IACAPAP Textbook of Child and Adolescent Mental Health

INTRODUCTION

Chapter

A.15

TELE-TREATMENT AND
TELE-CONSULTATION WITH
CHILDREN AND ADOLESCENTS:
BUILDING A GLOBAL NETWORK
Kathleen Myers MD, MPH; Ahsan Nazeer MD; David Roth MD;
Daniel Fung MD; Laura Ospina-Pinillos MD, PhD;
Nguyen Tan Dat MD, PhD; Maha Emadeldin MD;
Nazish Imran MD, PhD; Patricio Fischman MD.

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2019. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Myers K., Nazeer A., Roth D., Fung D., Ospina-Pinillos L., Nguyen T.D., Emadeldin M., Imran N.,
Fischman P. Tele-treatment and teleconsultation with children and adolescents: Building a global network. In Rey JM, Martin A(eds), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent
Psychiatry and Allied Professions 2022.

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IACAPAP Textbook of Child and Adolescent Mental Health

OVERVIEW

I

nformation and communication technologies (ICTs) offer great opportunities
to improve the healthcare challenges faced by low and middle-income
countries (LMICs). ICTs could help to provide accessible, cost-effective,
high-quality healthcare that often is not readily available to large segments of the
population in LMICs. Telemedicine is one form of ICT that is especially poised tomeet this challenge given its established and growing evidence-base and its widespread, successful implementation during the COVID-19 pandemic. There is no
one accepted definition of telemedicine. The World Health Organization (WHO,2009) has adopted a broad description: “The delivery of healthcare services, where
distance is a critical factor, by all healthcare professionals using information andcommunication technologies for the exchange of valid information for diagnosis,
treatment and prevention of disease and injuries, research and evaluation, andfor `the continuing education of healthcare providers, all in the interests ofadvancing the health of individuals and their communities” (WHO, 2009). Thisdefinition is captured, and expanded, in Figure 1 that depicts the relationships
among entities involved in both synchronous and asynchronous modalities.
Synchronous telemedicine refers to a real-time interaction using both video andaudio components (videoconferencing) between a patient at the originating site,i.e., the site of the patient during service delivery, and a health care professional at
the remote site, i.e., site of the healthcare professional who is providing services.
TeleTreatment is the prime example of synchronous telemedicine. Synchronous
telemedicine may also include a videoconferencing session between the primarycare professional at the originating site and a remote specialist without thepatient present, termed TeleConsultation. Asynchronous telemedicine refers to
the transmission of a patient’s health information from the originating site to theremote site to be interpreted by a healthcare professional at a later time without
direct interaction with the patient or primary care professional. TeleMonitoringis the prime example of asynchronous telemedicine, such as store-and-forward
modalities that are common in cardiac monitoring and radiology but emerging
in psychiatry with activities such as mood monitoring. TeleSupport is anotherasynchronous application that includes the vast array of services that an individual
professional or a facility may make available to patients, e.g., for psychoeducation.
Note that Figure 1 further clusters these specific applications as Telemedicine,
Telehealth, and TeleCare, terms that are used throughout this chapter to organize
the presentation on the telemedicine specialty of TeleMental Health (TMH).
When TMH specifically involves psychiatric services, the term Telepsychiatry isused (Turvey, Coleman Dennison, 2013). Although this chapter is intended for
all child and adolescent mental healthcare professionals, psychiatry is the most
likely mental health discipline to be integrated into telemedicine in LMICs given
its medical specialty. Therefore, we use the term child and adolescent psychiatrist,or psychiatrist, to refer to this overall group of child and adolescent mental healthprofessionals. Most of this chapter relates to TMH TeleTreatment and TMH
TeleCollaboration which have the strongest evidence-base. The broader modalities
of TMH TeleHealth and TMH TeleCare comprise the last part of this chapter.

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure 1 TeleMedicine, TeleHealth, and TeleCare

Courtesy of Jason Yap,
MD, Saw SweeHock School of Public Health, National University of Singapore

DEVELOPMENT OF CHILD AND ADOLESCENT TMH
TELETREATMENT AND TELECONSULTATIONThe Case for TMH TeleTreatment and TMH TeleConsultation
The WHO identifies children’s and adolescents’ (youth) mental health needs
as a leading cause of disability worldwide (WHO, 2009). The past few decades
have brought considerable insights into the early onset of psychopathology and theearly identification of developmental and psychiatric disorders. New approaches
to pharmacologic treatment and evidence-based psychotherapies have produced
interventions with improved prognoses for youth with chronic disorders. However,most youth with developmental and psychiatric disorders living in HICs are not
identified in a timely manner, often are never identified during development, and do
not receive these available interventions (Myers, Nelson, Rabinowitz et al., 2017).
This situation is even more poignant for youth living in LMICs who comprise up
to 50% of the population. They face social stigma for having a developmental or
psychiatric disorder and cannot find needed care due to the dearth of child andadolescent psychiatrists (Patel, Flisher, Nikapota et al., 2008). Further, their plightmay be worsening. In many LMICs, rapid urbanization and social change areproducing an increase in urban poverty and unemployment which are risk factors
for poor youths’ mental health. The widening of the already vast gap between
youths’ needs and the availability of mental health care resources will increase rates
of disability and add to the burden of disease for these youth, as well as for theircountries’ evolving social and economic progress.
LMICs need more child and adolescent psychiatrists. They will need toadapt available evidence-based treatments to their language and culture. However,
it is unlikely that the recruitment of these child and adolescent psychiatrists will
ever be able to keep pace with the increasing rate of youths’ needs, not even in
HICs (Satiani, Niedermier, Satiani, et al., 2018). Therefore, a mechanism is needed
to deliver these services to youth living in under-served areas. The advances oftechnological innovations make TMH TeleTreatment and TMH TeleConsultationa viable service delivery model to help meet these youths’ needs, while remaining

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IACAPAP Textbook of Child and Adolescent Mental Healthin their own communities.
Each country’s healthcare system has its own set of challenges; hence,
there is no universal formula that can be used to develop TMH TeleTreatment
and TMH TeleConsultation services in different countries. Financial factors,
including the cost of building and maintaining the infrastructure, pose one of
the biggest hurdles in many countries’ implementation of telemedicine-related
services. Successful programs consider each country’s geography, culture, religion,
existing healthcare system, and insights of dedicated psychiatrists. For example,
smaller middle-income countries with homogeneous populations, consistentgeographic terrains, and an established national healthcare system may readily
incorporate TMH TeleTreatment and TMH TeleConsultation into their services.
By contrast, lower-income countries with high levels of racial and ethnic diversity,
a variable geographic terrain, and a developing healthcare system may findnumerous impediments to implementing these modalities, such as installing theneeded infrastructure, differences between the culture and language of the urban
psychiatrists and rural populations, interpretations of mental illness, as well as
access to and trust in technology.
The Expansion of TMH TeleTreatment and TeleConsultation
The practice of TMH TeleTreatment has expanded beyond the intended goalof rectifying disparities in access to timely evidence-based care for rural and other
under-served communities (Duncan, Valasquez, Nelson, 2014; Myers, Sulzbacher,
Melzer, 2004; Myers, Valentine, Melzer, 2008). In HICs, TMH TeleTreatment
services are increasingly offered in varied settings, including small towns, innercities, mental health centers, correctional settings (Kaliebe, Heneghan, Kim, 2011;
Myers, Valentine, Morganthaler, et al., 2006), and other child-serving facilities(Cain, Spaulding, 2006; Myers, Valentine, Melzer, 2007), and, most recently, thehome (Comer, Furr, Cooper-Vince, 2014; Comer, Furr JM, Miguel E, et al., 2017)
which has increased greatly since the COVID-19 pandemic. Offering services tothe home can be convenient for families that are busy with other obligations.
TeleTreatment also allows family members to join the intervention session fromdifferent sites during the day, e.g., the child and mother at the school with thecounselor and father at work.
In most LMICs, the availability and use of TMH TeleTreatment and
TeleConsultation was very limited before the COVID 19 pandemic. For many
countries that changed with onset of the pandemic. For example due to theinability to provide in-person mental health services during the lockdown, many
Arab countries started to accept the concept of telemedicine-related services (ELHavek, Nofal, Abdelrahman, et al., 2020). In Egypt, TeleConsultation services
have been used to cover the private sector and non-governmental organizations,such as the Egyptian Red Crescent.
The TMH Tele-Consultation model has its greatest potential for supporting
primary care physicians in rural areas who are front-line health care professionals
and provide basic mental health care. In September 2020 due to the COVID-19
pandemic, the Vietnamese Ministry of Health launched a remote healthcare
consultation and support (TeleConsultation) network that connects 27 central or
end-line hospitals in Hà Nội and Ho Chi Minh City with a thousand community
medical examination and treatment facilities, including those in mountainous

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IACAPAP Textbook of Child and Adolescent Mental Healthareas and on islands (Tuoi Tre News, 2020). There is potential to utilize this
TeleConsultation service to support these thousand community sites withpsychiatric consultation. Such TeleConsultation can provide needed psychiatriccare during stressful times, such as the pandemic, and can help to build community
physicians’ skills in providing mental health care. These efforts demonstrate how
quickly a country can mobilize and utilize existing infrastructure and personnel
when motivated. A strong centralized government, as in Vietnam, may be especiallyefficient in mandating these efforts.
Schools are a naturalistic site for services given that youth are there during
the day and their educational impact is only minimally disrupted when services areoffered on campus. Further, many schools in LMICs have school health officers orcounselors who could assist with mental health care if given appropriate support(Grady, Lever, Cunningham, et al., 2011; Stephan, Lever, Bernstein, et al., 2016).
With the onset of the global COVID-19 pandemic, the TMH TeleConsultation
model was implemented in Singapore. Consultations of school counsellors withchild and adolescent psychiatrists went online rapidly. This approach demonstrated
how the limited workforce of child and adolescent psychiatrists could extend
support to community mental healthcare professionals who work as front-line
providers with youth (Renjan and Fung, 2020).

THE EVIDENCE-BASE SUPPORTING TMH TELETREATMENT AND TELE-CONSULTATIONThe evidence-base supporting TMH TeleTreatment and TMH
TeleConsultation as effective service-delivery models is well established forthe adult population and is emerging gradually for youth. Several studies haveestablished the feasibility and acceptability of TeleTreatment and TeleConsultation
with youth, as briefly summarized below.
Multiple studies have demonstrated the feasibility of implementing TMH
TeleTreatment with youth across diverse settings (Boydell, Volpe, Kertes et al.,2007; Duncan, Velasquez, Nelson, 2014; Gibson, Coulson, Miles, et al., 2011;
Jacob, Larson, Craighead, 2012; Jones, Shealy, Reid-Quinones, et al., 2014; Myers,
Valentine Melzer, 2007; Nelson, Bui, 2010; Wood, Stathis, Smith, et al., 2012).
Youth 2-21 years old with a broad range of psychiatric diagnoses and developmental
disorders have been evaluated and treated through videoconferencing (Elford,
White, Bowering, et al., 2000; Reese, Jamison, Wendland, et al., 2013; Myers,
Sulzbacher, Melzer, 2004). School-aged children comprise the modal age group,
and attention-deficit/hyperactivity disorder (ADHD) and depression are themost commonly treated disorders, consistent with in-person care (Nelson,
Barnard, Cain, 2003; Myers, Vander Stoep, Zhou, et al., 2015). Children who
are uncooperative pose challenges, but can be treated with assistance by staff at
the patient site if services are provided at a mental health or primary care clinic.
Additional problem-solving is needed if services are provided in the home. Childand adolescent psychiatrists determine the appropriateness of youth for care via
TMH TeleTreatment based on developmental considerations, parents’ preferences,
support at the patient site, as well as the psychiatrist’s resourcefulness.
Some authors have suggested that TMH TeleTreatment may especially

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IACAPAP Textbook of Child and Adolescent Mental Healthsuit adolescents as they are comfortable with technology and may feel more incontrol of their personal space during videoconferencing (Pakyurek, Yellowlees,
Hilty, 2010). Adolescents may also have decreased concerns about confidentiality
as the child and adolescent psychiatrist is outside of their local community. Whilethese theories are interesting, there are no data regarding adolescents’ preference
for TMH TeleTreatment.
Diagnostic assessments for disruptive behavior disorders (Myers, Vander
Stoep, Zhou et al., 2015), autism and other developmental disorders (Reese, Jamison,
Wendland, et al., 2013; Szeftel, Frederico, Hakak, et al., 2012) and psychotic
disorders (Stain, Payne, Thienel, et al., 2011), as well as other disorders treated inusual outpatient clinics have been reliably conducted through videoconferencing(Elford, White, Bowering, et al., 2000; Myers, Vander Stoep, McCarty, et al.,2010). Several studies have demonstrated the acceptability to referring primary care
physicians (Myers, Valentine, Melzer, 2007), parents (Greenberg, Boydell, Volpe,
2006; Myers, Valentine, Melzer, 2008), and youth (Boydell, Volpe, Pignatiello,2010) of delivering services through videoconferencing. Satisfaction studies areimportant as they demonstrate the ability to develop a therapeutic alliance withyouth and families during a virtual visit (Glueck, 2013).
The delivery of pharmacotherapy through TMH TeleTreatment has been
described with youth in schools (Kriechman, Bonham, 2013), mental healthcenters and daycare (Spaulding, Cain, Sonnenschein, 2011), outpatient settings(Myers, Valentine, Melzer, 2008; Myers, Vander Stoep, McCarty, et al., 2010)
and juvenile justice facilities (Myers, Valentine, Morganthaler, et al., 2006). One
recent large community-based randomized trial provides solid evidence of theeffectiveness of short-term pharmacotherapy for ADHD delivered by child andadolescent psychiatrists through videoconferencing compared to TeleConsultation
to primary care (Myers, Vander Stoep, Zhou, et al., 2015). Further, psychiatrists
demonstrated good adherence to guideline-based pharmacotherapy (Rockhill, Tse,
Fesinmeyer, et al., 2016).
There is a robust literature supporting the feasibility of conducting
TeleTherapy with adults (Backhaus, Agha, Maglione, et al., 2012; Hilty, Ferrer,
Parish, et al., 2013; Osenbach, O’Brien, Mishkind, et al., 2013) and a developing
literature supporting feasibility with youth (Nelson, Patton, 2016). Most studies
of TeleTherapy conducted with youth have been descriptive (Duncan, Velasquez,
Nelson, 2014; Nelson, Patton, 2016; Slone, Reese, McClellan, 2012). Intervention
approaches have varied regarding their focus on the youth or on parenting strategies
and ranged from feasibility trials to pre-post intervention designs. Findings havebeen positive related to feasibility and satisfaction of families. A few reports notethe use of TMH TeleTreatment to address the mental health needs of youth withmedical conditions (Davis, Sampilo, Gallagher, et al., 2013).
Several randomized trials of psychotherapy with youth are noteworthy.
Comer and colleagues demonstrated that Parent-Child Interaction Therapy(PCIT) delivered through TeleTreatment into the home was comparable totraditional PCIT delivered in-clinic (Comer, Furr, Miguel, et al., 2017). Nelson
and colleagues (2003) found comparable reductions for childhood depressive
symptoms treated with eight sessions of cognitive-behavioral therapy (CBT)
delivered through TeleTreatment versus in-person. The behavioral TeleTreatment

