Telehealth for supporting child mental health

Advantages of telehealth

Telehealth is defined in the literature as ‘live’ consultations, delivered by practitioners in real time using technology such as videoconferencing and/or telephone (Reay, Kisely, & Looi, 2021; Zhou et al., 2020). An evidence review supported the effectiveness of telehealth in treating a wide range of child mental health issues including behavioural and communication problems, and anxiety and obsessive-compulsive disorder (Florean, Dobrean, Pasarelu, Georgescu, & Milea, 2020; Hansen, Broomfield, & Yap, 2019; McLean et al., 2021).

Practitioners reported the following advantages of telehealth practice:

• the ability to service families over a larger geographical area
• increased opportunities to check-in with families more frequently, including additional family members or caregivers who do not regularly attend clinic visits.

Advantages identified in the research evidence included:

• observation of natural interactions between children and their caregivers outside of a clinic-setting (Comer et al., 2017)
• opportunities to improve children’s care by engaging a multidisciplinary team, including specialists (e.g. multiple practitioners can attend a single consultation or review a client for follow-up remotely) (Margolis et al., 2018)
• improving families’ capacity to disclose personal information (e.g. ease of talking) by increasing their physical distance from the practitioner(s) (McLean et al., 2021)
• increasing child engagement using innovative technology and technology-based resources such as online drawing tools, novel screen backgrounds and online games (Montague, Varcin, Simmons, & Parker, 2015; Nelson & Patton, 2016; Nicholas et al., 2021).

Additionally, the literature shows that telehealth is especially advantageous for families living in rural and regional areas (Bradford, Caffery, & Smith, 2016; Campbell, Theodoros, Hartley, Russell, & Gillespie, 2020; Dadds et al., 2019; Hansen et al., 2019), and families experiencing socioeconomic disadvantage, for whom the cost of travelling and time taken off work are critical barriers in accessing child mental health support (Hopkins & Pedwell, 2021; Huang et al., 2019).

The unique challenges of delivering mental health support via telehealth

There are some unique challenges associated with telehealth which may adversely impact on service delivery (Campbell et al., 2020; Hopkins & Pedwell, 2021; McLean et al., 2021; Nicholas et al., 2021). These include:

• families’ access to, and/or confidence in using, telehealth technology (e.g. videoconferencing software, computers and a secure internet connection)
• technical difficulties (e.g. unstable internet connection)
• maintaining confidentiality and privacy (e.g. families living in apartments or small dwellings)
• managing multiple family members or groups
• loss of human connection and its impact on effectively engaging new clients
• managing conflict and risky situations; and
• adapting verbal and non-verbal communication for the telehealth context (e.g. looking directly at the camera to portray eye contact).

Exploring practitioners’ attitudes towards telehealth

A total of 12 practitioners from different professional backgrounds (e.g. paediatrics, general practice, nursing, research, workforce development and counselling) participated in semi-structured interviews to explore their experience with telehealth, and perceived gaps in knowledge and training.  Practitioners identified several advantages and challenges in delivering telehealth with children and families.

Perceived advantages

• Greater reach (e.g. ability to service families over a larger geographical area)
• Better flexibility (e.g. more opportunities for practitioners to check-in with families, reduced travel time and time off work for families)
• Cost savings
• Multidisciplinary care (i.e. multiple professionals can attend a single consultation)
• Real life observations
• Increased ease of talking (i.e. physical distance and familiar setting can increase disclosure)
• Well accepted by children

Potential challenges

• Difficulties engaging young children
• Difficulties maintaining children’s attention
• Reduced opportunities for human connection and rapport-building
• Limitations for de-escalating familial conflict
• Inequities in families’ access to technology and software (e.g. internet, computer)
• Technical difficulties (e.g. may disrupt consultation delivery)
• Managing multiple people (e.g. groups or several family members)
• Modifying entrenched verbal and non-verbal communication behaviour for telehealth
• Initiating difficult conversations
• Modelling behaviours
• Delivering parent training

Some practitioners reported a preference for telephone calls over videoconferencing but acknowledged that telephone support limited opportunities for practitioners to observe child and caregiver behaviour. Other practitioners preferred to use a hybrid model of care (described following), which used a combination of different telehealth services to supplement in-person consultations (e.g. clinic appointments, home visits). Across all forms of telehealth delivery, practitioners agreed that flexibility was critical for success, and that telehealth should be a choice, rather than a directive, based on the preferences of each child and their family.

