small randomized trials15,
110
tested the effectiveness of treatment for obsessive-compulsive disorder (OCD) and found that
compared to youth treated in-person those treated through telemental health had comparable or
superior outcomes. The behavioral treatment of tics through telemental health 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, 112, 113

B. Telemental Health Service Delivery to Clinical Settings

Child and adolescent telemental health 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
telemental health 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 daycares. Most reports focus on rural and other
non-metropolitan communities,33 but telemental health care to children in urban settings39 has been
reported. Unsupervised settings including patient homes are emerging points of service delivery which
bring both new benefits and risks.35, 71, 110, 114 Recent presentations described telepsychiatry services to

© American Telemedicine Association | Page 7
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 telemental health 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 telemental health with children and adolescents has focused on direct care12-16, 25-27, 31,
39, 42, 43, 84, 102, 104
and patient-centered consultation with recommendations to the referring primary care
provider for treatment.12, 88, 93, 97, 98, 117 Consultation conferences with a group of primary care providers
has 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 (ECHO) are also being evaluated in ADHD, autism, and other child
behavioral topic areas 119 in order to support primary care practices. Two under-reported areas for child
and adolescent telemental health care include specialist consultation to therapists in distant
communities and to youth in state custody.12

C. Telemental Health Practice in Community Settings

There is a long history of moving mental health care 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, telemental health services are being moved
outside of traditional mental healthcare settings. When telemental health 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, telemental health 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 primary care provider 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 health care 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 Further, 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 telemental health into the pediatric medical
home.126

School-based telemental health 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
telemental health 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

© American Telemedicine Association | Page 8
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 telemental health is the delivery of educational support services, such as counseling, occupational
therapy, or speech therapy, to youth who are home-bound 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
and colleagues have shown good adherence to the American Academy of Pediatrics’ (AAP) guideline-
based evaluation for ADHD when conducted in school settings.135 Reese and colleagues89 have
described an innovative, cost-effective, Integrated Systems Using Telemedicine (ISUT) 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. Telemental health 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
telemental health can deliver multi-systemic therapy, which includes a network of caregivers, school
officials, peers, and neighbors to promote positive behavioral changes. Delivering telemental health
services to such facilities provides challenges to privacy and confidentiality.30, 99-100
Home-based telemental health offers potential advantages to observe the youth in a naturalistic setting
and to practice skills in the lived environment. Comer and colleagues are testing the effectiveness of
telemental health 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 obsessive-
compulsive disorder (OCD).70 Further work in delivering parent-child interaction therapy (PCIT) through
videoconferencing is in progress. Case reports of telemental health services to the home have also
addressed support group services for homebound individuals and their caregivers108 and home-based
services for children who have experienced trauma.32


GUIDELINE FOR THE PRACTICE OF TELEMENTAL
HEALTH WITH YOUTH

The ATA Core and other Telemental Health Guidelines should be consulted for administrative and
technical aspects that are common to most telemedicine application areas. Detailed here are aspects
specific to child and adolescent telemental health.

A. Administration 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 to identify 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

© American Telemedicine Association | Page 9
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 in order to evaluate and improve services offered through new and established
telemental health 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 provider25, 137 and for the distant site.139 This includes determining which disorders meet
medical necessity criteria by third party payers in the jurisdiction in order to ensure sustainability of the
telemental health 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
(CPT) 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 telemental health services among local insurers.

Telemental health organizations and providers shall ensure that appropriate staff is trained and
available to meet the youth’s, the family’s, and provider’s needs before, during, and after telemental
health 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 telemental health 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, case manager, etc.) 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/her competence with evaluating and treating
children and adolescents across telemental health areas, and seek additional training/mentoring if gaps
are noted.

B. 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 onsite
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 onsite 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

© American Telemedicine Association | Page 10
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, etc.) 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 telemental health. 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 primary care providers.
Both adolescents and parents must consent to sharing the information.

Providers shall abide by confidentiality requirements related to both the clinical setting147 and
the school setting148, 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.

C. General Telemental Health Practices with Youth

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

1. Physical Location/Telemental Health Space

There are no specific guidelines for the space in which child and adolescent telemental health
sessions are conducted, but there are some considerations. Providers should communicate the

© American Telemedicine Association | Page 11
specific room requirements to patient sites before clinical services commence. Some remote
sites propose using a small room that accommodates adult telehealth services, or a convenient
conference room, or a medical examination room. All of these may have disadvantages for
telemental health with children and adolescents.20, 24, 42, 43 The room should be large enough for
at least one to two adults to attend and be included on screen. If more individuals will typically
interact with the youth and provider at one time, such as team-based assessments or group
therapy, a larger room should be considered. Both the distant site and originating site should
announce all parties who are present in their respective rooms, regardless of who is on camera.

The room should allow the child to move around, both for the child’s comfort and to allow an
appropriate examination of his/her skill, particularly for younger children whose motor skills and
exploratory abilities may be compromised. Too large a room, such as a conference room, may
allow the child to wander, making it difficult to maintain a presence on screen especially if the
camera at the patient site does not have pan/tilt capabilities. A medical examination room may
overstimulate the child and risk damage to equipment. The choice of room should also be
accessible to youth with mobility challenges. One approach to determine adequate room size
and configuration is to provide room dimensions to the site, ask a staff to sit about eight feet
from the proposed camera placement, and send a digital photograph to the provider to
determine whether there is adequate full body view of both the youth and parent.
The space at the patient site should be conservatively equipped according to the clinical
intervention. For example, psychotherapy sessions may warrant a comfortable but sparsely
decorated room to minimize distractions. Parental training for children’s behavioral disorders
may be facilitated by specific room arrangements to assist the parent in giving “clear
instructions” to the child. Diagnostic sessions are helped by including developmentally
appropriate implements such as a desk and crayons that allow assessment of the child’s fine
motor skills, creativity, and attention span. The child’s eagerness to share and describe his/her
work conveys interpersonal and communication skills. A small selection of toys may be provided
to determine the child’s interests and abilities, but noisy, multiple component, and messy toys
should be avoided as the sensitive microphones will pick up the noise and compromise
conversation. Clean-up after the session makes additional work for staff at the patient site.

Lighting is crucial so that the whole room should be easily visualized and interactions of the
youth and parent appreciated. Natural lighting can change during the day flooding the image on
the screen. Ceiling lighting often casts shadows. Room choice should consider the presence and
placement of windows, generally giving preference to rooms without windows and with
horizontal lighting. Lighting should allow full appreciation of the youth’s facial features or
expressions.

When telemental health sessions are conducted outside of traditional clinic settings, such as
school or home, finding the optimally sized, lighted, and private space may be challenging. In
school settings, the provider should assess whether the school has adequate infrastructure to
support a telemental health program as finding a private space in crowded, under-resourced
schools may be difficult.40,133 Many individuals may participate in the school-based encounter,
including the child, parent, school nurse, teacher(s), administrative personnel, case manager,
social worker, school psychologists, and others.40, 150 The provider should ensure that the room
can accommodate all participating individuals on-screen without obscuring observation of the
youth. When providing group therapy over videoconferencing, the room size should also be

© American Telemedicine Association | Page 12
 reviewed.

When using mobile devices for home-based work with active youth, cases with stands are often
recommended to protect the device as well as deliver a stable video image. Because mobile
devices make it feasible to move throughout the home to observe the child’s behavior, families
may need reminders to set the device on a table in order to maximize the transmission quality
as well as minimize distractions.

2. Presenter Assistance in Telemental Health Sessions

Most community-based settings utilize a presenter (often also the telemedicine coordinator) in
the telemental health encounters151 for both quality care and for reimbursement requirements.
A presenter may be more important for work with young people than with adults due to the
multiple individuals and procedures involved in the youth’s system of care. The provider should
determine the scope of the presenter’s assistance before the session (with scheduling,
paperwork, and socialization to the behavioral health system); during the session (with technical
and clinical support, including taking vital signs and assisting in emergency situations); and after
the session (with implementing recommendations, facilitating referrals, and coordinating with
the youth’s system of care). The provider may decide when to include the presenter in the
session; for example, if the presenter is outside of the room, the provider should determine
how he/she will be contacted to join the sessions should there be a need for assistance. Across
community settings, the provider should consider the training needs of the presenter, including
the ability to work with youth with behavioral health concerns and expectations associated with
the mental health setting (e.g., high level of confidentiality). Ahead of initiating telepractice, the
provider should collaborate with the patient site and the presenter to establish a safety protocol
in the event that the youth expresses imminent dangerousness that requires an intervention or
discloses harm to him/herself that requires mandated reporting to authorities.

3. Patient Appropriateness for Telemental Health Services

There are no established indications or contraindications for telemental health services with
young people, other than the youth or parent refusing services.

If care is delivered in a traditional clinic setting, the provider shall alert staff to any risks to the
youth’s safety so that they can be aware of need to assist or notify security or other resources. If
care is delivered outside of a traditional clinic setting, such as school, the provider shall
determine whether the school will be able to assist with the sessions and ongoing engagement
of student and family.40,133 Prior to initiating telemental health services, the provider should
obtain knowledge of school culture, resources, and capabilities and define expectations within
the school system. The provider should determine if he/she is going to provide direct patient
care or serve as a consultant to school staff, as well as outline the role of school personnel in the
youth’s care. In the school setting, particular attention should be paid to privacy. If care is
delivered at home,32, 35, 70, 71,136 the youth may be at increased risk to elope or to act out. A
responsible, trusted, and capable adult should be onsite and accessible to the provider to assist
in assessing potential harm or to intervene in the situation, if necessary. Families with
maltreatment histories may not be appropriate for remote treatment delivered to unsupervised
settings, such as the home.

© American Telemedicine Association | Page 13
 In some cases, a youth may act out even in the presence of an adult, for example a very
hyperactive preschooler, oppositional child, or uncooperative teen may attack the equipment,
aggress the caregiver, hide, or try to leave. Often, parents of children seeking mental health care
are themselves suffering psychiatric disorders and may be compromised in their ability to
supervise the youth during the videoconferencing sessions. Thus, the provider should conduct a
similar assessment of the ability of the accompanying adult to contain the youth and/or for the
adult him/herself to safely participate in sessions and follow treatment recommendations.

Relative contraindications for child and adolescent telemental health services to consider
include assessment in settings that are not considered neutral, such as the youth’s home or
other care site.71 Examples include child custody assessments, forensic evaluations, and
investigation of allegations of abuse or neglect, family therapy with a history of interpersonal
violence in the family and/or a volatile caregiver/parent. The child may not feel free to be
candid about his/her environment or circumstance with a potentially offending caregiver
nearby. In addition, in the home environment, the provider has less ability to redirect the
situation should the caregiver become angry/lose control. The environment itself may be
intimidating to the youth. Some children with developmental or psychotic disorders may not
tolerate the videoconferencing platform.

Therefore, the provider shall determine appropriateness for the site’s telemental health services
considering the youth’s and parent’s preferences, referral question, developmental and
diagnostic considerations, personnel and other resources available at the patient site. The
provider shall ascertain whether the youth can safely engage in the session either alone or with
the parent in the room and shall ensure that resources at the patient site are able to deal with
any potential risks to the patient, others, or the equipment. The provider shall assess the child's
willingness and capability to follow the provider’s instructions without local adult involvement.