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IACAPAP Textbook of Child and Adolescent Mental Healthof obsessive-compulsive disorder (OCD; Storch, Caporino, Morgan, et al., 2011)
and tics (Himle, Freitag, Walther, et al., 2012) has been shown to be comparable
to in-person treatment. Five small randomized controlled trials have demonstrated
the effectiveness of providing family interventions (Anderson, Byrne, Goodyear, etal., 2015; Gluekauf, Fritz, Ecklund-Johnson et al., 2002; Reese, Slone, Soares etal, 2012; Tse, McCarty, Vander Stoep, et al., 2015; Xie, Dixon, Yee et al., 2013).
Although the evidence-base for TeleTreatment with youth is emerging slowly, theavailable data support its feasibility, acceptability to participants, and effectiveness.
Crises often produce opportunities. Due to the COVID-19 pandemic,a group of general psychiatrists in Addis Adaba, Ethiopia transitioned to
TeleHealth, including TeleTreatment, for both existing and new patients (Tilahun,
Andebirhan, Eyasu, et al., 2020). These enterprising psychiatrists also rapidly
updated their website to remotely manage the administration of their practice.
They reported that patients were satisfied with the TeleTreatment services given theprotection from exposure to the virus; however, only 15% of patients continued
to use the TeleTreatment service when in-person appointments resumed. Patients
cited difficulties focused on interrupted transmissions, costs associated with thetechnology, and a preference for in-person appointments. The psychiatrists notedthat the interrupted transmissions interfered with clinical assessments and increased
their burden of home responsibilities. Their valuable experience led these authors
to call for a national health policy that integrates technology into the mental healthcare system to best serve patients during crises.
Even prior to the pandemic, the WHO started to examine digitalinterventions for depression. The Step-by-Step intervention uses various techniqueswith emphasis on behavioral activation (Carswell, Harper-Shehadeh, Watts,
et al., 2018; Harper-Shehadeh, Ramia, Cuipers, et al., 2020). Step-by-Step has
been designed so that it can be adapted for use in settings with different culturalcontexts and resource availability and to be meaningful in communities affected byadversity. While these efforts are in the early stages of testing, they emphasize theglobal look to digital interventions, including TeleTreatment, to help address theevolving crisis in mental health care for under-served populations.

LEGAL, REGULATORY AND ETHICAL ISSUES
Legal considerations can be a significant obstacle to the uptake of digitaltechnologies. These include an absence of an international legal framework to allow
physicians, including psychiatrists, to deliver services in different jurisdictions
and countries; a lack of policies that govern patient privacy and confidentialityvis à-vis data transfer, storage, and sharing between physicians and jurisdictions;
physician/psychiatrist authentication; and the liability risk for psychiatrists offering
TeleTreatment and TeleConsultation services. A few of these issues are reviewed
here.
Licensure is a complex issue. In the United States and Canada, there isno national licensure. Rather, individual states and provinces are responsible forlicensure (Kramer, Mishkind, Luxton, et al., 2013). If a psychiatrist seeks to provide
services in more than one state or province, licensure must be obtained in each of
those jurisdictions. The site of service is considered to be the patient’s location(originating site) at the time of service and not the patient’s official residence. As an

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IACAPAP Textbook of Child and Adolescent Mental Healthexample, if a student officially still resides with his parents in one state but moves
to another state where he receives TeleTreatment, that state is considered the siteof service. Therefore, the psychiatrist must be licensed in both his own state andthe student’s state.
In many LMICs, especially smaller countries, such rigid state or provincial
boundaries may not exist. For example, in Qatar, a small MIC with organizedpolicies for TeleTreatment and TeleConsulation, licensure applies to the entire
country. One of the challenges facing TeleTreatment in Egypt is the unavailabilityof regulatory bodies for training, certifying TeleTreatment systems and physicians,
and addressing best practice guidelines. Therefore, there is no legalization of
TeleTreatment in Egypt. However, during the COVID-19 pandemic, the “Doctors
Syndicate,” with the help of universities, began studying the use of TeleTreatment
including establishing the foundations and precautions for its use in patient care(Samir, 2020).
Many LMICs faced considerable challenges to psychiatric care prior to
the pandemic, including stigma regarding mental health conditions, a paucity ofresources, access to any existing services, limited child and adolescent psychiatrists,
and availability of psychopharmacology (De Sousa, Mohandas, and Javed, 2020).
Some LMICs had started to utilize telemedicine (including TMH TeleTreatment
and Teleconsultation) prior to the pandemic and were well poised to pivot to
TeleTreatment. Viet Nam had established a registration process for physicians
providing telemedicine services and required evidence that they met requirements
for using the relevant technology especially related to information security(Ministry of Health, 2017). Other LMICs shifted to TeleTreatment during the
pandemic, but without stringent regulatory authority to monitor the quality andethical standards of TeleTreatment services. There is now a call for TeleTreatment
regulation in Southeast Asia (Sabrina and Defi, 2021) and some individual
countries are moving toward such legislation, such as Singapore (Ministry of
Health, Singapore, 2022). Many other LMICs are developing relevant legislation
regulating the use and practice of TeleTreatment and TeleConsultation. Although
there will not be a single standard that can apply across all LMIC jurisdictions
given each unique geographical, cultural, and economic status, a few core issues
must be considered. These include accurate patient identification, data ownership,
cybersecurity and means of overcoming the limitations of virtual interactions. A
universal human factor will be the initial reluctance of patients, and psychiatrists,
to utilize TeleTreatment.
Payment for TeleTreatment Services varies significantly by country, possibly
by regions within a country, depending on the funding of its healthcare systemand particularly of its mental healthcare system. The WHO’s survey found that
almost 70% of countries surveyed indicated the need for more information on thecost and cost-effectiveness of telemedicine applications. Middle income countries
with a national healthcare system may easily incorporate TeleTreatment into theirservices, but low income countries with few psychiatrists and populations thatare skeptical about mental illness may struggle with such technology-mediatedservices.

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IACAPAP Textbook of Child and Adolescent Mental HealthSome middle income countries have addressed payment for TeleTreatment.
For example, Singapore’s healthcare system is subsidized by the government andincorporates telemedicine costs with physicians, including psychiatrists, andsubsidizes its use in the same way that it covers in-person services. There areissues related to the additional operational costs of the technology. These costs
could be passed onto the patient in a fee-for-service model (Sabrina, Defi, 2021).
Obviously, this approach would exclude some families from the advantages of
TeleTreatment. Qatar has both a public and private healthcare system. There is no
uniformly established model of reimbursement of TeleTreatment services distinct
from traditional in-person services. The Ministry of Public Health regulates
healthcare. Services to Qatari nationals is free of charge, while Qatari residents canobtain a Health Card for a minimal fee, giving them access to essential healthcare
services. Most private practices serve patients via out-of-pocket charges or throughprivate insurances. TeleTreatment in both the public and private sectors are funded
the same as for in-person services.
Lower income countries may be more challenged in developing financial
models for TeleTreatment. For example, Egypt has a dual system for mental healthservices, a public system managed by the Ministry of Health and a private sector
financed by out-of-pocket payments. Although the public system provides basic
universal coverage, reportedly it is burdened by chronic underfunding, low service
quality, and high out-of-pocket payments, in part due to the low expenditure forhealthcare services compared to other LMICs (Gericke, Britain, Elmahdawy, etal., 2018). Further, Egypt typifies the scenario presented by WHO regarding themental health needs of young people in LMICs. Its population is very young,and youth unemployment has become a major societal issue. It is difficult toconceptualize how the system could expand its TMH TeleTreatment services tomeet these needs given the current funding approach. Nonetheless, at the onsetof the COVID-19 pandemic, payment for TMH TeleTreatment services was
the same as for in-person service. Going forward, it will be informative to see
how Egypt addresses TMH TeleTreatment. These challenges may be experienced
by many other LMICs. Pakistan also has publicly funded hospitals, but private
healthcare and therapies are expensive and not affordable by the majority ofpatients. Affordability concerns regarding TeleTreatment and TeleConsultation are
significant as the country does not have a health insurance system.
Authentication of the parties involved in a TeleTreatment encounter
ensures accuracy of service delivery and protects against fraud. During the initial
encounter with a patient, the psychiatrist collects identifying information about
the patient, including location, such as a clinic, school or home, or other sites(American Telemedicine Association, 2013). If the patient site is a healthcare
facility, the staff may verify the patient’s identity. Typically, psychiatrists begin theinitial session by stating their name, credentials, and location (i.e., city). Countries
may vary as to whether they must include this information in the documentation.
For example, in Singapore, guidelines for telemedicine use and its ethical practice
are laid out specifically for adoption (Ooi, Koh, Tan, et al., 2015; Singapore Medical
Council, 2002; Singapore Medical Council, 2016). In Vietnam, physicians are
required to state their name, specialized, hospital, site, working years, educational
achievement, and license.
Privacy and Security of TeleTreatment services are a significant concern,

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IACAPAP Textbook of Child and Adolescent Mental Healthmainly if services are provided in non-clinical settings, for example, in a school or
the home. Youth and their parents deserve privacy, particularly regarding psychiatricand developmental conditions for which the parents may be blamed and the youth
stigmatized. Therefore, the site at which the youth receives services should havevisual and auditory privacy. Maintaining this privacy can be difficult to establish inhome settings. If a private space cannot be found, it may be necessary to ask otherfamily members to leave the home during the session.
Countries may have specific regulations regarding the protection ofhealthcare information, and TeleTreatment psychiatrists must comply with such
regulations. For example, in the United States, these protections are outlined in
the Health Insurance Portability and Accountability Act of 1996 (HIPAA;104th
Congress,1996). These regulations may indicate that popular video programs,
such as Face Time™ and Skype,Ⓡ are not appropriate for clinical work despite theiracceptable encryption. Software vendors enter into a Business Associate Agreementwith federal regulators attesting their due diligence to protect patient privacy anddata and agree to an audit of patient health information if a security breach occurs.
The Western concepts of confidentiality and privacy also apply to numerous
middle-eastern countries. For example, Qatar’s Law No. 2, Article 20, prohibits
medical professionals from disclosing confidential information of a patient, andin case of violations imposes strict disciplinary measures. In 2015, the Ministryof Public Health published a National Health, e-Health, and Data Management
Strategy (QNeDP) which provides a comprehensive vision for e-healthcare
developments to improve healthcare delivery in the State of Qatar. This strategy
included a framework for digitalizing healthcare and personal health information
while maintaining robust privacy and security standards. In 2017, Qatar became thefirst country among its neighboring seven countries to introduce a comprehensive
data protection law, Personal Information Privacy Protection Law (PIPPL), tosafeguard personal information.
In Vietnam in 2014, the Ministry of Health addressed the use of digital
healthcare noting measures to ensure confidentiality of information (Ministryof Health, 2014). Regulations for telemedicine include requirements for an
organization or individual to satisfy certain guidelines including technical factors
such as adequate storage capacity and qualified operators that affect clinical work
as well as security (Ministry of Health, 2017).
Due to the evolving nature of telemedicine generally, some LMICs do not
yet have regulations to ensure privacy, but are addressing this issue, directly or
indirectly. A cross-sectional study among Egyptian psychiatrists suggested highlevel of acceptability for TeleTreatment and TeleConsulation noting that it would
be beneficial for patient care. They supported integrating it into the current healthcare system, but had a concern about the privacy, confidentiality and security ofthe patient’s data (Kamel, Westenberg, Choi, 2020). Egypt’s Mental Health Act of2009 ensured the confidentiality of information of psychiatric patients (Loza, El
Nawawi, 2012) and internet security is covered under Law no. 175 of 2018 forcybersecurity (Chawki, 2020; International Labour Organization, 2018). Thus,
LMICs may have components of patient privacy and data security that can bereferenced while awaiting development of formal guidelines.
Overall, child and adolescent psychiatrists interested in including

