Child Psychiatry Consult

Telemental health reaches underserved children, builds partnerships


 

The patient, a 10-year-old girl, was exhibiting defiant and angry behavior at home. Her pediatrician in rural Vermont was not able to support the family optimally, so he referred her to Dr. David C. Rettew.

Dr. Rettew soon learned that the girl blamed herself for her father’s absence, and she interpreted efforts by her mother to set limits as evidence that her mom didn’t love her.

Dr. David C. Rettew Courtesy David C. Rettew, MD

Dr. David C. Rettew

“During the course of the interview, it became clear that the girl had some specific thoughts that were likely fueling her anger,” said Dr. Rettew, director of the Pediatric Psychiatry Clinic at the University of Vermont, Burlington. “She also met criteria clearly for ADHD, which had never been diagnosed. The consultation recommendations not only included some possible medications to try, but also some specific areas that could be addressed for psychotherapy that could really help the relationship between this child and her mother.”

The successful intervention took place via a secure, two-way videoconference. It is one example of how physicians at the University of Vermont are using telemental health to treat children in underserved areas. As part of a state-funded training program, child psychiatry fellows at the university consult with primary care doctors at federally qualified health centers across the state. The primary care physicians discuss patient cases with fellows via phone or email and can refer patients for in-person or telemental health assessments.

The program has been running for about 5 years and so far has yielded countless benefits, said Dr. Rettew, who directs the university’s Child and Adolescent Psychiatry Fellowship Program. “It helps keep the care housed and centered within the primary care home. That can help coordination of services so that care isn’t fragmented around multiple centers. It also allows evaluations to happen that wouldn’t happen otherwise because it’s too much of a hardship for families to travel long distances and come for regular follow-up appointments.”

Dr. Allison Y. Hall

Dr. Allison Y. Hall

University of Vermont physicians also use telemedicine to consult with other mental health clinicians across the state. Child psychiatrist Allison Y. Hall provides in-person training to clinicians and then counsels and supervises their efforts through a telemedicine unit.

“For this purpose, it’s great,” said Dr. Hall, who practices at the Vermont Center for Children, Youth, and Families, which is housed within the university’s psychiatry department. “There’s more confidentiality than Skype, for instance. It’s wonderful to be able to reach clinicians at a great distance.”

On a broader scale, telemental health is a promising tool to address the shortage of mental health providers in the United States, said Dr. Robert C. Gunther, a pediatrician at the University of Virginia Health System in Fishersville. Recent research found that one in three children receiving outpatient care for mental health conditions saw only their primary care doctor for care (Pediatrics. 2015 Nov;136;e1178-85).

Dr. Robert C. Gunther

Dr. Robert C. Gunther

“There is a tremendous need for pediatric mental health care,” Dr. Gunther said in an interview. “There is a great shortage of child psychiatrists and other child mental health specialists. Telemental health can help in areas where geography or financial barriers exist to accessing care.”

Data from the Children’s ADHD Telemental Health Treatment Study (CATTS) illustrates the impact that telemental health can have on children facing such barriers to care. Researchers randomized 223 children referred by 88 primary care providers in seven underserved communities into two study groups. Children in the first group were seen by child psychiatrists via videoconference six times over 22 weeks; treatment included pharmacotherapy. Their caregivers received behavior training provided in person by community therapists who were supervised remotely. Children in the second group were treated by their primary care physicians and received one telepsychiatry consult.

Children in both groups improved; however, those randomized to the telemental health model improved “significantly more than patients in the augmented primary care arm” (J Am Acad Child Adolesc Psychiatry. 2015 Apr;54[4]:263-74).

Courtesy David C. Rettew, MD

“The CATTS trial demonstrated the effectiveness of a telehealth service model to treat ADHD in communities with limited access to specialty mental health services,” investigators concluded.

But Dr. Joshua J. Alexander, chair of the American Academy of Pediatrics Section on Telehealth Care, notes that some mental health conditions fit more smoothly within the telemental health model than others. ADHD is the most common condition treated by telemental health, he said. The model also has shown success in the treatment of childhood adjustment disorders, anxiety, oppositional defiant disorder, mood disorders, anxiety, and depression.

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