4. Working with Diverse Youth and Families

Telepractice often involves a racial, ethnic, and cultural gap between providers and patients.152
With CATMH’s expanded reach, comes providers’ obligation to assess their competence with
diverse child and adolescent populations. However, there is limited research regarding the
delivery of telemental health services to children and families across cultures. Therefore,
cultural humility153 is recommended, recognizing the life-long, process-oriented approach to
striving toward competency with the vulnerable groups served in telepractice. Following their
discipline’s ethical best practices, providers should consider their patients’ unique needs based
on age, sex, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation,
disability, language, and socioeconomic status154,155 with adaptation to telepractice.3,24,144,156
Providers should carefully attend to both verbal and nonverbal communication clues and
communication styles that may vary across cultures. For instance, storytelling approaches may
be common in some American Indian cultures and additional time should be utilized to
accommodate this preferred style.144 The provider may formulate the patient/client’s needs
within a cultural framework, including consideration of the youth’s cultural identity; cultural
conceptualization of distress; psychosocial stressors and resilience; and cultural features of the
client-provider relationship.114 The impact of technology on the cultural formulation should be
considered. Culturally sensitive protocols should be considered drawing on broad community
input and families’ preferences for bilingual providers from the same cultural background.157, 158

© American Telemedicine Association | Page 14
 A related concern in non-metropolitan communities is the difference from values held by urban
providers, as well as overgeneralizing about rural communities.68, 69 To develop rapport and a
therapeutic alliance, providers may learn about the family’s community, their values, and
resources. The local telemedicine coordinator and/or telepresenter, as well as community
health workers (when available), can provide valuable information about the community to
assist the provider. For example, an urban-based provider may be concerned about guns in the
home of a youth who is depressed, but families in rural communities may not readily remove
guns from the home. A Caucasian provider practicing in a major suburb may not understand that
an Inupiat family living a subsistence lifestyle may not attend appointments during fishing or
hunting season. First generation children in immigrant families may differ in their acculturation
and language from their parents providing complex cultural issues for evaluation. Respectful
questions about cultural and a means of assessing cultural differences should be established so
that the provider can optimize cultural competence in their telepractice with the youth and
parent. A visit to the patient site may help to appreciate cultural differences.

5. Consult Request Data

Information should be available that meets legal and regulatory requirements for referral and
that prepares the provider for the telemental health evaluation and treatment. The assessment
of children and adolescents often requires information beyond that obtained for adults.
Multiple informants are common. Youth often have had prior assessments, such as
developmental evaluations, psychological or educational testing, and implementation of an IEP.
Procedures shall be established between organizations and providers for sharing patient
information relevant to the telemental health evaluation.

6. Clinical Findings and Reports

The sharing of clinical history and results shall comply with established legal and regulatory
requirements. Providers and organizations shall have agreements in place that outline the
procedure for maintaining clinical history and results. For CATMH encounters in community
settings such as schools or correctional settings or in unsupervised settings such as the home,
providers shall establish procedures for information sharing that comply with guidelines
outlined by their professional organizations for care provided outside of traditional clinical
settings.134, 159Care coordination needs across systems of care should be considered in relation
to clinical findings and reports. Best practices in secure data exchange should be followed.

D. Technology Considerations

There is no clear evidence that the specific technology affects the quality of clinical care or
outcomes. The provider should choose videoconferencing technology that is appropriate to and
adequate for the clinical services to be delivered to children and adolescents. Determination of
the optimal technology should consider clinical factors such as assessment of the
developmental mental status examination and monitoring of treatment response, as well as
systems factors such as resources at the patient site, other services available, and timeliness of
services.

© American Telemedicine Association | Page 15
Youth are dependent upon their parents to access care. Therefore, providers should establish a
therapeutic alliance with the parent as well as the youth. The technology may pose a challenge
to alliance-building. Providers may include an introduction to and explanation of the
technology in user-friendly terms and ensure that both youth and parents feel that their
perspectives are understood. As distortion of the video and audio signals can interfere with
alliance-building, the provider should use bandwidth sufficient to detect accurate visual,
auditory, and interactional cues that represent the youth’s and parent’s affective states and
interpersonal relatedness. Sufficient bandwidth is also needed for diagnostic determination and
treatment monitoring. For example, tics may be idiopathic and present prior to any telemental
health appointment or may develop in response to pharmacotherapy. Affective blunting may
be present at initial evaluation due to an autism spectrum disorder, a mood disorder, or
internal stimuli—or may develop as a response to neuroleptic treatment. Sufficient bandwidth
is needed to minimize the time delay in verbal transmission so that the provider can readily
assess any anomalies of the child’s language use, speech and prosody. Younger children’s voices
may not carry as well as adolescents’ or parents’ voices. Therefore, providers should ensure
that microphones are sensitive to the auditory range of adults’, adolescents, and children’s
voices and that they are placed close enough to detect children’s vocal range but not irrelevant
noise due to children’s play or environmental sounds.

Cameras with pan-tilt-zoom capabilities at both the provider’s and patient’s sites have
particular relevance for work with children and adolescents. The provider may establish rapport
with youth by giving them a tour around their office, showing them that no one else is in the
office, as well as scanning the patient’s room to understand who is present. Control of the
camera at the patient site assists in evaluating dysmorphology and developmental anomalies by
zooming in on facial features, and assessing motor and activity skills by following the patient
around the room.

Even with adequate bandwidth and a pan-tilt-zoom camera, it may not be possible to fully
assess eye contact due to the placement of the camera. Assessing eye contact is an essential
component of the developmental evaluation of young people, particularly during a telemental
health encounter when there is decreased access to other non-verbal means of communication
as occurs during a in-person encounter. The provider shall determine whether apparent
decreased eye contact represents a technical limitation or clinical impairment. Providers may
query the youth and parent about the youth’s ability to sustain eye contact and the related
context.

Overall, until further research clarifies the relationship of bandwidth and technology to clinical
outcomes, providers should consider their planned clinical work in the context of the relevant
technology. For example, diagnostic assessments may require higher bandwidth and screen
resolution than ongoing treatment when the provider and client have an established working
alliance. More work is particularly needed to determine whether the delivery of services
through mobile devices affects the quality or outcomes of care.

E. Telemental Health Interventions with Youth

© American Telemedicine Association | Page 16

1. General Assessment, Outcome Evaluation and Psychological Testing

Initial assessment through telemental health should be consistent with professional best
practices such as the AACAP Practice Parameter “Assessment of Children and Adolescents”.160
The provider shall oversee alignment with standards of care and modify accordingly to add
necessary elements (e.g., interpreter) and advocate for additional specialized assessment, as
indicated, even if not available through videoconferencing The provider shall consider all
information necessary to inform decision-making during the time with the patient and family. As
for in-person care, standard clinical assessment shall attend to interview logistics, settings, and
the variety of parties involved. This includes collecting pre-session information, history, mental
status examination, physical examination, laboratory or imaging studies, and other pre-session
information necessary for the service delivery in question. The same attention should be given
to patient engagement strategies and to the patient’s cultural context as in the in-person
setting.81, 144

As documentation of measurement-based care is becoming the standard for usual practice,
providers should document the efficacy of all mental health interventions, any complications of
treatment, and the decision-making taken to improve treatment response and minimize adverse
effects. Providers may use a variety of approaches to documentation, particularly quantitative
measures that can be readily reviewed across providers.

There is little information concerning cognitive and neurocognitive testing of youth using
videoconferencing, either with self-administered or staff-assisted instruments at the patient
sites. Information regarding psychological assessment over videoconferencing is largely a
downward extension from adult findings which reflect that such testing is feasible and accurate
across a variety of adult populations and disorders.2, 161 Reliability and validity of the testing
instrument in the telemental health context should be considered. One study with children and
young adults, compared in-person and videoconferencing modalities to assess
neuropsychological status in rural youth experiencing early onset psychosis and found that
videoconferencing produced higher ratings than the in-person assessments, and that
participants were satisfied with the videoconferencing modality.90 An ongoing pediatric trial
assessing the utility and validity of an autism spectrum disorder (ASD) assessment protocol
conducted via videoconferencing is using well-validated assessment measures (e.g., the Autism
Diagnostic Observation Schedule-Module 1 and the Autism Diagnostic Interview-Revised).
Preliminary results are promising.89

In school-based telemental health, the provider can readily obtain input from the current
teacher in relation to other students in his/her class as well as input from the prior teacher, and
coordinate information from multiple documents as well as rating scales competed online. Such
systems-based assessment lays the foundation for a multi-pronged treatment approach,
consistent with best practices.135

2. Pharmacotherapy

As with adult telemental health practice,2 expert pharmacotherapy is one of the most frequently
requested services for young people. The pharmacotherapy services delivered and the
infrastructure needed at the patient’s and telepsychiatrist’s sites may be determined in part by

© American Telemedicine Association | Page 17
the model of care, i.e., provider-focused consultation, patient-focused consultation,
collaborative care, or direct service. While telepsychiatrists are the most frequent providers of
pharmacotherapy using videoconferencing, the guidance is applicable across providers serving
youth, including developmental pediatricians, general pediatricians, family practice physicians,
nurse practitioners, and physician assistants. Providers delivering pharmacotherapy services
shall be aware of their professional organizations’ positions on telepsychiatry. Procedures
should ensure effective communication between the sites, guide medical record
documentation, and maintain compliance with regulatory guidelines. For direct services, the
telepsychiatrists shall follow the ATA’s general guidelines to establish and communicate to all
parties methods for obtaining initial prescriptions, medication refills, and for reporting and
documenting adverse effects.1,2,3

The delivery of pharmacotherapy via telepsychiatry to children and adolescents is guided by
evidence-based and consensus-based treatments established for traditional in-person
treatment,54 extrapolation from general videoconferencing reports,1, 2, 3, 162 descriptive
telemental health reports with children and adolescents21,22 and the limited outcome studies
conducted with youth.12, 83, 85, 101 The prescribing telepsychiatrist shall comply with the practice
parameters established by the American Academy of Child and Adolescent Psychiatry54,163-164 for
pharmacotherapy in general and for specific disorders. Child and adolescent telepsychiatry may
entail a few considerations beyond in-person care. A high quality audio-video connection helps
to discern details relevant to developmental and clinical examination during both the initial
evaluation and follow-up medication assessments. As parents must consent to
pharmacotherapy for their children under the age of majority, telepsychiatrists shall ensure that
parents understand the risks and benefits of pharmacotherapy and provide educational
information as indicated. Initial medications and refills for non-controlled drugs are provided
through usual procedures established for in-person care.

Federal regulations165 now allow e-prescribing of controlled substances during in-person care.
However, federal legislation regarding the prescription of controlled substances through
videoconferencing165-166 has implications for telemedicine, especially for the treatment of
children with ADHD. The Ryan Haight Online Pharmacy Consumer Protection Act of 2008166 was
designed to expunge illegitimate online pharmacies that dispensed controlled substances
without contact with the individual and without physician oversight. The Act placed certain
restrictions around the practice of “prescribing by means of the internet.” While the Act
specifically designates that telemedicine is an exception to the Act, it technically requires that
providers conduct at least one in-person evaluation of the patient prior to prescribing a
controlled substance via telemedicine. Alternatively, patients being treated by and physically
located in a hospital or clinic registered with the DEA in the presence of a DEA-registered
practitioner may be prescribed controlled substances via telemedicine. The letter of this
legislation is difficult to follow and severely dilutes the value of telemedicine practice. However,
the DEA recently noted that it does not intend to interfere with the legitimate prescribing of
controlled substances during telemedicine practice.167 It has further promised to promulgate
future rules around telemedicine prescribing and to establish a special telemedicine registration.
Unfortunately, these provisions have been left incomplete since 2008. Several states have
enacted legislation to allow the prescription of controlled substances through telemedicine
practice, particularly for telepsychiatry. Providers should carefully review both federal and state
guidelines in establishing their telepractice regarding the prescription of controlled substances
and act in the best interests of their patients.

© American Telemedicine Association | Page 18
 Assessing the effects of pharmacotherapy requires timely follow-up, history from the youth and
parent, input from other relevant adults, assessment of side-effects, and monitoring of selected
physiologic parameters. Adherence to these guidelines will require assistance at the patient site,
for example to monitor vital signs, height and weight.21,22 Telepsychiatrists should ensure that
such assessments are made in accordance with treatment guidelines and that staff obtains
appropriate training in conducting the assessments. They may also consider training staff to
assist with other assessments such as screening for abnormal movements with the Abnormal
Involuntary Movement Scale.168-169 The staff may be instructed in the appropriate dissemination
and completion of rating scales for routine outcomes monitoring or other aids to monitoring
treatment response.12,101, 170-171 If the optimal frequency of follow-up visits is not feasible due to
agency limitations, telepsychiatrists may arrange with a staff at the patient site or the PCP to
check in with the family and communicate findings with the telepsychiatrist. Finally, the
telepsychiatrist may train staff at the patient site to assist in coordinating care with the youth’s
system of care including obtaining any laboratory or imaging studies.