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TeleTreatment in their practice should check their country’s regulations, as well as
commercial vendors’ compliance with the country’s regulations for TeleTreatment.
Even if no such regulations exist, good clinical judgment always applies.
Informed Consent also involves a process that varies by state and country
regarding the need for specific consent to receive services through videoconferencing(Shore, Yellowlees. Caudill et al., 2018; Yellowlees, Shore, Roberts, 2010). Somesites may require a separate form for TeleTreatment services, while others may
presume that consent for any outpatient care also covers TeleTreatment. Someelements for consent include confidentiality and the limits to confidentiality whenusing electronic communications; potential for technical failure, emergency plans;
documentation, recording, and storage of information; protocols for coordinationof care with other physicians and contact between sessions; and conditions underwhich services may be terminated and a referral made for in-person services(Kramer, Luxton, 2016).
Qatar provides an example of this issue. Qatar has no specific laws requiring
informed consent for routine follow-up care via telemedicine; however, it isuniversally considered a best practice to seek the consent and discuss the limitation
before the tele-encounter. Also, as most healthcare professionals in Qatar are
Western-trained, they continue to follow the processes and procedures of thesystems in which they are trained, including obtaining consent before any patientencounter. Other countries will likely address this issue specific to their workforce,
culture, and population as their TMH TeleTreatment services evolve.
Emergency Care is a highly desired service, especially for under-served
communities. Local civil commitment laws due to violence to self or others, duty
to warn and protect the citizenry requirements, and mandated reporting of childendangerment vary across sites. Psychiatrists and staff should prepare a crisis planwith the family and share those parts of the plan relevant to other members of thepatient’s system of care, such as other caregivers, primary care physicians, or schools.
These crisis procedures are discussed as part of the informed consent process andare worth repeating, at least in part, during the initial encounter (Shore, Hilty,
Yellowlees, 2007).
Ethical and Cultural Issues in TeleTreatment parallel issues encounteredduring in-person services but complicated by the inclusion of technology(American Academy of Child and Adolescent Psychiatry, 2012; Turvey, Coleman,
Dennison, 2013). In all countries, issues about confidentiality, dignity, andprivacy are of primary concern. TeleTreatment must be implemented equitably
with the highest ethical standards to maintain the dignity of all individuals andensure that differences in education, language, geographic location, physical andmental ability, age, and sex will not lead to the marginalization of care. As LMICs
develop TeleTreatment and TeleConsultation services they will need to adapt
currently available approaches to their own religion and values as culture affects
the acceptance of TeleTreatment (Alajlani, Clarke, 2013).
Singapore has already addressed many of these issues in their establishmentof ethical codes and guidelines (Singapore Medical Council, 2002; 2016). But,
other countries are just starting to consider all of the factors.
Qatar provides an excellent example of the unique complexities each

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IACAPAP Textbook of Child and Adolescent Mental Healthphysician/psychiatrist must consider in deciding whether to include TeleTreatmentin their practice. Qatar is a cosmopolitan Muslim country with an affluent
expatriate population from different faiths. On Hofstede’s model of five culturaldimensions (Hofstede, 2011; The Hofstede Insights Network, 2022) Qatar is
low on individualism, high on masculinity, and high in power distance (Rathod,
Pinninti, Irfan et al., 2017). Individualism defines a culture in which moreemphasis is placed on individual identity than on a family’s or a tribe’s identity.
Family values and traditions are held high, and parents and elders are given rights
to make decisions for the family, including influencing the patient’s willingness toreceive or reject the offered services. Qatar is also a hierarchical society in whichpeople accept the power-holders including allowing doctors to make treatment
decisions on their behalf. High masculinity indicates a culture with a high degreeof gender differentiation. Qatar is also a religiously liberal country in which people
maintain conservative values. Although Islam does not prevent Muslims fromseeking necessary medical care, patients generally prefer to interact in a sociallyand religiously appropriate way. Home is considered a very personal space andnot everyone is welcome to visit all parts of the house. This aspect of the culture
presents unique challenges in managing young children, especially those with
ADHD or developmental disabilities via TeleTreatment as most of the children
do not tend to sit and engage with the psychiatrist. The majority of females also
like to cover themselves while interacting with anyone other than their immediatefamily members, which may interfere with conducting a traditional mental status
examination during TeleTreatment. As a result of the above, bringing psychiatrists
into homes via videoconferencing can feel very aversive to the families who are notaccustomed to this model of care.
Psychiatrists interested in TeleTreatment will need to conduct a needs
assessment focused on whether their services are needed, the communities’
willingness to engage in TeleTreatment, and, if willing, the conditions under which
TeleTreatment may be feasible. For example, TeleTreatment may only be possible
for clinic-to-clinic services, i.e., from the psychiatrist’s clinic to the community’s
clinic; disruptive children may not be included in the entire session; women andtheir families will need to decide whether TeleTreatment is an option for them. The
ethical and cultural aspects of TMH TeleTreatment is probably the most importantarea in which the approaches developed by HICs may not be directly translated to
LMICs. Culturally appropriate flexibility and creativity are needed.

TECHNICAL ASPECTS OF TMH TELETREATMENT
AND TELECONSULATION
Telecommunications technology refers to the technical methods orprotocols used to establish an asynchronous connection (Health Resources andServices Administration, 2022a; 2022b). The WHO found that over 50% ofsurveyed countries wanted more information on the infrastructure necessary
to implement telemedicine solutions (WHO, 2009). HICs mostly consideredbarriers to telemedicine implementation to include issues related to legal
implications surrounding patient privacy and confidentiality, competing healthsystem priorities, and a perceived lack of demand. LMICs were more likely toconsider barriers related to resource issues such as high costs, underdeveloped
infrastructure, and lack of technical expertise. Cost-effectiveness is a vital issue

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IACAPAP Textbook of Child and Adolescent Mental Healthfor both HICs and LMICs when considering optimal ways to reach their underserved populations, e.g., whether the cost of the technology and its maintenanceare feasible and sustainable. Mobile technologies are increasing around the globe
and will likely be the means for making TeleTreatment and TeleConsultation
possible for many rural communities in both HICs and LMICs,
Overview
Selecting the best technology can be a daunting process because thetechnology is rapidly changing, and many vendors offer a wide range of commercial
plans. The technology chosen should provide the best clinical experience, or an“authentic doctor-patient experience.”
General Review
Videoconferencing equipment varies in expense and should be selected tomeet the clinical need, space considerations, and cost. Across all devices, highquality cameras and microphones optimize the clinical experience. Both thepsychiatrist’s and patient’s sites should have access to 1) modern, well-functioning
equipment, including camera, monitor, microphone, and speakers; 2) encrypted
software; 3) secure clinical space for the equipment; and 4) consistent high-speed
connectivity. Consideration should be given to initial and ongoing technicalsupport and costs.
Start the selection process by prioritizing the features and functions needed
to deliver mental health services. Second, consider the budget, staffing resources,
and startup timetable. Thirdly, decide whether the program needs to connect to an
existing videoconferencing network that may determine the choice of technology.
The clinical goals of the program should influence the selection of technology, as
specific clinical services and populations may require different technologies. For
example, diagnosing neurodevelopmental and movement disorders may require
higher resolution video to observe the physical abnormalities, while group therapy
may require multiple microphones, capability for breakout groups, and chatfunctions. Financial factors related to software subscriptions, hardware purchases,
Internet service provider (ISP) contracts, space, and staffing play an essential rolein selecting telecommunication technology. The psychiatrist and remote site staff
must realistically consider their technical and financial ability to operate andmaintain the technology. Ongoing, easily accessed consumer-friendly technicalsupport is often noted as a critical factor in program success and sustainability.
Lastly, deciding to extend an existing videoconferencing system or replace it witha cloud-based system will restrict the decision to a smaller number of vendors andtechnology options. Psychiatrists should discuss options with various commercial
vendors that advertise online.
Standards-based Systems
If the program will build upon an older system at a major medical center oruniversity, it is likely a standards-based application/platform, sometimes referred toas “legacy hardware.” These proprietary systems offer the highest quality of audio
and video, as well as the most stable data connection, giving participants the mostlife-like or “telepresence” experience. They transmit data over digital subscriberlines (DSL). This telephone company-based end-user connection transmits secure,point-to-point, high-bandwidth (≥ 1.5 Mbps), high-definition video and audio

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IACAPAP Textbook of Child and Adolescent Mental Healthsignals over fiberoptic systems. Typical DSL broadband capacities are 1.5, 3, 5, 10,
12 Mbps, which seem small compared to residential ISP plans that offer 300 Mbps,
but because these systems use a static Internet Protocol (IP), they are guaranteed
this speed at all times, and the connection is more stable than the dynamic IPs
used in residential connections. These systems also offer many sophisticatedfeatures, including the ability to zoom and pan/tilt cameras at both sites, connect
to medical devices like stethoscopes, and connect to multiple microphones andlarge (and multiple) monitor systems. The advantage of such features is that they
enable psychiatrists to closely examine patients and control how they view theparticipants in multipoint conferencing. These systems require technical support
to operate with other legacy systems. Despite their superior functioning, standardsbased systems are predominantly used in large organizations because they require
a considerable initial investment and high costs for maintenance, technical staff,
and related IT infrastructure.
Consumer-based Systems
Standards-based systems are not feasible for individual healthcare providers
or small group practices. Consumer-based software platforms, or applications(“apps),” are now available at reasonable prices with the need for minimal technicalskills. These systems transmit data over the internet and the consumer interface
software runs on personal computers, tablets, and smartphones. Subscriptions
to these cloud-based services are sold based on the number of users or accounts,
ranging from free single account packages to enterprise-level subscriptions withhundreds of accounts. Enterprise-level contracts often include an option topurchase the software to allow consumers to host the service on their server. Local
hosting can significantly improve the telepresence quality of the videoconference.
In the United States, software vendors who advertise telemedicine solutions must
provide appropriate software encryption and sign Business Associate Agreements
to comply with HIPAA regulations. Such agreements are also standard in Canada
and many European countries. LMICs may have other approaches to regulations
regarding clinical applications of these platforms.
Recent advances in hardware and software signal compression have enabledthese internet-based systems to deliver the high-quality video and audio signals
necessary for clinical work. They are highly flexible, adaptable, and consumerfriendly, enabling rapid deployment to various settings with minimal training,
startup costs, and fixed costs. The flexibility and portability of these systems givepsychiatrists options to choose a hardware and software combination that meets
their financial, clinical, and logistical needs and limitations. The COVID-19
pandemic has demonstrated how easily medical centers, private practices, andfamilies can integrate consumer-grade systems into daily life if the appropriate
infrastructure is available. Relevant information regarding consumer-grade
systems for health care professionals seeking to establish TeleTreatment services
is summarized in an online toolkit (National Telehealth Technology Assessment
Resource Center, 2022). Interested purchasers should review systems offered bycommercial vendors advertised online.
There are disadvantages to conducting clinical sessions over consumer cloudbased applications that utilize the internet. The foremost is the highly variable
quality and speed of the connection, which impacts the quality of streaming audio

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IACAPAP Textbook of Child and Adolescent Mental Healthand video. The connection quality and speed can be affected by many factors,
including nearby internet traffic (for cable-modem connections), inclement
weather, network failures, local electrical device interference to WiFi signals, andintranet network traffic origination and destination sites. Other disadvantages tothese cloud-based platforms include variable customer support from the vendor,
a greater chance that end users will inadvertently alter the hardware or software,
limited ability to connect peripheral devices such as a stethoscope, and usually no
ability to control the camera at the patient’s site. They usually do not connect tolegacy video conferencing devices installed in many healthcare centers, schools,
and other organizations. In LMICs, and in some HICs including rural areas in
the United States, one of the major challenges to implementing consumer-based
equipment is the cost of extending broadband and cellular devices infrastructure.
Finally, initially, consumer cloud-based systems have been considered less securethan standards-based, legacy systems. Over the past two decades, technologicalimprovements have decreased this concern.
Countries vary in their current status of technology development. In
Qatar, access to the internet and technology was never considered an obstacle,
as almost 100% of the population has access to ultra-high-speed internet andcommunication devices. Due to onset of the COVID-19 pandemic in 2020, theState of Qatar imposed strict restrictions to limit the spread of coronavirus. The
healthcare facilities were directed to use virtual audio consultations from hospital
networks to provide care to the population in need. Because of the confidentiality
concerns, the use of commercial applications, including Zoom, Skype, andWhatsApp, was strictly prohibited. Because of the need to have video capabilities,
the Ministry of Public Health later introduced a proprietary HIPPA-compliant
audio/video software across Qatar’s healthcare system. At the beginning of 2020,
an Information Technology helpdesk across the nation’s hospitals started installingthe software on the hospital desktops, and workflows in the electronic medical
records systems were built. Clinical informatics made physicians’ and patients’
workflows to follow. Health care professionals across different specialties were later
trained on its use.
Egypt is, perhaps, showing the way forward for many LMICs. Over the past
five years there has been a rapid increase in the rate of internet usage, predominantly
through smart phone accessibility, now estimated as almost 50% penetrationand increasing. Usage has focused on personal and social interests. Its use fortelemedicine applications still faces many difficulties like the unavailability of an
efficient infrastructure such as high bandwidth and the relevant equipment in therural areas. However, President Abdel Fatah al-Sisi’s “Egypt Produces Technology”
initiative aims to revolutionize internet connection between cities (Reda, 2018).
The Egyptian Information Society tries to improve the accessibility of telemedicine
by developing ICT human capacities and providing socio-economic applications
for healthcare systems (Hussein, Khalifa, 2012). It seems only a matter of time
until the population’s use of mobile technology, the government’s vision, andsocietal pressures converge to bring Egypt into the “digital health community” andmake TMH TeleTreatment and TeleConsultation an option for selected families.
In summary, choosing the best videoconferencing platform is a complicateddecision. Health care professionals must consider their budget for initial andongoing costs, the available bandwidth at all sites, the technical sophistication of

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IACAPAP Textbook of Child and Adolescent Mental Healthusers, access to technical support, and the need to control the remote equipment.
Other helpful resources are available from the National Telehealth Technology
Assessment Resource Center, 2022).
Smart Phones and Other m-Health Devices
Mobile technology has spread rapidly around the globe. However, thegrowth in mobile technology has not been equally distributed, either acrossnations or within them (Pew Research Center, 2019). For example, among
HICs with advanced economies ownership of mobile devices ranged from 100%in South Korea to 90% in Greece, while in LMICs with emerging economies
ownership ranged from 93% in South Africa to 64% in India. Ownership ofmobile devices predominantly means smart phones. Their ownership ranges
from a median of 76% of advanced economies to 45% in emerging economies.
Whether in advanced or emerging economies, younger people, those with higher
levels of education and those with higher incomes, are more likely to be digitallyconnected, predominantly through smart phones. By the end of 2020, 46.45
percent of the world’s population owned a smartphone. With many people using
more than one smartphone, the actual number of smartphone subscriptions ismuch higher. As of 2021, smartphone users are using an estimated 6.4 billion
smartphone subscriptions, a figure that is expected to climb to 7.5 billion by 2026
(O’Dea, 2021). As the population of young people is growing across the globe, it
is anticipated that ownership of smart phones will continue to grow (Pew ResearchCenter, 2019). The global availability of smart phones, and other digital devices,with their embedded video components has greatly expanded the potential for
TeleTreatment and TeleConsultation in LMICs.
In summary, choosing the best videoconferencing platform is a complicateddecision. Child and adolescent psychiatrists must consider their budget for initialand ongoing costs, the available bandwidth at all sites, the technical sophisticationof users, access to technical support, and the need to control the remote equipment.
Most important in LMICs is the access to videoconferencing equipment of their
medical colleagues in distant communities, and individual families who may
seek services on their own rather than through their community health clinic.
Some helpful resources are available from the National Telehealth Technology
Assessment Resource Center (2022) and the National Consortium of TelehealthResource Centers (2022).