Hybrid models of care

Hybrid models of care combine different forms of service delivery including in-person support, telehealth and independent online learning, to deliver mental health support to families. Overall, evidence shows that hybrid models of care, which combine in-person visits with various forms of telehealth (e.g. videoconferencing, telephone consultations, home visits, phone applications and websites), are advantageous for delivering mental health support. Qualitative reports from Australian parents receiving community-based child mental health support indicated a preference for supplementing in-person visits with telephone calls or videoconferencing (Owen, 2020).

Practitioners interviewed recognised hybrid models of care as the most beneficial for children and families, in that they offer flexibility and save travel time. Practitioners also liked that hybrid models of care provided more opportunities for them to check in with families and assess child wellbeing. For most practitioners, the hybrid model they used was developed as a result of trial and error, based on what practices they felt worked best with families, the nature of the service delivery, and the preferences of caregivers. These models typically combined phone and/or videoconferencing with home visits (or webinars as a ‘soft’ entry point to further face-to-face support). Some practitioners also used phone applications and websites to supplement telehealth consultations, particularly with children and young people to help maintain their engagement over time.

Resources and training available to upskill practitioners in using telehealth to support child mental health

Practitioners can access several resources to increase their knowledge and expertise in using telehealth with children and families. These include online learning and training modules, systematic reviews and evidence summaries, published guidelines, checklists and factsheets. Most existing resources are not mental health-specific and cover a range of topics to build practitioners’ understanding of:

• telehealth technology
• data and privacy laws
• logistical considerations
• preparing families
• reviewing professional codes of ethics
• different models of telehealth care
• engaging children; and
• adapting communication styles for telehealth.

Unfortunately, no ‘single’ resource addresses every relevant topic on effective telehealth practices for engaging children and families, and few resources provide opportunities for professionals to practice their telehealth skills and increase their confidence (e.g. practical exercises, interactive activities and video demonstrations).

What practitioners can do

The evidence identified several strategies to increase telehealth effectiveness for practitioners working with children experiencing mental health challenges:

• Extensive preparation, both for themselves (practicing with the technology) and families (exploring their preferences for service delivery, identifying concerns and inequities in access to essential technology and equipment) (Edirippulige & Armfield, 2017).
• Increase opportunities for human connectedness and rapport-building through more frequent contact (McLean et al., 2021; Nicholas et al., 2021).
• Practice verbal and non-verbal communication skills (Edirippulige & Armfield, 2017; Hopkins & Pedwell, 2021).
• Modify session length based on children’s age and stage of development (Campbell et al., 2020).
• Use age-appropriate strategies to engage younger children and infants (Campbell et al., 2020).
• Undertake risk assessments to identify and mitigate potential harm (Hopkins & Pedwell, 2021).

Further reading

References

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Bennett, S. D., Heyman, I., Coughtrey, A. E., Varadkar, S., Stephenson, T., Epilepsy and Mental Health Programme Development Grant Research Group, & Shafran, R. (2021b). Telephone-guided self-help for mental health difficulties in neurological conditions: A randomised pilot trial. Archives of Disease in Childhood, 106(9), 862–867. doi: https://dx.doi.org/10.1136/archdischild-2019-318577

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Campbell, J., Theodoros, D., Hartley, N., Russell, T., & Gillespie, N. (2020). Implementation factors are neglected in research investigating telehealth delivery of allied health services to rural children: A scoping review. Journal of Telemedicine and Telecare, 26(10), 590-606. doi: https://doi.org/10.1177/1357633X1985647

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