3. Psychotherapy Approaches

There is an increasing request for psychotherapy services for children and adolescents delivered
through videoconferencing to diverse settings including clinics, schools, corrections, and
home.102 As outlined in the general ATA telemental health guidelines, standard practice
guidelines for therapy shall direct psychotherapy services within the telemedicine setting.1,2,3
Evidence-based practice and empirically supported treatments shall be followed and adapted by
the telemental health provider as appropriate for videoconferencing with the child and
adolescent group and their parents. Persons engaged in providing psychotherapy services shall
be aware of their professional organizations positions on telemental health and incorporate the
professional association standards whenever possible.

The provider shall approximate all introductory approaches as in onsite settings, including
introducing the rationale for psychotherapy and building rapport with the youth and parent. The
patient and parent should be encouraged to provide input about strengths and challenges of
delivering services over videoconferencing throughout the course of therapy. Providers shall
provide all key elements of the individual and family approaches. This includes attention to both
session content and process. Psychotherapy outcome should be monitored in ways consistent
with the onsite setting, including monitoring process measures (e.g., relationship, satisfaction)
and clinical outcome measures, as part of continuous improvement processes.

There is very limited information about individual and family therapy with youth using
videoconferencing. Providers should consider adapting best practices and evidence-supported
approaches from the in-person setting,171 following professional guidance around dissemination
and implementation.60 Similarly, providers should follow all best practices in delivering pediatric
psychology interventions.172

To date, no specific theoretical orientation or approach has been contraindicated specific to
telemedicine. Cognitive behavioral approaches are among the most common approaches
reported in the adult and youth literature and may lend themselves to the telemedicine format
due to structure and skills building focus.102 As in in-person settings, best practices with children
and adolescents often include working both together and alone with the child and with his/her
parent. Providers should work with presenters to assist with managing attendees’ entry to the

© American Telemedicine Association | Page 19
 room and participation in the session and to ensure privacy (e.g., no eavesdropping). In home-
based settings, providers should acknowledge their decreased ability to manage attendees and
their reliance on the patient/parent to assist the provider. Some therapy modalities that require
direct one-on-one interaction (e.g., play therapy) may require additional consideration when
implemented through videoconferencing.

Some approaches may require additional coaching of parents rather than direct implementation
by the therapist (e.g., time-out strategies). The expectations concerning parent participation
should be established before service initiation. For example, if telemental health services are
provided at the school setting, the level and means of parent participation should be discussed.

When providing group therapy and support groups over videoconferencing, the provider shall
follow the same best practices utilized in traditional settings. In one model, there is a group at a
distant site and the group leader(s) connects by videoconferencing. In another model, the group
members and the group leader(s) are all at different locations and all connect using multi-point
functions of the technology. The group therapy leader(s) should consider the telepresenting
needs at the distant site. For example, if the presenter is assisting in managing an anger
management group, the presenter may need training ahead of time to defuse possible
outbursts.

4. Case Management

Videoconferencing allows collaboration among multiple participants and input into treatment
plans from various experts regardless of geographic location .2, 3, 173 Coordination of care is
especially important for high risk youth who have multiple agencies involved in their lives.28
These youth may need more frequent clinical contact than can be provided by the CATMH
provider. Therefore, CATMH providers should work with PCPs, clinicians, case managers, and
stakeholders to individualize clinical contacts within the youth’s system of care. 28, 154 These
interim contacts may benefit from indirect collaboration with the CATMH provider, such as
through telephone or email. In order to facilitate care coordination, providers shall share
information with other stakeholders as indicated in the youth’s treatment plan and with
appropriate consent, as well as receive information from such stakeholders to inform the
treatment plan and assess outcome. These care coordination efforts shall follow all best
practices for the secure exchange of clinical information. Finally, those providers employing case
management should follow best practices from onsite case management.

F. Mental Health Emergencies with Youth

Providing mental healthcare to children and adolescents via videoconferencing involves particular
considerations regarding patient safety in both supervised and unsupervised settings.114, 174-176 This is
particularly true as telemental health extends access to underserved populations (e.g., rural
populations, diverse populations) that have increased risk for suicide. In addition to mental health
emergencies, the provider should consider whether there are risks of general health emergencies, such
as services to homebound patients or young people receiving hospice care, and should plan accordingly
with the caregivers. The provider shall abide by the aforementioned legal and regulatory guidelines
(Section 5b) in the jurisdiction where the patient(s) is receiving services. Providers should reference the
ATA Practice Guidelines for Pediatric Telehealth for broader guidance about management of pediatric
emergency contingencies.

© American Telemedicine Association | Page 20

When telemental health services are provided to youth in community settings such as a local clinic,
community-based outpatient clinic, school site, or other facility where dedicated staff may be present,
providers shall become familiar with the facility’s emergency procedures (if already established). If the
facility does not have procedures in place, the provider should coordinate with the patient site to
establish basic procedures, including: 1) identifying local emergency resources and phone numbers; 2)
becoming familiar with location of the nearest hospital emergency department capable of managing
psychiatric emergencies; and 3) having patient’s family / support contact information. 4) collection of
contact information for other local professional associations, such as the city, county or state, provincial
or other regional professional association(s) in case a local referral is needed to follow-up with a local
professional.

If the patient is in a setting without clinical staff (e.g., the home), the provider should discuss emergency
procedures with the patient and caregiver as part of the informed consent process and document the
plan. The plan should include a release of information to contact a family or community member who
could provide support in an emergency, including assisting in evaluating the nature of the emergency
and/or initiating 9-1-1 from the patient’s home telephone. Providers should consider risks to safety in
the patient’s physical environment, such as access to weapons in the home environment, proximity to
windows, or other household hazards. Suffocation is becoming an increasing risk for youth that should
be monitored.177 Providers should also be aware of other youth in the home as this may impact safety
management planning.
Whether an emergency occurs in a clinically supervised or unsupervised setting, the provider shall
consider the potential delay for emergency response due to geographical location. Further, the team
may not have extensive experience in mental health emergencies with youth. The provider should
remain available to the emergency responders to facilitate evaluation and disposition planning.

It is possible that a patient or parent(s) will not cooperate in the youth’s emergency management, which
underlies the practice of involuntary civil commitment. Therefore, any emergency plan shall include
knowledge of local civil commitment law, procedures for commitment, and resources to assist in the
process. Strategies for transportation or other logistical issues in case of an emergency shall be
developed prior to initiating an intervention treatment for patients in clinically unsupervised settings.


ADDITIONAL TELEMENTAL HEALTH CONSIDERATIONS
WITH YOUNG PEOPPLE

A. Ethical Considerations

Ethical considerations may be magnified in the telemental health 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 telemental health
setting, including work with children and families. Practice guidelines from professional organizations
assist in informing best ethical practice. Such organizations include the American Telemedicine
Association,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 and the Ohio Psychological

© American Telemedicine Association | Page 21
Association,185 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 that adheres to ethical telemental health principles shall:

a. Incorporate organizational values and ethics statements into the administrative policies and
procedures for telemental health;
b. Be aware of medical and other professional discipline codes of ethics when using telemental
health;
c. Inform the patient and parent of their rights and responsibilities when receiving care at a
distance (through telemental health) including the right to refuse to use telemental health;
d. Provide patients, parents, and providers with a formal process for resolving ethical
questions and issues that might arise as a result of a telemental health encounter; and
e. Eliminate any conflict of interest to influence decisions made about, for, or with patients
who receive care via telemental health. Best ethical research practices shall also be followed
in telemental health, as in all telemedicine setting.

B. Telemental Health Competencies

The growth of telemental health 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 in order 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, telemental health 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 telemental health competencies has been contextualized using the training
milestones set forth by the Accreditation Council of Graduate Medical Education (ACGME).186 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,
inter-professional practice, and integrated care. There is a growing consensus across allied mental
health disciplines for such competencies.187

Several strategies help providers to build and maintain competencies. Providers and trainees may
complete self-study.114, 188 There is a range of online resources that provide dynamic information on the
changing telemedicine landscape, including: professional organizations;189 telehealth resource
centers;190 federal resources;191 grant-supported resources;192 and private companies. Potential
telemental health providers may shadow an established provider to help consolidate interest and skills,

© American Telemedicine Association | Page 22
or opt not to use telemental health if it is not a good professional fit. Participating in telemental health
committees or professional work groups and ongoing peer-to-peer support build knowledge and skills.
Increasingly, training programs are incorporating telemental health rotations and seminars to teach
technological approaches to health care, as well as to provide experience with improving access to care
for diverse patient populations (e.g., rural families, American Indians).

C. 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 in order to expose them early in their training to both telemental health best
practices and opportunities to work with underserved populations. These experiences may range from
shadowing a telemental health provider to formal telemental health training rotations. The supervisor
may consider the range of telemental health training resources (e.g., online resources, readings,
guidelines, etc.) 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

D. 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.191 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. Telemental health 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 telemental health 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 telemental health 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 lexicon193 and by efforts toward a standard telemental health evaluation
model.194

Emerging behavioral health models195 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 telemental health
services with applications in social media, asynchronous mental health, mHealth, virtual technologies,
virtual reality, augmented reality, intelligent wearable devices, and artificial intelligence—all to improve

© American Telemedicine Association | Page 23
the quality and effectiveness of youth-centered care for all young people in need of mental healthcare
services.


SUMMARY

The evidence-base supporting the effectiveness of CATMH is developing incrementally. The existing
research, published reports, and clinical expertise indicate that CATMH is feasible, acceptable to
referring PCPs as well as to patients and their families, and increases access to care for youth who are
not well served by traditional models of care. Multiple studies have found that the therapeutic
relationship is preserved during sessions. Clinical outcomes appear comparable to the same
interventions delivered in-person and superior to care that is routinely available in distant communities.
Further work is now needed to investigate the range of applications appropriate for CATMH and to
examine their effectiveness.

While awaiting further research to establish an evidence-base, best practices for CATMH indicate
consideration of several modifications from general adult practice. A needs assessment will determine
the feasibility and sustainability of a CATMH program, particularly as scarce resources are allocated to
the adult chronically mentally ill. Legal guidelines may vary for services delivered to youth. Collaborative
relationships are needed with community stakeholders, such as schools and PCPs. The teleprovider must
work carefully with the site to determine the resources required for successful sessions, such as the size
and configuration of the treatment room, its accoutrements, and accommodations for accompanying
adults. The telepresenters’ roles will usually be expanded beyond tasks outlined for adult sessions,
including assistance with behavioral management during the session and coordination with the youths’
system of care between sessions. As for adult telemental health practice, the choice of technologies
should consider resources at both the provider and patient sites, but should additionally consider the
bandwidth, monitor resolution, and camera functionality needed to assess children’s clinical features
and to practice interventions such as teaching parents behavioral management skills.

As the growing need for child- and adolescent-trained mental health providers will not be met in the
foreseeable future, technology will be leveraged to increase access to and improve the quality of mental
healthcare available for all youth. CATMH programs should, and must be, implemented as part of
mainstream mental healthcare.


CONCLUSIONS

To conclude, the ten top, or most salient, modifications of telemental health practice for work with
children and adolescents, includes the following:

• Technology options may vary by site. Providers shall choose videoconferencing technology that
is appropriate to the clinical application. Bandwidth, screen size, and camera functionality all
affect the youth’s developmental assessment including appreciation of motor skills, language
abilities, interests and relatedness.

© American Telemedicine Association | Page 24
• Environment should facilitate the assessment, particularly of younger children, by providing an
adequate room size, furniture arrangement, toys, and activities that allow the youth to engage
with the accompanying parent, presenter, and provider and demonstrate age-appropriate skills.

• Legal and regulatory guidelines vary across states. The provider shall practice within the
jurisdictional policies and regulations for the treatment of youth with particular attention to the
age of majority, consent to care, and mandated reporting. Special attention should focus on
regulatory issues in the treatment of vulnerable youth, such as those in state custody.

• Extended participation of family members, or other relevant adults, is typical of mental health
treatment of children and adolescents, including CATMH. Providers should adhere to usual in-
person practice for including relevant adults, with appropriate modifications for delivering
service through videoconferencing. Extended participation may include a “presenter.” Providers
should consider how the “presenter” may facilitate sessions (e.g., vital signs, assistance with
rating scales, managing active children, assisting with any urgent interventions) and train the
“presenter” accordingly. Providers should consider how the presenter’s involvement may
adversely affect service delivery (e.g., social familiarity with the family, perceived confidentiality,
sharing information with other team members).