ESTABLISHING A TELETREATMENT AND
TELECONSULTATION PRACTICE
The following is a brief overview of issues for child and adolescent
psychiatrists in LMICs to consider in determining the relevance and capabilityof TeleTreatment and TeleConsultation for their clinical practice, whether atuniversity and major medical centers or in private practice. The information has
been gleaned from established practices in HICs as well as from new practices
developed during the COVID-19 pandemic. More information can be foundthrough several practical and free online sources in the United States, including:the National Telehealth Technology Assessment Resource Center (2022); theNational Consortium of Telehealth Resource Centers (2022); Health and Human
Resources (2022), andTelehealth.HHS.Gov (2022). The last source provides

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IACAPAP Textbook of Child and Adolescent Mental Healthinformation specific to services delivered from the home. LMICs will likely needto modify the guidance from these centers to address their country’s regulations
and resources. For example, these centers do not emphasize services provided
through smart phones which may be the most prominent devices used in LMICs.
Feasibility and Sustainability of a TeleTreatment and TeleConsultation
Practice
The WHO has noted that among surveyed countries, one of the mostrequested areas of information was the clinical uses of telemedicine, requested
by almost 60% of countries surveyed (WHO, 2009). The WHO also noted that
TMH TeleTreatment appears poised to play an increasingly important role within
healthcare systems to address mental health disorders which comprise one of themost disabling conditions of youth in LMICs, similar to its impact on youth in
HICs. The successful pivot from in-person care to TMH TeleTreatment due tothe COVID-19 pandemic catapulted TeleTreatment into mainline practice inmany HICs (Sharma, Sasser, Schoenfelder Gonzalez, et al., 2020). The availability
and use of telemedicine services in most LMIC countries was limited before
COVID 19. However with deficiency of in-person mental health services during
the lockdown many countries started to accept the concept of TeleTreatment. It
will be interesting to see the feasibility and sustainability of TeleTreamtent and
TeleConsulation services in MICs as the pandemic resolves.
Implementing a TMH TeleTreatment in LMICs will likely evolve similarly tomost HICs. TeleTreatment services will likely first be tested at academic and major
medical centers in a “hub-and-spoke” model. Then, once feasibility is demonstrated
and the infrastructure emplaced, other sites and individual psychiatrists canintegrate TeleTreatment into their practices. This “top-down” approach does
not preclude individual child and adolescent psychiatrists in LMICs with anestablished middle class patient populations and sustainable financial models fromincorporating TeleTreatment into their practices ahead of demonstrated feasibility
by major centers (Personal communications, Patricio Fischman MD, Santiago,
Chile; Ahsan Nazeer MD, Doha, Qatar, 2022). In the absence of demonstrated
feasibility and national regulations, innovative psychiatrists may forge their own
TeleTreatment model of care.
Indeed, the COVID-19 pandemic forced most psychiatrists to be innovative.
During the pandemic, individual psychiatrists and clinics developed their own
TeleTreatment services and bypassed the “top-down” “hub-and-spoke” approach.
They already have the components of a “bottom-up” developmental model. Goingforward, it will be exciting to watch the development of TeleTreatment in LMICs.
TMH TeleConsultation services to primary care settings in rural communities
from psychiatrists at academic and major medical centers are anticipated to be themost efficient use of the very scarce child and adolescent psychiatry workforce
in LMICs. TeleConsultation has the added potential to increase primary care
physicians’ skills in caring for youths’ mental health problems without the burdenof traveling to distant sites for training. Financial models will be important todetermining whether TeleConsultation is feasible and sustainable.
Determining the feasibility of TMH TeleTreatment and TeleConsultation
services is based on an accurate needs assessment that identifies the mental health

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IACAPAP Textbook of Child and Adolescent Mental Healthneeds of the patient site and determines whether the proposed service is likely tomeet those needs and complement existing services. It is helpful to visit the patient
site for collaborative problem solving with local stakeholders, such as physicians,
educators, and parents. Child and adolescent psychiatrists may approach this topic
by identifying a problem of most significant concern to parents. For example,
autism spectrum disorders are increasingly identified in LMICs, but these children
may be excluded from educational opportunities. They are at risk to not meet theirinnate potential, and parents are left with few resources in caring for their children.
Child and adolescent psychiatrists may render TeleTreatment to children and theirparents and TeleConsultation to the community to explore educational options,
including behavioral management within the classroom. TeleConsultation to
the primary care physician may also help to conduct medication trials to address
disruptive behaviors or mood and anxiety disorders.
The sustainability of TeleTreatment services is usually thought to relate
to sources of revenue and reimbursement. It may be more helpful to consider
sustainability within the context of the community’s needs. For example, a medical
center may not benefit directly from these services, but there could be a financial
benefit to the institution if emergency room services decrease. The community
may also benefit from lower expenses related to correctional or educational services
for youth. Families may benefit from direct or indirect services to their children
if demands on the family are decreased and parents are able to continue working.
With technology costs lowering, more infrastructure being built, and families
increasingly purchasing mobile devices, the main issues for sustainability will
be developing financial models that balance community needs with sources ofreimbursement. Countries will vary depending on their resources and plans formoving forward. Two examples follow.
In Qatar, COVID-19 induced a paradigm shift, and the public healthsystem started providing primary and urgent medical services via telemedicine.
These consultations are of no charge to the patient and are covered by the
Ministry of Health. In un-published surveys, most recipients have recommended
that telemedicine services remain in place even after the end of the COVID-19
pandemic. In the private sector, however, telemedicine services, including
TeleTreatment, are provided on an out-of-pocket charge basis to the patients, andthe feasibility in that sector depends upon the continued financial health of the
population and their preference for an in-person vs. telemedicine appointment.
It is too early to predict the course that telemedicine applications will take in theinsurance and private reimbursement model.
Vietnam is at the other end of the spectrum in terms of population,
government, and financial models. Physicians are less interested in telemedicine
applications for many reasons. One of these reasons is the impact on their revenue
stream. In Vietnam, the cost of medical examination and treatment is usually
very low compared to the cost of medicines. With the telemedicine system,
doctors only advise without selling medications. There is no financial incentive
to consider telemedicine applications. However, Vietnam is a country with great
potential to develop a telemedicine system, including TMH TeleTreatment and
TeleConsultation, because the internet system is very popular. The proportion ofpeople with smartphones has increased by 150% the past few years and 70-80%
of the population can connect to the internet at very low cost. Especially, after the

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IACAPAP Textbook of Child and Adolescent Mental Health

COVID-19 pandemic, millions of Vietnamese pupils and students have become
accustomed to virtual group studying or meeting. The growth of this young
population of “digital natives” is converging with the government’s increasing
efforts to develop policies and processes to increase the country’s mental healthsystem. The country is moving toward a hybrid health care system with traditional
in-person and TMH services.
Patient Population and Models of Care
The patient site should identify the patients to be served but child andadolescent psychiatrists make the final determination regarding inclusion andexclusion criteria based upon their judgment and ability of the patient site toattend to acutely suicidal or agitated patients with the psychiatrist’s collaboration.
Exclusion criteria may include youth without accompanying guardians, patients
without a primary care physician, or patients whose physician is uncomfortablein collaborating in the treatment of youth with psychiatric disorders. Different
healthcare organizations may have different exclusion criteria for services. For
example, in a tertiary care pediatric hospital in Qatar, patients are excluded fromtelemedicine applications, and instead are scheduled for an in-person session when
the patient’s condition is considered high-risk; when a patient is likely to need aphysical examination; when the patient has a condition that affects his/her ability
to use the technology; when a patient or parent prefers an in-person appointment
or when communicating with children and young people is difficult. Child andadolescent psychiatrists using TeleTreatment in their private practices may set theirown inclusion and exclusion criteria.
Several models of care have been used to provide TMH services in HICs
including consultation to the local physician who continues to manage the patient,collaboration with the local physician or another clinician to share treatment ofyouth, and direct services to youth (Goldstein, Myers, 2014; Hilty, Yellowlees,
Cobb, et al., 2006). Child and adolescent psychiatrists may move flexibly between
these models depending on their and local physicians’ decisions regarding theyouth’s status. One concern is that in LMICs, non-physician mental healthclinicians are generally not available, thus placing the burden on the community
physician to provide care when the psychiatrist is unavailable, and to continue carewhen the patient becomes stable.
Administrative Issues
Establishing a TeleTreatment program requires several administrative steps.
Protocols are helpful, including a business plan with startup and sustainability
considerations and information describing the sharing of services with potentialsites and patients. The workflow must be considered, including procedures related
to patient scheduling, support staff, and responsibilities during the encounter.
Creating a position for a telepresenter is helpful in medical centers, as he/she brings the patient to the sessions, obtains vital signs, assists with obtaining
medication consent and rating scales to document treatment progress, provides
psychoeducational materials, fields patient calls between sessions, submits andretrieves laboratory testing, and coordinates the response to safety concerns(American Telemedicine Association, 2022). Often, the telepresenter joins thesessions to facilitate these tasks. The psychiatrist must directly train the telepresenter.

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IACAPAP Textbook of Child and Adolescent Mental HealthA telepresenter is not usually an option in private practice of TeleTreatment,
and the psychiatrist must make arrangements to obtain supportive information.
For example, youths’ vital signs may be obtained from primary care physiciansor schools if a nurse or health officer is available. Rating scales may be provided
through email or a patient portal. The child and adolescent psychiatrist will needto establish a collaboration with community laboratories. These professionals often
are innovative in determining how to ensure that their care complies with clinicalpractice parameters and professional standards of care.
In the United States, TeleTreatment involves some unique issues indocumentation and billing. The documentation must indicate that the clinicalvisit is conducted through videoconferencing and the location of the patient andpsychiatrist during the session. Billing is usually based on the duration of thesession with a modifier added to usual billing codes to specify delivery throughvideoconferencing. For example, a 40-minute in-person pharmacotherapy session
is designated 99215, while the corresponding videoconferencing session code is
99215GT. Child and adolescent psychiatrists in other countries must determine
the appropriate approach to billing to optimize revenue and to avoid fraud in thefinancial aspects of their practice. A national healthcare system may simplify thisprocess.

OVERCOMING THE CHALLENGES INHERENT IN
CREATING AN AUTHENTIC PSYCHIATRIST-PATIENTRELATIONSHIPS DURING TELE-TREATMENT
Non-Verbal Interactions Engage the Patient
In-person care at medical centers prepares patients for their clinical session
through anticipatory activities such as walking through a lobby, registration, andcheck-in, encountering other patients, viewing various clinical staff, completing
paperwork. Even in-person care at a private office involves a few anticipatory steps.
TeleTreatment obviates these steps, especially if the session occurs in the home. The
patient sits down in front of the camera, and the session starts. Psychiatrists must
immediately engage patients’ attention and convince the patient of their ability tobuild a trustworthy, competent, empathic, and responsive relationship (Riggio,
Feldman, 2014). Psychiatrists who naturally create good rapport are instinctuallycommunicating non-verbally as well as verbally. Spoken language alone does noteffectively communicate ideas and feelings to other people. It is often not what issaid, but how it is said, that matters most to patients (Burgoon, Guerrero, Floyd,
2016; Riess, Kraft-Todd, 2014). Over two-thirds of communicated meaning
can be attributed to nonverbal messages (Leathers, Eaves, 2016). A speaker’s
intentions, priorities and emotions are more effectively communicated when using
non-verbal forms of communication to reinforce and clarify spoken words. During
videoconferencing sessions, cameras, microphones, and speakers alter voice andappearance and flatten emotional expressions and patients’ ability to detect thepsychiatrist’s non-verbal communication is diminished. The psychiatrist mustcompensate for this limitation. Therefore, most experienced psychiatrists providing
services through videoconferencing slightly modify their communication style toestablish a therapeutic relationship. The intent is to replicate good bedside mannerover the camera, forge a strong engagement and sustain good rapport with the

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IACAPAP Textbook of Child and Adolescent Mental Healthpatient, while appearing attentive and genuinely interested in the patient. In thischapter, nonverbal communication is defined as everything that occurs during
the session except for the contextual meaning of the spoken words, including thenature, location, and decoration of the room, the psychiatrist’s physical appearance,
the distance between participants, body movements, posture, gestures, facial
expressions, eye contact, touch, and the tone, pacing, and volume and intonationof the psychiatrist’s voice. These interactions develop spontaneously during inperson sessions but require active attention. Many of these modifications are
summarized in Table 1.

