Remotely delivering real-time parent training to the home: An initial randomized trial of Internet-delivered parent-child interaction therapy (I-PCIT).

OBJECTIVE: Remote technologies are increasingly being leveraged to expand the reach of supported care, but applications to early child-behavior problems have been limited. This is the first controlled trial examining video-teleconferencing to remotely deliver behavioral parent training to the home setting with a live therapist. METHOD: Racially/ethnically diverse children ages 3-5 years with disruptive behavior disorders, and their caregiver(s), using webcams and parent-worn Bluetooth earpieces, participated in a randomized trial comparing Internet-delivered parent-child interaction therapy (I-PCIT) versus standard clinic-based PCIT (N = 40). Major assessments were conducted at baseline, midtreatment, posttreatment, and 6-month follow-up. Linear regressions and hierarchical linear modeling using maximum-likelihood estimation were used to analyze treatment satisfaction, diagnoses, symptoms, functioning, and burden to parents across conditions. RESULTS: Intent-to-treat analyses found 70% and 55% of children treated with I-PCIT and clinic-based PCIT, respectively, showed "treatment response" after treatment, and 55% and 40% of children treated with I-PCIT and clinic-based PCIT, respectively, continued to show "treatment response" at 6-month follow-up. Both treatments had significant effects on children's symptoms and burden to parents, and many effects were very large in magnitude. Most outcomes were comparable across conditions, except that the rate of posttreatment "excellent response" was significantly higher in I-PCIT than in clinic-based PCIT, and I-PCIT was associated with significantly fewer parent-perceived barriers to treatment than clinic-based PCIT. Both treatments were associated with positive engagement, treatment retention, and very high treatment satisfaction. CONCLUSION: Findings build on the small but growing literature supporting the promising role of new technologies for expanding the delivery of behavioral parent training. (PsycINFO Database Record

Teletherapy delivery of caregiver behavior training for children with attention-deficit hyperactivity disorder.

BACKGROUND: Preliminary studies suggest that videoteleconferencing (VTC) may be an effective means to deliver behavioral interventions to families. Subjects consisted of a subsample of children (n=37) and caregivers who participated in the Children's Attention-Deficit Hyperactivity Disorder (ADHD) Telemental Health Treatment Study (CATTS) (n=223), a randomized trial testing the effectiveness of delivering treatments for ADHD to families residing in their home communities using distant technologies. Families randomized to the CATTS intervention arm received pharmacotherapy and caregiver behavior training. MATERIALS AND METHODS: Thirty-seven families from the CATTS intervention arm participated. All families received pharmacotherapy through VTC. Twelve families received the caregiver behavior training through VTC, or teletherapy, and 25 received the intervention in-person. We assessed children's outcomes at 25 weeks with the Vanderbilt ADHD Parent Rating Scale and the Columbia Impairment Scale. We assessed caregivers' outcomes using measures of distress in caring for a child with ADHD, including depression, stress, strain, and empowerment. We used analysis of covariance to assess outcomes from baseline to 25 weeks. RESULTS: Families in the two conditions showed comparable attendance at sessions and satisfaction with their care. Caregivers in both conditions reported comparable outcomes for their children's ADHD-related behaviors and functioning, but caregivers in the teletherapy group did not report improvement in their own distress. CONCLUSIONS: Findings support the feasibility, acceptability, and effectiveness of treating children with ADHD through teletherapy. Future work should investigate how teletherapy may improve caregivers' distress. Teletherapy is a promising modality for delivering behavioral interventions for children with ADHD.

Telemental health: responding to mandates for reform in primary healthcare.

Telemental health (TMH) has established a niche as a feasible, acceptable, and effective service model to improve the mental healthcare and outcomes for individuals who cannot access traditional mental health services. The Accountability Care Act has mandated reforms in the structure, functioning, and financing of primary care that provide an opportunity for TMH to move into the mainstream healthcare system. By partnering with the Integrated Behavioral Healthcare Model, TMH offers a spectrum of tools to unite primary care physicians and mental health specialist in a mind-body view of patients' healthcare needs and to activate patients in their own care. TMH tools include video-teleconferencing to telecommute mental health specialists to the primary care setting to collaborate with a team in caring for patients' mental healthcare needs and to provide direct services to patients who are not progressing optimally with this collaborative model. Asynchronous tools include online therapies that offer an efficient first step to treatment for selected disorders such as depression and anxiety. Patients activate themselves in their care through portals that provide access to their healthcare information and Web sites that offer on-demand information and communication with a healthcare team. These synchronous and asynchronous TMH tools may move the site of mental healthcare from the clinic to the home. The evolving role of social media in facilitating communication among patients or with their healthcare team deserves further consideration as a tool to activate patients and provide more personalized care.

Research in child and adolescent telemental health.