• Medication interventions, their therapeutic benefits and adverse effects should be monitored
and documented. Providers may choose the approach to monitoring and documentation.
Medications designated as “controlled substances” by the DEA need special considerations for
CATMH, particularly for the treatment of youth with ADHD.

• Extra-clinic settings are common treatment sites for youth due to their involvement in school-
based health clinics, telemental health consultation to a youth’s system of care, and to
correctional settings. When CATMH services are delivered outside of traditional clinic settings,
providers should work with staff to ensure safety, privacy, appropriate setting, and
accommodations particularly if multiple staff participate in sessions, such as in school IEP
meetings or forensic evaluations.

• Needs assessment may help to determine the site’s readiness and feasibility for implementing a
telemental health treatment service for youth, as well as the potential for sustainability in the
face of multiple competing funding demands.

• Teletherapy should adhere to evidence-based and best practice guidelines developed for in-
person treatment with consideration of modifications needed to reliably implement
interventions through videoconferencing. Providers should work with “presenters” to set up
and facilitate the sessions, as needed. Therapeutic benefits and adverse effects should be
documented.

• Appropriateness for telemental care shall consider safety of the youth, the availability of
supportive adults, the mental health status of those adults, and ability of the site to respond to
any urgent or emergent situations. Safety protocols should be established

• Learn and update competencies with youth. The variety of sites in which mental healthcare
services are delivered to youth (e.g., mental health clinics, primary care clinics, schools,
community sites, home) and the variety of providers (master’s trained therapists, primary care

© American Telemedicine Association | Page 25
 providers, psychologists, psychiatrists, school counselors, behavioral therapists, others) indicate
considerable differences across providers in training and skills for treating youth. Clinicians
providing CATMH services shall ensure their competencies in treating youth and delivering
treatment through videoconferencing.


APPENDIX

REFERENCES

1. Turvey C, Coleman M, Dennison O, Drude K, Goldenson M, Hirsch P, et al. ATA practice guidelines for
video-based online mental health services. Telemed J E Health 2013;19(9):722-730.

2. Grady BJ, Myers KM, Nelson EL, Belz N, Bennett L, Carnahan L, et al. Evidence-based practice for
telemental health. Telemed J E Health 2011;17(2):131-148.

3. Yellowlees P, Shore J, Roberts L. Practice guidelines for videoconferencing-based telemental health–
October 2009. Telemed J E Health 2010;16(10):1074-1089.

4. Spargo G, Karr A, Turvey CL. Technology options for the provision of mental health care through
videoteleconferencing. In: Myers K, Turvey C. eds. Telemental Health: Clinical, Technical and
Administrative Foundation for Evidence-Based Practice. London: Elsevier Insights, 2013:135-151.

5. Chou T, Comer JS, Turvey CL, Karr A, Spargo G. Technological considerations for the delivery of real-time
child telemental health care. J Child Adolesc Psychopharmacol 2016; 26(3):192-197.

6. National Telehealth Technology Assessment Resource Center (TTAC), Toolkits.
www.telehealthtechnology.org. Retrieved August 5, 2016.

7. Yellowlees PM, Odor A, Losif A-M, Parish MB, Nafiz N, Patrice K, et al. Transcultural psychiatry made
simple—Asynchronous telepsychiatry as an approach to providing culturally relevant care. Telemed J E
Health 2013;19(4):259–264.

8. Backhaus A, Agha Z, Maglione ML, Repp A, Ross B, Zuest D, et al. Videoconferencing psychotherapy: A
systematic review. Psychol Serv 2012;9(2):111-131.

9. Gros DF, Morland LA, Greene CJ, Acierno R, Strachan M, Egede LE, et al. Delivery of evidence-based
psychotherapy via video telehealth. J Psychopathol Behav Assess 2013;35(4):506-521.

10. Hilty DM, Ferrer DC, Parish MB, Johnston B, Callahan EJ, Yellowlees PM. The effectiveness of telemental
health: A 2013 review. Telemed J E Health 2013;19(6):444-454.

11. Himle MB, Freitag M, Walther M, Franklin SA, Ely L, Woods DW. A randomized pilot trial comparing
videoconference versus in-person delivery of behavior therapy for childhood tic disorders. Behav Res
Ther 2012;50(9):565-570.

© American Telemedicine Association | Page 26
12. Myers K, Vander Stoep A, Zhou C, McCarty CA, Katon W. Effectiveness of a telehealth service delivery
model for treating attention-deficit/hyperactivity disorder: a community-based randomized controlled
trial. J Am Acad Child Adolesc Psychiatry 2015;54(4):263-274.

13. Nelson EL, Barnard M, Cain S. Treating childhood depression over videoconferencing. Telemed J E Health
2003;9(1):49-55.
14. Slone NC, Reese RJ, McClellan MJ. Telepsychology outcome research with children and adolescents: a
review of the literature. Psychol Serv 2012;9(3):272-292.

15. Storch EA, Caporino NE, Morgan JR, Lewin AB, Rojas A, Brauer L, et al. Preliminary investigation of web-
camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder. Psychiatry
Res 2011;189(3):407-412.

16. Xie Y, Dixon JF, Yee OM, Zhang J, Chen YA, DeAngelo S, et al. A study on the effectiveness of
videoconferencing on teaching parent training skills to parents of children with ADHD. Telemed J E
Health 2013;19(3):192-199.

17. American Academy of Child and Adolescent Psychiatry, Committee on Quality Issues. Practice parameter
for telepsychiatry with children and adolescents. J Am Acad Child Adolesc Psychiatry 2008; 47(12):1468-
1483; Available at: www.jaacap.com/content/pracparam. Retrieved August 5, 2016.

18. American Psychological Association. Guidelines for the practice of telepsychology. 2013. Available at:
http://www.apa.org/practice/guidelines/telepsychology.aspx. Retrieved August 5, 2016.

19. Ohio Psychological Association. Telepsychology Guidelines. 2010. Available at:
http://www.ohpsych.org/psychologists/files/2011/06/OPATelepsychologyGuidelines41710.pdf.
Retrieved August 5, 2016.

20. Cain S, Nelson EL, Myers K. Child and adolescent telepsychiatry. In: Dulcan MK ed. Dulcan’s Textbook of
Child and Adolescent Psychiatry. Washington DC: American Psychiatric Press, 2015: 669-688.

21. Cain S, Sharp S. Telepharmacotherapy for children and adolescents. J Child Adolesc Psychopharmacol
2016;;26(3):221-228.

22. Carlisle LL. Child and adolescent telemental health. In: Myers K, Turvey C. eds. Telemental Health:
Clinical, Technical and Administrative Foundation for Evidence-Based Practice. London: Elsevier Insights,
2013:197-221.

23. Duncan AB, Velasquez SE, Nelson EL. Using videoconferencing to provide psychological services to rural
children and adolescents: A review and case example. J Clin Child Adolesc Psychol, 2014; 43(1):115-127.

24. Gloff N, Lenoue S, Novins D, Myers K. Telemental health for children and adolescents. Int Rev Psychiatry-
Spec Iss: Telepsychiatry 2015;27(6):513-524.

25. Glueck DA. Telepsychiatry in private practice. Child Adolesc Psychiatr Clin N Am 2011;20(1):1-11.

26. Goldstein F, Myers K. Telemental health: A new collaboration for pediatricians and child
psychiatrists. Pediatr Ann 2014;43(2):79-84.

© American Telemedicine Association | Page 27

27. Nelson E, Patton S. Using videoconferencing to deliver individual therapy and pediatric psychology
intervention with children. J Child Adolesc Psychopharmacol 2016; 26(3):212-220.

28. Winters NC, Pumariega A, Work Group on Community, Child, and Adolescent Psychology, Work Group
on Quality Issues. Practice parameter on child and adolescent mental health care in community systems
of care. J Am Acad Child Adolesc Psychiatry 2007;46(2):284-299.

29. Fox KC, Conner P, McCullers E, Waters T. Effect of a behavioural health and specialty care telemedicine
programme on goal attainment for youths in juvenile detention.
J Telemed Telecare 2008;14(5):227-230.

30. Kaliebe KE, Heneghan J, Kim TJ. Telepsychiatry in juvenile justice settings. Child Adolesc Psychiatr Clin N
Am 2011;20(1):113-123.

31. Myers KM, Vander Stoep A, McCarty CA, Klein JB, Palmer NB, Geyer JR, et al. Child and adolescent
telepsychiatry: Variations in utilization, referral patterns and practice trends. J Telemed Telecare
2010;16:128-133.

32. Nelson E, Fennel S, Sosland J, Lassen S, Wendland M, Art W, et al. Telepsychology best practices in
translating evidence-based services for child trauma to the home. Poster presented at the National Child
and Adolescent Psychology Conference, Lawrence, KS, October 2014.

33. Nelson EL, Bui T. Rural telepsychology services for children and adolescents. J Clin
Psychol 2010;66(5):490-501.

34. Nelson E, Carmack A. The use of telemental health services for college students at rural universities.
Poster presented at the American College Health Association conference, Boston, May 2013.

35. Nelson E, Myers K. Home-based child telemental health 101: Clinician perspectives on delivering safe &
effective care. Telemed J E Health 2015;21(5):A-42.

36. Palomares RS, Bufka LF, Baker DC. Critical concerns when incorporating telemental health services in
outpatient settings and private practice. J Child Adolesc Psychopharmacol 2016; 26(3):252-259.

37. Savin D, Garry MT, Zuccaro P, Novins D. Telepsychiatry for treating rural American Indian youth. J Am
Acad Child Adolesc Psychiatry 2006;45:484-488.

38. Savin D, Glueck D A, Chardavoyne J, Yager J, Novins DK. Bridging cultures: Child psychiatry via
videoconferencing. Child Adolesc Psychiatr Clin N Am 2011;20(1):125-134.

39. Spaulding R, Cain S, Sonnenschein K. Urban telepsychiatry: Uncommon service for a common need. Child
Adolesc Psychiatr Clin N Am 2011;20(1):29-39.

40. Stephan SH, Lever N, Bernstein L, Edwards S, Pruitt D. Telemental health in schools. J Child Adolesc
Psychopharmacol 2016;26(3):266-272.
41. Szeftel R, Federico C, Hakak R, Szeftel Z, Jacobson M. Improved access to mental health evaluation for
patients with developmental disabilities using telepsychiatry. J Telemed Telecare 2012;18(6):317-321.

© American Telemedicine Association | Page 28

42. Glueck DA. Establishing therapeutic rapport in telemental health practice. In: Myers K, Turvey C. eds.
Telemental Health: Clinical, Technical and Administrative Foundation for Evidence-Based Practice.
London: Elsevier Insights, 2013:29-46.

43. Goldstein F, Glueck D. Developing rapport and therapeutic alliance during telemental health sessions
with children and adolescents. J Child Adolesc Psychopharmacol 2016; 23(3):204-211.
44. Health Resources and Services Administration (HRSA). Data Warehouse Preformatted Reports. N.D.
Available at: http://datawarehouse.hrsa.gov/tools/hdwreports/Reports.aspx. Retrieved August 5, 2016.

45. Thomas KC, Willis AR, Konrad TR, Holzer CE, Morrissey JP. County-level estimates of mental health
professional shortage in the United States. Psychiatr Serv 2009; 60(10):1323-1328.

46. Centers for Disease Control and Prevention. Mental health surveillance among children–United States,
2005-2011. MMWR Morb Mortal Wkly Rep 2013;62(Suppl;May 16):1-35.

47. Newacheck PW, Taylor WR. Childhood chronic illness: Prevalence, severity, and impact. Am J Public
Health 1992;82:364-371.

48. Weisz JR, Kazdin AE. Evidence-Based Psychotherapies for Children and Adolescents, Second Edition. New
York, NY: Guilford Press, 2010.

49. Roberts MC, Aylward BS, Wu YP eds. Clinical Practice of Pediatric Psychology. New York: Guilford Press,
2014.

50. American Psychological Association. Are psychologists in the states that have the most mental illness?
Monitor on Psychology 2014;45(10):13. Available at:
http://www.apa.org/monitor/2014/11/datapoint.aspx. Retrieved August 5, 2016.