Table 1. Non-Verbal Communication in TeleTreatment
Nonverbal communication to consider during TeleTreatment
includes:• The nature, location, and decoration of the room
• Physical appearance• Individuals’ distance from one another• Body movements, posture, and gestures• Facial expressions• Touching the other person• The tone, rate, and volume of the psychiatrist’s voice

The first non-verbal communication is patients’ view of the psychiatrist as
the camera frame limits patients’ ability to see the psychiatrist and his or her nonverbal communications. They have less access to environmental information toshape their perception of the psychiatrist as trustworthy, competent, and empathic.
For example, a restrictive view that only shows the psychiatrist’s head and neckdoes not convey a real person. The psychiatrist’s physical appearance, grooming,
uniform/dress, and interactions become a more significant part of how patientsmake a first impression (Glueck, 2013). Hygiene and attire should be the same aspresented during in-person sessions. If the psychiatrist’s non-verbal communication
does not support verbal communication, the psychiatrist seems odd or insincere(Knapp, Hill, Horgan, 2014). For example, if providing medication informationin an overly casual manner may alarm the patient regarding the psychiatrist’s caring
about the patient’s safety. This weakens the doctor-patient relationship (Henry,
Fuhrel-Forbis, Rogers, et al., 2012).
Erect and open body posture that directly faces the camera and monitor
communicates to patients that the psychiatrist is a confident, non-judgmental, andtrustworthy authority figure who pays attention to their needs (Brugel, PostmaNilsenova, Tates, 2015). Looking away from the camera and monitor with crossed
arms indicates that the psychiatrist is closed to the patient. Moving towards oraway from the camera approximates the effect of interpersonal space during inperson sessions. For example, moving slightly closer to the camera communicates

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IACAPAP Textbook of Child and Adolescent Mental Healthmore interest or attention. If the patient seems defensive, moving slightly awayfrom the camera conveys the perception of giving the patient more distance. The
picture-in-picture function on the computer screen helps psychiatrists to monitor
how their image is projected and to stay within the frame, as noted on the lower
right-hand corner of Figure 2.
As patients can only see facial expressions, gestures, movements, andactivities that fall within the camera frame, psychiatrists must replace large gestureswith smaller ones that are more easily seen. Common gestures like outstretchedarms can be replaced with hand gestures or emotionally congruent facial
expressions. Hand gestures like waving and the thumbs-up sign can also replaceculturally relevant handshakes and “fist-bumps” that are lost in videoconferencing.

Figure 2
Monitoring On-Screen
Presence

The technology interferes with the psychiatrist’s and patient’s ability tointeract as they would during an in-person visit, as summarized in Table 2. The
psychiatrist’s tone of voice can also affect the relationship (McHenry, Parker, Baile,
et al., 2012). The psychiatrist must sound honest, compassionate, and intelligent
while speaking slowly, loudly, and clearly enough to be easily heard and understood
through the microphone, without sounding robotic. Many psychiatrists who are
new to TeleTreament speak robotically due to performance anxiety or distractions
by the electronics (e.g., a medical record that is simultaneously projected onto a
monitor during the session). Psychiatrists may modulate the pitch of their voiceslightly to avoid sounding anxious or robotic, but the challenge then is to avoid
seeming theatric. Smiling while speaking makes the psychiatrist sound warm andapproachable. Placing a smiley face sticker next to the camera is a good reminder
for those who often look or sound too serious.
Table 2. Establishing Rapport during TelepTreatment
TeleTreatment technology affects the ability to:• See the patient• Be seen by the patient• Be heard and understood• Make gestures• Maintain eye contact• Touch• Smell• Demonstrate usual good bedside manner
Encouraging patients to speak more is associated with feeling that theirneeds are fulfilled (Dijkstra, Albada, Klockner Cronauer, 2013). However, theslight audio transmission delay during videoconferencing affects communication.
Therefore, pauses and turn-taking are essential for the psychiatrist to manage thecommunication. Giving the patient an extra moment to reply in conversation
may seem like a long pause but will replicate a usual pause during an in-person

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IACAPAP Textbook of Child and Adolescent Mental Healthconversation. During multi-center sessions, as shown in Figure 3 of several
clinicians coordinating care, the psychiatrists may need to allow for even longer
pauses.
The slight audio transmission delay also makes the use of verbal
encouragements, such as “yes, tell me more;” or “go on,” more challenging. If
the patient has already resumed speaking, and hears the psychiatrist’s encouraging
statements, he/she stops speaking to listen to the psychiatrist, thereby interferingwith communication. Therefore, experienced psychiatrists frequently use gestures,such as the thumbs-up gesture, to facilitate the reciprocal exchange of information
while maintaining engagement and without interrupting the patient. The othernon-verbal rapport-building strategy is to nod and smile periodically while
the patient is talking, thereby indicating that the psychiatrist is listening andencouraging the patient to continue. Consider placing another sticky note thatsays, “Nod and smile!” on the monitor until this becomes natural. Overall, thepsychiatrist must tend to turn-taking during the session to ensure that everyone
has the chance to participate and that the session is not dominated by the mosttalkative participants. It is helpful to address individual participants by their names
so that they know when it is their turn or when the psychiatrist is specificallyspeaking to that participant.

Figure 3
Multi-Site
Videoconferencing

Optimizing the Telepsychiatry Experience
Room Selection
Optimizing the TeleTreatment experience begins with appropriate room
selection, as noted in Table 3. In TeleTreatment, as soon as the camera is turned
on, the psychiatrist suddenly finds him/herself in front of the patient. As thepatient can be at any site, including home, school, or another clinician’s office, it
is up to the psychiatrist to make the session an authentic clinical experience. To
start, attention is given to selecting, arranging, and appointing the rooms at boththe patient’s and psychiatrist’s sites. Psychiatrists often work with a wide range ofrooms and, with proper arrangements, sessions can be successfully conducted inclassrooms, conference rooms, treatment rooms, offices, living rooms, and evenbedrooms. After the room at the patient’s site is selected, the setting should be
reviewed to consider whether it will support videoconferences, accommodate
the routine number of participants, and maximize participants’ focus during thesession.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table 3. Selecting an Appropriate Space
Room selection should ensure that:• Everyone feels comfortable• Everyone is on camera and able to see each other• Everyone is able to hear each other• The room maintains visual and auditory privacy• Room size accommodates the clinical encounter with the childor adolescent and accompanying adult(s)Figure 4
Arranging Space For
Individual Session
Note Room Size, Lighting,Framing, Uncluttered,
Neutral Wall Color, Soft
Surfaces, Child’s Image• Distractions are minimized• Décor minimizes camera distortion• Demonstrate usual good bedside manner
Figure 4 shows an ideal arrangement in a clinic for an individual session inwhich the child appears comfortable, and the camera distance optimally allows
observation of both her affect and overall body habitus and movement. Figure
5 shows another in-clinic arrangement for a child, this time accompanied by two
adults. All participants are comfortably well-spaced on screen, although the child’s
lower body is not visible obscuring possible developmental anomalies or tremors.
Figure 6 shows a session conducted in a medical clinic. The large room allows
the child to move around so that the psychiatrist can observe gross motor skills
and activity level. The size of the room also allows the psychiatrist to rearrange
the chairs to facilitate interventions between mother and child. However, themedical equipment may distract the child and endanger equipment if the childis hyperactive oppositional, or aggressive. The child may also veer off screen,even hide from view, so that the psychiatrist cannot observe potential damage
to equipment, or to the child from the equipment. Techniques are needed tomaintain the child’s engagement and protect the examination room. The opposite
situation is shown in Figure 7. In this in-home session, the small space causes themother to lean to the side to be fully seen, an awkward position that does notconvey the usual parent-child interaction. These examples demonstrate issues inestablishing a site for TeleTreatment. Choosing the optimal space should facilitatea naturalistic arrangement that allows the psychiatrist to conduct an evaluationthat is comparable to a usual in-person session.

Figure 5
Arranging Space For
Multiple Participants

Figure 6
Arranging Space in a
Medical Clinic

Figure 7
Arranging Space at Home

Power and Network
One of the most important considerations in room selection for sites using
cloud videoconferencing is proximity to the WiFi router to maintain a strong
Internet connection. If connecting through a computer, it should be plugged
into the router with an Ethernet cable to provide the most robust video andauditory signal. Most software automatically downgrades the picture and soundto match the worst connection, so one slow site compromises the experience foreveryone involved. Plugging the router, modem, computer, and monitor(s) into a

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IACAPAP Textbook of Child and Adolescent Mental Healthcombination surge protector and battery backup will ensure that the connection
will not drop if there is a momentary electrical surge or loss of power.
Room Setup
Selecting a room with a camera-friendly color scheme makes it easier for thecamera to focus on the participant instead of the background. The camera should
be focused on a wall painted a soft neutral shade to help the participant’s image
stand out from the wall, as shown in Figures 4 and 5. Decorations and patterns
that are small, intricate, highly detailed, or cluttered may distort video images
and trick the camera into focusing on the background rather than on the patient.
Figures 6 and 7 show cluttered backgrounds that risk poor focus if the camera has
low resolution. There should be nothing directly behind the participant’s headbecause the camera’s poor depth projection makes them appear to grow out of theparticipant’s head. The decorations in the psychiatrist’s room should be minimaland professional, reflecting the services delivered.
CamerasCamera placement will determine the framing of the video image, including
who and what is visible on the screen. It will affect the psychiatrist’s ability tocomplete an accurate mental status examination. Cameras should be positioned
at a distance from the patient that balances visualization of the child’s overall
presentation, including motor abilities and activities as well as facial features andexpressions, as best noted in Figures 4 and 6. This is a particular challenge withsmart phones that provide a restricted visual range. Psychiatrists will have to obtainvarious views of the youth when families are using a smart phone.
Participants naturally look at the monitor to relate to one another during
videoconferencing. However, the camera is typically placed on top of the screen
so that participants appear to be gazing downward. Psychiatrists’ eye contact issignificantly related to patients’ perceptions of the psychiatrist’s connectedness andempathy (Montague, Chen, Chewning, 2013). Therefore, psychiatrists’ cameras
should be directly in front of them, positioned at eye level, as shown in Figure 8.
This positioning makes the psychiatrist gaze towards the camera when looking at
the screen. Alternatively, if the psychiatrist wants to display the patient’s image on
the full screen, they should follow the “1/3 Rule” ----position oneself and adjust
the camera so that the eyes appear to be about 1/3 down from the top of thecamera on top of monitor screen. Assessing eye contact is an essential componentof the developmental evaluation of children and establishing a therapeutic alliance,
particularly during a videoconferencing encounter when there is decreased accessto other non-verbal means of communication. The psychiatrist should determine
whether apparent decreased eye contact of the child represents a technical limitation
or a clinical impairment.
If a single participant is using a phone or tablet, it should be positioned
in vertical/portrait orientation, as shown in Figure 9. This orientation adjustment
improves the eye contact between participants because the participant’s eyes arecloser to the camera. If the device needs to capture two or more people in theframe, turning the device to a horizontal/landscape orientation will create a larger
frame covering more of the room. Again, a caveat in using smartphones is thatthe smartphone in any orientation will capture a limited aspect of the child or

TeleTreatment A.15

Figure 8
Optimizing Eye Contact

Figure 9
Establishing Eye Contact
on Smart Phones

25IACAPAP Textbook of Child and Adolescent Mental Healthadolescent, which is not optimal for conducting a thorough evaluation or assessing
medication side-effects. Nonetheless, in LMICs, many small clinics and families
will only have the option of a smartphone. Thus, the psychiatrist must be creativein obtaining the desired information, such as asking the family to prop the phone
in various orientations to observe the youth in different activities that will facilitatean accurate evaluation.
Psychiatrists who use an electronic medical record (EMR) during a session
spend 30% of a visit gazing at the EMR (Montague, Asan, 2014). If an EMR isused during the TeleTreatment session and can be projected onto a screen, it shouldbe placed in a vertical window above or below the monitor with the participants’images, as shown in Figure 10. This placement style causes the psychiatrist to
constantly nod up and down positively and affirmatively when glancing alternately
at the monitor and the EMR. By contrast, if the EMR window were placed lateral
to the participants’ monitor, the psychiatrist would constantly be making negative,
lateral head-shaking gestures during the session. This vertical positioning of twomonitors also has the “side effect” of causing the psychiatrist to make eye contact
as his/her gaze passes the camera in alternating gaze between the patient’s image
on the bottom monitor and the EMR on the upper monitor. Psychiatrists should
minimize the time spent looking at the EMR to maintain eye contact and rapport
with the patient, even if this means charting very little during the session or,
preferably, charting later.
Figure 10 TeleMedicine, TeleHealth, and TeleCare

Courtesy of Shabana Khan MD, NYU LangoneChild Psychiatry

Inevitably, at some point, problems arise with the video connection. If thepatient cannot see the psychiatrist, a few steps may correct the problem. First
check that the correct camera has been selected in the software and confirm camera
selection in program settings or permissions. Close other videoconferencing apps
and ensure that the camera is not covered by a sticker or other item.
Lighting
Lighting affects the quality of the videoconferencing session (Onor, Misan,2005). Cameras need more light than human eyes to produce a clear image. An
insufficiently illuminated room prevents participants from seeing each other,detecting non-verbal communication, identifying physical signs and symptoms
and, therefore, detracts from the authenticity of the experience. Backlighting

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IACAPAP Textbook of Child and Adolescent Mental Healthshould be avoided, which occurs when a bright light comes from behind theperson, such as when seated in front of a bright light or window, as shown in Figure
11 which causes the person to be silhouetted. Natural light from any angle in theroom can also distort images. For example, in Figure 2, if the window is facing
west, the psychiatrist’s image may be washed out during the afternoon sun. Figure
12 shows several variations in lighting, with optimal lighting shown in frame 2
in which artificial light is diffusely distributed over the entire site. On the left
side of Figure 13, glare occurs on the hard shiny surface behind the psychiatrist,
which the psychiatrist on the right avoids by covering the rear mirror with a cloth.
Finally, glare-producing surfaces are not always due to vertical surfaces behind thepsychiatrist. Figure 14 demonstrates the severe glare resulting from the large shiny
horizontal desk surface. It is also worth noting here, that the large hard desk may
interfere with the audio signal. In general, a room with a steady source of diffuse
artificial light is best. Copious indirect lighting, such as floor lamps that bounce
light off the ceiling, is the key to a good lighting plan. It looks natural, softer, andavoids glare or shadows. Removing or covering reflective surfaces that cause glare,
such as mirrors, whiteboards, or large desks and tables also optimizes the video
image. This issue should be considered early in room selection when the positionof the camera is determined.
Privacy
Problems with privacy can be managed by modulating different elements ofthe videoconferencing chain. This is handled at two levels. At the software level,
most commercial videoconferencing vendors advertise whether they meet privacy
and security standards. The second aspect of privacy is restricted access to thevideoconferencing room. Enforcing this restriction may be challenging in small
communities with limited room availability. Ground-level offices with windows,
such as shown in Figures 2 and 15, may enable people outside to view the session.
Home-based services provide major challenges as space must not be accessible tonon-participating family members during the session. The living room or kitchen
table may be most convenient, but these are high-traffic areas that risk intrusionsof privacy. Individual sessions, and some parent-child sessions, may be conductedaway from other family members, such as in a bedroom, office, or porch.
Audio privacy is a major obstacle. If the patient site is a clinical examination
room, it will have been soundproofed. However, the videoconferencing equipment
is often set up in a conference room, private office, or home with inadequatesoundproofing. Sound privacy may be determined by asking a staff to stand outside
the doors and windows during a mock session and report whether they can hear
the conversation. Some psychiatrists and patients wear headphones, but this does
not prevent the family from hearing children talking about their concerns. Somesteps to improve audio privacy are summarized in Table 4.