Over the past decade telepsychiatry, and more broadly telemental health (TMH), services with children and adolescents have been implemented with diverse populations in many geographic areas across the United States. The feasibility and acceptability of child and adolescent TMH have been well demonstrated, but little research exists on the efficacy and effectiveness of TMH in improving the mental health care and outcomes for underserved youth. This article summarizes the state of research in child and adolescent telemental health TMH and examines studies in other areas of telemedicine that may inspire and guide child and adolescent telepsychiatrists to collect data on the process and outcomes of their own work.

Attention-deficit/hyperactivity disorder and telemental health.

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders diagnosed in children and adolescents (youth). ADHD is equally distributed geographically, but services are not. Access to expert evaluation and treatment remains limited for youth with ADHD living in rural areas, as well as for ethnic and racial minority youth. Telepsychiatry is a service delivery model with the potential to reach these youth and to develop collaborative models of care among local primary care physicians, remote telepsychiatrists, and local families. Care delivered through telepsychiatry can readily adhere to the practice parameters of the American Academy of Child and Adolescent Psychiatry. Work to date indicates that ADHD is the most common disorder treated through telepsychiatry. This article reviews the status of child and adolescent telepsychiatry, with particular focus on its potential to improve the care and outcomes of underserved populations of youth diagnosed with ADHD.

Child and adolescent telepsychiatry: variations in utilization, referral patterns and practice trends.

Seattle Children's Hospital is a tertiary referral hospital that has provided telepsychiatry to seven partner sites in the north-west since 2001. Service utilization data, patient demographics and diagnoses were collected for the period from the service inception in October 2001 until November 2007. During the study period, 701 patients were treated with a mean of 2.8 appointments per patient (SD 1.9). Five psychiatrists and four psychologists provided care. Utilization varied across referring sites and was largely dependent upon the availability of telepsychiatrists, although the degree of support from administration and stakeholders also contributed to the success of the service. A total of 190 primary care practitioners referred patients to telepsychiatry, including 106 family physicians and 71 paediatricians. Paediatricians referred to the service more frequently than family physicians (t = 2.8, P < 0.05). Overall, telepsychiatry with young people is feasible, acceptable and increases access to mental health care. There appear to be four core components necessary to a successful telepsychiatry programme: psychiatrists who are interested in exploring new ways to reach underserved young people; clearly identified stakeholders who can collaborate with one another to make good use of the telepsychiatry service; a children's mental health 'champion' who represents these stakeholders and wants services for their community; and a stable administration that perceives telepsychiatry as valuable for their patients and their doctors.

Child and adolescent telepsychiatry: utilization and satisfaction.

Access to psychiatric care for children and adolescents is limited outside of urban areas. Telepsychiatry provides one mechanism to bring needed services to youth. This investigation examines whether telepsychiatry could be successful in providing needed services. Using interactive video teleconferencing at 384 kilobits per second, psychiatrists based at a regional childrens hospital provided consultation and management services to patients at 4 sites across Washington State located 75150 miles from the childrens hospital. Twelve-month review of billing records provided utilization data. Surveys of parents satisfaction over 12 months examined whether parents would accept and be satisfied with the care rendered to their children. Over the study year, 387 telepsychiatry visits were provided to 172 youth 221 years old with a mean of 2.25 visits per patient. The demographic and diagnostic profile of this sample was consistent with usual outpatient mental health samples. Parents endorsed high satisfaction with their childrens telepsychiatric care, with an indication of increasing satisfaction upon return appointments. Parents demonstrated some differential satisfaction, tending to higher satisfaction with their school-aged childrens care and lower satisfaction with their adolescents care. Telepsychiatry offered through a regional childrens hospital was well utilized and parents were highly satisfied with their childrens care. The stage is now set for integrating telepsychiatry into a system of care that meets youths overall needs and for controlled studies demonstrating the efficacy of telepsychiatry with youth.

Feasibility, acceptability, and sustainability of telepsychiatry for children and adolescents.

OBJECTIVE: This study examined the feasibility, acceptability, and sustainability of a telepsychiatry service for children and adolescents living in nonmetropolitan communities. METHODS: Using high-bandwidth interactive video teleconferencing, psychiatrists at a children's hospital provided care to patients of primary care physicians at four nonmetropolitan sites. Review of one-year utilization provided feasibility data. Surveys of referring physicians examined acceptability of telepsychiatry. Reimbursement records provided sustainability data. RESULTS: Overall, 387 sessions were provided to 172 youths (mean=2.25 sessions) whose clinical profiles were representative of national samples. Referring providers endorsed high satisfaction with telepsychiatric care, although pediatricians were consistently more satisfied than family physicians. Sustainability of telepsychiatry is challenged by infrastructure costs and low reimbursement by public payers. CONCLUSIONS: Telepsychiatry is a feasible and acceptable approach to providing psychiatric services to youths in underserved communities. Sustainability will depend on developing financial alternatives to fee-for-service, especially if caseloads emphasize publicly funded programs.