51. Comer JS, Barlow DH. The occasional case against broad dissemination and implementation: Retaining a
role for specialty care in the delivery of psychological treatments. Am Psychol 2014;69(1):1-18.

52. Hyde PS. Report to Congress on the Nation’s Substance Abuse and Mental Health Workforce Issues.
2013;10. Available at: https://store.samhsa.gov/shin/content/PEP13-RTC-BHWORK/PEP13-RTC-
BHWORK.pdf. Retrieved August 5, 2016.

53. Sandler I, Ostrom A, Bitner MJ, Ayers TS, Wolchik S, Daniels VS. Developing effective prevention services
for the real world: A prevention service development model. Am J Community Psychol 2005;35(3-4):127-
142.

54. Walkup J. Practice parameter on the use of psychotropic medication in children and adolescents. J Am
Acad Child Adolesc Psychiatry 2009;48(9):961-973.
55. Merikangas KR, He JP, Burstein M, Swendsen J, Avenevoli S, Case B, et al. Service utilization for lifetime
mental disorders in US adolescents: Results of the National Comorbidity Survey-Adolescent Supplement
(NCS-A). J Am Acad Child Adolesc Psychiatry 2011;50(1):32-45.

56. Association of American Medical Colleges, Center for Workforce Studies. Physician specialty data book.
Washington DC: Association of American Medical Colleges, 2012. Available at:

© American Telemedicine Association | Page 29
 https://www.aamc.org/download/313228/data/2012physicianspecialtydatabook.pdf. Retrieved August
5, 2016.

57. Flaum M. Telemental health as a solution to the widening gap between supply and demand for mental
health services. In: Myers K, Turvey C. eds. Telemental Health: Clinical, Technical and Administrative
Foundation for Evidence-Based Practice. London: Elsevier Insights, 2013:11-25.

58. Thomas CR, Holzer CE. The continuing shortage of child and adolescent psychiatrists. J Am Acad Child
Adolesc Psychiatry 2006;45(9):1023-1031.

59. American Psychological Association. Report on Evidence-Based Practice with Children and Adolescents.
Washington, DC: American Psychological Association, 2008. Available at:
https://www.apa.org/practice/resources/evidence/children-report.pdf. Retrieved August 5, 2016.

60. American Psychological Association. Underserved population: Practice setting matters. 2011. Available
at: http://www.apa.org/workforce/snapshots/2011/underserved-population.pdf. Retrieved August 5,
2016.

61. Kazdin AE, Blase SL. Rebooting psychotherapy research and practice to reduce the burden of mental
illness. Perspect Psychol Sci 2011;6(1):21-37.

62. Michalski DS, Kohout JL. The state of the psychology health service provider workforce. Am Psychol
2011;66(9):825-834.

63. Insel T. Where are we going? Director’s Blog: Psychiatry: National Institute of Mental Health, 2011.
Available at: http://www.nimh.nih.gov/about/director/2011/psychiatry-where-are-we-going.shtml.
Retrieved August 5, 2016.

64. Kirch DG, Henderson MK, Dill MJ. Physician workforce projections in an era of health care reform. Annu
Rev Med 2012;63:435-445.

65. U.S. Department of Health and Human Services. The Affordable Care Act. 2010. Available at:
http://www.hhs.gov/healthcare/about-the-law/read-the-law/index.html. Retrieved August 5, 2016.

66. 111th Congress PL 111-148. Patient Protection and Affordable Care Act. 2010. Available at:
http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf. Retrieved August 5,
2016.

67. Centers for Medicare & Medicaid Services. The Affordable Care Act: Lowering Medicare Costs by
Improving Care. 2013. Available at: http://www.cms.gov/apps/files/ACA-savings-report-2012.pdf.
Retrieved August 5, 2016.

68. Lambert D, Ziller EC, Lenardson JD. Rural children don't receive the mental health care they need.
Research & Policy Brief 2009. Available at:
https://muskie.usm.maine.edu/Publications/rural/pb39/Rural-Children-Mental-Health-Services.pdf.
Retrieved August 5, 2016.

© American Telemedicine Association | Page 30
69. Smalley B, Warren J, Rainer J. Rural Mental Health: Issues, Policies, and Best Practices. New York:
Springer, 2013.

70. Comer JS, Elkins RM, Chan PT, Jones DJ. New methods of service delivery for children’s mental health
care. In: Alfano CA, Beidel D. eds. Comprehensive Evidence-Based Interventions for School-Aged Children
and Adolescents. New York: Wiley, 2014:55-72.

71. Crum KI, Comer JS. Using synchronous videoconferencing to deliver family-based mental healthcare. J
Child Adolesc Psychopharmacol 2016;26(3): 229-234

72. Federal Communications Commission. Broadband progress report and notice of inquiry on immediate
action to accelerate deployment GN Docket No. 14-126. 2015. Available at:
https://apps.fcc.gov/edocs_public/attachmatch/FCC-15-10A1.doc. Retrieved August 5, 2016.

73. U. S. Department of Commerce. National Telecommunications & Information Administration (NTIA),
Broadband Brief No. 2. 2013. Available at: http://www.ntia.doc.gov/report/2013/broadband-availability-
beyond-ruralurban-divide. Retrieved August 5, 2016.

74. Pew Research Center. Internet, Science & Tech Report. Technology device ownership: 2015. Available at:
http://www.pewinternet org/2015/10/29/technology-device-ownership-2015/. Retrieved August 5,
2016.

75. Pew Research Center. Internet, Science & Tech Report. A majority of American teens report access to a
computer, game console, smartphone and a tablet: 2015. Available at: http://www.pewinternet
org/2015/04/09/a-majority-of-american-teens-report-access-to-a-computer-game-console-smartphone-
and-a-tablet/. Retrieved August 5, 2016.

76. Comer JS. Introduction to the special section: Applying new technologies to extend the scope and
accessibility of mental health care. Cogn Behavior Pract, 2015; 22, 253-257

77. Hilty DM, Schoemaker EZ, Myers K, Snowdy CE, Yellowlees PM, Yager J. Need for and steps toward a
clinical guideline for the telemental health care of children and adolescents. J Child Adolesc
Psychopharmacol 2016;26(3):283-295

78. Bashshur RL, Shannon GW, Bashshur N, Yellowlees PM . The empirical evidence for telemedicine
interventions in mental disorders. Telemed J E Health. 2015.[Epub ahead of print]. PMID: 26624248;
PMCID: PMC4744872 [Available on 2017-02-01] DOI: 10.1089/tmj.2015.0206

79. Boydell KM, Volpe T, Kertes A, Greenberg N. A review of the outcomes of the recommendations made
during paediatric telepsychiatry consultations. J Telemed Telecare 2007;13(6):277-281.

80. Boydell KM, Volpe T, Pignatiello A. A qualitative study of young people’s perspectives on receiving
psychiatric services via televideo. J Can Acad Child Adolesc Psychiatry 2010;19(1):5-11.

81. Gibson KL, Coulson H, Miles R, Kakekakekung C, Daniels E., O’Donnell, S. Conversations on telemental
health: listening to remote and rural First Nations communities. Rural Remote Health 2011;11:1656.

© American Telemedicine Association | Page 31
82. Jones AM, Shealy KM, Reid-Quinones K, Moreland AD, Davidson TM, Lopez CM, et al. Guidelines for
establishing a telemental health program to provide evidence-based therapy for trauma-exposed
children and families. Psychol Serv 2014;11(4):398-409.

83. Myers KM, Sulzbacher S, Melzer SM. Telepsychiatry with children and adolescents: Are patients
comparable to those evaluated in usual outpatient care? Telemed J E Health 2004;10:278-285.

84. Myers K, Valentine JM, Melzer SM. Feasibility, acceptability, and sustainability of telepsychiatry for
children and adolescents. Psychiatr Serv 2007;58:1493-1496.

85. Myers KM, Valentine JM. Melzer SM. Child and adolescent telepsychiatry: Utilization and satisfaction.
Telemed J E Health 2008;14:131-137.

86. Wood J, Stathis S, Smith A, Krause J. E-CYMHS: An expansion of a child and youth telepsychiatry model in
Queensland. Australas Psychiatry. 2012;20(4):333-337.

87. Elford DR, White H, Bowering R, Ghandi A, Maddigan B, St. John K, et al. A randomized controlled trial of
child psychiatric assessments conducted using videoconferencing. J Telemed Telecare 2000; 6:73-82.

88. Lau ME, Way BB, Fremont WP. Assessment of SUNY Upstate Medical University's child telepsychiatry
consultation program. Int J Psychiatry Med 2011;42(1):93-104.

89. Reese RM, Jamison R, Wendland M, Fleming K, Braun MJ, Schuttler JO, et al. Evaluating interactive
videoconferencing for assessing symptoms of autism. Telemed J E Health 2013;19(9):671-677.

90. Stain HJ, Payne K, Thienel R, Michie P, Carr V, Kelly B. The feasibility of videoconferencing for
neuropsychological assessments of rural youth experiencing early psychosis. J Telemed Telecare
2011;17(6):328-331.

91. Blackmon LA, Kaak HO, Ranseen J. Consumer satisfaction with telemedicine child psychiatry
consultation in rural Kentucky. Psychiatr Serv 1997;48(11):1464-1466.

92. Elford DR, White H, St. John K, Maddigan B, Ghandi M, Bowering R. A prospective satisfaction study and
cost analysis of a pilot child telepsychiatry service in Newfoundland. J Telemed Telecare 2001;7:73-81.
93. Greenberg N, Boydell KM, Volpe T. Pediatric telepsychiatry in Ontario: Caregiver and service provider
perspectives. J Behav Health Serv Res 2006;33(1):105-111.

94. Hilty DM, Yellowlees PM, Nesbitt TS. Evolution of telepsychiatry to rural sites: changes over time in types
of referral and in primary care providers' knowledge, skills and satisfaction. Gen Hosp Psychiatry
2006;28(5):367-73.

95. Jacob MK, Larson JC, Craighead WE. Establishing a telepsychiatry consultation practice in rural Georgia
for primary care physicians: A feasibility report. Clin Pediatr (Phila) 2011;51(11):1041-1047.

96. Kopel H, Dossetor D. Evaluating satisfaction with a child and adolescent psychological telemedicine
outreach service. J Telemed Telecare 2001;7(2):35-40.

© American Telemedicine Association | Page 32
97. Pakyurek M, Yellowlees P, Hilty D. The child and adolescent telepsychiatry consultation: Can it be a more
effective clinical process for certain patients than conventional practice? Telemed J E Health
2010;16(3):289-292.

98. Kriechman A, Bonham C. Telemental health in primary care. In: Myers K, Turvey C. eds. Telemental
health: Clinical, technical and administrative foundation for evidence-based practice. London: Elsevier,
2013;155-170.

99. Bastastini AB. Improving rehabilitative efforts for juvenile offenders through the use of telemental
healthcare. J Child Adolesc Psychopharmacol 2016;26(3): 273-277.

100. Myers K, Valentine J, Morganthaler R, Melzer S. Telepsychiatry with incarcerated youth. J Adolesc Health
2006;38(6):643-648.

101. Rockhill CM, Tse YJ, Fesinmeyer MD, Garcia J, Myers K. Telepsychiatrists' medication treatment
strategies in the children's attention-deficit/hyperactivity disorder telemental health treatment study. J
Child Adolesc Psychopharmacol 2016:;26(8):662-671.

102. Nelson E, Duncan A. Cognitive-behavioral therapy using televideo. Cogn Behav Pract 2015;22(3):269-
280.

103. Osenbach JE, O'Brien KM, Mishkind M, Smolenski DJ. Synchronous telehealth technologies in
psychotherapy for depression: a meta-analysis. Depress Anxiety 2013;30(11):1058-1067.

104. Anderson KE, Byrne C, Goodyear A, Reichel R, Le Grange D. Telemedicine of family-based treatment for
adolescent anorexia nervosa: A protocol of a treatment development study. J Eat Disord 2015;11(3):25.

105. Davis AM, Sampilo M, Gallagher KS, Landrum Y, Malone B. Treating rural pediatric obesity through
telemedicine: Outcomes from a small randomized controlled trial. J Pediatr Psychol 2013;38(9):932-943.