Figure 11
Backlighting Darkens theParticipant’s Image
Courtesy of David Roth MD,
Mind-Body Clinic, Honolulu

Figure 12
Controlling Light to
Optimize View
Courtesy David Roth MD,
Mind-Body Clinic, Honolulu

Figure 13
Avoid Surfaces that Cause
Glare
Courtesy of David Roth MD,
Mind-Body Clinic, Honolulu

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IACAPAP Textbook of Child and Adolescent Mental Health

Table 4. Improving Audio Privacy
Ways to improve audio privacy include:• Choose a room away from clinic or home traffic• Close windows and doors• Block gaps below doors• Place a white noise machine outside and beside the door to thetelepsychiatry room.

Figure 14
Shiny Horizontal Surfaces
Cause Glare
Courtesy of David Roth MD,
Mind-Body Clinic, Honolulu• Put carpet or an area rug on the floor.
• Add pillows to couches, curtains on windows, and/or tapestries onwalls to absorb sound• When remodeling, use decoupling soundproofing construction
techniques.

• Consider using a headset microphone to block others from hearing
patients’ verbalizations

Figure 15
Compromised Privacy
Courtesy of David Roth MD,
Mind-Body Clinic, Honolulu

Audio quality: distractions and audio signal
Audio privacy and comfort also relate to the ambient noise, including
printers, air conditioners, fans, intercoms, pets, lawn equipment, and outsidetraffic, and varies from room to room. The microphones are sensitive and canamplify these sounds, which affects the quality of the sessions, including noisefrom clicking of the keyboard when psychiatrists type notes during sessions. As
noted in Figure 10, a quiet keyboard minimizes the noise from clicks when typing.
Noise can also be minimized by using an underlayment or pad under the keyboard
to soften the sounds.
Rooms should be selected to minimize these common interfering sounds.
However, most rooms are not perfectly quiet, and the psychiatrist should workwith staff at the patient site or at the patient’s home to implement strategies todecrease background noise. Some approaches to do such are summarized in Table
5. If services are provided in the home, other household members should be
forewarned to stay out of the room during the session.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table 5. Minimizing Background Noise
Approaches to minimizing background noise include:• Close windows and doors• Turn down/off window and portable air conditioners, fans
• Do not to run other equipment (e.g., printers, fax machines,
dishwashers)• Turn off electronics• Keep pets out of the room
• Encourage the patient site to only allow quiet toys without multiple
parts,such as foam blocks, books, markers, action figures and dolls

Audio communication depends on the quality of the microphone andspeakers. Computers, tablets, and phones often have built-in microphones andspeakers that are adequate for providing clinical services. However, if psychiatrists
can add a peripheral device to their system, a quality microphone can filter out
background noise and improve communication. If the psychiatrist is the only
person in the room, he/she could use a headset microphone that eliminates mostbackground sounds and ensures that participants’ voices are not overheard. Perhaps
the most common audio problem relates to selection of the correct settings. If
the psychiatrist has difficulty hearing the patient, ensure that the correct output
device (speaker) is selected and if the patient has difficulty hearing the psychiatrist,
ensure that the patient has selected the correct input device (microphone). If
audio problems cannot be resolved, the psychiatrist can call the patient on thephone and just use the computer for video. The chat box can indicate this process
to the patient. Echoes are another common problem. This may occur when aspeaker systems is connected to a computer, tablet or phone. In these cases, theexternal speakers should be disconnected. Echoes may also occur with Bluetoothor Airplay connected speakers. Finally, feedback loops can develop making
conversation impossible. The loop can be broken by having one or both sites
mute their microphones when not speaking. Alternatively, participants should use
headphones to eliminate the loop.
Finally, it is essential to have a backup plan in case the audio connection
fails. Usually, a conference speakerphone can be used to provide an adequate
audio connection while not seriously compromising synchrony with the video
signal. The audio device in the videoconference software must be muted to avoid
echoes and feedback due to running two microphones simultaneously. If thevideoconferencing is provided by a smartphone, and another phone is not available,
the videoconferencing session may have to be terminated and then reconnected byaudio only to finish the session. Inevitably, at some point, bad connections occur.
It may be necessary for both sites restart their software. If the connection is still
poor, the internet modem and router may need to be restarted.

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IACAPAP Textbook of Child and Adolescent Mental HealthSummary
Psychiatrists who are effective TeleTreatment clinicians can create authentic
psychiatrist-patient relationships by supplementing good bedside manner with afew media-based skills, strategies, and techniques that make TeleTreatment lookeasy. The resulting interactions feel authentic to both patients and psychiatrists.
With sufficient practice, psychiatrists can be as effective and comfortable treating
patients via videoconferencing as they are in other clinical venues. Additional
resources on optimizing the telepsychiatry session are available through the
National Consortium of Telehealth Resource Centers (2022) and the National
Telehealth Technology Assessment Resource Center (2022).

INTERVENTIONSInterventions provided via TeleTreatment to children and adolescents should
be consistent with clinical practice guidelines established by the American Academyof Child and Adolescent Psychiatry (AACAP, 2022) or other national psychiatricorganizations with child and adolescent based guidelines. They should also follow
guidelines established specifically for TeleTreatment (American Academy of Childand Adolescent Psychiatry Committee on Telepsychiatry and the Committee on
Quality Issues, 2017; American Telemedicine Association, 2013).
Developing rapport during videoconferencing
In addition to translating clinical practice guidelines to the videoconferencing
venue, particular attention to cultural context is needed as psychiatrists located inurban/suburban areas and families in distant communities often differ in theircultural heritage and values (Brooks, Spargo, Yellowlees, 2013). Some simple
research into the psychiatrist’s partner communities may help in developing
rapport, and trust. Further, while interventions developed in HICs may focus on
the child or adolescent, interventions adapted to LMICs may focus on the familyor the parents’ relationship with the youth. Thus, the psychiatrist needs to adjust
the approach to deliver culturally competent care.
Most youth quickly develop a rapport during TeleTreatment with just a
few strategies to engage the youth. A virtual handshake, “high 5s,” or “fist pumps”
quickly engage youth, as shown in Figure 16. At the beginning of the session,asking about friends, favorite activities, or the school verbally engages youth. The
youth often wants to understand how the session works. A simple discussion that
includes the psychiatrist’s location often readily engages youth. If the youth isanxious or shy, the parent may start the conversation and the psychiatrist tells the
youth to offer his opinion if he does not agree with the parent’s viewpoint.
School-aged children, the modal patient presenting for TeleTreatment
services, are readily engaged. Younger school-aged children love to draw apicture and then share it with the psychiatrist over the camera and monitor. The
psychiatrist asks the child to tell a story about the picture, allowing him/her toevaluate the child’s intellect, cognitive organization, language skills, activity level,
concentration, as well as the ability to enjoy interpersonal relations. Older schoolaged children enjoy doing spelling or math problems that the psychiatrist assigns
and then reviewing progress together. Of course, best results are obtained to startwith relatively simple assignments so that the child can demonstrate proficiency.

TeleTreatment A.15

Figure 16
Engaging Youth over the
MonitorCourtesy of David Roth MD,
Mind-Body Clinic, Honolulu

30IACAPAP Textbook of Child and Adolescent Mental Health

Youth with Attention-deficit Hyperactivity Disorder (ADHD) need a modified
approach for their own welfare and to protect items in their room. After initial
engagement over the monitor, it may be most helpful to allow these children toplay or roam for a while, then bring them back again for interaction. Likely they
will not spend time drawing or doing a written assignment, but they may engage
by talking about an issue of their choosing or showing something they enjoy, like apet, music, a toy, etc. It may be possible to use wired ear phones so that they haveto stay near the camera. Youth with Oppositional Defiant Disorder (ODD) may
need extra motivation to stay in the frame for brief one to five minute intervals.
Rewards may increase duration of their engagement. If youth with ODD agree
to participate but off camera, just keep them talking and let them decide whento come back on camera ---- which they usually do when the parent(s) starts
discussing an issue with which they disagree. Of note, if the family is using aphone for the session, they can switch to the rear-facing camera to clandestinely
show the youth’s behavior during the session. But beware. If youth are off camera
and their parent(s) is occupied speaking with the psychiatrist, the child may cause
damage in the room that is not noted until too late. It is best to keep the youth on
camera if at all possible.
If youth become agitated, it may be necessary to excuse them from thesession and ensure other family members’ safety prior to continuing the session.
Sometimes they will agree to communicate via chat of texting instead of interacting
verbally. Encourage these patients to bring familiar and calming items to distract
them while speaking with the parent(s), or just to use while taking a break during
the session. Caution is warranted here as well. If the youth is allowed to bringelectronics, it will be difficult to engage them. So one of the few “rules” is noelectronics!! Of course, some psychiatrists and parents will state that this is the only
way to get an opportunity to talk without interruptions from the youth. Perhaps“the rule” is electronics only at the end, but do not expect the child to re-engage
and do expect a possible tantrum if the electronics are taken away which could
delay ending the session.
Children with developmental disorders such as autism spectrum disorder(ASD) may be wary of interacting over the monitor. Consider allowing them tostay in the background if they want, speaking and engaging as they are able. The
main issue is that the psychiatrist must be creative in keeping the child in thesession while also conducting an appropriate clinical assessment.
Special assessment is also needed regarding the child’s appropriateness fora traditional play session. An adult should be readily available nearby if a playsession is attempted or if impaired children are engaged individually. Alternatively,
the school-aged child may be observed interacting with staff in a structured or
free play session, or engaged directly in play, such as developing a scenario withpuppets.
Young children have other considerations. Preschoolers should be observed
in developmentally appropriate interactions with their parent(s) and, if indicated,
to examine separation anxiety or other clinically relevant concerns, with anunfamiliar adult, perhaps a staff member. Direct interaction with the young childis essential, such as distinguishing colors, pointing to body parts, relating a story
with a special toy, or even singing their ABCs with the psychiatrist. It is helpful to

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IACAPAP Textbook of Child and Adolescent Mental Healthspend more time at the beginning of each session engaging the child after greetingthe parent(s). The child should be allowed to play with selected toy(s) while
speaking with the parent(s). This is not just to keep the child busy, but to note
how the child plays, his/her attention span, imagination, and ability to entertain
him/herself. It is also an opportunity to test how much the child really listens toand understands the conversation.
Adolescents may be more challenging to engage, especially if depressed.
Spending some time privately with the teen, just as during in-person sessions, will
best facilitate engagement. They may engage better in their room or otherwise
securely away from their parents. The psychiatrist may have to go online with theteen to share a favorite electronic game, music, or website. Anxious youth are more
likely to engage but they may not want to see their image in the picture-in-picturefeature on the screen. So, it may need to be turned off. With anxious youth, it isbest to start speaking about concrete topics, for example their interests or recent
activities, then move to topics that are anxiety provoking.
Youth who are suicidal, manic or psychotic can be treated throughTeleTreatment by setting up the session in collaboration with others either at thepatient site or within easy access. Having a written protocol and triage processestablished prior to meeting with these high-risk youth will reduce the likelihood ofa crisis and/or provide ease of responding if there is a crisis (Sharma, Feuer, Stuart,
et al., 2022). The protocol includes steps to contact supportive and crisis services
in the youth’s area and the youth’s consent to contact the parent(s). The protocol
needs to be in place including the youth’s signed consent prior to the session if the
youth’s high-risk status is known ahead of time. Clear communication among all
relevant team members is important to safe TeleTreatment interventions.
Closing a TeleTreatment session is as important as beginning a session. The
psychiatrist prepares for the closing by verbally and non-verbally communicatingthat the session is ending. Verbally, the psychiatrist may summarize the session,state the plan made such as laboratory testing or the medication prescribed, notea plan for follow-up, and make a traditional closing remark, such as wishing thepatient well. Non-verbally, the psychiatrist may move back from the camera, breakeye contact, and raise a hand to signal good-bye, Figure 17. The closing should feelnatural to the patient.