Ten-year review of rating scales, VII: scales assessing functional impairment.

OBJECTIVE: This is the seventh in a series of 10-year reviews of rating scales. Here the authors present scales measuring functional impairment, a sequela of mental illness. The measurement of functional impairment has assumed importance with the recognition that symptom resolution does not necessarily correlate with functional improvement. METHOD: The authors reviewed functional impairment from multiple sources over the past 20 years. Thus, this article includes a variety of scales ranging from those that have been subject to critical review with strong psychometric support to those that have not been critically reviewed but are in widespread use to those that are still finding their niche. RESULTS: These scales represent a continuum of constructs from symptoms to functional impairment to contextual factors that affect youths' functioning. Most older scales have focused on developmentally delayed youths. Newer scales strive to measure functional impairment separate from symptomatology. Some newer scales are also keyed to determination of level of service need. CONCLUSIONS: Scales measuring functional impairment can elucidate the impact of illness on youths, identify targets for treatment, determine service needs, and monitor treatment effectiveness. These scales are widely used in community mental health and health service delivery. They can assist in providing evidence-based treatment.

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

Several studies have described successful applications of telepsychiatry with children and adolescents. However, there has been little examination of the populations served by telepsychiatry and the ability to evaluate youth accurately through this medium. In this article, we examined whether telepsychiatry patients are representative of those in usual outpatient care. Participants included 369 patients 3-19 years old evaluated at two clinics. A new telepsychiatry clinic (TPC) developed to provide services to under-served communities, and a child and adolescent psychiatric outpatient clinic (CAPOC) that served youth from predominantly metropolitan areas were included in the study. The telepsychiatry sites were linked using ISDN lines at 384 KB/sec. We examined these two samples regarding demographics, payor status, and diagnostic profiles. Results indicated that youth evaluated through the TPC were broadly comparable to youth evaluated in the CAPOC. Therefore, telepsychiatry appears to serve youth that are representative of those seeking psychiatric care, and it is not restricted to youth with no medical insurance or with selected diagnoses. The similarity of diagnoses further suggests that telepsychiatry provides adequate technical resolution and doctor-patient rapport to detect psychopathology of youths. These findings suggest the need for further systematic investigation of telepsychiatry as a tool for providing psychiatric care to young people.

Ten-year review of rating scales. VI: scales assessing externalizing behaviors.

OBJECTIVE: This is the sixth article in a series of 10-year reviews of rating scales. The current article reviews scales that assess externalizing behaviors such as disruptive behavior disorders and aggression. METHOD: Relevant scales were found by searching popular electronic databases. The search was then broadened by a review of the references in selected articles. Due to the paucity of well-established scales, any such scales with potential utility for elucidating the functioning of youths with externalizing behaviors were selected. RESULTS: None of these scales is diagnosis-based, although some correlate with DSM-IV-defined disruptive behavior disorders. Most scales assessing disruptive behavior disorders have a solid normative base, good psychometric functioning, and high clinical utility. Scales assessing aggression comprise a bimodal group. Several have been adapted from the adult literature and are widely used in clinical practice, while others address theoretical aspects of aggression and are used predominantly in research. Empirical support for all of the scales assessing aggression varies widely, although several show potential for routine clinical practice. CONCLUSIONS: Overall, these scales measure a variety of constructs with considerable utility for assessing youths' externalizing behaviors, predicting outcome, and evaluating treatment effects. Many need further validation with youth.

Ten-year review of rating scales. V: scales assessing attention-deficit/hyperactivity disorder.

OBJECTIVE: This article summarizes information on scales assessing attention-deficit/hyperactivity disorder (ADHD) in children and adolescents. METHOD: The authors sampled articles on ADHD over the past decade. Several popular older ADHD measures have recently been revised, and new ADHD scales have been developed. The authors selected primarily ADHD scales based on the DSM-IV construct of ADHD that also have multiple literature citations. They then reviewed their psychometric properties. Those with adequate psychometric functioning plus considerable literature citations, known wide usage in clinical practice, or a current niche are presented here. RESULTS: Several rating scales consistent with the DSM-IV conceptualization of ADHD are now available for use in both home and school settings. Many of the instruments demonstrate solid psychometric properties and a strong normative base. However, some popular scales have not been adequately investigated. Some measures are restricted to the comprehensive assessment of ADHD, whereas others also include symptoms of other disorders. The potential applications for these scales with youths diagnosed with ADHD are broad. CONCLUSIONS: Rating scales can reliably, validly, and efficiently measure DSM-IV-based ADHD symptoms in youths. They have great utility in research and clinical work, assist treatment planning, and help to ensure accountability in practice.