106. Shaikh U, Cole SL, Marcin JP, Nesbitt TS. Clinical management and patient outcomes among children and
adolescents receiving telemedicine consultations for obesity. Telemed J E Health 2008;14(5):434-440.

107. Cohen GM, Irby MB, Boles K, Jordan C, Skelton JA. Telemedicine and pediatric obesity treatment: Review
of the literature and lessons learned. Clin Obes 2012;2(3-4):103-111.

108. Kim H, Spaulding R, Werkowitch M, Yadrich D, Piamjariyakul U, Gilroy R, Smith CE. Costs of
multidisciplinary parenteral nutrition care provided at a distance via mobile tablets. J Parenter Enteral
Nutr 2014;38(2 Suppl):50S-7S.

109. Nelson E, Barnard M, Cain S. Feasibility of teletherapy for childhood depression. Couns Psychother Res,
Special Technology Edition 2006;6(3):191-195.

110. Comer JS, Furr JM, Cooper-Vince CE, Kerns CE, Chan PT, Edson AL, et al. Internet-delivered, family-based
treatment for early-onset OCD: A preliminary case series. J Clin Child Adolesc Psychol 2014;13(1):74-87

111. Glueckauf RL, Fritz SP, Ecklund-Johnson EP, Liss HJ, Dages P, Carney P. Videoconferencing-based family
counseling for rural teenagers with epilepsy: Phase 1 findings. Rehab Psychol 2002;47(1):49-72.

© American Telemedicine Association | Page 33

112. Reese RJ, Slone NC, Soares N, Sprang R. Telehealth for underserved families: An evidence-based
parenting program. Psychol Serv 2012;9(3):320-322.

113. Tse YJ, McCarty CA, Stoep AV, Myers KM. Teletherapy delivery of caregiver behavior training for children
with attention-deficit hyperactivity disorder. Telemed J E Health 2015;21(6):451-458.

114. Luxton D, Nelson E, Maheu M. A Practitioner’s Guide to Telemental Health. Washington, DC: American
Psychological Association Press, 2016

115. Bodaghi, M. Using telepsychiatry to implement evidence-based practice. Clinical Perspective Presented
at the 63rd Annual Meeting of the American Academy of Child and Adolescent Psychiatry. San Antonio,
Texas, October 29, 2015.

116. Feuer V, Hartselle S, Merson J. Use of telepsychiatry in emergency room settings. Clinical Perspective
Presented at the 63rd Annual Meeting of the American Academy of Child and Adolescent Psychiatry. San
Antonio, Texas. 2015.

117. Pignatiello A, Teshima J, Boydell KM, Minden D, Volpe T, Braunberger PG. Child and youth telepsychiatry
in rural and remote primary care. Child Adolesc Psychiatr Clin N Am 2011;20(1):13-28.

118. Dobbins M, Roberts NK, Vicari SK, Seale D, Bogdanich R, Record J. The consultation conference: A new
model of collaboration for child psychiatry and primary care. Acad Psychiatry 2011; 35(4):260-262.

119. University of New Mexico School of Medicine. Project ECHO. 2016. Available at: http://echo.unm.edu/.
Retrieved August 5, 2016.

120. Hilty DM, Yellowlees PM. Collaborative mental health services using multiple technologies: The new way
to practice and a new standard of practice? J Am Acad Child Adolesc Psychiatry 2015;54(4):245-246.

121. American Academy of Pediatrics. The new morbidity revisited: A renewed commitment to the
psychosocial aspects of pediatric care. Pediatrics 2001;108(5):1227-1230.

122. Yellowlees PM, Hilty DM, Marks SL, Neufeld J, Bourgeois JA. A retrospective analysis of a child and
adolescent eMental Health program. J Am Acad Child Adolesc Psychiatry 2008;47(1):103-107.

123. American Academy of Pediatrics. Committee on Pediatric Workforce. 2015. Available at:
https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Pages/Committee-on-
Pediatric-Workforce.aspx. Retrieved August 5, 2016.

124. Fortney JC, Pyne JM, Edlund MJ, Williams DK, Robinson DE, Mittal D, Henderson KL. A randomized trial
of telemedicine-based collaborative care for depression. J Gen Intern Med 2007;22(8):1086-1093.

125. Fortney JC, Pyne JM, Mouden SB, Mittal D, Hudson TJ, Schroeder GW, Rost K. M. Practice-based versus
telemedicine-based collaborative care for depression in rural federally qualified health centers: a
pragmatic randomized comparative effectiveness trial. Am J Psychiatry 2013;170(4):414-425.

© American Telemedicine Association | Page 34
126. McWilliams JK. Integrating telemental healthcare with the patient-centered medical home model. J Child
Adolesc Psychopharmacol 2016; 26(3):278-282.

127. Freeman KA, Duke DC, Harris MA. Behavioral health care for adolescents with poorly controlled diabetes
via Skype: Does working alliance remain intact? J Diabetes Sci Technol 2013; 7(3): 727-735.

128. Clawson B, Selden M, Lacks M, Deaton AV, Hall B, Bach R. Complex pediatric feeding disorders: Using
teleconferencing technology to improve access to a treatment program. Pediatr Nurs 2008;34(3):213-
216.

129. Mulgrew KW, Shaikh U, Nettiksimmons J. Comparison of parent satisfaction with care for childhood
obesity delivered in-person and by telemedicine. Telemed J E Health 2011;17:383-387.

130. Witmans MB, Dick B, Good J, Schoepp G, Dosman C, Hawkins ME, et al. Delivery of pediatric sleep
services via telehealth: The Alberta experience and lessons learned. Behav Sleep Med 2008;6:207-219.

131. Hommel KA, Hente E, Herzer M, Ingerski LM, Denson LA. Telehealth behavioral treatment for medication
nonadherence: A pilot and feasibility study. Eur J Gastroenterol Hepatol 2013;25(4);469-473.

132. Lipana LS, Bindal D, Nettiksimmons J, Shaikh U. Telemedicine and in-person care for pediatric
obesity. Telemed J E Health 2013;19(10):806-808.

133. Grady BJ, Lever N, Cunningham D, Stephan S. Telepsychiatry and school mental health. Child Adolesc
Psychiatr Clin N Am 2011;20(1):81-94. 134. Cunningham DL, Connors EH, Lever N, Stephan SH. Providers'
perspectives: Utilizing telepsychiatry in schools. Telemed J E Health 2013;19(10):794-799.

134. Walter HJ, Berkovitz IH. Practice parameter for psychiatric consultation to schools. J Am Acad Child
Adolesc Psychiatry 2005;44(10):1068-1083.

135. Nelson E, Duncan AB, Peacock G, Bui T. Telemedicine and adherence to national guidelines for ADHD
evaluation: A case study. Psychol Serv 2012;9(3):293-297.

136. Comer JS, Furr JM, Cooper-Vince C, Madigan RJ, Chow C, Chan P, et al. Rationale and considerations for
the internet-based delivery of parent-child interaction therapy. Cogn Behav Pract 2014;22(3):302-316.

137. Glueck DA. Business aspects of telemental health in private practice. In: Myers K, Turvey C. eds.
Telemental Health: Clinical, Technical and administrative foundation for evidence- based practice.
London: Elsevier, 2013:111-133.

138. U.S. Department of Health and Human Services. Increasing access to behavioral health care through
technology. Meeting Summary for March 30, 2012. Rockville, MD, 2013. Available at:
http://www.hrsa.gov/publichealth/clinical/BehavioralHealth/behavioralhealthcareaccess.pdf. Retrieved
August 5, 2016.

139. Lambert D, Gale J, Hartley D, Croll Z, Hansen A. Understanding the business case for telemental health
in rural communities. J Behav Health Serv Res. 2016; 43(3): 366–379.

© American Telemedicine Association | Page 35
140. Webside Matters: The Telehealth Report. Telemedicine Reimbursement, A Guide to Getting Paid, 2015.
Available at: https://www.americanwell.com/telemedicine-reimbursement/. Retrieved August 30, 2016.

141. Thomas L, Capistrant G. American Telemedicine Association. State telemedicine gaps analysis:. Coverage
& reimbursement–Parity laws for private insurance. 2016. Available at:
https://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/3c09839a-fffd-46f7-916c-
692c11d78933/UploadedImages/Policy/State%20Policy%20Resource%20Center/Coverage%20-
%202016_50-state-telehealth-gaps-analysis--coverage-and-reimbursement.pdf . Retrieved August 30,
2016.

142. Center for Connected Health Policy, the National Telehealth Policy Resource Center. State

telehealth policies and reimbursement schedules, a comprehensive plan for the 50 States
and District of Columbia. 2016. Available at: http://cchpca.org/state-laws-and-reimbursement-policies.
Retrieved August 5, 2016.

143. American Medical Association, CPT: 2015 Standard Current Procedural Terminology (CPT) Standard
Edition, American Medical Association, October 2014.

144. Brooks E, Spargo G, Yellowlees P, O’Neil P, Shore J. Integrating culturally appropriate care into
telemental health practice. In: Myers K, Turvey C. eds. Telemental Health: Clinical, Technical and
Administrative Foundation for Evidence-Based Practice. London: Elsevier Insights, 2013:63-79.

145. Kramer GM, Mishkind MC, Luxton DD, Shore JH. Managing risk and protecting privacy in telemental
health: an overview of legal, regulatory, and risk management issues. In: Myers K, Turvey C. eds.
Telemental Health: Clinical, Technical and Administrative Foundation for Evidence-Based Practice.
London: Elsevier Insights, 2013;83-107.

146. Kramer GM, Luxton DD. Telemental health for children and adolescents: An overview of legal,
regulatory, and risk management issues. J Child Adolesc Psychopharmacol 2016;, 26(3): 198-203.
147. U.S. Department of Health and Human Services. (2016). Summary of the HIPAA Privacy Rule. Available at:
http://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html. Retrieved August 5,
2016.

148. U.S Department of Health and Human Services. (2008). Joint guidance on the application of the Family
Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of
1996 (HIPAA) to student health records. Available at: http://www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-
hipaa-guidance.pdf. Retrieved August 5, 2016.

149. U.S. Department of Education (2015). Family Educational Rights and Privacy Act Regulations (FERPA).
Title 34: Education. Part 99-Family Educational Rights and Privacy. Available at
http://www2.ed.gov/policy/gen/reg/ferpa/index.html. Retrieved August 5, 2016.

150. Nelson E, Velasquez SE. Implementing psychological services over telemedicine. Prof Psychol Res Pr
2011;42:535-542.

151. Leenknecht CK, Winters JM, Antoniotti N, Workgroup on Telepresenting Standards and Guidelines.
Expert consensus recommendations for videoconferencing-based telepresenting. Washington, DC:

© American Telemedicine Association | Page 36
 American Telemedicine Association, 2011. Available at: http://www.americantelemed.org/docs/default-
source/standards/expert-consensus-recommendations-for-videoconferencing-based-
telepresenting.pdf?sfvrsn=4. Retrieved August 5, 2016.

152. Myers KM, Cain S, Workgroup on Quality. Practice parameter for telepsychiatry with children and
adolescents. J Am Acad Child Adolesc Psychiatry 2008;47(12):1468-1483.

153. Hook JN, Davis DE, Owen J, Worthington Jr EL, Utsey SO. Cultural humility: Measuring openness to
culturally diverse client/patients. J Couns Psychol 2013;60(3):353-366.
154. Pumariega AJ, Rothe E, Mian A, Carlisle L, Toppelberg C, Harris T, et al. Practice parameter for cultural
competence in child and adolescent psychiatric practice. J Am Acad Child Adolesc Psychiatry
2013;52(10):1101-1115.

155. U.S. Department of Health and Human Services. Indicators of Cultural Competence in Health Care
Delivery Organizations: An Organizational Cultural Competence Assessment Profile. 2002. Available at:
http://www.hrsa.gov/CulturalCompetence/healthdlvr.pdf. Retrieved August 5, 2016.

156. Kataoka S, Novins D, DeCarlo Santiago C. The practice of evidence-based treatments in ethnic minority
youth. Child Adolesc Psychiatr Clin N Am 2010;19(4):775-789.