Figure 17
Closing the Session with a
Friendly Gesture
Courtesy of David Roth MD,
Mind-Body Clinic, Honolulu

In each of these intervention scenarios the main message is that psychiatrists
conducting TeleTreatment sessions must be flexible and creative in applying theirclinical skills to ensure that they transcend the technology engage the youth,
develop trust with both the youth and parents(s), obtain an accurate evaluationand make an appropriate treatment plan.
Pharmacotherapy during videoconferencing
Pharmacotherapy can be provided readily during TeleTreatment.
Approaches to medication management depend on the model of care (Cain,
Sharp, 2016; Myers, Valentine, Melzer, 2007) including direct-to-patient
treatment as shown in Figure 18. All models of pharmacotherapy require
maintenance of communication with the primary care physician throughout thisprocess. In the United States, medications that are not labeled as “controlled” or“scheduled” substances and, therefore, not regulated by the Drug Enforcement

TeleTreatment A.15

Figure 18
Pharmacotherapy with
Youth

32

IACAPAP Textbook of Child and Adolescent Mental HealthAdministration (DEA), can be prescribed as during in-person practice. Controlled
or scheduled medications have additional regulations, as regulated by the Ryan
Haight Online Pharmacy Consumer Protection Act (110th Congress, 2008)
that regulates internet prescribing. This regulation requires an existing patientphysician relationship before prescribing a controlled substance or the presence ofanother DEA-registered physician at the patient’s site during any virtual session.
Obviously, restrictions on prescribing dilute the value of TeleTreatment (Kafterian,Caudill, Kim, et al., 2019). LMICs, as well as other HICs, may also regulate theprescription of such controlled substances, although countries new to telemedicine
may not. Psychiatrists should establish procedures to ensure compliance withcurrent legislation in their countries. Of note, during the COVID-19 pandemic in
the United States, this regulation was waived (https://telehealth.hhs.gov/providers/
policy-changes-during-the-COVID-19-public-health-emergency/prescribingcontrolled-substances-via-telehealth/ ) indicating that the federal legislature knows
the barriers to implementing telemedicine on a nation-wide scale. Psychiatrists andpolicy-makers are preparing arguments to federal agencies to maintain these gains
after the pandemic has resolved.
Tracking vital signs, height, and weight, obtaining rating scales, assessing
adverse effects, and monitoring physiologic status with laboratory monitoring areaccomplished during clinic-based TeleTreatment sessions with coordination fromthe staff at the clinic. Such monitoring for sessions conducted at home should becoordinated with the primary care clinic or school. Abnormal movements due
to antipsychotic medications can be assessed remotely by the psychiatrist using
the Abnormal Involuntary Movement Scale (Amarendran, George, Gersappe, etal, 2011) or a nurse at a clinic or school can be trained to complete the scalein-person. An important aspect of medication management is providing care or
assisting staff in between the sessions. Families should be given clear directions forrequesting refills, asking questions and reporting adverse effects.

Figure 19
Evaluation of Children with
Developmental Delays

Figure 20
Evaluation of Children with
Developmental Delays

Psychotherapy during videoconferencing
Models of psychotherapy through videoconferencing are evolving. Autism
spectrum disorders and other developmental disorders are increasingly recognizedacross LMICs, similar to HICs. Early identification and intervention are crucial
to helping these children develop their innate potential. Psychiatrists in distantcan virtually provide the evaluation for early identification, as shown in Figure 19,
and then join the local clinical team for intervention planning that includes theparent(s), the primary care physician, school system, and specialists from selecteddisciplines.
As noted in the section “The Evidence-Base in Support of TeleTreatment
with Children and Adolescence,” the delivery of behavioral and cognitive behavioral
therapies through videoconferencing is feasible, although most psychotherapy
outcome studies have been small and effectiveness is not clearly established.
The interventions that appear to be the most readily adaptable to TeleTreatment
are those involving the parent interacting with the child, such as Parent-ChildInteraction Therapy (PCIT) for pre-school-aged children (Lyon, Budd, 2010) as
shown in Figure 20 and child-directed therapy as shown in Figure 21. Childfocused interventions include tics and obsessive-compulsive disorder using theparent as a local coach to translate the psychiatrist’s behavioral components to the

TeleTreatment A.15

Figure 21
Parent Coaching & ChildDirected Play
Courtesy of Yaniz Padilla
Dalmau PhD, Seattle
Children’s

33

IACAPAP Textbook of Child and Adolescent Mental Healthyouth.
Less has been documented for TeleTreatment with adolescents. Working
with depressed teens who are often very withdrawn or irritable can be challenging(Figure 22). However, clinical work during the pandemic lends experiential
validation to the feasibility of delivering cognitive-behavioral intervention to teenswith anxiety and depression (personal communication, Schoenfelder Gonzales,2021). Structured cognitive-behavioral protocols may require some flexibility toaccommodate youths’ ability to work through the technology.
The pandemic has encouraged clinicians to be creative. Groups for parentsof children with attention-deficit hyperactivity disorder (ADHD) and anxiety
disorders have been successfully implemented. Considerable time is needed toestablish these groups. However, experience has demonstrated that these groups
are feasible, and early evidence suggests that they are acceptable to clinicians andparents. However, the corresponding children’s groups for ADHD and anxiety
that typically accompany the parent groups have been difficult to implement as
these children require ongoing adult supervision that is typically not included inthese groups when delivered in-person.
Group therapy via videoconferencing for parents of children with ADHD
and anxiety disorders is feasible, as demonstrated during the pandemic (personalcommunication, Schoenfelder Gonzales, 2021). TeleTreatment provides an
excellent venue for youth with medical disorders that preclude their meetingin-person, such as youth with cystic fibrosis or who are immunocompromised.
Group therapy via TeleTreatment appears promising for bringing evidence-based
treatments to youth in distant communities who typically do not have access togroup interventions as recent experience has demonstrated the feasibility andsuccess of group TeleTreatments for youth with anxiety or depression who weretransitioned from in-clinic treatment to TeleTreatment during the COVID-19
pandemic. An unanticipated benefit of these virtual groups is that they do not
require clinic space that is often limited. Going forward, these successful experiences
encourage psychiatrists to use their creativity and local resources to explore otherapplications of TeleTreatment options with youth and their parents.

Figure 22
TeleTreatment with
Depressed Teens

Figure 23
School-Based
TeleConsultation

Figure 24
TeleConsultation to SchoolCounselor

TeleConsultation
TeleConsultation involves multiple venues. One of the most common
TeleConsultation in child and adolescent psychiatry involves the school system.
Psychiatrists consult to school nurses or health officers regarding the medical
aspects of a youth’s mental or behavioral disorder, Figure 23, and with school
counselors and therapists, Figure 24. Note that schools usually have limited space
to accommodate Tele-Consultation, or other virtual services. Thus, a classroom
or office room is often used that does not have an optimal set up. This is noted
in Figure 24 that shows cluttered backgrounds that can cause visual reflections
and hard surfaces that can cause auditory distortions. One aspect that can becontrolled is minimizing shuffling of all those papers on the TeleConsultant’s
desk that interfere with the microphone. Another example is shown in Figure 25.
TeleConsultation from psychiatric experts to school systems are often conductedin large conference rooms with large tables. The long hard surface of conferencetables may cause echoes that interfere with the audio quality, but the non-shiny,
matte finish of the table surface prevents glare.

TeleTreatment A.15

Figure 25
TeleConsultation with
School Team
Courtesy, Antonio
PignatielloMD, Hospital for
Sick Children, Toronto, ON)

34

IACAPAP Textbook of Child and Adolescent Mental Health

These situations represent the realities of doing TeleConsultation and
TeleTreatment in the “real world.” Psychiatrists must balance the benefits ofproviding services that would otherwise be unavailable for a community versus
suboptimal conditions.
The most common, and valued, use of TeleConsultation for child andadolescent psychiatry in LMICs involves consultation from a child and adolescent
psychiatrist to primary care professionals in distant communities, with or without
the family present, as shown in Figure 26. These TeleConsultations are beneficial to
stakeholders. Families do not need to travel to urban areas for treatment, primarycare professionals increase their skills and obtain support in treating their young
patients’ needs, and child and adolescent psychiatrists at major medical centersprovide new learning experiences for their trainees.

Figure 26
TeleConsultationto Primary
Care

EVALUATING A TELETREATMENT SERVICEIn HICs, the demand for all telemedicine services has outpaced developmentof an optimal evidence-base supporting its efficacy. Ongoing evaluation of
TeleTreatment and TeleConsultatin services will help all countries to determine
the feasibility of implementing a program within their selected geographicalareas, populations, and disorders. Evaluation may include process variables,such as the description of the population served, appointments kept or canceled,hospitalizations required or averted, collaboration in the community, types ofservices provided, and adherence to treatment plans. Routine documentation ofadverse events and measurement of outcomes with standardized rating scales help
to demonstrate the safety of treatment and patients’ progress. Assessment may
also include satisfaction ratings from the referring primary care physicians andother stakeholders, input from teachers, and parents’ perceptions of treatment andprogress. Psychiatrists should also consider evaluating caregivers’ burden and how
this is reduced by having access to TeleTreatment services (Vander Stoep, McCarty,
Zhou C, et al., 2017). Exploring the virtual relationship between the patient andpsychiatrist could help understand salient mediating factors when delivering
care remotely. Kramer and colleagues (2012) have described a model to informoverall TeleTreatment research design, and Slone and colleagues (2012) describe
additional guidance specific to pediatric research settings. Such evaluations can be
published in a community’s newsletters or on social media for local professionalorganizations, or submitted to national publications. Even simple sharing at
professional meetings can help to ensure best practices-care for other child andadolescent psychiatrists seeking to incorporate TeleTreatment into their practices.

BEYOND TRADITIONAL VIDEOCONFERENCING
TeleTreatment, as described above, uses technology to replicate thetraditional model of care, that is, one-physician-to-one-patient. While this modelis important to providing direct service to under-served youth, it does not create
new resources; it only redistributes the existing workforce which is sparse in
LMICs. Approaches are needed to leverage the existing psychiatric workforce andthe technology to reach more youth and to support their primary care physicians.
Here we address WHO’s broader definition of telemedicine that includes digitaltechnologies that are used to “…deliver healthcare and improve the health of

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35

IACAPAP Textbook of Child and Adolescent Mental Healththe patient.” The available and emerging technologies are particularly suited tosituations in which the traditional synchronous, doctor-patient virtual officevisit is impossible or inefficient. They focus on TeleConsultation to primary care
physicians and direct-to-patient asynchronous models. Multiple terms have beenused to refer to these technologies such as “e-health” or “connected health.” We use
the term “digital health.”
Digital Health to Support Primary Care Professionals’ Role in Mental
Health CareThe Extension for Community Healthcare Outcomes model, or Project
ECHOTM(https://echo.unm.edu) is a model that leverages both the psychiatricworkforce and the videoconferencing technology but transcends the traditionalmodel of one-physician-one-patient care. Project ECHOTM was founded at
the University of New Mexico in 2003 by Sanjeeva Arora MD. Dr. Arora wasconcerned about the lack of specialists to consult to primary care physicians
in managing patients’ special needs. He notes that Project ECHOTM seeks
to ensure that “the right knowledge exists at the right place at the right time”(About Us (unm.edu). A medical specialist at a university or other major medical
center consults simultaneously to multiple primary care physicians across a broad
geographical area with the aim to improve those physicians’ skills in best practicescare for managing common and complex medical diseases. A schematic of Project
ECHOTM is shown in Figure 27.
Figure 27 Multiple Physicians and Patients

In child and adolescent psychiatry, the psychiatrist meets on screen with agroup of primary care physicians who alternate in presenting specific cases (Project
ECHO (psychiatry.org). The psychiatrist also provides psychoeducation on topics
chosen from the primary care physicians’ feedback. Other clinicians may join the
consultation, such as psychologists or dieticians (Alicata and Cheng, 2018). A
sample child and adolescent Project ECHOTM psychiatry program is shown in
Figure 28. Thus, Project ECHO® virtually redistributes the psychiatric workforce

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Figure 28
28ECHOTM for Child &Adolescent Psychiatry
Courtesy of Daniel Alicata
MD, PhD at University of
Hawaii36

IACAPAP Textbook of Child and Adolescent Mental Healthand supports primary care physicians so that patients can obtain appropriate carein their own communities. It also allows the primary care physicians to serve as an
ongoing support network for one another. In the United States, these programs are
typically funded by the individual states, or grants.
This model is increasingly finding applications in the United States
demonstrating its feasibility and its acceptance by physicians in diverse settings.
The major limitation is finding child and adolescent psychiatrists who are interested
in the model and primary care physicians who are willing to manage psychiatricconditions. Project ECHOTM has started to find applications for medical
disorder in some LMICs (Partner Portal (unm.edu) but not yet for mental healthdisorders. These programs for medical disorders have been funded by WHO orother global organizations such as the Fogarty International Center at the National
Institute of Health (Fogarty International Center (nih.gov) in the United States in
conjunction with individual LMIC governments. Considering the severe paucityof psychiatrists in LMICs, the Project ECHOTM model is an ideal mechanism
to disseminate the expertise of child and adolescent psychiatrists at academic
and major medical centers to physicians in rural communities. Countries withnationalized healthcare systems may be especially suited to invest in training a
new breed of child and adolescent psychiatrists to deliver the Project ECHOTM
model.
Store-and-forward telehealth is one approach that leverages the limited
workforce and the widely available m-health technology. It has been explored
predominantly with adults. A clinician (various disciplines) at an originating site
conducts and records a structured interview with a patient and then forwards therecording to a psychiatrist who reviews the recording and offers an opinion on
diagnosis and treatment planning, which is then implemented by the consulting
primary care physician. This approach has shown good feasibility with adults(Yellowlees, Parish, Gonzalez, et al., 2018). A variation has been described withyouth. Parents use their smart phone to record selected, protocol-driven samplesof their children’s behaviors in the home setting in selected situations, such as task
demand. The recording is uploaded to a secure website for review by a behavioral
health expert who provides feedback to the family and primary care physician.
This approach has shown good accuracy, reliability, sensitivity, and specificity(Smith, Rozga, Matthews, et al., 2017) for providing high quality informationthat primary care physicians used for diagnosing autism and authorizing neededinterventions for children with autism spectrum disorders. Potential broader
applications are evident, for example to sample a child’s behavior in the classroom
for later assessment by a psychiatrist at a distant site. To date, funding for thisapproach has been through grants.
Telephony is a low tech approach to leveraging the psychiatric workforce
by supporting primary care physicians in youth mental health care. The frequency
and longevity with which most youth visit a trusted primary care physician makeprimary care a feasible and scalable solution to address youth behavioral healthcare needs. Primary care physicians often serve as default mental health providers,
but lack the time and training to optimally manage most behavioral healthconcerns and they lack realistic referral options. Most view their primary role inbehavioral healthcare as limited to screening, diagnosis, education, and medication
management (Stein, Storfer-Isser, Kerker, et al., 2016; Pidano, Honigfeld, Bar-

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IACAPAP Textbook of Child and Adolescent Mental Health