157. Chong J, Moreno F. Feasibility and acceptability of clinic-based telepsychiatry for low-income Hispanic
primary care patients. Telemed J E Health 2012;18(4):297-304.

158. Ye J, Shim R, Lukaszewski T, Yun K, Kim SH, Ruth G. Telepsychiatry services for Korean immigrants.
Telemed J E Health 2012;18(10):797-802.

159. Penn JV, Thomas C. Practice parameter for the assessment and treatment of youth in juvenile detention
and correctional facilities. J Am Acad Child Adolesc Psychiatry 2005;44(10):1085-1098.

160. King RA. Practice parameters for the psychiatric assessment of children and adolescents. J Am Acad Child
Adolesc Psychiatry 1997;36(10):4S-20S.

161. Collum MC, Grosch MC. Special considerations in conducting neuropsychology assessment over
videoteleconferencing. In: Myers K, Turvey CL. eds. Telemental Health: Clinical, Technical, and
Administrative Foundations for Evidence-Based Practice. London: Elsevier Insights, 2013:275-293.

162. Rockhill CM. Special considerations for conducting psychopharmacologic treatment over
videoteleconferencing. In: Myers K, Turvey C. eds. Telemental Health: Clinical, Technical and
Administrative Foundation for Evidence-Based Practice. London: Elsevier Insights, 2013:315-343.

163. American Academy of Child and Adolescent Psychiatry. Practice parameter on the use of psychotropic
medication in children and adolescents. J Am Acad Child Adolesc Psychiatry 2009;48(9):961-973.

164. American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of stimulant
medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry
2002, 41(2 Supplement): 26S–49S.

© American Telemedicine Association | Page 37
165. U.S. Department of Justice (USDOJ). DEA Website. N.D. Available at:
http://www.deadiversion.usdoj.gov/21cfr/cfr/1300/1300_04.htm. Retrieved August 5, 2016.

166. 110th Congress PL 110-425. Ryan Haight Online Pharmacy Consumer Protection Act. 2008. Available at:
https://www.gpo.gov/fdsys/pkg/PLAW-110publ425/html/PLAW-110publ425.htm. Retrieved August 5,
2016.

167. James Arnold, Chief, Liaison & Policy Section, Drug Enforcement Administration, United States
Department of Justice. Telemedicine and the Controlled Substances Act. Presentation at the Short
Course, 21st Annual Meeting of the American Telemedicine Association, Minneapolis MN, May 2016.

168. Amarendran V, George A, Gersappe V, Krishnaswamy S, Warren C. The reliability of telepsychiatry for a
neuropsychiatric assessment. Telemed J E Health 2011;17(3):223-225.

169. Northern Arizona Regional Behavioral Health Authority. AIMS Test Demonstration video. N.D. Available
at: www.rbha.net/presentations/AIMSDemo/player.html. Retrieved August 5, 2016.

170. Liu F, Rockhill CM. Innovative use of technologies to improve quality of child mental health care.
Presented at the 62nd Annual Meeting of the American Academy of Child and Adolescent Psychiatry.
San Antonio, Texas, 2015.

171. Society of Clinical Child & Adolescent Psychology. Online Training in Evidence-Based Practice. 2015.
Available at: https://www.clinicalchildpsychology.org/practice-resources-0. Retrieved August 5, 2016.

172. American Psychological Association. Division 54 evidence-based practice resources. 2016. Available at:
http://www.apadivisions.org/division-54/evidence-based/. Retrieved August 5, 2016.

173. Grady BJ, Myers KM, Nelson EL, Belz N, Bennett L, Carnahan L, et al. Telemental Health Standards and
Guidelines Working Group. Practice guidelines for videoconferencing-based telemental health. 2009.
Available at: http://www.americantelemed.org/docs/default-source/standards/practice-guidelines-for-
videoconferencing-based-telemental-health.pdf?sfvrsn=6. Retrieved August 5, 2016.

174. Luxton DD, O'Brien K, McCann RA, Mishkind MC. Home-based telemental healthcare safety planning:
what you need to know. Telemed J E Health 2012;18(8):629-633.

175. Luxton DD, Sirotin AP, Mishkind MC. Safety of telemental healthcare delivered to clinically unsupervised
settings: A systematic review. Telemed J E Health 2010;16(6):705-711.

176. Shore JH, Hilty DM, Yellowlees P. Emergency management guidelines for telepsychiatry. Gen Hosp
Psychiatry 2007;29(3):199-206.

177. Sullivan EM, Annest JL, Simon TR, Luo F, Dahlberg LL. Suicide trends among aged 10–24 Years—United
States, 1994-2012. MMWR Morb Mortal Wkly Rep 2015;64(08):201-205.

178. Nelson EL, Davis K, Velasquez S. Ethical considerations in providing mental health services over
videoconferencing. In: Myers K, Turvey C. eds. Telemental Health: Clinical, Technical and Administrative
Foundation for Evidence-Based Practice. London: Elsevier Insights, 2013:47-60.

© American Telemedicine Association | Page 38
179. American Telemedicine Association. Telemedicine practice guidelines. 2012. Available at:
http://www.americantelemed.org/resources/telemedicine-practice-guidelines/telemedicine-practice-
guidelines#.VbliHsjn_Qw. Retrieved August 5, 2016.
180. American Academy of Child and Adolescent Psychiatry. Code of ethics. 2009. Available at:
https://www.aacap.org/App_Themes/AACAP/docs/about_us/transparency_portal/aacap_code_of_ethi
cs_2012.pdf. Retrieved August 5, 2016.

181. American Academy of Child and Adolescent Psychiatry. Practice Parameters. 2016. Available at:
http://www.aacap.org/aacap/resources_for_primary_care/practice_parameters_and_resource_centers
/practice_parameters.aspx. Retrieved August 5, 2016.

182. American Psychiatric Association, Ethics Committee. Position Statement on the Ethical Use of
Telemedicine. Washington, DC: American Psychiatric Association Press, 2007.

183. National Association of Social Workers. Standards for Technology and Social Work Practice. 2005.
Available at: https://www.socialworkers.org/practice/standards/naswtechnologystandards.pdf.
Retrieved August 5, 2016.

184. National Board for Certified Counselors. The Provision of Distance Professional Services 2012. Available
at: http://www.nbcc.org/Assets/Ethics/NBCCPolicyRegardingPracticeofDistanceCounselingBoard.pdf.
Retrieved August 5, 2016.

185. Ohio Psychological Association. Telepsychology Guidelines. 2010. Available at:
http://www.ohpsych.org/psychologists/files/2011/06/OPATelepsychologyGuidelines41710.pdf.
Retrieved August 5, 2016.

186. Hilty DM, Crawford A, Teshima J, Chan S, Sunderji N, Yellowlees PM, et al. A framework for
telepsychiatric training and e-health: Competency-based education, evaluation and implications. Int Rev
Psychiatry-Special Issue 2015;27(6):569-592.

187. Hilty DM, Maheu M, Hertlein K, Long R, Randall A, Drude K: The need for e-behavioral health
competencies: an approach based on competency frameworks and common themes across fields. J
Technology in Behav Sci, In Press

188. Myers K, Turvey C. Telemental Health: Clinical, Technical and Administrative Foundation for Evidence-
Based Practice. London: Elsevier Insights, 2013.

189. American Telemedicine Association. Learning Center, delivering online video based mental health
services. 2014. Available at: http://www.americantelemed.org/news-landing/2014/06/20/american-
telemedicine-association-launches-online-telemental-health-course#.VomnGY3MvmQ. Retrieved
August 5, 2016.

190. Office for the Advancement of Telehealth (OAT). Telehealth Resource Centers. 2015. Available at:
http://www.telehealthresourcecenter.org/. Retrieved August 5, 2016.

191. SAMHSA-HRSA Center for Integrated Health Solutions. Telebehavioral Health Training and Technical
Assistance. N.D. Available at: http://www.integration.samhsa.gov/operations-
administration/telebehavioral-health. Retrieved August 5, 2016.

© American Telemedicine Association | Page 39

192. University of Colorado. Telemental health guide. N.D. Available at: http://www.tmhguide.org/.
Retrieved August 5, 2016.

193. American Telemedicine Association. A Lexicon of Assessment and Outcome Measurements for
Telemental Health. 2013. Available at:
http://www.americantelemed.org/docs/default-source/standards/a-lexicon-of-assessment-and-
outcome-measurements-for-telemental-health.pdf?sfvrsn=2. Retrieved August 5, 2016.

194. Kramer GM, Shore JH, Mishkind MC, Friedl KE, Poropatich RK, Gahm GA. A standard telemental health
evaluation model: the time is now. Telemed J E Health 2012;18(4):309-313.

195. Mohr DC, Burns MN, Schueller SM, Clarke G, Klinkman M. Behavioral intervention technologies:
evidence review and recommendations for future research in mental health. Gen Hosp Psychiatry
2013;35(4):332-338.

196. American Telemedicine Association. Telemedicine nomenclature. 2012. Available at:
http://www.americantelemed.org/resources/nomenclature#.Vez8xxFViko. Retrieved August 5, 2016.

197. California Telemedicine & eHealth Center. A glossary of telemedicine and ehealth. 2006. Available at:
http://www.caltrc.org/wp-content/uploads/2013/10/ctec_glossary_final.pdf. Retrieved August 5, 2016.

198. World Health Organization (WHO). Mental health: A state of well-being. 2014. Available at:
http://www.who.int/features/factfiles/mental_health/en/. Retrieved August 5, 2016.

199. Centers for Disease Control and Prevention. Mental health basics. 2013. Available at:
http://www.cdc.gov/mentalhealth/basics.htm. Retrieved August 5, 2016.


GLOSSARY

This guideline uses the nomenclature set forth by the American Telemedicine Association,196 and used in
other guidelines as well as the California Telemedicine and eHealth Center Glossary.197 Several terms
specific to child and adolescent mental health follow:

• Young people or youth: the guideline is broadly inclusive of children and adolescents across the
0-21 year age range, as defined by the National Institutes of Health. If a section is specific to
children or adolescents, the guideline uses that developmentally specific term. For youth being
seen through telemental health, the terms “patient” and “client” are used interchangeably.

• Parents: the adults with responsibility for caring for the youth, including biological parents,
adoptive parents, foster parents, relatives, and other adult guardians who are in the parenting
role.
• Mental health: “a state of well-being in which the individual realizes his or her own abilities, can
cope with the normal stresses of life, can work productively and fruitfully, and is able to make a
contribution to his or her community.”198

© American Telemedicine Association | Page 40
• Mental illness: “collectively all diagnosable mental disorders” or “health conditions that are
characterized by alterations in thinking, mood, or behavior (or some combination thereof)
associated with distress and/or impaired functioning.” In this guideline we also include youth
with developmental disabilities who present for mental health care.199

• Mental health services: services that promote mental health and/or intervene in relation to
mental illness, including prevention, assessment, treatment, consultation, and
maintenance/support

• Providers: also called “teleproviders”. Any licensed professional using videoconferencing to
provide care synchronously regardless of discipline.

• Telemedicine: the use of medical information exchanged from one site to another via electronic
communications to improve patients' health status.

• Telehealth: the term is often used to encompass a broader definition of remote healthcare that
does not always involve clinical services. Videoconferencing, transmission of still images,
eHealth including patient portals, remote monitoring of vital signs, continuing medical
education and nursing call centers are all considered part of telemedicine and telehealth.

• Telemental health: also called telebehavioral health. An umbrella term to refer to all of the
names and types of behavioral and mental health services that are provided via synchronous
telecommunications technologies.

• Telepractice: The clinical practice of mental health care through videoconferencing.

• Telepsychiatry: the specific provision of psychiatric care through videoconferencing

• Telepsychology: the specific provision of psychological care through videoconferencing.

• Presenter (Patient Presenter), also known as a telepresenter: An individual with a clinical
background trained in the use of telehealth equipment who must be available at the originating
site to “present” the patient, manage the cameras and perform any “hands-on” activities to
complete the tele-exam successfully

• Facilitator, also known as a telefacilitator: An individual who may or may not have a clinical
background who is present with the patient during a telemedicine encounter. Responsibilities
may vary with practice site, but may include scheduling, organizing, executing the connection
and/or patient presenter functions. Examples may include a clinical provider, support staff or
parent/guardian.