Halpern, et al., 2014) and express a desire for reassurance from specialists in thisrole (Pidano, Honigfeld, Bar-Halpern et al., 2014). The universally available
telephone / smart phone comprises an effective and efficient approach to deliver
this reassurance (Hilt, 2016; Hilt, Romaire, McDonell, et al. 2013). Telephonyprograms provide behavioral health consultation with several components: 1)
Phone consultation on specific cases, 2) training of primary care physicians inbehavioral health topics through educational venues; and 3) provision of referral
information. Each program also incorporates its own site-specific components,
such as a videoconference in the primary care office with patients who pose
particular challenges to diagnosis and treatment planning (www.seattlechildrens.
org/healthcare-professionals/access-services/partnership-access-line). In the UnitedStates there are now over 25 of these programs affiliated in the National Networkof Child Psychiatry Access Programs (NNCPAP; https://nncpap.org/). The successof these programs is evidenced by their ability to modify PCPs’ management ofchild and adolescent behavioral health conditions (Hilt, Romaire, McDonell etal., 2013; Platt, Pustilnik, Connors, et al., 2018). Such telephony programs holdconsiderable promise for LMIC governments that seek to support their primarycare physicians and improve the mental health of their young people. Generally,
these initiatives are funded by their state governments.
Egypt introduced a variant of telephony during the pandemic
lockdown (EL Havek, Nofal, Abdelrahman, et al., 2020). They established a
specialized national child and adolescent mental health helpline. Services including
providing parenting advice and psychological support. With more challenging
cases suggesting psychiatric disorders, parents are encouraged to seek available
psychiatric help from the nearest mapped services. In cases of emergencies, suchas abuse, a specific protocol was applied. To ensure continuity of the services
to children with autism spectrum disorders, some centers provided training tomothers with weekly follow up calls.
The MH2 is an early research effort that is testing a parent web-based “app”
designed to optimize medication titration of Attention-Deficit Hyperactivity
Disorder (ADHD) for children (Paschall, Marti, Cheung, et al., 2018). The
treatment of ADHD remains suboptimal in HICs, especially in community
settings. Given near-universal access to smart phones in the United States,
m-health holds promise for improving treatment, and for developing familycentered care. The parents use the MH2 “app” to obtain education about ADHD,
understand medication side-effects, set reminders for medication administration,
document medication adherence, and enter ADHD behavior ratings for theirchild in response to medication titration. The MH2 program aggregates theseparent-generated data and sends them to their physician. Then, during in-person
visits, results are displayed on the physician’s iPad to facilitate medication decisionmaking collaboratively between the physician and family.
Early results of process variables with several samples indicated that parents’use of the main features of the MH2 “app” was feasible and was sustained during
early medication titration, although consistency of use varied widely and frequency
of use decreased over three test sessions. Ratings of parent competence, treatment
acceptability, medical-management self-efficacy and medication adherence rates
improved moderately from baseline to end of the study and were substantiallyhigher than those reported among parents of children served in comparable, low

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IACAPAP Textbook of Child and Adolescent Mental Healthincome, publicly funded mental health programs. A downside of these outcome
variables was that they varied so widely. Overall, the authors concluded that MH2
facilitated parent-centered medication decision-making during early stimulant
medication treatment. More reports on the MH2 system should be forthcoming.
Digital Health for Direct-to-Patient Care
i-Therapies are asynchronous, self-administered, psychotherapy
interventions delivered to patients at convenient times, in a non-clinical setting,on their preferred electronic device. Development of these interventions
recognizes the large number of youth in need of mental health treatment, thescarcity of psychiatrists and other mental health clinicians, and the inability ofmany families to access services even when they are available. i-Therapies arebeing tested predominantly in HICs with government-supported healthcare,including Great Britain, Sweden, the Netherlands, Australia, and New Zealand(Lenhard, Andersson, Mataix-Cols, et al., 2017; Merry, Stasiak, Shepherd, et al.,2012; Stasiak, Fleming , Lucassen, et al., 2016). Generally, they have a theoreticalorientation based on Cognitive-Behavioral Therapy (CBT) for depression
and anxiety (Schniering, Einstein, Rapee, et al., 2017) for which they havedemonstrated effectiveness, although perhaps more for anxiety than for depression(Christ, Jschouten, Blankers et al., 2020).
A strength of i-therapies is their reliable delivery of the intervention’scontent, whereas “real world” therapists may deviate in implementing manualized
protocols. The downside is that many youth drop out after completing only a few
modules, consistent with the adherence challenges common to other online selfhelp tools (Ebert, Zarski, Christensen, et al., 2015). In adult studies, support bya therapist or coach by phone or “chat” increases adherence. Such asynchronous
support may be needed with youth. Perhaps the success of i-therapies will be in a
hybrid model that alternates in-person and i-therapy sessions, thereby efficiently
decreasing the number of in-person sessions needed to achieve effectiveness; orin which in-person sessions support the use of i-therapies. These approaches havesome potential to turn therapy around, i.e., the delivery of the intervention is
primarily through i-therapy while the therapist provides support for use of the
i-therapy modality and/or additional services as indicated. While a promising
approach for universal dissemination of therapies for milder behavioral andmental health disorders, funding for i-therapies has not been adequately addressed,
particularly for use in private practice.
The internet and mobile health technologies (m-health) are emerging asa major asynchronous source of health information (Eysenbach, Powell, Kuss, etal., 2002). Kauer, Mangan, Sanci, 2014; Wood, Benson, LaCroix, et al., 2005),
which has implications for young people who prefer online environments as theirprimary mode of communication (Thayer, Ray, 2006). Teens may use their mobile
devices to learn about their health, including their mental health. Psychiatrists
may integrate these digital technologies into their practices to appeal to teens.
They may strengthen the impact of their interventions with online “homework”
between in-person sessions. Digital technologies may also be used to efficiently
conserve the scarce psychiatric workforce, for example by alternating in-personwith online sessions. Following are some evolving digital healthcare approaches inchild and adolescent psychiatry.

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IACAPAP Textbook of Child and Adolescent Mental Health

Recognizing this trend, digital self-help programs online and through“apps” are proliferating for youth (Thayer, Ray, 2006; Blanchard, Herrman, Frere,
et al., 2012; van der Zanden, Kramer, Gerrits, et al., 2012; Price, Yuen EK,
Goetter E, et al., 2014; Merry, Stasiak, Sherherd, et al., 2012). These low risk
technologies have the potential to efficiently increase youths’ knowledge of mental
health and mental health conditions (van der Zanden, Kramer, Gerrits, et al.,2012) and increase autonomy in self-monitoring and determining their need forassistance (Bradford, Rickwood, 2015; Hetrick, Robinson, Burge, et al., 2018;
Iorfino, Cross, Davenport, et al., 2019; Kauer, Reid, Crooke, et al 2012; OspinaPinillos, Davenport, Iorfino, et al., 2018; Ospina-Pinillos, Davenport, Ricci, et al.,2018) and finding referral resources (Kim, Coumar, Lober, et al., 2011). They may
also find useful psychoeducation materials for self-administered interventions for
milder problems (Hoek, Marko, Fogel, et al., 2011; Kollins, DeLoss, Canadas, etal., 2020; Tait, Christensen, 2010).
Youth can find “apps” that aim to provide self-screening, monitoring, andeven treatment for selected conditions, such as insomnia, depression, and anxiety(Calear, Christensen, 2010; Hoek, Marko, Fogel, et al., 2011; Ospina-Pinillos,
Davenport, Iorfino, et al., 2018; Ospina-Pinillos, Davenport, Ricci, et al., 2018;
Lenhard, Andersson, Mataix-Cols, et al., 2017; Merry, Stasiak, Shepherd, et al.,2012; Stasiak , Fleming, Lucassen, et al., 2016); Tait, Christensen, 2010; Thabrew,
Stasiak, Hetrick, et al., 2018). Some of these “apps” are based on solid research(Merry, Stasiak, Shepherd, et al., 2012; Whiteside, Biggs, Tiede, et al., 2019).
However, this potential to aid youths’ efforts to tend to their mental healthneeds is offset by several factors. Most of these “apps” lack an established evidencebase regarding their validity, reliability, and effectiveness. Also, there is insufficient
data regarding the potential adversities of such untested “apps” (Grist, Porter,
Stallard, 2017; Leigh, Flatt, 2015). Many “apps” are proprietary and must bepurchased, making them inaccessible for the 90% of youth aged10 to 24 years old
who live in LMICs (Das Gupta, Engelman, Levy, et al., 2014), who, then, are at
risk of experiencing not only physical and social but also technological inequalities
in health. Until there is formal evidence supporting such “apps,” psychiatrists
can help their patients to choose an appropriate “app” by using the American
Psychiatric Association’s “app” evaluation model to critically assess accessibility,
privacy and security, clinical foundation, engagement, and interoperability (Lagan,
Sandler, Trouous, 2021); however, there is no centralized database for users to view
the performance of these “apps” when assessed via this model. Another available
evaluation frameworks include the Mobile App Rating Scale (MARS) (Stoyanov,Hides, Kavanagh, et al., 2015) or the Adapted MARS (Roberts, Davenport, Wong,et al., 2021).
Despite the potential benefits of m-health tools to help youths’ mental
health, uptake has been limited due to difficulties with engagement, adherence, andattrition (Clark, Kuosmanen, Barry, 2015; Eysenbach, 2005; Garrido, Millington,
Cheers, et al., 2019). Many explanations have been proposed, most specificallythe need for participatory design methodologies with youth in construction of
the tools (Bjerkan, Hedlund, Hellesø, 2015; Hagen, Collin, Metcalf, et al., 2012;
Ospina-Pinillos, Davenport, Ricci, et al., 2018). Multiple technological solutions
have been proposed, particularly “gamification” ( Burns, Davenport, Christensen,
2013). Cheng, 2020; Cheng, Piper, Ottavio, et al., 2021); Fleming, Stasiak,

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IACAPAP Textbook of Child and Adolescent Mental HealthMoselen, et al., 2019).
It is not yet clear whether the experience of m-health will be different in
LMICs. Given the dearth of child and adolescent psychiatrists, as well as othermental health clinicians, uptake would, ideally, be better than in HICs. Ninety
percent of the world population aged 10 to 24 years lives in a LMIC (Das Gupta,
Engelman, Levy, et al., 2014). As m-health technologies become more widelydistributed, youth and their families may access psychoeducation sites to identify
their conditions and to seek clinical services, if their LMIC has a mental healthworkforce. Psychiatrists in these countries could incorporate m-health into theirpractices to augment their sessions, or to efficiently alternate in-person and selfadministered sessions that would, thereby, optimize utilization of the country’s
psychiatric workforce and minimize youths’ absences from school and parents’absences from work. Primary care providers can utilize m-health to obtain
education in mental health (Patel, Saxena, Lund, et al., 2018), access guidelines
regarding mental health conditions and interventions, and provide information totheir patients. They may also obtain digital consults from available psychiatrists at
major medical centers.
There are several concerns regarding the use of m-health as a solution
to the dearth of mental health services in LMICs, beyond the concerns cited for
HICs above. First, as noted for HICs, many available “apps” and other resources
are not sufficiently examined to allow their recommendation. It is tempting tothink that an available digital intervention is better than no intervention (Garrido,
Millington, Cheers, et al., 2019). There is just not sufficient evidence to know
this; and, if families must pay for an intervention, there is risk of indirect harm.
Second, many m-health “apps” are not available in varied languages (OspinaPinillos, Davenport, Navarro-Mancilla, et al., 2020). Third, even if translated into
a country’s language, these “apps” may not be vetted for cultural relevance. Finally,families in LMICs may not be receptive to m-health modalities, and only trust
clinical information conveyed by a physician during an in-person visit.
Going forward, we support the Lancet Commission on Global Mental
Health and Sustainable Development (Patel, Saxena, Lund, et al., 2018) and theWorld Economic Forum (2019) that propose that the internet and other digital
tools can expand equal access to care and treatment, or at least reduce the barriers
to equal access. Recognizing the diversity of the global community, they also
advocate for the development of regulations and policies regarding the use of healthinformation technologies for mental health care. The response of LMICs to theserecommendations will require that psychiatrists, cultural advocates, technology
specialists, and governments collaborate to explore m-health approaches to improvethe mental health, well-being, and future of their burgeoning young populations.
Each country’s approach and solution will rely on its internal strengths, values, andgoals for their young citizens.

SUMMARYIn HICs, the convergence of increasing clinical needs, limited mental
health resources, and advancing health technologies have made TeleTreatment
and TeleConsultation an attractive approach to deliver evidence-based treatment

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IACAPAP Textbook of Child and Adolescent Mental Healthdirectly to youth and families who are not well served by traditional models of
in-person care. The COVID-19 pandemic removed many barriers to thesemodalities. A rapidly developed evidence-base and clinical experience during the
pandemic have demonstrated the feasibility and acceptability of implementing
TeleTreatment services with youth and their families in their homes. Following the
pandemic, in-home services are likely to be maintained in mainstream psychiatricpractice, but to what extent is not yet clear. Going forward, psychiatrists must keep
abreast of technical, financial, and regulatory changes in this rapidly evolving field.
Establishing an authentic patient-psychiatrist relationship and a successful practicerequires psychiatrists to expand their repertoire of interpersonal relatedness andonline presentation to optimize patients’ experience.
TeleTreatment and TeleConsultation were incorporated in some LMICs
despite the lack of prior experience, demonstrating the potential to include thesevenues when motivation is high. Generally, TeleTreatment in LMICs takes
advantage of the widespread availability of smart phones. However, the dearthof a child and adolescent psychiatric workforce makes a consultative model frompsychiatrists to community primary care physicians a more feasible and efficientmodel of care.
There are many models of digital mental health evolving. These exciting
advances should be helpful for LMICs to reach their population of young
people with psychiatric conditions. However, for most of the self-administered,asynchronous technologies the lack of an evidence-base supporting their efficacy
limits their recommendation. Some self-administered “apps” may be financially
unfeasible for families in LMICs. Support by governments, particularly thosewith social healthcare systems may make some of these evolving mental healthtechnologies options in LMICs.
We need to take advantage of the opportunity that the COVID-19 pandemic
has presented to reconsider our models of mental healthcare and their relevance for
LMICs. Each LMIC should consider how the available mental health technologies
could help their young, and growing, population, how to support the technologythat is the “best fit” for them, and move forward with implementing digital mental
healthcare. It is time for our world to connect.

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IACAPAP Textbook of Child and Adolescent Mental Health

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