• Telemedicine coordinator: the telemedicine coordinator is often the presenter. This
professional, at the patient site, serves as a liaison between the provider and the family and
assists with scheduling, paperwork, and follow-up.
• Provider Site: the location of the clinician rendering the specialty or consultative services. This
has been referred to as the “remote site” or “hub” for programs that coordinate services to
multiple patient sites.

© American Telemedicine Association | Page 41
 • Patient Site: The site where the patient is presented during a telemedicine encounter, or where
the professional requesting consultation with a specialist is located. This has been referred to as
the “originating site” or the “spoke site” for programs that deliver services to multiple different
sites. For clarity we use the term patient site.

• Videoconferencing: Also called televideo or videoteleconferencing. Interactive teleconferencing
with video capabilities.

• Clinically supervised setting. Telemental health settings with clinical staff on site with the youth,
most often including a presenter.

• Clinically unsupervised setting. Telemental health settings without clinical staff on site with the
youth, such as when care is provided directly to a patient who is located in his or her home at
the time of the contact.


TABLE: EFFECTIVENESS OF CHILD AND ADOLESCENT TELEMENTAL HEALTH


EFFECTIVENESS OF CHILD AND ADOLESCENT TELEMENTAL HEALTH

CITATION SAMPLE & TOPIC ASSESSMENT METHODS COMMENTS ON FINDINGS
Outcome of Randomized Controlled Trials by Disorder
13
Nelson et al., 28 youth Diagnostic interview and rating scale CBT intervention for depression;
2003 (age 8-14 years; M=10.3 for depression TMH and in-person intervention
years) showed comparable reduction in
depressive symptoms
Depression

15
Storch et al., 31 youth Diagnostic interview and rating scales TMH superior to in-person
2011 (age 7-16 y/o; M=11.1 y/o) for OCD, anxiety and depression intervention on all measures

OCD

11
Himle et al., 20 children Diagnostic interview and rating scales TMH and in-person interventions
2012 (age 8-17y/o) for tic disorders and functional showed comparable symptom
impairment reduction and functional
Tourette’s Disorder or improvements
Chronic Motor Tic Disorder
16
Xie, et al., 22 children Symptom rating scales, parenting skills, TMH-service delivery as effective
2013 (age 6-14y/o) functional impairment as in-person delivery for parent
skills and children’s improved
ADHD and Behavioral behaviors
disorders
12
Myers et al., 223 youth Diagnostic interview, symptom rating TMH short term intervention was
2015 (age 5 – 12 y/o) scales, functional impairment more effective than single PCP
teleconsultation in improving
ADHD and ODD ADHD, ODD, role performance
and impairment

© American Telemedicine Association | Page 42
 113
Tse et al., 38 youth Diagnostic interview, symptom rating TMH delivery of parent training as
2015 (ages 5 to 12 y/o) scales, functional improvement effective as in-person delivery

ADHD and ODD
110
Comer et al., 22 children Family-based CBT for OCD; utilization, TMH was feasible for the delivery
2016 (4-8 y/o; M=6.5 y/o) engagement, satisfaction rating scales, of FB-CBT; Symptom and
functional impairment. functioning utcomes were
OCD comparable for TMH and in-
person treatment at post-
treatment and follow-up

Pre-Post or Comparison Studies

Glueckauf et al., 22 adolescents Symptom rating scales, alliance, issue- TMH, telephone, and in-person
111
(age: M=15.4y/o) specific measures of family problems, equally effective in reduction of
2002 36 parents adherence to treatment symptoms and problem severity.
Therapeutic alliance high.
Family conflict and children
with epilepsy
29
Fox, et al., 190 youth in juvenile Attainment of goals formulated during TMH services were associated
2008 detention incarceration with teens’ attaining goals
(age 12-19 y/o; M=17 y/o) formulated during incarceration
to improve family relations and
Goal Attainment problematic behaviors.
Yellowlees, et 41 children in an e-mental Broad band rating scale assessing Videoconsultation to PCPs
122
al., health program spectrum of behavior and symptoms associated with 3-month
2008 (Child Behavior Checklist) improvements in the Affect and
Oppositional behaviors in Oppositional Domains of the Child
boys; Affective symptoms Behavior Checklist.
in girls
112
Reese et al., 8 children Parenting intervention’ rating scales TMH associated with improved
2012 (age: M=7.6 y/o child behaviors and decreased
parent distress
ADHD

Satisfaction, Feasibility and Utilization Studies

Blackmon et al., 43 children Consultation evaluation scale TMH comparable to in-person
91
(age 2-15 y/o; M=9 y/o) intervention
1997
92
Elford et al., 30 children Questionnaire TMH evaluation associated with
2001 (age: 4-16 y/o; M=13 y/o) high satisfaction of children,
teens, parents, and psychiatrists
Various disorders
96
Kopel et al., 136 “young persons” Questionnaire TMH consultation associated with
2001 Various disorders high satisfaction by families and
rural health workers in Australia.
83
Myers et al., 159 youth Demographic, diagnostic, utilization, TMH patients in distant
2004 (age 3-18 y/o) payer status communities were
demographically and clinically
Various disorders representative of patients in in-
person clinic. More “adverse case
mix” for TMH sample. Parents
endorsed high satisfaction with
care.

Greenberg et al., 35 PCP’s, 12 caregivers Focus groups with PCP’s, interviews PCPs and caregivers in rural
93
(Mean age: 9.3 y/o) with caregivers Canada endorsed high
2006 satisfaction with TMH
Various disorders consultations but frustration with

© American Telemedicine Association | Page 43
 ability to implement
telepsychiatrists’
recommendations
100
Myers et al., 115 incarcerated youth Satisfaction survey Incarcerated youth endorsed high
2006 (age 14-18 y/o) satisfaction with TMH care.
Various disorders Describes diagnostic assessment
and medication management of
incarcerated youth; consultation
with staff
94
Hilty, et al., 15 PCP’s for children and PCP satisfaction survey PCP satisfaction was high and
2006 adults --- 400 patients increased over time
(number of children not
specified)
Various disorders
79
Boydell et al., 100 consultations and 54 Interviews with case managers Multiple system-level and
2007 case managers telepsychiatrists’ recommendations patient-level factors and local
availability of resources affected
Various disorders implementation of
recommendations. Technology
was not identified as an issue
84
Myers et al., 172 patients Satisfaction survey PCPs endorsed high satisfaction
2007 (age 2-21 years old) with TMH services Pediatricians
387 visits more satisfied than family
physicians
Various disorders

85
Myers et al., 172 patients Parent satisfaction survey Parents endorsed high
2008 (age 2-21 y/o) satisfaction with TMH services;
387 visits greater satisfaction for TMH with
children than with teens.
Various disorders

80
Boydell et al., 30 “young people” Qualitative study of youths’ perspective Participants expressed the
2010 importance of their relationship
Various disorders with the psychiatrist and noted
how they actively took
responsibility and exerted control
within the session
31
Myers et al, 190 PCP’s Patient demographics, diagnoses, TMH with young people was
2010 701 patients utilization. feasible and acceptable; variable
(7 to 18 y/o) implementation across
telepsychiatrists
Various disorders
97
Pakyurek et al., 5 Children/adolescent in Descriptive effectiveness General satisfaction; opinion that
2010 primary care TMH may be superior to in-
person for consultation for
Case studies selected patients
88
Lau et al., 45 children and Description of patients referred for TMH reaches a variety of
2011 adolescents consultation, reason for consultation, children, with consultants
(age: 3-17 y/o; M=9.7 y/o) treatment recommendations providing diagnostic clarification
and modifying treatment plans
Various disorders

95
Jacob et al., 15 children Parent Satisfaction Survey Patient satisfaction high and PCPs
2012 (age 4-18 y/o; M=9.73 y/o) found recommendations helpful.

Various disorders

© American Telemedicine Association | Page 44
 135
Nelson et al., 22 youth Chart review TMH delivery of ADHD treatment
2012 (M=9.3 y/o) feasible.

ADHD

41
Szeftel et al., 45 patients – 31 of them Description of utilization, diagnostic TMH consultation altered
2012 under 18 y/o evaluation, symptom severity, diagnosis and changed
medication changes, symptom medication regimen. TMH helped
Developmental disorders improvement PCPs with recommendations for
developmental disabilities.

Diagnostic Validity
87
Elford et al., 25 children Diagnostic interviews TMH evaluation showed 96%
(age 4-16 y/o) concordance with in-person
2000 evaluation.
Various disorders
90
Stain et al., 11 adolescents and young Diagnostic interview TMH-assessed diagnoses were
2011 adults strongly correlated with
(age 14-30 y/o) assessments conducted in-person

Psychotic disorders
89
Reese et al., 21 children Diagnostic interviews, symptom rating TMH and in-person structured
2013 (age: 3-5 y/o) scales, parent satisfaction diagnostic evaluations
comparable in reliability,
Autism accuracy, observer-report and
parent-report of symptoms, and
parent satisfaction

Psychosomatic Pediatrics Interventions

Clawson et al., 15 youth Rating scales for family satisfaction, TMH was feasible with the
128
(age 8 months – 10 y/o) psychiatrists’ satisfaction, outcomes pediatric feeding disorder
2008 population and resulted in cost-
Pediatric feeding disorders savings. Psychiatrists satisfied
with modality
106
Shaikh et al., 99 youth Retrospective review of patient medical TMH consultation associated with
2008 (age 1-17 y/o) records changes to diagnoses. A subtest
of patients with repeated
Obesity and weight sessions showed improved health
management behaviors, weight maintenance,
and/or weight loss
Witmans et al., 89 children Sleep diary; Childhood Sleep Habits; TMH consultation on sleep
130
(age 1-18 y/o; M=7.5 y/o) rating scales; satisfaction survey management was feasible.
2008 Patients were satisfied with the
Sleep disorders delivery of multidisciplinary
pediatric sleep medicine services
through TMH
Mulgrew et al., 25 youth Consulting psychiatrists’ listening skills TMH consultation for weight
129
(age 4-11 y/o) and patients’ ease of understanding management was rated by
2011 instructions, quality of care, satisfaction parents as less effective than in-
person consultations in explaining
Obesity/weight children’s health condition.
management Parents endorsed comparable
satisfaction with the two service
delivery models.
105
Davis et al., 58 youth Family-based multi-disciplinary TMH multi-disciplinary
2013 (age 5-11 y/o; M=8.6 y/o) behavioral group intervention. intervention and a structured PCP
Body Mass Index (BMI), visit showed comparable

© American Telemedicine Association | Page 45
 24-hr dietary recall improvements regarding BMI,
Obesity/weight ActiGraph, rating scales nutrition, physical activity. TMH
management Feeding assessment scale appears a feasible approach to
interventions for weight
management
Freeman et al., 71 youth Family-based behavioral intervention, TMH and in-person service
127
(Mean age=15 y/o) rating scale for therapeutic alliance, delivery showed comparable
2013 service utilization therapeutic alliance for youth
with poorly controlled diabetes
Teens with poorly and their parents. TMH treatment
controlled diabetes of youth with diabetes is feasible
Hommel et al., 9 youth Brief intervention for multi-component TMH intervention for
131
(M=13.7 y/o) non-adherence treatment protocol inflammatory bowel disease is
2013 Pill count, disease severity, feasibility, feasible and well accepted by
acceptability, families with cost savings due to
Inflammatory bowel decreased travel. Adherence to
disease treatment regimen varied for the
medications involved.
132
Lipana et al., 243 youth Review of medical records comparing TMH service delivery was
2013 (M=11 y/o) patients in different service models feasible. Outcomes were
regarding demographics, utilization, comparable to the non-
Obesity/weight diagnostic change, nutrition, activity randomized in-person
management level, screen time, weight management comparison group regarding
enhanced nutrition, increasing
activity, and decreasing screen
time
ADHD: attention-deficit hyperactivity disorder; CBCL: Child Behavior Checklist; CBT: cognitive-behavioral therapy; PCP: primary
care provider; OCD: obsessive compulsive disorder; ODD: oppositional defiant disorder; PCP: primary care provider; TMH:
telemental health

© American Telemedicine Association | Page 46